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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
March-April 2017
Volume 28 | Issue 2
Page Nos. 241-451

Online since Thursday, March 23, 2017

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Obesity and kidney disease: Hidden consequences of the epidemic Highly accessed article p. 241
Csaba P Kovesdy, Susan Furth, Carmine Zoccali, World Kidney Day Steering Committee
Obesity has become a worldwide epidemic, and its prevalence has been projected to grow by 40% in the next decade. This increasing prevalence has implications for the risk of diabetes, cardiovascular disease and also for chronic kidney disease (CKD). A high body mass index is one of the strongest risk factors for new-onset CKD. In individuals affected by obesity, a compensatory hyperfiltration occurs to meet the heightened metabolic demands of the increased body weight. The increase in intraglomerular pressure can damage the kidneys and raise the risk of developing CKD in the long-term. The incidence of obesity-related glomerulopathy has increased ten-fold in recent years. Obesity has also been shown to be a risk factor for nephrolithiasis, and for a number of malignancies including kidney cancer. This year the World Kidney Day promotes education on the harmful consequences of obesity and its association with kidney disease, advocating healthy lifestyle and health policy measures that makes preventive behaviors an affordable option.
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Update on pathogenesis, management, and treatment of hypertension in autosomal dominant polycystic kidney disease Highly accessed article p. 253
Imed Helal, Fadel Al-Rowaie, Ezzedine Abderrahim, Adel Kheder
Hypertension is a common early finding in autosomal dominant polycystic kidney disease (ADPKD). Improvements in screening and diagnosis of ADPKD have allowed earlier diagnosis, later onset of end-stage renal disease, and better survival. However, the main and most effective therapy remains control of hypertension. Hypertension is the most important modifiable risk factor in ADPKD. Therefore, early management of hypertension reduces the incidence of cardiovascular events in ADPKD patients. Stimulation of the renin–angiotensin–aldosterone system (RAAS) plays a central role in the pathogenesis of hypertension in ADPKD. Therapies that block the RAAS have improved patient management, blood pressure control, and ADPKD patient survival. This review highlights the current understanding of the epidemiology, potential pathogenetic mechanisms and proposes a strategy for the treatment and management of hypertension in ADPKD.
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Associations between clinical characteristics and angiotensin-converting enzyme gene insertion/deletion polymorphism in Moroccan population with Type-2 diabetic nephropathy p. 261
Maria Mansouri, Amal Zniber, Lamia Boualla, Ghizlane El Badaoui, Mariam Benkacem, Kaoutar Rifai, Abdelmjid Chraibi, Loubna Benamar, Abdelaziz Sefiani, Rabia Bayahia
Diabetic nephropathy (DN) is one of the severe complications of Type-2 diabetes mellitus (T2DM) and a major cause of end-stage renal disease in these patients. Results from published studies on the relationship between angiotensin-converting enzyme (ACE) insertion/ deletion (I/D) gene polymorphism and patients with DN are still conflicting. We compared the clinical characteristics and the genotype frequencies of ACE polymorphism in 130 T2DM Moroccan patients with DN and 85 T2DM Moroccan patients without DN (controls) using specific primers in a polymerase chain reaction. The degenerative complications of diabetes were significantly higher in the group with nephropathy. The distribution of the I/D genotypes was in Hardy–Weinberg equilibrium. The D allele was the most frequent allele in the Moroccan population in both groups studied (P = 0.68), however, there was no significant difference between the genotypes in T2DM patients with or without DN (P = 0.78). The ACE gene I/D polymorphism was not associated with an increased risk of DN in the Moroccan population.
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Assay of urinary protein carbonyl content can predict the steroid dependence and resistance in children with idiopathic nephrotic syndrome p. 268
Niranjan Gopal, Bidhan Chandra Koner, Atanu Bhattacharjee, Vishnu Bhat, Sathish Babu Murugaiyan, Prakash H Muddegowda
Nephrotic syndrome in pediatric age is mostly idiopathic. Idiopathic nephrotic syndrome (INS) by default is treated with steroids from the very beginning. Some do not respond to steroids and are grouped later as either steroid-resistant (SR) or steroid-dependent (SD) cases. The protein selectivity index often fails to predict the SR and SD cases. The SD and SR cases of INS exhibit higher degrees of oxidative stress compared to steroid responders. Proteins get carbonylated when they are exposed to free radicals. The significance of excretion of these carbonylated proteins in urine is yet to be studied in detail. In this study, 70 cases of INS were enrolled, and urinary protein carbonyl content (UPCC) was estimated by Levine’s method before starting the steroid therapy. All the cases were followed up and, based on the response to steroid therapy, were grouped as Group A (n = 47). Steroid sensitive and Group B (n = 23), SD + SR cases. UPCC was significantly higher in Group B compared to Group A. Receiver–operating curve showed at a cutoff limit of 5.10 nmoles/mg of protein, UPCC can predict SD or SR cases with 83.3% sensitivity and 85.2% specificity and area under the curve of 0.833, P<0.05. UPCC levels more than 5.10 nmoles/mg of protein, before starting the therapy can predict SD or SR in pediatric INS cases.
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Dynamic renal scintigraphic estimation of deceased donor kidneys in a rat model p. 273
Huseyin Aydin Mitil, Zehra Pınar Koç, Yunus Guzel, Mustafa Kom, A Belin Ozer, I Hanefi Ozercan, Tansel Ansal Balcı
At present a large number of the renal transplantations are being performed from the deceased donors. The success of these transplantations depends on the viability of the deceased donor kidneys. The aim of this study was to investigate the reliability of scintigraphic estimation of function of deceased donor kidneys by comparing the histopathologic and scintigraphic findings. Ten rats were included in the study (2–3 months old, 250–300 g, all male). Control scintigraphy was performed to all the rats by injection of 37 MBq Tc-99m DTPA from the tail vein in a dynamic manner. Brain death of the rats was achieved by inflation of a Fogartys catheter in the cranial cavity. Immediately, after brain death confirmation, dynamic renal scintigraphy was performed with the same parameters of control scintigraphy. In the comparison of scintigraphies obtained in the before and just after brain death period, there was impairment of tubular functions, concentration and excretion functions in the postbrain death period. In the immediate postbrain death period, there was a significant elevation in the glomerular filtration rate and time to maximum concentration values. In the histopathological evaluation of the kidney samples in the postbrain death period, there were definitive findings of tubular impairment. Dynamic renal scintigraphy also demonstrated definite impairment of tubular system and tubular functions in the deceased donor kidneys. This could explain the reason of the increased frequency of acute tubular necrosis seen among deceased donor kidneys.
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Spectrum of renal injury in pregnancy-induced hypertension: Experience from a single center in India p. 279
Mahesh Eswarappa, Madhyastha Rakesh, Puri Sonika, K Snigdha, M Midhun, K Kaushik, Gurudev Konana Chennabasappa, Bande Sujeeth
Pregnancy-induced hypertension (PIH) is a known complication of late pregnancy and is an important cause of maternal and fetal morbidity and mortality. Data on clinical profile, especially renal profile of preeclampsia and eclampsia in Indian women are lacking. The aim of our study was to examine the renal profile and clinical outcomes of patients diagnosed with PIH in our institution with a focus on the spectrum of acute kidney injury (AKI). In this prospective, observational study, 347 patients with a diagnosis of preeclampsia-eclampsia, who were undergoing treatment at the M. S. Ramaiah Medical College, were included in the study. The study duration was from 2010 to 2014. Details regarding epidemiologic data, obstetric data, laboratory parameters as well as maternal, renal, and fetal outcomes were noted. Patients with preexisting hypertension, diabetes mellitus, or chronic kidney disease were excluded from analysis. The overall incidence of preeclampsia was 3.4%. Hemolysis, elevated liver enzymes, and low platelets syndrome was seen in 31 patients (9%); 56 patients (19%) had AKI with a mean serum creatinine of 3.2 mg/dL and mean proteinuria of 2.8 g/24 h. Nineteen patients required dialysis. Persistent renal failure was seen in 2.5% of the cohort. Maternal mortality was 2.5%, largely secondary to sepsis. Primiparity was a major risk factor. In this study, we found a low rate of preeclampsia in a low-to-moderate risk cohort, with an incidence of AKI and maternal mortality consistent with reported literature.
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Validation of bioelectrical impedance analysis for assessing dry weight of dialysis patients in Pakistan p. 285
Huma Asmat, Romaina Iqbal, Fatima Sharif, Aamer Mahmood, Aamir Abbas, Waqar Kashif
Accurate dry weight estimation (DW) to achieve euvolemia is one of the key objectives of hemodialysis (HD). While conventionally DW is estimated by clinical examination, bioelectrical impedance analysis (BIA) has been proposed as an objective method to determine DW and has been tested extensively in the Western population. We aim to validate BIA for determining DW in a Pakistani population against the conventional clinician’s method. This is a single-center validation study conducted at two outpatient HD units of Aga Khan Hospital, Karachi. One hundred and forty-eight DW readings of patients who were on maintenance HD were taken both by BIA technology and by clinical assessment. The clinician was blinded to readings obtained by BIA. Data analysis was carried out using the Statistical Package for Social Sciences (SPSS) version 19. Median age of patients was 63 years (range 12–89). Nearly 54.1% of the samples were female (n = 80). Spearman’s correlation between the clinician’s estimate and BIA-derived DW showed a correlation coefficient of 0.982, which was statistically significant (P <0.001). This association remained significant when stratified analysis was carried out by dividing the sample into subgroups according to age, gender, body mass index, and total body water content. Inter-rater reliability analysis using the kappa statistics showed almost perfect agreement between the two methods, κ = 0.929 (95% confidence interval, 0.878–0.980, P <0.001). BIA has been validated as a tool for DW assessment of HD patients in Pakistan in comparison to clinical method.
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Anatomical study of renal and accessory renal arteries p. 292
Anand A Jamkar, Bashir Khan, Deepak S Joshi
In recent years, more conservative methods of surgery of the renal artery are coming up. Hence, a precise knowledge of renal vasculature has become a necessity. Knowledge of the existence of accessory renal arteries is important; otherwise, they may get inadvertently damaged during renal surgery. Furthermore, their presence must be considered while evaluating a donor’s kidney for possible renal transplantation. The study may also be useful to clinicians performing invasive techniques, vascular surgeries, other uro-radiological procedures, and in cases of trauma. Keeping this in mind, this study was conducted on 530 adult cadavers. A total of 1060 kidneys obtained from these cadavers were dissected and accessory renal arteries were looked for; 24.99% of the specimens showed the presence of accessory renal arteries. In 20.75%, one accessory renal artery was found, and in 4.24% of specimens, two accessory renal arteries were seen.
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Biopsy of small kidneys: A safe and a useful guide to potentially treatable kidney disease p. 298
Kamel El-Reshaid, Wael El-Reshaid, Dalal Al-Bader, Jozsef Varro, John Madda, Hosameldin Tawfik Sallam
Over the past four years, all patients with unexplained rapid progression of their renal disease were subjected to kidney biopsy, despite their small size (<9 cm), to define its etiology. Children, pregnant women, morbidly obese patients, and those with an unstable cardiovascular state, septicemia, bleeding diathesis as well as those kidney size with size <6 cm were excluded from the study. Doppler ultrasound was used to exclude renovascular/ischemic nephropathy. The procedure was performed by an interventional radiologist using a biopsy gun technique and under ultrasound guidance. The actual diagnosis was established in 29 cases while seven had advanced sclerosing glomerulonephritis. Eleven cases had evidence of vasculitis, of which two were due to polyarteritis nodosa and two were due to crescentic immunoglobulin A disease. The remaining patients had a secondary form of focal segmental glomerulosclerosis (n = 4), interstitial nephritis (n = 4), malignant nephro-angiosclerosis (n = 2), and single patient with primary hyperoxaluria, light chain cast nephropathy, amyloidosis, and thrombotic microangiopathy. All, except eight with advanced glomerulosclerosis, had improved or became stable with specific treatment. Our study shows that biopsy of small-sized kidneys, in patients with unexplained renal deterioration, is safe, and its diagnostic value can improve their morbidity and even mortality.
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Clinical variables differentiating diabetic from nondiabetic kidney disease in patients with diabetes: A single-center study p. 307
Salman Imtiaz, Beena Salman, Kiran Nasir, Murtaza F Drohlia, Aasim Ahmad
Patients with diabetes may have kidney diseases other than the diabetic kidney disease. Kidney biopsy is the investigation of choice when this is suspected. This retrospective analysis included all patients known to have diabetes mellitus (DM) and who had a kidney biopsy at our center between 1998 and 2014. The aim of this study was to assess if an association exists between the clinical factors on the presence or absence of diabetic nephropathy (DNP). A total number of 206 patients were included in our study. The association between the diabetic retinopathy (DRP) and DNP was high (P = 0.001). We found that the DRP is highly specific for the presence of DNP [89.7% (78 out of 87)] whereas sensitivity of DRP for DNP was 56.3% (67 out of 119). Among other factors, only duration of DM showed a significant association (P = 0.005) (odds ratio: 1.1085 and confidence interval: 1.025–1.149) with the development of DNP. We conclude that the absence of DRP is strongly associated with the presence of nondiabetic renal disease while the presence of DRP has a low sensitivity for the presence of DNP.
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Factors influencing patency of Brescia-Cimino arteriovenous fistulas in hemodialysis patients p. 313
Venu Manne, Surya Prakash Vaddi, Vijaya Bhaskar Reddy, Sridhar Dayapule
Autologous arteriovenous fistula is gold standard to maintain vascular access for hemodialysis patients. As per the Kidney Disease Outcomes Quality Initiative guidelines, distal veins are preferred as the first choice. In this study, a total of 134 patients and 138 fistulas were evaluated from April 2015 to March 2016. Demographic factors and clinical factors were taken into consideration. Our study showed that age, sex, diabetes, and type of construction (end-to-side vs. side-to-side) had no influence over fistula patency rates. Intradialytic hypotension was one of the risk factors for loss of fistula patency. Smoking and history of hypertension were associated with reduced patency rates (P<0.001). Primary failure was more with distal fistulas (15.2%).
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Risk factors for contrast-induced nephropathy after coronary angiography p. 318
Sandeep Kumar, Ranjith K Nair, Naveen Aggarwal, AK Abbot, J Muthukrishnan, K.V. S. Hari Kumar
Contrast-induced nephropathy (CIN) is of concern after the use of radiocontrast media for coronary angiography (CAG) and percutaneous coronary intervention (PCI). We studied the incidence of CIN and its risk factors in patients undergoing CAG. In this prospective study, we included all patients with normal renal parameters undergoing CAG with nonionic radiocontrast media. We excluded patients with known chronic kidney disease, baseline creatinine more than 1.5 mg/dL, significant hypotension, anemia, and patients with acute myocardial infarction undergoing emergency PCI. Serum creatinine was done at baseline and serially for seven days after the procedure. Appropriate statistical tests were used to analyze the results and P <0.05 was considered statistically significant. The study population (n = 500, 348 males and 152 females) had a mean age of 56.6 ± 12.5 years. Twelve patients (2.4%) developed CIN and were equally distributed irrespective of the age, diabetes, or PCI procedure. CIN was observed to be more common in patients with hypertension than in those without hypertension (P = 0.0158). The total volume of contrast administered to CIN group (175 ± 59.3) was not significant as compared to that of non-CIN (159.1 ± 56) group (P = 0.334). None of the patients in our study required renal replacement therapy, and there was no mortality. CIN is observed in 2.4% of patients undergoing CAG and had a self-limiting course. Hypertension is the only observed risk factor, and further large-scale studies are necessary to delineate the novel risk factors for CIN in the general population with normal kidney function.
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Association between angiotensin-converting enzyme insertion/deletion gene polymorphism and end-stage renal disease in lebanese patients with diabetic nephropathy p. 325
Sarah Fawwaz, Mahmoud Balbaa, Hana Fakhoury, Jamila Borjac, Rajaa Fakhoury
Diabetic nephropathy (DN) is one of the leading causes of end-stage renal disease (ESRD). The development and progression of nephropathy is strongly determined by genetic factors, and few genes have been shown to contribute to DN. An insertion/deletion (I/D) polymorphism of the gene encoding angiotensin-converting enzyme (ACE) was reported as a candidate gene predisposing to DN and ESRD. Accordingly, we investigated the frequency of ACE I/D polymorphism in 50 patients with DN, of whom 33 had ESRD and compared them with 64 patients with type 2 diabetes mellitus (T2DM) but with normal renal function. Polymerase chain reaction amplification, using specific primers, was performed to genotype ACE I/D. Chi-square test was used to assess the differences between the groups. The frequencies of the ACE genotypes were as follows: 48% D/D, 40% I/D, and 12% I/I in patients with DN in contrast to 32.8% D/D, 45.3% I/D, and 21.9% I/I in T2DM. The distribution of the D/D, D/I, and I/I genotypes did not significantly differ between T2DM and DN. However, having the D allele carried a risk for the development of DN [odds ratio (OD), 1.71, P = 0.054]. On the other hand, the distribution of the D/D, D/I, and I/I genotypes was significantly different between T2DM and ESRD patients, χ2 = 7.23, P = 0.027. This was reflected by the D allele which carried a risk for the development of ESRD (OR, 2.51, P = 0.0057). These findings suggest that the D allele may be considered as a risk factor for both the development of DN and the progression of DN to ESRD in Lebanese population with T2DM.
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Associated anomalies and clinical outcome in children with ectopic kidney p. 330
Cagla Serpil Dogan, Mustafa Erman Dorterler, Mustafa Devran Aybar, Halil Ciftci, Mehmet Gulum, Yigit Akin, Ercan Yeni
Urological anomalies can be seen in children with renal ectopia (RE) and can result in renal impairment. Therefore, we evaluated associated anomalies and renal outcome in our patients with RE. Sixty-eight children who were diagnosed with RE between January 2009–May 2014 were retrospectively studied. A total of 68 patients, 36 (52.9%) boys, with a median age of 67 months (4–201) and a median follow-up period of 14 months (3–113) were included in the study. Simple RE (S-RE) was found in 51 (75%) patients, of which 46 were unilateral and five were bilateral (discoid kidney). Crossed RE (C-RE) was detected in 17 (25%) patients. Voiding cystourethrogram was performed in 21/51 (41.2%) patients in S-RE group and 5/17 (29.4%) in C-RE group. We did not find vesicoureteral reflux (VUR) in any of the patients with C-RE, whereas, in S-RE group, VUR was demonstrated in six (6/21 - 28.6%) patients. Pelviureteric junction obstruction in ectopic kidney was found in two patients with S-RE and one with C-RE. Two patients (2/17 - 11.7%) had neurogenic bladder due to meningomyelocele, accompanied by imperforate anus in C-RE group. There were no significant differences in other associated urological anomalies between two groups. Renal impairment developed mostly in patients with additional urinary anomaly. The children with RE may have associated urinary anomalies, of which VUR is the most common. Complete urological investigation and regular follow-up are required in selected cases.
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Basilic vein transposition: A viable alternative for multiple failed arteriovenous fistulas - A single center experience p. 336
Saurabh Sudhir Chipde, Santosh Agrawal, Jaisukh Kalathia, Udit Mishra, Rajeev Agrawal
Primary use of the autogenous arteriovenous access is recommended by the National Kidney Foundation-Dialysis Outcomes Quality Initiative guidelines. In spite of troublesome comorbidities associated with basilic vein transposition (BVT), it is still the most preferred technique when autologous veins are not suitable to construct radio-cephalic fistula (RCF) and brachiocephalic fistula (BCF), arteriovenous fistula (AVF). The present study highlights our experience with BVT, with small incision technique, over a period of two years with excellent outcome. This retrospective study included all the patients who underwent BVT at our tertiary care center between March 2013 and March 2015. It was performed in patients with failed previous RCF or BCF or who had small caliber or thrombosed cephalic veins. The patients with minimum 3 mm basilic vein diameter on Doppler were only included in the study. A 3-cm horizontal incision was made in antecubital fossa to expose brachial artery and basilic vein. Multiple longitudinal separate second skin incisions (2–3 cm) were made to explore proximal part of basilic vein. Side branches of the vein were isolated and ligated. The divided basilic vein in antecubital fossa was brought over fascia through newly created subcutaneous tunnel followed by end-to-side anastomosis. A total of 18 (12 males and 6 females) underwent BVT in the two years period. The mean fistula maturation time was 42 ± 10 days. Maturation rate was 100%, and the postoperative flow rate was 290 ± 22 (mL/min). No bleeding, thrombosis, failure, pseudo aneurysm, or rupture occurred in our patients. Arm edema occurred in ix (33%) patients, infection in three (17%), and lymphorrhea in five (28%). The mean follow-up was six months. BVT is an alternative method with excellent initial maturation and functional patency rates requiring less extensive skin incision and surgical dissection. It is the most durable hemodialysis access procedure for those patients having multiple forearm AVF surgeries.
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Depression and anxiety disorders in chronic hemodialysis patients and their quality of life: A cross-sectional study about 106 cases in the northeast of morocco p. 341
Abdelilah El Filali, Yassamine Bentata, Naima Ada, Bouchra Oneib
Hemodialysis (HD) has a severe impact on the life of HD patients. The aim of this work was to assess the prevalence of depression and anxiety disorders, suicidal ideation, and the quality of life among HD patients. Associated factors were also studied. A cross-sectional study was carried out among 103 HD patients treated at the HD Center of Al Farabi Hospital of Oujda during a period of six months in 2015. The Mini-International Neuropsychiatric Interview and European Quality of Life-5 Dimensions (EQ-5D) were used for the assessment. Major depressive episode (MDE) was found in 34% of our patients, whereas anxiety disorder was observed in 25.2%. Suicidal ideation was found in 16.5% and 1.9% of our patients planned their suicide. The EQ-5D index was 0.41 ± 0.36 and the EQ-Visual Analog Scale score was 45.73 ± 14. Multivariate analysis showed that MDEs were associated with three factors: marital status, pain, and anxiety disorder. There was also an association between anxiety disorder and age and EQ-Visual Analog Scale score. Suicidal ideation was associated with marital status and anxiety disorders. Together, these results underline the importance of the collaboration between nephrologists and psychiatrists for a better care of HD patients.
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Analysis of patients with end-stage renal disease on dialysis in Tabuk City, Saudi Arabia: A single-center, three-year retrospective study p. 349
Fahad M Almutairi, Mohammed A Al-Duais, Kamal A Shalaby, Mohamed I Sakran
This study was performed to analyze various demographic data such as age, gender, nationality, status of the patients, and the causes of end-stage renal disease (ESRD) of 349 patients who were undergoing hemodialysis (HD) during the period from January 2013 to December 2015 at the Dialysis Center of King Khalid Hospital in Tabuk City. One hundred and fifty-two patients (43.6%) were on HD in 2015. Age of the patients ranged from 9 to 93 years and the mean age was 51.3 ± 17.6 years. Majority of the patients, i.e., 140 (40.1%) were in the age group of 40–59 years, followed by the age group of 60–79 years by 27.8% (97 patients). Saudis constituted 84.2% (294) and non-Saudis accounted 15.8% (55) of the patients over the years studied. There were 198 males (56.7%) and 151 females (43.3%). The death rate in 2014 was 6.2%, whereas it increased in 2015 to 10.5%. The high escape rate (10.3%) of patients was in 2014. Diabetic nephropathy was the most common cause of ESRD, accounting for 30.4% of all cases, followed by unknown etiologies accounting for 25.2%. Nearly 22.6% of all ESRD cases had hypertension. Primary glomerular disease was seen in 8.9% and obstructive uropathy in 3.7%. Other causes constituted 7.4% of the cases. The data of ERSD patients in Tabuk City are comparable with that of other regions of the Kingdom of Saudi Arabia. We conclude that analysis studies of HD centers help to understand the problems and the needs of the patients, find the solutions, and create a connection between the consumers and health-care providers.
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Profile of glomerular diseases associated with hepatitis B and C: A single-center experience from India p. 355
Nishad Raveendran, Pankaj Beniwal, Amith Vijay Leon D'Souza, Rajendra Singh Tanwar, Piyush Kimmatkar, Dhananjai Agarwal, Vinay Malhotra
Hepatitis B and C are known to affect kidneys in a number of ways. Glomerular diseases associated with hepatitis B and C include membranous nephropathy (MN), membranoproliferative glomerulonephritis (MPGN), focal segmental glomerulosclerosis, immunoglobulin A nephropathy, rarely amyloidosis, and fibrillary and immunotactoid glomerulopathy. In a retrospective analysis of kidney biopsy of 534 patients, we found 16 (2.9%) patients of hepatitis B and 11 (2.05%) patients of hepatitis C with glomerular disease. The most common form of glomerulonephritis in hepatitis B patient was MN and in hepatitis C patient was MPGN.
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Prevalence of the metabolic syndrome in kidney transplant recipients: A single-center study p. 362
Maryam Hami, M Ghorban Sabbagh, A Sefidgaran, MJ Mojahedi
Metabolic syndrome (MS) is characterized by a combination of cardiovascular (CV) risk factors (hypertension, dyslipidemia, obesity, and alterations in glucose homeostasis). Insulin resistance is suggested to be the common pathogenic background. This syndrome is also a risk factor for diabetes and chronic kidney disease. In renal transplant recipients, MS has been shown to be an independent risk factor for chronic allograft dysfunction, graft failure, new-onset diabetes, and CV disease. We performed a cross-sectional study on 106 stable renal transplant recipients to detect MS between January 2013 and August 2013. This syndrome was diagnosed according to the National Cholesterol Education Program–Adult Treatment Panel III criteria. Patients with history of diabetes mellitus were excluded from the study. In this group of patients, 56 (52.8%) had MS. There were 32 males (57.1%) and 24 females (42.9%). The mean age of the MS group was significantly higher than the non-MS group. The mean serum creatinine was higher in the MS group than the non-MS group, but there was no significant difference between them (P >0.05). The calculated glomerular filtration rate was also similar in the two groups (P >0.05). The patients with MS had higher body weight (64.61 ± 14.17 kg vs. 58.76 ± 11.70 kg, P <0.05) and also higher body mass index (BMI) (P <0.05). The prevalence of BMI >25 kg/m2 in the MS group was 75% versus 25% in the non-MS group (P <0.05). Since MS is an important and common risk factor in renal transplant recipients, we have to try to prevent it by educating the patients to control it by modifying their lifestyle. Efforts toward promoting healthy diets, physical activity, and blood pressure control must be undertaken.
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Analysis of renal diseases detected in renal biopsies of adult patients: A single-center experience p. 368
Salman Imtiaz, Murtaza F Drohlia, Kiran Nasir, Beena Salman, Aasim Ahmad
Renal biopsy is crucial while evaluating for the diagnosis of glomerular, vascular, tubulointerstitial, and genetic diseases. It gives vital information which helps in estimating the disease prognosis, progression, and management. This is the retrospective analysis of all adult patients aged above 18 years, who underwent percutaneous renal biopsy at The Kidney Center Post Graduate Training Institute, Karachi, over a duration of 18 years, i.e., January 1, 1996, to December 2013. Renal graft biopsies and those which were inadequate were excluded from analysis. Of the1962 biopsies performed, we included 1521 biopsies in our assessment. The mean age of the population was 38 ± 15.26 years (range 18–88 years). There were 920 (60.5%) males and 601 (39.5%) females. The most common clinical indication of kidney biopsy was nephrotic syndrome, i.e., 741 (45.7%), followed by chronic kidney disease, 253 (16.6%); acute renal failure, 184; (12.1%) and rapidly progressive glomerulonephritis (GN), 124 (8.2%). Primary GN was found in the majority of the patients, 984 (64.7%), followed by secondary GN in 249 (16.4%), tubulointerstitial disease in 224 (14.7%), and vascular disease in 64 (4.2%). In primary GN, focal segmental glomerulosclerosis was the most common histopathological diagnosis in 297 (19.5%) patients, followed by MGN in 224 (14.7%), chronic GN in 98 (6.4%), crescentic GN in 93 (6.1%), minimal change disease in 87 (5.7%), membranoproliferative glomerulonephritis in 58 (3.8%), and postinfection glomerulonephritis in 53 (3.5%) patients. This study shows that focal segmental glomerulosclerosis is the most common lesion in renal biopsy in the young age group followed by membranous nephropathy. Diabetic nephropathy and chronic interstitial nephritis were dominant secondary pathological lesions in older age group, whereas lupus nephritis was the most common secondary disease in young age females.
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Anti-glomerular basement membrane: A rare cause of renal failure in children p. 379
Indira Agarwal, Ahmad Al-Ghitany
Anti-glomerular basement membrane (GBM) disease is a rare cause of acute renal failure and known to have bad prognosis regarding renal functions recovery and patient survival specially when diagnosed late and presents with severe renal failure that requires dialysis. We report a case of 11-year-old child with acute renal failure secondary to anti-GBM disease and associated with antineutrophil cytoplasmic antibody-positive vasculitis. He was treated with plasmapheresis, steroids, and cyclophosphamide with recovery of his kidney functions.
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Anesthetic management of two cases of Bardet-Biedl syndrome for renal transplantation p. 384
Kalpana S Vora, Manisha P Modi, Bina P Butala, Veena R Shah
Bardet–Biedl syndrome (BBS) is a multisystem autosomal recessive disorder with clinical and genetic heterogeneity. It is a type of ciliopathy characterized by retinal dystrophy, central obesity, polydactyly, cognitive impairment, and gonadal and renal dysgenesis. It has been suggested that the involved proteins attach to the basal body of ciliated cells making this a disorder of ciliary dysfunction. We report two cases of typical BBS in a 17-year-old female and 29-year-old male patient, who presented for live-related renal transplant. We discuss the relevant points of the syndrome regarding anesthetic management.
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Eculizumab experience in an adult patient with atypical hemolytic uremic syndrome p. 388
Funda Sari, Ayça Inci, Volkan Karakus, Banu Yilmaz, Metin Sarikaya, Refik Olmaz, Erdal Kurtoglu
Atypical hemolytic-uremic syndrome is a disease characterized by nonimmune hemolytic anemia, thrombocytopenia, and renal failure. In this study, we present a case of a patient with atypical hemolytic-uremic syndrome treated successfully with eculizumab. A 20-year-old female was admitted with clinical signs of atypical hemolytic syndrome. The laboratory findings were as follows: hemoglobin 9.2 g/dL, platelet count 18 × 103/μL, creatinine 4.69 mg/dL, schistocytes were in peripheral blood smear, lactate dehydrogenase 2080 U/L, and emergency plasmapheresis procedure with fresh frozen plasma were initiated. The patient was anuric within 12 h of her admittance. ADAMTS13 activity was normal. Her mother’s cousin developed acute rejection immediately after receiving a renal transplant and died two months later. As she did not respond to the treatment and considering her family history, eculizumab was initiated which resulted in platelet counts starting to rise on day 5, and the patient no longer needed dialysis after 22 days.
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Hyponatremia secondary to acute urinary retention p. 392
Jignesh Parikh, Shashank Dhareshwar, Shobhana Nayak-Rao, Indira Ramaiah
Acute urinary retention is a rare cause of hyponatremia. Symptomatic acute hyponatremia is of grave medical concern and needs to be managed aggressively. In our two cases with acute urinary retention, a simple bladder catheterization and drainage of urine followed by conservative management resulted in complete resolution of symptoms and normalization of sodium levels. Association of bladder distension and hyponatremia is considered to be due to release of vasopressin triggered by bladder distension itself or by pain due to bladder distension. These cases are presented to bring to light an unusual and easily treatable cause of hyponatremia.
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Successful cadaveric transplantation of a splitted crossed fused disc type ectopic kidney to two patients with end-stage renal disease p. 396
Reza Mahdavi Zafarghandi, Nasser Mogharabian, Akram Asadpour
Cadaveric donors with congenital renal anomalies are often refused because of technical difficulties. As the waiting periods for kidney transplants continue to increase, transplant centers need to consider them also as potential donors. This paper describes transplantation of a crossed fused disc type ectopic kidney to two patients with end-stage renal disease, after parenchymal transection. The transplants were successful with minimal complications, and the recipients had immediate graft function. It is now one year from transplantation, with excellent renal functions.
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Eosinophilic peritonitis in a continuous ambulatory peritoneal dialysis patient: Inflammation and irritation without infection p. 401
Muhammad Asim
A 52-year-old patient developed idiopathic eosinophilic peritonitis (EP) four weeks after starting continuous ambulatory peritoneal dialysis that resolved spontaneously without any clinical sequelae. This case is reported to emphasize the fact that EP can mimic infectious peritonitis in its mode of clinical presentation and that distinction between these two entities is important given their prognostic and therapeutic differences.
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The mystery of the nonfunctioning catheter: An unusual complication of peritoneal dialysis outflow failure p. 405
Pramod K Guru, Beth Piraino
Noninfectious complications of peritoneal dialysis (PD) remain an important impediment to successful implementation of PD. Rare noninfectious complications of the PD catheter are sparsely reported. We report an unusual complication of outflow failure due to a peritoneal catheter that separated into two distinct intra-abdominal segments, due to an unusual method of placement in which two catheters were connected to make a long intra-abdominal portion to permit a high exit site on the abdominal wall. The application of this unusual rather a unique technique led to separation of the two catheter portions and the outflow failure shortly after the patient started continuous ambulatory PD. We reviewed other unusual causes of PD catheter failure, and these included luminal stones blocking the PD catheter, pneumomediastinum related to inappropriate technique, catheter deformation and leak due to the use of antibiotic ointment at the exit site of polyurethane catheters, vesicoperitoneal fistula and perforation of the bladder from the placement of PD catheters, rare site migrations of the catheter, and subcutaneous titanium connector infection in a presternal catheter. Knowledge of these unusual complications may allow prevention and/or early recognition.
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Pseudohyperkalemia: Look before you treat p. 410
Ana Rivera De Rosales, Duminda S Siripala, Shirisha Bodana, F Ahmed, Damodar R Kumbala
Pseudohyperkalemia is defined as a reported rise in serum potassium concentration along with a normal effective plasma potassium concentration. We present a case report of a 57-year-old gentleman with a history of chronic lymphocytic leukemia, who presented with an elevation in serum potassium along with a normal plasma potassium concentration. Through an exploration of the literature, we demonstrate that pseudohyperkalemia is an important phenomenon to watch for as it may sometimes lead to unnecessary and potentially dangerous treatment.
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Vasculitis and vasculopathy in Lupus Nephritis: Clinical variability, outcome, and new insight into treatment p. 415
A Kaul, V Agrawal, D Bhaduaria, Vikas Agrawal, Narayan Prasad, Amit Gupta, RK Sharma
More than 50% of patients with systemic lupus erythematosus (SLE) have renal involvement at presentation or during their illness. Lupus nephritis (LN) encompasses several patterns of renal disease, including glomerular, tubulointerstitial, and vascular pathologies. The presence and significance of renal vascular lesions (VLs) are often overlooked. VLs in LN are not rare with an incidence of 10%–40% on renal biopsies from various studies and their presence is often labeled as poor prognostic markers. The current treatment protocol for LN is mainly based on the glomerular pathology, and no guidelines/consensus exists for treatment of LN with VLs. We describe the clinical presentation, course, response to therapy, and outcomes in five patients with SLE with histological evidence of renal VLs.
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Aggressive angiomyxoma of transplanted kidney mimicking posttransplant lymphoproliferative disorder p. 425
Ujjwal Gorsi, Priyanka Naranje, Manish Rathi, Ritambhara Nada, Niranjan Khandelwal
Angiomyxoma is a scarce neoplasm arising from the soft tissues of perineum and pelvis, more commonly seen in the females. For such a tumor to arise in a renal allograft is rare and has previously been reported only in few case. We report a case of aggressive angiomyxoma arising de novo in the renal allograft nine-year posttransplantation. We describe its imaging features on ultrasound and computed tomography which closely mimic the more usual tumor of the transplanted kidney, posttransplant lymphoproliferative disorder and suggest that angiomyxoma may be considered as a differential diagnosis in a case of soft tissue mass arising within the renal allograft.
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Possible effect of statins on serum vitamin D levels in patients with chronic renal disease p. 428
Faizan Mazhar
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The complications of ultrasound-guided percutaneous renal biopsy p. 430
Gioacchino Li Cavoli, Luisa Bono, Calogera Tortorici, Tancredi Vincenzo Li Cavoli, Carlo Giammarresi, Angelo Ferrantelli, Ugo Rotolo
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Unusual isolated fungal infection of renal allograft p. 432
Anjana Singh, Sanjeet Kumar Singh, Kumar Awadhesh
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The cutoff 1st day urine specific gravity in critically ill children: Predictive factor for early abnormal glomerular filtration rate p. 435
Majid Malaki
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Snakebite-induced acute kidney injury requiring dialysis in second trimester of pregnancy: Successful outcomes in a therapeutic quagmire p. 437
H Satish, S Jayachandran, PS Priyamvada, A Keepanasseril, J Sravankumar, G Sankar, P Sreejith
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Association between autosomal dominant polycystic kidney disease and autoimmune diseases: A simple coincidence or more? p. 441
Samia Barbouch, Meriam Hajji, Fatima Jaziri, Amel Harzallah, Eya Fellah, Hafedh Hedri, Fethi Ben Hamida, Khaoula Ben Abdelghani, Taieb Ben Abdallah
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Relationship between ABO blood group and end-stage renal disease in Latakia, Syria p. 445
Usama Alanan, Abdulfattah Abbas, Ibrahim Sulaiman
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Deceased Heart Beating Donor and Organ Transplantation in Saudi Arabia-2016 p. 446

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