Alaa Sabry

Long-term follow-up of living kidney donors: a longitudinal study

To analyse retrospectively the general health status and renal and cardiovascular consequences of living‐related kidney donation, as the long‐term effects of unilateral nephrectomy for kidney donation are of particular interest with the currently increasing practice of living‐donor transplantation.

Can Donor Implantation Renal Biopsy Predict Long-Term Renal Allograft Outcome?

Background: Donor kidney implantation biopsy (IB) is performed on a regular basis, particularly as part of clinical studies. Objective: To determine the utility of donor implantation renal biopsy to predict the long-term renal allograft outcome. Methods: A Medline search for studies in English was performed with the following key words: implantation biopsy, renal transplantation and long-term outcome. Results: Sixteen trials involving 8,122 kidney transplants were identified, of which 6 were prospective studies. The histological abnormalities were scored mainly by the Banff schema and the graft outcome was defined either by delineating the delta changes in the pathology score or glomerular filtration rate. Normal histology with a well-functioning renal allograft had a favorable outcome. The extent to which the baseline tubular atrophy, interstitial fibrosis, glomerulosclerosis and vascular changes had on the long-term outcome varied from one study to another. Conclusion: Abnormal IB has a better chance of predicting early graft outcome. The review questions the current wisdom for routine IB on all donors. In some donor kidneys, a biopsy provides significant prognostic information, such as older donor kidney, those with history of hypertension, diabetes, cardiovascular disease, and kidneys with abnormal creatinine. Future research on IB is necessary to find a more useful method to predict the long-term transplant outcome.

Correlation between levels of TNF-α and IL-6 and hematological involvement in SLE Egyptian Patients with lupus nephritis

BackgroundSystemic lupus Erythematosus (SLE) is a rheumatic autoimmune disease characterized by multisystem organ involvement and by high titers of auto antibodies against several nuclear and cytoplasmic antigens. Numerous abnormalities of the cytokine network have been described in patients suffering from SLE. However the role of cytokines in different organ involvement is not yet well defined.ObjectiveTo determine if levels of Interlukin-6 (IL-6) and Tumor necrosis factor (TNF-α) correlate with SLE disease activity in Egyptian SLE patients and more specifically with hematological involvement.MethodsLevels of TNF-α and IL-6 in serum samples from sixty individuals (40 with Systemic lupus Erythmatosus and 20 healthy controls) were determined and renal biopsies were obtained from SLE patients.ResultsLevels of TNF-α and IL-6 were higher in SLE patients with active compared with inactive hematological disease. Further analysis showed that this association was dependent on inverse correlation (P=0.017, r=−0.49) for IL-6 and (P=0.76, r=−.243) for TNF-α. The mean level of TNF-α and Il-6 was (766.95±357.82 pg/ml) and (135.4±54.23 pg/ml) respectively for patients with active disease while it was (314.01±100.87 pg/ml) and (47.33±18.61 pg/ml) for those with inactive disease and (172.7±39.19 pg/ml) and (21.15±10.99 pg/ml) for the healthy control group respectively. The difference was statistically significant (P=0.002). We found significant positive correlations between TNF-α and IL-6 and the SLE Disease Activity Index (SLEDAI) score. (r=+0.743 and +0.772 respectively).ConclusionRaised level of Il-6 and TNF-α may influence the development of anemia in Egyptian patients with Lupus Nephritis.

Acute postinfectious crescentic glomerulonephritis: clinicopathologic presentation and risk factors.

Background: Glomerular crescent formation is a feature of the most severe forms of human glomerulonephritis. The postinfectious form of rapidly progressive glomerulonephritis with crescents is a form of immune complex glomerulonephritis which seem to have a better prognosis. A relatively poorer prognosis for crescentic postinfectious glomerulonephritis in South Africa has been reported. In the present study, we have tried to determine the mode of presentation, and the prognostic factors for renal and patient outcome for cases with postinfectious crescentic glomerulonephritis (CGN). Methods:Between 1990 and 2000 a total number of 128 patients with CGN were managed at our center, among them 23 cases were diagnosed as postinfectious CGN. They were followed-up for a mean period of 40.1 ± 28.9 months. Among them 12 were males and 11 were females. The median age was 12.35 years (range 4–55 years). The median serum creatinine at presentation was 7.24 mg/dl (range 1.3–14.5 mg/dl). We studied the clinical, laboratory and histopathological data .of our cases and their impact on the renal and patient outcome. Results:By univariate study the risk factors for renal dysfunction were the age, hypertension, and nephrotic range proteinuria during the follow-up period. By multivariate analysis only the, hypertension, and presence of nephrotic range proteinuria during the follow-up period were the significant risk factors. The risk factors that significantly affected patient mortality were hypertension and serum creatinine at last follow-up. Conclusion: postinfectious CGN is a severe form of glomerulonephritis that usually presents with rapidly progressive renal failure. The persistence of hypertension and nephrotic range proteinuria during the follow-up are major bad prognostic predictors for renal dysfunction.

Cinacalcet Hydrochloride Therapy for Secondary Hyperparathyroidism in Hemodialysis Patients

This study compared the efficacy of a cinacalcet‐based regimen with unrestricted conventional therapy (vitamin D and phosphate binders) for achieving Kidney Disease Outcome Quality Initiative (K/DOQI) targets for dialysis patients. In this multicenter, prospective study, hemodialysis patients with poorly controlled secondary hyperparathyroidism (SHPT) were randomized to receive a cinacalcet‐based regimen (n = 55) or a conventional therapy (n = 27). Doses of cinacalcet, vitamin D sterols, and phosphate binders were adjusted during a 12‐week dose‐titration phase to achieve intact parathyroid hormone (iPTH) levels ≤ 31.8 pmol/L. The primary end point was the percentage of patients with values in this range during a 24‐week efficacy‐assessment phase. The clinical response to 36‐week cinacalcet treatment was evaluated. A dual energy X‐ray absorptiometry was performed before and after 36 weeks of cinacalcet therapy. Fifty‐eight percent of the cinacalcet group reached the primary end point, as compared with 19% of the conventional therapy group (P = 0.001). A higher percentage of patients receiving the cinacalcet‐based regimen versus conventional therapy achieved the targets for calcium, phosphorus and Ca × P. Achievement of targets was greatest in patients with less severe disease (intact PTH range, 31.8 to 53 pmol/L). Cinacalcet therapy increased proximal femur bone mineral density (BMD), but did not affect the lumbar spine. Itching intensity decreased significantly. Cinacalcet based treatment facilitates achievement of the K/DOQI targets for iPTH and bone mineral metabolism compared with conventional therapy in hemodialysis patients. Suppression of iPTH with cinacalcet reverses bone loss in the proximal femur. Cinacalcet alleviated itching.

Anticoagulation therapy during haemodialysis : a comparative study between two heparin regimens

Low-molecular-weight heparins have been suggested as providing well tolerated, efficient, convenient and possibly more cost-effective anticoagulation for haemodialysis than unfractionated heparins (UFHs). A single-bolus dose at the start of haemodialysis effectively prevents clot formation in the dialyser and air trap with fewer side effects and possible benefits on uraemic dyslipidaemia. The safety, clinical efficacy and cost of two anticoagulation regimens in 23 haemodialysis patients were compared over 12-month period. The study comprised two stages: the first stage in which UFH was used for 6 months and the second stage in which UFH was replaced by tinzaparin sodium. The relationship between the anticoagulant effect of tinzaparin sodium and clinical clotting during haemodialysis was recorded. Clinical clotting (grades 1–4) was evaluated by visual inspection after blood draining of the air trap every hour and by inspection of the dialyser after each session. The costs and effects of both anticoagulant protocols on the lipid profile were also compared. Anticoagulation with tinzaparin sodium resulted in less frequent dialyser and air-trap clotting compared with UFH (P = 0.001 and 0.04, respectively). Over 24 weeks, no changes in standard serum lipid profiles were observed. There was statistically significant improvement in dialysis adequacy – evidenced by improved single-pool Kt/V 6 months after tinzaparin sodium use (1.40 ± 0.28 tinzaparin sodium versus 1.23 ± 0.28 for UFH) without any change in the haemodialysis prescription. The total cost of 24-week use of tinzaparin sodium was 23% more expensive compared with that of UFH. Tinzaparin sodium should be considered as an effective, well tolerated and may be a superior alternative to conventional heparin anticoagulation in haemodialysis. However, at least – on the short term – tinzaparin sodium therapy did not affect lipid profile in haemodialysis patients. Currently, the direct cost in Saudi Arabia is a little more than standard heparin by about 23%.

Effect of Colchicine on Chronic Ciclosporin Nephrotoxicity in Sprague-Dawley Rats

Thirty male Sprague-Dawley rats were given ciclosporin (Cs) orally, 15 mg/kg daily for 80 days. Fifteen served as positive controls, while the other 15 were given daily colchicine at a dose of 30 µg/kg in addition to Cs. Additional 15 rats were given olive oil only and served as negative controls. The animals were subjected every other week to laboratory assessment of serum creatinine, sodium, potassium, and Cs whole-blood trough levels; also urine samples were examined for creatinine, sodium, potassium, and protein concentrations. At the end point, the animals were sacrificed, and kidney tissue was examined for histopathological changes. Comparing negative control versus Cs-treated and Cs-plus-colchicine-treated rats, there were no significant differences in serum creatinine, creatinine clearance, and serum and urine values of sodium and potassium as well as urinary protein/creatinine ratios. Yet histopathological examination of kidney tissues showed focal tubular atrophy and interstitial fibrosis in inner medulla and inner stripe of the outer medulla in all Cs-treated animals and in only 1 of the colchicine-treated group, but in none of the negative controls. Histological changes in other kidney zones in different animal groups were minor and not different. From this study, we may conclude that colchicine is of protective value against chronic Cs nephrotoxicity in Sprague-Dawley rats.

Factors affecting response to hepatitis b vaccine among hemodialysis patients in a large Saudi Hemodialysis Center

The aim of this study is to determine the response to hepatitis B virus (HBV) vaccination in patients on hemodialysis (HD) and to identify the factors that could affect this response. This retrospective study was carried out during the period from January 2009 to December 2009 in the Prince Salman Center for Kidney Diseases (PSCKD), Riyadh, and included 144 patients (78 males and 66 females) on regular HD, all of whom received hepatitis B vacci-nation. Patients were divided into two groups according to the level of hepatitis B surface antibodies (HBsAb): Responders group (>10 IU/L) and non-responders group (<10 IU/L). The study looked at the factors that may affect the responsiveness to hepatitis B vaccination, like gender, age, co-existence of hepatitis C virus (HCV) infection, dialysis adequacy that was evaluated by urea reduction ratio (URR) and Kt/V, hemoglobin level, albumin level, protein catabolic rate (PCR), body mass index (BMI), subjective global nutritional status (SGA) and HbA1c. There were 129 patients (89.6%) in the responders group including 69 males and 60 females and 15 patients (10.4%) in the non-responders group including nine males and six females. The mean age in the responders group and the non-responders group was 50.56 ± 15.35 and 56.87 ± 12.52 years, respectively (P = 0.128). The mean value of the PCR was 1.03 ± 0.17 and 0.88 ± 0.17 g/kg/day in the responders group and non-responders group, respectively (P = 0.002). There was no statically significant difference between the two groups regarding the presence or absence of HCV infection, age, gender, diabetes mellitus, URR, Kt/V, hemoglobin level and albumin level. We report a high response rate (89%) for HBV vaccination in our HD patients. The PCR was the only factor that affected the response to HBV vaccination in these patients.

Markers of Tubular and Glomerular Injury in Predicting Acute Renal Injury Outcome in Thermal Burn Patients: A Prospective Study

Background/aim. Thermal injury elicits several systemic consequences. Acute renal failure (ARF) is a well-known complication of severe burn and is an important factor leading to an increase in mortality. We aimed to focus on early diagnosis of acute renal failure occurring in major burns and to determine the predictors for acute renal failure. Subjects and methods. Forty patients with moderate to severe thermal burn injury—second- to third-degree with >20% of total body surface area—constituted the material of our study. The following parameters were recorded: age, sex, cause of the burn injury, burn surface of second and third degrees expressed as total body surface area burned in %, and Apache II score. All patients were subjected to routine investigations, including serum creatinine, blood urea nitrogen, fractional excretion of sodium, urinary malondialdehyde and microalbuminuria, completed on days 0, 3, 7, 14 and 21. Results. Nine patients (22.5% of all cases) developed acute renal failure, and four patients required supportive dialysis. The group that developed ARF showed rising markers of glomerular damage with appearance of microalbuminuria on day 0 that was maximal (3–4 times its normal level) at day 14 and constant with elevated serum creatinine, as well as burn size in the third week that progressed to overt proteinuria in three cases. Urinary malondialdehyde was also elevated before developing acute renal failure about three times their normal values, gradually increasing on day 14, associated with rising microalbuminuria followed by its decrease after controlling of septicemia. Two cases (22.2%) in ARF group who developed septicemia and required dialysis died on the 32nd and 36th days post-burn. Burn size and occurrence of septicemia were the only predictors of acute renal failure using multiple regression analysis (SE B 0.003 and 0.104; p value of 0.001 and .0371, respectively). Conclusions. Acute renal failure, which complicates 22.5% of burn patients, was found to be related to the size and depth of burn. Microalbuminuria and urinary malondialdehyde are useful markers for prediction of renal outcome in such group of patients. In our study. burn size and septicemia proved to be the only clinical parameters that predict renal outcome.

Effect of Spontaneous Closure of Arteriovenous Fistula Access on Cardiac Structure and Function in Renal Transplant Patients

Background/Aim: The effect of spontaneous closure of arteriovenous fistula (AVF) used for hemodialysis on the heart is not adequately studied. The aim of this study was to assess the effect of spontaneous AVF closure in the early period after renal transplantation on the patient’s outcome. Methods: Seventeen patients (13 males, 4 females) who had their AVF thrombosed within the first month after transplantation were retrospectively compared to another well-matched and persistent AVF group of patients comprising of 34 patients (27 males, 7 females). Echocardiographic assessment was done before transplantation and at 1 year after transplantation. Results: In the thrombosed fistula group, there was a trend towards lower values of left ventricular end-systolic andend-diastolic diameters as well as end-systolic and end-diastolic volumes of the left ventricle, but it did not reach statistical significance. The persistent AVF group had significantly higher estimates for cardiac output and cardiac index (p < 0.05). Both groups were comparable for left ventricular mass, left ventricular mass index, and left ventricular systolic and diastolic functions. There was no difference regarding patient and graft survival in both groups. Conclusion: Spontaneous AVF thrombosis did not offer a cardiac beneficial effect and routine fistula closure is not warranted.