We conducted this study to determine the prevalence of elevated erythrocyte sedimentation rate (ESR) in chronic hemodialysis patients and to evaluate the dialytic and serum factors that might explain this elevation. ESR was measured using the Westergren method immediately before and immediately after dialysis sessions in 200 stable (i.e. with no other obvious systemic illnesses) hemodialysis patients and in 50 hemodialysis patients during concurrent acute illnesses. ESR was found to be > 25 mm/h in 180 (90%) patients, >50 mm/h in 76 (38%) and > 100 mm/h in 64(32%) patients. The mean pre dialysis ESR was not significantly different from the mean post dialysis ESR (77 ± 38 Vs 78 ± 35 mm/h, respectively). The mean ESR in the 50 patients during acute illnesses was not significantly different from the mean ESR measured during the stable state. Among all dialytic, biochemical and serum factors that were studied in this population, fibrinogen was the only factor that independently correlated significantly with ESR (P=0.015). In conclusion, this study showed that our dialysis patients had a tendency for elevated ESR and almost one third of them (32%) had ESR >100 in the absence of malignancy or other clinical factors known to cause such levels. There was a significant correlation between elevated ESR and fibrinogen level. Thus, an ESR of > 100 does not necessarily warrant extensive investigations for causes other than the renal failure/hemodialysis state unless other indicators exist to justify the search.

[ABSTRACT]  [FULL TEXT]  [PDF]  [PubMed]

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Today, ultrasound is one of the most commonly used diagnostic tools, the reasons being that it is non-invasive, reliable, widely available, and affordable. In this paper, we review the place of ultrasound in the diagnosis and follow-up of patients with kidney diseases. We briefly discuss a wide range of kidney diseases for which ultrasound imaging is still performed as one of the initial steps of diagnosis. To achieve this, five following categories are addressed: congenital anomalies of the kidney; renal cystic diseases; renal infections; kidney stones; and kidney tumors. The sonographic findings of these diseases are discussed.

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The congenital nephrotic syndrome (CNS) is an uncommon disorder with onset of the nephrotic syndrome usually in the first three months of life. Several different diseases may cause the syndrome. These may be inherited, sporadic, acquired or part of a general malformation syndrome. The clinical course is marked by failure to thrive, recurrent life threatening bacterial infections, and early death from sepsis and/or uremia. A characteristic phenotype may be seen in children with CNS. The majority of reported cases of CNS are of the Finnish type (CNF). Although the role of the glomerular basement membrane has been emphasized as the barrier for retaining plasma proteins, recent studies have clearly shown that the slit diaphragm is the structure most likely to be the barrier in the glomerular capillary wall. The gene (NPHS1) was shown to encode a novel protein that was termed nephrin, due to its specific location in the kidney filter barrier, where it seems to form a highly organized filter structure. Nephrin is a transmembrane protein that probably forms the main building block of an isoporous zipper-like slit diaphragm filter structure. Defects in nephrin lead to the abnormal or absent slit diaphragm resulting in massive proteinuria and renal failure

[ABSTRACT]  [FULL TEXT]  [PDF]  [PubMed]

Hemodialysis (HD) patients are at considerably high risk for vascular access­related blood stream infections (VRBSI) that result in serious complications. Such severe infections are a great deal more frequent with central venous catheters (CVCs) and polytetrafluoroethylene (PTFE) grafts than with arteriovenous fistula (AVF). Nonetheless, the CVCs, though having "undesirable" side effects, remain "unavoidable" for the patients requiring instant dialysis access, as a consequence of the unpredictable course of chronic renal disease. Although early antibiotic treatment should include the coverage for Staphylococcus aureus, the treatment of catheter-related blood stream infections (CRBSI) remains controversial. Antimicrobial- anticoagulant 'locks' have shown promising results in several recent randomized controlled trials in the treatment and prevention of CRBSI. Policy of increasing AVF prevalence beyond 50% is bound to have an enduring positive effect on HD outcomes. Standard infection control measures for hygiene and aseptic handling of CVCs cannot be overemphasized. The catheters with 'bioactive' surface with thrombo-resistant and infection-resistant properties will be available in the near future.

[ABSTRACT]  [FULL TEXT]  [PDF]  [PubMed]

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To determine the correlation between protein-to-creatinine ratio (PCR) and 24-hour urinary protein (UP), we measured proteinuria in 68 patients attending the nephrology clinic at Jordan University Hospital by 24-hour urine protein excretion and protein-to-creatinine ratio. The cutoff values for spot urine protein-to-creatinine ratio in predicting 24-hour protein "threshold" excretion of 0.5, 1.0 and 3.5 g/day were determined using receiver operating characteristic curves. A very good correlation (r= 0.832, P< 0.0001) was found between spot urine protein-to-creatinine ratio and 24-hour urine protein excretion. Bland-Altman plot showed the two tests had reasonable limits of agreement at low level of protein excretion but the limits became wider as the protein excretion increased. For protein excretion < 2.0 g/day, the limits of agreement of spot urine (PCR) and (UP) were +1.48 and -1.2 g/day. The spot urine protein-to-creatinine ratios of 0.72 (sensitivity 0.97; specificity 1.0), 1.2 (0.97; 0.89) and 3.23 (1.0; 0.86) mg/mg reliably predicted 24-hour urine total protein equivalent "thresholds" of 0.5, 1.0 and 3.5 g/day, respectively. We conclude that the protein-to-creatinine ratio in spot urine specimens is an accurate, convenient, and reliable method to estimate the protein excretion in urine. However, the protein-to-creatinine ratio will likely be within clinically acceptable limits only when proteinuria is at reasonably low levels.

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Since the initial successful kidney transplantation in humans, the field of renal transplantation has made significant progress. Patient survival and graft survival have improved tremendously. Our armamentarium of immunosuppressive drugs and antimicrobial agents has expanded, as our understanding of their effects and proper utilization. Enhanced surgical techniques also improved the overall survival of kidney recipients. However, infectious complications remain a major cause of morbidity and mortality in this patient population. In this article, we provide an overview of infections in kidney transplant recipients, a detailed illustration of specific infectious agents with a focus on cytomegalovirus, and finally we lay some general principles for limiting the burden of infectious complications in kidney transplants through proper infection control measures.

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HSP is the most common systemic vasculitis in children that is characterized by small vessel leukocytoclastic vasculitis. However, it is a self limiting disease, with few documented cases in Middle Eastern countries. Classic symptoms of the disease have been established in the literature, but new clinical features have recently been reported from Middle Eastern countries which include penile swelling, temperomandibular joint involvement, skin rash over the flexor surfaces of the extremities, and pleural hemorrhagic effusion. Familial Mediterranean fever (FMF) may present as HSP. The prevalence of the FMF gene in Middle Eastern countries raises interesting questions regarding the use of colchicine in HSP patients.

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Hyponatremia secondary to the syndrome of inappropriate anti-diuretic hormone secretion is commonly observed in patients with various neurological disorders. Cerebral salt wasting (CSW), although uncommon, has also been reported to frequently result in hyponatremia. Here, we report a case of CSW in a patient with head trauma without evidence of cerebrovascular injury or brain edema. He was diagnosed on the basis of high fractional excretion of urinary sodium and uric acid along with extremely low serum uric acid. Improvements in serum sodium levels after saline hydration and fludrocortisone administration further supported the diagnosis, even in the presence of normal brain and atrial natriuretic peptide levels.

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Candiduria is a common nosocomial infection afflicting the urinary tract. This review is aimed at providing an updated summary of the problem in hospitalized adult patients. A review of English Medline literature published between Jan 1970 until June 2007 was performed. Reviews, clinical trials and case-controlled studies in adult patients were included. Risk factors for candiduria included urinary indwelling catheters, use of antibiotics, elderly age, underlying genitourinary tract abnormality, previous surgery and presence of diabetes mellitus. Presence of candiduria may represent only colonization and there are no consistent diagnostic criteria to define significant infection. Candiduria may not be associated with candidemia and most cases are asymptomatic. Asymptomatic candiduria is usually benign, and does not require local or systemic antifungal therapy. Physicians need to confirm the infection by a second sterile urine sample, adopt non-pharmacologic interventions and modify risk factors. Mortality rate can be high particularly in debilitated patients and awareness to validate candiduria is necessary to stratify treatment according to patient status. Appropriate use of anti fungal drugs, when indicated, should not replace correction of the underlying risk factors. Treatment of symptomatic candiduria is less controversial and easier.

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Hepatorenal syndrome (HRS) is the most appalling complication of acute or chronic liver disease with 90% mortality rate. Single pass albumin dialysis (SPAD) can be considered as a noble liver support technique in HRS. Here, we present a case of a young healthy patient who developed hyperacute fulminant liver failure that progressed to HRS. The patient was offered SPAD as a bridge to liver transplantation, however, it resulted in an excellent recovery.

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Rhabdomyolysis is a clinical and biochemical syndrome that occurs when skeletal muscle cells disrupt and release creatine phosphokinase (CK), lactate dehydrogenase (LDH), and myoglobin into the interstitial space and plasma. The main causes of rhabdomyolysis include direct muscular injury, strenuous exercise, drugs, toxins, infections, hyperthermia, seizures, meta­bolic and/or electrolyte abnormalities, and endocrinopathies. Acute kidney injury (AKI) occurs in 33-50% of patients with rhabdomyolysis. The main pathophysiological mechanisms of renal injury are renal vasoconstriction, intraluminal cast formation, and direct myoglobin toxicity. Rhabdo­myolysis can be asymptomatic, present with mild symptoms such as elevation of muscular en­zymes, or manifest as a severe syndrome with AKI and high mortality. Serum CK five times higher than the normal value usually confirms rhabdomyolysis. Early diagnosis and saline volume expansion may reduce the risk of AKI. Further studies are necessary to establish the importance of bicarbonate and mannitol in the prevention of AKI due to rhabdomyolysis.

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The Micturating Cystourethrogram (MCU) is a tough and stressful examination for patients and their parents as well as the radiologists and pediatric radiology nurses. Even though, it is one of the most commonly used fluoroscopic procedures in pediatric radiology practice, there is no definite agreement as to the best way to perform it, considering that this examination results in the children receiving a high dose of radiation to the gonadal region. This review was undertaken to determine the best way to perform the MCU in modern pediatric radiology practice.

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Children with acute renal failure (ARF) may be treated in pediatric renal or intensive care (PICU) units where there is an increasing use of continuous renal replacement therapies such as hemofiltration (HF). Over three years, we prospectively recorded details of all patients with ARF treated both within our regional pediatric renal unit, in two local neonatal intensive care units (NICUs), and one PICU, which are all supported by our institution. Our study included eighty-three ARF patients (43% male) with a median age of 5.7 years (range 1 day - 19.8 years); 41% of patients were < 2 years, 20% 2-5 years, 13% 5-10 years and 26% > 10 years of age. A total of 37 patients (45%) were treated in the renal unit versus 46 (55%) patients in NICU/PICU. The initial treatment modality was conservative in 33%, peritoneal dialysis (PD) in 23%, hemodialysis (HD) in 15%, HF in 28%, and isolated plasmafiltration in one percent of the patients. About 16% of the patients required more than one treatment modality. Outcome data at three months showed normal renal function in 49%, deaths in 20%, dialysis dependent disease in 14%, chronic renal failure (GFR < 60ml/min/1.73m ² ) in eight percent, and proteinuria and/or hypertension in seven percent of the patients. Only one (3%) death occurred in 37 patients treated in the renal unit compared to 16 deaths in 46 patients (35%) treated in the NICU/PICU. Our findings further confirm the low mortality rate with isolated renal failure and the substantial mortality and renal workload in intensive care areas where renal failure is often part of multi­organ failure. Further prospective studies will be required to analyze the impact of early hemofiltration in such patients.

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Many methods are used for the placement of Tenckhoff catheters. Eighteen consecutive Tenckhoff catheters were placed under local anesthesia through a mini laparotomy with a reduced operating team. There were only three total catheter failures. Complications were infrequent and operating time was less than one hour on average. This simple procedure should be a part of the training program of all junior surgeons and nephrologists.

[ABSTRACT]  [FULL TEXT]  [PDF]  [PubMed]

Thrombotic microangiopathy (TMA) is a rare but devastating disorder; it involves small vessels and is characterized by intravascular thrombi of aggregated platelets leading to thrombocytopenia and variable degrees of organ ischemia and anemia, which is due to erythrocyte fragmentation in microcirculation. Childhood cases with predominant renal involvement are referred as the hemolytic uremic syndrome (HUS), and adults with major central neurological involvement are labeled as thrombotic thrombocytopenia purpura (TTP). Endothelial damage due to toxins and/or lack of defense against complement activation have a central role. Recent discovery of the von Willebrand Factor cleaving protease (ADAMTS 13) has offered new insight into the pathogenesis of TMA. TMA is also a well-recognized serious complication of renal transplantation. Clinical features of intravascular hemolysis are not always found. It may occur as de novo or recurrent and the majority of de novo cases are related to cyclosporin therapy. Viral infections, severe renal ischemia and acute vascular rejection are less frequent causes. Recurrence is negligible in diarrhea-associated HUS in childhood, but non-diarrheal HUS recurs in majority of adults following renal transplantation. Renal transplantation is contraindicated in familial/relapsing recurrent forms of HUS.

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Renal failure is present in about 20% of patients with multiple myeloma (MM) at diagnosis. Renal function impairment is usually caused by the so-called "myeloma kidney" and is associated with shortened survival in patients treated with conventional therapy. Renal failure is reversible in up to 50% of patients, particularly when its degree is moderate and it is related to precipitating factors such as hypercalcemia. In our experience, approximately 10% of newly diagnosed patients with MM have renal failure severe enough to require dialysis. Despite its frequency, there are few reports dealing with MM and renal failure.

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In most Western countries, diabetic nephropathy (DN) has become the single most common condition found in patients with end-stage renal disease (ESRD). This is to some extent due to better survival of diabetic patients with renal failure, but mostly due to the dramatic increase in the prevalence of type 2 diabetes. The majority of type 2 diabetic patients with renal failure suffer from nodular glomerulosclerosis (Kimmelstiel-Wilson); but ischemic nephropathy, irreversible acute renal failure (mostly acute on chronic) and diabetes co-existing with primary renal diseases are common as well. Classical DN evolves in a sequence of stages. After a period of glomerular hyperfiltration, increased urinary albumin excretion [microalbuminuria (MA)] i.e. 30-300 mg/day or 20 - 200 µg/minute indicates the onset of overt DN. Risk factors for development of DN are positive family history, hyperglycemia in the mother during pregnancy, high blood pressure, obesity and insulin resistance. Poor glycemic control (HbA1c) and elevated systolic blood pressure (> 135 mm Hg) interact in enhancing the risk of DN. Proteinuria and smoking are major promoters of progression. The risk of onset of microalbuminuria can be reduced by lowering of blood pressure and specifically by blockade of the renin angiotensin system (RAS). In patients with established DN, the target systolic blood pressure should be <130 mm Hg and RAS blockade is obligatory. Treating all cardiovascular risk factors is a high priority. Antihypertensive management is rendered difficult by extreme volume sensitivity, pronounced activation of the RAS and autonomic neuropathy. Cardiac events are excessively frequent, glycemic control becomes difficult and autonomic diabetic neuropathy with gastroparesis and diabetic foot are additional problems. Hemodialysis or continuous ambulatory peritoneal dialysis should be started relatively early. In the absence of contraindications, transplantation (renal transplantation, combined kidney/pancreas transplantation or pancreas after kidney transplantation) is the treatment of choice.

[ABSTRACT]  [FULL TEXT]  [PDF]  [PubMed]

The exact prevalence of chronic kidney disease in India is not clear in the absence of regular national registry data and provided only by small observational series or rely on reports from personal experience, but the quality of data is quiet uneven. There are only three population based studies in India commenting on the magnitude of chronic kidney disease. In a prevention program started at community level in Chennai, the reported prevalence is 0.86% in the project population and 1.39% in the control region. The second study is based on Delhi involving 4972 urban patients. The prevalence of chronic renal failure (defined as serum creatinine more than 1.8 mg/dL) to be 0.79 % or 7852 per million/population. The third study perhaps the only longitudinal study to identify the incidence of end stage renal disease is based on 572,029 subjects residing in city of Bhopal suggests that the average crude and age adjusted incidence rates of end stage renal disease were 151 and 232 per million population respectively. The resources and skill for taking care of this large case load, both in terms of personal and health care infrastructure do not exist currently and would need to be created. To tackle the problem of limited access to renal replacement therapy, an important method would be to try and reduce the incidence of end stage renal disease and the need of renal replacement therapy by preventive measures. It is clear that treatment of chronic kidney disease and its advanced stage end stage renal disease is expensive and beyond the reach of average Indian. Thus it is crucial that prevention of chronic kidney disease has to be the goal of medical fraternity, government of India and the general public. This article suggests a series of primary, secondary and tertiary preventive measures for prevention of chronic kidney disease. Clearly there are already many effective and attractive interventions for the treatment and prevention of chronic kidney disease exist and many more surely be developed.

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