Iranian Journal of Kidney Diseases
Volume:7 Issue: 2, Mar 2013

Renal artery stenosis in elderly patients is mainly caused by atherosclerosis. The prevalence of this disorder in patients with chronic kidney diseases is reported to be 0.5% to 5.5%. However, because the patients with atherosclerotic renal artery disease are mostly asymptomatic, the true prevalence is expected to be higher. Renovascular hypertension and ischemic nephropathy are two main consequences of this disease, but it is difficult to determine in which patient the progress of stenosis may cause these syndromes. The big challenge in renal artery stenosis is how to manage the patients. In the past 70 years, it has been believed that simply maintaining of kidney perfusion by opening the stenosis could control blood pressure and preserve kidney function. Nowadays, the blood pressure can be controlled well by medical treatment without the need for revascularization; however, management of ischemic nephropathy remains a dilemma. With advancements in understanding the pathophysiology of changes in the parenchyma of the kidney after stenosis, it is now generally accepted that only a minority of patients with ischemic nephropathy will benefit from revascularization. Nonetheless, finding these patients is critical and need more randomized trials to show who mostly benefit from revascularization and when it may save the kidney.

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About 10% to 15% of in-hospital urinary tract infections (UTIs) are due to Candida species, and the prevalence is still increasing. A cross-sectional study was conducted to determine fungal causative agents of UTI in asymptomatic and symptomatic diabetic patients and associated risk factors. Between May and June 2010, a total of 422 diabetic patients with asymptomatic UTI (n = 387) and symptomatic UTI (n = 35) were investigated for UTI at Gondar University Hospital. Clean-catch midstream urine specimens were collected from each participant. Fungal urine culture and identification were done using standard microbiologic procedure. The age range of the participants was 20 to 84 years (mean, 42.3 years). Significant candiduria was detected in 7.5% and 17.1% of asymptomatic and symptomatic diabetic patients, respectively. The overall prevalence of significant candiduria in both groups was 8.3%. Candida species were isolated in 38 urine samples. Of these, 84.2% were from the asymptomatic diabetic patients and the remaining 15.8% were from the symptomatic patients. The most common species were C albicans (42.0%), C glabrata (34.2%), and C tropicalis (15.8%). Significant candiduria was strongly associated with being female. The presence of candiduria in diabetic patients should not be neglected. Although C albicans is the organism most often associated with serious fungal infection, other Candida species are also isolated as clinically important opportunistic pathogens in type 2 diabetic patients.

Chronic illnesses, including nephrotic syndrome (NS), are associated with psychosocial stress. Our study aimed to assess psychological problems in children with NS. Sixty children with NS were assessed at the Children Hospital, in Cairo for behavioral changes. They responded to the Arabic version of the Strength and Difficulties Questionnaire. The results were compared between those with steroid-sensitive NS (SSNS), steroid-dependent NS (SDNS), and steroid-resistant NS (SRNS). Three groups of patients with SSNS, SDNS, and SRNS, each consisting of 20 children aged between 4 and 16 years, were included. The SRNS group was significantly different from the other two groups regarding age at the onset of disease, total serum protein, serum albumin, serum calcium, and estimated glomerular filtration rate (lowest in the SRNS group) as well as 24-hour urine protein, blood urea nitrogen, and serum total cholesterol (highest in the SRNS group). In the SRNS group, the scores for emotional symptoms, peer relationship problems, and the total score were higher and the prosocial score was lower than the other groups, but with no statistical significance. Emotional symptoms, conduct problems, peer relationship problems, hyperactivity, and the overall poor behavior scores might be more likely to be seen in children with SRNS group than other NS treatment status. We recommend that attention to behavioral problems of children with NS should be given early in the course of disease.

Diabetic nephropathy is the major cause of end-stage renal disease worldwide. Silymarin is a flavonoid mixture obtained from Silybum marianum. Various preclinical and clinical studies have revealed that it has antidiabetic activity. The objective of this study was to evaluate the effect of silymarin on type 2 diabetic nephropathy in rats. Non-insulin-dependent diabetes mellitus was induced in overnight-fasted male albino Wistar rats by an intramuscular injection of streptozotocin and nicotinamide. Eighteen rats with diabetic nephropathy and 6 rats without induced nephropathy were divided into 4 groups, each containing 6 animals. Group 1 was the normal control and group 2 was the DM control. Groups 3 and 4 were rats with diabetic nephropathy that received 60 mg/kg and 120 mg/kg of silymarin for 60 days. At the end of the study period, the diabetic control group had significantly higher blood glucose, glycosylated hemoglobin, urine volume, serum uric acid, and urine albumin levels when compared to the normal control group. Silymarin-treated groups showed significantly lower levels of blood glucose, glycosylated hemoglobin, urine volume, serum creatinine, serum uric acid, and urine albumin, when compared to the diabetic control group. Histopathological studies reports strongly supported the protective effect of silymarin. These findings suggest that silymarin has protective effects for kidneys affected by type 2 diabetes mellitus. If the safety and efficacy is confirmed in humans, silymarin will be a good medication to prevent nephropathy-induced premature death in diabetic patients.

Patients on hemodialysis are a high-risk group for human T-lymphotropic virus 1 (HTLV1) infection and other viruses transmitted by blood or blood products. The Razavi and South Khorasan provinces in Iran are the endemic areas for this virus. This study compares proviral load of HTLV1 in patients on hemodialysis with otherwise healthy carriers of HTLV1. In this case-control study the proviral load of the HTLV1 virus was compared between 25 patients on long-term hemodialysis who were positive for HTLV1 and 25 healthy carriers of HTLV1, to determine the effect of uremia and chronic hemodialysis on the proviral load. Virus proviral load was determined using a real-time polymerase chain reaction method. There was a significant difference in the proviral load between the hemodialysis patients and the control group (903 ± 182 copies per mL versus 117 ± 186 copies per mL, respectively; P =. 008). No significant correlation was found between the proviral load and haematocrit or serum levels of urea, creatinine, parathyroid hormone, calcium, and phosphorus level in hemodialysis patients, but proviral load of HTLV1 was significantly correlated with leukocyte count (r = -0.46, P =. 02), hemodialysis duration (r = 0.48, P =. 02), and the numbers of blood transfusions (r = 0.71, P <. 01). The immune deficiency related to end-stage renal disease and uremia is the probable cause of significantly higher HTLV1 proviral load in hemodialysis patients compared to healthy HTLV1 carriers. This high HTLV1 proviral load might be due to immune dysfunction in chronic hemodialysis patients.

Valvular abnormalities frequently occur in patients with chronic kidney failure. This study evaluated the prevalence of heart valve calcification (HVC) in hemodialysis patients and factors associated with it. Medical charts of 129 hemodialysis patients were reviewed retrospectively. Demographic features and laboratory analysis of the patients were systematically recorded. Echocardiographic findings were collected, including ejection fraction, aortic valve calcification (AVC), mitral valve calcification (MVC), left ventricle mass, left ventricle mass index, and pulmonary artery pressure. Valvular abnormalities were found in 43 patients (33.3%); 30 patients (23.3%) had MVC, 28 (21.7%) had AVC, and 15 (11.6%) had both MVC and AVC. Patients with HVC were older than other patients (P <. 001). On echocardiography, higher left ventricle mass, left ventricle mass index, and pulmonary artery pressure levels were found in patients with HVC. Regarding the lipid profile, serum calcium, serum phosphorus, calcium-phosphorus product, and parathyroid hormone concentrations, there were no significant differences between patients with and without HVC. Ejection fraction levels were significantly lower in patients with HVC (P =. 002) and serum albumin level of patients with HVC was significantly diminished. This study failed to show an association between HVC in hemodialysis patients and calcium-phosphorus product and parathyroid hormone levels; however, age and diabetes mellitus could be regarded as risk factors. In addition, HVC may lead to increased left ventricle mass index and pulmonary artery pressure and decreased ejection fraction, and low albumin levels may be attributable to inflammation.

This study evaluated the influence of interleukin-10 (IL10) gene -1082G>A and tumor necrosis factor-alpha (TNF) gene -308G>A polymorphisms in the donor and recipients on the acute rejection (AR) episodes and delayed graft function (DGF) in kidney transplant recipients. The IL10 -1082G>A and TNF -308G>A polymorphisms were determined in 100 kidney allograft recipients and their donors using the polymerase chain reaction-amplification refractory mutation system polymerase chain reaction-restriction fragment length polymorphism methods. Transplantation outcomes were determined in terms of AR and DGF criteria. The A allele of the TNF polymorphism (high producer) in the donors was associated with DGF in the recipients (odd ratio, 3.1; 95% confidence interval, 1.2 to 8.1). There was also a significant association between the combination of donor's IL10-TNF genotypes and DGF (odd ratio, 4.8; 95% confidence interval, 1.4 to 17.1); the frequency of a combination of IL10 AA or GA and TNF AA or GA was higher in the recipients with DGF. No association was found between the donors and recipient's IL10 -1082G>A and TNF -308G>A polymorphisms and AR. No association was detected between recipients and donor's IL10 polymorphisms or recipient's TNF polymorphisms and DGF. This study showed that donors with high TNF production may have increased risk of DGF in their recipients. Routine screening of these gene polymorphisms may have a clinical role in identifying patients at risk of DGF.

This study aimed to investigate the effectiveness of low-dose daclizumab for prevention of acute kidney allograft rejection and to evaluate differences between men and women receiving living donor transplants. This randomized controlled trial was performed on 120 living donor kidney transplant recipients. Participants in the case group received a low dose of daclizumab (1 mg/kg) before and 14 days after transplantation in addition to their standard immunosuppressant regimen. Participants in the control group received the standard treatment protocol only. Acute rejection episodes and graft survival were compared between the two groups. Additionally, graft survival of women and men was compared separately between the two groups. Acute rejection was significantly less frequent in the daclizumab group than in the controls (6.7% versus 18.3%; P =. 048). The 6-month survival rates were 95% (95% CI, 92% to 98%) in the daclizumab group and 85% (95% CI, 81% to 89%) in the control group (P =. 03). The 6-month graft survival rates of the women were 97% (95% CI, 95% to 99%) in the daclizumab group and 74% (95% CI, 65% to 83%) in the control group (P =. 02). However, the difference in graft survival rates was not significant among the men. The use of induction therapy with two doses of daclizumab reduces the incidence of acute rejection and improves graft survival of living donor kidney transplant reciepients. This study showe that these effects are prominent among the female recipients.

The objectives of this study were to determine the impact that medical and socioeconomic status have on incident peritoneal dialysis (PD) use. In a prospective cohort study, 77 consecutive end-stage renal disease patients (53% women, mean age, 57.5 ± 16.5 years) who were planned to start dialysis were assessed for PD eligibility. The physician's referral rate for PD consultation was 71%. One-half of the patients had important medical and socioeconomic barriers to PD, such as lack of family support, learning and performance disability, and less-than-ideal home situation. Patients with barriers were older, low educated, and more likely to be diabetic. In conclusion, consultation with a multidisciplinary team and the availability of health care systems financial supports are important drivers of PD. In addition, there is a likely need for further educational activities focused on PD, in order to change physician's preference towards hemodialysis.

An Aspergillus fungal ball is a rare cause of ureteral obstruction attributed to indwelling catheters, stents, antibiotics, anastomotic leaks, obstruction, and immunosuppressive therapy and other immunocompromised states. We describe a case of unilateral ureteral obstruction caused by Aspergillus terreus following ureteroscopic lithotripsy and ureteral stenting in a 45-year-old diabetic man. The patient was successfully treated with endoscopic removal of the fungal mass and oral voriconazole. We also review briefly the clinical features, treatment, and outcome in 9 previously reported diabetic patients with ureteral obstruction due to aspergillosis. Obstructive uropathy related to Aspergillus mass may be suspected in diabetic patients with a history of manipulation, impaired kidney function, and persistent passage of a soft mass in urine. Direct microscopy and culture of multiple urine and ureteral washing are necessary for early diagnosis. Antifungal therapy and endoscopic removal of the mass are needed to reduce morbidity.

Intravenous self-infusion of tap water has never been reported in the literature. We present a 24-year-old healthy man who self-administered 2.5 L of tap water over 2 hours and developed acute illness including fever, change of mental status, acute hemolysis, low-grade disseminated intravascular coagulation, and acute kidney injury.

Idiopathic infantile hypercalcemia (IIH) is a rare disorder caused by CYP24A1 loss-of-function mutation, resulting in impaired degradation of 1,25-dihydroxyvitamin D3. Pamidronate, an intravenously administered bisphosphonate, which is a potent inhibitor of bone resorption, has been reported only once for treatment IIH. We present a case of a previously healthy 5-month-old boy with IIH, where calcemia peaked to 5 mmol/L. Treatment with methylprednisone and furosemide had only minor effects; therefore, 2 intravenous infusions of pamidronate (0.6 mg/kg per dose) corrected the serum calcium level to 2.95 mmol/L. Furthermore, CYP24A1 homozygous mutation p.R396W (c.1186c>t) was identified in this patient, confirming the clinical diagnosis of IIH. In conclusion, IIH has a favorable outcome once properly detected and appropriately treated. Pamidronate has a beneficial effect in those patients with IIH where glucocorticoids and furosemide fail to meet the expectations.