Several reports have discussed the neurotoxic effects of star fruit (Averrhoa carambola) in patients with chronic kidney disease (CKD). There is also some evidence highlighting the potentially harmful effects on patients with apparently normal renal function, who after consuming this fruit, developed acute renal injury. We performed a systematic review of the literature in the two main global databases (PubMed and Embase) as well as in Lilacs, for Latin American publications. We also included case reports, case series, or review articles which presented individual patient data. Animal or in vitro studies were excluded. We initially screened 259 references, of which 42 were selected for full-text review and 26 were finally selected for data extraction. A total of 123 patients from eight countries were documented: Brazil, with 47 cases, had the highest reported incidence, followed by Taiwan (36), Bangladesh (20), China and France (8 each), Sri Lanka (2), and Thailand and Colombia (1 each); 28 (22%) of the patients died. Despite the relatively low frequency of star fruit consumption, it has become a global issue. Patients with already diagnosed CKD are the obvious target for preventive measures, but persons with undiagnosed kidney conditions could also be at risk.

Prevalence of chronic kidney disease (CKD) is increasing worldwide principally among the elderly population many of whom will eventually need renal replacement therapy. The relationship between frailty and CKD in the elderly population has been recognized. However, studies concentrating on frailty in pre-dialysis patients are limited. CKD predisposes to frailty through many potential mechanisms; anemia, bone mineral disease, oxidative stress, and malnutrition which in turn lead to progression of CKD culminating in a vicious cycle. Identifying potential causes of frailty in elderly pre-dialysis patients and recognizing individuals at risk should be an area of focus to nephrologists and researchers. Modalities that may improve frailty in elderly pre-dialysis patients such as treatment of anemia and bone mineral disease may improve outcome. However, this has not been established and further research is needed. The aim of this review is to address the importance of recognizing frailty in elderly pre-dialysis patients using simple tools and describing its implications on clinical outcome.

Quinalphos or Ekalux, an organophosphate pesticide, is used in controlling the pests of a variety of crops. Quinalphos was studied on male Sprague-Dawley albino rats. The acute po LD50 of technical Ekalux was 19.95 mg/kg in males. Ekalux, produced several pathological changes in the kidney. A glomerulus demonstrated capillary lumina occluded by degenerated cellular debris. Basement membrane showed irregular wrinkling and branching. The proximal tubular cells showed damage such as dilation of endoplasmic reticulum, accumulation of glycogen granules, and pyknotic nucleus. The changes also included swelling of the mitochondria and reduction of the cristae up to total destruction. The distal tubular changes included electron lucency and vacuolation of cytoplasm. The distal convoluted tubule wall showed edematous epithelial cells, formation of blebs, and microvilli loss. These results suggest that subchronic exposure of rats to Ekalux causes ultrastructural changes in renal corpuscle and marked ultrastructural changes in proximal and distal tubules.

Erythropoietin resistance index calculation has been used as a tool to evaluate anemia response to erythropoietin therapy. Very little has been reported in its use when using darbepoetin and factors influencing in Arab patients. Darbepoetin resistance index (DRI) was calculated in all our patients using darbepoetin. This was correlated to demographic, clinical, and laboratory parameters. Of the 250 patients, 40.4% were diabetic, 71.1% on hemodialysis, and 28.6% on hemodiafiltration), 23.9% with PermCaths (PC), and 76.1 % with arteriovenous fistula (AVF). The mean DRI was 10.96 ± 12.9 I. Females had 45% higher DRI than males (P = 0.005), and patients with PC had a 66% higher DRI than those with AVF (P = 0.029). Patients with Vitamin D level below the 50^th percentile had 55.9% higher DRI than those above it (P = 0.05). DRI was negatively correlated with age (P = 0.018), dialysis vintage (P = 0.039), interdialytic weight gain P = 0.007), Vitamin D level, and serum albumin (P = 0.005) and positively correlate with parathyroid hormone (PTH) level (P = 0.000). No impact was seen by the mode of dialysis, being diabetic, using anti-hypertensive therapy, body mass index, Kt/V, serum iron, total iron binding capacity, transferrin saturation, ferritin, C-reactive protein, Ca, or P. DRI in our Arab patients was comparable to erythropoietin resistance indices reported in other communities. Higher DRI was observed in females, PC users, lower serum albumin, lower Vitamin D, and shorter dialysis vintage. A negative correlation existed between DRI and age, dialysis vintage, interdialytic weight, and serum albumin and a positive correlation with PTH level.

Integrated multidisciplinary predialysis education (MPE) is usually provided to support and prepare the pre-end-stage renal disease (ESRD) patients before the initiation of renal replacement therapy (RRT). However, the impact of MPE is not known in our population, which is comprised patients of Asian origins and recipients of a totally subsidized health-care system. This research compared the survival probability, sociodemographic, and clinical characteristics of MPE patients and non-MPE patients (or crashlanders). A retrospective cohort study was conducted to investigate ESRD patients who started RRT in Brunei Darussalam from January 2013 to December 2014. Data were extracted from the computerized clinical database and dialysis records. A total of 351 new cases of ESRD patients who started on hemodialysis during the study period were included in the study. The median age was 56.0 years, with a slight male preponderance (56.6%). The MPE group was significantly older (P = 0.001) and more likely to have a history of diabetes mellitus (P = 0.013), ischemic heart disease (P = 0.014), and hypertension (P = 0.016). Despite being older and having more comorbidities (P = 0.028), MPE patients have a better survival probability (P = 0.028) and a 34% decreased risk of dying. Of those who died, older age (P = 0.001), higher serum creatinine (P = 0.01), and lower hemoglobin level (P = 0.017) were significant prognostic indicators. MPE before the initiation of RRT contributed to greater survival probability in near ESRD patients. The survival benefits were evident despite the presence of inherent risks (older age and presence of comorbidities) in the MPE population in comparison with the non-MPE cohort.

Sickle cell nephropathy is a severe complication of sickle cell disease (SCD) that has a wide range of manifestations, from asymptomatic microalbuminuria to end-stage renal disease (ESRD). The data on patients with SCD who develop ESRD are scarce. The aim of this study was to explore the course of patients with SCD who developed ESRD and received renal replacement therapy (RRT). The course of patients with SCD who developed ESRD and started dialysis at two centers in the Eastern Province of Saudi Arabia was retrospectively analyzed. Parameters included age at initiation of dialysis, survival until death or kidney transplantation, hospitalization due to pain crisis, disease-related parameters, and requirement for blood transfusion. Sixteen patients with SCD developed ESRD and started RRT with either hemodialysis or peritoneal dialysis. The mean age at initiation of dialysis was 46.6 years. The majority of patients (10 out of 16) were resistant to erythropoiesis-stimulating agents (ESA) and required blood transfusion repeatedly. Pain crises were infrequently encountered. Median survival was 54 months. Four patients received kidney transplantation with good outcome. In conclusion, most patients with SCD who developed ESRD were resistant to ESA and required repeated blood transfusion. The rate of hospitalization due to pain crisis was relatively low. Survival on dialysis was comparable to that of patients with no SCD, and the post-transplant course was relatively benign.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with end-stage renal disease. Chronic kidney disease (CKD)-associated cardiovascular mortality is more prevalent in those with diastolic heart failure and is an early predictor, while increased left ventricular mass (LVM) is a strong independent risk factor. Hypovitaminosis D is extensively being studied as a nontraditional risk factor for CVD. The aim of the present study is to look at the association of Vitamin D and other parameters of mineral bone disorder (MBD) with diastolic dysfunction and LVM in nondiabetic young adult patients with CKD. This was a hospital-based, cross-sectional observational study. Groups I and II comprised nondiabetic predialysis CKD patients (stage 4 and 5) and healthy controls, respectively. Groups IA and IB comprised cases with and without diastolic dysfunction, respectively. Vitamin D level was measured by enhanced chemiluminescence method and intact parathyroid hormone (iPTH) by electrochemiluminescence method. Parameters for diastolic function and LVM were assessed by Doppler echocardiography, tissue Doppler imaging, and M-mode echocardiography. Vitamin D level was significantly lower in Group I as compared to Group II. Diastolic dysfunction was present in 48.8% of the cases and was significantly associated with serum phosphorus and calcium-phosphorous product, but not with Vitamin D level. A statistically significant positive correlation between LVM and iPTH was found in our study. Hyperphosphatemia and high calcium-phosphorous product can be a better early predictor of diastolic dysfunction than Vitamin D while secondary hyperpara-thyroidism with increased LVM may be a bad prognostic marker.

Assessing hepatic fibrosis in hemodialysis patients with chronic hepatitis C (CHC) can help to evaluate the long-term prognosis, complications of hepatitis C virus (HCV) as well as eligibility for renal transplantation,. Our aim was to assess liver fibrosis in Egyptian hemodialysis (HD) patients infected with CHC genotype 4 using a fibroscan. This cross-sectional observational study was conducted over two years on a cohort of 134 Egyptian patients on prevalent HD at Kasr Al Ainy Hospital. All patients were subjected to routine laboratory evaluation including, hepatitis B surface antigen, hepatitis B core antibody, hepatitis Be antigen, hepatitis C antibody (HCVAb) and human immunodeficiency virus antibody, quantitative polymerase chain reaction (PCR) for both HCV and hepatitis B virus (HBV), serum hyaluronic acid level, and alpha-fetoprotein (AFP). Fibroscan was performed on all HCV-positive patients. The mean age was 47.43 ± 12.65 years, 50.7% were male, and 49.3% were female. The most common causes of end-stage renal disease were hypertensive nephropathy (32.1%) and diabetic nephropathy (18.7%). HCVAb was positive in 57.5% of the patients and HBV was positive in 3%. Forty HCV-positive patients (57.1%) who underwent fibroscan had mild to significant fibrosis, and thirty patients (42.9%) had advanced fibrosis. There was significant correlation between HCV PCR and duration on HD, number of blood transfusions, and hyaluronic acid (HA) level. In addition, there was a significant correlation between serum HA and HD duration as well as liver fibrosis. No significant correlation was found between duration on HD and fibrosis stage (P = 0.619); also, no significant correlation was noted between the age of the patients and HA level or stage of fibrosis (P = 0.970). Fibro-scan is a simple noninvasive test that can be used to assess liver fibrosis in HD patients with CHC. Most of the study patients had mild to significant fibrosis.

Cytomegalovirus (CMV) is one of the most frequently encountered opportunistic viral pathogens in kidney transplant recipients. In this study, we retrospectively reviewed all living related and unrelated kidney transplant recipients on regular follow-up from January 2006 to June 2015, who were suspected to have CMV clinically and confirmed by DNA polymerase chain reaction (PCR). CMV PCR was detected in 102 kidney transplant recipients. The median time of detection after kidney transplant was 21 months, ranging from 15 days to 84 months. There were 58 male and 44 female patients. The induction immunosuppression in living related kidney transplants was with antithymocyte globulin or basiliximab, whereas the most common maintenance immunosuppressive regimen was with cyclosporine, mycophenolate mofetil, and prednisolone. Most of the transplant recipients were asymptomatic at the time of detection of CMV PCR (67%). Fever, mainly low grade, was the main presentation in 16% of patients, followed by diarrhea (15%) and pneumonitis (2%). The most common hematological abnormality was lymphopenia seen in 46% of patients, followed by anemia (40%) and thrombocytopenia (14%). The common biochemical abnormalities found were elevated alanine aminotransaminase (18%) and hyperbilirubinemia (9%). The serum creatinine was found to be above baseline in 72% of patients. All patients with CMV infection were treated with intravenous ganciclovir, 2.5–5 mg/kg q 12 hourly, according to creatinine clearance, for 21 days. The treatment was successful in all but two patients, who died during the treatment period. There was a significant improvement in the kidney and liver functions after successful treatment of CMV infection. Our study shows that CMV infection should be considered in a patient presenting with unexplained rise in serum creatinine, low-grade fever, diarrhea, or anemia. A significant improvement in kidney and liver functions was observed after successful treatment of the infection.

Aging of the population and the increased prevalence of diseases such as diabetes and arterial hypertension result in an increasing need of dialysis treatment. Herein we describe a cohort of elderly patients on peritoneal dialysis (PD) and assess the influence of the modality on the long-term survival. Out of a multicenter prospective cohort of 2,144 BRAZPD PD incident patients during a period from December 2004 to October 2007, 762 elderly adults, defined as patients ≥65-year-old, were eligible for the study, 413 started on automated PD (APD) and 349 on continuous ambulatory PD (CAPD). Patients were followed until death, transfer to hemodialysis, recovery of renal function, loss to follow-up, or transplantation. Demographics and clinical data were evaluated at baseline and described as mean ± standard deviation, median, or percentage. Competing risk and time-dependent Cox analysis were performed, having dialysis modality APD] vs. CAPD as a dependent variable, as hazard ratio (HR) is not proportional throughout the therapy time. Mean age was 74.5 ± 6.8 years in APD, 74.6 ± 6.7 in CAPD, 50.8% females in APD, 54.4% in CAPD. The frequently observed comorbidities were diabetes (52.3% in APD and 47% in CAPD) and left ventricular hypertrophy (36.3% in APD and 46.1% in CAPD) whereas 93.6% presented Davies score ≥2. In Cox time-dependent analysis, HR did not show difference up to 18 months HR = 1.11, confidence interval (CI) = 0.85–1.46], but thereafter, APD modality revealed lower risk of mortality (HR = 0.25, CI = 0.0073–0.86), when compared with CAPD. After adjustment for the confounding factors, CAPD presented a higher risk of mortality (HR = 4.50, CI = 1.29–15.64). No differences in survival were observed up to 18 months of therapy; however, beyond 18 months, APD modality was a protection factor.

Mortality in systemic lupus erythematosus (SLE) has decreased with the advent of immunosuppressive therapy and the development of hemodialysis. This study aims to evaluate the survival rate, factors of poor prognosis, and causes of death in SLE in a Tunisian series. The records of all SLE patients followed up in a single center during 1974–2014 were reviewed. The causes of death were identified. Prognostic factors of survival were analyzed by multivariate analysis using the comparison of the survival rates by the log-rank test. Two hundred ninety-nine patients with SLE were included (274 women, 25 men) aged meanly of 27.52 years at diagnosis. The death occurred in 50 cases (16.7%). The mean age at death was 28.46 years (14–69 years). The patient survival rates at 5, 10, and 20 years were 83.8%, 78.6%, and 56.7%, respectively. The leading causes of death were active SLE (50%) and infectious complications (36%). Independent factors of poor prognosis identified by multivariate analysis were myocarditis (P = 0.029), splenomegaly (P = 0.0015), and worsening of renal function (P = 0.004). Remission was identified as a protective factor (P = 0.047). Our study shows that renal disease remains the primary cause and the main predictor of death in SLE, which is consistent with the literature data.

Hepatitis C virus (HCV) is a common infection affecting 15% of hemodialysis population in Saudi Arabia resulting in delay in transplantation and long-term complications. The use of peginterferon resulted in sustained virologic response (SVR) in 40%–85% of patients, especially if combined with ribavirin. The treatment is hampered by the high dropout due to anemia and requirement of blood transfusion resulting from this therapy. Some studies have shown that the addition of increasing dose of erythropoiesis-stimulating agents (ESA) and reduced dose of ribavirin results in reduced dropout rate with high SVR. We conducted an open-label prospective study using either peginterferon α-2a alone (Group I, 32 patients) or peginterferon α-2a plus adjusted dose ribavirin (Group II, 26 patients). A total of seven patients dropped from the study (2 in Group I and 5 in Group II). Analysis was done only on patients who completed the study (thirty patients in Group I and 21 in Group II). There was no significant difference in the demographic data, HCV genotype, liver biopsy grade and stage, and laboratory tests between the two groups. Patients received ESA to combat expected anemia. Group II had a better early virologic response than Group I [17 out of 21 (80%) and 14 out of 30 (47%) respectively, P = 0.014] and better SVR [18 out of 21 (85%) and 15 out of 30 (50%) respectively, P = 0.009]. There were no differences in mean white blood cells, hemoglobin, and platelets between the two groups at any time with only four patients dropping out due to anemia or side effect of medications. Alanine aminotransferase was lower in both treatment groups compared to baseline with no difference between the groups. Peginterferon α-2a and ribavirin are superior to peginterferon α-2a alone in treating hemodialysis patients with chronic HCV infection.

The United States Renal Data System showed 1.2% and 1.6% incidences of tuberculosis (TB) in patients on peritoneal dialysis and hemodialysis (HD), respectively. Kidney transplant (KTX) patients have higher rates. We studied the epidemiology and outcome of TB in patients with kidney dysfunction in a tertiary care hospital in the past decade. We examined data of patients with TB with and without kidney dysfunction from 2006 to 2015 through an electronic system. Statistical analysis was completed using Stata software, Chicago, IL, USA. We found 581 patients with active TB of whom 37 had renal dysfunction including chronic kidney disease, HD, and KTX. No difference was found in the prevalence, age, or gender predilection. The age ranged from 1 to 95 with a mean (standard deviation) of 38.6 (21.1) years. The incidence of TB is 3 per 100,000. The number of patients per year with active TB ranges from 52 to 128 and 3 to 4 in the general population and kidney dysfunction group, respectively. Sixty-five percent of patients with kidney dysfunction had pulmonary TB, 5% had pleurisy, and 30% had extrapulmonary TB. Eighty-four percent of patients with kidney dysfunction completed the course of treatment with 16% treatment failure and 0.4% developed multidrug-resistant TB; 8% were lost to follow-up and 8% died during the treatment period. This study showed no gender predilection for TB in the general population and immunocompromised. Duration of symptoms before diagnosis of TB was shorter in kidney dysfunction patients in comparison to the general population. TB cultures were the most positive tests whereas bronchoalveolar lavage and skin test were the least positive for detecting TB in the kidney dysfunction group. Improvement in registries and screening is required to enhance the capturing rate and detection among this group, as well as providing accurate data to health authorities and the public about the magnitude, future trends, treatments, and outcomes regarding TB in kidney dysfunction.

Age is an important risk factor for cardiovascular disease in the general population and in dialysis patients. The aim of this study is to investigate the influence of age on the cardiovascular status of asymptomatic predialysis patients with chronic kidney disease (CKD). Echocardiography and carotid ultrasound were performed in 61 patients with CKD stages 4–5, who were divided by age into two groups: group 1 (≥65 years, n = 31) and group 2 (<65 years, n = 30). Data were compared with those of control group (≥65 years, n = 20). Group 1 patients had significantly higher left ventricular mass index (LVMI), (P <0.001), worse LV diastolic function (lower E/A ratio: P<0.05, E’ velocities: P< 0.001, E’/A’ ratio: P <0.001, and a higher ratio E/E’: P <0.05) and a higher prevalence of aortic (P <0.01) and mitral calcification (P <0.001) compared to group 2 patients. Elderly patients also had significantly increased intima-media thickness (IMT, P <0.001) and a greater prevalence of carotid plaques (P <0.05) and calcifications (P <0.001) than younger patients. Multiple regression analysis showed that IMT, LVMI, and E/A ratio were independent variables associated with aging (R² = 0.605). We concluded that older CKD patients demonstrated more profound structural and functional abnormalities of the myocardium, as well as more prominent vascular changes compared to younger CKD patients. The changes in IMT, LVMI, and E/A ratio are independently associated with aging of CKD patients.

Acute poststreptococcal glomerulonephritis (PSGN) is the most common type of glomerulonephritis seen in children. It can affect multiple organs with heart being frequently involved. Yet, there are very few studies on cardiac status in children with PSGN and hence this study was conducted. All consecutive children from 1 month to 12 years of age, admitted over a two-year period with a diagnosis of PSGN, were included in the study. An electrocardiogram (ECG) and two-dimensional echocardiogram were performed in all patients on admission and repeated at six and 12 weeks, if abnormal. A total of thirty patients (18 males and 12 females) were enrolled in the study. The median age was six years. Prolonged QTc interval was found in 11 patients (37 %), of whom nine had hypertension. Seven of the 30 patients had a left ventricular ejection fraction (LVEF) <60%. The same patients also had left atrium/aorta ratio >2 and E/A ratio >2. LVEF returned to normal by six weeks in all except one patient, in whom it was normal by 12 weeks. Two of seven patients with low LVEF had normal blood pressure. All the seven patients recovered completely on follow-up. ECG and echocardiographic abnormalities may be seen in the acute phase of PSGN but are usually transient, returning to normal in most patients by three months. Although hypertension is the most common cause of cardiac failure, the role of primary myocardial dysfunction should also be considered.

Renal failure in diabetes is a common cause of renal replacement therapy. The affected kidney goes through various changes in all compartments progressively. The classification of diabetic nephropathy is based on glomerular lesions and displays a heterogeneous morphology. Abnormalities in tubulointerstitial and vascular compartments are important in assessing the outcome of these patients. We applied the new pathologic classification of diabetic nephropathy by Tervaert et al to classify the renal damage in diabetes. This is a prospective study over two years. We analyzed 74 renal biopsies in diabetic patients, both type-1 and type-2. Indications for biopsy were rapid onset of proteinuria, absence of retinopathy, presence of hematuria, active urine sediment, and rapid unexplained deterioration of renal function. Biopsy was done to rule out nondiabetic renal disease or any other associated pathology with diabetic nephropathy. In our study, 53 patients were male and 21 patients were female. Age ranged from 27 to 82 years. The mean ± standard deviation age at the time of the biopsy was 54.09 ± 11.59 years. Mean duration of diabetes was 10.2 years. Proteinuria ranged from 1 to 26 g. Type-111 histopathological lesion was the most common lesion observed in our series. There was a correlation between the degree of tubulo-interstitial damage with renal function. There was no correlation between the fundal changes and degree of proteinuria with the histological class of diabetic nephropathy. Application of the classification by Tervaert et al to diabetic lesions reduces the inter-observer variability and also helps in prognosticating and management of patients.

Diabetic nephropathy (DN) is one of the major complications of type 2 diabetes mellitus (T2DM). The diagnosis of DN is mostly clinical. Kidney biopsy is indicated only if nondiabetic renal disease (NDRD) is suspected. This study is aimed to assess the prevalence of NDRD and to determine predictor and prognostic factors of DN, NDRD. It was a retrospective analytic study including T2DM patients in whom renal biopsies were performed at our department from 1988 to 2014. Seventy-five patients were included. Mean age was 52.7 years with sex ratio at 1.56. Renal biopsy findings were isolated NDRD in 33 cases, NDRD superimposed on DN in 24 cases, and isolated DN in 18 cases. Most common NDRD found were focal segmental glomerulosclerosis (21%) and membranous nephropathy (19%). Multivariate analysis showed that the absence of ischemic heart disease [odds ratio (OR) = 0.178, 95% confidence interval (CI) = 0.041–0.762], absence of peripheral vascular disease (OR = 0.173, 95% CI = 0.045–0.669), and presence of hematuria (OR = 7.200, 95%CI = 0.886–58.531) were independent predictors of NDRD. 24 patients reached end-stage renal disease 55% in DN group, 16% in DN associated to NDRD group, and 30% in NDRD group. The prevalence of NDRD found in our study confirmed usefulness of renal biopsy in patients with T2DM, especially in those without degenerative complications, hypertension, and insulin therapy.

Prevalence, clinicopathological features, and outcome of childhood idiopathic steroid-resistant nephrotic syndrome (ISRNS) vary in different countries. We report on these parameters in a single center in Khartoum. We retrospectively reviewed all the records of children with idiopathic nephrotic syndrome (INS) followed up in the pediatric renal unit, Soba Hospital, Khartoum between 2001 and 2012. ISRNS was defined as no remission within four weeks of daily prednisolone at a dose of 60 mg/m². In 430 children with INS 130 (28%) had SRNS with a mean age of 7.7 ± 4.12 years. Males were 78 (60%). At presentation, hematuria was recorded in 57%, hypertension was recorded in 48%, and renal impairment in 15%. Histopathology showed focal segmental glomerulosclerosis in 40.8%, mesangioproliferative glomerulonephritis (22.3%), mesangiocapillary glomerulonephritis (16.9%), minimal change disease (MCD) (16.2%), and membranous glomerulonephritis (3.8%). Therapy included cyclosporine in 38.5%, additional therapy with cyclophosphamide, mycophenolate mofetil or tacrolimus in 20.8%, and steroids ± diuretics ± angiotensin converting enzyme (ACE) inhibitors in 40.7%. After 3.64 ± 2.84 years, 26.8% had complete remission (CR), 18.6% partial remission (PR), 26.8% were unremitting, 21.5% had chronic kidney disease (CKD), 1.6% died, and 4.6% were lost to follow-up. Non-MCD cases had significantly lower CR and higher CKD rates than MCD (P = 0.047 and 0.041, respectively). Cyclosporine ± additional therapy was significantly associated with higher rate of CR than steroids ± ACE inhibitors ± diuretics (P = 0.001), but the prevalence of CKD between the two groups was not significantly different (P = 0.604). Impaired renal function and hypertension at presentation were risk factors for CKD (P = 0.001 and 0.001, respectively). In Sudanese children with ISRNS, non-MCD lesions were the most common lesions. This pattern in addition to the lack of adequate therapy may explain the relatively lower CR and higher CKD rates. Impaired renal function and hypertension at presentation were risk factors for progression to CKD.

Acute kidney injury (AKI) is common in hospitalized patients with mortality varying from 10% to 80%. It is crucial to know the incidence and etiology of AKI to promote prevention strategies. Our study aimed at obtaining a comprehensive review of the pattern and spectrum of patients who presented for emergency hemodialysis to Kasr Al-Aini Hospital between October 2012 and October 2014. We analyzed clinical and laboratory factors in all such patients. Two thousand twenty three patients were included of which patients with AKI were 728 patients (36%). Cardiac diseases were the cause of AKI in 171 patients, other prerenal causes were found in 55 patients, drug induced AKI in 113 patients, and obstetric causes in 48 patients. Glomerulonephritis was responsible for AKI in 101 patients, lupus nephritis was found in 33 patients of them. Patients with chronic kidney disease who presented with acute exacerbation were 243 patients (12%). Patients who were discovered to be with end-stage renal disease during their first presentation itself were 1052 patients (52 %). Diabetes mellitus was present in 50.12%, while hypertension was present in 29.56%. Hepatitis C virus was present in 17.3%, while HBsAg was present in 0.8%. Drugs and obstetric causes represented a larger fraction among our cases than seen in developed countries. Lupus nephritis was also a common cause of AKI.

Occult hepatitis B infection (OBI) is a potential cause of infection transmission in patients with chronic kidney disease (CKD) and dialysis-dependant patients. It is liable to be missed since the marker for OBI, hepatitis B core antibody (HBcAb), is not done routinely. We carried out a study to assess the prevalence of OBI in CKD Stage II–V or requiring renal replacement therapy. It was a cross-sectional study carried out at Fatima Memorial Hospital, Lahore, from May 2104 to May 2015. A total of 188 patients were included in this study, 124 were dialysis dependent and 64 had acute or CKD Stage II–V. About 17.55% (n = 33) of patients had isolated HBcAb positive. Nearly 33.5% (n = 63) of patients were found to have hepatitis B surface antigen positive, indicating development of immunity by exposure to virus. About 20.74% (n = 39) of patients were co-positive with HBcAb also. The prevalence of isolated HBcAb in dialysis and CKD patients is high; therefore, testing for HBcAb should be a routine part of screening in our CKD population to rule out OBI. Further confirmation with polymerase chain reaction analysis for HBV viral DNA is recommended. Considering our circumstances, a consensus statement from the hepatologists and nephrologists is needed to further plan for the management of such cases.

We aim to evaluate the disturbances in mineral metabolism, abnormalities in bone mineral density (BMD), and extraskeletal calcification in newly detected, untreated predialysis stage 4 and 5 chronic kidney disease (CKD) patients at a tertiary care hospital in North India. This is cross-sectional observational study. A total of 95 (68 males, 27 females) newly detected patients underwent clinical evaluation, biochemical assessment [serum calcium, phosphorus, alkaline phosphatase (ALP), albumin, creatinine, intact parathyroid hormone (iPTH), 25- hydroxyvitamin D (25(OH)D)], BMD measurement (at spine, hip, and forearm) by dual-energy X-ray absorptiometry (DXA), lateral abdominal radiograph [for abdominal aortic calcification (AAC)], skeletal survey (to look for any abnormality including fractures), and echocardiography [for any cardiac valvular calcification (CVC)]. Symptoms related to CKD-mineral bone disorder were seen in 33.6% of the study patients. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism, and hypovitaminosis D was 64.2%, 81.1%, 49.5%, and 89.5%, respectively. CVC was seen in 22.1% of patients on echocardiography, mostly involving the mitral valve. Patients with CVC were more likely to be males and smokers. There was no significant difference in iPTH levels between patients with or without CVC. AAC was seen in 10.5% of patients on lateral abdominal X-ray. Patients with AAC had higher levels of iPTH, phosphorus, and ALP and lower levels of calcium compared to patients without AAC. BMD by DXA showed a low bone mass in 41.05% of our patients and was more prevalent in CKD stage 5. Most of the study patients had hyperparathyroidism and low 25(OH)D levels. Our study shows that newly detected, naïve Indian CKD patients have a high prevalence of disturbances of mineral metabolism including hyperparathyroidism, Vitamin D deficiency, abnormal BMD, and valvular and vascular calcification, even before initiating dialysis.

The incidence of acute kidney injury (AKI) is high in the elderly, who comprise an ever-growing segment of the population. Elderly patients pose a different set of diagnostic and therapeutic challenge owing to their associated comorbidities. AKI in the elderly is associated with an increased risk of mortality, morbidity, prolonged length of stay, and progression to chronic kidney disease. Data regarding the clinical profile of AKI in the elderly from the South Indian population are limited. Hence, we present this analysis of the etiological and prognostic factors associated with AKI in elderly population from South India. This is a cross-sectional, prospective, observational study conducted in a tertiary care teaching hospital from Bengaluru, during the period from May 2011 to October 2012. Institutional Ethical Committee clearance was obtained. Informed consents were obtained from patients who fulfilled the inclusion criteria. Elderly patients >60 years of age with features of AKI (Risk, Injury, Failure, Loss, and End-stage criteria) 1 at admission and those who developed AKI following hospital admission were included in the study. Demographic details, detailed medical history, comorbid conditions, etiological factors, prognostic factors, and outcomes were collected. Statistical analysis was done using Statistical Package for the Social Sciences software. Two hundred patients fulfilled the inclusion criteria and were enrolled into the study. The mean age was 70.5 years. Fifty-nine percent were males and 41% were females. Peak incidence of AKI was in the age group 60–69 years. Diabetes was seen in 44%, hypertension in 35%, ischemic heart disease in 19%, and chronic obstructive pulmonary disease in 12% of cases. Ninety-one percent had AKI at admission, and the rest developed it during hospitalization. The average duration of hospital stay was seven days. Etiological factors for AKI were medical in 87% of the cases, surgical in 11%, and gynecological in 2%. Sepsis was the most common etiology of AKI among the medical cases. Among sepsis, pneumonia and urosepsis were the most common causes of AKI. Medical AKI had a better outcome compared to surgical causes of AKI. Fifty-six (28%) patients required dialysis. Forty-four patients received hemodialysis and 12 received peritoneal dialysis. The overall mortality in the study group was 15%. Mortality among oliguric AKI (25%) was higher than in nonoliguric AKI (5%) patients (P = 0.002). The mortality rate was higher among postsurgical AKI compared to the medical causes (P <0.001) and in patients who required dialysis. Sepsis is the most common cause of AKI in elderly with high morbidity and mortality. Oliguria, postsurgical AKI, and need for dialysis were independent predictors of mortality.

The use of an automated biopsy device, and real-time ultrasound for percutaneous kidney biopsies (PKBs) has improved the likelihood of obtaining adequate tissue for diagnosis and also has reduced the complications associated with the procedure. We aimed to determine the frequency and type of complications associated with PKB and to determine the diagnostic yield. It was a retrospective file-based review of cases who underwent PKB of native kidney between January 2003 and December 2013 at the Aga Khan University Hospital in Karachi, Pakistan. PKBs were performed by trained nephrologists or radiologists using an automated device with a 16/18-gauge needle under real-time ultrasound. The data obtained included age, gender, clinical and histopathological diagnosis, and complications associated with the procedure (minor: hematuria, local infections, and hematoma; major: transfusions, severe infections, surgery, nephrectomy, arteriography, embolism, and death. Yield of the procedure was based on the number of glomeruli obtained. Patients having major complications were compared with the patients who had minor or no complications. A total of 433 native kidney biopsies were performed. The mean age of the patients was 41 ± 15.9 years, and 58% of the patients were male. The main histological findings were membranoproliferative glomerulonephritis (17.6%) followed by focal and segmental glomerulosclerosis (16.4%) and interstitial nephritis (13.9%). Majority of the procedures were performed by nephrologists (67.4%). The overall complication rate was 14.2%. Among those, 21 patients (4.8%) had a major complication while the others had minor complications. Of those who had a major complication, 17 patients required blood transfusion(s) and had hematuria or a major hematoma, three had prolonged hospitalization >24 hours, and one patient required surgical intervention. Only 10 procedures (2.3%) had inadequate tissue to establish the histopathologic diagnosis. PKB under real-time ultrasound guidance is a safe and efficacious procedure to establish the histological diagnosis of the renal disease.

Collagenofìbrotic (collagen type III) glomerulopathy (CG) is a rare nonimmune-mediated glomerular disease. It is characterized by massive deposition of organized collagen type III fibers, which is localized in the mesangial and subendothelial glomerular areas and associated with increased serum levels of procollagen type III peptide. Association with systemic diseases and malignancies is extremely rare. Herein, we present a case of a nine-year-old girl, known case of type I diabetes mellitus, who presented with fever, nephrotic range proteinuria, generalized edema, and hypertension. Clinical examination did not show nail abnormalities or bone abnormalities. Renal biopsy revealed mesangial expansion and remarkable narrowing and obliteration of the glomerular capillaries by pale, amorphous material. Immunohistochemical study demonstrated diffuse linear glomerular capillary and tubular basement membrane staining for immunoglobulin G (IgG) and albumin. Ultrastructural examination identified massive mesangial and sub-endothelial deposition of dense frayed, curvilinear banded fibers with characteristic features of type III collagen. The patient was diagnosed to have combined CG and diabetic nephropathy (DN). This is the first report of CG in association with diabetic changes in renal biopsy. In this report, we describe the clinicopathological characteristics of this disease, review CG in pediatric population, and explore its association with DN.

Carbamazepine intoxication manifests as altered mental status ranging from drowsiness to a coma and/or cardiac abnormalities such as sinus tachycardia, prolongation of the QRS interval, ventricular tachycardia, and hypotension. The patient may be agitated, but central nervous system (CNS) depression and presentation with coma is more common and could be lethal. Serious CNS toxicity often requires hemoperfusion and/or hemodialysis (HD). Herein, we present a case of a comatose patient, who was treated with a combination of hemoperfusion and HD in series. Our approach to treat the patient with a combination of hemoperfusion and HD was based on evidence from the literature supporting that the hemoperfusion and HD in series might provide the best clearance of carbamazepine.

Sickled erythrocytes in patients of sickle cell trait with microscopic hematuria have rarely been reported so far. A 30-year-old female underwent delivery of a healthy full-term baby by cesarean section. However, postcesarean, she had pain in abdomen and fever, for which she was advised blood and urine examination. The hemogram suggested mild leukocytosis with neutrophilia and the urine showed red blood cells, some of which were sickled. The patient was advised hemoglobin electrophoresis which suggested sickle cell trait (Hb-AS). We conclude that sickled erythrocytes should not be ignored in a sample of urine as it may serve as an important clue to the diagnosis of sickle cell trait or disease.

Milk-Alkali syndrome (MAS) consists of a triad of hypercalcemia, metabolic alkalosis, and acute renal failure. We hereby report a 75-year-old Indian gentleman who presented to our emergency department with a history of generalized weakness and easy fatigability. Investigations were consistent with MAS secondary to calcium carbonate and calcitriol treatment to prevent osteoporosis, aggravated by H1N1 influenza vaccine. The patient was treated with hemodialysis and zoledronate. To our knowledge, this is the first reported case of such association in the literature.

Multicystic renal dysplasia (MCRD) is the most common cause of abnormally enlarged kidney, diagnosed on antenatal ultrasound examination. It is an abnormality of the embryonic development in which the renal parenchyma is substituted by nonfunctioning renal tissue made up of cysts which do not communicate with each other. Vesicoureteric reflux (VUR), pelviureteric junction obstruction, vesicoureteric junction obstruction, and ureterocele are the most commonly seen abnormalities in contralateral kidney. Here, we report a case of prenatal diagnosis of unilateral MCRD with VUR in contralateral kidney. In conclusion, we want to emphasize optimal use of ultrasound imaging to detect such abnormalities as early as possible to guide the proper management.

Leiomyoma, the benign tumor of smooth muscle cell origin, is commonly seen in genitourinary and gastrointestinal tracts. Primary intracranial leiomyoma, however, is extremely rare occurrence. We hereby report a case of Epstein-Barr negative primary intracranial leiomyoma in a middle-aged renal transplant recipient, which mimicked left frontal parasagittal meningioma on neuroimaging. The tumor was completely excised and diagnosis of leiomyoma was clinched on pathological analysis with immunohistochemistry. The patient improved after tumor removal, and no evidence of tumor recurrence was noted on follow-up study after 10 months postsurgically.

Dense deposit disease or membranoproliferative glomerulonephritis type II is a rare glomerulopathy characterized on renal biopsy by deposition of abnormal electron-dense material in the glomerular basement membrane. The pathophysiologic basis is uncontrolled systemic activation of the alternate pathway of the complement cascade. C3 nephritic factor, an autoantibody directed against the C3 convertase of the alternate pathway, plays a key role. In some patients, complement gene mutations have been identified. We report the case of a child who had persistent microscopic hematuria, proteinuria, and hypocomplementemia C3 for over 2 months. Renal biopsy confirmed the diagnosis of dense deposit disease.

Hypocomplementic urticarial vasculitis syndrome (HUVS) is an autoimmune disease characterized by recurrent urticaria, arthritis, and glomerulonephritis (GN). Anti-C1q antibody is the marker of HUVS together with low levels of classical pathway complements which are C2, C3, C4, and C1q. We report a case of a 6-year-old boy who presented with episodes of rashes, injected conjunctiva, abdominal pain, and arthritis, diagnosed as HUVS. He had low C3, low CH50, normal C4, and positive C1q antibody. His urinalysis showed intermittent microscopic hematuria only. One year later, his laboratories showed persistent low C3 and positive Anti-ds DNA. The urinalysis showed hematuria, pyuria, and nephrotic-range proteinuria. Urine protein to creatinine ratio was 101.8 h mg/mmol. Kidney biopsy showed mesangioproliferative GN consistent with the diagnosis of HUVS. The patient was treated initially with prednisolone then azathioprine was added to the regimen. He showed good response with the disappearance of hematuria and proteinuria. Nine months later, he had no skin rashes with normal urinalysis and normal anti-ds DNA antibody. We report a case with HUVS and GN with positive anti-dsDNA antibody that revealed good response to combination of immunosuppressive therapy.

Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug-induced hypersensitivity is a severe adverse drug-induced reaction. Aromatic anticonvulsants, such as phenytoin, phenobarbital, and carbamazepine, and some drugs, can induce DRESS. Atypical crystalluria can be seen in patients treated with amoxycillin or some drugs and can cause acute renal failure. We describe a 66-year-old man who presented fever and rash and acute renal failure three days after starting amoxycillin. He was also using phenytoin because of cerebral metastatic lung cancer. Investigation revealed eosinophilia and atypical crystalluria. The diagnosis of DRESS syndrome was made, amoxicillin was stopped, and dose of phenytoin was reduced. No systemic corticosteroid therapy was prescribed. Symptoms began to resolve within three to four days. The aim of this paper is to highlight the importance of microscopic examination of urine in a case with acute renal failure and skin lesions to suspect DRESS syndrome.

Paraproteins can cause a variable set of pathologic changes in the kidney. The introduction of novel anti-plasma cell agents capable of reversing renal failure have revolutionized the management of paraprotein-mediated kidney injury. Activation of the transcription factor nuclear factor kB (NF-kB) has been shown to be involved in the development of human glomerulonephritis (GN). Inhibitors of NF-kB may provide potential agents for treatment of immune complex GN. In this paper, we report a patient with IgA nephropathy and IgG kappa myeloma, who responded dramatically to chemotherapy targeted toward myeloma. Our findings support the idea that drugs modulating NF-kB may add another dimension to the management of IgA nephropathy.

Compared with the general population, cancer risk in kidney transplant recipients is much higher. In the present study, we report a patient who was diagnosed with posttransplant lymphoproliferative disorder (PTLD) and had a fulminant course, dying within few days of diagnosis. This case report highlights the importance of timely detection and treatment of PTLD as it is associated with high mortality rate.