Iranian Journal of Kidney Diseases
Year:2014 | Volume:8 | Issue:3|Papers Count:23

Kidney donation and transplantation in Iran has passed a long history from the first kidney transplant in 1967, starting living related transplant in 1988 to 1989, adopting state-regulated living-unrelated donor kidney transplant program in 1988, religious approval from the Supreme Religious Leader for brain death in 1989, legislation law for cadaveric transplant in 2000, and increased number of cadaveric transplants, which put the country ahead of all country members of the Middle East Society for Organ Transplantation in performing deceased donor kidney and liver transplants in 2011 to 2012.

Generalized joint hypermobility (GJH) is an inherited connective tissue disease with joint hypermobility in the absence of a rheumatologic disease. Generalized joint hypermobility occurs in about 66% of school children with arthralgia of unknown origin. Some data suggest that GJH is more prevalent at earlier age and GJH patients often lead to normal lives. Disorders and disabilities in different organs can be seen GJH. Previous studies reported that children with GJH more frequently had sphincter dysfunction and nonneurogenic bladder. They believed that this condition manifested usually as constipation and possibly fecal soiling in boys and as urinary incontinence and possibly urinary tract infections in girls.

Cardiovascular disease (CVD) is the most common cause of morbidity and mortality in patients with chronic kidney disease (CKD). Hospitalizations of dialysis patients happen frequently and about one-third are from CVD. The annual cardiovascular mortality in dialysis patients is significantly higher than in the general population and about half of the deaths in dialysis patients are assigned to CVD. Different methods are used for cardiovascular evaluation in patients with CKD. Echocardiography, as a noninvasive and available technique, is the most useful imaging modality for a cardiac assessment.

Kidney transplantation is generally accepted as the best way for renal replacement therapy in patients with end-stage renal disease. Kidney transplant recipients could have a relatively high quality of life compared with maintenance hemodialysis. Despite the successful kidney transplant surgeries, rejection rate has still a high percentage in these patients; about 10% of them experience rejection within the first year. Knowing the high rate of complications and risk factors affecting kidney allograft survival, most of which are predictable and preventable, this issue has become increasingly important. Long-term kidney allograft survival has not paralleled improvements made in the past three decades in short-term survival.

Cytomegalovirus (CMV) is a beta herpes virus that can infect several organs. It is transmitted through infected body secretions, blood, and organ allografts, and is considered as the leading infectious reason of mortality and morbidity in organ transplantation. It is also the most important cause of infectious disease after kidney transplantation. Cytomegalovirus infection is defined according to the American Society of Transplantation’s recommendations for use in clinical trials as evidence of CMV replication without any symptoms. The existence of CMV symptoms, which can be characterized as a viral syndrome (fever, malaise, leukopenia, and thrombocytopenia) or as a tissue invasive disease confirmed the diagnosis of CMV disease. In addition, recurrent CMV infection is defined as new detection of CMV infection in a patients that has had previously documented CMV infection.

Systemic lupus erythematosus is a group of diseases that seem to become separate entities by etiology in the near future. Its pathogenesis remains elusive; however, multifactorial interactions among genetic and environmental factors may be involved. Systemic lupus erythematosus is the perfect prototype of autoimmune disorder with multiple derangements, starting from innate immunity to adaptive immune system leading to loss of self-tolerance. An overview of the pathogenesis of systemic lupus erythematosus is the focus of this review.

Organ transplantation as an undeniable life-saving therapeutic modality fundamentally requires infrastructure, devoted and trained professionals, and positive public attitude to be set up in a well-organized manner at the national level. In addition to sharing achievements and reviewing the increasing trend of transplanted organs in the past 12 years following legislations in Iran, this report raises some concerns from the point of transplantation outcome view.

Introduction. Generalized joint hypermobility is deemed to be an underlying risk factor for many clinical conditions. The goal of this study was to determine the prevalence of generalized joint hypermobility in patients with vesicoureteral reflux.Materials and Methods. This was a cross-sectional study on 313 children, 3 to 15 years old, with a history of urinary tract infection. Generalized joint hypermobility was evaluated according to the Beighton scores. Urinary tract ultrasonography and cystography were done if indicated. Participants were divided into 2 groups, group 1 without urinary tract abnormality and group 2 with primary vesicoureteral reflux, which were compared with the control group.Results. Generalized Joint hypermobility was documented in 37.2% of the children in the control group and 45.7% of those in group 1 (P= .25). This rate was 62.3% in group 2 (P< .001 compared to controls; odds ratio, 2.79; 95% confidence interval, 1.61 to 4.82). Generalized Joint hypermobility was seen in 44.1% of the children with mild VUR, 60.5% of those with moderate VUR, and 86.2% of those with severe VUR. There was a significant relationship between the hypermobility incidence and the urinary reflux severity (P= .003).Conclusions. This study showed the prevalence of GJH in children with VUR was more than that in the general population, and the prevalence of hypermobility syndrome increased with the reflux severity.

Introduction. Opiates are traditionally used for treatment of some acute heart disorders. There are only few reports on the effects of long-term treatment of cardiovascular diseases with morphine. This study aimed to investigate the effects of chronic low-dose morphine use on the cardiovascular system in two-kidney one-clip (2K1C) hypertensive rats.Materials and Methods. Male Wistar rats were divided into two groups as the sham and 2K1C groups and each group was further subdivided into saline and morphine treatment subgroups. Blood pressure, heart rate, plasma rennin activity, serum nitric oxide concentration, and baroreflex sensitivity were measured.Results. Morphine significantly attenuated systolic blood pressure, diastolic blood pressure, and mean arterial pressure in the 2K1C animals. In addition, morphine decreased plasma rennin activity in the 2K1C group. Serum concentrations of nitric oxide were also decreased, and morphine prevented the reduction of nitric oxide. The baroreflex sensitivity was also improved following morphine administration in the 2K1C group.Conclusions. According to the results presented in this study, chronic administration of low-dose morphine reduces regulated hypertension in the 2K1C rats, probably via a nitric oxide-dependent pathway.

Introduction. Diabetic Nephropathy (DN) is one of the main complications of diabetes mellitus, mostly ending to end-stage renal disease. Leptin and C-reactive protein (CRP), as inflammatory markers implicated in the progression of DN, increase in diabetes mellitus, while transferrin and albumin, as members of anti-oxidant defense mechanism, are found to decline.Materials and Methods. In a controlled clinical trial, 65 patients with type 2 DN were assigned to receive lovastatin or placebo, for 3 months, to assess statins’ impact on serum levels of leptin, CRP, transferrin, albumin, and lipid profile.Results. Serum levels of CRP (3.52±4.16 mg/dL to 2.84±3.06 mg/dL, P= .02), leptin (10.78±8.30 mg/dL to 7.80±5.41 mg/dL, P= .006), low-density lipoprotein cholesterol (116.16±46.54 mg/dL to 85.46±29.22 mg/dL, P< .001), and total cholesterol (199.00±43.33 mg/dL to 164.67±35.19 mg/dL, P< .001) were lowered after lovastatin therapy. Mean serum level of high-density lipoprotein cholesterol increased (40.00 mg/dL to 42.80 mg/dL, P= .005) after the treatment. Lovastatin had no significant effect on albumin and transferrin. Placebo did not change any of the parameters after 3 months.Conclusions. The effect of statins on the inflammatory markers involved in the development of DN is a new approach to evidence supporting the pleiotropic effect of this drug group.

Introduction. Cardiovascular disease is the major cause of death in hemodialysis patients. Regular aerobic or intradialytic exercise may play a role in reducing cardiovascular mortality in these patients. The aim of this study was to evaluate the relationship between intradialytic exercise and echocardiographic findings.Methods and Materials. Forty patients were enrolled in the study from Shahrekord Hemodialysis Center. They were randomly assigned into the exercise and control groups. In the exercise group, the patients had a 30-minute exercise program per dialysis session, 3 times a week, for 3 months. Electrocardiography and echocardiography were done at the beginning of the study and 3 months later.Results. The mean age and body mass index of the patients were 43.2±10.5 years and 21.7±5.4 kg/m2, respectively. Left ventricular ejection fraction increased and systolic pulmonary artery pressure and right ventricular size decreased significantly after the study in the exercise group patients.Conclusions. Our results showed the improvement of cardiac systolic and diastolic function in patients who had physical exercise during dialysis sessions. Regular intradialysis exercise can be suggested for hemodialysis patients without cardiac disease.

Introduction. Free triiodothyronine (FT3) is a marker of comorbidity in end-stage renal disease and in many acute and chronic diseases. There is lack of data about the link between FT3 levels and malnutrition and inflammation in hemodialysis patients. The objective of the present study was to investigate the link between FT3 and malnutrition and inflammation in hemodialysis patients.Materials and Methods. A total of 84 patients were included in the study (38 men and 46 women; mean age, 56.2±14.8 years; hemodialysis duration, 95.72±10.35 months). Serum FT3, free thyroxin, and thyroid-stimulating hormone concentrations were determined. Demographic data and laboratory values were evaluated. Patients' comorbidity status was determined using the Charlson Comorbidity Index (CCI), and malnutrition-inflammation status was determined by Malnutrition-Inflammation Score (MIS).Results. Serum FT3 concentration inversely correlated with age (r= -0.328, P= .002), CCI (r= -0.591, P< .001), C-reactive protein (r= -0.299, P= .01), and MIS (r= -0.671, P< .001), and positively correlated with serum albumin (r= 0.389, P< .001). In multivariate linear regression analysis, FT3 was independently associated with MIS (b, -0.14; 95% confidence interval, -0.175 to 0.063, P= .003), adjusted for CCI, C-reactive protein level, serum albumin level, and MIS.Conclusions. The results of this study indicate that FT3 is negatively correlated with inflammatory markers, namely C-reactive protein, and it is independently related with MIS in hemodialysis patients. Therefore, we suggest that FT3 can be accepted as an inflammatory marker in hemodialysis patients.

Introduction. The aims of this study was to evaluate maintenance hemodialysis population in a tertiary care hospital based dialysis unit for vascular access (VA) types, to compare native arteriovenous fistula (AVF) and arteriovenous graft (AVG) survival, and to assess risk factors for access failure.Materials and Methods. A total of 182 patients on maintenance hemodialysis were evaluated and followed up in terms of VA type and VA outcomes.Results. Among 103 prevalent patients, 15.5% initiated dialysis with AVF. At the time of the study, 67.9% of the prevalent patients had an AVF and 29.1% had AVG. Of 79 incident patients, 64% were followed up for more than 3 months by nephrologists before initiation of dialysis. Among these patients, 13.6% were initiated with AVF. There were 25 primary failures and 50 secondary failure episodes. Of the 50 secondary failures, 15 were AVF failures and 31 AVG failures. Vascular access survival was significantly superior with AVF as compared with AVG (P= .03). With longer dialysis periods, failure rates were higher. Follow-up with nephrologists prior to initiation of dialysis had a major influence on VA.Conclusions. Arteriovenous fistula is the best VA for maintenance hemodialysis. However, when the vasculature is not ideal for AVF, AVG should be constructed. A small percentage of our patients had fistula at initiation of dialysis. This is mainly due to late nephrology referrals and also due to reluctance of patients to undergo surgical access placement when they are relatively asymptomatic.

Introduction. Kidney allograft failure is a major concern in kidney transplant recipients. We separately assessed risk factors for long-term and short-term survival of death-censored kidney allograft.Materials and Methods. This study included 397 kidney recipients who underwent surgery in Afzalipour Hospital, Kerman, Iran, from 2004 to 2010. The Cox mixture cure model was used to fit independent variables for prediction of graft survival in short-term and long-term.Results. Allograft failure occurred in 43 kidney transplant recipients (10.8%). Among the long-term survivors, hypertension (odds ratio, 3.35; 95% confidence interval [CI], 1.6 to 6.7), a serum creatinine level greater than 1.6 at hospital discharge (odds ratio, 15.1; 95% CI, 7.2 to 31.9), and donor age (odds ratio, 1.14; 95% CI, 1.09 to 1.18) were significant predictors of allograft failure. Overweight, obesity, and male donor were associated with better survival. In short-term survivors, a high body mass index (hazard ratio, 3.59; 95% CI, 1.2 to 10.7) and longer duration of pretransplant dialysis (hazard ratio, 2.4; 95% CI, 1.07 to 5.7) were associated with graft failure, while the risk of allograft failure decreased in recipients who received kidney transplants from living donors versus deceased donors (hazard ratio, 0.3; 95% CI: 0.11 to 0.78) and with each 1-year increase in donor age (hazard ratio, 0.91; 95% CI, 0.86 to 0.96).Conclusions. Many efforts have been made to improve short-term survival of kidney allograft. The cure analysis extends the knowledge by showing that control of which variables can improve both long-term and short-term survival rates.

Introduction. Recurrence of cytomegalovirus (CMV) infection following solid organ transplantation causes mortality and morbidity in allograft recipients. The aim of this study was to evaluate prevalence and risk factors of recurrent CMV infection in kidney transplant patients.Materials and Methods. Four hundred and twenty-seven consecutive kidney transplant recipients were included in this retrospective cohort study. Both donors and recipients were CMV seropositive. Recurrent CMV infection (symptomatic or asymptomatic) was defined as detection of CMV infection in a patient who has had previously documented infection and who had not have virus detected for an interval of at least 4 weeks during active surveillance.Results. Of 427 recipients, 71 (16.6%) had CMV infection, of which 19 (4.4%) were recurrent infection. Donor source, dialysis duration before transplantation, recipient and donor age and sex, and administration of antithymocyte globulin and prophylactic treatment ganciclovir were not associated with CMV infection or recurrence. The use of tacrolimus in the immunosuppressive regimen as compared to cyclosporine was an independent risk factor for CMV infection but not recurrent infection.Conclusions. Intensive immunosuppressive regimen, such as using tacrolimus, might be associated with a higher risk for CMV infection, but this study was not able to document the same association for recurrent CMV disease. In patients receiving immunosuppressive regimens that include tacrolimus and antithymocyte globulin, prophylactic treatment for CMV disease with ganciclovir is recommended.

This study sought to determine the prevalence of fibromyalgia syndrome and to identify whether fibromyalgia was associated with various clinical symptoms and laboratory parameters in hemodialysis patients. One hundred and forty-eight hemodialysis patients were examined for fibromyalgia symptoms according to the American College of Rheumatology criteria. Demographic characteristics, as well as causes of kidney failure, dialysis duration, and symptoms related to fibromyalgia were investigated. Of 148 patients, 18 (12.2%) were diagnosed with fibromyalgia. Patients with fibromyalgia had significantly poorer sleeping satisfaction than the control group (P= .02). The Beck Depression Inventory score was higher in 77.8% of the fibromyalgia patients than that in the control group (P= .006), but there was no significant difference in the anxiety score between the two groups (P= .86). In conclusion, there was a higher prevalence of fibromyalgia in hemodialysis patients than previously reported. Sleep disturbances and depression levels correlated with fibromyalgia.

Ciprofloxacin is a commonly used antibiotic. Renal side effects are rare and are usually immune mediated. Clinical and experimental studies have suggested that crystalluria and crystal nephropathy occur in alkaline urine. Preexisting kidney function impairment, high dose of the medication, and advanced age predispose to this complication. We report a case of crystal nephropathy in a young woman treated with ciprofloxacin and a nonsteroidal anti-inflammatory drug.

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder characterized by the development and growth of cysts in the kidneys. Non-nephritic-range proteinuria is a common presentation in ADPKD patients; however, nephrotic syndrome is a rare coincidence. A 52-year-old man is described who was diagnosed with secondary amyloidosis with ADPKD. To our knowledge, this is the first case of amyloidosis associated with frequently infected renal cysts. Patients with ADPKD who show massive proteinuria should be investigated in terms of concomitant glomerular disease.

We present acute phosphate nephropathy in a 28-year-old man, which was developed after a car accident due to rhabdomyolysis. Treatment of acute kidney injury was done with administration of sodium bicarbonate.

Alport syndrome is a progressive hereditary disease caused by mutations in the genes encoding type IV collagen. Persistent microscopic hematuria is the hallmark of Alport syndrome, occurring in almost all boys according to previous reports. We report the case of a 20-year-old man presented with proteinuria but no hematuria that was initially misdiagnosed with refractory nephrotic syndrome and was eventually diagnosed with Alport syndrome following kidney and skin biopsy. During the followup period, he experienced a rapid progression to end-stage renal disease. Timely diagnosis of Alport syndrome is important, because patients may benefit from early intervention and avoid suffering from unnecessary nephrotoxic drug use.

Calciphylaxis is characterized by calcification and thrombosis of arteries resulting in ischemic necrosis of predominantly skin and subcutaneous tissue. Primarily affecting patients with end-stage renal disease, calciphylaxis is diagnosed rarely in the absence of renal replacement therapy. We report an elderly obese woman presented with leg pain and ulceration. She had chronic kidney disease, diabetes mellitus, hypertension, and peripheral vascular disease. Angiography revealed occlusion of the left superficial femoral, popliteal, and distal tibial arteries. Amputation was performed. Histological examination demonstrated medial calcification, intimal hyperplasia, and thrombosis of small- and medium-sized arteries in the subcutaneous tissue. This case features calciphylaxis in a patient with chronic kidney disease before the onset of uremia. Calciphylaxis and atherosclerotic peripheral vascular disease have several risk factors in common. This report calls attention to a disorder that can be masqueraded as leg ulceration due to peripheral vascular disease in the absence of renal replacement therapy.

Dear Editor: With great interest, we recently read the article by Makhlough and collegues titled "Relationship Between Serum Intact Parathyroid Hormone and Pruritus in Hemodialysis Patients" published in your most valuable journal. This study focused its massage on sociodemographic and laboratory factors affecting on pruritus in hemodialysis patients. It is of interest that the authors concluded high levels of intact parathyroid hormone (PTH) correlated with the severity of pruritus in hemodialysis patients. Akhyani and colleagues showed there was no significant relationship between pruritus and serum level of PTH in hemodialysis patients. In addition, another study found that PTH injection in to the skin did not lead to pruritus, so PTH itself was not pruritugenic.

Dear Editor: The optimal treatment of a disease requires the knowledge of the etiology of the disease. However, in real life, this is largely elusive in the majority of diseases affecting the humans. The situation with regard to nephrotic syndrome (NS) in children is also no exception. The vast majority of cases of NS belong to the idiopathic category. Traditionally, immune pathogenesis has been thought to play the predominant role in the pathogenesis of the disorder. This is the basis for the use of steroids and immunosuppressive drugs for the empirical treatment of this condition. Since steroids form the mainstay of treatment of idiopathic NS in children, the disease is often classified on the basis of response to this treatment into steroid sensitive (SSNS) and steroid resistant (SRNS) types. Among these, the later poses significant therapeutic challenges to the pediatric nephrologists.