End Stage Renal Failure

Background: Hemodialysis (HD) seems to be the most often used Renal Replacement Therapy (RRT) modality worldwide, and it is the primary modality in the majority of instances with extended RRT. The ability to provide our patients with high-quality HD treatment while also increasing their chances of survival is heavily reliant on the functionality of the vascular access (VA). Despite the fact that it is a very necessary component of all clinical practise standards, it is the most expensive individual component of RRT. Objectives: This study was aimed at comparing between the group with Angio access failure and group without Angio access failure and predicting Angio access failure among end stage renal failure patients in Southern Egypt. Subjects and Methods: a prospective cohort study among 125 patients with end stage renal failure at Aswan University. The research comprised patients who had NCVA placement [intra-atrial catheter (IAC) and trans-lumbar catheter (TLC)] between January 1, 2020, and December 31, 2020. The duration of previous RRT was significantly higher among the Angio access failure than the group without Angio access failure. In multivariate analysis using logistic regression, the age, duration of previous RRT, diabetes, IHD (ischemic heart disease), PVD (peripheral vascular disease) and CVD (cardiac vascular disease) were significantly direct predictors of the Angio access failure in the first one year. In conclusion the failure of Angio access was positively associated with age, previous RRT and other comorbidities.

Calciphylaxis is a rare condition affecting patients suffering from end-stage renal failure, characterised by cutaneous ischaemia and necrosis. The management of calciphylaxis is challenging owing to the lack of optimal medical therapy, although parathyroidectomy has shown some benefit. We present a case of severe proximal calciphylaxis treated with a small dose of the calcimimetic 'Cinacalcet'.

bAcKGrOUND: Iodine 131 ablation following total thyroidectomy is considered an indispensable element of successful treatment of differentiated thyroid carcinoma (Dtc). because of the essential role of the kidneys in iodine clearance, 131 I therapy of Dtc in patients with end stage renal disease, particularly those maintained on haemodialysis, present a number of special features: the 131 I activity needs to be modified, the haemodialysis sessions need to be adjusted at the time of 131 I therapy, and there are radiation safety considerations during dialysis. there is considerable controversy over these crucial questions in the reports published so far in the literature, which concern a total of fourteen patients. ObJEctIVE: the aim of our study was to present our experience on 131 I treatment of 5 Dtc patients with end stage renal disease. DEsIGN: the data of 5 Dtc patients with end stage renal disease, treated with 131 I, were retrospectively analysed; four cases were treated for remnant ablation and one for locoregional progression. In order to allow for prolonged plasma clearance of 131 I, we used a lower activity of radioiodine, reduced to roughly 40-50% of the empirically calculated activity used for normal individuals; dialysis sessions were performed immediately before and at 48 hours after 131 I administration. All patients had 131 I retention measurements performed post dialysis; in two of them some additional measurements such as iodine clearances were also performed. rEsULts: None of the patients experienced any short-term side effects, while they all had undetectable thyroglobulin levels on the first post therapy evaluation off thyroxine. 131 I elimination in the first haemodialysis was about 60%. staff incidental exposure and 131 I contamination were insignificant. cONcLUsIONs: On the basis of our experience, an empiric activity of 40-50% of that used for normal individuals appears to be effective as well as safe. these encouraging findings are discussed in relation with other reports in the literature.

Son dönem böbrek yetersizliği, insidansı ve prevalansı son 30 yılda dramatik bir şekilde artan ciddi, küresel bir sağlık sorunudur. Böbrek yetersizliğinde, akciğer fonksiyon bozuklukları oldukça sık görülmektedir. Hem akut hem de kronik böbrek yetersizliği seyrinde görülebilen pulmoner ödem, özellikle son dönem böbrek yetersizliği olan hastalarda da azalmış immün yanıt ve sıvı dengesindeki değişikliklere bağlı olarak sıklıkla görülen bir komplikasyondur. Bu olgu sunumunun amacı; son dönem böbrek yetersizliği olan ve rutin hemodiyaliz tedavisi gören bir hastada pulmoner ödem nedeniyle mortalite ile sonuçlanan bir tabloyu sunmaktır.

ABSTRACT. Rat remnant kidney is an established model of renal tubulointerstitial fibrosis and progression to end-stage renal failure. The morphologic lesions comprise nephron loss and regeneratory tubular hypertrophy, interstitial infiltration, predominately by macrophages, and progressive fibrosis. A critical role in this complex pathology was assigned to tubulointerstitial blood microvessels that regulate the supply of oxygen and nutrients of tubuli. Whereas some investigations reported a rarefaction of the vascular network in association with the degenerative cortical changes, others observed an increase in vascularization. Here these discrepant findings are addressed by reinvestigation of the vascularization of rat remnant kidneys by the use of two novel endothelial lineage specific, discriminatory markers,i.e., the membrane mucoprotein podoplanin with specificity for lymphatic endothelia, and the glycosyl-phosphatidylinositol (GPI)–anchored membrane enzyme aminopeptidase P that...

Background: End stage renal failure (ESRF) has become a major health problem in Sub Saharan Africa (SSA). There were limited data about causes of ESRF in the Sudan. Methods: This is a cross sectional hospital based descriptive study. The subjects of the study are ESRF adults' patients on regular haemodialysis treatment in 15 haemdoialysis centres in Khartoum State-Sudan. Clinical and epidemiological data were obtained from 1583 patients. The medical files of each patient were reviewed to identify the cause of ESRF. Concerning the causes of ESRF, diabetes was diagnosed based on the past medical history and result of the glucose tolerance test, hypertension was diagnosed based on past history of hypertension based on blood pressure of more than 140/90 mmHg, glomerulonephritis was diagnosed based on results of previous kidney biopsies and on clinical grounds, polycystic kidney disease and obstructive uropathy were diagnosed based on abdominal ultrasound and other imaging modalities, sickle cell anaemia was diagnosed based on the result of haemoglobin electrophoresis, systemic lupus erythematosus was diagnosed based on the clinical criteria in addition to lab results of auto antibodies, and analgesic nephropathy was diagnosed based on past medical history of chronic analgesic drugs usage with no other identifiable risk factors. We included all ESRF patients on regular haemodialysis treatment. We excluded ESRF patients less than 18 years old. The results showed that the mean age of ESRF Patients was 49 ± 15.8 (years) and 63.4 % were male and 76.3 % were unemployed. The mean duration of haemodialysis is 4.38 ± 4.24 (years). The most common cause of ESRF in our patients was hypertension (34.6 %) followed by chronic glomerulonephritis (17.6 %), diabetes mellitus (12.8 %), obstructive uropathy (9.6 %), autosomal dominant poly cystic kidney disease (ADPKD) (4.7 %), chronic pyelonephritis (4.6 %), analgesic nephropathy (3.5 %). However in (10.7 %) no cause was found. In patient aged less than 40 years old the leading cause of ESRF was glomerulonephritis (29.3 %) followed by hypertension (25 %). In patient aged between 40 to 60 years old the leading cause of ESRF was hypertension (38.5 %) followed by diabetes mellitus (14 %). In patient aged older than 60 years the leading cause of ESRF was hypertension (38.4 %) followed by diabetes mellitus (23.3 %). Conclusions: ESRF in Sudan affects the economically productive age group; unemployment rate among ESRF patients is high. The study showed that hypertension is a leading cause of ESRF in Sudan followed by chronic glomerulonephritis. Hypertension and diabetes mellitus are the leading causes of ESRF among patients over 40 years old.

Renal transplantation remains the most effective treatment of End Stage Renal Failure (ESRF). In this cross sectional study we explore the reasons behind refusal of renal transplantation among adults' Sudanese haemodialysis patients. The subjects of the study are ESRF adults' patients on regular haemodialysis treatment in 15 haemdoialysis centres in Khartoum/Sudan. All patients who are on regular haemodialysis were interviewed by questionnaire to explore the reasons of refusal of renal transplantation. A total of 1583 ESRF adults' patients on regular haemodialysis have been participated in the study, 381 (24.1%) patients refused kidney transplantation. The mean age of patients refusing kidney transplantation was (58.5 + 15.1 years); 77.4% of them were ≥50 years old, 59.2% were males and 88.1% were unemployed, patients older than 50 years old and unemployed are tend to refuse renal transplantation (P < 0.001). The main reason of refusal was that the patients refuse to accept kidney from living donors (34.8%). 17.6% of patients decline kidney transplantation because of financial reason, 18.1% of patients refused to do transplantation because of fear of transplant surgery, 15.7% of patients believe that kidney transplantation is against their religious values, 11.9% of patients refused transplantation because they don't have enough knowledge on renal transplantation, only 0.5% of patients refuse transplantation because of side effect of immunosuppressive drugs. In conclusion, in this study we found that elderly and unemployed ESRF patients tend to refuse renal transplantation, the most important * Corresponding author. reason behind refusal of renal transplantation is refusal of accepting kidney donation from living related donors. This reflects the need for development of cadaveric donors program in the Sudan. ESRF patients need education and counseling on renal transplantation.

Insulin-like growth factor system components in hyperparathypositive correlations with IGFBP-3 and IGFBP-5 (that is, stimroidism and renal osteodystrophy. ulatory IGF system components). A positive correlation was Background. The insulin-like growth factor (IGF) system observed between IGF-II and IGFBP-6. ESRF patients with plays a key role in regulation of bone formation. In patients mixed uremic bone disease and histologic evidence for osteopewith renal osteodystrophy, an elevation of some IGF binding proteins (IGFBPs) has been described, but there is no study nia revealed significantly (P Ͻ 0.05) higher levels of IGFBP-2 measuring serum levels of both IGF-I and IGF-II as well as and IGFBP-4 but lower IGFBP-5 levels. Histologic parameters IGFBP-1 to -6 in different forms of renal osteodystrophy and of bone formation showed significant positive correlations with hyperparathyroidism. serum levels of IGF-I, IGF-II, and IGFBP-5. In contrast, Methods. In a cross-sectional study, we investigated 319 pa-IGFBP-2 and IGFBP-4 correlated positively with indices of tients with mild (N ϭ 29), moderate (N ϭ 48), preuremic (N ϭ bone loss. Moreover, dialysis patients with low bone turn-37), and end-stage renal failure (ESRF; N ϭ 205). The ESRF over (N ϭ 24) showed significantly (P Ͻ 0.05) lower levels of group was treated by hemodialysis (HD; N ϭ 148), peritoneal IGFBP-5, PTH, B-ALP, and OSC than patients with high bone dialysis (PD; N ϭ 27), or renal transplantation (RTX; N ϭ 30). turnover. As controls without renal failure, we recruited age-matched Conclusion. Patients with primary and secondary hyperparahealthy subjects (N ϭ 87) and patients with primary hyperparathyroidism showed lower levels of the putative stimulatory thyroidism (pHPT; N ϭ 25). Serum levels of total and free IGFBP-5 but higher levels of IGFBP-1, -2, -3, and -6, whereas IGF-I, IGF-II, IGFBP-1 to -6, and biochemical bone markers total IGF-I and IGF-II levels were not or only moderately including intact parathyroid hormone (PTH), bone alkaline increased. The marked increase in serum levels of IGFBP-4 phosphatase (B-ALP), and osteocalcin (OSC) were measured appeared to be characteristic for chronic renal failure. IGFBP-5 by specific immunometric assays. IGF system components and correlated with biochemical markers and histologic indices of bone markers were correlated with clinical and bone histologic bone formation in renal osteodystrophy patients and was not findings. Mean values Ϯ sem are given. influenced by renal function. Therefore, IGFBP-5 may gain Results. With declining renal function a significant increase significance as a serological marker for osteopenia and low was measured for IGFBP-1 (range 7-to 14-fold), IGFBP-2 bone turnover in long-term dialysis patients. (3-to 8-fold), IGFBP-3 (1.5-to 3-fold), IGFBP-4 (3-to 19fold), and IGFBP-6 (8-to 25-fold), whereas IGFBP-5 levels tended to decrease (1.3-to 1.6-fold). In contrast, serum levels of IGF-I, free IGF-I, and IGF-II remained constant in most Bone remodeling is regulated by systemic hormones patients. Compared with renal failure patients, pHPT patients and locally produced factors acting in concert to maintain showed a similar decline in IGFBP-5 levels and less elevated bone mass [1,. Insulin-like growth factors (IGFs) are levels of IGFBP-1 (3.5-fold), IGFBP-2 (2-fold), IGFBP-3 (1.2among the most important regulators of bone cell funcfold), and IGFBP-6 (4-fold) but no elevation of IGFBP-4 levels. In all subjects, free and total IGF-I levels showed significant tion because of their abundance and their proven ananegative correlations with IGFBP-1, IGFBP-2, and IGFBP-4 bolic effects on the skeleton (decreasing collagen degradation, increasing bone matrix deposition, and increasing osteoblastic cell recruitment) 4]. The key role of the

groups 2, 4, and 5 vs. groups 1 and 3). Time-course analysis Evidence for a PTH-independent humoral mechanism in postrevealed that the up-regulation of Na/Pi protein by sera from transplant hypophosphatemia and phosphaturia. groups 2, 4, and 5 was observed as early as four hours of Background. Patients undergoing successful kidney transincubation, whereas augmented abundance of Na/Pi mRNA plantation often manifest overt hypophosphatemia associated was only seen after eight hours of incubation. The addition of with exaggerated phosphaturia during the early post-transplant PTH (1-34) to sera from groups 2, 4, and 5 abolished the period (2 weeks to 3 months). The mechanism for this phenomenon has not been fully elucidated. We tested the hypothesis augmented expression of NaPi protein. We labeled OK cell that a circulating serum factor [non-parathyroid hormone (nonsurface membrane proteins with N-hydroxysuccinimide bound PTH)], which operates during chronic renal failure (CRF) to to biotin (NHS-SS-biotin). Biotinylated transporters incubated maintain phosphate (Pi) homeostasis, can increase fractional with the different sera were precipitated by strepavidin and excretion of Pi (FE PO4 ) in normal functioning kidney grafts identified by Western blot analysis. Cells incubated in sera during the early post-transplant period, thereby causing phosfrom group 2 showed increased membrane bound transporter phaturia and hypophosphatemia. when compared with control sera, whereas the intracellular pool Methods. Five groups of patients were studied: control subof the transporter was comparable between the two groups. jects (group 1, N ϭ 16), "early" (2 weeks to 1 month) post-Conclusion. A non-PTH circulating serum factor (possibly transplant patients (group 2, N ϭ 22), "late" (9 to 12 months) phosphatonin) that increases FE PO4 during CRF is also responpost-transplant patients (group 3, N ϭ 14), patients with adsible for phosphaturia and hypophosphatemia in the early pevanced CRF (glomerular filtration rate ϭ 30 to 40 mL/min; riod following successful kidney transplantation. The putative group 4, N ϭ 8), and patients who suffered from end-stage factor inactivates Na/Pi activity along with inhibition of the renal failure and were treated by chronic hemodialysis (group 5, transporter trafficking from the cell membrane into the cytosol. N ϭ 14). Group 2 manifested significant hypophosphatemia and phosphaturia when compared with groups 1 and 3 (Pi ϭ 0.9 Ϯ 0.003 mg/dL, FE PO4 ϭ 68Ϯ 5%, P Ͻ 0.0005 vs. groups 1 and 3). Sera were taken from each of the five subject groups Patients receiving renal transplant from either living and applied to the proximal tubular opossum kidney (OK) related or cadaveric donors frequently (50 to 80% incicells. The activity of Na/Pi-type 4 (that is, OK-specific type II dence) develop hypophosphatemia [1-3]. These patients transporter) was evaluated by measuring Na ϩ -dependent 32 Pi often exhibit phosphaturia [2], decreased renal phosflux. The expression of Na/Pi type II mRNA and the abundance phate (Pi) threshold (Tm PO4 /GFR), and increased rates of Na/Pi protein were determined by Northern and Western blot assays, respectively. of fractional excretion of Pi (FE PO4 ) in the face of stable Results. When compared with sera from groups 1 and 3, and normal glomerular filtration rates (GFRs). Thus far, 10% sera taken from groups 2, 4, and 5 (incubated overnight the mechanism for post-transplant hypophosphatemia with OK cells) inhibited 32 Pi flux by 25 to 30% (P Ͻ 0.0003). has not been fully elucidated. It has been thought, how-Both Na/Pi mRNA and the expression of Na/Pi protein were ever, that this syndrome is somehow linked to disordered markedly augmented under the same conditions (P Ͻ 0.05 regulation of renal tubular reabsorption of Pi. Pi reabsorption in the renal proximal tubule, which is a major

Background. Recovery of dialysis-independent renal function in long-term dialysis patients has not been studied extensively. The aim of this study was to investigate the effect of dialysis modality on the likelihood, timing and durability of recovery of dialysis-independent renal function. The study reviewed all patients in Australia and New Zealand who commenced dialysis for treatment of end-stage renal disease (ESRD) between 1963 and 2006. Dialysis modality was assigned at 90 days. A supplementary analysis was also conducted using a contemporary cohort that included data on comorbidities, smoking and eGFR at dialysis onset. Results. During the study period, 15 912 individuals received peritoneal dialysis (PD) and 23 658 received haemodialysis (HD). Renal recovery occurred in 176 (1.1%) PD and 244 (1.0%) HD patients. Using multivariate Cox proportional hazards regression analyses, dialysis modality was not independently predictive of time to renal recovery (HR 0.92, 95% CI 0.76-1.13, P = 0.4). Recovery was significantly more likely in patients with higher baseline eGFR, with no hypertension or peripheral vascular disease, and with certain causes of kidney failure (autoimmune renal disease, haemolytic uraemic syndrome, interstitial nephritis, obstructive uropathy, paraproteinaemia and renovascular nephrosclerosis). Recovery was less likely in Maori/Pacific Islanders and polycystic kidney disease. Among patients who recovered, 328 (78%) subsequently experienced renal death, mostly within the first year. The duration of renal recovery was not associated with initial dialysis modality (OR 0.82, 95% CI 0.50-1.32). Conclusions. Dialysis modality is not associated with the likelihood, timing or durability of spontaneous recovery of dialysis-independent renal function in patients thought to have ESRD.

Rheumatoid arthritis (RA) is a chronic inflammatory disorder, characterized by a persistent immune cell infiltrate in the synovium accompanied by high levels of inflammatory mediators and synovial hyperplasia. Despite significant therapeutic advances, RA remains an important unmet medical need. To discover potential new genes controlling inflammation and apoptosis in synoviocytes, genes induced by the two pro-inflammatory cytokines, tumor necrosis factor α (TNF-α) and interleukin 17A (IL-17A), were systematically searched. We identified Amphoterin-induced gene and ORF 2 (Amigo-2), a novel antiapoptotic adhesion molecule, as synergistically upregulated by the IL-17A/TNF combination specifically in RA synoviocytes. In addition, when RA synoviocytes were cocultured with immune cells, Amigo2 expression was significantly increased in both fibroblasts and immune cells. This induction persisted in RA synoviocytes even after the removal of the immune cells. Amigo2 induction was ERK-dependent and on the contrary, inhibited by JNK. Furthermore, Amigo2 expression levels correlated with apoptosis of the cells when exposed to the proapoptotic agent cadmium (Cd). Interestingly, exposure of the cells to HMGB1 in inflammatory conditions increased synergistically Amigo2 expression and significantly reduced Cd-mediated cellular toxicity. Our findings support a model whereby cell-cell contact with immune cells and exposure to the combination of both inflammatory cytokines and HMGB1 in the joints of RA patients increases Amigo2 expression in synoviocytes in an ERK-dependent manner which, in turn, enhances cellular adhesion and promotes cell survival and cellular proliferation.

Background. Analysing a 12-lead surface electrocardiogram (ECG), the inter-lead variability of the P wave interval, i.e. P wave dispersion, is defined as the difference between the maximum and the minimum P wave duration. Our aim was to assess the effect of haemodialysis on P wave duration and dispersion in non-diabetic patients with end-stage renal failure on chronic haemodialysis. Methods. Twenty-eight patients (14 men and 14 women, mean age 58"16 years, average duration of dialysis 4.5"2.8 years) were examined. Prior to haemodialysis, echocardiography (M-mode and twodimensional) was performed. Haemodialysis sessions were carried out with polysulfone dialysers and bicarbonate dialysate fluids. Twelve-lead ECGs were recorded at the beginning, 15 and 30 min after starting dialysis, at the end, and 2 h after completion of each session. Ionic parameters were checked during the study. P wave durations were measured with calipers in three consecutive complexes of each lead by one observer. Results. P maximum was 58"16 ms at the beginning, and showed an increase by the end of dialysis to 98"8.9 ms (P-0.0001). Pre-dialysis P dispersion was 23"10 ms and increased to 41"16 ms by the end of the sessions (P-0.0001). In patients with a left atrial diameter larger than 45 mm, P dispersion increased from 23"11 to 53"10 ms (P-0.0003) by the end of the sessions. Conclusions. According to our results, ionic imbalance and dialysis itself may cause changes in P duration and dispersion simultaneously.

Background: Angiotensin converting enzyme inhibitors (ACEIs) are commonly used in the treatment of hypertension. We describe the first cases of angiotensinconverting enzyme inhibitor (ACEI) -induced intestinal angioedema in the postpartum period. Both patients presented with hypovolemic shock and acute abdominal complaints. The first patient underwent laparotomy because of the suspicion of internal bleeding. Only large amount of ascites was found. After exclusion of other causes, the diagnosis of ACEI-induced intestinal angioedema was made. Pattern recognition in our second patient prevented invasive examinations. Both patients made full recovery after discontinuation of angiotensin converting enzyme inhibitor and with supportive therapy. Identification of ACEI-induced intestinal angioedema as a cause of abdominal complaints and hypovolemic shock may avoid unnecessary invasive examinations. ACEIs should not be first choice in the treatment of hypertension in the postpartum period.

Background: Angiotensin converting enzyme inhibitors (ACEIs) are commonly used in the treatment of hypertension. We describe the first cases of angiotensinconverting enzyme inhibitor (ACEI) -induced intestinal angioedema in the postpartum period. Both patients presented with hypovolemic shock and acute abdominal complaints. The first patient underwent laparotomy because of the suspicion of internal bleeding. Only large amount of ascites was found. After exclusion of other causes, the diagnosis of ACEI-induced intestinal angioedema was made. Pattern recognition in our second patient prevented invasive examinations. Both patients made full recovery after discontinuation of angiotensin converting enzyme inhibitor and with supportive therapy. Identification of ACEI-induced intestinal angioedema as a cause of abdominal complaints and hypovolemic shock may avoid unnecessary invasive examinations. ACEIs should not be first choice in the treatment of hypertension in the postpartum period.

Purpose: The aim of this study was to investigate the incidence of left ventricular geometric patterns in patients with chronic kidney disease (CKD).Materials and Methods: A total of 162 patients (100 males) with stage 2–5 CKD were included in the study. Patient age was between 17 and 79 years. Left ventricular geometry (LVG) patterns were calculated as left ventricular normal geometry (LVNG), left ventricular concentric remodeling (LVCR), concentric left ventricular hypertrophy (cLVH) and eccentric left ventricular hypertrophy (eLVH) by echocardiographic parameters.Results: The incidence of LVH was 45.1%. LVG patterns were found as follows: eLVH in patients 18(11.1%), cLVH in 42(25.9%), LVCR in 51(31.5%), and LVNG 51(31.5%). LVNG was found 10.38% and 34.27% in CKD stage 2 and dialysis, respectively. LVCR was as high as 62.3% in CKD stage2. cLVH and eLVH were found as 35.92% and 29.13% in stage 5 non-dialysis and dialysis, respectively. There was a relationship between clinical char...

The magnitude of type II diabetic nephropathy dilemma is observable in the growing number of diabetic patients with end-stage renal lesion receiving various modalities of treatment. Progressive glomerulopathy associated with proteinuria and hypertension is strongly causative of renal failure and mortality in diabetic patients. Besides hypertension, diabetes exceeds all other glomerulopathies in causing end-stage renal failure. Alterations in glomerular structure and function observed in diabetic patients are

A prospective analysis of all new pediatric cases of chronic renal failure (CRF) was performed at our hospital over a 1-year period. The diagnosis of CRF was based on serum creatinine >2 mg/dl with supportive clinical, laboratory, and radiological findings. There were a total of 48 patients with CRF with a median age of 13 years (range 10 days to 16 years). The causes of CRF included glomerulonephritis (37.5%), obstruction and interstitial (52%), hereditary (6.3%), and undetermined (4.2%). Patients were symptomatic for a mean of 33.2 months (range 10 days to 11 years) at presentation. Eight patients (16.7%) had acute reversible deterioration of renal function at presentation. This was due to accelerated hypertension in 2, infection in 3, volume depletion in 2, and nonsteroidal antiinflammatory drugs in 1 patient. At presentation, 22 (46%) children had mild to moderate renal failure and 26 (54%) had end-stage renal disease. Twenty-one children (43.7%) had associated illness at presentation. Mean follow-up was 22.9 weeks (range 2-126 weeks). At the end of the study period, 10 (21%) patients were on conservative treatment, 7 (14.6%) on maintenance dialysis, 8 (16.7%) patients had functioning allografts, 4 (8.3%) patients had died, and 19 (39.6%) opted against further therapy. We conclude that CRF in Indian children carries a poor prognosis due to late referral and the limited availability and high cost of renal replacement therapy.

Patients with end-stage renal and hepatic failure may be treated with combined liver and kidney transplantation (CLKTx). We reviewed the indications and outcomes of 16 CLKTx performed at the University of Minnesota between 1980 and 1994. The majority of the recipients (87.5 %) were young patients affected by congenital hepatic anomalies and concomitant end-stage renal failure. Fourteen were treated with cyclosporinbased immunosuppression and had an excellent outcome: with an average of 6 years of follow-up, patient survival was 85.7 %, liver graft survival 85.7 %, and kidney graft survival 72 %. The incidence of rejection episodes was similar to the rate of rejection in our solitary kidney and liver transplants. In conclusion, our experience supports the value of CLKTx in treating patients with simultaneous failure of both organs or with congenital enzymatic hepatic deficits leading to renal failure.

Background. Renal artery stenosis (RAS) is a cause of endstage renal failure. We studied the effect of percutaneous renal artery intervention (PRI) in patients with advanced, progressive disease at risk for renal failure, hypothesizing a beneficial effect. Methods. Thirty-nine primary and 14 secondary PRIs were performed on 28 patients with atherosclerotic RAS, serum creatinine >300 lmol/L, and progressive loss of renal function ≥1 year before PRI. Renal function and RA patency were prospectively followed for 12 months after primary and secondary PRI. The intervention's effect on the progressive loss of renal function was calculated by comparing reciprocal slopes of serum creatinine against time before and after PRI. Results. Progression of renal failure slowed significantly following PRI. Mean (±SE) slopes of reciprocal serum creatinine values were: 6.69 ± 0.97 L lmol -1 day -1 (×10 -6 ) before and 6.76 ± 3.03 L lmol -1 day -1 (×10 -6 ) after PRI (P = 0.0007). Fifteen patients (53.5%) showed improvement or stabilization of progressive renal dysfunction. Out of 11 patients expected to become dialysis dependent within one year, 8 (72.7%) experienced an improvement in renal function sufficient to remain dialysis-free. Favorable outcome correlated with a lower creatinine level (P = 0.0137) and a more negative slope of progression (r = 0.49, P = 0.020) at entry. Mortality was 10.7%, and rate of local complications was 7.1%. Deterioration of renal function following PRI was suspected in 17.9% of patients. Conclusion. PRI may improve renal function and ultimately delay dialysis in patients with advanced renal failure. Possible advantages must be weighed against the risk of renal failure advancement and high procedure-related complication rate. Renal failure attributable to atherosclerotic renal artery stenosis (RAS) is increasingly recognized as an important cause of renal insufficiency . Particularly in the elderly population it is a major factor responsible

Los aloinjertos compuestos vascularizados (ACV) son una alternativa para la reconstrucción de lesiones que afectan la integridad corporal (amputaciones, malformaciones, etc.). Los ACV tienen tejidos de las tres capas germinales (nervios, músculo, vasos sanguíneos, hueso, articulaciones, entre otros), son susceptibles al daño por isquemia, necesitan inmunosupresión para evitar su rechazo y deben ser reparados vasos sanguíneos como parte del procedimiento del trasplante. Alrededor del mundo se han hecho más de 100 aloinjertos compuestos vascularizados (cara, extremidad superior, pierna, útero, pared abdominal, laringe y otros). En México, desde 2005 se estableció el Subcomité de Trasplante de Tejidos Compuestos (SCO-TTCO) en el Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán» (INCMNSZ), desde entonces una de las principales tareas fue la sensibilización para dar a conocer el programa y encontrar donadores de extremidad superior (ES). Esta sensibilización la llevamos de manera directa a través de los integrantes del equipo, dirigida a gente joven y personal de salud; a través de redes sociales, pláticas con pacientes, participación en la formación de coordinadores hospitalarios de donación de órganos

Los aloinjertos compuestos vascularizados (ACV) son una alternativa para la reconstruccion de lesiones que afectan la integridad corporal (amputaciones, malformaciones, etc.). Los ACV tienen tejidos de las tres capas germinales (nervios, musculo, vasos sanguineos, hueso, articulaciones, entre otros), son susceptibles al dano por isquemia, necesitan inmunosupresion para evitar su rechazo y deben ser reparados vasos sanguineos como parte del procedimiento del trasplante. Alrededor del mundo se han hecho mas de 100 aloinjertos compuestos vascularizados (cara, extremidad superior, pierna, utero, pared abdominal, laringe y otros).1-4 En Mexico, desde 2005 se establecio el Subcomite de Trasplante de Tejidos Compuestos (SCOTTCO) en el Instituto Nacional de Ciencias Medicas y Nutricion «Salvador Zubiran» (INCMNSZ), desde entonces una de las principales tareas fue la sensibilizacion para dar a conocer el programa y encontrar donadores de extremidad superior (ES). Esta sensibilizacion la llev...

Objective. The ItalKid Project is a prospective, population-based registry that was started in 1990 with the aim of assessing the epidemiology of childhood chronic renal failure (CRF), describing the natural history of the disease, and identifying factors that influence its course. This article reports the epidemiologic results. Methods. Prevalent and incident cases of CRF in children and adolescents were identified throughout Italy (total population base: 16.8 million children) by regularly asking all of the pediatric hospitals and adult nephrology units potentially involved in caring for children with kidney disease to report all cases that meet the inclusion criteria and then to update the clinical information regarding all previously reported patients on an annual basis. The inclusion criteria were 1) creatinine clearance (Ccr; according to Schwartz's formula) <75 mL/min/ 1.73m 2 bsa (predialysis) and 2) an age of <20 years at the time of registration. Results. By December 31, 2000, 1197 patients (803 boys) had been registered. The mean incidence was 12.1 cases per million (range: 8.8 -13.9), and the (point) prevalence was 74.7 per million of the age-related population. The mean age at registration was 6.9 ؎ 5.4 years, and the mean Ccr was 41.7 ؎ 20.5 mL/min/1.73 m 2 . The leading causes of CRF were hypodysplasia associated with urinary tract malformations (53.6%) and isolated hypodysplasia (13.9%), whereas glomerular disease accounted for as few as 6.8%. Hypodysplasia associated with primary vesicoureteral reflux (VUR) alone was responsible for as many as 25.8% of the cases, thus being the leading single cause with a female-to-male ratio of 1:3.2. The diagnosis of VUR was established early in life at an overall median age of 3 months (range: 0 -180). However, the diagnosis was made significantly later among girls, whose median age at diagnosis was 9 months (range: 0 -156; 95% confidence interval: 21.2-49.3) as against 2 months among boys (range: 0 -180; 95% confidence interval: 10.9 -21.2). occurred during puberty and early postpuberty, leading almost 70% of the patients to end-stage renal failure by the age of 20 years. When the population was subdivided on the basis of Ccr at the time of registration, the probability of kidney survival at 20 years of age was significantly different, being 63% in patients with mild renal failure (Ccr 51-75 mL/min), 30% in those with moderate renal failure (Ccr 25-50 mL/min), and 3% in those with severe renal failure (Ccr <25 mL/min). The incidence of renal replacement therapy was 7.3/y/100 patients, and the case-fatality rate on conservative treatment was 1.41%. Conclusions. This study provides important and recent epidemiologic information concerning CRF in children and adolescents: a mean annual incidence of 12.1 new patients per million of the age-related population with a very high proportion (57.6%) of hypodysplastic renal diseases with or without urinary tract malformation. By the age of 20 years, the cumulative probability of end-stage renal disease in the population as a whole was 68%. The probability of kidney survival sharply declined during puberty and early postpuberty. This is the first prospective evaluation of the incidence and outcome of CRF in children, including those with mild and moderate renal impairment. Pediatrics 2003;111:e382-e387. URL: ; kidney disease, renal failure, children, adolescents, epidemiology, vesicoureteral reflux.

Background. Late referral (LR) to the nephrologist of patients with progressing chronic kidney disease (CKD) has numerous deleterious effects and is observed in many countries. The contributing factors associated with LR are controversial and poorly defined. We hypothesized that these factors might be better identified by analysing patients starting dialysis in three distinct European countries within the same area. Method. The referral and progression of kidney failure patterns were analysed with demographic, clinical and biological data in 279 non-selected consecutive patients starting dialysis in eight centres of three adjacent regions in France, Italy and Switzerland. Results. Early referral (>6 months before the start of dialysis) was seen in 200 patients (71.6%), intermediate referral (1-6 months) in 42 (15.1%) and LR (<1 month) in 37 (13.3%). However inter-centre variations were between 2 and 19% for LR and 6-50% for combined late and intermediate referral. There were no differences at the national levels, but LR was more frequent in the large city centres than in the private or regional structures, with 31 out of 169 (18.3%), two out of 55 (5.4%) and four out of 55 (7.3%), respectively, of their patients (P<0.01). By multivariate analysis, it appears that, besides the presence of an active cancer and the CKD progression rate, the centre structure and the referring physician (primary care physicians and nephrologists are less responsible for LR than other medical specialists) play a significant role in the practice of LR. Conclusions. Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approach.

This study aimed to examine the long-term outcome for patients with end-stage renal failure (ESRF) who survived multiple-organ failure. We performed a review of databases from the renal medicine service and intensive care units (ICU) of the participating hospitals within Imperial College Healthcare NHS Trust, London, UK. Patients with ESRF admitted to ICU who required support of two or more organ systems or were ventilated for more than 36 hours were included. To provide a comparison we examined the survival of a comparator group of ESRF patients in the general population with similar demographic and disease characteristics to our study group. We also examined the outcome for ESRF patients admitted to ICU who died prior to discharge. Survival data for two years following discharge from ICU were examined for the impact of age, prior dialysis history, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and medical or surgical status. Of the 199 patients who met the inclusion criteria, 111 (56%) survived their ICU stay. Sixty-two (56%) of the survivors remained alive two years following discharge. There was no group difference in survival with regards to age, dialysis history or APACHE II scores. Those admitted with a medical rather than surgical diagnosis were less likely to survive two years (P < 0.01). Patients who died in ICU had higher APACHE II scores (P < 0.0001) and were more likely to have a medical diagnosis. By log rank analysis two-year mortality was significantly higher (P = 0.003) in the ICU survivors than the comparator group with ESRF. This difference was lost when patients who died within a month of discharge were excluded. Conclusions ESRF patients with multiple-organ failure have a high mortality, with the increased risk of death continuing into the early post-ICU period. Those with non-surgical diagnoses have the highest risk. Survival within the group who live beyond the early post-ICU period appears similar to the background population of ESRF patients.

Simple renal cysts (solitary or multiple) Cysts of the renal sinus (or peripelvic lymphagiectasis) Acquired cystic kidney disease (in patients with chronic renal impairment) Multilocular cysts (or multilocular cystic nephroma) Multicystic dysplastic or multicystic kidney* Autosomal dominant polycystic kidney disease* Tuberous sclerosis complex von Hippel-Lindau disease Autosomal recessive polycystic kidney disease* Nephronophthisis Orofaciodigital syndrome type 1 *Common type of cystic disease of the kidney

La dialyse péritonéale occupe une place importante dans la prise en charge de l'insuffisance rénale au stade terminal, notamment chez le jeune enfant. L'optimisation de son efficacité nécessite l'emploi de solutions de dialyse biocompatibles mais aussi l'amélioration du recrutement de la surface péritonéale d'échange (SPE). Les modèles expérimentaux animaux sont une étape essentielle pour mesurer la SPE. Nous proposons une méthode, rapide, de mesure in vivo de la SPE chez le rat à l'aide de données de microtomodensitométrie (TDM) et à partir de la mesure du volume de dialysat obtenu par dilution isotopique de nanocolloïdes-99mTc.

Background. End-stage renal failure requiring dialysis is one of the most serious complications of diabetes mellitus, and diabetes is the most common cause of end-stage renal failure. The aim of this large, observational study is to describe the population-based incidence and prevalence rates and outcomes of diabetic individuals in Ontario, Canada who require dialysis therapy. Methods. Two cohorts of patients, those with diabetes and those without, were created between April 1, 1994 and March 31, 2000 (total of 8.4 million) and followed until March 31, 2001 using several large, linked administrative databases at the Institute for Clinical Evaluative Sciences. The incidence, prevalence and mortality on dialysis for each cohort were determined. A multivariate Cox proportional hazards analysis, adjusting for age, sex and co-morbidity, was used to determine the independent impact of diabetes on patient survival. Results. The average annual incidence rate of dialysis was 12 times greater in persons with diabetes (130 per 100 000) vs without diabetes (11 per 100 000). By 1999-2000, diabetic patients comprised 51% of the incident dialysis population. The average annual prevalence rate was 10 times greater in the diabetic cohort. Patients with diabetes had more co-morbidities at the start of dialysis and poorer 3 year survival (55 vs 68%; P<0.0001). Conclusions. The incident and prevalent rates of dialysis for patients with diabetes mellitus are many times the rates of those without diabetes. Patients with diabetes mellitus often start dialysis with significant co-morbidities, which may contribute to the relatively high rate of mortality on dialysis.

Background Idiopathic membranous nephropathy (IMN) is one of the most common forms of autoimmune nephritic syndrome in adults. The purpose of this study is to evaluate whether polymorphisms of PLA2R1 affect the development of IMN. Methods Taiwanese-Chinese individuals (129 patients with IMN and 106 healthy controls) were enrolled in this study. The selected single nucleotide polymorphisms (SNPs) in PLA2R1 were genotyped by real-time polymerase chain reaction using TaqMan fluorescent probes, and were further confirmed by polymerase chain reaction-restriction fragment length polymorphism. The roles of the SNPs in disease progression were analyzed. Results Genotype distribution was significantly different between patients with IMN and controls for PLA2R1 SNP rs35771982 (p = 0.015). The frequency of G allele at rs35771982 was significantly higher in patients with IMN as compared with controls (p = 0.005). In addition, haplotypes of PLA2R1 may be used to predict the risk of IMN (p = 0.00...

Glomerulopathy with fibronectin (FN) deposits (GFND) is an autosomal dominant disease with age-related penetrance, characterized by proteinuria, microscopic hematuria, hypertension, and massive glomerular deposits of FN that lead to end-stage renal failure. The genetic abnormality underlying GFND was still unknown. We hypothesized that mutations in FN1 , which encodes FN, were the cause of GFND. In a large Italian pedigree with eight affected subjects, we found linkage with GFND at the FN1 locus at 2q32. We sequenced the FN1 in 15 unrelated pedigrees and found three heterozygous missense mutations, the W1925R, L1974R, and Y973C, that cosegregated with the disease in six pedigrees. The mutations affected two domains of FN (Hep-II domain for the W1925R and the L1974R, and Hep-III domain for the Y973C) that play key roles in FN–cell interaction and in FN fibrillogenesis. Mutant recombinant Hep-II fragments were expressed, and functional studies revealed a lower binding to heparin and t...

Subcutaneous fat necrosis of the newborn (SCFN) is an unusual disorder which occurs in term or post-term newborns due to perinatal stress. SCFN appears by firm nodules over the trunk, arm, buttock, thigh and cheeks in the first several weeks of life. Prevalence of SCFN is unknown. Race and sex do not play a role in this condition Hypocalcaemia and rarely hypercalcaemia are considered as major causes of morbidity and mortality in cases of SCFN. We report a case of SCFN in a two month male infant complicated with hypercalcemia and hyperuricemia.

End-stage renal disease patients (ESRD) suffer from procoagulant abnormalities that lead to excessive cardiovascular events, as well as from platelet dysfunction manifesting as an increased risk of bleeding. The exact pathogenesis of complex hemostatic disorders in ESRD patients is not completely understood. The aim of our study was to investigate the possible different effects of hemodialysis (HD) and peritoneal dialysis (PD) on platelet function in patients with ESRD by using the platelet function analyzer (PFA-100) which in vitro simulates the process of aggregation and platelet activation. Tests were performed with collagen/ epinephrine (COL/EPI) and collagen/adenosine-5-diphosphate (COL/ADP) cartridges. The study included 44 patients with ESRD undergoing regular HD (n=32) or PD (n=12). Although there were no significant differences in COL/EPI and COL/ADP tests, it is indicative that more than 50% of HD patients had COL/EPI test values above the upper limit. These findings correlated with a higher chance for bleeding in HD group. Additionally, patients in HD group were significantly older and had significantly lower platelet count compared to PD patients.

ranging from 63% to 85% and limb salvage from 52% to 87% in patients with ESRD. Overall survival in these patients has been consistently poor, which reflects their decreased life expectancy from multiple causes, including a high incidence of cardiac disease and infectious and access complications. In addition, ESRD has a negative impact on morbidity, mortality, and survival after lower extremity amputation. The risk/benefit ratio of infrainguinal arterial reconstruction for limb salvage in patients with chronic renal failure has thus not been clearly defined. The purpose of this retrospective review was to evaluate the perioperative and long-term results of patients with ESRD undergoing infrainguinal revascularization at a single institution. A retrospective review was performed of all patients undergoing infrainguinal revascularization for limb salvage between December 1994 and December 1999. During this time period, 461 grafts were created in 425 limbs in 368 patients. Indications for operation included tissue loss (284 [62%]), rest pain (141 [30%]), and acute arterial ischemia (36 [8%]). Comorbid Improvements in the medical management of endstage renal disease (ESRD) have allowed more patients to survive for prolonged periods dependent on renal replacement therapy. The high incidence of atherosclerotic vascular disease in this population has led to an increased number of dialysis-dependent patients requiring arterial reconstruction for limb-threatening infrainguinal vascular disease. 1 Recent reports have documented graft patency 27

The purpose of this article is to highlight some properties of the hypoproteic nutrition in chronic renal disease (CKD), which can be defined as real therapy and are often misunderstood. These include: preventing the worsening and rapid progression of residual renal function (RRF), delaying replacement treatment, reducing the production of much more toxic nitrogenous compound molecules, such as protein-bound uremic toxins, and obtaining a phosphorus balance that could lead to a better control of uremic osteopathy and a lower incidence of cardiovascular events, thus improving survival rates in end-stage renal disease (ESRD) patients. In turn, we acknowledge a new approach called "incremental dialysis", which, thanks to a lower protein intake, can be employed with many patients with limited RRF and a good dietetic compliance. In our opinion, this approach must be mandatory applied for reducing dialysis frequency, such as once-weekly haemodialysis (HD), via an intervention we define as a combined diet dialysis programme (CDDP). The term incremental HD (IH) is used and often confused with "infrequent dialysis" by many authors who use the same term interchangeably for once-and twice-weeklydialysis without proteic diet control and too limited RRF. However, the milestone concepts are as follows: adopting a dietary hypoproteic approach is needed for mediumadvanced stages of CKD by avoiding useless and harmful dialysis "overdose". Finally, in CKD nowadays, it is necessary to administer amino acids, while we must seriously consider the treatment of uremic dysbiosis, which heavily affects microbiota.

The hemolytic uremic syndrome (HUS) is rare and of guarded prognosis in adults. It expresses a renal thrombotic microangiopathy. We report the case of a young patient whose clinical presentation and exploration make a diagnosis of HUS likely. The atypical presentation provides an opportunity not only to discuss all diagnostic elements based on recent pathophysiological hypotheses, but also to highlight recommendations for the management of this severe disease.

Dosage recommendations for cidofovir are available for renally competent as well as impaired patients; however, there are no data for patients undergoing continuous renal replacement therapy. We determined the single-dose concentration-versus-time profile of cidofovir in a critically ill patient undergoing continuous venovenous hemofiltration (CVVH). One dose of 450 mg cidofovir (5 mg/kg) was administered intravenously due to a proven cytomegalovirus (CMV) infection and failure of first-line antiviral therapy. Additionally, 2 g of probenecid was administered orally 3 h prior to and 1 g was administered 2 h as well as 8 h after completion of the infusion. The concentrations of cidofovir in serum and ultrafiltrate were assessed by high-performance liquid chromatography. The peak serum concentration measured at 60 min postinfusion was 28.01 mg/liter at the arterial port. The trough serum level was 19.33 mg/liter at the arterial port after 24 h. The value of the area under the concentration-versustime curve from 0 to 24 h was 543.8 mg • h/liter. The total body clearance was 2.46 ml/h/kg, and the elimination half-life time was 53.32 h. The sieving coefficient was 0.138 ؎ 0.022. Total removal of the drug was 30.99% after 24 h. Because of these data, which give us a rough idea of the concentration profile of cidofovir in patients undergoing CVVH, a toxic accumulation of the drug following repeated doses may be expected. Further trials have to be done to determine the right dosage of cidofovir in patients undergoing CVVH to avoid toxic accumulation of the drug.

Background Idiopathic membranous nephropathy (IMN) is one of the most common forms of autoimmune nephritic syndrome in adults. The purpose of this study is to evaluate whether polymorphisms of PLA2R1 affect the development of IMN. Methods Taiwanese-Chinese individuals (129 patients with IMN and 106 healthy controls) were enrolled in this study. The selected single nucleotide polymorphisms (SNPs) in PLA2R1 were genotyped by real-time polymerase chain reaction using TaqMan fluorescent probes, and were further confirmed by polymerase chain reaction-restriction fragment length polymorphism. The roles of the SNPs in disease progression were analyzed. Results Genotype distribution was significantly different between patients with IMN and controls for PLA2R1 SNP rs35771982 (p = 0.015). The frequency of G allele at rs35771982 was significantly higher in patients with IMN as compared with controls (p = 0.005). In addition, haplotypes of PLA2R1 may be used to predict the risk of IMN (p = 0.00...

Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement (PRESERVE) study. Importance is given not only for the detection of proteinuria but also for the treatment with reninangiotensin-aldosterone system (RAAS) inhibitors • Ramipril in Heart Outcomes Prevention Evaluation (HOPE) and mini HOPE study and losartan in Losartan Intervention For Endpoint reduction in hypertension (LIFE) study resulted in significantly reduced cardiovascular risk in participants with renal impairment. In the Ongoing Telmisartan Alone and combination with Ramipril Global Endpoint Trial (ONTARGET) combination of telmisartan and ramipril resulted in greater reduction in proteinuria but significant increase in adverse events. In this issue, Kodali et al reports that proteinuria is a marker for CVD in patients with stage 5 CKD. The major limitation of this study is that they have taken already known cases of CAD, rather than following these patients for the development of CAD. However, the most important aspect of this study is that the study populations are only females for whom there are limited studies. This study by Kodali et al will add more information to the existing literature.