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Saudi Journal of Kidney Diseases and Transplantation
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   2009| July-August  | Volume 20 | Issue 4  
    Online since July 8, 2009

 
 
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ORIGINAL ARTICLES
Vascular complications following 1500 consecutive living and cadaveric donor renal transplantations: A single center study
Mehdi Salehipour, Heshmatollah Salahi, Hamed Jalaeian, Ali Bahador, Saman Nikeghbalian, Ehsan Barzideh, Ali Ariafar, Seyed Ali Malek-Hosseini
July-August 2009, 20(4):570-572
PMID:19587495
The aim of this study was to document vascular complications that occurred fol­lowing cadaveric and living donor kidney transplants in order to assess the overall incidence of these complications at our center as well as to identify possible risk factors. In a retrospective cohort study, 1500 consecutive renal transplant recipients who received a living or cadaveric donor kidney between December 1988 and July 2006 were evaluated. The study was performed at the Nemazee Hospital, Shiraz, Iran. The assessment of the anatomy and number of renal arteries as well as the incidence of vascular complications was made by color doppler ultrasonography, angiography, and/or surgical exploration. Clinically apparent vascular complications were seen in 8.86% of all study patients (n = 133) with the most frequent being hemorrhage (n = 91; 6.1%) followed by allo­graft renal artery stenosis (n = 26; 1.7%), renal artery thrombosis (n = 9; 0.6%), and renal vein thrombosis (n = 7; 0.5%). Vascular complications were more frequent in recipients of cadaveric organs than recipients of allografts from living donors (12.5% vs. 7.97%; P= 0.017). The occurrence of vascular complications was significantly more frequent among recipients of renal allografts with multiple arteries when compared with recipients of kidneys with single artery (12.3% vs. 8.2%; P= 0.033). The same was true to venous complications as well (25.4% vs. 8.2%; P< 0.001). Our study shows that vascular complications were more frequent in allografts with multiple renal blood vessels. Also, the complications were much less frequent in recipients of living donor transplants.
  13 3,506 1,125
RENAL DATA FROM THE ASIA - AFRICA
Prevalence of hepatitis C and B infection and HC V genotypes among hemodialysis patients in Khuzestan province, Southwest Iran
Mohammad Ali Assarehzadegan, Ghodratollah Shakerinejad, Reza Noroozkohnejad, Akram Amini, SA Rahim Rezaee
July-August 2009, 20(4):681-684
PMID:19587521
Hepatitis B (HBV) and C (HCV) virus infection are the most important infections transmitted by the parenteral route in hemodialysis patients. This study is the first report of prevalence of viral hepatitis and hepatitis C virus genotypes in southwest Iran among hemodialysis patients. A cross-sectional study was carried out among 214 hemodialysis patients of the Central hemodialysis unit, from March 2005 to August 2006. Serum samples were tested for HBsAg and anti-HCV using specific enzyme linked immunoassay (ELISA) kits and confirmed by PCR (HBV) and RT PCR (HCV). HCV genotypes were determined with HCV genotype specific primers using HCV genotype kit. Out of 214 hemodialysis patients, 34 were positive for anti-HCV (7.9%, 95% CI: 4.32-11.56) and 11 for HBsAg (5.1%, 95% CI: 2.18-8.1). The duration of treatment by hemo­dialysis was significantly associated with HBV and HCV positivity (P< 0.001). The predominant HCV genotype in the region was 1a (41.1%, 7/17), whilst genotypes 3a and 1b were found in 35.2% (6/17) and 23.5% (4/17) subjects, respectively. In conclusion although anti-HCV and HBsAg positivity in hemodialysis patients in Khuzestan province are smaller than those found in some other Iranian provinces and neighboring countries, they are still high. Enforcement of universal precautions in infection control, routine testing of patients, and serial determination of hepatic enzymes should be the common practice in dialysis centers in Iran.
  11 3,363 725
The prevalence, risk factors and awareness of hypertension in an urban population of Kerala (South India)
Avadaiammal Vimala, Suja Ann Ranji, Mattummal Thodi Jyosna, Vincy Chandran, Swetha Reba Mathews, Joseph M Pappachan
July-August 2009, 20(4):685-689
PMID:19587522
To determine the prevalence and possible risk factors for hypertension and prehy­pertensive state in Trivandrum City of Kerala (South India) using Joint National Committee (JNC) VII criteria, a team of trained fourth year medical students conducted a 10% random household survey in certain wards of the City. Households were selected using a random start and interval and all the members above the age of 10 years were interviewed using a standard questionnaire. The blood pressure (BP) was measured twice in each participant and the mean value of the two mea­surements was taken. A total of 482 individuals (212 males and 270 females) were interviewed in the survey. Overall prevalence of hypertension was 47% (n = 226) with equal sex ratio; 109 (21.6%) had stage-I hypertension, 45 (9.34%) had stage-II hypertension and 72 were taking drug treatment. Only 55 (11.4%) individuals had normal BP, while 201 (41.7%) were prehypertensives. Only 81 (16.8%) hypertensive patients were aware of their disease. Among the parameters such as dietary habits, physical activity, educational standards, salt intake, and diabetes mellitus, only high salt diet (P= 0.03) and diabetes mellitus (P= 0.004) had a significant association with hypertensive state. In con­clusion, the prevalence of hypertension is high but the awareness is low in our community, and intervention is necessary to impose control measures and to improve awareness.
  6 7,752 1,338
ORIGINAL ARTICLES
Early markers of renal injury in predicting outcome in thermal burn patients
Alaa Sabry, Ihab Wafa, Ahmed Bahaa El-din, Al Moddather El-Hadidy, Mohammed Hassan
July-August 2009, 20(4):632-638
PMID:19587506
Acute renal failure (ARF) is a well known complication of severe burn and is an important factor that can increase mortality. To determine the predictors of acute renal failure that occur in major burns, we studied 40 patients with moderate to severe thermal burn injury - second to third degree with > 20% of total body surface area. All patients were subjected to routine in­vestigations including: Serum creatinine, blood urea nitrogen, fractional excretion of sodium, uri­nary malondialdehyde and microalbuminuria on day 0, 3, 7, 14 and 21 of hospitalization. Nine patients (22.5 %) developed acute renal failure; 4 patients required supportive dialysis. The group that de­veloped ARF showed an increase of markers of glomerular damage with appearance of micro­albuminuria on day 0 that reached 3 - 4 folds above its normal level on day 14 and remained constant with elevated serum creatinine and burn size in the 3 rd week of ARF, and progressed to overt proteinuria in 3 cases. Urinary malondialdehyde increased 3 folds above normal values before de­veloping acute renal failure, and gradually increased on day 14, which coincided with the increased of microalbuminuria. Two cases (22.2%) in the ARF group who developed septicemia and required dialysis died on the 32 nd and 36 th days post-burn. Burn size and occurrence of septicemia were the only predictors of acute renal failure using multiple regression analysis (P value < 0.001 and < 0.0371, respectively). We conclude that acute renal failure complicates burn patients and is related to the size and depth of burn and occurrence of septicemia. Microalbuminuria and urinary malon­dialdehyde are useful markers for prediction of renal outcome in such group of patients.
  5 6,079 989
The prevalence of virulence genes of E. coli strains isolated from children with urinary tract infection
Shohreh Farshad, Fatemeh Emamghorashi
July-August 2009, 20(4):613-617
PMID:19587502
To evaluate the prevalence of virulence genes in E. coli strains isolated from urine samples of children with urinary tract infection(UTI) and their correlation with clinical data, we iso­lated E. coli strains from urine samples of children with UTI during the period of August 2005 - August 2006 and studied them for the presence of the virulence genes by PCR. A total of 96 E. coli strains were isolated. The prevalence of genes, pyelonephritis associated pili (pap genes), S-family adhesions (sfa gene), hemolysin (hly gene), and cytotoxic nercotizing factor type 1 (cnf-1-1 gene) among the isolated strains was 27.1%, 14.6%, 13.5% and 22.9 %, respectively. Pyelonephritis was more prevalent in the cases with positive virulence genes. The results showed significant correlation bet­ween age of the patient and the presence of the genes (P< 0.05). Cnf-1 gene was significantly more common in samples of patients with abnormal finding on the ultrasound of kidneys (P= 0.049). Our study demonstrated higher prevalence of pyelonephritis in the presence of E. coli virulence genes. Detection of the genes in urine samples may help in the management of UTI.
  3 4,974 1,168
REVIEW ARTICLES
Sodium balance-an integrated physiological model and novel approach
Santosh Patel
July-August 2009, 20(4):560-569
PMID:19587494
Various physiological mechanisms regulate sodium and water balance in the human body. These processes achieve acute and chronic sodium regulation and the simultaneous or se­quential changes can be explained using a single physiological model. Steady intracellular water and osmolality is necessary for cell membrane integrity and cellular processes. Body fluids protect circulatory blood volume by altering Na + and water balance. This is the most vital homeostatic function of the body. Changes in ECF volume are sensed by various cardinal sensors. Physio­logically, the main aim of Na + and water balance is to permit variable salt and water intake without large fluctuations in blood pressure or volume status. Homeostatic processes act in an integrated fashion to protect against any perturbations. Characteristically, these mechanisms are sequential as well as parallel. These may be synergistic or antagonistic to each other. Rapidity, sensitivity and potency of these powerful feedback systems differ. Various physiological and pathological insults determine the magnitude of response of these systems.
  3 8,895 2,214
SPECIAL ARTICLE
Pronase-free B-cell flow-cytometry crossmatch
AH Hajeer, S Saleh, P Sutton, A Shubaili, H Anazi
July-August 2009, 20(4):662-665
PMID:19587513
Detection of anti-class II antibodies by panel response assay (PRA) and flow cross­match techniques carries an important value in terms of graft function. Even low levels of pre­formed alloantibodies to HLA class II antigens represent a risk of rejection. We present here a method for blocking non-specific flow crossmatch reactions using pooled, heat-inactivated rabbit serum. This method shows very low background and minimal non-specific reactions. In addition, it avoids the use pronase enzyme that can non-specifically digest different cell surface proteins.
  3 4,225 852
CASE REPORTS
Short course of cyclophosphamide therapy may reduce recurrence in patients with tubulointerstitial nephritis and uveitis syndrome
Shahram Taheri, Diana Taheri
July-August 2009, 20(4):655-657
PMID:19587511
We report a 43-year-old woman with tubulointerstitial nephritis and uveitis syn­drome (TINU syndrome) presented with a 5-day complaint of chills and fever, anorexia, nausea, and vomiting. She had elevated BUN and creatinine and urinalysis revealed decreased concen­tration, proteinuria, hematuria, and pyuria. A kidney biopsy showed non-caseating granulomatous tubulointerstitial nephritis. She suffered from anterior uveitis one month before, which was managed with local ophthalmic steroids. She received two months of oral high dose prednisolone, which was tapered over the next two months, and two months of 2 mg/kg cyclophosphamide. Her renal function recovered during the first two months. Her kidney and ocular symptoms did not recur during one year of follow-up. We suggest short course of cyclophosphamide and prednisolone for treatment of TINU syndrome to decrease the recurrence of kidney and ocular involvement.
  2 2,500 513
Is pulmonary histoplasmosis a risk factor for acute renal failure in renal transplant recipients?
Vahid Pourfarziani, Saeed Taheri
July-August 2009, 20(4):643-645
PMID:19587508
Prolonged use of immunosuppressive medication is associated with an increased sus­ceptibility to viral, bacterial and fungal infections. This paper reports a 42 year old kidney transplant recipient with 10 years of stable allograft function who developed pulmonary histoplasmosis and consequently lost his kidney. This report corroborates the previously proposed threat of infection with H. capsulatum for kidney allograft rejection.
  2 2,316 387
Post transplant anaplastic large T-cell lymphoma
Afshin Azhir, Nahid Reisi, Diana Taheri, Atoosa Adibi
July-August 2009, 20(4):646-651
PMID:19587509
Post transplant lymphoproliferative disorders (PTLD) are a heterogeneous group of lymphoid proliferation that ranges from polyclonal hyperplasia to monoclonal malignant lym­phoma. We report a 13-year-old boy who was diagnosed with PTLD in February 2007 after 3 1/2 years of deceased renal transplantation. We treated him with an adapted ACVBP (doxorubicin, cyclo­phosphamide, vincristine, bleomycin and prednisone) regimen. He responded well to the chemo­therapy without deterioration of graft function.
  2 2,455 469
ORIGINAL ARTICLES
Renal involvement in behcet's disease
Mohammad Reza Ardalan, Shahram Sadreddini, Hamid Noshad, Aliasghar Ebrahimi, Mahsheed Molaeefard, Mohammad Hossein Somi, Mohammadali Mohajel Shoja
July-August 2009, 20(4):618-622
PMID:19587503
There are conflicting reports about the renal involvement in Behcet's disease (BD). In this study we aimed to study the frequency and type of renal involvement in a group of patients with BD in Azerbaijan province that is one of the prevalent areas of BD in Iran. All cases of BD were prospectively followed between June 2004 and January 2007, and evaluated for renal dys­function (serum creatinine > 1.7 mg/dL), glomerular hematuria and proteinuria. Those patients with proteinuria > 500 mg/day and serum creatinine level > 2 mg/dL, underwent renal biopsy. From a total number of 100 patients, six patients (6%) had obvious renal involvements. Four patients had glome­rular hematuria and proteinuria. Renal biopsy in two of them revealed measangial proliferative glumerulonephritis with IgA deposit in one of them and membranoproliferative glumerolonephritis in another one. Two remaining patients had serum creatinine > 2 mg/dL without any hematuria or proteinuria. Serologic study for viral agents and collagen vascular disease were negative in all patients with renal involvements. In conclusion, renal involvement in BD is not infrequent, although in most cases it is mild in nature and may be missed.
  2 5,218 962
Childhood primary glomerular diseases in the western region of Saudi Arabia
Sawsan M Jalalah, Awatif A Jamal
July-August 2009, 20(4):608-612
PMID:19587501
We report our institute experience on primary glomerular disease in children in the western region of Saudi Arabia over the last 18 years (1988 to 2006). A total of 169 cases were identified as primary glomerular diseases in children and adolescent with age range from first year of life till 18 years. Minimal change disease and focal segmental glomerulosclerosis were the com­monly encountered primary glomerular diseases (20.1%and 19.5% respectively), mesangioprolifera­tive glomerulonephritis IgM nephropathy (14.8%), IgA nephropathy (10.7%), postinfectious glome­rulonephritis (9.5%), membranous glomerulonephritis (7.1%), membranoproliferative glomerulone­phritis (5.9%) and mesangioproliferative glomerulonephritis with negative immunofluorescence (5.9%). The less frequently encountered primary glomerular diseases were congenital nephritic syn­drome Finnish type (2.4%), Alport syndrome (2.4%), dense deposit disease (1.2%), and mesangio­proliferative glomerulonephritis with IgG positive (0.6%). We concluded that minimal change di­sease and focal segmental glomerulosclerosis are the most common primary glomerular disorder en­countered in children in our series and with similar age distribution.
  2 1,877 450
Effect of dialysate temperature on hemodynamic stability among hemodialysis patients
Ahmad Taher Azar
July-August 2009, 20(4):596-603
PMID:19587499
Cooling the dialysate below 36.5°C is an important factor that contributes to hemody­namic stability in patients during hemodialysis (HD). In this study, the effect of dialysate tempe­rature on hemodynamic stability, patients' perception of dialysis discomfort and post dialysis fatigue were assessed in a group of patients on HD. A total of 50 patients, all of whom were on 3-times-per­week dialysis regimen, were studied. Patients were assessed during six dialysis sessions; in three sessions, the dialysate temperature was normal (37°C) and in three other sessions, the dialysate tem­perature was low (35°C). Specific scale questionnaires were used in each dialysis session, to evaluate the symptoms during the dialysis procedure as well as post-dialysis fatigue, and respective scores were noted. The results showed that usage of low dialysate temperature was associated with the fol­lowing: higher post dialysis systolic blood pressure (P< 0.05) and lower post dialysis heart rate (P< 0.01), with similar ultrafiltration rates, better intra-dialysis symptoms score and post-dialysis fatigue scores (P< 0.001, and P < 0.001, respectively), shorter post-dialysis fatigue period (P< 0.001) as well as higher urea removal (P< 00001) and Kt/V (P< 0.0001). Patients' perceptions were measured by a questionnaire, which showed that 76% of them felt more energetic after dialysis with cool dialysate and requested to be always dialyzed with cool dialysate. Low temperature dialysate is particularly beneficial for highly symptomatic patients, improves tolerance to dialysis in hypotensive patients and helps increase ultrafiltration while maintaining hemodynamic stability during and after dialysis.
  2 7,263 1,032
BRIEF COMMUNICATION
The effect of increasing blood flow rate on dialysis adequacy in hemodialysis patients
SR Borzou, M Gholyaf, M Zandiha, R Amini, MT Goodarzi, B Torkaman
July-August 2009, 20(4):639-642
PMID:19587507
Inadequacy of dialysis is one of the determinants of morbidity and mortality in pa­tients undergoing dialysis. The aim of this study was to assess the effect of increasing blood flow rate during hemodialysis (HD) on the adequacy of dialysis. In this study, 42 patients on mainte­nance HD were assessed. Body weight and blood urea nitrogen (BUN) levels before and after HD sessions were recorded on all the study patients. Volume of ultrafiltration, the duration of dialysis, percentage of filter clearance and flow rate of the dialysate were collected and documented in a checklist. Both Kt/V and urea reduction ratio (URR) were determined at two different blood pump speeds, i.e. 200 and 250 mL/min. During HD, hemodynamic status and vital signs of patients were monitored and controlled. After collecting the necessary data, efficiency of dialysis was calculated using the standard formula. Descriptive and analytical statistics was carried out to analyze the data. Using blood flow rate of 200 mL/min, 16.7% of patients had Kt/V higher than 1.3 and URR higher than 65. On the other hand, with flow rate of 250 mL/min, 26.2% of patients had Kt/V higher than 1.3 and 35.7% of subjects had URR higher than 65. Paired t-test with 95% confidence showed a sig­nificant difference in dialysis efficiency between two groups. Our data further confirm that increa­sing the blood flow rate by 25% is effective in increasing dialysis adequacy in HD patients.
  1 13,494 1,580
CASE REPORTS
Neo-bladder vaginal fistula: An unusual complication after orthotopic urinary diversion
Abhay Kumar, Suren K Das, Sameer Trivedi, Udai Shankar Dwivedi, Pratap Bahadur Singh
July-August 2009, 20(4):658-661
PMID:19587512
Development of neo-bladder vaginal fistula is not an unknown complication after cystectomy and orthotopic urinary diversion in females. Compared to native bladder, the wall of the neo-bladder is much thinner that may render it vulnerable to fistulization. Injury to the vagina during cystectomy is the most important predisposing factor. Herein, we present a case of neo-bladder va­ginal fistula and discuss the potential surgical and clinical factors contributing to its occurrence as well as the treatment options available.
  1 3,212 420
LETTERS TO THE EDITOR
Measurement of plasma levels of isoniazid for dose adjustment in the hemodialysis patients
Driss El Kabbaj, Mohammed Aatif, Leila Ait Moussa, Chems Eddoha Khassouani, Zouhir Oualim
July-August 2009, 20(4):666-667
PMID:19587514
  1 3,127 580
Polyorchidism in a patient with azoospermia
Hassan Ahmadnia, Mahmood Molaei
July-August 2009, 20(4):670-671
PMID:19587516
  1 1,680 365
Hyponatremia, rhabdomyolysis and acute kidney injury
Ankur Gupta, Ambar Khaira, Suresh C Tiwari
July-August 2009, 20(4):674-674
PMID:19587518
  1 2,664 646
ORIGINAL ARTICLES
Stage of urinary bladder cancer at first presentation
Pishtewan H Al-Bazzaz
July-August 2009, 20(4):628-631
PMID:19587505
The stage of urinary bladder cancer is an important factor in determining prognosis of the disease. This prospective study was performed to determine the stage of bladder cancer at first presentation at the Rizgary Hospital in the Erbil governorate in Iraqi Kurdistan. We evaluated 72 patients with bladder cancer. The grades and stages of bladder cancer of these patients were determined through physical examination and investigations. We found that 47.2% of patients had superficial cancer, 19.4% had tumor with invasion into the lamina propria and 30.6% of patients had tumor with invasion to muscle wall. Regional or distant metastases were found in 2.8% of patients. Well differentiated tumor was seen in 44.4% of the patients, moderately differentiated tumor was found in 38.9% and poorly differentiated tumor was found in 16.7% of the patients. Our study suggests that bladder cancer is diagnosed at a relatively early stage in the Erbil governorate. However, the situation can be further improved by adopting proper screening programs and performing appropriate investigations.
  1 3,641 532
Serum trypsin inhibitory capacity in hemodialysis patients
Mohammad Hashemi, Hamid Mehrabifar, Fatemeh Homayooni, Mohammad Naderi, Farzaneh Montazerifar, Saeid Ghavami
July-August 2009, 20(4):604-607
PMID:19587500
It has been established that overproduction of reactive oxygen species (ROS) occurs during hemodialysis causing oxidation of proteins. Alpha-1-antitrypsin is the major circulating anti­protease which contains methionine in the active site. The aim of the present study was to measure the level of serum trypsin inhibitory capacity (sTIC) in hemodialysis patients. This case-control study was performed in 52 hemodialysis patients and 49 healthy controls. sTIC was measured by enzymatic assay. The sTIC was significantly (P< 0.001) lower in hemodialysis patients (1.87 ± 0.67 µmol/min/mL) than healthy controls (2.83 ± 0.44 µmol/min/L). Reduction of sTIC may be due to the oxidation of methionine residue in the reactive site of alpha-1 antitrypsin.
  1 2,256 412
Crossmatch testing in kidney transplantation: Patterns of practice and associations with rejection and graft survival
Paolo R Salvalaggio, Ralph J Graff, Brett Pinsky, Mark A Schnitzler, Steven K Takemoto, Thomas E Burroughs, Luiz S Santos, Krista L Lentine
July-August 2009, 20(4):577-589
PMID:19587497
Methods of crossmatch testing prior to kidney transplantation are not standardized and there are limited large-scale data on the use and outcomes implications of crossmatch modality. Data describing the most sensitive crossmatch modality for crossmatch-negative kidney transplants were drawn from the Organ Procurement and Transplant Network Registry. Within the cohort transplanted in 1999-2005, we identified patient and transplant characteristics predictive of each testing modality by multivariate logistic regression. We assessed associations of crossmatch modality with rejection risk by logistic regression and with graft survival by Cox's hazards analysis. Among 230,995 transplants, use of flow cytometry with T-and B-lymphocytes (T&B FC) increased progressively in 1987-2005. Among the recent transplants performed in 1999-2005 (n=64,320), negative T&B FC crossmatch was associated with 15% lower relative risk of first-year acute rejection (adjusted HR 0.85, 95% CI 0.80-0.89) compared to negative T-antihuman-globulin and B-National Institutes of Health/Wash (T AHG &B) crossmatch. Five-year graft survival after transplant with negative T&B FC (82.6%) was modestly better than after negative T AHG &B (81.4%, P= 0.008) or T AHG crossmatch (81.1%, P< 0.0001), but on adjusted analysis was significantly different only among recipients from deceased donors and patients aged > 60 years. Many subgroups for whom negative T&B FC crossmatch predicted lower rejection risk (Caucasians, deceased donor recipients, re-transplants) were not more likely to be crossmatched by this method. We conclude that current practice patterns have not aligned utilization of T&B FC crossmatch with associated benefits. Prospective evaluation of the relationship of crossmatch modality with outcomes is warranted.
  1 4,434 694
REVIEW ARTICLES
Renal replacement therapy in sepsis-induced acute renal failure
Senaka Rajapakse, Chaturaka Rodrigo, Anoja Rajapakse, Dinoo Kirthinanda, Sujani Wijeratne
July-August 2009, 20(4):553-559
PMID:19587493
Acute renal failure (ARF) is a common complication of sepsis and carries a high mortality. Renal replacement therapy (RRT) during the acute stage is the mainstay of therapy. Va­rious modalities of RRT are available. Continuous RRT using convective methods are preferred in sepsis-induced ARF, especially in hemodynamically unstable patients, although clear evidence of benefit over intermittent hemodialysis is still not available. Peritoneal dialysis is clearly inferior, and is not recommended. Early initiation of RRT is probably advantageous, although the optimal timing of dialysis is yet unknown. Higher doses of RRT are more likely to be beneficial. Use of bio­compatible membranes and bicarbonate buffer in the dialysate are preferred. Anticoagulation during dialysis must be carefully adjusted and monitored.
  1 7,998 2,189
CASE REPORTS
Tri-filial presentation of familial tuberous sclerosis with renal tumors
Sushil R Ghoshal, Shankar D Chatterjee, Saugata Ray, Swarup Chakraborty, Arun Achar, TK Pathak
July-August 2009, 20(4):652-654
PMID:19587510
Tuberous sclerosis is a rare neuro-cutaneous syndrome with autosomal dominant penetrance. Only some organs are involved, e.g., skin (earthy skin thickenings, ash leaf patches), cerebral cortex (hamartomatous nodules) and kidneys, (angiolipoma, adenocarcinoma). These hamar­tomatous swellings resemble potatoes and hence, referred to as tubers. We herein report on three patients (all familial), father, son and granddaughter, with this rare involvement, from the eastern part of India. The father and son had involvement of only the skin (i.e. nose) and kidneys while the disease penetrated further in the subsequent filial generations with son and granddaughter having skin, brain and bilateral kidney involvement. This kind of tri-filial progression has not till date, been reported from this region, making it an interesting case presentation.
  - 1,868 349
LETTERS TO THE EDITOR
Cost of hemodialysis in Iran
Mitra Mahdavi-Mazdeh
July-August 2009, 20(4):675-676
PMID:19587519
  - 1,542 364
Diabetic nephropathy with crescentic GN
Kamal V Kanodia, Aruna V Vanikar, Kamal R Goplani, Hargovind L Trivedi
July-August 2009, 20(4):672-673
PMID:19587517
  - 1,758 426
Hypothermia in summer of Saudi Arabia with end stage renal failure suffering from diabetic nephropathy and malnutrition
Hamed Al-wadani
July-August 2009, 20(4):668-669
PMID:19587515
  - 1,966 383
ORIGINAL ARTICLES
Risk factors of hyperparathyroidism in advanced stages of chronic kidney disease
M El Kossi, A Rana, M El Nahas
July-August 2009, 20(4):623-627
PMID:19587504
The pathogenesis of renal osteodystrophy is not clearly defined. We evaluate in this study the potential effect of demographic and biochemical markers on parathormone (PTH) level in patients with chronic kidney disease (CKD) stages 4 and 5. We retrospectively studied 138 patients with CKD stages 4 and 5 selected from the database of the Sheffield Kidney Institute in the interval from 1996 to 2005. All patients had baseline as well as follow-up levels of PTH, adjusted serum calcium, phosphate, calcium phosphorus product, albumin, bicarbonate and estimated glomerular filtration rate (eGFR). At baseline, serum albumin, eGFR and adjusted serum calcium levels signi­ficantly negatively correlated with PTH serum levels. Adjusted serum calcium levels at last follow­up remained a significant negative predictor of PTH levels; however, baseline PTH levels demons­trated a significant positive correlation with final serum PTH levels. This study high lights the significance of serum PTH levels at presentation on the long-term effect of parathyroid gland function. This reinforces the need for early intervention to achieve optimal control of hyperpara­thyroidism in CKD patients.
  - 2,953 728
Risk factors of post renal transplant hyperparathyroidism
Alireza Hamidian Jahromi, Jamshid Roozbeh, Ghanbar-Ali Raiss-Jalali, Alireza Dabaghmanesh, Hamed Jalaeian, Ali Bahador, Saman Nikeghbalian, Mehdi Salehipour, Heshmat Salahi, Ali Malek-Hosseini
July-August 2009, 20(4):573-576
PMID:19587496
It is well recognized that patients with end stage renal diseases (ESRD) have hyper­plastic parathyroid glands. In most patients, a decrease in parathyroid hormone (PTH) occurs by about 1 year after renal transplantation. However, some renal transplant recipients continue to have elevated level of PTH. We prospectively evaluated 121 patients undergoing renal transplantation between August 2000 and 2002. The duration of dialysis, calcium (Ca), phosphorus (P), albumin, creatinine and iPTH levels were recorded prior to transplantation and three months and one year after transplantation. These 121 patients were on dialysis for an average period of 17.4 months prior to transplantation. An increase in the serum Ca and a decrease in serum P and iPTH level was seen in the patients after transplantation (P< 0.001). Hyperparathyroidism was in 12 (9.9%) and 7 (5.7%) patients three months and one year after transplantation respectively. Elderly patients and patients with longer duration on dialysis had an increased risk of developing post transplant hyperpara­thyroidism and hypercalcemia in the first year post transplant (P< 0.05). In conclusion age and duration on dialysis before transplantation seems to be important risk factors for post transplant hyperparathyroidism.
  - 4,540 797
The efficacy of darbepoetin alpha in hemodialysis patients resistant to human recombinant erythropoietin (rHuEpo)
Fayez Hejaili
July-August 2009, 20(4):590-595
PMID:19587498
Darbepoetin due to longer half life is convenient and effective for long term. This study was done to assess the efficacy of darbepoetin in the treatment of patients on high doses of erythropoietin (EPO) and to compare its efficacy in patients resistant and responsive to EPO. This is a prospective, controlled open label study assessing the efficacy of darbepoetin in 55 hemodialysis patients on high dose EPO and comparing its efficacy in the patients who were "EPO -resistant" (group 1, n= 28) and in those who were "EPO-responsive" (group 2, n= 27). The initial conversion ratio was 380 mcg darbepoetin: 1 U EPO/ week and the dose of darbepoetin was adjusted thereafter at fortnightly intervals with the aim of achieving and maintaining the hemoglobin level between 11-12 g/dL. The patients were followed up for 12 weeks following the introduction of darbepoetin. The impact of gender, baseline PTH, age, Kt/V, duration on dialysis, initial EPO dose on the response to darbepoetin was investigated. Continuous variables were compared using two tailed t-test and non-parametric by Fisher exact test. Overall darbepoetin was effective with 85.5 % of the patients responding and 21.8 % of the patients' able to maintain their hemoglobin with once fortnightly dose by the end of the study. Mean darbepoetin dose and the mean EPO to darbepoetin conversion ratio on completion of the study were 58.2 (42.4) mcg/week (0.983 (0.87) mcg/kg/week) and 384:1 respectively. Hemoglobin levels in groups 1 improved from 9.8 ± 0.9 g/dL to 12.0 ± 1.4 g/dL (0.0001) and 2 were and maintained it in group 2 at 11.9 ± 1.3 g/dL (P= 0.79). The doses of darbepoetin required in groups 1 and 2 were similar (54.3 ± 33 and 53.9 ± 47 mcg/week (P= 0.97) respectively and 0.89 ± 0.6 and 0.98 ± 1.0 mcg/kg/week (P= 0.8). 22 (78.6 %) of the EPO resistant patients responded to darbepoetin. In conclusion conversion from high dose EPO to darbepoetin proved successful even in patients who were resistant to EPO. The darbepoetin dose required in the EPO resistant and EPO responsive groups did not differ significantly and age, duration on dialysis and baseline PTH level had no impact on responsiveness to EPO or darbepoetin.
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RENAL DATA FROM THE ARAB WORLD
Infection-free hemodialysis: Can it be achieved?
Jafar Al-Said, Aimee C Pagaduan
July-August 2009, 20(4):677-680
PMID:19587520
Infection is the second most common cause of mortality in patients with end stage re­nal disease (ESRD). Following strict aseptic precautions during a hemodialysis (HD) session could reduce dialysis-related infection, thereby reducing mortality and morbidity rates. This retrospective study was undertaken to identify the prevalence of dialysis-related bacteremia, sepsis, and catheter infections during HD at Bahrain Specialist Hospital, Bahrain, after following rigid infection control pro­cedures. All HD sessions performed between January 2004 and December 2007 were included. Strict aseptic precautions were observed for every patient in our dialysis unit. The patients' demographic characteristics as well as presence of hypertension (HTN), diabetes mellitus (DM) and use of immunosuppressive drugs were recorded. Results of culture of dialysis catheter tip were collected for all catheters removed or changed during the study period. Catheter surface culture yielding more than 15 colonies and catheter lumen culture yielding more than 1000 CFU/mL were considered positive. All episodes of rigors, chills, bacteremia, and sepsis were recorded. Overall, a total of 1084 HD sessions performed on 46 patients were studied. The mean age of the study patients was 55.2 years (SE 2.5). Fifty four percent were male, 50% had DM, 85% had HTN and 11% were immunosuppressed. With implementation of strict aseptic precautions no catheter-related infection, bacteremia or sepsis was found. Culture of 50 dialysis catheters showed Diptheroid in three patients, MRSE in two patients and MSSE, Enterobacter, and Klebsiella in one patient each. None of the study patients had signs or symptoms of infection or bacteremia. Our study further indicates that following strict aseptic precautions during HD sessions can reduce, if not eliminate, infection as a major cause of mortality and morbidity.
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