Ahmed M. Alkhunaizi

Acute bile nephropathy secondary to anabolic steroids.

Renal dysfunction in cholestatic liver disease is multifactorial. Acute kidney injury may develop secondary to renal vasoconstriction in the setting of peripheral vasodilation and relative hypovolemia, tubular obstruction by bile casts, and direct tubular toxicity from bile. Anabolic steroids are frequently used by athletes to boost endurance and increase muscle mass. These agents are a recently recognized cause of hepatotoxicity and jaundice and may lead to acute kidney injury. To increase awareness about this growing problem and to characterize the pathology of acute kidney injury in this setting, we report on a young male who developed acute kidney injury in the setting of severe cholestatic jaundice related to ingestion of anabolic steroids used for bodybuilding. Kidney biopsy showed bile casts within distal tubular lumina, filamentous bile inclusions within tubular cells, and signs of acute tubular injury. This report supports the recently re-emerged concept of bile nephropathy cholemic nephrosis.

Acanthamoeba encephalitis in a patient with systemic lupus treated with rituximab

Acanthamoeba species are free-living protozoa that can infect humans and animals. Acanthamoeba can cause serious central nervous system infections in immunocompromised hosts. Here we report a case of Acanthamoeba encephalitis in a patient with lupus nephritis, 1 month after completing a course of rituximab, an anti-CD20 chimeric antibody.

Urinary stones in Eastern Saudi Arabia.

Introduction: Nephrolithiasis is a common problem worldwide especially in areas of the hot climate like Saudi Arabia. The aim of this analysis was to study the characteristics of urinary stones in Eastern Saudi Arabia and to report the following: Composition of urinary stones, age and gender distribution, seasonal variation of stone development, comorbid conditions associated with stone development and the incidence of urinary stones. Methods: All urinary stones that were submitted to the Johns Hopkins Aramco Healthcare, previously Saudi Aramco Medical Services Organization for analysis from January 2011 through January 2013 were analyzed. Results: A total of 384 urinary stones were collected and submitted for analysis from 347 patients. There was a male predominance with a male: female ratio of 3.9:1. The average age was 48.5 ± 12.8 years. Weight abnormality was predominant in both genders, and especially females. Calcium-based stones constituted the great majority (84.6%) followed by uric acid stones (12.8%). The other forms of stones were rare. More stones were recovered during the hot season, May to September. The calculated annual incidence of urolithiasis was 111/100,000 individuals. Conclusion: Calcium based stones are the most common urinary stones observed in Eastern Saudi Arabia. There is a clear association between the diagnosis of urinary stones and the hot season

Negative Staining for COL4A5 Correlates With Worse Prognosis and More Severe Ultrastructural Alterations in Males With Alport Syndrome

Introduction Alport syndrome (AS) is a genetic disorder characterized by progressive hematuric nephropathy with or without sensorineural hearing loss and ocular lesions. Previous studies on AS included mostly children. Methods To determine the prognostic value of loss of staining for collagen type IV alpha 5 (COL4A5) and its relationship with the ultrastructural glomerular basement membrane alterations, we performed direct immunofluorescence using a mixture of fluorescein isothiocyanate-conjugated and Texas-red conjugated antibodies against COL4A5 and COL4A2, respectively, on renal biopsies of 25 males with AS (including 16 who were diagnosed in adulthood). Results All patients showed normal positive staining of glomerular basement membranes and tubular basement membranes for COL4A2. Of the 25 patients, 10 (40%) patients showed loss of staining for COL4A5 (including 89% of children and 13% of adults) and the remaining 15 (60%) had intact staining for COL4A5. Compared with patients with intact staining for COL4A5, those with loss of staining had more prominent ultrastructural glomerular basement membrane alterations and were younger at the time of biopsy. By Kaplan-Meier survival analysis and Cox regression analysis, loss of staining for COL4A5 predicted earlier progression to overt proteinuria and stage 2 chronic kidney disease or worse. By multivariate Cox regression analysis, loss of staining for COL4A5 was an independent predictor of the development of overt proteinuria and stage 2 chronic kidney disease or worse. Discussion Thus, the COL4A5 expression pattern has an important prognostic value and it correlates with the severity of ultrastructural glomerular basement membrane alterations in males with AS. Loss of COL4A5 staining is uncommon in patients with AS diagnosed in their adulthood.

Renal Involvement in Methylmalonic Aciduria

True positive result denotes correct placement of hemodialysis catheter according to bubble-enhanced ultrasound and chest radiography. True negative result 1⁄4 incorrect placement of hemodialysis catheter according to bubble-enhanced ultrasound and chest radiography. False positive result 1⁄4 correct placement of hemodialysis catheter according to bubble-enhanced ultrasound not confirmed by chest radiography. False negative result 1⁄4 incorrect placement of hemodialysis catheter according to bubbleenhanced ultrasound not confirmed by chest radiography. Sensitivity 1⁄4 (true positive/[true positive þ false negative]). Specificity 1⁄4 (true negative/[true negative þ false positive]). Diagnostic accuracy 1⁄4 ([true positive þ true negative]/[true positive þ true negative þ false positive þ false negative). RESEARCH LETTERS

Prevalence of Microalbuminuria in Adult Patients with Sickle Cell Disease in Eastern Saudi Arabia

Background Proteinuria is a common feature of sickle cell nephropathy (SCN) that can progress to renal insufficiency and end stage renal disease. Microalbuminuria (MA) is the earliest manifestation of SCN and precedes the development of overt proteinuria. In addition to the renal consequences, MA is linked to cardiovascular complications. Periodic screening and early detection of MA allow early intervention that may reduce the risk of progression to advanced renal failure and cardiovascular diseases. Objective The aim of this study was to investigate the prevalence of MA in patients with SCD in the eastern region of Saudi Arabia. Methods A prospective cross-sectional observational study was conducted at Johns Hopkins Aramco Healthcare (JHAH). Urine samples of SCD patients 18 years old and older were tested for the presence of MA using urinary albumin over creatinine ratio (ACR). Correlation was tested with multiple variables including age, gender, body mass index (BMI), hemoglobin level, blood pressure, blood transfusion history, pain episodes, and use of hydroxyurea. Results Urine samples were tested on 72 patients. The mean age of the study cohort was 35 ± 16.9 years. Microalbuminuria was detected in 18 patients (25%). No correlation was found with any of the tested variables. Conclusion Microalbuminuria is a common finding in patients with SCD in eastern Saudi Arabia. Patients with SCD should be screened for MA, and those with positive tests should probably be treated with antiproteinuric agents that may slow the progression to advanced stages of renal failure and decrease the risk of cardiovascular diseases.

Fusarium Infection in a Kidney Transplant Recipient Successfully Treated with Voriconazole

Fusarium infections in solid-organ transplant recipients are rare and carry high mortality. We report a case of a kidney transplant recipient who developed infection with Fusarium species. The patient received treatment with oral voriconazole for five months with good response.

ANCA-positive crescentic glomerulonephritis in a patient with rheumatoid arthritis treated with anti-tumor necrosis factor alpha

Dear Editor, Anti-tumor necrosis factor alpha (anti-TNF-a) are widely used antibodies to treat aggressive cases of rheumatoid arthritis (RA). Although these agents are well tolerated, serious side-effects such as reactivation of tuberculosis, heart failure, hematologic diseases and flare of vasculitis have been reported. More recently, a few case reports of glomerulonephritis resulting from treatment with these agents have been reported. Here we report on the clinical course of a patient with rheumatoid arthritis who developed myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA) associated glomerulonephritis.

Angiosarcoma at the site of nonfunctioning arteriovenous fistula in a kidney transplant recipient

Angiosarcoma is a rare malignant neoplasm of the endothelial cells of blood vessels or lymphatics. We report a case of a 46-year-old male patient with a kidney transplant who developed epithelioid angiosarcoma at the site of a nonfunctioning arteriovenous fistula in the antecubital fossa 3 years after renal transplantation. The patient had skin, soft tissue, and bone metastasis on presentation. He died of systemic metastasis with respiratory failure.