There is still controversy about the efficacy of plasma exchange in the treatment of severe lupus nephritis. Some studies have reported no beneficial effect with plasma exchange, while others claim its usefulness when used in combination ("synchronization") with immunosuppressive drugs, particularly intravenous (i.v.) pulse doses of cyclophosphamide. We report here a 13 year old girl who presented twice with severe exacerbation of lupus nephritis (WHO class IV) leading to acute renal failure (ARF) necessitating dialysis, and who on both occasions responded well to i.v. pulse doses of cyclophosphamide and methylprednisolone plus plasma exchange. The second episode of ARF had occurred in spite of the patient being on maintenance therapy with prednisolone and i.v. cyclophosphamide. The course in this patient supports the view that the addition of plasma exchange to i.v. pulse cyclophosphamide might be effective in patients with severe lupus nephritis unresponsive to immunosuppressive drugs alone.

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Forty patients with end-stage renal disease on maintenance hemodialysis were categorized into three groups depending upon the route of administration of erythropoietin (EPO). Eighteen of these patients received i.v. EPO (group A), 11 were switched from i.v. to s.c. route (group B), and 11 other patients were started on s.c. EPO from the beginning of treatment (group C). They were studied to evaluate the efficacy of EPO and its dosage. The target hemoglobin was decided to be between 9 and 10.5 g/L. The hemogram of all these patients showed considerable improvement after EPO treatment. Mean hemoglobin level increased from 7.0 ± 1.0 in all the groups to 9.0 + 1.0, 9.1 ± 0.9 and 9.0 + 0.9 g/dl in groups A,B, and C respectively. Mean dose of EPO to achieve target hemoglobin was 120 ± 42.2, 42.6 + 16.2 and 36.6 + 11.1 U/Kg/week in groups A, B, and C respectively. Our observation illustrates that once weekly s.c. EPO is equally effective as i.v. EPO albeit at reduced dose and hence saving costs substantially without compromising patient care. Also, it maintains hemoglobin in target range in patients already stabilized on i.v. EPO.

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We reviewed 71 cases of children and adolescents with nephrolithiasis over a 9 year period (1982-1991). The mean age was 12.3 years. The male: female ratio was 2.5:1. Twelve patients (16.9%) had bilateral stones. Fifteen patients (21%) had documented urinary tract infection. Escherichia coli was the most common organism growing in the urine cultures. Five patients had metabolic abnormalities and four had genitourinary developmental anomalies. Of the 45 calculi recovered for analysis, 17 (37.8%) were predominantly calcium oxalate, 14 (31.1%) were mixed calcium oxalate and uric acid stones, two (4.4%) were uric acid, two (4.4%) were calcium phosphate, two (4.4%) were cystine and eight (17.8%) were struvite stones. Four patients passed their stones spontaneously. Forty-eight underwent open surgery, with complete stone clearance in 45 patients. Two patients needed nephrectomy, seven had their stones removed by endourological procedures, nine patients were referred to other centers for extra corporeal shock wave lithotripsy, while two did not need any intervention. After the initial hospitalization, 57 patients continued follow up for a mean period of 3.3 years. Of them sixteen patients (28.1%) had recurrence of stone disease. We conclude that renal stone disease in children in our area was not uncommon. The majority were calcium oxalate stones. The clinical manifestations were not specific. Open surgery was needed in the majority of patients. Due to significant recurrence rate, long term follow-up was essential. Follow up by a pediatric nephrologists and/or urologist would be advisable.

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Since glomerulonephritis is a typical inflammation, we are approaching the time when inhibitors of the mediators of inflammation will be used to modify the course of nephritides. In this category are thromboxane synthetase inhibitors and thromboxane antagonists as well as anti-leukotriene and anti-platelet activating factor agents. Corticosteroids are often limited by their side effects. Other approaches include the use of heparins, endothelin antagonists and E prostaglandins. This article presents the background knowledge to these considerations.

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Vascular access for hemodialysis has taxed the ingenuity of surgeons for a long time. Although the Brescia-Cimino arteriovenous fistula has become the principal access, usage of grafts become necessary when suitable artery and vein are not available for making a fistula. A total of 36 grafts for 24 patients were placed at the Riyadh Armed Forces Hospital between January 1988 and December 1989. Three of the grafts were autologous and 33 were synthetic. The forearm was the site of placement in 31 cases, four were placed in the thigh while one was placed in the arm. Twenty-eight complications were encountered during the follow-up period of which thrombosis was the commonest occurring in 14 instances (50%). A total of 23 secondary procedures were performed to prolong graft patency of which thrombectomy was the commonest (52.2%). Eight primary grafts had to be abandoned or replaced by secondary grafts. The overall patency for primary grafts was (87.5%) at six months, (79.1%) at one year and (70.8%) at two years.

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The files of 181 patients who underwent kidney transplantation at King Hussein Medical Center between 1983 and 1992 were reviewed to study the incidence and pattern of malignancy in them. Of them, 149 patients (82.3%) were recipients of live related donor allografts while 32 (17.7%) had received cadaveric allografts. Three patients (1.7%) developed malignancy giving an estimated annual incidence for post-transplant malignancy of 17/10,000 kidney transplanted patients. The first patient had squamous cell carcinoma of the nose, the second, Kaposi's sarcoma and the third, Non-Hodgkin's lymphoma involving the retroperitoneal lymph nodes. All these patients were on triple immunosuppressive drug protocol. The malignancies were diagnosed after a mean of 25.6 months following transplantation. The patient with squamous cell carcinoma responded to local excision of the tumor without altering the immunosuppressive therapy. The Kaposi's sarcoma regressed after discontinuation of cyclosporine without any adverse effects on the graft function while the patient with lymphoma died two months after the diagnosis was made. Our study shows that the incidence of malignancy after transplantation in Jordan is similar to what is reported in the literature.

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