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Saudi Journal of Kidney Diseases and Transplantation
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   2020| May-June  | Volume 31 | Issue 3  
    Online since July 10, 2020

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Management of pain at arteriovenous fistula puncture: Cryotherapy versus lidocaine/prilocaine
Loubna Kortobi, Hajar Belymam, Naoufal Mtioui Chkairi, Mohamed Zamd, Ghislaine Medkouri, Mohammed Benghanem Gharbi, Benyounes Ramdani, Selma Siham El Khayat
May-June 2020, 31(3):597-603
Pain at arteriovenous fistula (AVF) puncture is common in hemodialysis (HD) patients. The purpose of our work is to determine its frequency, to evaluate the efficiency of two techniques: anesthetic cream (Emla™) and cryotherapy, and to compare their efficiency. A prospective and interventional analytical study of HD patients was conducted in our structure. We included all patients with pain at AVF puncture. We evaluated the pain intensity using a visual analogue scale before and after our intervention: Emla™ cream during three consecutive HD sessions, then cryotherapy (ice cubes placed in latex gloves, during 5 min, directly applied on the puncture sites) during three consecutive HD sessions. The statistical analysis was performed using the Epi Info software. Eighty-four patients are undergoing HD in our structure, of which 32 (38%) report pain at AVF puncture. The mean value of the visual analog scale before the puncture was 7.19 ± 1.95 (4-10). Pain decrease was statistically significant for both techniques. Comparative analysis of the two techniques revealed a significant reduction in pain in favor of cryotherapy (P 0.001). The analgesic effect has been proved for both techniques. Cryotherapy provides higher efficiency, with fewer constraints, and could be proposed for the management of pain at AVF puncture.
  1,069 88 -
ABO-incompatible transplantation without conventional induction immunosuppression (IL-2RB or depleting agents)
Benil Hafeeq, Feroz Aziz, Sajith Narayanan, Ismail Naduvileparambi Aboobacker, Jyotish Chalil Gopinathan, Ranjit Narayanan, Julie Jose Binu, NA Uvais
May-June 2020, 31(3):572-581
Transplantation across the ABO blood group (ABOI-Tx) has facilitated to increase in donor pool for living donor kidney transplantation. Increased risk of rejection despite augmented immunosuppression has been the concern for many transplant programs in initiating an ABOI-TX program. The benefits of induction immunosuppression on long-term graft survival in immunologically low-risk individuals are still not clear. Increased immunosuppression of ABOI-Tx recipients before transplantation could provide an opportunity to transplant without induction with IL2-R blockers or Lymphocyte depleting agents. The aim of our study is to analyze the outcome of our series of 25 consecutive ABOI-Tx patients who underwent transplantation without routine thymoglobulin or IL2R-blocker induction. Our study is a prospective observational study for the first 25 consecutive patients who had undergone ABOI-Tx from two tertiary care centers in Kerala, India, having the same IS protocol. Anti-A and anti-B titers ≤1:512 by Gel-method (Biorad) were accepted for desensitization. Patients underwent CDC-crossmatch, Flow-crossmatch, and Luminex-anti-HLA-antibody-screen. Desensitization regimen included- Rituximab 200 mg on Day-21, Triple IS Prednisolone 10 mg, mycophenolate mofetil 1000 mg, and Tacrolimus 0.06 mg/bodywt from Day-14 and Plasma-exchange (PLEX) 3-4 sessions from day -7 to attain titer of 1:8 before transplantation. Transplantation was done without induction IS. Twenty-five patients underwent ABOI-Tx from both centers. Twenty recipients were male. The average age was 34.5 ± 8 years with follow-up of 503 ± 120 days. Eight donors were spouse, 13 were parents and three siblings. The average age of the donor was 46.3 ± 10.5 years. Twenty-two patients have normal functioning transplant with creatinine 1.23 ± 0.2 mg/dL. Kaplan–Meier analysis showed patient survival of 91.2% and death censored graft survival of 95.6% at 36 months. Two patients were lost; one on the postoperative day (POD)-3 due to ACS and second on POD-22 due to sepsis. One graft loss occurred due to posttransplant HUS. Of the functioning 22 allograft-recipients, one had cellular rejection, which resolved with pulse steroids; one developed HUS due to CNI, which recovered with PLEX and switch to non-CNI based IS. One patient developed AMR on POD-4, which was completely reversed with PLEX, intravenous immunoglobulin (IVIG), and augmentation of IS. Three patients had CMV viremia and another three patients had BKV viremia, all resolved with treatment and tailoring of IS. Achieving acceptable anti-A/B titers prior to transplantation is the most critical step in ABOI-Tx. Avoidance of induction IS can reduce cost and infectious complications. Our data showed that there is no increased incidence of rejections in the first post-transplant year for immunologically low-risk individuals from histocompatibility standpoint undergoing ABOI-Tx without induction immunosuppression.
  927 202 -
Barriers in knowledge and attitudes regarding organ donation among Urban Jordanian population
Fayez Abdulrazeq, Monica M Matsumoto, Mohammad Zourob, Abdulrahman Al-Dobai, Khadega Zeyad, Nemer Marwan, Abdulrahman Qeshta, Omar Aleyani
May-June 2020, 31(3):624-638
Low organ donation rates are a major obstacle to the expansion of transplant opportunities in the Middle East. Awareness and opinion about organ donation affect willingness to donate. This study aims to evaluate public attitudes and knowledge about deceased organ donation (DOD) in Jordan in support of larger efforts to increase donor rates. A mixed qualitative and quantitative approach was used. Qualitative, one-on-one interviews were used to create a quantitative survey, which was administered to randomly-selected individuals over a 5-month period. The questionnaire used series of statements to evaluate knowledge and attitude about DOD on a scaling system and converted to scores (0–4). A total of 15 qualitative interviews and 500 quantitative surveys (78.4% response rate) were completed. Only 78 (15.6%) knew they could donate their organs after death. Only 49 (9.8%) were registered as donors, although 373 (74.6%) knew about the registration process. Internet (52.2%) and social media (51.0%) were the most common sources of information. The overall knowledge score was moderately high at 68.8% (2.75 ± 1.31). Misconceptions persisted about body disfigurement, diagnostic accuracy of brain-death, and waiting list equity. The total attitude score was moderately positive at 65.8% (2.63 ± 0.02). Public awareness campaigns (85.3%, 3.42 ± 0.95) and regulatory legislation (78.8%, 3.15 ± 0.99) were considered especially positive, while negative attitudes about religious approval and paid donation were present. Female respondents had significantly higher scores on organ donation significance (P = 0.007) and overall attitude (P = 0.035) than males. The results of this study demonstrate knowledge gaps, misconceptions, and negative opinions on topics related to organ donation in Jordan. However, participants recognized the importance of educational campaigns and regulatory legislation and would likely benefit from information from health-care providers and religious leaders.
  896 63 -
Granulomatous interstitial nephritis in the military hospital of Morocco: Causes and outcomes
Yassir Zajjari, Mounia Azizi, Abdelali Bahadi, Dina Montasser, Taoufiq Aatif, Ahmed Alayoud, Driss El Kabbaj
May-June 2020, 31(3):589-596
Granulomatous interstitial nephritis (GIN) is a rare cause of renal failure. Most frequent etiologies are sarcoidosis, drugs, granulomatosis with polyangiitis, and infections agents (particularly renal tuberculosis). The aim of this retrospective study was to evaluate the clinical features, causes, and outcomes of patients with GIN in adult patients in a region of Morocco. All native renal biopsy (January 2008 to December 2017) were reviewed, but only cases of GIN were analyzed. Eleven cases of GIN were identified in this study, constituting 2.7 % of all native renal biopsies performed on this period (n = 407). There were 7 (63.6%) women, and the average age was 44.2 ± 13.9 years. The mean serum creatinine level at the renal biopsy was 39.1 ± 20.7 mg/L. The most common etiology was sarcoidosis (45.4%, n = 5) followed by drug-induced GIN (27.2%, n = 3). A good renal outcome was reported in patients with drug-induced GIN and sarcoidosis. However, no renal recovery was described in patients with other etiologies. One information from our report and the previously studies is that better data collection systems such as biopsy registries are needed to provide data on the epidemiology and treatment of rare kidney diseases.
  566 108 -
Effect of Ramadan fasting on arterial stiffness parameters among Egyptian hypertensive patients with and without chronic kidney disease
Ahmed A Eldeeb, Mostafa A Mahmoud, Ahmed B Ibrahim, Elshahat A Yousef, Alaa A Sabry
May-June 2020, 31(3):582-588
Arterial stiffness (AS) increases progressively in patients with chronic kidney disease (CKD). It is a strong predictor of cardiovascular and all-cause mortality. This study aims at evaluate of the effect of Ramadan fasting on AS parameters, augmentation index (AIx), and pulse wave velocity (PWV) in hypertensive patients with and without CKD. A cohort of 71 patients (mean age = 57.14 ± 14.5 years, 42 females and 29 males) were enrolled in this study; 34 with CKD and 37 without CKD. All patients had hypertension, while 25 patients also had diabetes mellitus. Serum creatinine (Cr), serum urea, estimated glomerular filtration rate (eGFR) by CKD-EPI formula, brachial and central systolic blood pressure (BSP and CSP respectively), brachial and central diastolic blood pressure (BDP, CDP, respectively), AIx and PWV (measured by cuff based oscillometric method) were assessed before and after Ramadan fasting. In patients without CKD BSP, BDP, CSP, and CDP significantly decreased (P = 0.0001, 0.0001, 0.0001, and 0.0001, respectively). In patients with CKD BSP and CSP significantly decreased (P = 0.005 and 0.005), while BDP and CDP decreased, but the change was not statistically significant. AIx significantly decreased in patients without CKD (P = 0.0001, mean 36.24 before and 26.22 after Ramadan fasting), but did not significantly change in patients with CKD (P 0.381 mean 25.94 before and 25 after Ramadan fasting). PWV decreased in both groups, but the change was not significant. Serum Cr significantly increased (P = 0.03 mean 1.06 mg/dL before and 1.11 mg/dL after Ramadan fasting), while eGFR did not significantly decrease (P = 0.072, mean 69.73 mL/ min/1.73 m2 before and 67.3 mL/min/1.73 m2 after Ramadan fasting) in patients without CKD. Serum Cr significantly decreased (P 0.028 mean 1.93 mg/dL before and 1.87 mg/dL after Ramadan fasting) and eGFR significantly increased (P 0.006 mean 32.65 mL/min/1.73 m2 before and 34.68 mL/min/1.73 m2 after RF) in patients with CKD. Ramadan fasting is associated with improved peripheral and central blood pressure control in hypertensive patients with and without CKD. It is also associated with improved arterial compliance (decreased AIx) in hypertensive patients without CKD.
  530 131 -
Chylous nephrogenic ascites in a hemodialysis patient
Muhammad Abdul Mabood Khalil, Mohamad Khairulsadek Haji Jukmin, Vui Heng Chong, Jackson Tan
May-June 2020, 31(3):687-692
Chylous nephrogenic ascites is rare in hemodialysis (HD) patients. We would like to share a rare case of chylous nephrogenic ascites in a HD patient. The patient has a history of straw-colored nephrogenic ascites which was drained through pigtail five times in the past. Later on, the ascites became turbid and milky. The chloroform test of the ascitic fluid showed fat globules with Oil Red-O stain, and the triglyceride concentration of ascitic fluid was 168.14 mg/dL (1.93 mmol/L) satisfying the criteria of chylous ascites. We believe that this may be caused by microtrauma from repeated pigtail insertions for ascites which was compounded by inadequate HD and noncompliance with fluids. Routine investigations including screening for malignancy, tuberculosis, cirrhosis, and heart failure did not reveal any other possible causes. Although there are few case reports of chylous ascites in peritoneal dialysis patients, it has never been reported in patients on HD.
  523 51 -
A multicenter study of malnutrition status in chronic kidney disease stages I–V-D from different socioeconomic groups
Sneha Haridas Anupama, Georgi Abraham, Merina Alex, Madhusudhan Vijayan, Kuyilan Karai Subramanian, Edwin Fernando, Vijayashree Nagarajan, Preethi Kondala Nageshwara Rao
May-June 2020, 31(3):614-623
There is a paucity of data on malnutrition in different socioeconomic status in chronic kidney disease (CKD) patients. Hence, this cross-sectional study was undertaken in CKD-ND and CKD-D. The aim of the study was to assess the prevalence of malnutrition in the various stages of CKD among the various socioeconomic groups, namely the low-income groups and the upper-middle-income groups. This is a cross-sectional study conducted among 394 patients. The patient data were obtained from three institutions: Institution 1, Institution 2, and Institution 3. Patients were predominantly from the South Indian population and were between the age groups of 18 and 80 years. Measurements: malnutrition was assessed using anthropometry, body composition monitor, biochemical parameters, and dietary recall. Subjective Global Assessment Scale for nondialyzed patients and Malnutrition-Inflammation Score for dialyzed patients were also collected . As per the CKD stages, we found the percentage of malnutrition to be 7% in Stage III, 14% in Stage IV, 18% in Stage V, and 68% in Stage V-D in the upper-middle-income group, whereas it was 10% in Stage III, 26% in Stage IV, 40% in Stage V, and 93% in Stage V-D in the low-income group. The severity of malnutrition was stratified according to the stages of CKD, and it was found to be higher in progressive stages of CKD among the low-income groups as compared to the high-income groups.
  481 82 -
Evaluation of electrocardiographic findings before and after hemodialysis session
Hela Jebali, Hiba Ghabi, Ikram Mami, Lilia Ben Fatma, Wided Smaoui, Badr Ben Kaab, Madiha Krid, Manel Ben Hlima, Tasnim Ben Ayed, Omar Guermazi, Mohamed Sami Mourali, Soumaya Beji, Mohamed Chermiti, Loumi Zied, Hanene Kateb, Mohanad Hassan, Fethi Ben Hmida, Lamia Raies, Mohamed Karim Zouaghi
May-June 2020, 31(3):639-646
Dialysis patients have higher rates of sudden cardiac death. The study of the electrocardiogram could identify patients at risk of developing rhythm disorders. The aim of this study was to evaluate the electrocardiographic findings before and after the hemodialysis (HD) session and to examine associations of clinical and serum electrolytes with electrocardiogram findings. We conducted a multicentric transversal study, including chronic HD patients during January 2018. Standard 12-lead electrocardiogram was recorded, before and after the HD session. A medical history was documented. It included age, gender, initial nephropathy, and comorbidities. Serum potassium and total serum calcium were measured before a routine HD session. Serum potassium was measured after HD session. Corrected QT for heart rate was calculated using Bazett’s formula. The study included 66 patients. Nineteen patients (28.8%) had hyperkalemia before the HD session and 44 (66.7%) patients had hypokalemia after the HD session. Seventeen patients had prolonged QTc interval (25.7%). On multiple regression analysis, only the prolonged QTc interval was significantly correlated with the serum potassium (P = 0.046).When comparing the mean values of electrocardiogram parameters before and after the HD session, we noted a significant change of heart rate (P = 0.001), R wave (P = 0.016), T wave (P = 0.001), and T/R (P = 0.001) wave. Delta K+ did not correlate with the change in T wave amplitude (r = 0.23, P = 0.59), R wave amplitude (r = –0.16, P = 0.2), T/R wave (r = 0.055, P = 0.65), or QRS duration (r = 0.023, P = 0.85). Delta QTc was correlated to ΔK+. We conclude that usual electrographic manifestations of hyperkalemia are less pronounced in HD patients. Our results confirmed the unstable status of cardiac electrophysiology during HD session.
  376 127 -
Effects of dietary counseling on sodium restriction in patients with chronic kidney disease on hemodialysis: A randomized clinical trial
Amanda Brito de Freitas, Bruna Bellincanta Nicoletto, Karina Sanches Machado d'Almeida, Nícia Maria Romano de Medeiros Bastos, Roberto Ceratti Manfro, Gabriela Corrêa Souza
May-June 2020, 31(3):604-613
Reducing dietary sodium has the potential to benefit patients with chronic kidney disease on hemodialysis (HD). This study was aimed to evaluate the effects of dietary counseling on sodium restriction and its relationship with clinical, dietary, and quality of life parameters in patients on HD treatment. This study was designed as a randomized clinical trial. The study included 87 patients on HD, divided into intervention (n = 47) and control (n = 40) groups. Anthropometric, clinical, sodium intake, and quality of life data were evaluated in both groups at four-time points: baseline (T0), 90 days (T3), 180 days (T6), and 365 days (T12). The intervention group received dietary counseling at the beginning and throughout the study. There were no between-group differences regarding anthropometric, clinical, and quality of life data at any of the time points. The mean age was 59 ± 14 years, and most of the patients were men (61%) and had hypertension (90%). Total sodium (g) and processed meat (mg sodium) intake significantly decreased in both groups [intervention: T0 = 3.5 (2.3–4.7); T12 = 2.0 (0.7–2.5); P <0.0001; control: T0 = 3 (1.5–4.9); T12 = 2.0 (0.8–3.3); P = 0.001; and intervention: T0 = 78 (25–196); T12 = 21 (0–78); P = 0.003; control: T0 = 97 (31–406); T12 = 44 (0–152); P = 0.004, respectively] . There was a significant decrease in the consumption of packaged seasonings (mg sodium) [T0 = 130 (0–854); T12 = 0 (0–0); P = 0.015] and instant noodles [T0 = 19 (0–91); T12 = 0 (0–0); P = 0.017] in the intervention group. Dietary counseling was effective in changing dietary habits. In both groups, there was a reduction in total sodium intake, which was greater in the intervention group. Moreover, a decrease in the intake of salty foods, such as packaged seasonings and instant noodles, was only observed in the intervention group.
  408 80 -
A rare cause of nephrotic syndrome
Remi George Thomas, RP Senthilkumar, Balaraman Velayudham, C Vasudevan, Thirumalvalavan Murugesan
May-June 2020, 31(3):676-680
Classical Alport syndrome is a rare X-linked disease of males (85%) presenting early with hematuria, ocular, and hearing defects. Proteinuria and renal failure are less common in the early stages. Here, we report the case of a young female with nephrotic range proteinuria, microscopic hematuria, and renal failure. A keen observation of abundant interstitial foam cells with suspicious glomerular basement membrane changes on kidney biopsy hinted the possibility of Alport syndrome. Further directed testing of the index patient and her family members including genetic analysis revealed a rare pathogenic variant of COL4A homozygous autosomal recessive Alport syndrome. Pedigree analysis showed that the peculiar inheritance could be due to maternal gonadal mosaicism or uniparental isodisomy of paternal genes alone.
  364 84 -
Consensus guidelines of cardiovascular risk assessment in kidney transplantation in Saudi Arabia: Review of current practice, evidence, and recommendations
Ziad Arabi, Abdulrahman Theaby, Abdulrazak Sibai, Muhammad A Bukhari, M Samir Al Chaghouri, Mouaz Al-Mallah, Wael Ohali, Khalid Abdullah, Hatim Kheirallah, Hasan Eid, Haitham Rojolah, Maryam Qaseer, Khalid Hamawi, Murtada Halim
May-June 2020, 31(3):655-675
Screening for cardiovascular (CV) disease before transplant is common. However, the clinical utility of screening asymptomatic transplant candidates remains unclear. There is a large degree of variation among the practices of the different transplant centers in the Kingdom of Saudi Arabia (KSA) and among the international guidelines. Opinions are mostly based on mixed observational data with a great potential for bias. When compared to the Western countries, renal-transplant candidates in the KSA are likely to have longer dialysis vintage, higher prevalence of catheter use, higher rate of uncontrolled hyperparathyroidism, and high prevalence of diabetes. These factors are likely to expose renal-transplant candidates to a higher CV risk than those in Western countries. In the absence of any published guideline for CV risk assessment of the renal-transplant candidate in the KSA, we present these guidelines as the first published guidelines in the KSA. These guidelines review the pertinent aspects from the most recent American College of Cardiology/American Heart Association guidelines for cardiac disease evaluation and management among kidney-transplant candidates and reflect on the local practices in the KSA. These guidelines overview many of the daily- encountered challenges in renal transplantation such as the indications for stress testing, screening coronary angiogram and prophylactic revascularization, screening and management of pulmonary hypertension, cardiac surveillance while on the waiting list and duration of dual-antiplatelet therapy before renal transplant. These guidelines were reviewed by a team of consultant nephrologists, cardiologists, anesthesiologists, and transplant surgeons from six major transplant centers in the KSA. The guidelines aim to standardize the practices of CV risk assessment in kidney transplantation in the KSA, according to the most up-to-date available evidence. The expected impact of these guidelines on the current practices is also reviewed here.
  364 61 -
Collagenofibrotic glomerulopathy: A case of glomerular deposition disease in the Indian subcontinent and review of the literature
Suny S Modi, S Balasubramaniam, K Sunilkumar
May-June 2020, 31(3):681-686
Collagenofibrotic glomerulopathy (CG) is a rare renal disease with unknown etiology, defined by deposition of Type III collagen fibers in the subendothelial space and mesangium seen on supported by electron microscopy. There are merely 19 cases reported in the literature from the Indian subcontinent. Herein, we present a case report of CG from the Indian subcontinent and review its literature mainly focusing on histopathological findings.
  327 38 -
Seroprevalence of Hepatitis B, C and coinfection among patients with chronic kidney disease in a Nigerian hospital
Adeyemi Ogunleye, Tosin T Oluwafemi, Akinwumi A Akinbodewa, Victoria O Daomi, Oluseyi A Adejumo, Temitope C Omisakin
May-June 2020, 31(3):647-654
Infectious diseases remain a major health challenge in developing countries, compounding the woes of growing noncommunicable diseases such as chronic kidney disease (CKD). Increased morbidity and mortality have been reported among CKD patients with hepatitis infection and may necessitate protocol for treatment, follow-up, and prevention of spread. We aimed to determine the prevalence of viral hepatitis B and C infections among CKD patients and the effects on their liver enzymes. In this retrospective study, 314 CKD patients screened for hepatitis C virus (HCV) and hepatitis B surface antigen (HBsAg) were reviewed. Participants were screened at the time of diagnosis of CKD or referral, using qualitative enzyme immunoassay rapid test kits before the initiation of treatment. Individuals who were reactive to human immunodeficiency virus were excluded, and data were analyzed using IBM SPSS Statistics version 21.0. Participants included 206 males (65.6%) and 108 females (34.4%), with a mean age of 50.5 ± 16.3 years. The seroprevalence of HBsAg, HCV, and coinfection was seen in 15.6% (49), 4.8% (15), and 0.92% of the patients, respectively. More than half (63.6%) of the seropositive patients were below 50 years of age. Alanine transaminase (ALT) activity was higher in HCV seropositive than negative (10.5 ± 10.5 vs. 21.2 ± 35.9) (P = 0.001), while aspartate transaminase (AST) and alkaline phosphatase (ALP) were similar. ALT, AST, and ALP were also similar between HBsAg-seropositive and HBsAg-negative patients. The prevalence of hepatitis B and C is high among our CKD patients. This suggests the need for improved screening and treatment of hepatitis infection in this group. Immunization may also be essential to prevent its spread among patients requiring hemodialysis.
  289 65 -
Risk-prediction model for COVID-19 infection in dialysis patients
Sora Yasri, Viroj Wiwanitkit
May-June 2020, 31(3):699-700
  264 66 -
Coronavirus-antibody immune complex: A nanostructure appraisal possible cause of nephropathology
Won Sriwijitalai, Viroj Wiwanitkit
May-June 2020, 31(3):694-695
  232 45 -
Author's reply
Ehsan Valavi, Majid Aminzadeh
May-June 2020, 31(3):697-698
  190 31 -
Refusal rate for dialysis in a rural community in Indochina: What about the rate?
Won Sriwijitalai, Viroj Wiwanitkit
May-June 2020, 31(3):693-693
  182 36 -
Expected tuberculosis detection rate among the patients with chronic kidney disease: A report from endemic country of tuberculosis
Pathum Sookaromdee, Viroj Wiwanitkit
May-June 2020, 31(3):701-702
  174 38 -
Remarks about the published study on “Changes in body mass index after pediatric renal transplantation”
Mahmood Dhahir Al-Mendalawi
May-June 2020, 31(3):696-696
  170 34 -
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