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   Table of Contents - Current issue
April-June 2017
Volume 17 | Issue 2
Page Nos. 43-73

Online since Thursday, September 21, 2017

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Corticosteroid in kidney transplant immunotherapy: rid off the giant Highly accessed article p. 43
Rotimi Oluyombo, Bridson M Julie, Ajay Sharma, Ahmed Halawa
Corticosteroid use to prevent rejection is ancient but pivotal in transplant immunotherapy. Its benefits are worrisomely being negated by its numerous side effects that affect the quality of life and add to the cost of treatment among transplant patients. The past three decades has witnessed an important dynamism with the advent of many other immunosuppressive agents in various combination protocols, which has led to reports of reduction in episodes of acute rejection. This, in addition to side effects, has raised the question of the need for chronic use of steroid or its avoidance from outset. The benefits of steroid-sparing are compelling especially in low-risk recipients and, recently, paediatric patients. The burden of cardiovascular diseases, the major cause of death in transplant patients, osteopenia and impaired growth among paediatrics confront both patients and their carers. Of concern, however, has been the variation and quality of study designs, which has made the report not only inconsistent but with weak evidence as well. The question still remains whether corticosteroid is disposable. We review corticosteroid use in transplant immunotherapy in the era of improved immunosuppression.
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Cardiovascular risk assessment in hemodialysis patients: relation to malnutrition, inflammation, and body fluid determined by bioelectrical impedance p. 52
Essam El Din Hassan El Kashef, Sameh Morsi Arab, Yasmine Salah Naga, Shaimaa Elsayed Mohamed Mohamed, Montasser Mohammed Hussein Zeid
Background Cardiovascular disease prevalence increases as the renal function declines across the spectrum of chronic kidney disease. In end-stage renal disease (ESRD), cardiovascular mortality may even account for 50% of mortality. The coexistence of malnutrition, inflammation, and atherosclerosis (the so-called MIA syndrome) has been observed in hemodialysis (HD) patients and is considered one of the cardiovascular risk factors unique to this population. In addition, chronic fluid overload is frequently present in HD patients. Objective The aim of the present study was to investigate the relationship between nutrition, inflammation, atherosclerosis, the presence of overhydration (OH) measured using multifrequency bioimpedance analysis, and the cardiac condition as assessed using echocardiography in HD patients. Patients and methods Thirty HD patients (mean age: 41.13±12.77 years, 15 were male and 15 were female) were enrolled in the Dialysis Unit of the Alexandria Main University Hospital. Serum albumin was used as a nutritional marker, and serum C-reactive protein (CRP) was used as an inflammatory marker. Doppler ultrasonography was performed to measure the carotid artery intimamedia thickness (CA-IMT) to assess the presence of atherosclerosis. Extracellular water (ECW), OH, and OH/ECW were measured using multifrequency bioimpedance analysis to detect OH. Cardiac condition was determined by means of echocardiographic measurement of the left ventricular mass index and ejection fraction (EF). Results Only two (6.6%) of the studied patients had a low albumin, 26 (86.6%) patients had a positive CRP, 23 (76.6%) patients had high carotid intimamedia thickness (CIMT), and nine (30%) patients had atherosclerotic plaques in the carotid artery. Bioimpedance showed OH in 15 (50%) patients, who had an OH/ECW ratio of more than 0.15. Echocardiography showed high left ventricular mass index in 55.5% and low EF in 16.6%. The presence of inflammation as indicated by CRP was associated with higher CIMT (r=0.520, P=0.003), higher interventricular wall thickness (IVWT) (r=0.469, P=0.007), and lower EF (r=−0.610, P<0.001). OH as assessed by OH/ECW was associated with higher CRP (r=0.553, P=0.002), higher CIMT (r=0.655, P<0.001), and lower EF (r=−0.742, P<0.001). Conclusion Inflammation, atherosclerosis, and fluid overload are prevalent in ESRD patients on MHD. Both inflammation and OH are correlated with increased CIMT and low EF, implicating them in the cardiovascular diseases commonly found in ESRD patients.
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Maintenance hemodialysis in Menoufia governorate, Egypt: Is there any progress? p. 58
Khaled M.A El-Zorkany
Introduction End-stage kidney disease (ESKD) has a major health impact worldwide. Hemodialysis (HD) is the basic renal replacement therapy in our country. In Egypt, like other developing countries, there is no electronic data system that permits simple measurable examination and assurance of the span of the issue for future plans. Aim The aim of this study was to assess the prevalence of ESKD patients on HD in Menoufia governorate, Egypt, as well as the clinical characteristics of such patients to make a core for national data registry. Patients and methods A questionnaire was conducted on ESKD patients on regular HD focusing on demographic data and clinical characteristics of the dialysis population, including smoking history, causes of ESKD, virology status, vascular access, blood transfusion, hemoglobin level, calcium, phosphorus, and parathyroid hormone. Results The prevalence rate of ESKD in Menoufia governorate was 483 patients per million populations. The mean age was 53.18±13.26 years [the highest proportion of patients (36.6%) was aged between 50 and 60 years]; there were 61.6% male and 38.4% female patients. The mean duration of dialysis was 3.78±3.372 years. The main causes of ESKD were hypertension (33.4%) and diabetic nephropathy (9.2%), and the unknown etiology accounted for 32.9% of all causes of ESKD. The prevalence of hepatitis C and B was found to be 42 and 2%, respectively, whereas the prevalence of hepatitis C virus (seroconversion was 7.9%). Conclusion In Menoufia governorate, the prevalence of ESKD patients on regular HD is steadily increasing than that previously reported, especially among older patients. Hypertension and diabetes mellitus are the most commonly accounted causes of ESKD, whereas undetermined etiology accounted for 32.9%. Hepatitis C infection and seroconversion among dialysis patients have been reduced.
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Primary hydatid cyst of the kidney presenting as a complex renal mass p. 64
Siraj Fouzia, Shruti Sharma, Vasudeva Pawan
Hydatid disease caused by Echinococcus granulosus is a rare parasitic disease mainly involving the liver and lungs. Renal involvement is uncommon and accounts for 2–3% of all cases. However, primary involvement of the kidney with sparing of liver and lungs is extremely rare. We report a case of primary renal hydatid disease in a 45-year-old woman who presented with left flank pain and a well-defined multicystic mass in the mid-pole of the left kidney. As it can clinically mimic malignancy, a high index of suspicion should be kept in mind when encountering a cystic renal mass in people from endemic areas.
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Eighteen years on postrenal transplantation, lymphoproliferative disorder, and its implication p. 67
Arun Kumar Narayanan, Rahul Ramachandran, Sreejith G Nair, Rekha A Nair, Sandeep Patil, Jayshree Ramdas Pisharody, Satish Balan, Keshavan Nair, Ramdas Pisharody
Post-transplant lymphoproliferative disorder (PTLD) represents a life-threatening disorder occurring after transplantation, ranging from a polyclonal mononucleosis-like illness to a monomorphic high-grade neoplasm with cytologic and histopathologic evidence indicative of transformation to lymphoma. PTLD of diffuse large B-cell lymphoma subtype isolated to the lungs is a rare diagnosis. We describe here a case of an immunocompromised adult diagnosed with diffuse large B-cell lymphoma PTLD limited to his lung with an associated mass and locoregional lymphadenopathy on imaging. Even more unique to our case was the absence of underlying cytomegalovirus and Epstein–Barr virus infection. In the post-transplant setting, immunocompromised state or Epstein–Barr virus-positive state has risk for PTLD. A live-related donor kidney transplant recipient, donor being the father, presented with cough, expectoration, and fever, which were not responding to sequential antibiotics. Evaluation showed large B-cell lymphoma of the lung after 18 years of transplant, which has not been reported before for its occurrence so late after renal transplantation.
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Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases p. 70
Ruba Abo Essa, Abdullah Muzalef, Saleh Al-Qahtani
The aim of this study was to know and validate whether the use of ventriculoperitoneal shunt (VPS) and peritoneal dialysis catheter (PDC) is a safe and acceptable option in children requiring PD and VPS. A case of myelomeningocele with accompanied paraplegia and hydrocephalus was treated surgically in the neonatal period with placement of VPS. Later the child developed a neurogenic bladder with recurrent cystitis, which culminated into severe bilateral ureterohydronephrosis and progressive chronic renal disease. In a second case, a boy with an immaculate past history, admitted in a local hospital for meningitis complicated by hydrocephalus, necessitating the insertion of VPS, was treated. During the course of his illness, the child developed acute renal failure, volume overload, and severe hypertension and ended up in our pediatric ICU. We experienced two cases in our artificial kidney unit with concomitant insertion of VPS and PDC with an excellent outcome. On the basis of the outcomes of our patients as well as results from other centers, we conclude that the concurrent use of a VPS and PDC is a safe and acceptable option in child requiring PD and VPS.
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Diabetic kidney disease updates crosswords: key answer p. 73
Hussein Sheashaa
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