Revista de nefrología y terapéutica

Patients with Chronic kidney Disease (CKD) are fragile. Hemodialysis, the most useful Renal Replacement Therapy in the world is the only treatment available in Madagascar. It is an invasive act exposing several complications. This study aims to assess the prevalence of the bacterial complication in hemodialysis. We conducted a retrospective, exhaustive, descriptive single centre study. Record based study was carried in Befelatanana Hemodialysis Centre, in Antananarivo, the Capital. All chronic hemodialyzed patients who presented an infection were included. Over 136 infections have been suspected but only 33.8% benefited a bacterial identification. In 42.65% of cases, infection begun in 20 days following the first hemodialysis session. Access vascular using catheter is the principal source of infection in 49.06%, followed by pulmonary infection. Staphylococcus aureus (34.3%) was the bacteria frequently en-countered. Sepsis appeared in 98.52% of cases and any patients presented a septic choc. All patients received an adjusted antibiotherapy according to susceptibility testing. The survival rate was in 100%. Treatment of chronic kidney disease is very expensive in Madagascar and 3% of patients have the opportunity to do hemodialysis. That explains our few studied population. In our cohort, access vascular related to femoral catheter represents the common source of infection (49.06%). This prevalence is higher than another American studies. Patients arrived lately at hospital with End-stage of chronic kidney Disease imposing starting hemodialysis in emergency with catheter. Another source of infection has been seen in another site. Patients can also contract infection independently of hemodialysis. Antibiotherapy allowed favorable evolution. To conclude, using access vascular with catheter is inescapable in our center. To fix that, promoting native fistula with early nephrology medical follows-up could be a good solution. Renal transplantation with living donor, the best and less expensive treatment than chronic hemodialysis is now in progress, in collaboration with the Malagasy Government.

Objective: To report an atypical case of renal scleroderma crisis without cutaneous involvement and no serological manifestation. Observation: A black African, 33 years old was hospitalized for a malignant hypertension. He reached rapidly the end-stage of chronic kidney disease due to a scleroderma renal crisis. Presumption diagnostic was established by clinical signs, biological and imagery investigations. Results: The patient didn’t have personal and familial medical backgrounds a part losing 20 kilos two months before hospitalisation. In admission, he has malignant hypertension 220/140 mmHg and there was no cutaneous involvement of scleroderma. Blood tests concluded a chronic kidney disease with an estimated Glomerular Filtration Rate less than 2 ml/mn/1.73 m2. The C- reactive protein was negative and the sedimentation rate in first hour was accelerated to 119 mm. The proteinuria was 0.8 g/24 hours. The immune balance of the ribonucleic acid polymerase, the anticytoplasmic antibodies, the antinuclear antibodies were repeated more times but were negative. Imagery investigations found systemic manifestation such as lung fibrotic with atelectasia. Heart doppler found hypertension in pulmonary artery and minim pericarditis. Renal Doppler confirmed hypotrophic sizes of both kidneys with high index resistances in small vessels. Renal biopsy was not done. Six months later appeared limit digitals ulceration on both fingers. The patient was treated by angiotensin-converting-enzyme inhibitor, calcic inhibitor and underwent to a chronic hemodialysis with significant improvement mainly about the blood pressure (120/70 mmHg). Conclusion: Any malignant hypertension in scleroderma in the absence of other causes with a rapid deterioration of renal function should think first of all a scleroderma renal crisis, cutaneous involvement and serological manifestation are not always obligatory.

Purpose: Hyponatremia is the most common electrolyte disorder seen in hospitalized patients. The prevalence has been reported to be 5-30% depending on the clinical setting. The aim of this study was to determine the prevalence and etiologies of hyponatremia in patients now receiving care in our hospital. Methods: We collected data on two separate days one month apart to evaluate the current prevalence and etiology of hyponatremia in patients in our hospital. We defined hyponatremia as a serum sodium level less than 135 mEq/L. We also divided hyponatremia patients into 2 groups depending on age to evaluate possible differences in etiology. Results: We found that 41 out of 879 patients (4.7%) were hyponatremic. Eighty-five percent of patient’s exhibited a serum sodium of 130-134 mEq/L. the majority of cases of hyponatremia were associated with medication use (34.1%). Other associated etiologies were hypovolemia, malignancy, lung disorders, congestive heart failure (CHF), patients on dialysis and postoperative patients. Twelve patients had data consistent with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In terms of age, 56% of patients were more than 65 years of age. Patients receiving diuretics was a frequent etiology in older individuals, while dialysis therapy was common in younger patients. Conclusion: Our findings suggest that the current prevalence of hyponatremia is not as high as reported in some previous studies. In addition, the hyponatremia observed tends to be mild and current related conditions include patients on dialysis therapy. Medication use continues to be a common responsible factor.

Objective: Normal hydration state without experiencing symptoms indicative of over or under hydration at or after the end of hemodialysis treatment or what we call "dry weight” DW is a challenge for most nephrologists. Different methods has been tried to achieve this goal. We performed this study to investigate and compare three different objective tools (2 medical devices and 1 laboratory value) body composition measurement (BCM), chest ultrasound and brain natriuretic peptide (BNP) to narrow the gap toward proper estimation of DW in Hemodialysis patients. Methods: 49 stable chronic hemodialysis patients underwent assessment pre and post hemodialysis using all the available modalities mentioned above. Results: BCM assessment showed pre dialysis 27 patients (55%) were classified as overhydrated, 18 patients (37%) as normohydrated and 4 patients (8%) patients as hypohydrated. Lung comets score before hemodialysis were 21.4 ± 17 and after hemodialysis were 9.1 ± 6.9. 19 patients (39%) had lung comets score <14, 21 (43%) between 14-30 and 9 (18%) >30. There was no difference in age, gender, SBP, and DBP between the three groups. Circulating BNP levels showed significant decrease (33%) from a mean of 10443 ± 17232 pg/ml predialysis to 6956 ± 13885 pg/ml post-dialysis (p=0.00). Conclusions: Chest ultrasound, BCM, and BNP measurements as indicators for volume status assessment showed significant reduction in overhydration after dialysis, which is related more to changes in volume status rather than to its absolute values before and after hemodialysis however the was no correlation between the three modalities as assessment tool for volume status.

Celiac disease is an autoimmune disorder affecting primarily the small intestine. Although rare celiac disease is a possible cause of diarrhea after renal transplantation. Our case is the first to report that tacrolimus could be cause of celiac disease after renal transplantation. A woman aged 34 years old, with a renal transplantation from a cadaveric donor. For maintenance therapy, she underwent tri-therapy with Tacrolimus. She was complaining from chronic diarrhea with weight loss unimproved at 16 months after the TR and despite the switch from Mycophenolate mofetil to Azathioprine. She had an anemia and signs of malabsorption with a congestive duodenitis in the gastroscopy and villous atrophy in moderate area in the biopsy. Celiac serology was positive. The patient underwent gluten-free diet during 6 months without improvement. Tacrolimus was stopped and switched to Cyclosporine A. After this attitude the diarrhea disappeared and we note a weight gain and improvement of biological parameters. Control of antibodies after conversion to cyclosporine A was negative. Celiac disease is rare in the transplant recipient and never confirmed with immunogical test. There was no case in the literature that reported tacrolimus as cause of celiac disease. Our case is the first witch reported celiac disease after transplantation and confirmed with an immunological test and it was caused by tacrolimus.

Atheroembolic renal disease (AERD) or cholesterol crystal embolisation often is an under diagnosed clinical illness. It is a multisystemic disease with progressive renal failure due to foreign body reaction of cholesterol crystals flushed into a small vessel system of the kidneys from the arteriosclerotic plaques. It usually occurs after vascular catheterization, anticoagulation and less frequently spontaneously. Renal and patient prognosis are usually poor. We hereby are reporting a case report of a 62-year-old male patient with dyslipidemia who underwent percutaneous coronary intervention for unstable angina and consecutive AERD with typical clinical appearance few days after the event. Rapid improvement of renal function was noticed after treatment with systemic corticosteroids.

Introduction: End-stage renal disease is associated with a high annual rate of cardiovascular disease mortality. To this date, there is no local research regarding this topic. Objective: To identify risk factors associated with mortality in prevalent chronic dialysis patients. Methods: A case-control study was conducted in 2011-2012, in the city of Cartagena, Colombia. Deceased adult patients were included in the period. Those with advanced cancer, AIDS, liver cirrhosis, Child-Pugh C or patients with incomplete records were excluded. For each case two controls matched by age, sex and dialysis shift were selected. The clinical records were reviewed to consider social and demographic data, comorbidities, clinical and paraclinical variables. Statistical analysis was performed using Chi square, Student t-Test, Mann-Whitney and Multivariate Logistic Regression Analysis. Findings: This study chose 85 cases from 109 deceased patients and 170 controls were chosen. No statistically significant differences were found among the patients treated under the Social Security System with regards to Comorbidities, Cause of ESRD, Pre-dialysis Blood Pressure, Hemoglobin, Kt/V, Calcium, Phosphorus, Triglycerides, Ferritin and intact parathyroid hormone (PTH) levels. Causal associations found for time variables in hemodialysis of less than one year include vascular access via catheter, anemia, total cholesterol, underweight and hypoalbuminemia. These were more frequently found in cases studied when compared to the controls. Multivariate logistic regression analysis showed that the factors associated with mortality were related to underweight (odds ratio [OR], 2.64; 95% Confidence interval [CI], 1.04 to 6.70) and to hypoalbuminemia (OR, 3.0; 95% CI, 1.21 to 7.43). Traditional risk factors did not show any causal association. Conclusion: The case control study showed that underweight and hypoalbuminemia have a statistically significant causal relationship with the factors associated with mortality on hemodialysis patients.

Introduction: Leclercia adecarboxylata is an opportunistic gram-negative bacillus from the enterobacteria group, rarely isolated. It is generally reported as a single infection in immunosuppressed patients and less frequently in poly-microbial cultures in immune-competent patients. Clinical case: 60-years-old male with chronic kidney disease in haemodialysis since 2010, first by arteriovenous fistula and since 2014 by right jugular tunnelled catheter. During a session of haemodialysis, he presents an episode of chills and fever without apparent infectious focus; infection of catheter is suspected. Blood cultures are ordered, as well as beginning empirical therapy with vancomycin and amikacin via catheter. Blood cultures reported multisensible Leclercia adecarboxylata, presenting a good clinical response and negative blood cultures after treatment. Discussion: L. Adecarboxylata is an unusually isolated pathogen in sepsis by haemodialysis’s catheter and understudied in the literature. The importance of our case consists in being the first report in Colombia. The experience in other reports of this microorganism suggests that it has successful results with antibiotic treatment and no there’s no need to remove the catheter.

Whipple's disease (WD) is a rare chronic and multi-systemic infectious illness. The exposing factor to WD is an underlying genetic predisposition that leads to colonization of T. whipplei throughout the intestinal tract. Here, we report the first case of WD, to our knowledge, with typical systemic and gastrointestinal manifestations, malabsorption syndrome and serious alteration leading to death in a kidney transplant recipient. We intend to describe its clinical presentation, the methods for its diagnosis, and the outcome of treatment. It's a 27-year-old man without history of arthritis or diarrheal illness. He received a cadaveric graft in 23/12/1999 at the age of fifteen. His HLA analysis was A1 A33 B14 B35 BRB1*01 DRB1*11. The recipient lived in an urban environment without well water or animals. Five years after transplantation, he complained of diarrhoea and fever with a negative infectious work up. These gastrointestinal symptoms were resolved after empiric antibiotics. The recipient was hospitalized in 2012, thirteen years after transplantation, to explore a second episode of chronic afebrile diarrhoea with loss of weight and worsening of the graft function. Labs showed malabsorption syndrome, anaemia and leukopenia but no inflammatory signs. Anti-gliadine and anti-transglutaminase antibodies were negative. Bacteriological and parasitological stools tests as well as blood cultures were negative. Cytomegalovirus antigenemia and tumor markers were also negative. The patient has not been treated with antibiotics for WD and MMF toxicity was more likely to be responsible of the malabsorption syndrome. The mycophenolate mofetil was switched to Azathioprine. In October 2015, he was hospitalized for fever, diarrhoea and arthralgia without arthritis, hypokalemia, dehydration, important loss of weight and worsening of the graft function. The endoscopic exploration showed erythematous antral mucosa, severe gastritis and duodenal lymphangiectasia. Biopsies showed atrophied villi, abraded epithelium and filled villi axis with foamy macrophages strongly stained in PAS coloration. This histologic aspect is typically suggestive of T. whipplei intestinal infection. Sixteen years after transplantation, the patient was dead after two days in the intensive care unit. The diagnosis of WD was certain based on clinical and histopathological proofs.

Background: Hypertension is a major risk factor of chronic kidney disease. With the rising prevalence of hypertension worldwide, the burden of patients with chronic kidney disease is expected to be higher. Early detection and treatment of hypertensive patients with renal impairment is therefore critically important and would prevent progression of kidney disease. This study aims to identify the predictors of chronic kidney disease (CKD) among patients with diagnosis of essential hypertension. Methods: This prospective, descriptive study, which was conducted at Hamad General Hospital involved patients with a diagnosis of essential hypertension, admitted to the medical ward during the periods from June 2013 till June 2014. Results: A total of 112 patients were enrolled in the study and the prevalence of CKD was 49.1%. Univariate analysis revealed that long standing hypertension (> 5 years), alcohol consumption, history of TIA/stroke, presence of proteinuria, history of CAD, ECG-determined left ventricular hypertrophy (LVH) and hyperlipidemia were probable predictors of CKD. Using multivariable logistic regression analysis we found long standing hypertension (≥ 5 years), presence of proteinuria and ECG-determined LVH to be independent predictors of CKD. Conclusions: CKD was found in 49.1% of our patients. Long standing hypertension, presence of proteinuria and ECG-determined LVH were independent predictors of CKD. We recommend utilizing resources to initiate CKD screening programs to assist in early diagnosis of CKD among hypertensive patients.

Introduction: Athletes are increasingly using whey protein–based dietary supplements that, used improperly, may create health risks. Objective: To evaluate changes in glomerular filtration, renal tubular function, and histopathological alterations associated with the use of protein-rich food supplements on the kidneys of Wistar rats. Method: Twelve Wistar rats were divided into control (Group I) and intervention (Group II) groups. Group II received the supplement for 14 fourteen days. Urine samples were collected from the animals for urinalysis and blood samples were collected for the determination of urea, creatinine, sodium, potassium, and chloride levels. At the end of the experiment, the animals were euthanized and the kidneys were collected for a histopathological study. Results: After the supplementation, reduced urea levels (p=0.00930) and increased urinary density (p=0.4645) were observed in Group II. The vast majority of Group II animals (67%) had significant proteinuria (p=0.040), and epithelial cells and waxy casts occurred in 50% and 67%, respectively. Histological analysis of the kidneys showed the presence of areas of peritubular blood vessel dilation and congested glomeruli. Conclusion: Use of the protein supplement changed glomerular filtration and tubular function as evidenced by significantly increased proteinuria as well as peritubular, glomerular, and vascular congestion on histopathological analysis.

Background: The differential diagnosis of neonatal metabolic acidosis is broad, including, among other things, lactic acidosis, inborn errors of metabolism and renal failure, in addition to diarrhea and renal tubular acidosis. The type of milk given to the newborn is less frequently evoked as a potential cause. Case-diagnosis: We report the case of a 6-day-old baby with severe metabolic acidosis secondary to undiluted goat’s milk. We will review other reported cases and analyse the composition of goat’s milk. Conclusion: When fed with undiluted goat’s milk, neonates, with their immature acid-base regulation capacities, can develop metabolic acidosis secondary to an increased protein load and chloride content. Undiluted goat’s milk should be considered in the differential diagnosis of neonatal metabolic acidosis.

Undescended glands are a rare cause of primary and secondary hyperparathyroidism. Patient and method: We report the case of a 35 year-old female with a 14 year-old history of chronic renal failure who presented a severe and persistent secondary hyperparathyroidism despite subtotal parathyroidectomy and removal of mediastinal ectopic parathyroid. The patient remained symptomatic with high iPTH levels at 1700 pg/ml. Result: A 99mTc-Sestamibi parathyroid scintigraphy was performed. Cervical SPECT/CT localized the pathological uptake in the fused images behind the right submandibular salivary gland, in the right jugulo-carotid bifurcation. Minimally invasive surgical intervention was successfully performed. The postoperative iPTH level was within the normal range.

Eosinophilic granulomatous with polyangiitis (EGPA) is systemic vasculitis characterized by concomitant symptoms of asthma, allergic rhinitis, and marked increase in peripheral eosinophilia. It was previously known as Churg-Strauss syndrome. EGPA incidence in Japan is very low, with only approximately 1,800 cases reported. Renal involvement occurs in approximately 20-25% of EGPA patients, and the most typical expression is pauciimmune crescentic glomerulonephritis. We herein report a case of 69-year-old Japanese woman with fever and high titer of myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA) and eosinophilia. Her renal biopsy showed massive interstitial nephritis with granulomatous vasculitis like lesion without apparent active crescent formation in glomeruli. Immediately after steroid treatment (prednisolone [PSL] 30 mg/day), she had symptomatic relief and was discharged with a reduction in MPO-ANCA.

Background: Tacrolimus is immunosuppressive agent used for the prevention of rejection in kidney transplant patients, has narrow therapeutic range, and variable pharmacokinetics. Objectives: To identify the optimum Tacrolimus blood trough level for Saudi kidney transplant patients (SKTP). Method: The research population consisted of 100 SKTP at the Armed Forces Hospital in the Southern Region (AFHSR) treated with Tacrolimus and followed-up for a period of 24 months (2012 till 2014). Results: A significant relationship between Tacrolimus trough level and incidence of kidney rejection was remarkably found only after 180 days post-transplantation. During this period, Tacrolimus mean trough level (ng/ml) was 7.4 ± 0.2 in SKTP with no rejection, 5.3 ± 0.7 for those with acute rejection, and 3.8 ± 0.4 for those with chronic rejection. Furthermore, the coefficient of variation (CV%) which reflects fluctuation in Tacrolimus trough level, was obviously high in SKTP with acute rejection in all post-kidney-transplant periods. Conclusion: After 6 month post- kidney transplantation in SKTP, Tacrolimus trough level (