Iranian Journal of Kidney Diseases
Year:2008 | Volume:2 | Issue:2|Papers Count:13

In the Middle East, transplantation practice was started in 1967 by the first kidney transplantation in Iran. However, it did not reach to a routine practice until the second half of the 80 decade, when appropriate legislations were enacted in most countries in the region. At present, kidney transplantation is active in most countries in the region including Saudi Arabia, Lebanon, Kuwait, Jordan, Syria, Libya, Egypt, Sudan, Qatar, Oman, Turkey, and Iran. Kidney transplantation is also limitedly done in Yemen, Algeria, Tunisia, United Arab Emirates, and Bahrain.

Posttransplant lymphoproliferative disorder is a heterogenous group of clonal hyperplasia/neoplasms that can range from benign to highly malignant lesions. Mortality rates can approach 60%. This entity has been on the rise for the last 2 decades with the advent of highly potent immunosuppressive agents. Epstein-Barr virus has shown to play a primary role in more than 90% of the cases. Although standard protocols do not exist for primary prevention and treatment, new agents are emerging that may play a role in treatment and prevention of this debilitating, and at times, fatal disease.

The incidence of end-stage renal disease (ESRD) in developing countries is 48 pmp to 240 pmp, compared with 76 pmp to 268 pmp in the developed regions of North America, Europe, and the Asia- Pacific region. In developing countries, ESRD seems to be at least as common, if not more common, as that in developed countries. The figures given probably underestimate the true incidence, because most of the people live in rural areas where there is limited access to healthcare facilities and patients do not have access to dialysis facilities in urban areas. In the absence of an established kidney transplant program, it is not viable economically to maintain large numbers of patients on a maintenance hemodialysis program in a developing country.

Introduction: Recent studies have shown that subclinical inflammation is a part of type 2 diabetes mellitus. This study was designed to explore the relationships between low-grade inflammation and renal microangiopathy in patients with type 2 diabetes mellitus. Materials and Methods: Sixty patients with type 2 diabetes mellitus were included in the study and further divided into normoalbuminurics, microalbuminurics, and macroalbuminurics, of 20 patients each. We analyzed serum concentrations of highsensitivity C-reactive protein (HS-CRP) and interleukin-6 (IL-6) and studied their correlation with proteinuria. The patients and a control group of 20 healthy individuals were followed-up for a period of 6 months and the markers measured again. Results: A positive correlation was found between urinary albumin excretion and levels of HS-CRP (r=0.781, P <.001) and IL-6 (r=0.708, P <.001). The level of glcosylated hemoglobin (HbA1c) showed a significant positive correlation with urinary albumin excretion (r=0.630, P <.001), CRP (r=0.750, P <.001), and IL-6 (r=0.680, P <.001). Levels of HbA1c, HS-CRP, and IL-6 significantly decreased in all three diabetic groups after 6 months of treatment. Also, the percentage of HbA1c decrement correlated well with the decrease percentage in HS-CRP (r=.277, P=.01). Conclusions: Inflammatory markers in early type 2 diabetic nephropathy are elevated and are independently associated with urinary albumin excretion. It is possible to hypothesize on the participation of locally released cytokines in the development of kidney damage.

Introduction: This study aimed at determination of circulating soluble interleukin-2 receptor (IL-2 R) alpha in the sera of patients with systemic lupus erythematosus (SLE) and correlating the level of expression of these receptors with the SLE disease activity. Materials and Methods: The study included 55 patients with SLE and 20 healthy volunteers as controls. The following investigations were done: serum complement component 3, complement 4, erythrocyte sedimentation rate, complete blood count, serum creatinine, creatinine clearance, 24-hour urinary protein, urinalysis, and serum soluble IL-2R alpha level. Kidney biopsy was performed and examined with light microscopy for patients with lupus nephritis by a single pathologist blinded to the clinical activity of the disease. The results were analysed in relation to the clinical activity index of systemic lupus activity measure (SLAM). Results: The study showed that levels of soluble IL-2R alpha were significantly higher in the total group of patients with SLE compared to the controls (P<.001). Furthermore, serum IL-2R alpha levels were significantly higher in patients with lupus nephritis than those without nephritis. There were strong positive correlations between IL-2R alpha levels and the SLAM score, histological activity index, erythrocyte sedimentation rate, and 24-hour urinary protein excretion. Also, significant inverse correlations with complement 3 and packed cell volume was observed (r=0.738; r=0.669; r=0.328; r=0.705; r=-0.444; r=-0.420, respectively). Conclusions: Serum soluble IL-2R alpha is a reliable marker of disease activity in patients with SLE and could be used as an indicator of early renal involvement with the possibility of using it for follow-up.

Introduction: Cutaneous and mucosal disorders are of the common problems in patients on long-term hemodialysis. The aim of this study was to evaluate the frequency of dermatologic problems among patients with end-stage renal disease (ESRD) who receive maintenance hemodialysis. Materials and Methods: One hundred and one patients with ESRD on hemodialysis were studied. All of patients were fully examined for cutaneous, nail, hair, and mucosal changes by a single dermatologist. Complementary diagnostic measures such as biopsy of the lesions were carried out, where necessary. Results: The patients were 43 (42.6%) women and 58 (57.4%) men with a mean age of 50.0±12.3 years. The duration of hemodialysis was 36.0±11.0 months. Dermatologic examination revealed that 95 patients (94.1%) suffered from cutaneous problems. Skin discoloration (66.3%) was the most common skin lesion. Pruritus was seen in 38.6% of the patients. Hair, mucous membrane, and nail problems were present in 37.6%, 23.8%, and 43.6% of the patients, respectively. There was a significant association of the number of cutaneous manifestations with the age of the patients (P= .001), but not with hemodialysis duration. The most common hair disorder was hair loss in 9.9% of the patients and the most common oral mucosal problem was furred tongue (7.9%). Of the nail disorders, nail bed paleness (16.8%) was the most common.Conclusions: Cutaneous and mucosal lesions in patients with ESRD can vary from each patient population to another. Factors such as diagnostic accuracy, climate, and early treatment influence some disorders such as pruritus, xerosis, and infections.

Introduction: The aim of this study was to determine access recirculation in functioning catheters in the regular and reversed positions. Materials and Methods. Access recirculation was measured in 2 sequential hemodialysis sessions in patients with functioning internal jugular catheters inserted not earlier than 2 weeks before the study: The arterial and venous lines were in their regular position during the first session and they were reversed during the second measurement. Changes in access recirculation were assessed. Also, type of the catheter and number of catheter insertions were evaluated in relation to access recirculation. Results: Twenty-five of the patients had a permanent catheter and 5 had a temporary catheter. During the first session, the mean of access recirculation was 6.9±6.7% in the patients with a permanent catheter and 7.8±8.4% in those with a temporary catheter (P=.45). The mean access recirculation was 7.1±6.9% (range, 0 to 20%) in the 30 patients on hemodialysis with the arterial and venous lines in their regular positions. When the lines were reversed, access recirculation increased significantly (P=.01) to a mean of 20.5±20.5% (range, 2.3% to 75%). There was no significant correlation between the type of catheter or the number of catheter insertions and access recirculation. Conclusions: After reversing the arterial and venous lines, access recirculation in both temporary and permanent functioning catheters may increase; therefore, dialysis adequacy might be impaired by reversed lines. Replacing malfunctioning catheters with new ones aseems to be better than reversing the lines.

Introduction: The electrocardiography (ECG) markers of corrected QT interval (QTc) and QTc dispersion are prolonged in patients on hemodialysis. This study was carried out to investigate if changes in these markers will reverse by successful kidney transplantation. Materials and Methods: Twenty-six kidney allograft recipients with functioning grafts, 26 patients on maintenance hemodialysis, and 22 healthy individuals were underwent a 12-lead ECG and laboratory studies for electrolytes and arterial blood gas. In the patients on dialysis, ECG and laboratory studies were performed prior to the start of a hemodialysis session. Both QT dispersion and maximum QT were corrected for heart rate (QTc dispersion and maximum QTc). The results were compared between the three groups. Results: The mean QTc dispersion was 30.3±15.2 ms, 27.6±8.3 ms, and 24.5±9.0 ms, and the mean maximum QTc was 464.7±23.0 ms, 436.3±19.0 ms, and 415.0±85.0 ms in the patients on dialysis, transplant recipients, and controls, respectively. The QTc dispersion value was lower in the transplant group than in the hemodialysis group, but the differences were not statistically significant. Whereas, the maximum QTc was significantly shorter in the transplant recipients as compared with the patients on hemodialysis (P<.02). There was a significant correlation between the maximum QTc and serum calcium level (P<.001), serum magnesium level (P<.001), and pH (P<.001). Conclusions: Prolonged maximum QTc decreases towards normal by successful kidney transplantation. These corrections are most likely due to normalization of electrolytes and the acid-base status from a uremic state to the normal kidney function.

Introduction. Cyclosporine has a narrow therapeutic serum level in kidney transplantation. Achieving the recommended therapeutic levels is necessary, but in different ethnic groups, the impact of the cyclosporine level on patient and graft survival has not been fully addressed yet. We investigated this issue by studying the 2-hour postdose serum concentration of cyclosporine (C2) and the longterm graft and patient survival in Iranian transplant recipients. Materials and Methods. A total of 397 kidney recipients were evaluated for the C2 serum levels. All patients were under treatment with prednisolone, mycophenolate mofetil, and cyclosporine (Neoral). Measurements C2 were considered at different time intervals: the first 2 months, 2 to 6 months, and after 6 months posttransplantation. The mean of C2 levels at specified intervals were evaluated and compared with the recommended optimal ranges. Patient and graft survival rate were also calculated. Results. In the studied patients, C2 levels were lower than the upper recommended range in 96.9%, 83.6% and 64.5% in the first 2 months, between 2 and 6 months, and after 6 months posttransplantation, respectively. The overall 5-year patient and graft survival rates were 95% and 85%, respectively. Conclusions. Despite the fact that the majority of the patients had C2 levels lower than the recommended values, we observed good patient and graft survival rates. Our data suggests that different populations may need different target levels definition.

Glomerulonephritis is reported as a rare extraintestinal manifestation of inflammatory bowel disease. We report a case of a 69-year-old woman who suffered from membranous glomerulonephritis, 3 years after diagnosis of nephrotic syndrome. She was admitted because of acute kidney failure, bloody diarrhea, and gastrointestinal symptoms. Further evaluation confirmed the diagnosis of ulcerative colitis.

Paget’s disease is a disorder of bone remodeling. Its occurrence in hemodialysis patients is very rare. Here, we report a case of Paget’s disease in a 77-year-old patient on hemodialysis who presented with elevated serum level of alkaline phosphatase without any clinical or laboratory findings of secondary hyperparathyroidism. To our best knowledge, this is the first reported case of Paget’s disease in a patient with end-stage renal disease from Iran.

The World Kidney Day (WKD) Steer ing Committee would like to express its sincere gratitude to the Iranian Society of Nephrology, the Kidney Foundations of Iran and the community of kidney healthcare professionals and volunteers for organizing such an excellent series of initiatives in Iran on the occasion of WKD. The importance of WKD is due to the activities that these individuals and organizations are conducting in Iran, led by people who understand the specific kidney health issues that exist in their country. By uniting together, we will continue to make meaningful progress in raising public awareness of chronic kidney disease (CKD) and inspiring positive changes in healthcare systems and practices around the world.

I read the original paper published in the previous issue of the Iranian Journal of kidney Diseases with great interest. The authors concluded that posttransplant diabetes mellitus (PTDM) was common in a group of kidney transplant patients. This result has been publicized by many articles in the literature; its incidence after kidney transplantation ranged between 7.9% and 50%.