Nephro-Urology Monthly
Volume:5 Issue: 2, Apr 2013

The prevalence of chronic kidney disease (CKD), as defined by the NFK-KDOQI (the national kidney foundation kidney disease outcomes quality initiative) guidelines, is a glomerular filtration rate less than 60 mL/min/1.73 m2 or the presence of microalbuminuria. CKD is increasing worldwide, leading to an increased risk of cardiovascular disease. There is general agreement on the importance of an early referral to a nephrologist and predialysis educational programs. Establishing the protocol for an early approach may assist in preventing the progression, and the most common complications of renal disease. Predialysis education helps patients in order to choose a renal replacement therapy (hemodialysis, peritoneal dialysis, transplantation) and improve their quality of life. Furthermore, adequate predialysis care allows the nephrologist to promptly prepare for vascular or peritoneal treatment. Regrettably, patients are often referred to the nephrologist when renal failure is already fall in the advanced stage. This is caused primarily by non-nephrologists failing to identify patients at risk for imminent renal failure. Furthermore, they may be defining the patient’s degree of renal failure according to the KDOQI classification. To further complicate matters, the serum creatinine alone does not provide an adequate estimate of renal function; however, both the MDRD (the modification of diet in renal disease) equation and the Cockcroft-Gault formula permit the more reliable and accurate estimation of the all-important glomerular filtration rate (GFR). Using the MDRD equation, the KDOQI guidelines recommend referral when GFR is less than 30 mL/min/1.73 m2. Late nephrology referral is an independent risk factor for early death while on dialysis; it is also associated with a more frequent use of temporary catheters, particularly in the elderly individuals. This subject underlines the importance of a multidisciplinary predialysis approach that may bring additional benefits – beyond referral to a nephrologist – including a reduced hospitalization period and a lower mortality rate. The KDOQI guidelines recommend evaluating the benefits and risks of starting renal replacement therapy when patients reach stage 5 (estimated GFR less than 15 mL/min/1.73 m2), although the ideal period for initiation of the replacement therapy remained a source of debate..

The presence of arterio-venous (A-V) fistula recirculation among hemodialysis (HD) patients markedly decrease adequacy of dialysis.. The present article summarize some of observations about clinical significance, causes, the most common techniques for measurement, and main source of pitfall in calculation of access recirculation.. A variety of literature sources such as PubMed, Current Content, Scopus, Embase, and Iranmedex; with key words such as inadequate dialysis and arterio-venous fistula access recirculation were used to collect current data. Manuscripts published in English language as full-text articles or as abstract form were included in our review study.. Any access recirculation among HD patients should be considered abnormal and if it presents prompt investigation should be performed for its causes. There are two most common techniques for accurate assessment of access recirculation: Urea (or chemical) and nonurea-based method by ultrasound dilution technique. The most common causes of access recirculation are the presence of high-grade venous stenosis, inadequate arterial blood flow rate, close proximity, or misdirection of arterial and venous needles placement by HD staff especially in new vascular accesses due to a lack of familiarity with the access anatomy.. The presence of access recirculation among HD patients can lead to significant inadequate dialysis thereby resulting in reducing the survival of these patients. Therefore, periodic assessment of access recirculation should be performed in HD wards..

Glomerular filtration rate (GFR) is widely estimated by serum creatinine based equations such as Cockcroft-Gault (CG) standardized for body surface, and an abbreviated formula derived from MDRD (modification of diet in renal disease) study. However, some studies suggested that creatinine based estimation of GFR formula can be replaced by cystatin C based formula.. The aim of this study was to determine whether cystatin C based equation could be used as an indicator for renal function in hemodialysis patients compared to MDRD equation; and whether cystatin C, a dialyzable molecule, was related to Kt/V, the marker for dialysis adequacy..Patients and In this cross-sectional study, 98 patients on chronic hemodialysis were included. Plasma levels of urea and creatinine were measured before and after dialysis, and cystatin C was measured before dialysis. GFR was calculated and compared.. The mean age of patients was 55.50 ± 16.10 (24-86) years and 66 cases were male (67.3%). The GFR was estimated at 6.05 ± 2.36 and 5.83 ± 2.19 cc/min by MDRD and cystatin C based formulas, respectively, with a significant correlation (r = 0.51; < 0.001). Serum cystatin C level was 9.74 ± 2.47 mg/L which showed significant reverse correlation with both MDRD (r = -0.46; P < 0.001) and cystatin C based formulas (r = -0.87; P < 0.001). Neither creatinine nor serum cystatin C showed correlation with Kt/V, as the marker of dialysis adequacy.. Serum Cystatin C may be considered as an indicator of renal function in patients under maintenance hemodialysis..

Solid organ transplantation patients are at high risk for opportunistic air-borne fungal infections due to using the potent immunosuppressive agents.. The current study aimed to qualitatively and quantitatively evaluate the fungal flora present in the air of Kidney transplant unit of Baqiyatallah hospital.. In this prospective study, air samples from patient room, baths site, ICU and isolated room, corridor site and outside the ward were obtained by settled plate technique using plates containing Sabouraud''s dextrose agar medium. In the current study, 36 agar plates containing Sabouraud dextrose agar medium were used. The plates were exposed for 20 min at height of 100-150 cm above the ground in units of hospital. Immediately after collection, samples were incubated at 27 ± 2ºC for four weeks. The slide culture method and Lacto-phenol cotton blue were used for definitive identification and staining fungal cultures, respectively.. The mean of colony forming units (CFUs) on indoor and outdoor plates was 6.6 ± 1.3 and 6 ± 1.9 / plate respectively. Statistical analysis showed that the observed difference is not significant. Also, the results showed that the mean of CFUs in the air of patient''s rooms (6.8 ± 1.7), halls (4.5 ± 1.7), bathrooms (6.8 ± 1.5), and ICU rooms (3.2 ± 1.8) were not significantly different. The mean of different fungal genera isolated from indoor and outdoor plates were 1.9 ± 0.2 and 4 ± 0.5 genera/plate respectively, that indicates significant difference between indoor and outdoor air quality (P < 0.001).. Lack of difference between quantity of outdoor and indoor air fungi indicates inefficiency of air control measures, and indoor lower genus diversity compared to outdoor air shows that there may be conditions that facilitate fungal growth in the environment of kidney transplantation unit..

Impaired fasting glucose (IFG), and impaired glucose tolerance (IGT) are two prediabetes conditions which have some correlation with macrovascular disorders. The risk of microvascular complications in these groups is not clear.. The prevalence of albuminuria in subjects with IFG and IGT was evaluated in the present study..Patients and In this study three groups of subjects were entered (45 subjects in each group): IFG, IGT, and normal glucose tolerance as control. The urine albumin-creatinine ratio was studied in morning spot urine samples to detect microalbuminuria. The subjects were followed up for two years, and blood sugar and urine albumin and glycosylated hemoglobin (HbA1C) were measured every 6 months.. The prevalence rate of microalbuminuria was 15.5% in the prediabetic groups, while no one had microalbuminuria in the control group (P = 0.005). The prevalence of microalbuminuria in patients with IFG or IGT was not significantly different (17.8% vs. 13.3%) (P = 0.4). Fourteen subjects (4 in IFG group and 10 in IGT group) developed diabetes mellitus within a 2-year follow-up period (P = 0.1). Thirty six percent of subjects with albuminuria, and twelve percent of subjects without albuminuria progressed to diabetes mellitus during a 2-year follow-up (P = 0.02, odd ratio = 4.1; CI95%, 1.13-15.1).. The risk of microalbuminuria in prediabetic subjects is high, and probably prediabetic subjects are at higher risk of progression to diabetes mellitus. We suggest periodically evaluation of albuminuria in prediabetic patients after the diagnosis..

Early predictive biomarkers for acute kidney injury (AKI) such as neutrophil elatinase-associated lipocalin (NGAL) could identify patients who may benefit from early initiation of treatment.. We aimed to obtain a cut off point for AKI prediction by urine NGAL in kidney transplantation..Patients and In a prospective cohort study, 64 adult who underwent kidney transplantation from living or deceased donors at Baqiyatallah transplant center between April 2009 and January 2010 were included. Patients divided into two groups based on the presence or absence of graft dysfunction. In this study, early graft dysfunction (post transplantation AKI) was defined as Cr level more than 1.5 mg/dL on the second postoperative day.. Post-transplant AKI was observed in 31 recipients. Mean urinary NGAL level was greater in recipients with AKI (P = 0.024). In linear regression model, AKI was only factor affected on urinary NGAL level (B = 299.8, P = 0.009). The best sensitivity and specificity for AKI detection by urinary NGAL observed at 2 hour after operation with cut-off point 204 ng/mL.. Our study showed in those who developed early post transplantation graft dysfunction the best AUC-ROC for urine NGAL observed at a cut-off value of 204 ng/mL after 2 hour post transplantation..

Chronic renal failure is an important and common complication of diabetes mellitus; hence, renal transplantation is a frequent and the acceptable treatment in patients with diabetic nephropathy requiring renal replacement therapy. On the other hand, renal transplantation and its conventional treatment can lead to increased diabetes outbreak in normoglycemic recipients. Also, uncontrolled hyperglycemia may be increased and allograft lost thus decreasing patient survival.. We aimed to assess the frequency of hyperglycemia in transplant patients and its risk factors..Patients and A large retrospective study was performed on 3342 adult kidney transplant recipients between 2008 and 2010. Demographic and laboratory data were gathered for each patient. All tests were done in a single laboratory and hyperglycemia was defined as a fasting plasma glucose of > 125 mg/dL. Univariate and multivariate logistic regression analyses were used to determine the risk factors of hyperglycemia following kidney transplantation.. There were 2120 (63.4%) males and 1212 (36.3%) females. Prevalence of hyperglycemia was 22.5%. By univariate linear regression, hyperglycemia was significantly higher in patients with CMV infection (P = 0.001), elevated serum creatinine (P = 0.000), low HDL (P = 0.01), and increased blood levels of cyclosporine (P = 0.000). After adjusting for covariates by multivariate logistic regression, the hyperglycemia rate was significantly higher for patients with Cyclosporine trough level > 250 (P = 0.000), serum creatinine > 1.5 (P = 0.000) and HDL< 45 (P = 0.03).. This study indicated that hyperglycemia is a common metabolic disorder in Iranian kidney transplant patients. Risk factors for hyperglycemia were higher Cyclosporine level, impaired renal function, and reduced HDL value..

Transurethral resection of the prostate (TURP) is the most common surgical treatment for benign prostatic hyperplasia.. The aim of the present study was to compare the conventional bipolar transurethral resection of prostate (TURP) with a modified transurethral resection of the prostate (M-TURP) in men with mild to moderate symptoms of benign prostatic hyperplasia..Patients and To compare and evaluate the clinical outcomes of M-TURP, a new electrosurgical suggested method, with the standard treatment, transurethral resection of prostate (TURP), 200 patients with benign prostatic enlargement causing moderate to severe clinical lower urinary symptoms were selected and divided into two equal groups of A and B. Patients of group A underwent M-TURP (incomplete bladder neck resection), resecting only from 1 to 11 O''clock position and group B underwent conventional TURP. These patients were evaluated between Jun 2008 and April 2011, after excluding 24 patients, finally 176 men were studied, 98 in the conventional monopolar transurethral resection of prostate (TURP) group and 78 in the (M-TURP) group. Postoperative follow up to assess the results of the surgeries and the complication rates, began from the operation and continued with postoperative visits of the patient at 24 hour after the catheter remove, two weeks, three months and finally six months.. The age range of both groups were the same (65-82 years old), preoperative IPSS score in study and control groups were 18 ± 3.3, 17 ± 4.6 (nonsignificant P value = ns) respectively. The size of prostate gland was 58 ± 3.5 g in study and 78 ± 1.2 g in control (ns) preoperatively. Intra and postoperative complications including hematuria (need for transfusion), urine retention (need for catheterization), fever after operation in study and control groups were 2.04%, 6.41%, 1.02% and 0.0%, 3.06%, 6.41% respectively. ISI score (stress incontinence score index) were 7 ± 2.5 and 19 ± 3.6 and UR (urge ratio) were %26 and %70 for study and control groups respectively; P < 0.05. IIEF (international index of erectile function) in study group was better than control (23 ± 3.2 vs.11 ± 1.7), P < 0.05.. The results of this study showed that the support of anterior fibro muscular zone (anterior lobe) of prostate after TUR-P has a significant role in postoperative complications, especially in postoperative stress incontinence. So, we strongly recommend to preserve this segment of prostate for prevention of incontinence and other intra and postoperative complications..

The complications of vascular access are the most imperative etiology for hospitalization, morbidity and mortality in chronic hemodialysis. The most prevalent complication of central catheter is dysfunction due to thrombosis. Aspirin is an anti-aggregative platelet drug that may increase the patency of permanent catheters (perm-cath).. The aim of this study was to evaluate the role of Aspirin in perm-cath survival..Patients and This study included a total of 185 ESRD cases according to the inclusion criteria for perm-cath insertion in hemodialysis. One hundred and eighty patients following perm-cath insertion had proper blood flow through perm-cath during hemodialysis. Patients were randomly divided between intervention (80 mg/day Aspirin initiated a day following catheter insertion) and control (placebo) groups. The average time that the perm-cath was functional was noted. Demographic characteristics included comorbidities and past history were also used to address probable influence on perm-cath function and patency.. The mean survival time of the catheter in Aspirin group was significantly higher than the control group (5.3 ± 4.7 month versus 3.9 ± 2.7 month, P = 0.012). No significant difference in major complications of Aspirin use (such as GI bleeding) was noted between two groups (P = 0.52). In terms of the patient’s demographic characteristics, those of the female gender and a history of diabetes mellitus were found to have significant influence on median survival rate of the catheters (P = 0.021, 0.043 respectively).. These results suggest that Aspirin use following perm-cath insertion might be beneficial for catheter survival. This increased survival time might enable patient’s use of AVF maturation for long term dialysis access..

Although Imperforate hymen is a rare condition, it is the most common obstructive anomaly of the female genital tract. The early diagnosis of this condition requires a high index of suspicion in newborns and in females without a history of menarche. Hydronephrosis is a known but rare complication of an imperforate hymen. Hereby we preset 2 cases of premenstrual adolescent with urinary retention and bilateral moderate to severe hydroureteronephrosis..

Autosomal polycystic kidney disease (ADPKD) is a genetic disorder with two causal PKD-1 and PKD-2. Genetic studies have demonstrated an important allelic variability between patients but few data are known about genetic variants in African populations. We report a new mutation found in a 41-year old women with mild chronic kidney disease secondary to ADPKD. Molecular genetic testing found a deletion of 2 nucleotides A and C at positions 7290 and 7291 followed by insertion of a 5-base pair (CTGCA) located in exon 18 of the PKD1 gene. This newly identified frame shifting was compared to the PKD gene database but no similar mutation was yet reported. Other screened family members did not present any mutation..