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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
November-December 2019
Volume 30 | Issue 6
Page Nos. 1190-1494

Online since Thursday, January 9, 2020

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REVIEW ARTICLES  

Chronic kidney disease among human immunodeficiency virus positive patients on antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis Highly accessed article p. 1190
Habtamu Wondifraw Baynes, Markos Negash, Demeke Geremew, Zegeye Getaneh
DOI:10.4103/1319-2442.275462  
Human immunodeficiency virus (HIV)-infected patients are at risk for renal disease as a consequence of complications of antiretroviral treatment. Particularly, the complication of kidney disease is high in patients who switched to Tenofovir Disoproxil Fumarate. The treatment is associated with nephrotoxicity, decrease in glomerular filtration rate, leading to kidney disease. This review focused on assessing the effect of antiretroviral therapy (ART) on kidney function among HIV-positive patients. Initially, the study protocol was registered on Prospero and given a unique identification number of CRD42018087686. We then conducted a systematic search of PubMed, Google Scholar, the Cochrane library, and Google from 2008 to September 2018. We found 742 study results eligible for this review. After stringent filtration mechanism, 15 qualified studies were used for systematic review and meta-analysis process. Cross-sectional, cohort, randomized controlled trials, and prospective studies were eligible for inclusion in the study. The overall pooled prevalence found in this meta-analysis was 6.42% with high statistical heterogeneity (I2 = 96.7%). The highest subgroup prevalence was reported from Ghana, with subgroup prevalence of 13.65% without statistical heterogeneity (I2 = 0.0%). Majority of chronic kidney disease (CKD) was in stage 3 with subgroup prevalence of 6.78% and tolerable statistical heterogeneity (I2 = 66.7%). There was high pooled prevalence of CKD among HIV-positive patients on ART in Sub-Saharan Africa. The highest subgroup prevalence was reported from Ghana. Majority of CKD was reported in stage 3.
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Continuous renal replacement therapy: Principles, modalities, and prescription Highly accessed article p. 1201
Ayman Karkar
DOI:10.4103/1319-2442.275463  
The mortality rate of critically ill patients with severe acute kidney injury (AKI) remains high. The associated sepsis and septic shock, as well as the presence of multiorgan failure, further increase the risk of death. Renal replacement therapy (RRT) represents the cornerstone of the management of severe AKI. Continuous RRT (CRRT) has been considered the predominant form of dialysis in the intensive care unit due to its accurate volume control, steady acid-base, and electrolyte correction and achievement of hemodynamic stability. This narrative review covers an introduction to CRRT, its physiologic principles, modalities, requirements, indications, and different elements of adequate prescription.
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ORIGINAL ARTICLES Top

Quality of life in living kidney donors: A single-center experience at the king abdulaziz medical city p. 1210
Basil Mohammed Alhussain, Abdulaziz K Alqubaisi, Aamir Omair, Wael A O'hali, Khalid O Abdullah, Abdulrahman R Altamimi
DOI:10.4103/1319-2442.275464  
Chronic kidney disease (CKD) results in irreversible decline in renal function, which ultimately progresses to end-stage renal disease (ESRD). Transplantation is the treatment of choice for ESRD, and this is possible only if donor kidneys are available. Several doubts can appear in the minds of donors and among general public regarding the quality of life (QOL) after donation which can affect the willingness to donate. Therefore, we aimed to assess the QOL in living kidney donors in King Abdulaziz Medical City, Riyadh, Saudi Arabia using the kidney disease QOL instrument short form (KDQOL-SF). This was a cross-sectional survey of living kidney donors between 18 and 65 years of age who donated their kidneys between 2008 and 2014 and was conducted in the hepatobiliary and transplantation department of our hospital. The study measured 17 domains in KDQOL-SF. Each domain score is up to 100; the higher the score in each domain, the better the QOL. Data will be entered and analyzed using Statistical Package for the Social Sciences version 21.0. The descriptive statistics will be presented as frequency and percentage for the categorical variables (e.g., gender and income) and the mean ± SD for numerical variables (e.g., QOL score). The study included 60 donors who donated during the study period between 2008 and 2014. Males were 49 (82%) with the age (mean ± standard deviation) as 32 ± 6.5 years. The donors reported an “overall-mean-score” of 86.7 ± 14.6. Four domains had lower scores between 60 and 80: “sleep” (61.8 ± 13.8), “emotional-well-being” (71.6 ± 11.1), “quality-of-social-interaction,” and “energy/fatigue.” The other 13 domains had scores >80. The two highest domains: “role-physical” (97.9 ± 13.3) and “effect-of-kidney-disease” (97.4 ± 8). Comparing males and females scores, work status was higher in males with P = 0.03. Our findings suggest that donors have a good QOL which may result in more donations. It is important to improve the standard of care for donors to enable them to live their life to the fullest.
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Nonadherence to dialysis among saudi patients – Its prevalence, causes, and consequences p. 1215
Alanoud Alhawery, Abeer Aljaroudi, Zainab Almatar, Abdulaziz Ayad Alqudaimi, Abdulla A Al Sayyari
DOI:10.4103/1319-2442.275465  
Dialysis nonadherence among Saudi hemodialysis (HD) patients has not been studied previously. We study its prevalence, causes, and consequences. All chronic HD patients at our center were enrolled. Their demographics as well as levels of hemoglobin (Hb), Kt/v, potassium, and phosphate; dialysis type; dialysis vintage; duration; and shift were recorded. Nonadherence, defined as missed dialysis session or patient–derived shortening of the dialysis session by >10 min at least once over a month’s period, was recorded. We analyzed the relationship of nonadherence to emergency room visits, hospitalizations, interdialytic weight gain (IDWG), intradialytic symptoms, home-to-hospital distance, and smoking habits. Two hundred and sixty-five patients were included; their mean age was 61.8 ± 18.2 years, 47.3% were male, dialysis vintage was 3.8 ± 3.3 years, 5.9% were on HD, and 34.1% were on hemodiafiltration. During the study period, the nonadherence rate was 25% for missed dialysis sessions and 72% for shortened dialysis on at least one occasion. Nonadherence was more likely to occur in males than females (75% and 66%, respectively, P = 0.05), in smokers (57.1% vs. 21.7%, P = 0.0003), and in night shifts rather than day shifts (33.6% vs. 20.6%, P = 0.042). Nonadherent patients had lower Kt/V than adherent patients (1.22 ± 0.2 and 1.31 ± 0.2, respectively P = 0.01), had higher mean IDWG (2.7 ± 1.0 and 2.4 ± 1.0 kg, respectively, P = 0.02), and are more likely to be hospitalized (50% vs. 32%, P = 0.01). On the other hand, no differences were observed in serum phosphate, potassium, or Hb levels; intradialytic symptoms; education; employment; the distance between the dialysis unit and home; type of dialysis; Charlson Comorbidity Index; or the dialysis vintage. The prevalence of nonadherence in our group was comparable to that of other reports and is more likely to occur in male patients, smokers, and those in night shifts. It is associated with lower dialysis adequacy, higher mean IDWG, and higher hospitalization rate.
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Peritoneal dialysis for the prevention of fluid overload in infants after cardiac surgery – A systematic review and meta-analysis Highly accessed article p. 1222
Girish Chandra Bhatt, Rashmi Ranjan Das, Bharat Chaudhary, Amit Kumar Satapathy, Shikha Malik
DOI:10.4103/1319-2442.275466  
The objective is to compare peritoneal dialysis with standard care therapy for the prevention of fluid overload in infants after cardiac surgery. We searched published literature through the major database up to December 2017. Randomized controlled trials (RCTs), quasi-randomized trials, and observational studies were included in the study. The primary outcome measures were as follows: all-cause mortality and duration of hospitalization. Of the 392-citation retrieved, full text of 7 was finally assessed for eligibility. Of these, a total of five studies (RCTs = 3, and observational studies = 2) were included. There was no significant difference between the prophylactic PD and the standard therapy group for any of the primary outcomes. The present systematic review shows that prophylactic PD is not beneficial compared to standard care in infants postcardiac surgery for congenital heart disease. The GRADE evidence generated was of “very low quality.”
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How informed are the Saudi public about the value of organ donation: A community-based cross-sectional study p. 1236
Abdulmalik Yousef Alnasyan, Khalid Abdulaziz Aldihan, Abdullah Abdulrahman Albassam, Faisal Ahmed Alhusain, Abdulrahman Rashed Al Tamimi
DOI:10.4103/1319-2442.275467  
Organ transplantation is often the ideal option for some end-stage organ diseases. However, organ donation is not keeping pace with growing demand for it. Saudi Arabia has one of the widest gaps between supply and demand with respect to transplants, estimated at 2-4 per million population. The purpose of this study is to survey the public’s perceptions and opinion about organ donation and transplants in general. This is a cross-sectional study targeting the age group of 18–60 years as they represent potential organ donors in any community. An Arabic-language questionnaire was distributed online. The questionnaire comprised specific questions to assess participants’ willingness to donate their organs. The study included 1453 Saudi adults. More than two-thirds (77.7%) expressed a willingness to donate. Interestingly, 325 (22.3%) refused organ donation in principle. Of the participants, 329 (29.1%) were willing to donate only to their relatives. Among those over 40 years, 77.4% were willing to donate to anyone in the community, compared to 78% of those under 40 years, P <0.001. Positive attitudes toward organ donation are evident in the high number of people willing to donate their organs.
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Infection associated relapses in children with nephrotic syndrome: A short-term outcome study p. 1245
Mukta Manta, Srijan Singh
DOI:10.4103/1319-2442.275468  
Children with nephrotic syndrome (NS) encounter multiple episodes of relapses associated/triggered by an episode of infection. The primary objective of this study was to find the proportion of infection associated relapses that resolve on the treatment of acute infection over an observation period of two weeks in children with NS. This prospective observational study enrolled 45 children with steroid-sensitive NS presenting with an infection associated relapse during the study period (February 2015 to February 2016). Baseline information and examination findings of all children were recorded. Biochemical and other investigations were performed according to the site of infection for all patients and were treated appropriately. None of the patients received daily 2 mg/kg of prednisolone during the observation period. All children were followed for two weeks for resolution of relapse and subsequently every month for another three months. The 45 patients (median age 66 months) enrolled in the study had 64 episodes of infections, of which upper respiratory tract infections (45%) were the commonest, followed by peritonitis (18.5%) and diarrhea in 12%. Twenty-seven (60%) patients achieved remission on symptomatic treatment of infection with/without the use of stress doses of prednisolone. Most (77.8%) patients who achieved remission without the use of daily 2 mg/kg of prednisolone did so within the 1st week and a majority of patients were still in remission at three months follow-up. We conclude that most infection associated relapses can be managed with treatment of underlying infection alone and use of stress doses of steroids for inducing remission without increasing the prednisolone doses to 2 mg/kg/d and thus reducing the cumulative steroid doses.
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The impact of gender matching between donor and recipient on the outcome of kidney transplant patients: A retrospective study Highly accessed article p. 1254
Maroun M Abou-Jaoude, Etienne El-Helou, Haydar A Nasser, Alaa H Kansoun
DOI:10.4103/1319-2442.275469  
The influence of donor and recipient gender on patients postkidney transplant (KT) is still controversial, and literature data do not present unanimous conclusions. We were concerned with the gender impact on the outcome of kidney transplantation at the level of acute rejection (AR), graft function represented by serum creatinine level, delayed graft function (DGF), graft survival, and infection rate. The impact of gender matching between donors and recipients was studied in 299 KT recipients performed in the Transplantation Unit, Middle East Institute of Health, Bsalim, Lebanon, between November 1998 and September 2014. The patients were divided into the following groups: Group I (131 patients, male donor to male recipient), Group II (55 patients, male donor to female recipient), Group III (88 patients, female donor to male recipient), and Group IV (25 patients, female donor to female recipient). AR and DGF were not statistically different among the four groups. Moreover, all groups showed excellent graft survival with no statistical difference. Interestingly, human leukocyte antigen AB-DR matching (P < 0.001) and sensitization were statistically different among the four groups (P = 0.05). The number of patients with infections was statistically significantly lower in Group I (35.4%) and Group III (37.5%) (P = 0.35). Most importantly, graft function, represented by serum creatinine, showed a statistically significant difference among the four groups (P <0.004), with Group II (male to female) and Group IV (female to female) showing the best improvement in five-year survival. However, Group III (female to male) had the worst posttransplant graft function. These results revealed that gender impacts graft function, and Group II, male donor to female recipient, had the best 5-year graft function. This emphasizes that gender should be regarded as a determinant for the success of kidney transplantation.
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Comparing diabetic and nondiabetic emphysematous pyelonephritis and evaluating predictors of mortality p. 1266
Sheshang Uday Kamath, Bhushan Patil, Umesh Shelke, Sujata Kiran Patwardhan
DOI:10.4103/1319-2442.275470  
Mortality among patients with emphysematous pyelonephritis (EPN) has reduced from 78% to 21%, yet it is one of the most serious urologic emergencies. This prospective observational study aims to study and compare clinical profile, management, and outcomes in diabetic and nondiabetic patients with EPN. All patients of EPN admitted to emergency medical services were included in the study. Patients were grouped into diabetic and nondiabetic EPN, and the eventual predictors of mortality were assessed. The mean age of patients was 55.43 years, with 36 (65.7%) female patients. Mortality was found to be 18.86%. On univariate analysis, the factors significantly associated with mortality include dyspnea at presentation, altered consciousness, blood pressure <90 systolic, oliguria, decreased platelet count (<100,000/mm[3]), urine culture positive for Escherichia coli, hyponatremia (Na <132), hyperkalemia (K >5.0), higher computerized tomography (CT) grade, and emergency nephrectomy as an intervention modality (P <0.05). Mortality was comparable among diabetics and nondiabetics. Diabetics had a lower CT score and higher creatinine (>2 mg/dL) as compared to nondiabetics. Most patients having urolithiasis were nondiabetic. Although nondiabetics had a higher CT score as compared to diabetics, the mortality in nondiabetics and diabetics was equivalent. This may suggest that either diabetics have a rapid deterioration of EPN status or intercurrent metabolic factors in diabetics may contribute to mortality among diabetics. Raised serum creatinine and immunocompromised status owing to diabetes may also play a role.
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Tubulointerstitial nephritis due to sarcoidosis: Clinical, laboratory, and histological features and outcome in a cohort of 24 patients p. 1276
Asma Zammouri, Samia Barbouch, Mariem Najjar, Raja Aoudia, Fatima Jaziri, Hayet Kaaroud, Hafedh Hedri, Ezzeddine Abderrahim, Rim Goucha, Fethi Ben Hamida, Amel Harzallah, Taieb Ben Abdallah
DOI:10.4103/1319-2442.275471  
Renal involvement is rare in systemic sarcoidosis. Among renal manifestations, tubulointerstitial nephritis (TIN) is the most commonly reported finding. We conducted the current study to investigate the clinical, laboratory, and histological features and to analyze the outcome of TIN due to sarcoidosis. We present a retrospective, single-center study of patients followed for sarcoidosis and presenting with TIN related to this systemic disease. Twenty-four patients were assessed (22 females/2 males). The mean age at diagnosis of TIN was 46.3 years. Extrarenal manifestations were dominated by thoracic involvement (95.8%), peripheral lymph nodes (54.2%), and skin lesions (33.3%). The mean proteinuria level was 0.68 g/24 h. Renal failure was diagnosed in 83.3% of cases with a median estimated glomerular filtration rate at 14.3 mL/min/1.73 m2. Nine patients presented with hypercalcemia and 12 patients with hypercalciuria. Renal biopsy was performed in 58.3% of cases. Six of the 14 patients presented with noncaseating granulomatous interstitial nephritis and eight with interstitial nephritis without granuloma. Granulomatous infiltration of renal parenchyma was complicated by vasculitis in two cases. Corticosteroid therapy was used in all patients. On follow-up analysis, four patients progressed to end-stage renal disease (ESRD) after a mean duration at 45.5 months. In the remaining patients, kidney function statistically significantly improved after one month of treatment compared to the time when the diagnosis was initially established (P = 0.031). We found that the predictive factors of progression to ESRD were multiorgan involvement (P = 0.032), advanced fibrosis F3 (P = 0.0006), and extensive interstitial granulomas (P = 0.007) and these were independently correlated with ESRD. Corticosteroid therapy seems to be effective in sarcoid TIN, but some degree of persistent renal failure is possible which can be predicted from both histologic findings and initial response to steroid therapy.
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The impact of reusable dialyzer membrane on end-stage renal disease patients’ Quality of life: A multicenter study in Jakarta, Indonesia p. 1285
Lucky Aziza Abdullah Bawazir, Maruhum Bonar Marbun, Wicensius Sianipar, Lies Luthariana
DOI:10.4103/1319-2442.275472  
Data from 8th Report of the Indonesian Renal Registry in 2015 reported that there was an increase in the prevalence of hemodialysis (HD) patients in Indonesia. Measures had been taken to reduce the cost of HD such as utilizing reusable dialyzer membrane. However, little is known on the impact of reusable dialyzer membrane on patients’ quality of life (QOL), and hence, this study was conducted. We conducted a multicenter study at Cipto Mangunkusumo Hospital, Koja District Hospital, and Cengkareng District Hospital with a total of 389 patients. Cipto Mangunkusumo Hospital represented single-use dialyzer group while, Koja and Cengkareng District Hospital represented reusable dialyzer group. Face-to-face interviews were conducted using Kidney Disease QOL-Short Form 36 questionnaires. Single-use dialyzer group’s scores were significantly higher than reusable dialyzer group’s scores in the following dimensions: kidney disease component summary (KDCS; 74.2 vs. 66.3; P <0.001), physical component summary (PCS; 70.6 vs. 55.2; P<0.001), mental component summary (MCS; 76.1 vs. 70.7; P= 0.023), and overall health rating (73.4 vs. 64.9; P <0.001). In the linear regression model, reusable dialyzer was still a strong predictor in KDCS (coefficient β = -9.3; P<0.001) and PCS (coefficient β = -17.2; P <0.001). Reusable dialyzer was associated significantly with patients’ QOL impairment. Unemployment, age, and illiteracy also showed significant association with patients’ QOL.
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Evaluation of the safety of arteriovenous fistula creation surgery in ambulatory versus inpatient hospital setting p. 1295
Roman Margulis, Domenic J Pedulla, Adam L Bromberg, Curtis Choice
DOI:10.4103/1319-2442.275473  
Arteriovenous fistula (AVF) creation surgeries necessary for dialysis in patients with end-stage renal disease have traditionally been performed in inpatient settings under general anesthesia. Although more recent studies have demonstrated that these surgeries can be safely performed in outpatient centers with low postoperative complication rates, a direct comparison to surgeries performed in inpatient settings has not been investigated. This study sought to directly compare the rate of complications and postoperative mortality in AVF creation surgeries performed in outpatient and inpatient surgical centers. This multicenter retrospective study recorded emergency department (ED) visits, inpatient admissions, and mortality following 179 outpatient and 146 inpatient AVF surgeries in 2015 and 2016. Rates of mortality at 30 days and ED visits and inpatient admissions at 24-h and seven-day time points were compared in inpatient and outpatient groups. Following outpatient and inpatient surgeries, the rates of inpatient admissions in seven days were 0.685% and 4.47%, respectively, and the rates of ED visits in seven days were 1.37% and 3.91%. There were no mortalities in either group in 30 days. There was no difference between groups in the rate of ED visits within seven days or hospital visits within 24 h. There was a significantly lower rate of admissions (P = 0.0386) and total hospital visits (P = 0.0131) within seven days for outpatient surgeries. This study provides a direct comparison of postoperative complications in inpatient and outpatient AVF surgeries, further suggesting that providers can safely perform AVF surgeries in ambulatory centers.
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Noninvasive method of differentiating diabetic nephropathy and nondiabetic renal disease using serum bone morphogenetic protein-7 and transforming growth factor-beta 1 levels in patients with type-2 diabetes mellitus p. 1300
Priyadarshini John, Manjusha Yadla
DOI:10.4103/1319-2442.275474  
Diabetic nephropathy (DN), one of the major complications of diabetes mellitus, is diagnosed by the presence of pedal edema, 24-h proteinuria >300 mg/day, and retinopathy. However, in view of variable clinical presentations and deviation from the above-said clinical features, it has become difficult to diagnose DN or the presence of nondiabetic renal disease (NDRD). Many biomarkers have been identified which could predict the progression of DN. Despite such advancement in science, it is still difficult to differentiate between DN and NDRD. Diabetes is a state of chronic inflammation. Among the pro-inflammatory cytokines, it has been shown that transforming growth factor-beta (TGF-β) and bone morphogenetic protein-7 (BMP-7) play a key role in the development and progression of DN. We assessed whether the levels of serum BMP-7 and TGF-β can help differentiate between DN and NDRD, thus serving as surrogate markers of DN.
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Risk of diagnostic errors when dealing with aggressive patients: Experimental study p. 1310
Ibrahim Al Alwan, Amir Babiker, Sarah M Al Yousif, Motasim Badri, Ali Al Haqwi
DOI:10.4103/1319-2442.275475  
Medical errors are still common despite advances in technology and policies to insure patients’ safety. They can be traceable as in medications or surgical errors, but may not be so in diagnostic errors that are patient, physician, or system related. This study aimed to explore whether aggressive behavior of some patients might affect physicians’ clinical reasoning and decision-making. The study was conducted in a format of observation skills clinical examinations (OSCEs). It included simulating patients (SPs) and family physicians in residency training in a clinical setup. The experiment included two arms of dealing with case scenarios with “Neutral” and “Aggressive” behaviors. Explanatory variables assessed were duration of consultation, correct diagnosis, and plan of appropriate management as well as patients’ satisfaction. Participants were 14 trained SPs who played the roles of aggressive and nonaggressive patients when they encountered 35 residents (18 were males) in family physicians [year 2 (R2), year 3 (R3) and year 4 (R4)]; in a total of seventy patient/doctor encounters. Compared with nonaggressive patients, aggressive patients had statistically significantly prolonged OSCE duration [mean (standard deviation) = 6.89 (1.35) and 6.11 (157) min, respectively; P = 0.031] and more patient consultation satisfaction (P <0.0001). However, no statistically significant differences were found in diagnostic accuracy (P = 0.626) and management (P = 0.621). In a stratified analysis, junior doctors had longer duration of consultation and seemed to perform better in management (higher patient satisfaction and better management outline) than their senior counterparts. Patients’ aggressive behavior led to longer duration of medical consultation. Poor management plan, albeit correct diagnosis, in senior doctors may be due to disruptive clinical reasoning in disturbed stressful situation. Coping strategies should be emphasized in medical education to ensure effective clinical reasoning in patient/doctor encounters.
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Arabic translation, adaptation, and validation of the kidney disease quality of life short-form 36 p. 1322
Sarra Elamin, Abdelbagi H E. Elbasher, Shima E E. Ali, Hasan Abu-Aisha
DOI:10.4103/1319-2442.275476  
The Kidney Disease Quality of Life Short Form 36 (KDQOL-36) is a self-reported measure of health for patients with chronic kidney disease. Our goal was to develop an Arabic version of KDQOL-36 that is linguistically and conceptually equivalent to the original English version. We translated KDQOL-36 into formal Arabic language using forward and backward translation. To assess conceptual equivalence, we administered the Arabic and English versions simultaneously to a group of 10 bilingual patients. To assess test–re-test reliability, we administered the instrument twice to a group of 10 hemodialysis (HD) patients. To assess internal reliability, convergent validity, and discriminate validity, we administered the instrument to 62 HD patients and 82 kidney transplant patients asking them to simultaneously fill the Depression, Anxiety and Stress Scale (DASS-21). The intraclass correlation coefficient (ICC) between the Arabic and English versions indicated excellent conceptual equivalence. The ICC between test and re-test scores revealed good reliability in the burden of kidney disease subscale and excellent reliability in the remaining four subscales. The translated version of KDQOL-36 had a Cronbach’s alpha of 0.81, indicating good internal reliability. We found significant negative correlations between the five subscales of the instrument and DASS-21, indicating good convergent validity. Kidney transplant recipients had significantly better scores than HD patients in the five subscales of the instrument, indicating excellent discriminate validity. The current Arabic version of KDQOL-36 has excellent conceptual equivalence with the original English version. It is a reliable and valid instrument for Arab kidney disease patients.
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Subjective hemodialysis adequacy can also be measured: Development and psychometric properties evaluation of subjective adequacy questionnaire p. 1333
Vajihe Biniaz, Hossein Karimi Moonaghi, Razieh Froutan, Abbass Ebadi
DOI:10.4103/1319-2442.275477  
Long-term prognosis of chronic hemodialysis patients is affected by dialysis adequacy that can have effect on the hemodialysis (HD) outcomes, especially mortality rate. Given the limited knowledge about HD patient’s perceptions and experiences about subjective HD adequacy (SHA) and the lack of SHA measuring questionnaire (SHAMQ), this study was conducted with the aim of developing the SHAMQ and evaluating its psychometric properties based on the operational definition of SAH concept. This mixed-method sequential exploratory design study was conducted from 2016 to 2018 in eight HD units of Mashhad, Iran. In qualitative phase, conventional content analysis method was used, and participants were recruited through purposive, snowball, and selective sampling techniques. Data were collected through semi-structured interviews with 25 HD patients, dialysis nurses, caregivers, and nephrologists, and analyzed using MAXQDA software (V10). SHAMQ was developed based on operational definitions extracted from qualitative phase. Quantitative and qualitative face and content validity; construct validity; internal consistency; and stability were used for psychometric properties evaluation of SHAMQ. Data were analyzed using Statistical Package for Social Sciences version 22.0 (IBM Corp., Armonk, NY, USA). Physical vitality, inner consistency, a sense of well-being, positive social interactions, effective self-empowerment, and weathering financial crisis were 6 generic categories emerged from qualitative phase. The final version of SHAMQ included 30 itemsin four factors (subscales). Scale-content validity index, Θ, and intraclass correlation were 0.92, 0.88, and 0.91, respectively. The results of this study showed that factors such as well-being, self-enforcement to effective care, physical vitality, and spiritual health are the most important SHA outcomes. The development of a scale for measuring SHA can help to the better evaluation of HD patients’ conditions and accordingly perform effective interventions.
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Comparison of sleep quality and dialysis adequacy of patients undergoing hemodialysis p. 1342
Banu Terzi, Eylem Topbaş, Hatice Çavuş Ergül
DOI:10.4103/1319-2442.275478  
Sleep, as one of the key life activities, is an important indicator of the quality of life. Chronic kidney disease, with a high prevalence, is a serious condition that can deteriorate the sleep quality of patients. This study was carried out to investigate the correlation between sleep quality and dialysis adequacy in hemodialysis (HD) patients on a population and sample consisting of 50 patients receiving HD treatment at a training and research hospital in Amasya. Data were collected using “Patient Information Form,” “Pittsburgh Sleep Quality Index (PSQI),” and “Good Dialysis Index (GDI).” Sleep patterns of patients during HD were observed and recorded for three weeks. The average age was 64.46 years (minimum: 22, maximum: 86; standard deviation: 14.612), 56% (n = 28) are women, 64% (n = 32) are married, 82% (n = 41) have PSQI score >5, and 60% were found to have 30 min weekly average sleep duration during HD sessions. A statistically significant relationship was found between the overall GDI scores and the overall Pittsburgh Sleep Quality Index (PSQI) scores of the patients (P <0.05). PSQI scores of patients increase with increasing GDI scores. Good dialysis adequacy improves the sleep quality of patients.
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Risk factors and short-term outcomes for methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization among hemodialysis patients p. 1351
Anna M Price, Nadia Sarween, Itisha Gupta, Jyoti Baharani
DOI:10.4103/1319-2442.275479  
Patients with end-stage renal disease are susceptible to infection, particularly methicillin-resistant Staphylococcus aureus (MRSA). Although MRSA-related mortality and morbidity have been studied, methicillin-sensitive Staphylococcus aureus (MSSA) has not been investigated to the same degree. Five hundred and seventy-eight chronic hemodialysis patients were followed up retrospectively for 18 months. Routine screening for MRSA and MSSA was instigated. Two hundred and eighty-eight patients (49%) had at least one positive MSSA or MRSA swab. There was no statistical difference in age, Charlson index, diabetes, sex, ethnicity, deprivation index, or the duration of dialysis between the positive and negative groups. There were however, less fistulas and more lines in the positive patients (P = 0.025). Binary logistic regression revealed patients with a body mass index of greater than 30 had a significantly increased risk of Staphylococcus aureus colonization P = 0.044, odds ratio (OR) 1.856 (95% confidence interval 1.016-3.397). Those who entered the study using a temporary line for vascular access also conferred a greater risk of colonization P = 0.029, OR 2.174 (95% CI 1.084–4.359). Patients with positive swabs had significantly more admissions (P = 0.033) and in particular, more infection-related admissions (P = 0.001). They were less likely to survive the follow-up period (P = 0.012) and had substantially more bacteremia (P <0.001). Following multivariable analysis, swab positivity remained an independent risk factor for mortality. MRSA and MSSA colonization in patients is associated with significant mortality and morbidity in dialysis patients. Patients dialyzing with lines are also more likely to colonize compared to those with more permanent forms of vascular access.
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Superior protective effects of febuxostat plus alpha-lipoic acid on renal ischemia/reperfusion-induced hepatorenal injury in rats p. 1364
Mahmoud M Farag, Sally M Ahmed, Wessam F Elhadidy, Radwa M Rashad
DOI:10.4103/1319-2442.275480  
A complex cascade of pathological events including oxidative stress and inflammation is involved in ischemia/reperfusion (I/R)-induced local and remote organ injuries. This study was performed to evaluate the effects of febuxostat (FEB), a selective xanthine oxidase (XO) inhibitor, and alpha-lipoic acid (ALA), a strong antioxidant, on the kidney and liver changes induced by renal I/R in rats. Renal I/R was induced in rats by clamping renal pedicles for 1 h followed by 2 h reperfusion. Fifty rats were assigned to five groups as follows: sham operated; vehicle + I/R; FEB + I/R; ALA + I/R, and (FEB + ALA) + I/R. Drug treatment was given 24 h and 1 h before I/R induction. Serum and tissue biochemical parameters and histopathological changes were examined after reperfusion. Serum creatinine, urea and uric acid levels, and alanine aminotransferase and aspartate aminotransferase activities were elevated after renal I/R. An increase in XO, myeloperoxidase, and malondialdehyde levels was observed in kidney and liver tissues with a concomitant decrease in both the glutathione level and superoxide dismutase activity. In addition, kidney and liver sections of vehicle-pretreated rats subjected to I/R exhibited a pronounced alteration in microanatomy. FEB, ALA, or FEB + ALA pretreatment attenuated the serum and tissue biochemical changes with amelioration of the histopathological changes in both the kidney and liver. The findings of this study revealed that FEB in combination with ALA had a greater protective effect than either drug alone. Thus, FEB and ALA co-administration may provide a potential superior therapeutic strategy to protect the kidney and liver against renal I/R-induced injury.
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Determinants of medical students for intention to organ donation: Application of theory of planned behavior p. 1375
Mohtasham Ghaffari, Sakineh Rakhshanderou, Katayoun Najafizadeh, Ali Ramezankhani, Marzieh Latifi
DOI:10.4103/1319-2442.275481  
Organ donation and transplantation save thousands of lives in the world. The aim of this study was identifying determinants of organ donation intention based on the Theory of Planned Behavior (TPB) among Iranian Medical Students. This cross-sectional study was performed during 2017 in Shahid Beheshti University of Medical Sciences. A sample of 438 students of Shahid Beheshti University of Medical Sciences was selected using multi-stage sampling method including stratified and random sampling. Data were collected by using a reliable and valid TPB-based questionnaire. All the participants filled the questionnaires and the data were extracted according to the previously described method. Data were analyzed by using the Statistical Package for the Social Sciences version 16.0 software. Descriptive statistic and Spearman correlation and Logistic regression were used for analyzing the data. Mean age of the participants was 20.92 ± 1.98 years. There was a significant linear positive correlation between behavioral intention and attitude, subjective norms, and perceived behavior control. Logistic regression analysis for assessing relation of TPB variables with behavioral intention showed that perceived behavioral control was more correlate with students’ intention for getting organ donation card (odds ratio: 1.049, confidence interval: 1.062, P <0.000) perceived behavioral control, explain student’s willingness to register as an organ donor. We must provide facilities so that students could register for organ donation easily.
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Chemerin level and the relation to insulin resistance in chronic kidney disease p. 1381
Sahier Omar El-Khashab, Mona Gamil, Ahmed Yamany Ali, Omar El-Khashab, Mohamed El-Khatib, Kariman Mohamed, Amal El-Shehaby, Soha Talat Hamed
DOI:10.4103/1319-2442.275482  
Chemerin has been associated with different components of the metabolic syndrome, including hypertension, hyperlipidemia, and insulin resistance (IR). The aim of this study was to evaluate serum chemerin level in chronic kidney disease (CKD) patients and its relation to IR. This study was conducted on 80 participants who were classified into three groups: Group I (30 CKD patients with mean age 53 ± 12 years), Group II (30 patients with end-stage renal disease on regular hemodialysis with mean age 48 ± 14.8 years) and Group III having 20 healthy age-and sex-matched controls. Serum chemerin level, fasting blood sugar, fasting insulin, HOMA-IR index calculation, urea, creatinine, estimated glomerular filtration rate, total cholesterol, and triglyceride were measured. Body composition was assessed by dual-energy X-ray absorptiometry. In Groups I and II, we found a significantly higher mean chemerin level compared to healthy controls (P <0.001), a highly significant positive correlation between mean chemerin level and the HOMA-IR index [r = 0.56, P <0.001/(r = 0.53, P <0.001)], and a highly significant negative correlation between mean chemerin level and GFR (r = -0.51, P <0.001/r = -0.46, P <0.001). In Group I, there was also a highly significant positive correlation between mean chemerin and systolic blood pressure (r = 0.31, P <0.05), diastolic blood pressure (r = 0.39, P <0.05 and creatinine (r = 0.34, P <0.05). Chemerin might be considered a uremic IR adipokine marker in CKD Stages 3, 4, and 5.
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Vitamin-D deficiency is encountered in almost all egyptian stage 3-5 chronic kidney disease patients in spite of the sunny weather p. 1389
Usama Sharaf El Din, Ahmed Fayed, Mahmoud M El Nokeety, Dina O Abdulazim, Mona M Salem, on behalf of the Vascular Calcification Group
DOI:10.4103/1319-2442.275483  
Currently, there is no available data about Vitamin D status among Egyptian chronic kidney disease (CKD) patients. This cross-sectional study is looking for the prevalence of Vitamin D deficiency among Stage 3a-5 CKD Egyptian patients and its possible associations. We studied 1624 Stage 3a-5 CKD adults (689 males and 935 females) together with 200 normal control persons. All the recruited candidates were tested for body mass index (BMI); serum levels of blood urea nitrogen, creatinine, calcium (Ca), phosphorus (P), parathyroid hormone (PTH), 25 hydroxy vitamin D (25(OH)D), albumin, and uric acid (UA); urine albumin/creatinine ratio (ACR), and estimated glomerular filtration rate. The optimal level of Vitamin D was encountered in only 1.4% of CKD patients versus 52% of the normal controls. A total of 1107 (68.2%) CKD patients versus 23 (11.5%) controls had serum 25(OH)D <20 ng/mL (mean ± standard deviation = 16.8 ± 5.8 versus 37.3±7.6 ng/mL for CKD versus control group, respectively, P <0.001). There was a highly statistically significant positive correlation between serum 25(OH)D and serum Ca (r = 0.299, P <0.001) and a highly statistically significant negative correlation between serum 25(OH)D on the one hand and serum P, serum PTH, serum UA, and urine ACR on the other hand (r = -0.46, -0.69, -0.73, and -0.8, respectively, P <0.001). Vitamin D deficiency is very common among Egyptian CKD patients. Serum P, UA, and urine ACR ratio are the most important variables which are found to be negatively associated with serum 25(OH)D.
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BRIEF COMMUNICATION Top

Prospective nonrandomized study with early steroid withdrawal (Day 5) postrenal transplant in low immunological risk patients: A singlecenter experience at prince sultan military medical city Riyadh p. 1398
Nawaz Zahir, Dujana Mousa, Alawi Al Taweel, Attia Ashraf, Akhtar Fahim, Khan Taqi, Rafat Zahid, Naveed Aslam
DOI:10.4103/1319-2442.275484  
Steroids remain an essential part of immunosuppressive therapy for renal transplant patients since the start of transplant era. Different immunosuppressive regimens are prescribed so as to minimize the side effects. The purpose of our study is to compare the outcome of early steroid withdrawal with steroid maintenance protocol. It is a prospective nonrandomized study. All patients that received renal transplants from January 2011 to December 2013 were included in the study. Early steroid withdrawal at day 5 was done in low immunological risk patients, and the results were compared with the steroid maintenance group, at one-year, posttransplant. Outcome measures included acute rejection (AR), slow graft function and delayed graft function (SGF and DGF), patient and graft survival, and new-onset diabetes after transplant (NODAT), dyslipidemia, hypertension, and obesity. A total of 249 patients were divided into two groups – 105 patients had early steroid withdrawal and 144 patients were maintained on steroid therapy. Outcome measures were compared one-year posttransplant. There was no significant difference in AR, patient and graft survival, creatinine level, and weight gain. However, a significant difference in systolic and diastolic blood pressure, lipid profile, NODAT, SGF, and DGF was found in the steroid group. Our study shows that early steroid withdrawal is a safe standard of care in low immunological risk patients.
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RENAL DATA FROM THE ARAB WORLD Top

Acute interstitial nephritis in the military hospital of Morocco: Clinical features and renal outcomes p. 1407
Yassir Zajjari, Dina Montasser, Aya Sobhi, Taoufiq Aatif, Mounia Azizi, Ahmed Alayoud, Driss El Kabbaj
DOI:10.4103/1319-2442.275485  
Acute interstitial nephritis (AIN) is a common cause of acute kidney injury, possibly with increasing incidence over recent years; therefore, epidemiological studies provide important information for clinical practice and investigations. The aim of this retrospective study was to describe the clinical features and outcome of patients with biopsy-proven AIN in a region of Morocco. All native renal biopsies (January 2008 to December 2017) on adults were reviewed, but only AIN cases were analyzed. Of the 407 renal biopsies performed in this period, 30 patients were included. The mean age of the patients was 47.1 ± 16.7 years; female gender was preponderant (60%). At the time of biopsy, the serum creatinine level was 33.9 ± 11.8 mg/L. The classic triad of fever, skin rash, and eosinophilia occurred in three (10%) patients. The common causes of AIN were drugs in 13 (43.3%) patients followed by autoimmune diseases in 11 (33.3%) patients. At six months postbiopsy, 26.7%, 33.3%, and 40% had partial, complete, and no recovery, respectively. In this study, a good outcome was associated with autoimmune diseases (P = 0.02) and with a higher intensity of interstitial edema (P = 0.01). However, a presence of a granuloma (P = 0.04), a higher percentage of interstitial fibrosis (P <0.01), and glomerulo-sclerosis (P <0.01) were associated with no recovery and steroids seem to have no effect in the recovery (P = 0.14).This information provides a contribution toward understanding the epidemiology of acute renal failure in Africa, with implications in planning future prospective studies.
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RENAL DATA FROM ASIA-AFRICA Top

Bone mineral density in children with relapsing nephrotic syndrome: A hospital-based study p. 1415
Tahmina Jesmin, Abdullah Al Mamun, Md Azizur Rahman, Samina Masud Santa, Syed Saimul Huque, Afroza Begum, Ranjit Ranjan Roy, Md Habibur Rahman, Golam Muin Uddin
DOI:10.4103/1319-2442.275486  
This cross-sectional analytical study was conducted from January 2012 to November 2014 in the Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, to evaluate the bone mineral density (BMD) values in children with relapsing nephrotic syndrome (NS). Thirty relapsing nephrotic patients were enrolled in this study. They were divided into two groups: Group I – Frequent Relapse (FR) with 21 patients and Group II – Infrequent Relapse (IFR) with nine patients. Children included were both males and females aged between four and 15 years with relapsing NS with normal renal function. Steroid-resistant NS or those with abnormal renal functions or who were on cyclosporine and calcium supplement with Vitamin D or children with secondary NS were excluded from the study. All the study population underwent dual-energy X-ray absorptiometry scan to see the BMD value. Mean age of the patients of Group I (8.43 ± 2.61 years) was lower than that of Group II (9.41 ± 2.94 years (P = 0.4043). Mean BMD Z-scores of Group I was significantly lower than that of Group II (-2.70 ± 1.28 vs. -1.30 ± 1.54, respectively; P = 0.0317). A significantly higher cumulative dose of prednisolone was administered to Group I compared with Group II (P = 0.00003). On multivariate analysis, the total dose of prednisolone (P = 0.03693), body mass index (BMI) (P = 0.00703), and age of onset of disease (P = 0.03465) had a linear relationship with dependent variable BMD Z-score. On univariate regression analysis, statistically significant inverse relationship was observed between cumulative dose of prednisolone (in grams) (P = 0.049) and BMI (P = 0.00) with BMD Z-score, but no relation was observed with duration of illness. Children with relapsing NS, especially those receiving higher doses of steroids, were at risk for low BMD.
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Pregnancy-related acute kidney injury: Etiologies and short-term outcomes in a tertiary hospital in Southwest Nigeria p. 1423
OA Adejumo, AA Akinbodewa, OC Enikuomehin, OM Lawal, OS Abolarin, OE Alli
DOI:10.4103/1319-2442.275487  
Although the incidence of pregnancy-related acute kidney injury (PRAKI) is declining in developing countries, it still remains a major cause of maternal and fetal morbidity and mortality. The aim of this study was to determine the etiologies, short-term outcomes, and their predictors in patients with PRAKI managed in a tertiary health facility in Southwest Nigeria over a four-year period. This was a four-year retrospective review of clinical records of patients managed for PRAKI in University of Medical Sciences Teaching Hospital, Ondo State, Nigeria. Thirty-two women with a mean age of 31.09 ± 7.50 years had PRAKI during the period reviewed. Twenty-four (75%) patients were multiparous and PRAKI was most common in the postpartum period (56.3%). Twenty-three patients (71.9%) were in RIFLE Stage 3, 24 (75%) received blood transfusion, 5 (15.6%) required intensive care unit (ICU) care, 24 (75%) needed dialysis while 19 (59.4%) had hemodialysis. The common causes of PRAKI were obstetric hemorrhage in 16 (50%), sepsis in seven (21.9%), and eclampsia in six (18.8%). Maternal and fetal mortality were 34.4% and 50% respectively. Seventeen (53.1%) had full renal recovery and only one (3.1%) became dialysis dependent. Significant factors that were associated with maternal mortality were admission to ICU (P = 0.01), hypotension (P = 0.02), and impaired consciousness (P <0.001) PRAKI is still relatively common and significantly contributes to maternal and perinatal mortality in Nigeria. Obstetric hemorrhage which is the most common cause of PRAKI is preventable and treatable. There is a need for physicians to effectively prevent and manage obstetric hemorrhage.
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Prevalence and risk factors of chronic kidney disease in overweight and obese population in a tertiary care hospital in North India p. 1431
Pradeep Kumar Rai, Punam Rai, Sonam Bedi
DOI:10.4103/1319-2442.275488  
Obesity has already been a global epidemic, and its prevalence has been projected to grow by 40% in the next decade. Its increasing prevalence has implications on the epidemiology of chronic kidney disease (CKD), which, in turn, could impact the health system and thereby the society in an adverse manner. Lack of community-based screening programs can lead to missed or late detection of CKD. The current study aims to estimate the prevalence of CKD in overweight and obese general population attending a screening camp in a tertiary care hospital in a North Indian city. In this cross-sectional study, 103 overweight and obese people from a community attending a health camp were screened for serum creatinine, urine analysis, random blood sugar, and uric acid. Demographic and anthropometric parameters were noted. Binary logistic regression analysis was used to find the predictors of CKD in these patients. The median age of the participants was 43 years with a male predominance (68%). More than half (58.4%) of the participants were obese and the remaining 41.6% were overweight. The overall prevalence of CKD was 17.5%. Individuals with obesity and diabetes were more prone to develop CKD (odds ratio = 4.868 and 7.941, respectively). CKD was prevalent in individuals with obesity. Obesity and diabetes were the significant predictors for the development of CKD. All the overweight and obese individuals should be periodically screened for kidney diseases.
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Women donate, men receive: gender disparity among renal donors p. 1439
Suraj Godara, Jitesh Jeswani
DOI:10.4103/1319-2442.275489  
In living donor kidney transplantation, a predominance of female-to-male donations has been observed. This gender disparity is more so in developing countries and requires targeted counseling and research to understand whether the cause is medical or sociocultural obstacles. The aim of this study was to analyze all living donor kidney transplants performed at a tertiary care center catering to patients of varied socioeconomic backgrounds. This was a retrospective cohort study of all 600 kidney donors who underwent donor nephrectomy at a single transplant center, Mahatma Gandhi Hospital, Jaipur, between 2013 and November 2018. Patient characteristics including gender, age, and relationship between donors and recipients were obtained. There was a significant increase in the amount of voluntary renal donations, almost doubling every year. Majority (78%) of the donors were females, whereas males contributed to 22% of renal donations. We observed that mothers were the highest number of donors accounting for 181 donations (n = 600), followed by wives who contributed to 102 of the renal donors (n = 600), and 98 (16.3%) fathers donated to their children. Fifteen percent of the donors donated kidney to their siblings. We found gender disparity in living donor kidney transplant in a single center that caters to a population of varied cultures and socioeconomic backgrounds. We anticipate these results will guide clinicians and living donor coordinators and lead to appropriate counseling for patients and potential donors.
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CASE REPORTS Top

A rare case of autosomal recessive ATP6V0A4 variant of distal renal tubular acidosis in a young female with recurrent nephrolithiasis p. 1442
Priya Haridas Anupama, Georgi Abraham, Lakshmi Shanmugasundaram, Sneha Haridas Anupama
DOI:10.4103/1319-2442.275490  
Homozygous autosomal recessive distal renal tubular acidosis (dRTA) is a rare entity. The intercalated cells in the collecting ducts are defective in apical proton secretion or basolateral bicarbonate reabsorption, due to mutations in genes encoding for proteins in a4 and B1 subunits of the V-ATPase and the anion exchanger Cl-/HCO- (kAE1). This results in decreased ammonium (NH4+) excretion and defective urine acidification. dRTA is characterized by hyperchloremic metabolic acidosis with normal anion gap, hypokalemia, hypercalciuria, hypocitranuria, and nephrocalcinosis. Autosomal recessive dRTA is associated with mutation in ATP6V1B1 (2p13) or ATP6V0A4 (7q34) genes. ATP6V1B1 mutation is associated with early – onset sensory neural hearing loss (SNHL), whereas ATP6V0A4 gene mutation may be associated with early-to late-onset SNHL. We report the case of a 30-year-old married woman diagnosed with dRTA at three months of age with mild SNHL, showing homogygous nonsense mutation in exon 3 of the ATP6V0A4 gene that resulted in a stop codon and premature truncation of the protein at codon 6.
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Tuberculosis as a microbiologically proven etiology of membranous nephropathy and interstitial nephritis p. 1447
Kiran Preet Malhotra, Abhilash Chandra, Namrata Rao, Saumya Shukla, Arsh Gupta
DOI:10.4103/1319-2442.275491  
Secondary causes of membranous glomerulonephritis (GN) include systemic lupus erythematosus, other autoimmune diseases, neoplasms, and infections such as hepatitis B and C viruses, syphilis, and parasites. The association of tuberculosis (TB) with membranous GN is rare. We report the first case of microbiologically proven tubercular interstitial nephritis and membranous nephropathy (MN) occurring concurrently in the same patient. The patient improved with the use of antitubercular therapy alone. TB should be recognized as a potentially treatable infectious cause of secondary MN.
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Epidermolysis bullosa complicated with nephrotic syndrome due to AA amyloidosis: A case report and brief review of literature p. 1450
Ayşe Seda Pınarbaşı, Ismail Dursun, Burcu Daldaban, Neslihan Günay, Sümeyra Çiçek, Nihal Şahin, Sibel Yel, Muammer Hakan Poyrazoglu, Hülya Akgün, Ruhan Düşünsel
DOI:10.4103/1319-2442.275492  
Epidermolysis bullosa (EB) encompasses a clinically and genetically heterogeneous group of rare inherited diseases characterized by marked mechanical fragility of epithelial tissues with blistering and erosions following minor trauma. Amyloidosis is one of the most important complications of EB mostly seen in recessive dystrophic EB (RDEB) patients and can involve the kidney, bowel, liver, and also respiratory system. Herein, we present a child, who is probably the youngest case of genetically diagnosed RDEB, complicated with amyloidosis reported in literature. A 6-year-old boy who was diagnosed with EB was referred to our center with nephrotic-range proteinuria and hypoalbuminemia. He had homozygous mutation in COL7A1 gene. Kidney biopsy was remarkable for amyloidosis with positive Congo red staining, and amyloid fibrils were seen on electron microscopy. Although he did not have any symptoms of autoimmune diseases and mutation in the MEFV gene, he was given colchicine because of positive family history for familial Mediterranean fever and amyloidosis.
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C1q nephropathy developing in a case of gastric carcinoma p. 1457
Kiran Preet Malhotra, Abhilash Chandra, Saumya Shukla, Alka Yadav, Nuzhat Husain
DOI:10.4103/1319-2442.275493  
C1q is a key intermediary in the classical complement pathway. It is known to be activated by several factors including immunoglobulins and charged molecules and is an initiator of the complement cascade. C1q nephropathy (C1qN) is a rare idiopathic glomerulonephritis characterized by predominant presence of glomerular deposits of C1q fraction of complement. Although few uncommon associations of C1qN have been seen with various disorders, we present the first case of C1qN diagnosed in an elderly male with gastric adenocarcinoma. Few months after the onset of symptoms related to gastric-outlet obstruction, the patient presented with oliguria and anasarca. A gastric biopsy revealed a well-differentiated gastric adenocarcinoma, while a renal biopsy showed mesangial hypercellularity with C1q dominant immunofluorescence deposits. The development of C1qN in this case may be a result of the activation of C1q by necrotic or apoptotic cancer cell debris. C1q has been shown to induce apoptosis experimentally in other cancers. The findings suggest a complex role for C1q in initiating tumor apoptosis and subsequent linkage with apoptotic cell products and immunoglobulins to initiate renal damage.
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Toxocariasis and nephrotic syndrome p. 1461
Yosra Ben Ariba, Rim Abid, Riadh Battikh, Bassem Louzir, Jannet Labidi
DOI:10.4103/1319-2442.275494  
We describe a case of toxocariasis as a rare cause of nephrotic syndrome in an adult woman. This rare association was confirmed by elevated Toxocara-specific immunoglobulin M titers. Renal biopsy was not done because of prolonged activated partial thromboplastin time. Our patient was treated with prednisone and albendazole. These treatments resulted in partial remission of renal symptoms as well as the abatement of the Toxocariasis infection. The relationship between toxocariasis infection and glomerular disease is still unclear. In the literature, exceptional renal impairment secondary to toxocariasis have been described, especially in children. To the best of our knowledge, this is the second case of nephrotic syndrome associated with toxocariasis in adults.
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Late occurrence of pelvi-ureteric junction obstruction in renal allograft and live-related kidney donor p. 1464
Kurian George, Ganesh Gopalakrishnan, Said Abdallah Al-Mamari, SB Viswaroop
DOI:10.4103/1319-2442.275495  
Pelvi-ureteric junction (PUJ) obstruction is an enigmatic condition. While in a reasonable majority it is clear cut, the diagnosis and the need for intervention in the remainder is still a challenge. We would like to share the details of two cases, one in a transplant recipient and the other in a living kidney donor, and propose an explanation as to why PUJ obstruction becomes manifest after such a long period of time. In this presentation, we would like to propose that forced drinking of fluids by patients who have an equivocal PUJ and a single kidney could tilt the balance resulting in overt PUJ obstruction.
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Simultaneous tubular and glomerular involvement with cryoglobulinemia vasculitis in multiple myeloma p. 1470
Zafirah Zahir, Vinita Agrawal, Asif Sadiq Wani, Narayan Prasad
DOI:10.4103/1319-2442.275496  
Renal manifestations in myeloma are varied. Tubulopathic light chains cause cast nephropathy or proximal tubulopathy, usually associated with tubulointerstitial nephritis. Glomerular involvement includes amyloidosis and monoclonal immunoglobulin deposition diseases. We report a case of multiple myeloma with systemic manifestation of Type-1 cryoglobulinemic vasculitis (skin rash and polyarthritis) and unusual renal manifestation with both tubular and glomerular involvement on renal biopsy along with features of cryoglobulinemic renal vasculitis. Renal biopsy showed light chain cast nephropathy and glomerular involvement. Glomeruli displayed membranoproliferative pattern with monoclonal immunoglobulin deposition disease and features of cryoglobuminemia. Immunoflourescence showed Kappa restriction in the tubular casts and glomerular deposits. Serum light chain assay and immunoelectrophoresis revealed IgG Kappa light chain restriction. The exact mechanism of the varied renal manifestations of multiple myeloma in different patients is not known.
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Multiple Loculated Peritoneal Abscesses in a Child with Nephrotic Syndrome: A Rare Presentation p. 1475
Md Azizur Rahman, Md Habibur Rahman, Md Rezaul Karim, Syed Saimul Huque
DOI:10.4103/1319-2442.275497  
Infection in nephrotic syndrome (NS) is an important cause of mortality and morbidity, especially during corticosteroid therapy. Delayed diagnosis and treatment of these infections can result in some severe consequences. Common infections are peritonitis, meningitis, pneumonitis, and cellulitis. They may even cause abdominal abscess formation. Although literature review reveals abdominal abscesses in NS, multiple loculated peritoneal abscesses are rare in childhood NS. Here, we report a case of multiple loculated peritoneal abscesses in an 8-year-old male child with NS.
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Simultaneous acute pancreatitis and angioedema associated with angiotensin-converting enzyme inhibitor p. 1479
Imen Gorsane, Tasnime Ben Ayed, Raja Aoudia, Hayet Kaaroud, Fethi Ben Hamida, Amel Harzallah, Taieb Ben Abdallah
DOI:10.4103/1319-2442.275498  
Angiotensin-converting enzyme inhibitors (ACEI) are commonly prescribed drugs for blood pressure (BP) control and renal protection. The use of ACEI is not associated with an increased risk of acute pancreatitis and ACEI-induced angioedema is rare. A 36-year-old woman presented with vomiting, headache, and aphasia. Her BP was 220/100 mm Hg. urine analysis revealed proteinuria (2+), hematuria (3+). Serum creatinine level was at 1125 μmol/L. She had anemia with 6.1 g/dL of hemoglobin and thrombocytopenia (61,000/mm3). Renal histology revealed lesions of thrombotic microangiopathy. The diagnosis of atypical hemolytic uremic syndrome was made by the complement factor I deficiency. Plasma exchanges could not be done. She was placed on peritoneal dialysis for renal insufficiency. We introduced an ACE (captopril) for the treatment of high BP. Twelve-hours after taking the first dose, she experienced severe epigastric pain and two episodes of vomiting. Serum lipase was 560 IU/L, and abdominal computed tomography showed Stage B pancreatitis. Twenty-four hours later, the patient developed marked edema of the neck region without dyspnea or dysphonia. Cervical ultrasound revealed the infiltration of the subcutaneous tissues. Captopril was stopped with the progressive disappearance of the edema. Serum lipase was 350 IU/L and then normalized at the end of the 4th day. Clinicians should be careful about widely used drugs and their side effects. ACEI can cause potentially life-threatening complications such as angioedema and acute pancreatitis. Possibly, there could be a common mechanism for the onset of pancreatitis and angioedema under ACEI.
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