To investigate the effect of parsley leaf tea on urine composition and the inhibitors of urinary tract stones formation, we studied 20 healthy volunteers who were divided into two groups: the first group of 10 subjects drank daily 1,200 mL of parsley leaf tea for 2 weeks, while the second group drank at least 1,200 mL daily of bottled water for the same period. This was followed by a 2-week "washout" period before the two groups were crossed over for another 2 weeks. During the experimental phase, 24-h urine samples were collected at baseline, on day 14, and at the end of the 6-week period and different urinary parameters were measured and analyzed statistically. We found no significant difference in the urine volume, pH, sodium, potassium, chloride, urea, creatinine, phosphorus, magnesium, uric acid, cystine, or citric acid. Further research is needed to evaluate the effects of parsley leaf tea on urinary parameters in healthy and stone-forming patients.

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Generalized edema is one of the most important complications in patients with nephrotic syndrome. Diuretics like furosemide are the first choice for reducing the edema. Hypo-albuminemia reduces the effect of furosemide, and thus, this drug is co-administered with albumin to reinforce the therapeutic effect and for the correction of reduced oncotic pressure. The aim of this study was to compare urine volume and 24-hour sodium levels after using furosemide alone versus using furosemide along with albumin in patients with nephrotic syndrome. In a randomized clinical trial, ten patients with nephrotic syndrome were chosen and were randomly allocated into four groups. Three therapeutic protocols were chosen, and at the end, each patient had received all three protocols randomly. Data were gathered and analyzed using non-parametric tests in SPSS software. The average urine volume after receiving albumin alone, furosemide alone and albumin plus furosemide were 742 mL (SD = 528), 1707 mL (SD = 745) and 2175 mL (SD = 971), respectively (P = 0.015); the fractional excretion of sodium was 1.96 (SD = 0.251), 3.18 (SD = 0.25), and 4.77 (SD = 8.45), respectively (P = 0.000); the 24-hour urinary sodium levels were 18.3 (SD = 6.68), 208.4 (SD = 5.27) and 206 (SD = 8.45), respectively; while the glomerular filtration rate (GFR) was 104.5, 96.6 and 106.6 (P = 0.021), respectively, in the three therapy groups. Our study shows that albumin administration alone and with furosemide in patients with nephrotic syndrome who had normal kidney function, results in different urine volumes and sodium levels. Co-administration of albumin and furosemide increased the urine volume and sodium level, which is due to increase in the GFR as well as the diuretic effects of furosemide.

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Among the different etiologies of acute renal failure (ARF), acute tubular necrosis (ATN) is one of the most common causes. There is no consensus on the duration of follow-up needed among these patients and also on choosing a reliable screening test to recognize early signs of chronic kidney injury that may ensue. The aim of this study was to evaluate the clinical and biochemical findings in children with a history of clinically recovered ischemic ATN, to detect the patients who may be at risk of ensuing chronic kidney disease. A cross-sectional study was carried out on 20 children between six months and 10 years of age, admitted at St. Al Zahra Hospital and Amin Children's Hospital, Isfahan, Iran, with a past history of ischemic ATN. Eighteen patients were evaluated between 12 and 24 months, and two patients were evaluated at 30 months. The second sample of urine while still fasting was used for assessing urinary sodium, creatinine and magnesium. The mean ages for study and control groups were 3.4 ± 1.3 years and 4.5 ± 1.1 years, respectively. Glomerular filtration rate, urinary magnesium, fractional excretion of magnesium (FEMg), urinary sodium and fractional excretion of sodium (FENa) were significantly higher in the study group compared to those in the control group. No significant differences were demonstrated in systolic and diastolic blood pressures between the two groups. Since FEMg can reflect tubular function for both the ability of tubules for reabsorption of the filtered magnesium and for retaining the intracellular magnesium, FEMg can be used as a marker to detect early stages of chronic renal injury. However, further studies with larger number of cases are needed to evaluate the sensitivity of this test.

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To evaluate the prevalence of anemia in a large cohort that comprises patients in different stages of chronic kidney disease (CKD) in the kingdom of Saudi Arabia (KSA), we conducted a multi-center cross-sectional study of a cohort of CKD patients who have not started dialysis. The study patients were recruited from the nephrology clinics in 11 different medical centers distributed all over the regions of the KSA. For the estimated glomerular filtration rate (GFR), we used the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. There were 250 study patients who fulfilled the criteria for the study. The patients were stratified according to their GFR as follows: stage 1: 19 patients, stage 2: 35 patients, stage 3: 67 patients, stage 4: 68 patients, and stage 5: 61 patients. The composite of proteinuria and abnormal imaging in stages 1 and 2 was satisfied in 100% of the cases. The prevalence of anemia was elevated for the hemoglobin levels below 12 g/dL (the level at which the evaluation of anemia in CKD should be initiated) in the different stages of CKD, that is, 42%, 33%, 48%, 71%, and 82% in the stages from 1 to 5, respectively. The prevalence was also elevated for the hemoglobin levels below 11 g/dL (the minimum hemoglobin level at which therapy should be initiated with erythropoietin), that is, 21%, 17%, 31%, 49%, and 72%, respectively for stages from 1 to 5. In conclusion, we found a large prevalence of anemia among the CKD population in Saudi Arabia, and the burden of patients who require treatment with erythropoietin is considerably large. However, the response to therapy will not require large doses according to the availability of long-acting erythropoiesis stimulating agents, which will render the therapy more convenient and less expensive.

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Chronic kidney disease (CKD) is one of the major health care burdens worldwide, with a significant increase in the number of patients and a huge increase in the financial demands in recent years. Patients with CKD usually progress through different stages before they reach end-stage renal disease. The rate and speed of renal function deterioration are variable, but uncontrolled hypertension and diabetes mellitus are major risk factors. Pre-dialysis care, with change of life style, blood pressure and glycemic control, the use of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, lipid-lowering agents and management of anemia and mineral bone disorder can improve quality of life, preserve functioning nephrons and reduce cardiovascular morbidity and mortality with significant reduction in management costs. Early referral of patients with CKD to the nephrologist allows for adequate exposure to educational programs, psychosocial preparation, participation in the decision of type of renal replacement therapy (RRT), pre-emptive kidney transplantation, early creation of dialysis access and adequate training in selected modality of RRT. The degree of involvement and interaction must be individualized according to the needs of the patient and the type of RRT planned. A multi-disciplinary team is crucial for the implementation of a variety of strategies and to intervene more effectively in meeting the health care needs of CKD patients.

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End stage renal disease (ESRD) is a devastating medical, social and economic problem in any community and needs dedicated supervision and health care. It is fatal unless treated properly. Despite the improvements in dialysis care, the mortality of patients with ESRD remains high. We retrospectively studied 242 patients with ESRD on regular hemodialysis (HD) at Gezira Hospital for Renal Diseases and Surgery, Sudan, from 1 January to 31 December 2008, to determine the mortality rate and causes of mortality. We found that the mortality rate was 7.44% per year and the leading cause of death was infections (45%) and cardiovascular (22%) diseases.

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Acute kidney injury (AKI) is a risk factor for increased mortality in critically ill patients. To assess the incidence, risk factors and outcome of patients who develop AKI in the intensive care units (ICUs), we retrospectively studied 235 patients admitted to the ICU of Shahid Mohamadi Hospital, Hormozgan, Iran, and compared those who developed AKI and those who did not. There were 31.1% of patients who developed AKI during ICU admission. There was a significant difference in the mean age, serum sodium (Na), potassium (K), urea, blood urea nitrogen (BUN) and creatinine (Cr) levels and also platelets, on admission, between patients with and without AKI. Acute physiology and chronic health evaluation (APACHE) II score on admission was significantly higher in AKI patients and Glasgow coma scale (GCS) was significantly lower. The mortality of AKI patients (72.6%) was significantly higher than non-AKI patients (25.91%). The number of underlying diseases and GCS and APACHE II score on admission were significantly different between the expired and survived patients. We conclude that age, first serum K level and APACHE II score on admission time were powerful independent predictors of developing AKI in ICU patients. The GCS on admission and the presence of two or more underlying diseases accurately predict the mortality in AKI positive ICU patients.

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To evaluate the prevalence of renal tubular dysfunction in children with β-thalassemia (β-T) major, we studied the glomerular and tubular function in 140 children with β-T major and compared them to a healthy control group at our center from May 2007 to April 2008. Fresh first morning samples were collected from each patient and analyzed for sodium, potassium, calcium (Ca), protein, uric acid (UA), creatinine (Cr), urine osmolality and urinary N-acetyl-β-D-glucosaminidase (UNAG) activity. Blood samples were also collected for complete blood count, blood urea nitrogen (BUN), fasting blood sugar, serum creatinine (SCr), electrolytes, and ferritin before transfusion. Among the study patients, 72 were males, and the mean age was 11.5 (ranging 7-16) years. SCr levels were all within normal limits and all of them had normal glomerular filtration rate (GFR). The mean UNAG was 17.8 IU/L in the study patients (normal 0.15-11.5 IU/L) and 3.2 IU/L in the control group (P < 0.001). Of the 82 study patients who had elevated level of UNAG, 58 (62.4%) had high blood levels of ferritin also (r = 0.2, P < 0.001) and 13 (15.9%) patients had hypercalciuria also (UCa/UCr > 0.21) (P = 0.006). Nine (6.4%) thalassemic patients with a mean age of 12 years had proteinuria (Upr/UCr > 0.2). Sixty-nine (49.3%) out of the 140 patients and 45 (65.2%) of the patients having UNAG had uricosuria also (UUA/UCr > 0.26). Ten (7%) patients had microscopic hematuria and 10 (7%) patients with a mean age of 13.5 years had glucosuria or diabetes mellitus. We conclude that tubular dysfunction is a relative common complication of the β-T major; UNAG and its index are the best to detect renal tubular dysfunction in these patients. Currently, periodic measurement of UCa/UCr and UUA/UCr ratios as well as urinalysis are recommended.

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We report a 50-year-old male patient with diabetes mellitus and hypertension who presented with low-grade fever, anuria and renal failure. He had no prior history of nephropathy and retinopathy. Since anuria persisted, a renal biopsy was performed using automated gun, under ultrasound guidance. Two hours after the renal biopsy was performed, the patient developed severe left loin pain that required analgesics and sedatives. Ultrasound of the abdomen performed immediately, two hours and four hours after the biopsy, did not reveal any hematoma. The hemoglobin was stable when the patient developed loin pain, but after eight hours decreased to 9.1 g/dL, and computed tomography scan of the abdomen revealed a big peri-nephric hematoma around the left kidney. He was managed with blood transfusions and a selective angiogram was done. It revealed a pseudoaneurysm and arterio-venous fistula from the segmental artery of lower pole of the left kidney; both were closed by using microcoils and liquid embolic agent N-butyl-cyanoacrylate (NBCA). The only risk factor the patient had at the time of renal biopsy was severe renal failure. Our case suggests that severe loin pain immediately after renal biopsy in a patient with renal failure warrants careful follow-up of hemoglobin and imaging, even if initial imaging is normal. Further fall of hemoglobin necessitates early evaluation with angiogram, which helps in diagnosing the treatable, although rare, complications like pseudoaneurysm and arterio-venous fistula.

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Isolated renal echinococcosis is a rare acquired disease of the kidney, caused by the parasite Echinococcus. The kidneys are involved in less than 2 % of all human hydatidosis; isolated renal involvement is even rarer. Based on the clinical and radiological findings, diagnosis of a rare case of isolated renal echinococcosis was made. The diagnosis was confirmed by laparoscopic surgery and histopathology.

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Type 2 diabetes mellitus (T2DM) is an independent risk factor for uric acid nephrolithiasis, and obesity augments this risk. We carried out this cross-sectional study on 25 patients of T2DM to assess the risk factors for uric acid nephrolithiasis and to assess their relation with components of the metabolic syndrome. A single 24-hour urine sample was analyzed for fasting urine pH, uric acid, creatinine and protein. Fasting serum sample was analyzed for HbA1c, glucose, creatinine, uric acid and lipid profile. Patients with past history of nephrolithiasis and significant hepatic or renal disease were excluded. The mean age of the participants was 51 ± 8.5 years and there were 16 females and nine males. Mean body mass index (BMI) was 27.3 ± 4.3 kg/m ² and waist circumference was 90.8 ± 7.8 cm. Urinalysis revealed mean uric acid excretion of 595 ± 103 mg/24 hours and fasting urine pH of 5.6 ± 0.4. Fasting urine pH correlated inversely with the body weight, BMI and low density lipoprotein (LDL)-cholesterol (P < 0.05). Total volume showed inverse correlation with age and disease duration and correlated positively with body weight and BMI. Uric acid excretion did not correlate with the components of metabolic syndrome. Our preliminary data showed that low urine pH as the main risk factor for uric acid nephrolithiasis was consistently found in our study patients with T2DM. Higher BMI further accentuates this risk. Further data from more number of patients are necessary to confirm these findings.

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The Wunderlich Syndrome refers to spontaneous perirenal hemorrhage often associated with underlying renal pathology. We report the case of a 23-year-old female with advanced tuberous sclerosis who presented in hypovolemic shock secondary to rupture of one of her massive bilateral angiomyolipomas (AMLs). The patient was able to be managed conservatively and subsequently retained full renal function. A review of the literature with a discussion of types of clinical presentation, diagnostic criteria, and methods of management of AMLs is included.

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We report the importance of elevated serum lactate dehydrogenase (LDH) and neutrophilia (NT) in two renal transplant recipients who developed renal impairment in the early post-operative period. One of our recipients developed oliguria and increased serum creatinine with unexplained elevation of LDH and NT. The biopsy was C4d positive with platelet and fibrin thrombi in the glomerular capillaries and arterioles and interpreted as acute vasculitis or thrombotic form of antibody-mediated rejection (VAMR) with positive donor-specific antibodies (DSA). Despite intensive treatment, this graft was lost. When another patient developed a similar picture, prompt immunoadsorption was started without waiting for a confirmatory biopsy or DSA, and both were later reported as positive. Improvement in renal function was associated with decreasing levels of LDH and NT. Neither of these was elevated in cases of acute cellular rejection (ACR) or antibody mediated rejection (AMR) with isolated tubular injury (TAMR). It may therefore be reasonable to assume that LDH and NT are potential diagnostic and prognostic markers of VAMR.

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Growth retardation is common among children with chronic kidney disease (CKD). Renal transplantation has beneficial effects on height and weight gain of children, but height gain occurs especially for those children who are transplanted at a younger age. This study was conducted for a cross-sectional evaluation of growth and body mass index (BMI) in children following kidney transplantation. All children who had been transplanted in our center and had regular follow-up were entered in this study. Those with primary non-functioning grafts were excluded from the study. Weight and height at transplantation and at 20 years of age or at a pre-determined period (1-4-2008 to 30-6-2008) were recorded. Their height, weight, BMI, standard deviation score (SDS) of height and weight at their pre- and post-transplantation period were compared. SPSS 15.1 software and paired t-test were used for comparison of means. Seventy-one children, 43 boys and 28 girls, were involved in this study. The mean age at transplantation was 12.6 ± 3.45 years, ranging from 3 to 19 years, and age at last visit was 16.9 ± 3.15 years. They had been followed-up for 7-175 months (mean, 51.6 ± 30.75 months). Their primary renal diseases were as follows: reflux, obstruction and dysplasia 29 (41%), hereditary 25 (35%), glomerular disease 14 (20%), unknown 3 (4%). Source of donor was living related in 27 (38%), with 15 being mothers, deceased in 35 (49%) and living unrelated in 9 (13%). SDS height improved dramatically in post-transplantation evaluation, but this did not happen for SDS weight and BMI. We can conclude that despite a dramatic effect of transplantation on growth, catch-up growth only occurred in a minority of the children.

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Renal insufficiency is a common complication early after hematopoietic cell transplantation (HCT). We retrospectively examined the incidence, risk factors and associated mortality of acute renal failure (ARF) in a cohort of 101 consecutive allogeneic HCT patients. These patients were reviewed to determine their baseline characteristics, the presence of co-morbid conditions and mortality rates at one year. ARF was defined by the doubling of the baseline serum creatinine (Scr) levels. The mean age of the 101 study patients was 34 ± 11.8 years. Of them, 58 (57.4%) had ARF, yielding an incidence of 2.6% per week during the first year following HCT. The peak frequency of ARF occurred during the second week (29.3%). The need for hemodialysis, a proof of the severity of ARF, was seen in 12 cases (20.7%). On univariate analysis, the Scr at one month greater than 90 μmol/L (P = 0.008), use of aminoglycosides (P < 10 ^-3 ), the presence of veno-occlusive disease (VOD) (P < 10 ^-3 ) and the need for admission to the intensive care unit (ICU) (P = 0.003) were associated with a significantly increased risk of ARF. On multivariate analysis, the independent variables associated with an increased risk for ARF were the presence of VOD [P = 0.07, relative risk (RR) = 2.06] and use of aminoglycosides (P < 10 ^-3 , RR = 11.2). The overall mortality rate among the study patients was 35.6% at the end of the first year. On multivariate analysis, only the use of aminoglycosides (P = 0.02, RR = 0.31), admission to the ICU (P < 10 ^-3, RR = 7.29) and the development of ARF (P = 0.001, RR = 8.97) were independent predictors of mortality. Our study shows that ARF is highly prevalent during the early period following HCT and increases mortality, particularly if dialysis dependent. It frequently occurs following VOD and aminoglycoside use. As the prognosis is rather grim, it is very important that the associated factors be identified early, for an effective prevention of this disease.

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The objective of this study was to evaluate the incidence of genital human papilloma virus (HPV) infection and cervical intra-epithelial lesions in transplanted patients. Cervical Papanicolaou (Pap) smear/HPV test and colposcopic examinations were performed in 58 patients who were candidates for renal transplant surgery; these tests were repeated one year later. Their age range was 26-53 years (mean, 37.2 years). Hypertension was the most common cause of renal insufficiency (34.4%), while in 41.4% of the patients, the causative pathology was unknown. In 24.1% of the patients, there was no history of dialysis, i.e. they had pre-emptive transplantation. The mean duration of marriage (years since first intercourse) was 16.2 years (range, 1-35). Coitus interruptus was the most common contraceptive method used (37.9%), followed by tubal ligation and condom (10.3% and 6.9%, respectively). All patients had negative Pap tests and normal gynecologic exam before undergoing transplantation. The Pap test remained normal after transplant surgery, although the HPV test became positive in four patients (6.9%). There were five cases of white epithelium on colposcopy, but biopsy showed normal metaplasia. Two cases of extensive anogenital warts were treated by CO ₂ laser, and one patient had recurrent warts, which responded well to second laser surgery. None of the study patients had squamous intra-epithelial lesions (SIL) or vulvar intra-epithelial neoplasia. Our study suggests that screening with HPV and Pap test should be performed before transplant surgery and should be repeated at regular intervals in order to avoid irreversible situations such as high-grade SILs, which are difficult to treat. Avoiding high-risk sexual relations in this group of patients is highly recommended.

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During the recent years, cinacalcet has markedly improved the management of hyperparathyroidism in patients on hemodialysis. However, to the best of our knowledge, there are no specific studies addressing the dose regimen of cinacalcet. The aim of the study was to evaluate the efficacy of cinacalcet on the achievement of targets in the treatment of hyperparathyroidism in two different dosage schedules. Twenty-seven adult patients who were on hemodialysis for more than four months and with severe secondary hyperparathyroidism (intact parathyroid hormone (iPTH) >88 pmol/L) resistant to conventional treatment were included in this prospective study. We used the targets of K/DOQI-clinical guidelines as optimal target of iPTH, calcium and phosphate. Group 1 received a single daily administration of 30 mg of cinacalcet along with the main meal as the starting dose, and the dose was titrated thereafter monthly. Group 2 received cinacalcet with the main meal twice weekly starting with a dose of 90 mg on the first day of the week and 120 mg at midweek and titrated thereafter monthly. The levels of iPTH decreased significantly (P = 0.0001) from 124.00 ± 44.77 pmol/L to 37.78 ± 12.49 pmol/L and from 109.61 ± 53.13 pmol/L to 33.93 ± 12.03 pmol/L after 12 weeks in groups 1 and 2, respectively. After 12 weeks, alkaline phosphatase declined significantly (P = 0.0001) from 143.42 ± 75.20 IU/L to 87.42 ± 14.46 IU/L in group 1 (P = 0.013), and from 148.00 ± 108.49 IU/L to 101.61 ± 46.62 IU/L in group 2 (P = 0.05). There were no significant differences between the reductions of iPTH, calcium phosphate product and alkaline phosphatase levels in both the groups in the vertical comparison at the end of the study. There was no noteworthy difference in side effects between both the groups. Our results indicate that cinacalcet twice weekly is reasonably safe and effective in suppressing high PTH levels in hemodialysis patients, with fewer side effects.

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The aim of present study was to determine the prevalence of O serogroups of Escherichia coli (E. coli) strains that cause community-acquired urinary tract infections (UTI) in children. In this study, 96 children with UTI referred to two Jahrom University-affiliated Hospitals in Iran were enrolled, during the period from August 2005 to August 2006. Drug sensitivity was tested by disk diffusion method and serotyping done by slide agglutination method. A total of 96 E. coli strains were isolated from urine samples of the study children whose age ranged from one month to 14 years. Cystitis was diagnosed in 49.2% and pyelonephritis in 50.8% of the study patients. Maximum drug resistance was seen with ampicilin (80.2%) and the least with imipenem (1.1%). The most common type of O antigen was O1 (12.2%). There was significant correlation between the presence of O antigens and sensitivity to nalidixic acid and gentamicin (P < 0.05). This is the first report of E. coli serotyping in children with UTI from the south of Iran and their relation to antibiotic resistance and clinical presentation. Further studies from other parts of Iran and on other serotypes are recommended.

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Nephrobronchial fistula is a rare complication seen in association with renal infections, trauma or stone disease. Xanthogranulomatous pyelonephritis (XGP) is an infectious disease with a potential for fistulization to lung, skin, colon and other organs. We present a case of nephrolithiasis complicated by obstruction leading to pyonephrosis and nephrobronchial fistula, treated successfully by nephrectomy and excision of fistulous tracts. Nephrobronchial fistula, although a rare complication of longstanding renal stone, should be considered when a patient presents with perirenal suppurative process. This clinical case illustrates the natural history of nephro-bronchial fistula and the relevance of early treatment of nephrolithiasis.

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The quality of the water used for dialysis has been suggested as a factor causing inflammation in patients on hemodialysis (HD). We therefore conducted this study to identify the effect of quality of the water on nutritional state, inflammation and need for human recombinant erythropoietin (EPO) in patients undergoing HD at Agadir, Morocco. This prospective study included patients on HD for at least one year. The water treatment was done according to the standard protocol, which was followed by additional enhancement of ultrafiltration using an additional polysulfone filter (diasafe, Fresenius, Bad Homburg, Germany) before the dialyser. Water was monitored regularly during the study period to ensure acceptable levels of bacterial count as well as endotoxin levels. Various parameters including dry weight, systolic and diastolic blood pressure (PA) before and after an HD session, need for human recombinant EPO, levels of hemoglobin (Hb), albumin, ferritin, C-reactive protein (CRP), and the dose of dialysis delivered (Kt/V) were measured first at the beginning of the study and thereafter, in the third, sixth and 12 ^th months of the study. The study involved 47 patients, and after 12 months of the study, an improvement in median dry weight (1.2 kg, P = 0017) and a simultaneous median reduction of 20.7 IU/kg/week of EPO, with an in-crease of the median level of Hb, was noted. The results of our study suggest that by improving the biocompatibility of HD with the use of good quality water, patients acquire a better nutritional, inflammatory and hematologic status.

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To evaluate the peritoneal dialysis (PD) program in our hospital, we retrospectively studied all patients dialyzed with this modality over the last 5 years. A total of 56 patients having end-stage renal disease (ESRD), with mean age ± SD of 49 ± 20 years (range 16-92 years), were dialyzed with PD: 38 (68%) patients with continuous ambulatory PD and 18 (32%) patients with automated PD. Twenty-six (46%) patients were females. The mean follow-up time of these patients was 17 ± 14 months. The underlying etiologies for ESRD in these patients were diabetes mellitus (48%), glomerulonephritis (9%), and hypertension (7%). Twenty-seven patients (48%) were put on PD from the start, while 29 (52%) patients were switched from hemodialysis (HD) to PD. Nineteen (34%) patients developed a total of 29 episodes of peritonitis. The incidence of peritonitis was 0.4 episode per patient-year. Exit-site infections occurred in 17 (30%) patients. No tunnel infection was observed during the study period. Non-infectious catheter-related complications occurred in 12.5% of the patients; six (11%) patients had hernia (umbilical or inguinal). At the end of the study, 23 (41%) patients continued on PD, 17 (30%) received a renal transplant, 7 (13%) suffered technique failure and subsequently switched to HD, and 9 (16%) patients died. To conclude, our study demonstrates that the rate of PD related complications is found to be quite low in our program, with an acceptable technique failure rate and mortality. Therefore, PD is a safe and an effective treatment modality in the integrated care approach to patients with ESRD.

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We present a kidney transplantation patient who developed rhabdomyolysis. The patient was initially immunosuppressed with tacrolimus, mycophenolate mofetil, steroids, and chimeric CD25 monoclonal antibody. He complained of severe precordial and appendicular pain on 25th day after the operation. The patient developed rhabdomyolysis manifested as a rise in serum creatine phosphkinase (CPK) and elevation of urinary myoglobulin at approximately the same time as his symptoms. Although he was switched from tacrolimus to cyclosporine (CYA), his muscle pain and levels of serum CPK did not improve. However, dividing the daily total amount of the calcinuerin inhibitors into more frequent doses in order to reach lower serum levels resolved the rhabdomyolysis. Therefore, we conclude that his rhabdomyolysis might be a dose-related problem of calcineurin inhibitor.

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Chronic kidney disease (CKD) is a massive global health-care problem. Cell therapy offers a potential treatment for CKD. The aim of this study was to investigate whether the administration of a population of stem cells could be used to treat adriamycin (ADR)-induced glomerulopathy in rats, a form of CKD. We intravenously transplanted metanephric mesenchymal cells (MMCs) into rats treated with ADR. We also induced MMC differentiation in vitro using a medium derived from serum and homogenates of ADR-induced glomerulopathy rats. We detected the induction of an early epithelial phenotype (cytokeratin-18 expression) and a proximal tubule phenotype (vitamin D receptor expression) in vitro, and MMC-derived epithelial cells corresponding to the proximal tubule and glomeruli in vivo. Transplantation of MMCs after induction of glomerulopathy significantly increased the creatinine clearance rate (Ccr), a marker for glomerular filtration rate, but had no significant effect on other parameters (24-hour urinary protein excretion, serum albumin, total cholesterol). In addition, there was no significant difference in blood urea nitrogen or serum creatinine levels in rats with and without ADR administration. Our results indicate that MMCs might survive, engraft and differentiate into renal epithelia in vivo when transplanted into ADR-treated rats. However, further studies are needed to determine whether MMC transplantation improves renal function and causes renal repair in this model.

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Vesicoureteric reflux (VUR) is found in 1% of all children and in 30%-50% of those with urinary tract infection. Furthermore, VUR in childhood is the main reason for pyelonephritis, hypertension and chronic kidney disease. Recently, a variety of procedures with low radiation have been recommended for diagnosis of VUR. Therefore, in this study, voiding urosonography (VUS) or cystosonography was performed for evaluation of VUR and for comparing it with radio nucleotide cystography (RNC). We studied 25 children admitted with initial diagnosis of VUR in our center in the year 2007. Simultaneously, RNC and VUS were performed for all the patients. VUR was detected in eight patients with the VUS procedure and in nine children with RNC. Another patient was diagnosed only by RNC, and two other patients by only VUS. The two methods were concordant in detection and exclusion of urinary reflux in 87% (P: 0.000, r: 0.728). Furthermore, the diagnosis of various grades of reflux by these two schemes were comparable (P: 0.0000, r: 0.724). Sensitivity and specifity of VUS was determined as 87% and 88%, respectively, with a 94% positive predictive value and a 77% negative predictive value. We conclude that VUS is a highly accurate, safe and inexpensive tool for the screening, diagnosis and follow-up of VUR.

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Advancements in ureteroscopy have now given the urologist virtually unrestricted access to calculi at all locations in the upper urinary tract. Retrograde intrarenal lithotripsy is a new modality to treat upper urinary tract stones in children. In this retrospective study, we present our experience in retrograde intra-renal lithotripsy in children over a period of 30 months. Fifty-six children with renal stones less than 1.5 cm in size, who underwent retrograde intrarenal lithotripsy during the period from January 2007 to June 2009 at Prince Hussein Urology Center, Royal Medical Center, Amman, Jordan, were included in the study. The average age was 8.2 years and male to female ratio was 2.1:1. The average size of the stone was 1.2 cm, ranging from 0.9 to 1.5 cm. Twelve patients (15.5%) had bilateral stones. All patients had a Double J stent inserted 2-4 weeks prior to the procedure. Ureteroscopy up to the renal pelvis was performed and fragmentation of the pelvic stones was performed by electrohydraulic lithotriptor and the patients were on follow-up during this period. Overall, a total of 78 procedures were performed in these patients. Twelve patients underwent bilateral procedures for bilateral disease, but in separate settings. Nine patients (16%) needed a second session for residual stones. Only four patients (7.1%) needed a third session. The clearance rate was 94.8%. Three patients (3.9%) developed upper urinary tract infection after ureteroscopy; one patient (1.7%) developed frank hematuria postoperatively that was treated conservatively. No residual stones or other complications were detected during an average of 34 months of follow-up. Thus, in the expanding field of pediatric urolithiasis, retrograde intrarenal lithotripsy seems promising and is less invasive and has fewer complications.

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The aim of this study was to find an accurate, easily available and safe imaging modality as an alternative to intravenous urography for the diagnosis of acute urinary obstruction. This retrospective study included 332 patients, who underwent both excretory urography (EU) preceeded by plain radiograph as well as ultrasonography for evaluation of acute flank pain. There were 198 male and 134 female patients. The presence or absence of urinary stones, level of obstruction, excretion delay on EU and dilated excretory system on either or both techniques were recorded. The sensitivity, specificity, predictive values, and accuracy for plain radiograph, ultrasonography, and for both modalities together were measured considering EU as a standard reference. The sensitivity and specificity of combined plain radiograph and ultrasound were 97% and 67%, respectively, with positive and negative predictive values and accuracy rates of 92%, 99%, and 97%, respectively. Our study suggests that the combination of plain radiograph and ultrasonography yields a high sensitivity, negative predictive value, and accuracy in depiction of urinary stones. Thus, EU need not be used as a routine diagnostic procedure in patients with acute obstructive uropathy.

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Qatar is one of the gulf countries with a current estimated population of 1.4 million. Diabetes mellitus, hypertension and chronic kidney diseases are major emerging epidemics, with an incidence of end-stage kidney disease (ESKD) of 202 patients per million population per year. Peritoneal dialysis (PD) was initiated in Qatar in 1997 with a rapid expansion in the number of patients. The study included all patients performing PD in Qatar, during the period from 1 January 2003 to 31 December 2007. Retrospective analysis of data included the records of 241 patients in terms of their demography, treatment, complications, and survival. During the study period, PD patients formed 23% of all the dialysis population in Qatar, with a mean annual expansion rate of 12%. Diabetic nephropathy was the commonest cause of ESKD seen in 43% of PD patients. All age groups were included in our program, with a mean age of 53 ± 13 years. Males represented 74%. Continuous ambulatory peritoneal dialysis remained the initial mode of PD, with significant numbers being changed to automated PD over the years. The 1- and 5-year survival rates were 91% and 26%, respectively, with cardiac causes being responsible for 86% of mortality. The rate of peritonitis was 0.24 ± 0.1 episodes per patient years, and technique survival at 1 and 5 year was 84% and 32%, respectively. We conclude that the components of the PD program in Qatar are comparable to that in other countries with a good outcome.

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To evaluate the utilization of critical care unit beds occupied by brain-dead patients during the period falling between confirmation of the diagnosis till, either, organ harvesting or patient's expiration. We studied all the consecutive patients who had been documented brain-dead from January 2001 to December 2009. Death by brain criteria was documented in 232 patients with a median age of 39 ± 18.2 years; 181 (78%) were Saudis and 175 (75.5%) were males. Only 37 deceased patients diagnosed by brain criteria were consented by their next-of-kin for organ donation; 26 (70.1%) of them were non-Saudis. The time from confirming death by brain criteria in the study patients until they were moved to a morgue or to the operating room for retrieval of organs were 93 ± 89.9 vs. 73 ± 48 h, respectively (P = 0.07). In conclusion, I believe a better utilization of the intensive care units' beds by other than brain-dead patients would not produce great cost savings, but may provide care for more patients with better quality of care.

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A 70-year-old lady with recurrent flash pulmonary edema and acute coronary syndrome was detected to have bilateral renal artery disease and uncontrolled hypertension. Her right kidney size was 9.3 Χ 3.2 cm [glomerular filtration rate (GFR) 32.65 mL/min], left kidney size was 6.8 Χ 2.9 cm (GFR 12.78 mL/min), with a total GFR of 45.43 mL/min. Angiogram showed significant bilateral atherosclerotic renal artery stenosis and 90% right coronary artery lesion. She underwent successful percutaneous transluminal angioplasty of right renal artery lesion. Her serum creatinine of 1.6 mg/dL (GFR 45.43 mL/min) came down to 1.3 mg/dL (GFR 63 mL/min) post procedure and her blood pressure was controlled. She then underwent percutaneous transluminal coronary angioplasty of right coronary artery lesion. Renal artery stenosis is an important cause of uncontrolled hypertension and progression to chronic kidney disease. An early intervention and prompt revascularization prevents recurrent flash pulmonary edema and end stage kidney failure.

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An 80-year-old man was diagnosed to have pneumonia and advanced chronic kidney disease. He presented with anuria and hemodialysis, by temporary femoral catheter, was initiated. He was empirically treated with imipenem/cilastatin 500 mg/24 h after hemodialysis. After 10 days of antibiotic intake, he developed severe diarrhea. Diagnosis of Clostridium difficile (CD)-associated diarrhea was confirmed by detection of the toxins A and B in his stool. Imipenem therapy was discontinued; Vancomycin 500 mg orally every 6 h and 1000 mg per rectum every day was added. After two weeks of this treatment, the patient reported complete resolution of the diarrhea and stool samples were negative for Clostridium toxin. In this case, the most possible cause of CD colitis was considered to be imipenem because of the temporal relationship between exposure to the drug and onset of symptoms.

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