Manouchehr Amini

Occult Hepatitis B Virus Infection in Hemodialysis Patients With Isolated Hepatitis B Core Antibody: A Multicenter Study

Occult hepatitis B virus (HBV) infection is characterized by presence of HBV infection with undetectable hepatitis B surface antigen (HBsAg). Occult HBV infection harbors potential risk of HBV transmission through hemodialysis (HD). The aim of this study was to assess the occult HBV infection in hemodialysis patients with isolated hepatitis B core antibody (anti‐HBc). A total of 289 HD patients from five dialysis units in Tehran, Iran, were included in this study. Hepatitis B surface antigen (HBsAg), Hepatitis B surface antibody (anti‐HBs), anti‐HBc, Hepatitis C antibody (anti‐HCV), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were tested in all subjects. The presence of HBV‐DNA was determined quantitatively in plasma samples of HD patients with isolated anti‐HBc (HBsAg negative, anti‐HBs negative and anti‐HBc positive) by real‐time PCR using the artus HBV RG PCR kit on the Rotor‐Gene 3000 real‐time thermal cycler. Of 289 patients enrolled in this study, 18 subjects (6.2%, 95% confidence interval (CI), 3.5%–8.9%) had isolated anti‐HBc. HBV‐DNA was detectable in 9 of 18 patients (50%, 95% CI, 27%–73%) who had isolated anti‐HBc. Plasma HBV‐DNA load was less than 50 IU/ml in all of these patients. Our study showed that detection of isolated anti‐HBc could reflect unrecognized occult HBV infection in HD patients. The majority of these infections are associated with low viral loads.

N-acetylcysteine does not prevent contrast-induced nephropathy after cardiac catheterization in patients with diabetes mellitus and chronic kidney disease: a randomized clinical trial

BackgroundPatients with diabetes mellitus (DM) and chronic kidney disease (CKD) constitute to be a high-risk population for the development of contrast-induced nephropathy (CIN), in which the incidence of CIN is estimated to be as high as 50%. We performed this trial to assess the efficacy of N-acetylcysteine (NAC) in the prevention of this complication.MethodsIn a prospective, double-blind, placebo controlled, randomized clinical trial, we studied 90 patients undergoing elective diagnostic coronary angiography with DM and CKD (serum creatinine ≥ 1.5 mg/dL for men and ≥ 1.4 mg/dL for women). The patients were randomly assigned to receive either oral NAC (600 mg BID, starting 24 h before the procedure) or placebo, in adjunct to hydration. Serum creatinine was measured prior to and 48 h after coronary angiography. The primary end-point was the occurrence of CIN, defined as an increase in serum creatinine ≥ 0.5 mg/dL (44.2 μmol/L) or ≥ 25% above baseline at 48 h after exposure to contrast medium.ResultsComplete data on the outcomes were available on 87 patients, 45 of whom had received NAC. There were no significant differences between the NAC and placebo groups in baseline characteristics, amount of hydration, or type and volume of contrast used, except in gender (male/female, 20/25 and 34/11, respectively; P = 0.005) and the use of statins (62.2% and 37.8%, respectively; P = 0.034). CIN occurred in 5 out of 45 (11.1%) patients in the NAC group and 6 out of 42 (14.3%) patients in the placebo group (P = 0.656).ConclusionThere was no detectable benefit for the prophylactic administration of oral NAC over an aggressive hydration protocol in patients with DM and CKD.Trial registrationNCT00808795

Chronic Kidney Disease After Hematopoietic Cell Transplantation: Frequency, Risk Factors, and Outcomes

BACKGROUND Occurrence of chronic kidney disease (CKD) after hematopoietic cell transplantation (HCT) is rare with relatively few reported cases. The aim of this study was to evaluate the frequency of CKD among patients who received HCT for hematologic and nonhematologic disorders. OBJECTIVE We performed a prospective study to evaluate the frequency of CKD and its risk factors. Between 1997 and 2006 there were 1693 patients engrafted at the Bone Marrow Transplant Research Center. METHOD CKD was defined as a doubling of serum creatinine level from the baseline and after 1 year from receiving a transplantation. The risk of CKD in relation to a non-based total body irradiation conditioning regimen, the type of graft (allograft autograft), and the incidences of graft-versus-host disease (GVHD), drug toxicity, and veno occlusive disease (VOD) were examined in 1963 HCT patients. RESULTS Kidney involvement developed in 66 patients (4%). By 6-12 months after HCT, approximately 33% of these patients developed CKD (23 patients: 19 allograft and 4 autograft). In most CKD patients, the cause was idiopathic. In 23 patients who developed CKD, 5 patients had acute kidney injury during the transplantation period with GVHD. Other renal involvements were as follows: hypertension (17%), proteinuria (15%), hydronephrosis (2%), hematuria (18%), and diabetes (3%). CONCLUSION The frequency of CKD in this study seems to be high. It is important to know the specific type of kidney damage, to determine when to be aware of the time of occurrence of renal complications and to understand the best methods to treat patients with renal injury secondary to nephrotic syndrome and idiopathic CKD.

Occult hepatitis C virus infection in Iranian hemodialysis patients.

Background: Occult hepatitis C virus (HCV) infection is defined as the presence of HCV-RNA in liver or peripheral blood mononuclear cells (PBMCs) in the absence of detectable hepatitis C antibody (anti-HCV) or HCV-RNA in the serum. Low concentrations of HCV-RNA may be detected in PBMCs of hemodialysis (HD) patients and this could have a great impact on the management of HD patients. Objectives: The aim of this study was to detect the occult HCV infection in Iranian HD patients. Patients and Methods: A total of 70 anti-HCV negative HD patients from three dialysis units in Tehran, Iran were included in this study. In these cases, presence of HCV-RNA in plasma samples was tested by reverse transcriptase-nested polymerase chain reaction (RT-nested PCR). In cases with negative anti-HCV and plasma HCV-RNA, genomic HCV-RNA was checked in PBMC specimens by RT-nested PCR. Results: Seventy anti-HCV negative HD patients were enrolled in the study. 32.85% and 1.43% of cases had elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) respectively. 7.14% of patients had elevated levels of both ALT and AST. HCV-RNA was negative in plasma samples of all anti-HCV negative HD subjects. The genomic HCV-RNA was not detected in any PBMC samples of HD cases with negative anti-HCV and plasma HCV-RNA. Conclusions: Occult HCV infection was not detected in our HD patients despite of elevated levels of liver enzymes in some participants. Further studies involving larger number of HD patients are required to elucidate the rate of occult HCV infection in HD cases.

Foot-drop: an unusual complaint in Henoch-Schönlein purpura

Sirs, Involvement of the peripheral nervous system in Henoch– Schonlein purpura (HSP) is rare [1]. Here, we introduce the reader to an uncommon neural manifestation of HSP in the lower limb. A 15-year-old boy presented at the emergency room of a hospital in Divan dare, a small city in the west of Iran, with abdominal pain, fever, bloody diarrhea and melena, arthralgia (both knees and elbows), gross hematuria, and palpable purpura on the buttock and behind the thigh. He was diagnosed with HSP and was treated with prednisolone 30 mg/day, which was reduced to 10 mg/day upon his discharge. He was admitted for 6 days, and, when he was discharged, the skin lesions had improved. Two weeks later, the patient developed a right-side incomplete foot-drop, which brought him to our center, Shariati Hospital. On his admission, hematuria and facial edema were observed. Physical examinations were not revealing, except for impaired dorsal flexion of the right ankle. Para-clinical findings were consistent with HSP: proteinuria (3,900 mg/24 h), and normal levels of C3, C4, and CH50. Results of tests for viral markers [hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV)], antinuclear antibodies (ANAs), cytoplasmic anti-neutrophilic cytoplasmic antibodies (C-ANCAs,) perinuclear anti-neutrophilic cytoplasmic antibodies (P-ANCAs) and cryoglobulin were negative. Serum level of immunoglobulin A (IgA) was 218 mg/dl (normal range 70–400 mg/dl). Ultrasonic evaluations of the urinary tract showed normal findings, except for increased cortical echogenicity of both kidneys. Histopathologic assessment of the renal biopsy showed diffuse mesangio-proliferative lesion with focal endocapillary proliferation and cellular crescents in 15% of the glomeruli. Immuno-fluorescence studies demonstrated IgA (2+) and C3 (1+) depositions in the mesangium. Electromyography and nerve conduction velocity (EMG/NCV) suggested mononeuropathy of the right deep proneal nerve, but, because the patient was unwilling, neural biopsy was avoided. Though not proven pathologically, the cause of the dropped foot was assigned to the underlying HSP, and an aggressive therapeutic strategy was adopted: intravenous administration of methylprednisolone (500 mg; three doses) and cyclophosphamide (750 mg), followed by oral treatment with prednisolone 15mg/day, which was increased to 40 mg/day (1 mg/kg) upon his discharge. Impaired dorsiflexion started to improve after 1 week from the beginning of the treatment. Although the patient received cyclophosphamide pulses monthly for three times, the hematuria relapsed when it was discontinued. With prescription of azathiopurine (100 mg/day) as an alternative, renal activity of HSP subsided again. Now, the patient has trace hematuria without proteinuria, and the foot drop has improved completely. The clinical feature of our patient was completely compatible with HSP. Although other vasculitis, especially microscopic polyarteritis nodosa (PAN), was demonstrated as differential diagnosis, the result of the renal biopsy, which showed mesangial deposition of IgA, confirmed the diagnosis [1]. Headaches and changes in mental status are the most frequent neurologic complications of HSP, followed by seizures, focal neurologic deficits, mononeuropathies, and polyradiculoneuropathies [2]. By reviewing the literature we found three reports of an association of HSP with manifestations of the peripheral nervous system (PNS), including involvement of the posterior tibial nerve Pediatr Nephrol DOI 10.1007/s00467-008-0952-5

Evaluation the effectiveness of an educational intervention to decrease central line-associated bloodstream infections among hemodialysis patients

The study aimed to compare the rates of central line-associated bloodstream infection (CLABSI) for all hemodialysis patients with a central catheter across the majority of Shariati hospital wards during a 6-month, 2-phase, before-and-after intervention. The median rate of CLABSI decreased from 18.1% at baseline to 6.5% after implementation of the intervention (64% reduction in CLABSI rate) (P = .002). The data analysis indicated that providing intensive training can positively influence the control of CLABSI in large teaching hospitals.

Association of overtime urine volume and ultrafiltration changes with patient survival in continuous ambulatory peritoneal dialysis patients.

Background: Associations between patient survival and baseline urine volume (UV), ultrafiltration (UF) volume, and combined UV and UF were evaluated in Iranian continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: From 1995 to 2006, data on 1472 CAPD patients from 26 centers were collected. Demographic, clinical, and laboratory characteristics were analyzed using STATA software. Baseline UV was considered as an indicator of residual renal function and patients with an annual decrease of more than 250 cc/day were placed in decreasing UV group. The role of a new variable, net positive fluid removal, which defines as the combination of baseline UV and UF, was also evaluated. Results: Patients with higher baseline UV were significantly more married and educated and candidate for CAPD based on positive selection criteria. In dichotomous categorization, mean of serum creatinine was lower and albumin was higher in patients with UV ≥ 1000 cc/day compared with UV < 250 cc/day. A significant correlation was found between baseline UV <250 cc/day and ≥1000 cc/day and patient survival. Patients with stable UV had better survival compared with patients with decreasing UV (p = 0.04). There was no correlation between UF and patient survival. Remarkable association with patient and technique survival and net positive fluid removal ≥2000 cc/day and <500 cc/day was observed. Multiple Cox regression analysis revealed significant correlation between net positive fluid removal ≥2000 cc/day and higher patient survival [p = 0.01, hazard ratio (HR) = 13.2], higher first albumin (albumin ≥ 3.5 mg/dL, p = 0.01, HR = 0.02), and lower negative selection (p = 0.0001, HR = 11.8). Conclusion: Loss of UV over time and lower net positive fluid removal increase mortality of PD patients.