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An evidence-based protocol for a comprehensive assessment of living kidney donors: individualizing the long-term risk of living kidney donation
Brian Camilleri, Bridson M Julie, Ajay Sharma, Ahmed Halawa
October-December 2016, 16(4):109-118
Kidney transplantation is the treatment of choice for patients with end-stage renal failure. Living kidney donation has increased over the past few years and now accounts for 34% of the total kidney transplant programme in the UK. Reasons for the increase in living kidney donation include shortage of deceased donor organs and the possibility to perform pre-emptive kidney transplantation and antibody-incompatible transplantation. In addition, some prefer living kidney donation as this option is associated with better patient and graft survival. However, although kidney donation is considered safe in low-risk individuals, it is important to remember that the donor will have to undergo major surgery and lead a life with a solitary kidney with associated lifelong implications including reduction in renal function. Despite various national guidelines, several studies have shown significant variation in acceptance criteria among centres. This mirrors the controversies as to whether donors with certain characteristics can be accepted for donation. This is particularly important given recent publications regarding the long-term risks associated with donor nephrectomy. In view of this, it is essential that prospective living kidney donors are fully informed of the risks associated with donor nephrectomy. This ensures that the process of living kidney donation is underpinned by informed consent that is freely given to ensure donor autonomy is safeguarded. In this review, we discuss the short-term and long-term risks associated with donor nephrectomy with a view to proposing a protocol to help individualize the assessment of the potential living kidney donor.
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Diabetic kidney disease: difference in the prevalence and risk factors worldwide
Osama Gheith, Nashwa Othman, Naryanan Nampoory, Medhat A Halimb, Torki Al-Otaibi
July-September 2016, 16(3):65-72
Diabetic nephropathy, which is defined as elevated urine albumin excretion or reduced glomerular filtration rate or both, is a serious complication that occurs in 20–40% of all diabetic patients. In this review, we try to highlight the prevalence of diabetic nephropathy, which is not an uncommon complication of diabetes all over the world. The prevalence of diabetes worldwide has extended epidemic magnitudes and is expected to affect more than 350 million people by the year 2035. There is marked racial/ethnic difference besides international difference in the epidemiology of diabetic nephropathy, which could be attributed to the differences in economic viability and governmental infrastructures. Approximately one-third of diabetic patients showed microalbuminuria after 15 years of disease duration and less than half develop real nephropathy. Diabetic nephropathy is more frequent in African-Americans, Asian-Americans, and Native Americans. Progressive kidney disease is more frequent in Caucasian patients with type 1 than in those with type 2 diabetes mellitus (DM), although its overall prevalence in the diabetic population is higher in patients with type 2 DM because this type of DM is more prevalent. Hyperglycemia is a well-known risk factor for diabetic kidney disease, in addition to other risk factors such as male sex, obesity, hypertension, chronic inflammation, resistance to insulin, hypovitaminosis D, dyslipidemia, and some genetic loci and polymorphisms in specific genes. Diabetic nephropathy is not an uncommon complication of diabetes (type 1 and 2) all over the world and in geriatric population. Management of its modifiable risk factors might help in reducing its incidence in the nearby future.
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Spectrum of renal diseases among patients admitted to the internal medicine unit through the emergency room and their outcomes: morbidity, mortality, and cost analysis
Salwa Ibrahim, Ahmed Fayed, Dawlet Belal
January-March 2016, 16(1):16-20
Renal disease is a common health problem that is linked to excessive morbidity and mortality worldwide. It is crucial to know the etiology and clinical features of renal diseases to promote prevention strategies and adequate management resources. This study aimed to perform a comprehensive review the spectrum of renal diseases among patients admitted to one internal medicine unit (unit 6) through the emergency room. We evaluated total admission cases to the unit 6 through the emergency room in 1 year between July 2010 and July 2011. The total capacity of the unit is 24 beds. The total number of patients admitted during the study period was 571. Their mean age was 50.72 ΁ 14.15 years (range 14-95 years). A total of 51.66% were males and 48.44% were females. The average duration of hospital stay was 6.43 ΁ 3.57 days (range 1-30 days). There were 200 patients with renal diseases (35.02%). Their mean age was 46.73 ΁ 15.76 years (range 16-87 years). In all, 55% were females and 45% were males, and the average duration of hospital stay was 7.59 ΁ 3.89 days (range 1-23 days). In all, 33% of patients had acute kidney injury represented, 51.5% had chronic kidney disease, 7.5% had glomerular diseases (nephrotic and nephritic syndromes), and 8% had obstructive uropathy. Fifteen patients died during their hospital stay (7.5%); their average age was 49.87 ΁ 11.42 years (range 28-65 years). There were four statistically significant mortality predictors among patients with kidney diseases (total leukocyte count above 19.55 cm 2 , serum potassium above 5.74 mEq/l, atrial fibrillation, and hypertension). The total cost of services provided for patients was 275 624 L.E. The total cost of services provided for patients with kidney diseases was 118 919.25 L.E. (43.15%).
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Urinary level of vitamin D-binding protein as a new biomarker for diabetic nephropathy
Samy A Khodeir, Nesin M Kotb, Kamal M Okasha, Kamal A Ahmed, Hala M Nagy
January-March 2016, 16(1):32-38
Diabetes is now the major cause of end-stage kidney failure, both in developing and developed nations. It is the primary diagnosis causing kidney diseases in 20-40% of patients starting treatment for end-stage renal diseases worldwide. The aim of the study was to evaluate the urinary level of vitamin D-binding protein (UVDBP) as a new biomarker for diabetic nephropathy (DN). Urine samples were obtained from 45 patients with type 2 diabetes mellitus and were classified into three groups (normoalbuminuric, microalbuminuric, and macroalbuminuric). Fifteen healthy participants served as the control group. The excretion levels of UVDBP were quantified with enzyme-linked immunosorbent assay. The results showed that UVDBP levels were significantly elevated in patients of the DN3 and DN4 groups compared with those of the DN2 group and normal controls. In conclusion, the current study demonstrated that UVDBP levels were significantly elevated in patients with DN. Moreover, a strong positive correlation was observed between the expression level of UVDBP and the development of DN. Thus, the findings indicate that UVDBP levels are a potential biomarker for the early detection of DN.
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The surgical aspect of renal hyperparathyroidism: a summary of the guidelines
Ahmed Halawa
January-March 2016, 16(1):1-2
Renal hyperparathyroidism is a common disease affecting the vast majority of chronic kidney disease (CKD) patients. With effective medical treatment, only 5-10% of CKD patients require surgical treatment. The medical treatment includes a wide variety of medications to replace the inactive vitamin D, suppress the hyperactive parathyroid glands and also to counteract the hyperphosphatemia. Based on publications from Egypt, the financial difficulties the CKD patients are suffering from does not allow the delivery of successful medical treatment. This is mainly due to the inability to use an effective and more expensive phosphate binder and active vitamin D (1). Also, calcimimetic therapy (e.g cinacalcet) is unaffordable and needs life-long administration. This has led to an increased prevalence of the florid disease compared to developed countries (2). The situation was made worse by the lack of understanding of the principles of diagnosis and surgical treatment of renal hyperparathyroidism among many clinicians. Surgeons rely mainly on imaging in the localization of the hyperplastic glands, which is well known to be not sensitive enough in this multi-gland disease (3). This often led to inadequate surgical management of this disease. Also, the multicentric nature of this condition (multi-gland, rather than a single-gland disease) is often undermined. The published reports from Egypt showed only a few centres dealing with this disease; however the number of patients reported is quite small with variable outcomes (4). The reported outcome demonstrates that more patients require surgery for the poorly controlled hyperparathyroidism that unmasks the lack of appropriate surgical experience in many district areas of Egypt.
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A woman with recurrent hematuria: a diagnostic challenge in Egypt
Mona Abdelrahim, Ayman Maher Nagib, Mahmoud Mohamed Khaled, Ehab Wafa, Ahmed Farouk Donia
January-March 2016, 16(1):44-47
Objectives Thin basement membrane disease (TBMD) or benign familial hematuria is common in women. The median age is 37 years among adults. About two-third of the patients with TBMD have at least one other hematuric family member when five relatives are tested. Case report We hereby present a case of adult TBMD to clarify the clinicopathological characteristics of the disease in 56-year-old woman with long-standing intermittent dark colored urine with proteinuria, normal serum creatinine, and with normal blood pressure. Renal pathology showed normal renal tissue by using the light and immunofluorescence examination. Thinning of the glomerular basement membrane, ranging from 110 to 200 nm, was demonstrated by using electron microscopy. Conclusion Although it is part of routine nephropathology worldwide, electron microscopic examination of renal biopsies are rarely used in Egypt. This important diagnostic pillar should be more frequently used among our patients, especially when clinicopathologic diagnosis is unclear.
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Study of patients with nephrotic syndrome in Sohag University Hospital
Ali Taha A Hassan, Amal Khalifa A Noreldin, Mahmoud I El Badry
January-March 2016, 16(1):21-31
Background Nephrotic syndrome is not a disease; it is the manifestation of a wide variety of underlying disease processes. Objectives The aim of the present study was to investigate different clinic-laboratory and histological patterns of nephrotic syndrome and the relationship between its clinical character and prognosis. Methods From January 2010 to December 2011 the authors of the present study retrospectively and prospectively studied 139 patients with nephrotic syndrome, diagnosed on the basis of heavy proteinuria greater than 3 g/day, hypoalbuminemia, evidence of fluid retention or edema, and hyperlipidemia. Results A total of 139 patients (M : F = 79 : 60) were included in the present study; their mean age was 33.9 ± 13.47 years (primary : secondary nephrotic syndrome = 80 : 59). Systemic lupus erythematosus was the most common underlying cause of secondary nephrotic syndrome [24 cases (40.7%)], followed by DM [13 cases (23.7%)]. Renal biopsy revealed 18 patients (30.5%) with membranoproliferative glomerulonephritis, 15 (25.43%) with membranous nephropathy, seven (11.86%) with mesangial proliferative glomerulonephritis, six (10.16%) with amyloidosis, five (8.47%) with focal segmental glomerulosclerosis, three (5.08%) with diffuse proliferative glomerulonephritis, one (1.69%) with focal proliferative, minimal mesangial, sclerosing glomerulonephritides, one patient (1.69%) with crescent glomerulonephritis, and another one (1.69%) with IgA nephropathy. A raised serum creatinine level was found in 49 (35%) patients, and 35 (74.4%) of them had normal renal function at the last follow-up. Complete remission of proteinuria occurred in 69 (49.6%) patients, partial remission in 53 (38.1%), and resistant proteinuria in 17 (12.2%). Conclusion Clinical features and biochemical values do not give many clues about the underlying histological types of glomerulonephritis. Therefore, renal biopsy should be carried out in all patients with adult nephrotic syndrome, as results permit us to establish a specific diagnosis, which helps in counseling the patients about the likely prognosis of their disease and to select a specific therapeutic regimen.
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Effect of moderate aerobic exercises on kidney function and lipid profile in chronic kidney disease patients
Awney F Rahmy, Walid M Afifi, Adel A.M. Ghorab, Hatim A Mostafa
July-September 2016, 16(3):97-105
Background Chronic kidney disease (CKD) is an important risk factor for cardiovascular diseases and mortality. Physical inactivity is a modifiable risk factor that may affect the development and course of CKD. It is well established that exercise improves a number of metabolic factors, as well as blood pressure and insulin resistance, which would be expected to preserve renal function and lower cardiovascular risks. Aim of the study The aim of this study was to investigate the effect of treadmill walking exercise (moderate aerobic exercise) on kidney function tests and lipid profile in patients with CKD stages 3 and 4. Patients and methods Fifty patients with CKD stages 3 and 4 participated in the study. They were selected from the outpatient clinic of Nephrology Department, Zagazig University Hospitals (during the period from January 2015 to June 2015). Their ages ranged from 45 to 55 years. They were divided into two groups: the study group (group B), which included 30 patients who received moderate aerobic exercises on treadmill three times per week for 3 months plus their medications, and the control group (group A), which comprised 20 patients who received their medications only with no training exercises. Urine and blood samples were collected for determining glomerular filtration rate (GFR), serum blood urea, serum creatinine, and serum lipid profile before the initiation of the training program and after the completion of the study (after 3 months). Results There was a statistically highly significant decrease in creatinine, blood urea, triglyceride (TG), cholesterol, and low-density lipoprotein (LDL), and an increase in GFR and high-density lipoprotein (HDL) (P<0.001) in group B after treatment compared with the pretreatment values with the following percent of improvement: creatinine −11.5%, blood urea −7.9%, TG −10.5%, cholesterol −13.1%, LDL −11.9%, GFR +17.4%, and HDL +12.6%. However, there were no significant differences between pretreatment and post-treatment values of creatinine, blood urea, or GFR in group A. There was a significant decrease in TG, cholesterol, and LDL, and a significant increase in HDL in group A after 3 months, with the following percent of improvement: TG −2.9%, cholesterol −3.4%, LDL −5.6%, and HDL +6.7%. There was a statistically significant difference in the post-treatment values of all parameters between the two groups. Conclusion It can be concluded that moderate aerobic exercises improve kidney function tests and lipid profile and can delay progression of CKD stages 3 and 4.
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Scientific Abstracts

April-June 2016, 16(2):51-63
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Vascular endothelial growth factor and insulin growth factor as an underlying paracrine action of mesenchymal stem cells transfused for the regeneration of stage II and III chronic kidney disease
Gamal Saadi, Mervat El Ansary, May A Hassaballa, Mona Roshdy, Eman A El-Aziz, Irene Bishai, Samah Mohamed, Mahmoud El Gaafary, Mahmoud Zidan
January-March 2016, 16(1):3-9
Mesenchymal stem cells (MSCs) are a group of multipotent cells found in cord blood, adipose tissue, bone marrow, and the stroma of various organs with a great potential for mesoderm-like cell differentiation. The aim of the present work was to study the paracrine effect of MSC transfusion in stage II and III chronic kidney disease, which is measured through the level of insulin growth factor-1 and vascular endothelial growth factor. Human bone marrow MSCs were isolated, expanded, and harvested after an average of 21-30 days not only morphologically, when the cells presented as a uniform spindle fibroblast and reached 70-80% confluence with a good cellular yield, but also through their immunophenotypic analysis, which showed positivity for CD29 and negativity for CD34. They were reinjected intravenously in 10 renal patients. To study the effect of such manipulation on the kidney, creatinine and creatinine clearance were measured at the day of injection (baseline), and the first and third month following injection. In addition, other modulators were measured during the first week of injection (day 0, 2, and 7) using enzyme-linked immunosorbent assay. To illustrate, for the first 3 months the creatinine and creatinine clearance reflected a significant renal improvement with an overall decrease of 14% and an increase of 23%, respectively. Although the third month's results may appear worse off than the first month's, they still were better than the baseline before transfusion. Therefore, such an improvement may be attributed to the growth factors released by the MSCs. In other words, both the vascular endothelial growth factor and insulin growth factor-1 showed an overall rise of 3 and 53%, respectively, in their level during the first week after transfusion. Therefore, MSCs transfused to the patients lead to the rise in such modulators, which in turn caused a significant improvement in renal functions. In conclusion, these findings may provide a novel therapy of regenerative medicine especially for chronic kidney disease where dialysis and renal transplantation are inevitable.
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Serum levels of soluble receptor for advanced glycation end product in type 2 diabetic patients: possible association with urinary albumin excretion
Kamal M Okasha, Samy A Khodeir, Shaza A Madkour, Heba A Mourad
January-March 2016, 16(1):10-15
Diabetes is now the major cause of end-stage renal failure worldwide, both in developing and in developed nations. Hyperglycemia is still considered the principal cause of complications of diabetes because of the formation of sugar-derived substances called advanced glycation end products. The formation of advanced glycation end product is markedly accelerated in diabetes because of the increased availability of glucose. The receptor for advanced glycation end products (RAGE) has been shown to be involved in the pathogenesis of diabetic complications. The aim of this work was to assess the possible association between soluble receptor for advanced glycation end products (sRAGE) and urinary albumin excretion in type 2 diabetic patients as an early predictor of microvascular complications such as diabetic nephropathy. The present study was carried on 70 individuals: 10 healthy individuals as control, 20 diabetic patients with normoalbuminuria, 20 diabetic patients with microalbuminuria, and 20 diabetic patients with macroalbuminuria. All participants were subjected to estimation of sRAGE by the sandwich enzyme-linked immunosorbent assay technique together with routine laboratory investigations. The results of this study showed that all diabetic patients had a low level of serum RAGE compared with the control group. Furthermore, a characteristic trend was observed whereas three groups of diabetic patients showed a decrease in RAGE in parallel with the severity of renal involvement. From this point of view, stimulation of sRAGE production should be considered a potential therapeutic target in diabetic patients.
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Diabetic nephropathy among diabetic patients attending El Mahalla General Hospital
Mostafa M Elnajjar, Alaa El Dien Dawood, Mahmud Abu Salem, Zeinab A Kasemy, Ola T Nohman
January-March 2016, 16(1):39-43
Objective The aim of this study was to study the prevalence of diabetic nephropathy (DN) and the related risk factors among diabetic patients attending El Mahalla General Hospital. Background DN is the leading cause of chronic kidney disease and end-stage renal disease in developing countries. Early detection and risk-reduction measures can prevent DN. In Egypt, the prevalence of DN as a cause of end-stage renal disease increased from 8.9% of patients in 1996 to 14.5% in 2002. Studies in patients who have or do not have clinically evident DN have identified a number of factors to be associated with an increased risk of renal involvement. Participants and methods This study was carried out on 100 diabetic patients who attended El Mahalla. All the participants studied were subjected to a full assessment of history, a general clinical examination, and laboratory investigations including determination of glycated hemoglobin (HbA1c), serum creatinine, estimated glomerular filtration rate, and the urinary albumin to creatinine ratio. Results The results showed that 78% of all the patients studied had DN. There were statistically significant relationships between nephrogenic diabetes and duration of diabetes (P = 0.008), higher systemic blood pressures (P = 0.003), an evident decrease in the glomerular filtration rate through the course of disease (P = 0.038), poor glycemic control (P = 0.036), obesity (P = 0.002), and a family history of diabetes (P = 0.006). There were no statistically significant relationships between nephrogenic diabetes and age, sex of the patient, use of oral contraceptive pills, and smoking. Conclusion Screening for microalbuminuria will enable early identification of patients with DN. Duration of diabetes mellitus and hypertension were strong predictors associated with the development of DN in the patients studied.
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Infectious Diseases in Renal Transplantation; Summary of Guidelines
Jesmar Buttigieg, Mohsen El Kossi, Ahmed Halawa
July-September 2017, 17(3):75-104
  218 141 -
Case-based review of cross-match techniques in kidney transplantation
Obadiah Moyo, Ajay K Sharma, Ahmed Halawa
October-December 2017, 17(4):107-114
To avoid renal allograft rejection and loss, human leucocyte antigen compatibility and lymphocytotoxic cross-matching of renal donors against prospective renal allograft recipients are obligatory and fundamental steps in pretransplant evaluation. The complement-dependent cytotoxicity assay has been the mainstay technique for ascertaining the presence of donor-specific antibodies since the 1970s. Improvement in the performance of cross-matching has seen the introduction of more sensitive and specific techniques such as flow cytometry, and highly sensitive enzyme-linked immunosorbent assay, Luminex platforms and virtual cross-match. This review article is an in-depth comparison of the advantages and disadvantages of each of the cross-match techniques. We demonstrate the application of these techniques through a clinical case scenario. A step-by-step analysis and interpretation of cross-match modalities of varying levels of sensitivity and specificity is needed to arrive at a pragmatic decision, which will lead to better transplantation outcome. In some patients with immunologically complex issues, a spectrum of cross-match techniques may be required for a safe outcome of transplant.
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Outcome of lupus nephritis after live-donor renal transplantation: single-center experience
Mohamed A Zahab, Yasser A Elhendy, Amir M Elokely, Mohammed A Fouda, Ayman F Refaie, Ayman M Nagib, Mona Abdulrahim, Mohamed Ghoneim
July-September 2016, 16(3):73-78
Aim/Objectives/Background Systemic Lupus Erythematosis (SLE) is a systemic autoimmune disease affects multiple organs with clinically heterogeneous outcomes. Lupus Nephritis (LN) is a common complication of systemic lupus erythematosus, and it occurs in 31–65% of SLE patients. kidney transplantation is the best long-term option for patients with End Stage renal Disease. The aim of this work is then to assess the patient and graft outcome for those who reached end stage renal disease and received kidney transplantation at urology and nephrology center, mansoura university. Subjects and Methods The material of this section include 23 kidney transplant recipients due to lupus nephritis. A 46 matched kidney transplant patients who were diagnosed as end stage renal disease due to other causes will serve as control group. Results and Conclusions Results of the study showed no difference in patient and graft outcome between kidney transplant recipients due to lupus nephritis and kidney transplant recipients due to other causes. The risk of recurrence of lupus nephritis in the graft is very low if compared with FSGS or MPGN. We concluded that kidney transplantation for lupus patients is safe and carries no risk for lower patient or graft survival. The risk of recurrence is much lower if compared with other glomerular diseases.
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Levels of serum vaspin and tumor necrosis factor-α in patients with type 2 diabetes mellitus in relation to kidney function and glycemic control
Effat A.E. Tony, Tahia H Saleem, Madeha M Zakhary, Nagwa S Ahmed, Samar M Kamel
October-December 2016, 16(4):131-143
Background Diabetes mellitus type 2 (T2DM) is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. Vaspin (visceral adipose tissue-derived serpin) is a member of the broadly distributed serpin (a protein superfamily of serine protease inhibitors of ∼500 genes) and is identical to serpin A12. The upregulation of vaspin can improve insulin resistance. Thus, identification of the protease inhibited by vaspin may lead to the development of novel strategies in the treatment of diabetes and insulin resistance. In patients with chronic kidney disease, the levels of vaspin appear to increase mostly because of reduced renal metabolism of vaspin. Tumor necrosis factor-α (TNF-α) is a cytokine involved in systemic inflammation. Its increased production has been observed in adipose tissue, and it has been implicated as a causative factor in obesity-associated insulin resistance, the pathogenesis of T2DM, and the development of diabetic nephropathy (DN) through several mechanisms. The association of T2DM patients (with and without impaired renal function) with serum vaspin and TNF-α levels is not clearly understood. This study aimed to evaluate the levels of vaspin and tumor necrosis factor (TNF) in T2DM patients and compare their levels with impairment in renal function in T2DM to determine whether circulating vaspin and TNF could be a biomarker of DN. Patients and methods This case–control observational prospective study was conducted on 73 patients with T2DM classified into two groups; group I included 20 T2DM patients with reduced renal function, and group II included 53 T2DM patients with normal renal function. The studied groups were recruited from the Diabetic Unit Outpatient Clinic, Department of Internal Medicine, Sohag University Hospitals, from December 2014 to December 2015. T2DM was diagnosed according to the American Diabetes Association Criteria. Totally, 12 age and sex matched apparently healthy individuals who served as the control group (group III) were enrolled in the study. The study was approved by the ethical committee of Faculty of Medicine, Sohag University, and written informed consent was obtained from each participant. All participants were subjected to thorough history taking, full clinical examination, and anthropometric measurements, including weight, height, and BMI. In addition, peripheral hemogram, random blood glucose evaluation, HbA1c determination, liver function tests, kidney function tests, lipid profile, and serum vaspin and serum TNF-α evaluation were carried out. Results In essence, significant correlations of vaspin and TNF were found with age of T2DM patients, hypertension, BMI, and lipid profile, but not with HbA1c. Moreover, higher levels of vaspin and TNF-α were significantly correlated with the degree of impaired renal function in T2DM patients. Notably, multivariate linear regression shows that BMI and age are negatively correlated with vaspin but not with TNF-α levels in T2DM patient with more impaired renal function. Conclusion Strict monitoring of T2DM can reduce the morbidity and mortality rate and will also improve the quality of life of diabetic patients. The association of renal insufficiency due to diabetes mellitus with serum vaspin and TNF-α levels is not clearly understood. However, vaspin may be beneficial as a positive biomarker for T2DM patients with impaired renal function and can be considered as a new prognostic marker for DN. Large studies are required to establish vaspin and TNF-α efficacy and safety in T2DM.
  234 54 -
Corticosteroid in kidney transplant immunotherapy: rid off the giant
Rotimi Oluyombo, Bridson M Julie, Ajay Sharma, Ahmed Halawa
April-June 2017, 17(2):43-51
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.
  215 61 -
Training the trainers, walking in a minefield
Ahmed Halawa
April-June 2016, 16(2):49-50
Introduction Hands-on training is always challenging especially when you deal with mature clinicians who are well established in their career. They may have difficulties in accepting new techniques and different approaches compared to doctors in training. Aims and objectives I’m presenting my personal experience in training general surgeons in Egypt; a journey started many years ago. Results With high-quality qualitative feedback, I managed to spread evidence-based practice in Egypt. raining the trainer concept has become widely accepted among many clinicians.
  204 61 -
Hemodialysis mining and patients intelligent clustering technologies
Mohammed El-Rashedy, Ahmed Akl
October-December 2016, 16(4):124-130
Background: Medical information systems collect vast amount of monitored clinical data. Interpreting the portions of the data that are relevant to the identification of a specific clinical problem can become a hard task. Data mining are largely used in a very wide range of applications. Data mining mainly depends on mathematical algorithms and analytical skills to drive the desired results from the huge database sets and/or collections. Clustering is one of the most important data mining techniques. Most of the earlier work on clustering has focused on numerical relationships between the values of the attributes, and ignored the inherent meaning of the values. Aim: In this work, an enhancement is added to the k-means algorithm for clustering data. Material & Methods: Furthermore, modification of the difference values between the attributes was done. The proposed clustering technique has been used to improve the quality, efficiency of health services and decision making in hemodialysis centers. Long experimentations and heavy tests were done on a variety of clustered different attributes for hemodialysis patient information systems. Results: The results showed that, our enhancement on the k-means algorithm has realized a better maximum distance and separate values for each cluster lower than the traditional k-means algorithm. Conclusion: The decision making for the session period and blood rate has been improved and made more accurate. This provides the robust and best dialysis adequacy for the specific patient case.
  173 77 -
Interleukin-10 gene polymorphism and graft outcome in live-donor kidney transplantation
Rashad Hassan Rashad, Khaled Mohamed Mahmoud, Tarek Medhat Abbas Abdel Hady, Amgad El-Baz El-Agroudy, Ahmed Farouk Hamdy, Amani Mostafa Ismail, Nagy Abd-El Hady Sayed, Mohamed Abd El-Kader Sobh
July-September 2016, 16(3):89-96
Background Polymorphism has been described in many immunoregulatory molecules that play a role in the rejection process. It has offered a possible explanation for the individual difference in rejection susceptibility and renal graft survival independent of other risk factors. The aim of this work was to study the impact of the interleukin-10 (IL-10) cytokine gene polymorphism on the clinical course and outcome of a renal transplant. Materials and methods This work included 50 transplant recipients treated with a sirolimus-based immunosuppressive regimen for IL-10 cytokine gene polymorphisms. After transplantation, patients were classified into two groups: in group A, patients (12 patients) received sirolimus, tacrolimus, and steroid and in group B, patients (38 patients) received sirolimus, mycophenolate mofetil, and steroid. The results were correlated with rejections (acute and chronic) and patient and graft survival. Results In our study, we found no impact of IL-10 on the incidence and degree of acute rejection episodes, incidence of chronic allograft nephropathy, pathological changes in protocol biopsies, graft function, and graft and patient survivals. Conclusion On the basis of this work, we concluded that there is no impact of IL-10 cytokine gene polymorphisms on the clinical course and outcome of a renal transplant. Genes other than IL-10 could probably be involved as key molecules in graft function.
  167 52 -
Use of proton-pump inhibitors and risk of kidney failure: an alarming sign!
Uday V Mateti
January-March 2017, 17(1):42-42
  165 51 -
Correlations of serum magnesium with dyslipidemia in patients on maintenance hemodialysis
Effat A.E. Tony, Mohammed A Tohamy, Nabila F Amin, Amal M Abdel-Aal, Sanaa Abdel Rahim
January-March 2017, 17(1):8-29
Background Chronic renal failure (CRF) is defined as a slowly progressive loss of kidney functions resulting in permanent kidney failure. Patients with chronic kidney disease (CKD) are at increased risk not only for end-stage kidney disease but also for cardiovascular (CV) disease. CKD is characterized by specific metabolic abnormalities of plasma lipoproteins (LPs). These abnormalities involve all LP classes and show variations depending on the degree of renal impairment, the etiology of the primary disease, the presence of nephrotic syndrome (NS), and the method of dialysis for patients undergoing renal replacement therapy. High LP-a indicates a coagulant risk for plaque thrombosis. Thus, it predicts risk for early atherosclerosis independently of other cardiac risk factors, including low-density lipoprotein (LDL), in patients with CKD. Dyslipidemia in CKD is associated with increased thickness and stiffness of the large arteries. Thus, strict control of dyslipidemia would be beneficial in preventing CVD, at least during the early stages of CKD. The kidney has a vital role in magnesium (Mg) homeostasis, and, although renal handling of Mg is highly adaptable, this ability deteriorates when renal function declines significantly. Mg homeostasis in humans primarily depends on the balance between intestinal uptake and renal excretion. Mg may be normal or decreased in dialysis patients, which is probably due to decreased dietary intake combined with impaired intestinal absorption. In patients on chronic hemodialysis (HD), the major determinant of Mg balance is concentration of Mg in the dialysate. Thus, in patients with CKD, there may be reduced intake, impaired absorption from the intestine, use of diuretics, and acidosis, which may result in decreased serum Mg, whereas reduced renal excretion may cause accumulation of Mg, resulting in increased serum Mg levels in CRF patients. This prospective study aimed to determine the correlation of serum Mg with dyslipidemia in patients on maintenance HD. Patients and methods This case–control observational prospective study was conducted on 37 end-stage renal failure patients on maintenance HD (age range: 20–70 years; mean age: 47.8±13.9 years; 16 men and 21 women) who were recruited from the Renal and Dialysis Unit, Department of Internal Medicine, Assuit University Hospitals, Egypt, from 2010 to 2012. In addition, 25 apparently healthy persons (age range: 17–70 years; mean age: 42.0±13.25 years; 13 male and 12 female) recruited mainly from among the medical staff and their families who underwent a health examination at Assuit University Hospitals were enrolled in the study as a control group. The study was approved by the ethical committee of the Faculty of Medicine, Assuit University, and written informed consent was obtained from each participant. The underlying causes of CRF were chronic glomerulonephritis, diabetes mellitus, chronic pyelonephritis, obstructive uropathy, analgesic and idiopathic nephropathy, polycystic kidney disease, and lupus nephritis. The duration of HD ranged from 5 to 15 years, with a mean duration of 7.0±2.9 years. The frequency of HD was three sessions per week. The type of dialyzer membrane was polysulfone with bicarbonate dialysate and the dialysate flow rate was 500 ml/min. Blood flow ranged from 250 to 300 ml/min. The Mg concentration in the dialysate fluid was 1 mEq/l. Dialysis adequacy was assessed by measuring urea kinetic modeling (mean urea kinetic modeling: 2.38±0.44). Glomerular filtration rate was estimated by the modified MDRD equation. Patients were excluded if they had been taking diuretics and/or lipid-lowering agents or had acute or chronic infections. All participants were subjected to thorough history taking, full clinical examination, and anthropometric measurements including weight, height, and BMI. Blood samples from both patients and controls were drawn in the morning after an overnight fast of 12–16 h. Peripheral hemogram, liver function, kidney function, lipid profile, LP-a, and serum electrolytes such as Ca, phosphorus (P), and Mg were assessed. An ECG was obtained with measurement of the corrected QT interval (QTc). Transthoracic echocardiography (ECHO) was performed in all studied groups on an interdialytic day in the evaluation phase. M-mode and two-dimensional images as well as spectral pulsed and color flow Doppler recordings were obtained. Results Significant renal dysfunction and lower levels of hemoglobin and platelets with higher mean corpuscular volume (MCV) and mean cell hemoglobin concentration (MCHC) with no statistical difference in the mean level of white blood cells (WBCs) were reported in our studied patients in comparison with controls. Notably, highly statistically significantly lower levels of high-density lipoprotein-cholestrol (HDL-C) with significantly lower levels of LDL-cholesterol (LDL-C) were seen in our HD patients. However, the mean levels of triglycerides (TG) and LP-a were statistically significantly higher, with no statistically significant differences in total cholesterol (TC) levels in the studied patients. The levels of P and Mg were highly statistically significantly higher, with lower Ca levels of no statistical difference, in HD patients. There were no statistically significant differences in the main levels of serum Mg among the studied patients. Lipid metabolism disturbances are frequently present in patients with CRF, representing an important factor in premature atherosclerosis development. The majority of patients with no ST-segment changes had more Mg retention and LP-a retention but with no statistical significance. Nonetheless, none of our patients had prolonged QTc interval in ECG, despite having more Mg retention and LP-a retention with no statistical significance. Left ventricular hypertrophy (LVH) was a striking finding in our patients who had more serum Mg retention and LP-a retention but with no statistical significance. A significant positive correlation between serum Mg level and ST-segment changes in ECG and a significant negative correlation between serum LP-a level and ST-segment changes in ECG were found in our studied patients. Moreover, there were positive correlations of serum Mg levels and LP-a levels with LVH in ECG and ECHO findings in our patients, with no statistical significance. The prolonged QTc interval in ECG had a significant positive correlation with the LP-a levels and a nonsignificant positive correlation with serum Mg level. A significant positive correlation of age with TC, TG, and HDL and a nonsignificant negative correlation with LDL were found in our studied patients. However, there were significant negative correlations of the duration of CKD with TC, TG, and LDL and a negative correlation with HDL in our studied patients, with no statistical significance. Nonsignificant negative correlations of BMI with LDL and HDL and significant negative correlations with TC and TG were found in our studied patients. Notably, there was a negative correlation of lipid profile with serum creatinine and blood urea. Nonsignificant negative correlations of serum calcium (Ca) and serum P with LDL were observed, whereas there were nonsignificant positive correlations of serum Ca with TC and TG and negative correlations of serum P with TC and TG, with no statistical significance. The HDL had a significant positive correlation with serum Ca and a significant negative correlation HDL was found in our studied patients, there was a significant negative correlation between HDL and serum phosphorus, however, serum Ca was positively correlated with HDL but with no statistical significance, but a significant positive correlation between LP-a level and MCHC. There were negative correlations between Mg level and hemoglobin, WBCs, and MCV, with no statistical significance, in our patients and significant negative correlations between Mg level and MCHC and platelets. In the current study, there were nonsignificant positive correlations between LP-a level and blood urea and a nonsignificant negative correlation with serum creatinine. Positive correlations of Mg level with blood urea and serum creatinine were found in the study. Notably, serum Mg was statistically significantly positively correlated with LP-a, TC, TG, and LDL-C; however, there was a highly significant negative correlation between HDL-C and serum Mg. No vascular calcification was found in any of the studied patients. Moreover, LP-a and serum Mg were statistically significantly positively correlated with TC, TG, and LDL-C, with nonsignificant negative correlation with HDL-C. A significant positive correlation of hypertension with LP-a and Mg level was found in our studied patients. Nonsignificant negative correlations of Mg level with the age of patients, height, and BMI were found in our studied patients, but significant positive correlations of LP-a with the age of patients and BMI and a nonsignificant positive correlation with weight were found. Meanwhile, there negative correlations of LP-a and serum Mg level with the duration of CKD and the height of patients. Serum P had a significant positive correlation with Mg level and a significant negative correlation with LP-a level in our study. However, a negative correlation of serum Ca with Mg and LP-a levels, with no statistical significance, was detected. In the multivariate logistic regression analysis of the association between serum Mg level, all laboratory parameters of end-stage renal disease (ESRD), and HD in the studied patients there were three factors associated with HD (Mg level, LDL-C, and LP-a). There was a 45-fold increase in the probability of HD per 1 mg/dl increase in the Mg level and this relation was statistically significant [odds ratio (OR)=45, 95% confidence interval (CI): 15.4–68.1, P<0.01]. Mg level revealed a 14% increase in the prediction level in the study sample compared with controls. There was also a 3% decrease in the probability of HD per 1 mg/dl decrease in the level of serum LDL, and this relation was statistically significant (OR=0.97, 95% CI: 0.95–0.99, P<0.05). LDL had a 5% increase in the predictive level. Moreover, there was 68% increase in the probability of HD per 1 mg/dl increase in the level of LP-a and this relation was statistically significant (OR=1.68, 95% CI: 1.01–2.3, P<0.05). LP-a revealed a 6% excess in the prediction of HD. Conclusion In essence, CKD is characterized by specific metabolic abnormalities of plasma LPs. High serum LP-a and low HDL-C are highly atherogenic and are two factors that accelerate atherosclerosis in patients with CKD and correlate with CV mortality. The kidney has a vital role in Mg homeostasis, and, although the renal handling of Mg is highly adaptable, this ability deteriorates when renal function declines significantly. Mg does not increase the LP synthesis. Patients with CKD on maintenance HD show positive correlations between serum Mg and serum HDL-C, LP-a, and TG levels. Therefore, Mg has a protective role in hypertension, arrhythmia, atherosclerosis, and vascular calcification in ESRD patients. Notably, the low serum Mg may be an independent risk factor for premature death in CKD patients. Although the exact role of Mg in bone metabolism is unclear, it may have both positive and negative effects, and it is uncertain what the optimal Mg levels are in uremic patients. Nonetheless, the dialysate Mg concentration is a major determinant of HD or peritoneal dialysis patients’ Mg balance, but the intradialytic CV and hemodynamic benefits of varying Mg concentration in patients’ dialysate are unclear. Acquired prolonged QT-interval syndrome is a highly prevalent condition in patients with CKD undergoing HD and is one of the known pathophysiological mechanisms of sudden death in this population. The high serum LP-a level and Mg depletion in CKD patients on maintenance HD displayed a high frequency of abnormal electrocardiographic findings, including a high prevalence of patients with prolonged QTc interval. Nephrologists must pay attention to identifying patients with prolongation of the QT interval and the associated clinical and laboratory conditions, such as structural changes of the heart, cardiac calcification, Mg depletion, high serum LP-a level, and the prescription of drugs that induce QT interval prolongation, particularly in patients already presenting an extended QT interval. LVH is a striking ECHO feature among our HD patients. Numerous studies now provide strong suggestive evidence for a protective role of Mg in vascular calcification, arrhythmias, and atherosclerosis in ESRD patients. Our results allow us to speculate on the possible salutary role of increasing plasma levels of Mg to facilitate the healing of vascular injuries and to prevent atherosclerosis, hypertension, arrhythmia, and chronic myocardial ischemia. Mg-based compounds have the additional advantage of being much cheaper to use than some newer alternatives. Nevertheless, in an era of numerous negative studies in nephrology, the long-term effects on either the inhibition of vascular calcifications, reduction of ischemic disease, prevention of arrhythmias, or changes in bone morphology have not been adequately investigated. Moreover, a link between BMI and the presence of Mg retention and high LP-a level was observed. New studies need to be outlined, using accurate nutritional status markers for HD patients, to better observe the possible link between malnourishment and prolonged QTc interval.
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Role of anti-phospholipase A2 receptor antibodies in monitoring of the clinical status in idiopathic membranous nephropathy in Egyptian patients
Rabab Mahmoud Ahmed Mahmoud, Mohammed Gamal El-din Saadi, Tarek Mohammed Fayad, May Abd El-Monem Hassaballa, Khaled Marzouk Sadek, Amr Mohammed Shaker, Mervat Mohammed El-Ansari
October-December 2016, 16(4):119-123
Aim Phospholipase A2 receptor (PLA2R) in the past few years has been identified as an antigenic target in idiopathic membranous nephropathy (IMN). The question remains, however, whether the diagnostic and prognostic values of anti-phospholipase A2 receptor (APLA2R) antibodies apply to patients with IMN who are of different ethnicities. The aim of this research was to assess the prevalence of APLA2R antibodies in Egyptian patients with IMN and to describe the clinical importance of measuring APLA2R antibodies in those patients. Patients and methods Using an indirect immunofluorescence (IF) assay, we measured APLA2R antibodies level in 30 patients with IMN in Egypt (three samples/patient). Patients were divided in two groups: group 1 included 15 consecutive patients at the time of diagnosis and group 2 included 15 consecutive patients during their remission or relapse period. Results APLA2R antibodies were detected in 40% of the patients in both groups equally. Overall, 68% of them had a nephrotic-range proteinuria (P=0.002). The titer ranged from 1 : 10 to 1 : 40. The reactive patients had significantly lower serum albumin levels at the presentation (P=0.049), and the average time to remission for them was longer in comparison with the nonreactive patients. Conclusion In our study, APLA2R antibodies were found in 40% of the patients. It correlates with the disease activity regarding remission and relapse, and its reactivity was higher in more severe disease.
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Paediatric renal diseases in a rural tertiary hospital in north-western Nigeria: pattern and outcome
Umma I Abdullahi
January-March 2017, 17(1):38-40
Context The trend of paediatric kidney disease is steadily rising and is contributing significantly to childhood morbidity and mortality. Aim This study aimed at determining the trends, pattern, and outcome of renal diseases in children over a 10-year period. Participants and methods This was a retrospective study of all the consecutive children admitted with renal diseases from January 2006 to December 2015. All relevant data were extracted from their case notes and analyzed appropriately. Results One hundred and two of 6269 children admitted during the study period had kidney disease, giving an overall prevalence of 1.2%. Sixty-one were boys whereas the remaining 41 were girls, with a male : female of 1 : 0.7. The age ranged from 10 to 180 months. There was a progressive increase in the number of admissions due to renal diseases from 0.9% in 2006 up to 3.4% in 2013 of the total annual admissions. Acute glomerulonephritis was the most common renal condition. The majority of children [94 (92.2%)] recovered fully, four (3.9%) were referred, one (0.98%) child left with his parents against medical advice, whereas three children died, giving a mortality rate of 2.9%. Conclusion There is a progressive increase in the prevalence of renal diseases among children studied, with acute glomerulonephritis being the most common condition seen.
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Effect of a single session of haemodiafiltration on nerve conduction, interleukin-6 and β2-microglobulin
Mohamed G Saadi, Bahaa Zayed, Mohamed Momtaz, Amr Shaker, Khaled Marzouk, Ann Ali, Rabab M Ahmed Mahmoud
July-September 2016, 16(3):79-88
Background β2-Microglobulin (β2-MG) is a uremic toxin that is retained in patients with end-stage renal disease. Interleukin-6 (IL-6) besides being an inflammatory marker has emerged as an independent predictor of mortality in end-stage renal disease patients. Objectives The aim of the present study was to investigate the effect of online haemodiafiltration (OL-HDF) by one session per week on the serum level of both IL-6 and β2-MG and to evaluate its effect on the changes in nerve conduction in patients on chronic haemodialysis (HD). Patients and methods Sixty patients on regular conventional HD for more than 5 years were subjected to one session of OL-HDF by using the ‘Gambro AK 200 ULTRA’ system for 4 h and two sessions of HD for 4 h per week with a follow-up for 3 months. Furthermore, urea reduction ratio was measured during one HD and one HDF session, serum β2-MG and IL-6 reduction ratio were measured during one HD and one HDF session, and during follow-up, the serum β2-MG level and IL-6 level were measured at four time intervals. Nerve Conduction Study (NCS) was done at the start of the HDF treatment and follow up 3 months post HDF treatment. Results Urea reduction ratio% was significantly higher with HDF than with HD (75.6 vs. 66.9%) and this difference was statistically significant (P<0.001). Reduction ratio of β2-MG level was 72.2% with HDF versus 26.6% with HD and this difference was statistically significant (P<0.001). The results of motor conductivity testing showed significantly higher nerve conduction velocity in post-HDF in comparison with pre-HDF in right median nerve (P<0.001) and in left peroneal nerve (P<0.001). The mean value of sensory response in amplitude as well as in nerve conduction velocity in right median nerve and left median nerve were significantly higher after HDF treatment period (P<0.05). Conclusion The OL-HDF had a good effect on clearance of β2-MG at the level of one session, at the level of follow-up for 3 months, the serum level of β2-MG did not significantly changed. Also improvement in some aspects of nerve conduction, but the level of IL-6 in OL-HDF increase.
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