A 21- year-old lady presented with chyluria, severe malnutrition, secondary amenorrhea, profound hypoalbuminemia, heavy proteinuria and renal tubular abnormalities suggestive of Type IV renal tubular acidosis. No particular cause for chyluria could be ascertained. She was successfully treated with an injection of 2% silver nitrate into the left ureter and urinary bladder. She continues to be well after 15 years of follow-up.

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HSP is the most common systemic vasculitis in children that is characterized by small vessel leukocytoclastic vasculitis. However, it is a self limiting disease, with few documented cases in Middle Eastern countries. Classic symptoms of the disease have been established in the literature, but new clinical features have recently been reported from Middle Eastern countries which include penile swelling, temperomandibular joint involvement, skin rash over the flexor surfaces of the extremities, and pleural hemorrhagic effusion. Familial Mediterranean fever (FMF) may present as HSP. The prevalence of the FMF gene in Middle Eastern countries raises interesting questions regarding the use of colchicine in HSP patients.

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Knowledge of the normal range of renal size is useful in appreciating variations that may occur due to morbidities. Ultrasound is a simple and safe method of evaluating renal sizes in all age groups. This is a prospective study of the assessment of renal dimensions in apparently healthy neonates at the University of Benin Teaching Hospital, Nigeria. One hundred and fifty neonates were studied, including eighty-five males (56.7%), and sixty-five females (43.3%). The mean length of the right kidney was 44.9 ± 3.2 mm and the mean length of the left kidney was 44.4 ± 3.5 mm. The difference in renal length between the two sides was not statistically significant. The height and weight of the child showed strong correlation with longitudinal renal measurements. The study also showed the independence of neonatal renal sizes on gender and race.

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Tunneled, cuffed central vein catheters (TCC) are widely used for delivering hemodialysis (HD). Among the complications associated with central vein catheters in HD patients, infection is the principal cause of morbidity and mortality. The optimal strategy for management of TCC infections is unclear. This prospective study was aimed at assessing the efficacy of antibiotic-lock therapy using vancomycin and gentamycin in preventing catheter­related blood stream bacterial infection in patients on HD. A total of 63 HD patients with 81 TCC were enrolled at the time of catheter insertion. Patients were randomized into two groups: Group I (33 patients, 37 insertions) included TCC with antibiotic lock therapy, and Group II (30 patients, 44 insertions) with routine TCC management. Infection-free catheter survival of both groups was evaluated and compared at the end of the 12-month study period. A total of 57 TCC infections were encountered with an incidence rate of 8.95 infections per 1000 dialysis sessions (DS). The rate of infection was significantly lower in Group I (4.54 per 1000 DS) as compared to Group II (13.11 per 1000 DS), p < 0.001. The incidence rates of bacteremia as well as clinical sepsis were also significantly lower in Group I than in Group II (p < 0.001). There was no statistically significant difference between the rates of access site infection in the two Groups (p > 0.05). Our study suggests that antibiotic-lock therapy using a combination of vancomycin and gentamycin is useful in preventing catheter-related blood stream infection in patients on HD.

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Goodpasture's syndrome (GPS) is a rare but severe immunological disease, which is characterised by rapidly progressive glomerulonephritis and intraalveolar hemorrhage (IAH) with the presence of anti-glomerular basement membrane (GBM) antibodies. We report four cases of GP's syndrome referred to the nephrology unit at Ibn Rochd UHC in Casablanca from January 1995 to December 2003. All patients had rapidly progressive glomerulonephritis (RPGN) with proteinuria and microscopic hematuria. Elevated blood pressure was noted in one case. IAH was manifested as hemoptysis in two cases, radiological signs in three cases and confirmed by broncho-alveolar lavage in all cases. Laboratory assessment revealed anemia in all cases. Renal biopsy showed extracapillary glomerulonephritis with linear deposits of IgG along the GBM. Renal failure was severe and hemodialysis was required in all cases. All patients were treated with prednisone and cyclophosphamide and none recovered renal function. Two patients died due to severe lung hemorrhage.

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Chronic renal failure (CRF) is a major public health problem. Early diagnosis and proper management have important roles in prevention of CRF progression to end-stage renal disease (ESRD). For this purpose, determining the etiology of CRF may be helpful. This study was conducted in the nephrology department at the Mostafa Khomeini Hospital in Tehran, Iran from March 2001 to March 2005, to determine the etiology of CRF in adult Iranian patients. A total of 1200 patients with a diagnosis of CRF were involved in the study. Relevant data were collected using a reliable questionnaire. All data analyses were carried out using SPSS and the χ2 test. Of the 1200 patients, 61% were males and 39% females. The most frequent age group was 61-75 years (38.3%) and the mean age of the study patients was 51.6 ± 17 years. The etiology of CRF in our series included: diabetes mellitus in 26.8%, hypertension in 13.5%, obstructive uropathy in 12%, cystic and congenital disorders in 10.3%, glomerulonephritis in 6.5%, urinary tract infections in 4%, vasculitis in 2%, tubulo-interstitial nephritis and pregnancy related in 0.8% each and unknown causes in 29.5% of the patients. Laboratory and ultrasonographic assessment at initiation of the study revealed blood urea nitrogen >100 mg/dl in 57.8% of the patients, serum creatinine >10 mg/dl in 40.3%, glomerular filtration rate (GFR) <10 ml/min in 61.3%, hemoglobin <10 g/dl in 65.8% and kidney size lesser than 8 cm in 46% of the cases. There was a significant statistical relationship between kidney size and duration of hypertension greater than five years (P = 0.017). The high frequency of CRF of unknown etiology in this study may be attributed to diagnostic limitations prevailing in our country. A GFR of <10 ml/min in 61.3% of the cases at presentation suggests late diagnosis and/or referral. Aggressive screening and treatment strategies to prevent ESRD are recommended.

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This study was designed to determine whether the serum levels of 25-OH vitamin D influence the occurrence of infection with Helicobacter Pylori (H.Pylori) in patients on maintenance hemodialysis (HD). The study subjects were patients with end-stage renal disease who were undergoing maintenance dialysis at the hemodialysis section, Hajar Medical, Educational and Therapeutic Center, Shahrekord, Iran. The serum 25-OH vitamin D level and serum H. Pylori specific IgG antibody titers were measured using an enzyme-linked immunosorbent assay (ELISA) method. A total of 36 patients were studied including 21 males and 15 females. The mean age of the study group was 47 (± 17) years. The mean level of serum 25-OH vitamin D was 0.5 ± 18.7 nmol/L (median: 3.5) while the mean value of serum H.Pylori specific IgG antibody titer was 7.7 (±9.9) u/ml (median: 2 u/ml). Thus, a significant positive correlation was found between the levels of serum 25-OH vitamin D and serum H. Pylori specific IgG antibody titers (data adjusted for age, urea reduction rate, duration and dose of dialysis) ( r=0.36, p=0.043). Our study suggests that vitamin D may positively affect the chronic inflammatory status of dialysis patients and may potentiate the immune response in such patients. Because of this immuno-modulatory effect, vitamin D analogs may offer new means to control the inflammatory status in patients on maintenance dialysis.

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Acute renal failure (ARF) is a common health problem worldwide. There is limited data on the pattern of ARF in Sudan. Moreover, glomerular diseases, which are a well-known cause of ARF, have not been accurately and adequately diagnosed previously. A retrospective study on the patterns of ARF was carried out in a general nephrology referral center in Sudan during the period from February 2003-February 2004. Patients from intensive care units with ARF and those who developed ARF after massive surgery were excluded from the study. Renal biopsy was performed when indicated and studied with light and immunofluorescent microscopy. Eighty-nine patients (57 (64%) cases were males, and mean age was 39±19.4 years) fulfilled the criteria for the diagnosis of advanced renal failure requiring renal function replacement therapy. Acute tubular necrosis (ATN) was diagnosed in 50 (56%) patients; 33 (66%) ATN patients had renal failure as a complication of volume depletion, fulminant infections (particularly malaria and typhoid fever) or snakebites, and 12 (13.4%) patients ingested paraphenylene-diamine (PPD) (hair/Henna dye) in suicidal attempts. Eight (9%) patients of the total study group had glomerular diseases and 11 (12.3%) had obstructive uropathy associated with ARF; the cause of ARF could not be determined in 17 (19%) patients. Fifty-three (60%) patients recovered their renal function, six (6.7%) patients progressed to chronic kidney disease (CKD), 16 (18%) died and 14 (16%) were lost to follow-up. In conclusion, patients with ARF associated with ATN had a favorable prognosis except when ATN was associated with PPD poisoning.

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There is wide disagreement about the measurement of various hemostatic parameters in patients with chronic renal failure (CRF) concerning treatment with either hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). This study aims to characterize the coagulopathy in patients with CRF both before initiating dialysis, when the patients are expected to have a steady hemostatic state, and after starting regular HD or CAPD. The measurements were repeated in a group of patients who received a successful renal transplant to see whether the coagulopathy associated with CRF would be corrected by this lasting therapy. The study, which was mainly cross-sectional and prospective, included two groups: 49 patients with CRF with their age ranging from 17 to 67 years were divided as follows: those on regular HD (n=20), CAPD (n=9) and patients after transplant (n=20). The tests were also done on 34 healthy controls. Significant hyper-fibrinogenemia was recorded in all three study groups. The HD group showed significant elevation in the plasma levels of AT III and total protein S, and a significant reduction in free protein S and protein C, when compared with healthy controls. These inhibitors, except total PS, displayed similar fluctuations in the CAPD group. In the transplant patients, there was significant elevation of AT III and total protein S, a reduction in free PS, and no significant changes in PC levels. A significant elevation was found in the levels of F1+2, TAT and D-Dimer in HD and in transplant patients, when compared with controls. In CAPD patients, only D-Dimer levels showed a significant increase. The tPA and PAI-1 levels in the three study groups were similar to the control group. Our study revealed significant activation of the hemostatic system, more pronounced in patients on HD than CAPD. This coagulopathy remained only partly corrected following successful kidney transplantation.

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To determine the incidence of rectourogenital fistulae and the possible role of fistulae on the mechanism of defecation in patients with high imperforate anus, we retrospectively studied 42 children, 38 males and four females, all with high imperforate anus presenting in the period from 1982 to1995. All children underwent radiological evaluation, to determine the level of the rectal pouch 18-24 hours after birth and to study the bony spine. A preliminary colostomy was performed in all patients after the diagnosis shortly after birth. Ultrasonography was performed in all the cases to assess the kidneys and ureters. All patients but one was operated on via a posterior sagittal anorectoplasty. Bowel control was assessed clinically regarding the presence of voluntary bowel movement, fecal soiling, incontinence and constipation. Eighteen (42.8%) patients were found to have recto­urogenital fistulae; 15 rectourethral, two rectovaginal and one rectovesical. Outcomes were known for 36 out of 42 patients; 15(41.6 %) had voluntary bowel movements, nine (25 %) had soiling, six (16.6%) had constipation and six (16.6 %) had incontinence. In conclusion, the presence of rectourogenital fistula in patients with high imperforate anus is another new prognostic factor for anorectal function which needs further clarification.

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The aim of this study was to determine whether positioning of the patient, prone or supine, plays a significant role on the treatment of stones in the proximal ureter with extracorporeal shock wave lithotripsy (ESWL). 68 patients with proximal ureteric stones underwent ESWL. The procedure was performed in the supine position in 35 (Group 1) and the prone position in 33 patients (Group 2). Stone-free rates, repeat ESWL rates, shocks per patient and shocks per session were compared in both groups. The mean session number per patient was 1.93 ± 0.82 in Group 1 and 1.88 ± 0.79 in Group 2 (P = 0.786). The stone-free rates, three months after ESWL, were 81.8% in Group 1 and 82.9% in Group 2 (P = > 0.05). Thus, these two parameters were similar in both Groups. Also, the number of shocks per session was 3066.1 ± 346.3 in Group 1 and 3148.5 ± 621.0 in Group 2. This difference was nonsignificant (P = 0.49). Our study suggests that the treatment of proximal ureteric stones with ESWL in the prone position is as safe and effective as when the patient is placed in the supine position.

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Sudden unexplained anuria in renal transplant patients could well be secondary to occult internal hemorrhage Erather than the usual vascular thrombotic or obstructive event, even in the completely stable patient. Urgent intervention in such bleeding states can save a patient's life and graft function. Graft survival is very exceptional in graft artery or vein thrombosis. Contrary to hemorrahagic events, life is usually not threatened by thrombotic events involving the renal graft vasculature. We present here three unfortunate cases that shared the problem of unexpected anuria due to a hemorrhagic event in apparently stable renal transplant patients.

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Growth retardation in children with chronic kidney disease (CKD) is multifactorial that include inadequate protein and calorie intake, persistent metabolic acidosis, calcitriol deficiency, renal osteodystrophy, drug toxicity, uremic toxins, and growth factor abnormalities such as insulin-like growth factor (IGF) and IGF binding proteins. In this study, we compare the IGF-1 levels in normal and growth retarded CKD children. Serum IGF-1 levels were determined in 22 children with end-stage renal disease, 26 children with CKD at different stages, 23 children with normal height and weight for age, and 23 children with constitutionally short stature. Mean serum levels of IGF-1 were 209 ± 141 ng/ml in the ESRD group (group 1), 159 ± 163 ng/ml in the CKD group (group 2), 420 ± 182 ng/ml in normal children (group 3), and 360 ± 183 ng/ml in children with constitutional short stature (group 4). The differences in the levels of IGF-1 in groups 1 and 2 were statistically significant when compared to groups 3 and 4 (p<0.0001 and p<0.02, respectively), while the levels of IGF-1 were not statistically different between groups 1 and 2. No correlation was found between IGF-1 levels and glomerular filtration rate, height or weight in groups 1 and 2. In conclusion, serum levels of IGF-1 in children with CKD are significantly lower than healthy children.

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We conducted this study to determine the achievements of the current practice guidelines in the management of anemia in the Arabian Gulf Countries. The survey was designed as a retrospective, one day screening of adult patients with end-stage renal disease in six Arabian Gulf countries including Saudi Arabia, Kuwait, Bahrain, Oman, United Arab Emirates and Qatar. Data were collected on patients undergoing chronic dialysis. For random patient sampling, each participating center drew up an alphabetical list of all hemodialysis (HD) or peritoneal dialysis (PD) patients which were 18 years or older and selected every fourth patient on the list. A total of 563 patients from 18 centers were included in the survey. The most common cause of end-stage renal failure was diabetic nephropathy, closely followed by chronic glomerulonephritis. The majority of patients were treated by HD, with only 20% receiving PD. The mean (±SD) hemoglobin (Hgb) concentration was 115 ± 15 g/L (median, 115 g/L; range, 61-159 g/L). The Hgb concentration was ≥110 g/L in 28%, ≥120 g/L in 38%, and <100 g/L in 16%. Information on their iron status was available for 97% of patients, ferritin levels were available for 97%, and TSAT values for 67% were available. The mean serum ferritin concentration for the study patients was 503 ± 406 ng/ml (median, 390 ng/ml; range, 20.0-2960 ng/ml); 90.5% had a serum ferritin concentration > 100 ng/ml. We conclude that the results of our study demonstrate anemia management in the Gulf countries which is comparable to the European Survey on Anemia Management 2003 (ESAM 2003). However, many patients still have not reached the current recommendation of anemia management.

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In the absence of formal registry data, the volume and causes of organ failure in Syria are difficult to establish with certainty. However, we evaluated in this study the extent of organ failure by collecting data from health care authorities in different medical institutions who are involved in caring for patients with organ failure. Subsequently, we assessed the problem of the widening gap between organ supply and demand in our country, and we highlighted the obstacles to initiating a national deceased donation program as a viable option to address the challenge of organ shortage. The estimated prevalence of corneal blindness in Syria is 2.3 per one thousand population. The estimated incidence of viral-induced cirrhosis is 49 - 67 per one million population (pmp); these include both HCV and HBV, which constitute the leading causes of liver failure. We estimated the incidence of end-stage renal disease (ESRD) to be from 80 - 100 pmp. Obstacles to initiating a national deceased donation program include lack of awareness of the public at large and health care professionals to the importance of organ donation and transplan­tation. Other obstacles include lack of adequate resources in terms of finance, personnel and services, and the unavailability of a national center for organ transplantation that influences public attitude, sets national guidelines, and supervises all activities related to organ donation and transplantation.

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In order to evaluate the effects of peritoneal dialysis as a modality of renal replacement therapy for adults with acute renal failure (ARF) of varied etiologies, we studied 43 ARF patients who underwent peritoneal dialysis at our hospital from April 2004 to November 2005. The age of the patients ranged from 18 to 75 years with a mean of 35 years. There was no significant difference in the incidence of ARF between males and females. Acute tubular necrosis secondary to acute gastroenteritis was the cause of ARF in 32 (80%) patients; four (10%) patients expired secondary to ARF. There was an average fall of around 60% in the S. creatinine at the end of PD. We did not notice any significant complications related to the procedure. We conclude that peritoneal dialysis is still a good option for the treatment of patients with ATN.

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An 18-year-old woman patient was discovered to have severe anemia and advanced renal failure during a routine prenatal follow-up at her 6th week of gestation. During the first few weeks of therapy, the hemodialysis frequency was increased gradually, and Erythropoietin was administered with intravenous iron therapy to keep the patient's hemoglobin above 115 gm/L. Blood pressure rose was controlled by alpha methyldopa. Obstetric follow-up consisted of monitoring the fetal activity and growth, placental maturity, and umbilical artery perfusion. On the 32nd week of gestation, the patient had a normal vaginal delivery of live female weighing 2,100 gm. the patient had a completely uneventful postpartum course, and the newborn baby was well. In conclusion, our index case illustrates that intensified dialysis regimens and attentive medical care results in a successful outcome of pregnancy in patients with end stage renal disease on hemodialysis.

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Hyperoxaluria can result in the deposition of oxalate in bones, arteries, eyes, heart, nerves, kidneys and other structures when there is a reduction in glomerular filtration rate. Liver and kidney transplantation is curative for patients with Type I primary hyperoxaluria. Here we report a case of recurrent oxalosis in a post-transplant kidney with early graft failure in an adult male.

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Between May 1998 and June 2006, 31 patients (21 males and 10 females) received a renal allograft from live-related donors at the Urology and Nephrology Center in the Al-Thawra Modern General Hospital Sana'a, Republic of Yemen. The cold ischemia time ranged between 48 and 68 minutes. The immunosuppressive protocol was double therapy (steroids and mycophenolate) in the first 8 cases. The subsequent cases received triple therapy with steroids, cyclosporine and mycophenolate. Episodes of acute rejection were treated with high dose steroids while anti-thymocyte globulin (ATG) was also used in cases of vascular or steroid resistant rejection. Primary graft function was achieved in 29 recipients (93.5%). The post-transplant complications, either surgical or medical, were comparable to those reported in the literature. The kidney transplantation program started sporadically in Yemen since 1998. However, a well-established program has been running regularly since the beginning of 2005.

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