Iranian Journal of Kidney Diseases
Volume:4 Issue: 4, Oct 2010

Dialysis and transplantation are life-saving but very expensive treatments. Current increases in the number of hemodialysis centers, machines, shifts, and kidney transplantations cannot keep pace with the increasing number of end-stage renal disease patients globally. The only way to decrease the incidence of end-stage renal disease is identifying patients with low glomerular filtration rate. The risk groups to be targeted, the expected outcomes, and the tests to be ordered are reviewed in this article. The ways that it is possible to make a screening program sustainable and likely cost-efficient model is discussed. It seems the high-risk target population for chronic kidney disease screening in our country can be those with diabetes mellitus, hypertension, hyperlipidemia, age over 40 years, and obesity (possibly abdominal obesity). Macroalbuminuria check in addition to serum creatinine measurement in high-risk population may look a practical approach to initiate a national program.

Introduction. End-stage renal disease is a serious illness with major consequences in both health and healthcare expenditures. The growing number of patients with end-stage renal disease in developing countries will consume a greater proportion of healthcare budget. We aimed to assess the costs of hemodialysis and kidney transplantation in a renal care center in Sudan.Materials and Methods. We conducted a cross-sectional study to estimate the costs of kidney transplantation and compare those with the costs of hemodialysis per year. We enrolled 78 patients on regular hemodialysis for at least 2 years and 33 kidney transplant patients on regular follow-up at Gezira Hospital for Renal Diseases and Surgery in Sudan.Results. The annual cost of hemodialysis was found to be US $ 6847.00. The total cost of the first year after transplantation was US $ 14 825.04 and the cost of kidney transplantation after the first year was US $ 10 651.00. The total hospitalization days and absence from work were less in the transplant group.Conclusions. Hemodialysis in Sudan is less expensive than transplantation

Introduction. This study was designed to determine the protective effect of red grape seed extract (RGSE) on gentamicin-induced nephrotoxicity in rats.Materials and Methods. Thirty male Wistar rats were divided into 3 groups to receive RGSE, for 60 days followed by intraperitoneal injection of saline solution (as placebo) for 8 days (group 1); RGSE followed by gentamicin for 8 days (group 2); and gentamicin without pre-medication of RGSE (group 3). Oral RGSE, 40 mg/kg/d, and intraperitoneal injection of gentamicin, 100 mg/kg/d, were administered in these groups of rats. Blood and urine samples were collected on days 0 and 68 of the study. Then, the kidneys were removed for pathologic examination.Results. On day 68, serum creatinine and blood urea nitrogen concentrations were highest in group 3, which was significantly higher than in group 1 (P =. 001 and P =. 004, respectively), while slightly higher than in group 2 (P =. 30 and P =. 50, respectively). Fractional excretion of sodium was not significantly different between the three groups. Histopathological evaluation showed that rats in group 3 had significantly higher degrees of severe acute tubular necrosis and interstitial mononuclear cell infiltration than the rats in groups 1 and 2 (P <. 001)Conclusions. This animal study suggests that pretreatment with RGSE protects against gentamicin-induced acute kidney injury as evident on tissue histology. However, this was not accompanied with significant improvement in biochemical markers of kidney injury.

. Childhood idiopathic nephrotic syndrome is characterized by frequent relapsing courses or steroid dependency. Levamisole is a popular drug for treatment of these patients. The purpose of this study was to evaluate levamisole in children with steroid-dependent nephrotic syndrome.Materials and Methods. We retrospectively studied 304 children with a diagnosis of steroid-dependent nephrotic syndrome or frequently relapsing nephrotic syndrome. The mean age at the time of diagnosis was 4.84 years. Following induction of complete remission with steroid therapy based on the International Study of Kidney Disease in Children’s protocol and when they were taking alternative days of steroid, 2.5 mg/kg of levamisole was administered.Results. The steroid dose was significantly decreased (mean reduction of 0.39 ± 0.46 g to 0.33 ± 0.38 g) after treatment with levamisole (P <. 001). The number of relapses also significantly decreased (mean reduction of 0.92 ± 0.98 episodes to 1.07 ± 1.20 relapses per year; P <. 001). The 14.5-month administration of levamizole had a sensitivity of 67.5% and a specificity of 71.9% to reach a dose reduction of more than 50% in steroid therapy. The duration of levamizole treatment was associated with more than 50% reduction in the number of relapses (P <. 001). A 14.5-month treatment with levamizole had a sensitivity of 62.3% and a specificity of 63.6% to reach a relapse reduction of more than 50%.Conclusions. Levamisole appears to be effective in prolonging the duration of remission and decreasing the steroid dose in children with steroid-dependent nephrotic syndrome.

Introduction. Urinary tract infection is the most common serious bacterial infection in children. The aim of this study was to compare the value of different laboratory and imaging techniques in detecting renal involvement in acute pyelonephritis.Materials and Methods. In a cross-sectional study of patients 1 month to 14 years of age diagnosed with urinary tract infection were examined with systemic inflammatory markers, renal ultrasonography, voiding cystourethrography (VCUG), and technetium Tc 99m dimercaptosuccinic acid (99mTc-DMSA) renal scintigraphy. A total of 1467 pediatric patients were eligible for treatment of pyelonephritis. Evaluations included a complete blood count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), urinalysis, urine culture, and measurement of serum blood urea nitrogen and creatinine levels.Results. The results of 99mTc-DMSA scans were normal in 20.2%, mild decreased cortical uptake in 45.0%, moderate decreased cortical uptake in 12.3%, severe decreased cortical uptake in 12.0%, and decreased cortical function plus irregularity or scar formation in 10.5%. Voiding cystourethrography showed vesicoureteral reflux in 25.9%. The sensitivity of 99mTc-DMSA for prediction of vesicoureteral reflux was 84.1% with a negative predictive value of 80.6%. Significant differences were found in the level of blood leukocyte count (P =. 03), urine leukocyte count (P =. 003), ESR (P =. 008), and age (P =. 04) between patients with normal and abnormal 99mTc-DMSA scan results.Conclusions. We found that in patient with clinical signs of pyelonephritis, 99mTc-DMSA renal scintigraphy can detect pyelonephritis more accurately than the other inflammatory and imaging tests.

Introduction. The impact of several environmental and genetic factors on diabetes mellitus and its complications is well documented. It has also been established that cytokines play key roles in the pathogenesis of nephropathy. Polymorphisms of the -590 region of interleukin (IL)-4 are associated with the regulation of expression of this gene. In this study, we aimed to find polymorphisms of this region in nephropathic type 2 diabetic patients.Materials and Methods. Peripheral blood samples were collected from 100 type 2 diabetic patients with nephropathy and 150 healthy controls. DNA was extracted and a polymerase chain reaction-restricted fragment length polymorphism technique was performed to examine polymorphisms in the -590 region of the IL-4 gene.Results. Our results showed a significant difference between the C/C, T/C, and T/T genotypes and the C and T alleles of the -590 region of IL-4 in nephropathic patients in comparison with the healthy controls.Conclusions. Results of this study suggest that the functional gene polymorphisms of IL-4 play an important role in the pathogenesis of diabetic nephropathy in patients with type 2 diabetes mellitus.

Introduction. Screening programs for chronic kidney disease (CKD) are deemed to be cost effective only when they are limited to high-risk groups. We screened a sample of high-risk population of Urima, Iran.Materials and Methods. As a pilot study for a national project, we enrolled 905 participants who had at least one risk factor for CKD (including hypertension, diabetes mellitus, or a family history of CKD). The study population was selected from among patients with Dm or hypertension and family members of those with CKD in Urima urban area and 2 randomly selected neighbor rural areas. Urine dipstick tests were done and blood sample was obtained to detect proteinuria and measure serum creatinine concentration, respectively.Results. A total of 607 participants (67.1%) were enrolled from rural areas and 298 (32.9%) from the urban area. The mean serum creatinine level was 1.27 ± 0.60 mg/dL. A high serum creatinine level was demonstrated in 343 participants (37.9%), and 212 (23.4%) were demonstrated to have proteinuria. There was a significant correlation between serum creatinine level and urinary protein excretion (P =. 001). There were no significant differences between rural and urban subgroups in terms of proteinuria (P =. 42) and serum creatinine level (P =. 08).Conclusions. The prevalence of a high creatinine level (37.9%) is so high in the high-risk population of Urmia. Our most important goal of implementing this preliminary study was to assess probable limitations and problems of performing an extensive national screening program for CKD in the future

Introduction. Helicobacter pylori infection in gastric mucosa may cause systemic inflammatory reaction. We investigated the inflammatory effect of H pylori infection on nutritional factors such as serum albumin in hemodialysis patients and influence of eradication of H pylori on this association.Materials and Methods. Ninety-eight patients on hemodialysis were divided into 2 groups according to H pylori infection. Eradication of H pylori, 8 weeks after treatment, was confirmed by urease breath test and H pylori stool antigen. Serum albumin, lipid profile, and metabolite levels were checked before and after 8 weeks and 6 months of eradication of H pylori.Results. Thirty-nine patients (39.8%) were infected with H pylori. There were no significant differences between the two groups in age, dialysis duration, serum albumin, serum creatinine, blood urea nitrogen, hemoglobin, serum calcium, serum phosphorus, and lipid profile. Thirty-seven patients with H pylori completed the treatment period. Eradication was successful in 30 patients (81.1%). Eight weeks and 6 months after anti-H pylori drug therapy, the mean serum albumin level significantly decreased from 4.2 mg/dL to 3.6 mg/dL (P <. 001) and 3.7 mg/dL (P <. 001), respectively. Significant decreases were seen in serum cholesterol (P =. 001), blood urea nitrogen (P =. 005), and serum calcium level (P =. 03) and a significant increase in hemoglobin level (P =. 02).Conclusions. Our study did not demonstrate nutritional benefits after H pylori eradication treatment, as the level of nutritional markers reduced. This relationship needs to be confirmed by further prospective studies.

Introduction. Helicobacter pylori infection can be diagnosed by biopsy-based or noninvasive methods. Our aim was to identify H pylori-positive patients on hemodialysis by the noninvasive method of H pylori stool antigen (HPSA) and investigate its diagnostic accuracy for assessment of the eradication of infection after treatment in comparison with urea breath test (UBT).Materials and Methods. Serology, HPSA, and UBT were performed on 87 hemodialysis patients. Infection with H pylori was confirmed if at least 2 tests were positive. Patients with H pylori infection received a 2-week course of triple therapy. To evaluate success of eradication HPSA and UBT were done after 8 weeks.Results. Eighty-seven patients were enrolled in the study, of whom 39 (44.8%) were proved to have H pylori infection. The HPSA was positive in the stool specimens of 37 patients (42.5%) and the serology test was positive in 39 (44.8%). The HPSA had a 87.1% sensitivity and a 93.7% specificity for detection of H pylori infection. Thirty-seven patients completed the treatment period. Success of H pylori eradication was documented in 30 of the 37 patients (81.1%) based on UBT. After the treatment, the HPSA was negative in 32 of 37 of the stool specimens (86.4%), showing a 42.8% sensitivity and a 93.3% specificity to detect the failure of eradication of H pylori.Conclusions. Helicobacter pylori stool antigen assay is a noninvasive reliable tool to screen H pylori infection before therapy and assess the success of eradication in patients on hemodialysis.

Introduction. Oxidative stress in patients with chronic kidney failure, particularly in hemodialysis patients, has been suggested to have a major role in the pathogenesis of atherosclerosis. We evaluated omega-3 fatty acids supplementation effects on oxidative and antioxidant factors in hemodialysis patients.Materials and Methods. In a clinical trial, patients on hemodialysis were divided into 2 groups in order to receive either omega-3 fatty aid capsule, 1 g 3 times a day, or placebo for 2 months. The two groups were comparable in terms of sex distribution, age, medications, diabetes mellitus, hemoglobin level, serum ferritin, and serum albumin. Blood samples taken from patients before and at the end of the study period were examined for oxidative stress markers including malondialdehyde, glutathione peroxidase, superoxide dismutase, and ferric reducing antioxidant power.Results. Seventy-five hemodialysis patients were divided into the omega-3 group (n = 37) and the control group (n = 38). Before the treatment period, the two groups were comparable in the malondialdehyde, glutathione peroxidase, superoxide dismutase, and ferric reducing antioxidant power levels. In the patients who received omega-3 fatty acids, antioxidant factors including glutathione peroxidase, superoxide dismutase, and ferric reducing antioxidant power were significantly increased after two months (P =. 02, P =. 02, and P =. 01, respectively); however, there was no significant changes in the control group in these markers. Malondialdehyde levels were significantly reduced after the study period only in the omega-3 group (P =. 007).Conclusions. The present study revealed that the supplementation with omega-3 fatty acids may result in better antioxidation status in patients on maintenance hemodialysis

Introduction. Hyperparathyroidism is a common finding in patients with renal insufficiency and parathyroid hormone (PTH) is considered a uremic toxin responsible for many of the abnormalities of the uremic state and bone disease. The aim of this study was to investigate the influence of permeability of low-flux versus high-flux dialysis membranes on intact PTH during hemodialysis in children.Materials and Methods. Forty-four children aged between 4 and 13 years old on regular hemodialysis were enrolled in a prospective study. Low-flux polysulfone membranes were used for at least 6 months and then the patients were switched to use high-flux polysulfone membranes for 3 months. Serum electrolytes and intact PTH before and after dialysis were compared before and after changes in dialysis membrane.Results. At the end of the 3-month use of high-flux filters, predialysis intact PTH level (49.40 ± 19.64 ng/dL) showed a highly significant decline (P <. 001) compared to the predialysis intact PTH (21.67 ± 4.85 ng/dL) with low-flux membranes at the start of the study. Intact PTH level correlated negatively with serum ionized calcium and positively with serum phosphorus levels only in the predialysis samples with the use of low-flux but not high-flux filters.Conclusions. In children, high-flux dialysis membranes are more efficient in removal of intact PTH, one of the middle-sized uremic toxins, than low-flux membranes.

Central vein catheterization is a routine and relatively safe procedure in critically ill patients. Complications with this procedure depend to the site of catheterization and the skill of the operator. In addition to the common complications with femoral vein catheterization there are some rare usually preventable side effects related to guide wire and catheter. In our patient who underwent femoral catheterization for acute hemodialysis, we report migration of guide wire through the systemic circulation from the femoral vein to the jugular vein. This is a very rare complication that is a human error and is totally preventable by doing the procedure by a skilled doctor and considering the standards described for central vein catheter insertion.

Posttransplant lymphoproliferative disorder (PTLD) is a well-documented complication that arises as a result of immunosuppression in the setting of solid organ or bone marrow transplantation. The disorder may be subtle and/or extranodal. We report a patient with extranodal lymphoma following kidney transplantation who had successful treatment with surgery and chemotherapy.