K. Kammoun

Secondary oxalosis due to excess vitamin C intake: a cause of graft loss in a renal transplant recipient.

Renal oxalate deposition can be seen with primary hyperoxaluria, malabsorptive states, ethylene glycol toxicity and, rarely, with excessive vitamin C ingestion. We report a case of secondary hyperoxaluria in which the diagnosis was not considered initially because there was no past history of urinary calculi and no evidence of nephrocalcinosis on plain X-ray of the abdomen and ultrasonography. The disease was detected and diagnosed only after kidney transplantation. Secondary oxalosis can cause graft loss or delayed graft function. Biopsy of the allograft should be carefully examined for oxalate deposits even in the absence of a family history. When oxalosis is diagnosed, intensifying hemodialysis (HD) to eliminate calcium oxalate can help in the recovery of renal function in some cases. Systematic vitamin C supplementation in HD patients should be avoided as it can be a cause of secondary oxalosis.

BK virus-associated hemophagocytic syndrome in a renal transplant recipient

Hemophagocytic syndrome (HPS) is a life-threatening hematological disorder in immunocompromised patients. Reactive HPS is observed in patients with systemic infection, neoplasia or auto-immune diseases. It is a rare hematological disorder after renal transplantation and must be suspected when fever and pancytopenia are seen in association with viral infections. HPS is usually associated with infection with the Cytomegalovirus and Epstein-Barr viruses. We report here a case of BK-virus-associated HPS.

Living and cadaver donor transplant programs in the Maghreb.

In the Maghreb, organ failure constitutes a major public health problem, especially given the increasing number of patients with chronic renal failure and the high cost of care. In this study, we attempted to seek the recommendations, through a questionnaire, of various officials related to organ transplantation as well as leaders of ethics committees and religious groups in different countries of the Maghreb. The objective was to improve the rate of organ donation and transplantation. We received 36 replies (62%) within the prescribed time limit. In our survey, 83% of the respondents felt that living donor transplantation should be promoted initially, followed gradually by measures to increase cadaver donor transplantation to achieve a target of about 30 transplants with cadaver kidney donors per million inhabitants. To expand the donor pool, 83% of the respondents proposed to expand the family circle to include the spouse and in laws. To improve the cadaver donation activity, one should improve the organizational aspects to ensure at least 50 renal transplantations per year (100%) and provide material motivation to the treatment team proportional to the activity of organ donation and transplantation. Finally, 93% of the respondents suggested suitable moral motivation of the donors.

Diet in chronic kidney disease in a Mediterranean African country

BackgroundMediterranean diet is characterized by low to moderate consumption of animal protein and high consumption of fruits, vegetables, bread, beans, nuts, seeds and other cereals. It has been associated with reduced risk of cardiovascular disease. However, it is not suitable for chronic kidney disease because of high potassium intake.DiscussionTunisia is an emerging Mediterranean country with limited resources, a high prevalence of chronic hemodialysis treatment and high dialysis expenditures. In order to limit dialysis cost, primary and secondary prevention of chronic renal disease are of paramount importance. In addition to drugs, secondary prevention includes diet measures (e.g. salt diet, protein diet). The aims of diet practice in chronic kidney disease are to slow chronic renal failure progression and to prevent its complications like hyperphosphatemia and hyperkaliemiae. A few decades ago, a Tunisian diet was exclusively Mediterranean, and protein consumption was not excessive. However, today, protein consumption is more comparable to western countries. Salt consumption is also excessive. Some Tunisian diets still include food with high potassium intake, which are not suitable for patients with chronic kidney disease. Therefore, the role of the dietician is extremely important to help calculate and create a dietary regimen tailored to each of our patients.SummaryAdvice about diets should be adapted to both the patient and population habits to improve adherence rate. As such, the purpose of this article is to provide our own experience regarding medical nutrition therapy in patients with chronic kidney disease in Tunisia, with some changes in food habits. Prevention is far better than treatment. In this perspective, dietary measures must be at the core of our intervention.

Risk factors for acute decompensation of chronic kidney disease in hospitalized patients in the nephrology department: a case-control study.

OBJECTIVE To investigate risk factors for acute kidney injury (AKI) in hospitalized patients with chronic kidney disease (CKD) a case-control study was conducted in the Nephrology Department of Hedi Chaker University Hospital in Sfax, Tunisia, for a 1-year period. METHODS All patients with baseline renal insufficiency hospitalized for AKI were considered as cases. They were compared with control patients with CKD. A conditional logistic regression model was used to identify independent risk factors for AKI in patients with CKD. RESULTS A total of 58 cases were compared with 114 control subjects. In multivariable models, baseline diabetes, cardiopathy disease, and exposure to non-steroidal anti-inflammatory drugs were independent risk factors for AKI in patients with CKD. However, exposure to calcium channel blockers (CCBs) was associated with decreased risk for AKI on CKD (OR = 0.4; CI 95%: 0.2 - 0.8, p = 0.007). CONCLUSIONS Patients with CKD may benefit from more aggressive cardiovascular screening to prevent episodes of acute kidney injury. More efforts should be made to prevent prescription drug abuse and to demonstrate the role of CCBs in renal protection in these patients.

The Increased Expression of Toll-Like Receptor 4 in Renal and Skin Lesions in Lupus Erythematosus

Toll-like receptor 4 (TLR-4), a bacterial lipopolysaccharide sensor, is an innate immunity essential modulator. It is expressed on both immune and non-immune cells and may contribute to the cutaneous and renal manifestations during lupus erythematosus (LE). Our purpose is to evaluate TLR-4 expression and analyzing its role in lupus nephritis (LN) and chronic cutaneous lupus erythematosus (CLE) pathogenesis. TLR-4 immunohistochemical staining was performed on 30 LN renal biopsies compared with 11 healthy renal tissues and 30 skin biopsies from CLE patients compared with 15 normal individuals. CLE patients’ biopsies showed a strong and diffuse TLR-4 expression throughout the epidermis and labeled inflammatory infiltrate and glands in the dermis whereas controls’ skin expressed weakly TLR-4 only in the epidermis basal layer. LN glomeruli and tubules showed an increased and more intense TLR-4 expression compared with normal controls where TLR-4 expression was weak and rarely detected in glomeruli, diffuse and weak in tubules. A significant difference in TLR-4 expression between LN classes, both in glomeruli and tubules, was observed. These data confirm an up-regulation of TLR-4 expression in the affected tissues of CLE and LN patients and highlight the critical role of TLR-4 in the pathogenesis of cutaneous and renal disorders in LE.

BLOOD PRESSURE BALANCE IN CHRONIC KIDNEY DISEASE

Objective: Hypertension is common in chronic kidney disease (CKD) and is a major determinant of CKD progression. Ambulatory blood pressure monitoring (ABPM) has been proposed as a better method to evaluate blood pressure (BP) in real life conditions. The objective of our study is to better specify the characteristics of ABPM in patients with CKD compared to the rest of the hypertensive population. Design and method: We conducted a retrospective study including all patients who benefited from an ABPM between January 2014 and Juin 2017. The CKD was established based on the definitions of KDIGO 2012. We divided our patients into 2 groups: G1: patients with ckd and G2: patients without CKD. The comparison between the 2 groups was carried out by Chi-square test and one factor ANOVA. Results: The study included 241 cases with a sex ratio of 0,84. The prevalence of CKD was 81% including 33 % stage 2, 56 % stage 3; 10 % stage 4 and 1% stage 5. Patients with CKD were older (55 ± 16 years vs 42 ± 15 years; p < 0,001). There were no significant difference regarding sex (p = 0,07) and body mass index (p = 0,06). The mean blood pressure (BP) in consultation was 157/85 (G1) and 145/ 86 (G2) (p = 0,03; p = 0,5). The indications of ABPM were different in the two groups: unbalanced hypertension (G1: 67%, G2: 37,5%), borderline hypertension (G1: 13.4%, G2: 22,5 % (G1: 1.7%, G2: 3%) and the search for masked hypertension (G1: 20%, 40%) with a significant difference (p = 0.002). In the ABPM, there was no difference in systolic and diastolic BP, whereas the difference was significant comparing patients having satges 4 and 5 CKD with other patients (149/82 vs 136 /78; p = 0,016; p = 0,3).The mean number of antihypertensive drugs was greater in the presence of CKD (1,8 ± 1,3 vs 0.8 ± 0,9; p < 0.001). Conclusions: BP should be monitored closely in hypertensive patients with CKD. ABPM seems to be the appropriate method in detecting hypertension and monitoring adequacy of treatment in patients with CKD.