Iranian Journal of Kidney Diseases
Year:2009 | Volume:3 | Issue:3|Papers Count:16

Human herpesviruses (HHVs) are able to escape from complete clearance by the immune system. Their ability to become latent is due to their delicate interferences with the immune system. This characteristic makes some of them known as important tumor viruses. Based on the prevalence of the seropositivity for the HHV-8, the world can be divided into 4 regions, one of which is the Middle East with a seroprevalence of 5% to 20%. The incidence of iatrogenic Kaposi sarcoma, a cancer linked with HHV-8 following organ transplantation, is 500 times higher than that in general population. In the Middle East, Kaposi sarcoma is the most common malignancy reported in kidney transplant recipients. In an immunocompromised host, the primary infection with HHV-8 presents with fever, hepatosplenomegaly, lymphoid hyperplasia, pancytopenia, and liver dysfunction. Occasionally, rapid-onset Kaposi sarcoma develops in association with apparent primary HHV-8 infection. In this article, the tumor genesis mechanism of HHV-8 in kidney transplant recipients was reviewed.

Introduction: Cyclosporine A is used in the treatment of idiopathic nephrotic syndrome. We conducted this study to evaluate the effect of cyclosporine and its combination with ketoconazole in Egyptian nephrotic children with steroid-resistant and steroid-dependant minimal change.Materials and Methods: Forty-eight children with minimal change lesions who received cyclosporine with or without ketoconazole were studied. Their mean age was 5.17±1.59 years, and they were 31 boys and 17 girls. The mean duration of the disease was 6.22 ± 3.16 years. Thirty-one of the children were steroid dependent and 17 were steroid resistant. Cyclosporine treatment was commenced after remission was attained and adjusted to a target trough level of 100 ng/mL. The mean cyclosporine therapy at a dose of 2.07 ± 0.91 mg/kg was administered for a mean of 25.75 ± 1.95 months. Thirty-three patients received adjunctive ketoconazole therapy.Results: Thirty-eight patients (79.2%) responded well to cyclosporine. Steroid therapy could be discontinued in 43 patients (89.6%), but 9 experienced relapse. Ten patients (20.8%) were resistant to cyclosporine therapy. Fifteen patients received cyclosporine alone, while 33 received concomitant cyclosporine and ketoconazole. The response to cyclosporine was significantly better in those on ketoconazole. The economic effect of ketoconazole therapy was a reduction in the costs of cyclosporine treatment by 47.4% at 1 year of treatment.Conclusions: Cyclosporine treatment in children with minimal change nephrotic syndrome is effective in preventing relapse and decreasing steroid toxicity. Its combination with low-dose ketoconazole is safe, reduces treatment costs, and improves the response to cyclosporine.

Introduction: Acute kidney failure (AKF) is a common clinical problem in neonatal intensive care units and is usually associated with a contributing condition such as sepsis, asphyxia, and heart failure. The aim of this study was to determine the types, frequency of associated contributing conditions, and short-term outcome of neonatal AKF.Materials and Methods: Medical records of neonates with a diagnosis of AKF from March 2003 to September 2006 were studied in a tertiary care children’s hospital in Tabriz, Iran. Results: Of 6042 hospitalized neonates, 151 with documented AKF (100 boys and 51 girls) were reviewed in the study. Ninety-one patients (60.3%) had been referred from other cities. Fifty-seven patients (37.7%) developed AKF following a surgery. Causes of AKF were intrinsic kidney failure in 52.3%, prerenal in 42.4%, and postrenal in 5.3%. Oliguria was observed in 72.2% of the patients. Perinatal asphyxia was present in 29.8% of the neonates, sepsis in 28.5%, respiratory distress syndrome in 25.2%, dehydration in 24.2%, and heart failure in 21.2%. Most patients (85.4%) had more than 1 associated contributing condition. Mortality rate was 20.5%. Most patients (76.2%) were discharged with normal kidney function and 3.3% with diminished kidney function. Initial admission to NICU, female sex, septicemia, and the need for mechanical ventilation were associated with a higher mortality rate.Conclusions: The frequency of associated contributing conditions and short-term outcome of neonatal AKF in our institution is comparable with other studies; however, intrinsic kidney failure comprises the most common form of AKF in our patients.

Introduction: High serum levels of lipoprotein(a) and homocysteine are risk factors of cardiovascular disease which are prevalent in patients on hemodialysis. Controversy exists about the effects of hydroxymethylglutaryl-CoA reductase inhibitors on serum lipoprotein(a) levels in patients on hemodialysis. Also, deficiency of some water soluble vitamins and administration of statins may raise serum levels of homocysteine in these patients. This study was designed to investigate serum levels of lipoprotein(a) and homocysteine in patients on hemodialysis who were taking a statin, vitamin B6, and folic acid.Materials and Methods: We investigated on 152 patients with maintenance hemodialysis who were taking atorvastatin or lovastatin, vitamin B6, and folic acid for at least 6 months. Their serum levels were obtained to measure lipoprotein(a) and homocysteine levels, as well as triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol.Results: The mean serum values of total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol and triglyceride were significantly less than the maximum reference values (P < .001). The mean serum level of lipoprotein(a) was also less than the reference value (P = .009), but homocysteine level was 33% higher on average than the reference value (P < .001). Conclusions: Our study demonstrated that in our patients on hemodialysis, the mean serum level of homocysteine was about 30% higher than the reference value although they were receiving vitamin B6 and folic acid. Hence, they were still exposed to the risk of cardiovascular disease.

Introduction. PDpoietin is a recombinant erythropoietin alfa that has been introduced by a manufacturer in Iran. We assessed the effectiveness and complications of PDpoietin in comparison with Eprex in anemic patients on hemodialysis. Materials and Methods. This clinical trial was performed in a multicenter setting. Patients with a hemoglobin level less than 12 g/dL were assigned into 2 groups in order to receive either Eprex (Janssen Cilag) or PDpoietin (Pooyesh Darou) for 3 months. Results. Forty-one and 34 patients completed the study in the PDpoietin and Eprex groups, respectively. The mean hemoglobin levels at baseline were not significantly different between the two groups of patients with PDpoietin and Eprex. In both groups, hemoglobin levels increased significantly, but there were no significant differences between the two groups at months 1, 2, and 3. At the end of the study, the mean hemoglobin levels reached 11.6±1.7 g/dL and 11.8±1.9 g/dL, respectively (P = .002; P = .01). The mean hemoglobin per cumulative of drug dose index (hemoglobin/[erythropoietin dose/1000 × injections per month]) was not significantly different between the two groups at different treatment stages, and it did not change significantly in each group during the course of the study. No serious complications were reported.Conclusions. Eprex and PDpoietin could equally increase the hemoglobin levels with no significant complication. Therefore, PDpoietin can be used for treatment of anemia in patients on dialysis, and the patients will have the advantages of its availability and low price.

Introduction: Purine metabolites constitute a major class of uremic toxins, and reliable characterization of which helps nephrologists to choose the most appropriate treatment for the patients individually. In the present study, we assessed plasma concentrations of hypoxanthine and uric acid as purine metabolites in patients on maintenance hemodialysis, before and after a dialysis session. Materials and Methods: A total of 20 patients on maintenance hemodialysis were enrolled in this study. All of the patients underwent a routine 4-hour dialysis, as scheduled 3 times per week. Polysulfone membranes and bicarbonate dialysis solution were used in all dialysis sessions. Blood specimens were taken from the arteriovenous fistula immediately before and after one hemodialysis session, in order to measure plasma concentrations of hypoxanthine and uric acid by high-performance liquid chromatography, and to compare the predialysis and postdialysis values.Results: Before hemodialysis, the mean plasma hypoxanthine and uric acid concentrations were 18.93 ± 8.28 mmol/L and 44.16±22.88 mmol/L, respectively. After hemodialysis, these concentrations reduced to 13.68 ± 4.42 mmol/L and 15.61 ± 11.12 mmol/L, respectively. Hypoxanthine concentration had a 27.7% decrease after hemodialysis (mean difference, 5.25 ± 6.24 mmol/L; 95% confidence interval, 2.32 to 8.10; P < .001). Also, uric acid concentration decreased by 64.6% (mean difference, 28.55 ± 14.39 mmol/L; 95% confidence interval, 21.81 to 32.28; P < .001).Conclusions: Plasma concentrations of hypoxanthine and uric acid are higher than normal before hemodialysis, and they decrease significantly after hemodialysis; however, both of them may be still higher than normal values.

Introduction: This study was conducted to compare marital adjustment between patients on long-term hemodialysis and healthy controls and to determine whether the psychological symptoms correlate with marital adjustment in these patients.Materials and Methods: In a case-control study, 40 patients on longterm hemodialysis and 40 healthy participants were compared for the quality of marital relationship. The Revised Dyadic Adjustment Scale was used for interviews of marital relationship, which includes total marital adjustment and its subscales of marital consensus, affection expression, marital satisfaction, and marital cohesion. Symptoms of anxiety and depression and the Ifudu comorbidity scale were also assessed in the patients group.Results: Marital consensus, affection expression, marital satisfaction, marital cohesion, and the overall marital relationship were significantly poorer in the patients on hemodialysis than in the controls. Also, symptoms of anxiety were more severe among the patients on hemodialysis in comparison with that in the controls. However, this was not the case for symptoms of depression. In the patients on hemodialysis, the severity of anxiety slightly correlated reversely with the total marital relationship score and marital satisfaction subscale. Depression correlated reversely with total marital adjustment, affection expression, marital satisfaction, and marital cohesion. Finally, some marital relationship subscales showed poorer results in men on dialysis, younger patients, and those with higher educational levels. Conclusions: Marital adjustment in patients on hemodialysis, which is linked with depressive symptoms and anxiety, is poorer compared to the healthy controls. This finding shows the necessity of an appropriate family approach for patients on long-term dialysis.

Introduction: Dialysis-induced oxidative stress is one of the mechanisms of atherosclerotic changes. Heparin, used in hemodialysis, is an anticoagulant drug with anti-inflammatory and antioxidant effects. This study was planned in order to evaluate the antioxidant effects of heparin and dalteparin (low-molecular weight heparin). Materials and Methods: Twenty-two patients underwent 3 hemodialysis sessions with 48-hour intervals. They underwent hemodialysis with heparin, with a bolus dose of 1000 U followed by 1000 U/h during the procedure. The second hemodialysis was done using hypertonic saline solution instead of heparin, and the third, using dalteparin, 4000 U, infused during hemodialysis. Before and after each dialysis session, we measured serum levels of total blood cholesterol, triglyceride, high- and low-density lipoprotein cholesterols and oxidized low-density lipoprotein cholesterol, in addition to total antioxidant capacity and paraoxonase 1 activity.Results: Serum concentrations of triglyceride, cholesterol, and oxidized low-density lipoprotein cholesterol, as well as paraoxonaseactivity and total antioxidant capacity equally increased after the three hemodialysis sessions. Heparin and daltepain increased total antioxidant capacity, but they did not change the ratio of paraoxonase 1 to high-density lipoprotein cholesterol after hemodialysis. No significant differences were found through the study between the two heparin products in their antioxidant activities. Conclusions: Regarding these findings and considering higher price and less availability of dalteparin in comparison to conventional heparin, we recommend using conventional heparin during hemodialysis as the anticoagulant-antioxidant agent.

Angiomyolipomas are benign neoplasms of the kidney which can clinically mimic renal malignancy. The imaging features are quite characteristic, and diagnosis can be clinched solely based on radiological investigations. Although mostly asymptomatic, they can be a cause of significant morbidity due to size and hemorrhage. We report a case of giant angiomyolipoma with a dilated vessel susceptible to hemorrhage.

CASE: A 38-year-old man was admitted to hospital for evaluation of kidney dysfunction. His serum creatinine on admission was 1.6 mg/dL. His past medical history was unremarkable and there was no family history of kidney dysfunction. His blood pressure was 130/80 mm Hg, and he had no history of hypertension. Physical examination revealed only mild pedal edema. On urinalysis, there were microscopic hematuria with dysmorphic erythrocytes and proteinuria. Twenty-four-hour urine collection revealed 1200-mg protein excretion per day. Studies of serum complements, antinuclear antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, and hepatitis viral markers had unremarkable results. The size of the kidneys was normal on ultrasonography. Biopsy of the kidney was performed, and light microscopic study of the tissue revealed 10 glomeruli all of which showing mesangial widening with hypercellularity. No obvious endocapillary proliferation or subendothelial deposits were identified (Figure 1). The immunofluorescence study revealed deposition of immunoglobulin A (IgA) and complement 3 (C3) in the mesangial regions (Figure 2). Based on pathologic findings, a diagnosis of mesangiopathic glomerulonephritis with IgA deposition, consistent with IgA nephropathy class III, was established.

Patients with kidney fai lure who are on maintenance hemodialysis are more frequently at risk of opportunistic fungal infections. Infection is the most common cause of death in patients with acute kidney failure. These patients have also limited urinary excretion that makes them susceptible to infectious diseases. One of the major causes of morbidity and mortality in patients undergoing hemodialysis is candidemia.

Swine influenza is caused by influenza A virus (H1N1) and is normally found in pigs. It is believed that antigenic shift has taken place in the virus, creating a new strain that has enabled the virus to infect humans and spread from person to person, leading to a pandemic.1 Since immunocompromised patients are more prone to develop severe manifestations of this virus, nephrologists around the world need to be more cautious. Kidney transplant recipients and patients with chronic kidney disease could be a highly susceptible group. Preventive measures for community such as frequent hand washing are also applicable to this group. Social distancing is another tactic. Also, the two neuraminidase inhibitors, oseltamivir and zanamivir, are active against H1N1 strains, which would be prescribed to patients with a kidney allograft and those with chronic kidney disease in the pandemic situation. Thus, nephrologists and healthcare personnel need to know their dosage adjustments.

Owing to the significance of immunological mechanisms in the human body, an ideal transplantation of body components is only feasible between identical twins, and in the absence of immunosuppression, it is the only possible model. In other conditions, both humoral and cellular immune responses will lead to immunological confrontation of the host body and the grafted cells, resulting in rejection episodes and allograft failure.

We would like to thank Gupta and colleagues for their attention and viewpoints. Hereby, brief clarification is presented. Unfortunately, we did not have facilities to measure rennin, aldosterone, and plasma rennin activity tests.

In the previous issue of the Iranian Journal of Kidney Diseases (volume 3, number 2, page 86), Afshar and colleagues reported their experience of urinary excretion of sodium and potassium in karate practitioners, following competitions.1 The authors concluded that karate may have no influence on urinary excretion of electrolytes. This conclusion was attributed to the short duration and anaerobic nature of kumite competitions. However, some of the reported data needs clarification and further elaboration.