C-reactive protein (CRP), a strong independent risk marker of cardiovascular disease (CVD), and tumor necrosis factor-alfa (TNF-α), a known pro-inflammatory cytokine, are elevated and have damaging effects in patients with chronic renal failure (CRF). Omega-3 fatty acids play an important modulatory role in inflammatory responses. The aim of this study is to review the alterations in serum levels of TNF-α, CRP and other parameters caused by omega-3 supplementation in dialysis patients. The clinical trial was performed in 37 patients with end-stage renal disease undergoing dialysis in hemodialysis centers of three university hospitals in Tabriz. Blood samples were obtained from the study patients for hemoglobin, albumin, ferritin, triglyceride, total cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL)-cholesterol, TNF-α and high specific-CRP (hs-CRP) measurement. The patients received 3 g omega-3 per day for 2 months. The side-effects noticed were nausea, diarrhea and dyspepsia and undesired drug smell. The difference noted in hemoglobin, albumin, ferritin, CRP, triglyceride, total, LDL and HDL-cholesterol before and after supplementation with omega-3 fatty acid was not statistically significant (P > 0.05). However, the use of omega-3 decreased the serum levels of TNF-α significantly. We conclude that the use of 3 g of omega-3 per day caused significant decrease in serum levels of TNF-α in the dialysis population, and its use is recommended in such patients.

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Congestive heart failure (CHF) is frequent in patients with chronic renal failure, and may contribute to high cardiovascular morbidity and mortality. There is little data in the literature about the safety and efficacy of use of spironolactone in patients with end-stage renal disease with heart failure. In this study, we evaluated the safety and efficacy of spironolactone in patients on continuous ambulatory peritoneal dialysis (CAPD) with CHF. This randomized pros­pective double-blind placebo-controlled clinical trial was performed at the St. Al-Zahra peritoneal dialysis center. Eighteen CAPD patients with New York Heart Association (NYHA) class III or IV heart failure, ejection fraction (EF) ≤45%, serum potassium level ≤5.5 mEq/L and who were eligible, were randomly assigned to taking either spironolactone (25 mg every other day) or placebo for six months. The serum potassium was measured monthly and echocardiography was repeated at the end of the study period. The serum potassium levels rose in both groups, and there was no statistically significant difference intragroup and between the groups during the study period. Only in one patient in the spironolactone group did the serum potassium level reach above the critical level (5.70 mEq/L) at the end of the second month of study, necessitating patient exclu­sion. The EF did not change significantly in the placebo group (33.3 ± 11.7 vs. 34.2 ± 11.6, F = 1, P = 0.363), but in the spironolactone group the EF rose significantly (25.7 ± 7.3 vs. 33.3 ± 7.8, F = 27.45, P = 0.002). Our study suggests that spironolactone could be used in CHF patients on CAPD to improve their cardiac function, but close monitoring of their serum potassium level is required.

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Carnitine deficiency is a commonly observed problem in maintenance hemodialysis (MHD) patients, which results in altered metabolism of fatty acids and subsequently development of dyslipidemia. To evaluate the effect of oral L-carnitine (LC) supplementation on lipid profile of adult MHD patients, we studied 30 of them (19 males, 11 females) who received LC supplementation of 250 mg tablets three times a day for eight weeks. They were compared with 30 matched patients as a control group. Serum lipid profiles were compared before and after the intervention between the two groups. There was a significant decrease of the values of the lipid profile in the intervention group before and after carnitine supplementation including the mean values of total cholesterol (190 ± 36.8 vs. 177 ± 31.2 mg/dL), triglyceride (210 ± 64.7 vs. 190 ± 54.1 mg/dL) and LDL-cholesterol (117 ± 30.1 vs. 106 ± 26.3 mg/dL), while the values did not change siginificantly from base line in the control group. However, the difference for HDL-cholesterol in intervention group was not statistically significant. None of the patients dropped out of the study due to drug side effects. Oral LC supplementation (750 mg/day) is able to improve lipid profile in patients on MHD. Further long-term studies with adequate sample size are needed to define the population of patients who would benefit more from carnitine therapy and the optimal dose and the most efficient route for administration of the drug.

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Hydronephrosis is probably the most common congenital abnormality detected prenatally by ultrasonography This study was performed to determine the cause and outcome of prenatal hydronephrosis in our hospital. A total of 45 infants, with 57 prenatally hydronephrotic renal units, were enrolled into this study. For the purpose of this study, the degree of hydronephrosis was defined as mild, moderate or severe. Postnatal ultrasonography was performed as soon as possible in those with bilateral hyronephrosis and 3-7 days after birth in those with unilateral hydronephrosis. Voiding cystourethrogram was performed in 6-8 weeks time. In the absence of vesicoureteral reflux (VUR), Diethylenetriamene penta acetate scan was performed to exclude obstructive uropathy. There were 29 males and 16 females (male:female ratio 1.8:1), and unilateral and bilateral hydronephrosis were seen in 33 (73%) and 12 (27%) of the cases, res­pectively. Hydronephrosis was caused by ureteropelvic junction obstruction (UPJO) in 20 (44.5%), VUR in 10 (22.2%), ureterovesical junction obstruction in four (8.9 %), posteriorurethral valves in four (8.9 %), UPJO with VUR in two (4.4%) and non-VUR non-obstructive in one (2.2%). During follow-up, 16 patients (35.5%) required operative intervention while seven (15.5%) improved spontaneously. Fetal hydronephrosis needs close follow-up during both ante­natal and postnatal periods. In this study, the most common cause for hydronephrosis were UPJO and VUR. Also seen in this study is the noteworthy point that mild fetal hydronephrosis is relatively benign and does not require surgical intervention in most cases and surgery should be performed only if there is renal function compromise. Prenatal consultation with a pediatric nephrologist and urologist is useful in decreasing parental anxiety and facilitating postnatal management.

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Posterior reversible encephalopathy syndrome (PRES) is characterized by acute onset of headache, nausea, focal neurological deficits or seizures along with radiological findings of white matter defects in the parietal and occipital lobes. Causes of PRES include uremia, hypertensive encephalopathy, eclampsia and immunosuppressive medications. Usually, the treat­ment of choice involves correcting the underlying abnormality. We describe an unusual case of recurrent PRES caused by uremia during a lupus flare in a patient with biopsy-proven Class IV Lupus Nephritis (LN) with vasculitis. PRES in systemic lupus erythematosis (SLE) is a rare clin­ical phenomenon and, when reported, it is associated with hypertensive encephalopathy. Our patient did not have hypertensive crisis, but had uremic encephalopathy. The patient's PRES-related symptoms resolved after initiation of hemodialysis. The temporal correlation of the correc­tion of the uremia and the resolution of the symptoms of PRES show the etiology to be uremic encephalopathy, making this the first reported case of uremia-induced PRES in Class IV LN with vasculitis.

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In some renal allograft recipients, anemia persists or develops following transplantation. Anemia is associated with pre-operative blood loss and allograft dysfunction, including delayed graft function, acute rejection and chronic allograft dysfunction. To study the prevalence and association of post-renal transplant anemia, we studied 200 renal transplant recipients; 131 (65.5%) patients were males and 69 (34.5%) patients were females, and age ranged from 17 to 67 years, with a mean of 37.7 ± 10.8 years. All patients were receiving cyclosporine, prednisolone and mycophenolate mofetil (MMF). Complete blood count was done at two times: three and six months post-renal transplant. There were 74% anemic patients three months after renal transplantation and 45% anemic patients six months after renal transplantation. High creatinine value, female gender, delayed graft function, episodes of acute rejection, perioperative blood loss and infections were the only significant independent risk factors for prevalence of anemia post-renal transplant. In our study, we did not find an association between MMF and cyclosporine nor angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptors blocker (ARBs) with anemia. This study demonstrates that anemia is a common complication during the first six months after kidney transplantation, with several risk factors precipitating this complication.

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This study was undertaken to determine the predisposing factors for renal scarring in children with urinary tract infection. In this prospective cohort study, 176 children with documented urinary tract infection were categorized into four groups: ≤1 year old, 1-2 years old, 2-7 years and 7-14 years old. Ultrasonography and Technetium-99 m-DMSA scan were used to detect the possible abnormalities. Infants under 12 months old presented as the most common group for renal scarring (27 cases, 52.9%), and vesicoureteral reflux (VUR) was diagnosed in 29 cases (56.8%). Fifteen (41.67%) children between the ages of one and two years had renal scar, and VUR was detected in half of the patients. In the third group, 36.3%, and in fourth group, 41.6% of the patients had renal scar. Also, 38.6% in group three and 50% in the final group had VUR. A co-incidental finding that was observed in this study was the high incidence of pseudohypoaldesteronism (PHA) in our patients: in 39.2% of the children in group one, 22.2% in group two and 4% in group three. In group four however, none of the patients had PHA. Risk of scar formation with urinary tract infection (UTI) was higher in the younger age group and in those with recurrent UTIs.

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We determined the performance of estimated glomerular filtration rate equations (eGFR) including MDRD2-Isotope Dilution Mass Spectrometry (MDRD2-IDMS), Cockcroft-Gault (CG) and Virga to measure post-transplant chronic kidney disease (CKD) stages 1-4, using simultaneous isotope GFR (iGFR) measurement. The study was conducted in 97 patients. The eGFR results measured by CG and Virga were normalized to 1.73 m ² . Analysis of relative and absolute bias, error, scatter, correlation coefficient of variance and accuracy within the 30% range from the reference iGFR result was performed using standard techniques. There were 135, 242, 314 and 82 scans, respectively, in CKD stages 1-4. Bias and accuracy of GFR estimators varied significantly across the CKD stages. In stages 1 and 2, CG had the best error of -12.7 and 0.2 mL/min/1.73 m ² , respectively, while Virga had the highest accuracy of 74.3% and 85.5, respectively. In stages 3 and 4, MDRD2-IDMS had the best error of -0.52 and 5.8, respectively. Accuracy was the best at 75.1% for Virga in stage 3, while it was the highest of 70.7% for MDRD2-IDMS in stage 4. Virga had the highest accuracy of 75.2% in stage 4. The worst bias was for MDRD2-IDMS in stage 2 (-36.8 mL/min/1.73 m ² ) and the best bias was for CG in stage 2 (-0.33 mL/min/1.73 m ² ). The eGFR estimators have inconsistent performances in the various stages of CKD and, thus, another limitation is added to their validity to substitute for the gold standard methods.

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There is very little information in the literature on the treatment and prognosis of primary focal segmental glomerulosclerosis (FSGS) among children in Pakistan. This is a review of 94 children (≤16 years) with a diagnosis of primary FSGS who presented to the Sindh Institute of Urology and Transplantation between 1995 and 2008. The clinical records and original renal biopsy reports were reviewed to determine demographic, clinical, laboratory and pathologic features. Renal biopsies were studied by light microscopy, immunofluoroscence and electron microscopy. Thera­peutic regimens and response to therapy were analyzed. Majority of the children (60, 63.8%) had steroid-dependant nephrotic syndrome (SDNS) and 33 (35%) had steroid-resistant nephrotic syndrome (SRNS). Cyclosphosphamide was used in SDNS, and this produced complete remission (CR) in 25/36 (69.4%), partial response (PR) in 4/36 (11%) and no response in 7/36 (19.4%) cases. Cyclosporine was used in SRNS and some SDNS children, and showed a CR in 30 (52.6%), PR in 20 (35%) and no response in seven (12.2%) cases. Tacrolimus was used in seven (7.44%) children. CR was obtained in two (28.5%) and PR in five (71.4%) cases. Renal insufficiency developed in 12 (12.7%) children. Results from this study show that majority of the children with primary FSGS at our center could achieve high rates of sustained remission with second- and third-line immunosuppressive therapies with fairly good prognosis.

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Malnutrition (MN) in hemodialysis patients (HDP) is prevalent worldwide. How­ever, data regarding the nutritional status among HDP living in Jeddah, Saudi Arabia, is lacking. The purpose of this study was to detect MN in HDP at the Jeddah Kidney Center, with an inexpensive nutritional assessment protocol consisting of anthropometric body mass index (BMI), triceps skin fold (TSF), mid-arm muscle circumference (MAMC) and biochemical (albumin) blood measurements and the seven-point subjective global assessment (SGA). A cross-sectional study assessed 269 HDP for MN through a questionnaire, SGA and anthropometric and biochemical measurements. Spearman's rank correlation coefficients were determined between SGA and anthropometric and biochemical measurements as well as the relative odds of MN. Statistical significance was P <0.05. These HDP were 48.7% moderately and 6.3% severely malnourished. Albumin, BMI, TSF and MAMC correlated positively with the seven-point SGA (r _s = 0.16, P = 0.007; r _s = 0.33, P <0.001; r _s = 0.29, P <0.001; and r _s = 0.34, P <0.001, respectively). Those HDP who were female (Odds ratio [OR] = 2.04, P = 0.036), older (≥55 years) (OR = 1.70, P = 0.087), uneducated (OR = 1.80, P = 0.072), with a lower BMI (<18 kg/m ²) (OR = 2.00, P = 0.077) and thinner TSF (OR = 1.45, P = 0.041) had a greater risk of MN. The high prevalence of MN was detected with an inexpensive protocol. Women with thinner TSF were more likely to be malnou­rished. The implementation of this protocol is warranted along with dietary education and counseling to decrease MN in HDP.

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Patients with chronic kidney diseases (CKDs) and cardiovascular diseases (CVDs) present with various degree of anemia. Anemia has been associated with poor outcome in patients with CKD and CVD. CVD is the commonest cause of morbidity and mortality in patients with CKD. CKD causes anemia and CVD, and this rapidly deteriorates when anemia is not corrected. This triad of CVD, CKD, and anemia has been termed cardio-renal-anemia syndrome. The objec­tive of this study is to highlight the importance of cardio-renal-anemia syndrome, their relation­ship, and management. Three patients with various stages of CKD who presented with anemia and cardiovascular abnormalities are reported. The patients responded well to various interventional measures, with improvement in their clinical and laboratory parameters. Cardio-renal-anemia syndrome is an entity that should be identified. Early and appropriate intervention leads to better outcome.

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An understanding of the epidemiology of community-acquired acute kidney injury (CAAKI) is necessary to establish its overall burden and plan potential preventive strategies. This study was done in an urban tertiary care center in northern India with the aim to identify the etiology and outcomes as well as the factors associated with in-hospital mortality of CAAKI patients. A five year retrospective analysis of all patients with CAAKI admitted to the Nephrology Department from January 2005 to December 2009 was done. From 5499 consecutive patients, 240 patients (2.5%), with a mean age of 39.8 ± 14.48 years, were diagnosed to have CAAKI as per our specified criteria. The most common cause of CAAKI was medical (77.5%), followed by obstetrical (14.2%) and surgical (8.3%) causes. Among the medical causes, acute diarrheal disease was the most common cause (29%), followed by malaria (18.8%) and sepsis (13.9%). Sepsis had the highest in-hospital mortality (46%). Nephrolithiasis was the most common surgical cause. Puerperal sepsis (44.1%), pre-eclampsia (23.5%), intrauterine death (11.8%), antenatal hemorrhage (11.8%) and post-partal hemorrhage (8.8%) were the obstetric causes of CAAKI. Among 45 patients who underwent a renal biopsy, acute tubulointerstitial nephritis (33.3%) was the most common, followed by acute tubular necrosis (22.2%), glomerulonephritis (17.7%), thrombotic microangiopathy (17.7%) and acute cortical necrosis (8.89%). Of the 83% patients who underwent dialytic therapy, 44.5% underwent hemodialysis, 22.5% continuous veno-venous hemodiafiltration, 21.6% sustained low efficiency dialysis and 11.4% peritoneal dialysis. The overall in-hospital mortality among patients with CAAKI was 26.20%. CAAKI remains a common problem affecting nearly 2.5% of patients attending nephrology units.

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To determine the patterns of the prevalent glomerulonephritis (GN) in our region, we studied the results of 511 consecutive renal biopsies performed on patients with proteinuria, hematuria and mild to moderate renal impairment at the Aga Khan University Hospital during a period of 18 years from January 1990 to December 2008. Primary glomerular disease accounted for two-thirds of the glomerular diseases, which in turn constituted 49% of all renal biopsies. The most common histological lesion was membranoproliferative disease (28%). Membranous GN was the second most common lesion (19%), followed by minimal change disease (16%) and focal segmental GN (11%). Secondary glomerular disease comprised 30% of glomerular diseases (21% of all the renal biopsies), with lupus nephritis forming the most common lesion (34%) followed by amyloidosis (22%), diabetic nephropathy (10%), Wagener's granulomatosus and post-infectious GN (9% each). Tubulointerstitial diseases accounted for 16% of all the renal biopsies. We conclude that there exists a wide variability in the different categories of primary and secondary glomerular diseases in our region as compared with different parts of the world. Future studies should be directed to analyze the causes for these variations.

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Chronic inflammation is highly prevalent in patients on hemodialysis (HD), as evidenced by increased levels of C-reactive protein (CRP). We compared CRP to high-sensitivity C-reactive protein (hs-CRP) to determine whether it has any clinical implications and prognostic significance in terms of mortality. CRP was measured using a standard immunoturbidometric assay on the COBAS^; INTEGRA system and hs-CRP was measured using the Dade Behring on the Konelab Nephelometer in 50 patients on HD. CRP (≥6 mg/L) and hs-CRP (≥3 mg/L) levels were elevated in 30% and 54% of the patients, respectively. A significant correlation was noted between hs-CRP and CRP levels (r = 0.98, P <0.001). Deming regression analysis showed that the slope was near one (r = 0.90; 0.83-0.94) and that the intercept was small. Multivariate regression confirmed that age above 40 years (RR = 3.69, P = 0.027) and duration on HD greater than five years (RR = 3.71, P = 0.028) remained significant independent predictors of serum hs-CRP. Thirteen patients died during follow-up (26%). Multivariate Cox regression demonstrated that hs-CRP (RR = 1.062, P = 0.03) and CRP levels (RR = 1.057, P = 0.009) and age (RR = 1.078, P = 0.001) were the most powerful predictors of mortality. The CRP standard assay presents a reasonable alternative to the hs-CRP assay in patients on HD. The advantages of the CRP standard assay are its online and real-time availability as well as lower costs, particularly in developing countries.

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Despite all developments in hemodialysis (HD), the mortality rate is still apparently higher than that in the general population, and worse health-related quality of life (HRQOL) is associated with increased mortality. We prospectively investigated the mortality status of HD patients during a five-year period and the association between mortality, HRQOL, laboratory parameters and clinical and sociodemographic characteristics at baseline. At the end of the five years, 293 patients out of 420 patients were still on HD treatment and 127 patients died. Those who died had a higher mean age, lower mean values of serum creatinine and albumin, higher prevalence of diabetes mellitus, received more HD twice weekly for less than 4 h in almost all HD sessions and had lower HRQOL than the survivors. We conclude that age, comorbidity, HD sessions lasting less than 4 h, malnutrition [hypoalbuminemia, low body mass index (BMI)] and lower physical component scores of SF-36 survey (PCS) were associated with higher risk of death in the HD population.

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The typing for HLA-C in transplantation was rather neglected in the past. However, several recent studies have emphasized its role in transplantation and its association with the outcome. Serological typing of HLA-C could identify only a limited number of HLA-C antigens, resulting in a number of HLA-C blanks. This was mainly due to the low expression of surface HLA-C and the small number of available specific anti-sera. Performing molecular methods has identified new HLA-C alleles and filled the blank of most serological typed antigens. In this study, we compared serological and molecular typing of HLA-C in two cohorts of healthy Saudis. Our serological typing method identified HLA-C1-7 with different frequencies, 23.5% of the alleles were not identified and thus defined as blank. Using the SSP molecular method, all samples were typed and all alleles were defined. Both methods showed that C*07 and C*06 have the highest frequency in the Saudi population. Our study emphasizes the importance of molecular methods in identifying all possible HLA-C alleles.

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Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication seen in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysisAPD after prolonged duration on dialysis. Patients usally present with vague complaints of abdominal pain, vomitting, diarrhea, weight loss and change in peritoneal transport characte­ristics. High degree of suspicion is needed in PD patients who have been on dialysis for prolonged duration and have been using high-concentrated dialysis fluid. Mycobacterium fortuitum (MF) is a rapidly growing, non-tuberculous mycobacterium that has rarely been reported as a pathogen causing peritonits in patients on PD. We report a case of CAPD presenting with culture-negative peritonits, which, on specific culture, grew MF and, on radiological evaluation, showed diagnostic features of EPS.

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Hepatitis B virus (HBV) infection is an important issue in hemodialysis. Risk factors and local prevalence varies between different regions. The current study was undertaken to determine the prevalence of HBV infection and its associated risk factors among hemodialysis patients from five hemodialysis centers in Tabriz, a Northwestern Iranian city. Hepatitis B serologic markers were evaluated in chronic hemodialysis patients. Patients (n = 412) were divided into two groups: Group 1 - patients with positive hepatitis B surface antigen (HBsAg) and Group 2 - patients with negative HBsAg. The median age was 54.9 years (range, 13-90 years). Thirteen patients (3.2%) were found to be positive for HBsAg. Among the studied factors, the history of war injury was significantly associated with the risk of HBV infection (P = 0.023). In conclusion, our study shows that the risk of HBV infection among Tabrizian hemodialysis patients is a factor of dialysis-independent parameters.

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Children with fever are a majority in the various emergency rooms all over the world, and especially in the tropics. Most in sub-Saharan Africa will be treated for malaria, whether confirmed or not. It therefore follows that some of the morbidities other than malaria may go undiagnosed. The comorbidities with malaria that may have similar presentation among under-fives therefore are difficult to detect, and diseases like respiratory tract infections and urinary tract infections (UTI) are left to debilitate affected children. The exact burden of UTI co-existing with malaria in Nigeria remains ill defined. This study looks at the co-existence of UTI in under- fives with a primary diagnosis of malaria. Well-nourished children aged less than five years with confirmed malaria seen at the Children Emergency Room of the University of Benin Teaching Hospital were recruited into a prospective cross-sectional study between June and August 2006. The prevalence of UTI was 9% (27 of 300 children), with those aged less than 24 months comprising the majority. The uropathogens isolated included Staphylococcus aureus (55.6%), Escherichia coli (29.6%) and Kleibsiella pneumonia (14.8%). The isolates demonstrated high in vitro sensitivity to clavulanic acid-potentiated amoxicillin, ciprofloxacin and gentamicin, but were resistant to other commonly used antibiotics like amoxicillin and co-trimoxazole. The study indicates that UTI is a silent comorbidity in children aged less than 5 years with malaria and there is a need to evaluate these children in order to prevent the long-term morbidity of chronic renal diseases.

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C1q nephropathy with hemolytic uremic syndrome (HUS) is an uncommon combi­nation associated with rapidly progressive renal failure. We report a case of C1q nephropathy with HUS in an 18-year-old man associated with rapidly progressive renal failure. The patient did not respond to treatment with steroids and was started on maintenance hemodialysis. C1q nephropathy with HUS is rare and can lead to rapidly progressive renal failure.

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Cystic dysplasia of the testis is a rare congenital anomaly. It presents a diagnostic challenge to the pediatrician and should be distinguished from malignant lesions. We herewith present a two-month-old boy who presented with right inguinal swelling. Detailed investigations including ultrasound and magnetic resonance imaging helped in establishing the diagnosis of cystic dysplasia. To the best of our knowledge, our case is the first case of cystic dysplasia of the rete testis in the literature, which presented as undescended testis (inguinal swelling), with no associated renal or ureteric anomalies.

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We studied the correlation between changes in the serum levels of vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) with complications such as acute graft versus host disease (aGVHD), veno-occlusive disease (VOD) or occurrence of infection after hematopoietic stem cell transplantation (HSCT). Serum VEGF and IL-6 levels were sequentially measured by enzyme-linked immunosorbant assay (ELISA) in 35 patients who had undergone HSCT. Serum levels of IL-6 in patients with aGVHD were increased in comparison with patients without aGVHD, but the difference was not statistically significant. Serum levels of VEGF were only increased in patients with aGVHD during the early days after transplantation. No signi­ficantly altered levels of IL-6 and VEGF were observed in patients with VOD or sepsis. These results demonstrate that rising levels of VEGF and IL-6 may be good and specific biomarkers for transplant aGVHD.

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Digestive tract complications are common in hemodialysis (HD) patients, and Helicobacter pylori (H. pylori) is thought to play an important role in the pathogenesis of gastrointestinal mucosal lesions in these patients. Also, reports indicate that cytotoxin-associated gene A (CagA) is the major factor involved in the pathogenesis of H. pylori disease. However, many issues regarding H. pylori infection in HD patients are still unclear. In this cross-sectional study, we investigated the effect of duration on HD on the prevalence of H. pylori infection and its virulent CagA(+) strain. One-hundred and fifty-one HD patients who were referred to our university HD center were included in the study. There were 78 males and 73 females, with a mean age of 54.2 ± 14.6 years (range: 19-87 years). They were tested for serum anti-H. pylori IgG antibody by the enzyme-linked immunosorbent assay method. Also, anti-CagA IgG antibody was tested in H. pylori-infected patients. The study patients were categorized into two groups: short-term HD duration (STHD: ≤3 years) and long-term HD duration (LTHD: >3 years). The overall prevalence of antibodies to H. pylori and CagA were 65.6% (99/151) and 25.3% (25/99), respectively. The prevalence of H. pylori infection among the STHD and LTHD patients were 49/89 (55.10%) and 49/62 (79.0%), respectively; P <0.05. The prevalence of anti-CagA antibody in infected STHD and LTHD patients was 24.5% (12/49) and 26.5% (13/49), respectively; P >0.05. Our study suggests that the prevalence of H. pylori infection is higher in patients on LTHD. More investigations are needed regarding the clinical consequences of H. pylori infection in HD patients.

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The dysfunction of the catheter in peritoneal dialysis (PD) is a frequent compli­cation. However, perforation of organs are rare, particularly that of the urinary bladder. This re­quires an early diagnosis and prompt treatment of patients. We report here the case of a 38-year-old woman having end-stage renal disease due to autosomal-dominant polycystic kidney disease treated by PD since November 2000. Three years later, she was treated for Staphylococcal peritonitis. Four months later, she presented with a severe urge to urinate at the time of the fluid exchanges. The biochemical analysis of the fluid from the bladder showed that it was dialysis fluid. Injection of contrast through the catheter demonstrated the presence of a fistula between the bladder and the peritoneal cavity. She underwent cystoscopic closure of the fistulous tract and the PD catheter was removed. Subsequently, the patient was treated by hemodialysis. One month later, a second catheter was implanted surgically after confirming the closure of the fistula. Ten days later, she presented with pain at the catheter site and along the tunnel, which was found to be swollen along its track. The injection of contrast produced swelling of the subcutaneous tunnel but without extravasation of the dye. PD was withdrawn and the patient was put back on hemodialysis. Bladder fistula is a rare complication in PD and diagnosis should be suspected when patient complains of an urge to pass urine during the exchanges, which can be confirmed by contrast study showing presence of dye in the bladder. PD may be possible after the closure of the fistula, but recurrence may occur.

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The Imersland-Gräsbeck Syndrome (IGS) is a rare inherited disorder characterized by megaloblastic anemia due to a selective Vitamin B ₁₂ malabsorption in association with mild proteinuria. This syndrome can be diagnosed and treated easily. Herein, we describe an infant with IGS as a rare etiology of growth retardation with diarrhea, vomiting and therapy-resistant proteinuria.

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This study was undertaken to assess the accuracy of computerized tomographic angiography (CTA) for the evaluation of renal vascular anatomy for pre-operative donor assessment in living kidney transplantation and to compare it with conventional angiography. CTA of 70 living donor kidney donors were analyzed by two blinded observers and compared with the intraoperative findings. Similarly, findings of formal angiography of 30 living donor kidney donors were compared with the intraoperative observations. In the CTA group, there were two patients each with two main renal veins discovered during surgery that had not been recorded on CTA. In the second group, there was one patient with unrevealed two main renal veins before surgery. In both groups, accessory renal arteries were diagnosed. Overall, the accuracy for renal main artery anatomy was 100% for both CTA and conventional angiography. Accuracy for renal main vein anatomy was 97.1% and 96.6% for CTA and conventional angiography, respectively. Hence, these two modalities had comparable results for assessment of main renal vasculature anatomy.

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Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to athero­sclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.

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We aimed from our study to assess how students and clinical supervisors perceive students' achievement in the internal medicine subspecialty clinical attachments in comparison with the general attachments. We conducted a cross-sectional study comparing students' self-assessment ratings during the Medicine Block general and subspecialties clinical attachments at our college of medicine during the period between February 2007 and June 2009. We assessed the level of agreement between students' self-assessment in the different subspecialties with their self-assessment in the general attachments. We repeated the same calculation for the supervisors' assessment. Eighty-three students were included; these students attended eight different clinical attachments. A total of 517 self-assessment forms were completed (120 general internal medicine clinical attachments and 397 forms in different specialty attachments). The clinical supervisors completed parallel assessment forms. The undergraduate medical students' perceived their achievement in the subspecialty attachments well. This was similar to their perception of their achievement in the general clinical attachments. The clinical supervisors perceived students achievement in the subspecialties to be similar to their achievement in the general clinical attachments. In conclusion, we do encourage the implementation of specialty and subspecialty undergraduate clinical attachments for all students as part of their curriculum requirements. Furthermore, we encourage the strategic utilization of specialties/subspecialties attachment distribution aiming to enhance students' future interest to achieve balance in the different health specialties/subspecialties manpower. Further research to support this recommendation is needed.

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