Arab journal of nephrology and transplantation最新文献

Introduction: Uremia is the most important systemic cause of pruritus. Uremic pruritus (UP) was found to affect 50-90% of patients undergoing dialysis and about 25% of patients with chronic kidney disease (CKD). Despite its high prevalence, morbidity and the marked influence on quality of life, UP remains poorly characterized.

Review: Triggering factors for UP may include cutaneous xerosis, uremic toxins, systemic inflammation and associated common co-morbidities such as diabetes mellitus, endocrinopathies,viral hepatitis and somatic neuropathy. Moreover, high pre-dialysis levels of blood urea nitrogen (BUN), β2-microglobulin, calcium and phosphate, as well as parathyroid hormone (PTH) were found to be related to UP. A new hypothesis of glycation, with advanced glycation end products (AGEs) accumulation in stratum corneum has been proposed as a possible underlying cause of UP. Common treatments used for UP include antihistamines, steroids, emollients, charcoal, erythropoietin and phototherapy (UVB). Other treatments with some reported efficacy are serotonin antagonists, selective serotonin reuptake inhibitors (SSRI), mast cell stabilizers, leukotriene receptor antagonists, κ-opioid agonists and nicotinamide. Many non-pharmacological treatments, including acupressure, are also used. In addition, improvement of dialysis modalities could relieve patients of UP. The future use of anti-glycation preparations for treatment of UP is supported by recent researches.

Conclusion: Recent researches on the process of glycation as a possible cause of UP may open the way for treatment with anti-glycation preparations. Nevertheless, associated co-morbidities with possible role should be concurrently treated.

Introduction: Our aim was to study the demographic and social characteristics of 189 living related kidney donors in Tunisia, and explore some of the social consequences of kidney donation.

Methods: This is a descriptive retrospective study of 189 living related kidney donors who had their nephrectomy in Charles Nicolle Hospital between 1986 and 2009. The demographic and social characteristics at the time of donation were studied and changes in the social and occupational status after donation were assessed.

Results: The average age at the time of donation was 41.8 ± 12.1 years (range: 20-67 years). Female predominance (59.2% of cases) was noted. Donors were siblings in 46% of cases, parents in 42% of cases and spouses in only 9% of cases. There were more mothers than fathers, more wives than husbands, but fewer sisters than brothers. Twenty-six percent of donors were illiterate and 40% were unemployed at the time of donation. After donation, the social status remained stable for 70% of donors. No divorces were reported. The occupational status was unchanged in 94% of cases. Sixteen percent of female donors had at least one pregnancy after nephrectomy. Nearly 90% of surveyed donors whose recipients were alive at the time of the survey were still in favor of kidney donation.

Conclusions: Women play an important role in living related kidney donation in Tunisia. Family situation and occupational status did not seem to be compromised after nephrectomy, and most donors were willing to donate if the decision was to be repeated.

Introduction: Hyperoxaluria is a metabolic disorder that can lead to end stage renal disease (ESRD). It can be either inherited or acquired. Primary hyperoxaluria (PHO) is more common and characterized by an excessive production of oxalate leading to recurrent urolithiasis and progressive nephrocalcinosis. Due to the high rate of consanguineous marriage in Jordan this disease is commonly diagnosed in pediatric nephrology clinics. We aimed to demonstrate the clinical pattern and progression to ESRD in pediatric patients with hyperoxaluria at Queen Rania Abdulla Children Hospital.

Methods: Medical records of all patients followed up in the pediatric nephrology clinic with the diagnosis of PHO during the period between September 2007 and March 2013 were reviewed.

Results: There were 70 patients with the diagnosis of PHO, 52.9% were males. The median age at presentation was 3 years ± 3 months with the youngest child being two months old. Diagnosis was made in the first year of life in 15.7% of patients. The most common presenting symptom was hematuria, while 14% of patients were asymptomatic and detected by family screening after the diagnosis of an index case. At the time of initial presentation, 15.7% of patients had ESRD and 25% had impaired renal function. Kidney stones were found in 57% of cases and nephrocalcinosis was found in 37%.

Conclusion: High index of suspicion is needed to diagnose PHO in children presenting with kidney stone or unexplained hematuria. Twenty-four hour urine collection for oxalate are required to make the proper diagnosis. Family screening, when appropriate, is indicated for early detection of PHO.

Introduction: Cardiovascular complications are the leading cause of death among renal transplant recipients; renal graft dysfunction has special effects on cardiovascular morbidity and mortality.

Review: Several studies have demonstrated a significant correlation between creatinine level and major coronary events, congestive heart failure and cerebrovascular events. Cardiovascular mortality has been related in different reports to serum creatinine levels and duration on renal replacement therapy. A low estimated glomerular filtration rate (eGFR) was also found to be a significant predictor of death in the pediatric kidney transplant population. Immunosuppressive therapy is also associated with several adverse effects. It has been shown that earlier withdrawal of steroids is associated with less cardiovascular effects, especially via reduction in the incidence of hypertension, hyperlipidemia, weight gain, and post-transplant diabetes. The introduction of calcineurin inhibitors (CNIs) has led to an increase in the number of renal transplant patients dying with a functioning graft, mainly because of cardiovascular disease. Compared to CNIs, mycophenolate mofetil has been proposed to reduce infiltration of circulating lymphocytes to the atherosclerotic plaque. Sirolimus is known to be associated with higher incidence of hyperlipidemia and hyperglycemia but lower incidence of hypertension.

Conclusion: Dialysis duration, renal allograft dysfunction and the immunosuppressive agents used enhance cardiovascular risk among the renal transplantation population. Transplanted children are at a particularly high risk of cardiovascular events post-transplantation.

Introduction: Acute post streptococcal glomerulo-nephritis (APSGN) is a form of acute nephritic syndrome characterized by edema, hematuria, proteinuria, and hypertension. The immediate prognosis of acute post-streptococcal glomerulonephritis in children is usually excellent, however, the long-term prognosis has been a subject of debate.

Methods: This is a retrospective and prospective cohort study of Sudanese children with APSGN followed in a tertiary care hospital between 2006 and 2010. Patients who presented for follow-up 1-5 years after initial diagnosis were assessed for proteinuria, hematuria, urinary albumin to creatinine ratio (ACR), hypertension, and glomerular filtration rate (GFR).

Results: Data of 69 children (46 males; 66.7%) was analyzed. At presentation, 29% had severe acute disease requiring dialysis. On discharge, 60 children (87%) recovered their renal function, seven children (10.1%) showed no recovery and two children (2.9%) died. Forty out of 69 children presented to follow-up 1-5 years after initial diagnosis. Thirty-four of these children (85%) had normal blood pressure and GFR while six children (15%) progressed to chronic kidney disease (CKD); three of whom died. Among children with normal GFR, eight (23.5%) had microalbuminuria plus hematuria and four (11.7%) had hematuria. Persistence of proteinuria and/or hematuria was universal among the 14 children with normal GFR who continued follow-up more than three years after initial presentation.

Conclusion: APSGN in this group of Sudanese children had a less favorable prognosis. This reflects the tertiary care set-up of this study. Persistence of hematuria and/or proteinuria was common on follow-up.

Introduction: Emphysematous pyelonephritis (EP) is an uncommon acute infection characterized by the presence of gas in the renal parenchyma. It is extremely rare in hemodialysis (HD) patients and diabetics account for most cases. It is a rapidly progressive and life threatening infection with a high mortality rate. We report a case of emphysematous pyelonephritis in a HD patient who was treated successfully with radical nephrectomy and antibiotic therapy.

Case report: A 46-year-old diabetic male with end stage renal disease (ESRD) secondary to diabetic nephropathy and on maintenance HD for the last five years presented with a two weeks history of fever and loin pain. He was treated with oral ciprofloxacin for one week with no improvement. His blood culture isolated Escherichia coli. Computed tomography scan of the abdominal disclosed an enlarged left kidney with massive gaseous collections. Accordingly, the diagnosis of emphysematous pyelonephritis was put forward, the patient underwent left nephrectomy together with intravenous imipenum and amikacin with good clinical response. The removed kidney showed features of acute pyelonephritis with micro-abscesses on histopathology. .

Conclusion: Emphysematous pyelonephritis should always be considered in diabetics presenting with fever, loin pain, and features of sepsis not responding to antibiotic therapy; even though being on dialysis. Computed tomography scan of the abdomen remains an early diagnostic tool. Early treatment with potent antibiotics with or without surgical intervention can save patients' life.

Introduction: C4d immunostaining of renal allograft biopsies is recommended for the diagnosis of antibody-mediated rejection (ABMR), but it was not available to us prior to June 2012. In June 2012, we were able to obtain anti-human C4d polyclonal antibody and decided to retrospectively evaluate archived kidney allograft biopsies at our center for C4d deposition.

Methods: Twenty-four paraffin blocks were available for this study. Immunostaining for C4d was performed using anti-human C4d polyclonal antibody by Immunohistochemistry. The score and pattern of C4d positivity were determined according to the Banff 2007 guidelines.

Results: All grafts were from living related donors with negative CDC cross-match. The indications for biopsy were primary, acute and chronic graft dysfunction in 29.2%, 33.3% and 37.5% of patients respectively. Two biopsies revealed extensive necrosis rendering it difficult to interpret the result of C4d staining. Among the remaining 22 biopsies, C4d staining was categorized as negative in 40.9%, minimal in 13.6%, focal in 22.7% and diffuse in 22.7%. The prevalence of C4d positivity among biopsies taken due to primary, chronic and acute graft dysfunction was 71.4%, 44.4% and 12.5% respectively.

Conclusion: C4d positivity was common in biopsies taken from this group of kidney transplant recipients and its prevalence was particularly high among biopsies taken due to primary graft non-function. This indicates that missed ABMR is an important cause for kidney allograft dysfunction in our setting.

Introduction: Systemic lupus erythematosus (SLE) is an unpredictable autoimmune systemic disorder that often involves the kidney. In this study, we aimed to assess the clinical characteristics, pathological findings, and therapeutic response of children presenting with lupus nephritis (LN).

Methods: We retrospectively studied 50 children with SLE admitted to the pediatric nephrology departments of four teaching hospitals in Baghdad between December 2009 and December 2011.

Results: The female to male ratio was 5:3. The median age was 11 years with a range of 5 -17 years. The commonest presenting features were weight loss (92%), fever (90%), edema (88%), arthritis (70%), hair loss (70%) and malar rash (60%). Examination revealed hepatosplenomegaly/lymphadenopathy in 20% of patients. Anti-dsDNA was positive in 92% of patients. Pathological examination revealed LN class I in 4%, class II (10%), class III (8%), class IV (74%) and class V (4%). All patients in class I, II and III achieved full remission after treatment with prednisolone. Thirty-one patients in class IV and V received induction treatment with cyclophosphamide followed by maintenance with cyclophosphamide (16 patients), mycophenolatemofetil (13 patients) or azathioprine (2 patients). Twenty-four of those patients achieved remission, four patients developed chronic kidney disease and three patients died. Five patients in class IV/V were treated with mycophenolate mofetil and three of them achieved remission, whilst three patients were treated with azathioprine and all of them achieved remission.

Conclusion: Diffuse proliferative glomerulonephritis (class IV) was the most common pattern of LN encountered in our study.