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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
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November-December 2018
Volume 29 | Issue 6
Page Nos. 1256-1536

Online since Thursday, December 27, 2018

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REVIEW ARTICLE  

Spectrum of glomerular diseases in Arab countries: A systematic review Highly accessed article p. 1256
Nasar Yousuf Alwahaibi, Halima Khalfan Al Issaei, Buthaina Saif Al Dhahli
DOI:10.4103/1319-2442.248285  PMID:30588955
According to the best of our knowledge, there is no review compiling incidence of glomerular disease in all Arab countries. Most of the Arab countries do not have a national renal biopsy registry. In addition, there is scanty data available on the epidemiology of glomerular diseases in Arab countries. In this review, we performed a systematic review analyzing the incidence of glomerular disease in all Arab countries. Relevant manuscripts in all 22 Arab countries found through searches of Medline, Science Direct, Embase, and Google Scholar were evaluated. The time was from January 1990 to March 2018. A total of 36 manuscripts containing 10,727 biopsies from 11 countries were analyzed. The male-to-female ratio was 1.2:1. Saudi Arabia had the largest number of published studies with 14 papers followed equally by Iraq, Jordan, and Sudan with three papers each. The average period of study was 8.17 years. Retrospective studies represented 86.11%. Focal and segmental glomerulosclerosis (FSGS) (27%), minimal change disease (14%), membranoproliferative glomerulonephritis (13%), mesangioproliferative glomerulonephritis (13%), and membranous glomerulopathy (11%) were the main types of primary glomerular diseases. The most common types of secondary glomerular diseases were lupus nephritis (LN) (58%), amyloidosis (10.19%), diabetic nephropathy (9.89%), hypertension (4.84%) and poststreptococcal glomerulonephritis (2.72%). In conclusion, FSGS and LN are the most common types of primary and secondary glomerular diseases, respectively, in all evaluated Arab countries. The trend of all types of glomerular diseases has not changed in the last three decades. We strongly recommend that each Arab country should have its own renal biopsy registry.
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ORIGINAL ARTICLES Top

Comparative analysis for optimizing the modified release tacrolimus (Advagraf) after kidney transplantation: A prospective randomized trial Highly accessed article p. 1267
Mohamed Adel Bakr, Ayman Maher Nagib, Ahmed Farouk Donia, Ahmed Abdelfattah Denewar, Mohamed Megahid Abu-Elmagd, Mohamed Hamed Abbas, Ahmed Mansour Abdel-Rahman, Mohamed Elsayed Mashaly, Mohamed Mohamed Elsaftawy, Mohamed Ahmed Ghoneim
DOI:10.4103/1319-2442.248303  PMID:30588956
Immunosuppression management in clinical transplantation aims to balance delivery of efficacy against adverse reactions using therapeutic drug monitoring. Adherence to posttransplant immunosuppressive medications and minimizing variability in drug exposure are important considerations in preventing rejection and maximizing overall transplant outcomes. The availability of once-daily tacrolimus may add a potential benefit by simplifying immunosuppressive regimens, though improving compliance among transplant recipients. The aim of our study is to investigate the safety and efficacy of the once-daily formulation of tacrolimus (Advagraf) against the usually used twice daily tablets (Prograf). A prospective randomized trial 1:2 was designed for 99 consecutive live-related renal transplant recipients who received their grafts at a single center (study group, Advagraf, 33 recipients and control group, Prograf, 66 recipients). The demographic data were homogeneous among both groups regarding donors and patients’ characteristics. Posttransplant hypertension, infection, malignancy, and diabetes mellitus were comparable among both groups. Renal function and rejection episodes showed no statistical significance among recipients of both groups. Despite slight higher Advagraf unit doses, there was no statistical difference regarding the tacrolimus trough levels, between the two groups. Our singlecenter experience revealed that the availability of once-daily tacrolimus formulation could give potential benefit of improved medication compliance and better allograft outcomes by decreasing pill burden and thereby simplifying dosing schedule, Advagraf was non-inferior to twice-daily tacrolimus regarding safety and efficacy. Although being nonsignificant, a trend for better kidney function was noted in this short-term study in the Advagraf group, so long-term follow-up is needed to verify this.
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Effect of thyroid function status in hemodialysis patients on erythropoietin resistance and interdialytic weight gain p. 1274
Fatemah Saleh Bin Saleh, Marriam Nasser Naji, Abdalla A. Eltayeb, Fayez Faleh Hejaili, Abdulla Ahmed Al Sayyari
DOI:10.4103/1319-2442.248310  PMID:30588957
Thyroid function abnormalities are common in hemodialysis (HD) patients. Here, we investigated their frequency and impact on intradialytic hemodynamics and erythropoietin resistance index (ERI). Demographic and laboratory data including thyroid-stimulating hormone (TSH), interdialytic weight gain, and intradialytic blood pressure (BP) changes were measured, and ERI was calculated. The prevalence and causes of abnormities in TSH and free thyroxine (FT4) and their effects on ERI and intradialytic hemodynamics were then assessed. One hundred and thirty patients (mean age, 57.1 ± 19.2 years; 66.4% diabetic, 86.7% hypertensive) were enrolled. Among them, 16.7% had hypothyroidism, 2.3% had hyperthyroidism, and 10.9% had subclinical hypothyroidism. TSH level was significantly associated with higher BP (P <0.05), lower albumin (3.6 ± 4.4 and 2.6 ± 1.8, respectively; P = 0.05), lower dialysis hours (3.9 ± 5.3 and 2.6 ± 1.8, respectively), and lower ERI (3.7 ± 4.4 and 2.4 ± 1.9, respectively; P = 0.05). FT4 was significantly associated with higher interdialytic weight gain (13.4 ± 4.3 and 11.8 ± 2.2 pmol/L, respectively; P = 0.009) and higher pre-HD diastolic BP (13.2 ± 4.0 and 12.0 ± 2.9 pmol/L, respectively; P = 0.05). A negative correlation was seen between TSH level and urea reduction ratio (r = 0.29, P = 0.002), serum albumin (r = 0.304, P = 0.001), hemoglobin level (r = 0.26, P = 0.005), and ERI (r = 0.2, P = 0.002). A higher TSH level was associated with hypertension, lower albumin level, fewer dialysis hours, and increased resistance to erythropoietin. TSH level was negatively correlated with dialytic adequacy, serum albumin level, hemoglobin level, and ERI.
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Assessment of left ventricular mass changes after arteriovenous fistula surgical banding in end-stage renal disease p. 1280
Camilo Cortesi, Juan C Duque, Sedki Mai, Laisel Martinez, Adriana Dejman, Roberto Vazquez-Padron, Loay Salman, Marwan Tabbara
DOI:10.4103/1319-2442.248299  PMID:30588958
Left ventricular hypertrophy (LVH) is a multifactorial complication frequently seen in patients with advanced chronic kidney disease. An arteriovenous fistula (AVF) is the preferred method for hemodialysis access. Once functional, AVFs demonstrate better patency rates and fewer complications when compared to other forms of vascular access. AVFs have been implicated in cardiac remodeling, but it is controversial whether those changes can be reversed by surgical ligation or blood flow reduction. In this study, we describe a cohort of asymptomatic patients with LVH who underwent AVF banding with a two-dimensional-echocardiogram done before and after the intervention to evaluate the association between AVF surgical banding and left ventricular mass (LVM) changes. Our results show that AVF surgical banding did not alter the left ventricular mass index (LVMI) with a mean prebanding LVMI of 70.3 ± 57.5 g/m2 and mean postbanding LVMI of 81.9 ± 55.9 g/m2, (P = 0.4). Our study shows that AVF flow reduction by surgical banding did not alter LVMI, and therefore LVH, in end-stage renal disease patients who have not yet shown clinical manifestations of cardiac disease.
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Clinical and laboratory findings of patients with diabetes undergoing kidney biopsy p. 1290
Ehab Mohammed, Ahmed Atris, Issa Al Salmi, Lubna Al-Menawi, Faisal Shaheen, Suad Hannawi
DOI:10.4103/1319-2442.248287  PMID:30588959
Diabetic kidney disease (DKD), one of the most frequent microvascular complications of diabetes mellitus (DM), is the leading cause of end-stage kidney disease worldwide. We reviewed all kidney biopsies performed at the Royal Hospital, Muscat, Oman, between January 2005 and December 2016, and data of 51 DM patients were analyzed. Of the 51 patients, 54.9% were male and 45.1% were female. The mean age was 50.8 (47.1–55.2) years; 86% were between 25 and 64 years old. Edema was the main clinical presentation (70.6%) with clinical urine changes in 84.3%. Diabetic retinopathy was present in 62.2% in ophthalmological examination of 44 patients. Majority (67.5%) of patients were in advanced chronic kidney disease Stages III, IV, and V. About one-quarter underwent hemodialysis at the time of admission. Majority (76.9%) were obese and hypertensive (78.4%). Low hemoglobin (51%), high triglyceride (35.7%), high total cholesterol (56.8%), low serum albumin (78.4%), nephrotic-range proteinuria (75.6%), and microscopic hematuria (77.1%) were the main laboratory findings. In addition, immunological investigations were examined and immunoglobulin A was the most common findings (35.7%) of serological investigations. About 24.4% had positive antinuclear antibody, 20.8% had positive anti-dsDNA, and 23.3% had positive extractable nuclear antigens. Also, p-antineutrophil cytoplasmic antibody (p-ANCA) was positive in 30% and c-ANCA was positive in 9.7%. This study represents the findings of the whole country for more than 10 years. It showed that only a small percentage of patients with DM undergo kidney biopsy. These patients have many clinical and laboratory abnormalities including those of specific immuno-logical investigations. Progression of DM nephropathy seems to be further aggravated by many coexisting risk factors of dyslipidemia and/or obesity. The prevalence of non-DKD is remarkably frequent in diabetics in whom nephrologists should consider kidney biopsy as an appropriate measure to enable better management.
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A single-center 4-year experience with 47 pediatric renal transplants: Evolving trends p. 1303
Hany M El Hennawy, Ahmed Al Hashemy, Nafaa Al Harbi, Wael T Habhab, Ahmed E Fahmy
DOI:10.4103/1319-2442.248297  PMID:30588960
Outcome of pediatric kidney transplantation (KT) has improved over the last several decades. We retrospectively reviewed the outcomes pediatric KT in King Faisal Specialist Hospital and Research Center-Jeddah, Saudi Arabia. Between May 2013 and November 2016, we performed renal transplantation in 47 children, 30 (64%) males, and 17 (36%) females. All patients received antibody induction with basiliximab or antithymocyte globulin along with triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil and steroids. Twenty-four (51%) and 14 (30%) patients were on hemodialysis and peritoneal dialysis, respectively. Average duration on dialysis was 18.3 months. Nine patients (19%) had preemptive transplant. Forty-five patients (95.7%) received kidneys from living donors, 38 (83%) males and nine (17%) females, mean age (years), and body mass index were 30.8 ± 8.82 and 23.8 ± 4.54, respectively. Forty-one donors had left nephrectomy. Four right nephrectomies were reported, all of them were through open nephrectomy. Open nephrectomy was reported in 21 (46%) patients. Several laparoscopic nephrectomy techniques were performed; conventional laparoscopic donor nephrectomy, laparo-endoscopic single-site donor nephrectomy, and hand-assisted laparoscopic surgery in 10, 11, and three patients, respectively. The most common etiologies of end-stage renal disease were focal segmental glomerulosclerosis 19%, posterior urethral valve 8.5%, and congenital abnormalities 8.5% respectively. With a mean follow-up of 54 months, one and 4-year graft survival rates were 95.7% and 91.5%, respectively. One-and four-year patient survival rates were 100%. Outcomes were similar in patients < or ≥10 years. The graft survival was comparable in laparoscopic versus open donor nephrectomy (P = 0.72). Average serum creatinine was 0.85, 0.79, 0.79, and 0.84 at 7, 30, 90, 365 days, respectively. Four patients lost their graft due to renal vein thrombosis, chronic allograft nephropathy (cadaveric donor), Antibody-mediated rejection, and hemolytic-uremic syndrome at 0.75, 9, 19, and 24 months, respectively. The incidences of acute rejection and major infection were 2% and 4%, respectively. One patient developed posttransplant lympho-proliferative disease that was treated and is still with excellent graft function. Our pediatric KT experience is encouraging. Acute rejection, patient, and graft survival rates are similar and even better than many of western reports.
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Impact of Enterobacteriaceae bacteremia on survival in patients with hepatorenal failure p. 1311
Amin Roshdy Soliman, Rabab Mahmoud Ahmed, Ahmed Abdalla, Mahmoud Soliman, Magee Saeed
DOI:10.4103/1319-2442.248293  PMID:30588961
Enterobacteriaceae are now the predominant pathogens isolated in patients with liver cell failure associated with bloodstream infections. We conducted a retrospective cohort study of patients who were admitted for the diagnosis of hepatorenal failure (HRF) between June 1999 and May 2008 to investigate the risk factors of Enterobacteriaceae bacteremia (EB). EB was defined as the isolation of an EB species from at least one blood culture within three months following diagnosis of HRF. Variables were collected from the medical records and analyzed in relation to EB. Twenty-four (32.5%) of the 73 patients developed EB. The origin of EB was abdominal in 21% of the patients, urinary in 12.5%, pulmonary in 16.5%, and primary in the remaining patients (50%). Two-thirds of EB occurred within 10 days following the development of HRF. The main pathogens were Escherichia coli (44%), Enterobacter species (20%) and Klebsiella pneumoniae (22%). Eighteen patients (75%) with EB died. Variables significantly associated with EB after multivariate analysis were a model for end-stage liver disease score >20 [odds ratio (OR): 2.84, P <0.02], posthepatitis B liver cirrhosis (OR: 4.72, P <0.05), posthepatitis C liver cirrhosis (OR: 3.48, P <0.05), and initial level of serum creatinine on admission to intensive care unit (OR: 2.56, P <0.02). EB is a frequent and severe complication of HRF. Patients with posthepatitis cirrhosis B and C, higher serum creatinine, and severe liver cell failure score have a high risk of developing EB.
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Posttransplant diabetes mellitus among live-related kidney transplant recipients: Sindh Institute of Urology and Transplantation experience p. 1320
Khadija Gul Mohammad, Muhammad Khalid Idrees, Tariq Ali, Fazal Akhtar
DOI:10.4103/1319-2442.248294  PMID:30588962
This cross-sectional study conducted at Sindh Institute of Urology and Transplantation, Karachi, Pakistan aimed to determine the frequency and risk factors of posttransplant diabetes mellitus (PTDM) among live-related kidney transplant recipients and their short-term prognosis and included renal transplant recipients (nondiabetic before transplant) of either gender, aged 18–60 years with transplant duration two to six months. Patients with two reading of fasting plasma glucose ≥126 mg/dL were labeled as diabetic. A total of 191 patients (154 males and 37 females) with the age between 18 to 60 years (31.5 ± 9.33 years) were included and 30 patients (15.8%) including 23 males and seven females had PTDM. Age of the patients between 26 and 35 years, previous hepatitis C virus (HCV) infection/antiviral therapy, and Tacrolimus as maintenance immunosuppression were found to be more frequent among those with PTDM. After six months of follow-up, the serum creatinine of patients with PTDM was significantly higher than that of those without PTDM (1.15 ± 0.28 vs. 1.01 ± 0.16, P ≤0.0121); however at one year follow up, there was no significant difference between the serum creatinine of both groups (1.28 ± 0.38 vs. 1.37 ± 0.59, P = 0.332). PTDM is an important metabolic derangement affecting a number of kidney transplant recipients. Its risk factors are previous HCV infection, tacrolimus as immunosuppression and young age. It can have an adverse effect on graft function and survival. Therefore, long-term follow-up is warranted to optimize the graft function and patient survival.
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Assessment of knowledge and attitude toward organ donation among the Saudi population in Riyadh City p. 1326
Dalia Saleh Alsharidah, Fay Saad Al-Dossari, Nouf AlMahmoud, Bothayna Abdullah Alanzan, Rawan Jamal Binkhulaif, Esraa Mohammad Bakhsh, Abeer Ali Alkhalaf, Budur Abdullah Bin Huzim, Nora Tarig Sarhan, Lujain Mohammad Sulayem, Dalia Saad ElFeky, Sadiqa Syed
DOI:10.4103/1319-2442.248304  PMID:30588963
We aimed to assess the knowledge and attitude of the Saudi population and students of health science colleges as well as healthcare workers in Riyadh city about organ donation (OD). Data of this study were collected from 648 Saudi residents of Riyadh city using interviewer-administered questionnaires and online surveys. The participants included 503 from the general population and 145 health science professionals. The subjects included 252 males and 396 females with mean age of 27.09 ± 9 years. Majority of the participants (60%) were aware of OD from media as the main source of information, while only 30% had knowledge about Saudi center for organ transplantation (SCOT). It was found that 47.7% of the population agreed to donate both organs and tissue and 26% of them accepted the idea of OD to please Allah. The most important barrier (13%) was the belief that their bodies should be kept intact after death followed by ignorance about OD. Among health science professionals, 63% thought that everyone should be automatically registered as an organ donor while 15% believed that the donated organs could be misused. The majority of Riyadh’s population knew the concept and procedure of OD; however, there was a lack of awareness of the presence of SCOT. Religion is not a barrier for OD in the Saudi population. Awareness programs are urgently needed to emphasize the importance of donation as well as clarification of wrong beliefs.
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Impact of correction of anemia in end-stage renal disease patients on cerebral circulation and cognitive functions p. 1333
Amr Mohamed Shaker, Osama Mohamady Mohamed, Moataz Fatthy Mohamed, Sahier Omar El-Khashaba
DOI:10.4103/1319-2442.248306  PMID:30588964
End-stage renal disease (ESRD) patients have been associated with accelerated vascular disease of the cerebral circulation due to uremic toxins. Furthermore, anemia increases cerebral oxygen extraction fraction which impairs the cerebral vasodilatory capacity. We evaluated the effect of correction of anemia on cerebral blood flow by measuring the mean blood flow velocity, resistance index (RI), and pulsatility index (PI) in the middle cerebral artery (MCA) in relation to cognitive functions. We measured the mean blood flow velocity, RI, and PI in MCA of 120 ESRD patients when the hemoglobin (Hb) ranges between 8 and 10 g/dL and after correction of anemia to two Hb ranges between 10–11.5 g/dL and 11.5–12.5 g/dL in the same patients using transcranial Doppler (TCD) ultrasound in relation to cognitive functions assessment by Mini–Mental State Examination. We observed that there is a mild-to-moderate cognitive impairment in hemodialysis (HD) patients associated with anemia. With the improvement of anemia, the cognitive functions improved. There was an improvement of blood flow of MCA with improvement of Hb. The improvement was obvious at Stage 3 (Hb 11.5–≤12.5 g/dL) in comparison to Stage 2 (Hb 10–<11.5 g/dL) with P <0.001 at all. The optimal Hb for HD patients ranges from 11.5 to ≤12.5 g/dL which associated with better improvement of cognitive function and cerebral circulation investigated by TCD ultrasound for MCA.
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Effectiveness of prehemodialysis preparatory program on improving coping among chronic kidney disease patients p. 1342
Sonali Tarachand Jadhav, Premila Lee, Chrishma Violla D’souza
DOI:10.4103/1319-2442.248295  PMID:30588965
Diagnosis of chronic kidney disease (CKD) and initiation of dialysis treatment is reported to be stressful for patients. It is essential that patients use effective coping strategies to deal with these stressors, since ineffective coping could have several adverse effects on various treatment-related as well as personal aspects of life, thereby lowering the quality of life in these patients. The study used a quasi-experimental design. The study population comprised 100 adult patients with Stage 3 and Stage 4 CKD whose glomerular filtration rate was deteriorating and required to undergo hemodialysis (HD) treatment. Carver’s Brief Cope Scale was used to assess coping strategies used. The study was carried out in a tertiary care hospital in Bengaluru, India. Patients in the intervention group received pre-HD preparatory program and those in the control group received standard care. Postassessment for coping strategies used was carried out two weeks after the delivery of intervention. Highly significant statistical differences were observed in the use of certain adaptive coping strategies among the experimental group as compared to the control group after implementation of pre-HD preparatory program. These adaptive coping strategies included self-distraction (P = 0.011), active coping (P = 0.000), planning (P = 0.026), acceptance (P = 0.001), and religion (P = 0.005). The intervention was not found to be significant in reducing use of maladaptive coping strategies (P = 0.095). In India, 61%–66% of patients who present to nephrologists are already in end-stage renal disease. These patients hardly receive any organized education that would prepare them to understand their disease and enable them to manage it to the best of their abilities. An ongoing patient education and counseling program led by trained nurse educator will help patients cope effectively with the diagnosis of CKD and its treatment.
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Arteriovenous fistula outcomes in human immunodeficiency virus-positive patients p. 1350
Juan C Duque, Laisel Martinez, Marwan Tabbara, Loay H Salman, Roberto I Vazquez-Padron, Adriana Dejman
DOI:10.4103/1319-2442.248312  PMID:30588966
Arteriovenous fistula (AVF) remodeling is an active area of research in vascular biology given the high rates of primary failure, complications, and cost burden for the health-care system. Comorbidities such as diabetes and different types of vascular disease are known to influence AVFs outcomes. However, little is known about the effects of immunosuppression, particularly human immunodeficiency virus (HIV) infection, on AVF primary failure and patency. This retrospective study assessed the impact of HIV infection and T-cell counts on AVF outcomes. Using a retrospective cohort of 495 patients, we compared the risk of AVF primary failure and primary unassisted patency on HIV-positive and nonimmunocompromised individuals using logistic regressions and Cox proportional hazard models. Within the HIV-infected subset (n = 43), we analyzed the association between immunological parameters such as T-cell counts and primary failure. Positive predictors of primary failure were HIV infection [odds ratio (OR) = 3.09, P = 0.002] and history of a previous AVF (OR = 2.18, P = 0.003). However, there was no difference in primary unassisted patency between HIV-positive and negative individuals after excluding primary failure cases. There was no association between T-cell subset counts and AVF outcomes. Our results indicate that HIV-positive individuals have a higher risk of AVF primary failure than nonimmunocompromised patients. However, this increased susceptibility is not explained by the degree of immunosuppression.
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Knowledge, attitudes, and practice of organ donation in Morocco: A cross-sectional survey p. 1358
Abdelkader Jalil El Hangouche, Oumaima Alaika, Hanan Rkain, Adil Najdi, Leila Errguig, Nawal Doghmi, Souad Aboudrar, Mohammed Cherti, Taoufiq Dakka
DOI:10.4103/1319-2442.248301  PMID:30588967
In any health system, public awareness of organ donation fundamentally affects the organ transplantation programs. The aim of this study was to evaluate the knowledge and perception of the people in Morocco toward organ donation as well as to identify the reasons and determinants for refusal of organ donation. This opinion survey included a representative sample of 2000 participants in Morocco, and data related to sociodemographic characteristics, knowledge and self-opinion about organ donation, and reasons behind refusal were collected. Statistical analysis showed that 55.2% of the participants were women, the median age was 21 years, and 60.8% of included participants had secondary education. Almost two-thirds of surveyed participants (62.3%) showed a low to mid-level of knowledge about organ donation and transplantation in Morocco. About half of the interviewed participants (48.8%) refused to donate their organs. Concern about risk of medical error and the belief in trafficking of procured organs were the main reasons for refusal, seen in 66% and 62% of the interviewees, respectively. Univariate and multivariate logistic regression models showed that the older, the less educated and the less informed a person is, the less he accepted organ donation. Therefore, promotion of organ donation in Morocco should involve a regular information and awareness among the general population.
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BRIEF COMMUNICATIONS Top

BK Virus nephropathy in living donor renal allograft recipients: An observational study from a large transplant center in India p. 1366
Pallav Gupta, Ashwani Gupta, A. K. Bhalla, Manish Malik, Anurag Gupta, Vinant Bhargava, D. S. Rana
DOI:10.4103/1319-2442.248313  PMID:30588968
BK virus is a polyoma virus which remains in latent phase in the urinary tract, particularly in the renal tubular epithelial cells. In immunosuppressed patients, it is activated and manifests as tubule-interstitial nephritis causing renal allograft dysfunction. A total of 402 patients who underwent renal allograft biopsy from 2013 to 2016 were included in this study; six patients were diagnosed to have BK virus nephropathy. Histopathology showed ground glass intra-nuclear inclusions accompanied by acute tubular injury, interstitial inflammation, and varying degree of interstitial fibrosis and tubular atrophy. Patients were managed with reduction in the overall immunosuppression. Only one patient progressed to graft failure on follow-up. The overall prevalence of polyoma virus at our center is 1.49%.
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G6PD deficiency is not an uncommon cause of pigment nephropathy p. 1371
Anupma Kaul, Pallavi Prasad, Niraj Kumari, D Bhaduaria, RK Sharma, N Prasad, A Gupta, Narendra Krishnani
DOI:10.4103/1319-2442.248316  PMID:30588969
Acute kidney injury (AKI) with evidence of hemolysis is associated with tropical infections. However, pigment-induced AKI can happen with relatively uncommon genetic causes of hemolytic anemia, i.e., glucose 6-phosphate deficiency (G6PD). We share our experience of three such patients whose clinical presentation was similar to jaundice, AKI with hemolysis with suspicion of thrombotic microangiopathy. On evaluation, all had a history of usage of anti-malarial and with G6PD estimation revealing deficient status even during the episode while other tests such as Coomb’s test and bone marrow biopsy was normal in all three patients. The kidney biopsy revealed acute tubular necrosis with red blood cell casts and pigments in all the cases. All patients were managed conservatively and showed complete recovery. Thus in tropical countries G6PD deficiency although is not common, should be considered among patients who have received antimalarial drugs presenting as AKI and a detailed hemolytic work-up needs to be carried out as an important cause of preventable recurrent AKI in tropical countries.
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SHORT REVIEW ARTICLE Top

Comparison of tacrolimus and cyclosporine for immunosuppression after renal transplantation: An updated systematic review and meta-analysis p. 1376
Anoush Azarfar, Yalda Ravanshad, Hassan Mehrad-Majd, Mohammad Esmaeeli, Shapour Badiei Aval, Maryam Emadzadeh, Maryam Salehi, Ali Moradi, Mohadese Golsorkhi, Mahmood Reza Khazaei
DOI:10.4103/1319-2442.248292  PMID:30588970
Kidney transplantation is usually followed by immunosuppressive therapy to prevent early rejection and prolong graft survival. The calcineurin inhibitors (CNIs) represent the most commonly used agents. However, available evidence suggests the poor outcome over the long term, maybe be due to the potential nephrotoxicity associated with CNIs. Several randomized trials have compared tacrolimus (TAC) with cyclosporine, to find the optimal agent for renal transplantation; however, studies have shown conflicting results. The aim of this study was to systematically review and update the evidence for the benefits and harm of TAC versus cyclosporine as the primary immunosuppression after renal transplantation. The study was a systematic review and meta-analysis. An electronic literature search was conducted to identify appropriated trial studies. The outcomes were presented as relative risk (RR), with 95% confidence intervals (CI). Statistical analysis used was meta-analysis. Twenty-one eligible randomized controlled trials were included in this systematic review. TAC was significantly superior to cyclosporine considering the total effect size of graft loss (RR 0.089; 95% CI0.057–0.122, P <0.001), acute rejection (RR 0.638; 95% CI 0.571–0.713, P <0.001) and hypercholeste-rolemia (RR 0.634; 95% CI, 0.539–0.746, P <0.001). On the contrary, cyclosporine seemed to be significantly superior to TAC with regard to diabetes (RR 1.891; 95% CI 1.522–2.350, P <0.001). However, no significant differences between the two CNIs were found with regard to mortality, infection, and hypertension. The review indicates that TAC is significantly superior to cyclosporine regarding graft loss, acute rejection, and hypercholesterolemia, but cyclosporine seems to be significantly superior to TAC regarding diabetes. However, further large randomized trials are suggested.
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RENAL DATA FROM THE ARAB WORLD Top

Mortality of diabetic on chronic dialysis in Tunisia p. 1386
Hela Jebali, M Laifi, I Mami, M Khadhar, M Chirmiti, S Beji, R Rheder, W Smaoui, M Krid, F Ben Hmida, L Rais, L Ben Fatma, MK Zouaghi
DOI:10.4103/1319-2442.248283  PMID:30588971
Survival rates of diabetic patients on maintenance hemodialysis (HD) are reported to be poorer in Tunisia than in developed countries. This study aims to specify the epidemio-logical, clinical, and biological characteristics of diabetic disease, chronic kidney disease (CKD), and comorbidities at the initiation of HD and investigate factors associated with mortality during the dialysis period. We retrospectively analyzed the outcome of diabetic patients who were initiated on HD from 2007 to 2012 at the Rabta Hospital of Tunis. During the follow-up period, all morbid events and deaths were recorded. Univariate analysis and multivariate analysis were performed to identify risk factors associated with mortality in our population. The study population included 142 patients. The mean age was 58.7 ± 11.9 years. The sex ratio male/female was 1.4. One hundred and twenty-seven patients were type 2 diabetics (89.4%). Diabetic nephropathy was the main initial nephropathy (87.3%). CKD was diagnosed at Stages 4 or 5 in 95.1% of cases. HD was started in emergency conditions in 68.6% of cases. The one-year and the five-year survival rates were 42% and 17%, respectively. At initiation of HD, low socioeconomic status (P = 0.001), advanced age (P = 0.008), low body mass index (P = 0.04), history of stroke (P = 0.04), peripheral neuropathy (P = 0.02), initial vascular access (P = 0.03), secondary hyperpara-thyroidism (P = 0.03), nephrotic-range proteinuria (P = 0.01), and glycated hemoglobin ≤7% (P = 0.03) were associated with higher mortality rate. During dialysis period, cardiovascular events (P = 0.02), infectious complications (P = 0.04), and secondary hyperparathyroidism (P = 0.04) were significantly more noticeable among deceased patients. Due to poor survival rates of diabetic patients on HD, prevention, early detection, and management of diabetic CKD patients should be the way to go forward.
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RENAL DATA FROM ASIA–AFRICA Top

Urinary schistosomiasis in Boko Haram-related internally displaced Nigerian children p. 1395
Saad Mohammed Yauba, Adamu Ibrahim Rabasa, Abubakar Garba Farouk, Hassan Abdullahi Elechi, Ibrahim Ummate, Bello Abdullahi Ibrahim, Halima Abubakar Ibrahim, Abubakar Sadiq Baba, Talatu Abubakar Boda, Wasiu Adekunle Olowu
DOI:10.4103/1319-2442.248286  PMID:30588972
We aimed to determine the prevalence of urinary schistosomiasis among internally displaced children in Maiduguri, Nigeria. Data on the children’s sociodemographic characteristics and risk factors for schistosomiasis were collected, over a period of six months, using an interview-based questionnaire. Ten milliliter of urine sample was collected from each child and investigated for hematuria and ova of Schistosoma haematobium. Two hundred and thirty-eight of 385 children had urinary schistosomiasis (62.0%); of this, 125 (53.0%) were males, with a male:female ratio of 1.1:1. Urinary schistosomiasis was the most common among 5–9 years’ age group, low social class children, and children of farmers, P <0.05. Stunting was significantly associated with urinary schistosomiasis, P <0.05. It is concluded that urinary schistosomiasis in children was more frequently associated with stunting and low social class. It was a very common disease among internally displaced children in Nigeria.
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Clinicopathological profile of pediatric renal biopsies at a tertiary care hospital, Pakistan p. 1403
Asim Sadaf, Moorani N Khemchand, Lateef Fouzia, Zubair Asia
DOI:10.4103/1319-2442.248290  PMID:30588973
Renal biopsy is an important tool for the diagnosis of acute and chronic glomerular diseases in children. We aimed to analyze the spectrum of clinical indications and histopathological patterns (HPP) in children who underwent renal biopsy (RB). This is a retrospective review of case records of 108 renal biopsies carried out from January 2010 to December 2015 at the Pediatric Nephrology Department, National Institute of Child Health Karachi, Pakistan. RB was performed under Ketamine-Midazolam sedation and real-time ultrasound. Trucut or monopty biopsy gun was used. Data obtained included age, gender, clinical indications, biochemical, urinary, and HPP. Data analyzed by descriptive statistics using SPSS version 20. Of the total 108 patients who underwent renal biopsy, males were 56.5%. The mean age of children at biopsy and disease onset was 7.0 ± 4.28 (0. 2–17) and 5.8 ± 4.09 (0.1–15) years, respectively. Common indications for renal biopsy in primary glomerulonephritis (PGN) were steroid-resistant nephrotic syndrome (SRNS, 36.1%), steroid-dependent nephrotic syndrome (SDNS, 21.3%), and acute nephritic syndrome (ANS) with acute kidney injury (12.0%). Other indications were systemic lupus erythematosus with nephritis and Henoch-Schonlein purpura among secondary GN. Histopathological pattern in PGN showed focal segmental glomerulosclerosis (FSGS, 25.9%), minimal change disease (MCD, 22.2%), membranoproliferative GN (MPGN, 12%), and IgM nephropathy (7.4%). Lupus nephritis (7.4%) was the most common among secondary GN (SGN). Among 22 SDNS; MCD was found in 16, FSGS in four, and MPGN in two children whereas among 40 SRNS; 10 had MCD, 16 FSGS, and two had MPGN. We concluded that most common indications of renal biopsy were SRNS followed by SDNS and ANS. FSGS was the predominant HPP among SRNS and MCD among SDNS.
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Pattern of glomerular disease and clinicopathological correlation: A single-center study from Eastern Nepal p. 1410
Manish Subedi, Bijay Bartaula, Ashok R. Pant, Purbesh Adhikari, Sanjib K. Sharma
DOI:10.4103/1319-2442.248302  PMID:30588974
The pattern of glomerular disease varies worldwide. In the absence of kidney disease/kidney biopsy registry in Nepal, the exact etiology of different forms of glomerular disease is primarily unknown in our country. We analyzed 175 cases of renal biopsies performed from September 2014 to August 2016 in Internal Medicine Ward at B.P. Koirala Institute of Health Sciences. The most common indication for renal biopsy was nephrotic syndrome (34.9%), followed by systemic lupus erythematosus (SLE) with suspected renal involvement (22.3%). Majority of patients were in the 30–60 years’ bracket (57.2%), with the mean age of the patients being 35.37 years. The average number of glomeruli per core was 13, with inadequate sampling in 5.1%. Immunoglobulin A (IgA) nephropathy (17%) was found to be the most common primary glomerular disease, followed by membranous nephropathy (14.6%) and focal segmental glomerulosclerosis (14.6%). The most common secondary glomerular disease was lupus nephritis (LN). Complications associated with renal biopsy were pain at biopsy site in 18% of cases, hematuria in 6%, and perinephric hematoma in 4% cases. Although the most common primary glomerular disease was IgA nephropathy, significantly higher population of SLE with LN among Nepalese in comparison with other developing countries warrants further evaluation. As an initial attempt toward documentation of glomerular diseases in the national context, this study should serve as a stepping stone toward the eventual establishment of a full-fledged national registry of glomerular diseases in Nepal.
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Assessment of knowledge of chronic kidney disease among non-nephrology nurses in Akure, South-West Nigeria p. 1417
Oluseyi Ademola Adejumo, Ayodeji Akinwumi Akinbodewa, Ikponmwosa Osamudiamen Iyawe, Akinbo Emmanuel, Olajumoke Ogungbemi
DOI:10.4103/1319-2442.248288  PMID:30588975
Health workers require adequate knowledge of chronic kidney disease (CKD) to be able to play their role in reducing the burden of CKD. Most previous studies focused on assessing knowledge of doctors on CKD; however, nurses are also important in primary, secondary, and tertiary prevention of CKD. This study assessed the knowledge of non-nephrology nurses on CKD with the aim of identifying areas of knowledge gaps which will be targets for future educational programs. This was a cross-sectional descriptive study carried out among nurses in Akure, Southwest Nigeria during their mandatory continuing professional development program required for practicing license renewal. Knowledge of CKD was assessed using self-administered pretested questionnaires. P <0.05 was taken as significant. One-hundred nurses participated in the study with a male:female ratio of 1:3.7. The mean duration of their nursing experience was 14.5 ± 9.1 years. Only 15% had nephrology posting during their training. Six (6%) of the respondents had good knowledge of CKD, 55 (55%) had fair knowledge, and 37 (37%) had poor knowledge. Only 5% was aware of renal care policy in Nigeria. Junior and intermediate cadre nurses had better knowledge of CKD than senior cadre nurses (P = 0.004). Nurses who had nephrology posting during their training had significantly higher mean knowledge score than others (14.38 ± 2.25 vs. 12.93 ± 3.10, P = 0.036). There were significant deficiencies in the knowledge of CKD among non-nephrology nurses who participated in the study. Junior and intermediate cadre nurses and those who had nephrology postings had better knowledge of CKD.
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Quality of hemodialysis services in a poor population, Sistan and Baluchestan province, Iran: A descriptive, prospective study p. 1424
Abbas Balouchi, Hosien Shahdadi, Ahmad Shahkzhi, Measam Irandgani, Somayeh Aboo, Enayatollah Bolaydehyi, Moslem Hooti, Christine M Lundquist, Saeid Shahraz
DOI:10.4103/1319-2442.248300  PMID:30588976
Managing patients with chronic kidney disease causes enormous financial burden on the Ministry of Health and Medical Education. In addition, there is a lack of feedback and adequate information in general. This study aimed at investigating quality-of-care indicators among hemodialysis (HD) patients. This descriptive, prospective study was conducted on 144 HD patients in Zabol and Iranshahr dialysis centers from March 21 to December 22, 2015. Measurement indicators included hemoglobin level, dialysis adequacy, albumin level, vascular access, and calcium and phosphorus levels. The mean hemoglobin and dialysis adequacy level at baseline were 10.58 ± 1.6 g/dL and 1.09 ± 0.18, respectively. At the end of the study, 49.6% of participants achieved target hemoglobin level. However, only 18.6% of patients achieved target dialysis adequacy at the end of the study. Dialysis adequacy was calculated by using an standard software for calculating the KT/V that provided by Iran ministry of health for all dialysis centers. The prevalence rate of use of central venous catheter was 43.2% at the end of the study. The majority of patients (59%) had albumin within normal limits and also achieved target in terms of calcium (52%) and phosphorus (59%) levels at the end of the study. Despite partial improvement in several indicators, none achieved target values which indicate the need for greater attention to quality-of-care indicators for correct planning, cost reduction, and efficiency improvement.
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Assessment of iron status in predialysis chronic kidney disease patients in a Nigerian Tertiary Hospital p. 1431
Ikponmwosa Osamudiamen Iyawe, Oluseyi Ademola Adejumo, Linda Iruobe Iyawe, Efosa O Oviasu
DOI:10.4103/1319-2442.248296  PMID:30588977
Anemia in chronic kidney disease (CKD) is associated with poor overall outcome if not promptly managed with erythropoietin when indicated. This study assessed iron status and associated factors in predialysis CKD patients in Southern Nigeria. This was a cross-sectional study that assessed and compared iron status in 100 predialysis CKD patients and 90 healthy controls. Mean age of the CKD patients was 49.39 ± 14.84 years. Iron deficiency was present in 14% of CKD patients compared to 3% of the controls (P = 0.021). Among CKD patients with ID, 11 (85.7%) had functional iron deficiency while three (14.3%) had absolute iron deficiency. Serum ferritin was significantly higher in the predialysis CKD patients (P = 0.001). There was no significant gender difference in iron indices among the CKD patients. Functional iron deficiency was present in 11 (11%) of the CKD patients compared to none among the control group (P = 0.003). There was no significant association between iron deficiency and age, gender, etiology, and stage of CKD. Functional iron deficiency was the predominant form of iron deficiency in our predialysis CKD patients, and there was no significant association with age, gender, stage, or etiology of CKD.
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A review of the epidemiology of chronic kidney disease in Pakistan: A global and regional perspective p. 1441
Salman Imtiaz, Beena Salman, Ruqaya Qureshi, Murtaza F Drohlia, Aasim Ahmad
DOI:10.4103/1319-2442.248307  PMID:30588978
Both the incidence and prevalence of chronic kidney disease (CKD) are rising with immense pace worldwide. People living in developing countries are speculated to suffer the consequences due to economic deprivation and high cost of treatment. The prevalence of CKD is highly variable in different parts of the world, due to various environmental, ethnic, socioeconomical, and rural-urban differences. It has become very important for the developing countries to understand the true nature of the disease and its prevalence, rather than to hypothesize or make supposition on the bases of Western data. It is imperative to understand the risk factors in our region or country. Few studies have reported that the prevalence of CKD in Pakistan and its risk factors. Through the internet, we searched the terms prevalence of CKD, and included articles that discussed the CKD prevalence in different regions. We reviewed all studies along with the global as well as regional data to have better insight into the problem.
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SPECIAL ARTICLE Top

The National Guard Health Affairs guidelines for the medical management of renal transplant patients p. 1452
Ziad Arabi, Abdulrahman Theaby, Mahfooz Farooqui, Mubarak Abdalla, Ali Hajeer, Khalid Abdullah
DOI:10.4103/1319-2442.248311  PMID:30588979
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CASE REPORTS Top

Safe correction of severe hyponatremia in patient with severe renal failure using continuous venovenous hemofiltration with modified sodium content in the replacement fluid p. 1470
Bashaer Y Alqurashi, Jawaher A Gramish
DOI:10.4103/1319-2442.248308  PMID:30588980
Optimal treatment of severe hyponatremia in patients requiring dialysis is not known. Rapid correction with the use of different dialysis modalities can lead to osmotic demyelination syndrome. We described a safe correction of severe hyponatremia in a 42-year-old male patient requiring dialysis, who was treated with continuous venovenous hemofiltration using hypotonic replacement fluid which was prepared and adjusted on a daily basis.
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Mammalian target of rapamycin inhibitors in a patient with polycystic kidney disease-1-tuberous sclerosis-2 contiguous gene syndrome p. 1475
Urmila Anandh, Gayatri Chandrasekar, Vikas Agarwal
DOI:10.4103/1319-2442.248317  PMID:30588981
The mutations associated with polycystic kidney disease are closely aligned with that of tuberous sclerosis (TSC) in chromosome 16. Occasionally, the presence of these mutations in an individual can lead to a presence of a disease phenotype with a combination of polycystic kidney disease and TSC (contiguous gene syndrome). We present a case report of a young girl who presented with skin lesions, central nervous system tubers, and cystic disease of the kidneys. She was treated with mammalian target of rapamycin inhibitors with a favorable outcome.
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Vitamin B1 for type B metabolic acidosis: An underrecognized approach p. 1480
Adriana Dejman, Jason Riveros
DOI:10.4103/1319-2442.248314  PMID:30588982
Lactic acidosis is a life-threatening and rather common complication and reason for consultation to the nephrologist. The cause for this condition is usually thought to be secondary to hypoperfusion and ischemia collectively. However, many other rare causes have been described, yet there is little awareness of these, consequently delaying optimal care. We present a multifactorial case of lactic acidosis due to thiamine deficiency, liver disease, and lymphoma; all underrecognized causes of Type B lactic acidosis.
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Encapsulating peritoneal sclerosis associated with Burkholderia pseudomallei peritonitis p. 1484
Zakaria Aulia, Wan Ahmad Syahril Rozli Wan Ali, Mohammad Arif Shahar
DOI:10.4103/1319-2442.248318  PMID:30588983
Burkholderia pseudomallei is a known motile organism in soil. Its infection is usually described in immunocompromised patients. It inflicts serious infection with high mortality and morbidity rate. We report a rare case of an end-stage renal disease patient on regular continuous ambulatory peritoneal dialysis (PD) who developed melioidosis PD peritonitis. Within a short period of time, she developed encapsulating peritoneal sclerosis evidenced by the intraoperative findings of intraabdominal cocooning. Choice and duration of antibiotic are important for proper eradication of the organism. Early diagnosis and treatment of both conditions also may improve the prognoses.
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Cerebral venous sinus thrombosis as a warning signal for double positive crescentic glomerulonephritis in a young male with complete renal recovery p. 1488
Vijoy Kumar Jha, KV Padmaprakash, Rajesh Pandey, Vivek Sharda, Alok Sharma
DOI:10.4103/1319-2442.248291  PMID:30588984
Double positive crescentic glomerulonephritis is relatively rare in young population and has variable outcomes. Although increased incidence of deep venous thrombosis in antineutrophil cytoplasmic antibody-associated vasculitis has been reported, cerebral venous sinus thrombosis (CVT) is very rare. We present a young male who presented with CVT followed by rapidly progressive crescentic glomerulonephritis and with appropriate therapeutic modalities he had complete renal and partial neurological recovery.
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Relapsing Serratia peritonitis resulting in peritoneal catheter loss p. 1494
Ilhan Kilic, Kultural Gungor, Ilhan Kurultak, Sedat Ustundag
DOI:10.4103/1319-2442.248298  
Serratia marcescens (SM) is an opportunistic Gram-negative bacterium. It can cause technique failure or severe sepsis despite being a rare agent causing peritonitis. We present a case of a 40-year-old woman with end-stage renal disease secondary to chronic glomerulo-nephritis on continuous ambulatory peritoneal dialysis (PD). She presented with severe abdominal pain and a cloudy peritoneal fluid. The fluid was cultured according to our unit protocol. The organism isolated was identified as SM; this was after the patient was treated for SM peritonitis one week earlier. The response to treatment with ceftazidime was poor despite being sensitive in vitro. The peritoneal catheter was removed due to rapid clinical deterioration. Piperacillin-tazobactam (PIP/TAZ) monotherapy was successfully administered subsequently. Eventually, she was transferred to hemodialysis (HD). SM is an uncommon cause of PD-related peritonitis. It may cause catheter loss and even death. In our case, the infection could be controlled only after catheter removal, and she was transferred to HD. Cephalosporins should rapidly be changed to PIP/TAZ when SM is isolated from the peritoneal fluid.
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Bile cast nephropathy causing acute kidney injury in a patient with nonfulminant acute hepatitis A p. 1498
Ranjani Ravi, Kedar Suthar, Praveen Murlidharan, K Lakshmi, Satish Balan, Mohammed Safeer
DOI:10.4103/1319-2442.248305  
Hepatitis A is usually a benign self-limiting disease with few or no extrahepatic manifestations. Acute hepatitis A causing severe renal dysfunction is not very common, although described. Patients developing renal dysfunction post hepatitis A infection usually have prerenal acute kidney injury (AKI) or acute tubular necrosis due to vomiting, diarrhea, and poor fluid replacement. However, if renal dysfunction persists, other causes need to be evaluated. The term cholemic nephrosis or more specifically bile cast nephropathy has been described in the setting of cholestatic jaundice and decompensated liver failure where bilirubin levels reach above 20 mg/dL. Herein, we describe the clinical course of a patient who developed acute hepatitis A with severe liver dysfunction and subsequently AKI which persisted for six weeks. Renal biopsy showed the evidence of bile cast nephropathy. After six weeks of hemodialysis, urine output improved. He slowly recovered both hepatic and renal functions.
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Monoclonal B-cell lymphocytosis with renal involvement p. 1502
Yao-Ko Wen
DOI:10.4103/1319-2442.248281  PMID:30588987
We report the case of a 70-year-old man with no relevant past medical history who presented with acute kidney injury. Kidney biopsy showed diffuse interstitial infiltration with typical chronic lymphocytic leukemia (CLL) phenotype B-cells. Subsequent studies revealed a normal lymphocyte count in the peripheral blood, and there was no evidence of lymphadenopathy or hepatosplenomegaly. Blood flow cytometry demonstrated a clonal B-cell population with a CLL phenotype. Without renal involvement, this case should be classified as monoclonal B-cell lymphocytosis. Renal function improved with steroid therapy. However, the patient developed CLL with significant lymphocytosis approximately two years later.
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Periarticular calcification mimicking inflammatory polyarthritis in chronic kidney disease p. 1506
Kumari Naidoo, Kwazi C. Z. Ndlovu, Girish M Mody
DOI:10.4103/1319-2442.248309  PMID:30588988
Periarticular calcification is a frequent radiographic manifestation in chronic kidney disease (CKD). However, clinical presentation as inflammatory periarthritis, tenosynovitis, and bursitis is unusual. A 34-year-old man with CKD on dialysis for three years presented with painful swollen joints. His adherence to regular dialysis, phosphate binders, Vitamin D supplements, and antihypertension therapy was poor. He had swelling of the right thumb, index, and little fingers; periarticular swelling of the left middle finger and right little toe; and extensor tenosynovitis of the wrists and right olecranon bursitis. Laboratory investigations showed the following: urea 36 mmol/L; creatinine 1764 umol/L; serum urate 0.37 mmol/L; corrected calcium 1.76 mmol/L; phosphate 4.32 mmol/L; 25-dihydroxycholecalciferol 30 ng/mL; and parathyroid hormone 104 pmol/L. Radiographs showed periarticular calcification corresponding to the sites of inflammation. The inflammation resolved with oral steroids. In our patient, deranged mineral and bone metabolism contributed to periarticular calcification at multiple sites, mimicking inflammatory polyarthritis.
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Short-course metronidazole-induced reversible acute neurotoxicity in a renal transplant recipient p. 1511
Pavitra Manu Dogra, Anil Kumar Bhatt, Sanjay Kumar Agarwal, Dipankar Bhowmik
DOI:10.4103/1319-2442.248315  PMID:30588989
Neurotoxic manifestations due to chronic metronidazole intake are well known, but neurotoxicity due to short-term use of metronidazole is very rare. We present a case of acute neurotoxicity due to short course of injectable metronidazole given in usual doses to a renal allograft recipient for persistent diarrhea. It responded to withdrawal of the offending drug. Tacrolimus trough concentration did not increase during neurotoxicity, thereby ruling out any metronidazole-tacrolimus interaction. Magnetic resonance imaging of the brain showed widespread osmotic demyelination and its recovery after drug withdrawal. This is the first reported case of a renal transplant recipient developing acute neurotoxicity due to short-term use of metronidazole, without any increase in tacrolimus trough concentrations.
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LETTERS TO THE EDITOR Top

Ig M nephropathy – A clinicopathological study – Our experience p. 1515
Boreddy Varalakshmi Devi, B Sangeetha Lakshmi, SV Padmavathi Devi, Rapur Ram, Vishnubotla Siva Kumar
DOI:10.4103/1319-2442.248282  PMID:30588990
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Magnitude of renal problem in fatal cases of Lassa fever: A summary on existed reports p. 1518
Sora Yasri, Viroj Wiwanitkit
DOI:10.4103/1319-2442.248319  PMID:30588991
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Norovirus-associated hemolytic uremic syndrome in a renal transplant recipient p. 1519
Lovy Gaur, Anurag Gupta, Aakash Shingada, AK Bhalla, Ashwani Gupta, Manish Malik, Vinant Bhargava, DS Rana
DOI:10.4103/1319-2442.248289  PMID:30588992
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SCOT DATA Top

Organ transplantation in Saudi Arabia – 2017 p. 1523
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