Children with acute renal failure (ARF) may be treated in pediatric renal or intensive care (PICU) units where there is an increasing use of continuous renal replacement therapies such as hemofiltration (HF). Over three years, we prospectively recorded details of all patients with ARF treated both within our regional pediatric renal unit, in two local neonatal intensive care units (NICUs), and one PICU, which are all supported by our institution. Our study included eighty-three ARF patients (43% male) with a median age of 5.7 years (range 1 day - 19.8 years); 41% of patients were < 2 years, 20% 2-5 years, 13% 5-10 years and 26% > 10 years of age. A total of 37 patients (45%) were treated in the renal unit versus 46 (55%) patients in NICU/PICU. The initial treatment modality was conservative in 33%, peritoneal dialysis (PD) in 23%, hemodialysis (HD) in 15%, HF in 28%, and isolated plasmafiltration in one percent of the patients. About 16% of the patients required more than one treatment modality. Outcome data at three months showed normal renal function in 49%, deaths in 20%, dialysis dependent disease in 14%, chronic renal failure (GFR < 60ml/min/1.73m ² ) in eight percent, and proteinuria and/or hypertension in seven percent of the patients. Only one (3%) death occurred in 37 patients treated in the renal unit compared to 16 deaths in 46 patients (35%) treated in the NICU/PICU. Our findings further confirm the low mortality rate with isolated renal failure and the substantial mortality and renal workload in intensive care areas where renal failure is often part of multi­organ failure. Further prospective studies will be required to analyze the impact of early hemofiltration in such patients.

The goal of this study was to evaluate the attitude of the physicians towards the follow-up of the renal transplant patients in the Kingdom of Saudi Arabia (KSA). We sent a questionnaire to 168 physicians working in 148 active dialysis centers in the KSA. The study was conducted from June­October 2005. There were 140 physicians (83.3%) who answered the questionnaire; they represented 136 (91.9%) dialysis centers. There were 43 (31.2%) respondents who had a transplant clinic for follow­up of transplant recipients. Of the 96 (69.1%) who did not have a clinic, 29 (30.2%) claimed expertise for follow-up of transplant recipients, six (6.2%) had a laboratory set-up to monitor the immunosuppressive drug levels and 40 (44.4%) felt the need for one. There were 121 (89%) respondents who would consider the chronic renal failure (CRF) patients for transplantation because it is the best form of therapy. Seventy­seven respondents (55%) had a protocol for work-up of the CRF patients for transplantation, 31 (22.3%) had a coordinator for the work-up of the transplant candidates, 34 (24.5%) had regular meetings to decide on the waiting list for transplantation, and 51 (37.8%) had affiliation with, or worked at a transplant center. Nevertheless, 127 (90.7%) respondents believed that the results of renal transplantation were good enough to recommend the procedure to all patients as early as possible. There were 133 (97.1%) respondents who believed that organ shortage was the major factor for the low percentage of renal transplantation. Only 52 (37.1%) respondents knew about the recent regulations established by the World Health Organization (WHO) for organ donation. There were 63 (48.1%) respondents who believed that seeking commercial renal transplantation outside the KSA to be unacceptable because of the medical and ethical complications involved. Many respondents (71.4%) from non-MOH hospitals, and those who had transplant clinics believed that the tacrolimus + mycophenolate combination was the most popular immunosuppressive regimen for renal transplant patients. Our survey suggests that the current practices concerning the work­up and follow-up of transplant patients in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit.

Differentiating acute tubular necrosis (ATN) from prerenal azotemia is critical for selecting the appropriate treatment. This study was conducted to evaluate the diagnostic value of Doppler ultrasonography in differentiating ATN from prerenal azotemia in children. A total of 50 oliguric or anuric children with previous normal renal laboratory data were included. Doppler examination and calculation of resistive index (RI) was performed within 24 hours of admission and in the recovery phase of ARF. The sensitivity and specificity of RI in differentiating ATN from prerenal azotemia were assessed. At the cut-off point of RI = 0.75, the sensitivity and specificity of RI in differentiating prerenal failure and ATN was 91.3% and 85.2%, respectively. We conclude that Doppler ultrasonography is helpful in differentiating ATN from prerenal azotemia in children. The cut-off value of 0.75 has the highest accuracy for this purpose.

Brain natriuretic peptide (BNP) levels increase in patients with congestive heart failure. Theoretically, BNP levels can be helpful in the determination of the "dry weight" of hemodialysis patients. To evaluate the effect of hemodialysis on the plasma concentration of BNP and to determine the factors that affect BNP levels during hemodialysis in patients with chronic renal failure, we studied five stable patients with chronic renal failure. A total of 15 blood samples were obtained for BNP levels at 24, 48 and 72 hours after the last hemodialysis session. The plasma BNP levels did not change significantly either with ultrafiltration volume or with time since last dialysis. However, the BNP levels correlated positively with the erythropoietin (EPO) dose (r=0.98, P<0.001) and negatively with the serum albumin levels (r = 0.94, P=0.02). Univariate analysis showed that the EPO dose (P=0.001) and the albumin level (P=0.02) were significant predictors of BNP level. Adjusted multivariate analysis showed significant interaction between the EPO dose and the albumin level (P=0.01, P=0.03 respectively. In conclusion: the plasma BNP levels were not significantly influenced by ultrafiltration volume or time since last dialysis. However, the BNP levels may be a useful prognostic parameter for assessing the risk of cardiovascular morbidity and mortality in hemodialysis patients.

A community survey of enuresis was carried out in November/December 2002 among 300 apparently healthy children aged 5-16 years selected systematically from the Ehor Local Government Area in Edo State, Nigeria. This was done with the aim of ascertaining the true prevalence of the disease and the contributions of some organic causative factors. The overall prevalence of enuresis was 21.3%. Of the 64 children who were enuretic, 58 (91%) had only nocturnal enuresis. No strict daytime enuresis was recorded. Combined daytime and night time enuresis accounted for only six (9.4%) cases. Ninety-four percent of cases of enuresis were primary, while only six were secondary. Prevalence of enuresis declined significantly with increasing age ( X 2 = 14 .93, df = 3; p = 002). There was a strong association between enuresis and family history of bed wetting (more so with siblings) ( X ² = 45.09, p < 0.000). Though not statistically significant, enuresis was more common in males, in children drawn from families of poor socio-economic status, among first order births, and among those with asymptomatic bacteriuria. Also, there was no significant association between enuresis and hemoglobin genotype. Organic conditions played a minimal role in the etiology of enuresis in the study location, but the morbidity occurred frequently enough to warrant health attention. A community approach is advocated because only an insignificant proportion is seen in orthodox health facilities.

We have investigated the influence of isolation of patients with different viral serology status on the transmission of viral hepatitis among patients on hemodialysis (HD). Our kidney center was designed to facilitate isolation of infected patients and implement infection control pre-cautions. These included separate rooms, separate entrances and exit sites, and designated HD machines for patients with hepatitis B, hepatitis C, and sero-negative patients. In addition, universal infection control polices and procedures were implemented. These included proper chemical and heat disinfection of all HD machines following each HD session. These measures were complemented with education and training of the nursing staff detailing strict adherence to all infection control policies and procedures. All of our patients and staff were vaccinated against hepatitis B. Our results showed that after four years of follow-up, there was a decrease in the annual incidence of hepatitis C seroconversion from an average of 2.4% to 0.2%. The current prevalence of hepatitis C is 29% compared to 57% at the start of the study. In addition, there have been no reported sero-conversion cases of hepatitis B. Furthermore, our data also confirmed that the prevalence of hepatitis C (as well as hepatitis B) is more frequent in HD (29%) than peritoneal dialysis (5%) units. Surgical procedures, blood transfusion, and frequent visits to different dialysis units remain the major risk factors for contracting viral hepatitis. In conclusion, these results clearly show that isolation of patients and machines, together with strict adherence to infection control policies and procedures, result in a significant decline in the incidence and prevalence and better control of viral hepatitis transmission among HD patients.

Ever increasingly potent but non-specific immunosuppression has necessarily brought with it the continuing risk of opportunistic infections and virus-induced malignancies. The improvement in graft and patient survival rates from transplantation has depended to a certain extent on parallel improvements in the diagnosis and treatment of infectious complications. This review will highlight some of the current problems and progress. The risks of infection are largely related to the total burden of immunosuppression rather than any particular drug, although sirolimus and the anti CD25 antibodies may be an exception. Almost all the post-transplant infections are treatable; a precise microbiological diagnosis is essential so that specific therapy can be used. Newer molecular diagnostic techniques are increasingly widely available, e.g.quantitative polymerase chain reaction. The transplant community will inevitably be faced with highly resistant bacteria such as. Methicillin resistant Staphylococcus Aureus (MRSA) and will have to develop appropriate strategies. New infectious organisms continue to be identified [e.g. Burkitt's Virus (BKV), West Nile virus and Avian influenza) and will continue to tax the ingenuity of transplant physicians and microbiologists.

We report a 19-year-old Saudi female with nephrotic syndrome whose renal biopsy revealed findings suggestive of minimal change glomerulonephritis (MCGN). She developed oliguric renal failure requiring hemodialysis. She remained dialysis dependent for five weeks and subsequently renal function recovered fully. She remained nephrotic and responded to a six week course of corticosteroids. She was followed for two years during which she had two relapses, which responded to steroids. Acute renal failure is uncommon in MCGN and is due to acute tubular necrosis induced by hypovolemia or drugs. This patient did not have any obvious precipitating factor, which led to acute reversible renal failure.

Polyoma virus nephropathy (BK virus) is being recognized as an important cause of graft failure. It is usually confused with acute rejection. No cases have been reported from the kingdom of Saudi Arabia. We report a case of a Saudi gentleman, who was transplanted outside the country, with persistently elevated creatinine and urethral stenosis. He was treated for acute rejection on more than one occasion with no significant improvement in his renal function. Polyoma virus nephropathy was diagnosed by detecting the virus DNA by the Poly chain reaction technique (PCR). The patient's renal function stabilized after the calcineurin inhibitors were discontinued.

Acute renal infarction presents in a similar clinical picture to that of a renal stone. We report a 55-year-old Saudi female, known to have atrial fibrillation secondary to mitral stenosis due to rheumatic heart disease. She presented with a two day history of right flank pain that was treated initially as a renal stone. Further investigations confirmed her as a case of renal infarction. Renal infarction is under-diagnosed because the similarity of its presentation to renal stone. Renal infarction should be considered in the differential diagnosis of loin pain, particularly in a patient with atrial fibrillation.

An extremely rare form of genitourinary tract tuberculosis (TB) is TB of the glans penis. Here, we report on two men with TB of the glans, both occurring secondary to their wives having genital TB. To the best of our knowledge, this is the first report of this nature from Iran. One case is a 48 year-old blind male with an asymptomatic papulo-pustular eruption over the glans and, the other is a 51 year-old male who had kidney transplantation in March 2004, and was referred to our transplantation clinic nine months later with papulonecrotic ulcer on the glans which did not respond to antibiotic therapy. Both patients responded well to anti-TB treatment. Our cases suggest that every papulonecrotic lesion on the glans must raise the suspicion of TB, and an underlying active or healed focus of TB should be thoroughly searched. Also, it is very important, particularly in endemic areas, that prior to transplanting a male patient, his female partner must be examined for TB of the genitalia.

Angiotensin converting enzyme inhibitor (ACEI)- induced acute renal failure (ARF) is not as commonly reported in children as in adults. We report two cases of idiopathic nephrotic syndrome that developed ARF following captopril (an ACEI) treatment for prednisolone-induced hypertension. The two cases further alert us to the potential risk of ACEI-induced ARF in any nephrotic child on ACEI treatment. Low or high dose ACEIs should be given with extreme caution in active nephrotics in view of their relative hypovolemic state that may provoke ARF. The nephrotic children, who must be treated with ACEIs with or without diuretics, should be closely monitored for the development of ARF during the use of ACEIs.

In an attempt to survey the attitude of the heads of some distinguished transplant programs in the Middle East countries towards the follow-up and complications that may ensue in the live renal allograft donors, we sent a questionnaire to 29 active renal transplant centers in the Kingdom of Saudi Arabia (KSA) and some other Middle East countries, which together perform about 1500 living renal transplantations annually. The study was performed during November-December, 2005. The questionnaire was intended to evaluate the presence of a protocol that guides the physicians in their selection, work-up and follow-up of the live renal allograft donors, the presence of regular time schedule for follow-up of the donors during the first year and thereafter, and the tests performed during these clinic visits, the physicians' perception towards the life-long health insurance of the live donors as well as the physicians' estimates of the major complications that may occur in the live donors such as hypertension, proteinuria, chronic renal failure, early surgical complications and depression. There were 20 responses (69%) from transplant centers that together perform about 1200 (80%) living renal transplantations annually. There were 18 (90%) respondents who had a protocol to guide the selection of the live renal allograft donors, 10 (52.6%) had a written policy for post-donation follow-up of live renal allograft donors, 15 (83.3%) would see the donors for the first time within three months post-discharge, 10 (66.7%) would see the donors every three months thereafter during the first year and 11 (68.8%) would see them once a year after the first year. There was a consensus among the respondents to monitor the renal function tests that include plasma urea creatinine and urinalysis. The post donation incidence of hypertension, proteinuria, chronic renal failure, early surgical complications and psychological problems such as depression was estimated by more than 80% of the respondents as 1-5%. We conclude that the current practices concerning the follow-up of renal allograft live donors by the dialysis centers in the Middle East seem promising. However, this being a questionnaire survey, results may not be totally accurate. Prospective studies are required to ensure that protocols for follow-up are abided by.

Thrombotic microangiopathy (TMA) is a rare but devastating disorder; it involves small vessels and is characterized by intravascular thrombi of aggregated platelets leading to thrombocytopenia and variable degrees of organ ischemia and anemia, which is due to erythrocyte fragmentation in microcirculation. Childhood cases with predominant renal involvement are referred as the hemolytic uremic syndrome (HUS), and adults with major central neurological involvement are labeled as thrombotic thrombocytopenia purpura (TTP). Endothelial damage due to toxins and/or lack of defense against complement activation have a central role. Recent discovery of the von Willebrand Factor cleaving protease (ADAMTS 13) has offered new insight into the pathogenesis of TMA. TMA is also a well-recognized serious complication of renal transplantation. Clinical features of intravascular hemolysis are not always found. It may occur as de novo or recurrent and the majority of de novo cases are related to cyclosporin therapy. Viral infections, severe renal ischemia and acute vascular rejection are less frequent causes. Recurrence is negligible in diarrhea-associated HUS in childhood, but non-diarrheal HUS recurs in majority of adults following renal transplantation. Renal transplantation is contraindicated in familial/relapsing recurrent forms of HUS.

Patients with End-stage Renal Disease being immunocompromised; are prone to a variety of infections, sometimes, rare ones, more than the general population. This fact should alert the physicians to be more vigilant and have a broader scope when considering the etiology of infections in such patients. We report the case of a 65-year-old man who had a very stormy hospital stay secondary to cerebral nocardiosis with multiple brain abscesses, prolonged unconsciousness and neurological deficits. However, the patient was treated successfully, surgically and chemotherapeutically. He was discharged home in a good condition.