Ehab W. Wafa

Human ochratoxicosis and nephropathy in Egypt: A preliminary study:

This preliminary study was designed in a trial to delineate the size of the problem of ochratoxicosis and its relation to genesis of lesions mounting to end stage renal disease (ESRD) or urothelial tumors in Egypt. This study comprised five groups of patients having renal diseases of different presentations; they are: patients with (ESRD) under conservative medical treatment (group 1), patients with (ESRD) under treatment with regular hemodialysis (group 2), renal allograft recipients (group 3), patients with nephrotic syndrome (group 4) and patients with urothelial tumors (group 5). In addition, two reference groups: potential related donors for renal transplantation (group 6) and healthy control with negative family history of renal disease (group 7). For all groups, laboratory, radiological and histopatho-logical evaluation of kidney status were carried out coupled with determination of ochratoxin A level in serum, in urine and in biopsy specimens of patients with urothelial tumors. High ochratoxin serum levels were found in patients with ESRD (groups 1 and 2) (P50.01), higher serum levels were detected in the group without dialysis (group 1) in comparison with the reference groups possibly due to ochratoxin. A clearance by dialysis. Ochratoxin A was detected in serum and urine of renal transplant recipients (group 3) (P50.01) and especially higher levels were found in patients with nephrotic syndrome (group 4) (P50.001). For the group with urothelial tumor (group 5), positive serum, urine and tissue biopsy specimens for ochratoxin levels were found (P50.01). The results could lead to the conclusion that ochratoxin A could be correlated to the genesis of renal disease leading to (ESRD) or causing urothelial cancer. A thorough and in depth study of the problem of ochratoxicosis and renal disease causation in Egypt is now recommended.

Weight gain after renal transplantation is a risk factor for patient and graft outcome.

Background. The present study aimed to evaluate the effect of weight gain after transplantation on patient and graft outcome. Methods. Patients receiving kidney transplants between April 1986 and April 2001 were divided according to their body mass index (BMI) at 6 months after transplantation into group I, BMI less than 25 (normal weight); group II, BMI greater than or equal to 25 and less than 30 (overweight); and group III, BMI greater than or equal to 30 (obese) after exclusion of pediatric patients (aged ≤18 years), second transplant recipients, those with a history of cardiovascular disease, and those with a BMI less than 25 and greater than 18.5 kg/m2. Six hundred fifty kidney transplant recipients were selected for this retrospective study. Results. There was a statistically significant increase in the incidence of posttransplant hypertension, diabetes mellitus, and ischemic heart disease in the obese group. The incidence and frequency of acute rejection episodes were similar in the three groups. A trend toward decreased graft and patient survival, which reached significance at 5 years and 10 years, was observed in the obese group. Conclusions. BMI has a strong association with outcomes after renal transplantation independent of most of the known risk factors for patient and graft survival.

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.

Magnetic resonance imaging as a sole method for the morphological and functional evaluation of live kidney donors

In this section, authors from Mansoura describe their experience with MRI as the sole method for the morphological and functional evaluation of live kidney donors. They recommend this technique in both instances.

Living-donor kidney retransplantation: risk factors and outcome

Authors from Mansoura in Egypt present a study of risk factors and outcome from living‐donor renal re‐transplantation. This is sometimes avoided as being unlikely to have a good outcome, but it is shown here to be the treatment of choice in patients who have lost the primary graft.

Digital subtraction angiography in potential live-kidney donors: a study of 1000 cases.

Intravenous digital subtraction angiography (IV-DSA) combined with excretory urography (IVU) were utilized to study the renal anatomy of 1000 potential live-kidney donors. In the entire series, 712 donors (71.2%) had bilateral single renal arteries, whereas 255 (25.5%) had unilateral multiple, 26 (2.6%) had bilateral multiple, and 7 (0.7%) had unilateral hypoplastic or absent renal arteries determined by IV-DSA. Major renal abnormalities that might be potentially significant for safe renal donation were detected in 76 donors (7.6%) by combined IV-DSA and IVU studies. In 10% of the potential donors, intraarterial digital subtraction angiography (IA-DSA) was required because of the equivocal results of IV-DSA. Of the 1000 potential donors, 700 underwent nephrectomy and the number of renal arteries at nephrectomy was compared with both IV-DSA and IA-DSA reports. Analysis of data revealed a sensitivity of 96% vs 95%, a specificity of 57% vs 75% and an overall accuracy 93% vs 90% for IV-DSA and IA-DSA, respectively. both IV-DSA and IA-DSA were accurate enough in identification of single renal arteries. However, the accuracy of IA-DSA was better than that of IV-DSA in visualization of double (84% vs 64%) and triple (66% vs 33%) renal arteries. It is concluded that IV-DSA combined with IVU is an effective technique for the evaluation of potential kidney donors. In cases where IV-DSA is equivocal, we recommend confirming IA-DSA.

Kimura disease: a case report and review of the literature with a new management protocol.

Kimura disease (KD) is a chronic inflammatory disorder with angiolymphatic proliferation, usually affecting young men of Asian race but is rare in other races. The etiology of KD is still unknown. It is often accompanied by nephrotic syndrome. Herein, we present an atypical manifestation of Kimura disease occurring in a Caucasian man with steroid-responsive early membranous glomerulonephritis. Kimura disease can present atypically in a middle-aged Caucasian man with secondary steroid-responsive nephrotic syndrome. Steroid, endoxan, and MMF can be used safely and successfully in such situation. The diagnosis of KD can be difficult and misleading, and patients with this disease are often evaluated using avoidable procedures by just not being aware of KD.

Bone mineral density in live related kidney transplant children and adolescents

Successful kidney transplantation corrects many of the metabolic abnormalities associated with development of renal osteodystrophy, but despite a well-functioning graft, osteopenia, remains prevalent in adult and pediatric kidney recipients. The factors that affect the bone mineral density (BMD) and the long term course of BMD after transplantation in children is still unknown. We performed a cross sectional study to determine BMD in 83 recipients who received living renal allotransplants in Mansoura Urology & Nephrology Center between 1981 and 2002 (mean age at transplantation 13.2 ± 3.1 years) by dual energy x-ray absorptiometry at various time intervals up to 16 years after transplantation (mean duration after transplantation was 48 ± 34 months, range 12–192 months). The mean ± SD for BMD was −2.28 ± 2.06 for lumbar 2-4 spine and −1.44 ± 1.44 for the total body BMD as corrected for body surface area. Osteopenia/osteoporosis were present in about two thirds of our kidney transplant recipients. The significant risk factors for osteopenia/osteoprosis using univariate analysis were the cyclosporine based immunosuppressive regimen, cumulative dose of steroids/m2 surface area, graft dysfunction and the urinary deoxypyridinoline. Using logistic regression analysis the cumulative steroid dose/m2 surface area and the urinary deoxypyridinoline were the major significant predictors for bone loss. In conclusion, osteopenia and osteoprosis are common in pediatric and adolescent renal transplant patients. The cumulative steroid dose and the urinary deoxypyridinoline were the major predictors for bone loss.

Sirolimus for visceral and cutaneous Kaposi's sarcoma in a renal-transplant recipient

The incidence of Kaposis sarcoma among recipients of solid organs is about 500 times the rate in the general population, suggesting a role for immunosuppression in its development. On the basis of these findings, we investigated the impact of sirolimus on cutaneous and disseminated visceral Kaposis sarcoma in a renal-transplant recipient. The introduction of sirolimus in this patient allowed complete regression of Kaposis sarcoma (cutaneous and visceral) with preservation of excellent renal function. Meanwhile, in view of the available observational reports, we think that sirolimus should be included in the standard treatment for Kaposis sarcoma after transplantation, to permit remission of the sarcoma (both cutaneous and visceral) while preserving the renal function.

Successful treatment of mucormycosis in a renal allograft recipient

IntroductionMucormycosis is a rare but potentially lethal fungal infection in renal allograft recipients with rhinocerebral mucormycosis is the most common presentation. The usual infection route is inhalation of the spores, but certain procedures such as intravenous cannulation and bladder catheterization are often the cause of infection.CaseA 50-year-old female dermatologist received an allograft from an emotionally related living donor, 24-year-old male with the same blood group and 3/6 mismatches. After severe attack of acute vascular rejection associated with rupture graft, that was managed properly she developed rinocereral mucormycosis. It was diagnosed early and aggressively treated with amphoteracin B and carefully monitored with favourable graft and patient survival. Up to our knowledge, this is the first case of renal transplant with extrarenal–ethemoidal sinus-mucor infection associated with acute vascular rejection that in spite of aggressive anti-rejection therapies with methylprednisolone, rituximab and plasma exchange, had favourable outcome in terms of graft and patient survival.ConclusionMucormycosis in a renal allograft recipient is an extremely rare and potentially lethal complication. Aggressive anti-rejection therapy is a risk factor for the development of this unfavourable outcome. Early diagnosis, aggressive treatment with amphoteracin B and careful monitoring can be helpful in treating these patients and achieve favourable prognosis.