Pruritus is commonly encountered in individuals with end-stage renal failure (ESRF) on dialysis. This study was performed in order to find out the prevalence and pattern of pruritus in patients on regular maintenance hemodialysis (HD) as well as to analyze its relationship to age, sex of the patient, site of itching and timing of hemodialysis. One hundred patients with ESRF (age ranging from 13 to 80 years) free from systemic, skin or psychiatric disorders and other secondary causes attributable to pruritis, undergoing maintenance HD (duration on HD 7-141 months; mean 49.9 and median 43 months) at Samtah General Hospital, Samtah, Gizan, Kingdom of Saudi Arabia were evaluated for pruritus on two occasions at one week interval by each author independently. The data were analyzed by simple descriptive statistics viz mean, median and chi-square test. Pruritus was observed in 27 of 40 males (67.5%) and 40 of 60 females (66.7%) with an overall prevalence of 67%. It was mild in 34 (50.8%), moderate in 22 (32.8%) and severe in 11 (16.4%). Sub-group analysis with reference to age and sex revealed that pruritus was significantly more in women aged 45 years and above, when compared with men of similar age-group (p < 0.05) or women below 45 years (p < 0.02). Pruritus was predominant in spinal dermatomes. Discomfort of pruritus was more during HD in three (two men and one woman) and HD gave relief for the day in 10 other individuals (four men and six women). Our study suggests that pruritus is observed in all age-groups and of both sexes of ESRF patients on HD although the intensity and site of itching and relationship to HD sessions varied with individuals.

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Patients with end-stage renal failure (ESRF) on maintenance dialysis, commonly develop secondary hyperparathyroidism and renal osteodystrophy (ROD). Alfacalcidol, taken orally or administered intravenously, is known to reverse these complications. In this study, 19 ESRF patients, who were on dialysis (13 on hemodialysis and six on peritoneal dialysis) for longer than six months and having serum parathormone levels at least four times normal and serum calcium less than 2.1 mmol/L, were randomly allocated to treatment with oral or intravenous (i.v.) alfacalcidol for a period of 12 months. There were six patients on hemodialysis (HD) and three on peritoneal dialysis (PD) in the oral treatment group while in the i.v. group there were seven patients on HD and three on PD. Clinical and serial biochemical assessments showed no statistically significant difference between the orally- and i.v.-treated patients in terms of suppressing secondary hyperparathyroidism and osteodystrophy. However, patients with features of mild ROD on bone histology, had more satisfactory changes in biochemistry when compared to others. Our results further support the use of intermittent oral alfacalcidol in ESRF patients because of its cost effectiveness, ease of administration and convenience, especially for peritoneal dialysis patients.

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Renal diseases associated with hepatitis C virus (HCV) infection are a significant problem for clinicians and diagnostic pathologists. A wide variety of disorders, including a spectrum of immune-complex glomerulonephritides, has been reported in association with hepatitis and cirrhosis caused by HCV. For some of these diseases, including membranoproliferative glomerulonephritis type I and cryoglobulinemic glomerulonephritis, plausible links between HCV and the glomerular pathology have been proposed. In other cases, the role of the virus in the pathogenesis of the renal disease is less certain. This communication catalogues the renal manifestations of HCV infection, providing clinical and pathological descriptions of the most prevalent disorders. Where available, evidence implicating HCV in the causation of the disorders is also discussed.

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Perirenal masses are an uncommon manifestation of malignant lymphoma. We report a 73-year-old patient who had this very unusual pattern of renal involvement in non-Hodgkin's lymphoma. Diagnosis was made on the basis of characteristic ultrasound and computed tomography findings and confirmed by histology from a specimen obtained by ultrasound guided biopsy.

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The objective of this study is to evaluate the use of ultrasound in the initial evaluation of renal colic. We studied prospectively 21 patients referred for radiographic evaluation for renal colic from January 1998 through April 1998. All sonographic studies were performed with real-time sector scanner (Kertz, Compeson 410 using 3.5 MHz Probe). Our sonographic criteria for a positive examination consisted of the visualization of urinary tract calculus and/or unilateral hydronephrosis with or without ureterectasis. The presence of urinary calculi was proven in 18 out of 21 patients (85%). The absence of calculi was established in three cases either by negative I.V.U. (2 cases) or by the clinical and sonographic demonstration of epididymitis as the cause in one patient. In the 18 patients with proven urinary calculi, ultrasound correctly identified the diagnosis in 15 cases (83%). Of those 15 visualized calculi, 11 were located at the ureterovesicular junction, two in the renal pelvis, one in the proximal third of the ureter, and one in the distal third. The sensitivity of ultasonography to detect renal calculi was 83% and the specificity, 100%. The one false positive examination with unilateral hydronephrosis proved to be due to a retroperitoneal liposarcoma. There were two cases in which the urinary tract ultrasound examination was negative. We conclude that ultrasound has a high diagnostic value when used as the first line investigation for the initial evaluation of renal colic.

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Renal transplant recipients are more prone to developing infections. We report a 37-year old renal transplant recipient who developed infective endocarditis of the aortic valve, heart failure and renal allograft dysfunction. He underwent aortic valve replacement which was followed by improvement in cardiac as well as allograft function.

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Despite the wide use of intravenous cyclophosphamide (IC) in lupus nephritis (LN), there are few published studies showing the effect of this treatment on renal histology. In this prospective study, we report the effect of IC on the evolution of histopathologic features in successive renal biopsies in patients with LN. Thirty patients with class IV or V LN were started on IC (10-15 mg/kg) administered once every month for six months followed by three monthly for another six doses making a total of two years of therapy. The clinical course of the disease, serum creatinine and 24 hours urinary protein and creatinine clearance were tested at entry and subsequently during each follow-up visit. Repeat renal biopsy was performed after completion of two years of therapy. The mean serum creatinine of the study patients was 166.3 + 42 tmol/L at entry which decreased to 104 + 46.4 tmol/L at two years (P < 0.01). The mean 24 hours proteinuria decreased from 2.81 + 2.4 g at entry to 1.39 + 1.54 g at two years (P < 0.003) and the mean creatinine clearance increased from 58 + 31 ml/min at the start of treatment to 64 + 32 ml/min at two years of therapy (P < 0.05). Nine patients had serum creatinine of > 200 tmol/L, of whom six progressed to variable degrees of chronic renal failure. Repeat renal biopsy was performed in 21 patients. The original biopsy of these patients showed class IV in 17 and class V in four patients. On repeat biopsy, five of class IV disease had progressed to advanced sclerosis, four to class V, and five remained unchanged. The remaining three patients with class IV LN changed to one each of class I, II and III. Of the four patients with class V, one progressed to advanced sclerosis, one changed to class III and two remained the same. There was a significant decrease (P < 0.05) in the activity index although there was a significant increase in the chronicity index (P < 0.001). Multivariat analysis for possible risk factors for progression to chronic renal failure showed initial high serum creatinine to be a powerful predictor of renal failure. In conclusion, IC pulse therapy is effective in improving or stabilizing renal function in patients with class IV or V LN. The only poor prognostic determinant observed was higher initial serum creatinine value.

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Fifty-eight patients on maintenance hemodialysis in a dialysis unit at Tunis, Tunisia were tested for anti-hepatitis C virus (anti-HCV) antibodies by second generation ELISA test, and for HCV-RNA by nested reverse transcriptase polymerase chain reaction (RT-PCR) of 5' non-coding region. Specificity of the antibodies was confirmed by immunoblot test. HCV genotype was defined using INNO-LIPA test. Twenty-seven out of 58 patients (46.5%) were reactive by ELISA. Transaminase levels were assessed over a six-month period and showed normal average values. Fourteen of the 27 anti-HCV positive patients (51%) were positive by RT-PCR. Type 1b HCV genotype was the most prevalent, seen in all the dialysis patients and one patient in addition, was co­infected with genotype 4. There was a significant correlation between the duration on dialysis (over five years) and the prevalence of anti-HCV-positive patients (P<0.005) while no correlation existed between the number of blood transfusions and the presence of anti­HCV antibodies. The present study illustrates the high prevalence of HCV infection among Tunisian dialysis patients (51%) and indicates that the spread may be nosocomial rather than transfusion-related.

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A large body of evidence suggests the existence of functionally polarized human T-helper responses based on their profile of cytokine secretion. Human T-helper cell clones can be divided into two mutually exclusive subsets, T-helper cell 1 (Th1) and T­helper cell 2 (Th2). Substantial work in several animal models has demonstrated that allograft rejection is associated with enhanced Th1 activity and tolerance with enhanced Th2. Some studies have not been consistent with this association. In this study, gamma interferon (INF-y) and interleukin 4 (IL-4) levels (as indicators of Th1 and Th2 activity, respectively) were assayed in supernatant of cultured peripheral lymphocytes. The levels of these cytokines were compared between a study group of 26 stable kidney transplant recipients immunosuppressed with cyclosporine A, corticosteroids and azathioprine or mycophenolate mofetil, and a control group of 10 healthy blood donors. The mean INF-γ and IL-4 levels in the control group were considered as the cutoff levels for comparison. Our results showed that 25/26 of the study patients (96%) had low levels of INF-γ compared to 4/10 of the control subjects (40%), (P<0.05). However, the IL-4 level was high in 10/26 of the study patients (38%) and 3/10 of the control subjects (30%), not a statistically significant difference, (P>0.05). In conclusion: These results suggest that well­established graft tolerance may be mediated via depressed Th1 activity rather than enhanced Th2 activity.

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A 35-year old male patient developed elevated transaminases about an year after cadaveric donor renal transplantation maintained on triple immunosuppression therapy. Azathioprine was discontinued and the liver enzymes normalized. Three years later, he showed evidence of cyclosporin (CyA) nephrotoxicity as well as sclerosing cholangitis. The dose of CyA was therefore reduced. This was followed shortly by deterioration of his renal function and mycophenolate mofetil (MMF) (3 gm daily) was therefore introduced. He developed intractable diarrhea, which improved on reducing the dose of MMF to 2 gm per day. Eventually, the patient seemed to stabilize on low dose CyA and prednisone (Pred) along with 2 gm of MMF. Four months later, the patient discontinued CyA on his own but continued with MMF and Pred. Over the following two years, his renal functions have remained stable with serum creatinine of around 120 µmol/L, despite the low immunosuppression being administered.

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