Iranian Journal of Kidney Diseases
Year:2010 | Volume:4 | Issue:3|Papers Count:19

Depression and anxiety are among the most common comorbid illnesses in people with end-stage renal disease (ESRD). Patients with ESRD face many challenges which increase the likelihood that they will develop depression or anxiety or worsen these conditions. These include a general feeling of unwellness; specific symptoms caused by ESRD or the patient’s treatment; major disruptions in lifestyle; the need to comply with treatment regimens, including dialysis schedules, diet prescription, and water restriction; ancillary treatments and hospitalizations; and the fear of disability, morbidity, and shortened lifespan. Depression has been studied extensively inpatients on maintenance dialysis, and much effort has been done to validate the proper screening tools to diagnose depression and to define the treatment options for patients on maintenance dialysis with depression. Anxiety is less well studied in this population of patients. Evidence indicates that anxiety is also common in maintenance dialysis. More attention should be paid to measuring the incidence and prevalence and developing methods of diagnosis and treatment approaches for anxiety in patients with ESRD. In this review, we attempted to underscore those aspects of depression and anxiety that have not been investigated extensively, especially with regard to anxiety. The interaction between racial/ethnic characteristics of patients on maintenance dialysis with depression and anxiety needs to be studied more extensively, in order to assess better approaches to healthcare for these individuals.

Introduction. The efficacy and safety of pegylated and standard interferon (IFN) have been scrutinized in meta-analyses; however, factors associated with hepatitis C viral response in patients on hemodialysis are not well investigated. Materials and Methods. We evaluated factors that could be associated with sustained virological response (SVR) to pegylated or standard IFN monotherapy in patients on hemodialysis with chronic hepatitis C virus (HCV) infection, by performing a systematic review of the literature with a meta-analysis of clinical trials. We used both Mantel-Haenszel and DerSimonian and Laird random effects models, with heterogeneity and sensitivity analyses. Results. Twenty-one studies on IFN-a2a or IFN-a2b (491 patients) and 12 on pegylated-IFN-a2a or PEG-IFN-a2b (279 patients) were evaluated. The pooled SVR for standard and pegylated IFN monotherapy in random effects model was 39.1% (95% confidence interval [CI], 32.1 to 46.1) and 39.3% (95% CI, 26.5 to 52.1), respectively. Pooled dropout rates were 22.6% (95% CI, 10.4 to 34.8) and 29.7% (95% CI, 21.7 to 37.7), respectively. Female gender, HCV-RNA copies per milliliter, HCV genotype, alanine transaminase pattern, duration of infection, liver fibrosis stage, and treatment duration were not associated with SVR. Only an age less than 40 years was significantly associated with SVR in both models (odds ratio, 2.17; 95% CI, 1.03 to 4.50). Conclusions. Additional benefit of monotherapy with pegylated IFN in patients on hemodialysis with HCV infection in terms of viral response and adverse events is still unclear. According the current literature, younger age was the only determinant of SVR.

Hypophosphatemia is defined as a serum phosphate level of less than 2.5 mg/dL (0.8 mmol/L). Hypophosphatemia is caused by inadequate intake, decreased intestinal absorption, excessive urinary excretion, or a shift of phosphate from the extracellular to the intracellular compartments. Renal phosphate wasting can result from genetic or acquired renal disorders. Acquired renal phosphate wasting syndromes can result from vitamin D deficiency hyperparathyroidism, oncogenic osteomalecia, and Fanconi syndrome. Genetic disorders of renal hypophosphatemic disorders generally manifest in infancy and are usually transmitted as an X-linked hypophosphatemic rickets. Symptoms of hypophosphatemia are nonspecific and most patients are asymptomatic. Severe hypophosphatemia may cause skeletal muscle weakness, myocardial dysfunction, rhabdomyolysis, and altered mental status. The diagnostic approach to hypophosphatemia should begin with the measurement of fractional phosphate excretion; if greater than 15% in the presence of hypophosphatemia, the diagnosis of renal phosphate wasting is confirmed. Renal phosphate wasting can be divided into 3 types based upon serum calcium levels: primary hyperparathyroidism (high serum calcium level), secondary hyperparathyroidism (low serum calcium level), and primary renal phosphate wasting (normal serum calcium level). Phosphate supplementations are indicated in patients who are symptomatic or who have a renal tubular defect leading to chronic phosphate wasting. Oral phosphate supplements in combination with calcitriol are the mainstay of treatment. Parenteral phosphate supplementation is generally reserved for patient with lifethreatening hypophosphatemia (serum phosphate < 2.0 mg/dL). Intravenous phosphate (0.16 mmol/kg) is administered at a rate of 1 mmol/h to 3 mmol/h until a level of 2 mg/dL is reached.

Introduction. In autosomal recessive distal renal tubular acidosis (DRTA), a substantial fraction of the patients have progressive bilateral sensorineural hearing loss. This coexistence is due to the mutations of a gene expressed both in the kidney and in the cochlea. The aim of this study was to assess the correlation between hearing loss and DRTA.Materials and Methods. In this study, 51 children diagnosed with renal tubular acidosis were evaluated. Diagnosis of DRTA was based on clinical manifestations and detection of normal anion gap metabolic acidosis, urine pH higher than 5.5, and positive urinary anion gap. Audiometry was performed in children with DRTA and sequencing of the ATP6V1B1 gene was done for those with sensorineural hearing loss.Results. Twenty-seven patients (52.9%) had DRTA, of whom 51.9% were younger than 1 year old, 55.6% were boys, and 44.4% were girls. Eleven patients (40.7%) had bilateral sensorineural hearing loss, consisting of 5 of 15 boys (33.3%) and 6 of 12 girls (50.0%). There was no correlation between hearing loss and gender. Three patients with hearing loss had mutation in the ATP6V1B1 gene (11.1% of patients with DRTA and 27.3% of patients with DRTA and hearing loss).Conclusions. This study indicated that a significant percentage of the children with DRTA had sensorineural hearing loss and mutation in ATP6V1B1 gene. It is recommended to investigate hearing impairment in all children with DRTA.

Introduction. Bone marrow-derived stem cells have a potential capacity to differentiate and accelerate recovery in injured sites of body. Also, factors like granulocyte colony stimulating factor (GCSF) can promote their mobilization to the injured sites. We aimed to investigate the role of GCSF as an alternative therapeutic option instead of mesenchymal stem cells (MSCs) in reperfusion injury. Materials and Methods. Twenty-nine rats with induced reperfusion injury were divided into 3 groups to receive MSC, GCSF, or nothing (control). Kidney function was assessed by blood urea nitrogen and serum creatinine levels. Histological grading was performed to evaluate the extent of tubular injury and the rate of recovery. Results. All the rats reached recovery after 14 days. Rats in the MSC group reached early functional and histological recovery compared to the controls on the 7th day of the study (P = .01 and P = .02, respectively). Compared to the control group, the GCSF group showed a more significant histological recovery on the 7th day (P = .04), but kidney function was ameliorated on the 14th day (P = .04). Both the GCSF and control groups had a significant number of CD34+ cells, which were detected by flow cytometry on the 7th day after reperfusion injury. Conclusions. We found therapeutic effects following administration of both MSC and GCSF which was more evident with MSC in the setting of reperfusion injury. More investigation is required to find optimal time, dose, and route of administration as well as other possible contributing factors.

Introduction. Despite many beneficial effects, hemodialysis may cause pulmonary dysfunction. On the other hand, patients with end-stage renal disease are potentially prone to lung edema and respiratory dysfunction. This study was conducted to evaluate the alterations of pulmonary function indicators after hemodialysis, measured by spirometry. Materials and Methods. A total of 26 patients on hemodialysis for at least 3 months were studied. They were all older than 18 years old. None of the patients was a current or recent smoker, and none of them had a history of respiratory diseases, current or recent respiratory infections, musculoskeletal disorders, or tuberculosis. All of the patients underwent the spirometry test before and after a 4-hour hemodialysis session, and the forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), vital capacity (VC), and FEV1/FVC ratio were measured. Results. After hemodialysis, the FVC significantly increased (P = .02), while no significant improvement in the FEV1, VC, and FEV1/FVC ratio were observed. Gender was related to the changes in VC, with better results in women (P < .001). There was no association between the changes in spirometry parameters and age, body mass index, cause of kidney failure, type of anion used for hemodialysis, and weight changes.Conclusions. According to our results, pulmonary function, especially the FVC, improves after a session of hemodialysis.

Introduction. Staphylococcus aureus is currently the most common cause of infection in hospitalized patients. Patients on hemodialysis are at increased risk due to their immunocompromised state. The present study was designed to determine the frequency of S aureus nasal carriage in patients on hemodialysis.Materials and Methods. This study was undertaken in 2 dialysis centers to establish the frequency of S aureusnasal carriage at teaching hospitals of Mazandaran University of Medical Sciences, in the north of Iran. Standardized nose swabs were rotated into the anterior nares of the patients, and the samples were cultured on a blood-agar medium. Having grown the colony, gram stain, catalase, manitol, DNAase, and coagulase tests were all performed. Pattern of antibacterial sensitivity was determined by using the disc diffusion method. Also, agar dilution method was used to determine minimal inhibitory concentration of oxacillin and vancomycin.Results. Of 84 patients on hemodialysis, 31 (36.9%) were nasal carriers of S aureus, of whom 23 (74.2%) were resistant to methicillin. Of the methicillin-resistant S aureus isolates, 3 (13.0%) were resistant to vancomycin and 7 (56.5%) had reduced susceptibility to vancomycin in agar dilution method. Resistance frequencies to clindamycin, ciprofloxacin, and trimethoprim-sulfamethoxsazole were 12.9%, 9.7%, and 19.3%, respectively. However, all microorganisms were sensitive to rifampicin.Conclusions. Patients on hemodialysis are at an increased risk of S aureus infections; thus, screening of these susceptible patients should be considered as a health priority. Meanwhile, microbial sensitivity tests should be ordered for all cases in order to optimize treatment options.

Introduction. Acquired cystic kidney disease (ACKD) occurs in patients with prolonged uremia, and early detection is important, because clinically significant complications, especially renal cell carcinoma, are associated with ACKD. Materials and Methods. In a cross-sectional study, we evaluated our patients on hemodialysis, in Ahvaz, Iran, using ultrasonography. The criteria for the diagnosis of ACKD were the presence of at least 4 bilateral renal cysts in patients with noncystic primary kidney diseases as the leading cause of kidney failure.Results. A total of 148 patients (95 men and 53 women) were included in the study. The prevalence of ACKD was 20.3% (18.9% in men and 22.6% in women). The mean age in patients with and without ACKD was 60.6 ±16.8 years and 53.6 ± 14.9 years, and the mean hemodialysis duration was 44.2 ± 18.7 months and 34.3 ± 23.5 months, respectively. There were no significant differences in the frequency of ACKD in the men and the women (P = .59) and in the etiology of end-stage renal disease (P = .64). It was significantly more likely to see ACKD in patients with a history of 3 years or longer being on hemodialysis than in those with a shorter dialysis duration (P = .001). Conclusions. Acquired cystic kidney disease is common in patients on hemodialysis, and we suggest that renal ultrasonography be performed in patients with 3 years or more history of being on renal replacement therapy.

Introduction. We aimed to determine oral microflora of patients on long-term hemodialysis and kidney transplant recipients, and to compare them with individuals without kidney disease.Materials and Methods. We studied on 3 groups including patients on at least 6 months of hemodialysis, kidney transplant recipients for more than 2 years, and controls with a normal kidney function. Staining and culture were applied for samples from the dorsum of the tongue and the oral floor in order to detect aerobic and anaerobic bacteria and Candida. Results. The participants were 49 patients on hemodialysis, 50 kidney transplant recipients, and 50 volunteers in the control group. The abundance of Candida was significantly higher in the hemodialysis and transplant groups compared with the control group. The mean of various microorganisms was found to be significantly higher in the hemodialysis group than the control group (P = .03); however, the frequency of these microorganisms in the transplant group was lower than that in the hemodialysis group. Adjusting for confounding factors, the odds of having Candida in the hemodialysis and transplant groups were 3.54 (95% CI, 1.21 to 10.41) and 3.49 (95% CI, 1.27 to 9.18) times higher compared to the control group, respectively. Conclusions. Hemodialysis and kidney transplantation could affect oral microflora. Candida was significantly more frequent in these patients compared to healthy adults. Streptococcus mutans, Lactobacilli, Porphyromonas, and Candida is seen slightly less frequently after kidney transplantation, which might be in favor of promising effects of kidney transplantation on oral microflora.

Introduction. Oral hygiene in kidney transplant recipients contributes to maintenance of the transplanted organ and its function. Thus, an investigation of oral lesions could be counted as a notable work. These patients have the potential to be involved with lesions developed as a result of the administration of immunosuppressive drugs. The aim of this study was to investigate oral lesions in a group of kidney transplant recipients.Materials and Methods. The present study was a cross-sectional research on 100 patients with a kidney transplant for at least 3 months. Oral mucosa was assessed clinically for any lesion. Additional data on systemic diseases, transplant duration, and medications were recorded.Results. Twenty-four percent of the patients had at least 1 oral lesion. The most common lesion was oral candidiasis in 16% of the participants (13 cases of acute pseudo membranous and 3 cases of chronic oral candidiasis). Gingival enlargement was seen in 7% of the kidney transplant recipients, and 2% had a coated tongue.Conclusions. Elimination of oral fungal lesions in kidney transplant recipients is highly recommended. We hope this study can shed light on this particular aspect of healthcare in kidney transplant recipients.

Introduction. Evidence demonstrates that cardiovascular risk reduces after kidney transplantation, but is still a major cause of death. With increasing inclusion of diabetic patients for kidney transplantation, the evaluation of cardiovascular disease in this population becomes more important. We compared arterial stiffness and pulse wave reflection as well as other cardiovascular risk factors in kidney transplant patients with and without diabetes mellitus. Materials and Methods. One hundred kidney transplant recipients, including 33 diabetic patients, were evaluated for their renal cardiovascular risk factors, including blood pressure, lipids, glucose control, homocysteine, and arterial stiffness indexes. The tests were repeated after 1 year in 47 individuals. Results. There was no significant difference in pulse wave velocity (PWV) between the diabetic and nondiabetic groups, despite a greater augmentation index (AI) in the diabetic group (20.5±2.3 versus 13.1± 2.2). Multivariable analysis revealed that diabetes mellitus was a significant determinant for AI independently of age, blood pressure, post transplant time, gender, and glomerular filtration rate (R2 = 39%). Repeated test after 1 year demonstrated a significant reduction in the carotid-femoral PWV (P = .03) and systolic blood pressure (P = .007).Conclusions. In contrast to nontransplant groups, AI was significantly greater in diabetic kidney transplant patients compared to their nondiabetic counterparts, despite a comparable PWV. However, carotid-femoral PWV improved after 1 year. These may reflect progressive ventricular and large arterial function improvement despite remained small arterial defects after transplantation. It also suggests potential role of arterial evaluation in risk assessment among kidney transplant patients.

Introduction. There is little data about the pattern of disease progression in kidney transplant recipients with chronic allograft dysfunction (CAD). Extrapolating the current classification of chronic kidney disease for CAD, we studied the pattern of progression of CAD in 5 stages among our kidney transplant recipients.Materials and Methods. We performed a retrospective cohort study on 214 kidney transplant recipients with CAD. The selection criteria were a functioning kidney allograft for at least 1 year after transplantation and a progressive decline in allograft function. An event history analysis in survival data was carried out based on the stages of CAD at baseline and the end of the study. Results. At the beginning of the study, 54.7% of the patients had CAD stage 1; 37.9%, stage 2, and 7.5%, stage 3. At the end of study, 10.3% were in stage 2; 39.7%, stage 3; 23.4%, stage 4; and 26.6%, stage 5. Patients with CAD stage 5 were 17.1% of those in stage 1, 32.1% of those in stage 2, and 67.7% of those in stage 3 at baseline. There was a significant correlation between stage of CAD at the beginning of the study and the stage of CAD at the end (r = 0.465, P < .001).Conclusions. Because the decline in kidney allograft function was relatively faster in advanced stages of CAD, strategies to increase allograft survival by improving the baseline level of allograft function can be more effective than strategies to slow down progression of advanced stages of CAD.

Childhood hypertension has been extensively focused on in the past decades because of its increasing incidence, which is related to physicians’ awareness and the increasing number of obese children. Age, gender, and body size are the main determinants of blood pressure in children. The revised childhood blood pressure tables of the National High Blood Pressure Education Program are a prerequisite for classification of childhood hypertension. Although these tables provide a reasonable basis, they are intricate and height percentile is needed for final diagnosis. Many attempts have been done to decrease such complexity. We present new formulas that are concise and memorable, and will help physicians to screen prehypertensive and hypertensive pediatric patients.

Hypertension in children is not as frequent as in adults. In addition, most of the times, we encounter secondary hypertension rather than essential hypertension in children. This demands careful history taking, physical examination, and laboratory and imaging investigations to find the underlying cause. Here, a case of a boy with tuberous sclerosis is reported who presented with hypertension and abdominal pain associated with bilateral renal cystic disease.

Brown tumors with non-neoplastic process are noticed in patients with end-stage renal disease suffering from a severe form of secondary hyperparathyroidism. Herein, we report a patient with chronic kidney allograft failure returned back to hemodialysis who experienced manifestations of cauda equina compression secondary to a lumbar brown tumor. Also, we had another patient on hemodialysis with a demineralized lesion affecting the cervical vertebrae. Although brown tumor is a rare complication, these two cases highlighted the importance of neurological symptoms in uremic patients. Spinal decompression surgery, in order to alleviate pressure on neurological structures, together with subtotal parathyroidectomy, was highly indicated.

CASE PRESENTATION: PatientDr Nafar: A 48-year-old lady was admitted 45 days after unrelated living kidney transplantation because of acute allograft dysfunction. She was on hemodialysis for 2 months before transplantation due to kidney failure caused by autosomal dominant polycystic kidney disease. The donor was a healthy 28-year-old man. Panel reactive antibodies test and cytotoxicity leukocyte cross-match were negative. The patient had been discharged 11 days after transplantation with a serum creatinine level of 0.9 mg/dL. The immunosuppressive regimen consisted of cyclosporine, mycophenolate mofetil, and prednisolone. Seventeen days earlier, she was admitted to hospital because of increased serum creatinine to 1.78 mg/dL. She was treated with 3 doses of 500-mg methylprednisolone and cyclosporine dose reduction because of the high serum cyclosporine trough level (429 ng/mL). She was discharged after 7 days with a serum creatinine of 1.2 mg/dL….

To the editor, Continuous arteriovenous hemodialysis (CAVHD) is a highly effective modality for the replacement of kidney function in patients with acute kidney failure. In patients with acute kidney failure and compromised circulation, hemodialysis may lead to serious hypotension or cardiac arrhythmia.1 This fact may limit possible treatment; restriction of the patient’s fluid intake may be attempted, usually with a concomitant restriction of nutrition. With continuous hemofiltration, however, almost any quantity of fluid can easily be removed over a 24- hour period. We had a patient on CAVHD who showed a good control of uremia and hypervolemia and stable hemodynamics while on CAVHD.

To the editor: I am writing in connection with the paper published in the April 2010 issue of the Iranian Journal of kidney Diseases, entitled “Risk Factors for Contrast-related Acute Kidney Injury According to Risk, Injury, Failure, Loss, and End-stage Criteria in Patients With Coronary Interventions.1” The authors followed comprehensively 290 patients who underwent angiography and evaluated the risk factors for occurrence of acute kidney injury by change of creatinine. The idea of dividing patients according to the Risk, Injury, Failure, Loss, and End-stage criteria is remarkable, but I have some concerns...

To the editor: I read the article entitled “Renal Involvement in Patients With Hepatitis C Virus Infection” by Saddadi and colleagues, which was published in the Iranian Journal of Kidney Diseases.1 The aim of this study was to appraise kidney involvement in patients with hepatitis C virus (HCV) infection. Patients with diabetes mellitus (DM) were excluded. However, HCV infection has been associated with a greater incidence of DM.2 Moreover, DM can lead to kidney failure, while it was not looked at in this report.