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Saudi Journal of Kidney Diseases and Transplantation
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   2011| November-December  | Volume 22 | Issue 6  
    Online since November 8, 2011

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Arterial embolization for spontaneous rupture of renal cell carcinoma
Mohammed Habib
November-December 2011, 22(6):1243-1245
  3 2,834 386
Comparison of the number of patients admitted with renal colic during various stages of peri-ramadan month
Norouzy Abdolreza, Afroushte Omalbanin, Toosi Seyedeh Mahdieh, Mohamadzade Rezaie Mohammad Ali, Mohajeri Seyed Amir Reza, Sabery Maryam, Nematy Mohsen
November-December 2011, 22(6):1199-1202
Ramadan fasting for Muslims means abstinence from eating, drinking, and smoking from sunrise to sunset. There are concerns whether the occurrence of renal colic increases during the month of Ramadan. In view of the importance of fasting among Muslims, the occurrence of renal colic during Ramadan fasting has been compared during the following periods: two weeks before commencement of Ramadan (stage-1), during the first two weeks (stage-2), the last two weeks (stage-3), and, two weeks after Ramadan (stage-4). This was a prospective observational study, which was carried out in patients with symptoms of renal colic who were referred to the emergency wards in two major hospitals in Iran. During the study period, 610 subjects were admitted with renal colic during the four periods of study; there were 441 males (72.3%) and 169 females (27.7%). The number of patients with renal colic was highest during the first two weeks of Ramadan in comparison with the other periods (stage-1: 157, stage-2: 195, stage-3: 139, stage-4: 119, P < 0.05]. Results from this study show that the number of admissions due to renal colic was high during the first two weeks of Ramadan. However, the number of admissions decreased during the last two weeks of Ramadan and this trend continued after Ramadan.
  2 3,365 480
Association of Helicobacter pylori IgG antibody with various demographic and biochemical parameters in kidney transplant recipients
Azar Baradaran, Hamid Nasri
November-December 2011, 22(6):1115-1120
Few reports are available regarding the promoting factors that affect Helicobacter pylori (H. pylori) infection in renal transplant (RTx) patients. We report a cross-sectional study that was conducted on a group of stable RTx patients to investigate the relationship of various demographic and biochemical parameters of these patients with serum H. pylori IgG antibody titer as a sign of H. pylori infection. A total of 72 patients who were referred to the clinic for continuing their treatment were enrolled in this study. These patients included 47 males and 25 females. The mean age of the study patients was 44 (±12) years. The mean length of time after they received a transplanted kidney was 67.5 (±42) months (median: 62 months). The mean value of serum H. pylori-specific IgG antibody titer among these patients was 3 (±4.6) U/mL (median: 1 U/mL), and that of intact parathormone (iPTH) was 18.4 (±8.2) pg/mL (median: 16.5 pg/mL). The mean serum magnesium (Mg) was 1.9 (±0.20) mg/dL (median: 1.9 mg/dL) and the mean creatinine clearance was 53 (±11) mL/min (median: 56 mL/min). In this study population, there was no significant difference in the H. pylori IgG antibody titers, serum iPTH, Mg, calcium, alkaline phosphatase and albumin levels as well as body mass index (BMI) between males and females or diabetics and non-diabetics. There was no significant relationship between serum H. pylori IgG antibody titers and the age of the patients, BMI, serum Alb, phosphorus, Ca, serum leptin and serum ALP. Significant negative correlation between serum H. pylori IgG antibody titers and serum Mg (r = -0.30, P = 0.01) and serum iPTH (r = -0.25, P = 0.03) was seen. A significant positive correlation was found between serum H. pylori IgG antibody titer and creatinine clearance (r = 0.26, P = 0.02), and a near-significant positive correlation was found with the duration of RTx (r = 0.20, P = 0.08). Our study shows that the correlation of H. pylori IgG antibody titer with some demographic and biochemical indices in RTx recipients may be different from what has been reported in hemodialysis patients. Larger clinical studies are needed to assess the clinical implications of our findings.
  2 3,031 798
The effect of L-Carnitine supplementation on lipid parameters, inflammatory and nutritional markers in maintenance hemodialysis patients
MM Suchitra, VL Ashalatha, E Sailaja, A Madhusudhana Rao, V Sheshadri Reddy, Aparna R Bitla, V Sivakumar, P.V.L.N. Srinivasa Rao
November-December 2011, 22(6):1155-1159
Protein energy malnutrition and inflammation are common and usually concurrent in maintenance hemodialysis (MHD) patients. Carnitine, a small molecule involved in fatty acid metabolism, is significantly decreased in long-term HD patients. L-Carnitine supplementation may have potential benefits in improving dialysis-related disorders. However, there are conflicting reports with regard to the beneficial effects of L-Carnitine supplementation. Hence, the present study was carried out to evaluate the effect of L-Carnitine supplementation on lipid parameters, apoproteins and inflammatory and nutritional markers in HD patients. A total of 35 patients with end-stage renal disease, on MHD for a period of 2 to 5 years were recruited into the study. The study group consisted of 20 patients who received Carnitine supplementation intravenously three times a week after each HD session, at 1 g/dose, while the control group consisted of 15 patients without supplementation with L-Carnitine. Highly sensitive C-reactive protein (hsCRP), total protein, albumin, lipid profile and apoprotein AI and B were determined at baseline and at the end of the study. A significant decrease in the hsCRP levels was observed in the Carnitine-supplemented group (P < 0.05). However, no significant change was observed in the lipid parameters and nutritional markers in the Carnitine-supplemented group. In conclusion, the present study demonstrates the significant benefit of L-Carnitine supplementation on inflammatory status in MHD patients as noted by marked decrease in hsCRP levels in comparison with the control group.
  2 5,011 1,288
Simvastatin ameliorates gentamicin-induced renal injury in rats
Mosadegh Jabbari, Zohreh Rostami, Aria Jenabi, Leila Zahedi-Shoolami, Ahmad Mooraki
November-December 2011, 22(6):1181-1186
Gentamicin nephrotoxicity is one of the most common causes of acute renal failure. Simvastatin is one of the antioxidative drugs, which has anti-inflammatory and anabolic effects and modulates the immune system. The present study was conducted to assess the effect of simvastatin on ameliorating the gentamicin-induced renal injury in 87 Sprague-Dawley rats, which were allocated randomly to 11 study groups: (A) and (B) groups with only gentamicin in 2 dosages; (C), (D), and (E) gentamicin 50 mg/kg/day and simvastatin with different dosage; (F), (G), and (H) gentamicin 80 mg/kg/day and simvastatin with different dosage; (I) only simvastatin; (J) Injected normal saline; (K) control (no gentamicin and no simvastatin) group. Our study intervention period for injection of drugs was 12 days. Serum creatinine level and clearance were measured in all groups. At the end of the study, the rats were killed and both kidneys were removed and processed for histopathologic examination using the standard methods. The 50 mg/kg/day dose was utilized because it induces a mild form of renal toxicity, whereas the 80 mg/kg/day dose cause a more severe degree of renal injury. Morphologic examination of specimens from all rats was qualitatively assessed with blindness to treatment groups and proximal tubular profiles that were presented in each file were counted. The results demonstrated amelioration of gentamicin-induced renal toxicity in rats by simvastatin due to its antioxidant drug dose-related effect.
  2 3,502 633
Liposarcoma of spermatic cord
Ammar Fadil Abid
November-December 2011, 22(6):1205-1207
  1 4,513 346
Rhabdomyolysis, acute kidney injury and transverse myelitis due to naive heroin exposure
Ankur Gupta, Ambar Khaira, Suman Lata, Sanjay Kumar Agarwal, Suresh C Tiwari
November-December 2011, 22(6):1223-1225
Heroin exposure can cause various complications like seizures, stroke, spongiform encephalopathy, transverse myelopathy, plexopathy, compartment syndrome, rhabdomyolysis and renal failure due to various mechanisms. We report here a young male who smoked heroin for the first time and developed transverse myelitis, rhabdomyolysis and acute kidney injury requiring dialysis. His renal recovery was complete by four weeks, while neurological improvement occurred 8 to 12 weeks later. This case suggests a common pathogenic mechanism of heroin intoxication involving multiple systems of the body.
  1 6,643 720
Acute urine retention induced by ceftriaxone
Kamal F Akl, Amira T Masri, Maali M Hjazeen
November-December 2011, 22(6):1226-1228
Ceftriaxone is known to cause biliary pseudolithiasis and, rarely, nephrolithiasis. When used in neonates receiving intravenous calcium, fatal lung and kidney calcifications occur. There is no satisfactory explanation for the pseudolithiasis, and the mechanism of stone formation remains unknown. Herein, we report a child with acute urinary retention (AUR) secondary to ceftriaxone therapy. The AUR developed on the second hospital day. The urinary excretion of uric acid was elevated. In retrospect, there was a positive paternal family history of gout and stones. A positive family history of gout or stones is a pointer to the possibility of AUR or urolithiasis in patients on treatment with ceftriaxone. If urinary symptoms develop, it is worth checking for crystalluria. This will avoid many unnecessary investigations and procedures.
  1 3,624 769
Uremic bleeding with pericardial and subconjunctival hemorrhage
Adindu Chijioke
November-December 2011, 22(6):1246-1248
  1 2,974 338
Copper sulphate poisoning and exchange transfusion
Muneeba Malik, Abeera Mansur
November-December 2011, 22(6):1240-1242
  1 6,130 433
Acute renal failure: Nephrosonographic findings in asphyxiated neonates
Mohd. Ashraf , Nazir Ahmed, Javed Chowdhary, Riyaz U Saif
November-December 2011, 22(6):1187-1192
To determine the incidence of acute renal failure (ARF) and nephrosonographic findings among asphyxiated neonates, and to correlate this with uric acid levels and the severity of hypoxic encephalopathy, we studied 80 full-term appropriate-for-date singleton neonates with perinatal asphyxia, and 30 healthy full-term neonates as controls from March 2006 to February 2007. A detailed history, thorough clinical examination along with investigations, including urine examination, 24-h urine collection, ultrasonography of abdomen and cranium, serum electrolytes, blood urea nitrogen, serum creatinine, and serum uric acid were obtained. ARF developed in 45% (36/80) of the asphyxiated neonates. Forty-eight (60%) neonates showed significant elevation of blood urea and 41 (51.3%) neonates had significant elevation of serum creatinine than the control group (P < 0.001). Sixty-two (77.5%) neonates developed significant elevation of serum uric acid levels, and nephrosonography revealed hyperechogenicity in all of them, while only two among the healthy neonates showed the raised uric acid levels (P < 0.001). Nonoliguric renal failure was seen 28/36 (77.8%) of the neonates with ARF, whereas eight (22.2%) neonates had oliguric renal failure. Eight (27.8%) patients among ARF patients maintained abnormal biochemical parameters after 2 weeks, and of whom four patients died after variable lengths of time with a mortality rate of 11.11%. Kidneys are the most common organs involved in perinatal asphyxia, and uric acid might be a causative factor for failure in addition to hypoxic insult. Routine use of kidney function test, along with abdominal ultrasonography form an important screening tool to detect any additional morbidity in these patients.
  1 5,397 765
Changes of serum calcium, phosphorus, and parathyroid hormone concentrations and ocular findings among patients undergoing hemodialysis
Farzad Pakdel, Hamidreza Samimagham, Amin Shafaroodi, Mehrdad Sheikhvatan
November-December 2011, 22(6):1142-1148
There are various reports of ocular abnormalities in metabolic disorders. This study was done with the aim to investigate the relationships between the amounts of serum calcium, phosphorus, and parathyroid hormone concentrations and ocular findings in patients undergoing hemodialysis. Fifty eight patients with end stage renal failure undergoing hemodialysis were randomly selected and enrolled in this prospective study. Demographic data, history of diabetes mellitus and hypertension, and duration of hemodialysis were recorded. Serum calcium, phos­phorus, alkaline phosphatase (ALP), and parathyroid hormone (PTH) concentrations were mea­sured. Also, blood urea nitrogen (BUN) and weight of the patient was measured just before and three minutes after the hemodialysis. Patients also underwent a complete ocular examination including visual acuity, intraocular pressure (IOP), biomicroscopic examination, and fundoscopy. In univariate analysis, adverse relationships were found between the ocular hypertension and ALP concentration (P = 0.017) and also between the visual acuity and phosphorus concentration (P = 0.033). However, in multivariate regression analysis and with regard to the patients' charac­teristics and medical history in a multivariate model, no relationships were found between ocular findings and serum calcium, phosphorus, ALP, and PTH concentrations. No relationships were found between the serum concentrations of calcium, phosphorus, ALP, and PTH and ocular findings in patients with end stage renal failure undergoing hemodialysis.
  1 3,517 746
Obesity and metabolic syndrome in hemodialysis patients: Single center experience
Khalid Al Saran, Sameh Elsayed, Alaa Sabry, Mahmoud Hamada
November-December 2011, 22(6):1193-1198
Recent evidence highlights the relationship between metabolic syndrome (MS) and increased risk of cardiovascular (CV) diseases. The overall prevalence of the MS is increased in hemodialysis population. To evaluate the prevalence of the MS and obesity in our hemodialysis (HD) patients, we studied 234 HD patients and 34 patients were excluded from the study due to incomplete data at the time of analysis. For the remaining 200 patients, 92% were below the age of 70 years old, 162 (81%) were hypertensive, 90(45%) were diabetic, 54 (27%) had ischemic heart diseases, and 116 (58%) had MS. The incidence of MS in the male and female patients was 50% and 67%, respectively, with a mean abdominal girth more than 94 cm in males and only 14% of the patients revealed abdominal girth measurement below 80 cm in females. We conclude that there is a high prevalence of obesity and MS in our HD patients. Such patients may be at risk of developing morbidities and may benefit from therapy such as lifestyle changes including weight reduction and increased physical activity.
  - 3,267 628
Isolated sarcoid renal granulomatous tubulointerstitial disease
Amal Abdel Ghani, Salah Al Waheeb, Ekhlas Al Homoud
November-December 2011, 22(6):1208-1210
A 37-year-old lady presented with hypercalcemia and acute renal impairment. She had no previous medical problems apart from the use of non steroidal anti-inflammatory drugs for nonspecific body pains. Her abdominal ultrasound scan as well as urine studies were nonspecific. Further workup for hypercalcemia (skeletal survey, high resolution computed tomography (CT) of the chest and abdomen, purified protein derivative (PPD) test, serum protein electrophoresis, tumor markers, immunology screening, and Bence Jones proteinuria) was negative. Serum angiotensin converting enzyme was high. Renal biopsy showed extensive lymphocytes and multinucleated giant cells infiltration forming interstitial non necrotizing granulomata. Immune staining as well as staining for acid fast bacilli was negative. The possibility of sarcoid renal granulomata was raised and the patient was started on oral prednisolone with subsequent normalization of renal functions and serum calcium after one month of treatment.
  - 2,782 418
Renal cell carcinoma associated with granulomatous reaction
Deepti A Narasimhaiah, Marie T Manipadam, Karthikeyan Aswathaman, Sriram Krishnamoorthy
November-December 2011, 22(6):1211-1214
Granulomatous inflammation is a distinctive pattern of chronic inflammatory reaction characterized by accumulation of epithelioid histiocytes and multinucleate giant cells. The cause of granulomas can be infectious or non-infectious. Granulomas have been described within the stroma of malignancies like carcinomas of the breast and colon, seminoma and Hodgkin's lymphoma, where they represent T-cell-mediated reaction of the tumor stroma to antigens expressed by the tumor. Granulomatous reaction in association with renal cell carcinoma (RCC) is uncommon, with only few published reports in the literature. We describe three cases of conventional (clear cell) RCC associated with epithelioid granulomas within the tumor parenchyma.
  - 3,348 499
Renal abscess due to Escherichia coli in a child
VP Baradkar, M Mathur, S Kumar
November-December 2011, 22(6):1215-1218
Among the various intraabdominal abscesses, renal abscess is a rare entity, especially in children and accounts for a number of cases of "missed diagnoses." Drainage of pus and appropriate antibiotic therapy is the gold standard for treatment. Here we report a case of left renal abscess in a 6-year-old female child secondary to renal calculus. The patient presented with abdominal pain and mild fever for three months and the diagnosis was made by X-ray in the kidney, ureter and bladder (KUB) region, intravenous pyelography and ultrasonography of the abdomen. Escherichia coli was isolated from pus obtained by percutaneous drainage under sonographic guidance. The patient responded to intra-venous ceftriaxone, amikacin, and percutaneous drainage.
  - 3,997 602
Spontaneous remission of post-transplant recurrent focal and segmental glomerulosclerosis
Bassam Saeed, Houda Mazloum, Munaf Askar
November-December 2011, 22(6):1219-1222
A 12-year-old girl with a history of steroid and cyclosporine (CsA) resistant nephrotic syndrome owing to focal and segmental glomerulosclerosis (FSGS) has progressed to end-stage renal disease (ESRD) for which she underwent hemodialysis for 18 months before she successfully received a fully matched kidney transplant from her sister at the age of nine years. The post transplantation (Tx) period was marked by an early and massive proteinuria indicating recurrent FSGS for which she received 12 sessions of plasmapheresis (PP); unfortunately, she did not appear to have any response to the PP therapy; thereafter, a conservative management comprising essentially enalapril and losartan has been initiated and was also not successful during the first four months, however, a very gradual response has been noticed to occur after five months of conservative therapy and ultimately, the patient attained complete remission after 21 months of treatment. Amazingly, 15 months after discontinuation of enalapril and losartan, she remained in a complete and sustained remission with a good renal allograft function. To the best of our knowledge, this is the first case ever reported in the literature of a "spontaneous" remission of post transplant recurrent FSGS.
  - 2,646 459
Nocardia infection in a renal transplant recipient
KK Kaswan, AV Vanikar, A Feroz, HV Patel, M Gumber, HL Trivedi
November-December 2011, 22(6):1203-1204
Opportunistic infection occurs in up to 20% renal transplant patients and is associated with a high mortality. We report a 47-year-old diabetic female with 1-year-old deceased donor renal allograft on triple drug immunosuppression. She developed cytomegalovirus retinitis at ten months post-transplant followed by nocardiasis manifested by hemiparesis with comatose state due to lumbar epidural and multiple brain abscesses, in spite of immediately curtailing immunosuppression. She recovered with linezolid and cotrimoxazole and was discharged two weeks later. She is maintaining stable graft function with serum creatinine 1.4 mg/dL on cyclosporin 2.5 mg/kg/day and prednisone10 mg/day with maintenance therapy for nocardiasis.
  - 3,331 530
Motor disability in end-stage renal failure: An epidemiological study on Italian dialyzed patients
Gisella Vischini, Andrea Tendas, Michele Ferrannini, Laura Scaramucci, Giuseppe Di Segni, Marco Giovannini, Pasquale Niscola, Roberto Palumbo
November-December 2011, 22(6):1236-1237
  - 1,876 292
Presentation of seven members of a family with the Alport's syndrome
Ymer Elezi, Blerta Rugova, Arjeta Hasani, Erblin Elezi, Bejtush Zylfiu, Skender Telaku, Ibrahim Rrudhani
November-December 2011, 22(6):1238-1239
  - 2,723 325
A five-year etiology and antimicrobial susceptibility patterns of urinary pathogens in children at Princess Rahmah Hospital, Jordan
Mohammad Al-Shara
November-December 2011, 22(6):1249-1252
  - 2,136 369
Hematuria following Karate (Kumite) competitions in females
Mona Sarhadi, Suzan Sanavi, Reza Afshar
November-December 2011, 22(6):1253-1255
  - 2,939 356
Urachal mucinous cystadenoma
Sudipta Saha, Ashesh Jha, Sanjay Gupta
November-December 2011, 22(6):1256-1258
  - 2,688 343
Groin urinoma: A delayed complication of bladder injury
Shafiq Ahmed, George Mathews John, Kim J Mammen
November-December 2011, 22(6):1259-1260
  - 4,286 319
Antibody-mediated rejection: Importance of lactate dehydrogenase and neutrophilia in early diagnosis
Muhammed Mubarak, Khawar Abbas
November-December 2011, 22(6):1261-1262
  - 1,866 289
Author's Reply
Taqi Khan, AB Mirza, A Haleem, R Zahid, HA Hussaini, MA Sulaiman, D Mousa
November-December 2011, 22(6):1263-1265
  - 1,688 181
The prevalence of tuberculosis in recipients of renal transplantation
MJ Mojahedi, Behzad Feizzadeh, B Aghdam, R Hekmat
November-December 2011, 22(6):1266-1268
  - 2,259 481
The deleterious effect of metabolic acidosis on nutritional status of hemodialysis patients
Tayebeh Soleymanian, Ahad Ghods
November-December 2011, 22(6):1149-1154
One of the main causes of protein-energy malnutrition in patients on maintenance hemodialysis (MHD) is metabolic acidosis. The aim of this study was to evaluate the effect of metabolic acidosis on nutritional status in a group of MHD patients with adequately delivered dialysis treatment. Of 165 eligible anuric MHD outpatients with Kt/V ≥ 1 and no underlying inflammatory diseases, 47 subjects were enrolled. In order to evaluate the effect of different parameters on serum albumin, we measured the pre-dialysis serum albumin, blood pH, serum bicarbonate (HCO 3‾ ), Kt/V, normalized protein catabolic rate (nPCR) and body mass index (BMI) in these patients. The mean age of the study patients was 55 ± 13.8 years; there were 22 females and six diabetics. The average Kt/V was 1.22 ± 0.16, pH was 7.40 ± 0.15, serum HCO 3‾ was 23.18 ± 2.38 mEq/L, serum albumin was 4.03 ± 0.56 g/dL, nPCR was 1.00 ± 0.16 g/kg/day, post-dialysis body weight was 58.50 ± 11.50 kg and BMI was 23.47 ± 2.70 kg/m 2 . There was a statistically significant direct correlation between serum albumin and BMI (r = 0.415, P = 0.004), and between serum albumin and serum HCO 3 (r = 0.341, P = 0.019). On multiple regression analysis, the predictors of serum albumin were serum HCO3‾ and BMI (direct effect) and nPCR (inverse effect). In 17 patients on MHD with serum HCO3‾ <22 mEq/L, there was a significant inverse correlation between HCO 3 and nPCR (r = 0.492, P = 0.045), and these patients had significantly lower serum albumin compared with patients with serum HCO3‾ >22 mEq/L (P = 0.046). These data demonstrate that patients on MHD with metabolic acidosis had a lower serum albumin concentration despite adequate dialysis treatment. The inverse effect of nPCR on serum albumin concentration in acidotic MHD patients may be due to hypercatabolism in the setting of metabolic acidosis, leading to deleterious effects on the nutritional status of patients on MHD.
  - 2,674 528
Kidney imaging in management of delayed febrile urinary tract infection
Sayed Abolhassan Sayedzadeh, Majid Malaki, Maryam Shoaran, Massood Nemati
November-December 2011, 22(6):1160-1163
We report a cross-sectional study performed to evaluate the imaging findings of 40 children, aged one month to five years (16.65 ± 14.97 months), who presented with protracted fever of more than 48 hours due to urinary tract infection (UTI). About 85% of the patients had positive Tc99-Dimercaptosuccinic acid (DMSA) scan and 58% had vesicoureteral reflux (VUR). Kidney sonography aided in the diagnosis and treatment in 10% of the patients. Age, sex, presence or laterality of VUR did not contribute to defective DMSA scan (pyelonephritis) (P > 0.05). Delayed diagnosis and treatment of febrile UTI is associated with a high incidence of positive findings of DMSA scan irrespective of age, sex or presence/absence of VUR. In mild VUR, the DMSA scan may be normal while in patients with moderate and severe VUR the DMSA scan is almost always abnormal. Thus, our study shows that a normal DMSA scan can help in ruling out moderate to severe forms of VUR and that cystography remains an excellent and standard tool for the diagnosis of VUR.
  - 2,325 528
Renal sonographic parameters in human immunodeficiency virus - infected subjects and relationship to CD4 cell count
Ademola A Adeyekun, Evelyn I Unuigbe, Abel N Onunu, Chukwuemeka O Azubike
November-December 2011, 22(6):1164-1168
Nephropathy in human immunodeficiency virus (HIV)-infected patient is common and constitutes a major cause of endstage kidney disease. CD4 cell count is a useful parameter in the assessment of the degree of immunosuppression among HIV-infected patients. Manifestations of renal disease are thought to be more profound when CD4 cell counts are low. Sonography is a safe and inexpensive method of evaluating renal disease, including renal sizes and degree of echogenicity. Ultrasound examination was carried out prospectively at the University of Benin Teaching Hospital on 120 HIV-infected patients comprising 45 males (37.5%) and 75 females (63.5%). Renal sizes and degree of echogenicity were assessed. Correlation with CD4 + cell counts of the patients was done. Mean CD4 cell count mean was 18.34 ± 142.18 cells/mm 3 with female patients having a significantly higher cell count compared with males. Seventy-four patients (63.8%) had a cell count of <200 cells/mm 3 . Renal sizes were normal in 85%, small in 7%, and large in 8% of patients. Fifty patients (41.7%) had increased renal echogenicity and 8 (6.7%) had severe increased echo-texture. CD4 cell count did not correlate with renal sizes and echotexture. Results of this study show that large kidneys and marked increase in renal echotexture were not common even in a population of patients where the majority had CD4 cell count < 200 cells/mm 3 . This study shows that increased renal sizes and degree of echogenicity alone are not useful predictors of renal involvement in HIV/AIDS.
  - 3,024 334
The safety and efficacy of endoscopic incision of orthotopic ureterocele in adult
Mukesh Kumar Vijay, Preeti Vijay, Arindam Dutta, Aman Gupta, Punit Tiwari, Suresh Kumar, MK Bera, RK Das, AK Kundu
November-December 2011, 22(6):1169-1174
Endoscopic incision is a good management option for orthotopic ureterocele. But most of the literature has shown its efficacy only in children. We have done this retrospective study to evaluate the safety and efficacy of endoscopic incision of orthotopic ureterocele in adults. From March 2004 to January 2008, at our center, 26 adults underwent transurethral, transverse incision of an ureterocele. The perioperative data of these patients were retrospectively analyzed. The literature was reviewed to identify all the reported options for management of this relatively rare condition in adults. Unilateral ureterocele was present in 24 patients and two patients had bilateral ureterocele. One patient had associated upper tract stones. Three patients had associated stones in ureterocele. Transurethral, transverse incision of ureterocele was given in all patients. The mean postoperative hospital stay was 50.5 h. Twenty-three patients were available for follow-up at three, six and 12 months. All patients were symptom free. At three months ultrasound and intravenous urography revealed no residual ureterocele but four patients showed residual hydronephrosis, but with a decrease in the grade indicating decompression. Micturating cystourethrography revealed vesico-ureteral reflux (VUR) in two patients and the reflux persisted in one patient even at 6 months. We conclude that in adults, management with endoscopic incision of orthotopic ureterocele is safe and effective. VUR may occur in a few cases.
  - 6,260 681
Kidney trauma with underlying renal pathology: Is conservative management sufficient?
Rabii El-Atat, Amine Derouiche, Mohamed Riadh Ben Slama, Mohamed Chebil
November-December 2011, 22(6):1175-1180
To evaluate the pre-existing renal lesions (PERL) found incidentally during evaluation for blunt renal trauma, determine their importance, and suggest guidelines for effective management, including conservative treatment, we reviewed 180 patients who were hospitalized with blunt renal trauma between 1992 and 2008. Thirty of the 180 (16.6%) patients had PERL, which had been undiagnosed. The mean follow-up was 5 years (range 1-9 years). There were 24 men and 6 women with a mean age of 30 years (range 14-80 years). The most common cause of blunt renal injuries was falls and sports. Renal stones were present in 14 patients, pelvi-ureteric junction obstruction in 12, ectopic kidney in two, and megaureter and renal cyst in one case each. Ureteral stenting was used in four cases, and early nephrectomy was required in the other four. Fourteen patients underwent surgery for the PERL and not trauma, with a pyeloplasty in eight cases, partial nephrectomy in three cases, percutaneous nephrololithotomy in two cases, and ureteroneocystostomy in one case. In our study, the conservative treatment was possible in 73% of cases. We believe the published data support increasing conservative attempts in the hemodynamically stable patient.
  - 5,085 552
Technical modifications of ureteroneocystostomy in renal transplantation: An 18-year experience
M.R. Mohamadi Fallah, Afshari A Taghizadeh, AH Sharafi
November-December 2011, 22(6):1121-1127
The treatment of choice for patients with end-stage renal disease is renal transplantation. Urinary tract reconstruction is usually done by anti-reflux ureteroneocystostomy, of which there are several techniques. In this study, a comparison of previous studies related to complications and outcome of various extra-vesical uereteroneocystostomy techniques that were used in our center was made. From the year 1988, when renal transplantation was first performed in our center, we utilized many ureteroneocystostomy techniques including Lich-Grigoir, Barry, Tagochi, and finally Barry-Tagochi. With each conversion, we compared the results of the earlier technique with the new one. In addition, we collected the results of four previous studies conducted by our surgeons and analyzed the complications seen with ureteroneocystostomy. A total of 717 renal transplant recipients were included in our study; 214 of these patients were reimplanted by the Barry-Tagochi technique, 155 cases by the Barry technique, 44 cases by the Tagochi technique, and finally, 304 cases by the Lich-Grigor technique. There was no significant difference in the overall complications, urinary leakage and ureteral stenosis, and obstruction between the four groups. However, complicated hematuria was significantly more frequently seen in the Tagochi group (P = 0.002). Also, the mean time taken for ureteroneocystostomy was longer in the Lich-Grigor group (P = 0.001). We found that the Barry-Tagochi technique had an overall incidence of urological complications similar to that of the other extravesical techniques and was less time consuming.
  - 3,246 569
Safety and efficacy of angiotensin converting enzyme inhibitors and angiotensin receptor blockers in chronic allograft injury
PR Shah, VB Kute, DS Saboo, KR Goplani, MR Gumber, AV Vanikar, HV Patel, HL Trivedi
November-December 2011, 22(6):1128-1132
Angiotensin II plays a crucial role in the development of chronic allograft injury (CAI). Clinical experience with angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blockade (ARBS) in CAI has unfortunately been limited. We carried out a prospective one year single center case controlled study to analyze the effect of ACEI /ARBS on the progression of CAI and in decreasing proteinuria. One hundred patients with CAI were evaluated. Of the 100 patients, 50 were selected to receive ACEI/ ARBS (group 1) and 50 managed without ACEI/ARBS (group 2). Their remaining management was similar in both the groups. Patients with hyperkalemia, history of allergic reactions, ACEI/ARBS intake and pregnancy were excluded. Average time for development of CAI was 19.6 ± 12.7 months in group 1 vs. 20.8 ± 12.8 in group 2. In group 1, mean systolic/diastolic BP was 136/82 mmHg at the time of establishment of CAI and 124/76 mmHg at the end of one year, and in group 2, it was 138/86 mmHg vs. 126/80 mmHg, respectively. Mean glomerular filtration rate (GFR) was 48.78 ± 13.4 in the former vs. 44.23 ± 8.14 in the latter. ACEI/ARBS administration was associated with stabilization of serum creatinine. GFR was maintained up to one year after CAI. Group 1 had a decrease in proteinuria by 1.41 g/day as compared with group 2 with proteinuria of 0.83 g/day. ACEI/ARBS administration is beneficial in CAI for BP control and significant decrease in proteinuria along with the stabilization of graft function.
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Association of adequate dialysis parameters with left ventricular hypertrophy in hemodialysis patients
Moncef El M'barki Kadiri, Rhita Bennis Nechba, Yasse R Zajjari, Driss Kabbaj, Majid Bouzerda, Zouhir Oualim
November-December 2011, 22(6):1133-1141
  - 2,839 464
Preliminary audit on early identification and management of chronic kidney disease in adults in an acute general medical unit in Sri Lanka
Suneth De Silva, Dinushi Weerasinghe, Anoja Rajapakse, Chinthaka Maithripala, Senaka Rajapakse
November-December 2011, 22(6):1285-1288
This was the first round of an audit to analyze how closely the National Institute of Clinical Excellence (NICE) guidelines on early identification and management of chronic kidney disease in adults is adhered to by a medical ward in the National Hospital of Sri Lanka. One hundred consecutive patients who were not diagnosed to have chronic kidney disease (CKD) but had risk factors for future development of CKD were selected from the male and female wards of the University Medical Unit, National Hospital, Colombo, Sri Lanka. Data were collected by interviewing patients and from the case notes, and entered on a proforma designed based on the recommendations outlined in the NICE guidelines on the prevention of CKD. Target blood pressure was achieved in 66% (n=66). Urine ward test was performed only in 58% of the patients, and this was positive for protein in 15 patients. Investigations to exclude urinary tract infection were performed in 12%. Measurement of serum creatinine was carried out in 40%, but estimated glomerular filtration rate, albumin:creatinine ratio and protein:creatinine ratio were not carried out in any of the patients. Forty percent of the patients were educated by ward staff regarding CKD, 22% on risk factor modification, 23% regarding renal replacement therapy, 34% regarding dietary modifications and 67% regarding importance of exercise. Twenty-six percent of the patients were not educated on any of the above components. ACEI, ARB and statins were prescribed only in 47%, 9% and 64%, respectively. Although follow-up was indicated in all these patients, it was arranged only in 17%. The concurrence with NICE guidelines on CKD prevention was found to be poor. Strategies for improvement are discussed.
  - 2,750 393
Epidemiology of chronic kidney disease in a Sri Lankan population: Experience of a tertiary care center
Eranga S Wijewickrama, Dinushi Weerasinghe, Pubudu S Sumathipala, Charith Horadagoda, Rushika D Lanarolle, Rezvi MH. Sheriff
November-December 2011, 22(6):1289-1293
Chronic kidney disease (CKD) is a growing problem in Sri Lanka. Diabetes and hypertension are the main contributors to the disease burden. A new form of CKD of uncertain etiology (CKD-u) is the predominant form of CKD in certain parts of Sri Lanka, threatening to reach epidemic proportions. A cross-sectional descriptive study was carried out over a three-month period at the National Hospital of Sri Lanka to identify the underlying etiologic factors for the disease in a cohort of patients with CKD. A total of 200 patients were studied with a mean age of 50.57 years. Of them, 108 (54%) were in CKD stage V. Majority of the patients were from the western province (137, 68.5%) with only five (2.5%) from provinces with high prevalence of CKD-u. The most common underlying causes of CKD were diabetes (88, 44%) and hypertension (34, 17%). However, in patients younger than 40 years of age the most common cause was glomerulonephritis (20, 42.6%). Diabetes was the most common cause of CKD among patients from the western province (74, 54%). The prevalence of CKD-u was twice as high in patients from areas outside the western province compared with patients from this province (P > 0.05). The low prevalence of CKD-u in the study population could be the result of poor representation of patients from provinces with high prevalence of CKD-u.
  - 5,706 786
Anti-HCMV IgG positivity rate among renal transplant recipients in Baghdad
Basam M Al-Alousy, SH Hasan Abdul-Razak, Karim S Al-Ajeeli, Karim A Al-Jashamy
November-December 2011, 22(6):1269-1274
In developing countries, the majority of infection by human cytomegalovirus (HCMV) occurs during childhood and continues as a latent infection. By adulthood, almost all the population may show anti-HCMV IgG as positive. This study was undertaken to determine the correlation between the prevalence of HCMV antibodies and HCMV infection during post transplant period among renal transplant patients in Baghdad. 43 renal transplant patients attending three renal transplantation centers, and 40 healthy individuals who served as controls were enrolled in this study. 18 (41.9%) were transplanted recently and they were under post-operative follow-up and 25 (58.1%) were transplanted more than one year ago. Detection of anti-HCMV IgG was carried out using enzyme-linked immunosorbant assay (ELISA). The results revealed that anti-HCMV IgG was significantly higher among renal transplant recipients compared to healthy controls (97.7% vs 85%, P = 0.04). The anti-HCMV IgG positivity rate was not affected by patients' age, sex, and duration after transplantation or immunosuppressive therapy. We conclude that the high anti-HCMV IgG positivity rate among Iraqi renal transplant recipients make them prone to considerable risk of reactivation of HCMV infection.
  - 2,050 272
Achievements of kidney disease outcomes quality initiative goals in hemodialysis patients at Jordan University Hospital
Ayman M Wahbeh, As'ad T Ibrahim, Naeim G Salah
November-December 2011, 22(6):1275-1279
This study was conducted to assess the current practice patterns of care for hemodialysis (HD) patients at the Jordan University Hospital Dialysis Center using Dialysis Outcomes Quality Initiative Guidelines as the reference. In a cross-sectional study, we assessed 61 patients on HD. The Kt/V was calculated, and data on serum levels of hemoglobin, iron, ferritin, transferrin saturation, calcium, phosphate, and intact parathormone (PTH) were collected. The values were compared with the dialysis outcomes quality initiative (K/DOQI) recommended target values. Forty-one patients (67.2%) had an arteriovenous fistula as the primary access. The mean hemoglobin level was 10.8 ± 1.4 g/dL, 9.8% of patients had mean serum ferritin < 100 ng/dL and 14.7% had transferrin saturation < 20%. The mean serum calcium level was 9.1 ± 0.9 mg/dL and serum calcium level between 8.5 and 10.5 mg/dL was found in 82% of HD patients. The mean serum phosphorus was 3.9 ± 1.1 mg/dL and 59% of patients had serum phosphorus between 3.5 and 5.5 mg/dL. The mean serum PTH was 364 ± 315 and 14 patients (23%) had serum PTH between 150 and 300 pg/mL. The achieved standard of HD among our study patients was acceptable and, in many aspects, comparable with the NKF-KDOQI guidelines. However, there is still need to improve the management of anemia and control of hyperparathyroidism.
  - 3,042 429
Chronic renal failure in Al-Anbar of Iraq
Sami M Awad
November-December 2011, 22(6):1280-1284
There is no precise study of the epidemiology and prevalence of chronic renal failure in Al-Anbar, Iraq. Therefore, we studied 230 hemodialysis (HD) patients at the HD unit of Al-Ramadi teaching hospital during the period from April 1, 2008 to April 1, 2009. There were 124 (53%) male patients with a mean age of 48 ± 18.5 years, and 146 (63%) patients were older than 40 years. The estimated prevalence of chronic renal failure was 141 patients per million population. Diabetes mellitus (33%) and hypertension (22.6%) were the most common causes of chronic renal failure, followed in order by obstructive uropathy in 17.3%, undetermined causes in 14%, pyelonephritis in 4.7%, glomerulonephritis in 4.3%, and polycystic kidney disease in 3.9%. This study suggests that large number of patients with end-stage renal disease (ESRD) have diabetes and hypertension. However, those patients with undetermined cause still form a significant portion of etiology of ESRD, and this reflects late referral combined with diagnostic limitations.
  - 2,914 478
Organ transplantation in Saudi Arabia

November-December 2011, 22(6):1294-1303
  - 2,127 242
What makes an effective clinical trainer?
Mohammed Alsultan
November-December 2011, 22(6):1229-1235
This study aims at identifying characteristics and behavioral patterns associated with the ideal tutor in different medical fields. This study is expected to answer two questions, first is effective supervision and how can this be determined? And secondly, what skills and qualities do effective supervisors need? An English limited search was performed in many databases including MEDLINE, BEI, and International ERIC for the last 20 years using many search items to identify characteristics cited in the literature as being important for effective clinical teaching. One hundred thirty two articles identified the review excluded literature relating to research supervision. Findings revealed that some of these investigations relied on the tutor's point of view, others on a resident's or a student's opinion or both. Descriptors for effective clinical teachers were categorized into three main classes: (a) teaching skills (i.e. well-prepared, practices evidence-based medicine and believes in its principles and applications, effective, accessible, and provides and accepts both positive and negative feedback), (b) personality (i.e. enthusiastic, respectable, sincere, confident, humanitarian, and compassionate), and (c) attitude (i.e. health advocate, good role-model, encouraging, non-judgmental, aware of learners' growth, well-groomed, and appropriately dressed). Other factors such as the trainer's health (i.e. professional, personal, and spiritual fulfillment) and his/her scholarly activities were also identified.
  - 3,954 737
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