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Saudi Journal of Kidney Diseases and Transplantation
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   2011| July-August  | Volume 22 | Issue 4  
    Online since July 9, 2011

 
 
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REVIEW ARTICLES
Renal transplantation in developing countries
Jacob A Akoh
July-August 2011, 22(4):637-650
PMID:21743206
Patients with established renal failure, living in developing countries, face many obstacles including lack of access to transplantation centers, quality and safety issues, and exploittation associated with transplant tourism. This review aims to determine the state and outcome of renal transplantation performed in developing countries and to recommend some solutions. The lack of suitable legislation and infrastructure has prevented growth of deceased donor programs; so, living donors have continued to be the major source of transplantable kidneys. Transplant tourism and commercial kidney transplants are associated with a high incidence of surgical complications, acute rejection and invasive infection, which cause major morbidity and mortality. Developing transplant services worldwide has many benefits - improving the results of transplantation as they would be performed legally, increasing the donor pool, making transplant tourism unnecessary and granting various governments the moral courage to fight unacceptable practices. A private-public partnership underpinned by transparency, public audit and accountability is a prerequisite for effective transplant services in the developing world. Finally, lack of dialysis facilities coupled with better outcomes in patients spending <6 months on dialysis prior to transplantation favor pre-emptive transplantation in developing countries.
  7,669 1,403 2
ORIGINAL ARTICLES
Nutritional assessment of patients on hemodialysis in a large dialysis center
Khalid Al Saran, Sameh Elsayed, Azeb Molhem, Areej AlDrees, Huda AlZara
July-August 2011, 22(4):675-681
PMID:21743210
Management of the nutritional aspects of chronic kidney disease (CKD) presents a number of challenges. This study was performed to assess the nutritional status among patients on maintenance hemodialysis at the Prince Salman Center for Kidney Diseases, Riyadh, Saudi Arabia. The study included 200 patients with a mean age of 50 ± 16 years; there were 108 males (54%) and 92 females (46%). Nutritional assessment was made by the Subjective Global Assessment (SGA) score. In the present study, 4% of the patients were found to be underweight, 49% had average weight, 27.5% were overweight, 14% were obese, and 5.5% had morbid obesity. Severe malnutrition by SGA significantly correlated with duration on dialysis, functional capacity, and associated co-morbid diseases. The number of patients included in this study was small and we recommend multi-center studies with a larger number of patients for better evaluation. Also, we recommend a survival trial to evaluate the relationship between low serum albumin and patient survival in the Saudi population.
  6,586 1,385 2
Factors predicting malnutrition in hemodialysis patients
Moncef El M'Barki Kadiri, Rhita Bennis Nechba, Zouhir Oualim
July-August 2011, 22(4):695-704
PMID:21743213
Signs of protein-energy malnutrition are common in maintenance hemodialyis (HD) patients and are associated with increased morbidity and mortality. To evaluate the nutritional status and relationship between various parameters used for assessing malnutrition, we performed a cross-sectional study in 37 HD patients treated with thrice weekly sessions for at least two weeks. Global nutritional status was evaluated by the dual-energy X-ray absorptiometry (DEXA) scan. Body weight and several laboratory values, including serum albumin (Salb), serum prealbumin, bicarbonate, cholesterol, serum C-reactive protein (SCRP), and hemoglobin, were recorded. Dose of dialysis was evaluated by urea kinetic modeling. The patients were subdivided into two groups based on body mass index: group I, normal nutritional status (71%) and group II, malnutrition (29%). The clinical factors associated with malnutrition included advanced age and cardio-vascular diseases (CVD), decreased fat mass (FM) measured by DEXA, low Salb and prealbumin, and severe anemia. The Salb level was not only a predictor of nutritional status, but also was independently influenced by age and SCRP, which was more common in malnourished patients than in patients with normal nutritional status. Both low Kt/V and less weekly dialysis time were associated with malnutrition. The FM and lean body mass (LBM) calculated by DEXA correlated with CVD and other markers of malnutrition (Salb, total cholesterol).
  5,626 1,451 3
Desensitization protocol for highly sensitized renal transplant patients: A single-center experience
Vivek B Kute, Aruna V Vanikar, Hargovind L Trivedi, Pankaj R Shah, Kamal R Goplani, Himanshu V Patel, Manoj R Gumber, Rashmi D Patel, Kamal V Kanodia, Kamlesh S Suthar, Varsha B Trivedi, Pranjal R Modi
July-August 2011, 22(4):662-669
PMID:21743208
Highly sensitized patients are destined to remain untransplanted for long. Early transplantation results in cost-saving, reduced morbidity/mortality and improved quality of life. We carried out a prospective study to evaluate the efficacy and safety of desensitization protocol vis-à-vis patient/graft survival in living donor renal transplantation in highly sensitized patients. Between December 2008 and April 2010, 34 renal transplant (RTx) patients underwent desensitization protocol. An anti-human globulin-enhanced lymphocytotoxicity crossmatch assay (AHG-CDC) ≥25% and T-cell median channel shift (MCS) >50, B-cell MCS >100 [flow crossmatch (FXM)] were considered crossmatch (XM) positive. All patients were administered bortezomib (1.3 mg/m 2 , days 1, 4, 8, 11), plasmapheresis, rabbit-anti-thymocyte globulin (r-ATG), mycophenolate mofetil (MMF) and intravenous immunoglobulins (IVIg). LCXM and FXM were repeated post-protocol. In the event of persistent sensitization, additional bortezomib cycle was repeated along with plasmapheresis, IVIg, calcineurin inhibitors (CNI) and rituximab. If the cross match (CMX) was negative or acceptable, patients underwent RTx. Post-transplant immunosuppression consisted of prednisone, CNI and MMF. Biopsy was performed in the event of graft dysfunction and treated accordingly. There were 18 males and 16 females, with a mean age of 37.4 years. Mean dialysis duration was 14.9 ± 17.6 months. Average third party transfusions were 6.2 ± 4.5, 17.6% had autoimmune diseases, 20.6% were multi-para. Pre-protocol AHGXM was 55.3 ± 24.5%, T-cell crossmatch (TCXM) was 122.4 ± 91.4 MCS and B-cell crossmatch (BCXM) was 279 ± 142.9 MCS. Totally, 85.3% responded within 1 month with reduction in AHG-CDC to 19.9 ± 5.2%, TCXM to 24.7 ± 19.4 MCS and BCXM to 74.7 ± 34.8 MCS. Side effects noted in 38.2% were manageable. Over follow-up of 0.92 ± 0.8 years, patient/graft survival was 100%/88.2% and mean serum creatinine was 1.27 ± 0.32 mg/dL. Acute rejections were noted in 24.1%, who responded to steroids + rabbit antithymocyte globulin (rATG). Five (14.7%) patients were transplanted after changing donors. Our desensitization protocol seems to be safe and effective. Bortezomib may offer new possibilities in desensitization protocols.
  5,231 1,301 2
Poor prognostic factors of lupus nephritis
Khawla Kammoun, Faigal Jarraya, Lamia Bouhamed, Mahmoud Kharrat, Saloua Makni, Mohamed Ben Hmida, Hafedh Makni, Neila Kaddour, Tahia Boudawara, Zouhir Bahloul, Jamil Hachicha
July-August 2011, 22(4):727-732
PMID:21743218
The occurrence of renal involvement during the clinical course of systemic lupus erythematous (SLE) is generally considered to be the most important factor influencing the prognosis in terms of morbidity and mortality. The factors influencing prognosis in lupus nephritis (LN) are variable in literature. Our aim was to determine predictive factors of poor prognosis in LN among our population. In this retrospective study, 82 cases of LN observed over 18 years were studied. There were 12 males and 70 females with a mean age of 26.9 ± 11 years. At presentation, the mean proteinuria was 3.9 ± 4 g/day; the nephrotic syndrome, hematuria, leukocyturia and renal failure were observed in 67.1%, 63.4%, 56.1% and 37.8% of cases, respectively. LN was of class I, II, III, IV and V in 4.9%, 13.4%, 23.2%, 50% and 8.5% of the cases, respectively. Fifteen patients developed end-stage renal failure and/or died. The presence of hypertension, renal failure, massive proteinuria and high activity index score of LN was associated with poor renal prognosis.
  5,015 1,069 -
Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of urinary protein in acute kidney injury
Sufi M Suhail, KT Woo, HK Tan, KS Wong
July-August 2011, 22(4):739-745
PMID:21743220
Recent experimental and clinical studies have shown the importance of urinary proteomics in acute kidney injury (AKI). We analyzed the protein in urine of patients with clinical AKI using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) for its diagnostic value, and followed them up for 40 months to evaluate prognosis. Urine from 31 consecutive cases of AKI was analyzed with SDS-PAGE to determine the low, middle and high molecular weight proteins. Fractional excretion of sodium (FENa) was estimated from serum and urine creatinine and sodium (Na). The cases were followed-up for 40 months from the end of the recruitment of study cases. Glomerular protein was higher in the hematuria group when compared with the non-hematuria group (P <0.04) and in the AKI group than in the acute on chronic renal failure (AKI-on-CRF) group (P <0.002). Tubular protein was higher in the AKI-on-CRF group (P <0.003) than in the AKI group. Tubular protein correlated with FENa in groups with diabetes mellitus (DM), AKI-on-CRF, and without hematuria (P <0.03, P <0.02 and P <0.004, respectively). Pattern of protein did not differ between groups with and without DM and clinical acute tubular necrosis (ATN). At the end of 40 months follow-up, category with predominantly glomerular protein progressed to chronic renal failure (CRF) or end-stage renal failure in higher proportion (P <0.05). In clinical AKI, we observed that glomerular protein dominated in cases with glomerular insult, as indicated by hematuria. Tubular protein was common in the study cases with CRF, DM and cases without hematuria. This indicates tubulo-interstitial injury for AKI in these cases. Patients with predominantly glomerular protein had an adverse outcome.
  4,981 915 1
CASE REPORTS
Necrotic crescentic glomerulonephritis and IGA nephropathy: Lee-Haas classification revisited
Wael Latif Jabur
July-August 2011, 22(4):784-787
PMID:21743230
Capillary necrosis is frequently encountered in most forms of proliferative glomerulonephritis, and varies in severity from only occasional finding to severe form of glomerular vasculitis. We report a patient who presented with features of acute glomerulonephritis. Kidney biopsy showed crescents in 30% of the glomeruli, diffuse mesangial expansion and hypercellularity with IgA deposits on immunofluorescence. The relevance of the Lee-Haas classification is discussed in relation to assessing prognosis.
  4,284 505 -
Severe hypoglycemia in peritoneal dialysis patients due to overestimation of blood glucose by the point-of-care glucometer
Hasan M Al-Dorzi, Hythem Al-Sum, Salem Alqurashi, Saleh J Aljaser, Yaseen M Arabi
July-August 2011, 22(4):764-768
PMID:21743225
Although overestimation of blood glucose (BG) by certain glucometers in peritoneal dialysis (PD) patients has been reported, awareness of this problem by healthcare providers of multiple disciplines and different specialties is probably insufficient. This is a case series of four patients who had severe symptomatic hypoglycemia and normal BG by point-of-care glucometer at a tertiary care center from December 2007 to September 2008. We report four insulin-treated diabetic patients (age = 58.2 ± 16.2 years, 3 men and 1 woman) on PD, who had acute decrease in level of consciousness in the emergency department (n = 1) and the hospital ward (n = 3). While they had their symptoms, they all had normal BG measured by the Accuchek glucometer (7.1 ± 3.3 mmol/L); nonetheless, simultaneous or near-simultaneous laboratory-measured BG levels were very low (2.0 ± 1.3 mmol/L). The mean difference in BG was 5.8 mmol/L (12 simultaneous or near-simultaneous measurements). Three patients had icodextrin-based PD in the night before symptomatic hypoglycemia. The first two patients, whose treatment for hypoglycemia was delayed, remained comatose and died later. The latter two patients were promptly treated with intravenous dextrose and did not have any neurologic sequelae. One of them died later from multiple organ failure. Over-estimation of BG in peritoneal dialysis patients by certain point-of-care glucometers is a serious problem and can be fatal. Increased awareness of this problem for all healthcare providers and use of appropriate glucometers are required.
  4,143 528 -
SCOT FORUM
A young man with polyuria and lethargy
Salman Imtiaz, Shahid Qayyum, Hala Kafouri, Habib ur Rehman , Mohammad Al Khoiter, Akram Askar
July-August 2011, 22(4):847-852
PMID:21743247
We report a 20-year-old man who presented to our emergency room with a history of polyuria, weakness, constipation, nausea, and vomiting of two months duration. History and clinical examination revealed a significant weight loss and mild hepatomegaly. Laboratory investigations revealed hypokalemia, hypernatremia, and severe metabolic acidosis and anemia. Ultra-sound of the abdomen revealed enlarged kidneys without hydronerphrosis. The patient developed paralysis due to further decline in serum potassium level, which improved after an aggressive fluid and electrolyte management. He was investigated extensively for polyuria and type of acidosis. The kidney biopsy showed interstitial leukemic infiltration. He was managed accordingly and recovered from the condition. This case demonstrates an unusual presentation of a hematological malignancy, which was a diagnostic as well as a management challenge.
  4,060 370 -
BRIEF COMMUNICATION
Mucormycosis in renal transplant recipients: Predictors and outcome
SM Godara, VB Kute, KR Goplani, MR Gumber, DN Gera, PR Shah, AV Vanikar, HL Trivedi
July-August 2011, 22(4):751-756
PMID:21743222
Mucormycosis, though uncommon, is associated with high mortality in transplant recipients. This study was conducted to assess the incidence and risk factors associated with mucor infection and its outcome. We retrospectively reviewed the hospital records for evidence of mucor infection in patients transplanted between January 2005 and December 2009 at the Department of Nephrology and Clinical Transplantation (IKDRC), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India. The patient demographics, symptoms, diagnostic techniques and outcomes were analyzed. Out of a total of 1,330 transplants, 16 patients (1.20%) had evidence of mucor infection, including 14 males and two females. The mean age of the patients was 43.8 years. The time interval between transplantation and disease onset varied greatly (range: 1 month to 7 years; median 13.8 months). The presenting symptoms were fever (87.5%), severe headache (56.2%), facial swelling (56.2%), watering of eyes (56.2%), cough (31.2%), respiratory distress (18.7%) and pain abdomen (12.5%). Suspected patients were evaluated by computerized tomographic (CT) scan/magnetic resonance imaging (MRI), bronchoalveolar lavage (BAL) and biopsy, and the diagnosis was confirmed by culture. Of the 16 patients studied, nine had rhinocerebral mucormycosis, five had pulmonary mucormycosis and one case each had infection at the graft anastmosis site and disseminated mucormycosis. Early and intensive treatment with liposomal amphotericin-B was instituted in all patients, and extensive debridement was performed in addition in 11 cases, and one patient was subjected to graft nephrectomy; 10 patients (62.5%) survived. Our study suggests that rhinocerebral is the most frequent site of mucormycosis and it can occur very early or late in the post-transplant period. Early diagnosis and combined surgical debridement and parenteral liposomal amphotericin-B along with reduction of immunosuppression improve the patient survival.
  3,640 780 3
ORIGINAL ARTICLES
Percutaneous ultrasound-guided renal biopsy
Anuj Mishra, Rajab Tarsin, Basma ElHabbash, Nuri Zagan, Rabia Markus, Sawsen Drebeka, Khaled AbdElmola, Taib Shawish, Abdulhafidh Shebani, Tamer AbdElmola, Ahmad ElUsta, Ehtuish Faraj Ehtuish
July-August 2011, 22(4):746-750
PMID:21743221
This study was done to assess the safety and efficacy of real-time ultrasound-guided percutaneous renal biopsy (PRB) and to determine the optimal period of observation required as well as to ascertain the risk factors for any ensuing complications. Between 1 st February 2006 and 31 st January 2008, a total of 86 PRBs were performed by the radiologist using an automated biopsy gun with 16-gauge needle at the National Organ Transplant Centre, Central Hospital, Tripoli, Libya. Prior to the procedure coagulation profile was done in all the patients. All patients were kept on strict bed rest for 6-hours post-procedure. Of the 86 renal biopsies performed, 78 patients were referred from Rheumatology Department and 8 were post-kidney transplant recipients. There were 23 males with age ranging from 15 to 56 years and 63 females with age ranging from 16 to 66 years. A mean of 17.5 glomeruli were present in each specimen. A glomerular yield of less than five glomeruli was seen in only four biopsies. Class I lupus nephritis (LN) was seen in one patient, class II LN in seven patients, class III LN in 13 patients and class IV LN in 29 patients. All the eight renal allografts were diagnosed as either acute tubular necrosis or acute interstitial rejection. The overall complication rate was 5.8% and these complications were observed within 6 hours of biopsy. No late complications were seen. PRB under real-time ultra-sound guidance is a safe and efficacious procedure to establish the histological diagnosis of the renal disease and may be done as an out-patient procedure. A post-biopsy observation time of 6 hours appears to be optimal.
  3,512 666 1
Microalbuminuria in children with sickle cell anemia
Blessing Abhulimen-Iyoha Imuetinyan, Michael Ibadin Okoeguale, Gabriel Ofovwe Egberue
July-August 2011, 22(4):733-738
PMID:21743219
Microalbuminuria (MA) is an early marker of various diseases affecting the renal system. Its relevance in children with sickle cell anemia (SCA), who are known to be prone to renal complications, has not been fully explored, particularly in the study locale. Besides, its occurrence in this group of patients remains under-reported in locations where the burden of SCA is enormous. To assess its prevalence in this cohort, 69 children with sickle cell anemia (in their steady state), aged 1-16 years, were consecutively enrolled and evaluated. The study, spanning from November 2006 to February 2007, was cross-sectional and descriptive. Employing a semiquantitative method, MA in an early morning spot urine sample was determined in each subject. Also evaluated were the anthropometry, blood pressure (BP) and packed cell volume. Prevalence of MA in the study subjects was 20.3%. Though not significant, prevalence of MA was more in females (25.9%) than in males (16.7%). Prevalence of MA increased with increasing age and was also significantly associated with weight (P = 0.033), but was independent of family history of hypertension. BP recordings, both systolic and diastolic, in the study subjects were within normal range. MA occurs significantly enough in children with SCA to warrant routine screening for it. Such a measure could assist in the early detection of ensuing renal complications and can pave way for improved management of a sickler who is particularly prone to such problems. In addition, interventional measures, known to retard rate of deterioration of kidney function due to prolonged proteinuria, could also be instituted early.
  3,427 723 2
Dyslipidemia in dialysis patients
Ahmed H Mitwalli, Awatif A Alam, Jamal S Al Wakeel, Arthur C Isnani
July-August 2011, 22(4):689-694
PMID:21743212
In order to evaluate the lipid profiles of dialysis patients, we retrospectively reviewed all the chronic kidney disease (CKD) patients on chronic hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD), followed up between June 2004 and May 2005, in two tertiary hospitals in Riyadh, Saudi Arabia. There were 380 patients including 206 (54.2%) females and the mean age of the patients was 45.9 ± 15.8 years. The mean dialysis duration was 65.0 ± 58.3 months. Diabetes was present in 97 (25.5%) of the patients and hypertension in 84 (22.1%). Younger patients had more disturbed lipid profile than elderly patients, and females had higher lipid values than males. The CAPD patients had worse lipid profile than those on HD, irrespective of age, sex and duration of dialysis. The presence of diabetes, hypertension, smoking and cardiovascular disease (CVD) all contributed to the worsening of lipid profiles of our patients. Dialysis patients showed improvement in lipid profile initially followed by gradual deterioration. We conclude that dyslipidemia, which increases the risk of CVD by increasing atherogenesis, progresses over time in dialysis patients and becomes worse in CAPD patients.
  3,252 875 -
CASE REPORTS
Multicystic nephroma masquerading as Wilms' tumor: A clinical diagnostic challenge
Bhupendra R Mehra, Anand P Thawait, Md. Jawed Akther, Ravinder R Narang
July-August 2011, 22(4):774-778
PMID:21743227
Multicystic nephroma (MCN) is an uncommon, non-heritable, unilateral, benign tumor that represents 2-3% of all primary renal tumors in the pediatric age group. It is characterized by bimodal age incidence with 50% of cases seen in children less than four years of age. Presented here is an 8-month-old boy with asymptomatic, gradually progressive renal lump of two months duration, with no other complaints. Ultrasound of the abdomen showed a well-defined multi-septated cystic mass involving whole of the kidney. Computerized Tomography (CT) scan revealed a unilateral cystic lesion involving almost the entire left kidney. Keeping in mind the age, clinical presentation and radiological appearance, the possibility of cystic variant of Wilms' tumor could not be ruled out pre-operatively. An elective left nephrectomy was done. The histopathological report revealed MCN of the left kidney. Only a few cases have been reported from India. We report here one such pediatric case.
  3,540 475 -
HIV-Associated immune complex glomerulonephritis with "lupus-like" features
Nestor M Pakasa, PM Binda
July-August 2011, 22(4):769-773
PMID:21743226
Renal structural abnormalities in HIV/AIDS infected patients have been infrequently and incompletely reported in patients from sub-Saharan Africa. We report an immune complex glomerulonephritis with "lupus-like" features in a ten-year-old HIV+ boy who was evaluated at the University Hospital of Kinshasa. The light microscopic examination of the renal biopsy displayed a predominantly membranoproliferative glomerulonephritis with prominent focal segmental necrotizing injury, numerous wire-loops, and a spiky membranous nephropathy. In addition, there were prominent tubular injury, microcysts filled with periodic acid-Schiff (PAS) positive casts, edema and an inflammatory infiltrate of the interstitium, features of a classic HIV-associated nephropathy (HIVAN). Electron microscopy revealed large subendothelial, intra-membranous, subepithelial and mesangial deposits. The combination of these findings, while being consistent with lupus nephritis WHO grade IV/V, the tubulointerstitial HIVAN-like changes and the absence of clinical evidence of lupus disease favored an HIV-associated immune complex glomerulonephritis with "lupus-like features".
  3,305 660 -
ORIGINAL ARTICLES
Anti-ENA antibody profile in hepatitis C patients undergoing hemodialysis
Raymond G Batchoun, Malek A Al-Najdawi, Sameh Al-Taamary
July-August 2011, 22(4):682-688
PMID:21743211
Infection with hepatitis C virus (HCV) is increasing all over the world, especially among hemodialysis patients. HCV is one of the major autoantibody inducing viruses, where anti-nuclear antibodies (ANA), anti-smooth muscle antibodies (ASMA), anti-liver kidney microsome antibodies (LKM-1), and rheumatoid factor (RF) have been related to HCV. Few studies have investigated the presence of anti-extractable nuclear antigens (ENA) antibodies in chronic liver diseases, especially in chronic hepatitis C cases, but none investigated its immunostimulation role in hemodialysis units. The aim of the study was to assess the prevalence of HCV among chronic kidney disease- Stage 5 (CKD5) patients undergoing hemodialysis and the prevalence of ENA antibodies among them. Sera of 134 patients with chronic kidney disease undergoing hemodialysis, were screened for HCV antibodies and ENA antibodies profile, using ELISA and Immunoblot technique. 41 HCV-positive blood bank donors were used as controls. Sixty-four (47.7%) of 134 patients undergoing hemodialysis were infected with HCV. Thirty-three (51.6%) of 64 patients with HCV infection undergoing hemodialysis had anti-ENA antibodies: 9 (27.3%) showed anti-SSA antibodies and 22 (66.7%) had anti-SSB antibodies. The prevalence of anti-ENA antibodies was significantly higher in the patients with HCV infection, undergoing hemodialysis, compared with both control groups (hepatitis C-positive blood bank donors and hepatitis C-negative patients undergoing hemodialysis). Seventeen of 33 HCV antibodies-positive males undergoing hemodialysis had anti-ENA antibodies, compared with 16 of 31 females, indicating no sex related difference. This study emphasizes the high prevalence of HCV infection in our hemodialysis patients, comparable to that of other Middle Eastern countries, but higher than Western ones. A strong association was observed between anti-HCV positivity and hemodialysis duration, as well as anti-ENA antibody profile. However, these antibodies were gender independent.
  3,167 526 -
RENAL DATA FROM ASIA-AFRICA
HLA polymorphism in Sudanese renal donors
Ameer M Dafalla, DJ McCloskey, Almutaz A Alemam, Amel A Ibrahim, Adil M Babikir, Nagla Gasmelseed, Mohamed El Imam, Ahmed A Mohamedani, Mubarak M Magzoub
July-August 2011, 22(4):834-840
PMID:21743245
The main objective of this study is to provide a database for renal transplantation in Sudan and to determine the HLA antigens and haplotype frequencies (HFs) in the study subjects. HLA typing was performed using the complement-dependant lymphocytotoxicity test in 250 unrelated healthy individuals selected as donors in the Sudanese Renal Transplantation Program. Considerable polymorphism was observed at each locus; A2 (0.28), A30 (0.12), A3 (0.09), A24 (0.09), A1 (0.09), and A68 (0.06) were the most frequent antigens in the A locus, while B51 (0.092), B41 (0.081), B39 (0.078), B57 (0.060), B35 (0.068), B 50 (0.053) and B 52 (0.051) were the most common B locus antigens. DR13 (0.444) and DR15 (0.160) showed the highest antigen frequencies (AFs) in the DR locus. In the DQ locus, DQ1 showed the highest gene frequency (0.498), while DQ2 and DQ3 AFs were (0.185) and (0.238), respectively. The most common HLA-A and -B haplotypes in positive linkage disequilibrium were A24, B38; A1, B7; and A3, B52. The common HLA-A and -B HFs in positive linkage disequilibrium in the main three tribe-stocks of the study subjects (Gaalia, Nile Nubian and Johyna) were A24, B38 for Gaalia; A24, B38 and A2, B7 for Johyna; and A2, B64 and A3, B53 for Nile Nubian. These results suggest that both class I and class II polymorphisms of the study subjects depict considerable heterogeneity, which reflects recent admixture of this group with neighboring Arabs and African populations.
  3,007 431 2
ORIGINAL ARTICLES
Prevalence of mixed hepatitis C virus (HCV) genotypes among recently diagnosed dialysis patients with HCV infection
Mohammed A Al Balwi
July-August 2011, 22(4):712-716
PMID:21743215
Hepatitis C virus (HCV) infection is considered a major health problem recognized globally. HCV is a major cause of chronic liver disease that may lead to cirrhosis and hepatocellular carcinoma. The aim of this study was to investigate the prevalence of multiple (mixed) HCV genotypes in Saudi patients recently diagnosed with HCV infection and their association with various clinical risk factors. We examined a total of 1,292 newly diagnosed HCV-positive cases between January 2006 and July 2009 at the Molecular Pathology Laboratory, King Abdulaziz Medical City, Riyadh. The clinical and laboratory data of the study patients were collected. The HCV-RNA viral load and its genotyping were carried out with RT-PCR technology to assist in the follow-up and management of HCV-infected patients undergoing antiviral therapy. Twenty-two patients (1.7%) were found to have mixed HCV genotypes; of them, mixed genotypes associated with genotype-4 were seen in 19 patients (86%), mixed genotypes associated with genotype-1 were found in 68.4%, with genotype-3 in 26.3% and with genotype-2 in 5.3%. Additionally, mixed genotypes associated with genotype-1 were seen in three cases (13.6%); they were associated with genotype-2 in two (66.7%) and with genotype-5 in one patient (33.3%). In conclusion, the prevalence rate of mixed HCV genotypes in the cohort of the newly infected Saudi patients was 1.7%, with genotype-4 being the most frequent genotype encountered.
  2,781 644 1
LETTERS TO THE EDITOR
Vascular access surgery: Excellent success rates with the use of a vascular dilator
Kushraj Lohani, Sandeep Guleria, Vemuru Sunil Kumar Reddy
July-August 2011, 22(4):802-804
PMID:21743235
  3,033 344 -
ORIGINAL ARTICLES
Artificial neural network for prediction of equilibrated dialysis dose without intradialytic sample
Ahmad Taher Azar, Khaled M Wahba
July-August 2011, 22(4):705-711
PMID:21743214
Post-dialysis urea rebound (PDUR) is a cause of Kt/V overestimation when it is calculated from pre-dialysis and the immediate post-dialysis blood urea collections. Measuring PDUR requires a 30-or 60-min post-dialysis sampling, which is inconvenient. In this study, a supervised neural network was proposed to predict the equilibrated urea (C eq) at 60 min after the end of hemodialysis (HD). Data of 150 patients from a dialysis unit were analyzed. C eq was measured 60 min after each HD session to calculate PDUR, equilibrated urea reduction rate eq (URR), and ( eq Kt/V). The mean percentage of true urea rebound measured after 60 min of HD session was 19.6 ± 10.7. The mean urea rebound observed from the artificial neural network (ANN) was 18.6 ± 13.9%, while the means were 24.8 ± 14.1% and 21.3 ± 3.49% using Smye and Daugirdas methods, respectively. The ANN model achieved a correlation coefficient of 0.97 (P <0.0001), while the Smye and Daugirdas methods yielded R = 0.81 and 0.93, respectively (P <0.0001); the errors of the Smye method were larger than those of the other methods and resulted in a considerable bias in all cases, while the predictive accuracy for ( eq Kt/V) 60 was equally good by the Daugirdas' formula and the ANN . We conclude that the use of the ANN urea estimation yields accurate results when used to calculate ( eq Kt/V).
  3,016 351 4
CASE REPORTS
Joubert syndrome with nephronophthisis in neurofibromatosis type 1
Javed Ahmed, Uma S Ali
July-August 2011, 22(4):788-791
PMID:21743231
Joubert syndrome (JS) is a rare developmental disorder of the central nervous system, characterised by brainstem and cerebellar malformations, hypotonia, episodic hyperapnea and apnea and mental retardation. It may be associated other systemic abnormalities like ocular (e.g., retinal dysplasia, etc.), oculomotor, musculoskeletal and renal (e.g., cystic dysplasia, nephronophthisis), with renal failure. We describe a case of JS with nephronophthisis in neurofibromatosis Type 1 leading to end-stage renal disease, a association that has never been described earlier in the medical literature to the best of our knowledge.
  2,921 416 1
Combined liver and kidney transplantation in a highly sensitized and positively cross-matched patient
Salem Alqurashi, Abdullah A Alsayyari, Khalid Abdullah, Abduljalil Alwan, Ali H Hajeer
July-August 2011, 22(4):757-760
PMID:21743223
Combined liver kidney transplantation (CLKT) has been used on many occasions and proved to be a successful event for both liver and kidney in highly sensitized patients. Our aim was to review the immunological and other laboratory results of a CLKT in a highly sensitized patient. CLKT was used to treat a highly sensitized, 42-year-old female. She was suffering from end-stage liver disease due to hepatitis C virus (HCV) infection and renal disease due to diabetic nephropathy. Cross-matching, panel reactive assay (PRA) and routine laboratory tests for liver and renal function were carried out before and after the CLKT. Prior to the CLKT, the patient was highly sensitized with human leukocytes antigens (anti-HLA) class I antibodies (>90%). Patient was offered CLKT from a deceased donor. She had donor-specific antibodies, class I and II. Both T and B CDC cross-matches (XM) were positive pre-transplant and eight hours post-transplant. Both cross-match and PRA results became completely negative six days post CKLT. Almost 30 months post CLKT, her renal function is normal and negative for class I and II PRA. Liver graft appears to be protective for renal graft when they are combined even in highly sensitized patients. CLKT is very useful in overcoming sensitization in addition to treating end-stage liver and renal diseases.
  2,533 633 1
Long neglected neurogenic bladder
Pooja Binnani, Ruchi Gupta, Nikhil Kedia, Sainath Pattewar, Madan Mohan Bahadur
July-August 2011, 22(4):782-783
PMID:21743229
Urinary diversion is indicated for the management of the neurogenic bladder. However, there is a risk for developing pyocystitis in this type of patients. We present a case of young female who presented with a history of frequent urinary tract infection (UTI) post urinary diversion for neurogenic bladder. Ever since she underwent simple cystectomy, there have been no further episodes of UTI.
  2,780 359 -
ORIGINAL ARTICLES
The influence of increased peritoneal membrane surface area on dialysis adequacy
Abdullah Alhwiesh, Saied Esam, Ibrahiem Saeed, Mohamed Ahmmed, Fahad Almohana
July-August 2011, 22(4):717-722
PMID:21743216
The adequacy of peritoneal dialysis is generally dependant on the choice of peritoneal fluid, the intraperitoneal fill volume and the contact time. Moreover, the peritoneal surface area acts as a major factor in the exchange dynamics of a peritoneal membrane. We designed a mechanism to increase the membrane surface contact area by using an abdominal belt in order to exert enough pressure on the fill volume, to effectively recruit more area in contact for exchange. We studied 12 patients on regular continuous ambulatory peritoneal dialysis (CAPD) at our center from January to October 2008. The age of patients ranged from 44 to 75 years, with a median of 55 years. All the patients were maintained on the same prescription four months before and during the study. Dialysis solutions were 1.36% Deaneal® , two liters, three exchanges and the last fill volume was two liters 7.5% Extraneal® . The belt was applied to all the patients most of the day and all night. We then observed its effect on dialysis adequacy, reflected by various parameters over a period of eight months. The average Kt/V before wearing the belt was 1.89 and improved after applying the belt to 2.3 (P <0.05). Our study suggests that increasing the abdominal pressure by wearing an abdominal belt rendered the filling volume of the PD dialysate to have a better contact with the peritoneal membrane and improved the dialysis adequacy. Studies with larger sample size are required to confirm the results.
  2,724 379 -
REVIEW ARTICLES
Can we improve the diagnosis of renal failure? A revised coding system for the Middle East and North Africa
Guy H Neild, D Deren Oygar, Mohamed Ben Hmida
July-August 2011, 22(4):651-661
PMID:21743207
We reviewed the regional data on primary renal disease (PRD) causing end-stage renal failure (ESRF) during the decade 2000-2009. Reporting was generally inconsistent and diagnostic groups were poorly defined. We propose a system in which all diagnoses fall into one of eight broad groups: ESRF of uncertain etiology, congenital abnormalities of the kidney and urinary tract (CAKUT) and acquired uropathy, glomerular diseases, tubulo-interstitial disease (TID), other congenital and familial diseases, diabetes, renovascular disease and other specified diagnoses. Each group has sub-headings; for instance, primary glomerulonephritis, secondary glomerulonephritis, and hereditary glomerular disease. For each sub-heading, there is a list of specific diagnoses similar to that used by the European Dialysis and Transplant Association (EDTA) and United States Renal Data System (USRDS) coding systems. We also recommend that "etiology unknown" group should be reported in more detail as either "glomerular phenotype" or "tubular phenotype" and careful attention be paid to evidence for a family history of renal disease. To improve reporting, all patients who are diabetic, and all who have evidence of familial inheritance, should be recorded and a diagnostic category should be chosen. Thus, a diabetic patient is designated as "diabetic nephropathy" only if he/she fulfils the case definition for that diagnosis. We believe that the collection can be done much better as exemplified by the pediatric community, where data collection is very consistent, and there is a low rate of "unknown disease".
  2,513 553 1
LETTERS TO THE EDITOR
Renal biopsy findings in lupus nephritis
Khader N Mustafa, Tariq N Aladily, Maha S Shomaf, Ayman M Wahbeh
July-August 2011, 22(4):815-817
PMID:21743241
  2,514 504 -
CASE REPORTS
ADAMTS-13 deficiency following Hemiscorpius lepturus scorpion sting
Ehsan Valavi, Mohammad Javad Alemzadeh Ansari, Sudabeh Hoseini
July-August 2011, 22(4):792-795
PMID:21743232
Hemiscorpius lepturus is a lethal scorpion with potentially cytotoxic venom. Various degrees of local and systemic toxicity have been observed after its envenomation ranging from local erythema to disseminated intravascular coagulation, renal failure and severe pulmonary hemorrhage. In this case report, we report on a seven-year-old patient who developed the hemolytic uremic syndrome (HUS) after being stung by the scorpion H. lepturus. This condition is characterized by microangiopathic hemolytic anemia, thrombocytopenia, increased serum levels of lactate dehydrogenase and uremia. We evaluated the causes of HUS and found that the levels of C3, C4, CH50 and H factors were normal, but the activity of Von Willebrand factor cleaving protease was decreased (less than 5% of the normal activity). The patient improved after administering therapy with plasma exchange.
  2,534 455 -
ORIGINAL ARTICLES
Growth indices in urinary tract infection children with or without vesicoureteral reflux
Majid Malaki, Sayed Abolhassan Sayedzadeh, Maryam Shoaran
July-August 2011, 22(4):723-726
PMID:21743217
To determine the growth quality in children, less than 5 years of age, affected with urinary tract infection (UTI) and to compare the indices between patients with and without vesico-ureteral reflux (VUR) based on their reflux severity and/or laterality, we studied 106 children less than 5 years of age with UTI at Imam Reza Hospital of Kermanshah, Iran, and divided the study group into four subgroups based on their cystouretrography results as follows: Group 0: without reflux (as control group); Group 1: mild VUR; Group 2: moderate VUR; and Group 3: severe VUR. In all the subgroups, weight height index (WHI) was lower than 100% and was 96%, 93%, 95%, and 98%, respectively. We found no correlation between reflux severity and WHI in all the subgroups. In addition, the difference in the mean height standard deviation score (HSDS) (0.10, -0.12, -0.19, and -0.22, respectively) in the different subgroups was statistically insignificant. The mean WHI in the group with unilateral and bilateral reflux was 94.5% ± 8.9% and 95.0% ± 8.16%, respectively, while the mean HSDS was -0.16 ± 0.35 and -0.18 ± 0.38, respectively, and the difference was statistically insignificant in both the cases. We conclude that in children with UTI and normal glomerular filtration rate, the existence of reflux with all grades of severity and laterality exerts no impact on the growth index.
  2,406 440 1
CASE REPORTS
Cystic renal neoplasm causing hypertension in a 2-year-old child
Suresh Babu, Rajul Agarwal, Kathiresan Narayansamy, Rejiv Rajendranath, Satheesan Balasubramanian
July-August 2011, 22(4):779-781
PMID:21743228
Cystic neoplasms of kidney in pediatric age group include a wide variety of tumors, both of benign and malignant pathology. In a child, renal neoplasms with associated hypertension are rare. Here, we present a 2-year-old child who had a multicystic renal tumor with hypertension. She underwent radical nephrectomy subsequent to which hypertension disappeared. The postoperative pathology revealed multicystic nephroma.
  2,490 347 -
RENAL DATA FROM ASIA-AFRICA
Laparoscopic trans-mesocolic pyeloplasty in children: Initial experience from a center in India
Muneer Khan, Shahnawaz Ahangar, Syed Sajjad Nazir, Syed Javid Farooq Qadri, Nazir Ahmad Salroo
July-August 2011, 22(4):841-846
PMID:21743246
The aim of the present study is to report our experience with laparoscopic pyeloplasty via trans-mesocolic approach in children with left pelvi-ureteric junction (PUJ) obstruction. Between May 2007 and May 2008, 12 children aged between five and 16 years, with documented PUJ obstruction on the left side, underwent laparoscopic pyeloplasty via trans-mesocolic approach. The outcome was assessed by post-operative isotope renal scan. The mean age of the study patients was eight years, ranging between five and 16 years. There were five males and seven females in the study. All children underwent Anderson Hynes Pyeloplasty by a single surgeon. All cases were stented with a JJ stent for a period of six weeks post-operatively. The procedures were completed successfully in all patients without need for conversion to open pyeloplasty in any patient. The mean operative time was 95 min, with a range of 80-140 min. The average blood loss was 57 mL. The mean hospital stay was 3.5 days with a range of 2.5 to six days. All children returned back to school within nine days following surgery. The mean follow-up period was 12 months (range, nine to 14 months). Eleven of the patients were completely asymptomatic, while one reported mild flank pain. All children underwent renal scans and renal ultrasound three months after stent removal. Ten had improved function on the scan while in one patient, the function remained the same and, in another, it showed obstructed response to diuretic, although the symptoms had improved. In all the cases, renal ultrasound showed a decrease in the severity of hydronephrosis by at least one degree. These results confirm that laparoscopic pyeloplasty by trans-mesocolic approach in children for left-sided PUJ obstruction is safe and feasible.
  2,437 352 -
RENAL DATA FROM THE ARAB WORLD
Why does kidney allograft fail? A long-term single-center experience
Sameer Alarrayed, Amgad El-Agroudy, Ahmed Al-Arrayed, Sumaya Ghareeb, Eman Farid, Taysir Garadah, Sadiq Abdulla
July-August 2011, 22(4):818-824
PMID:21743242
We studied the characteristics and the predictors of survival in Bahraini renal transplant recipients with an allograft that functioned for more than 10 years. Seventy-eight patients underwent renal transplantation between 1982 and 1999. Among them, 56 patients maintained functioning allografts for more than 10 years (range 10-30 years). Characteristics of the surviving patients, data on graft survival, and determinants of outcome were obtained by reviewing all medical records. The mean age at time of renal transplantation was 33.6 ± 15.3 years. The source of the graft in 42 (75%) recipients was from living related donors with a mean age of 31.4 ± 7.7 years, and it was the first graft in 48 recipients. The primary immunosuppression regimen consisted of cyclosporine (CsA) and prednisolone. Azathioprine (AZA) was given to 52 (92.9%) recipients, while four patients received steroids and AZA only. Induction therapy was administered to 30 patients in the CsA group. Acute rejection episodes occurred in eight (14.3%) patients, of whom two experienced two episodes. During the last follow-up in January 2010, the mean serum creatinine was 118.3 ± 46.5 μmol/L. A history of cancer was noted in one patient, whereas hypertension was encountered in 54% and diabetes mellitus in 20.5%. We compared the graft functioning group with the graft failure group and found that the independent determinants of long-term graft survival included time of late acute rejection episodes and histopathologic findings of chronic allograft damage, post-transplant hypertension and serum creatinine at one year. We conclude that renal transplantation even in its earliest years and despite the associated numerous complications has provided a ten-year or more of near-normal life to patients with end-stage renal disease.
  2,336 446 2
Acute renal failure in Yemeni patients
Muhamed Al Rohani, Husny Aljawshaei, Elham Aduolimi
July-August 2011, 22(4):829-833
PMID:21743244
Acute renal failure (ARF) is defined as a rapid decrease in the glomerular filtration rate, occurring over a period of hours to days. The Science and Technology University Hospital, Sana'a, is a referral hospital that caters to patients from all parts of Yemen. The aim of this study is to have a deeper overview about the epidemiological status of ARF in Yemeni patients and to identify the major causes of ARF in this country. We studied 203 patients with ARF over a period of 24 months. We found that tropical infectious diseases constituted the major causes of ARF, seen in 45.3% of the patients. Malaria was the most important and dominant infectious disease causing ARF. Hypotension secondary to infection or cardiac failure was seen in 28.6% of the patients. Obstructive nephropathy due to urolithiasis or prostate enlargement was the cause of ARF in a small number of patients. ARF was a part of multi-organ failure in 19.7% of the patients, and was accompanied by a high mortality rate. Majority of the patients were managed conservatively, and only 39.9% required dialysis. Our study suggests that early detection of renal failure helps improve the outcome and return of renal function to normal. Mortality was high in patients with malaria and in those with associated hepatocellular failure.
  2,336 393 2
LETTERS TO THE EDITOR
Mesenteric cavernous hemangioma in a cryptorchid man
Hassan Ahmadnia, Alireza Khooei, Ehsan Mansourian
July-August 2011, 22(4):812-814
PMID:21743240
  2,373 295 -
RENAL DATA FROM THE ARAB WORLD
Acute kidney injury in a teaching hospital in Oman
Farida Balushi, Saif Khan, Dawood Riyami, Mohammed Ghilaini, Mahfooz Farooqui
July-August 2011, 22(4):825-828
PMID:21743243
To determine the incidence, etiology and outcome of acute kidney injury (AKI) at a teaching hospital in Oman, we studied all adult cases that developed AKI at our hospital from July 2006 to June 2007. Data from the hospital information system (HIS) for all adult admissions in the wards and intensive care units for the study period were obtained, and included baseline serum creatinine, serum creatinine on the day of diagnosis, peak serum creatinine, urine output in the last six and 12 hours at the time of diagnosis, etiology of acute renal failure, presence of any co-morbid conditions, and renal replacement therapy and outcome. Of the 19,738 adult admissions, there were 108 episodes of AKI in 100 patients. The incidence of acute renal failure was 0.54%. The etiology of AKI was pre-renal in 55 (50.9%), obstructive in 5 (4.6%) and acute tubular necrosis (ATN) in the remaining 48 (44.4%) patients. Renal replacement therapy (RRT) was required in 24.1% of cases. Of the patients who developed AKI, 36 (33.33%) died during same hospital admission, 37 (34.26%) recovered to discharge with no renal impairment, 32 (29.63%) recovered with residual renal impairment and 2 (1.85%) recovered with dialysis dependence.
  2,222 440 -
ORIGINAL ARTICLES
Prognosis of HTLV-1 positive renal transplant recipients in Iran
Orode Naghibi, Fatemeh Nazemian, Massih Naghibi, DB Ali Javidi
July-August 2011, 22(4):670-674
PMID:21743209
The human T lymphocyte virus-1 (HTLV-1) is the responsible pathogen for diseases such as HTLV-1 associated myelopathy (HAM) and adult T-cell leukemia (ATL). Mashhad, in northeast Iran, with high instances of this infection, has a noticeable number of infected renal failure patients. Since immunosuppressive drugs might decrease the latency period of HTLV-1 or increase its complications, the question arises whether HTLV-1 positive renal failure patients are suitable candidates for kidney transplants. To answer this, HTLV-1 positive recipients were evaluated in our study. Patients were divided into two groups. First group consisted of patients at the Imam Reza Hospital dialysis center. Second group had 20 kidney transplantation recipients consisting of ten infected and ten uninfected recipients as control from Imam Reza. Medical history of these patients was recorded and evaluated. The follow-up periods were between one and six years. Among them, 3.8% of patients undergoing dialysis were infected. The most important fact resulting from this study is that none of the infected recipients suffered from HAM or ATL during the follow-up period. In addition, it did not show any significant difference in the incidence of post-transplant complications between the infected and non-infected groups. Our study indicates that HTLV-1 positive patients may undergo kidney transplant without fear of increased incidence of side effects than those found in uninfected recipients. Because of short-term follow-up, probable long latency period of the virus, and the limited number of infected recipients, further work on this issue would be prudent.
  2,177 456 1
CASE REPORTS
Hemodialysis catheter related rhodococcus bacteremia in immunocompetent host
Pranav Dalal, Twinkal Dalal, Gaurav Shah
July-August 2011, 22(4):761-763
PMID:21743224
Rhodococcus equi (R. equi) is an uncommon cause of infection in immunocompetent individuals. We describe a case of R. equi bacteremia associated with hemodialysis (HD) catheter in an immunocompetent patient. A 38-year-old female with end-stage renal disease (ESRD) of uncertain etiology, on HD for the past 15 months who was previously healthy otherwise, was admitted with the complaints of intermittent fever, mild nausea and occasional vomiting for two weeks. Last HD was performed four days earlier through a tunneled right internal jugular permacath. Clinically the patient was afebrile and in no acute distress. She was hemodynamically stable with no peripheral stigmata of an endovascular infection. Physical examination was essentially normal. Initially, the patient was treated with intravenous vancomycin with each HD, retaining the catheter. However, due to persistently positive blood cultures, HD catheter had to be removed. The patient became afebrile and nausea and vomiting resolved. She improved clinically, and repeated surveillance blood cultures done after the removal of catheter were reported negative. Subsequently, a new HD catheter was inserted for her. Although R. equi is an uncommon cause of infection in immunocompetent individuals, it does occur with considerable mortality and morbidity, and a high index of clinical suspicion is required to recognize this infection in immunocompetent individuals.
  2,065 355 -
LETTERS TO THE EDITOR
Hypophosphatemia in peritoneal dialysis patients
Mohammadreza Ardalan, Nazli Azabdaftari, Hamid Noshad, Mohammadali Mohajel Shoja
July-August 2011, 22(4):810-811
PMID:21743239
  2,018 346 1
Effect of post-transplant weight at one year on renal allograft function
MR Gumber, SH Jain, VB Kute, MS Gireesh, PR Shah, HV Patel, KR Goplani, AV Vanikar, HL Trivedi
July-August 2011, 22(4):799-801
PMID:21743234
  1,804 343 -
A page in transplantation
Okidi Okechukwu, Sunil Reddy, Sandeep Guleria
July-August 2011, 22(4):796-798
PMID:21743233
  1,751 249 -
Epidemiology of hepatitis C in the Middle East: All available data
Seyed Moayed Alavian, Seyed Yasser Saiedi, Seyed-Hosein Alaei
July-August 2011, 22(4):808-809
PMID:21743238
  1,530 338 1
SCOT DATA
Dialysis in the Kingdom of Saudi Arabia

July-August 2011, 22(4):853-861
  1,600 246 -
LETTERS TO THE EDITOR
The seroprevalence of anti-HCV in high-risk dialysis patients
Salem A Bin Selm
July-August 2011, 22(4):806-807
PMID:21743237
  1,551 279 -
Tumor marker and hemodialysis
Viroj Wiwanitkit
July-August 2011, 22(4):805-805
PMID:21743236
  1,275 296 -
Author's Reply
Farahnaz Fallahian
July-August 2011, 22(4):809-809
  898 171 -
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