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Saudi Journal of Kidney Diseases and Transplantation
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   2006| July-September  | Volume 17 | Issue 3  
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Renal Osteodystrophy: Review of the Disease and its Treatment
Abdullah M.W El-Kishawi, AM El-Nahas
July-September 2006, 17(3):373-382
Renal osteodystrophy (ROD), which is most evident in patients on renal replacement therapy (RRT), usually begins when the kidney function starts to deteriorate. The spectrum of skeletal abnormalities seen in ROD is classified according to the state of bone turnover. In the past two decades, the prevalence of high turnover ROD has decreased while low bone turnover has become increasingly recognized. Secondary hyperparathyroidism represents a common disorder in patients with chronic kidney disease (CKD); it develops as a result of hyperphosphatemia, hypocalcemia and impaired synthesis of renal vitamin D with reduction in serum calcitriol levels. Patients with secondary hyperparathyroidism have a range of symptoms that affect their quality of life. The aim of treatment of ROD is to reduce the incidence of uremic bone disease as well as cardiovascular morbidity and mortality caused by elevated serum levels of parathormone (PTH) and calcium X phosphorus product. Treatment measures include control of phosphorus retention and prevent hyperphosphatemia, maintaining serum calcium concentrations within the normal range and prevent excess PTH secretion.
  16,554 3,280 3
Autosomal Dominant Alport's syndrome: Study of a Large Tunisian Family
M Kharrat, S Makni, K Makni, K Kammoun, K Charfeddine, H Azaeiz, F Jarraya, M Ben Hmida, MC Gubler, H Ayadi, J Hachicha
July-September 2006, 17(3):320-325
Alport's syndrome is a hereditary nephritis that may lead to end-stage renal disease (ESRD) in early adult life. It is a clinically and genetically heterogeneous nephropathy. Alport's syndrome is often associated with sensorineural deafness and/or ocular abnormalities. In contrast with the well-known X-linked phenotype, very little is known about the autosomal dominant form caused by mutations in COL4A3 and COL4A4 in the chromosome region 2q35-q37. We describe a Tunisian family with autosomal dominant Alport's syndrome in which males and females were equally affected. Two members reached ESRD at age 40 and 53 years, respectively. Three members experienced isolated microhematuria and one member experienced sensorineural deafness. No eye abnormalities were observed. Immunohistochemical studies showed a normal distribution of the α5 (type IV collagen) chain in the epidermal basement membrane. Genetic analysis demonstrated that a common haplotype co-segregated with the disease in the heterozygous state in all affected patients, thereby, confirming an autosomal dominant mode of inheritance. The same haplotype was observed in two asymptomatic children. We conclude that autosomal dominant Alport's syndrome, follows a rare mode of inheritance and exhibits a milder phenotype than usually observed in classic X-linked Alport's syndrome. The frequency of this mode of inheritance should be confirmed by a larger study.
  9,334 624 6
Acute Tubulointerstitial Nephritis and Anterior Uveitis (TINU Syndrome): A Report of Two Cases
Fatima Mortajil, Hasnaa Rezki, Khadija Hachim, K Zahiri, Benyounes Ramdani, Driss Zaid, Saida Skalli
July-September 2006, 17(3):386-389
TINU or Dobrin syndrome is a rare oculo-renal inflammatory condition which is comprised of acute idiopathic tubulointerstitial nephritis and uveitis. We report here two female patients aged 35 and 44 years, who were admitted with severe renal failure of acute onset (serum creatinine of 607 and 310 Umol/L [Editor note: do you mean "µmol/L"?] respectively) with the first patient requiring hemodialysis. The cause of acute renal failure was unclear on clinical and laboratory assessment, and a percutaneous renal biopsy was performed which showed features of acute tubulointerstitial nephritis in both cases. Both patients were started on oral steroids at a dose of 1 mg/kg/day. There was progressive improvement of their renal function. Three months later, the two patients presented with bilateral anterior uveitis requiring local corticosteroid therapy. This was followed by total resolution of the uveitis. The cause of the interstitial nephritis and the uveitis could not be identified in the two cases. The renal function was normal in these patients after 24 and 27 months of follow-up, respectively. Dobrin or TINU syndrome is rare, and must be considered in patients who present with acute tubular interstitial [Editor note: for consistency with the title, you may wish to replace this with "tubulointerstitial"] nephritis and anterior uveitis.
  8,429 792 2
Renal Transplantation across the ABO Barrier
Ahmed M Alkhunaizi
July-September 2006, 17(3):311-315
Some patients with end-stage renal disease do not have suitable living related donors due to ABO incompatibility. Crossing the ABO barrier has long been considered an absolute contraindication to kidney transplantation. Although transplantation using A 2 kidneys has been performed in a few centers over the past two decades with variable success, the presence of blood group antigens can cause immediate or early graft loss due to preformed antibody-mediated hyperacute rejection. Over the past few years, novel protocols designed to reduce anti-donor antibodies have allowed successful transplantation across the ABO barrier. This requires careful preoperative conditioning, which will be described in this article.
  6,083 570 -
Obstructive Uropathy in Sudanese Patients
M El Imam, M Omran, F Nugud, M Elsabiq, K Saad, O TAHA
July-September 2006, 17(3):415-419
In this paper we describe the causes, patterns of presentation, and management of obstructive uropathy in Sudanese patients in a retrospective multi-center audit. All patients who presented with obstructive uropathy during 2005 were included in this study. All of the patients were subjected to serial investigations including imaging and tests of renal function. Diversion, stenting, and/or definitive surgery were performed in order to relieve the obstruction. Five hundred twenty patients were diagnosed with obstructive uropathy during this period; 345 (66%) patients presented with chronic obstruction and 175 (34%) with acute obstruction. Of the study patients, 210 (40%) presented with significant renal impairment; 50 (23%) of them required emergent dialysis. The patterns of clinical presentation of the obstructed patients included pain at the site of obstruction in 48%, lower urinary tract symptoms in 42%, urine retention in 36.5%, mass effect in 22%, and anuria in 4%. Patients in the pediatric age group constituted 4% of the total. The common causative factors of obstruction included congenital urethral valves, pelvi-ureteral junction obstruction, urolithiasis, and iatrogenic trauma, especially in the obstetric practice. Renal function was completely recovered with early management in 100% of patients with acute obstruction and was stabilized in 90% of patients with chronic obstruction. Four patients were diagnosed with end-stage renal failure; two of them were transplanted. The mortality rate in this study was less than 0.3%.
  5,621 615 -
Acute Renal Failure due to Lymphomatous Infiltration: An Unusual Presentation
Kais Harzallah, Jannet Laadidi, Kais Chatti, Imed Hlel, Fethi Bougrine, Ammar Bouziani, Nejib Ben Abdallah, Bassam Louzir, Salah Othmani, Ezzedine Boussema
July-September 2006, 17(3):395-398
Renal lymphoma occurs most often as a part of a multi-systemic disseminated lymphoma or as a recurrence of the tumor. Renal involvement usually occurs late in the course of the disease and is clinically silent. Acute renal failure (ARF) from lymphomatous infiltration has been described but is quite rare. We report a 50-year-old Caucasian woman, who presented with features of ARF. Physical examination showed that her arterial blood pressure was 190/100 mm Hg with no lymphadenopathy or hepatosplenomegaly. Her urine output was about 100 ml/day, and urinanalysis revealed + proteinuria and microscopic hematuria. Biochemical findings revealed severely impaired renal function with a serum creatinine of 693 µmol/L. The patient's lactate dehydrogenase was elevated at 632 U/L. An abdominal ultrasound showed bilateral, large non-obstructed kidneys and a hypoechoic mass arising in the right lobe of the liver. An ultrasound-guided percutaneous liver biopsy showed typical features of B-cell lymphoblastic lymphoma. The patient expired two days later, even before any specific treatment could be started.
  4,688 519 4
High Prevalence of Masked Hypertension in Treated Hypertensive Patients with Type 2 Diabetes Mellitus
Abdulkareem Alsuwaida, Robert Parkes, Jeffrey So, Denice Feig, Alexander Logan
July-September 2006, 17(3):326-337
This study was undertaken to determine whether self-measured home blood pressure (BP) readings were comparable to clinic visit BP readings in hypertensive type II diabetic patients. We measured the BP of 27 hypertensive patients at home and during the clinic visits over a three week period. The BP readings were analyzed using a mixed linear model with mean daytime ambulatory measure as a covariate. We found that, although there was no significant difference in the mean systolic BP between home and clinic readings (0.6 mm Hg), the mean home BP readings were significantly higher (difference = 6.8 mm p<0.0006). The proportion of masked hypertension, defined as elevated home systolic or diastolic BP (or both) values despite normal clinic visit BP values, was 40.7%. Three diastolic and one systolic BP measurement at home achieved a reliability coefficient of 0.8. Self-measurement of BP gave highly reliable readings when they were compared with blind readings taken by a trained professional using a mercury sphygmomanometer. We conclude that self-measured BP at home identifies a high prevalence of masked hypertension in treated hypertensive type 2 diabetic patients and that it represents a valuable management adjunct to ensure maximum benefit from antihypertensive drug therapy.
  4,642 508 1
Prevalence and Pattern of Renal Osteodystrophy in Chronic Hemodialysis Patients: A Cross Sectional Study of 103 Patients
Mahdia A Buargub, Muna F Nabulsi, Taher A Shafeh
July-September 2006, 17(3):401-407
This cross sectional study was conducted to determine the prevalence and pattern of renal osteodystrophy (ROD) in patients on maintenance hemodialysis (HD) in Tripoli, Libya. A total of 103 randomly selected patients, of whom 53% were males, were investigated. Their mean age was 47.6 +/-12.5 years. They were on dialysis for a mean duration of 6.2 +/- 4.3 years. Pre-dialysis serum levels of intact parathyroid hormone (iPTH), osteocalcin, alkaline phosphatase, albumin, total calcium and phosphate were measured in all the patients. Depending on serum iPTH levels, the patients were divided into three groups: hyperpara­thyroid bone disease (iPTH > 450 pg/ml), adynamic bone disease (iPTH< 60 pg/ml), and a group with apparently normal bone (iPTH 60 pg/ml to 450 pg/ml). As a whole, the mean serum levels of iPTH, osteocalcin, alkaline phosphatase and corrected total calcium were high in all study patients (373.7 pg/ml, 251.3 ng/ml, 254.9 IU/l, and 9.9 mg/dl respectively). The prevalence of ROD among these patients was 55.3%. Of these, 29 (28.1%) had laboratory evidence of hyperparathyroid bone disease, while 28 patients (27.1%) had laboratory evidence of adynamic bone disease. In only 18 patients, (17.4%) the serum levels of iPTH were within the target range recommended by the K/DOQI guidelines (150-300 pg/ml). This cross sectional study, albeit in a limited number of patients, shows that the prevalence of ROD in our institution is high, possibly because of inadequate patient monitoring and lack of insight into ROD among both patients and physicians.
  4,194 694 8
Incidence and Types of Malignancies in Renal Transplant Recipients in Iraq
Iqdam K Altaee, Nedham A Jaleel, Harith M Aljubury, Ihsan A Alshamaa, Shawqi Gazala
July-September 2006, 17(3):408-414
We retrospectively reviewed the records of 273 renal transplant recipients who received allograft transplants between 1994 and 2004 and recorded the incidence and types of de novo malignancies that developed in these patients. The study was carried out at the Al-karama and Al-rasheed kidney transplant centers in Baghdad, Iraq. A total of 16 patients developed malignancies. The tumors included Kaposi's sarcoma (KS) in eight patients, squamous cell carcinoma (SCC) in four, basal cell carcinoma (BCC) in two and both renal cell carcinoma of the allograft and brain tumor in one patient. Thus, KS was the most common malignancy encountered in our series, with a prevalence of 2.9%, followed by SCC observed in 1.5% and BCC found in 0.7 % of the patients. The average latency period between transplantation and development of malignancy was 6.5 months for KS, 3.0 months for SCC and 8.5 months for BCC. To our knowledge, this is the first long-term follow-up study for malignant complications identified in kidney recipients in Iraq.
  3,866 939 5
Correlation of Serum Magnesium with Serum Parathormone Levels in Patients on Regular Hemodialysis
Azar Baradaran, Hamid Nasri
July-September 2006, 17(3):344-350
Secondary hyperparathyroidism (SHPT) is a common, important, and treatable complication of end-stage renal disease. This study was conducted to investigate the role of serum magnesium (Mg) in regulating the secretion of parathyroid hormone (PTH) by the parathyroid gland in patients on maintenance hemodialysis (HD). Pre-dialysis serum levels of calcium (Ca), phosphorus (P), Mg, alkaline phosphatase (ALP), intact serum PTH (iPTH), serum 25-hydroxy Vitamin D (25-OH Vit D) and plasma bicarbonate (HCO3) were measured. The Urea Reduction Rate as well as duration and dosage of HD treatment were noted. Our study did not show any significant correlation between serum Mg levels and duration of HD treatment, levels of serum ALP, and plasma HCO3, Ca and P. An inverse correlation, albeit insignificant, was found between the serum Mg levels and iPTH (r=-0.30 p=0.079); also, a significant positive correlation was found between serum Mg levels and serum 25-OH Vit D levels (r= 0.40 p= 0.009). Our findings are in agreement with previous data, which suggest that factors other than serum Mg are more important in the regulation of PTH secretion in HD patients. A positive and strong association between serum Mg with 25-OH Vit D needs to be studied in greater detail.
  4,093 646 7
Darbepoetin Use for the Treatment of Anemia in Hemodialysis Patients in Saudi Arabia
Faissal A.M Shaheen, Nabila Akeel, Adnan Alfi, Ali Harbi, Nauman Tarif, Mohammad Ziad Souqiyyeh
July-September 2006, 17(3):365-372
Erythropoietin replacing proteins have improved patient outcomes and quality of life. Darbepoetin has a 3-fold longer half-life than recombinant human erythropoietin (rHuEPO). In this study, we investigate the efficacy and safety of the conversion of stable hemodialysis patients from the current short-acting r-HuEPO (EPO alfa or beta) to the long-acting darbepoetin. In addition, we verified the appropriateness of the current ratio of conversion of the short acting to the long-acting erythropoietin in an open label prospective multi-center study. The study design included 12 weeks darbepoetin administration. The conversion ratio was 200 IU of short acting r-HuEPO to 1 microgram of darbepoetin. We adjusted the dose of darbepoetin to maintain hemoglobin levels between 110-120 g/L. There were 33 patients who satisfied the entry criteria. The study was conducted from January-June, 2005. The study patients included 18 men and 15 women, the mean age was 50.4 ± 12.3 years and the mean duration on HD was 323 ± 51.9 days. There was a significant decrease in the mean dose of darbepoetin from 37.3 ± 12.9 ug/week at week 1 of the study to 20.8 ± 16.6 ug/week by the end of week 12 (p< 0.00003) while the hemoglobin level was maintained within the previously defined range. The initial conversion ratio from short-acting erythropoietin to darbepoetin was 200 IU to 1 microgram. However, at the end of week 12, the mean dose of darbepoetin decreased to an equivalent conversion ratio to 361 IU: 1 microgram. This may reflect great savings in the cost of treatment. Our experience with darbepoetin reveals that darbepoetin is effective and safe for the treatment of anemia in hemodialysis patients and has a more convenient dosing schedule than short-acting erythropoietin. The darbepoetin dosage decreases over time and savings are expected to greater with darbepoetin more than with short-acting erythropoietin with time.
  4,083 538 5
Hyponatremic Hypertensive Syndrome in an Obese Man with Renal Ischemia
Khawer Saeed
July-September 2006, 17(3):390-394
Renovascular hypertension occasionally manifests as an electrolyte disorder. The combination of hyponatremia and renovascular hypertension is known as hyponatremic­hypertensive syndrome. This syndrome was initially reported in children. Here, we describe a 45 year-old Saudi man who was admitted to the hospital with generalized body weakness and inability to walk. He was confused and was noted to have severe hypertension and very low serum sodium and potassium. The patient was recently started on captopril for blood pressure control, which was discontinued because of deterioration of renal function. Color Doppler renal ultrasound, and magnetic resonance angiography confirmed the diagnosis of renal artery stenosis.
  4,132 456 -
Fungal Abdominal Wall Abscess in a Renal Transplant Recipient
R Suzan Sanavi, Reza Afshar, Hossein Nejad Gashti
July-September 2006, 17(3):383-385
The incidence of fungal infection is significantly higher in patients with end­stage renal disease and renal transplant recipients than in normal individuals. Candidia Albicans is an uncommon cause of abdominal wall abscess. We describe a 37 year-old renal transplant recipient with such an infection. He presented with atypical clinical manifestations and an insidious course, but was successfully treated with antifungal therapy.
  3,323 350 -
The Renal Allograft Donor with Isolated Microhematuria
Ayman Karkar
July-September 2006, 17(3):316-319
Recently, there has been extensive debate about extending the criteria for accepting living donors to include the presence of mild renal abnormalities such as isolated microhematuria. Hematuria defined as the detection of greater than five red blood cells per high power field can be associated with abnormalities throughout the urinary tract. Detection of casts or dysmorphic red blood cells in the urine sediment with or without proteinuria could indicate underlying intrinsic renal disease. Anatomic causes, such as stones and tumors, should be excluded; cystoscopy may be indicated to exclude bladder pathology. Obviously, urinary tract infection, uncontrolled hypertension and latent diabetes mellitus must be excluded. Microscopic hematuria could be associated with mesangial IgA deposits; as 10% of first-degree relatives of patients with IgA glomerulonephritis suffer from microhematuria and/or proteinuria that may require consideration of renal biopsy. Microhematuria could also be associated with other known hereditary renal diseases such as C3 deposits disease, IgM nephropathy, autosomal dominant polycystic kidney disease, Alport's syndrome or thin basement membrane disease. In conclusion, careful assessment of isolated microhematuria, in the context of living kidney donation, is mandatory as results may reveal occult renal disease that may contraindicate kidney donation.
  2,806 501 -
Survey of the Attitude of Physicians towards Establishing and Maintaining a Peritoneal Dialysis Program
Muhammad Ziad Souqiyyeh, Faissal A.M Shaheen
July-September 2006, 17(3):355-364
In an attempt to evaluate the attitude of physicians towards establishing and maintaining a peritoneal dialysis (PD) program in the Kingdom of Saudi Arabia (KSA), we sent a questionnaire to 160 physicians; the heads of the 148 active dialysis centers in the KSA and 12 other consultants working in these centers. This covered decision makers in 109 centers (73.6%) in the Ministry of Health (MOH), 18 (12.2%) in Governmental-non-MOH centers, and 21 (14.2 %) in private hospitals that, together, care for a population of more than 7300 patients on chronic hemodialysis (HD) and 559 on PD. The study was performed between September and December 2005. A total of 145 of the 160 physicians (90.6%) from 141 dialysis centers (95.2%) answered the questionnaire. There were 81 respondents (56.3%) who believed that follow-up of the PD patients should be available in all the dialysis centers, 80 (55.2%) would like to have a PD clinic at their centers, and only 20 (13.8%) had PD clinics in their centers. However, 93 (66.4%) respondents did not request from the administration of their hospitals to open a PD clinic and 62 (44.6%) admitted to having no expertise in managing the patients on PD, while 53 (38.1%) claimed that they did not have enough space in their dialysis centers to start a PD program. Regarding training and expertise, 57 (40.7%), 58 (43.3%), 48 (35.6%) and 72 (52.9%) physicians had training in continuous ambulatory PD (CAPD), intermittent peritoneal dialysis (IPD), automated peritoneal dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and acute PD, respectively. The comparisons between the health sectors in the KSA showed that MOH had significantly less active PD programs, and this reflected tremendously on the knowledge of the staff. Our survey indicates that the current practices concerning the PD programs in the KSA are modest, and that a new strategy is required to spread this modality of therapy horizontally in all the dialysis centers, and vertically by introducing the latest technologies in the field of PD, such as automated PD machines and connectology. There is also a need to increase the awareness of physicians about the benefits and applicability of PD. National guidelines and training are indispensable and cannot be overemphasized to improve this service, especially in the MOH hospitals.
  2,535 373 1
Tolerance and Efficacy of Interferon-alpha in Hemodialysis Patients in Tripoli
Mahdia Buargub, Suheir El Huni, Moh'd Tagdi
July-September 2006, 17(3):338-343
A prospective non-randomized study was conducted at the Department of Infectious Diseases at Tripoli Medical Center. We evaluated the tolerance and efficacy of interferon-alpha (IFN) monotherapy in our hemodialysis (HD) patients with chronic hepatitis C virus (HCV) infection. Patients with evidence of active viral infection i.e. positive polymerase chain reaction (PCR) results and who were potential transplant candidates were included in the study. They received three million units of IFN-alpha, administered subcutaneously, three times a week for 12 months. The treatment was discontinued in 12 out of the 35 treated patients (i.e drop out rate 34.2%). Among the 23 patients who completed the treatment course, 14 (60.8%) became PCR negative, and by the end of eighteen months, nine of the patients maintained PCR negativity (39%). Thus, a sustained virological response was observed in nine (25.7%) of the 35 enrolled patients. Our study suggests that the efficacy of IFN-alpha in our patients was less than anticipated and the tolerance to the drug was poor. However, studies involving larger numbers of patients are required to optimize the treatment protocol.
  2,496 370 9
Epstein-Barr Viral Infection in Renal Allograft Recipients: A Single Center Experience
Zakie Rostam Zadeh, Khadije Makhdumi, Shaker Salari Lak
July-September 2006, 17(3):351-354
In this study we attempted to identify the factors involved in Epstein-Barr viral (EBV) infection among renal allograft recipients. We studied 68 renal allograft recipients hospitalized at the Imam Khomeini Medical Center from 2001 to 2004. Blood samples were obtained from the patients before renal transplantation and repeated every 3 months during the first year after transplantation. Enzyme linked immunosorbant assay (ELISA) tests were performed on these samples to determine if antibodies to EBV antigens, such as viral capsid antigen(VCA)IgM, VCAIgG or Epstein Barr neoantigen (EBNA)IgG, were present. The types of prescribed immunosuppressive agents and the incidence of acute allograft rejection were closely observed to define their association with EBV. EBV infection developed in 58 (85.3 %) patients and active disease in 10 (14.7%). EBV was detected in 40 (58.8%) patients during the first year after transplantation. There was EBNAIgG seropositivity in 65 (95.6%) patients before transplantation; this number increased to 68 (100 %) after transplantation. In contrast, VCAIgG seropositivity increased from 92.6% before transplantation to 96.9% after transplantation; whereas VCAIgM seropositivity increased from 17.6% before transplantation to 58.8% after transplantation. There were no statistically significant differences in the reactivation of EBV infection between the different immunosuppressive regimens, between the groups of acute rejection and no acute rejection, or between the groups that received and did not receive anti-lymphocyte globulin (ALG) We conclude that most EBV activation after transplantation may represent a secondary form of a preexisting infection and we could not find a clear association with a specific immunosuppressive regimen, including the use of ALG. Further investigation is thus required to elucidate the factors involved in the reactivation of the EBV infection in the transplant population.
  2,375 374 -
Kidney Transplantation in Iraq
Usama Nihad Rifat
July-September 2006, 17(3):399-400
  2,251 301 1
Chronic Allograft Nephropathy
Abdul Qadir Jumani
July-September 2006, 17(3):420-424
  2,053 341 1
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