Iranian Journal of Kidney Diseases
Volume:1 Issue: 2, 2007 Oct

Introduction. Chronic Hepatitis C Virus (HCV) infection has been associated with glomerular disease in native and transplanted kidneys. We evaluated the presence of HCV infection at the time of transplantation and occurrence of proteinuria in Egyptian kidney transplant patients and their link with graft survival. Materials and Methods. This retrospective study was done on 273 patients with end-stage renal disease transplanted in Mansoura Urology and Nephrology Center Between 1993 and 1996. Their sera were routinely assayed for anti-HCV antibodies at the time of transplantation. The relationship between the HCV and the development of posttransplantation proteinuria was evaluated, along with the possible effects of proteinuria on long-term graft survival. Results. A total of 169 kidney recipients (61.9%) were positive for anti-HCV antibodies. The mean durations of post-transplant follow-ups were 87.73 ± 26.79 months (range, 19 to 123 months) and 84.29 ± 28.55 months (range, 11 to 123 months) for the patients with and without anti-HCV antibodies, respectively. The patients in these groups were comparable regarding the incidence of proteinuria (33% and 32%, respectively) and its quantity (median, 0.6 g/d and 0.4 g/d, respectively). Irrespective of the HCV infection, patients with nephrotic-range proteinuria showed a worse graft survival (P <. 001) and a higher frequency of chronic allograft nephropathy (P =. 03) compared with nonproteinuric patients. Conclusions. There is a high prevalence of HCV infection in our patients with end-stage renal disease awaiting kidney transplantation. The incidence and quantity of proteinuria do not increase by HCV infection, and nephrotic-range proteinuria is independently associated with chronic allograft nephropathy and a poorer graft outcome

Disparities in access to care for patients with end-stage renal disease (ESRD) and particularly to kidney transplantation, as well as discrepancies in follow-up and outcomes have been extensively documented as they relate to race, ethnicity, gender, socioeconomic factors, urban/rural residence, and geographic region. Furthermore, these inequalities seem to be increasing in various parts of the world and it is imperative to develop policies to address them among various population groups, identifying factors that might provide improved care for all patients with kidney disease. Numerous studies from various parts of the world have demonstrated racial, ethnic, and geographic differences regarding the delivery of healthcare to patients with ESRD. To the author’s knowledge, although this issue has been studied at transplant centers in Iran on an individual basis, it has not been extensively studied on a national scale. In this paper, the current world literature will be reviewed, with the goal of emphasizing the need to initiate and expand full-scale studies to detect and remedy any existing inequalities in Iran, a vast country with an ethnically, culturally, and economically diverse population. The author proposes the designation, at the national level, of a task force to study disparities and to provide insight into the means of correcting them. As Iran continues to attain a position of regional leadership in the realm of organ transplantation, it seems prudent to invest in research aimed at detecting and remedying any inequalities in the provision of equivalent and just care for patients with ESRD.

The incidence of acute rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract. The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study.Treatment of acute cellular rejection in kidney transplant recipients include pulse steroid for the first rejection episode. It can be repeated for recurrent or resistant rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of rejection episodes, the use of potent drugs, time of rejection from transplantation, and response to treatment.

Introduction. Although intermittent hemodialysis (IHD) is the standard therapy in patients with acute renal failure, it is associated with several drawbacks. Extended daily dialysis (EDD) has been described as a compromise between IHD and continuous therapies and could potentially overcome problems associated with IHD.Materials and Methods. We compared EDD with IHD each administered in 15 patients with acute renal failure. The IHD was administered 4 hours per session thrice weekly, while EDD was given for 8 hours per session daily with the same machines at similar blood and dialysate flow rates. Treatment outcome, metabolic control, and hemodynamic stability were assessed in the patients of each group.Results. A total of 140 EDD treatment sessions and 82 IHD sessions were administered. Patients in the EDD and the IHD groups received a mean of 74.67 ± 29.70 hours and 21.73 ± 5.99 hours of dialysis, respectively (P <. 001). The median urea reduction ratio in the EDD group was significantly higher (83.82% versus 64.66%, P <. 001). Patients on EDD showed faster normalization of deranged metabolic parameters. Hemodynamically, EDD was better tolerated compared to IHD. The median predialysis mean arterial pressure in the EDD and IHD patients were 103.3 mm Hg and 100 mm Hg, respectively, while the postdialysis values were 78.6 mm Hg and 73 mm Hg, respectively. Conclusions. Extended daily dialysis appears to be a promising technique for dialysis in moderately ill patients having up to 2 organ failures.

Introduction. One of the most common complaints in patients with end-stage renal disease (ESRD) is uremic pruritus. In the recent years, many drugs have been proposed for its treatment which have had paradoxical outcomes. We studied the antipruritus effect of montelukast sodium, a leukotriene receptor antagonist, in patients on hemodialysis.Materials and Methods. The study was conducted as randomized, single-blind, placebo-controlled crossover study in 5 hemodialysis centers. Sixteen patients with refractory pruritus were selected and were divided into 2 groups to receive firstly montelukast and then placebo, or vice versa. Patients were treated by montelukast tablets, 10 mg daily, for 20 days and the washout period was 14 days. Results. Of 16 patients whom were included in the study, 1 died during the placebo period of myocardial infarction and another patient who received montelukast for 20 days faced hemoglobin decrease during the placebo period diagnosed as myelodysplastic syndrome. At the end of the treatment with montelukast, pruritus was reduced by 35% (95% CI, 9.5% to 62.5%), while it was reduced 7% (95% CI, 0.5% to 15.9%) with placebo (P =. 002). The patients’ compliance was assessed satisfactory, except for 1 patient who exited the study due to anemia.Conclusions . Montelukast is more effective than placebo in the treatment of uremic pruritus not responding to the currently available antipruritus drugs, and it can be considered as a new and rather safe and effective treatment option in uremic patients.

Introduction. Peritoneal effluent cancer antigen 125 (CA125) concentration is a marker of mesothelial cell mass in patients on continuous ambulatory peritoneal dialysis (CAPD). Accordingly, we aimed to observe the effects of CAPD duration, sex, and peritoneal membrane efficacy on CA125 levels in peritoneal effluent. Materials and Methods. In 30 patients who were on CAPD for 6 months, concentrations of CA125 were determined in the 4-hour effluent peritoneal dialysate at the 6th and 12th month of CAPD initiation. The laboratory results were assessed in relation to the patients’ sex and peritoneal membrane efficacy which was measured by the peritoneal equilibration test, weekly creatinine clearance, and the Kt/V. Results. The patients were 16 men and 14 women with a mean age of 34.3 years (range, 17 to 56 years). With increasing the duration of CAPD, dialysate CA125 levels decreased significantly (P <. 001). Whereas, there were no significant changes in Kt/V and creatinine clearance at 12 months. In the men, the CA125 levels were significantly lower 6 months after the start of CAPD compared to the women (P =. 047). I n low transporter and low average transporter patients, peritoneal effluent had slightly higher levels of CA125 in comparison with those in high transporter and high average transporter patients (P =. 08). Conclusions. We found that peritoneal effluent CA125 level decreases in both men and women with increasing of CAPD duration, without any association with peritoneal transport parameters. Of interest, there was a gender difference in the CA125 levels in our series.

The incidence of acute rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract. The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study.Treatment of acute cellular rejection in kidney transplant recipients include pulse steroid for the first rejection episode. It can be repeated for recurrent or resistant rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of rejection episodes, the use of potent drugs, time of rejection from transplantation, and response to treatment.

Introduction. Chronic Hepatitis C Virus (HCV) infection has been associated with glomerular disease in native and transplanted kidneys. We evaluated the presence of HCV infection at the time of transplantation and occurrence of proteinuria in Egyptian kidney transplant patients and their link with graft survival. Materials and Methods. This retrospective study was done on 273 patients with end-stage renal disease transplanted in Mansoura Urology and Nephrology Center Between 1993 and 1996. Their sera were routinely assayed for anti-HCV antibodies at the time of transplantation. The relationship between the HCV and the development of posttransplantation proteinuria was evaluated, along with the possible effects of proteinuria on long-term graft survival. Results. A total of 169 kidney recipients (61.9%) were positive for anti-HCV antibodies. The mean durations of post-transplant follow-ups were 87.73 ± 26.79 months (range, 19 to 123 months) and 84.29 ± 28.55 months (range, 11 to 123 months) for the patients with and without anti-HCV antibodies, respectively. The patients in these groups were comparable regarding the incidence of proteinuria (33% and 32%, respectively) and its quantity (median, 0.6 g/d and 0.4 g/d, respectively). Irrespective of the HCV infection, patients with nephrotic-range proteinuria showed a worse graft survival (P <. 001) and a higher frequency of chronic allograft nephropathy (P =. 03) compared with nonproteinuric patients. Conclusions. There is a high prevalence of HCV infection in our patients with end-stage renal disease awaiting kidney transplantation. The incidence and quantity of proteinuria do not increase by HCV infection, and nephrotic-range proteinuria is independently associated with chronic allograft nephropathy and a poorer graft outcome.

Introduction. Kidney transplant recipients are at increased risk of cancers, most frequently skin cancers, and in some regions, Kaposi sarcoma and non-Hodgkin lymphoma. We sought to investigate the associate of the most frequent malignancies among our patients with human leukocyte antigens (HLAs). Materials and Methods. We performed a retrospective study on 44 kidney allograft recipients who had posttransplant malignancy and 44 kidney allograft recipients without malignant lesions (control group). All of the patients had been treated by immunosuppressive regimens including cyclosporine plus prednisolone or cyclosporine, prednisolone, and mycophenolate mofetil. Data on HLA typing were achieved from their transplant records. Results. There were 15 patients (34.1%) with Kaposi sarcoma; 13 (29.6%) with non-Hodgkin lymphoma, 6 (13.6%) with skin cancer, 2 (4.5%) with ovary cyst adenocarcinoma, and 8 (18.2%) with other tumors. The mean interval from transplantation to diagnosis of malignancy was 15.3 month. Twelve patients died of cancer during the follow-up (mean, 12.3 years). No significant difference was noted in the age, sex, and time of transplantation between these patients and those in the control group. Kaposi sarcoma was associated with HLA-CW4 (P =. 03) with an odds ratio of 4.96 (95% confidence interval, 2.90 to 8.12). Conclusions. We found HLA-CW4 as a risk factor of Kaposi sarcoma in kidney allograft recipients. Screening for malignancies after kidney transplantation sounds very important with special attention to the specific environmental and genetic factors in each populatio

Multicystic dysplastic kidney is a noninherited congenital disease. Association of this disease with abnormalities of various organs is common. We, however, report a rare case of multicystic dysplastic kidney associated with congenital ichthyosiform erythroderma in an infant. Different developmental origins of the skin and the kidney can explain the scarcity of concurrent congenital skin and kidney abnormalities. Nonetheless, the development of both organs depends on mesenchyme-epithelial interactions for inductive signaling. It seems defects in the production of signaling molecules can explain such an association.