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Saudi Journal of Kidney Diseases and Transplantation
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  Citation statistics : Table of Contents
   2010| September-October  | Volume 21 | Issue 5  
    Online since August 31, 2010

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Plasmacytoma of the kidney
Ritesh Mongha, Srinivas Narayan, Arindam Dutta, Sushma Sharma, Chatterjee Uttara, Anup Kumar Kundu
September-October 2010, 21(5):931-934
Extramedullary plasmacytoma is a rare malignant neoplasm typically arising outside the bone marrow of patients who show no clinical evidence of multiple myeloma. Kidney is a rare site for plasmacytoma. We present here a case of primary renal plasmacytoma confirmed on histo­pathology of the specimen and immuno-histochemistry studies. Patient was treated with radical nephrectomy followed by radiotherapy. The case is presented due to its rarity.
  4 4,006 603
Hyperhemocysteinemia and cardiovascular risks in hemodialysis patients
Mohammad Mahdi Sagheb, Mohammad Ali Ostovan, Zahra Sohrabi, Elham Atabati, Ghanbar Ali Raisjalai, Jamshid Roozbeh
September-October 2010, 21(5):863-866
The risk of premature and progressive occlusive vascular disease is high in chronic uremic patients, and it accounts for more than 40% of the mortality in dialysis patients. End stage renal failure (ESRF) patients exhibit elevated plasma homocystein levels, about four fold as much as those in the controls, and it is now considered as a causative factor for increased risk of cardiovascular death among these patients. The aim of this study was to evaluate the relationship of total plasma homocysteine level and echocardiographic abnormalities as a surrogate of cardiac disease outcome in hemodialysis patients. 123 adult patients on maintenance hemodialysis and having echocardiography done during January till November 2006 were enrolled in this cross­sectional study. Plasma homocysteine level was directly related to the presence of aortic regur­gitation r= 0.27 P= 0.009. There were negative correlations between ejection fraction (EF), left ventricular systolic dimension (LV.S) (r= - 0.71, P= 0.0001), left ventricular diastolic dimension (LV.D) (r= -0.23 p= 0.01) and age (r= - 0.021 P= 0.02). In conclusion we did not find the para­doxical reverse epidemiology in our patients and plasma total homocysteine level was in direct correlation with cardiac risk factors such as left ventricular mass index and aortic regurgitation.
  4 3,103 609
Methods used to reduce the prevalence of hepatitis C in a dialysis unit
Magdi M Hussein, Jaap M Mooij
September-October 2010, 21(5):909-913
In the present study, we report on the follow-up of the epidemiology of hepatitis C viremia in our dialysis unit after our previous report, over the period from July 1, 2003 to December 31, 2005. The methods to reduce the prevalence of hepatitis C viremia in our center included: strict adherence to universal infection control precautions, separation of hepatitis C virus (HCV) positive patients from the negative patients and using specially designated machines for them, and from July 2003, periodic testing of all patients for HCV-RNA. Following the application of the above men­tioned methods, we have not had, since 31 December 2005, any case of sero-conversion from HCV­negative to HCV-positive in our dialysis unit and the only HCV-positive patients present were those who were already positive at entry. The overall prevalence of HCV-RNA positive patients in our unit has presently come down to 6.5%. Although isolation and use of designated machines for HCV-RNA positive patients is not recommended following the latest guidelines of "Kidney Disease: Improving Global Outcomes" (KDIGO, 2008), the present study supports previous reports that these measures might be beneficial, when there is a high prevalence of HCV-RNA positive patients, and in units where due to understaffing or other causes, break in infection control pro­cedures is likely to occur.
  3 2,819 569
Goodpasture's syndrome in children
Banani Poddar, Sanjay Singhal, Afzal Azim, Sanjeev Gulati, Arvind Baronia
September-October 2010, 21(5):935-939
Goodpasture's syndrome is an autoimmune disease that has rarely been described in children, and only 21 cases have been reported till now. Here is a case of a 9-year-old boy who was diagnosed to have Goodpasture's syndrome.
  3 5,220 810
Urinary tract infections in the era of newer immunosuppressant agents : A tertiary care center study
Pallavi Khanna, Georgi Abraham, Asik Ali Mohamed Ali, Prathiba Evelyn Miriam, Milly Mathew, MK Lalitha, Nancy Lesley
September-October 2010, 21(5):876-880
We studied the incidence and the risk factors predisposing to post transplantation urinary tract infection (UTI) and the association with use of different immunosuppressive regimens. We performed a retrospective analysis of 152 recipients of renal transplantation over a period of two years. Seventy one (46.71%) patients had culture positive UTI, Escherichia coli (45.1%) being the commonest. Thirty four (22.39%) patients had acute rejection and 14.4% of those had suffered UTI in the early post transplant period. Immunosuppression included induction with various anti­bodies and maintenance on antirejection medications. Trimethoprim-sulphamethoxazole was given as prophylaxis throughout the period. The UTI was treated according to microbiological sensitivity. 2.8% died due to urosepsis. In our retrospective analysis renal transplant recipients under the age of 45, female gender and diabetics suffered more UTI. Combination therapy with micro-emulsion form of cyclosporine A, prednisolone and azathioprine developed more UTI (P= 0.0418).
  3 5,097 774
Oxidative stress in hemodialysis patients receiving intravenous iron therapy and the role of N-acetylcysteine in preventing oxidative stress
G Swarnalatha, R Ram, Prasad Neela, M U.R Naidu, KV Dakshina Murty
September-October 2010, 21(5):852-858
To determine the contribution of injectable iron administered to hemodialysis (HD) patients in causing oxidative stress and the beneficial effect of N-acetylcysteine (NAC) in re­ducing it, we studied in a prospective, double blinded, randomized controlled, cross over trial 14 adult HD patients who were randomized into two groups; one group received NAC in a dose of 600 mgs twice daily for 10 days prior to intravenous iron therapy and the other group received placebo. Both the groups were subjected to intravenous iron therapy, 100 mg of iron sucrose in 100 mL of normal saline given over a period of one hour. Blood samples for the markers of oxidative stress were taken before and after iron therapy. After the allowance of a week of wash out period for the effect of N-acetylcysteine we crossed over the patients to the opposite regimen. We measured the lipid peroxidation marker, malondiaaldehyde (MDA), to evaluate the oxidative stress and total anti-oxidant capacity (TAC) for the antioxidant level in addition to the highly sensitive C-reactive protein (HsCRP). Non-invasive assessment of endothelial dysfunction was measured by digital plethysmography before and after intravenous iron therapy. There was an increase of MDA (21.97 + 3.65% vs 7.06 + 3.65%) and highly sensitive C-reactive protein (HsCRP) (11.19 + 24.63% vs 13.19 + 7.7%) after iron administration both in the placebo and the NAC groups. NAC reduced the baseline acute systemic generation of oxidative stress when com­pared to placebo, which was statistically significant with MDA (12.76 + 4.4% vs 9.37 + 4.40%: P = 0.032) but not with HsCRP though there was a declining trend (2.85 + 22.75 % vs 8.93 + 5.19%: P = 0.112). Pre-treatment with NAC reduced the endothelial dysfunction when compared to placebo, but it was not statistically significant, except for reflection index (RI). We conclude that in our HD patients NAC reduced the oxidative stress before and after the administration of intravenous iron therapy in addition to the endothelial dysfunction induced by this treatment.
  3 4,123 972
Childhood idiopathic steroid resistant nephrotic syndrome in Southwestern Nigeria
Wasiu A Olowu, Kayode A Adelusola, Olufemi Adefehinti
September-October 2010, 21(5):979-990
Clinical charts of 23 Nigerian children diagnosed with Idiopathic Steroid Resistant Nephrotic Syndrome (iSRNS) between January 2001 and December 2007 were retrospectively re­viewed to determine their clinicopathologic characteristics and outcome. iSRNS (54.8%) was pri­mary in 19 patients (83%) and secondary in four (17%). The mean age at diagnosis was 8.3 ± 3.5 years (2.1-13 years). Histopathology revealed membranoproliferative glomerulonephritis (MPGN) in 43.5%, focal and segmental glomerulosclerosis (FSGS) in 39.1% and mesangial proliferative glo­merulonephritis in 8.7% of the patients while minimal change disease (MCD) and membranous nephropathy accounted for 4.35% each. Routine treatment protocol comprised pulse intravenous (i.v.) cylophosphamide infusion and i.v. dexamethasone ΁ lisinopril or spironolactone. Cumulative Com­plete Remission (CR) rate was 57.12%. The overall median time to CR from start of steroid sparing agents in 12/21 treated patients was 4.5 weeks. CR was better achieved in MPGN than FSGS (P = 0.0186). Five patients had eight relapses with the overall median relapse-free duration being four months. Cumulative renal survival at 36 months was 41.8%. The median follow-up duration was eight months. Our study revealed that there was a high prevalence of iSRNS and preponderance of non-MCD lesions, with MPGN and FSGS being the major morphologic lesions. The outcome with steroid and cyclophosphamide-based treatment for iSRNS was further enhanced with addition of either lisinopril or spironolactone.
  3 6,801 863
Disseminated invasive aspergillosis successfully treated with micafungin in a renal transplant recipient
Jamal Wadi, Shaher Ibrahem Al-kawasmeh, Mahmoud Turki Kamel, Bashar Belal AlJayyousi
September-October 2010, 21(5):914-918
Earlier experience with micafungin demonstrated a successful outcome in treating pulmonary aspergillosis in leukemic patients. We report a case of renal transplant recipient (RTR) who developed disseminated invasive aspergillosis. The patient was treated with micafungin with complete clinical and radiological response.
  2 3,600 577
Glomerular malondialdehyde levels in patients with focal and segmental glomerulosclerosis and minimal change disease
Simin Torabi Nezhad, Babak Momeni, Mitra Basiratnia
September-October 2010, 21(5):886-891
Minimal Change Disease (MCD) and Focal and Segmental Glomerulosclerosis (FSGS) are often studied together, because both present with heavy proteinuria and the nephrotic syndrome. The precise distinction between MCD and FSGS is sometimes difficult because of inadequate number of glomeruli for definite diagnosis. Some evidence suggests that markers of lipid peroxidation, such as Malondialdehyde (MDA) is an index of free radical mediated injury and may be involved in the pathogenesis of FSGS. In this study, we assessed the immuno­reactivity of MDA, the end product of lipid peroxidation in glomeruli of patients with idiopathic FSGS, MCD as well as normal controls (NC). Our results showed that the immunostaining level of MDA was significantly higher in patients with FSGS (mean = 1.5) than in either patients with MCD (mean = 0.16) or normal controls (mean = 0.11) with P value < 0.001. Glomerular MDA level correlated well with the degree of glomerulosclerosis in patients with idiopathic FSGS. Our data demonstrates that the glomerular level of MDA is higher in idiopathic FSGS than MCD. We suggest that MDA immunostaining can be helpful in differentiating between FSGS and MCD in problematic cases and when we do not have enough glomeruli for definite and correct diagnosis.
  2 2,944 441
Post-transplantation diabetes mellitus; frequency and related risk factors: A single center study
Ali Ghafari, Reza PourAli, Nariman Sepehrvand, Sanaz Hatami, Vanooshe Modarres
September-October 2010, 21(5):842-845
Post-transplantation Diabetes Mellitus (PTDM) is a serious complication after organ transplantation, which could lead to cardiovascular morbidity and mortality. The rate of PTDM increased in recent years, probably due to new immunosuppressive drugs such as Tacrolimus. In this study, we retrospectively evaluated the frequency of PTDM and related risk factors in 644 non diabetic patients who underwent renal transplantation. Data was analyzed by chi-square and Fisher's exact test in SPSS software ver11.5. Among 644 patients PTDM developed in 10.2% similar to literature. PTDM was significantly correlated to age (P value = 0.000), positive familial history (P= 0.003) and HBV infection (P= 0.046). In conclusion, PTDM is not uncommon in Iranian patients and a positive family history of diabetes, HBV infection and older age increases the likelihood to develop PTDM.
  2 3,039 686
Fasting Ramadan in chronic kidney disease patients: Clinical and biochemical effects
Bassam Bernieh, Mohammad Raafat Al Hakim, Yousef Boobes, Fikri M Abu Zidan
September-October 2010, 21(5):898-902
Fasting of the month of Ramadan is a pillar of Islam. Muslim patients with chronic kidney disease (CKD) usually fast this month. To determine the effects of fasting on renal function in CKD patients, we prospectively studied 31 (19 males and mean age 54 ±14.2 years) CKD patients during the month of Ramadan 1426 Hijra (4 th October - 4 th November 2005); 14 patients were in stage III CKD, 12 had stage IV and 5 had stage V. The mean estimated glomerular filtration rate (e-GFR) was 29 ± 16.3 mL/min. Diabetes was the main cause of CKD (19 (61%) patients), and hypertension was present in 22 (71%) patients. Clinical assessment and renal function tests were performed one month prior to fasting then during and a month later. Medications were taken in two divided doses at sunset (time of breaking the fast) and pre dawn (before starting the fast). All patients fasted the whole month of Ramadan with a good tolerance, tendency to weight reduction, and lower systolic and diastolic blood pressure. eGFR showed a significant improvement during the fast and the month after. The blood sugar was high during fasting with an increment in the Hb A1c. There was better lipid profile, reduction of the pro­teinuria and urinary sodium. We conclude that this study demonstrates a good tolerance and safety of fasting Ramadan in CKD patients.
  2 9,369 1,385
Profile of living related kidney donors: A single center experience
S Hajji, K Cheddadi, G Medkouri, M Zamd, K Hachim, GM Benghanem, B Ramdani
September-October 2010, 21(5):967-970
The living related donor still represents the unique source for renal transplantation in Morocco. Since 1986, 127 living related potential donors have been evaluated and 100 patients have been transplanted at the Ibn Rochd UHC in Casablanca. We retrospectively studied the potential donors and determined their profile and the exclusion criteria. The mean age at the time of donation was 37 +/- 11 years (range 18-66 years) and 60% of donors were women. The predominant sources of donors were sisters, brothers and mothers of recipients in 34%, 31% and 24% respectively. Forty three percent of them were married, 20% housewives and 17% unemployed. In addition, 37% were illiterate, 45% school graduates, and 18% university graduates. Donors and recipients were incom­plete HLA match in 72.7%, identical in 19% and different in 8.3%. The cross matching test was negative in all cases. The mean plasma creatinine was 0.8 ± 0.1 mg/dL with mean creatinine clearance of 103.16 ± 18.18 mL/min.
  2 2,578 360
Prevalence of central vein stenosis following catheterization in patients with end-stage renal disease
Minoo Naroienejad, Dariush Saedi, Asieh Rezvani
September-October 2010, 21(5):975-978
To determine prevalence of central vein stenosis following catheterization with double-lumen temporary catheters, we performed color Doppler sonography in 100 consecutive patients. We detected central vein stenosis in 18 cases; 11 patients in subclavian vein (SCV), 4 patients in internal jugular vein (IJV) and SCV, 2 patients in SCV and brachiocephalic vein, and 2 patients in IJV stenosis. There were statistical difference between groups with and without ste­nosis regarding time from discontinuation of catheters and use of aspirin (ASA). We could not find any statistical difference between these two groups regarding age, sex, duration of having chronic kidney disease (CKD), and duration of catheter remaining in place. We also found that there was a high proportion of stenosis in patients who still had catheter in their veins (15 from 44 patients, 34%) in comparison with patients who had already the catheters removed from their veins (3 from 56 patients, 5%). We conclude that stenosis of central veins can result from long indwelling time of central catheter used for hemodialysis. Aspirin may have a protective role against stenosis.
  2 3,338 683
Chronic kidney disease in older people; Disease or dilemma?
Aimun K Ahmed, Siobhan H.M Brown, Ahmed H Abdelhafiz
September-October 2010, 21(5):835-841
The majority of patients diagnosed with Chronic Kidney Disease (CKD) are elderly and CKD is linked with poor cardiovascular, cognitive, and disability outcomes in these people. Only a minority of these patients will progress to end stage renal disease (ESRD) while the majority will die due to cardiovascular disease. Thus, only a small number of these patients with CKD will benefit from specialist nephrologist assessment. The priority for the remainder should be cardiovascular disease prevention. We have reviewed specific issues relevant to older people to determine high-risk groups with CKD that are likely to benefit from a more intensive risk reduction intervention and to allow identification of clinically relevant renal disease.
  2 15,182 1,094
Porphyria cutanea tarda in a chronic hemodialysis patient
Jannet Labidi
September-October 2010, 21(5):919-922
End-stage renal failure and long-term hemodialysis (HD) treatment promote the development of genetically conditioned porphyria cutanea tarda (PCT). Iron overload is often asso­ciated with this disease and is thought to play a role in its pathogenesis. We report a case of HD­related PCT, which improved with deferoxamine treatment. A 33-year-old woman, with end-stage renal failure on HD since 1998, presented with a history of blisters on the face and dorsum of the hands, of several months duration. Laboratory analysis showed: hemoglobin 10.4 g/dL; a moderate hepatic cytolysis; ferritin 1300 μg/L (Nl: 8-120 μg/L) and negative serology for HIV, HBV and HCV. Porphyrin analyses showed a PCT pattern. Skin biopsy findings and direct immunofluo­rescence were consistent with PCT. The patient received deferoxamine (40 mg/kg intravenously every week for 6 weeks) which led to dramatic improvement of the symptoms. Several treatments are proposed in the management of dialysis-related PCT. This case confirms that deferoxamine can induce rapid and prolonged remission.
  1 4,625 752
Frank hematuria as the presentation feature of acute leukemia
Owais M Suriya, Aamer Aleem
September-October 2010, 21(5):940-942
Muco-cutaneous bleeding is a common presenting feature of acute leukemias. Mucosal bleeding usually manifests as gum bleeding and/or epistaxis but may occur in any mucosal surface of the body. Hematuria as an isolated or main presenting feature of acute leukemia is rare. We describe two cases of acute leukemia, a 19 year old male with acute lymphoblastic leukemia and a 52 year old male with acute myeloid leukemia, both presenting with gross hematuria. There was no demonstrable leukemic infiltration of the urinary tract on imaging studies. Hematuria in these patients was likely to be due to occult leukemic infiltration of the urinary system, aggravated by thrombocytopenia, as it subsided after starting chemotherapy. Our cases highlight that hematuria should be remembered as a rare presenting feature of acute leukemia.
  1 7,975 454
Lupus cystitis in an Omani girl
Amar Al-Shibli, Suhail Al-Salam, Bassam Bernieh, Hilal Matta, Ibrahim Al Attrach
September-October 2010, 21(5):943-946
Systemic Lupus Erythematosus (SLE) is an autoimmune disease characterized by multiple organs involvement. Bladder involvement (Lupus cystitis) is a rare manifestation of SLE, and occurs in association with gastrointestinal manifestations. We report a case of lupus inters­titial cystitis with bladder irritation and bilateral hydroureteronephrosis in an adolescent female who was treated with intravenous methylprednisolone pulse therapy followed by oral pred­nisolone and mycofenolate mofetil (MMF). Her symptoms ameliorated, and the hydrouretero­nephrosis improved. She was presented again with systemic flare up of the disease together with hydrouretronephrosis, but without bladder irritation symptoms. The diagnosis of lupus cystitis was confirmed by radiographic abnormalities, cystoscopy and bladder biopsy.
  1 3,632 468
Associations of various histological morphologies of renal involvement in hepatitis B infection: Analysis of 118 subjects
Hossein Khedmat, Saeed Taheri
September-October 2010, 21(5):964-966
  1 2,199 554
Posterior reversible encephalopathy syndrome
Kamal F Akl, Osama A Samara
September-October 2010, 21(5):957-958
  1 3,468 860
Proteinuria in adult Saudi patients with sickle cell disease is not associated with identifiable risk factors
Aamer Aleem
September-October 2010, 21(5):903-908
Renal involvement in patients with sickle cell disease (SCD) is associated with signi­ficant morbidity and mortality. Proteinuria is common in patients with SCD and is a risk factor for future development of renal failure. We sought to identify risk factors, if any, associated with pro­teinuria in adult Saudi patients with SCD. We studied 67 patients with SCD followed-up at the King Khalid University Hospital, Riyadh, Saudi Arabia. All patients underwent 24-hour urine collection to measure creatinine clearance and to quantify proteinuria. In addition, blood was examined for evaluation of hematological and biochemical parameters. Clinical information was gathered from review of the patients' charts. A urine protein level of more than 0.150 grams/24 hours was consi­dered abnormal. Urine protein was correlated with various clinical and laboratory parameters. Thirty­one males and 36 females were evaluated. The mean age of the cohort was 23.8 (± 7.2) years. Twenty-seven patients (40.3%) had proteinuria of more than 0.150 grams/24 hours. The study group had a mean hemoglobin level of 8.5 (± 2.8) g/dL and mean fetal hemoglobin (HbF) level of 14.4% (± 7.3%). Majority of the patients (61) had hemoglobin SS genotype and six patients had S-β0 thala­ssemia. None of the parameters evaluated correlated with proteinuria although there was a border­line association with older age and higher systolic blood pressure (P = 0.073 and 0.061 respec­tively). Hydroxyurea use for more than a year was not beneficial. In conclusion, our study suggests that proteinuria in adult Saudi patients is not associated with any clear identifiable risk factors.
  1 3,139 473
Surrogate markers of subtle renal injury in patients with visceral leishmaniasis
NAA Elnojomi, AM Musa, BM Younis, MEE Elfaki, AM El-Hassan, EAG Khalil
September-October 2010, 21(5):872-875
Sudanese Visceral Leishmaniasis (VL) is a disease of children that is characterized by fever, hepatosplenomegaly, lymphadenopathy, pancytopenia, and renal injury. Microalbumi­nuria (MA) and urinary retinol binding protein (urRBP) are useful markers for glomerular and tubular dysfunctions, respectively. We report the prevalence of subtle renal injury in 88 para­sitologically confirmed VL patients in a cross-sectional and hospital-based study. Blood and urine were collected before treatment for hematological, biochemical profiles in addition to MA and urRBP measurement using competitive solid phase, sandwich enzyme-linked immune sorbent assay (ELISA), and immunoturbidometry. All the patients had normal serum urea and creatinine levels and no detectable urRBP. However, 40% of the patients had MA detected by ELISA, and 42% were reactive with turbidometry. The sensitivity, specificity, positive and negative predictive values for MA turbidometric technique were calculated as 100%; 96%; 95% and 100%, res­pectively. In conclusion; subtle renal injury in VL is mainly glomerular. Turbidometry for MA measurement is a simple, inexpensive, sensitive, and specific technique with high predictive values.
  1 2,529 395
Management of superficial bladder carcinoma: Time to rethink the treatment strategies in the era of orthotopic neo-bladder
Pratap B Singh, Abhay Kumar, Suren K Das, Ashwani K Pandey, Girish K Sharma, Harbans Bansal Samir Swain, Sameer Trivedi, Udai S Dwivedi
September-October 2010, 21(5):881-885
The objective of this study was to evaluate the recurrence and progression, on long-term follow-up, of patients with superficial bladder cancer managed with bladder sparing approach. A total of 48 patients with superficial bladder cancer, initially treated with bladder sparing approach between 1990 and 1992, were available for long-term follow-up ranging bet­ween 10 and 15 years; the remaining patients were lost to follow-up. All patients had undergone transurethral resection and adjuvant intravesical therapy. Recurrence was treated with resection and adjuvant therapy or radical cystectomy in cases of progression. Out of 48 study subjects, 11 had T1G1, 23 had T1G2 and 14 had T1G3 tumor. In the T1G1 group, 45.5% had recurrence. Four had single recurrence managed successfully with TURBT and intravesical therapy. One had multiple recurrences and underwent radiotherapy after the fifth recurrence. In the T1G2 group, 82.6% had recurrence and majority (60.8%) had multiple recurrences. Out of 14 cases with multiple recurrences, eight patients ultimately progressed to invasive bladder carcinoma and underwent radical cystectomy. Majority of these underwent ileal conduit because ileal neo­bladder could not be created due to severe fibrosis. All 14 patients with T1G3 had recurrence, of whom three (21.4%) had single recurrence. Out of the 11 other patients (78.6%) who had multiple recurrences, nine developed invasive bladder carcinoma and underwent radical cystectomy. Orthotopic neo-bladder could be performed only in one patient and the remaining had ileal conduit or Mainz pouch. We conclude that in the era of orthotopic neo-bladder offering good quality of life, radical cystectomy should be considered at the earliest opportunity in patients with aggressive superficial bladder cancer.
  1 3,721 534
Metformin induced severe hypophosphatemia in a patient on hemodialysis
Tilemachos Tsitsios, Nikolaos Sotirakopoulos, Karmen Armentzioiou, Irini Kalogiannidou, Alexandros Kolaggis, Konstantinos Mavromatidis
September-October 2010, 21(5):923-926
A 67-year-old diabetic and hypertensive woman presented to us with very low serum phosphate levels (PO4 - =1.1 mg/dL) about 40 days after initiation of hemodialysis (HD). The phosphate binders were discontinued, because they were thought to be the cause of hypo­phosphatemia. However, the serum phosphate levels continued to remain low during subsequent follow-up visits over one month (PO4 --- = 0.7 and 0.6 mg/dL respectively). The patient had been started on metformin hydrochloride (850 mg thrice a day) about 18 days after the beginning of HD. The drug was stopped immediately (approximately 50 days after it was started) and the serum phosphate levels increased progressively, reaching 4.3 mg/dL. During the period with hypophos­phatemia, the patient suffered from very intense fatigue and weakness (she was unable to walk), anorexia, diarrhea and tenesmus. There were no features suggestive of rhabdomyolysis, hemo­lysis, low blood pressure or hypoglycemia; she had low white blood cell and platelet counts. The patient was in good clinical condition 2-3 days after the discontinuation of metformin and she recovered totally 15 days later. This case is presented due to its rarity as well as the observation that despite the patient having severe hypophosphatemia, she showed only side effects of metformin. Hypophosphatemia caused only intense fatigue and no other symptoms.
  - 3,531 666
Liposarcoma scroti: A rare tumor
Rajul Rastogi, PK Karan, Anubhav Sarikwal, Vaibhav Rastogi
September-October 2010, 21(5):927-930
Malignant extratesticular tumors (EXTT) are rare. Majority of EXTT are benign; lipoma being the commonest. Most of the malignant tumors are solid and have nonspecific features on ultrasonography (US). Computed tomography (CT) and magnetic resonance imaging (MRI) are more helpful. The authors report a rare case of liposarcoma of scrotum that was suspected on ultra­sonography and computed tomography and confirmed on histopathology.
  - 5,773 506
Hypercalcemia with renal failure in a patient with immunoblastic variant of non-hodgkins lymphoma of the bone
V Sivakumar, C Krishnakishore, P Sriramnaveen, G Sivaramakrishna, B Vijayalakshmi Devi, AY Lakshmi, M Kumaraswamy Reddy
September-October 2010, 21(5):959-960
  - 2,111 335
Urinary tract infection in Iraqi children
Mahmood Dhahir Al-Mendalawi
September-October 2010, 21(5):961-963
  - 1,962 416
Effects of cryoanalgesia on post nephrectomy pain in kidney donors
Hassan Ahmadnia, Mahmood Molaei, Sadegh Golparvar
September-October 2010, 21(5):947-948
  - 2,453 403
Protein-to-creatinine ratio: A valid estimate and alternative to 24 hour proteinuria
Ayman Karkar, Mohammed Abdelrahman
September-October 2010, 21(5):949-950
  - 120,409 1,422
Persistent headache in a child with the nephrotic syndrome
Syed Ahmed Zaki, Preeti Shanbag
September-October 2010, 21(5):951-953
  - 5,218 440
Th-17 Lymphocytes
E Nigel Wardle
September-October 2010, 21(5):954-956
  - 1,933 374
Are elderly end-stage renal disease patients more susceptible for drug resistant organisms in their sputum?
Ghanshyam Palamaner Subash Shantha, Anita A Kumar, Anish George Rajan, Kuilan Karai Subramanian, Yadav Srinivasan, Georgi Abraham
September-October 2010, 21(5):892-897
End stage renal disease (ESRD) patients are at risk for pneumonia in view of their impaired immune status. Similar empiric antibiotic regimens are used in elderly as well as young ESRD patients with respiratory tract infections. We conducted an observational, cross sectional study between June 2007 and June 2008 in 100 ESRD patients half being > 65 yrs. All patients had positive sputum culture and chest X-ray findings of pneumonia Streptococcus pneumoniae was the commonest in younger while Klebsiella pneumoniae in > 65yrs old patients. Elderly patients had significant resistance to common antibiotics. Ceftrioxone was the most suitable antibiotic in the younger patients while a combination of piperacillin with gentamycin was the best choice in the geriatric age group. In conclusion, organisms cultured from sputum in ESRD patients with pneumo­nia were different in the ESRD patients of more than and less than 65 years of age as well as the drug susceptibility. We should probably redefine the management of pneumonia according to the sensitivities in our local populations to better treat these patients.
  - 4,769 411
Malnutrition predicting factors in hemodialysis patients
Soodeh Razeghi Jahromi, Saeed Hosseini, Effat Razeghi, Ali pasha Meysamie, Haleh Sadrzadeh
September-October 2010, 21(5):846-851
Malnutrition is a predictor of increased mortality in chronic hemodialysis (HD) patients. Various factors may contribute to malnutrition in these patients including energy and protein intake, inflammation, and comorbidity. To determine the importance of these factors in malnutrition of chronic HD patients, we studied 112 chronic HD patients in two centers was evaluated with the Dialysis Malnutrition Score (DMS) and anthropometric and biochemical indices. Seventy six (67.8%) patients were classified as malnourished. According to DMS score, poor protein intake (r= -0.34, P< 0.01), comorbidities (r= -0.24, P< 0.05), poor energy intake (r= - 0.18, P< 0.005), and inflammation (r= -0.16, P< 0.05) were significant predictors of malnutrition in descending order of importance. Multiple regression analysis showed that only poor protein intake was the explanatory variable of anthropometric measurements decline including body mass index, triceps skin fold thick-ness, mid arm circumference, mid arm muscle circumference, fat free mass, fat mass, albumin, creatinine and transferrine. None of the mentioned factors predicted the decrease of biochemical markers. We conclude that the frequency of malnutrition is high in our population and poor protein intake is the primary contributing factor for this condition. There­fore, providing enough protein may be a simple and effective way in preventing malnutrition in these patients.
  - 6,041 1,459
Interrupting connection of superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas
Majid Moini, Mohammad R Rasouli, Shahram Salehirad, Maryam Nazarinia
September-October 2010, 21(5):859-862
We hypothesized that interrupting the connection between superficial and deep veins of the upper extremity at the elbow for creation of hemodialysis arteriovenous fistulas (AVFs), in addition to adequate dilation of the elbow veins, will reduce the risk of steal syndrome and venous hypertension. In this prospective study over a period of one year, patients who were candidates for creation of elbow AVFs based on Doppler ultrasound findings and physical exa­mination, were enrolled into the study. For creation of AVFs, based on the anatomy of the vessels, side-to-side or end-to-side anastomosis between the brachial artery and either cephalic or median antecubital or basilic veins was performed. In some cases, Gracz AVF was created. For inter­rupting the connection between superficial and deep veins, the perforating vein was either ligated or used for anastomosis. The patients were then followed-up regarding patency rate of the AVF and complications. AVFs were created in 50 patients and the duration of follow-up varied from one to eight months. About 56% (n = 28) of the patients had history of failed AVF or arterio­venous graft and 48% (n = 24) of them had history of insertion of a dual-lumen catheter for hemo­dialysis. Neuromuscular problem (n=1) and infection (n=1) were the observed complications. None of the patients developed steal syndrome or venous hypertension. At the end of the study, 47 AVFs (94%) were patent and adequate. Our study suggests that interrupting the connection between the superficial and deep venous systems of the upper extremity can reduce the risk of development of steal syndrome and venous hypertension despite side-to-side anastomosis. These techniques provided acceptable patency rate for elbow AVFs.
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Cinacalcet effect on severe hyperparathyroidism
Khalid Al Saran, Alaa Sabry, Ahmed Yehia, Azeb Molhem
September-October 2010, 21(5):867-871
To determine the efficacy and safety of cinacalcet, a calcimimetic drug that suppress parathyroid hormone (PTH) production, we studied its effect on 20 patients (13 males) on maintenance hemodialysis (HD), 80% of them have persistent high PTH levels (i.e. more than 80 pmol/L), the remaining patients had PTH levels more than 60 pmol/L. Five of 20 (25%) patients dropped out from the study (2 because of severe GIT upset, one showed severe myalgia and arthralgia, one patient due to non compliance and one died at home due to cardiac arrest). The remaining 15 patients (10 males) had a mean age of 40 ± 12.86 years and dialysis duration of 29.13 ± 18.27 months. The follow-up period on cinacalcet was 4 months with a single daily oral dose started with 30 mg/day and increased gradually according to the PTH levels. Nine (60%) pa­tients were on concomitant active vitamin D during the study period with a mean dose of 7.33 ± 3.39 μg/week. There was a significant decrease in the serum PTH levels at the end the study compared to that at the start (46.4 ± 4.7 pmol/L versus 93.3 ± 25.6 pmol/L, respectively, P< 0.000), and the target PTH level (< 31.6 pmol/L) was achieved in 54% of patients. No significant changes in serum Ca and phosphorous levels were observed. We conclude that cinacalcet is an effective therapy to suppress the serum PTH levels and allows favorable management of the serum calcium and phosphorus levels in HD patients. The drug was well tolerated; however, GIT discomfort is a significant side effect that may necessitate drug withdrawal in some patients.
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Ethical disputes in living donor kidney transplantation: What should we do to save lives?
Hossein Khedmat, Saeed Taheri
September-October 2010, 21(5):971-974
Living donor kidney transplantation has strong opposition and proponents. Opponents argue that this would exploit poor and female while proponents discuss the high mortality rate of ESRD patients and the low risk of a living donation. In this debate, we reviewed disputes in ethical aspects of living donor kidney transplantation to reach to a good overview of the current concepts on the issue. "To save an innocent human life is equal to saving the humankind." Holy Quran; AlMaeda:32
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Epidemiology and transmission of hepatitis G virus infection in dialysis patients
Farahnaz Fallahian, Seyed-Moayed Alavian, Mehrnaz Rasoulinejad
September-October 2010, 21(5):831-834
Hepatitis G virus (HGV) or GB-virus type C (GBV-C) is distributed globally and is present in the volunteer blood donor population. For epidemiological studies, HGV is of interest in hemodialysis patients who are at risk of parenterally transmitted infections. The role of HGV in producing illness and hepatic disease has yet to be determined. A review of literature was performed in 2009 to summarize scientific reports on epidemiology and pathogenesis of the HGV infection and its exposure through hemodialysis.
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Organ donation and transplantation in the Kingdom of Saudi Arabia 2009

September-October 2010, 21(5):991-995
  - 2,892 214
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