Iranian Journal of Kidney Diseases
Volume:9 Issue: 5, Sep 2015

End-stage renal disease (ESRD) is a rapidly growing global health problem within the past decades due to increased life expectancy, diabetes mellitus, hypertension, and vascular diseases. Since ESRD is not curable definitively, patients suffering from ESRD have a very low quality of life; therefore, symptomatic management is the cornerstone of medical treatment. Uremia affects almost all body organs, such as skin, through different mechanisms including biochemical, vascular, neurologic, immunologic, hematologic, endocrine, and electrolyte and volume balance disturbances. Some of these conditions are associated with significant morbidity, and patients with ESRD commonly present with a spectrum of dermatologic disorders. Each one has its own unique presentation and treatment approaches. In this review article, we discuss the clinical presentation, pathophysiology, and treatment of the most common skin disorders associated with ESRD.

Kidney transplantation has become the treatment of choice for patients with end-stage renal disease. Six decades of success in the field of transplantation have made it possible to save thousands of lives every year. Unfortunately, in recent years success has been overshadowed by an ever-growing shortage of organs. In the United States, there are currently more than 100 000 patients waiting for kidneys. However, the supply of kidneys (combined cadaveric and live donations) has stagnated around 17 000 per year. The ever-widening gap between demand and supply has resulted in an illegal black market and unethical transplant tourism of global proportions. While we believe there is much room to improve the Iranian model of regulated incentivized live kidney donation, with some significant revisions, the Iranian Model could serve as an example for how other countries could make significant strides to lessening their own organ shortage crises.

Olive leaves are traditionally used in the Mediterranean basin in many medical conditions for its potent antioxidant activity. Cyclosporine A, a well-known immunosuppressant, can induce nephrotoxicity through oxidative stress. This study investigated the effect of olive leaf extract (OLE) on cyclosporine-induced nephrotoxicity in rats. Thirty Wistar rats (180 g to 200 g) were classified into 5 groups, each containing 6 rats. The first group received normal saline and served as control. The second group was treated with cyclosporine, 25 mg/kg for 21 days for nephrotoxicity induction. Groups 3 to 5 were treated with cyclosporine, 25 mg/kg in addition to different doses of OLE (40 mg/kg, 80 mg/kg, and 120 mg/kg), respectively, for 21 days. After 21 days, the rats'' body weights were recorded and the rats were sacrificed. Blood samples were collected and the animals were necropsied. Both kidneys were removed, one for histopathological and one for antioxidant activity evaluations. Cyclosporine significantly reduced body weight and kidney weight; serum total protein, albumin, and sodium levels; and renal glutathione peroxidase, catalase, and superoxide dismutase. It also increased serum urea, creatinine, and calcium levels as compared to the control group. Groups 4 and 5 showed a significantly greater body weight and kidney weight; higher serum sodium, total protein, and albumin levels; greater glutathione peroxidase, catalase, and superoxide dismutase; and lower serum urea, creatinine, and calcium levels as compared to group 2. Treatment with OLE can alleviate cyclosporine-induced nephrotoxicity when used in a proper dose.

Apelin is an adipokine secreted by the adipose tissue and by the endothelial cells in various parts of the body. Apelin is also expressed by the glomerular arteriolar rectus and glomerular capillary cells. We evaluated the relationship between the initial serum levels of apelin 13 with the trend of glomerular filtration rate (GFR) during a 1-year follow-up of patients with chronic kidney disease (CKD). Ninety-nine patients with CKD in the predialysis stages were included and completed the study. The demographic data, medications, and comorbidities of the patients were recorded. The relationship between the baseline apelin 13 levels and the 1-year GFR loss was evaluated. The mean 1-year GFR loss 1.6 mL/min for those with CKD stage 3, 5.1 mL/min for those with CKD stage 4, and 2.6 mL/min for those with CKD stage 5. Fifty-eight patients (58.6%) had a GFR loss less than 5 mL/min and 41 (41.4%) had a GFR loss of 5 mL/min and greater, for whom the mean apelin 13 levels were 2169 ± 1807 mL/min and 2513 ± 1920 mL/min, respectively (P =. 36). There was no significant correlation between the apelin 13 levels and GFR loss (P =. 35). To our knowledge, this study was the first that clinically examined the relationship between apelin 13 and CKD progression. Apart from the diabetic nephropathy, several factors causing comorbidity and progression may have probably masked this potential relationship.

Urinary tract infection (UTI) among children is sometimes associated with anorexia and sometimes failure to thrive. Appetite-regulating hormones may be a causative factor. Leptin regulates appetite, food intake, and body weight via hypothalamic melanocortin-4 receptor. Leptin is also a potential cytokine for inflammation. The aim of this study was to evaluate serum and urine leptin before and after treatment of children with UTI. In this before-after study, serum and urine leptin were measured in 40 patients with UTI at admission and 5 days after treatment. Pyelonephritis was suggested by signs and symptoms and confirmed with positive urine culture and dimercaptosuccinic acid renal scintigraphy. Other measurements included urinalysis, urine culture, urine creatinine level, complete blood count, erythrocyte sedimentation rate, C-reactive protein level and serum levels of urea, creatinine, glucose, cholesterol, and triglyceride. The mean serum leptin level was 6.85 ± 18.90 ng/mL before the treatment and 8.29 ± 18.30 ng/mL after the treatment, the difference of which was not significant (P =. 64). There were significant correlations between serum leptin and age, weight, and C-reactive protein. Urine leptin levels were reduced significantly from 0.75 ± 0.82 ng/mL to 0.46 ± 0.27 ng/mL after the treatment (P =. 03). A significant correlation was observed between urine leptin level with age and weight. Serum leptin level did not change significantly after treatment of UTI, but urine leptin significantly decreased. Serum leptin level was higher in patients with anorexia in comparison with children with normal appetite; however, the difference was not significant.

There is limited data about urolithiasis in young infants. We reviewed clinical, imaging, and biochemical data of urolithiasis in the first 2 months of life. In an 11-year period, 77 of the 1172 children diagnosed with urolithiasis (6.8%) were 60 days old and younger (64.9% boys and 35.1% girls). Routine diagnostic assessments included urinalysis and urine culture; measurement of calcium, uric acid, oxalate, and creatinine in nonfasting random urine; measurement of blood urea nitrogen and serum creatinine, sodium, potassium, calcium, and phosphorus levels; and venous blood gasometry. Urinary calculi were diagnosed using tridimensional ultrasonography with 5-MHz, 7.5-Mhz, and 10-MHz probes. The most common symptom was irritability (37.6%). A family history of urinary calculi was documented in 49.4% of the patients. The calculi were 0.5 mm to 6 mm in length. Eight infants (10.4%) had urinary tract infection. Hypercalciuria was found in 21 of 62 patients (33.8%). There were no cases of hyperuricosuria, hyperoxaluria, or struvite calculus. Vesicoureteral reflux was reported in 9 of 20 patients who underwent voiding cystourethrography. Two-thirds of asymptomatic and 85% of symptomatic infants were diagnosed during summer and autumn, and the peaks of calculus visits were in September, October, and November. Of 43 infants (55.8%) who were followed up (Mean, 16.2 ± 15.2 months), none needed calculus removal interventions. Hypercalciuria is the most common urinary metabolic abnormality in young infants with urinary calculus. Infection was not an important factor for our cohort in the pathogenesis of the disease.

Health-related quality of life (HRQOL) is an index to calculate wellbeing of patients and is an important concept in patients with end-stage renal disease. There are many studies calculating HRQOL for patients on different treatment modalities of end-stage renal disease. Pooling reports from Iran, this systematic review aimed to measure the HRQOL in patients on hemodialysis and peritoneal dialysis using meta-analysis techniques. Four databases including PubMed and Scopus in English and the SID and IranMedex in Persian were searched. Based on the inclusion criteria, 26 English and Persian-language articles reporting HRQOL in the scales between zero and 100 (or scales convertible to this range) for hemodialysis or PD were included in the meta-analysis. The mean HRQOL scores ranged between 34.40 and 69.16 for hemodialysis reports and between 38.00 and 65.70 for PD reports. The pooled quality of life scores for hemodialysis and PD were 52.257 and 52.722, respectively (t = 0.928, P =. 36). The results showed that HRQOL in patients using hemodialysis and peritoneal dialysis were not significantly different. Similar studies in other countries had found similar results.

Development of delayed graft function is more prevalent in patients receiving a kidney allograft from brain-dead than living donors. This study aimed to evaluate the association between urine neutrophil gelatinase-associated lipocalin (NGAL) levels in brain-dead donors and subsequent allograft function. Urine NGAL concentration was measured in urine samples obtained from 24 brain-dead kidney allograft donors before organ retrieval. The 24 kidney recipients were followed for 6 months. The immunosuppressive therapy was similar for all of the recipients. Following transplantation, plasma creatinine was recorded daily during the recipient''s stay in the hospital and then at 1, 3, and 6 months after transplantation. Delayed graft function was defined as the need for dialysis in the first 7 days after transplantation. The mean age of the donors was 28.7 ± 11.2 years and 70.8% were men. Their median urine NGAL level was 7.4 ng/ml (range, 2 ng/mL to 45 ng/mL). Urine NGAL levels were only associated with the need for cardiopulmonary resuscitation (P =. 007). On the 1st day after transplantation, 16.7% of the recipients developed delayed graft function, which was declined to 12.5% on the 2nd day and to 8.3% during the 3rd day and the following days. No significant association was observed between the donor''s urine NGAL levels and graft function (P =. 86). Our results did not show any association between urine NGAL levels and outcome of allograft function obtained from brain-dead donors. Larger studies are required to confirm this finding.

Hemodialysis patients face oxidative stress and inflammation induced by both kidney dysfunction and hemodialysis procedure. These are supposed to be partly responsible for the excessive cardiovascular morbidity and mortality in hemodialysis patients. We investigated the impact of kidney transplantation on the biomarkers of oxidative stress and inflammation. In a prospective cohort study on 32 kidney transplant candidates on hemodialysis, biomarkers of oxidative stress and inflammation were compared before and 3 months after kidney transplantation and were compared with each other as well as their values in the kidney allograft donors as the controls. These biomarkers included total antioxidant capacity, total thiol molecules, lipid peroxidation, plasma catalase, superoxide dismutase, glutathione peroxidase, and C-reactive protein. The mean age of the patients was 38.0 ± 15.5 years. The levels of total antioxidant capacity, total thiol molecules, and activity of glutathione peroxidase were significantly lower and the level of activity of plasma superoxide dismutase was significantly higher in the hemodialysis patients before transplantation as compared to the values for the controls and after transplantation. Lipid peroxidation was significantly higher in the patients before transplantation compared to the controls. A significantly higher level of C-reactive protein was noted in the hemodialysis patients as compared to their levels after transplantation and also C-reactive protein in the controls. These results suggest that oxidative stress and inflammation are elevated in hemodialysis patients which could be improved partly and significantly by restoration of kidney function after kidney transplantation.

Fabry disease, an X-linked lysosomal storage disorder, is caused by α-galactosidase A deficiency and leads to accumulation of glycospinhgolipids in most tissues, with life-theratening consequences in the kidney, heart, and cerebrovascular system. Enzyme replacement therapy is available as 2 different preparations: agalsidase alfa and agalsidase beta. Enzyme replacement therapy is started as soon as the diagnosis is confirmed, but there is no data available in the literature about its safety during preganacy. Herein, we described 2 patients with Fabry disease who received agalsidase beta during their pregnancy. This report is important as the data about enzyme replacement therapy during pregnancy is restricted with case reports.

Immunoglobulin G4 (IgG4)-related kidney disease is a systemic autoimmune disease which characterized by elevated serum IgG4 and dense infiltration of IgG4-positive plasma cells into tubular interstitium. It can be a mimicker of acute renal insufficiency. We herein report a rare case of IgG4-related kidney disease as a cause of acute renal insufficiency.