Wided Smaoui

The diagnosis of tuberculosis in dialysis patients

The incidence of tuberculosis (TB) is high in patients undergoing chronic dialysis than it is in the general population. The diagnosis of TB is often difficult and extrapulmonary involvement is predominant. This study investigates the spectrum of clinical presentations and outcome in dialysis patients during a nine-year period. TB was diagnosed in 41 patients. Anti-TB drugs, adverse effects of therapy, and outcome were noted. Thirty-eight patients (92.6%) were on hemodialysis and three were on peritoneal dialysis (7.3%). The mean age at diagnosis was 50.8 years and the male/female ratio was 1.16. Four patients had a history of pulmonary TB. Extrapulmonary involvement was observed in 32 (78 %) patients. The bacteriological confirmation was made in 41.46% and histological confirmation was made in 26.83%, and in the rest, the diagnosis was retained on the criterion presumption. Nineteen patients (46.34%) developed adverse effects of antitubercular drugs. Eight patients (19.51%) died during the study from TB or adverse effects of treatment. Low urea reduction ratio and female sex were associated with poor prognosis in our study. The clinical manifestations of TB in patients on dialysis are quite nonspecific, making timely diagnosis difficult, and delaying the initiation of curative treatment, which is a major determinant of the outcome.

Infections chez les insuffisants rénaux hémodialysés chroniques: étude de 125 cas

Introduction : l’infection est une cause majeure de morbi-mortalite chez les hemodialyses chroniques. Notre objectif etait de determiner leurs caracteristiques clinico-biologiques, bacteriologiques et evolutives.

Prévalence de l’infection a cytomégalovirus chez les receveurs de reins

Introduction : l’infection a Cytomegalovirus (CMV) chez le patient transplante renal peut mettre en jeu le pronostic vital mais aussi la survie du greffon vu l’augmentation du risque de rejet aigu d’ou l’interet d’une prophylaxie. Methodes : nous rapportons une serie de 61 patients transplantes du rein et mis sous prophylaxie anti –CMV et nous etudions la prevalence de l’infection a CMV dans notre serie. Resultats : la prophylaxie anti–CMV proposee dans notre serie est la Valaciclovir (Zelitrex*) des J1 de greffe renale pendant 3mois si le profil CMV est D+ /R+ ou D-/R+ ou D-/R- et pendant 6 mois si D+/R. Nous realisons la serologie CMV a J1, J7 post greffe renale ainsi qu’au 3 eme mois, 6 eme et 12 eme mois apres la transplantation renale. Pendant la periode de l’etude qui s’etend de Decembre 2011 a Juin 2016, nous avons collige 2 cas d’infection a CMV soit 5%. Comme 1 ere observation; Il s’agissait d’un patient âge de 43 ans transplante renal par un donneur vivant apparente. Le profil CMV etait D+/R+. Apres la transplantation renale le patient a ete mis sous traitement prophylactique par Valaciclovir pris pendant 25 jours puis arrete par le patient. Il presentait 30 jours apres l’arret du Valaciclovir, une diarrhee avec fievre et a la biologie une leucopenie, une CRP elevee et une creatinine a 1,3 mg/dl. Une PCR CMV en temps reel est fortement positive. Le traitement par Ganciclovir a ete instaure avec evolution favorable et PCR CMV negative. A J21 de Ganciclovir on a note une aggravation de la leuco-neutropenie. Apres 12 jours d’arret de Ganciclovir, le taux de globules blancs est revenu a la normale spontanement. La deuxieme observation etait porte sur une Patiente A.N âgee de 41 ans, transplantee renale a partir d’un donneur vivant apparente et un statut serologique D+/R+ mise sous prophylaxie par Valaciclovir pendant 90 jours. Elle a presente une insuffisance renale aigue (IRA) (creatinine passant de 176 µmol/l a 316 µmol/l) a 3 mois post transplantation renale. La biopsie du greffon a montre un rejet aigue humoral Borderline et elle etait mise sous Rituximab et Immunoglobulines intra-veineuses. L’evolution etait marquee par la stagnation de la creatinine. Devant l’IRA, la leucopenie et la thrombopenie une PCR CMV a ete pratiquee revenue positive, et la patiente a ete traitee par Cymevan pendant 21 jours. L’evolution a ete marquee par la normalisation du bilan hematologique et l’amelioration de la fonction renale (creatinine = 132 μmol/l). Dans notre centre, nous preconisons la prophylaxie anti-CMV systematique par Valaciclovir. Le 1er cas d’infection a CMV que nous avons note est survenu chez un patient qui n’avait pas pris le Valaciclovir. Chez la deuxieme patiente, l’infection a CMV est survenue a l’arret de la prophylaxie dans un contexte de forte immunosuppression pour un rejet humoral. Conclusion : le faible effectif et le recul court dans notre etude ne permettent pas de conclure. Des etudes plus larges seront d’un grand apport.

PProbable fièvre bilieuse hémoglobinurie secondaire à la prise d’un traitement antipaludéen préventif

Introduction : l’hemolyse aigue compliquee d’une insuffisance renale aigue, en particulier la fievre bilieuse hemoglobinurique (FBH), est une complication rare mais grave, consecutive a la prise d’antipaludiques. La FBH se voit actuellement au cours du traitement curatif ou preventif d’un paludisme. Methodes : Mr SK âge de 40 ans sans antecedents pathologiques a sejourne en Afrique (Gabon et Mali) pendant une semaine, ou il a pris le Quinimax comme un traitement antipaludien preventif en deux prises. Une heure apres la deuxieme prise medicamenteuse il presente des vomissements, douleurs abdominales et 3 episodes d’hematurie. L’examen clinique etait sans particularite, les bandelettes urinaires ont montre une faible proteinurie sans hematurie, la biologie a montre une insuffisance renale aigue et une perturbation transitoire du bilan hepatique sans signes d’hemolyse. La goutte epaisse n’a pas montre la presence de Plasmodium falciparium. La ponction biopsie renale a montre une necrose tubulaire aigue. Le diagnostic le plus probable etait une hepatonephrite d’origine immuno allergique, mais l’evolution rapidement favorable etait contre. Resultats : le Quinimax ne peut provoquer une necrose tubulaire aigue que par le biais d’une hemolyse intra vasculaire, un tableau qui peut se voir au cours de la fievre bilieuse hemoglobinurique (FBH). Notre patient a developpe une necrose tubulaire aigue sans stigmates d’hemolyse ni d’infection par le Plasmodium falciparium. Conclusion : notre observation pose la problematique des hemolyses aigues intra vasculaires au cours des traitements antipaludiques. Elle peut se manifester par une hemoglobinurie avec une insuffisance renale aigue au cours du traitement curatif et preventif d’un paludisme et impose l’arret de tout traitement des l’apparition d’un ictere ou d’urines colorees.

A case of renal granulomatosis with polyangiitis following intravesical bacillus Calmette-Guérin therapy

Various adverse reactions may occur after intravesical bacillus Calmette-Guérin (BCG) therapy. Although the virulence of attenuated BCG is low, serious complications such as bacterial cystitis, bladder contractures, granulomatous prostatitis, epididymitis, orchitis, and systemic reactions such as fever and malaise have been described. Disseminated granulomatosis such as hepatitis and pneumonitis have also been described, but are rare. We report here the case of a 67-year-old patient who presented with renal granulomatosis with polyangiitis following intravesical BCG therapy for superficial bladder tumor. The biological evaluation revealed the presence of perinuclear anti-neutrophil cytoplasmic antibodies with specificity for antimyeloperoxidase. Renal biopsy specimen revealed pauci-immune crescentic glomerulonephritis with segmental glomerular necrosis, presence of granulomas and no evidence of any caseating necrosis. He received antituberculosis drugs in addition to corticosteroids and cyclophosphamide without any improvement of the renal function.

Determinants of patency of arteriovenous fistula in hemodialysis patients

The arteriovenous fistula (AVF) is the vascular access of the first choice for hemodialysis (HD). Studies on patency of AVF and its affecting factors reveal a high risk for access failure. The aim of this study was to assess the primary and secondary AVF patency and their determinant factors. It was a retrospective, descriptive study conducted in the HD facility of the Nephrology Department in Rabta University Hospital. We included AVF created before December 2009 in end-stage renal disease (ESRD) patients. The end of the follow-up was fixed in December 2013. We included 126 AVFs created in 111 patients; 22.5% were aged >65 years, 39.6% were diabetic, 68.5% were hypertensive, and 26.1% had peripheral vascular disease. The primary patency rates were 78% at one year and 42% at five years. The secondary patency rates were 80% at one year and 69% at five years. Multivariate analysis revealed that the factors affecting the primary patency of AVF were: the use of jugular catheter for longer than three months (odds ratio (OR):1.91, P = 0.044) and a C-reactive protein >5 mg/L (OR: 1.7, P = 0.049). Aging (>65 years) (OR: 2.46, P = 0.042), referral time to a nephrologist <6 months before onset of ESRD (OR: 2.87, P = 0.015), absence of an antiplatelet therapy (OR: 4.47, P = 0.005), and serum phosphorus <45 mg/L (OR: 2.07, P = 0.045) were the significant impairing risk factors for secondary AVF patency. Our study suggests that early referral and creation of AVF and maturation before ESRD as well as its adequate monitoring are essential for maintaining patency.

Nephrotoxicity of Ciprofloxacin: Five Cases and a Review of the Literature

Fluoroquinolones are usually well tolerated with a minimum of serious adverse effects; renal toxicity is uncommon. Apart from the renal side effects of ciprofloxacin, we aimed to highlight the renal impact of a ciprofloxacin overdose, and thus conducted a prospective study in the Department of Nephrology at La Rabta Hospital between 2010 and 2015. The cohort database was continually updated until the inclusion of five patients who were subjected to an overdose and who were initially admitted to the medical intensive care unit and then transferred to our department for acute renal failure (ARF) due to ciprofloxacin ingestion requiring urgent hemodialysis. All patients developed ARF after 12–36xa0h of ingestion. Renal ultrasound was normal in all cases. Twenty-four-hour proteinuria was present but not significant in one case, while microscopic hematuria was present in one case. Treatment consisted of supportive therapy and extrarenal purification by conventional intermittent hemodialysis. Four patients recovered normal renal function within 3xa0weeks and the remaining patient eventually had chronic kidney failure.

FGF 23, PTH and vitamin D status in end stage renal disease patients affected by VDR Fok I and Bsm I variants

OBJECTIVESnThe aim of this study was to evaluate the association between two VDR SNPs FokI and BsmI and mineral status in ESRD patients.nnnDESIGN AND METHODSnOur case-control study included 100 patients with chronic renal failure in ESRD and 149 healthy subjects. We measured the serum Vitamin D levels and the serum intact PTH level by Electrochemiluminescence Technology (cobas E411 analyzer). We evaluated the serum FGF23 levels by indirect ELISA method. The genotyping of two VDR gene variants FokI and BsmI was carried out by PCR-RFLP technique.nnnRESULTSnIn our study, the FokI TT genotype was associated with lower risk of ESRD development (ORu202f=u202f0.176, Padju202f=u202f0.039). The difference in PTH and FGF23 levels between cases and controls was statistically significant. The expression of FokI CT genotype in subjects with diabetic nephropathy was associated with a negative correlation between VD and PTH levels (ru202f=u202f-0.620, Pu202f=u202f0.032) and a positive correlation between VD and FGF23 levels (ru202f=u202f0.967, Pu202f=u202f0.012). A significant differences in VD levels between patients and controls was observed in the presence of FokI TT (Pu202f=u202f0.044) and CT (Pu202f=u202f0.036) genotypes. The expression of FGF23 serum level was significantly elevated in patients than in controls in the presence of the FokI CC and BsmI AG genotypes.nnnCONCLUSIONSnIn conclusion, our study shows the existence of an association between VDR FokI, BsmI polymorphisms and mineral status in ESRD patients. The presence of VDR variants affect the protein expression of VD, phosphorus, FGF23 and PTH.

A rare cardiac manifestation in autosomal-dominant polycystic kidney disease

Autosomal-dominant polycystic kidney disease (ADPKD) is a systemic disorder associated with various extrarenal complications. There is little information regarding the occurrence and distribution of cardiovascular abnormalities during the course of ADPKD. The major cardiovascular complications of ADPKD include valvulopathies and vascular ectasia. Aneurysm of the atrial septum (ASA) is a very rare manifestation in ADPKD. A 37-year-old woman who was diagnosed with ADPKD was admitted to our hospital for advanced renal failure. Pelvic computed tomography revealed multiple variable-sized cysts in both kidneys. Trans-thoracic echocardiography showed ASA while the patient was completely asymptomatic.

Acute renal cortical necrosis in pregnancy: Clinical course and changing prognosis

Obstetric cortical renal necrosis is a serious complication that can lead to chronic renal failure and the need for chronic dialysis. The aim of renal cortical necrosis therapy is to restore hemodynamic stability, institute early dialytic therapy, and treat the underlying cause of the disease. Most cases of renal cortical necrosis do not recover a normal renal function despite intensive care. We describe the course of a patient who was diagnosed with acute renal cortical necrosis in pregnancy treated with hemodialysis for three years but then she recovered her renal function.