Developing a non-invasive method such as diffusion-weighted magnetic resonance imaging (DWMRI) could be used as a feasible and reproducible modality in the differential diagnosis of allograft dysfunction. We assessed the functional status of the renal allograft by DWMRI and its applicability in assessment of graft dysfunction on all end-stage renal transplant patients who attained normal renal function on the 7 ^th day post-transplantation. Follow-up imaging of the recipient allograft was performed at the end of 90 and 180 days and in case of graft dysfunction. Kidney biopsies were performed to correlate with the corresponding MRI. The apparent diffusion coefficient (ADC) maps of the cortex and medulla were obtained by studying the DWMRI. The ADC values were significantly lower in the medulla compared with the cortex in normal donor kidneys and normally functioning transplanted kidneys, while they decreased significantly when rejection occurred. The reduction in ADC values occurred both in the cortex and in the medulla, and correlated with the degree of rejection on the kidney biopsies. The ADC values increased significantly during the recovery from rejection. We conclude that DWMRI can be beneficial in the diagnosis and follow-up of transplant patients during acute rejection.

Adequate intravascular volume maintenance is essential to ensure early graft function during renal transplantation. Various recommendations on optimum fluid therapy are based, at best, on sparse evidence, and that too only from observational studies. This prospective randomized controlled study was done to evaluate the effect of 20% human albumin on the early graft function in living donor renal transplantation. Eighty patients undergoing renal transplantation were randomly assigned to one of the intraoperative fluid regimens, 0.9% normal saline with 20% human albumin (albumin group) or 0.9% normal saline alone (saline group), after confirming the exclusion criteria. Intravenous fluid infusion was given to keep central venous pressure (CVP) between 12 to 15 mm Hg. The statistical package of social sciences, SPSS version 12, was used for statistical analysis. The intraoperative fluid volume infused [albumin group - 3381 ± 1021.2 vs. saline group - 3487 ± 978.5 (mL)] to maintain target CVP was comparable between the two groups (P value >0.05). Statistically, no significant difference was found between the two groups in terms of post transplant serum creatinine [day one; 2.76 ± 1.0 vs. 2.58 ± 0.94, day three; 1.48 ± 0.53 vs. 1.43 ± 0.71, day seven; 1.42 ± 0.6 vs. 1.42 ± 0.53 (mg/dL)] and urine output [day one; 13122.5 ± 5767.8 vs. 13909.4 ± 5324.7, day three; 9233.9 ± 3267.4 vs. 9250 ± 4794.2, day seven; 7517.6 ± 3043.6 vs. 6921.4 ± 3170 (mL)] (P value >0.05). Postoperative change in body weight [1.89 ± 3.82 vs. 2.48 ± 3.89 (kg)], tissue edema (10% vs. 7.5%), and pulmonary edema (2.5% vs. 5%) did not differ significantly (P >0.05). Twenty percent human albumin given intraoperatively, as a volume expander, does not improve early graft function in living donor renal transplantation. It should be used selectively rather than as a routine protocol.

As the cases of kidney transplant are increasing, the need to apply the factors to increase the success of transplant seems necessary. Mannitol increases the osmotic pressure and urine volume as a protective agent on renal tubules. We aimed to evaluate the effect of mannitol on short-term outcome of kidney transplantation by comparing two groups based on prescribing mannitol to donors. In a randomized clinical trial, 60 kidney recipients were assigned in two groups (30 in each), except that in one group donors received mannitol. They were studied with respect to age, gender, weight, blood urea nitrogen (BUN), creatinine (Cr), sodium (Na), potassium (K) and arterial blood gas (ABG) before and after surgery, and their pulse rate (PR) and blood pressure (BP) before, during and after surgery. Their urine volume was assessed in the operation room and the first 24 h after surgery. The short-term outcome, including BUN and Cr in the first 10 days after transplant, have been charted. Both the case (mannitol-positive donor patient) and the control (mannitol negative) groups were the same regarding the results gained for pre- and post-operative parameters. Follow-up assessments showed no significant differences in renal function. Based on this, we conclude that mannitol administration to donors does not have a beneficial effect on the prognosis and short-term outcome of transplantation on recipients; therefore, we feel that it should not be advised for kidney donors.

Reperfusion injury predisposes the kidney allograft to acute rejection. Apoptosis is a mechanism that results in graft injury, and TP53 is an important involved gene. To determine the association between single nucleotide polymorphism (SNP) in the pro-apoptotic protein p53 (rs1625895) and acute rejection in renal transplants, we studied 100 recipients of kidney allografts and 100 healthy individuals served as controls. The polymorphism was determined by the polymerase chain reaction restriction-fragment length polymorphism (PCR-RFLP) test. Overall, 31 recipients developed rejection. There was no difference in the genotype frequencies between the recipients and the controls. However, we found a difference of genotype and allele frequencies between recipients with and those without rejection. The WW genotype was more frequent in recipients with rejection. Although rejection is a complex immunologic event and functional importance of SNPs has not been confirmed yet, we suggest that wild type p53 may promote apoptosis during inflammation.

To determine the prevalence of controlled parathyroid hormone (PTH) serum levels with intensified therapy for chronic kidney disease mineral and bone disorder (CKD-MBD) in the dialysis population, we studied 563 chronic hemodialysis patients recruited from three different dialysis centers from three different major cities in the Kingdom of Saudi Arabia. The trend of the routine monthly chemistries related to CKD-MBD was evaluated besides the whole-molecule PTH serum levels over 28 months (January 2011 to April 2013). The cost ratios of the medications to the estimated dialysis total cost were calculated. There were 323 (57.4%) males in the study, and the mean age of the patients was 50.2 ± 15.2 years; 371 (65.9%) patients were initiated on dialysis before 2011. The causes of the original kidney disease included diabetes mellitus in 163 (29%) patients. Parathyroidectomy was performed in 23 (4.1%) patients and only six (23%) patients underwent the operation during the study period; most of the parathyroidectomies (69%) were performed before 2011. The trend of the medians of monthly serum levels of calcium, phosphorus, albumin, bicarbonate, alkaline phosphatase, serum levels of PTH and vitamin D25 assays showed better control of the levels with time. The added cost of cinacalcet was more significant than the other drugs, including vitamin D and phosphate binders, but the cost was minimal in comparison with the whole dialysis bill. The ratios of the discontinuation rates to the total patient-months of treatment for the different drugs were in the range of 3-4% and mostly due to transient overdosing of medications. We conclude that the trends of the median serum levels of PTH and related minerals in the CKD patients in our dialysis patients suggested a good inclination toward control and prevention of the vascular calcifications prevalent in the CKD-MBD. The popularity of use of new drugs such as cinacalcet is promising and does not seem to add much to the current out-patient cost of chronic dialysis.

Accelerated atherosclerosis is very common in hemodialysis (HD) patients and is related to morbidity and mortality. The aortic knob width (AKW), which can easily be calculated on chest radiographs has also been found to be related to atherosclerosis in patients with normal renal function. The importance of AKW in HD patients is not known. The current study is aimed to investigate factors associated with increased AKW in HD patients. The study participants had their medical history taken and a physical examination conducted, with calculation of dialysis adequacy and AKW. AKW was calculated from the chest x-rays at the end of the dialysis session, when the patients were in their dry weight. A total of 91 HD patients and 65 patients with normal renal function (as a control group) were included. The mean of the AKW was 35.0 ± 5.8 mm in HD patients and 26.6 ± 4.3 mm in the control group (P <0.0001). Stepwise linear regression analysis of both groups combined revealed that age (P: 0.001), male gender (P <0.0001), systolic BP (P <0.0001), presence of HD treatment (P: 0.016), and albumin levels (P: 0.021) were inde­pendently related with increased AKW. On the other hand, in HD patients stepwise linear regression showed that age (P <0.0001), pre-dialysis systolic BP (P: 0.003), male gender (P <0.0001), being a non-smoker (P: 0.002), total cholesterol (P: 0.001), and intact parathormone levels (P: 0.005) were independently associated with increased AKW. In conclusion, AKW is increased in HD patients when compared with the normal population. These preliminary findings may enhance the use of chest radiography as a screening method, and if confirmed, can assist risk stratification in HD patients.

Renal failure is accompanied by oxidative stress, which is caused by enhanced production of reactive oxygen species (ROS) and an impaired antioxidant defense. We studied 73 hemodialysis (HD) patients (39 males and 34 females) aged 24-75 years; the patients were randomized into two subgroups according to the type of hemodialysis membrane (35 patients were dialyzed on cellulose and 38 patients on polysulfone F7/F9 membrane dialyzers) and we assessed their antioxidant and lipid peroxidation status levels. The total antioxidant status (TAS) levels including whole blood levels of malondialdehyde (MDA) and glutathione (GSH); glutathione peroxidase (GSH-Px) , superoxide dismutase (SOD), and catalase (CAT) activities were measured, before and after hemodialysis. The MDA levels significantly increased 52.0% and 16.9% post dialysis among the cellulose and the polysulfone dialyzer users, respectively, (P <0.05). The TAS levels significantly decreased, 22.0 and 16.5% in the cellulose and polysulfone dialyzer users, respectively, (P <0.05). The erythrocyte SOD activity decreased 25.1 and 19.1% in the cellulose and the polysulfone dialyzer users, respectively, (P <0.05). The GSH concentrations, post dialysis, decreased 49.9 and 6.8% in the cellulose and polysulfone dialyzer users, respec­tively, (P <0.05). In contrast, the erythrocyte activity of CAT, post dialysis, increased 15.0 and 37.3% in the polysulfone and the cellulose dialyzer users, respectively, (P <0.05). We conclude that the type of the dialysis membrane affects the oxidative status after HD with possible consequences on patient morbidity and mortality.

Implantation of peritoneal dialysis (PD) catheters via the laparoscopic technique is expanding, but none of the studies concerning this technique have compared its outcome with the percutaneous insertion done by the nephrologist. We compared the technical survival and outcome of 52 PD catheters placed in 43 patients with end-stage renal disease (ESRD) in our center from March 2006 to October 2007. Of these, 27 PD catheters were inserted percutaneously by a nephrologist (group 1) and 25 were placed by a surgeon using the conventional laparoscopic technique (group 2). Very obese patients, those with previous abdominal surgery, and those who refused local anesthesia were excluded from the study. All catheters were evaluated for mechanical and infectious complications and the overall technique survival was analyzed. The incidence of complications in PD catheters did not largely differ between the two groups. Early catheter-related infection episodes (within two weeks of catheter placement) occurred in three of 22 (13.6%) patients in group 1, versus three of 21 (14.3%) patients in group 2 (P >0.05). The incidence of exit site leak was higher in group 2 (19.0%) compared to (4.5%) group 1 (P <0.001). Moreover, catheter survival was comparable in both groups (81.8% at 12 months and 77.3% at 18 months in group 1) versus (85.7% at 12 months and 80.9% at 18 months in group 2) (P >0.05). We conclude that in our study, the percutaneous bedside placements of PD catheters done by nephrologists were comparable with the laparoscopic insertions performed by surgeons where the high-risk patients were avoided, and the former provided a safer and more reliable access that allowed a rapid initiation of PD.

This study was undertaken to compare the outcomes of living donor renal transplant recipients using peritoneal dialysis (PD) and hemodialysis (HD) as a bridge modality for renal replacement therapy till renal transplantation. The demographic profiles of the recipients and donors, the patients' native kidney disease (diabetic versus non-diabetic), duration on dialysis, requirement of anti-hypertensive drugs, number of blood transfusions, human leukocyte antigen (HLA) mismatch status, pre- and post-transplant infectious complications, and post-transplant outcomes of patients were compared between the two groups. The demographic features of the study patients were similar in the two groups. The duration of dialysis prior to transplant was significantly longer in the PD group than in the HD group of patients. The anti-hypertensive drug requirement was lower and the hemoglobin level and residual urine volume at the time of transplant were relatively better in the PD patients compared to the HD patients. The number of acute rejection episodes, delayed graft function, surgical complications, glomerular filtration rate at one month and at the last follow-up, were also similar in both groups. The short-term and long-term graft survival was similar in both groups of patients. The one-, two-, five-, and eight-year death-censored graft survival rates of the PD patients were 98, 95, 85, and 73%, respectively, and in the HD group of patients, they were 100, 93, 84, and 79%, respectively. The one-, two-, five-, and eight-year patient survival rates in the PD group were 97, 92, 77, and 66%, respectively, and in the HD group, they were 97, 92, 79, and 69%, respectively. Our study suggests that the outcomes of the living donor renal allograft recipients did not differ between the groups of patients who used PD or HD as renal replacement therapy prior to renal transplantation.

Post-infectious glomerulonephritis (PIGN) still remains one of the most common glomerulonephritis in the developing world. We studied the epidemiology and clinical spectrum of PIGN in adults to identify the clinical, biochemical and histological factors that would predict renal outcome. Data of 102 adult PIGN patients treated between 2009 and 2011 with a mean fol­low-up of 12 months (6-36 months) were analyzed retrospectively. The mean age of the patients was 32.7 ± 15 years, with a male to female ratio of 1.2:1. At presentation, 99% of the patients had edema and oliguria, 73% had hypertension, 55% had macrohematuria and 60% had nephrotic range proteinuria. About 14% presented with complications (pulmonary edema-6%, seizure-1%, dialysis requiring renal failure-7%) and 9% had comorbid illness. Sixty percent of the patients had serum creatinine >2 mg/dL at presentation, which was persistent in 30% at the end of one week and 68% had hypo-complementemia. Renal biopsy revealed diffuse proliferative glomerulonephritis in 70% of the patients. At 12 months, 2% had persistent hypertension, 10% had persistent proteinuria and hematuria and 11% had serum creatinine >1.5 mg/dL. Univariate analysis with the Fischer Exact test revealed age >40 years, male gender, serum creatinine >2 mg/dL at one week, comorbid illness, requirement of dialysis, crescents in >30% glomeruli and persistent proteinuria and microscopic hematuria at 12 months as significant risk factors for poor renal outcome. Serum creatinine >2 mg/dL at one week and persistent proteinuria at 12 months were the independent risk factors that predicted poor renal outcome at one year.

Contrast-induced nephropathy is the third most common cause of acute renal failure in hospitalized patients. The purpose of this study was to compare three supportive treat­ments for prevention of contrast-induced nephropathy in high-risk patients undergoing coronary angiography. In this randomized clinical trial study, 150 patients with at least one risk factor, such as, congestive heart failure, history of diabetes mellitus, age >65 years or renal failure were randomly assigned to three equal groups: First group (Sodium (Na) bicarbonate infusion), second group [(N-Acetylcysteine (NAC) + Sodium Chloride (Nacl)], third group (Nacl). Angiography was performed with 350 mgI/mL of Iohexol (Omnipaque). Serum creatinine (Cr), blood blood urea nitrogen (BUN), and urine pH were measured at the start of angiography and 48 hours later. The three groups had no significant difference in demographic characteristics or other risk factors before intervention (P >0.05). Forty eight hours after exposure, the Cr level increased signi­ficantly in the Nacl group (P = 0.039), while these changes were not significant in the other groups (P >0.05). The incidence of contrast-induced nephropathy was not statistically significant between all the groups (P = 0.944). Although the Cr clearance had no statistically significant difference, it was lower in the NaCl group. Therefore, Na bicarbonate may be the treatment of choice in the prevention of contrast-induced nephropathy, because of less prescribed fluid volume and a lesser time required for infusion of the fluid.

Children with nephropathic cystinosis (NCTN) have evidence of defective intellec­tual functions and behavioral disorders. This prospective study was performed to detect the cognitive dysfunctions in patients with this rare hereditary lysosomal storage disease, define their behavioral phenotypes, and study the findings on magnetic resonance imaging (MRI) of the brain. Thirteen patients with confirmed diagnosis of cystinosis (mean age ± SD 5.9 ± 3.0, range 1.5 - 12 years) were subjected to the Stanford Binet test, Porteus Maze test, Child Behavior Checklist, and MRI brain. Thirteen age- and sex-matched children served as the control subjects (mean age ± SD 5.9 ± 2.9, range 1.7 - 12 years). The intelligence quotient (IQ) was significantly lower in patients with cystinosis (P <0.001), with a significant defect in verbal (language, memory, and compre­hension) and non-verbal abilities (visual perception and visiospatial and motor performance). A discrepancy between both abilities was detected - the non-verbal ability being lower; however, it did not reach statistical significance. Furthermore, analysis revealed the visiospatial ability to be significantly lower compared to the visual perception. In comparison to healthy controls, children with NCTN had evidence of increased incidence of behavioral problems, mainly social (P = 0.023). An MRI of the brain revealed varying degrees of atrophic changes in seven patients. Patients with NCTN need a wider scope of attention and care, encompassing not only the metabolic multisystem derangement, but also the neuropsychological impairment in the context of multidisciplinary management. This approach is crucial in formulating comprehensive plans for social and educational rehabilitation.

An ideal anesthetic technique for a renal allograft recipient must ensure hemodynamic stability, enhance graft reperfusion, and provide good postoperative pain relief. Hence, a combined general and epidural anesthesia is preferred. In our clinical practice, it has been observed that in chronically ill end-stage renal disease (ESRD) patients, a bolus injection of epidural local anesthetics invariably necessitated the use of vasopressor agents. Such hemodynamic fluctuations may not be favorable for the graft. A prospective, randomized, double-blind study was conducted on 50 ESRD adults, 18-55 years, scheduled for elective live related kidney transplantation. The patients randomly received either epidural fentanyl (50 μg) and normal saline (10 mL) or epidural fentanyl (50 μg) and bupivacaine (0.5%; 10 mL) followed by standardized general anesthesia. Perioperative hemodynamics and vasopressor requirements were compared with both regimens. Early graft function was assessed by the onset of diuresis after declamping, serial creatinine values, glomerular filtration rate, and 24-hour urine output estimation. In the preoperative period, statistically significant reduction in the mean arterial pressure and the cardiac index occurred in 60% of the patients receiving epidural bupivacaine boluses. These hypotensive episodes required a therapeutic intervention prior to general anesthesia, that is, intravenous mephenteramine (3-6 mg; 9.60 ± 2.32 mg) and crystalloid infusion (189.28 ± 21.29 mL). Intraoperative hemodynamic parameters, surgical blood loss, and transplanted kidney function were comparable between the groups. We concluded that the use of regional anesthetics needed to administered cautiously in renal transplant recipients to maintain hemodynamic parameters.

With regard to the significant morbidity and mortality due to tuberculosis in lung transplant recipients, the identification of brain-dead organ donors with latent tuberculosis by use of the QuantiFERON TB Gold (QFT-G) test may be of help to reduce the risk of TB reactivation and mortality in lung recipients. This study was conducted in the National Research Institute of Tuber­culosis and Lung Diseases (NRITLD) in Iran, from January to March 2013. A total of 38 conse­cutive brain-dead donors, not currently infected with active tuberculosis, were recruited. The medi­cal records of all the study enrollees were reviewed. A whole-blood IFN- release assay (IGRA) in reaction to early secreted antigenic target 6 (ESAT-6), culture filtrate protein 10 (CFP-10), and TB7.7 antigens, was performed and the released Interferon- was measured via enzyme-linked immunosorbent assay (ELISA). The data was analyzed with QFT-G software which was provided by the company. The demographic, characteristics and other variables were entered into SPSS version 11.5. The QFT-G test results of three donors (7.9%) turned out to be positive, negative for 24 donors (63.1%), and indeterminate for 11 cases (28.9%). Our study revealed the potential advantages of QFT-G in lowering the incidence of donor-derived post-transplant tuberculosis among lung recipients. However, a high rate of indeterminate results restricted the performance of QFT-G in this study.

To determine the risk factors, course of hospital stay and mortality rate among women with post-partum acute kidney injury (AKI), we studied (of 752 patients with AKI admitted to a tertiary care center during the study period between November 2009 and August 2012) 27 (3.59%) women with post-partum AKI. The data regarding age, parity, cause of renal failure, course of hospital stay and requirement of dialysis were recorded. Sepsis was the major cause (70.3%) of post-partum AKI. Other causes included disseminated intravascular coagulation (55.5%), pre-eclampsia/eclampsia (40.7%), ante- and post-partum hemorrhage (40.7% and 22.2%) and hemolytic anemia and elevated liver enzymes and low platelet count syndrome (29.6%); most patients had more than one cause of AKI. We found a very high prevalence (18.5%) of cortical necrosis in our study patients. A significant correlation was also found between the creatinine level on admission and the period of onset of disease after delivery. In conclusion, several factors are involved in causing post-partum AKI in our population, and sepsis was the most common of them.

Different types of skin disorders are prevalent among kidney transplant recipients. The development of nodular skin lesions in these patients would usually raise a suspicion of Kaposi's sarcoma. We report a patient, who presented with nodular skin lesions one year post transplant, but the biopsy revealed a rare diagnosis - Mycobacterium fortuitum (M. fortuitum) infection of the skin, subcutaneous, and renal allograft. He was treated successfully with an initial two-week course of intravenous cefoxitin, followed by a six-month course of ciprofloxacin, clarithromycin, and co-trimoxazole. There are a few reported cases of M. fortuitum infection in renal transplant recipients in the literature - notably urinary tract infection, allograft infection, and psoas abscess, but to the best of our knowledge this is the first case demonstrating extensive infection involving the skin, subcutaneous tissue, and renal allograft. Physicians vested with the care of renal transplant patients should be aware of this rare infection in these patients.

We report a renal allograft recipient on triple immunosuppression with prednisolone, azathioprine and cyclosporine who presented with ductal infiltrating carcinoma of the right breast eight years post-transplant, followed two years later with left ovarian papillary carcinoma.

Overdose with calcium channel blockers is uncommon, but is associated with high mortality. The management includes fluid resuscitation, calcium gluconate, glucagon, vasopressors, and high-dose insulin-euglycemia therapy. We describe a rare case of massive overdose of lercanidipine with shock, refractory to conventional therapies and multi-organ failure. Charcoal hemoperfusion with continuous venovenous hemodiafiltration was then used successfully and the patient showed remarkable recovery.

We present a 38-year-old man who presented to the emergency department with complaints of a snake bite. He developed acute kidney injury (AKI) and the kidney biopsy showed necrotizing glomerulonephritis, which is rarely reported in AKI after snake bite.

Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft tissue infec­tion. NF may result from any injury to the skin or from hematogenous spread. However, con­current emphysematous pyelonephritis and necrotizing fasciitis of the left thigh has not been reported. We report a case of emphysematous pyelonephritis and necrotizing fasciitis of the left thigh after intramuscular administration of diclofenac that improved with aggressive management including broad-spectrum antibiotics, nephrectomy and surgical intervention.

We report a very rare case of acute pyelonephritis in a 51-year-old female with a history of chronic kidney disease (CKD) and diabetes caused by a normally benign and a well-known human commensal organism, Saccharomyces cerevisiae that is very often prescribed as a probiotic in modern medical practice. The causal role of S. cerevisiae was confirmed by its isolation in blood, urine, stool as well as vaginal swabs thus proving its virulent nature in suitable situations.

Lactic acidosis is the result of imbalance between the systemic formation of lactate and its hepatic metabolism. In cancer patients, lactic acidosis is mainly associated with hematologic malignancies (leukemia and lymphomas) and the mechanism is known as Warburg's effect. We report a 76-year-old male known to have hypertension and coronary artery disease, who presented with abdominal distension and lactic acidosis. His initial evaluation showed multiple liver masses that were biopsied and the patient was diagnosed with undifferentiated carcinoma of unknown primary, involving the liver. The patient had progression of lactic acidosis leading to his death on day-15. As the lactic acidosis was not in the setting of hypoxia or hemodynamic instability, we made the diagnosis of malignancy-associated type B lactic acidosis, also known as the Warburg's effect. Warburg's effect can occur in solid cancer if the tumor involves the liver. It has bad prognostic implications. The use of intravenous bicarbonate as a temporary measure is of controversial benefit, as it can potentially worsen the metabolic acidosis and its use should be limited to patients with very low pH. In cancer patients, the use of lactatebased intravenous fluids can be potentially harmful and can increase the risk of tumor metastasis, at least in animal malignancy models.

A kidney biopsy is an important tool for nephrologists in the diagnosis of renal conditions, but not without the risk of bleeding due to its invasive nature. There is abundance of literature on bleeding complications secondary to this procedure in high-risk patient groups such as amyloidosis and chronic hypertension. An undefined and unrecognized risk is a peritoneal penetration. We report here a case where, despite adequately preparing a patient for a kidney biopsy, distortion of the peritoneum and retroperitoneum from previous surgery resulted in a fatal outcome. This was due to loss of peritoneal integrity and the consequent loss of local anatomical hemostatic mechanism.

Renal zygomycosis, caused by invasive fungi, is a rare and potentially fatal infec­tion. The patient usually presents with non-specific symptoms and renal failure. A 34-year-old male non-diabetic and without any predisposing factors for systemic fungal infection presented to the emergency department with diffuse abdominal pain, high-grade fever and acute renal failure with a serum creatinine of 6.5. A computed tomography showed bilateral diffuse globular nephromegaly. A urine smear for fungal examination showed right angle branching hyphae and kidney biopsy showed fungal hyphae within the glomeruli, tubules and interstitium. Although radiological investigations can give us a clue, the definitive diagnosis can only be made by kidney biopsy. A high index of suspicion and timely diagnosis is important for a proper management.

The objective of this study was to assess the effect of hepatitis C virus (HCV) infection on graft and patient survival in a cohort of Libyan renal transplant recipients. Medical records of 241 renal transplant (RT) patients who have been followed-up at the Benghazi Nephrology Center up to February 2010 were reviewed. Based on the presence or absence of anti-HCV antibodies and HCV-RNA in the serum, patients were divided into two groups: HCV-positives and HCV-negatives. Anti-HCV antibodies were detected by the enzyme-linked immunosorbent assay technique and HCV-RNA by the polymerase chain reaction. Of the 241 RT patients, 162 were male and 79 were female. One hundred and ten patients (45.6%) were HCV-positives and 131 (54.4%) were HCV-negatives. Acute graft rejection was significantly higher among HCV-negative than HCV-positive patients (42 patients versus 28 patients, respectively; P < 0.001). Conversely, chronic graft rejection was higher among HCV-positives than that among HCV-negative patients (35 patients versus 24 patients, respectively; P <0.05), and this difference became more significant after a 12-month period of transplantation (P <0.01). Seventeen patients died during the follow-up: Seven HCV-positives (6.3%) and 10 HCV-negatives (7.6%), and there was no significant difference in the death rate following RT between the two groups (P = 0.08). Among the seven deaths of HCV-positives, liver disease-related complications were the main cause of death in three (42.8%) HCV-positive patients compared with none in the HCV-negative patients. The presence of HCV infection influenced chronic graft survival in RT patients and a higher proportion of HCV-infected patients had hepatic dysfunctions after RT. An increase in fatal liver complications was noted in HCV-positive patients with RT. In addition to pre-RT-specific therapy of HCV infection, all measures should be taken to prevent HCV infection pre- and post-RT. HCV-infected RT recipients need close monitoring for graft and liver function to prolong allograft and patient survival.

This study retrospectively investigates the indications and results of renal biopsy in children to determine the patterns of childhood kidney disease in a single tertiary children's hospital in Egypt. We included all the patients who underwent ultrasound-guided renal biopsy from 1998 to 2012. All the kidney biopsies were studied under light microscopy, while immunofluorescence and electron microscopy were performed when indicated. A total of 1246 renal biopsies were performed over 15 years, on 1096 patients. The mean age of the patients at the time of biopsy was 9.2 ± 3.7 years. The main indication for a biopsy was the steroid-resistant nephrotic syndrome (n = 354, 28.4%), followed by the atypical nephrotic syndrome (n = 250, 20.1%), and renal abnormalities in the systemic diseases (n = 228, 18.3 %). In the 1226 pathologically diagnosed specimens, primary glomerulonephritis was the most common finding (n = 826, 67.4%), followed by secondary glomerulonephritis (n = 238, 19.4%). The most common causes of primary glomerulonephritis were Minimal Change Disease (MCD) (n = 267, 21.8%), diffuse proliferative glomerulonephritis (n = 188, 15. 3%), and focal proliferative glomerulonephritis (n = 164, 13.3%). Lupus nephritis (n = 209, 17%) was the most common cause of secondary glomerulonephritis. We conclude that the steroid-resistant nephrotic syndrome was the most frequent indication for biopsy and minimal change disease was the most common histopathological finding in our population.

The aim of this study is to assess the current situation of hypertension (HTN) care, to explore the barriers and to suggest the practical solutions to improve the quality of HTN care in primary health care centers (PHCC) in the Aseer region, KSA. This cross-sectional study was conducted in PHCCs in this region in 2010. Data collection sheets used to achieve the aims of this study consisted of three checklists, the first one derived from the quality assurance manual and HTN records used at the PHCCs giving details of the structural base of HTN care. Satisfaction with HTN care was assessed by using a five-point Likert scale questionnaire, while the third part was assessed by a checklist designed for the HTN care processes. Data were coded, entered and analyzed using SPSS version 16. The total number of HTN patients registered at PHCCs in Aseer region was 23,156 patients. Of them, 15,942 (69%) had files at PHCCs. Most of the essential infrastructures were acceptable, except training of doctors and nurses on HTN, which were 75% and 89%, respectively. About 40% of patients were on Beta blockers or ACE inhibitors and 30% were being given Aspirin in addition. HTN was uncontrolled among 45% of patients, while the defaulter rate was 22%. The rates of complications ranged from 0.7% for stroke to 7% for ischemic heart diseases. It was found that more than one-third of the patients had obesity and diabetes, while 10% suffered from dyslipidemia. Health teams were unsatisfied with the community participation (43%), patient compliance with appointment (32%) and coordination with hospitals (20%). They were satisfied with the health team (85%), while satisfaction with other items ranged from 60% to 75%. This study revealed that HTN patients received insufficient care, which could be attributed to many different barriers. In order to improve the quality of HTN care for HTN, these barriers should be overcome by implementation of the recommendations.

Chronic kidney disease is one of the main public health concerns in Sri Lanka. In comparison with dialysis, successful kidney transplantation improves both patient survival and quality of life, relieves the burden of dialysis in patients suffering from end-stage renal disease and decreases the cost of healthcare to the society and government. The objective of this retrospective cohort study was to evaluate graft and patient survival rates in patients who were transplanted from living donors at the Nephrology Unit of the National Hospital of Sri Lanka from January 2005 to January 2011. Data were collected using an interviewer-administered questionnaire and through a review of past medical records. The Kaplan-Meier method was used to determine the survival rate, the log rank test was used to compare survival curves and the Cox proportional hazard model was used for multivariate analysis. Mean follow-up was 26.44 ± 16.6 months. The five-year death-censored graft survival of kidney transplant recipients from living donors in our center was 93.5% and the five-year patient survival was 82.2%, which is comparable with other transplant programs around the world. The number of acute rejection episodes was an independent risk factor for graft survival. Delayed graft function, younger recipient age and unknown cause of end-stage renal disease were found to be risk factors for graft failure but after adjusting for confounding factors, and the difference was not apparent.

Chronic kidney disease is an emerging public health issue in Africa. At end-stage renal disease (ESRD), patients need hemodialysis (HD), which may expose them to blood transmitted infections, such as the hepatitis C virus (HCV). Sub-Saharan Africa has the highest HCV prevalence in the world, but data on HD patients is scarce and shows an exceptionally high rate in Senegal. To assess the efficacy of preventive measures in reducing HCV infection among dialysis patients, we retrospectively conducted a cross-sectional study in three Senegalese HD centers, including all HD patients who performed HCV serology between 1 ^st and 31 ^st August 2011. The demographical, clinical, and biological data were collected for each patient. We included 106 patients with a mean age of 43.4 ± 15.8 years (range from 18 to 80 years), with 52.8% males. HD vintage was 60.5 ± 15 months (range from six to 206 months). The main causes of kidney disease included nephrosclerosis (36%) and diabetes (24%). The prevalence of HCV was 5.6%, with one patient co-infected with the hepatitis B virus. After adjusting for age and sex, HD vintage was the only risk factor for HCV infection, while nutritional status and the number of blood transfusions did not significantly correlate with HCV infection. We conclude that during the past decade, the prevalence of HCV infection in HD patients living in Senegal has declined considerably, mainly because of improved transfusion measures and better clinical practice in the HD centers. Such efforts should be maintained and reinforced to reduce the seroprevalence of HCV infection.

This questionnaire-based study included 69 patients from the Republic of Guinea with end-stage renal disease (ESRD) and was conducted over 12 months. The factors that affected their quality of life (QoL) were determined. The included ESRD patients had an estimated creatinine clearance (CCr) of <15 mL/minute using MDRD formula. We used the SF36 question­naire and classified the results into two groups: Scores <50/100 as poor QoL and scores 50/100 as good QoL. Factors that determined the QoL were cessation of all activities and additional effort required, severe or mild pain, good or bad health, and reduced or not reduced social and physical activities. Of the 69 patients, 32 (46.3%) had a good QoL and 37 (53.7%) had a poor QoL. The estimated CCr was similar in both groups. The average age of the poor QoL group was 54 ± 4 years, the good-QoL group's average age was of 47.6 ± 4 years (P = 0.01). Patients with a good QoL had better overall health, but this was not statistically significant [OR = 0.42 (0.14-1.28); P = 0.14]. Patients with a poor QoL had more severe pain (P = 0.002); however, good QoL did not protect against mental problems [OR = 46.67 (8.18-351.97); P = 0.0001]. Mental status (P = 0.01) and social activities (P = 0.001) were reduced, and there were more comorbidities in the poor-QoL group (29.7%, with >4, P = 0.01). Good QoL was associated with younger age, fewer comorbidities, less severe physical pain, and fewer physical or social limitations. QoL could be increased by improving comorbidity treatments, giving more effective pain control, and providing more assistance for social and physical limitations.

Acute renal failure (ARF) is reported in some severe forms of malaria such as black water fever (BWF). It is associated with a high mortality rate and can be managed effectively with adequate renal replacement. A prospective survey of children with dark urine after a malarial infection with Plasmodium falciparum was coupled with a chart review study of patients managed in the past 11 years in the Pediatrics' Kinshasa University Hospital. Eighty-nine cases of ARF were identified, but data from only 63 patients were available, of whom 44 (69.8%) had severe malaria (39 with BWF and 5 with cerebral malaria). The mean age of the patients was 8.2 ± 1.73 years. Of the 39 cases of BWF, an association with quinine ingestion was observed in 32 children (82%). Urea and creatinine levels were elevated in all cases (135.4 ± 88.2 and 3.83 ± 2.81 mg/dL, respectively). Oligo-anuria was observed in 44.4%, severe metabolic acidosis (bicarbonate <15 mEq/L) in 61.5% and hyponatremia (<130 mEq/L) in 33.3%. Peritoneal dialysis was required in 36 patients, including 20 with BWF. The remaining patients were managed with conservative treatment. Twenty-eight children (44.4%), including 20 on dialysis, fully recovered and 14 died (22.2%), including eight cases of BWF. Our study suggests that ARF is commonly associated with BWF in Congolese children. Elevated urea and creatinine and severe metabolic acidosis were observed more often than other clinical/metabolic disturbances. Severe renal impairment remains a significant complication with a high mortality rate in low-resource settings.