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Chronic renal failure (CRF) remains a major cause of morbidity and mortality world-wide and consumes substantial percentage of health budgets in the developed countries. Dialysis, in particular, continuous ambulatory peritoneal dialysis (CAPD), as a form of therapy in the management of CRF, has its own side effects and can contribute to the morbidity and mortality. The end result of these side effects is loss of effective surface area consequent on the development of peritoneal sclerosis. Peritoneal sclerosis in CAPD occurs gradually over repeated number of dialysis sessions. Serial observations of changes in the peritoneum, as a dialyzing surface, are difficult and it is only available by peritoneal biopsy, which is an invasive procedure. However, the discovery of some markers in the effluents of CAPD patients as a measure of peritoneal membrane status has reduced the need for this invasive procedure. In particular, the discovery of cancer antigen 125 (CA 125) in the effluent has provided a much-needed tool to follow the changes in peritoneal membrane of CAPD patients and prevent the occurrence of much dreaded peritoneal sclerosis.

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A 30-year-old seventh gravida presented with acute renal failure at 28 weeks of gestation. All her previous pregnancies were normal. With a differentional diagnosis of acute pyelonephritis, acute interstitial nephritis (cefuroxime induced) or rapidly progressive glomerulonephritis, treatment with antibiotics, intensive hemodialysis (HD) and pulse methylprednisolone followed by oral prednisolone was initiated. She was maintained on HD 5-6 times per week aiming at serum urea level of less than 15 mmol/L. After six weeks on HD, she underwent a cesarean section at 34 weeks of gestation with delivery of a baby weighing 1.6 kg. Percutaneous left renal biopsy performed one week post-delivery showed anti-glomerular basement membrane (GBM) antibody-mediated crescentic glomerulonephritis. The anti-GBM antibody, which was negative during pregnancy, was found to be positive at this juncture and remained so until ten months post-delivery while on HD. The patient continues to be on regular maintenance HD.

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Shewanella alga is a rare gram-negative marine bacterium. Its role as a pathogenic organism is gradually evolving with sporadic cases being reported in humans. We report a case of vascular steal syndrome secondary to a polytetrafluoroethylene (PTFE) graft in the upper extremity of an end-stage renal disease (ESRD) patient on maintenance hemodialysis, which was complicated by infection with S. alga. This resulted in extensive myonecrosis requiring amputation of the limb. To our knowledge this is the fourth case of primary S. alga infection, and the first case in a hemodialysis patient reported in the medical literature from the United States. We also discuss the biochemical tests for identification and differentiation of S. alga from a closely related strain S. putrefaciens.

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β2-microglobulin is a non glycosylated single chain protein present in light chain of HLA-class I. It is synthesized in the body and excreted in the urine. Its level increases in the blood of the chronic renal failure patients and may deposit in the soft tissue as β2-microglobulin derived amyloidosis, which appear clinically after 5 years of dialysis. We studied 64 patients (49(76%) men) with end stage renal disease (ESRD) on regular hemodialysis. The mean age was 34.3 ± 12 years and the duration of dialysis ranged between 0.4-12 years. Twenty-five healthy persons with mean age 34 ± 17.6 years were used as a control group. The blood level of β2-M in the control group ranged from 0.73-3.81 mg/l, while the range in the study group was 5.2-51.8 mg/l. In the urine of the control group, β2-M level ranged from 0-0.7 mg/l, while in the control group it ranged from 0.07-11.8 mg/l. There was significant difference in the β2-M level in both control and study groups. A direct correlation was found between the duration of dialysis and the level of β2-M in the blood. The traditional low flux dialyzer membrane had no effects on β2-M level in our series. We conclude that there is increased tendency with time for retention of β2-M in the ESRD patients on chronic dialysis. Using dialyzers with high flux synthetic membrane (e.g. acrylonitrile, polyamide, and polysulphone) rather than the low flux membrane may allow substantial removal of β2-M molecules, especially in patients who have little chance of receiving renal transplantation.

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We report a case of botryoid rhabdomyosarcoma with cartilaginous differentiation in the urinary bladder of a 24-year-old male. The tumor possessed the diagnostic histologic and immuno-histochemical characteristics of botryoid rhabdomyosarcoma. Foci of immature cartilage were noted within the tumor. Cartilaginous differentiation in rhabdomyosarcoma has been reported in tumors of the uterine cervix only. To the best of our knowledge, this is the first case reported of botryoid rhabdomyosarcoma with cartilaginous differentiation in the urinary bladder of an adult.

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To document the pattern of childhood renal diseases in the mid-western zone of Nigeria, we evaluated 195 children in the pediatric in-patient service at the University of Benin Teaching Hospital (UBTH) from 1997-2002. There were 250 renal disease episodes that occurred in 195 children. Renal disease accounted for 4.5% of total pediatric admissions. Urinary tract infection (UTI) was found in 82 (32.8%) cases caused largely by Escherichia coli in 39 (47.6%) followed by Staphylococcus aureus in 21 (25.6%). Other morbidities were nephrotic syndrome 61(24.4%), characterized by high incidences of associated UTI and steroid resistance; acute glomerulonephritis (AGN) in 50 (20.0%), complicated commonly by UTI and congestive cardiac failure; chronic renal failure in 24 (9.6%), resulting mainly from obstructive uropathy and glomerulonephritidis and nephro­blastoma in 17 (6.8%). Rare conditions included acute renal failure, urethral prolapse, vesico-ureteric reflux, polycystic kidney disease, urolithiasis and meatal stenosis among others. We conclude that potentially preventable renal diseases are still highly prevalent in our society to warrant community-based interventions. Preventive measures are advocated.

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Between 1990 and 1999 a total of 186 patients with staghorn renal stones were treated in our unit. Of them, 76 patients were managed by extra-corporeal shockwave lithotripsy (ESWL) alone using a third generation Siemen's Lithostar Plus lithotriptor. Sixty-one of these patients who completed a follow-up of 41 months formed the subjects of this study. ESWL was done after routine stenting of the affected side in all cases except one. The mean number of ESWL sessions was 5.2, delivering an average 15,940 shocks per patient. The average hospital stay was 21.68 days and the duration of the treatment was 1-41 months (mean 6.75 months). Significant complications occurred in 35 patients (57.4%) eight of whom sustained multiple significant complications. A total of 162 auxiliary procedures were used in conjunction with ESWL and in the management of complications. The stone free rate at three months was 18%, but rose by the end of the treatment period (41 months) to 63.9%. Our study indicates that ESWL monotherapy is associated with high morbidity rates, high rates of unplanned invasive procedures as well as prolonged treatment periods and hospitalization. Thus, ESWL monotherapy is not adequate for the management of staghorn calculi.

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The aim of this study is to evaluate the early complications seen after donor nephrectomy in living donor renal transplantation. Between November 1989 and June 1998, 270 living donor nephrectomies were performed at the Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran. Sixty donor records which were incomplete were discarded from this study. A questionnaire with relevant queries was prepared and sent to all the donors. The information sought included age, gender, marital status, drug addiction and smoking, blood pressure, blood group, serological tests, blood tests for hematology and biochemistry, coagulation profile, urine reports, nephrectomy site, duration of anesthesia, intra-operative and early post-nephrectomy complications, hypertension, respiratory and genitourinary complications, water and electrolyte imbalance, hemorrhage, and wound infection. Statistical analysis was done using Fox Pro and SPSS software. It was noted that females donated more kidneys to there relatives (p < 0.05) and had a higher prevalance of anemia (p < 0.01). More males were addicted to smoking and/or opium than females (p < 0.01), and fewer addicts donated their kidneys (p < 0.05). The site of nephrectomy was similar between men and women. Complications were significantly greater in addicted donors (p < 0.05). Hemorrhage occurred more commonly in association with right nephrectomy (p < 0.05), while wound infection occurred more commonly in men (p < 0.05). There were no deaths. Our results suggest that living donor nephrectomy is safe and is assosiated with minor complications causing little morbidity and no mortality.

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The incidence and prevalence of end-stage renal disease (ESRD) is increasing. Diabetic nephropathy has increased in absolute numbers and as a proportion of patients with ESRD. This is almost totally accounted for by the explosive outbreak of Type 2 diabetes mellitus (DM). The world is in the midst of an epidemic of Type 2 DM and hence this trend is likely to continue for some more time. The contribution of glomerulonephritis as a proportion of patients with chronic renal failure (CRF) has declined due to increase in other causes such as diabetes. The annual incidence of IgA nephropathy, which is also a very common cause of renal insufficiency, has not changed. The incidence of focal segmental glomerulosclerosis is increasing while that of membranoproliferative glomerulonephritis is decreasing. Peak incidence of ESRD due to hypertension has shifted to a higher age-group. The proportion of renovascular disease as a cause of ESRD is also increasing. Human immunodeficiency virus associated nephropathy is the third leading cause of ESRD in African-Americans aged 20-64 years. Other diseases such as analgesic nephropathy and lead nephropathy are slowly disappearing. The significance of elevated body lead in patients with varying degrees of renal insufficiency requires further evaluation. The incidence of CRF is significantly higher in the elderly and hence there is a "graying" of CRF population. Census projections show that this trend will continue into the foreseeable future. The incidence and prevalence of ESRD vary between different populations, countries and within countries. The reason for the variations requires further study.

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A 63-year-old woman presented with severe volume depletion and pre-renal azotemia. She had xerostomia, xerophthalmia and cervical lymhadenopathy. Urine examination revealed proteinuria, hematuria and glycosuria. Laboratory studies, after volume repletion, revealed hyper-gammaglobulinemia. Renal biopsy showed interstitial nephropathy and salivary-gland biopsy showed glandular atrophy and diffuse fibrosis. Diagnosis of leishmaniasis was established by bone marrow examination and serology. The patient was treated with pentavalent antimonial (Glucantime) with an excellent response. The treatment, however, had to be interrupted because of transient nephrotoxicity. After a break of four weeks, the antimonial was reinstituted with no more side effects. Both the sicca syndrome and the nephropathy responded very well to the treatment at nine months follow-up. In this case the presentation of visceral leishmaniasis was atypical, probably because of the partially suppressed immunity. The clue to the diagnosis was the polyclonal hypergammaglobulinemia.

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Hepatitis C virus (HCV) infection is a major health problem in hemodialysis patients. Identified risk factors include duration on dialysis and blood transfusion. A more important risk factor contributing to the high prevalence of anti-HCV, particularly in the developing countries, could be the non-adherence to the known universal infection control precautions. The factors that might help reduce and/or prevent the spread of HCV infection among patients on dialysis include: early screening of patients for anti-HCV, reduction of the number of blood transfusions given, strict application of universal infection control precautions and isolation of patients or machines which ever feasible. The issue regarding isolation of anti­HCV positive patients is controversial and although it is not recommended by the Centers for Disease Control to isolate these patients, it may be advisable to do so, particularly in the developing countries, wherein a high prevalence of anti-HCV exists among the dialysis population.

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This study was conducted at the Aga Khan University Hospital, Karachi, Pakistan to evaluate factors that affect outcome following revascularisation in patients with renovascular hypertension. We included all the patients diagnosed to have renovascular hypertension, confirmed by renal angiography, between July 1997 and September 2000. Of the total 15 patients, nine were males and six were females. Eleven patients received venous grafts, three received polytetraflouroethyline (PTFE) grafts while one patient underwent angioplasty and stenting. All were followed-up for a period of nine months (median) with the range from 2 to 84 months. A total of 33.3% of the study patients were completely cured, as they became normotensive without anti-hypertensive therapy after operation, while 27% showed marked improvement in blood pressure control post-operatively. Thus, extended cure or improvement of renovascular hypertension was achieved in 60% of patients. Normal pre-operative serum creatinine level, high pre-operative unstimulated peripheral renin levels and renal vein renin ratio of at least 1.75:1 were the most significant predictive factors for favorable outcome (p <0.012). The pre-operative severity and duration of hypertension as well as degree of disparity in kidney sizes did not predict the post-operative improvement in renal function and blood pressure control.

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This study was designed to evaluate the attitudes of the physicians in Saudi Arabia towards the use and monitoring of heparinization in hemodialysis patients. A questionnaire was sent to 162 physicians who collectively looked after 7390 patients in the 144 active dialysis centers in Saudi Arabia. A total of 142 out of the 164 (87.6%) physicians answered the questionnaire. Physicians who used conventional heparin were the vast majority; 131 (92.3%), while only four (2.8%) used low molecular weight heparin and seven (4.9%) used either of the two types. The method used for routine heparinization was constant infusion by 96 (84.5%) respondents, repeated bolus doses by 40 (28.2%) and either method by six (4.2%). A protocol for the use of heparin was available for only 100 (70.4%) of the respondents. To monitor heparinization, whole blood partial thrompoplastin time was used by 81 (57%) respondents, although 106 (74.6%) respondents believed that this test was reliable, reproducible and proportional to the serum concentration of heparin. The activated clotting time was used by only 39 (17.6%) and not available to 47 (33.1%); 84 (59.2%) believed in its reliability and reproducibility, while 11 (7.7%) did not and 47 (33.1%) had no idea. The Lee White clotting time was used by only 25 (17.6%) of the respondents; 37 (26%) considered it reliable and reproducible. The use of the automated devices at the bedside to perform the clotting time tests in the dialysis unit was believed to facilitate the monitoring process effectively by 106 (74.6%) respondents, while 19 (13.4%) did not believe in them. Accordingly, 127 (89.4%) respondents would use the automated devices in case they were available to them. In conclusion, a protocol to guide the heparinization in dialysis in Saudi Arabia is lacking in many centers and there is a need to provide them with automated bedside devices that monitor the clotting time for better implementation of the protocols.

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To measure the prevalence of the most common causes of end-stage renal disease (ESRD) among patients on maintenance hemodialysis (MHD), we studied the records of 248 hemodialysis patients in the Jeddah Kidney Center in December 2000. We found that the majority of cases of ESRD were of unknown etiology (42.7%). Hypertension was the most common known cause (36.3%) followed by diabetes mellitus (14.5%). We conclude that hypertension and diabetes constitute the most frequently known causes of ESRD among hemodialyzed (HD) patients in the Jeddah region.

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We performed a crossover study to compare the effect of vitamin E-modified dialyzers on acute intra-dialytic symptoms, with other membranes. Twenty patients on hemodialysis were studied. They were divided into two equal groups of low-flux (C15NL, E15NL) and high-flux (F60, EE15NL) membrane dialyzers. Within each group, a vitamin E-modified dialyzer was compared with another dialyzer in a crossover design over a two­month period. All study patients were seen during each dialysis session by a physician and the occurrence of intra-dialytic symptoms were recorded. There was a significant overall improvement in the incidence of acute intra-dialytic symptoms with the use of vitamin E­modified dialyzers as compared with the other membranes. This effect was more for cuprophane than polysulfone. The occurrence of hypotensive episodes did not differ. Our study indicates that we can achieve a reduction in the incidence of acute intra-dialytic symptoms with the use of vitamin E-modified membrane as compared to cuprophane and polysulfone.

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