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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Inflammation is a complex process that reflects the local and systemic responses to different immunological and non-immunological stimuli, enable resistance to disease, repair of tissue damage, and restoration of normal function with the least possible tissue damage. This is achieved by intact regulatory immune system, which includes pro- and anti-inflammatory cytokines, chemokines, growth factors, complement cascade system, renin-angiotensin system, and different sets of adhesion molecules expressed on leukocytes and vascular endothelium, in addition to neutrophils, monocytes/macrophages, and different subsets of T-lymphocytes. Once imbalance occurs in the different factors of the inflammatory response to injurious stimuli, inflammation will proceed and exacerbate tissue damage. Inflammation can be initiated by different stimuli such as deposition or formation of antibody-antigen immune complexes, sensitized T-cells, trauma, tissue necrosis, or infection. It is characterized by activation of acute phase response and release of reactants/markers such as C-reactive protein. Renal inflammation can occur either as an isolated local acute inflammatory reaction or as part of a systemic inflammatory disorder. Recently, there have been tremendous advancements in the fields of immunology and molecular biology that helped in exploring the mechanisms of renal inflammation. This has been accompanied by extensive in vitro and in vivo studies that led to a better understanding of phenotypic changes and multifunctional potentials of local and infiltrating cells, role and control of different inflammatory mediators, adhesion molecules, and the rennin-angiotensin system within the site of inflammation. These achievements helped in researching into ways to modulate renal inflammation, control the severity of renal injury, promote regeneration and tissue repair, and induce tolerance.

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This study was undertaken to assess potassium level and electrocardiographic (ECG) changes post hemodialysis and whether fall in potassium level during dialysis may potentiate cardiac arrythemia. We studied 21 chronic hemodialysis (HD) patients who had their serum electrolytes measured before and immediately after dialysis session, and ECG performed at the same time. The patients included 14 females and 7 males with a mean age of 53.1±15.6 years and range from 26 to 81 years; 9 (43%) patients were diabetics. All the patients had been on dialysis for a minimum of 6 months each Pre-HD serum potassium levels had no correlation with any ECG parameters except a negative correlation with the T wave amplitude r=-0.5, p=0.021. ECG parameters significantly changed post­HD; the T wave amplitude decreased, and the R wave amplitude increased. A comparatively higher R wave significantly decreased the T to R wave ratio post dialysis. The QRS duration and QTc interval also increased significantly. The patients with post-HD serum potassium of < 3.5 -in comparison to those with levels >3.5 mmol/L -had a higher R wave amplitude and a significantly less T to R wave ratio (11.8±9.7 vs 6.4±5.1, p=0.045 and 0.4±0.38 vs 1.0±0.97, p=0.049, respectively. In patients with serum potassium decrement of > 2.0 mmol/L, the T to R wave ratio decreased significantly, 0.32±0.21 vs 0.85 ±0.26, p=0.023; The T wave amplitude decreased more than the rise in R wave. Multiple regression analysis did not reveal any relationship of pre or post HD ECG changes and serum potassium, serum calcium or net change in serum potassium post-HD. We conclude that post-HD serum potassium decrement results in a decrease in T to R wave ratio on ECG; this change may have an arrhythmogenic potential.

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Tuberculosis (TB) of the kidney and urinary tract has non-specific symptoms and is easily overlooked. We performed this retrospective study to analyze different findings on excretory urography (IVP) of patients with renal TB. The IVP slides of 25 patients (14 females/11 males, age range 12-63 years) with renal TB diagnosed over a 20-years period were studied for the presence of characteristic findings. They included: renal parenchymal mass, autonephrectomy, hydronephrosis, ureteral stricture and dilatation, and bladder involvement and fibrosis. In our study, the most common findings were ureteral stricture and dilation (13/25, 52%), bladder involvement 13/25 (52%), autonephrectomy 12/25 (48%) and renal parenchymal calcification 10/25 (40%). The most common combined pattern was ureteral stricture-dilation with contralateral autonephrectomy and bladder irregularities. We conclude that kidney TB remains undiagnosed until the advanced stages and awareness about the IVP imaging pattern could help in early diagnosis of this entity.

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Sarcoidosis is a systemic disease characterized by chronic granulomatous inflammation. Chronic kidney disease (CKD) was reported in less than 1% of patients of sarcoidosis. The prevalence of tubulo-interstitial nephritis (TIN) in sarcoidosis varies from 7 to 27%. In this retrospective study, we present 15 patients with interstitial or glomerular renal involvement secondary to sarcoidosis diagnosed in our center from 1975 to 2006. Patients were 13 (96.6%) females and two males with a mean age of 56.5 years. CKD was present in 14(93.3%) patients, proteinuria in 13(96.6%), and nephrotic syndrome in one. Pulmonary involvement was present in 10 (66.6%) patients. Renal biopsy performed in 12 (80%) patients revealed TIN lesions in 10 (66.6%) patients, extracapillary proliferative glomerulonephritis (GN) in one, and membranous GN type 2 in another. Corticosteroid therapy using prednisolone 0.5 to 1 mg/kg per day was used in 12(80%) patients. Ten (66.6%) patients were followed up for a mean period of 25 months (ranged from 2 to 48 months). The outcome was favorable with 7 (46.6%) patients improved their renal function, 6 (40%) remained with a moderate CKD, one normalized his renal function, and one died suddenly after 2 months of initiating the treatment corticosteroids. We conclude that corticosteroid treatment is efficient in TIN and variably efficient in GN. Patients with sarcoidosis may cause advanced renal failure, which renders it a serious nephrological condition.

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Lupus nephritis (LN) is the most common and serious manifestation of systemic lupus erythematousus (SLE). The World Health Organization (WHO) and International Society of Nephrology/Renal Pathology Society (ISN/RPS 2003) classifications tend to correlate with the clinical syndrome and provide valuable information regarding prognosis and guideline for treatment. We retrospectively studied patients with biopsy proven lupus nephritis at our center from 1999 - 2003 to find whether clinical and laboratory parameters used to evaluate how close the diagnosis correlated with WHO and/ or ISN/RPS 2003 classification. There were 144 patients of whom 84.7 % were females with a mean age of 25.6 ± 10.3 years at the time of renal biopsy. The most frequent SLE presenting features were arthralgia, edema and hypertension. WHO class IV and ISN/RPS class IV were compatible with these most frequent SLE presenting features in 56% and 54.9% of the cases, respectively. Edema, hypertension, increased BUN and Creatinine, increased 24 hours urine protein excretion and decreased serum albumin level were related with a worse class of lupus nephritis. We conclude that there is a correlation between some clinical and laboratory findings, and histopathological lupus classification on renal biopsy ,which remains indispensable in the management of lupus nephritis.

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Common complications that can occur following internal jugular vein catheterization used for hemodialysis (HD) include internal carotid artery puncture, thrombosis, and infection. We present a case of Horner's syndrome following internal jugular venous cannulation as a possible complication.

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The initial treatment of bladder cancer is transurethral resection (TUR), but this cancer recurs at an important rate, and has 14% chance of progression after TUR alone. Intravesical chemotherapy with Bacillus Calmette-Guerin (BCG) is effective against recurrence and progression of bladder cancer. However, this therapeutic expose to many local and systemic side-effects. We report a case of 63-year-old man who presented bladder tuberculosis after a BCG therapy, which required 6 months of antitubercular therapy.

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Renal osteodystrophy is a complication of chronic kidney disease (CKD) that present in low and high turnover patterns. This disorder has a key role in the disability of CKD patients in whom early diagnosis and treatment can result in better outcome. We studied hyperparathyroidism prevalence and its relationship with renal osteodystrophy in our advanced CKD population. We included 80 patients (of whom 44 (55%) were diabetic) during 6 months period. The patients answered a questionnaire about symptoms related to bone disease and blood levels of parathormone (PTH), calcium, phosphorus, and alkaline phosphatase were obtained, in addition to hand and skull radiographs in all the study patients. Prevalence of clinically evident hyperparathyroidism in our patients was 45%. Hyperparathyroidism had significant relationship with alkaline phosphatase and radiological findings, but did not have a significant relationship with dialysis duration, age, sex, familial history, diabetes mellitus, or hypertension. We conclude that secondary hyperparathyroidism is prevalent in our dialysis population and has high correlation with serum alkaline phosphatase levels and radiological changes.

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Pruritus is a common problem in dialysis patients. The aim of this study was to determine the cause(s) of pruritus and its relationship with inflammatory proteins. In a cross sectional study, all patients on hemodialysis at the Emam Khomaine and Sina Hospital, Tehran, Iran who did not have any pruritus-producing skin lesions were studied. They were questioned about the occurrence of pruritus during the preceding two weeks. Variables including inflammatory proteins (C-reactive protein, albumin, ferritin, transferrin, fibrinogen), hemoglobin, red blood cell indices, iron, iron binding capacity, transferring saturation, urea, creatinine, calcium, phosphorus, calcium x phosphorus product, alkaline phosphatase and parathormone were determined. Data were analyzed using Anova or Chi-square tests for evaluation of difference between variables. Of the 164 patients studied, 80 (49%) had pruritus. Of these, 45 subjects (23.8%) had severe and 35 (21.3%) mild to moderate pruritus. There were no significant differences between groups with or without pruritus for age, sex, duration on dialysis, dialysis adequacy, cause of renal failure and erythropoetin usage. Mean CRP was 16.6 mg/L; 58.5% of the patients had CRP > 10 mg/L. There was no significant correlation between CRP levels and presence or severity of pruritus. Also, none of the other inflammatory proteins revealed any significant differences. Among the other parameters, only the mean MCV levels were significantly different between the three groups (P < 0.05). Our study suggests that inflammatory proteins do not play any part in hemodialysis associated pruritus.

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Renal artery stenosis in renal transplantation (TRAS) is an avoidable short or long-term surgical complication. The etiology is multifactorial, but faulty anastomosis is a major factor. In our transplant center, we evaluated the incidence of TRAS with the use of two different suturing techniques of the anastomosis site between the allograft renal and iliac arteries in two groups of renal transplant recipients, group A: 14 patients (6 males and 8 females with age 16 to 59 and mean age of 38 years) in whom the allograft arteries were anastomosed with a continuous suture technique, and group B: 14 patients (7 males and 7 females, with age 32 to 61 and mean age of 46.6 years) in whom the allograft arteries were anastomosed with a combined suture technique (continuous and interrupted). Post transplantation, the velocity of blood flow in the renal and iliac arteries at the site of anastomosis was measured by color Doppler ultrasound. The ultrasonographer was blinded to the surgical technique in both study groups. The ratio of the maximum velocity of blood at the site of anastomosis to that in the iliac artery of less than 2.5 was considered as non-significant stenosis, while a ratio of more than 2.5 was considered significant stenosis. In group A there were 9 cases of non-significant stenosis in comparison to 3 cases in group B, while there were no cases of significant stenosis in group A in comparison to 3 cases in group B; the difference was not statistically significant. We conclude that there was no difference in the incidence of stenosis in the compared surgical techniques of anastomosis in our study groups. This suggests that other factors such as gentle handling of tissue, enough spatula, margin reversion, and comparable diameter of the anastomosed vessels may be more important in the prevention of renal allograft stenosis than the type of suture technique.

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Dialysis and transplantation have prolonged survival and quality of life in patients with chronic kidney disease (CKD). This is an exploratory/descriptive study, looking into the socio­demographic profile and social factors in these patients associated with acceptance of therapy. Association between attitudes and demographics were examined. A total of 670 patients with CKD were prospectively evaluated during the years 2000-2003 and based on the degree of renal failure, were categorized into conservative therapy, dialysis alone, or transplantation. A detailed psycho-social assessment and counseling regarding the treatment options was done. The mean age of the study patients was 49.27 ± 16.7 years. Of the study patients, 66.7% were males, 70.6% were married, 40% were undergraduates, 34% were employed, 41.6 and 37.3% were respectively from low- and middle-income groups, 60% lived in nuclear families and 64% had an urban background. Patients with CKD Stages II - IV (37.3%) were advised conservative treatment, while CKD Stage V patients were advised dialysis alone in 35.5% and dialysis and transplantation in 64.5%. The major psycho-social factors negatively influencing the acceptance of treatment were finance (69.3%), logistics (66.0%), no willing donors (11.0%), no medically fit donors (13.0%) and/or lack of social support (17.0%). Statistically significant association was noted between attitudes and marital status (p < 0.05, education and domicile (p = 0.05), occupation, income and family type (p < 0.05). Our study suggests that finance is one of the important factors deciding the acceptance of treatment. Social factors negatively affecting were logistics, lack of willing and medically fit donors and lack of social support.

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This study was undertaken to determine the age, sex, pattern of presentation, histopathology and outcome of management of adult patients with malignant renal tumors (MRT) in Nigeria. Using hospital records, a retrospective study was performed covering the period between January 1997 and December 2006. A total of 18 adult patients had been diagnosed to have MRT during this period. Information extracted and analyzed included the age of the patient, sex, presentation, investigations, type of histopathology, management and duration of follow-up. The mean age of the study patients was 47.5 years (range 16-80 yrs). The male: female ratio was 13 : 5 and the mean duration of symptoms was 43.6 weeks (range 2-104 wks). Sixteen patients (88.9%) presented in advanced stage. Symptoms included loin pain in 17 (94.4%), abdominal swelling in 15 (83.3%), weight-loss in 13 (72.2%) and hematuria in nine (50.0%). Ultrasound and intravenous urography assisted greatly in making the diagnosis. Thirteen patients (72.2%) underwent radical nephrectomy, tumors were not resectable in two (11.1%) and three others (16.7%) were deemed unfit to undergo surgery. The average tumor mass removed at surgery was 1.884 Kg (range 0.48-3.82 Kg). Renal cell carcinoma (RCC) accounted for 13 of the tumors (72.2%). Surgical complications include primary-hemorrhage, septicemia and tumor recurrence in one patient each (7.6%). Morbidity and mortality rates were 7.6% each. The average post-operative hospital stay and follow-up duration were 9.3 days and 37.5 months respectively. Our study suggests that RCC is the major MRT in our community. Most cases still present late with loin pain and swelling, weight loss and hematuria. This late presentation and sarcomatous type of tumor have negative influence on prognosis. Radical nephrectomy is beneficial in operable, locally advanced, non-metastatic MRT.

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While good organ quality and ideal transplant conditions eliminate many of the know factors that compromise initial graft function (IGF), poor early graft function (EGF) still occurs after living donor kidney transplantation (LDKT). Uncontrolled pre-transplant hypercalcemia and hyperparathyroidism are associated with impaired allograft function. Between April 2004 and January 2006, data were collected on 354 LDKT recipients including 252 males and 102 females, to determine risk factors for poor EGF, defined as either delayed or slow graft function (DGF or SGF). Of the 354 recipients, 318 (89%) had IGF, 22 (6.2%) had SGF and 14 (4%) had DGF. Donor female gender (P = 0.04) and duration on dialysis (P = 0.02) were associated with poor EGF. Recipients with DGF had higher serum phosphate (P = 0.07) and calcium x phosphate product ( P = 0.01) than recipients with IGF and SGF. The serum parathormone (PTH) levels were higher in recipients with SGF and DGF although the difference was not statistically significant (P = 0.1). Serum calcium levels did not correlate with the occurrence of poor EGF (P = 0.9). Our study suggests that serum phosphate and calcium x phosphate product serve as risk factors for DGF while serum PTH level may play a role as a risk factor for SGF and DGF.

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Amyloidosis is a rare systemic disorder of protein metabolism with progressive extra­cellular deposition of insoluble fibrillary protein, disorganization of tissue architecture, and subsequent organ dysfunction. Primary amyloidosis is the most common form of this disorder, however, it can develop secondary to plasma cell dyscrasias such as multiple myeloma (MM); 10-15% of MM patients may develop amyloidosis of vital organs. Amyloidosis is usually associated with bleeding, but less commonly with thrombosis. We present a 52-year-old Saudi female with amyloidosis secondary to multiple myeloma. She presented with both venous and extensive arterial thrombosis. Although relatively rare, plasma cell dyscrasias such as amyloidosis and multiple myeloma could present with thrombotic rather than hemorrhagic complications.

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Reactivation of infection with the cytomegalovirus (CMV) in renal transplant recipients may cause significant morbidity and mortality. To evaluate factors associated with activation of CMV replication, we followed prospectively a group of 68 renal transplant recipients for 12 months. The control group consisted of healthy blood donors (n = 37). Sera were collected periodically from these patients and analyzed for the presence of specific anti-CMV antibodies. Enzyme-linked immunoassay based on recombinant CMV proteins was used to detect the following antibody specificities: IgG and IgM. During the first year after transplantation, reactivation of CMV occurred in 48 recipients (70.6%). Detailed analysis did not show any association of reactivation with the type of basic immunosuppressive therapy, prophylactic or therapeutic use of anti-lymphocyte antibodies, as well as occurrence of acute rejection episodes. There was a borderline association (P=0.068) between the presence of CMV infection and EBV reactivation. In conclusion, results of our study suggest that CMV infection may represent a factor activating EBV replication

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Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end­stage renal disease and a common indication for renal transplantation. Patients with ADPKD show some differences in graft outcome and complications following renal transplantation. This study was undertaken to evaluate the demographics, outcome and complications of renal transplantation in patients with ADPKD. In a retrospective case-control design, 51 patients with ADPKD were recognized amongst a total of 1200 renal transplant patients. For each case, a matched control based on sex, age (± 5 years) and type of kidney donor, was selected. All relevant data were gathered using patients' records and PNOT software. There were 34 males (66.7%) and 17 females (33.3%) with ADPKD. Mean age at transplantation was 42.6 ± 14.3 years and source of donor organ was predominantly live unrelated (72.5%). Forty patients (78.4%) had extra-renal manifestations of ADPKD, the most common of which were cardiac valvular disease (24 cases, 47.1%), and liver cysts (10 cases, 19.6%). Rejection occurred in 12 patients in the case-group (23.5%) in comparison to nine patients (17.6%) in the control group (p > 0.05). Twenty-nine cases (56.9%) did not develop any complications. The common complications noted after transplantation included infections (15.7% in cases vs 19.6% in controls), and cerebrovascular accidents (13.7% in cases vs 16.6% in controls). Patient outcome after short- and long-term follow-up was slightly better in the ADPKD population than the control group; however, it was not statistically significant. Also, no complication was found to occur more frequently in ADPKD patients.

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Calciphylaxis is a dreaded complication of chronic renal failure characterized by nodular subcutaneous calcification and pain. Full tissue necrosis often leads to ulceration, secondary infection and high mortality rate. We herewith present a 65-year-old Saudi gentleman who presented with multiple necrotic skin lesions of both proximal and distal distribution. Skin biopsy confirmed the diagnosis of calciphylaxis. Patient was started on sevelamer hydrochloride and low calcium dialysate to which he responded dramatically without the need for parathyroidectomy. To our knowledge, this is the first reported case of calciphylaxis with both proximal and distal distribution.

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Duplication of the bladder is a rare congenital anomaly with an unknown embryological basis. A 12-year-old boy with dysuria was found to have a tri-radiate external urethral meatus instead of a vertical slit. Cystourethroscopy revealed two bladders with bifid proximal urethra. Magnetic resonance imaging (MRI) revealed duplication of colon and bladder. He did not have any symptoms related to the urinary tract.

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Hepatitis C virus (HCV) infection has been recognized as an emerging problem in dialysis patients and its prevalence varies considerably among different areas of the world. The prevalence of HCV infection in hemodialysis (HD) patients and its associated risk factors is not well documented in our country. We therefore performed this study aiming to discuss prevention of further transmission of HCV infection among our patients. Between September 2003 and September 2005, 169 patients with end-stage renal failure on HD at the Renal Transplant Center, Medical City Teaching Hospital, Baghdad, were involved in this prospective study. There were 102 (60.4%) males, and 67 (39.6%) females, with age ranging from 14-67 years. Anti-HCV antibodies were positive in 12 of these patients (7.1%). Female gender, age > 60 years, dialysis duration < six months, history of having received blood transfusion(s), and < 9 hours per week of HD were significant predictors of anti-HCV positivity. We conclude that adherence to universal infection precautions, regular HCV screening of transfusions and of patients on HD and the use of separate machines for those who are anti-HCV positive, are important factors. To further reduce the prevalence in our patients, erythropoietin should replace blood transfusions as also testing for HCV RNA using polymerase chain reaction before starting HD.

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Delayed graft function (DGF), a term employed when a newly transplanted organ does not function efficiently is commonly observed following cadaveric renal transplantation but is very rare after living related transplants. We present a 31-year-old female recipient of a related donor kidney (mother) who had DGF following trans­plantation due to acute tubular necrosis, probably caused by partial allograft arterial thrombosis, which recovered function after 60 days. Appropriate use of allograft biopsy should be encouraged even in resource-limited settings lest the allograft be assumed to have failed irreversibly.

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Recently with introduction of laparoscopic nephrectomy, the procedure has become more appealing to living donors because of smaller laparoscopic incision and decreased length of hospital stay. However, because of the relatively prolonged warm ischemia time, increased operating time, and delayed graft function, the current laparoscopic donor nephrectomy is still subject to further development. We introduced a modified anterior abdomen incision for donor nephrectomy with advantages of laparoscopic procedure but with shorter warm ischemia and operation time. In 15 donors, a 10 cm incision was performed in the upper side of the abdomen between the rectus muscle and the tip of the ribs, while the donor was in flank position. Then, the kidney was exposed and freed followed by ureter nephrectomy. Afterwards, the abdominal wall was repaired without drain. The time of operation (from incision skin to suturing of skin) was from 1-1.5 hours with a few seconds of warm ischemia time. The donors experienced tolerable pain and all of them were discharged from hospital two days post operation. all grafts in recipients started to diurese immediately. Cosmetic appearance of wounds after operation and six months later were good. In conclusion, the modified anterior abdominal incision is safe and comparable with the conventional laparoscopic procedure in the size of the incision, the cosmetic appearance, the incision pain, and time of discharge. It may be advised as an alternative laparoscopic nephrectomy procedure.

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Continuation of low-dose maintenance immunosuppressive therapy in end­stage renal allografts (ESRAs) that are left in situ is controversial. We studied the outcome of 85 patients (mean age 33.3 ± 13.4 and range of 12-56 years) on hemodialysis with ESRAs, and without immunosuppressive therapy in our center from July 1991 to July 2003. Twelve (14.1%) study patients underwent allograft nephrectomy within a mean interval of 44.5 months after graft failure. The rest of the patients remained stable without fever, hematuria, graft tenderness, or localized edema during a mean interval of 46.5 ± 45.2 months of follow-up. These results are promising and suggest that maintenance immuno­suppressive therapy in patients with ESRAs and on dialysis may not be necessary to avoid allograft nephrectomy. Prospective studies are warranted to substantiate these results.

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An increased risk of venous thromboembolism has been demonstrated following renal transplantation. Commonly reported sites have been deep vein thrombosis, pulmonary thromboembolism and vascular thrombosis involving the graft. Cerebral venous thrombosis (CVT) has not been reported in literature so far. A 36-year-old male patient, transplanted in Jan 2005 with normal graft functions, was admitted with history of headache, blurring of vision and vomiting. Examination revealed papilledema and no neurological deficits. Baseline investigations and analysis of cerebrospinal fluid were normal. Cerebral magnetic resonance venogram revealed extensive CVT involving superior sagittal sinus, bilateral transverse sinuses and the right sigmoid sinus. He was investigated for a thrombophilic disorder; serum homocysteine, protein C and S levels, antiphospholipid antibody and antithrombin-III levels were done despite which no conclusive diagnosis could be arrived at. To our knowledge, this is the first report of extensive CVT described in a transplant recipient. No definite prothrombotic or predisposing factors could be identified in our patient and the cause of CVT remains unclear.

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Post mortems or autopsies are essential part of medical undergraduate training. This article reflects on the author's memories as a medical student at University College Hospital Medical School, London.

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