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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
September-October 2021
Volume 32 | Issue 5
Page Nos. 1201-1510

Online since Wednesday, May 4, 2022

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REVIEW ARTICLES  

Application of theory of planned behavior on organ donation behavior: A systematic review Highly accessed article p. 1201
Marzieh Latifi, Jandir Pauli, Sanaz Dehghani, Marzeyeh Soleymani Nejad
DOI:10.4103/1319-2442.344739  
Organ donation saves lives and improves the quality of life. There is a shortage of organ donors worldwide. Behavior theories, such as the theory of planned behavior (TPB), help identify the antecedents of organ donation behavior and design effective interventions. The TPB suggests that intention is driven by constructs: attitude, subjective norm, perceived behavioral control (PBC), and intention. TPB can help improve organ donation behavior. This study aimed to analyze TPB-based interventions on Organ donation. Relevant studies were identified searching electronic databases, i.e., PubMed, Scopus, Science Direct, and Google Scholar from January 1, 2000 to February 30, 2020. None MeSH terms in title or abstract were searched, including: “theory of planned behavior*” and “Tissue donation” or “Tissue procurement” or “Organ procurement system” or “Organ procurement” or “Organ donation.” Two authors independently reviewed the full texts and extracted all critical data from the included studies. Seventeen studies were assessed as having a reasonable methodology design. Studies show that TPB-based interventions can improve organ donation. Among TPB’s constructs, PBC is the moderator and the determinant of organ donation behavior which its determination is different in different cultures. Attitude, subjective norms, moral norms, and anticipated regret should be considered in related interventions plus PBC. Increasing knowledge can facilitate organ donation behavior. Removing related cultural issues, removing fear due to misunderstanding of Brain death, improving trust, and improving moral values have effects on the behavior of organ donating.
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Beta 2 microglobulin in kidney failure: A review and an algorithm for renal replacement therapy Highly accessed article p. 1214
Alain G Assounga
DOI:10.4103/1319-2442.344740  
For decades, beta 2 microglobulin (B2M) has been a subject of great interest in nephrology and other fields such as multiple myeloma. B2M, a 99 amino acid protein, is associated with amyloid deposits in patients undergoing renal replacement therapy (RRT). The source of information is published articles on B2M in chronic renal failure since 1960. We have reviewed literature published since 1960 to date, highlighting the milestones of the role of B2M in chronic kidney disease (CKD) and B2M serum values in patients treated by various RRTs. B2M deposits associated with the disease include carpal tunnel syndrome, spondyloarthropathy, and arthritis of large joints such as the shoulders. The role of RRT in the removal of B2M in CKD is discussed. Recent reports include factors affecting the process of fibrillation and deposition of B2M in tissues. A comparative report of various modalities of treatment on the serum levels of B2M is provided. The presence of significant residual urine output in continuous ambulatory peritoneal dialysis patients may explain why peritoneal dialysis is a modality that is associated with the lowest level of serum B2M. Patients treated with hemodiafiltration or hemodialysis (HD) using high flux dialyzers have lower levels of B2M than those treated by HD with low flux dialyzers. Finally, based on the literature review, an algorithm for RRT using B2M level monitoring and other variables is proposed and needs evaluation in a controlled trial.
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Coronavirus Disease 2019 and the Kidney Highly accessed article p. 1220
Ajay Jaryal, Sanjay Vikrant
DOI:10.4103/1319-2442.344741  
Coronaviruses are ubiquitous pathogens and have caused epidemics in the recent past. Coupled with globalization, they have the potential to transform into the pandemic, as is the case of coronavirus disease 2019 (COVID-19). Primarily to start as a respiratory illness, they are known to cause systemic disease and affect many organ systems. Due to the lack of, universally proven, specific anti-viral therapy, the mainstay of treatment is “supportive care” and some of the patients afflicted with it, require intensive care and organ support for lungs and/or kidneys. Patients with the diseases of the kidney, particularly those on dialysis and kidney transplant recipients, are predisposed to the worst outcomes with COVID-19. It also leads to acute kidney injury, which is an important and independent determinant of prognosis in these patients. It also creates a huge demand for the delivery of renal replacement therapy. COVID-19 is an emerging and evolving disease, and so, it is important to understand the mechanism and management of kidney diseases in COVID-19.
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ORIGINAL ARTICLES Top

Safety of denosumab in patients with chronic kidney disease p. 1235
Nasra K Al Adhoubi, Issa Al Salmi
DOI:10.4103/1319-2442.344742  
Chronic kidney disease (CKD) is associated with bone and mineral disturbances in the form of renal osteodystrophy. The American College of Rheumatology Guidelines for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis 2017 recommend against treatment with denosumab in adult patients who have received an organ transplant and who are continuing treatment with glucocorticoids due to lack of adequate safety data on infections in adults treated with multiple immunosuppressive agents. Therefore, this study was conducted to compare the safety of denosumab in patients with CKD, especially in a group of patients who received immunosuppressive medications, and to assess the rate of infections in such group in comparison to patients with normal renal function. We retrieved all data of patients who are receiving denosumab in our institute through search in the medical record system (Al-Shifa System). We excluded all patients with malignancy and all patients who were prescribed denosumab but did not receive it. During the period from 2006 to 2018, 314 patients were treated with denosumab therapy. Out of 84 patients who were fulfilling the inclusion criteria, 24 (28.5%) patients had normal kidney function and 60 (71.4%) patients had CKD. Forty-three percent of all patients with CKD developed side effects after taking denosumab. In comparison, only 17% of patients with normal kidney function developed side effects. Of patients with CKD and infections, 50% of them had moderate infections and required admission. Out of these patients, 76% were in immunosuppressive medications and 61% of the patients were receiving steroids more than 2.5 mg per day. Using Chi-square test and the nonparametric independent samples Kruskal–Wallis test, there was a significant association between the dose of steroids and the rate of side effects with a significance level of <0.014 and 0.009, respectively. Hypocalcemia was detected in two patients (3.3%), and they had CKD stage V. Denosumab is associated with increased risk of infection in CKD patients on steroids or multiple immuno-suppressive medications. There was no deterioration in renal function while using denosumab. In this regard, close monitoring of this group of patients is essential, as well as medication adjustments.
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Kidney dysfunction and oxidative stress in doxorubicin-induced nephrotic rat: Protective role of sesame oil p. 1243
Somayyeh Mahzari, Sara Hosseinian, Mousa-Al-Reza Hadjzadeh, Reza Mohebbati, Zahra Samadi Noshahr, Abolfazl Khajavi Rad
DOI:10.4103/1319-2442.344743  
Doxorubicin (DOX) is an antineoplastic agent which it’s clinical use has been limited due to its major side effects including cardiotoxicity and nephrotic syndrome. Sesame oil (SO) is an important edible oil with many pharmacologic effects. The aim of the present study was to investigate the effect of SO against DOX-induced nephropathy in the rat. In this study, two doses of SO (3 and 6 mL/kg) were administrated orally for six consecutive weeks and DOX (mg/kg) was intravenously injected on the 4th day of the experiment. Blood and urine samples were collected on days 1, 14, 30, and 42 for subsequent measurement of biochemical parameters. The left kidneys were removed for subsequent assessment of total thiol content, malondialdehyde (MDA) concentration, and renal activities of catalase and superoxide dismutase enzymes. DOX caused significant proteinuria, hypoalbuminemia, and hyperlipidemia compared to control group. Significant decrease in antioxidant enzyme activities and total thiol contents and significant increase in MDA levels were also observed following DOX injection when compared to control group. Oral administration of SO significantly reversed DOX-induced proteinuria, hypoalbuminemia, and hyperlipidemia compared to DOX group. Furthermore, compared to DOX group, SO significantly increased total thiols content. MDA concentration significantly decreased following SO administration when compared to DOX group. The current study suggests that SO is able to improve kidney function as well as kidney tissue oxidative damage in DOX-induced nephrotic the rat.
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An experimental study to evaluate the effect of low-intensity intradialytic exercises on serum urea, creatinine, and fatigue of chronic kidney disease patients undergoing hemodialysis p. 1253
Anubha Devagourou, Kamlesh Kumari Sharma, Raj Kanwar Yadav, Vishwa Prakash Gupta, Mani Kalaivani
DOI:10.4103/1319-2442.344744  
In chronic kidney disease (CKD) toxins accumulate in the muscles and cause fatigue, mental impairment, and muscle dysfunction (cramps). Exercise results in the opening of capillaries thereby increasing blood flow and allowing greater movement of urea and creatinine from the tissues to the vascular compartment and subsequent removal through dialysis. An experimental study of 64 CKD patients (32 each in experimental and control group), six low-intensity intra-dialytic exercises (IDE) were implemented for experimental group using video demonstration at 90 min after initiation of hemodialysis (HD) repeated thrice at an interval of 10 mins. Pre- and post-HD serum urea, creatinine, and fatigue levels were assessed at baseline, two, four and six weeks. Fatigue was measured using FACIT scale. Significant difference was found between the control and experimental group in serum urea, creatinine and fatigue levels (P = 0.007, P = 0.001, P = 0.001) at six weeks post HD. The experimental group showed a significant decrease in creatinine levels from baseline to six weeks (P = 0.04). Ninety-seven percent of patients were compliant to low-intensity IDE with patients feeling better and comfortable along with decrease in felt fatigue levels. No significant association was found between duration of illness, duration of maintenance HD and comorbidities and serum urea, serum creatinine, and fatigue levels (P = 0.5, P = 0.21, P = 0.78). The present study shows low-intensity IDE when performed regularly, was effective in decreasing serum urea, creatinine, and fatigue levels of CKD patients undergoing HD with vital signs remaining within the normal range. No overt complications were reported; hence, the exercises were safe.
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The relationship of electrophysiological parameters of uremic polyneuropathy and uremic toxins in patients with chronic kidney disease p. 1264
Anand Bakre, Parag Aradhey, Sourya Acharya, Sunil Kumar
DOI:10.4103/1319-2442.344745  
We aimed to study the correlation of measurable uremic toxins with electrophysiological parameters of uremic polyneuropathy in chronic kidney disease (CKD) patients. This study was conducted between January 2018 and December 2018, 40 CKD patients on hemodialysis (HD) and 40 controls were included in the present study. Prevalence of peripheral neuropathy in CKD patients was 50% clinically and 65% of patients found to have neuropathy by electrophysiological study. The mean age of patients was 36.9 ± 12 years in which, 26 (65%) were male and 14 (35%) were female. All patients were recently diagnosed CKD on HD since <1 year duration. In the present study 16 (40%) patients had mild-to-moderate neuropathy and 4 (10%) had severe neuropathy according to modified NDS score. The most common pattern of neuropathy was axonal and mixed sensorimotor. On correlation of serum creatinine (Cr) and blood urea nitrogen (BUN) with nerve conduction study parameters, statistically significant association was present but other uremic toxins including serum potassium, calcium, phosphorus, uric acid, and parathyroid hormone did not correlate with neuropathy indices. Peripheral neuropathy is common in CKD patients causing significant morbidity at very early stage and though BUN and Cr are dialyzable toxins, they correlate significantly with neuropathy severity and can be guiding markers for optimization of dialysis therapy.
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Comparison of short-term outcomes with and without induction therapy in low-risk renal transplant recipients p. 1273
Sabina Yusuf, Devinder Singh Rana, Anurag Gupta, Ashwani Gupta, AK Bhalla, Manish Malik, Vinant Bhargava
DOI:10.4103/1319-2442.344746  
With low rates of rejection with current immunosuppression consisting of steroids, mycophenolic acid and tacrolimus, the question arises whether induction offers any additional benefit in low-risk renal transplant recipients. This study evaluated outcomes with and without induction in low-risk renal transplant recipients. A prospective observational study in which 100 low-risk renal transplant recipients were included and divided into two groups – one that received induction (IND) and another that did not (NO IND). They were followed for 1.5 years. Three endpoints were compared - efficacy of induction, patient and graft survival, and adverse effects. Incidence of rejection in early posttransplant period did not differ (4% NO IND vs. 6% IND; P = 0.171). Rejection as cause of late graft dysfunction was seen in 16% in IND vs. 20% NO IND; (P = 0.603). No difference in serum creatinine at end of 1.5 years was seen. Graft survival was also similar. Relapsing and recurrent urinary tract infections (46% IND vs. 16% NO IND; P = 0.09), hospitalization requiring infections (76%IND vs. 64% NO IND; P = 0.119 NS) were more common in IND. Cytomegalovirus infection affected only IND (6% vs. none; P = 0.07). Patient survival at 1.5 years was comparable (94% IND vs. 96% NO IND; P = 0.646). The study showed comparable results between IND and NO IND with however an increased incidence of infections and hospitalizations in the IND group. The use of induction may be avoided in low-risk renal transplant recipients.
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Antithrombin III level in children with nephrotic syndrome, its correlation to thromboembolic complications, and serum albumin level p. 1283
Sherin Khamis Hussein, Ahmed Hafez Mohammed, Rehab Ahmed Mohammed, Hadeer Abdelghafar
DOI:10.4103/1319-2442.344747  
Nephrotic syndrome (NS) is one of the most common pediatric diseases with many complications. Thromboembolic complication is the most serious complication. The aim of this study was to predict the possible risk of thromboembolic complication development in children with NS due to antithrombin III deficiency. This study was conducted in the Outpatient Nephrology Clinic of Children’s Hospital in Fayoum University Hospital. It included 27 children with NS and 27 healthy children as a control group in an analytic study with cross-sectional comparative design. Laboratory investigations were done in the form of complete blood picture, serum levels of albumin, total protein, creatinine, urea, cholesterol, triglycerides, urine analysis, albumin/creatinine ratio, prothrombin time, and INR. The serum antithrombin III level was measured by double ELISA technique. Data analysis was performed using the Statistical Package for the Social Sciences software version 18. Student’s t-test was used to compare measures of two independent groups of quantitative data. One-way ANOVA test was used to compare more than two independent groups of quantitative data. Kruskal–Wallis test was used in comparing more than two independent nonparametric groups. Bivariate Pearson correlation test was used to test the association between variables. The level P ≤0.05 was considered significant. There were significant decreases in antithrombin III, albumin, and total protein levels in the study group during relapse and improved after steroid. There were no thromboembolic complications detected among the study group. NS causes heavy proteinuria with loss of many important proteins as antithrombin III. Serum antithrombin III level is significantly decreased in children with NS, and it correlated with serum albumin. Although patients in the study have thrombocytosis, hypercholesterolemia, and decreased serum level of antithrombin III, none of the children in the the study showed thrombotic complication, so we conclude that, thromboembolism is uncommon in children with NS may be due to early diagnosis and proper treatment.
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Pretransplant donor-specific anti-human leukocyte antigen antibodies despite a negative complement-dependent lymphocytotoxicity crossmatch: Is it wise to desensitize before kidney transplant? p. 1289
Mohamed Abdel Monem, Torki Al Otaibi, Amin Roshdy Soliman, Merfat Elansary, Mona Aziz Ibrahim, Bahaa-Eldin Zayed, Osama Ashry Gheith, Ayman Maher Nagib, Khaled Abdel Tawab, Yahya Makkeyah, Zakaria Elsayed Zakaria, Medhat A Halim, Tarek Mahmoud, Prasad Nair
DOI:10.4103/1319-2442.344748  
The significance of pretransplant donor-specific antibodies (DSAs) despite negative complement-dependent lymphocytotoxicity crossmatch (CDC-XM) would be useful for clinical decision-making. Hence, we aimed to determine the impact of pretransplant DSA despite negative crossmatch on the outcome of kidney transplantation. One hundred and eleven kidney recipients were prospectively enrolled in this study after being transplanted at Hamed Al-Essa Organ Transplant Center of Kuwait between January 2011 and December 2013. Of them, 50 recipients with positive DSA at the time of transplant were subjected to desensitization (Group 1). Three local protocols were utilized; first included plasma exchange, high-dose intravenous immunoglobulin (IVIG), and rituximab; second included immunoadsorption plus RTX, and the third included high-dose IVIG and rituximab. The second group included 61 recipients with negative DSA. All recipients had negative CDC-XM and flow cytometry crossmatch at the time of transplant. Panel-reactive antibody (±DSA) levels with mean fluorescence intensity and graft function were monitored along the first 24 months for all patients. There were no statistically significant differences between the two groups regarding early posttransplant graft function, patient and graft survivals. Pretransplant DSA with negative CXM carries a minimal clinical risk with optimized immunosuppression.
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Insulin resistance in nondiabetic chronic kidney disease patients p. 1300
Praveen Nallamothu, Harini Devi Nimmanapalli, Alok Sachan, P VLN Srinivasa Rao, Sivakumar Vishnubotla
DOI:10.4103/1319-2442.344749  
Chronic kidney disease (CKD) is accompanied by numerous metabolic derangements due to risk factors such as oxidative stress, chronic inflammation, and endothelial dysfunction. Insulin resistance (IR) has been reported as an independent risk factor for cardiovascular morbidity and mortality in patients with CKD. As reported from previous studies, it has been shown that IR is also seen in mild-to-moderate stages of CKD. Hence, the present study aimed to study IR in nondiabetic CKD patients and correlated with different stages of CKD. A two-year cross-sectional study was conducted in 175 patients among whom 25 healthy controls and 150 nondiabetic CKD patients in different stages are included. In the present study, fasting insulin and homeostatic model assessment for IR (HOMA-IR) levels were found to be higher in all nondiabetic CKD patients when compared to controls which was found to be statistically significant (P <0.05). In the present study, IR, as evidenced by HOMA-IR, is noted in patients on predialysis, continuous ambulatory peritoneal dialysis (CAPD), and postrenal transplant patients. Hence, periodic monitoring of IR by HOMA-IR might be prudent in CKD patients on predialysis, CAPD and in postrenal transplant patients. Interventions targeting IR in this patient population can also decrease cardiovascular morbidity and mortality.
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Chronic kidney disease in Hepatitis C and its association with liver cirrhosis and viral load: Revealing the importance of hematuria p. 1310
Felix Firyanto Widjaja, Aida Lydia, Cosmas Rinaldi Adithya Lesmana, Pringgodigdo Nugroho
DOI:10.4103/1319-2442.344750  
Hepatitis C virus (HCV) contributed as a risk factor for chronic kidney disease (CKD). Many studies only showed it associated with estimated glomerular filtration rate (eGFR) reduction and albuminuria, but none revealed hematuria data. Besides, liver cirrhosis and viral load as risks for CKD are still yet to be established. This study aimed to assess the prevalence of CKD and its component in hepatitis C and to associate it with liver cirrhosis and viral load. A cross-sectional study using consecutive recruitment on the basis of anti-HCV positivity was done from August 2018 until January 2019. The participants with any renal abnormality on the first meeting were followed prospectively for at least three months. The study was done in Hepatology Clinic Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Liver cirrhosis was defined using transient elastography (>11 kPa). A baseline viral load >100,000 IU/mL was considered as high. CKD was defined as persistence of decreased eGFR and/or albuminuria and/or hematuria for three months. Logistic regression models were used to evaluate adjusted odds ratio (aOR) with adjustment for age, sex, diabetes mellitus, and hypertension. Of the 185 participants, prevalence of CKD was 23.2% [confidence interval (CI) 95% 17.1%–29.3%]. Decreased eGFR was present in 22 (11.9%), albuminuria in 29 (15.7%), and hematuria in 13 (7%). Liver cirrhosis was associated with CKD (aOR 2.948, CI 95%: 1.218–7.136) but not viral load (aOR: 0.93, CI 95%: 0.396–2.185). Renal examination is recommended in all patients with hepatitis C, particularly in patient with liver cirrhosis.
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Public survey of financial incentives for kidney donation in Bahrain p. 1319
Amgad E El-Agroudy, Adel A Alalwan, Mohamed R Rajab, Asma M Alqahtani
DOI:10.4103/1319-2442.344751  
With the increasing prevalence of end-stage kidney disease in Bahrain, kidney donation is of vital importance. In this study, we want to assess how financial incentives will influence peoples’ views and decisions regarding kidney donation. The aim is to establish strategies to increase the number of kidneys for transplantation in Bahrain. We adapted a previously established questionnaire on financial incentives for living kidney donations. The questionnaire assessed the public opinion in Bahrain on how kidney donation can be influenced by two different financial incentives, namely 10,000 Bahraini Dinars and life-long health insurance. We collected a convenient sample of 446 participants by distributing an electronic version of the questionnaire. IBM SPSS Statistics version 23 software was used for data entry and analysis. Of the total participants, 39% were male and 61% were female. Eighty percent of the participants believed that their chances for kidney donation will not increase in turn of receiving a financial compensation, while 20% of them believed that it will increase. Our study found that generally married participants (70%) find it a preferable development for health insurance companies to offer financial compensation for kidney donation, while nonmarried participants (30%) found it not a preferable but also not an adverse development (P = 0.038). Furthermore, there is a positive correlation between age and preferable views toward financial incentives to increase kidney donation (P <0.001). Although financial incentives for kidney donation might encourage a minority of the population, the majority will not be influenced by implanting a financial incentives’ system for kidney donation.
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Platelet indices as an assessment tool of septic acute kidney injury p. 1330
Mahmoud Emara, Sabry Shoeib, Abeer Reda, Mohamed Helwa, Zeineb Kassemy, Mohamed Abdelhafez
DOI:10.4103/1319-2442.344752  
Platelet (PLT), one of blood cells, plays a major role in physiological and pathological processes such as coagulation, thrombosis, inflammation, and keeping the integrity of vascular endothelium. There are a group of parameters that are used to measure the total amount of PLTs, PLTs morphology, and proliferation. PLT indices are associated with the severity of illness and patients’ prognosis. It was reported that mean platelet volume (MPV) was raising synchronously with interleukin (IL)-6 and C-reactive protein in sepsis, and was correlated to the severity of the disease. We aimed to study PLT indices and its changes in sepsis and septic acute kidney injury (AKI) patients to assess the disease and its severity. The present study is a cross-sectional study, had been carried out at Menoufia University hospitals from August 2017 to August 2019. The various platelet indices [MPV, platelet distribution width (PDW) and plateletcrit (PCT)] are considered as outcome variables were compared among controls, cases with sepsis, and cases with sepsis associated AKI. Group I (31) cases with the clinical diagnosis of septic AKI, Group II (33) cases with the diagnosis of sepsis, and Group III (28) consecutive persons marked as negative in the output of the cell counter were taken as controls. Data were tabulated and statistically analyzed. There were 15 men and 15 women for Group I (septic AKI), 17 males and 16 females for Group II (sepsis) and 15 men and 13 women healthy controls as a control group. According to PLT indices MPV, there was a significant statistical difference (P1 <0.01) between Group I and II of patients as it were12.06 ± 1.23, 11.01 ± 1.20, respectively, and PDW also there was a significant statistical difference (P1 <0.01) as it were16.01 ± 2.33, 13.97 ± 2.14, respectively, and PCT there was no significant difference between the two groups. Furthermore, there was a significant statistical difference between Group I and II of patients according to procalcitonin, TNF-α and IL-10. From these results, we conclude that there were a statistical significant difference between the patient groups of critically ill.
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Urinary pigment epithelium-derived factor as a marker of diabetic nephropathy in Egyptian patients with type 2 diabetes mellitus p. 1340
Ahmed Fayed, Ahmed Rabiee, Omar El-Saadany, Mohamed Shaban, Dina Hesham, Hany Elghobary, Hany Hammad, Moataz Fatthy
DOI:10.4103/1319-2442.344753  
Diabetic nephropathy (DN) is the most common cause of end-stage renal disease. Urinary pigment epithelium-derived factor (PEDF) has also been shown to suppress the expression of fibrogenic, pro-inflammatory, and angiogenic factors, thus contributing to pathological changes in early DN. We aimed to study the role of urinary PEDF as a biomarker for the detection of chronic kidney disease progression in patients with type 2 diabetes mellitus (T2DM). Sixty patients with T2DM were recruited in addition to 20 nondiabetic healthy volunteers. Urinary PEDF using enzyme-linked immunoassay technique was performed to all subjects, and correlations between it and different clinical parameters were examined. Our study showed a statistically significant correlation between urinary PEDF level and duration of DM (P <0.001), glycosylated hemoglobin (P <0.001), serum creatinine (P <0.001), urinary albumin-to-creatinine ratio (P <0.001), and stage of diabetic retinopathy by fundus examination (P <0.001). Urinary PEDF is a good indicator of progression of DN and microvascular damage (as a complication of diabetes) in general. It was also increased in case of poor diabetic control.
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Infections from temporary catheters in hemodialysis patients in Kosovo p. 1348
Ibrahim Rudhani, Naim Morina, Gresa Elezi, Ahmet Avdulahu
DOI:10.4103/1319-2442.344754  
The objective of this study is to evaluate the frequency of infections from central venous temporary catheters and the type of a microorganism caused, from January 2017 up to December 2019. This study was performed on patients who were on hemodialysis (HD) through the central temporary venous catheter, right and left femoral vein, right jugular vein, and right subclavian vein.The patients in the HD center in Pristina, Kosovo, were used as a clinical sample. In this study, 1902 patients with temporarily central venous catheters (CVCs) were involved, while the control group consisted of 642 patients. Both groups were matched for age and gender. In all patients and the subjects of the control group, following data were obtained: Anamnesis, medical examination, as well as biochemical and hematological laboratory tests, CVC swab and antibiogram and hemoculture. Data analysis was performed using the descriptive statistical methods and the Chi-square test comparing the laboratory results of a HD patients treated through the central temporary venous catheter. Based on the results of this research, higher incidence of infections occurred with femoral vein access, compared to other CVCs accesses. The most common microorganisms responsible were Staphylococus epidermidis, while the 2019 had the highest incidence of infection.
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Impact of frailty and viral load on acute kidney injury evolution in patients affected by Coronavirus Disease 2019 p. 1356
Gustavo Aroca-Martínez, Carlos G Musso, Lil Avendaño-Echavez, Henry J González-Torres, María Vélez-Verbel, Stefani Chartouni-Narvaez, William Peña-Vargas, Antonio Acosta-Hoyos, Leila Ferreyra, Andrés Cadena-Bonfanti
DOI:10.4103/1319-2442.344755  
This paper describes the main characteristics of coronavirus diseases 2019 (COVID-19) patients suffering from acute kidney injury (AKI) assisted at a high complexity clinic in Barranquilla, Colombia. The patients included in this study (n = 48) were those with a positive diagnosis of COVID-19 confirmed by polymerase chain reaction detection of severe acute respiratory syndrome coronavirus 2, who had developed AKI during their hospital stay. Serum and urine parameters, as well as patient’s viral load and clinical frailty scale (CFS) were recorded. A statistical analysis of the recorded parameters, such as comparisons, and correlations between variables of interest, were explored. The prevalence of COVID-19 induced AKI was 41%, being the majority of them classified as AKI network classification 3, with a renal replacement therapy requirement of 29%, and an associated mortality of 73%. AKI patients’ mortality showed a significant positive correlation (33%) with patients’ CFS score but not with their viral load. COVID-19 induced AKI significantly correlated with patients’ frailty status but not to their viral load.
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Validity and reliability of the Arabic-translated kidney disease quality of life survey among long-term dialysis patients in Saudi Arabia p. 1365
Numan A Alabdan, Abdulla A Al-Sayyari, Fayez F AlHejaili, Yousif A Alrajhi, Shazia M Adnan, Asrar S Aldelhm, Rayan M Hakami, Senthilvel Vasudevan
DOI:10.4103/1319-2442.344756  
One of the tools used to measure the quality of life in hemodialysis (HD) patients is the Kidney Disease Quality of Life (KDQOL) survey. The KDQOL has been through several developmental processes, with the most recent one being the KDQOL-36™. Our study evaluated the validity and reliability of the Arabic-translated KDQOL-36™ survey in Saudi chronic dialysis patients. This cross-sectional study was conducted at four HD centers in Saudi Arabia. The KDQOL-36™ survey was translated into Arabic according to the RAND Corporation’s basic guidelines for translating surveys. The validation process was achieved by assessing reliability and validity. The reliability of the translated survey was established by Cronbach’s alpha to measure internal consistency and the intra-class correlation coefficient (ICC) to measure the test–retest reliability. The validity of the translated survey was established based on content validity and convergent validity. The study included 184 patients (36–65 years; 60.9% of men). Regarding reliability, Cronbach’s alpha for the subscales ranged from 0.63 to 0.89, and ICCs ranged from 0.60 to 0.88. For content validity, an expert panel reviewed the questions in depth. In addition, we found a positive relationship between all sub- and overall health-rated scores (P <0.01). The Arabic-translated version of the KDQOL-36™ survey is reliable and valid for evaluating the quality of life in Saudi chronic dialysis patients.
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Impact of the Living Donor Age and the Hormonal Profile of Algerian Renal Transplant Recipients p. 1374
Nadia Djebli-Azzal, Yasmina Benazzoug, Medina Arab, Tahar Rayane, Lamia Abib, Mohamed El Hadi Cherifi
DOI:10.4103/1319-2442.344757  
Kidney transplantation is the best treatment received by an uremic patient. One of the major advantages of transplantation is restoring a hormonal profile as before the chronic kidney disease. However, the posttransplant state depends on several factors including the quality of the graft. In this study, we assessed the donor age in living donors-recipients as well as the exploration of their hormonal profile. This is a single-center follow-up study over a period of 3 years, including 90 kidney recipients transplanted by living donors. We performed blood measurements of parathyroid hormone, prolactin, follicle stimulating hormone, luteinizing hormone, testosterone, estradiol, blood glucose, urea, creatinine, total cholesterol, triglycerides, high density lipoprotein-cholesterol, uric acid, albumin, and 24-h proteinuria. Glomerular filtration rate, body mass index, and low-density cholesterol were calculated. To analyze the donor age effect on recipients, the patients were divided into two groups according to donors age (<40 years and ≥40 years). The hormonal profile was normal for almost the majority of patients. In addition, we noted a return to dialysis associated with certain metabolic abnormalities and a donor age >40 years. Exploring the hormonal profile of the recipient is recommended. The donor age significantly influences the recipient fate but not their hormonal profile.
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BRIEF COMMUNICATIONS Top

Impact of patient counseling on treatment adherence behavior and quality of life in maintenance hemodialysis patients p. 1382
Maria James, Anjitha Roy, Edwin Antony, Shaji George
DOI:10.4103/1319-2442.344758  
Life in end-stage renal disease (ESRD) is miserable; food and fluid restrictions are mandatory due to impaired renal function. Patient involvement forms a key role in the management of ESRD. Hence, a direct impact of patient counseling on treatment adherence and quality of life (QOL) could be established, which forms the basis of this study. We conducted a prospective interventional study of 10 months, where the ESRD-Adherence Questionnaire and Kidney Disease QOL (KDQOL) data were used to study the effect of patient counseling. A total of 121 patients enrolled in the study with mean age of 62.14 ± 11.41 years. The adherence factors indicated that 97% were adherent to dialysis sessions, followed by 67.77% toward diet and 60.33% toward fluid. On assessing the influence of counseling on QOL and adherence to various factors affecting ESRD, a positive correlation could be observed, which indicates the impact of pharmacist intervention in improving the QOL and patient compliance, thus the need for periodic counseling was established as an effective way to improve health-related QOL and awareness in ESRD.
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Nephrotic syndrome in elderly: Etiologies, management, and prognosis p. 1388
Imen Gorsane, Tasmime Ben Ayed, Meriam Hajji, Samia Barbouch, Taieb Ben Abdallah
DOI:10.4103/1319-2442.344759  
The elderly population has significantly increased in the world. Nephrotic syndrome (NS) is one manifestation of glomerular nephropathy in the elderly. The objective of our study is to determine NS particularities in the elderly and to identify the factors predicting progression to chronic end-stage renal disease (ESRD). This is a retrospective and descriptive study, carried out between January 1, 1975 and December 31, 2017. It includes participants aged 65 years old or over hospitalized for NS. A multivariate study was carried out and the dependent variable was the evolution to ESRD. We studied 115 patients with an average age of 71 ±5 years (65–83) and a sex ratio (male/female) of 1.7. Twenty-three percent of patients were diabetic. The median proteinuria was 4.7 g/L (3–19.5). NS was impure in 89.5% of patients. Renal biopsy was performed in 45 patients (39.13%). NS was secondary in 65.2% of cases mainly to amyloidosis (35.6%). Idiopathic nephropathy was dominated by membranous nephropathy (9.5%). Treatment was etiopathogenic in only 18 patients (15.6%). At the end of follow-up, 15.8% of patients achieved complete or partial remission and 56.6% progressed to ESRD. The multivariate study found as independent risk factors of progression to ESRD: uremia >17 mmol/L [adjusted odds ratio (aOR) = 33.2 (1.3–837.7); P <0.05],, phosphoremia ≥1.6 mmol/L [aOR = 22.1 (1.8–266.5); P <0.05], serum potassium ≥4.3 mmol/L (aOR = 24.7 (2.4, 251.5); P <0.01], extra-renal signs [aOR = 38.9 (2.4–634.3); P = 0.01], secondary nephropathy [aOR = 74 (3.1–1788.2); P <0.01] and membranoproliferative glomerulonephritis [aOR = 48 (1.4–1675.5); P <0.05]. The protective factors were hemoglobinemia ≥9.3 g/dL [aOR = 0.007 (0–0.2); P <0.01], kidneys well differentiated [0.032 (0.003–0.4); P<0.01] and treatment with two diuretics [aOR = 0.03 (0.00–30.4); P <0.01]. It is important to recognize the spectrum of kidney diseases in the elderly to improve the progression factors to ESRD.
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Feto-maternal and renal outcomes of nephrotic syndrome in pregnancy p. 1397
Anupma Kaul, Dharmendra Bhaduaria, Mandakini Pradhan, Manoj Jain, Narayan Prasad, M Patel, Amit Gupta, RK Sharma
DOI:10.4103/1319-2442.344760  
Proteinuria can range from subnephrotic to nephrotic amounts during pregnancy, though nephrotic syndrome (NS) is rare (0.012%–0.025%). Without a renal biopsy, this distinction may be difficult at times. The objective of our study was assessing about renal and feto-maternal outcomes of these patients. This study was done in a tertiary-care hospital in north India from 2010 to 2019. We included all pregnant women with nephrotic-range proteinuria, with no signs or symptoms suggestive of pre-eclampsia. We studied their treatment modalities, renal, maternal, and fetal outcomes. Eighteen eligible pregnant women diagnosed with NS with no features suggestive of pre-eclampsia or associated comorbidities were included. The gestational age of presentation was 23.2 ± 1.36 weeks. The average proteinuria was 4.38 ± 0.76 g/day. The patients were managed conservatively without kidney biopsy. About 16.7% of pregnancies had worsening of hypertension and acute kidney injury which recovered after delivery. Anasarca was troublesome for four patients requiring fresh-frozen plasma infusion. All were managed conservatively; however, five patients were started on empirical immunosuppression, all five with steroids, while two required the addition of calcineurin inhibitors as well. All had live births, but 25.7% each had preterm and intrauterine growth restriction while one required neonatal intensive care unit admission. The degree of proteinuria had an impact on maternal and fetal outcomes, especially on risk to pre-eclampsia. NS during pregnancy needs evaluation and counseling. Majority of them can be managed conservatively yet specific therapies can safely be tried among symptomatic ones. Despite good outcomes, a sizeable risk to maternal and fetal complications can occur.
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RENAL DATA FROM THE ARAB WORLD Top

End-stage renal disease at dialysis initiation: Epidemiology and mortality risks during the first year of hemodialysis p. 1407
Tasnim Mesbahi, Samia Barbouch, Mariem Najjar, Safa Fattoum, Hela Jebali, Raja Trabelsi, Mohamed Mongi Bacha, Wided Smaoui, Cyrine Karoui, Fethi Ben Hamida, Hafedh Hedri, Lamia Rais, Mondher Ounissi, Mohamed Karim Zouaghi, Taieb Ben Abdallah
DOI:10.4103/1319-2442.344761  
Chronic kidney disease (CKD) treated by hemodialysis (HD) is a worldwide major public health problem. Its incidence is getting higher and higher, leading to an alarming social and economic impact. The survival of these patients is significantly low, especially during the first year of treatment. The purpose of our study was to identify the epidemiological and clinico-biological characteristics of patients at the HD initiation and to reveal the predictive factors of mortality at three months and one year of HD. This is a prospective, analytical, and descriptive study dealing with 229 patients with an end-stage renal disease (ESRD), followed up in the Nephrology Department of Charles Nicolle Hospital and La Rabta Hospital in Tunisia, that was started HD between January and June 2017. A multivariate logistic regression analysis allowed us to identify the independent predictors of mortality at three months and one year. The average age was 60.2 ± 15.3 years, with a gender ratio of 1.41. Seventy-eight percent of patients had more than two comorbidities, 59% had diabetes, and 88% had hypertension. Diabetic nephropathy was the leading etiology of kidney disease (48.9%), while 11% of nephropathies were of unknown etiology. Only 58% were early referred to a nephrologist. The average glomerular filtration rate at HD initiation was 6.06 ± 2.33 mL/min/1.73 m2. Hypocalcemia and hyperphosphatemia were noted, respectively, in 60.8% and 84.9% of cases. Anemia was objectified in 98.6% of cases. HD was started in an emergency in 56.8% of cases. One of the most urgent indications was acute pulmonary edema (APE) for 43.8% of patients. Only 10.5% of patients had functional arteriovenous fistula at the dialysis initiation. Patients were hemodialyzed one, two, or three sessions per week, respectively, in 23.2%, 26.6%, and 50.2% of cases. The crude mortality rate was 25% and 13% in, respectively, one year and three months of HD. On multivariate analysis, we identified heart failure and insufficient dialysis dose per week as predictive factors of mortality at the 1st year of HD. C-reactive protein more than 21 mg/L, insufficient dialysis per week, modified Charlson Comorbidity Index less than 6, and APE at the dialysis initiation were identified as predictive factors of three-month mortality. Despite the short period of study, this work revealed the alarming conditions of patients at HD initiation. This critical situation is due to the delay in CKD diagnosis, the late nephrologist referral, and the lack of preparation before HD initiation.
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RENAL DATA FROM ASIA–AFRICAS Top

Causes of hospitalization in patients on maintenance hemodialysis with arteriovenous fistula in a tertiary care hospital in West Bengal, India p. 1418
Tanmoy Chattopadhyay, Avinandan Banerjee, Himel Mondal
DOI:10.4103/1319-2442.344762  
Patients with renal failure and on maintenance hemodialysis (HD) have a higher propensity toward cardiovascular and infectious diseases. The aim of this study was to find the causes for hospital admission in patients suffering from kidney failure and on maintenance HD. This cross-sectional, observational study was conducted in a tertiary care hospital in West Bengal, India, from January to December, 2015. Patients with chronic kidney disease stage 5 for more than one year and on HD with arteriovenous fistula admitted for other than HD were included in the study. Days of hospital stay and current diagnosis were stored for further analysis. Data were expressed in mean, standard deviation, percentage, and frequency. All the statistical tests were carried out in GraphPad prism 6.01. Data of total 49 (30 male, 19 female) patients with mean age 55.8 ± 10.98 years (range 27–75 years) were analyzed. Eighteen (36.73%) and 48 (97.96%) patients were suffering from type 2 diabetes mellitus and hypertension (HTN), respectively. Average stay in hospital was 10.31 ± 6.07 days (range: 5–43 days). Most common causes for hospitalization were left ventricular failure (LVF) (59.18%) followed by respiratory tract infection (RTI) (14.29%). In patients with renal failure receiving maintenance HD, LVF is the most common cause for hospital admission followed by RTI. Hence, the management of HTN and preventive measures for RTI should be stressed in HD patients.
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Surgical management of secondary hyperparathyroidism in dialysis patients in Senegal p. 1424
Maria Faye, Niakhaleen Keita, Ahmed Tall Lemrabott, Ilham Algouzmari, Moustapha Faye, Mansour Mbengue, Seynabou Diagne, Bacary Ba, Ameth Dieng, Mamadou Aw Ba, El Hadj Fary Ka
DOI:10.4103/1319-2442.344763  
Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease. Surgical management occurs in severe forms and/or unresponsive medical treatment. The aim of this study was to outline the indications of parathyroidectomy and its evolution after surgical approach. It was a five-year multicenter backward study in Otorhinolaryngology Department of Fann Hospital and four dialysis centers in Dakar. We include all patients with SHPT who underwent surgery. Preoperative clinical and paraclinical parameters, clinical-biological evolution, and histology findings of the resected parathyroid specimen were collected. Out of 58 patients with hyperparathyroidism, 18 patients required parathyroidectomy, corresponding to a prevalence of 31%. Mean age of patients was 46.6 ± 15.29 years and sex ratio 0.61. Mean duration on dialysis was 44.4 ± 30 months. Ten patients (55.56%) had bone pain and nine patients (50%) had joint pain. Mean serum calcium was 97.27 ± 8.66 mg/L. Mean blood phosphorus levels were 40.47 ± 9.99 mg/L. Mean iPTH rate was 1493.22 ± 1014.93 ng/mL, with a maximum of 5000 ng/mL (77N). Mean value of 25-OH Vitamin D was 32.89 ± 16.02 ng/mL. Parathyroidectomy was indicated after failure of medical treatment with persistence of a serum intact parathyroid hormone concentration above 800 μg/mL in all patients. Subtotal parathyroidectomy (7/8) was performed in 11 patients (61.1%). Two patients (11.11%) benefited from a selective parathyroidectomy (3/4). Evolution was favorable for 13 patients, corresponding to a success rate of 72.2%. It was unfavorable in five patients including one patient with hypoparathyroidism and four patients with recurrent hyperparathyroidism. Surgery for patients with renal hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves efficient control of hyperparathyroidism in developing countries.
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Management of severe hypernatremic dehydration and acute kidney injury in children in a critical care nephrology and dialysis unit p. 1431
Afroz Shireen, Ferdaus Tahmina, Yasmin Farhana, Tanjila Umme, Baroi Sukriti, Md Kawser Hossain
DOI:10.4103/1319-2442.344764  
Our study aimed to manage the children presented with severe hypernatremic dehydration and acute kidney injury (AKI) an updated fluid management protocol was used to find out the rate of decline of serum sodium per day and their outcome. This is a prospective interventional study was conducted from November 2015 up to October 2016 in the Critical Care Nephrology and Dialysis Unit of Dhaka Shishu (Children) Hospital, Bangladesh. A total of 45 children with hypernatremia and AKI were evaluated. Patients were treated by the calculated amount of dextrose in normal saline mixed with various dilutions of 3% NaCl with a difference of serum to infusate sodium concentration around 10 mEq/L as per the American Academy of Pediatrics - 2005. Intermittent peritoneal dialysis was done when in the failure stage of AKI or when serum sodium (Na+) >180 mEq/L. Depending on the outcome samples were divided into survival and death groups. Data were processed by software STATA 13 and analysis was done by one-way ANOVA, Tukey test, Chi-square test, F-test, and Student’s t-test. Age ranged from one month to 6½ years and 91% were infants. Total 64% of patients were in the failure stage of AKI and majority were in the death group, 31% in injury and 4.4% patient in the risk stage. Out of 45 cases, 30 (67%) had severe hypernatremia. Significant reduction of serum Na+ was found and the rate of decline between days was optimum (8.4 mmol/L/day). Overall 60% survived with normal renal functions and 40% died. The calculated amount of dextrose in normal saline mixed with various dilutions of 3% NaCl is safe in severe hypernatremic dehydration with AKI.
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Organ donation for transplantation in Bangladesh p. 1441
Md Sanwar Siraj
DOI:10.4103/1319-2442.344765  
Organ transplantation is a treatment of modern medicine and technology that saves the lives of hundreds and thousands of medically suitable end-stage organ failure patients. The first successful kidney transplantation from living-related donors in Bangladesh was successfully performed in 1982 and regularly from 1988. This was then followed by deceased cornea in 1984, and liver and bone marrow from living-related donors in 2010 and 2014 respectively. The Human Organ Transplantation Act was first passed by the parliament of Bangladesh in1999, allowing both brain death donation and living-related donor transplantations. Before the legislation of 1999, religious approval (fatwa) from religious leaders was obtained that acknowledged brain death donation and allowed deceased donation for transplantations. The existing act was revised in January 2018. From 1982 to 2017, only 1791 kidney, six liver, and 25 bone marrow transplantations were carried out from living-related donors. Deceased transplantations have not been started yet in Bangladesh. Only 5500 deceased corneas have been used for transplantation purposes. There are long-standing concerns about the lack of transplantation of the vital organs from deceased donors in Bangladesh and its impact on the increasing demand for procuring organs from living donor. On the other hand, living-related donors are very scarce. Numerous vital organ failure patients are often forced to buy organs from poor people. It creates an illegal and unethical market in human organs in Bangladesh.
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Chronic renal failure in the brazzaville university hospital center: Epidemiological, clinical and evolutionary aspects p. 1450
Daniel Tony Eyeni Sinomono, Richard Loumingou, Gael Clovis Gassongo Koumou, Gael Honal Mahoungou, Jean Lucien Mobengo
DOI:10.4103/1319-2442.344766  
Chronic kidney disease (CKD) is a major global public health problem today. In Congo, we have very little epidemiological data. Our goal is to describe the epidemiological, clinical, therapeutic, and progressive aspects of IRC in Brazzaville. We carried out a retrospective and descriptive study on patients with chronic renal failure, hospitalized in the nephrology and dialysis department of the Brazzaville teaching hospital from January 1, 2016, to December 31, 2018. The data were established from patient medical records. The statistical analysis was done with the Epi info software. During our study, 953 patients were hospitalized in nephrology, of which 497 (52.1%) presented with CKD, only 407 files were usable (42.7%). Their average age was 51.8 ± 15.2 years; with a male predominance of 59.1%. The first three causal nephropathies are diabetes mellitus (23.3%), high blood pressure (21.8%), and chronic nondiabetic glomerulonephritis (15.5%). In 22.3% of cases, the causative nephropathy remained undetermined. CKD was declared terminal in 295 patients (74, 2%); 73 (19.8%) of whom were able to access dialysis. Erythropetine (EPO) was indicated in 316 patients (77%), only 8.4% received it. The mortality rate was 49.9%. Our study reveals the major health issue of IRC in the Congo. The intervention of all the actors of national public health is necessary to face this scourge, which makes us ask for help from all international and national donors.
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CASE REPORTS Top

Wernicke's encephalopathy – An oddball complication of nephrotic syndrome p. 1456
Aliza Mittal, Sarbesh Tiwari, Binit Sureka, Kuldeep Singh
DOI:10.4103/1319-2442.344767  
Metabolic encephalopathies are a common cause of altered mental status in various states of malnutrition. However, a high index of suspicion is required to recognize them and differentiate Metabolic Disorders from other causes of altered mental status such as infections. A 6-year old with steroid-resistant nephrotic syndrome (NS), peritonitis, and prolonged diarrhea and vomiting, developed a brief episode of altered mental status six days after starting tacrolimus. On imaging, there were features suggestive of Wernicke’s encephalopathy and it ruled out other causes of seizure in the given scenario. The child was treated with thiamine supplementation and the changes reversed four weeks after treatment. This is to emphasize that although an uncommonly reported complication of nephrotic state, one should have a high index of suspicion for these metabolic encephalopathies, especially in the setting of malnutrition, where these children are highly predisposed to multivitamin deficiency.
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A rare case of ureteric involvement in xanthogranulomatous pyelonephritis associated with giant ureteric calculus: An unusual entity p. 1461
Suman Sethi, Sudhir Mehta, Sourabh Gupta
DOI:10.4103/1319-2442.344768  
Xanthogranulomatous pyelonephritis (XGPN) is an uncommon chronic destructive granulomatous inflammation of the kidney with variable clinical and radiological presentation. Due to its similarities to other benign and malignant pathologies, a high index of suspicion is required for preoperative diagnosis, which will ensure appropriate management of this condition. The invasion into the surrounding structures such as pararenal spaces, psoas muscle, small bowel, diaphragm, lung or soft tissues has been reported. However, involvement of ureter is very rarely reported. We report a rare case of left-sided gross hydronephrosis with staghorn calculus with giant uretic calculi, postnephrectomy on the biopsy diagnosis of XGPN was made, which also revealed involvement of ureter also.
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Transcatheter mitral valve repair with a mitraclip for severe mitral regurgitation in a patient on hemodialysis p. 1465
Hirotaka Sato, Tsutomu Sakurada, Shigeki Kojima, Takeshi Okamoto, Yugo Shibagaki, Yuki Ishibashi, Masaki Izumo, Yoshihiro J Akashi
DOI:10.4103/1319-2442.344769  
A 55-year-old male patient undergoing hemodialysis (HD) had shortness of breath, New York Heart Association (NYHA) class IIm (moderate limitation of physical activity) due to chronic heart failure. His past medical history was remarkable for chronic heart diseases and severe functional mitral regurgitation (MR), with an ejection fraction of only 33%. The cardiologist considered this severe MR as the cause of his symptom. Due to the multiple comorbidities and low cardiac function, transcatheter mitral valve repair (TMVR) using a MitraClip was selected as an alternative to surgery. TMVR with MitraClip was successfully performed. Postoperatively, the degree of MR decreased from severe to trivial, with an obvious improvement in symptoms to NYHA class I. He was discharged without any postoperative complications. TMVR with MitraClip is an effective nonsurgical treatment for mitral valve disease in HD patients with multiple comorbidities.
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Distal renal tubular acidosis and nephrocalcinosis as initial manifestation of primary sjögren's syndrome p. 1470
Aglaia Chalkia, Panagiota Giannou1, Konstantinos Thomas, Dimitrios Vassilopoulos, Dimitrios Petras
DOI:10.4103/1319-2442.344770  
There is a well-established association between primary Sjögren’s syndrome and distal renal tubular acidosis (dRTA). dRTA is a relatively infrequent manifestation of primary Sjögren’s syndrome which can present with life-threatening electrolyte abnormalities while, in some patients, it could be the first manifestation of the syndrome. We report the case of a 35-year-old woman who presented with unexplained episodes of generalized weakness, severe hypokalemia, nephrocalcinosis, and normal anion gap metabolic acidosis. Subsequent evaluation revealed primary Sjögren’s syndrome as her underlying condition. The patient responded well to potassium supplementation, sodium bicarbonate, and oral prednisolone. After four years of follow-up, there were no other extraglandular manifestations, the renal function remained stable and the acidosis was partially improved without the need for oral bicarbonate. This case demonstrates that dRTA could be the initial manifestation of primary Sjögren’s syndrome and highlights the necessity for increased vigilance for patients presenting with persistent hypokalemia or nephrocalcinosis so that an early diagnosis can be made allowing for better control and prevention of disease progression.
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Diabetic muscle infarction: An unusual cause of acute limb pain in patients on maintenance hemodialysis p. 1475
Manish R Balwani, Amit S Pasari, Amol R Bhawane, Priyanka R Tolani
DOI:10.4103/1319-2442.344771  
Diabetic muscle infarction is underdiagnosed complication occurring in dialysis patients with advanced diabetes mellitus. Atherosclerotic vascular disease and long-standing diabetes are risk factors for this painful condition. Most common presenting symptom is localized pain in the affected limb. We present here a case of muscle infarction occurring in a diabetic patient on maintenance hemodialysis (HD). Our patient had low-grade fever and pain in right thigh which restricted his movements for one month. His pain worsened during and post-HD. External examination of right lower limb was normal except for tenderness in the right thigh region. Laboratory examination showed leukocytosis with normal serum creatine phosphokinase levels. Magnetic resonance imaging of the thigh was suggestive of muscle infarction. Patient was treated with bed rest, analgesics, antiplatelets and blood transfusion. HD prescription was changed to sustained low-efficiency dialysis with reduced ultrafiltration. Gradually, in a week, his fever and pain subsided and he was able to walk on his own. Thus, it is important to identify this clinical condition early in the course of illness to further prevent its progression.
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Heterozygous laminin β2 mutation in C3 glomerulopathy p. 1479
Manish R Balwani, Amit S Pasari, Amol R Bhawane, Priyanka R Tolani
DOI:10.4103/1319-2442.344772  
C3 glomerulopathy is usually seen with the presence of C3 nephritic factor, homozygous or heterozygous mutations in the regulatory complement proteins factor H, factor I, or C3. We describe the presence of heterozygous laminin β2 mutation in a patient of C3 glomerulonephritis with ocular and central nervous system involvement, the significance of which is unknown.
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Primary retroperitoneal hydatid cyst masquerading as malignancy p. 1482
Narender Goel
DOI:10.4103/1319-2442.344773  
Hydatid cysts, usually found in liver and lungs, are rare to be primarily located in the retroperitoneal region. It may mimic malignant mass and differentiation may be difficult. Surgical exploration in undiagnosed cases may lead to adverse complications. High index of suspicion is crucial, especially in patients from endemic region. Diagnosis can be aided by imaging and serologic testing for Echinococcus IgG. We present a 61-year-old Tibetan female visiting to North America and found to have a complex cystic and solid capsulated right retroperitoneal mass. Echinococcus IgG western blot assay was positive, and the patient was diagnosed to have primary retroperitoneal hydatid cyst.
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Bariatric surgery and hemodialysis: A case report of a patient with less 40 kilograms and without dialysis p. 1485
Rita Valério Alves, Hernâni Gonçalves, Paulo Santos, Ana Vila Lobos
DOI:10.4103/1319-2442.344774  
Obesity is an important risk factor for chronic kidney disease. Bariatric surgery (BS) may improve long-term kidney outcomes, but there is no agreement regarding the benefit and timing of BS in patients with end-stage renal disease. We present a 46-year-old male patient with type 2 diabetes mellitus, in hemodialysis (HD), and with a body mass index (BMI) of 39.79 kg/m2, who was submitted to laparoscopic one-anastomosis gastric bypass surgery. Eight months after surgery, and after a 40-kg weight loss, the patient showed signs of kidney function improvement and HD was discontinued. At this moment, one year after, the patient has an estimated glomerular filtration rate of 21.2 mL/min/1.73 m2 and a BMI of 25.61 kg/m2. To our knowledge, this case report seems to be the first one to talk about a HD patient that improved kidney function enough to stop dialysis.
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A case of cholesterol embolization syndrome mimicking rapidly progressive renal failure causing end-stage kidney disease p. 1489
Keshavamurthy Ganapathy Bhat, Vijoy Kumar Jha, M Harish Kumar, Vikrant , Debasish Mahapatra
DOI:10.4103/1319-2442.344775  
Cholesterol embolization syndrome is an uncommon complication of coronary angioplasty. Its clinical manifestations are nonspecific and may be ascribed to other causes mimicking vasculitis syndrome. In an appropriate clinical setting, the diagnosis can be confirmed by tissue biopsy. In this case report, we present a middle-aged male who presented with cutaneous and renal manifestations within two weeks of primary angioplasty. The patient had progressive clinical deterioration in the form of dry gangrene of toes and end-stage renal disease requiring surgical amputation and maintenance hemodialysis respectively within two months of symptoms onset.
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LETTER TO THE EDITORS Top

Heparin-free sustained low-efficiency dialysis in critical children in resource-constraint settings p. 1495
Sidharth Kumar Sethi, Timothy Bunchman, Supratim Sarkar, Khalid Alhasan, Rupesh Raina
DOI:10.4103/1319-2442.344776  
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A child with central cyanosis and acute kidney injury: A clinical spotter p. 1497
Azmeri Sultana, Sidharth Kumar Sethi, Nobo Krisna Ghosh, Rupesh Raina
DOI:10.4103/1319-2442.344777  
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The relationship of immunosuppressive adherence and disability levels among renal transplantation patients p. 1499
Salah Aberkane, Moussa Hamidani, Amine Baziz
DOI:10.4103/1319-2442.344778  
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Coronavirus Disease 2019-associated mucormycosis and cytomegalovirus coinfection in a kidney transplant recipient p. 1501
Praveen Kumar Etta, Thatipamula Madhavi, Naveen Reddy Avula
DOI:10.4103/1319-2442.344779  
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Coronavirus Disease-19 in a patient with minimal change nephrotic syndrome undergoing rituximab monotherapy p. 1505
Tomo Suzuki, Kanako Nagaoka, Yoshinori Takahashi, Ryosuke Osawa, Naoto Hosokawa
DOI:10.4103/1319-2442.344780  
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Transplantation of a severe acute respiratory syndrome Coronavirus 2 recovered patient complicated by the second infection in the immediate transplant: A challenging clinical scenario p. 1507
Hari Shankar Meshram, Vivek Kute, Sanshriti Chauhan, Ruchir Dave
DOI:10.4103/1319-2442.344781  
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