Iranian Journal of Kidney Diseases
Volume:6 Issue: 6, Nov 2012

Herbal medicines are being used with greater frequency by practitioners of natural medicine in the United States. Many categories of herbs are used، primarily angiotensin antagonists، nonspecific nephroprotective، and immunomodulating/adaptogenic herbs. The most common herbs in each category are discussed both from a historical and scientific perspective. For the first time، a case series of the use of the proposed herbal angiotensin antagonist herb indigenous to the United States، Lespedeza capitata، is reported based on the author''s clinical practice.

The reabsorption of salt in the distal nephron is predominantly mediated via the thiazide-sensitive sodium chroride cotransporter, NCC (SLC12A3), and the chloride-bicarbonate exchanger pendrin (SLC26A4, PDS), with pendrin working in tandem with the epithelial sodium channel and NCC working by itself. Single deletion of NCC or pendrin in genetically engineered mouse models does not cause salt wasting or excessive diuresis under basal conditions. Both pendrin knockout and NCC knockout mice, however, show signs of volume depletion or develop hypotension during salt restriction. These findings have led investigators to conclude that pendrin and NCC are predominantly active during salt depletion and their contribution to salt reabsorption at baseline conditions is small. We hypothesized that pendrin may compensate for loss of NCC under basal conditions, thereby masking the role that each transporter plays in salt reabsorption. To test this hypothesis, double knockout of pendrin and sodium chloride cotransporter was generated by crossing animals with single deletion for NCC and pendrin. The double-knockout mice show significant salt and fluid wasting, along with severe volume depletion, metabolic alkalosis and prerenal failure under baseline conditions. Volume depletion, metabolic alkalosis and prerenal failure were significantly corrected with salt repletion. We conclude that pendrin plays an essential role in the distal tubule salt reabsorption in the setting of sodium-chloride cotransporter inactivation. We propose that pendrin could be a novel target for a new diuretic that in conjunction with thiazide can be an effective regimen for patients with fluid overload.

Congenital nephrotic syndrome (CNS), an uncommon form of kidney disease, presents during the first year of life and is a diagnostic and therapeutic challenge for the pediatricians as well as pediatric nephrologists. Our study is the first study of Iranian children with CNS in two pediatric nephrology centers in Tehran, Iran. We reviewed medical charts of 30 infants diagnosed with CNS from 1990 to 2005. There were 15 boys and 15 girls with CNS (mean age, 1.7 months). The presentation of the disease was nephrotic syndrome in 96.6% of the patients. Eighty percent of the patients presented within 3 months of life and 16 in the neonatal period. The Finnish type of CNS was seen in 43.3% and diffuse mesangial sclerosis in 50%. Preterm labor and low birth weight was seen in 20%. A family history of nephrotic syndrome in infancy was noted for 8 children (26.7%). Numerous complications of nephrotic syndrome occurred in 73.3%. Seventy percent of the patients had 27 episodes of infections. Sepsis was seen in 43.3% of the children, of which 61.5% were caused by gram-negative bacteria and 38.6% were caused by Staphylococcus aureus. Thrombotic complications and hypertension developed in 6.6% and 23.3% of the patients, respectively. The mortality rate of patients was 86.6%. Diffuse mesangial sclerosis is an important cause of CNS. The outcome of our patients was poor and most of our patients died before reaching the age of 5 years old.

The incidence of contrast-induced nephropathy (CIN) ranges between 10% and 50% among high-risk patients. Whether medications that affect rennin-angiotensin-aldosterone system (RAAS) have any impact on the development of CIN remains uncertain. We performed a retrospective study of patients with CKD stages 3 and 4 who were either on or off RAAS blockade therapy at the time of coronary angiography. Development of CIN was defined by a 25% increase of serum creatinine from baseline or an increase in serum creatinine by 0.5 mg/dL from baseline. Serum creatinine values were recorded before contrast exposure and for 5 days after coronary angiography. A total of 178 patients with CKD who had coronary angiography during the study period were included, of whom 62 (35%) were on ACE inhibitors, 12 (7%) were on ARBs, and 1 (1%) was on combination of ACE inhibitors and ARBs. The estimated glomerular filtration rate was 44.0 ± 11.5 mL/min. The odds ratio of acute kidney failure on day 5 was 0.73 (95% confidence interval, 0.31 to 1.69) for the ACE inhibitors and 0.46 (95% confidence interval, 0.06 to 3.70) for ARBs. Multivariable analysis revealed the findings to be independent of demographic variables, comorbidities, type of contrast medium, and the prophylactic strategies. Patients on RAAS blockade therapy before contrast exposure did not have an increased incidence of CIN. There was also no increased incidence of CIN with ACE inhibitors or ARBs in the subgroups at higher risk, such as those with diabetes mellitus.

Renal involvement is the major cause of mortality and morbidity in children with Henoch-Schonlein purpura. The purpose of this study was to determine the predictive factors of Henoch-Schonlein nephritis (HSN) and correlations between clinical and pathologic findings. Demographic characteristics and clinical manifestations of 105 children with Henoch-Schonlein purpura were retrospectively evaluated. Kidney biopsy with pathologic scoring was performed in 17 patients. Sixty-one boys and 44 girls were included in this study. The mean age at presentation was 73.0 ± 33.4 months (range, 12 to 156 months). Thirty-nine percent of patients had renal involvement. Their mean age at presentation of HSN was 87.4 ± 30.9 months, which was significantly higher than the age of those without nephritis. Age at presentation was the only predictor of renal involvement. Hematuria and proteinuria were the most common laboratory findings of HSN, followed by nephrotic syndrome and acute nephritis. The most common histologic findings were grades 3 (especially 3B) and 2 of the International Study of Kidney Disease in Children classification, respectively. Higher pathologic grades were more frequent in patients with nephrotic syndrome and acute nephritis. Similarly, there was a positive relationship between the severity of proteinuria and both pathologic grading and scoring, especially crescent formation, endocapillary proliferation, and tubular atrophy. There was a significant correlation between the severity of renal involvement and pathologic grading and scoring in HSN. The severity of proteinuria was a significant determinant of renal pathologic findings.

The ankle-brachial index (ABI), measurement of carotid artery intima-media thickness (CIMT), and assessment of the thickness of interventricular septum (IVS), are noninvasive methods used to predict subclinical atherosclerosis in hemodialysis patients. This study aimed to determine the prevalence of peripheral arterial disease and to assess the correlations between ABI, CIMT, the thickness of IVS, and blood parameters in hemodialysis patients. The ABI, CIMT, and the thickness of IVS were measured in 50 patients on hemodialysis. Data were collected regarding the levels of calcium, urine nitrogen, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglyceride, cholesterol, creatinine, albumin in serum, as well as erythrocyte sedimentation rate. Ten percent of the patients showed a reduced ABI (< 0.9). The mean values for ABI, CIMT, and IVS were 1.09 ± 0.13, 0.68 ± 0.11mm, and 9.83 ± 1.65 mm, respectively. The levels of calcium, cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride in the serum of the patients with normal ABI were significantly higher than in patients with reduced ABI. There was a negative correlation between ABI and levels of serum LDLC (r = -0.29, P =. 04) and triglyceride (r = -0.32, P =. 02). The prevalence of peripheral arterial disease in the patients with CRF was 10% and it was correlated with several classical risk factors for atherosclerosis, including elevated LDL and cholesterol levels. CIMT and the thickness of IVS showed no apparent association with ABI.

This study was designed to compare an antidepressant medication, citalopram, with psychological training in hemodialysis patients with symptoms of anxiety and depression. A total number of 44 hemodialysis patients scored 8 and more on the Hospital Anxiety and Depression Scale (HADS) were randomly allocated to two groups to receive citalopram, 20 mg/d, for 3 months or to attend 6 sessions of 1-hour psychological training. A nephrologist and a senior psychiatry resident were responsible for training of the patients, which contained explaining the anatomy of the kidneys, causes of kidney failure, treatment modalities, the mechanism involved in hemodialysis, the required care in hemodialysis patients, stages of adaptive reaction in human, and techniques of problem solving, stress management, and muscle relaxation. Both groups completed the HADS once before and once after the treatment. The final results of the two groups were compared. Citalopram administration led to a significant decrease in the patients'' depression score (P =. 001), anxiety score (P =. 048), and total HADS score (P =. 002). Psychological training sessions also decreased significantly depression (P =. 04), anxiety (P =. 03), and total HADS scores (P =. 045). There was no significant difference in the amount of decrease in the scores of depression (P =. 65), anxiety (P =. 19), and the total HADS (P =. 66) between the two groups. Psychological training and citalopram have similar effects on improving the symptoms of anxiety and depression in hemodialysis patients.

Although maintenance dialysis in patients with end-stage renal disease prevents death from uremia, patient survival remains an important issue. This study is the first in Iran to evaluate long-term survival of patients with ESRD. This retrospective study was conducted on 1861 patients with ESRD referred to 12 hemodialysis centers in Khuzestan province, Iran. The period of study was 21 years, which was between 1989 to may 2010. The median follow-up duration was 46.0 months. Patients who died within 90 days of commencing dialysis were excluded. The patient''s death as outcome measure was recorded and the survival was estimated by the Kaplan-Meier method. The mean age of 1861 patients at initiation of hemodialysis was 51.2 ± 17.2 years, and 1120 were men (60.2%). Diabetes mellitus (32.9%) and hypertension (24.1%) were the most common known causes of ESRD in our patients. Regardless of the cause of ESRD, 1-, 5-, 10-, and 15-year survival of hemodialysis patients was 83%, 25.2%, 3.8%, and 1.0% respectively. Survival of diabetic patients was significantly lower than nondiabetic patients (P

Patients with end-stage renal disease who receive hemodialysis are prone to visual disturbances. The aim of this study was to evaluate the effects of metabolic changes on visual parameters during hemodialysis sessions. Demographic information including history of underlying diseases, wearing eyeglasses, any ocular diseases or surgeries, and hemodialysis duration and frequency were recorded in 65 hemodialysis patients. The best corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution and spherical equivalent (SE) per diopter were measured before and after hemodialysis. Other systemic and metabolic parameters including systolic blood pressure, body weight, KT/V, and blood levels of glucose, urea, and sodium were recorded. A total of 130 eyes of 38 men and 27 women with ages ranged from 24 to 90 years (mean, 60.3 ± 16.7 years) were enrolled. The mean BCVA changed significantly after hemodialysis (0.29 ± 0.48 increased to 0.31 ± 0.49; P <. 001). The mean SE changes were significant as well (-0.33 ± 0.31 D decreased to -0.40 ± 0.12 D; P <. 001). There was a weakly positive correlation between the BCVA and blood glucose changes (P =. 05, r = 0.166). There were significant associations between diabetic retinopathy and wearing of eyeglasses with BCVA and SE (P <. 001 for both). Hemodialysis could influence on visual parameters such as BCVA and refractive status by means of changes in blood glucose or possibly other systemic parameters.

Methylene tetrahydrofolate reductase (MTHFR) is an enzyme involved in the metabolism of homocysteine to methionine, and folic acid is an essential cofactor. Mutations in the MTHFR gene lead to hyperhomocysteinemia and vascular thrombosis. Heterozygous mutation involving a single nucleotide polymorphism in the MTHFR gene leading to vascular thrombosis is very rare. We present a case of segmental renal artery thrombosis secondary to this mutation and to the best of our knowledge, it is the first case to be reported. Though easily treatable, this is a condition which is seldom investigated in the workup of thrombotic disorders.

Hemophagocytic lymphohistiocytosis (HLH) is still an important elusive and misdiagnosed condition despite of improved knowledge. Nephrotic syndrome associated with HLH is not a common feature and has been rarely reported in hemophagocytic syndrome. We report a 27-year-old man with HLH who progressed to multi-organ failure as well as nephrotic-range proteinuria, generalized edema, and hypoalbuminemia.