Year : 2016 | Volume
: 16 | Issue : 2 | Page : 51--63
|How to cite this article:|
. Scientific Abstracts.J Egypt Soc Nephrol Transplant 2016;16:51-63
|How to cite this URL:|
. Scientific Abstracts. J Egypt Soc Nephrol Transplant [serial online] 2016 [cited 2020 Apr 9 ];16:51-63
Available from: http://www.jesnt.eg.net/text.asp?2016/16/2/51/188529
O-1 Study of the effect of donor source on graft and patient survival in pediatric renal transplant recipients
Gheith O, Al Otaibi T, Nampoory MRN, Halim M, Said T, Abdul-Tawab K, Hosni W, Mansour H, Rashad Hassan, Ahmed Mosaad, Nair MP
Hamed Al-Essa Organ Transplant Center, Kuwait
Introduction: Evaluation of the impact of kidney donor sources on the outcome of renal transplantation is not adequately studied.
Aim of the study: We aimed to compare the long-term outcome of kidney transplantation from different sources among a pediatric recipient population.
Patients and methods: This study comprised 105 pediatric recipients who received their kidney grafts between 1994 and 2011 at Hamed Al-Essa Organ transplant center of Kuwait. These patients were further subdivided into three groups according to donor source (37 with live related donors); (31 with emotionally related donors) and (35 with cadaveric donors). All patients’ data were assessed with special emphasis on graft and patient survival as well as post-transplant medical complications.
Results: All groups –with mean follow up seven years-were comparable regarding pre-transplant demographic features especially diabetes, anemia, hypertension, tuberculosis, bone disease and viral profile. We found that patient survival at 1, 5, and 10 years was comparable in all groups. In our series, we observed that rejection rate in the 3 groups was comparable (p>0.05). However, kidney survival was poor among cadaveric group compared to other groups despite potent induction and maintenance immunosuppression. This could be explained by poor HLA match; high PRA; higher incidence of ATN and NODAT in the same group (p<0.05).This was translated as significantly higher mean serum creatinine. The overall incidence of post-transplant complications was comparable among the three groups except significantly higher post-transplant diabetes among emotionally related donors group (p=0.004).
Conclusion: Pediatric renal transplants have good long term patient outcome irrespective of the donor source; with poorer cadaveric grafts and higher risk of NODAT among emotionally related donors.
O-2 Study of The Role of Anti-Phospholipase A2 Receptor Antibodies in monitoring of the Clinical Status in Idiopathic Membranous Nephropathy in Egyptian Patients
Mohammed Gamal El-Din Saadi, Tarek Mohammed Fayad, Mervat Mohammed El- Ansari, May Hassaballa, Rabab Mahmoud Ahmed Mahmoud, Khaled Marzouk, Amr Shaker.
Internal Medicine and Nephrology Department, Kasr Al-Ainischool of Medicine, Cairo University
Background: Idiopathic membranous nephropathy, is the most common cause of the nephrotic syndrome, it is an antibody-mediated autoimmune glomerular disease. In 2009, podocyte phospholipase A2 receptor (PLA2R) was reported as an antigenic target in autoimmune adult membranous nephropathy. APLA2 could be a useful biomarker for diagnosing IMN and monitoring disease activity.
Objectives: We explored the prevalence of anti-PLA2R antibodies in a cohort of patients with IMN in Egypt. We also sought to determine the correlation between the APLA2 and its titer to the clinical status of these patients.
Method: Using an indirect immunofluorescence assay, we measured anti-PLA2R antibodies in 90 samples of 30 patients with IMN in Egypt in different stages of their clinical course.
In brief, blood samples and urine samples are collected for the measurement of serum creatinine,albumin, cholesterol,Triglycerides, CBC, erythrocytes sedmentation rate,Fasting blood sugar, Post prandial blood sugar,C3, C4, ANA, anti DNA, ANCA, HCV antibody and HBs Antigen and Urine analysis, 24 h protein in urine.
Results: We measured the level of anti PLA2R antibodies in 30 patients which divided into two groups; group (1) included 15 patients recently diagnosed as IMN before starting immunosuppression and group (2) which is a heterogeneous group included 15 patients with idiopathic membranous nephropathy during their remission or relapse period. Anti-PLA2R antibodies were detected in (12/30) 40% in both groups equally (6/15).The titer ranged from 1:10 to 1:40. APLA2 was found in 15 / 22 samples (68.1%) in patients with nephrotic range proteinuria this was statistically significant (P value 0.002). The reactive patients had lower serum albumin at the presentation and this was statistically significant also (P value 0.049). There was no correlation between the intensity of protinuria and the titer of antibodies (P value > 0.05). APLA2 correlate with the disease activity, as measured by urinary protein and serum albumin levels. It was noticed that; the average time to remission was longer in the reactive patients (statistically insignificant). It was also found that APLA2 reactive patients had more frequent use of diuretics and MMF than the non-reactive group and this was statistically significant P value (0.007) and (0.01) respectively.
Conclusion: In our study APLA2 was detected in (40%) of the patients and it correlates with the disease activity as regarding remission and relapse and its reactivity was higher in more severe disease. But there is no correlation between the intensity of proteinuria and the APLA2 titer.
O-3 Total Parathyroidectomy with Auto-transplantation and thymectomy in ESRD patients – Long-term follow up.
Hanan Mostafa1, Ibraheem Shalaby2, Ashraf Hamed2, Ibrahim El Zayat2, Mohamed El Maddawi2, Nevein Nabeeh1, Ayman Sabry1, Hosam Fouda1, Mohammed Abdelgawad1, Ahmed Ibrahim1, Mohamed Mahmoud1, Mohammed Abdalla1, Osama El Shahat1 and Ahmed Halawa3
1Department of Nephrology and 2Surgery, Mansoura International Hospital, Mansoura, Egypt, 3Sheffield Kidney Institute, Sheffield, United Kingdom
Background: Renal Hyperparathyroidism is a disabling disease. It affects all CKD patients if left without preventive measures. We started this project in 2012 in cooperation with Sheffield Kidney Institute, University of Sheffield. We established a tertiary referral centre in Egypt to treat this disease and also train surgeons to perform this operation safely and effectively.
Objectives: To present our long term follow up of our approach in surgical treatment of this disease
Patients & Methods: Retrospective review of 66 cases underwent total parathyroidectomy, thymectomy and auto-transplantation, performed over three years period. Patients were selected based on symptoms of CKD-MBD with intact PTH level of 1000 pg/ml and above. We do not rely on per-operative imaging to localize the hyperplastic glands due to the known lack of sensitivity and specificity in a multi-gland disease. Three/four glands excision was performed by a surgeon who is trained to perform this operation. Tiny portions of a relatively healthy gland (equivalent to the size of a normal gland) were auto-transplanted into sternomastoid muscle pouches if 4 or more glands were found.
Results: 66 patients attempted curative surgery when medical treatment failed. We considered biochemical persistence/recurrence when the PTH is persistent >400 pg/ml. Six patients had persistent were one or 2 glands were not found in the neck or activation of the remnant parathyroid cells. One patient had recurrence of Hyperparathyroidism one year after potential curative surgery (11% persistent/recurrence rate). 5 patients have hypoparthyroidism (7%), 3 of them managed well with conservative treatment. Only 2 patients have symptomatic hypocalcaemia requiring hospital admission. A single case of unilateral RLN injury was and one case of transient SLN injury were reported.
Conclusion: Our data demonstrates our experience in the management of this disabling disease where we achieved control of the parathyroid glands dysfunction (hyper/hypoparathyroidism) in 82% of our patients.
O-4 Fluorescein Angiography and the Kidney: Friend or Foe?
Mohamed E. Elraggal1, Ahmed F. Elkeraie2, Ahmed M. Abdelhadi3,
1Nephrology, Kidney and Urology Center, Alexandria, 2Nephrology, Alexandria Univ, Alexandria, 3Ophthalmology, Alexandria Univ, Alexandria, Egypt
Background: Fluorescein angiography (FA) is an indispensable tool for diagnosis and management of diabetic retinopathy (DR). However, safety of fluorescein sodium on renal functions is not fully understood.
Methods: 100 type 2 diabetic patients presenting to the ophthalmology outpatient clinic at Alexandria main university hospital were included in our study. Serum creatinine and cystatin-C were measured just before and 2 days after FA. Urinary NGAL as a tubular biomarker was measured also before and 4 hours after FA. Renal injury was defined as 25 % increase in serum creatinine, cystatin-C or urinary NGAL.
Results: The mean of serum creatinine was 0.99 ± 0.36 mg/dl and 1.0 ± 0.36 mg/ dl before and after FA respectively with no statistically significant change (P=0.061). Only one patient (out of 100) experienced more than 25% rise in serum creatinine from baseline. Serum Cystatin-C and urinary NGAL increased significantly after FA (P>0.001). Mean of serum Cystatin-C was 0.89 ± 0.34mg/l and 0.95 ± 0.36 mg/l before and after FA respectively. 11 patients experienced more than 25% rise in serum cystatin-C from baseline. Mean of urinary NGAL was 21.78 ± 23.90 ng/ml and 27.15 ± 28.17 ng/ml before and after FA respectively. 40 cases had ≥25 % increase in urinary NGAL level from baseline, of which, 33 had an increase of ≥50 %.
Conclusions: Using ordinary biomarkers as serum creatinine, FA was thought to be kidney friendly. Nevertheless, using more sensitive early biomarkers as serum cystatin-C and urinary NGAL, FA is not as innocent as previously thought. A creatinine negative, biomarker positive change may implicate a form of subclinical AKI.
O-5 An effective treatment with Rituximab for the maintenance of remission in frequently relapsing minimal change disease
Eugenia Papakrivopoulou1, Ali Shendi Mohamed2,3, Alan Salama1, Mariam Khosravi1, John Connolly1and Richard Trompeter1
1CL Centre for Nephrology, Royal Free Campus, University College London2 Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Zagazig University, Egypt3 ISN / UK RA Fellow, UCL Centre for Nephrology, Royal Free Campus, University College London
Background: Treatment of frequently relapsing or steroid-dependent minimal change disease (MCD) in children and adults remains challenging. Corticosteroids and/or other immunosuppressive (IS) agents are the mainstay of treatment but patients often experience significant toxicity from prolonged exposure and may either become treatment-dependent and/or resistant. Increasing evidence suggests that rituximab (RTX) can be a useful alternative to standard immunosuppression, however data on optimal treatment regimes (timing/dose/frequency), long-term efficacy, and safety are still limited.
Methods: We undertook a prospective trial of the effect of RTX in 15 young adults with frequently relapsing or steroid-dependent, biopsy-proven MCD. All patients were in remission at the start of treatment and on a calcineurin inhibitor (CNI). Two doses of RTX (1gr) were given six months apart to the majority of patients (n=12). A subset of these patients (n=4) also received an additional dose 12 months after their last dose, in order to examine the benefit of re-treatment. Biochemical and clinical parameters were monitored over an extended follow-up period of up to 43 months.
Results: Median steroid-free survival was 25 months (range 4-34) for the group overall. Steroids were discontinued in all patients within 3 months of the first RTX infusion. Compared to the year before RTX, mean relapse frequency (number per patient per year) decreased from 2.60±0.28 to 0.4±0.19 (p<0.001). Seven relapses occurred during the follow-up period, five of which (71%) occurred when CD19 counts were greater than 100 cells/ml. Immunoglobulin levels remained unchanged and no major side effects were observed throughout the follow up period.
Conclusions: These results demonstrate that RTX therapy is effective at maintaining prolonged steroid-free remission and reducing relapse frequency in this group of young-adult patients. Our study lends further support for the role of RTX in the treatment of young adult patients with frequently relapsing or steroid-dependent MCD.
O-6 Prevalence of Pregnancy among Females on Regular Haemodialysis
Maysa Samir Zahran, Mohammed Gamal El-Din Saadi, May Abdel-Monem Hassaballa, Magdy Mosaad El-Temamy, Hussein Saeed EL-Fishawy, Sameh Abdalla
Internal Medicine and Nephrology Department, Kasr Al-Ainischool of Medicine, Cairo University
Background: Chronic kidney disease is a major public health problem worldwide. It affects 3% of women of childbearing age. Pregnancy in these women is frequently associated with adverse outcome. Up to date, there are no available registries about the prevalence of pregnancy in women with CKD in Egypt.
Objective: To detect incidence of pregnancy among married females in childbearing period on hemodialysis, detecting outcome and complications.
Methods: We conducted a multi center retrospective descriptive study on patients from several dialysis centers in Damietta hemodialysis centers and other centers. For all hemodialysis patients who got pregnant, detailed information were collected which included full history talking, gynecological and obstetric history and complete clinical examination. Their clinical characteristics were analyzed over the last 10 years.
Results: Results of the study revealed that conception was reported 46 times in 41 women representing 8.3% with a yearly frequency of 0.83%. Age and duration of marriage were similar among pregnant (mean age: 29.6 years; mean duration: 8.7 years) and non pregnant (mean age: 29.8 years; mean duration: 9.3 years). Regarding outcome, 50% of pregnancies ended in abortion, 46% in delivery and 4% to stillbirth. Better fetal outcome was not correlated with maternal age (P: 0.68) or serum albumin (P: 0.14). There was positive correlation of fetal outcome with hemoglobin level (P: 0. <0.001), dialysis dose (P: <0.001) and urea rate reduction (P: 0.009), while there was negative correlation of fetal outcome with predialysis serum urea (P: 0.005), presence of polyhydramnios (P: 0.025) and preeclampsia (P: 0.027) and duration of dialysis before pregnancy (P: 0.007).
Conclusions: the incidence of pregnancy among married females in childbearing period on regular hemodialysis was 8.3% which represents an indicator for the successful dialysis regimen in Egypt. Dialysis dose and urea rate reduction were increased in those with favorable outcome. On the other hand, poor pregnancy outcome in our study has been related to polyhydramnios, preeclampsia and long duration of dialysis before conception. The high rate of poor pregnancy outcome points to the fact that this issue needs to be more investigated in a trial to reach to the best regimen for a better outcome.
O-7 Correlation between Vascular Calcification and Silent Vertebral Fractures in Chronic Kidney Disease Stages 3 and 4.
Amr M Ebied1, Doaa I Hashad2, Mohamed M El shafei3, Sara T Ibrahim4
1Professor of Internal Medicine, 2Assistant Professor of Clinical and Chemical Pathology, 3Lecturer in radiodiagnosis 4Resident in internal Medicine Department, Nephrology Department, Alexandria university hospital, Alexandria, Egypt
Background: Vascular calcifications and the bone fractures are frequent complications associated with chronic kidney diseases (CKD). The aim of this study was to investigate the association between vascular calcifications, osteoporotic vertebral fractures in patients with CKD stages 3 and 4.
Methods: The study was conducted on 50 subjects (30 patients with CKD stages 3 and 4 and 20 healthy volunteers as a control).Vascular calcifications (aortic artery calcifications and coronary artery calcifications (CACs)) and osteoporotic vertebral fractures were assessed by non contrast multidetector computed tomography (MDCT) for chest, abdomen & pelvis. Clinical, biochemical and therapeutic data were collected.
Results: Vertebral fractures were absent in the entire patients with CKD stages 3&4 who were included in our study, but osteopenia was present in 30% of them and this was significantly higher than the control group of same age and sex (5%). The presence of aortic calcifications was insignificantly higher in CKD patients (66.6%) than the control group of same age and sex (60%), however the presence of CAC was significantly higher in CKD patients (43.3%) than the control group of same age and sex (0.0%). Vascular calcifications were higher in patient with osteopenia than those without and this was statistically significant (P<0.001).
There was a statistically significant positive correlation between serum phosphorus levels, serum calcium x phosphorus product and vascular calcifications. None of the biochemical variables (serum calcium, serum inorganic phosphorus, calcium phosphorus product, intact PTH and bone specific ALP) showed any significant association with osteopenia in our CKD patients.
Conclusions: Vertebral fractures are absent in patients with CKD stages 3 and 4 but osteopenia is present. There is strong relation between vascular calcifications (aortic calcifications and CACs) and osteopenia.
O-8 Age Adjusted Prevalence of Hypertension in ESRD Patients On Haemodiaysis - A One Center Study
Hussam Shwaib1,3,4, Mohamed Elhassan3, Abdalhameed Omer2,3, Mohamed Hyder3, Hussam Sayed3, Mohamed Abdellateef3, Mohamed Koko3, Dina H. ElBashir3,4,5
1University of Khartoum, Faculty of Medicine, Department of Community Medicine, 2University of Khartoum, Faculty of Medicine, Department of Obstetrics and Gynecology 3Federal Ministry of Health 4Al-Academy Teaching Hospital 5Ministry of Health, Khartoum State, Sudan
Background: The United States Renal Data System (USRDS) data shows hypertension (HTN) as one of top three causes of End stage renal disease. In the U.S; the prevalence of HTN is nearly 30% while in Sudan it is 23.6% in Khartoum state. Uncontrolled HTN is difficult to manage as chronic kidney disease (CKD) progresses and is a predictor of poor outcome. the prevalence of HTN and status of blood pressure (BP) control in these patients is lacking in Sudan and has not been properly investigated.
Methods: A cross-sectional hospital based study was performed in Al-Academy dialysis center in which 122 patients were interviewed. The patients were divided into 3 groups, 18-45, 46-65 and older than 65 years with a male/female ratio of 1.6. Analysis was performed with age adjustment and Kruskal-Wallis Test was used to test the differences between the groups.
Results: For the18-45 year age group, the overall prevalence of HTN was 69%; of which 89.56% had both systolic and diastolic HTN while only 11.53% had diastolic HTN. The 46-65 year age group had an overall prevalence of 55.1% of which 51.85% had both systolic and diastolic HTN; 37.03% had isolated diastolic HTN. Finally, the prevalence of HTN in those older than 65 years was 51.6%; of which 81.25% had isolated diastolic HTN and 18.75% had both systolic and diastolic HTN. There was no statistical differences between the groups regarding the Systolic blood pressure values (P= 0.28) but a difference was found for the diastolic blood pressure values (P<0.05)
Conclusion: The prevalence of HTN for age groups 18-45, 46-65 and those older than 65 years of age were 69%, 55.1% and 51.6% respectively with the majority having both systolic and diastolic HTN except the age group >65 years in which isolated diastolic HTN dominated.
P-1 Renal Biopsy Registry Program in Alexandria Area
Mahmoud S. AbdElHady1, Ahmed F.Elkeraei1, Mona A. Salem2, Nahed M. Baddour2, Yasser A. Nienaa1
1Nephrology Department, Alexandria University, Egypt, 2Pathology Department, Alexandria University, Egypt
Background: Accurate documentation of the spectrum of renal diseases prevalent in a particular area over a particular period of time is imperative nowadays. Many countries now have their own databases about renal biopsy and the epidemiology of specific glomerular diseases in these countries like the Italian and Japanese renal biopsy registry database (IRBRD) & (J-RBRD). In our study we tried to identify the pattern of renal pathology among renal biopsy specimens in Alexandria, Egypt.
Methods: 550 adult native renal biopsies were evaluated - which were performed during 2014 and 2015 - from two nephron-pathology centers.
Results: Primary Glomerular diseases were more common in females. The most abundant histopathological pattern was Mesangioproliferative GN (26%), Membranoproliferative GN (23.8 %), FSGS (12.3), Membranous nephropathy (4.7%) IgA nephropathy (4.5%), Minimal change disease (2.1 %, Nodular GN (2.7 %}, amyloidosis (2.7%) and fibrillary GN (2.5%), acute interstitial disease (3.6%), chronic interstitial disease (2%), ESRD (2.7%). Lupus nephritis was the most common secondary glomerulonephritis.
Interestingly, 74% of IgA patients presented with nephrotic syndrome, while only 14.8 % presented with hematuria. Immunohistochemistry was done on (19%) of specimens while EM was performed less frequently (2.36%).
The most common indication for renal biopsy was nephrotic syndrome (59%) followed by AKI (22.7%), CKD (11.3%) then urinary abnormalities (6.9%). At the time of the biopsy 60% of the patients presented with elevated kidney functions. 10.5% of the performed biopsies were inadequate where the biopsy included only renal medulla or inadequate number of glomeruli. A very common encountered problem was the paucity of clinical data or nothing at all in many reports.
Conclusion: Conduction of a trusted national registry will help in prevention and treating renal diseases. This needs a good cooperation between nephrologists and pathologists with Collection of all clinical, serological and pathological data.
P-2 Renal Biomarkers in Diabetes, Role Beyond Nephropathy, Relation to Retinopathy
Mohamed E. Elraggal1, Ahmed F. Elkeraie2, Ahmed M. Abdelhadi3
1Nephrology, Kidney and Urology Center, Alexandria, 2Nephrology, Alexandria Univ, Alexandria, 3Ophthalmology, Alexandria Univ, Alexandria, Egypt
Background: Diabetic nephropathy and retinopathy remain two of the most frequent complications of diabetes and is the leading cause of end-stage renal disease (ESRD) and blindness worldwide. The concordance rate between both complications is often present in diabetic patients.
Methods: We tried to study the relation between renal biomarkers including serum creatinine (SCr), urinary albumin/creatinine ratio (ACR), serum cystatin-C (cysC) and urinary NGAL (uNGAL) with diabetic retinopathy (DR) in 100 diabetic patients. Patients were classified according to severity into 3 stages: no diabetic retinopathy (No DR), Non-Proliferative DR (NPDR) and proliferative DR (PDR).
Results: Urinary ACR, serum cysC and uNGAL were higher significantly among patients with DR (NPDR & PDR) than patients without, while SCr showed a non –significant rise with progression of retinopathy. All markers were higher among PDR than NPDR group.[INLINE:1]
Conclusions: Renal biomarkers namely urinary ACR, serum cysC and uNGAL may point to a more advanced stage of diabetic retinopathy, which might be an aid to identify the degree of retinopathy beside the traditional fundus examination.
P-3 Prevalence of Hepatitis E Virus among Hemodialysis Patients: One Egyptian Center Study
Maysaa El Sayed Zaki1, Mostafa Abdelsalam2, Nahla Hamed Anbar3, Basem Salama El-deek4
1Clinical Pathology Department, 2Internal Medicine Department, 3Emergency Hospital, 4Community Medicine Department, Mansoura Faculty of Medicine, Egypt
Background: In Egypt Hepatitis E virus (HEV) is considered as an endemic infection. The aim of the present study was to determine the prevalence of HEV infection among HD patients and to study the risk factors associated with such infection.
Methods: The study included ninety six cohort HD patients in Mansoura University Hospital, Egypt in addition to one hundred sixty seven healthy blood donors. Full virological markers assay for hepatitis B, C and E viruses were performed. Positive samples for serological markers for hepatitis E were subjected to nested PCR for HEV.
Results: HCV IgG was the predominant serological markers among HD (42.7%) followed by HEV IgG (22.9%). Serological virological markers for HCV and HEV were significantly higher in HD patients compared to healthy blood donors (18.6%-5.9%, P=0. 0001, P=0. 02 respectively). HEV viremia was detected in statistically significantly higher percent of HD patients (36.4%) compared to blood donors (20%), P=0. 07. The duration of dialysis and the number of blood transfusion units had no statistically significant association with HEV viremia. HCV antibodies were prevalent among 50% of patients with HEV viremia.
Conclusion: From this study we can reason that HEV is common infection among hemodialysis patients. Further studies are obliged to clear up the wellspring of HEV disease in dialysis units in Egypt.
P-4 Preoperative Imaging in Renal Hyperparathyroidism; A pilot Study
Osama El Shahat1, Hanan Mostafa1, Ibrahim Shalaby2, Ashraf Hamed2, Ibrahim El Zayat2, Mohamed El Maddawi2, Mohammed Abdelgawad1, Ayman Sabry1, Nadia Mohsen1, Hamed Ezat1, Mohammed Abdalla1, Ahmed Halawa3
1Department of Nephrology and 2Surgery, Mansoura International Hospital, Mansoura, Egypt, 3Department of Surgery, Sheffield Kidney Institute, Sheffield, United Kingdom
Introduction: There is traditional practice among renal physicians that preoperative imaging is a prerequisite for parathyroidectomy. There is wrong belief that imaging is required to confirm the diagnosis. There is also a claim that preoperative imaging is useful in detecting ectopic parathyroid gland. This could be true in primary disease and in redo cases but these scans are not sensitive in multi-gland disease where the diagnosis is entirely clinical.
Aims: To identify the sensitivity and the specificity of preoperative imaging in our hands
Materials &Methods: We conducted a retrospective analysis of patients who had parathyroidectomy and also who are on the waiting list for this operation. We compared the results of neck ultrasound scan and isotope scan with the operative finding confirmed by the histology reports of the retrieved specimens to calculate the actual sensitivity and specificity of these tests. Also we calculated the predicted sensitivity and specificity for those on the waiting list. The clinical data of 18 patients were analyzed. 14 patients had parathyroidectomy and 4 patients awaiting this operation.
Results: There is 100% mismatch between the histology reports and both ultrasound scan and isotope scan. None of these scans detected more than 2 glands or detected ectopic parathyroid glands.
Conclusion: Poor actual and predicted sensitivity and specificity of preoperative imaging in multi-gland disease. In the presence of high PTH, radiological diagnosis is not required. We do not recommend preoperative imaging in multi-gland disease. We also recommend restricting the preoperative imaging to redo cases to identify the anatomy.
P-5 Is renal amyloidosis uncommon in Egypt?: A 25 year study
Amal M. Labib, Marwa M. Shakwer, Manal I. Salman, Elham I. Seif
Pathology Department, Faculty of Medicine, Ain Shams university Cairo Egypt
Amyloidosis comprises a large group of different diseases, which are characterized by symptoms caused by the deposition of amyloid in vital organs.These diseases are usually progressive, and most amyloid syndromes are fatal (3,5,7).Nevertheless,some of these diseases can now be treated successfully (2,4,6,8,10).
The kidneys are one of the most frequently affected organs in systemic amyloidosis, and renal amyloidosis is one of the main differential diagnosis in the investigation of nephrotic proteinuria in adults, particularly elderly patients (11).Renal amyloidosis accounts for about 2% of native kidney biopsies worldwide and AL amyloid is far more common than AA (9).
A retrospective study, was carried out in pathology department of Ain Shams faculty of medicine from Jan.1990 to Dec.2015.
The total number of renal biopsies examined were 3962, histological confirmation of amyloid deposits in kidney tissues were done in 118 cases (2.97%).
P-6 Variability of eGFR using different creatinine and Cystatin-C based GFR equations among Egyptian diabetic patients.
Mohamed E. Elraggal1, Ahmed F. Elkeraie2
1Nephrology, Kidney and Urology Center, Alexandria, 2Nephrology, Alexandria Univ, Alexandria, Egypt
Background: Estimated glomerular filtration rate (eGFR) equations are not very accurate in adequately assessing/predicting the actual GFR. Serum creatinine-based equations depends on body muscle mass, protein content in diet and tubular secretion of creatinine. Serum cystatin-C (cysC) is considered a better accurate estimation of GFR as it avoid the fallacies of serum creatinine.
Methods: We compared different equations of eGFR by measuring serum creatinine and cysC to hundred diabetic patients. eGFR was calculated using MDRD, CKD-EPI creatinine, CKD-EPI cysC, CKD-EPI creatinine-cysC.
Results: eGFR differed significantly between creatinine (MDRD & CKD-EPI Cr) and cysC-based equations (CKD-EPI cysC) (P>0.001). While eGFR using CKD-EPI creatinine-cysC had a mean value between both.[INLINE:2]
Conclusions: Estimated GFR is still an inaccurate tool for predicting true GFR. Measuring GFR (mGFR) - using either iothalamate, inulin or radioisotope scan – is still the most accurate tool to know the true GFR especially in research purposes.
P-7 Assessment Of Nutritional Needs For Patients Undergoing Hemodialysis
Dina Gamal Hussein1, Magda Abd El-aziz Mohammed2, Eman Saleh Shahin3, Doaa, Hamed Mohamed4, Amal Baker Abo El-ata3
1Technical Health Institute, 2Faculty of Nursing, Ain Shams University, Cairo, 3Faculty of Nursing, Port Said University, 4National Nutrition Institute, Egypt
Background: Nutrition management is an important component in the prevention of malnutrition in patients with moderate to severe kidney disease. Renal insufficiency and chronic renal failure require nutritional treatment that includes dietary modifications in potassium, protein, and sodium intake based on the patient’s nutrition status. These changes are incorporated to lessen uremic symptoms and slow the decline in kidney function.
Objectives: To assess nutritional needs for patients undergoing hemodialysis at El -Hussein university hospital in Cairo and at Port Said city governmental hospitals.
Methods: A convenience sample of 100 stable patients, with mean age (43.33±9.165) years, on HD treatment for at least 6 months from two hemodialysis units in Cairo and at Port Said city governmental hospitals. Nutritional assessment of these patients was done using anthropometric parameters, food frequency questionnaire and 24 recall assessment.
Results: The mean of BMI 27.19±3.57 kg/m2, IDWG 85% was between 2-5% of dry body weight which acceptable. Nutrients intake of this patients showed a low energy intake (22.17± 5.125) Kcal/Kg IBW/d, protein (1.23± 0.371) gm /Kg IBW/d with high biological value (HBV) <50% of protein in 98 % of patients, as regard saturated fatty acids (SFA) 80% reported intake ≥7% of total kcal. As regard mineral intake, k+ >40 mg/kg/d, Ph >16mg/kg/d, Na >2000mg/d, Ca <500mg/d and fluids >1000 ml/d were detected in (18%, 57%, 87%, 33% and 89%) of patients, respectively. Also, there are significances between sociodemographic variables, dietary habits and nutritional needs and must be taken into consideration in the nutritional assessment (p< 0.05).
Conclusion: This study shows that in stable dialysis patients, abnormalities of nutritional parameters are over prevalent than expected by analysis of dietary food intake. So dietetic counseling is very important in HD patients, as well as reevaluation of type of dietary protein and energy requirements.
P-8 Screening of The Adverse Effects of Substances of Abuse on Kidney Functions: An Egyptian Single Center Study
Ekramy Elmorsy1, Mostafa Abdelsalam2, Ahmed Mohammed Abd El-Whab2, EmadFekry1, AmalMisbah Elsaid3, AlaaSabry2, Maysaa El Sayed Zaki4, Nahla Anber5
1Department of Forensic Medicine and Clinical Toxicology, Mansoura Faculty of Medicine, 2Department of Internal Medicine, Mansoura Nephrology and Dialysis Unit, Faculty of Medicine, Mansoura University, 3Clinical Pathology, Mansoura Chest Hospital, Ministry of Health, 4Clinical Pathology Department, Mansoura faculty of Medicine, 5Emergency Hospital, Mansoura Faculty of Medicine, Egypt
Recently, substance abuse has become an increasingly prevalent problem all over the world. The kidneys - As an excretory organs- are highly vulnerable to the toxic effect of abuse substances. This study was aiming to study the nephrotoxic effect of commonly abused substances in Egypt on the kidney functions among abusers. In this study we have investigated the effects of commonly abused drugs in Egypt (tramadol, cannabis, opiates, barbiturates and benzodiazepines)on kidney functions (serum creatinine and blood urea nitrogen [BUN]).One Hundred - eighty four persons were screened for these substances using enzyme multiplied immunoassay technique (EMIT), positive samples were further confirmed by gas chromatography-mass spectroscopy (GC- MS). Eighty-nine cases showed positive results by GC-MS. Tramadol was the most commonly abused substance in the studied population (29 cases). Our data showed that substance abuse significantly increased level of serum creatinine and BUN among abusers (The mean level of serum creatinine level was statistically higher in abusers (1.08±0.4mg/dl) compared with nonabusers (0.85±0.25 mg/dl), this difference was statistically significant (P=0.0002).Thirty-seven abusers showed serum creatnine level ≥1.2 mg/dl. The mean level of BUN was also statistically higher in abusers (13.45±3mg/dl) compared with non- abusers (11.7±2.5 mg/dl) compared with non- abusers (11.7±2.5 mg/dl), again the difference was statistically significant (p=0.0007).Tramadol and other opioids were shown to be the most toxic to the kidneys. Kidney injury marker 1 (KIM1) and albumin/creatinine ratio (ACR) showed that tramadol renal injury is mainly tubular, while other opiates produce tubular and glomerular adverse effect. Substance abuse- especially tramadol and other opioids significantly impairs the kidney function in healthy abusers, so they should be considered as a risk factor for renal injury.
P-9 Study The Effect of Online Hemodiafiltration on Serum Homocysteine and Lipids as Cardiovascular Risk Factors
Rabeiy D1, Adam AG2, El-Wakil HS2
1Department of Nephrology, Ras El-Teen Hospital, Alexandria, 2Department of Nephrology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Background: Hyperhomocysteinemia and dyslipidemia are common among chronic kidney disease (CKD) patients and represent independent risk factors for atherosclerotic cardiovascular disease (CVD).
Aim of the study: to compare the effects of pre-dilution online hemodiafiltration (OL-HDF) and conventional high-flux hemodialysis on serum homocysteine, troponin and lipid profile as cardiovascular risk factors.
Methods: This prospective, controlled study involved 30 CKD patients divided as 20 ESRD patients were on regular low flux HD thrice weekly, 4 hours each (study group or group 1), and 10 patients were CKD stage V before starting dialysis (control group or group 2). Group 1 was further subdivided into 10 patients arranged to do pre-dilution OL-HDF for 8 weeks (OL-HDF group), and the other 10 patients did regular high flux dialysis for 8 weeks (HF group). Serum homocysteine, Troponin I-hs, and lipid profile levels were assessed before and after the study period for group 2 and once for group 1. The mean age of studied groups was 55.200 ±13.489 years, and the mean age of control group was 57.1± 15.821 years.
Results: There were significant reduction in serum Homocysteine, Cholesterol and TG among the OL-HDF group vs. HF group after the study period, (P=0,028) vs. (P=0.10), (P=0.030) vs. (P=0.214), (P=0.005) vs. (P=0.074) respectively. No significant reduction in serum Troponin I among the studied groups after the study period, but still more reduction was observed among OL-HDF group vs. HF group, (P = 0, 093) vs. (P = 0.317).
Conclusions: OL- HDF has advantages over conventional HD in better clearance of homocysteine, reducing dyslipedemia. This may have a positive impact in reducing cardiovascular risk among hemodialysis population.
P-10 Catheter related blood stream infection (CRBSI), a management protocol development process.
Mohamed Essam(1)*, Marwa Meheisen(2), Alyaa Elghitany(3), Mahmoud Abdelghany(4), Ahmed Elkeraie(1,5)
(1)Nephrology Department, Kidney and Urology Center, (2)Microbiology Department, Alexandria Main University Hospital, (3)Clinical Pharmacology Department, Kidney and Urology Center, (4)Quality Department, Kidney and Urology Center, (5)Nephrology Department, Alexandria Main University Hospital
Background: Intravascular hemodialysis catheters play a central role in management of patients with renal impairment. Catheter related blood stream infection (CRBSI) is one of the major complications of intravascular catheters. CRBSI is associated with increased morbidity, mortality and health care cost. The objective of our work was to develop a management protocol for proper diagnosis and treatment of such condition.
Methods: We firstly revised results of all paired blood cultures drawn for suspected CRBSI in 2014 at our center. We then reviewed all major guidelines discussing CRBSI prevention, diagnosis and management in the literature. Finally, we developed this protocol with the cooperation of nephrology, microbiology and clinical pharmacy department.
Results: Paired blood culture results revealed 60% gram negative organisms and 40% gram positive organisms (of which 50% were Methicillin-resistant Staphylococcus aureus “MRSA”). A prevention, diagnosis and management protocol was developed and implemented starting the first of January 2015.
Conclusion: A protocol is needed for proper prevention, management and follow up of patients with CRBSI. Results of blood cultures have to be reviewed periodically to have a comprehensive idea about the organisms and the antibiogram. Implementation and follow up of such a condition with subsequent modification will help to supply good care for these patients and will surely decrease morbidity and mortality of such condition.[INLINE:3]
P-11 Hemoglobin Level is A Determinant of Health Related Quality of Life among Pre End Stage Renal Disease Patients
Samar Abd ElHafeez1, Sunny Sallam1, Zahira Gad1, Hala ElWakil2, Giovanni Tripepi3, Carmine Zoccali3
1Epidemiology Department, High Institute of Public Health, Alexandria University, Egypt, 2Internal Medicine Department, Faculty of Medicine, Alexandria University, Egypt, 3CNR-IBM, Epidemiology and Pathophysiology of Renal diseases and Hypertension of Reggio Calabria, Italy
Introduction: Patients with chronic kidney disease (CKD) endure compromised health-related quality of life (HRQOL). Anemia is prevalent in CKD patients. It is associated with adverse clinical outcomes and negative impacts on HRQOL. This study aims at examining the relationship between hemoglobin (Hb) level and HRQOL among pre end stage renal disease (pre-ESRD) patients
Methods: Cross-sectional study was conducted in Alexandria Main University Hospital among pre-ESRD adult patients. Those with ESRD, history of blood loss or transfusion, or malignancy were excluded. Demographic and clinical data were collected. Proteinuria was detected by dipstick. Glomerular filtration rate was assessed by CKD-EPI equation. Complete blood count, fasting and random blood sugar, serum creatinine were measured. HRQOL was assessed by the translated Arabic version of Kidney Disease Quality of Life- Short Form 1.3 questionnaire. HRQOL data were summarized into physical, mental, and kidney disease composite summaries (PCS, MCS, and KDCS, respectively). The influence of the demographic and clinical variables on HRQOL was explored by univariate and multivariate analyses.
Results: Of 500 patients (52% males, age mean ±SD was 51±14 years) 28.8% were stage 3 and 71.2% were stage 4 CKD, 48.8% were diabetics, 59.4% had hypertension, and 32.6% had cardiovascular diseases. Hb mean ± SD was 11.4±2.3 g/dl. The mean± SD of PCS, MCS, and KDCS were 33.8±9.7, 43.6±7.1, and 60.2±9.03, respectively. ANOVA showed significant improvements in PCS, MCS, and KDCS scores (p<0.001) with increasing Hb from <9 g/dl to >13 g/dl. In a multiple linear regression; Hb remained the only significant correlate for HRQOL. Increasing Hb level by 2g/dl increased PCS by 2.72, MCS by 0.87, and KDCS by 1. In ROC analysis, Hb significantly (p<0.05) discriminated between patients based on HRQOL (AUC= 0.65 for PCS and 0.69 for KDCS)
Conclusion: Higher Hb improves HRQOL. This has implications on the management of CKD patients.
P-12 Assessment of Health-Related Quality of Life in Patients Receiving Regular Hemodialysis
Mahmoud A. Mohamed, Eman E. Elgohary, Yasser A. Nienaa
Nephrology Unit, Internal Medicine, Department, Faculty of Medicine, Alexandria University, Egypt
Background: End-stage renal disease (ESRD) is a non-curable condition imposes a considerable burden on patients and their families. Although advances in hemodialysis (HD) treatment have contributed to improved patients’ survival, they’re still subjected to multiple threats and stressors that may worsen their health-related quality of life (HRQOL). It’s been proven that the patient’s perception is more important than the clinical assessment in determining HRQOL. Culture and values plays a vital role in shaping perception of HRQOL. Lower HRQOL scores were strongly associated with higher morbidity and mortality.
Aim: To assess self-perception of ESRD patients undergoing regular HD of their HRQOL and explore resulted HRQOL scores.
Material & Methods: This cross-sectional descriptive study was carried out at HD unit, Karmouz Hospital, Alexandria, Egypt in September 2015. The study targeted adults with ESRD maintained on regular HD for ≥1year. (Hospitalized, severely ill patients, physically or mentally handicaps were excluded). We used a validated Arabic form of kidney disease quality of life short form (KDQOL SF-36) questionnaire (version 1.3) as a self-report instrument to measure HRQOL. Data were mathematically treated to obtain a “0-100”-ranged score, as higher scores indicate better HRQOL.
Results: We studied 81 HD patients (49males + 32females) aged 50.6±12.7 years, HRQOL scores were poor in all domains and subscales, with mean total score of 47.2±25.2. Unemployed and/or anemic patients had statistically significant reduced HRQOL (P=0.03, P=0.02 respectively). Scores varied according to age, sex, marital status, education level, presence of co-morbidities, dyslipidemia and hypoalbuminemia but without statistical significance. Multiple linear regression analysis for scores demonstrated that working status was the only significant predictor (employed patients’ scores were higher than unemployed ones by 8.648 units, while controlling other predictors (p=0.028).
Conclusion: All domains of HRQOL were reduced in HD patients. Anemia and unemployment adversely affected HRQOL scores.
P-13 Helicobacter Pylori infection does not aggravate Iron Deficiency Anemia in Hemodialysis Patients
Mahmoud Abdelaziz, Zainab Ahmed Ali-Eldin, Aber Halim Baki, Hesham Al-Sayed
Institution: Kafr El-Sheikh General Hospital
Background: Among the disorders that may affect patients with ESRD, anemia is the most responsive to treatment, any reversible cause should be identified, and the most common reversible cause is iron deficiency. We investigate the relation between Helicobacter pylori infection and iron deficiency anemia in hemodialysis population.
Material and Methods: This is a cross sectional study included 90 adult patients with end stage renal disease on maintenance hemodialysis randomly selected from dialysis unit in Kafr El-Sheikh General hospital. Iron deficiency anaemia was determined by hemoglobin, serum iron, ferritin, and transferrin saturation values.Helicobacter pylori diagnosis done by detection of Helicobacter pylori antigen in stool.
Results: It was found that H. pylori stool antigen was positive in 50 patients (55.6%), while 40 patients were negative H. pylori (44.4%). No significant differences were found between Helicobacter pylori positive and negative groups in any of the variables analyzed: hemoglobin (8.96±1.8 vs.9.76±1.4 g/dl), serum iron (86 ± 17.5 vs. 87 ± 18.2 pg. /dl), ferritin (284.8 ± 60.5 vs. 301.4 ± 50.1 ng/dl), transferrin saturation index (26.79 % ± 18.42 % vs. 29.83% ± 18. 01 % ug/dl).
Conclusion: Helicobacter pylori infection has a non-significant effect on iron deficiency anaemia in hemodialysis patients. We recommend that the diagnosis of Helicobacter pylori infection must be reserved for clinical peptic ulcer suspicion.
P-14 Epidemiological study of end stage renal disease(ESRD) patients on maintenance hemodialysis inDakahlia Governorate, Egypt
Nephrology Department, Mansoura International Hospital, Mansoura – Egypt
Background: In Egypt there is no updated official renal registry apart from individual regional studies. The last Egyptian renal registry dates back to 2008 containing 2004 data. This study aimed at investigating some of the epidemiological aspects of ESRD patients on maintenance hemodialysis in Dakahlia Governorate.
Methods: Descriptive cross-sectional study design was used. A questionnaire based survey on hemodialysis patients in Dakahlia Governorate during the year 2014 was undertaken focusing on demographic data, vascular access, hepatitis C status and causes of ESRD. Data were also derived from the relevant national and regional records.
Results: The prevalence of ESRD patients on maintenance hemodialysis in Dakahlia Governorate was estimated to be 3530 patients with a prevalence rate of 619.3 pmp at the end of 2014. According to epidemiological data from 748 patients (21.3%), the mean age was 53±13 years, males 58%, females 42%. The mean duration on dialysis was 48±33 months. The cause of ESRD was unknown in 37%, HTN in 27.8% and DM in 24.6%. Around 87% of the patients started dialysis with a temporary CVC and the prevalence of HCV among dialysis patients was found to be 56%.
Conclusion: The true burden of ESRD/RRT in Dakahlia Governorate and Egypt in general is far from being established. A national registry of ESRD in Egypt is highly recommended & is a crucial issue for accurate healthcare policy planning. Further epidemiological studies are needed to describe the pattern of the disease in Egypt and to improve the overall quality of renal care management.
C-1 Nephrotic syndrome as the Initial Presentation of Polycythemia Vera
Shehab T1,3* and Ismail W2
1Department of Nephrology, Cairo Kidney Center, 2Department of Pathology, Medical School of BaniSuef University, 3Department of Nephrology, El Sahel Teaching Hospital, Egypt
Polycythemia Vera as an entity of myleproliferative neoplasms (MPNs) has infrequent renal involvement which is usually late and rarely recognized. It is characterized clinically by nephrotic range proteinuria and renal insufficiency which was usually diagnosed as FSGS. The histopathological pattern of renal affection is mostly glomerular and is characterized by a combination of mesangial sclerosis, mesangial hypercellularity, segmental sclerosis and features of chronic thrombotic microangiopathy (TMA). Clinical and histological awareness is needed to establish diagnosis and achieving possible reversibility
C-2 Recurrent Hyperparathyroidism after Parathyroidectomy in tertiary Hyperparathyroidism in hemodialysis patient.
Ahmed El Beally, Hanan Mostafa, Mohamed Yassein, Ahmed El Nakeeb, Osama El Shahat
Nephrology Department, Mansoura International Hospital, Mansoura, Egypt
Most patients with chronic renal failure develop secondary hyperparathyroidism. The prevalence of this disease based on bone biopsies is approximately 67%. Only 5% of these patients require parathyroidectomy because most are treated pharmacologically using calcium and vitamin D, either orally or intravenously, with maintenance of adequate calcium levels during dialysis. Recurrent hyperparathyroidism appears in 10–70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation but also depends on the histologic pattern of the glands removed. Case A 51 years old Male patient from el Giza married and has 2 offspring on HD 20 years ago with no special habits of medical importance.Referred from His Dialysis Unit for redo parathyroidectomy operation.The condition started 16 years ago by generalized bone ache and bone deformities. Then Patient had 3 parathyroidectomy operations among this period. 13 April 2002 1st Operation, Removal of only 3 lobes of parathyroid Left lower lobe not removed After 10 years from 1st operation patient complaining of sever bone ache again and bone deformities progressively increased PTH 1180 Pg/Ml. 3 January 2012 2nd Operation, Left lower parathyroid gland is removed. PTH and S.Ca become Normal After Surgery but At MARCH 2014 PTh 2320 pg/ml,Calcium 13.6 mg\dl. TC 99M Show left supra-clavicular ectopic parathyroid gland, This Left supra-clavicular ectopic parathyroid gland is removed. Post op. lab is PTh 310 pg/ml Calcium 9.2 mg\dl. Now PTh 1154 pg/ml Calcium 14.4 mg\dl. Surgeons in our hospital are reluctant from surgery. The patient receive Cinacalcet 60 mg once daily with poor response clinically and laboratory Discussion Shall we proceed for parathyroid scanning by different modalities for possible surgical intervention? Is there any line of medical treatment to avoid surgical intervention?
C-3 Acute T cell-mediated rejection accompanied by c4d negative acute antibody mediated rejection early post kidney transplantation: A case report
Mahmoud Mohamed Khaled, Mohamed Hamed Abbas, Ayman Fathi Refaie
Department of Dialysis and Transplantation, The Urology Nephrology Center, Mansoura University, Egypt
Objectives: Acute rejection, which consists of antibody-mediated rejection (AMR) and T-cell-mediated rejection (ACR), remains a therapeutic target for long-term allograft survival in patients who underwent kidney transplantation. It is important to diagnose AMR, ACR, or both, since therapeutic options vary. With regard to AMR diagnosis, C4d immunoreactivity in peritubular capillaries (PTCs) was previously used as a distinct AMR feature, but its low sensitivity has since been recognized, and ‘C4d-negative AMR’ has replaced the definition in the new version of the Banff classification system 2013.
Case report: We report a case of combined acute T cell mediated rejection with c4d-negative antibody mediated rejection and positive post-transplant donor specific antibodies early post-transplant. A 40 year- old preemptive male patient has received a left iliac renal allo-transplantation from his sister with pre-transplant anti HLA antibodies 0% for both class I and II. At day 2 post-transplant there was significant rise of the serum creatinine. The renal biopsy revealed combined acute T cell-mediated rejection with c4d negative ABMR with ATN and positive donor specific antibodies (DSA). He was managed using a combination of anti thymocyte globulin, immunoglobulin and plasma exchange with full recovery of the kidney functions.
Conclusion: Post-transplant positive donor specific antibodies are of great importance in conjunction with microcirculation inflammation to diagnose c4d negative antibody mediated rejection.
C-4 None diabetic renal disease; a conclusive renal biopsy can overcome diagnosis delay
Mohamed O. Ezwaie1,2, Sahar J. Kharraz1, Rehab M. Tawerghi, Jebril S. Elobidi1, Aisha A. Jazwee1
1Nephrology and hemodialysis division, Benghazi medical center, and 2Department of medicine, faculty of medicine, Benghazi university, Libya
Diabetic patients are at risk of developing renal dysfunction, as part of microvascular complications of diabetes mellitus. But they could develop renal dysfunction, due to non-diabetic renal diseases; as a result of glomerulopathy, either in primary or secondary forms (glomerulonephritis, or vasculitis), or as part of tubulointerstitial involvement due to paraproteinemia. Herein we report two cases of diabetic patients, who had different clinical profiles; in terms of their diabetes type, clinical presentation and decline of renal dysfunction from the of time of diagnosis of diabetes mellitus. A clinical scenario that resulted in a diagnosis and management delay, until a conclusive renal biopsy reported the definitive diagnosis, with implementation of therapeutic protocols, and satisfactory outcomes in both patients.
C-5 Skin biopsy can support the diagnosis of Mixed Cryoglobulinemia in special situation.
Ayman Sabry, Mohammed Abd Al Gawaad, Hamed Ezat, Nevein Nabeh, Ahmed Hamza, Osama El Shahat
Nephrology Department Mansoura International Hospital, Mansoura, Egypt
A 35-year-old female patient presented with painful rash distributed at trunk, upper and lower limbs for one month duration which started by gradual onset and progressive course & associated with fever, decrease urine output, dysuria, myalgia, and productive cough associated with sputum whitish in colour, exacerbating at night. She is known stone passer with history of stone removal of the right kidney. She is DM, HTN and HCV +ve. On examination there was painful ulceration of the tongue, whitish in color. BP 160/90 mmHg. BW 116.5 Kg, BMI 37. There is painful purpuric papule with a raised edge distributed at the trunk and upper and lower limbs and there is ulceration at the back of the leg bluish discoloration of little and 3rd toe of the right lower limb and 3rd toe of left lower limb associated with severe pain, There is pitting edema of both lower limbs extending to the knee, dorsalis pedis artery is not felt on both sides. Abdominal examination revealed splenomegaly and raised purpuric eruption on the skin. Chest exam revealed decrease air entry with stony dullness in both sides of the chest.
Investigations revealed Hb : 6.9 gm/dl, Plt :99,000/cc, S.Cr 6.3 mg/dl with basal 0.7 mg/ dl, blood urea 280 mg/dl, U.A 18, S.Ca 9 mg\dl, S.Po4 6.9 mg\dl, decrease C4, normal level of C3, Rheumatoid factor +ve. Urine analysis : Albumin +, Leucocyte esterase present+++, WBC 120 -140, 24 hour urine collection Volume 800 cc and Total protein : 3654 mg, HCV RNA-PCR Quantitative 423.056. Abd US on Rt kidney shows mild back pressure and a lower calyceal stone about 12.5 mm, left kidneywas normal. Right and left lower limbs color Duplex was done and revealed Weak flow is seen in the right lower part of anterior tibial artery. Provisional Diagnosis was vasculitis. Renal biopsy was difficult to do due to obesity. Skin biopsy was done and revealed leukocytoclastic vasculitis associated with cryoglobulinemia. The diagnosis was Mixed Cryoglobulinemia.The patient received 2 haemodialysis sessions due to uremic symptoms, four plasmapheresis sessions, prednisolone, cyclophosphamide with good response and Planning for treatment of hepatitis C.
C-6 AKI in a pregnant woman
Mohamed Yassein, Tamer Adel, Ahmed Mousa, Ahmed Mahmoud, Osama El Shahat
Nephrology Department, Mansoura International Hospital, Mansoura, Egypt
A 34 year old female patient, married 4 years ago, with 3 offspring, the youngest is 6 days, previous two uncomplicated pregnancies, suffered from headache of rapid onset which started at 36th week of gestation when she accidently discovered HTN which was difficult to control. She became distressed, overloaded, urgent Caesarean Section was done. On the next day the patient developed fever, chills, nausea and vomiting,her creatinine was 8 mg/dl, TLC 24000,Hb 7 g/dl, INR=1.3, K=5.8 mmol/l, T.Bil=0.7 mg/dl, ALT=225, AST=925,Abd U/S shows mild enlarged coarse liver. Obstetrician Consultation was done and no intrauterine remnants were found. UOP was 1000 ml/24 hours. Echocardiography revealed a mass in the main pulmonary artery with MPAP=46 mmHg. She received LMWH + warfarin and a potent antibiotic was added. The patient improved and UOP increased to 5000 ml/24hour, creatinine 3.2 mg/dl, ALT&AST returned to normal but D dimer was high 3600. New echo became free and creatinine decreased to 1.7 mg/dl, and TLC returned to normal with resolution of symptoms and the patient was discharged and was advised to follow up in the outpatient clinic.