Iranian Journal of Kidney Diseases
Volume:2 Issue: 4, 2008 Oct

Introduction. The aim of this study was primarily to determine if there was any relationship between hemoglobin levels and vascular access (VA) survival. In addition, other risk factors were evaluated with special stress on sex, age, diabetes mellitus, smoking, and medications. Materials and Methods. This study comprised 200 patients who had been on renal replacement therapy for more than 1 month through a permanent VA. The patients were categorized based on their mean blood hemoglobin levels. The possible risk factors for VA failure were also evaluated which included age at the beginning of hemodialysis, sex, diabetes mellitus, baseline levels of intact parathyroid hormone, and antihypertensive therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Results. The younger the age the longer the duration of survival of left radial, left brachial, and right radial fistulas; however, sex had no significant impact on the duration of fistulas. Diabetic patients were more likely to have failed VA compared to nondiabetics. In addition, optimization of hemoglobin levels between 10 g/dL and 12 g/dL was associated with longer fistula survival. A higher risk of right radial arteriovenous fistula failure among hypertensive patients who received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers compared to those without these drugs.Conclusions. Severe anemia, age, diabetes mellitus, and smoking are the main risk factors of VA failure. Our study showed that patients on hemodialysis should benefit from anemia correction, with a target hemoglobin level between 10 g/dL and 12 g/dL, without incurring any increased risk of VA failure.

Approximately, 10% to 15% of patients with end-stage renal disease are on peritoneal dialysis (PD) worldwide, with a dramatic difference in the use of PD among various countries. Recent data show a survival benefit of PD over hemodialysis which is maintained up to the 3rd year. The quality of life studied by various models is as good as, if not better than, that in patients on hemodialysis, for at least the first 2 years. In most countries that locally manufacture PD solutions, PD is significantly cheaper than hemodialysis. Several studies have found a better immediate graft function, lower rate of delayed graft function, and lower use of immunosuppressive medication after kidney transplantation in patients previously on PD compared to those on hemodialysis. There is a significantly lower rate of hepatitis C and hepatitis B infections in patients on PD compared to those on hemodialysis. Longer maintenance of residual renal function in PD compared to hemodialysis adds to the lower morbidity and the survival benefit of PD mentioned above. Many developments in the prevention of the causes of technique failure, including measures to prevent serious peritonitis episodes and new biocompatible PD solutions, together with the possible advantages of some types of catheters and implantation techniques, encourage us to believe that we can offer successful long-term PD in the near future. Overall, the new insight into the pathogenesis of peritoneal membrane changes, the response of the industry to this knowledge by producing new biocompatible PD solutions, the decrease in the peritonitis rate and the introduction of assisted PD at home encourages us to believe that the future of PD is indeed bright.

Introduction. The latent nature of chronic kidney disease (CKD) in primary stages precludes early diagnosis. This necessitates plans such as screening, but we should first introduce CKD as a public health problem. This study was designed to define the burden of CKD in Iran. Materials and Methods. We calculated disability-adjusted life years (DALYs) according to the World Health Organization’s practical guidelines for national burden of disease studies. The sum of years of life lost and years lived with disability were estimated for CKD stages 1 to 4 and end-stage renal disease (ESRD) based on the national registry data and the published reظorts about CKD in Iran in 2004. Results. Over 700 000 people were estimated to have CKD in Iran in 2004 and 61 000 new cases of CKD were anticipated. The prevalence rate of CKD was estimated to be 1083 and its incidence rate was 173. 5 per 100 000 population. Chronic kidney disease was responsible for 1 145 654 DALYs. The highest DALYs for stages 1 to 4 of CKD were due to unknown etiology, diabetes mellitus, and hypertension (382 000 years, 347 400 years, and 311 800 years, respectively). The DALY for ESRD and CKD stages 1 to 4 were 21 490 years and 1 124 164 years, respectively. Conclusions. The present study provides an estimate of the burden of CKD in Iran. As CKD can be controlled by practical cost-effective plans, we strongly recommend the information given by this study be considered for future action plans.

Introduction. The aim of this study was to assess urinary interleukin-8 (IL-8) levels in pyelonephritis and its relation with the clinical course of the infection and of inflammatory changes detected by renal scintigraphy.Materials and Methods. In this quasi-experimental before-after study, we evaluated 91 children aged 1 to 144 months (mean 34.4 ± 35.2 months) with pyelonephritis. Inflammatory markers including erythrocyte sedimentation rate, C-reactive protein, leukocyte count, and urinary IL-8, together with the results of ultrasonography, voiding cystourethrography, and dimercaptosuccinic acid renal scintigraphy were evaluated in these children. The ratios of urinary IL-8 to creatinine (IL-8/C) before and after the treatment were compared with each other.Results. Urinary IL-8/C levels were significantly higher after the empirical treatment in comparison with those before the treatment (0.19 ± 0.21 versus 0.51 ± 0.53, P <. 001). No correlation was found between the urinary IL-8 levels and leukocyturia, urine culture results, other inflammatory markers, or findings of imaging examinations. Conclusions. We found high urinary IL-8 levels in children with pyelonephritis. We also documented its increasing after the treatment. We conclude that evaluation of urinary IL-8 can be a noninvasive test for diagnosis of upper urinary tract infection and its response to treatment.

Introduction. Antibiotic resistant mutants producing extended-spectrum beta-lactamase (ESBL) have emerged among Escherichia coli and Klebsiella pneumoniae. This study was done to determine the frequency of ESBL-producing E coli and K pneumoniae species isolated from urine samples of our patients. Materials and Methods. A study was conducted on 164 urine isolates (124 E coli and 40 K pneumoniae) in the laboratory Loghman Hakim Hospital in Tehran, Iran, in 2007. Microbial sensitivity tests were done on Mueller-Hinton agar plates with disk diffusion method. Broad-spectrum resistance was defined as resistance to ampicillin or cephalothin; ESBL resistance, as resistance of these bacteria to one of ceftriaxone, ceftazidime, or ceftizoxime; and MDR-ESBL; as resistance to 3 of the following antibiotic groups: trimethoprim-sulfamethoxazole, aminoglycosides, fluoroquinolones, and nitrofurantoin. Results. An ESBL resistance was detected in 52.5% of isolates with K pneumoniae and 45.2% of those with E coli. The MDR-ESBL pattern was detected in 26.8% of the isolates. These included 30.0% of the K pneumoniae and 25.8% of the E coli isolates. Broad-spectrum resistance was detected in all K pneumoniae isolates and 87.9% of 124 E coli isolates. Conclusions. Our study showed a high rate of ESBL resistant strain of E coli and K pneumoniae and the emergency of multiple drug resistance to these bacteria in our patients in Tehran, Iran.

Introduction. Undergoing transplantation is extremely stressful, and a recipient is likely leave the hospital burdened with fears of an uncertain future. A paucity of knowledge on the long-term survival of rehospitalized kidney transplant recipients is the likely the reason that physicians fail to provide this group of patients with promising information and reassurance about their future. We sought to describe the long-term patient and graft survival after nonfatal rehospitalization in kidney recipients with a normal graft function after discharge. Materials and Methods. We reviewed the follow-up data (from the time of discharge after first rehospitalization) of 253 kidney transplant recipients who had been discharged from rehospitalization with a normal kidney function (serum creatinine less than 1.6 mg/dL). Patient and graft survival rates 6 months and 1, 2, and 5 years after discharge were determined. Results. The mean duration of follow-up (from the time of discharge after the first rehospitalization) was 38.9 ± 11.2 months (range, 6 to 84 months). The overall patient survival rates were 98%, 97%, 95%, and 93% at 6 months, 1 year, 2 years, and 5 years, respectively. Graft survival rates at these times were 88%, 82%, 77%, and 63%, respectively. After the first posttransplant rehospitalization, 54 patients (21.9%) experienced more hospitalization episodes (mean, 2.6± 2.0 times), while 193 (78.1%) had no further hospitalizations during the follow-up period. Conclusion. Kidney transplant recipients who are rehospitalized should be reassured about favorable chances of survival if discharged with a normal graft function.

Introduction. Little information exists on the burden of intensive care unit (ICU) to the posttransplant rehospitalizations of kidney allograft recipients. We do not clearly know the extent of the need for ICU during rehospitalizations and causes of readmissions. In this study, we aimed to assess ICU admissions of kidney transplant recipients, to determine the risk factors of ICU admissions in rehospitalized patients, and to evaluate the additional burden of ICU admission. Materials and Methods. A total of 581 posttransplant rehospitalizations of kidney transplant recipients were assessed for ICU admission. Clinical characteristics of the patients and the length of hospital stay, transplantation-admission interval, hospitalization costs, and mortality rate were reviewed. Results. Twenty-five rehospitalized kidney transplant recipients (4.3%) had been admitted to ICU with kidney dysfunction (36.0%), cerebrovascular accident (24.0%), sepsis (16.0%), brain tumor (8.0%), brain abscess (4.0%), diabetic ketoacidosis (4.0%), trauma (4.0%), and hemodynamic shock (4.0%). The risk factors of referral to ICU were higher age (P =. 001) and hospitalization for cerebrovascular accident (P =. 001) and malignancy (P =. 004). Additional burdens were 1.8, 3.3, and 11.4 times as high as the rehospitalization burden for the length of hospital stay, hospitalization costs, and mortality rate, respectively. Conclusions. Age and some special causes of hospitalizations are risk factors of ICU admission of kidney transplant recipients, and this occurs in about 5% of rehospitalizations. Admission to ICU adds considerably to the burden of rehospitalizations, warranting measures to prevent conditions that lead to the need for intensive care in these patients.

Introduction. Lifestyle after transplantation is the key link between transplantation and its outcome, and it is crucial to comply with the recommended life style behaviors. Our aim was to assess the compliance of kidney transplant recipients to the recommended life style behaviors in Mansoura, Egypt. Materials and Methods. One hundred kidney transplant patients were surveyed on their compliance with the recommended lifestyle behaviors including transplant medications, preventing from infections, diet, exercise, regular medical visits, personal hygiene, sexual activity, and cancer prevention. Results. Most of the kidney recipients were compliant with the immunosuppressants. One-third of the participants were compliant with low-salt diet. Noncompliance with annual dental and eye checkup was reported in the majority of the subjects 94.0%. Compliance with infection prevention was partial. Half of the patient had a poor compliance with exercise or were not complying the recommendations at all. Only 9.0% of the patients were avoiding sun exposure. The majority of women were not compliant with breast self-examination. One-third of the patients consulted with their nephrologists about their sexual problems, and only half of the women were compliant with family planning program. The women were less compliant than men with medications (P =. 02), and poor compliance with medications was more frequent among those with living unrelated donors (P =. 04). Conclusions. Our kidney transplant patients had good compliance with immunosuppressive medications, but not with most of the recommended behaviors. Intensive assessment of patients before and after transplantation should be done to identify their needs which help planning to improve their compliance.

Introduction. Limited data with adequate sample size exist on the development of posttransplant lymphoproliferative disorder (PTLD) in living donor kidney recipients. W e conducted a retrospective cohort study on the data of 10 transplant centers to identify the incidence of PTLD in Iran. Materials and Methods. Data of 9917 kidney transplant recipients who received their kidneys between 1984 and 200 8 were reviewed. Fifty-one recipients (0.5%) who developed PTLD were evaluated with a median follow-up of 47.5 months (range, 1 to 211) months. Results. Patients with PTLD represented 24% of all posttransplant malignancies (51 out of 211 cases). There was no relationship between PTLD and sex (P =. 20). There were no statistically significance differences considering the age at transplantation between patients with and without PTLD. The late-onset PTLD (70.6%) occurred more frequently compared to the early form. There was no signification relationship between early-onset and late-onset groups in terms of clinical course and outcome. In patients who received azathioprine, PTLD was more frequent when compared to those who received mycophenolate mofetil (P <. 001). The lymph nodes were the predominantly involved site (35.3%), followed by the gastrointestinal tract, brain, kidney allograft, lung, ovary, vertebrae, and palatine. Age at diagnosis and the time from transplantation to diagnosis were comparable for various involvement sites of PTLDs. The overall mortality in this series of patients was 51.0%. Conclusions. P osttransplant lymphoproliferative disorder is a rare but devastating complication and long-term prognosis can be improved with early recognition and appropriate therapy.

We present an adolescent with McArdle disease and recurrent acute kidney failure due to rhabdomyolysis. The patient was admitted with acute kidney failure for 3 times and due to a history of proximal weakness, fatigue, and muscular cramps after physical activities a glycogen-storage disease was suspected. Serum creatine phosphokinase and urine myoglobin were found to be elevated. McArdle disease was diagnosed based on pathologic examination of muscle tissue specimen. Patients presenting with rhabdomyolysis following strenuous exercise should be evaluated for McArdle disease.