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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
September-October 2020
Volume 31 | Issue 5
Page Nos. 883-1179

Online since Saturday, November 21, 2020

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Nicotinamide Therapy in Dialysis Patients: A Systematic Review of Randomized Controlled Trials Highly accessed article p. 883
Salman Hussain, Ambrish Singh, Thamir M Alshammari, Anwar Habib, Md. Sarfaraj Hussain, Robin Jha, Mohd. Akhtar, Abul Kalam Najmi
Randomized controlled trials (RCTs) have presented variable findings concerning the reduction of phosphorous level by nicotinamide. This systematic review is aimed to explore the safety and efficacy of nicotinamide in hemodialysis patients and was conducted by adhering to the PRISMA guidelines. Studies for inclusion were identified by running the suitable keywords in PubMed, Embase, and Cochrane Central till June 13, 2018. Cochrane risk of bias tool was used to judge the quality of the included RCTs. The primary outcome was change in serum phosphorus, calcium, and calcium–phosphorus product levels. Change in other biochemical parameters including serum calcium, parathormone, platelets, lipid profile parameters, and the safety profile was considered under secondary outcomes. Review Manager (RevMan v5.3) was used for the risk of bias estimate. A total of 12 articles were qualified for inclusion in this study. All the included RCTs showed a statistically significant reduction in mean serum phosphorous and calcium–phosphorus product levels in the treatment arm as compared to the placebo group. Among several biochemical parameters analyzed, only high-density lipoprotein (HDL) was found to be significantly increased from baseline to the endpoint of the study in the nicotinamide group, while the placebo group showed no significant difference. Flushing and diarrhea, followed by thrombocytopenia, were the most commonly reported adverse events in the treatment group. Nicotinamide was found to be effective in reducing the phosphorous level and calcium–phosphorus product level and increasing the HDL cholesterol level in dialysis patients. The safety profile was found to be satisfactory.
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The Proportion of Bifidobacterium and Escherichia coli in Colon of Children with Recurrent Urinary Tract Infection Highly accessed article p. 898
Sudung Oloan Pardede, Kanya Ayu Paramastri, Badriul Hegar, Achmad Rafli
Recurrent urinary tract infection (UTI) in children is a well-known risk factor of chronic kidney disease. Periurethral area is normally inhabited by non-pathogenic flora, such as Bifidobacterium sp., and pathogenic flora from gastrointestinal tract, such as Escherichia coli (E. coli), which can cause UTI. Dysbiosis between pathogenic and non-pathogenic bacteria leads to infections, but studies regarding dysbiosis and recurrent UTI have not yet been documented. To estimate the proportional differences between gastrointestinal E. coli and Bifidobacterium sp. in children with recurrent UTI, a cross-sectional study was conducted in children from age six months to <18 years old diagnosed with recurrent UTI in Dr. Cipto Mangunkusumo Hospital. Healthy children matched in gender and age were recruited as control group. Stool samples were obtained from all the children in the two groups. Stool DNA was extracted using real-time polymerized chain reaction method to count E. coli and Bifidobacterium sp. proportion. Children with recurrent UTI had significantly higher proportion of E. coli compared to control group (10.97 vs. 4.74; P = 0.014) and lower proportion of Bifidobacterium sp. (6.54 vs. 9.33; P = 0.594). In children with recurrent UTI group, E. coli proportion was found higher than Bifidobacterium sp. although not statistically significant (10.97 vs. 6.54; P = 0.819). In healthy controls, Bifidobacterium sp. proportion was significantly higher than E. coli (4.74 vs. 9.33; P = 0.021). The total amount of E. coli (996,004 vs. 1,099,271; P = 0.798) and Bifidobacterium sp. (835,921 vs. 1,196,991; P = 0.711) were higher in secondary UTI compared to the simple UTI. Proportion of E. coli is higher in children with recurrent UTI than in healthy children. The proportion of E. coli is higher than Bifidobacterium sp in the colon of children with recurrent UTI.
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Multiple Drug Resistant Urinary Tract Infection in Kidney Transplant Recipients: A Retrospective Cohort Study Highly accessed article p. 905
Rashid bin Hamid, Shanila Javaid, Muhammad Tassaduq Khan, Naranjan Lal, Shubha Luxmi, Sabahat Sarfaraz
Urinary tract infection (UTI) is the most common infectious disease in post-kidney transplantation patients. The objective of the study was to investigate the prevalence, impact and risk factors of multiple drug resistant (MDR) UTI in kidney transplant recipients. This retrospective cohort study recruited 72 kidney transplant recipients between March 2017 and February 2018. Urine cultures performed during the 1st year of posttransplantation with reference to clinical data were evaluated. Predesigned questionnaire was used to collect data regarding demographic, transplant related, and microbiological information. Multivariate analysis was performed to ascertain risk factors of MDR UTI. Out of 72 patients, 28 (38.9%) had culture guided clinical UTI. Overall, 59 UTI episodes were noted throughout the duration of this study. Eschericia coli were found to be the most frequent uropathogen of UTI among kidney transplant recipients (n = 32, 54.2%). MDR bacteria were responsible for 27.1% (n = 16) of the post-transplantation UTI episodes among patients, with E. coli (n = 9, 56.3%) being the predominant bacterial pathogen. Most of the MDR strains of E. coli (n = 7, 77.8%) were extended spectrum beta-lactamase positive. Female gender (P <0.001), prolonged Foley's catheterization (P = 0.002), coexisting diabetes mellitus (DM) (P <0.001) and induction of anti-thymocyte globulin (ATG) therapy (P <0.001) were independently associated with high risk of MDR UTI. The allograft rejection was found to be significantly higher in patients of posttransplantation UTI with MDR uropathogen (P = 0.009). In conclusion, E. coli were the most prominent uropathogen of UTI with and without MDR pathogen in the present study. Female gender, prolonged Foley's catheterization, coexisting DM, and induction of ATG therapy were the risk factors independently associated with MDR UTI in kidney transplant recipients. MDR organisms were significantly associated with allograft rejection.
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Antibodies to Erythropoietin Are Associated with Erythropoietin Resistance in Hemodialysis Patients in KwaZulu-Natal (South Africa) p. 917
Sherilene Benjamin, Jamila Adam, Suresh Babu Naidu Krishna, Alain G Assounga
Recombinant human erythropoietin (rHuEPO) is a glycoprotein and biological equivalent to the endogenous compound administered to treat anemia of end-stage renal disease patients. Resistance to rHuEPO has been reported, whereby patients require higher and higher doses of rHuEPO to maintain an adequate hemoglobin level. In this study, assessment of native and administered erythropoietin (EPO), antibody and hemoglobin levels was carried out on a sample of patients with renal failure on hemodialysis (HD). This is a randomized controlled trial where consecutive subjects attending HD units at Addington Hospital and King Edward Hospital, Durban (South Africa) were included until the target number was reached. Forty patients with renal failure on HD and receiving recombinant EPO Beta (Recormon) for treatment of anemia via the subcutaneous route in weekly doses of 2000 IU, 4000 IU, 6000 IU, 8000 IU, 12,000 IU, or 18,000 IU according to the severity of the anemia were included after obtaining informed consent. Also included in the study were 10 HD patients not on rHuEPO therapy and 10 healthy individuals from the Durban University of Technology, recruited as described above to form the control group. ELISA was used to measure serum levels of EPO as well as antibodies to EPO. Results were analyzed by descriptive, inferential methods and by logistic regression analysis using IBM SPSS Statistics for Windows version 22.0. Antibodies to EPO were found in almost all patients who were receiving EPO. The highest levels of antibody to EPO were found to be associated with patients receiving the highest weekly dose of EPO (18,000 IU). Logistic regression analysis also revealed that serum levels of EPO, gender or age were not associated with any significant variation of serum antibody level. High levels of serum antibodies to EPO are a risk factor for EPO resistance.
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Prevalence, Location, and Determinants of Valvular Calcifications in Congolese Patients on Chronic Hemodialysis: A Multicenter Cross-Sectional Study p. 927
Yannick M Engole, Yves N Lubenga, Yannick M Nlandu, Jean Robert R. Makulo, Vieux M Mokoli, Charles K Kahindo, Marie France I. Mboliasa, Evariste M Kadima, Augustin L Longo, Aliocha. Nkodila, Justine B Bukabau, François B Lepira, Nazaire M Nseka, Ernest K Sumaili
Valvular calcifications (VCs) are one of the major cardiovascular complications in patients on chronic hemodialysis (HD) due to its prevalence and predictive morbidity and mortality. The current study assessed the prevalence, location, and risk factors of VC among chronic HD Congolese patients in Kinshasa. This observational study involved three HD centers in Kinshasa between March and August 2016. Consecutive consenting adults on maintenance HD for at least six months were recruited. VCs were defined as a luminous echo on one or more cusps of the aortic or mitral valve. Risk factors of VC were determined by multivariate analysis. Sixty patients (mean age: 52.5 ± 15.9 years) were enrolled. The mean serum calcium and phosphorus were7.9 ± 1.3 mg/dL and 5.7 ± 1.7 mg/dL, respectively. VCs were encountered in 38% of the whole group in aortic and mitral valvular location in 64% and 23%, respectively. Hypertension, age >60 years, tobacco use, and hyperphosphatemia were independently associated with VC. Despite a young age of patients, VCs were a common finding and associated with both traditional and chronic kidney disease-specific risk factors.
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Aspirin-Triggered Lipoxin Protects Lipopolysaccharide-Induced Acute Kidney Injury via the TLR4/MyD88/NF-κB Pathway p. 937
Pei Zhang, Hongjun Peng, Chunlin Gao, Zhongmin Fan, Zhengkun Xia
The protective effect of aspirin-triggered lipoxin (ATL) on lipopolysaccharide (LPS)-induced acute kidney injury (AKI) and its possible mechanisms were explored. To induce acute renal injury, mice were treated with LPS. Concentration of serum creatinine (SCr) and blood urea nitrogen (BUN) was detected, and inflammatory cytokines and AKI biomarkers were determined by ELISA. The relative protein expression levels of TLR4/myeloid differentiation factor 88 (MyD88)/NF-κB signal pathway was assessed by Western blot. Mice subjected to LPS (4 mg/kg) treatment exhibited AKI demonstrated by markedly increased SCr and BUN levels compared with controls (P <0.01). Treatment with ATL decreased SCr and BUN levels after LPS injection (P <0.01). AKI biomarkers, such as urine NGAL, KIM-1, netrin-1, and L-FABP levels, increased by LPS and were inhibited by ATL (P <0.01). ATL also reduced LPS-induced secretion of inflammatory cytokines such as tumor necrosis factor-alpha, interleukin (IL)-1β, IL-6, and IL-8 (P <0.01). Furthermore, mice pretreated with ATL before exposure to LPS showed a reduction in TLR, MyD88, and p65 phosphorylation (P <0.01), which are the key factors of the TLR/MyD88/NF-κB signaling pathway. These results indicated that ATL had protective effects on renal function and showed amelioration of LPS-induced kidney injury. The mechanisms underlying the protective effects of ATL can be considered are related to attenuation of the TLR4/MyD88/NF-κB signaling pathway.
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Association of Urinary Vitamin D Binding Protein and Neutrophil Gelatinase-Associated Lipocalin with Steroid Responsiveness in Idiopathic Nephrotic Syndrome of Childhood p. 946
Amit Choudhary, PS Mohanraj, Sriram Krishnamurthy, Medha Rajappa
Idiopathic nephrotic syndrome (NS) is one of the most common kidney diseases of childhood. In this study, we assessed urine Vitamin-D binding protein (VDBP) and neutrophil gelatinase-associated lipocalin (NGAL) levels as a predictor of steroid responsiveness in idiopathic NS. This cross-sectional study included children with steroid-resistant NS (SRNS) (n = 28), steroid-sensitive NS (SSNS) (n = 28), and healthy controls (n = 28). Urine levels of VDBP and NGAL were measured using a commercially available ELISA kit and normalized to urine creatinine (Cr). Urine microalbumin (MALB) was measured using nephelometer, and MALB/Cr was calculated. Urine Vitamin-D binding protein (uVDBP) and urine neutrophil gelatinase-associated lipocalin (uNGAL) levels were statistically significantly higher (P < 0.001) in patients with SRNS (701.12 ± 371.64 ng/mL and 28.42 ± 15.40 ng/mL, respectively) than in patients with SSNS (252.87 ± 66.34 ng/mL and 8.86 ± 5.54 ng/mL, respectively) and normal controls (34.74 ± 14.10 ng/mL and 6.79 ± 1.32 ng/mL, respectively). Estimated glomerular filtration rate shows a significant negative correlation with MALB/Cr, uVDBP, and uNGAL. However, uVDBP and uNGAL showed a much higher discriminatory ability for differentiating SRNS from MALB/Cr. uVDBP and uNGAL at the cutoff value of 303.81 and 13.1 ng/mL, respectively, yielded the optimal sensitivity (82% and 86%) and specificity (78% and 89%) to distinguish SRNS from SSNS. Urine levels of VDBP and NGAL can predict steroid responsiveness in patients with idiopathic NS.
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Multi National Survey of the Advice Given to Muslim Kidney Graft Recipients by Muslim Nephrologists about Lifestyle and Religious Rituals with Potential Medical Risk p. 957
Ziad M S. Arabi, Elwaleed A Elhassan, Mubarak I Abdalla, Mahfooz A Farooqui, Atif A Mateen, Saleh Kaysi, Syed A Alam, Saif A Khan, Mohamed F Elmuzaini, Mourad M Al Sabbagh, Abdulrahman R Altheaby
Muslim renal transplant recipients often ask their physicians if performing certain lifestyles or religious obligations may be harmful to their health. Permissibility as advised by an expert Muslim physician is considered as being religiously accepted. A cross-sectional, survey-based study was conducted enquiring what nephrologists would advise their transplant recipients to do, about some lifestyles and religious duties. Fifty-eight nephrologists responded to the survey. Of these, 77% routinely follow-up post-transplant patients; 34% were from Saudi Arabia, 18% from the USA, and 20% from Pakistan. Fifty-four percent of the respondents would let patients with stable graft function fast during Ramadan, while 20% would not recommend fasting at any time following transplantation. This response did not change much if the patient was diabetic although in these patients, not recommending fasting at any time increased to 32%. For kidney donors, fasting would be allowed by 58% of the respondents once the kidney function stabilizes. About 50% would let their patients perform Omrah or obligatory Hajj any time after 12 months following transplantation, and only about 3% would not recommend that at any time after transplantation. For nonobligatory Hajj, 37% and 22%, respectively, would allow. Sixty-one percent would delay the pregnancy in nullipara with stable renal function, and none of the nephrologists would deny the opportunity to pregnancy at any time. In multiparous transplant recipients, the respective frequencies would be 45% and 20%. To our knowledge, this the first study exploring the consensus among Muslim nephrologists regarding the advice they would give on performance of potentially risky lifestyles and religious rituals by Muslim posttransplant patients.
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A Comparative Study of the Use of Dexamethasone, N-acetyl Cysteine, and Theophylline to Ameliorate Renal Ischemia–Reperfusion Injury in Experimental Rat Models: A Biochemical and Immuno-histochemical Approach p. 982
Ahmed Salaheldin Sayed Zeid, Safinaz Salaheldin Sayed
Renal ischemia–reperfusion injury (IRI) is commonly encountered in clinical practice during renal transplantation. In a trial to find the drug that best safeguards the kidney against IRI, dexamethasone (Dex), N-acetyl cysteine (NAC), and theophylline (Theo) were tested in experimental rat models. This study included 105 adult male albino rats, which were randomly assigned to the following five groups: Group I – sham-operated, n = 5, Group II – IRI n = 25, Group III – IRI + Dex n = 25, Group IV – IRI + NAC n = 25, and Group V –IRI + Theo n = 25. IRI was induced for 40 min followed by reperfusion. Rats were sacrificed 1, 2, 4, 6, and 24 h after reperfusion. This was preceded by blood and urine sampling for biochemical study of serum Cystatin C (Cys C), serum creatinine, and urinary Cys C. Kidneys were processed for histopathological evaluation and immune-histochemical staining for Cys C. The expression of Cys C in the proximal tubular cells was significantly lower in the IRI group compared to that of the sham group. There was a significant rise in the levels of serum and urinary Cys C after 1 h in the IRI group, while the rise in creatinine occurred later. Dex was superior to NAC and Theo 24 h after the IR insult, and the serum levels of creatinine and Cys C were significantly lower in this group than the other two drug groups (P <0.001 in both cases). Our study revealed a clear benefit for the use of Dex to ameliorate IRI over NAC and Theo if used immediately following the insult. The effect is evident 24-h after its use. The role of serum Cys C as an early marker of acute kidney injury compared to serum creatinine is confirmed.
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Impact of One-Year Serum Creatinine on Long-term Renal Graft Survival in a Living-Related Renal Transplant Program p. 998
Syed Haider Nawaz, Mirza Naqi Zafar, Mohammad Afzal, Syed Ali Anwar Naqvi, Muhammed Mubarak, S Adibul Hasan Rizvi
This study was carried out to determine the impact of one-year posttransplant serum creatinine (SCr) levels on the long-term outcomes of living-related donor kidney transplants. A retrospective cohort study included 773 adult living-related renal transplant recipients from 2010 to 2012, with a minimum follow-up period of five years. Demographics and posttransplantation follow-up data including immunosuppression regimens, rejection episodes, and survival rates were evaluated. Patients were divided into four cohorts (G1, G2, G3, and G4 based on SCr at the end of the 1st year: G1, SCr <88.4 μ mol/L; G2, 88.5≤ SCr ≤ 132.6 μmol/L; G3, 132.7≤ SCr ≤176.8 mol/L; and G4, SCr ≥176.9 μ mol/L). Comparisons between the groups used the Chi-square test for qualitative parameters and analysis of variance for continuous variables. Five-year graft survival for G1 was 98% as compared to 76% in G4 (P <0.001). Recipients of G4 encountered more acute rejection episodes in 21% of the cases as compared to 7.3% in G1 (P = 0.001). Donors were older in G4 (42.07 ± 10.4 years) as compared to G1 (30.1 ± 8.5 years) (P = 0.001). A third of the donors in G1 were HLA identical as compared to 7% in G4. Prediction of long-term graft survival is possible by the SCr level at one year post transplant. This can be of great importance, especially to identify those patients who require close monitoring in follow-up. Donor age, HLA, and acute rejection impact SCr at one year and hence graft outcome.
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Changes in Left Ventricular Mass and Cardiovascular Risk Factors after Kidney Transplantation Highly accessed article p. 1006
Sandeep Sreedharan, Anil Mathew, Zachariah Paul, Navin Mathew, KR Sundaram, George Kurian, Rajesh Nair
Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m2, P <0.001) and improvement in ejection fraction (57.8 ± 7 vs. 60.1 ± 1.9, P = 0.015) at the end of six months. There were significant differences in the mean hemoglobin, systolic, and diastolic blood pressures (P <0.001) during the study. There was also a significant reduction in the number of antihypertensive drugs required for blood pressure control. There was a significant reduction in LVH in the study group. There was also improvement in systolic and diastolic functions of the heart. There was also a significant improvement in blood pressure control both in terms of mean blood pressure levels as well as in terms of the number of anti-hypertensive drugs needed for blood pressure control. Renal transplantation ameliorates cardiovascular risk in renal transplant recipients.
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The Comparison Spondin 2 Levels in Primary Glomerular Diseases p. 1014
Serdar Kahvecioglu, Alparslan Ersoy, Yasemin Üstundag, Yavuz Ayar, Cuma Bülent Gül, Abdülmecit Yildiz, Selin Akturk Esen, Ibrahim Dogan, Aysegul Oruc
Spondin 2 (SPON2) plays an important role in multiple processes and is a member of the Spondin 2/F-spondin family of extracellular matrix proteins. We investigated serum SPON2 levels and its correlation with renal functions and urine protein excretion in different glomerular diseases. The cohort included 97 consecutive adults with persistant proteinuria (>300 mg/day) with the diagnosis of focal segmental glomerulosclerosis (FSGS), membranous glomerulonephritis (MN), IgA nephropathy (IgAN), membranoproliferative glomerulonephritis (MPGN), and AA amyloidosis and the control groups with 15 polycystic kidney disease (PKD) and 32 healthy people. Serum SPON2 levels in MN (64.6 ng/mL), FSGS (47.8 ng/mL), IgAN (52.6 ng/mL), MPGN (54.6 ng/mL), and AA amyloidosis (60.7 ng/mL) groups were higher than those of the control (26.4 ng/mL) and nonglomerular disease groups (PKD) (15.3 ng/mL). Only serum SPON2 levels were correlated with serum uric acid and triglyceride levels in patients with glomerular disease. This is the first study to show that serum SPON2 levels are similar in different glomerular diseases and that there is no correlation between SPON2 and proteinuria grade.
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Improving Effect of Aminoguanidine on Lipopolysaccharide-Caused Kidney Dysfunction in Rats p. 1025
Mahmoud Hosseini, Farimah Beheshti, Akbar Anaeigoudari
Kidneys have been shown to be the main target for toxins. Lipopolysaccharide (LPS) is a bacterial endotoxin which can involve in pathogenesis of endotoxemia-caused kidney dysfunction. Excessive production of free radicals such as nitric oxide (NO) and pro-inflammatory cytokines have been reported to contribute in kidney dysfunction. The purpose of this study was to investigate the effect of inducible nitric oxide synthase (iNOS) inhibition against LPS-induced kidney dysfunction in rats. Male rats were assigned into five groups. Control animals were injected saline; LPS group received 1 mg/kg of LPS for five weeks; LPS-AG50, LPS-AG100, and LPS-AG150 groups received AG (50, 100, and 150 mg/kg, respectively) 30 min before LPS. All drugs were administered intraperitoneally. LPS injection enhanced the level of blood urea nitrogen (BUN) and creatinine compared with the control group. Pretreatment with AG resulted in a significant reduction in BUN and creatinine in LPS-AG100 and LPS-AG 150 groups with respect to the LPS group. LPS administration led to a significant increase in interleukin (IL)-6, malondialdehyde (MDA), and NO metabolites as well as a significant decrease in the content of total thiol groups and superoxide dismutase (SOD) and catalase (CAT) activity. Pretreatment with AG reduced the level of IL-6, MDA, and NO metabolites and enhanced the content of total thiol groups and SOD and CAT activity in LPS-AG groups compared to the LPS group. The results of the present study show that inhibition of iNOS has a protective effect against kidney dysfunction caused by LPS.
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Incidence of Contrast-Induced Nephropathy after Coronary Procedures in the United Arab Emirates: A Single-Center Study p. 1034
Ahlam Al Awadhi, Samir Mohammad Ali Aljabbari, Siddiq Anwar, Amar H Khamis, Abdul Majeed Brek Al Zubaidi, Stephen Geoffrey Holt, Alawi Alsheikh-Ali
Contrast-induced nephropathy (CIN) is a major cause of morbidity and mortality in patients undergoing coronary procedures. The reported incidence of CIN ranges from ~3% to 30%. The profile of patients undergoing coronary procedures in the United Arab Emirates (UAE) differs from those included in published reports of CIN, and the incidence of CIN after coronary procedures in the UAE remains unknown. We conducted a retrospective analysis of all adult patients who underwent coronary procedures at a large tertiary care facility in the UAE in 2013–2014. Patients on dialysis or missing creatinine values were excluded. CIN was defined as an increase of creatinine of ≥44 μmol/L within 48–72 h after coronary procedures. Most patients (84.8%) underwent coronary procedures for urgent/emergent indications. The incidence of CIN was 44 out of 1010 (4.35%), with 17 out of 44 (38%) of CIN patients requiring dialysis. After adjusting for baseline differences, older patients, use of angiotensin-converting enzyme inhibitors, and oxygen use during the procedure were associated with a 20.6% increased risk of development of CIN. The risk of in-hospital mortality was significantly higher in the CIN group (29.5% vs. 1.8%).
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Ethical and Cultural Issues in Transplantation: The Views and Attitudes of Nurses p. 1042
Elif Gezginci, Sonay Goktas, Sabiha Caglayan
Organ transplantation is lifesaving for individuals with end-stage organ failure. However, many people are still waiting for organ transplantation due to religious beliefs and the perspectives of society. Many studies on organ donation have shown that the knowledge levels and attitudes of nurses have an important effect on organ donation rates. The aim of this study was to evaluate the views and attitudes of nurses about ethical and cultural issues related to transplantation. This descriptive study was conducted on 220 nurses who worked in a university hospital in Istanbul, Turkey. Data were collected using a questionnaire form included sociodemographic characteristics, ethical-cultural values, and knowledge levels about transplantation of the participants. Descriptive statistics and Chi-square test were used for the analysis of data. The mean age of the participants was 24.8 ± 6.04 years. Sixty percent of the participants reported that a person with brain-death was the most ideal candidate for organ donation. Seventy-seven percent of them suggested that organ sale was the most common ethical problem in organ transplantation. Sixty-three percent reported that the patient awaiting transplantation for a long time had priority order for organ transplantation. Most of the nurses (91.0%) believed that organ transplantation was religiously and culturally appropriate; however, 67.7% of them reported that it was not considered appropriate by the society due to religious and cultural beliefs. Sixty-two percent of them suggested that the society believed that organ transplantation was unlawful (haram) religiously. Nurses generally had positive views and attitudes about organ transplantation.
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The Effect of Renal Transplantation on Cardiac Functions p. 1051
Kerem Can Yilmaz, Arzu Neslihan Akgun, Suzan Keskin, Orcun Ciftci, Gokhan Moray, Haldun Muderrisoglu, Mehmet Haberal
Chronic renal failure is a well-known risk factor for cardiovascular poor outcome. Despite advances in dialysis and renal transplantation, these patients still have high cardiovascular morbidity and mortality. The aim of our study was to evaluate the changes in blood parameters and echocardiographic parameters of patients undergoing renal transplantation in our center. One hundred and eighty-three patients who underwent renal transplantation between September 2012 and January 2016 were included in the study. Pre- and postoperative hemoglobin values, lipid profiles, ejection fractions, presence of left ventricular hypertrophy, presence of diastolic dysfunction, and valve pathologies were retrospectively scanned. Data were obtained from all patients in terms of blood parameters, but we compared 92 patients’ echocardiographic data because of lack of both pre- and postoperative echocardiography records. In our study, 124 patients (67.8%) were male, and the mean age was 42.6 ± 14.4 years. Hemoglobin levels (11.2 ± 1.98, 12.7 ± 2.2 mg/dL, P <0.001) and high-density lipoprotein (HDL) values (37.6 ± 10.5, 46.6 ± 13.6 mg/dL, P <0.001) were found to be different significantly. In echocardiographic evaluation, there was no difference between pre- and postoperative ejection fractions in 92 patients. However, patients with preoperative ejection fraction <50% had a significant increase in postoperative ejection fraction (40.1 ± 6.2, 48.4% ± 9.4%, P = 0.012). Renal transplantation can improve left ventricle ejection fraction in patients with basal ejection fraction less than 50% and also provide a significant increase in hemoglobin and HDL levels in all patients. This suggests that renal transplantation may reverse the process for dilated cardiomyopathy and may improve cardiac function in patients with low ejection fraction. However, transplantation should be performed as early as possible in these patients.
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Colistin-induced Nephrotoxicity in a Tertiary Teaching Hospital p. 1057
Dalal A Al-Abdulkarim, Omar A Alzuwayed, Maha Al Ammari, Shatha Al Halwan, Nada Al Maklafi, Abin Thomas
Colistin-induced nephrotoxicity is a well-known major adverse event, which may occur within seven days [early acute kidney injury (AKI)] with a high mortality rate of 70% or after seven days (late AKI). The main objective of this retrospective study is to assess the severity and associated risk factors for the development of colistin-related nephrotoxicity. An observational retrospective cohort study was conducted over 12 months (January–December 2017). All patients with a baseline normal renal function, who received intravenous colistin for >72 h, were included. Nephrotoxicity was defined using the RIFLE criteria (Risk, Injury, Failure, Loss, and End-stage renal disease). The demographic and clinical variables were retrieved from the hospital's electronic medical record system and compiled in an electronic database. All the statistical analysis was carried out by SAS JMP from SAS Institute Inc., Cary, NC. Seventy patients met the inclusion criteria. Colistin-induced nephrotoxicity occurred in 45.71% of the patients, of whom 40.6% were at Risk, 21.9% at Injury, and 37.5% at Failure according to RIFLE criteria. In patients who developed AKI, the average total colistin dose received before AKI was 4.4 mg/kg/day. More than half of the AKI group (53.13%) received an inappropriate total dose of colistin. Age, 65 years and older, was significantly associated with a high risk of nephrotoxicity (P <0.05), which developed within 6.8 ± 0.44 days from receiving a colistin dose. Clinical pharmacy services were consulted in 28.13% of the cases, and the dose was adjusted in 37.5% of the patients. Colistin nephrotoxicity is common and is associated more with older age group and inappropriate dosing.
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Five-Year Mortality Analysis in Hemodialysis Patients in a Single-Center in Dubai p. 1062
Maseer Ahmed, Fakhriya Alalawi, Hind AlNour, Kashif Gulzar, Amna Alhadari
The purpose of this study is to determine the mortality among patients on hemodialysis (HD). This observational cohort study was conducted at Dubai Hospital during the period between January 2012 and December 2016. All adults’ patients with end-stage renal disease (ESRD) on HD irrespective of their age, gender, and duration of dialysis were enrolled. Mortality among these patients along with certain information like age at the time of death, gender, cause of ESRD, comorbidities, and serology report, were collected. Out of a total of 411 patients, 112 (27.3%) patients died during the study period, 56% were male and their median age at the time of initiation of dialysis and at the time of death was 59.38 ± 13.5 and 63.8 ± 13.6, respectively. Thirteen patients suffered early mortality; i.e., died within 365 days of initiation of dialysis. Diabetes mellitus (DM) was the most common cause of ESRD (73%) among the deceased populations, whereas hypertension was the most prevalent comorbidity in our study group. Anemia (46%), hypoalbuminemia (54%), and hypoparathyroidism (72%), whereas high ferritin (63%) and abnormal phosphorus (61.6%) were predominant biochemical parameters in the deceased patients. The leading cause of death was cardiovascular in 48 patients (42.85%) followed by infection/sepsis (21 patients, 18.75%), unknown causes/sudden death (including sudden death at home) in 18 patients (16.07%) and cerebrovascular events in seven patients (6.2%). Other causes include gastrointestinal hemorrhage, liver disease, and pulmonary embolism. In general, older age group, DM, prolonged duration on dialysis and cardiac diseases were the common causes of mortality in our study population. We found that the conventional risk factors such as old age, diabetes, cardiovascular disease, duration on dialysis, dialysis adequacy, low hemoglobin and low albumin, abnormal phosphorus, and high ferritin are comparatively prevalent in our study patients. Monitoring and timely intervention of these risk factors can help in reducing mortality in future.
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Multicenter Review of Glomerular Diseases in the Emirates of Abu Dhabi: Six Years' Experience p. 1069
Hefsa Al Shamsi, Reem El Tahrawi, Basim Hindawy, Emad Khater, Mohamed Hassan
Glomerulonephritis (GN) is a rising paramount renal disease that varies in etiology from inherited or acquired factors. Its severity can range from asymptomatic depictions to end-stage renal disease. The aim of this study was to study the patterns of biopsy-proven GN based on the data from a multicenter in Abu Dhabi. Included kidney biopsies were from all patients above the age of 18 years, over a six-year period from 2010 to 2015, who had diagnosis of glomerular disease other than diabetes mellitus. The number of reviewed biopsies was 416. The most common type of GN among the study sample was IgA GN (22.8%) followed by focal segmental glomerulosclerosis (20.4%) and systemic lupus erythematosus (SLE) (19.7%). The least common types were pauciimmune (1.7%). There was female preponderance in lupus nephritis and pauciimmune GN. The nationality comparison did not reveal a predominate GN among Emirati nationals. The age relationship to GN types showed that majority (82.9%) of SLE patients, MCD (74.55%), and noncategorized (71.4%) patients are young aged between 18 and 39 years. On the other hand, 57.1%, 25%, and 16.7% of patients with pauciimmune, other GN types, and membranoproliferative GN, respectively, are 60 years and older. This study shows the histopathological variety of glomerular disease in Abu Dhabi. It could be a driving point to help understand GN better in the region.
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Clinicopathologic Features and the Association with Short-Term Outcome of Primary Membranous Nephropathy in Children: A Single-Center Study from Pakistan p. 1078
Madiha Aziz, Afshan Ehsan, Muhammed Mubarak, Ali Asghar Lanewala, Seema Hashmi
Membranous nephropathy (MN) is an uncommon cause of steroid-resistant nephrotic syndrome in children. Our study aimed to determine the clinicopathologic features of primary MN in children and their association with short-term outcome. This observational study was conducted from January 2009 to June 2017 at the Pediatric Nephrology Department. A total of 50 children were diagnosed with primary MN. Their clinical, laboratory, and histopathological findings on renal biopsy were recorded. The minimum follow-up was for six months. Clinicopathologic features were correlated with the outcome at the last follow-up. Data analysis was done using IBM SPSS Statistics for Windows software version 20.0. The mean age at onset was 10.92 ± 3.08 years (range: 4–17 years). The male-to-female ratio was 3:1. The serum albumin of ≤2.5 g/dL was seen in 40 patients (80%), hypertension was present in 38 (76%), and heavy proteinuria was seen in 32 children (70%). The mean estimated glomerular filtration rate (eGFR) at presentation was 178.71 ± 0.78 mL/min/1.73 m2. At the initial visit, nine children (18.4%) were in chronic kidney disease stage 2 and one (2%) in stage 4. Phospholipase A2 receptor antibody was present in five (15%) of 32 children tested. At the last follow-up (28 interquartile range: 25.5 months), 11 children (26%) were in complete remission and 25 (66%) had achieved partial remission. The mean eGFR had reduced to 145.84 ± 78.05 mL/min/1.73 m2. Patients with normal initial eGFR were more likely to go into remission (P = 0.001). The short-term outcome of childhood primary MN is relatively good in our setup. A multicenter collaborative study is required to determine prognostic factors and to standardize treatment in this uncommon nephropathy.
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Clinicopathological Spectrum of Renal Amyloidosis in Young p. 1085
Neha Garg, Sonal Jain, Shivangi Chauhan, Sonali Dixit, Sonal Sharma
Amyloidosis is a complex multi-system disorder characterized by deposition of an aberrant protein in tissues with kidney being the main target organ. The age of presentation of amyloid A (AA) amyloidosis is highest among adults aged 60–80 years followed by 45–55 years. However, presentation in younger age group is rare. We aimed to study the clinicopathological spectrum of patients with biopsy-proven renal AA amyloidosis aged <35 years in the last five years. This retrospective study was done on patients admitted from January 2015 to December 2019. Nine cases of AA amyloidosis diagnosed on kidney biopsy in ≤35 years of age were included in the study. Clinical, laboratory, and demographic data of all patients were obtained. Histopathological and direct immunofluorescence findings were further evaluated. The mean age (±standard deviation) was 22.5 ± 6.7 years with a range of 14–32 years. The most common underlying disorder of AA renal amyloidosis was Tuberculosis (TB) (88.88%, 8/9) with cyclosporine induced in one of the cases (11.11%). In all nine cases, glomeruli were mostly enlarged with moderate to marked mesangial expansion with thickened arteries and arterioles due to deposition of pink hyaline acellular material. Renal amyloidosis is rare in young age and is mostly secondary in nature. The association of TB with renal amyloidosis is common in adults (3.6%–50%), but only infrequently reported in children. It is important, especially in developing countries to be aware, as successful treatment of TB can result in remission of nephrotic syndrome due to secondary renal amyloidosis.
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Clinical Profile, Histopathological Features and Outcome of IgA Nephropathy in a Tertiary Care Hospital in India p. 1091
Vijoy Kumar Jha, Debasish Mahapatra, Anantharam Jairam
IgA nephropathy (IgAN) is reported to be more common in Asians and is considered to be a very progressive disease with worse outcome. The present study encompasses a cohort of biopsy-proven IgAN in a tertiary care hospital to characterize the initial clinical presentation, Oxford classification profile and one year follow up of patients with clinical and biochemical investigations. All renal biopsies with a diagnosis of primary IgAN were included. In all biopsies with ≥8 viable glomeruli, the MEST-C scores were analyzed, according to the Oxford criteria. Demographic and clinical data included age, gender, presence of hypertension, presence of hematuria and edema. Baseline investigations include urine protein semiquantitative, spot urine protein creatinine ratio, 24-h urinary protein, serum creatinine, and serum albumin. All the details of the use of antiproteinuric drugs and immunosuppressive drugs were recorded. Total 48 renal biopsies (21.62%) were diagnosed as primary IgAN. Thirty-seven (77.08%) had renal dysfunction on initial presentation out of which 31 (64.5%) patients had subnephrotic range proteinuria (SNRP). MEST-C lesions distribution were interpreted in 39 patients. 42.85% of patients with nephrotic range proteinuria (NRP) and 55.55% of patients with SNRP had renal deterioration during follow up period while 28.57% patients with NRP and 41.66% patients with SNRP had reached end-stage renal disease (ESRD). Our study population of IgAN has a unique clinical profile with hypertension, microscopic hematuria and subnephrotic proteinuria as the predominant clinical presentation. In spite of low MEST-C score in our study cohort, the disease has an aggressive course with 47.91% of patients with renal function deterioration and about one third follow up patients approaching ESRD during the study period.
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Catching the Worm Early: An Atypical Case of Bancroftian Filarial Nephropathy p. 1101
Arvind Krishnakumar, Anna T Valson, Neelaveni Duhli, Anjali Mohapatra, Kakde Sailesh Tulsidas, Santosh Varughese
Filarial glomerular disease has been attributed to circulating immune complex deposition. We report here a rare manifestation of filarial nephropathy with microfilariae documented in glomerular capillaries in addition to immune complex glomerulonephritis, thus suggesting that direct toxicity may also contribute to the pathogenesis of this entity.
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Leukocytoclastic Vasculitis Associated with Bortezomib Therapy p. 1106
Thiagarajan Raj Yashwanth, Raveendran Vairakkani, Nagalakshmi Dhanapal Srinivasaprasad, Suren Sujith, Kaliaperumal Thirumalvalavan, Mervin Edwin Fernando
A 28-year-old male, 10 years post live-related renal transplant with stable graft function of 1.4 mg/dL, presented with complaints of loss of appetite and vomiting for three days. On evaluation, he was found to have significant graft dysfunction with a creatinine of 10.3 mg/dL. He was initiated on hemodialysis in view of uremic gastrointestinal symptoms. Graft biopsy done revealed acute cell-mediated rejection BANFF IIB and diffuse C4d-positive antibody-mediated rejection. He was treated with intravenous methylprednisolone, therapeutic plasma exchange, and intravenous immunoglobulin therapy, following which his graft function improved gradually. He received multiple injections of bortezomib as a part of anti-rejection treatment protocol and developed peripheral neuropathy, leukocytoclastic vasculitis, and varicellosis. This case report is to highlight the unusual phenomenon of leukocytoclastic vasculitis in a post renal transplant setting secondary to bortezomib therapy.
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Spontaneous Renal Artery Dissection with Bilateral Renal Infarction Successfully Treated with Rivaroxaban p. 1110
Anam Haider, Muhammad Raheel Abdul Razzaque, Sonia Yaqub
Spontaneous renal artery dissection (SRAD) causing bilateral renal infarction is a rare condition. It may present with nonspecific symptoms, resulting in delayed diagnosis. We report a case of SRAD in an adult male who presented with flank pain and fever. The patient was initially worked up for possible pyelonephritis, which came back negative. Later, a diagnosis of SRAD with bilateral renal infarction was made on contrast-enhanced computed tomography (CT) abdomen followed by CT angiogram. The patient was treated with rivaroxaban and antihypertensive therapy. He was followed up for 12 months after the initial presentation and repeat imaging showed no new infarcts and a stable renal function.
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A Modified Regimen of Methylprednisolone, Cyclophosphamide, and Mycophenolic Acid for Severe IgA Vasculitis with Nephritis in a Child p. 1117
Sudung O Pardede, Angela Grace, Meilania Saraswati, Cahyani G Ambarsari
IgA vasculitis with nephritis (IgAVN), which was formerly known as Henoch–Schonlein purpura nephritis, commonly manifests with mild symptoms. However, in rare circumstances, IgAVN in children can progress to kidney failure. Despite the successful treatment of severe IgAVN with a combination of immunosuppressive medications including corticosteroids, no consensus has been established for IgAVN treatment. Here, we present a case of severe IgAVN in an eight-year-old Indonesian boy who was treated with simultaneous methylprednisolone, cyclophosphamide, and mycophenolic acid. He experienced recovery of kidney function within one month, while proteinuria resolved in five months, and hematuria resolved within a year after treatment initiation. No recurrences were noted during the two-year follow-up. Although our immunosuppressive regimen may seem very potent, it was shown to have tolerable side effects and could be beneficial for kidney recovery. Importantly, they have also been shown to prevent progression to chronic kidney disease in children with severe IgAVN.
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Acute Kidney Injury due to Povidone-Iodine p. 1125
Dorsaf Zellama, Sinda Ayed, Awatef Azzabi, Sanda Mrabet, Wissal Sahtout, Asma Fradi, Narjes Ben Aicha, Yosra Guedri, Abdellatif Achour
Povidone-iodine is a broad-spectrum antiseptic applied topically to treat wounds and prevent their infection. Despite the apparent innocuousness of this agent, several cases of acute kidney injury (AKI) due to iodine toxicity have been reported. We report a case of severe AKI that occurred in a 32-year-old female three days after a hysteroscopy for the diagnosis of primary sterility using povidone-iodine as the local antiseptic agent. We made a clinical diagnosis of tubular necrosis related to iodine toxicity in view of the clinical presentation and high blood iodine concentration. The patient was treated with hemodialysis until urine output and renal function improved. Physicians must be aware of the possible nephrotoxicity secondary to povidone-iodine use. Patients receiving povidone-iodine, especially those who already suffer from kidney failure, should be closely monitored. The discontinuation of this agent, with the use of hemodialysis, is usually effective.
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Two Peculiarities of the Nutcracker Syndrome: Rare Association with Multiples Thrombosis and Successful Medical Treatment (Pentoxifylline) p. 1129
Yosra Ben Ariba, Sonia Achouch, Marwa Omrani, Imen Ourteni, Jannet Labidi
The nutcracker syndrome (NCS) is a rare condition characterized by the entrapment of the left renal vein between the superior mesenteric artery and the aorta. Clinically, it presents with hematuria, flank pain, and symptoms of pelvic venous congestion. It is more frequent in females. Conservative treatment is usually proposed children but in adults, NCS has to be treated by surgical or endovascular methods. Drug therapy is not proposed for the treatment of NCS. We report a case of a young patient who presented with recurrent gross hematuria. Our patient was treated with pentoxifylline three times daily and anti-coagulation, with a favorable outcome.
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Metabolic Acidosis, Hyperkalemia, and Renal Unresponsiveness to Aldosterone Syndrome: Response to Treatment with Low-Potassium Diet p. 1134
Sushil K Mehandru, Attiya Haroon, Avais Masud, Jay Shah, Supreet Kaur, Aisha Masud, Amir Hossain, Arif Asif, Tushar J Vachharajani
Gordon syndrome involves hyperkalemia, acidosis, and severe hypertension (HTN) with hypercalciuria, low renin and aldosterone levels. It is commonly observed in children and adolescents. Such patients respond successfully to sodium restriction and thiazide diuretics. In this article, we present three cases of metabolic acidosis, hyperkalemia, and renal unresponsiveness to aldosterone (MeHandRU Syndrome). All three patients did not have HTN or hypercalciuria and demonstrated normal renin and aldosterone levels. These patients did not respond to thiazide-type diuretic therapy and salt restriction. Two males (aged 55- and 62-year) and a female patient (aged 68-year) presented to the clinic with unexplained hyperkalemia (5.9 mEq/L, 5.9 mEq/L and 6.2 mEq/L, respectively). On physical examination, blood pressure (BP) was found to be normal (<140/90 mm Hg). Over the counter potassium supplement, nonsteroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, potassium sparing diuretic use, as well as hyporeninemic hypoaldosteronism states such as diabetes mellitus were excluded. Plasma renin and aldosterone levels were normal. All three patients had low transtubular potassium gradient, despite high serum potassium levels. None of the patients reported a family history of hyperkalemia or kidney failure. All failed to demonstrate a response to hydrochlorothiazide and salt restriction. After careful consideration, strict low potassium diet (<2 g/day) was initiated in consultation with the dietician. Diuretic therapy was discontinued while BP remained within normal range (<140/90 mm Hg). At eight weeks, all three patients demonstrated normalization of potassium and correction of acidosis. At follow-up of six months, all patients are maintaining a normal potassium level. We suggest that potassium restriction can be successful in patients presenting with MeHandRU syndrome.
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Intra-abdominal Hypertension as a Cause of Oliguric Acute Kidney Injury in a Patient with Chronic Lymphocytic Leukemia p. 1140
Dimitris Xydakis, Ergini Antonaki, Anna Boula, Emilia Stavroulaki, Aristea Hatzivasili, Dimitra Liapi
Acute kidney injury (AKI) is a well-known complication in patients with chronic lymphocytic leukemia (CLL). It could occur via diverse mechanisms such as leukemic infiltration, extrarenal obstruction, tumor lysis syndrome, glomerular diseases, and medication side effects. The incidence of kidney disease at the diagnosis of CLL is about 10%. We report a case of AKI, in a patient with a known history of CLL, due to abdominal compartment syndrome, caused by extremely enlarged intra-abdominal lymph masses. To the best of our knowledge, no case of AKI due to such cause has been reported so far.
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Acquired Bartter Syndrome in Primary Sjögren Syndrome p. 1144
Aya Fraj, Mounira El Euch, Fatima Jaziri, Asma Kefi, Khaoula Ben Abdelghani, Sami Turki, Taieb Ben Abdallah
Renal tubular involvement in Sjögren's syndrome (SS) often described with renal tubular acidosis, nephrogenic diabetes insipidus, or rarely with Fanconi syndrome. SS presenting with clinical features of Bartter's syndrome or Gitelman's syndrome is rare. We report a case of a female patient who presented an acquired Bartter syndrome with a primary SS.
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The Overlap of Inflammatory and Fixed Lesions in Takayasu's Arteritis p. 1148
Gioacchino Li Cavoli, Luisa Bono, Francesca Finazzo, Mario Giuseppe Vallone, Calogera Tortorici, Vitalba Azzolina, Riccardo Dell' Utri, Tancredi Vincenzo Li Cavoli, Rosalia Mongiovi, Antonio Amato, Franca Servillo, Barbara Oliva, Onofrio Schillaci
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Be Aware! COVID-19 Can Remain Active on Environmental Surfaces in Hemodialysis Settings and Endanger the Patients' Life p. 1150
Nader Aghakhani, Narges Rahbar
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A Forgotten Cause of Thrombocytopenia in Post Renal Transplant Setting p. 1152
Sahil Bagai, Kunal Raj Gandhi, Gagandeep Chhabra, Rahul Grover, Dinesh Khullar
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Thiopurine S-methyltransferase Genetic Polymorphism and Its Contribution for Azathioprine-Induced Myelosuppression in Kidney Transplant Recipients: A Summative Analysis p. 1154
Pathum Sookaromdee, Viroj Wiwanitkit
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Anti-Neutrophil Cytolasmic Antibodies-Associated Vasculitis Associated with Diffuse Alveolar Hemorrhage in a Maintenance Hemodialysis Patient p. 1156
Fatih Yilmaz, Hasan Sözel, Meryem Keleş
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The Effect of the Family-Centered Empowerment Model on Post-dialysis Fatigue in Hemodialysis Patients, Urmia, Iran p. 1159
Nader Aghakhani, Rahim Baghaei
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Home Dialysis: Lessons from COVID-19 and Other Viral Outbreaks p. 1161
Abdelaali Bahadi, Driss ElKabbaj
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A Multicenter Study of Malnutrition Status in Chronic Kidney Disease Stages I–V-D from Different Socioeconomic Groups p. 1162
Georgi Abraham
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Deceased Donation after Brain Death (DBD) and Organ Transplantation p. 1163
Besher Al Attar
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