Iranian Journal of Kidney Diseases
Volume:6 Issue: 2, Mar 2012

World Kidney Day on March 8th 2012 provides a chance to reflect on the success of kidney transplantation as a therapy for end-stage kidney disease that surpasses dialysis treatments both for the quality and quantity of life that it provides and for its cost effectiveness. Anything that is both cheaper and better, but is not actually the dominant therapy, must have other drawbacks that prevent replacement of all dialysis treatment by transplantation. The barriers to universal transplantation as the therapy for end-stage kidney disease include the economic limitations which, in some countries place transplantation, appropriately, at a lower priority than public health fundamentals such as clean water, sanitation, and vaccination. Even in high-income countries, the technical challenges of surgery and the consequences of immunosuppression restrict the number of suitable recipients, but the major finite restrictions on kidney transplantation rates are the shortage of donated organs and the limited medical, surgical, and nursing workforces with the required expertise. These problems have solutions which involve the full range of societal, professional, governmental, and political environments. World Kidney Day is a call to deliver transplantation therapy to the one million people a year who have a right to benefit

Chronic, progressive, and irreversible loss of a transplanted kidney function, previously named chronic allograft nephropathy, is the leading cause of chronic allograft failure among kidney transplant recipients. Chronic allograft dysfunction (CAD) is a multifactorial process associated with progressive interstitial fibrosis and tubular atrophy. Current Data confirms that an additive series of time-dependent immunological factors such as acute and chronic antibody- and/or cell-mediated rejection and nonimmunological factors are involved in development of interstitial fibrosis and tubular atrophy as the fundamental parts of CAD. The use of calcineurin inhibitors has produced a major impact on achieving successful organ transplantation; however, although this assumption has been doubted recently, calcineurin inhibitors are deemed to be associated with nephrotoxicity and subsequent interstitial fibrosis, tubular atrophy, and kidney dysfunction. The early fibrotic changes are due to implantation stress, T-cell–mediated rejection, and infection; however, usually they do not lead to progressive fibrosis and allograft dysfunction per se. In the setting of CAD, many factors occurring lately after 1 year, such as chronic antibody-mediated rejection, recurrent or de novo glomerulonephritis, and nonadherent adequately address the existence of ongoing injuries and progression to fibrosis. Identification of patients who are at risk, close clinical monitoring, and optimization and individualization of their maintenance immunosuppressive regimen are among the means that could help us to improve the long-term outcome of kidney transplantation.

With the rising incidence of metabolic syndrome and progressive kidney disease, efforts to halt this progression have become the mainstay of therapies in the era of modern nephrology. The necessity of one versus two kidneys has occupied the minds of leading scientists and philosophers throughout the ages and has laid the foundation for our understanding of progressive kidney disease. This review focuses on the major discoveries of the leading thinkers who with their paradigm shifting ideas and skepticism pushed the boundaries of our knowledge and shaped the theory of hyperfiltration.

Introduction. The aim of this study was to test whether Nigella sativa (NS) seeds can reduce cisplatin-induced toxicity. Materials and Methods. Thirty rats were divided into 3 groups to receive distilled water (control group), cisplatin (3 mg/kg per body weight for 3 days), and cisplatin and alcoholic extract of NS (100 mg/kg per body weight). Biochemical and histopathologic parameters were compared between the three groups on days 14 and 42 of the study. Results. Blood urea nitrogen increased in the cisplatin and NS groups on days 14 and 42 compared to day 0 (P <. 001). It was significantly in the cisplatin than in the control group on day 14 (P <. 001). Serum creatinine had a similar profile in the cisplatin and NS groups as blood urea nitrogen. Serum triglyceride increased in the cisplatin and NS groups on day 14, but it decreased on day 42 (P <. 05). Urine glucose concentration decreased in the cisplatin group on days 14 and 42 compared to day 0 (P <. 001), and the same trend was seen in the NS group (P <. 001). Histology of the kidneys exposed to cisplatin showed significant kidney injury, but the rats treated with NS showed a relatively well-preserved architecture. Conclusions. Cisplatin-induced nephrotoxicity was confirmed in our study. Nigella sativa seeds had nonsignificant effects on biochemical parameters, although the histopathologic properties of the kidneys relatively recovered after NS use.

Introduction. Methotrexate is an antifolate medication frequently used in the treatment of malignant and nonmalignant diseases. The usage of high-dose methotrexate was limited to patients with osteosarcoma, Ewing sarcoma, lymphoma, and acute lymphoblastic leukemia. One of the major side effects of high-dose methotrexate is nephropathy. The aim of present study was to determine the renal side effects of high-dose methotrexate in patients with malignancies. Materials and Methods. In a study of 102 patients with osteosarcoma (n = 72), Ewing sarcoma (n = 15), and lymphoma (n = 15), treated with high-dose methotrexate, clinical and laboratory data including kidney function tests were recorded at baseline and during follow-up visits. The mean duration of follow-up was 6 months. Results. The mean age of the patients was 19.5 years (range, 5 to 80 years). The total courses of methotrexate therapy were 273 (median, 2.67 per patient). The mean creatinine level was 0.82 mg/dL. Of the 102 patients, 3 (2.9%) developed acute kidney injury with an at risk phase. Another patient (1.0%) developed acute kidney injury and its phase was injury according to the RIFLE criteria. None of the cases were failed and acute kidney injury was alleviated in all of the affected patients. Conclusions. Our data revealed a low prevalence of acute kidney injury with high-dose methotrexate therapy. In addition, these toxicities were limited to the first and second phases of the RIFLE classification, all of which resolved spontaneously.

Introduction. End-stage renal disease has been associated with premature atherosclerosis of the cerebral circulation. The risk of stroke, a frequent complication of uremia as a result of cerebral blood flow reduction, is high in dialysis patients. This study aimed to assess brain hemodynamics between hemodialysis interval periods by transcranial Doppler ultrasonography. Materials and Methods. In a case-control study, to evaluate cerebral circulation homodynamics, 20 hemodialysis patients and 20 age- gender-matched healthy control subjects underwent transcranial Doppler ultrasonography. Blood parameters were also measured simultaneously. Among hemodialysis patients, these studies were performed 48 hours after a dialysis session. Results. The mean blood flow velocity (MV) values were significantly higher in the middle cerebral artery (P =. 007), anterior cerebral artery (P =. 003), posterior cerebral artery-segment 2 (P =. 03), basilar artery (P =. 05) in hemodialysis patients compared to the controls. The MV had a negative meaningful correlation with hemoglobin and hematocrit in most intracranial arteries of the patients, but no significant correlation was observed between these variables and MV of the arteries in the control group. Conclusions. The MV of the cerebral arteries significantly increases in hemodialysis patients, which could be due to the decrease in hemoglobin levels in these patients.

Introduction. Early prediction of the efficacy of treatment in peritonitis complicating peritoneal dialysis (PD) is the best way to reduce morbidity. We studied the prognostic value of the third-day dialysis effluent leukocyte count after antibiotic therapy for prediction of treatment outcomes. Materials and Methods. Medical records of 31 children on PD, younger than 15 years old, admitted in Ali-Asghar Children's Hospital because of PD-related peritonitis, were reviewed retrospectively. Peritonitis was defined by fever, abdominal pain, and cloudy effluent with a leukocyte count greater than 100/mm3 or a positive dialysis effluent culture for microorganisms. For each episode of peritonitis, the leukocyte count of the effluent was measured on the third day after initiation of empiric therapy and culture results were recorded. The receiver operating characteristic curve was used to perform predicting value assessments. Results. Of 60 episodes of peritonitis, 68.3% were treated successfully. Of the remaining episodes, 15.8% resulted in mortality, 57.9% required catheter removal, and 26.3% led to both. The mean PD effluent leukocyte count on the third day after initiating empiric antibiotics was significantly higher in the group with treatment failure (2258 ± 796/mm3) than in the group with successful treatment (1325 ± 669/mm3; P <. 001). The cutoff point of 1240/mm3 was found with optimized sensitivity (100%), specificity (63.4%), positive predictive value (55.9%), and negative predictive value (100%) for prediction of treatment failure (P <. 001). Conclusions. This study showed that the third-day dialysis effluent leukocyte count predicted short outcomes of peritonitis.

Introduction. We aimed determine the impact of an 8-week intradialytic exercise program, consisting of 15 minutes of cumulative duration low-intensity exercise during the first 2 hours of dialysis on serum electrolytes levels and hemoglobin. Materials and Methods. In a randomized controlled trial of in an outpatient hemodialysis unit, clinically stable hemodialysis patients (n = 47) were included and assigned into the aerobic exercise group (n = 25) and the control group (n = 23). Aerobic exercises were done in groups, 15 min/d, 3 times a week, for 2 months. The main outcome measures were biochemical variables including serum levels of calcium, phosphate, and potassium levels and hemoglobin level. Results. After an 8-week intervention, significant improvements were seen in serum phosphate levels (decreased by 1.84 mg/dL) and serum potassium levels (decreased by 0.69 mg/dL). No side-effects were observed. Serum calcium and hemoglobin levels did not change significantly in the exercise group. Conclusions. A simplified aerobic exercise program is a complementary, safe, and effective clinical treatment modality in patients with end-stage renal disease on dialysis.

Introduction. For continuous hemodialysis, an appropriate vascular access, mostly through an arteriovenous fistula (AVF), is crucial. The Brescia-Cimino (BC) method is a common surgical method for AVF creation. However, this method is sometimes not possible, due to a small venous diameter or its wide distance from the artery. We evaluated the success rate of bifurcated vein patch (BVP) technique as an alternative method to BC for AVF placement in hemodialysis patients. Materials and Methods. Candidates for AVF vascular access for hemodialysis were assigned into 2 groups of 50 patients, and AVF was placed using the BC method in one group and the BVP method in the other group. Immediate AVF thrill after the operation, first-day postoperation thrill, weighting period, and nursing staff satisfaction for hemodialysis were compared between the BC and BVP methods. Results. Although the weighting period in the BVP group was longer than that in the BC group, other parameters were similar between the two groups. The AVF thrill intensity after the operation was good to excellent in 87% of the cases with the BC method and good in 95% of those with BVP. Satisfaction of dialysis nursing staff during hemodialysis was reported as 87% good and 4% average in the BC group and 75% good and 20% average in the BVP group. Conclusions. Bifurcated vein patch can be an appropriate alternative technique for cases in which the commonly used BC method is not possible for AVF placement

Introduction. In hemodialysis patients, 25-hydroxyvitamin D conversion to active 1,25-dihydroxyvitamin D by the kidneys is very limited. The expression of both vitamin D receptor and 1?-hydroxylase in cells of the immune system and in both osteoblasts and osteoclasts makes it possible that 25-hydroxyvitamin D could play an important role in both inflammation and bone metabolism acting in a autocrine and/or paracrine way in these patients. Materials and Methods. Thirty-three hemodialysis patients not under vitamin D receptor agonist treatment were enrolled into the study. Serum levels of 25-hydroxyvitamin D, C-reactive protein (CRP), interleukin-6 (IL-6), receptor activator of nuclear factor-kappaB ligand (RANKL), and osteoprotegerin, as well as intact parathyroid hormone were assessed by immunoassays. Results. Regarding inflammation, 25-hydroxyvitamin D inversely correlated with both CRP and IL-6. Regarding bone metabolism, 25-hydroxyvitamin D was positively related to osteoprotegerin, but negatively to the RANKL. The latter could be the result of parathyroid hormone suppression by 25-hydroxyvitamin D, since 25-hydroxyvitamin D negatively correlated with parathyroid hormone, which in turn was positively related to RANKL. Conclusions. Serum 25-hydroxyvitamin D is inversely correlated with markers of inflammation and may suppress osteoclastic activity in hemodialysis patients

Introduction. Chronic kidney disease is a permanent condition which requires renal replacement therapy (hemodialysis, peritoneal dialysis, or transplantation) to maintain life. The present study aimed to investigate the association of self-esteem with health locus of control in dialysis patients. Materials and Methods. A sample of 144 patients was recruited from 3 General Hospitals in the broader area of Athens, consisting of 84 patients undergoing in-center hemodialysis and 60 patients on continuous ambulatory peritoneal dialysis. Measurements were conducted with the World Health Organization Quality of Life instrument, in which self-esteem is addressed by 1 item, and the Multidimensional Health Locus of Control inventory. Results. The results indicated that self-esteem had a significant positive association with internal health locus of control. Self-esteem was also inversely related to the dimension of important others measured by the Multidimensional Health Locus of Control inventory. Conclusions. Findings of this study provide evidence that there is a strong relation between self-esteem and health locus of control in dialysis patients

Introduction. This study was conducted to evaluate preventive effect of a combination of heparin and aspirin on vascular thrombosis and kidney transplant outcomes of pediatric kidney transplant recipients. Materials and Methods. Twenty-four pediatric kidney transplant recipients received heparin, 50 U/kg, every 8 hours for 7 postoperative days, and aspirin, 5 mg/kg, thrice a week from day 3 of transplantation for 3 months. These patients were compared with a matched group of pediatric kidney allograft recipients in terms of development of thrombosis and serum creatinine level at 1 year postoperation. Results. The mean age of patients was 9.4 ± 3.2 years. No vascular thrombosis was developed among the 24 patients with anticoagulant therapy, while in the control group, 5 grafts (7.9%) developed thrombosis (P =. 19). Serum creatinine levels at 1 year were lower in the children with anticoagulant therapy as compared with the controls (P =. 02). Conclusions. Our study revealed a reduction in kidney allograft thrombosis incidence in children who received heparin and aspirin after transplantation, which was clinically important although the difference was not statistically significant. Lower serum creatinine levels as compared with a historical cohort group were seen 1 year after transplant surgery. These findings are required to be confirmed by further studies.

A young boy with prior constipation developed recurrent severe calcium phosphate kidney calculi, sometimes sufficient to cause acute kidney failure and hydronephrosis. After several major surgeries, food allergies were determined by serum immunoglobulin E testing, and when he finally went on a gluten-free diet, he stopped forming calculi and has had no surgeries related to kidney calculi since. Hyperoxaluria was not identified in this child by 24-hour urine analysis, unlike most other reports of kidney calculus formation in individuals with gluten intolerance.

Membranoproliferative glomerulonephritis (MPGN) is characterized by proliferation of mesangial and endothelial cells and by thickening of the peripheral capillary walls. Type II of the MPGN is associated with complement abnormalities which are factor H deficiencies due to mutations in the complement factor H (CFH) gene. We report a 15-year-old boy diagnosed with MPGN II in whom genetic analyses of the CFH gene revealed that the patient was heterozygote for a polymorphism in exon 2 of the CFH (c.184G>A), heterozygote for a polymorphism in exon 9 of the CFH (c.1204C>T), and heterozygote for a polymorphism in exon 10 of the CFH (c.1419G>A). These data recapitulate a prototypical complement genetic profile, the presence of major risk factors for MPGN II, which support the hypothesis that these dense deposit diseases have a common pathogenic mechanism involving dysregulation of the alternative pathway of complement activation.