Reza Afshar

Effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis

Physical function limitation is a common disorder in chronic hemodialysis (HD) patients, relating to increased morbidity and mortality. The aim of this study was to determine the effects of aerobic and resistance trainings on blood lipids and inflammation status in HD patients. Out of 30 volunteer males who had been undergoing conventional maintenance HD within an HD unit in Tehran, 21 subjects were enrolled. They were randomly assigned into aerobic exercise group – resistance training group undergoing an 8-week intradialytic exercise program (three times/week) and control group (n = 7, each). Training program consisted of 10-30 min stationary cycling at an intensity of 12–16 out of 20 at the rate of perceived exertion (RPE) of Borg scale in aerobic group and using ankle weights for knee extension, hip abduction and flexions at an intensity of 15–17 out of 20 at the RPE of Borg scale in resistance group. Fasting blood samples for serum biochemistry were drawn at baseline and 8 weeks. The age, HD duration, and physical activity score were 51.6±18.9yrs; 25.1±13.9 mo, and 19.2±7.6, respectively. Diabetes mellitus (43%), hypertension (28%), and obstructive uropathy (14%) were the most common underlying diseases. Aerobic and resistance exercises were correlated with serum creatinine (P< 0.0001 and P<0.001) and hs-CRP levels (P=0.005 and P=0.036) reduction so that aerobic exercise induced more reduction. These exercises had no influence on weight, Kt/V values, serum urea, albumin, hemoglobin, and lipid levels (P>0.05). Both intradialytic aerobic and resistance exercises showed beneficial effects on inflammation status without any influences on serum lipid levels probably due to short duration of the study which was not accompanied with body weight changes. Solute removal had no change during exercise programs. There is a need for more investigation on the role of exercise in HD patients.

Attitude and willingness of high school students toward organ donation

Public awareness of organ donation fundamentally affects the organ transplantation programs. This study was performed to assess the attitude and willingness of high school adolescents regarding organ donation. The study population consisted of 416 high school girls who were studying in four grades of three educational courses. Data were collected by a questionnaire and included demographic variables and attitude and willingness, which were assessed based on the Likert scale. The SPSS v.16 was used for data analysis. The mean age of the study subjects was 16.26 ± 1.06 years, 31% studied in grade-1, 27% in grade-2 (25% natural sciences, 27% mathematics and 48% humanities), 26% in grade-3 (30% natural sciences, 34% mathematics and 36% humanities) and 16% in pre-university stage (32% natural sciences, 42% mathematics and 26% humanities). The students had a highly positive attitude toward organ donation (mean score 4.2 ± 0.54). The greatest willingness for organ donation was concerning the kidney (88%) and heart (84%), followed by the liver (83.4%), pancreas (79.6%), cornea (67.8%) and skin (51%). Willingness for deceased as well as living organ donation was indicated by 92% and 47%, respectively, of the participants. Organ donation was considered acceptable only to relatives by 5% of the participants when the donors were deceased donors and by 16% of the participants when the donors were living donors; donation to all needy persons from deceased donors was accepted by 87% of the participants and from living donors by 31%. The purpose of donation was stated as lending help to others by 89% and progression of science by 40.2% of the participants. Willingness for organ donation from a deceased relative was declared by 63% of the students. There was significant positive correlation between willingness for organ donation and attitude (P <0.001). In addition, attitude and willingness had positive correlation with educational levels, age and educational courses. Our study suggests that Iranian adolescents have a great attitude and willingness toward organ donation, which reflects favorable knowledge of transplantation. Further research on public awareness in both genders and various age ranges is needed.

Anemia after kidney transplantation in adult recipients: prevalence and risk factors.

OBJECTIVE To evaluate the prevalence of anemia and appraise its risk factors at 6 months after renal transplantation. MATERIALS AND METHODS This retrospective study was performed between 2008 and 2010 in 2713 adult kidney transplant recipients to determine the prevalence of posttransplantation anemia. Anemia was defined as hemoglobin concentration of 12 g/dL or less in women and 13 g/dL or less in men. RESULTS The prevalence of posttransplantation anemia was 52.7%, with severe anemia (hemoglobin≤11 g/dL) detected in 24.4% of patients. Impaired renal function was the only risk factor associated with anemia (odds ratio, 3.6; P=.047). However, severe anemia after kidney transplantation was correlated with female sex (P=.001), renal allograft dysfunction (P=.00), and cytomegalovirus infection (P=.002). CONCLUSION The present study demonstrated a quite high prevalence of posttransplantation anemia, in particular associated with impaired renal allograft function. Severe anemia was correlated with female sex, degree of kidney graft dysfunction, and cytomegalovirus infection.

Subacute thyroiditis following ginger (Zingiber officinale) consumption.

A woman with subacute thyroiditis following ginger consumption is presented. The diagnosis was confirmed by physical examination and laboratory tests, in two distinct episodes. The patient was cured and recommended to refuse ginger consumption.

The pattern of proteinuria following karate (Kumite) competitions.

Sir, Despite the large amount of proteins in the plasma, the urine is virtually protein free due to the selectivity of the glomerular barrier [1]. The major component of urinary protein is a tubular protein (Tamm-Horsfall) while albumin constitutes 30–40% of the total urinary protein. Various physiologic settings, including exercise, can induce a transient increase in the urinary protein excretion that is usually benign and reversible. The type of post-exercise proteinuria depends on the intensity of exercise rather than its duration, so that moderate exercise induces glomerular and heavy exercise glomerular-tubular mixed-type protein loss [2]. Post-exercise proteinuria may be due to the loss of the charge selectivity from the glomerular capillary wall, a relative preservation of the glomerular filtration rate, proteinuria out of proportion of maximal tubular reabsorption capacity following heavy exercise [2,3] and oxidative stress produced by free radicals due to enhanced oxygen consumption in muscles [4]. The purpose of our study was to compare the amount and pattern of proteinuria before and after karate (Kumite) competition in 18 male practitioners, aged 18–21 years, with similar physical characteristics. All practitioners competed in three rounds, each lasted 3 min, with a 10 min resting interval between them. Urine samples were collected just before the competition and during 24 h thereafter. Total urinary protein, urinary beta2-microglobulin B2M as tubular and albumin as glomerular protein were assayed. Before competition, the mean value of total urinary protein, albumin and B2M as basal levels were 70.68 ± 12.5, 4.84 ± 3.17 and 0.0217 ± 0.0133 mg/day, respectively. After competition, the mean values of 24-h total urine protein (196.05 ± 70.88 mg/day), albumin (34.07 ± 32.88 mg/day) and B2M (0.0933 ± 0.0372 mg/day) levels were significantly increased (P = 0.023, P = 0.001 and P < 0.001). This study revealed significantly increased proteinuria of a mixed type (albumin and B2M) in all practitioners following exhaustive short-term competition. Despite the mixed type of proteinuria, we observed a six-fold increase compared to the basal level in urine albumin (versus four-fold increase for urinary B2M) suggesting a more prominent role of glomerular proteinuria probably due to glomerular membrane permeability changing factors, such as sympathetic overactivity and competitive stress. Conflict of interest statement. None.

Effects of continuous and intermittent trainings on exercise-induced hematuria and proteinuria in untrained adult females

Sir, Exercise can induce temporary proteinuria (18–100%) and hematuria (20–100%), which usually resolve within 24–48 h [1]. Proteinuria is mainly influenced by exercise intensity rather than duration, while hematuria depends on both duration and intensity [2, 3]. Most investigations regarding this issue have been conducted on professional athletes with a particular type of exercise. This study was designed to compare the effects of intermittent and continuous (without interval rest) trainings on exercise-induced urinary abnormality in untrained (no training in prior 3 months) single female runners (20–29 years). Of 90 student volunteers, 45 otherwise healthy females who had normal basal urine samples were enrolled in the study. Physical characteristics of the participants included age: 22.9 ± 1.99 years; body mass index: 23.5 ± 4.3 kg/m2 and VO2max: 37.38 ± 8.4 mL/kg/min. The participants were randomly divided into: intermittent training Group A, continuous training Group B and control Group C (each, n = 15). All participants performed an exhaustive running (up to maximal capacity) [4], then immediately and 1 h later urine samples for evaluation of hematuria and proteinuria were collected. Two days later, training groups were separately scheduled for intermittent and continuous trainings (each session consisted of a 10-min warming up, distance running with 1:3 ratio for work to recovery periods in Group A only and a 10-min cooldown exercise) three times per week for 12 weeks (Table 1) [4, 5]. Table 1 Protocol of training in Groups A and B Two days after the last session, all participants did an exhaustive running session again and urine samples were collected. The participants were not in menstrual cycle during any of the samplings. First post-exhaustive (PE) samples showed hematuria by phase-contrast microscopy in 100% of participants, which decreased to 75% (only in training groups) after a training programme; however, this difference was not statistically significant (P = 0.083). Mean urinary protein at different stages of the study were obtained: basal, first and second (PE) in Group A: 40.96 ± 11.6, 175.7 ± 15.93 and 175.1 ± 15.87; Group B: 39.98 ± 10.9, 168.8 ± 11.18 and 168.2 ± 11.4 and Group C: 42.89 ± 8.9, 169.5 ± 10.9 and 169.4 ± 10.9 (mg/day). Despite significant urinary protein elevation following exhaustive exercise in all groups (P < 0.05), no significant difference was found between pre- and post-training values in Groups A and B and also between groups (P = 0.095, 0.061). Exercise-induced hematuria is attributed to various mechanisms including increased body temperature, hemolysis, free radicals, lactic acidosis and catecholamine release [2]. It seems that physical training may have a protective influence on red cell passage through the glomerular basement membrane (GBM), whereas proteinuria remains unchanged [2]. We conclude that adaptive mechanisms against sudden increase in body temperature, dehydration, renal ischemia and red cell peroxidation may modify the influence of hemodynamic alterations on GBM, while charge selectivity permeability remains unchanged. Further research regarding this issue, particularly in males, and with larger samples is recommended.

Rhino-orbitocerebral mucormycosis in a patient with idiopathic crescentic glomerulonephritis.

Mucormycosis, caused by mucorales, is an acute, rapidly progressive infection associated with high mortality. Rhino-orbitocerebral infection is the most common variant and is generally seen in association with immune deficiency syndromes. Prompt medical treatment of this infection and debridement decreases the mortality rate. We describe a 47-year-old man with crescentic glomerulonephritis on maintenance prednisolone therapy. He had earlier received steroid and cyclophosphamide pulse therapies. Renal functions improved following immunosuppressive treatment. In the third month of maintenance therapy, he presented to us with left-sided facial swelling and bloody nasal discharge. He had high blood sugar and acidic blood pH (ketoacidosis), probably due to steroid therapy. Magnetic resonance imaging of the head and sinuses showed inflammation and mass in the ethmoid sinus and nose with partial septal destruction, proptosis, global destruction of the left eye, brain infarction and carotid artery obliteration. Endoscopic biopsy of the sinuses revealed severe tissue necrosis. Samples of nasal discharge and biopsy tissue showed aseptate hyphae on light microscopy and culture, compatible with Rhizopus. The patient was treated with amphotericin B and multiple wound debridements along with ethmoidectomy and enucleation of the left eye. He was discharged in good general condition but with mild right hemiparesis. On follow-up examination at one year, there were no signs of fungal infection or renal dysfunction.

Renal Replacement Therapy: Challenge on the Best Therapeutic Modality

Before 1970, therapeutic modalities for patients with end-stage renal disease (ESRD) were limited and a small number of patients underwent regular dialysis because few dialysis facilities were available. Patients had to be screened for the eligibility of maintenance therapy, and treatment was offered merely to patients who had renal failure as the predominant clinical feature. Kidney transplantation was in the early stages of development as a preferable therapeutic approach and most patients thought that the diagnosis of chronic renal failure corresponds to death.

Outcomes of two different polytetrafluoroethylene graft sizes in patients undergoing maintenance hemodialysis.

Arteriovenous access creation is mandatory for maintenance hemodialysis. If native fistula placement was not possible or failed, a prosthetic conduit would be the best substitute. The purpose of this prospective study was to compare outcomes of two different sizes of polytetrafluoroethylene (PTFE) grafts, in hemodialysis patients, at the Mustafa Khomeini Hospital in Iran. The study population consisted of 586 end-stage renal disease referrals for vascular access construction (January 2003 to January 2007) of which eventually 102 subjects were candidates for PTFE graft who were followed for one year. Data were collected by a questionnaire and analyzed using the SPSS, life table, Kaplan- Meier and Log-Rank tests. Out of 102 PTFE implantation candidates (mean value of age 51.7 ± 17.06 yrs), 56% were male and 44% female. PTFE grafts of 8 mm and 6 mm sizes were randomly placed in 57 and 45 subjects, with distribution of 83%, 12% and 5% in arm, forearm and thigh. The most underlying diseases were hypertension and diabetes. There was a significant difference in complication rates between patients with and without underlying diseases [42% vs. 10% (P = 0.03)]. One-year patency rates were 42.2% and 36.5% for 6 mm and 8 mm grafts and 28.2% vs. 52% in patients with and without underlying diseases respectively. Despite more complication frequency in 8 mm grafts, the patency and complication rates of two graft groups did not significantly differ. Hypertension and diabetes could have contributory roles in graft complication rate, which may be preventable. Non-tapered grafts of 6 mm and 8 mm sizes have not significant different outcomes. Further research is recommended with larger sample size and longer duration.

Urinary abnormalities following karate (kumite) competitions

Sir, Recently, our group conducted a supplementary study on urinary abnormalities following karate (kumite) competitions in professional female athletes. In a previous issue of NDT Plus [1], our group presented data showing significantly increased proteinuria of a mixed type (albumin and beta2-microglobulin or B2M) with prominence of albumin, as a glomerular urine protein, in 18 professional (18–21 years) male karatekas. This recent study has focused on 17 healthy (16–25 years) female karatekas, who volunteered to participate in the study, in order to detect karate-induced urinary abnormalities. The competitions were held with similar characteristics of three rounds of 1.5-min duration which had been interspaced with a 10-min resting interval. Urine samples were collected just before the match and 24 h thereafter to measure total urinary protein, albumin, B2M, sodium, potassium and calcium levels. All values were compared with pre-exercise 24-h urine values. There was significantly increased mixed-type proteinuria (total protein of 190.01 ± 92.54 vs. 68.6 ± 45.51 mg/day, P = 0.001; albumin of 30.07 ± 28.81 vs. 3.71 ± 2.3 mg/day, P = 0.001; and B2M of 0.0702 ± 0.0135 vs. 0.015 ± 0.01 mg/day, P < 0.01) compared with basal levels. Furthermore, similar to previous study, daily urinary electrolytes (sodium 121.65 ± 20.40 vs. 118.21 ± 21.25, P = 0.825; potassium 41.53 ± 10.80 vs. 43.59 ± 11.86, P = 0.426; and calcium 190.88 ± 80.44 vs. 182.76 ± 87.33, P = 0.755) excretions did not change significantly following the competitions. Urinary glucose in both pre- and post-exercise urine samples was not found. Based on the aforementioned data, it seems that karate (kumite) competition in both genders does not have significant influence on some urinary electrolyte and substance excretions. This finding may be attributed to appropriate tubular transport, short duration of competitions, adequate hydration of athletes and efficacious regulatory mechanisms in order to maintain normal blood levels [2]. However, because of the intensity of this exercise which results in sympathetic stimulation, the glomerular permeability and protein excretion may be changed [3,4]. We recommend further researches on karate-induced urinary abnormalities. Conflict of interest statement. None declared.