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Saudi Journal of Kidney Diseases and Transplantation
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   2013| March-April  | Volume 24 | Issue 2  
    Online since March 26, 2013

 
 
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ORIGINAL ARTICLES
Predictors of quality of life in hemodialysis patients
Magda Bayoumi, Ali Al Harbi, Abdulkareem Al Suwaida, Mohammed Al Ghonaim, Jamal Al Wakeel, Adel Mishkiry
March-April 2013, 24(2):254-259
DOI:10.4103/1319-2442.109566  PMID:23538347
Quality of Life (QoL) is a consistent and powerful predictor that affects the out-come in end-stage renal disease (ESRD) patients on dialysis. This study was undertaken to identify the factors that might predict QoL scores among ESRD patients on hemodialysis (HD). The study was conducted at three HD units in Saudi Arabia from January 2007 to January 2008. We studied 100 HD patients (53 males and 47 females) and used the SF-36 and KDQoL-SF forms covering six domains of QoL, namely physical, emotional, social, illness impact, medical and financial satisfaction, and overall general health. The mean age of the study patients was 47.5 ± 13.8 years and the mean duration of dialysis was 77.2 ± 75.5 months. The QoL scores were 45.8 ± 17.1 for general health, 53.1 ± 32.0 for physical QoL, 50.5 ± 14.8 for emotional QoL, 54.9 ± 18.1 for social QoL, 46.5 ± 13.7 for illness impact, and 45.9 ± 12.2 for the medical and financial domain. The total QoL score was 49.5 ± 13.7. The male patients had statistically significantly reduced QoL and younger patients had better QoL scores. The QoL scores revealed a decreasing trend with decreasing level of education; they were elevated among employed patients. Multiple linear regression analysis demonstrated that age, dialysis duration, and male sex were negative predictors of QoL score. We conclude from our study that QoL is reduced in all the health domains of HD patients. Older age, male gender, unemployment, and duration of dialysis adversely affected the QoL scores. Adequate management of some of these factors could influence patient outcomes.
  5 4,844 1,253
RENAL DATA FROM THE ARAB WORLD
Progression of diabetic nephropathy, risk of end-stage renal disease and mortality in patients with type-1 diabetes
Yassamine Bentata, Intissar Haddiya, Hanane Latrech, Kalid Serraj, Redouane Abouqal
March-April 2013, 24(2):392-402
DOI:10.4103/1319-2442.109617  PMID:23538374
Numerous studies have shown that diabetic nephropathy (DNP) is associated with an elevated risk of progression toward end-stage renal disease (ESRD) as well as increased cardiovascular mortality. The majority of these studies are from the developed countries. The factors leading to the progression of DNP may not be quite the same in the developing countries. The aim of this study was to evaluate the risk factors of progression toward ESRD and mortality among type-1 diabetes (T1D) patients with DNP in a developing country. This prospective study was conducted enrolling 72 patients with T1D in September 2006, including T1D patients with DNP defined as microalbuminuria, proteinuria, and/or renal failure, and following them up for five years. The mean age was 29.5±7.5 years with a mean duration of diabetes of 17 (11-20) years. At the time of enrollment, 43.1% had arterial hypertension, 69.4% had proliferative retinopathy, 44.4 had clinical neuropathy, 25% lived in rural areas, and 51.4% had macroalbuminuria. Progression toward ESRD was observed in 34.7% of cases. In multivariate analysis, diastolic blood pressure (P = 0.006) and blood hemoglobin (P = 0.003) were identified as the risk factors associated with ESRD. Death occurred in 18.3% of cases, including 92.3% on hemodialysis with a median hemodialysis duration of six (1-60) months. In multivariate analysis, the ESRD was identified as risk factor for death (P <0.001). DNP due to T1D remains a disease involving a heavy burden of morbi-mortality and is difficult to manage in a developing country because of the low socioeconomic level of patients and the lack of reliable epidemiological data.
  3 3,228 729
CASE REPORTS
Cytomegalovirus ischemic colitis and transverse myelitis in a renal transplant recipient
Imen Gorsane, Sabra Aloui, Ahmed Letaif, Rim Hadhri, Faouzi Haouala, Ameur Frih, Naceur Ben Dhia, Mezri Elmay, Habib Skhiri
March-April 2013, 24(2):309-314
DOI:10.4103/1319-2442.109588  PMID:23538355
We report a rare case of cytomegalovirus (CMV)-associated ischemic colitis and transverse myelitis (TM) occurring precociously after renal transplantation. A 57-year-old male was transplanted with a cadaveric kidney on 5 June 2009. The patient was CMV seropositive and the donor was seronegative. Transplantation was followed shortly by TM, which resulted in paraplegia. The results of magnetic resonance imaging of the spinal cord showed abnormalities. Twenty days after transplantation, he developed abdominal pain with malena and was diagnosed as having CMV-associated ischemic colitis confirmed by colonoscopy and biopsy. Serological data and identification of the viral genome by polymerase chain reaction were confirmatory for CMV. Treatment consisted of intravenous ganciclovir, followed by polyvalent immunoglobulin. The outcome was favorable. Symptomatic CMV infection is relatively common among the renal transplant population. Early colonoscopy is beneficial for making a quick diagnosis and therefore helps to institute a prompt management of CMV colitis. Myelitis is less common in transplant recipients and diagnosis, therefore, was more difficult.
  2 2,128 428
Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC): Report of three cases with a novel mutation in CLDN19 gene
Amar Al-Shibli, Martin Konrad, Waleed Altay, Omar Al Masri, Lihad Al-Gazali, Ibrahim Al Attrach
March-April 2013, 24(2):338-344
DOI:10.4103/1319-2442.109601  PMID:23538362
Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC) is a rare autosomal recessive disorder that is caused by mutation in the genes coding for tight junction proteins Claudin-16 and Claudin-19. Affected individuals usually develop nephrocalcinosis and progressive renal failure; some of them may have ophthalmologic involvement as well. Phenotypic description of three affected individuals from the same Middle Eastern kindred (two sisters and their cousin) is presented. This includes both clinical and laboratory findings upon initial presentation and subsequent follow-up. Molecular analysis of the CLDN19 gene was performed on the three cases and one set of parents. A novel homozygous missense mutation in CLDN19 (c.241C>T, p.Arg81Cys) was detected in all three affected children. The parents were heterozygous. Clinical and laboratory data in the three children with renal and ocular manifestations of FHHNC are described. Genetic analysis revealed a novel mutation in the CLDN19 gene. FHHNC is a rare cause of nephrocalcinosis, and we believe that it should be considered in the presence of nephrocalcinosis with hypercalcuria and hypermagnesuria.
  2 3,367 633
ORIGINAL ARTICLES
Pseudo-bartter syndrome, pattern and correlation with other cystic fibrosis features
Muna M Dahabreh, Abdelhamid S Najada
March-April 2013, 24(2):292-296
DOI:10.4103/1319-2442.109579  PMID:23538352
Pseudo-Bartter Syndrome (PBS), although quite common in patients with cystic fibrosis (CF), is often missed as simple dehydration or Bartter syndrome. This study was performed in patients with PBS to compare the pattern and course of the disease with those with CF not manifesting with this syndrome. All patients with CF who attended the respiratory clinic at Queen Rania Al-Abdallah Hospital from January 2000 to April 2010 were included in this retrospective case-control study. A specially formulated data sheet was used and those with PBS and those not having the syndrome were identified. A total of 110 patients (51% female) with CF with a median age of seven years were followed-up. Eighteen (16.3%) of them had one or more episodes of PBS. The median follow-up period was 6.2 years. All the episodes occurred during summer and in infancy. Median age of the initial episode of PBS was three months. One-third of them were initially followed at the nephrology clinic. Three patterns of PBS were identified: single episode in three (16.6%) patients, recurrent in 12 (66.6%) patients and chronic in three (16.6%) patients. Early colonization of Pseudomonas spp before 1 st birthday was seen in 44% patients with PBS compared with 12% in other CF patients (P-value = 0.0075). The total number of colonized patients and other CF features at the time of the study did not differ significantly among patients, although the mean Shwachman-Kulczycki score is significantly lower in those with recurrent PBS (69 compared with 85 in other CF patients). Gene mutation was identified in only 30% of the entire cohort. PBS is common in patients with CF, and it should be kept in mind in any patient with hypotonic dehydration and metabolic alkalosis. Recurrent pattern is associated with earlier Pseudomonas colonization.
  2 3,967 9,556
Glycated albumin versus glycated hemoglobin as glycemic indicator in hemodialysis patients with diabetes mellitus: Variables that influence
Dawlat Sany, Yasser Elshahawy, Walid Anwar
March-April 2013, 24(2):260-273
DOI:10.4103/1319-2442.109568  PMID:23538348
The significance of glycated albumin (GA) compared with casual plasma glucose (PG) and glycated hemoglobin (HbA1c) was evaluated as an indicator of the glycemic control state in hemodialysis (HD) patients with diabetes. In HD patients with diabetes (n = 25), the mean PG, GA and HbA1c levels were 192.9 + 23 mg/dL, 278.8 + 43 μmol/L and 5.9 + 0.5%, respectively, which were higher by 43.9%, 67.04% and 18%, respectively, compared with HD patients without diabetes (n = 25). HbA1c levels were significantly lower than simultaneous PG and GA values in those patients in comparison with the three parameters in patients who had diabetes without renal dysfunction (n = 25). A significant negative correlation was found between GA and serum albumin (r = 0.21, P <0.05) in HD patients with diabetes, whereas HbA1c correlated positively and negatively with hemoglobin (r = 0.11, P <0.01) and weekly dose of erythropoietin injection (r = -0.19, P < 0.01), respectively. Although PG and GA did not differ significantly between HD patients with diabetes and with and without erythropoietin injection, HbA1c levels were significantly higher in patients without erythropoietin. Categorization of glycemic control into arbitrary quartiles by GA level led to better glycemic control in a significantly higher proportion of HD patients with diabetes than those assessed by HA1c. Multiple regression analysis demonstrated that hemoglobin in addition to PG emerged as an independent factor associated with HbA1c in HD patients with diabetes, while PG, body mass index and albumin were an independent factor associated with GA. Conclusion: it is suggested that GA provides a significantly better measure to estimate glycemic control in HD patients with diabetes and that the assessment of glycemic control by HbA1c in these patients might lead to likely underestimation as a result of the increasing proportion of young erythrocyte by the use of erythropoietin.
  2 4,484 1,326
The clinical factors' prediction of increased intradialytic qt dispersion on the electrocardiograms of chronic hemodialysis patients
Dina Oktavia, Suhardjono , Sally Aman Nasution, Siti Setiati
March-April 2013, 24(2):274-280
DOI:10.4103/1319-2442.109571  PMID:23538349
Ventricular arrhythmias and sudden death are common in patients on maintenance hemodialysis (HD). The increase in QT dispersion (QTd) on the electrocardiogram (ECG) reflects increased tendency for ventricular repolarization that predisposes to arrhythmias. The purpose of the study was to identify the clinical factors that may predict the increased intradialytic QTd and to assess differences in QTd before and after HD. Each of 61 chronic HD patients underwent 12-lead ECG and blood pressure (BP) measurement before and every 1 h during a single HD session. The QT intervals were corrected for heart rate using Bazett's formula. Intradialytic QTd increased in 30 (49%) patients. There was no correlation between the increased QTd and the clinical factors including hypertension, pulse pressure, intradialytic hypotension, left ventricular hypertrophy, old myocardial infarct, diabetes mellitus, and nutritional status. The means of QT interval and QTd increased after HD session (from 382 ± 29 to 444 ± 26 ms, P <0.05; and from 74 ± 21 to 114 ± 53 ms, respectively, P <0.05). We conclude that the increased intradialytic QTd could not be predicted by any of the clinical factors evaluated in this study. There was significant difference in the means of QTd before and after HD session.
  1 1,824 418
Risk factors and consequences of delayed graft function
Mondher Ounissi, Mejda Cherif, Taieb Ben Abdallah, Mongi Bacha, Hafedh Hedri, Ezzedine Abderrahim, Rym Goucha, Adel Kheder, Riadh Ben Slama, Amine Derouiche, Mohamed Chebil, Rafika Bardi, Imen Sfar, Yosr Gorgi
March-April 2013, 24(2):243-246
DOI:10.4103/1319-2442.109564  PMID:23538345
The impact of delayed graft function (DGF) on the outcome of renal transplantation remains controversial. We analyzed the risk factors for DGF and its impact on graft and patient survival. A total of 354 renal transplants performed between June 1986 and April 2000 were analyzed. Variables analyzed included donor and recipient age, method and duration of renal replacement therapy, HLA mismatch, cold and warm ischemia times, biopsy-confirmed acute rejection, length of stay in the hospital, serum creatinine at the end of first hospitalization as well as graft and patient survival at one, three, five and ten years. The study patients were divided into two groups: patients with DGF (G1) and those without DGF (G2). DGF occurred in 50 patients (14.1%), and it was seen more frequently in patients transplanted from deceased donors (60% vs. 40%, P <0.0001). The cause of DGF was acute tubular necrosis, seen in 98% of the cases. Univariate analysis showed a statistically significant difference between the two groups G1 and G2 in the following parameters: average duration on dialysis (52.3 vs. 36.4 months, P = 0.006), HLA mismatch (44.9% vs. 32.11% P = 0.015), donor age (35.9 vs. 40.2 years, P = 0.026), cold ischemia time (23 vs. 18.2 h, P = 0.0016), warm ischemia time (41.9 vs. 38.6 mn, P = 0.046), length of stay in the hospital during first hospitalization (54.7 vs. 33.2 days, P <0.0001), serum creatinine at the end of first hospitalization (140 vs. 112 μmol/L, P <0.0001) and at three months following transplantation (159 vs. 119 μmol/L, P = 0.0002). Multivariate analysis revealed the following independent risk factors for DGF: deceased donor (RR = 13.2, P <0.0001) and cold ischemia time (RR = 1.17, P = 0.008). The graft survival at one, three, five and ten years was 100%, 93%, 88.3% and 78.3% in G1 versus 100%, 95.9% 92.8% and 82.3% in G2; there was no statistically significant difference. The patient survival at one, three, five and ten years was 100%, 91.3%, 83.6% and 74.4% in G1 versus 100%, 95.9%, 94% and 82.6% in G2 with a statistically significant difference (P = 0.04). Prolonged cold ischemia time and transplantation of kidneys from deceased donors were the main risk factors for DGF in our study. Also, DGF significantly affected patient survival but had no influence on graft survival.
  1 2,697 636
Value of sonography in the diagnosis of mild, moderate and severe vesicoureteral reflux in children
Atoosa Adibi, Alaleh Gheysari, Afshin Azhir, Ali Merikhi, Salmam Khami, Nazila Tayari
March-April 2013, 24(2):297-302
DOI:10.4103/1319-2442.109582  PMID:23538353
This study was conducted to determine the positive predictive value (PPV) of gray scale sonography in the diagnosis of mild, moderate and severe vesicoureteral reflux (VUR). This cross-sectional descriptive analytic study was conducted in the University Clinic of Isfahan University of Medical Sciences in 2008. The study was performed on children aged two to 12 years; female children with febrile urinary tract infection (UTI) and clinical suspicion of VUR and males with history of UTI and VUR who attended follow-up during the six months study period were selected. Non-cooperative patients were excluded from the study. A total of 90 patients were studied. The data gathering method was sequential. The following sonographic parameters were assessed in all the study patients: antero-posterior pelvic diameter, distal ureteric diameter and stasis of urinary system, which were measured at rest and during and after the Valsalva maneuver. Also, the vesicoureteral junction distance and distance of vesicoureteral junction to the midline were measured on both sides at rest. We then referred them for radionuclide cystography (RNC) and the results of the two methods were compared. Data were analyzed with SPSS program and t-test and chi square formulas were used. The sensitivity of ultrasound in the diagnosis of VUR was 70.9% and the specificity was 51.4%. Thus, the PPV was 69.64% and the negative predictive value was 52.94%. Although the most definite diagnosis of VUR is made with micrurating cystoureterography or RNC, sonography may be used as the first step in evaluation for VUR, especially in high-grade VUR.
  1 2,655 559
RENAL DATA FROM ASIA-AFRICA
Acute renal failure in children in a tertiary care center
Malobika Bhattacharya, Dhulika Dhingra, Mukta Mantan, Sukesh Upare, Gulshan Rai Sethi
March-April 2013, 24(2):413-417
DOI:10.4103/1319-2442.109620  PMID:23538377
In this retrospective study, records of all patients aged one month to 12 years who presented with acute renal failure (ARF) between May 2005 and August 2010 were retrieved. Clinical details, biochemistry, need for renal replacement therapy (RRT), cause of ARF and outcome at discharge were recorded. During this period, 230 children presented with ARF; their median age at presentation was 30 months (range: five-144 months); 120 (52.2%) were males. The causes of ARF were acute tubular necrosis (ATN) in 121 (52.6%), glomerular disorders in 5.7%, structural anomalies of the urinary tract in 9.6% and hemolytic uremic syndrome in 27 (11.7%). The mean duration of hospital stay was 17.8 ± 7.6 days. RRT was required for 54 patients (23.6%); peritoneal dialysis in 49 and hemodialysis in five patients. Complete recovery was noted in 99 study patients (43.2%) and sequelae remained in 84 patients (36.7%). Forty-six patients (20.1%) with ARF died. ATN secondary to septicemia was the most common cause of ARF in our study.
  1 2,080 520
Bacteriological study and structural composition of staghorn stones removed by the anatrophic nephrolithotomic procedure
Hamid Shafi, Zahra Shahandeh, Behzad Heidari, Farahnaz Sedigiani, Arsalan Ali Ramaji, Yousef Reza Yousefnia Pasha, Ali Akbar Kassaeian, Abazar Akbarzadeh Pasha, Mir Muhammad Reza Aghajani Mir
March-April 2013, 24(2):418-423
DOI:10.4103/1319-2442.109623  PMID:23538378
This study was conducted to determine the composition of staghorn stones and to assess the proportion of infected stones as well as the correlation between infection in the stones and bacteria grown in urine. Samples of 45 consecutive stones removed through anatrophic nephrolithotomic procedures were taken from the operation site and samples of urine were obtained by simultaneous bladder catheterization. The frequency of infection in the stones and correlation between infection of stone and urine samples were determined with respect to the composition of the stones. Twenty-two males and 23 females, with respective mean ages of 48.3 ± 15.6 years and 51 ± 7.4 years, were studied. The stone and urine cultures yielded positive results in ten and 16 patients, respectively, of a total of 45 patients (22.2% and 35.5%, respectively). Calcium oxalate was the main constituent of staghorn stones, seen in 31 patients (68.8%), uric acid in 12 patients (26.6%) and struvite and/or calcium phosphate in 11 patients (24.4%). In seven of ten stones with bacterial growth, bacteria were isolated from urine cultures as well, which accounted for a concordance rate of 70%. The bacteria grown in the stone were the cause of urinary tract infection (UTI) in 43.5% of the cases. Stone infection was significantly associated with UTI (OR = 6.47; 95% CI 1.43-31.7, P = 0.021) and presence of phosphate in the stones (OR = 18, 95% CI 3.28-99.6, P = 0.0006). E. coli was the most common bacteria grown from the stones, and was isolated in 50% of the cases; Ureaplasma urealyticum was the most common organism causing UTI, grown in 62.5% of the urine samples. There was a high concordance rate between bacteria in the stones and urine. These findings indicate that the urine culture can provide information for selection of an appropriate anti-microbial agent for stone sterilization. In addition, preventing re-growth or recurrence of stones and treatment of post-surgical infections would be facilitated based on the results of the urine culture.
  1 4,505 784
REVIEW ARTICLES
Autosomal dominant polycystic kidney disease: New insights into treatment
Imed Helal
March-April 2013, 24(2):230-234
DOI:10.4103/1319-2442.109561  PMID:23538343
Autosomal dominant polycystic kidney disease (ADPKD) is the world's most common inherited kidney disease. An increasing number of animal and human studies have enhanced our understanding of the molecular and cellular pathology of ADPKD. New treatment options are being tested in clinical trials in spite of the failure of mammalian target of rapamycin inhibitor therapy. The main and most effective therapy remains control of hypertension by renin-angiotensin-aldosterone system (RAAS) blockade. This review focuses only on promising therapies, including dual inhibition of RAAS, vasopressin receptor antagonists, increased fluid intake, and blockade of certain receptors of cyclic adenosine monophosphate. Also, the paper reviews what these advances mean to patients and clinicians and elaborates on how these changes can be immediately applied to clinical practice. There is an urgent need for discovery of new therapies targeted toward ADPKD in comparison with therapeutic progress of all other renal diseases.
  1 5,738 1,480
CASE REPORTS
Candida lung abscesses in a renal transplant recipient
Ankur Gupta, Dipankar M Bhowmik, Pavitra M Dogra, Satish Mendonca, Amit Gupta
March-April 2013, 24(2):315-317
DOI:10.4103/1319-2442.109589  PMID:23538356
We herein report a renal allograft recipient five years post transplant who had bilateral lung abscesses. The abscess grew Candida tropicalis on bronchoalveolar lavage. The patient was administered amphotericin B, but succumbed to massive hemoptysis. The case highlights a fungal complication in renal transplant and need for early suspicion and prompt therapy.
  - 1,610 349
Renal transplant in a tuberous sclerosis patient with bilateral giant renal angiomyolipomas and concurrent renal carcinoma
Manzoor Hussain, Muhammed Mubarak, Gohar Sultan, Ejaz Ahmed, Mahira Yunus, Mirza Ali Salehi, Muhammad Asif, Syed A. A. Anwer Naqvi, Syed A. H. Rizvi
March-April 2013, 24(2):318-321
DOI:10.4103/1319-2442.109591  PMID:23538357
Co-existence of angiomyolipoma (AML) and renal cell carcinoma (RCC) in the same tumor mass is very rare and only eight cases have been reported. We present a case of a young female with tuberous sclerosis complex (TSC) with bilateral huge renal AMLs. Both tumors were removed, one of which revealed co-incidental RCC. She was subsequently successfully transplanted a kidney from her brother and is maintaining normal graft function eight months post-transplant. No recurrence or metastases of RCC has been detected till the last follow-up.
  - 2,354 384
Hemodialysis treatment on an adult patient with down syndrome associated with ectopic right kidney chronic obstructive nephropathy and secondary amyloidosis
George Kosmadakis, Despoina Smirloglou, Athina Gobou, Theodoros Draganis, Spyridon Michail
March-April 2013, 24(2):322-325
DOI:10.4103/1319-2442.109593  PMID:23538358
In the present report, we describe an unusual case of an adult patient with Down syndrome and ectopic right kidney, who developed end-stage renal disease due to chronic obstructive nephropathy and secondary amyloidosis and was successfully treated with hemodialysis.
  - 2,020 267
Delayed compartment syndrome following brachiocephalic arteriovenous fistula formation in a hemodialysis patient
Sammy Al-Benna, Haussam Elenin
March-April 2013, 24(2):326-329
DOI:10.4103/1319-2442.109595  PMID:23538359
Delayed compartment syndrome following the surgical creation of an arteriovenous fistula (AVF) for vascular access is rare. A 71-year-old male patient experienced left anterior forearm compartment syndrome caused by a brachiocephalic AVF. The fistula failed after five days. Immediate radiological de-clotting failed and the thrombosed fistula was de-clotted with the help of a Fogarty balloon. On Day 11, the patient developed symptoms and signs of acute anterior forearm compartment syndrome and underwent immediate surgical decompression of the superficial and deep flexor compartments, which resulted in an excellent outcome. Iatrogenic forearm compartment syndrome is a rare but potential complication after creation of AVF. The critical errors regarding compartment syndrome are failure to recognize or failure to act. This case report illustrates that swift diagnosis and immediate surgical intervention results in an excellent outcome and avoids the morbidity associated with this potentially devastating and debilitating process.
  - 2,281 299
Rhabdomyolysis and acute renal failure following prolonged surgery in the lithotomy position
Adnane Guella, Ibrahim Al Oraifi
March-April 2013, 24(2):330-332
DOI:10.4103/1319-2442.109597  PMID:23538360
Operative positions commonly used in urogenital surgeries when perineal exposure is required include the lithotomy and the exaggerated lithotomy positions (LPs), which expose patients to the risk of rhabdomyolysis. We report a patient with bladder outflow obstruction, benign prostatic hypertrophy and a very large bladder stone, which was removed with cystoscopy and cystolitholapaxy in the LP. The procedure was complicated by posterior bladder perforation and abdominal distention leading to prolonged surgery duration (5.5 h). The patient developed rhabdomyolysis and acute renal failure (ARF) without compartmental syndrome. On the other hand, there was a potential role of glycine solution, used for bladder irrigation, in the appearance of ARF. Overall, our case shows that rhabdomyolysis and ARF can develop in operative positions, and duration of surgery is the most important risk factor for such complications.
  - 2,775 443
Crescentic glomerulonephritis developing in the course of idiopathic membranoproliferative glomerulonephritis
Alok Sharma, Ruchika Gupta, Charanjit Lal, Sanjay K Agarwal, Amit K Dinda
March-April 2013, 24(2):333-337
DOI:10.4103/1319-2442.109599  PMID:23538361
Membranoproliferative glomerulonephritis (MPGN) is a rare cause of the nephrotic syndrome in adults and children. Though small focal crescents may be seen in up to 10% of cases of MPGN, the presence of more than 50% crescents (crescentic MPGN) is rare. Very few cases of crescentic transformation of MPGN, documented by subsequent renal biopsies, have been described in the literature. A young female patient underwent kidney biopsy for the nephrotic-nephritic syndrome and was diagnosed as idiopathic MPGN. She was administered immunosuppressive therapy (steroids and cyclophosphamide), with which her renal functions stabilized. Six months later, she presented with features suggestive of rapidly progressive renal failure and underwent a second renal biopsy. The second biopsy showed crescentic glomerulonephritis with immune complex deposition, suggestive of MPGN. A final diagnosis of crescentic transformation of MPGN was made. Crescentic transformation of MPGN is a rare occurrence, but needs to be considered in a patient diagnosed as MPGN and presenting with rapidly progressive renal failure. The cause of such transformation remains to be elucidated.
  - 2,179 445
LETTERS TO THE EDITOR
Effect on early graft function of high-dose desmopressin in transplant recipients with bleeding disorders
Despoina Tramma, Catherine O'Brien, Sally-Anne Hulton
March-April 2013, 24(2):364-365
DOI:10.4103/1319-2442.109604  PMID:23538365
  - 1,680 258
The risk factors of anemia after kidney transplantation
Zohreh Rostami, Behzad Einollahi
March-April 2013, 24(2):366-367
DOI:10.4103/1319-2442.109605  PMID:23538366
  - 866 237
Author's reply
Dawlat Sany
March-April 2013, 24(2):367-369
  - 470 116
Impact of hemodialysis session on endothelial function and oxidative stress - evaluation in maintenance hemodialysis
Gangadhar Taduri, Dakshinamurty Kaligotla Venkata, Vijay Kumar Kutala, Naidu Mur
March-April 2013, 24(2):370-372
DOI:10.4103/1319-2442.109608  PMID:23538367
  - 1,108 251
Accidental placement of the continuous ambulatory peritoneal dialysis catheter into the urinary bladder
Syed Aijaz Nasir, M Ashraf Bhat, Muzafar M Wani, Syed Tufail, Imtiyaz A Wani, Suhail Mantoo
March-April 2013, 24(2):373-375
DOI:10.4103/1319-2442.109609  PMID:23538368
  - 1,767 343
Deciphering Alport syndrome
Dilip Gude, Sashidhar Chennamsetty, Ratan Jha
March-April 2013, 24(2):376-378
DOI:10.4103/1319-2442.109611  PMID:23538369
  - 1,169 374
Renal school: Dubai experience
Fakhriya Alalawi, Hind Alnour, Amna Al Hadari, Mona Al Rukhaimi
March-April 2013, 24(2):379-381
DOI:10.4103/1319-2442.109612  PMID:23538370
  - 1,113 220
Inappropriate use of urinary catheter and its common complications in different hospital wards
Mohd. Nazli Kamarulzaman
March-April 2013, 24(2):382-383
DOI:10.4103/1319-2442.109614  PMID:23538371
  - 1,468 380
Takayasu's arteritis presenting as renovascular hypertension
Gioacchino Li Cavoli, Calogera Tortorici, Luisa Bono, Angelo Ferrantelli, Carlo Giammarresi, Ugo Rotolo
March-April 2013, 24(2):384-386
DOI:10.4103/1319-2442.109615  PMID:23538372
  - 1,705 358
ORIGINAL ARTICLES
Acute renal failure associated with malaria in children
Syed Ahmed Zaki, Prithi Shenoy, Preeti Shanbag, Anupama Mauskar, Asmita Patil, Leena Nagotkar
March-April 2013, 24(2):303-308
DOI:10.4103/1319-2442.109585  PMID:23538354
Acute renal failure is one of the serious complications of malaria with untoward consequences including increased risk of mortality. This study was conducted to evaluate the incidence, clinical features, course, outcome, and predictors of mortality of acute renal failure (ARF) in children with malaria in the pediatric general wards and intensive care unit of our medical center from 1 January 2009 to 31 December 2009. Data of all children from 1 month to 12 years of age with confirmed malaria either on peripheral smear and/or OptiMal test were reviewed. Those suffering from ARF were selected for further study. Twelve (eight Plasmodium falciparum; three Plasmodium vivax, and one mixed infection) out of 227 (5%) cases of confirmed malaria had ARF. In addition to ARF, most of the patients had at least one other manifestation of severe malaria. Nine (75%) patients recovered completely, while 3 (25%) died. Presence of associated cerebral malaria, hyperbilirubinemia, and disseminated intravascular coagulopathy (DIC) was a poor prognostic factor and predictor of mortality. In conclusion, ARF can complicate both P. falciparum and P. vivax malaria. Malarial ARF as an isolated complication has a good prognosis. The presence of multiorgan involvement and delayed diagnosis increases morbidity and mortality.
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Post-transplantation lymphoproliferative disorders (PTLD) localized in the central nervous system: Report from an international survey on PTLD
Hossein Khedmat, Saeed Taheri
March-April 2013, 24(2):235-242
DOI:10.4103/1319-2442.109563  PMID:23538344
Post-transplantation lymphoproliferative disorders (PTLD) localized to the central nervous system (CNS) is a rare but potentially fatal side-effect of immunosuppression for organ transplantation. Till now, to the best of our knowledge, the total number of such cases reported worldwide is less than 100. In this survey, we collected the data of PTLD localized to the CNS (CNS-PTLD) and compared this data with other PTLD patients with localizations to other areas serving as the control group. A comprehensive search was performed for studies reporting CNS-PTLD data in the Pubmed and Google scholar search engines. Finally, international data from 21 different studies were included in the analysis. Overall, 367 patients were entered into analysis. Organ recipients with CNS-PTLD had comparable gender make up, lymphoma cell types, Epstein-Barr virus infection rate, remission and mortality rates, with PTLD patients having other localizations. Multiorgan involvement as well as disseminated lymphoma were significantly more prevalent in the control group (P <0.05). At the last follow-up, 192 (60%) patients were dead (47 missing data). Irrespective of whether the overall death or only death due to PTLD was used as the final outcome, we found that the survival rates were similar for patients of the two groups (P = 0.895). Renal transplant recipients are at greater risk for developing CNS involvement by PTLD, while heart and liver recipients represent significant lower risks for the same. This study showed that PTLD patients who had CNS presentation have quite a comparable outcome compared with those with other areas of localization. However, further prospective studies are needed for reaffirming our findings.
  - 2,457 676
The new technique of using the epigastric arteries in renal transplantation with multiple renal arteries
Mohammad Ali Amirzargar, Hooshang Babolhavaeji, Shahriar Amir Hosseini, HabibMousavi Bahar, Mahmood Gholyaf, Farahnaz Dadras, Farhad Khoshjoo, Mahnaz Yavangi, Nasibeh Amirzargar
March-April 2013, 24(2):247-253
DOI:10.4103/1319-2442.109565  PMID:23538346
The most common anatomic variant seen in the donor kidneys for renal transplantation is multiple renal arteries (MRA), which can cause an increased risk of complications. We describe the long-term outcomes of 16 years of experience in 76 kidney transplantations with MRAs. In a new reconstruction technique, we remove arterial clamps after anastomosing the donor to the recipient's main renal vessels, which cause backflow from accessory arteries to prevent thrombosis. By this technique, we reduce the ischemic times as well as the operating times. Both in live or cadaver donor kidneys, lower polar arteries were anastomosed to the inferior epigastric artery and upper polar arteries were anastomosed to the superior epigastric arteries. Injection of Papaverine and ablation of sympathic nerves of these arteries dilate and prevent them from post-operative spasm. Follow-up DTPA renal scan in all patients showed good perfusion and function of the transplanted kidney, except two cases of polar arterial thrombosis. Mean creatinine levels during at least two years of follow-up remained acceptable. Patient and graft survival were excellent. No cases of ATN, hypertension, rejection and urologic complications were found. In conclusion, this technique can be safely and successfully utilized for renal transplantation with kidneys having MRAs, and may be associated with a lower complication rate and better graft function compared with the existing techniques.
  - 2,093 466
Prevalence of hyponatremia among patients who used indapamide and hydrochlorothiazide: A single center retrospective study
M Al Qahtani, A Alshahrani, A Alskaini, N Abukhalid, N Al Johani, M Al Ammari, L Al Swaidan, S Binsalih, A Al Sayyari, A Theaby
March-April 2013, 24(2):281-285
DOI:10.4103/1319-2442.109574  PMID:23538350
Hyponatremia is the most frequently encountered electrolyte abnormality among hospitalized patients and thiazide users. In this large single-center retrospective study, we aim to determine the prevalence and risk factors of hyponatremia among patients at the King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.To the best of our knowledge, this is the first such study in Saudi Arabia. A chart review was done for the years 2011-2012 of all admitted Saudi patients at KAMC who were treated with indapamide and hydrochlorothiazide. A total of 2000 patients were included [1237 females (629 indapamide and 608 hydrochlorothiazide) and 762 males (371 indapamide and 391 hydrochlorothiazide)]. Majority of the patients had type-2 diabetes mellitus (T2DM) with an overall prevalence of 72.2%. The overall prevalence of hyponatremia, regardless of severity, in the indapamide group was 37.3% versus 38.7% in the hydrochlorothiazide group. Stratification for age revealed that older patients had relatively higher levels of sodium (Na) as compared with younger patients, and this inverse association was significant (R = - 0.123; P <0.001). Increasing age, female gender and presence of T2DM were the significant risk factors for hyponatremia, explaining the 4.7% of the variance perceived (P <0.001). Our study suggests that the prevalence of hyponatremia among Saudi thiazide users is relatively high, and more so for the elderly and for those with T2DM. Early identification of this condition is important and caution should be exercised while prescribing thiazide drugs, particularly to those who are most at risk of developing hyponatremia to prevent related complications.
  - 2,718 630
Glomerular filtration barrier in pediatric idiopathic nephrotic syndrome
Alok Sharma, Ruchika Gupta, Arvind Bagga, Amit K Dinda
March-April 2013, 24(2):286-291
DOI:10.4103/1319-2442.109577  PMID:23538351
Nephrotic syndrome (NS) is a common proteinuric disorder with defect in the perm-selectivity of the glomerular filtration barrier (GFB). Ultrastructural morphometric evaluation of the GFB in pediatric NS has been attempted in only a few studies. This study was aimed at qualitative and quantitative evaluation of the alterations involving the GFB in pediatric idiopathic NS with an attempt to correlate these alterations with the clinico-laboratory data. For this study, renal biopsies from nine patients with NS and two children with interstitial nephritis were included. Relevant clinical and laboratory data, including degree of 24-h proteinuria and renal function tests, were recorded. Renal biopsies were reviewed for morphologic and electron microscopic diagnosis. Ultrastructural morphometry of the GFB was performed using image analysis software. The age at onset of NS, duration of illness, presence of hypertension, and renal function tests were comparable between the group of patients with minimal change disease (MCD) and those with mesangioproliferative glomerulonephritis (mesPGN)/focal segmental glomerulosclerosis (FSGS). However, the latter group showed higher 24-h proteinuria compared with the group with MCD. Among the detected ultra-structural changes, glomerular basement membrane thickness and foot process width were significantly different between the MCD and the mesPGN/FSGS groups. The slit pore diameter in the glomeruli showed a positive correlation with the degree of proteinuria. We conclude that our study demonstrated remarkable differences in certain parameters and the glomerular ultrastructural alterations in the various categories of NS. These differences might underlie the observed variation in response of these entities to various therapies.
  - 2,044 579
RENAL DATA FROM ASIA-AFRICA
Outcome of deceased donor renal transplantation - A single-center experience from developing country
Himanshu V Patel, Vivek B Kute, Ghanshyam H Ghelani, Aruna V Vanikar, Pankaj R Shah, Manoj R Gumber, Hargovind L Trivedi
March-April 2013, 24(2):403-407
DOI:10.4103/1319-2442.109618  PMID:23538375
Renal transplantation (RTx) is considered as the best therapeutic modality for patient suffering from end-stage renal disease (ESRD). Dearth of donor kidneys is a major problem everywhere, and deceased donor renal transplantation (DDRTx) is seen as at least a partial solution. Even so, DDRTx accounts for only less than 4% of RTx in India. We report our 6-year single-center experience on DDRTx vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function (DGF). Between January 2005 and March 2011, 236 DDRTx were performed. Majority of the donors were those with brain death due to road traffic/cerebrovascular accidents. The commonest recipient diseases leading to ESRD were chronic glomerulonephritis (42.8%), diabetes (12.7%), and hypertension (10.6%). Mean recipient age was 36.2 ± 14.2 years; 162 were males and 74 were females. Mean donor age was 45.3 ± 17.13 years; 144 were males and 92 were females. Mean dialysis duration pre-transplantation was 18.5 ± 2.5 months. All recipients received single-dose rabbit-anti-thymocyte globulin induction and steroids, calcinueurin inhibitor, and mycophenolate mofetil/azathioprine for maintenance immunosuppression. Delayed graft function was observed in 29.6% patients and 22% had biopsy-proven acute rejection. Over the mean follow-up of 2.18 ± 1.75 years, patient and graft survival rates were 74.57% and 86.8%, respectively, with mean SCr of 1.42 ± 0.66 mg%. DDRTx achieves acceptable graft function with patient/graft survival, encouraging the use of this approach in view of organ shortage.
  - 1,664 365
Prevalence of hypertension in healthy school children in Pakistan and its relationship with body mass index, proteinuria and hematuria
Arshalooz Jamila Rahman, Farah Naz Qamar, Sohail Ashraf, Zubair Ali Khowaja, Shafaq Binte Tariq, Hira Naeem
March-April 2013, 24(2):408-412
DOI:10.4103/1319-2442.109619  PMID:23538376
To determine the prevalence of high blood pressure (BP) in healthy school Pakistani children and its association with high body mass index (BMI), asymptomatic hematuria and proteinuria, we studied 661 public school children and measured their body weight, height and BP and urine dipstick for hematuria performed on a single occasion. Hypertension (BP >95 th centile) and pre-hypertension (BP >90 th centile) were defined based on the US normative BP tables. Over-weight and obesity were defined according to the World Health Organization (WHO) classification of BMI. The mean age of the children was 14 ± 1.3 years. The mean BMI was 18.5 ± 4.3 kg/m 2 . The majority (81.8%) of the children were found to be normotensive (BP <90 th centile). Pre-hypertension was observed in 15% and hypertension in 3% of the children. Overweight was observed in 7.7% and obesity in 1% of the children. The independent risk factors for hypertension and pre-hypertension were age of the child (RR 1.2 95% CI 1-1.4), gender (RR 2.0 for being female 95% CI 1-4.4), BMI >25 (RR for BMI b/w 25-30 = 2.6, RR for BMI >30 = 4.3), positive urine dipstick for proteinuria (RR = 2.3 95% CI 0.7-7.7) and positive urine dipstick for hematuria (RR 1.0 95% CI 0.2-8.3). Hypertension in children is strongly correlated with obesity, asymptomatic proteinuria and hematuria. Community based screening programs for children should include BP recording, BMI assessment and urine dipsticks analysis and approach high-risk groups for early detection and lifestyle modifications.
  - 3,730 751
RENAL DATA FROM THE ARAB WORLD
Pattern of glomerular diseases in oman: A study based on light microscopy and immunofluorescence
Nasar Yousuf Alwahaibi, Taiseer Ahmed Alhabsi, Samira Abdullah Alrawahi
March-April 2013, 24(2):387-391
DOI:10.4103/1319-2442.109616  PMID:23538373
Light microscopy and immunofluorescence play an important part in the final diagnosis of renal biopsy. The aim of this study was to analyze the pattern of various glomerular diseases in Oman. A total of 424 renal biopsies were retrospectively analyzed at the Sultan Qaboos University Hospital between 1999 and 2010. Focal and segmental glomerulosclerosis (FSGS), minimal change disease (MCD), membranous glomerulopathy (MGN) and IgA nephropathy were the most common primary glomerular diseases encountered, accounting for 21.2%, 17%, 12.3% and 8.3%, respectively, of all cases. Lupus nephritis was the most common secondary glomerular disease and was the most prevalent among all biopsies, accounting for 30.4% of all biopsies. Amyloidosis was seen in only two cases. The presence of fluorescein isothiocyanatefibrin in all renal cases was low when compared with IgG, IgA, IgM, C3 and C1q markers. In conclusion, based on the findings of this study, lupus nephritis was the most common of all glomerular diseases and FSGS was the most common primary glomerular disease. The importance of fluorescein isothiocyanate-fibrin in the diagnosis of renal biopsy needs to be further investigated.
  - 1,780 385
REVIEW ARTICLES
Encapsulating peritoneal sclerosis: Common or rare in peritoneal dialysis?
Konstantina Triga
March-April 2013, 24(2):223-229
DOI:10.4103/1319-2442.109562  PMID:23538342
Encapsulating peritoneal sclerosis (EPS) is a serious and often fatal complication of long-term peritoneal dialysis (PD) with severe malnutrition and poor prognosis. It causes progressive obstruction and encapsulation of the bowel loops. As EPS becomes more prevalent with longer duration of PD, large multicenter prospective studies are needed to establish its incidence and identify risk factors, therapeutic approach, and prognosis.
  - 4,170 1,477
SCOT DATA
Deceased heart beating donor and organ transplantation in Saudi Arabia

March-April 2013, 24(2):424-429
  - 904 146
SPECIAL ARTICLES
Acute kidney injury: Global health alert
Philip Kam Tao Li, Emmanuel A Burdmann, Ravindra L Mehta
March-April 2013, 24(2):345-350
DOI:10.4103/1319-2442.109602  PMID:23538363
Acute kidney injury (AKI) is increasingly prevalent in developing and developed countries and is associated with severe morbidity and mortality. Most etiologies of AKI can be prevented by interventions at the individual, community, regional and in-hospital levels. Effective measures must include community-wide efforts to increase an awareness of the devastating effects of AKI and provide guidance on preventive strategies, as well as early recognition and management. Efforts should be focused on minimizing causes of AKI, increasing awareness of the importance of serial measurements of serum creatinine in high risk patients, and documenting urine volume in acutely ill people to achieve early diagnosis; there is as yet no definitive role for alternative biomarkers. Protocols need to be developed to systematically manage prerenal conditions and specific infections. More accurate data about the true incidence and clinical impact of AKI will help to raise the importance of the disease in the community, increase awareness of AKI by governments, the public, general and family physicians and other health care professionals to help prevent the disease. Prevention is the key to avoid the heavy burden of mortality and morbidity associated with AKI.
  - 1,965 487
Knowledge translation through clinical pathways: Principles for practical development and successful use
Imad S Hassan
March-April 2013, 24(2):351-363
DOI:10.4103/1319-2442.109603  PMID:23538364
Proper implementation of guidelines is clearly associated with better medical outcomes. Success of guidelines' implementation depends on the tools used to accomplish it. Clinical pathways, also known as Integrated Care Pathways, represent one such tool that clearly promotes the implementation of guidelines and research evidence into clinical practice. They also encourage multidisciplinary teamwork, help in staff education, and aid in clinical research and audit. Additionally, they help in cutting hospital care costs. Important steps for a successful pathway development and implementation include getting leadership support, involving relevant people, selecting the right area of practice, using multiple implementation strategies and regularly assessing and monitoring pathway implementation.
  - 2,241 549
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