Iranian Journal of Kidney Diseases
Volume:1 Issue: 1, 2007 Jul

Skin cancers are the most common tumors among transplant recipients who receive immunosuppressive agents. Kaposi sarcoma (KS) is one of the most common malignancies to occur in kidney transplant recipients, especially in the Middle East countries. Its prevalence in comparison with other neoplasms is also relatively higher in Iran (> 35%). The KS-associated herpesvirus or human herpesvirus 8 is a newly discovered herpesvirus found in all forms of the KS including those among immunosuppressed transplant recipients. Kaposi sarcoma usually regresses after withdrawal or reduction of immunosuppressive agents. A wide variety of therapies have been used for KS, including radiotherapy and administration of interferon and different chemotherapeutic regimens. Sirolimus exhibits antiangiogenic activity related to impaired production of vascular endothelial growth factor and limited proliferative response of endothelial cells to the stimulation by vascular endothelial growth factor. Therefore, it can inhibit the progression of KS. Accordingly, replacement of calcineurin inhibitors by a sirolimus can show promising results in the prevention of KS.

Menstrual problem is common among women with chronic kidney disease, and patients with end-stage renal disease usually have amenorrhea. The rate of pregnancy in women on dialysis is low. Fetal survival in this population has improved, with half of such pregnancies resulting in delivery of a live infant. However, prematurity remains common and accounts for the low-birth weight of these infants. Intensifying hemodialysis by increasing the frequency of treatments is associated with longer gestation and increased likelihood of a successful pregnancy. Intense hemodialysis also improves the control of maternal intravascular volume and reduces the risk of hypotension due to excessive ultrafiltration. Women with chronic kidney disease tend to experience decreased libido and reduced ability to reach orgasm. Sexual difficulties in uremic patients are often worsened by hemodialysis, with a lowered frequency of intercourse, reduced sexual desire, and an increased incidence of sexual failure. There have been ongoing improvements in survival and quality of life after kidney transplantation. In most patients, sexual desire increases significantly after successful transplantation; however, improvement in the frequency of sexual activity and the overall sexual satisfaction is not as high as that in sexual desire. These have been accompanied by an improvement in reproductive function. Pregnancy success rate exceeds 90% after the first trimester in women with kidney transplant. Contraceptive counseling should be provided before transplantation, because ovulatory cycles may begin within 1 to 2 months after transplantation in women with functioning grafts. Breastfeeding is discouraged for patients taking any immunosuppressive drugs

Introduction. Acute tubular necrosis (ATN) is a challenging problem that still requires to be studied in animal models. Our aim was to prepare an established experimental model of inducing reversible ATN in rats by determining the optimum duration of ischemia induction to the kidney. Materials and Methods. Twenty-four hour after nephrectomy of the right kidney and clamping the pedicle of the left kidney for durations ranging from 10 to 55 minutes, the kidney function and the histologic changes were evaluated. Accordingly, the optimum duration of clamping was determined and in the next step, it was considered for induction of reversible ATN in another group of rats. This group was followed up for 14 days and the pathologic course and function of the kidney were observed. Results. Reversible ATN developed by 47-minute clamping of the renal pedicle. Blood urea nitrogen and serum creatinine levels were elevated up to threefold within 24 hours after the induction of ischemia and they decreased to their reference ranges after 12 and 6 days, respectively. In the histologic study of the kidneys, the least extend of injury was noted by the 14th day following the ATN induction. Even on the 14th day of the follow-up, some signs of ATN remained indicating that the tissue regeneration was not complete yet. Conclusions. To integrate the experimental models of ATN, a rat model with 47-minute clamping of the renal pedicle for induction of ischemia seems appropriate. The resultant ATN remains for a long duration, while kidney function is alleviated.

Introduction. Staphylococcal infections are a major cause of morbidity and mortality in patients on hemodialysis. We conducted a study of nasal and skin colonization in patients receiving maintenance hemodialysis. Materials and Methods. From September 2003 through June 2004, we evaluated 69 patients who were receiving maintenance hemodialysis via an internal fistula or graft. Four samples were obtained for culture from both nares and needle insertion sites on the skin by standard methods. The growth of Staphylococcus aureus was recorded during the study.Results. Of the 69 patients, 28 (40.5%) had S aureus present in the nose and 9 (13.0%) had it present on the skin around the access site at some times during the study period. The presence of S aureus on the skin of the access site was significantly related to the simultaneous presence of this organism in the nose (P =. 03). Conclusions. From our observations, it can be concluded that the nose provides an environment in which S aureus can propagate and maintain itself for prolonged periods. As skin colonization with S aureus is a risk factor for the development of staphylococcal infection, it could be recommended that effective removal of S aureus from the nose would be critical for prevention of vascular access site infection.

Introduction. Our aim was to evaluate the degree of achievement of the recommended values in National Kidney Foundation Dialysis Outcomes Quality Initiative (K/DOQI) guidelines for the laboratory indicators of bone metabolism in patients undergoing hemodialysis (HD) in Tehran province.Materials and Methods. We evaluated the laboratory information of 2630 HD patients in Tehran province. Demographic data of the patients and the clinical information including the duration of dialysis session, dialysate calcium concentration, Kt/V, and serum values of calcium, phosphorus, and intact parathyroid hormone (PTH) were recorded. The laboratory values were compared to the recommended ranges by the K/DOQI work group in patients with end-stage renal disease. Results. Only 1.8% of the patients could enjoy a successful management according to the K/DOQI recommendations for the 4 target laboratory tests of serum calcium, phosphorus, intact parathyroid hormone, and calcium-phosphorus product. Hypocalcemia was diagnosed in 33.2% of the patients, whereas 13.6% were diagnosed with hypercalcemia. Hypophosphatemia and secondary hyperparathyroidism were diagnosed in 6.8% and 24.2% of the patients, respectively. Conclusions. Our findings proved that complying with the recommendations established by the K/DOQI work group in the clinical management of mineral metabolism is very demanding. Phosphate binders frequently lead to untoward toxicities and imbalance in bone metabolism of patients on HD, warranting new cost-effective therapies with fewer side effects. It would be of great interest to analyze, in the future, the benefits derived from the effect of new therapies such as calcimimetics or new phosphate binders regarding the achievement of the K/DOQI guidelines.

Introduction. Fungal peritonitis (FP), causing catheter obstruction, dialysis failure, and peritoneal dysfunction, is a rare but serious complication of peritoneal dialysis. In this study, the frequency and risk factors of FP are evaluated in children who underwent peritoneal dialysis.Materials and Methods. A retrospective multicenter study was performed at the 5 pediatric peritoneal dialysis centers in Iran from 1971 to 2006, and FP episodes among 93 children were reviewed. Risk ratios were calculated for the clinical and demographic variables to determine the risk factors of FP. Results. Ninety-three children aged 39 months on average were included in study. Sixteen out of 155 episodes of peritonitis were fungi infections, all by Candida albicans. The risk of FP was higher in those with relapsing bacterial peritonitis (P =. 009). Also, all of the patients had received antibiotics within the 1 month prior to the development of FP. Catheters were removed in all patients after 1 to 7 days of developing FP. Six out of 12 patients had catheter obstruction and peritoneal loss after the treatment and 5 died due to infection.Conclusions. Fungal peritonitis, accompanied by high morbidity and mortality in children should be reduced by prevention of bacterial peritonitis. Early removal of catheter after recognition of FP should be considered.

Introduction. Pruritus is one of the frequent discomforting complications in patients with end-stage renal disease. We prospectively evaluated the effectiveness of doxepin, an H1-receptor antagonist of histamine, in patients with pruritus resistant to conventional treatment.Materials and Methods. A randomized controlled trial with a crossover design was performed on 24 patients in whom other etiologic factors of pruritus had been ruled out. They were assigned into 2 groups and received either placebo or oral doxepin, 10 mg, twice a day for 1 week. After a 1-week washout period, the 2 groups were treated conversely. Subjective outcome was determined by asking the patients described their pruritus as completely improved, relatively improved, or remained unchanged/worsened. Results. Complete resolution of pruritus was reported in 14 patients (58.3%) with doxepin and 2 (8.3%) with placebo (P <. 001). Relative improvement was observed in 7 (29.2%) and 4 (16.7%), respectively. Overall, the improving effect of doxepin on pruritus was seen in 87.5% of the patients. Twelve patients (50.0%) complained of drowsiness that alleviated in all cases after 2 days in average. One patient refused to continue the treatment due to its sedative effect.

Introduction. To investigate the oxidative stress and its association with antioxidants in patients on hemodialysis, we evaluated the levels of albumin, C-reactive protein (CRP), ferritin, vitamin E, glutathione, and total antioxidant capacity in these patients. Materials and Methods. In a cross-sectional study, we enrolled 25 patients on maintenance hemodialysis and measured the inflammatory and oxidative stress indicators consisting of the plasma concentrations of glutathione, vitamin E, and total antioxidant capacity. The acute-phase inflammatory response was assessed by determining the serum levels of CRP and albumin as well as the plasma level of ferritin. Antioxidants and acute-phase reactants in men and women and their association with age and their correlations with each other were analyzed. Results. The mean age of the patients was 53.6 ± 14.1 years (range, 29 to 70 years). They had been on hemodialysis for a mean duration of 4.66 ± 5.08 years. There were no association of sex or age with the levels of antioxidants and acute-phase reactants. Plasma level of glutathione significantly correlated with CRP (r = 0.48; P =. 01) and serum albumin (r = 0.42; P =. 04). Duration of dialysis did not correlate with the antioxidants or acute-phase reactants.Conclusions. Although it is reasonable to see an association between acute-phase reactants and levels of antioxidants in patients on hemodialysis, we failed to show such a relation. It is recommended that other biomarkers of oxidative stress and their relation in patients with kidney failure be investigated.

Infective endocarditis (IE) is a serious complication in kidney transplantation, leading to graft loss and a high mortality rate. We report 4 successfully managed cases of IE in kidney transplant recipients. Blood culture revealed Enterococcus in 2 patients, group D Streptococcus in 1, and no bacteria in 1. All of the patients were diagnosed based on at least 2 major Duke criteria for diagnosis of IE. Although a mild increase in the serum creatinine level was observed in 3 out of 4 patients, no graft rejection occurred during the follow-up. Early diagnostic and therapeutic intervention, particularly intensive antibiotic therapy and surgical management can preserve the patient and the kidney allograft. Studies on previous recurrent infections and simultaneous diseases such as cytomegalovirus in these patients are warranted.