Fethi Ben Hamida

Urinary tract infections following renal transplantation: A single-center experience

Urinary tract infection (UTI) is the most frequent infectious complication among renal transplant recipients and a frequent cause of bacteremia, sepsis and acute graft failure. To evaluate the incidence, risk factors, type of pathogens and long-term effect of UTIs on graft and patient survivals in our center, we performed a retrospective cohort study reviewing the medical records of patients who received a renal transplant at our center from June 1986 to December 2009, excluding patients who lost their grafts in the first month due to arterial or veins thrombosis and acute antibody-mediated rejection. We studied 393 kidney-transplanted recipients; at least one UTI occurred in 221 (53.69%) patients during the follow-up period. The most frequent pathogens isolated in urine culture were Escherichia coli (n = 39, 18.4%) and Klebsiella pneumonia (n = 31, 14.6%). When patients with UTIs were compared with those without UTIs, female gender and use of mycophenolate mofetil or azathioprine seemed to be risk factors for UTIs on univariate analysis. However, female gender was the only independent risk factor on multivariate analysis RR = 1.964 (1.202-3.207), P = 0.007. This study confirmed that UTIs remain a major problem in renal transplant recipients, and female gender was the only independent risk factor.

Insuffisance rénale aiguë secondaire à la povidone iodée

Resume Introduction La povidone iodee est un antiseptique largement utilise surtout en usage cutane. Malgre son innocuite, des cas d’insuffisance renale aigue rentrant dans le cadre d’une toxicite a l’iode ont ete rapportes. Observation Une femme âgee de 37 ans, sans antecedents particuliers etait suivie pour une sterilite primaire de 4 ans. Elle a eu, dans le cadre de l’exploration de cette sterilite, une hysteroscopie avec opacification par de la povidone iodee. En post operatoire immediat, une insuffisance renale aigue oligurique s’est developpee. Apres traitement par diuretiques et 5 seances d’epuration extra renale, l’evolution etait favorable avec declenchement de la diurese a J18 suivi d’une normalisation de la fonction renale. Discussion La toxicite a l’iode est plus importante quand la povidone iodee est administree in situ au contact des muqueuses. L’insuffisance renale aigue est a type de necrose tubulaire aigue comme chez cette patiente. En l’absence d’autre cause, cette insuffisance renale aigue a ete rattachee a la povidone iodee. Conclusion L’insuffisance renale aigue secondaire a la toxicite a l’iode reste possible surtout si la povidone iodee est administree au contact des muqueuses. L’evolution est en general favorable apres l’arret du contact avec cet agent et le traitement symptomatique.

Short- and long-term outcomes of kidney donors: A report from Tunisia

Kidney transplantation remains the best treatment option of end-stage renal disease. Kidney donations are of particular interest with the currently increasing practice of living-donor transplantation. The purpose of this study was to analyze retrospectively the general health status as well as renal and cardiovascular consequences of living-related kidney donation. A total of 549 living-related kidney donors had donated their kidneys between 1986 and 2007. We attempted to contact all donors to determine short- and long-term outcome following kidney donation. All kidney donors who responded underwent detailed clinical and biochemical evaluation. The data were compared with age-matched health tables of the Tunisian general population. In all, 284 donors (52%) had a complete evaluation. They included 117 men and 167 women with a mean age of 42 ± 12 years. The major peri-operative complications that occurred in these donors included four cases of pneumothorax, six cases of surgical site infection, one case of phlebitis and one case of pulmonary embolism. None of the study cases died. The median length of hospital stay after donor nephrectomy was 6.5 days (range: 3-28 days). The median follow-up period was eight years. The mean creatinine clearance after donation was 90.4 ± 25 mL/min in men and 81.5 ± 27.2 mL/min in women. Proteinuria was >300 mg/24 h in 17 cases (5.9%). Fifty-eight (20.4%) donors became hypertensive and 19.6% of the men and 37.2% of the women became obese. Diabetes mellitus developed in 24 (8.4%), and was more common in patients who had significant weight gain. Our study suggests that kidney donors have minimal adverse effects on overall health status. Regular follow-up identifies at-risk populations and potentially modifiable factors. Creation of a national registry of living donors and their monitoring are an absolute necessity.

Nodular glomerulosclerosis in patients' without history of diabetes mellitus: a case report.

IntroductionDiabetic nephropathy can occur during the course of both type1 and type 2 diabetes mellitus. The characteristic lesions are diffuse or nodular (Kimmelsteil-Wilson) diabetic glomerulosclerosis. The reported cases represent unusual presentations of diabetes mellitus.Case presentationWe report the case of a 49-year-old man without prior history of diabetes mellitus who presented with rapidly progressive renal failure and whose renal biopsy revealed nodular (Kimmelsteil-Wilson) glomerulosclerosis lesions characteristic of diabetes.ConclusionRenal manifestations of diabetes mellitus may antedate other more common presenting symptoms of this disease and we critically review the literature on this subject.

A Case of Type 1 Autoimmune Pancreatitis (AIP), a Form of IgG4-Related Disease (IgG4-RD)

Patient: Male, 70 Final Diagnosis: IgG4 RD Symptoms: Jaundice Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare disease Background: Type 1 autoimmune pancreatitis (AIP), also known as lymphoplasmacytic sclerosing pancreatitis (LPSP), is a rare cause of chronic pancreatitis, characterized by a fibro-inflammatory process. However, patients with AIP may have a good response to corticosteroid therapy. We describe a Tunisian patient with AIP that was confirmed to be an IgG4-related disease (IgG4-RD). Case Report: We describe a case of a 70-year-old man who was admitted to hospital for obstructive jaundice and abdominal pain. Serum liver function tests were abnormal and upper abdominal computed tomography (CT) imaging showed diffuse pancreatic swelling and strictures of the main pancreatic duct without any focal lesion. Pancreatico-biliary magnetic resonance imaging (MRI) showed a thickened rim surrounding the pancreatic duct Serum IgG4 levels were elevated, resulting in a diagnosis of IgG4-related AIP. The patient showed a good clinical, biochemical, and radiological response following steroid therapy in combination with azathioprine. Conclusions: The diagnostic workup of IgG4-RD is complex and usually requires a combination of clinical examination, imaging, and serological analysis. As this case report has demonstrated, IgG4-RD should be considered in patients who present with pancreatitis or AIP, because of the favorable response to steroid therapy, particularly when treatment is initiated early.

Clinicopathological findings and outcome of lupus nephritis in Tunisian children: a review of 43 patients

We report clinical and renal histological data, treatment modalities and outcome of 43 Tunisian children with biopsy-proven lupus nephritis seen over a 23-year period. There were 39 girls and 4 boys with a mean age of 12.5 years at diagnosis of lupus nephritis and followed for a mean period of 77 months. Renal symptoms included urinary abnormalities in all patients, hypertension in 40% of cases, nephrotic syndrome in 60% of cases and renal failure in 25% of cases. Class IV and class III nephritis were observed in 48.8 % and 30.2 % respectively. Corticosteroids were used in all cases, associated to immunosuppressive therapy in 23%. Overall survival was 86% at 5 years and 74% at 10 and 15 years. Renal survival was 83% at 5 and 10 years and 63% at 15 years. Initial renal failure and tubulointerstitial fibrosis were significantly increased risk for the development of end-stage renal disease in our study group. Renal histological findings provide the basis for treatment recommendations. Timely performed renal biopsy is greatly needed to accurately determine the prognosis and to guide treatment in children lupus nephritis.

Maladie cœliaque de l’adulte révélée par une polysérite

Celiac disease (CD) is an autoimmune disease affecting multiple organs. It often presents as gastrointestinal manifestations associated with malabsorption. However, serosa involvement uncommonly reveals this enteropathy, making the diagnosis difficult. We here report the case of JA, aged 63 years, admitted to hospital to detect the cause of malabsorption syndrome associated with polyserositis signs including pleurisy, pericarditis, ascites and hydrocephalus. The diagnosis of CD was based on endoscopic signs without serology tests. Patients evolution was partially favorable, due to lack of compliance with a gluten-free diet. Our study reports the first case of CD revealed by polyserositis. CD should be suspected in patients with malabsorption syndrome, in the absence of evocative signs.La maladie cœliaque (MC) représente une maladie auto immune touchant plusieurs organes. Elle est souvent révélée par des manifestations digestives avec une malabsorption biologique. Cependant, l’atteinte des séreuses peut exceptionnellement révéler cette entéropathie rendant le diagnostic difficile. Il s’agit du patient JA âgé de 63 ans admis pour exploration de syndrome de malabsorption avec des signes de polysérite à type de pleurésie, péricardite, ascite et hydrocéphalie. Le diagnostic de MC a été porté devant des signes endoscopiques sans arguments sérologiques. L’évolution était partiellement favorable à cause de la mauvaise adhésion au régime sans gluten. Notre observation est le premier cas rapporté d’une polysérite révélant la MC qui devrait être évoquée devant tout syndrome de malabsorption en l’absence de signes évocateurs.

Factors associated with relapse of lupus nephritis: A single center study of 249 cases

This is a retrospective cohort study over 20 years (1990-2013) that included all patients with biopsy-proven lupus nephritis (LN) followed up at our nephrology department. We aimed to determine the clinicobiologic predictors of flare-up of LN. Flare was defined as an increase in systemic lupus erythematosus (SLE) disease activity index (SLEDAI) score of at least four points. Clinical manifestations and laboratory parameters were assessed and the SLEDAI score was determined for each patient. We included patients with SLE who fulfilled at least four of the American College of Rheumatology criteria for the classification of SLE. A total of 249 patients including 227 females and 22 males with a median age at diagnosis of 34.32 years (range 16-69) were studied. The mean follow-up duration was 122.4 ± 27 months. Renal symptoms included hypertension in 40%, nephrotic syndrome in 30%, and renal failure in 69.4% of the cases. Class IV and class III nephritis (ISN/RPS) were observed in 44.9% and 24% of the patients, respectively. On univariate analysis, flare predictors were age <30 years (P = 0.02), lymphocytopenia (P = 0.002), the presence of diffuse proliferative LN (P = 0.009), and discontinuation of immunosuppressive therapy (P = 0.004). Our study suggests that these markers should be monitored routinely as prognostic parameters in SLE to characterize patients who are at risk and who should be followed more closely.

Acute kidney injury with granulomatous interstitial nephritis and vasculitis revealing sarcoidosis

Sarcoidosis is an inflammatory disease that affects mostly the lungs and lymph glands. Renal involvement is rare and especially vasculitis. We report a case who presented an acute kidney failure and had sarcoidosis with vasculitis and nodular splenic involvement. A 35-year-old woman presenting a Lofgren syndrome was hospitalized for acute renal failure with cervical lymphadenopathy without other clinical findings. Laboratory data disclosed elevated angiotensin converting enzyme serum level. Abdominal ultrasound showed a multinodular spleen. Renal histology revealed granulomatous interstitial nephritis with necrotizing vasculitis. Outcome was favorable after the institution of high dose corticosteroids along with cyclophosphamide. Renal involvement is rare in sarcoidosis. However, the diagnostic delay should be avoided to improve the outcome.

Mineral and Bone Status in Tunisian Maintenance Hemodialysis Patients: The National Bone and Mineral Metabolism Observatory

In Tunisia, data assessing the status of mineral and bone disorders (MBD) among dialysis patients is scarce. In order to address this gap in the literature, we sought to conduct this observational study including 4868 patients from 108 hemodialysis facilities nationwide, aiming to: (i) report parameters of MBD during the first quarter 2006, (ii) determine the levels of compliance with the recommendations of the Kidney Disease Outcome Quality Initiative (K/ DOQI), and (iii) compare these levels of compliance with those of Dialysis Outcomes and Practice Patterns Study (DOPPS). Mean serum phosphorus, calcium, calcium- phosphorus product and intact parathyroid hormone (iPTH) concentrations were respectively 1.74 mmol/L, 2.28 mmol/L, 3.95 mmol²/l² and 254 pg/ml. MBD’s measures were met the K/DOQI’s guidelines in 44.1% of cases for serum phosphorus, 42.5% of cases for serum calcium, 68.6% of the cases for calcium phosphorus product, 20.2% of cases for iPTH and 3.3% of cases for these four parameters taken together. These results were comparable to those observed in the DOPPS study. The most phosphate binder prescribed was calcium carbonate (91.2% of cases) with high average daily dose (superior to 1500 mg in 45.8% of cases). Sevelamer and aluminum salt were prescribed respectively in 0.5% and 0.10% of patients. The only active vitamin D available in Tunisia was alfacalcidol; it was prescribed in 49.7% of patients with a mean weekly dose of 4.04 μg. A calcium dialysate bath of 1.75; 1.50 and 1.25 mmol/L were prescribed respectively in 80.2%, 14.7% and 5.1% of cases. This is the first exhaustive study reporting MBD abnormalities in Tunisia and, to our knowledge, in Africa. A second study was stated in January