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   2020| July-September  | Volume 20 | Issue 3  
    Online since July 17, 2020

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BK virus infection in renal transplant recipients: an overview
Fakhriya Alalawi, Hind Alnour, Mohsen El Kossi, John Jenkins, Anna Taku, Ajay K Sharma, Ahmed Halawa
July-September 2020, 20(3):127-150
Although BK virus (BKV) was discovered in 1971, it took almost three decades for this virus to be routinely considered as a possibility among a plethora of causes of renal dysfunction in a kidney transplant recipient. BKV infection, an early complication of renal transplant, often presents within the first year after transplantation. It presents as an asymptomatic gradual rise in creatinine with tubulointerstitial nephritis that mimics acute rejection and poses a diagnostic and therapeutic dilemma. More frequent diagnosis of BKV infection over the past 2 decades is a consequence of more potent immunosuppression (aimed to prevent acute rejection episodes and, thereby, improving allograft survival). Untreated BKV infections cause renal allograft dysfunction and subsequently allograft loss. A routine screening protocol for early recognition of asymptomatic BKV infection has been reported to result in better allograft outcomes. This review is aimed to discuss the most recent evidence addressing the virology, pathogenesis, clinical features, diagnostic tools, screening protocols, treatment strategy, and short-term and long-term renal allograft survival concerning BKV infection.
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Prevalence and correlates of depression among patients with chronic kidney disease
Olufisayo K Adesokun, Chukwuma U Okeafor, Princewill C Stanley
July-September 2020, 20(3):173-178
Background This study sought to determine the prevalence and correlates of depression among patients with chronic kidney disease (CKD). Patients and methods This is a comparative cross-sectional study of 69 patients with CKD, who were selected by systematic random sampling and matched (by age and sex) with a control group of 69 hospital workers. Eligible and consenting participants completed a sociodemographic questionnaire and were interviewed with the Mini International Neuropsychiatry Interview. Data were analyzed with the Statistical Package for Social Sciences, version 21. P value less than 0.05 was considered significant. Results The mean age of the patients was 44.7 years (SD ±10.14 years). The patients included 53% females. The prevalence of depression among patients with CKD was 34.8% compared with 2.9% in the control group (P=0.0001). A significant relationship was found between the average monthly income and presence of depression in patients with CKD (P=0.015). There was no association found between the prevalence of depression and the stage of CKD. Conclusion Depression is very common in patients with CKD. Assessment for depression should be integrated into the care plan for patients with CKD, so as to ensure early detection and prompt intervention.
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Effect of improving dialysis adequacy on the right ventricular functions
Alaa Sabry, Ahmed Bahy, Mohamed Atta, Elshahat A Yousef
July-September 2020, 20(3):165-172
Background Right ventricular dysfunction (RVD) is a common finding in hemodialysis (HD) patients especially those who are inadequately dialyzed. The aim of this study is to evaluate the effect of improving dialysis adequacy, anemia, and hypertension treatment on the RV function in a cohort of HD patients. Patients and methods The study included 60 HD patients admitted in Mansoura University Hospital, Nephrology Unit. Assessment of patients included complete clinical evaluation, estimation of Kt/V, urea reduction rate, and RV function assessed by echocardiography; all were done at the beginning of the study and 6 months after initiation of protocols of therapy needed for improvement of dialysis adequacy, anemia, and hypertension. Tissue Doppler imaging-derived myocardial performance index was used as the main index of RVD. Results The study results revealed an increased prevalence of RVD in maintenance HD patients. Moreover, this study showed a significant improvement of the mean tissue Doppler-derived myocardial performance index in the studied patients at the end of the study (after improvement of Kt/V, anemia, and hypertension), compared with initial values at the start of the study, from 0.54±0.03 to 0.48±0.02, respectively, with significant P value of 0.001. Conclusion RVD is common among HD patients, but improving dialysis adequacy together with proper management of hypertension and anemia plays an essential role in the improvement of RVD.
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Evaluation of chemokine receptor 2 polymorphism in patients with end-stage renal disease
Manal M Alkady, Phebe L Abdel-Messeih, Hussein S El-Fishawy, Eman M Eltahlawy
July-September 2020, 20(3):151-156
Background The inflammatory state accompanying end-stage renal disease (ESRD) is hallmarked by renal infiltration of monocytes/macrophages, which are the major source of chemokines and chemokine receptors. We aimed to determine the frequency and association of chemokine receptor 2 (CCR2)-V64I polymorphism in patients with ESRD. Patients and methods A total of 35 patients attending the hemodialysis unit and 21 healthy controls were recruited in this study. The PCR-restriction fragment length polymorphism technique was used to assess genotype frequencies of CCR2-V64I. Results The frequency of genotypes GG, AG, and AA in patient group was 65.7, 25.7, and 8.6%, respectively, in comparison with 81.0, 14.3, and 4.8%, respectively, in the control group. Therefore, the patient group showed higher frequency of AG and AA genotypes and a lower frequency of GG genotype than the control group but this difference was not significant. The frequencies of A and G alleles did not show a significant difference between the two groups. The frequencies of G and A alleles were 78.6 and 21.4%, respectively, in the patient group in comparison with 88.1 and 11.9%, respectively, in the controls. Patients carrying the genotypes AA and G/A showed rapid progression to ESRD than those with genotype G/G. No significant association was found between the occurrence of polymorphism and the presence of hypertension or diabetes mellitus. Conclusion The CCR2-V64I gene polymorphism may play a role in the pathogenesis and severity of ESRD in Egyptian patients. To uncover this role, further analyses should be carried out on larger population-based studies.
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Complications of permanent vascular access in hemodialysis patients
Kinan Abdosh, Ibrahim Suliman, Ghanim Ahmed
July-September 2020, 20(3):157-164
Background Vascular access (VA) complications are still considered a significant cause of morbidity and mortality in hemodialysis (HD) patients. The research aimed to study the complications of permanent VA in HD patients: single-center experience. Patients and methods This was a 1-year prospective, observational study conducted in a HD Unit, Department of Nephrology in 2018. 230 HD patients were recruited for the study, and they were subjected to clinical examination in each HD session. Culture and sensitivity of a swab sample of the VA was performed to confirm the diagnosis of infection. Also, Doppler ultrasound was used to evaluate the VA when there had been a suspicion of complications. Data were analyzed using the software Statistical Package for The Social Sciences. Results Arteriovenous fistula (AVF) was the predominant VA, and radiocephalic AVF was the most common type, followed by the brachiocephalic type. The most frequent complication was aneurysm (39.6%), followed by thrombosis (7%), stenosis (5.2%), infection (4.3%), and arterial steal syndrome (2.2%). Thrombosis was the leading cause of AVF failure, and antiplatelet therapy was a protective factor from thrombosis. Infection was the second cause of VA failure and Staphylococcus aureus infection was the most common type. Elbow AVF was considered as a predisposing risk factor of arterial steal syndrome. Conclusion VA complications are not rare, and they could cause VA failure. So, it is necessary to make more efforts and work as a multidisciplinary team.
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Assessment of malnutrition in patients with chronic kidney disease undergoing hemodialysis
Anusha Racha, Mahija Reddy Kanthala, Shravani Komuravelly, Venkateshwarlu Eggadi, Sharavana Bhava Bandaru, Rajendra Prasad
July-September 2020, 20(3):179-185
Background Malnutrition is the utmost predominant problem that arises in patients undergoing hemodialysis. Muscle wasting arises as a prevailing case, and so, it acts as a crucial indicator of morbidity and mortality in hemodialysis patients. Patients and methods This study encompasses 175 participants for a period of 6 months. Graded questionnaires and clinical findings were used to assess nutritional status. Results The mean age was 49.26±13.35 years, and 73% were males. Mean serum albumin and hemoglobin levels were 2.78±0.75 and 9.01±1.60 g/dl, respectively. According to the National Kidney Foundation, 49.71% of participants were malnourished whose BMI was less than 20. The results of mini-nutritional assessment scores revealed that a greater number of patients were at risk of malnutrition (56.5%) and subjective global assessment scores showed a moderate risk (63.4%). On assessing the clinical findings, 96% were anemic, 90.2% were fatigue, 62.8% complained of headache, and 69.1% had anorexia. Conclusion It is necessary to have the right amount of nutrition each day as it boosts the quality of life and further research should pinpoint the management strategies to control malnutrition in patients with chronic kidney disease.
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Combined membranous glomerulonephritis and plasma cell-rich acute rejection in renal transplant recipient presented as nephrotic syndrome: case report and review of literature
Osama Gheith, Islam Elsawi, Ayman Nagib, Medhat A Halim, Mohamed A El-Hameed, Ahmad Altaleb, Torki Al-Otaibi
July-September 2020, 20(3):186-190
Despite the contentious trials to improve the rates of acute rejection episodes and improve the renal allograft survival with potent immunosuppressants, the occurrence of more than 10 % of the inflammatory cells infiltrating renal allograft as mature plasma cells is uncommon and was recognized as plasma cell rich acute rejection (PCAR). Combination of PCAR with other glomerulopathies has not been reported before. Here, we report a case of late-onset PCAR associated with membranous glomerulonephritis (MGN) diagnosed at an early stage (2 years after transplantation). A 58-year-old male patient had end-stage kidney disease secondary to diabetic nephropathy and he was maintained on hemodialysis for 2 years until he underwent overseas living kidney transplantation. He presented to our center in Kuwait on the sixth day postoperatively, with stable renal function. He was maintained on steroid, cyclosporine, and mycophenolate mofetil. Two years after transplant, he developed picture of nephritic syndrome. His graft biopsy showed plasma cell-rich interstitial infiltrate associated with mild edema and focal tubulitis (PCACR) in addition to MGN. Further immunohistochemistry tests revealed both B-cell and T-cell markers (CD20 and CD3) were expressed in the lymphoplasmacytic infiltrate with predominant T lymphocytes. The possibility of multiple myeloma was ruled out. He received pulse steroid 1 g od for 3 days. His maintenance immunosuppression was intensified to tacrolimus-based regimen. Cluster differentiated lymphocyte count showed high CD-19 cells; therefore, we gave him a single dose of rituximab (375 mg/m2). Follow-up graft biopsy (1 month later) revealed MGN with complete resolution of plasma cells. His proteinuria started to improve after 4 months of management. He is enjoying stable graft function with controlled diabetes mellitus. PCAR is a treatable form of acute cellular rejection, and its combination with MGN will need special care with specific CD20 ablation therapy.
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