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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
November-December 2020
Volume 31 | Issue 6
Page Nos. 1180-1469

Online since Friday, January 29, 2021

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Pregnancy-associated hemolytic uremic syndrome Highly accessed article p. 1180
Sami Alobaidi, Ammar AlDabbagh, Amany Alamoudi, Murad Almowarey, Ahmed Akl
Pregnancy-associated hemolytic uremic syndrome (P-aHUS) is not an uncommon condition. It is considered a medical emergency that is associated with a high risk of mortality and serious morbidity. End-stage renal disease as a consequence of P-aHUS occurs in >50% of the patients if left untreated; the majority of identified cases (79%) are during the postpartum period. Its mechanism of action is related mainly to the disturbance in the activation of the complement alternative pathway, leading to damage of the microvascular endothelium. The clinical picture of P-aHUS mimics several conditions occurring during post-partum thrombotic microangiopathy, for example, severe pre-eclampsia, hemolysis, elevated liver enzymes, and low platelet count, thrombotic-thrombocytopenic purpura, and acute fatty liver of pregnancy. Genetic analysis of known genetic mutations together with the analysis of anti-CFH antibodies might confirm the diagnosis of aHUS in the post-partum period. The absence of causative genetic mutations does not always exclude a diagnosis of aHUS, since 40% of patients show no known genetic abnormalities. The mainstay of management is supportive care and immediate initiation of plasmapheresis. Eculizumab has been proved to be both safe and effective in inducing and maintaining remission in P-aHUS and it is recommended to be started as soon as the diagnosis is established.
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Genetic screening in children with challenging nephrotic syndrome Highly accessed article p. 1189
Bassam Saeed
Genetic screening paradigms for the nephrotic syndrome (NS) in the developed world are well established; however, screening in developing countries has received only minor attention. We retrospectively analyzed a cohort of all children who underwent genetic testing for challenging NS from our registry in the 10-year interval from 2000 to 2010 and based on 58 patients aged 0–12 years with at least one of the following clinical diagnosis: Nonsyndromic steroid-resistant nephrotic syndrome (SRNS), familial NS, and congenital NS. Of these, 23 patients (~40%) had a history of familial disease occurrence. All cases were screened for NPHS2 and WT1 mutations by direct sequencing of all exons of the genes. In addition, all patients who were diagnosed during the first three months of life were screened for NPHS1 mutations too. A genetic disease cause was identified in 12 patients (20.7%); of these, five novel mutations, all in NPHS2 accounting for 42% of all mutations and 9% of the cohort. Nine patients were found to have NPHS2 mutations. Only one case with SRNS had a mutation in WT1. Of the five congenital NS, two cases were found to have NPHS1 mutations and one case with NPHS2 mutation. Therefore, mutations in NPHS2 were the most commonly identified and explained in 15.5% of the screened patients and WT1 mutation in 1.7% of cases, whereas NPHS1 mutations were found in 40% of congenital NS cases. A genetic disease cause was identified in 20.7% of the screened patients. Among 12 identified mutations, abnormalities in NPHS2 (n = 9) were most commonly identified.
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Urinary podocalyxin: Is it a real index of disease activity in egyptian patients lupus nephritis? Highly accessed article p. 1198
Ahmed Fayed, Mahmoud M Elnokeety, Mohamed Elyamny, Hany Hammad, Dina Hesham Ahmed Soliman, Reham Abdelghany Ahmed
Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease characterized by production of a number of antinuclear antibodies. Podocyte injury is an important feature and can be detected by several markers including podocalyxin. We aimed to evaluate the impact of SLE on urinary levels of podocalyxin and to determine its relationship to renal biopsy, proteinuria, and disease activity in lupus nephritis (LN) patients. Sixty individuals were recruited; 30 SLE patients with LN as well as 30 healthy volunteers and they were subjected to full history, clinical examination, kidney function, protein/creatinine ratio, urinary podocalyxin, and kidney biopsy. Patients with LN had higher level of urinary podocalyxin (3.96 ± 2.24) than the other group (0 ± 0), (P <0.001). Class IV LN was the most common class found among LN patients [18 cases (60%)]. There was a statistically significant positive correlation between SLE disease activity index score, protein/creatinine ratio, and urinary podocalyxin (P <0.001, r = 0.98) (P <0.001, r = 0.765). There was a statistically significant negative correlation between serum albumin, serum calcium, and urinary podocalyxin (P = 0.001, r = -0.589) (P = 0.025, r = -0.407). Urinary podocalyxin level significantly predicts the pathological impact of SLE on the kidney and could be used as a noninvasive marker for such effect and its progression.
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Interleukin 18 as a new inflammatory mediator in left ventricular hypertrophy in children with end-stage renal disease p. 1206
Ahlam Badawy, Dalia A Nigm, Ghada M Ezzat, Yasser Gamal
Left ventricular hypertrophy (LVH) represents an important determinant of increased cardiovascular morbidity and mortality (CV) in end-stage renal disease (ESRD) patients. The role of inflammatory markers in pathogenesis of LVH in children with ESRD is not fully described. The aim of this study is to evaluate relation of some inflammatory markers [as hs C-reactive protein (hsCRP) and interleukin (IL) 18] with LVH in children with ESRD on regular hemodialysis (HD). This is a cross-sectional study performed on 50 children on regular HD. Demographic data were recorded. Echocardiography was performed at baseline to determine those with LVH. Biochemical parameters: hemoglobin (HB), hsCRP, IL 18, phosphorus, calcium, serum albumin, and lipid profile were evaluated and correlated with LVH. Data were analyzed using Student’s t-test, and logistic regression to determine the relationship between LVH and other variables. LVH was present in 33 (66%) participants. Mean left ventricular mass index was 56.88 ± 22.23 g/m.2.7 Concentric remodeling, concentric hypertrophy, and eccentric hypertrophy were present in 4%, 22%, and 44% of the participants. In univariate analysis, children with LVH had significantly lower levels of HB and serum albumin but higher levels of hsCRP, and IL 18 compared to those without LVH. On multivariate analysis: only hsCRP, and IL 18 were significantly associated with LVH. This study shows that elevated hsCRP and IL-18 are independent determinants of LVH in HD children. Understanding the role of inflammatory molecules in the pathogenesis of LVH in ESRD is important for prediction of high-risk group and implementation of targeted anti-inflammatory therapies.
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Causes of the delay in creating permanent vascular access in hemodialysis patients p. 1217
Maha A Alfarhan, Shahad A Almatrafi, Sumaia M Alqaseer, Yara A Albkiry, Abdulla AlSayyari
Majority of the chronic kidney disease (CKD) patients undergo hemodialysis (HD) with central venous catheter which has multiple complications. This study aims to identify the physicians’ perspectives regarding the reasons of delayed arteriovenous fistula (AVF) creation in the Kingdom of Saudi Arabia to improve the quality of CKD patients’ care and prognosis and prevent complications. A cross-sectional descriptive study was conducted on KSA nephrologists using a questionnaire which includes factors associated with delay in AVF creation, which were categorized into patient, physician, and hospital factors. The optimal timing of starting dialysis was also assessed. In a total of 212 participants, 131 (61.8%) were of consultant level, with the largest numbers being from the Central region (52.4%). The most important patient factors associated with delay in AVF creation were denial of kidney disease or the need of AVF (76.4%), dialysis fears and practical concern (75.9%), and patient refusal (73.1%). The most important physician and hospital factors were insufficient conduction of predialysis care and education (63.7%) and late referral to a nephrologist (56.6%). Participants would create AVF when the patient reaches Stage 4 CKD (69.3%) or Stage 5 (27.4%), and 88.7% of the participants would do so 3–6 months before the anticipated start of HD. Over two-thirds of the participants (68.4%) chose patient as the main factor contributing to the delay of permanent vascular access. A validated approach to patient selection, patient-centered predialysis care, and referral to vascular access creation that could be applied on different types of patients in different regions is required.
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A study of quality of life among hemodialysis patients and its associated factors using kidney disease quality of life instrument-SF36 in Riyadh, Saudi Arabia p. 1225
Abdulaziz Ajeebi, Abdulkarim Saeed, Alwaleed Aljamaan, Mujahid Alshehri, Majed Nasradeen, Nouf Alharbi, Aamir Omair, Abdulla A Al-Sayyari
We aimed in this study to assess the quality of life for kidney-ill patients using Kidney Disease Quality of Life Instrument-SF36 (KDQOL-SF36) and the impact of other demographic, clinical, and social factors on patients’ QOL. The quality of life was assessed using an Arabic version of KDQOL-36. The KDQOL-36 subscales Physical Component Summary (PCS), Mental Component Summary (MCS), Burden of Kidney Disease, and Effects of Kidney Disease were calculated. The effect of sex, diabetic status, diabetes mellitus, marital and status employment status, etc. on these subscales was evaluated. Reliability was determined by calculating Cronbach’s alpha. A total of 254 patients were enrolled. The mean age was 58.2 (standard deviation 18.2) years; 61% were male, 56.7% diabetic and 20.1% were employed. The mean domain scores on the PCS, MCS, burden of kidney disease, and effects of kidney disease subscales were 49.4, 38.7, 52.6, and 37.2, respectively. Afternoon shift patients score highest among all shifts in MCS and PCS (P = 0.0001). The MCS score (38.7 ± 28.7) was significantly lower than PCS (49.4 ± 16.5) (P = 0.0001). The “effect of kidney disease” subscale was higher in males (P = 0.02), employed patients (P = 0.02), in the afternoon dialysis shift (0.0001). For PCS higher scores were seen in males (P = 0.0001), in non-diabetics (compared to diabetics) (P = 0,006), in the employed patients (P = 0.02). The highest score was seen in the “burden of kidney disease” subscale and the lowest in the “effects of kidney disease” subscale. Higher scores were seen in males, in nondiabetics, in the employed patients.
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Echocardiographic findings in children with chronic kidney disease p. 1234
Bahia Moustafa, Hanan Zekry, Rania Hamdi Hashim, Doaa Mohamed Salah, Ahmed Abdelwahed Abdelfattah, Rodina Sobhy
Cardiovascular diseases (CVD) are considered major cause of morbidity and mortality among children with chronic kidney disease (CKD). This study aims to determine the incidence of CVD in children with CKD, to analyze risk factors and early predictors for late onset atherosclerosis. Thirty-five CKD children [25 on regular hemodialysis (HD) and 10 on conservative management] were evaluated clinically. Left ventricular (LV) functions and carotid artery intima-media thickness (c-IMT) were assessed using conventional echocardiography, pulsed wave Doppler (PWD) and tissue Doppler imaging (TDI). There was decreased E/A ratio and increased E/E' ratio in 66% and 77% of patients, respectively signifying diastolic cardiac dysfunction. There was a significant correlation between increased A' value (peak late diastolic annular velocity) and both increased serum cholesterol and anemia (P = 0.009, 0.004 respectively). Serum high density lipoprotein (HDL) significantly correlated negatively with inter-ventricular septal thickness and LV end-diastolic dimensions (P = 0.05, 0.02, respectively) and positively with E' value (peak early diastolic annular velocity) (P = 0.04). Abnormal c-IMT correlated significantly with HD duration (correlation coefficient = 0.428, P = 0.01) and with both increased serum cholesterol and decreased serum HDL (P = 0.021, 0.031, respectively). Diastolic dysfunction and abnormal LV dimensions are present in patients with CKD even those on conservative management. TDI appears to be more impressive than PWD in assessing early myocardial dysfunction. Increased c-IMT and dyslipidemia are prevalent in patients with CKD and more prevalent in patients on HD.
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Evaluation of visual evoked potentials and brain-stem auditory evoked response in patients of chronic kidney disease p. 1245
HK Aggarwal, Deepak Jain, Shailesh Bhatia
Chronic kidney disease (CKD) is associated with functional changes in the central nervous system (CNS) which, in the initial stages do not manifest clinically. Early involvement of the CNS can be identified by the assessment of the electrocortical activity. Visual evoked potential (VEP) and brain-stem auditory evoked response (BAER) are useful tests for the early diagnosis of CNS involvement in CKD and are more sensitive compared to electroencephalography. One hundred adult CKD patients (stage 3–5 and 5D) and 50 controls were included in the study. Clinical and biochemical parameters were assessed and all the patients and controls underwent VEP and BAER evaluation. Evaluation of the VEP showed prolonged latencies of all the three peaks (N75, P100, and N145) compared to controls. Furthermore, all the absolute and interpeak BAER latencies for the CKD patients were similarly prolonged compared to controls. CNS dysfunction is common in CKD patients. The electrophysiological tests of VEP and BAER can be used for the early diagnosis of these disorders, even in the sub-clinical stages, thus allowing for their better management.
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Significance of ambulatory blood pressure monitoring in assessment of potential living kidney donors p. 1254
Niamh M Brady, Hatem Ali, Fiona Biggins, Aimun Ahmed
The most recent British Transplant Society (BTS) guidelines recommend that office blood pressure (BP) monitoring in living donors is sufficient for the assessment of hypertension (HTN) and those with BP >140/90 should be further assessed using ambulatory BP monitoring (ABPM). ABPM can detect diurnal and nocturnal variation in BP, thus it can identify masked HTN. The aim of the current study is to assess reliability of ABPM vesus office BP monitoring for assessment in living kidney donors. Office and ABPM of all potential kidney donors at a single center from April 2009 to March 2017 were retrospectively reviewed and compared. Age, sex, body mass index, kidney function, and echocardiography results were collected and analyzed. Two hundred and sixteen kidney donors were stratified based on their BP readings into four groups; group 1 (masked HTN: normotensive in office and hypertensive in ABPM), group 2 (sustained normotension: normotensive in office and in ABPM), group 3 (sustained HTN: hypertensive in office and in ABPM), group 4 (white-coat HTN: hypertensive in office and normotensive in ABPM). Thirteen percent of patients were diagnosed with masked HTN. Office systolic BP monitoring was significantly higher in patients older than 50 years old compared to other younger populations. However, this significant difference in systolic BP was diminished when assessment with ABPM was performed. In conclusion, ABPM is a reliable modality for the identification of masked HTN and white coat HTN. Masked HTN is correlated with increased risk of end organ damage and risk of death in potential kidney donors. Transplant physicians cannot rely solely on office BP monitoring in the assessment of potential living kidney donors. ABPM should be integral part of routine assessment of potential living kidney donors.
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Diagnosis of iron deficiency in hemodialysis patients: Usefulness of measuring reticulocyte hemoglobin equivalent p. 1263
Dawlat Sany, Yasser El Shahawi, Jenan Taha
The evaluation of iron status in dialysis patients provides information essential to the planning of adequate recombinant human erythropoietin treatment. To diagnose iron deficiency in patients undergoing hemodialysis (HD), reticulocyte hemoglobin content and percentage of hypochromic red cells are incorporated into the European best practice guidelines on anemia management in chronic kidney disease (CKD), the mean reticulocyte hemoglobin content (Ret-HE) was proposed as alternatives to standard biochemical tests. Reticulocyte hemoglobin content and percentage of hypochromic red cells are incorporated into the European best practice guidelines on anemia management in CKD. Our aim was to assess the value of Ret-HE parameter, in terms of the sensitivity and specificity for detecting iron deficiency, in HD patients. We studied 50 patients undergoing HD three times weekly , to clarify the accuracy of Ret-HE in diagnosing iron deficiency in dialysis patients, we initially compared Ret-HE with such iron parameters as serum ferritin levels, transferrin saturation, and hypochromic red blood cell (Hypo%) which has been established as indicators of functional iron deficiency. Ret-HE mean value in anemic patients was (25.84 ± 4.23 pg) and had good correlation (P <0.001) between Ret-HE, serum iron, ferritin, transferrin, and transferin saturation in dialysis patients. Receiver operating characteristic curve analysis revealed, values of the area was 0.887, and at a cutoff value of 27.0 pg, a sensitivity of 90.4% and a specificity of 80.8% were achieved. The newly proposed Ret-HE can provide clinicians with information equivalent to iron deficiency anemia markers. Ret-HE is a new parameter that is easily measurable is suggested as reliable parameters for the study of erythropoiesis status in HD patients.
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Validation of acute kidney injury prediction scores in critically ill patients p. 1273
Ahmed Mohamed Zahran, Yasser Ibrahim Fathy, Asmaa Esmail Salama, Mohamed Esam Alebsawi
Prediction of acute kidney injury (AKI) in critically ill patients allows prompt intervention that improves outcome. We aimed for external validation of two AKI prediction scores that can be bedside calculated. A prospective observational study included patients admitted to medical and surgical critical care units. Performance of two AKI prediction scores, Malhotra score and acute kidney injury prediction score (APS), was assessed for their ability to predict AKI. The best cutoff point for each score was determined by Youden index. Area under the receiving operation characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to assess performance of each score. Univariate and multivariate regression analyses were done to detect the predictability of AKI. Goodness-of-fit and kappa Cohen agreement tests were done to show whether the expected score results fit well and agree with the observed results. AKI prevalence was 37.6%. The best cutoff values were 5 and 4 for Malhotra score and APS, respectively. Area under the curve for Malhotra 5 was 0.712 and for APS 4 was 0.652 with nearly similar sensitivity and specificity. Regression analysis demonstrated that Malhotra 5 was the independent predictor of AKI. Goodness-of-fit test showed significant results denoting lack of fit between the scores and the actual results. Kappa test showed moderate agreement for Malhotra 5 and fair agreement for APS 4. Both scores showed moderate performance for AKI prediction. Malhotra 5 showed better performance compared to APS 4. Multicenter international study is warranted to develop a universal model that can predict AKI in critically ill patients.
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Blood pressure standards for pre-school children in Saudi Arabia p. 1281
Abdullah A Al Salloum, Mohammed I El Mouzan, Ahmad H Al Sharqawi, Ahmad A Al Omar, Mansour M Alqurashi, Abdullah S Al Herbish
The prevalence of hypertension (HTN) in children is increasing. Early detection of HTN in childhood may prevent the occurrence of complications in adult age. Blood pressure (BP) varies between populations according to ethnic and environmental factors. Based on these variations, reference norms developed for one particular population may not be applicable to others. Thus, this study aimed to provide age-, gender-, and height-related BP reference standards using oscillometric techniques for pre-school children in Saudi Arabia. A sub-sample of preschool children aged from 2 to 6 years was selected by multi-stage probability sampling of Saudi population. The samples represented Saudi children from the whole country. Data were collected through a house-to-house survey of all selected households in all 13 regions in the country. Oscillometric devices were used to measure the BP. Data were analyzed to study the distribution pattern of systolic (SBP) and diastolic BP (DBP) and to develop reference values based on age, gender, and height. The values for each age and height percentile were compared with the recent (2017) values of the North American children. A total of 2553 Saudi Arabian children (1299 boys and 1254 girls) aged 2–6 years with complete data on age, gender, height, SBP, and DBP were considered for analysis. Values for SBP and DBP were significantly higher in Saudi children than in the North American children. This study adds evidence to the BP variations between populations with influences such as genetic and environmental factors. The need of every population to define its normal BP standards is essential to avoid unnecessary investigations and anxiety in patients and their parents.
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Experiences of stress appraisal in hemodialysis patients: A theory-guided qualitative content analysis p. 1294
Mohammad Ali Morowatisharifabad, Mohtasham Ghaffari, Yadolah Mehrabi, Jafar Askari, Samad Zare, Somayeh Alizadeh
Chronic renal failure and prolonged hospitalization for the treatment of renal disease incur immense stress and anxiety in patients. Considering the increased prevalence of renal failure, the present study aimed to explain the experiences of stress assessment in hemodialysis (HD) patients based on the transactional model of Lazarus and Folkman. The data collection method was semi-structured interview with 22 patients from dialysis centers in Tehran. Sampling was purposive and continued until data saturation. Data were analyzed using the directed content analysis method. Data analyzed to the extraction of 80 codes that were classified into two predetermined categories of appraisal structures in the transactional stress model, including primary and secondary appraisal, and also seven subcategories (perceived susceptibility, perceived severity, motivational relevance, casual focus, perceived control over outcoms, perceived control over emotions, and self-efficacy). During this study, 15 sub-subcategories were obtained for the stress appraisal in HD patients. The results showed that the subcategories of perceived susceptibility, perceived severity, and casual focus were the most effective factors in the stress appraisal in HD patients. According to the results, an arrangement should be made so that HD patients can evaluate the stressful conditions properly. patients need help to improve their evaluation in subcategories of motivational relevance, perceived control over outcomes, perceived control over emotion, and self-efficacy. In this regard, one of the best models that can be used to identify the appraisals in HD patients and design appropriate interventions for them is the transactional model.
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Myringosclerosis in hemodialysis patients with hyperparathyroidism p. 1303
Alsayed Alnahal, Mohamed Waheed, Walid Ahmed Ragab Abdelhamid
Myringosclerosis is the final stage of the middle ear lamina propria inflammation or trauma; it starts with collagen production in excess amounts in the lamina propria of the middle ear mucosa. Then, hyalinization and calcification occur. Later on, metaplasia of bone or cartilage can occur. A similar sequence occurs with hyperparathyroidism in chronic kidney disease. This study is aimed to detect the prevalence of myringosclerosis in patients of our hemodialysis (HD) unit and find out any association between hyperparathyroidism and myringosclerosis in chronic HD patients. A total number of 86 patients were selected according to the inclusion criteria. They were divided into two groups: Group 1 (58 patients myringosclerosis free patients on regular HD), Group 2 (28 patients myringosclerosis-positive patients on regular HD). No statically significant difference was found in serum parathyroid hormone levels between the two studied groups. Serum creatinine was significantly higher in Group 2, serum ferritin was significantly lower in Group 2, and mean corpuscular volume of red blood cells was highly significantly lower in Group 2. Myringosclerosis affects 32% of our HD patients and we could not detect any strong correlation between myringosclerosis and hyperparathyroidism.
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The protective effect of alpha-lipoic acid on the expression of collagen IV, renal function, and oxidative stress induced by diazinon in the renal parenchyma of rat p. 1310
Amir Delavar, Mohammad Reza Nikravesh, Mehdi Jalali, Mahmoud Gorji Valokola, Fatemeh Rahimi Anbarkeh
Diazinon (DZN) is an organophosphate pesticide that is commonly used in agriculture worldwide, including in Iran, and unfortunately, it leads to a variety of negative effects on the environment, animals, and humans. Alpha-lipoic acid (ALA) is an antioxidant agent that acts via scavenging of oxygen-free radicals. Collagen IV is a component of the main base membrane structure and DZN may also affect the expression of this key protein. The aim of this study was to evaluate antioxidant properties of ALA on the expression of collagen IV, renal function, and oxidative stress induced by DZN in renal tissue. In this experimental study, 30 adult male Wistar rats were randomly divided into five groups (n = 6) including: the control group, DZN (40 mg/kg) group, ALA (100 mg/kg) group, ALA (100 mg/kg) + DZN (40 mg/kg) group, and sham group. On day 0 and after 6 weeks, the urine and blood samples were collected to measure glomerular filtration rate (GFR). After 6 weeks, the rats were anesthetized and the left kidney was used for immunohistochemistry study and the right kidney was used to evaluate the oxidative stress parameters. The results have shown that ALA significantly improved the biochemical parameters including superoxide dismutase, glutathione peroxidase, glutathione S-transferase, glutathione reductase, and GFR. In addition, ALA significantly prevented the expression of collagen IV that was changed by DZN administration in rats. We concluded that when exposed to DZN, depletion of antioxidant enzymes is accompanied by the induction of oxidative stress that might be beneficial in monitoring DZN toxicity and alpha-lipoic acid, as an antioxidant can overcome the toxicity induced by DZN in the kidney.
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Serum cystatin C unmasks renal dysfunction in cirrhosis and performs better in estimation of glomerular filtration rate p. 1320
Balaraman Velayudham, Remi George Thomas, C Vasudevan, RP Senthilkumar, Thirumalvalavan , Murugesan
In this study, we aimed to measure glomerular filtration rate (mGFR) using 99Tc DTPA in patients with Child-Pugh C cirrhosis and normal serum creatinine levels; and to compare the performance of creatinine and cystatin C-based equations [estimated GFRs (eGFRs)] to 99TcDTPA GFR in the same group. We selected a group of 65 consecutive patients with advanced liver cirrhosis and apparently normal renal function by serum creatinine alone. Patients with confounding and reversible factors were excluded. Demographic data, blood, urine, and imaging tests along with simultaneous measurement of serum creatinine and cystatin C were analyzed. The GFR was measured by 99Tc DTPAscintigraphy (mGFR) in 41 patients. We compared the performance of chronic kidney disease epidemiology collaboration (CKD-EPI-creatinine, CKD-EPI-cystatinC, CKD-EPI-creatinine-cystatinC) and Modification of Diet in Renal Disease equation equations for bias (mean difference), precision (root mean square error), and accuracy (P10 and P30). Bland–Altman plots were used to show the agreement of eGFR and mGFR. Twenty-five out of 41 patients (61%) had significant renal dysfunction (GFR ≤60 mL/min/ 1.73m2) by 99TcDTPA in our study and three patients were already in Stage 4 CKD. Unlike serum creatinine, serum cystatin C values were deranged in these patients. Among all GFR estimating formulae, CKD-EPI-creatinine-cystatinC combined equation had the least bias (-2.3), superior precision (7.1), highest P30 accuracy (78%), good sensitivity (87.5%), and best specificity (96%) in our study. Two-thirds of patients with cirrhosis had significant renal impairment despite having normal serum creatinine. Isolated serum creatinine values are misleading in cirrhosis. Cystatin C unmasks renal dysfunction in these patients. CKD-EPI-creatinine-cystatinC equation showed the best correlation and accuracy with 99TcDTPA GFR in our study. Creatinine based GFR estimation is fallacious in cirrhosis. Cystatin C and equations based on it may be worthwhile in liver disease.
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Thrombotic microangiopathy in a renal allograft: Single-center five-year experience p. 1331
Aruna V Vanikar, Kamal V Kanodia, Kamlesh S Suthar, Lovelesh A Nigam, Rashmi D Patel, Umang G Thakkar, Aanal H Mehta
Thrombotic microangiopathy (TMA) is devastating for renal transplantation (RT) causing graft/ patient loss. We present 5-year experience of TMA in RT in retrospective study of indicated renal allograft biopsies with TMA. Patient–donor demographics and associated histological findings with respect to transplants under tolerance induction protocol (Group 1) were compared with patients transplanted under triple immunosuppression (Group 2). Statistical analysis was performed using IBM SPSS Statistics version 20. Sixty-one (4.1%) of 1520 biopsies [Group 1:17 (1.9%)/882, Group 2:44 (6.9%)/638] revealed TMA. Tacrolimus trough levels were normal. There was no evidence of systemic involvement in any patient. Mean age was 36.8 years with 70.6% males, HLA-match, 2.6/6, and the most common original disease unknown (41.2%) in Group 1, and 35.9 years with 86.4% males, HLA-match, 2.1/6, and the most common original disease unknown (50%) in Group 2. Biopsies were performed at mean 5.1-year posttransplant in Group 1 and 2.3 years in Group 2. Acute TMA constituted 47% Group 1 and 43.2% Group 2 biopsies; of these, antibody-mediated rejections were observed in 58.8%, T-cell mediated rejections in 11.8%, tacrolimus toxicity in 76.5%, and other findings in 35.3% Group 1; and 61.4%, 25%, 50%, and 18.2%, respectively, in Group 2 biopsies. Higher rejection activity scores were more in Group 2. Postbiopsy 1- and 5- year patient survival was 94.1%, 86.9% in Group 1 and 92.1%, 88.3% in Group 2; 1- and 4-year graft survival was 52.9%, 15.9% in Group 1 and 20.3%, 5.4% in Group 2. TMA was poor prognosticator for RT, especially under triple immunosuppression. Antibody- mediated rejection and tacrolimus toxicity were more prone to TMA.
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Knowledge and attitude toward organ donation among medical staff and outpatients at King Abdulaziz Medical City, Riyadh, Saudi Arabia p. 1344
Ibrahim Altraif, Nourah Altuwaijri, Lamia Aldhbiban, Fai Alhoshan, Raghad Alomari, Afaf Moukaddem, Hamad Alashgar, Fajr Alqahtani
Organ transplantation is still the treatment of choice for end-stage organ failure. Despite the establishment of the Saudi Center for Organ Transplantation (SCOT), the organ supply still does not meet the increasing demand. This study aims to assess the knowledge of Saudis about organ donation both among the public and the medical staff and to assess the trend in the change from 1996 until now. A cross-sectional study was conducted among Saudis above the age of 18 years. A self-administered, 25-item, questionnaire was completed by participants including both outpatients and medical staff at King Abdulaziz Medical City using a convenient sampling technique. A total of 376 individuals answered the questionnaire; 238 (63.1%) heard about SCOT, of whom 124 (70.5%) were males. Health-care professionals had better attitude and knowledge on organ donation (P <0.05). Compared to the results from 1996to 2017, there was (51.22%) to (30.4%) decrease in people who allowed their families to donate their organs; on the other hand, there was an increase in the percentage of people who had the correct knowledge that Islam supports organ donation. Unsatisfactory levels of awareness impacted negatively on the knowledge and attitude of the population that is showed by the minor improvements over the years, and the slight proportion of participants who owned a donor card. Although 97.6% of the participants knew about the concept of organ donation, only 66.5% were familiar with the positive Islamic opinion. Based on the results of the comparison with the study in 1996, we conclude that more efforts from both the governmental and religious authorities are needed to increase awareness.
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Awareness, knowledge, and perception of chronic kidney disease patients at renal medicine outpatients’ clinic p. 1351
Fatma Al Rahbi, Issa Al Salmi
Chronic kidney disease (CKD) is a major cause of morbidity and mortality. Awareness and education of CKD patients positively influence its medical management and significantly diminish the economic burden on public health. We conducted a pretested, structured, questionnaire-based survey to assess the awareness, knowledge, and perception of CKD patients at Renal Medicine Outpatients’ Clinic. The questionnaire was distributed to all CKD patients of at least one-year duration after their diagnosis. A total of 200 patients completed this study, mainly from the capital region. The mean age was 50 (17.1) years for males and 42.3 (16) years for females. The majority (74%) knew the reason for their referral to a nephrologist. Nearly 38% of the patients with CKD reported their shock and anger when informed about their kidney status by the nephrologist at the first encounter. Almost 64% of the patients reported having no knowledge of their CKD status and only 18% of the participants were aware that they were in CKD Stage 5, but according to the medical health computerized system, 44% were in CKD Stage 5. In addition, only 50% of them were aware of renal replacement therapy options. Patients and their family should receive enough information and education regarding the nature of kidney disease and the treatment options to allow them to make an informed decision about the management of their CKD. A well-informed decision-making in the treatment of CKD can provide health professionals with evidence on how to best deliver education programs for patients and their families. It may also enhance communication and improve the capacity of patient and family involvement in shared decision-making.
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Effect of branched chain amino acid supplementation on dialysis adequacy and nutritional parameters in hemodialysis patients p. 1361
Sameh Abou Zeid, Ahmed Rabiee, Fatma A El Refaey, Nevine Sherif
Malnutrition in hemodialysis (HD) patients is caused by deficient nutrient and protein intake and has a negative impact on patient outcomes. The assessment of dialysis adequacy in these patients depends to a large extent on the calculation of urea clearance using dialyzer clearance of urea (K) multiplied by the duration of the dialysis treatment (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL); Kt/V. This study aims to detect the effect of branched-chain amino acid (BCAA) supplementation on Kt/V and other nutritional parameters such as serum albumin as well as body mass index. Forty-six patients from the HD Unit of Mostafa Mahmoud Hospital were included in this study. Daily intake of BCAA was continued for three months. At the start of the study, before the intervention, and at the end of the 3rd month, we measured serum albumin, valine, leucine, iso-leucine, and Kt/V. Analysis of data was performed using paired and independent t-test. We found that BCAA has a highly significant effect on increasing the level of albumin, leucine, isoleucine, valine, and Kt/V in HD patients (P <0.001) (Paired t-test). BCAA supplements could be used in this patient population to improve dialysis adequacy and outcome.
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Prognostic value of the Oxford classification and the Oxford score in IgA nephropathy: A Tunisian study p. 1366
Hela Jebali, Hiba Ghabi, Ikram Mami, Badr Ben Kaab, Lilia ben Fatma, Wided Smaoui, Slim Haouet, Hend Ben Mahjouba, Mohanad Hassan, Fethi Ben Hmida, Lamia Raies, Mohamed Karim Zouaghi
Immunoglobulin A nephropathy is the most common primary glomerular disease. The main challenge in this disease is the evaluation of prognostic factors for end-stage renal disease. The aim of our study was to describe the characteristics of immunoglobulin A nephropathy, to evaluate the histological data according to Oxford classification, and to identify factors associated with renal survival. This was a retrospective study, including adults with primary immunoglobulin A nephropathy. The study was conducted over a period of 10 years. Renal biopsies were scored according to Oxford classification. Oxford score, based on the sum of the different histological lesions of Oxford classification, was calculated for each patient. We included 50 patients with a gender ratio (male:female) of 2.8. The average age was 35.6 ± 10.6 years. Fifty-eight percent of the patients had hypertension (HTN). The median proteinuria was 1.9 g/day. The median of the glomerular filtration rate was 47.6 mL/min/1.73 m2. According to Oxford classification, mesangial proliferation, endocapillary proliferation, glomerulosclerosis, interstitial fibrosis, and/or tubular atrophy and crescents were present in 40%, 38%, 88%, 36%, and 22% of the cases, respectively. The median Oxford score was 2. The median follow-up duration was 30 months. Ten patients (20%) reached end-stage renal disease. At univariate analysis, HTN, glomerular filtration rate, proteinuria, tubular involvement, and Oxford score >3 were associated with progression to end-stage renal disease (ESRD). Tubular involvement was an independent risk factor for ESRD. Our study confirms the prognostic value of the Oxford classification in immunoglobulin A nephropathy.
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Postdiarrheal hemolytic uremic syndrome in Egyptian children: An 11-year single-center experience p. 1376
Riham Eid, Ashraf Bakr, Atef Elmougy, Mohamed M Zedan, Nahla A Allam, Amr Sarhan, Ayman Hammad, Ahmed M El-Refaey, Nashwa Hamdy
Hemolytic-uremic syndrome (HUS) is a leading cause of childhood acute kidney injury (AKI) worldwide, with its postdiarrheal (D+HUS) form being the most common. Scarce data are available regarding D+HUS epidemiology from developing countries. This study aims to reveal the characterization of D+ HUS in Egyptian children. This is a retrospective study of all children with D+HUS admitted to a tertiary pediatric hospital in Egypt between 2007 and 2017. The study included epidemiological, clinical and laboratory data; management details; and outcomes. A cohort of 132 children aged 4months to 12 years was analyzed. Yearly incidence peaked in 2017, and spring showed the highest peak. All cases had a diarrheal prodrome that was bloody in 83% of the cases. Edema and decreased urine output were the most frequent presentations (50.3% and 42.4%, respectively). Escherichia coli was detected in 56 cases. Dialysis was performed in 102 cases. Eight patients died during acute illness, while five patients experienced long-term sequels. Lactate dehydrogenase (LDH) positively correlated with serum creatinine and negatively correlated with reticulocytic count. Univariate analysis showed that longer anuria duration, short duration between diarrheal illness and development of AKI (P = 0.001), leukocyte count above 20 × 109 cells/L (P ≤ 0.001), platelet count below 30 × 109 cells/L (P = 0.02), high LDH levels (P = 0.02) and hematocrit above 30% (P = 0.0001), need for dialysis (P = 0.03), and neurological involvement (P ≤ 0.001) were associated with unfavorable outcomes. This is the first report with a detailed insight into the epidemiology of D+HUS in Egyptian children. The incidence of D+HUS is increasing in our country due to increased awareness of the disease and the poor public health measures. Anuria duration, leukocyte count, and neurological involvement are predictors of poor outcome in the current work, and LDH is introduced as a marker of disease severity.
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Attitude and levels of awareness toward organ donation and transplantation among healthcare providers: A cross-sectional study p. 1388
Hatan Mortada, Nawal Mashni Alharbi, Marya Abdullah Alsuhaibani, Rawan Abdullah Buhlagah, Yasmina Nezar Mohamed, Amjad Alharbi, Osama Y Safdar
End-stage organ damage is the major cause of death worldwide. The number of donors is low, and one of the challenging phases in organ donation is the availability of organ donors. There are many studies that suggest a strong correlation between knowledge and beliefs toward organ donation. A study conducted among Health-Care Providers in the Intensive Care Units at a Tertiary Center at Riyadh reported that only 57% of the health-care providers in the Intensive Care Unit were willing to donate their organs. The objective of our study was to evaluate the knowledge, attitude, and awareness of organ donation and transplantation among health-care providers at different hospitals around the Kingdom of Saudi Arabia. The data of this cross-sectional descriptive study were collected between February and July 2018 in different hospitals all around the Kingdom of Saudi Arabia. The investigators formulated a questionnaire based on several published studies. Ethical approval was obtained from the Unit of Biomedical Ethics, Research Committee at King Abdul Aziz University. Of the 241 participants, 130 (53.9%) were female. In addition, 110 (45.6%) of them were medical residents. Moreover, 224 (92.9%) participants were aware of the concept of organ donation. The overall level of knowledge is good (55.2%).The study showed 62.2% have participated in the organ donation program for their close relatives only. In conclusion, the level of perception and knowledge about organ donation among health-care providers was inadequate, although they showed positive attitudes toward this issue.
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Bilateral renal cortical necrosis in a child with acute pancreatitis p. 1395
Vybhav Venkatesh, Aradhana Aneja, Aditi Kumar, Raja Ramachandran, Sadhna Bhasin Lal
Bilateral renal cortical necrosis (RCN) as a cause of acute kidney injury is very rare in the pediatric population. Progression to end-stage renal disease is seen virtually in every patient with RCN. There are many causes for the occurrence of cortical necrosis in children, with severe pancreatitis being a rarity. In this report, we describe a child with severe acute pancreatitis complicated by bilateral RCN.
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Rapidly progressive immunoglobulin M monoclonal gammopathy presenting with nephrotic syndrome and hepatic failure p. 1399
Yao-Ko Wen
We report a 73-year-old male with no relevant past medical history who presented with nephrotic syndrome and jaundice. Subsequent studies revealed immunoglobulinM (IgM) monoclonal gammopathy. Kidney biopsy revealed monoclonal Ig deposition disease and amyloidosis. Bone marrow biopsy demonstrated <10% infiltration by lymphoplasmacytic cells. However, rapidly progressive hypergammaglobulinemia of IgM and hyperbilirubinemia were noted. Despite aggressive treatment, the patient developed acute kidney injury and complications of hepatic failure. He eventually died of pneumonia, just two months after diagnosis.
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Anticoagulant-related nephropathy: A case report p. 1403
Kee Tat Lee, Wan Syahira Wan A Kammal, Boon Huei Kong
Anticoagulant-related nephropathy (ARN) is a recently described disease entity which is an underdiagnosed complication of anticoagulation. Despite widespread usage of anticoagulants, ARN is not commonly reported. We report a case of a 64-year old man with biopsy-proven ARN who presented with over anticoagulation and acute chronic kidney injury while on warfarin therapy for his left lower limb deep-vein thrombosis. Various investigations were performed and renal biopsy confirmed the diagnosis of anticoagulant-related nephropathy.
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Chyluria with massive proteinuria: Do not reach for the biopsy gun! p. 1407
Manoj K Sudrania, Anna T Valson, Anuj D Dangi, Nitin S Kekre
We report on a patient presenting with persistent chyluria due to filariasis, whose clinical course was complicated by massive proteinuria and severe hypoalbuminemia. Treatment with dietary manipulation, antifilarials, and sclerotherapy resulted in successful reversal of the above abnormalities. It has been reported that chyluria is not associated with massive proteinuria, or that even in cases of massive proteinuria, hypoalbuminemia is not seen and implies a glomerular pathology. We argue that chyluria is always associated with proteinuria, which may be massive, and does not warrant a kidney biopsy unless proteinuria persists despite resolution of chyluria.
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Septicemic melioidosis complicating undiagnosed chronic kidney disease and beta-thalassemia minor in a Bangladeshi farmer p. 1411
Muhammad Abdur Rahim, Muhammad Abu Yousuf Khan, Tufayel Ahmed Chowdhury, Mehruba Alam Ananna
Melioidosis is an emerging infectious disease in many countries including Bangladesh. Patients with diabetes mellitus are at increased risk for infection by Burkholderia pseudomallei, the causative agent for melioidosis. Here, we report an autochthonous case of septicemic melioidosis occurring in a middle-aged non-diabetic Bangladeshi farmer who presented with prolonged pyrexia and splenomegaly. Diagnostic workup revealed splenic micro-abscesses, previously undetected chronic kidney disease (CKD) and beta-thalassemia minor. This case stresses the importance of searching for less common risk factors for melioidosis such as CKD and hemolytic anemia.
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The significance of anti-phospholipase receptor antibodies in a patient with membranous nephropathy p. 1415
Jayaprakash R Dasari, Pallavi Reddy, Yeshwanter Radhakrishnan, Nikhil Nair, Ronith Chakraborty, Lena Nemer, Rupesh Raina
Membranous nephropathy (MN) is the major cause of nephrotic syndrome in adults and may be secondary to systemic lupus erythematosus or malignancy in 25% of patients. Without any etiology, it is called primary MN, which is usually associated with phospholipase A2 (PLA2) receptor antibodies. Secondary MN can appear months before a secondary cause is identified. Here, we report a case of MN, that was found to be secondary to pancreatic adenocarcinoma and positive for PLA2 receptor antibodies.
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Rare renal pathologic manifestation of antineutrophil cytoplasmic antibodies associated vasculitis as suppurative interstitial nephritis: A case report and review of the literature p. 1420
Sultan Ozkurt, Mustafa Fuat Acikalin, Cigdem Mengus, NazifeSuleYasar Bilge, Ahmet Ugur Yalcin
A 69-year old male patient attended our clinic with fatigue, fever, anuria, nephritic syndrome and severe renal failure. Kidney biopsy showed pauci-immune crescentic glomerulonephritis with an unusual association of suppurative interstitial nephritis. Though most patients with renal involvement linked to antineutrophil cytoplasmic antibodies associated vasculitis (AAV) have pauci-immune glomerulonephritis, only a few patients were identified to have atypical renal pathology. In most cases, mononuclear tubulointerstitial infiltrate may be a feature of AAV, suppurative interstitial nephritis is very rare. In the literature, we found only one case reported associated with suppurative interstitial nephritis without glomerulonephritis who later developed classic pauci-immune necrotizing glomerulonephritis. Here, we report a case diagnosed as AAV, presenting with pauci-immune crescentic glomerulonephritis and suppurative interstitial nephritis. It is not clear whether suppurative interstitial nephritis is a severe disease variant in AAV-associated renal disease. As described in the first case the lack of improvement in renal functions in spite of intense immunosuppressive treatment leads to the conclusion that suppurative interstitial nephritis is a marker of poor prognosis.
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Meropenem at recommended dose is a potential risk for seizure in hemodialysis patient p. 1427
Abdullah Al-Hwiesh, Amani Alhwiesh, Ibrahiem Saeed Abdul-Rahman, Ali Al-Harbi, Dujanah Mousa, Sami Skiker, Abdulaser Abdulkhani, Hesham Beheri, Morwa Radi, Dalal AlKhaldi, Azeeza Aldwaihi, Saad Alqahtani
Dosage adjustment of meropenem is usually recommended in hemodialysis (HD) patients and about 30% of meropenem is cleared during regular HD sessions. However, most of the published trials excluded patients on regular HD. Little is known about the accurate dosage of meropenem needed to avoid central nervous system toxicity. Herein, we report a 65-year-old Saudi female, a known case of end-stage renal disease on regular HD, who was admitted because of pyelonephritis and started on meropenem in the recommended dose according to cultures and sensitivity. She developed tonic-clonic convulsions after the 7th dose. Seizures were completely aborted after discontinuation of the offending drug. The recommended dosage of 500 mg daily in HD patients may still be too high particularly in Asian patients owing to their relatively small body mass index.
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Successful desensitization and kidney transplantation in the presence of donor-specific anti-human leukocyte antigen antibodies in kidney transplant recipients p. 1432
Muhammad Tassaduq Khan, Rashid bin Hamid, Sabahat Sarfaraz, Naranjan Lal, Jaleel Ahmed, Shobha Luxmi
Kidney transplantation has indisputably revamped renal medicine and restored hope among patients coming across fatal end-stage renal disease. However, sensitization of human leukocyte antigen (HLA) triggers extensive immunological fences to successful kidney transplantation and henceforth, transplant candidates are frequently demoted to the ever-growing waiting list owing to preformed donor specific antibodies (DSAs). Over the past few years, the advent of desensitization protocols has significantly overpowered the immunological barriers and enhanced the outcomes of kidney transplant recipients with DSAs against HLA. Those desensitization protocols include combination of plasmapheresis, high-dose intravenous immunoglobulin (IVIG), low-dose IVIG, rituximab, and/or bortezomib. These immunomodulatory treatments either eliminate DSAs or prevent their production. Lately, our transplant center developed and used a desensitization protocol (Two sessions of plasmapheresis on day 1 and 2 → injection rituximab on day 2 after plasmapheresis →no plasmapheresis on day 3 → eight sessions of plasmapheresis after day 3 and IVIG 100 mg/Kg/dose after each session of plasmapheresis → repeat HLA antibody detection test to confirm if DSAs are present against HLA with median fluorescence intensity (MFI)values <1000 and complement dependent cytotoxicity (CDC) crossmatch is negative for both T and B lymphocytes; if NO then continue plasmapheresis sessions with IVIG 100 mg/kg/dose till MFI values are <1000 and CDC crossmatch is negative for both T and B lymphocytes or if YES then proceed for transplantation → repeat dose of rituximab post-transplantation) to evaluate its effectiveness in improving kidney function in patients post-desensitization and kidney transplantation.
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Successful experience of coronavirus disease-2019 pneumonia in a renal-transplant recipient p. 1439
Gioacchino Li Cavoli, Antonio Amato, Chiara Iaria, Francesco Onorato, Francesca Finazzo, Rosalia Mongiovi, Barbara Oliva, Vitalba Azzolina, Tancredi Vincenzo Li Cavoli, Camillo Carollo
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Comment on “Biopsy-proven renal pathologies: Experience from multan institute of kidney diseases” p. 1441
Gioacchino Li Cavoli, Calogera Tortorici, Luisa Bono, Angelo Ferrantelli, Camillo Carollo, Vitalba Azzolina, Antonio Amato, Rosalia Mongiovì, Barbara Oliva, Carlo Giammarresi, Carmela Zagarrigo, Tancredi Vincenzo Li Cavoli, Franca Servillo, Onofrio Schillaci, Angelo Tralongo
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Can transmembrane protease serine 2 be attributed to coronavirus disease-2019 related acute kidney injury predominance in males? p. 1443
Lujain Mohammad Dkhil AlDkhil, Abeer Ageel Alenazi
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Favorable kidney recovery by extracorporeal light chain removal and anti-myeloma treatments in patients with newly diagnosed multiple myeloma and acute renal failure p. 1445
Giorgio Silvestrini, Paola Tatangelo, Laura Scaramucci, Germana Sfara, Francesco Bondanini, Pasquale Niscola, Paolo de Fabritiis, Roberto Palumbo
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The specificity of the novel coronavirus infection in transplantation recipients p. 1448
Driss Elkabbaj, Abdelali Bahadi
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Management of kidney transplant recipients with coronavirus disease 2019 p. 1451
Muhammad Tassaduq Khan, Rashid bin Hamid, Naranjan Lal
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Novel coronavirus infection (COVID-19) and renal failure: An observation from cases in the 1st month of outbreak p. 1455
Pathum Sookaromdee, Viroj Wiwanitkit
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Coronavirus disease 2019: Implications of severe acute respiratory syndrome coronavirus 2 in acute kidney injury p. 1456
Abeer Ageel Alenazi, Lujain Mohammad Dkhil AlDkhil
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Renal replacement therapy in the Kingdom of Saudi Arabia p. 1458
Besher Al Attar
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