The Tunnelled Atrial Catheter: A Promising Solution for Vascular Capital Depletion in Dialysis despite Associated Thrombi.

Introduction: Longer survival in dialysis led to a higher incidence of vascular access complications and failure. With the limited access to kidney transplantation programs and peritoneal dialysis, exhaustion of vascular access for hemodialysis is an increasingly common situation. Among the available options, atrial tunneled dialysis catheter (ATDC) has been reported as an effective vascular access in this population. Methodology. We report the experiences of two nephrology centers in Tunis with ATDC as an ultimate vascular access for dialysis. Case Reports. Two patients with exhausted vasculature underwent ATDC insertion in 2020 and 2022, respectively, as a vascular access of last resort. Both patients underwent CRBI, which resolved with favorable outcomes. One case was complicated by post-operative thrombosis and was successfully treated with thrombolysis. Both patients are currently on dialysis via their ATDC with a catheter patency of 29 months. Conclusion: ATDC is a life-saving and safe vascular access in cases of depleted vasculature. Little more than 50 cases have been reported in the literature during the last 30 years. As the frequency of vasculature exhaustion is expected to increase, preservation of veinous access in patients at risk of chronic kidney disease have never been more crucial.

Systemic lupus erythematosus presenting as lupus erythematosus tumidus and lupus nephritis: a case report.

BACKGROUND: Lupus nephritis and lupus erythematosus tumidus (LET) are uncommon manifestations of systemic lupus erythematosus (SLE), and their coexistence as the initial presentation of SLE is exceedingly rare. Here, we report such a case, emphasizing the diagnostic challenges and therapeutic implications of this unusual association. CASE REPORT: A 38-year-old North African woman presented in Nephrology department with a history of lower extremity edema, fatigue, and weight loss of 3 kg in 4 weeks. Physical examination revealed LET lesions on the chest and the Neck. Laboratory investigations showed lymphopenia, low C3 and C4 complement levels, positive antinuclear antibodies, anti-dsDNA antibodies, and anti-SSA/Ro antibodies. Renal function tests showed normal serum creatinine and nephrotic proteinuria. Renal biopsy revealed Class V lupus nephritis. Skin biopsy confirmed the diagnosis of LET, with the presence of lymphohistiocytic infiltrates and dermal mucin. The patient was diagnosed with SLE based on the 2019 EULAR/ACR criteria and treated with prednisone (1 mg/kg/day) and hydroxychloroquine. She showed significant improvement in her cutaneous and renal symptoms at 6 and 12 months follow-up. CONCLUSION: The rarity of the coexistence of LET and lupus nephritis as the initial manifestation of SLE, especially in the North African population, underscores the need for further research to elucidate the immunopathogenic mechanisms and prognostic factors associated with this association.

[Type IVa2 urinary lithiasis and associated pathologies: About 3 cases]. / Lithiase urinaire de type IVa2 et pathologies associées : à propos de 3 cas.

INTRODUCTION: Urinary lithiasis is a very common condition. The morpho-constitutional analysis of urinary stones is important for etiological diagnosis. It guides the explorations and the specific management. Type IVa2 stones are rare, have particular morphology and correspond to very targeted pathologies. We propose to report our cases of patients diagnosed with type IVa2 urinary lithiasis. METHODS: Our retrospective work focused on three cases of patients with the morphological type of renal lithiasis IVa2, collected between 2008 and 2020 in the Medicine A Department of Charles Nicolle Hospital in Tunis. RESULTS: All three patients were female; average age 37.6 years. The clinical symptomatology was identical marked by renal colic with recurrent episodes. The presence of a type IVa2 stone, isolated or associated with other components, guided the etiological investigation to look for a secondary or primary cause of distal renal tubular acidosis. We retained the diagnosis of a primary hyperparathyroidism in one case and a primary Gougerot-Sjögren's syndrome in the second case, and probable in the last case. CONCLUSION: Determination of urolithiasis nature (morphological and chemical), although carried out late, was of major interest to us and allowed us to make the diagnosis of distal tubular acidosis.

Thirty years of experience with anti-neutrophil cytoplasmic antibody glomerulonephritis in Charles Nicolle Hospital-Tunisia: a retrospective cohort study.

Introduction: antineutrophil cytoplasmic antibodies (ANCA) associated Glomerulonephritis (GN) is rare but a life-threatening disease especially, particularly in patients with advanced renal failure at presentation. This study aims to evaluate the epidemiological, clinical and histopathological features of renal involvement and investigate factors associated with ESRD. Methods: patients with renal biopsy-proven ANCA associated glomerulonephritis were included retrospectively over a thirty years period. The renal survival, defined as time to reach ESRD, was evaluated based on clinical parameters, histopathological classification as well as the renal risk score. Results: a total of 65 patients with crescentic GN were included in the study. The mean age was 47.9 years ± 22.4 years (range: 18-78) with an M/F sex ratio at 1.13. Hematuria, proteinuria and oliguria were found in respectively 100%, 81.5% and 56.2% of cases. Sixty patients (92.3%) had renal failure at presentation, and 30 patients (46%) required initial hemodialysis (HD) therapy. The pattern of glomerular injury was categorized as mixed in 43.7% of cases, sclerotic in 34.3%, crescentic in 16.6%, and focal class in 6%. Regarding renal risk score, patients were classified in the category low risk, intermediate risk and high risk with respectively 16.9%, 44.6% and 38.4%. All patients received corticosteroids and immunosuppressive treatment. Complete, partial remission and relapses were noted in respectively 15.3%, 18% and 72% of cases. Factors associated with ESRD were serum creatinine level >500 µmol/l (P=0,0016), CRP level >60 mg/l (P = 0,0013), interstitial fibrosis (P=0,0009) and glomerulosclerosis> 10% of total glomeruli (P=0,001). The survival rate was 89%, 60.9% and 32.8% at respectively 1, 5 and 10 years. Death occurred in 10 cases (15%) caused mostly by infections (40%). Initial serum creatinine level>140 µmol/l (P=0,02), alveolar hemorrhage (P=0.001) and infections (P=0,0001) were associated with mortality. Conclusion: in our cohort of ANCA GN, confirms the data showing improved patient survival but constantly high relapse risk. In addition, we observed that ANCA GN classification was predictive, as the risk of progressing to ESRD increased with the ascending category of focal, crescentic, mixed and sclerotic GN.

[Renal involvement in sarcoidosis: Prognostic and predictive factors]. / Atteinte rénale au cours de la sarcoïdose : facteurs pronostiques et prédictifs.

INTRODUCTION: Sarcoidosis is a systemic granulomatous disease that primarily affects the respiratory system and lymphatic vessels. Renal involvement is rare, poorly studied and found in less than 10% of cases. The objective of our study was to identify factors of poor renal prognosis and predictive factors of renal involvement during sarcoidosis. METHODS: It's a retrospective study including patients hospitalized in our department for sarcoidosis with renal involvement over a period of 40 years. To study renal survival, we identified two groups of patients with renal manifestations of sarcoidosis by following their evolution: group A (n=26) represents those with renal remission or deterioration of renal function but without progression to end-stage renal disease and group B (n=8) those with progression to end-stage renal disease. To detect the predictive factors of end-stage renal disease in patients with sarcoidosis, we compared the clinical and paraclinical characteristics of our patients (group 1) to those of 44 patients with sarcoidosis without renal impairment followed in our department during the same period (group 2). RESULTS: Renal involvement was observed in 34 patients hospitalized for sarcoidosis (43.6%). There were 28 women and 6 men with a sex ratio of 0,21. The mean age at diagnosis of sarcoidosis was 47.1 years. The median time from sarcoidosis diagnosis to renal disease was 2 months (range 1-72). Tubulointerstitial nephropathy was the most frequent renal manifestation observed in 24 patients (70.6%). Hypercalcemia and hypercalciuria were found in 52.9% and 46.4% respectively. Renal failure was noted in 25 patients (73.5%). Corticosteroid therapy was initiated in 33 patients (97%) associated with immunosuppressive therapy in 3 cases. Predictive factors of end-stage renal disease were advanced age at diagnosis of nephropathy (P=0.007), comorbidities (P=0.002), multi-organ involvement (P=0.041), initial renal failure (P=0.013), interstitial fibrosis (P=0.006) and renal granulomas (P=0.007). Predictive factors of renal impairment during sarcoidosis were multi-organ involvement, inflammatory syndrome and hypercalcemia. CONCLUSION: Renal envolvement, although rare during sarcoidosis, can influence the prognosis hence the great interest of its early detection to prevent progression to end-stage renal failure.

[Etiologies and prognostic factors of acute interstitial nephritis]. / Étiologies et facteurs pronostiques des néphropathies interstitielles aiguës.

INTRODUCTION: Acute interstitial nephritis represents a clinically and etiologically heterogeneous group of kidney diseases. The aim of our study was to explore the main causes of biopsy-proven acute interstitial nephritis and to identify predictive factors of renal outcome. METHODS: We conducted a retrospective monocentric study which included patients with biopsy proven AIN, followed in our department during the period between 1980 and 2018. The non-recovery of kidney function or an estimated glomerular filtration rate˂60 mL/min/1.73 m2 were considered as a worse renal outcome. RESULTS: A total of 65 acute interstitial nephritis patients were enrolled. The mean age of patients was 41.3±16 years with a female predominance (78%). Drug-induced etiology was the most common (29%). The most frequent culprit drugs in our study were NSAID followed by antibiotics. The renal prognosis was unfavorable in 21 cases (32%). The independent predictive factors for renal outcome were : a percentage of sclerotic glomeruli greater than 15% (P=0.004), absence of interstitial edema (P˂0.001), non-use to corticosteroid therapy (P=0.02) and a delay in initiating corticosteroid therapy greater than 21 days (P=0.02). CONCLUSION: Drugs currently represent the most common cause of acute interstitial nephritis. The renal prognosis is often favorable, but the progression can be towards chronic renal failure in the event of diagnostic and therapeutic delay. Our data suggest a beneficial influence of steroids on the outcome of acute interstitial nephritis.

National Epidemiological Study about Hepatitis C Virus Infection among Dialysis Patients.

The World Health Organization estimates that 3% of the general population is infected with this virus. Hepatitis C remains the main viral infection in dialysis patients, and the severity of this infection is the risk of developing cirrhosis or hepatocarcinoma. We aim to determine the prevalence of hepatitis C in dialysis patients, to calculate the rate of hepatitis C virus (HCV) seroconversion, and to identify the risk factors for seroconversion. This is a nationwide multicenter observational study including all dialysis patients regardless of age and gender. Those with acute renal failure and vacationers were excluded from the study. We included 185 centers including 176 hemodialysis (HD) centers and nine peritoneal dialysis (PD) centers with a total number of patients at 11,238, a number of HCV-positive patients at 402, and a number of functional machines at 3139. The mean age of a patient was 55.6 years (range: 18-65), and sex ratio was 0.9. The prevalence of HCV-positive patients is 3.6%; it is higher in private centers with an average of 2.7 compared to 1.18 in public centers with a significant difference (P = 0.009). The prevalence of HCV-positive patients was significantly higher in HD centers compared to PD centers, in centers where the number of generators was >15 and when the number of patients per center is >70. One hundred and fifty-six patients seroconverted after dialysis, i.e., a prevalence of seroconversion at 1.3% with a mean delay of 6.052 ± 5.3 years. Our study shows a lower prevalence of HCV seroconversion than that reported in the literature; this requires a national survey to be carried out by homogenizing virological diagnostic kits and treating infected patients to eradicate this infection in dialysis patients.

Nephrotic syndrome in elderly: Etiologies, management, and prognosis.

The elderly population has significantly increased in the world. Nephrotic syndrome (NS) is one manifestation of glomerular nephropathy in the elderly. The objective of our study is to determine NS particularities in the elderly and to identify the factors predicting progression to chronic end-stage renal disease (ESRD). This is a retrospective and descriptive study, carried out between January 1, 1975 and December 31, 2017. It includes participants aged 65 years old or over hospitalized for NS. A multivariate study was carried out and the dependent variable was the evolution to ESRD. We studied 115 patients with an average age of 71 ±5 years (65-83) and a sex ratio (male/female) of 1.7. Twenty-three percent of patients were diabetic. The median proteinuria was 4.7 g/L (3-19.5). NS was impure in 89.5% of patients. Renal biopsy was performed in 45 patients (39.13%). NS was secondary in 65.2% of cases mainly to amyloidosis (35.6%). Idiopathic nephropathy was dominated by membranous nephropathy (9.5%). Treatment was etiopathogenic in only 18 patients (15.6%). At the end of follow-up, 15.8% of patients achieved complete or partial remission and 56.6% progressed to ESRD. The multivariate study found as independent risk factors of progression to ESRD: uremia >17 mmol/L [adjusted odds ratio (aOR) = 33.2 (1.3-837.7); P <0.05],, phosphoremia ≥1.6 mmol/L [aOR = 22.1 (1.8-266.5); P <0.05], serum potassium ≥4.3 mmol/L (aOR = 24.7 (2.4, 251.5); P <0.01], extra-renal signs [aOR = 38.9 (2.4-634.3); P = 0.01], secondary nephropathy [aOR = 74 (3.1-1788.2); P <0.01] and membranoproliferative glomerulonephritis [aOR = 48 (1.4-1675.5); P <0.05]. The protective factors were hemoglobinemia ≥9.3 g/dL [aOR = 0.007 (0-0.2); P <0.01], kidneys well differentiated [0.032 (0.003-0.4); P<0.01] and treatment with two diuretics [aOR = 0.03 (0.00-30.4); P <0.01]. It is important to recognize the spectrum of kidney diseases in the elderly to improve the progression factors to ESRD.

Evolutive profile of hemodialysis vascular accesses Hemodialysis accesses.

INTRODUCTION: Arterio-venous fistula (AVF) is the first-choice vascular access for hemodialysis (HD). Hemodialysis catheter (KT) may be a temporary or permanent alternative. AIM: To evaluate indications of KT and AVF and their predictive factors of complications. METHODS: It's a retrospective multicentric study interesting KT and AVF in patients treated by hemodialysis, in the Kef Governorate in north-western Tunisia, during the period from 01/07/18 to 31/12/18. RESULTS: We included 288 AVF and 148 KT that were created on 205 patients. The average age was 58.14 years, the sex ratio was 1.5. Hypertensive patients and diabetics represented respectively 83.9% and 27.3% of the population. Diabetic nephropathy was the most common (25.9%). For the KT, the main indication was the wait for AVF creation (68.9%). The overall incidence of immediate complications was 11.5%. Dysfunction was reported in 23.6% of cases with obesity and tunneled type of KT as contributing factors. KT infection was occuring in 39.2% of cases. It was promoted by prolonged duration of use and hemoglobin level < 8g/dl. The use of antiseptic lock reduced infections' risk (p=0.011). For AVF, the most common complications were thrombosis (36.2%), aneurysm (29.9%) and stenosis (22.6%). Survival rate was 60% at 2000 days. The AVF impairing factors were diabetes (p=0.05), obesity (p=0.05), anterior AVF creation (p=0.011), AVF grafts (p=0.016), and anticoagulant therapy (p=0.0001). Antiplatelet therapy improved AVF patency (p=0.02). CONCLUSION: Much remained to be done to reduce KT complications, creation of AVF on time and prevention of their complications.

Clinical study on autosomal dominant polycystic kidney disease among North Tunisians.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disease, which usually manifests in adulthood. It is characterized by the development of multiple cysts in the kidneys and many other extrarenal manifestations. We aimed to determine the factors that contribute to the progression of ADPKD to end-stage renal disease (ESRD). In a retrospective multicentric study, we reviewed the records of 569 patients with ADPKD, hospitalized at a nephrology department or followed up at the outpatient department of university and regional hospitals, covering the north and center of the country, during the period 1969-2016. The mean age of the study patients was 48.54 ± 13.68 years and 14% were young adults (<40 years). There were 272 female and 297 male patients (sex ratio: male/female = 1.09). A family history of ADPKD was found in 43.7% of cases. Renal symptoms were dominated by loin pain, renal failure, hypertension, and hematuria, seen in, respectively, 51.9%, 48.2%, 29.1%, and 24.6% of the patients. The median serum creatinine level was 459 µmol/L (range: 47-2454), and hypertension had preceded the onset of ADPKD in 28.8% of cases. Extrarenal manifestations consisted of urologic complications (54.6%), liver cysts (43.5%), cardiac involvement (31.9%), cerebral aneurysms (12.9%), and gastrointestinal involvement (9.4%). ESRD occurred in 43.1% after a mean follow-up of 47 months (range: 0-384). Risk factors for poor renal prognosis were age >40 years (P = 0.009), hematuria (P = 0.034), hemoglobin >14 g/dL (P = 0.0013), high uric acid level (P = 0.001), and leukocyturia (P = 0.02). Death occurred in 59 cases (10.3%), mostly caused by infections (44.1%). In our study, ADPKD was lately diagnosed in most cases. Family screening is important, which will enable early detection and management of the complications associated with ADPKD.

Simultaneous acute pancreatitis and angioedema associated with angiotensin-converting enzyme inhibitor.

Angiotensin-converting enzyme inhibitors (ACEI) are commonly prescribed drugs for blood pressure (BP) control and renal protection. The use of ACEI is not associated with an increased risk of acute pancreatitis and ACEI-induced angioedema is rare. A 36-year-old woman presented with vomiting, headache, and aphasia. Her BP was 220/100 mm Hg. urine analysis revealed proteinuria (2+), hematuria (3+). Serum creatinine level was at 1125 µmol/L. She had anemia with 6.1 g/dL of hemoglobin and thrombocytopenia (61,000/mm3). Renal histology revealed lesions of thrombotic microangiopathy. The diagnosis of atypical hemolytic uremic syndrome was made by the complement factor I deficiency. Plasma exchanges could not be done. She was placed on peritoneal dialysis for renal insufficiency. We introduced an ACE (captopril) for the treatment of high BP. Twelve-hours after taking the first dose, she experienced severe epigastric pain and two episodes of vomiting. Serum lipase was 560 IU/L, and abdominal computed tomography showed Stage B pancreatitis. Twenty-four hours later, the patient developed marked edema of the neck region without dyspnea or dysphonia. Cervical ultrasound revealed the infiltration of the subcutaneous tissues. Captopril was stopped with the progressive disappearance of the edema. Serum lipase was 350 IU/L and then normalized at the end of the 4th day. Clinicians should be careful about widely used drugs and their side effects. ACEI can cause potentially life-threatening complications such as angioedema and acute pancreatitis. Possibly, there could be a common mechanism for the onset of pancreatitis and angioedema under ACEI.

Peritoneal dialysis in diabetes patients.

INTRODUCTION: Peritoneal dialysis (PD) is a renal replacement therapy (RRT) in end stage kidney disease patients with several advantages and disadvantages. AIM: To evaluate the epidemiological, clinical, biological and outcome of diabetic patients in PD in our service and to determine the factors influencing overall survival and technique. METHODS: This was a retrospective study that included 90 diabetic patients supported on PD in our Department of Nephrology and Internal Medicine A in Charles Nicolle Hospital of Tunis from 1983 to 2016. RESULTS: There were 90 patients with mean age of 57 years. The sex ratio M/W was 1.3. Diabetes was type 2 in 84.44%. Complications were decreased ultrafiltration (26.66%), displacement of the catheter (20%), umbilical hernia (3.33%), malnutrition (2.22%) and peritonitis (45.55%). The number of peritonitis was 1 episode every 38.64 patient months. Transfer to hemodialysis was indicated in 37.78% of cases. Death occurred in 33 patients. Causes were cardiovascular (21.11%), septic shock (10%) and complicated peritonitis (5.55%). A statistically significant correlation was found between patient survival and death from cardiovascular events (p = 0.048), type 2 diabetes and high peritoneal permeability (p = 0.033) and technical survival and systolic arterial pressure> 139.5mmHg (p = 0.01). Overall survival at 5 years was 66% and technical survival was 28%. CONCLUSION: PD is an interesting way of RRT in diabetic patients. Good control of diabetes complications and those of PD technique is essential to increase survival.

Management of acute pyelonephritis.

INTRODUCTION: Acute pyelonephritis (APN) results from bacterial invasion of the renal parenchyma. The aim of this study was to investigate the epidemiological, clinico-biological, therapeutic and evolutionary APN and to identify the risk factors of this renal disease. METHODS: We conducted a retrospective and descriptive study, over a period of 37 years (1977-2014), including 43 patients with APN, hospitalized in our Department. RESULTS: There were 43 patients with mean age of 36.98 years. The sex ratio M/W was 0.39. The history of our patients was diabetes (16.28%), recurrent urinary tract infection (25.58%), chronic kidney failure (CKF) (46.51%), Renal lithiasis (9.3%), malformative uropathy (9.3%) and immunosuppressive therapy (23.3%). Typical clinical triad (fever, back pain and urinary functional signs) was present in 25 patients (58.14%). The Gram-negative bacilli represented 97.67% of bacteria isolated in urine culture, dominated by Escherchia coli in 83.72% of cases. APN was simple in 19 cases (44.18%) and at risk of complications in 24 cases (55.81%). Thirty-nine patients (90.69%) had non-severe APN. Four patients (9.3%) had severe APN. Complications were found in 30.23% of cases: acute renal failure (ARF) (30.23%), renal abscess (2.33%), septic shock (4.65%). Risk factors for developing ARF were the higher age group to 60 years (p = 0.02) and CKF (p = 0.001). A significant correlation was found between vesicoureteral reflux and recurrent infections (p = 0.01). Five years renal survival was 69%. CONCLUSION: APN induced ARF is a serious risk for progression to CKF.

Renal amyloidosis in ankylosing spondylitis: A monocentric study and review of literature.

Secondary renal amyloidosis (RA) is the most common type of renal involvement in ankylosing spondylitis (AS). We assessed the epidemiologic and clinico-biological profile of AS patients with RA, to analyze treatment modalities and prognostic aspects, and to determine predictive factors of RA during AS. This was a retrospective study including 13 cases of RA among 212 cases who presented with AS, during the period from 1978 to 2006. The median age of the patients at the time of diagnosing AS was 47 years (range: 19-67). There were 11 males and two females. RA onset was diagnosed after a mean follow-up of 144.6 months (range: 10-505) from the AS diagnosis. We noted erosive peripheral arthritis, lumbar stiffness with bamboo spine, and coxitis in 23.1%, 76.9%, and 30.8% of cases, respectively. Nephrotic syndrome was found in eight patients (61.5%). At the time of diagnosing RA, six patients had renal failure. Amyloid deposits were histologically proven by salivary gland biopsy in six cases (46.1%) and by renal biopsy in seven cases (53.8%). Four patients received a long-course treatment with colchicine but with a good outcome only in two cases. In our series, AS was more severe among patients with RA. Four predictive factors of RA were identified: smoking (P = 0.04), erosive peripheral arthritis (P = 0.002), bamboo spine (P = 0.001), and biologic indicators of inflammation (P = 0.0001). High erythrocyte sedimentation rate was identified as the only independent risk factor of RA during AS (P = 0.0001). Renal function as well as urinalysis should be monitored at regular intervals to detect early renal involvement during AS.

Cyclosporine therapy in steroid-dependent or steroid-resistant idiopathic focal and segmental glomerulosclerosis.

Focal and segmental glomerulosclerosis (FSGS) is a heterogeneous entity. Previous few studies have evaluated the efficacy of calcineurin inhibitors in primary FSGS and have suggested positive benefit. In this single-center, retrospective study (1975-2014), we report our experience in Tunisian adults with primary FSGS treated with cyclosporine A (CsA). It includes patients histologically proven FSGS and managed in the Charles Nicolle Hospital at Tunis, Tunisia. The dose of CsA was adjusted to maintain a whole blood trough level of 80-150 ng/mL. The observation period was 6.8 ± 3.7 years after CsA treatment. Twenty-three patients with idiopathic FSGS, treated with CsA, were studied. The mean age was 26.69 ± 10.1 years, and the sex ratio was 2.83. Eight patients (35%) had a steroid-dependent nephrotic syndrome (NS), and 15 patients (65%) had for steroid-resistant NS. After a median follow-up of 16.5 months on CsA, we noticed complete remission of the NS in eight cases (35%) after 12.12 ± 8 months, partial remission in five (22%) after 3 ± 0.7 months, dose-dependent remission to CsA (2.87 mg/kg/day) in four (17%), and a no response in six patients (26%). Eleven patients (48%) showed improvement of renal function, while eight (35%) developed end-stage renal disease (ESRD) after 35.7 ± 20.9 months. Predictive factors of progression to ESRD were creatinine clearance <90 mL/min before introduction of CsA (P = 0.0054) and CsA-resistance (P = 0.053). Our study suggests that CsA is effective in the treatment of patients with idiopathic FSGS. Initial renal function and cyclosporineresistance are the predictive factors of ESRD in steroid-resistant or -dependent FSGS.

Renal impairment in multiple myeloma: A single center experience.

To determine the features of the different forms of kidney diseases associated with multiple myeloma (MM), we retrospectively studied 144 patients with kidney injury and MM at our institute from 1974 to 2014. The mean age of the patients was 60.1 years and the male:female ratio was 1.25. Renal disease was concomitant with the discovery of MM in 92% of cases. The mean follow-up of our patients was 2.1 years. Initial renal insufficiency was found in 131 (91%) patients. Cast nephropathy of the distal tubule was found in 110 (26%) patients, renal amyloidosis in 16 (11.1%), and light chain deposition disease in five (3.47%). Twelve (8.3%) patients had chronic glomerular nephropathy. Twenty-six patients reached end-stage renal failure within 13.4 months. Renal survival was 30.45 months. Predictive factors for improvement of renal function undergoing chemotherapy included serum creatinine <250 µmol/L, proteinuria <1 g/24 h, and the non-use of renal replacement therapy. Multiple pathogenic mechanisms can contribute to kidney injury in myeloma patients. Novel myeloma agents have shown considerable promise in reversing renal failure in some patients and improving outcomes.

[Brown tumors in chronic hemodialysis patients]. / Les tumeurs brunes chez les hémodialysés chroniques.

PURPOSE: Brown tumors are rare and severe manifestations of secondary hyperparathyroidism. We propose in this study: to define and illustrate brown tumors observed in our hemodialysis center; to show the frequency for 20 years in our center; to identify risk factors compared to the rest of dialysis patients; and finally to offer improved support for reducing the incidence. PATIENTS AND METHODS: We conducted a retrospective and descriptive study, over a period of 20 years (1993-2013), including 311 cumulative patients which are chronic hemodialysis in our unit. RESULTS: Twenty-one patients had brown tumors (6.75%). The average age was 36.1 years and the sex ratio M/F is of 0.6. The average time between the start of hemodialysis and the diagnosis of brown tumor was 87.6 months. Clinical symptoms were dominated by bone pain, found in 76.1% of cases. The most frequent locations were costal (28.5% of cases), while spinal involvement was less frequent (4.76% of cases). The location was multifocal in 57.1% of cases. The mean serum calcium was of 2.08 mmol/L, the serum phosphate of 2.25 mmol/L, alkaline phosphatase of 1709 IU/L and the average value of parathyroid hormone of 1934 pg/mL. Radiography was the key of diagnostic. Resonance magnetic imaging and computed tomography had an interest in the exploration of spinal locations and maxillo-mandibular locations. All patients underwent parathyroidectomy and it was total in one patient. Tumorectomy was necessary in three patients (14.2% of cases). The outcome was favorable in 85.7% of cases. CONCLUSION: Our work relates one of the most important series published of brown tumors and is characterized by the multifocal character of these tumors.

Erectile dysfunction in hemodialysis patients.

Erectile dysfunction (ED) is a common problem seen among patients on hemodialysis (HD), but it is still a taboo subject in our country. The attention given to this sexual problem remained low, and the prevalence of ED among these patients has not been well characterized. We carried out this study in order to determine the prevalence and severity of ED in HD patients. We conducted a descriptive cross-sectional study in our HD unit in March 2013. ED was evaluated using the International Index Erection Function. Thirty patients with a mean age of 49.1 years were eligible for this study. The main causes of chronic kidney disease were hypertension (62.5%) and diabetes (41.6%). The prevalence of ED was 80%, including 33.3% severe ED. Plasma levels of gonadotropins: luteinizing hormone (LH), follicule-stimulating hormone were in the standards except for one patient who had an elevated level of LH. Prolactin was elevated in four cases. ED was present in 8.4% of patients before the discovery of renal failure and in 91.6% of patients at the beginning of dialysis. For 19 patients (79.1%), the ED had increased during the dialysis sessions. A significant number of our HD patients presented with ED of varying degrees. Nephrologists should pay attention to the problem of ED in order to improve the quality of their life.

Post kidney transplantation Kaposi's sarcoma: the experience of a Mediterranean North African center.

BACKGROUND: The aim of this study was to determine the overall and specific incidences of Kaposi's sarcoma (KS) in a cohort of 568 kidney transplant recipients (KTR) in a single North African Mediterranean center. PATIENTS AND METHODS: The records of 568 patients, who underwent kidney transplantation (KT) between June 1986 and December 2013, were retrospectively reviewed. Incidence was calculated by dividing the number of the different events by the total duration of follow-up. Survival rates and cumulated frequencies of KS were calculated according to the actuarial method. RESULTS: Twelve patients developed KS corresponding to an overall prevalence of 2.1% and an annual incidence of 0.27% patient-years. Median time to diagnosis of KS was 23.3 months. Eleven patients presented with skin lesions; three had oral localizations and one had conjunctival involvement. Asymptomatic gastric localization was observed in one patient. Therapeutic management, consisting in reduction of immunosuppression in all cases and their conversion to sirolimus in four patients, resulted in complete regression of KS in seven patients. Graft loss was observed in three cases and four patients died of unrelated- KS causes. CONCLUSION: KS is the most post KT malignancy observed in our country and is characterized by a predominance of limited superficial forms.

Impact of the components of metabolic syndrome on survival in a group of hemodialysis.

BACKGROUND: Metabolic syndrome is defined by the combination of high blood pressure, dyslipidemia, central obesity and a state of insulin resistance. Its prevalence is high in hemodialysis. AIM: The aim of this work is to see the impact of metabolic syndrome on mortality and morbidity in our hemodialysis patients. METHODS: This is a retrospective study of 120 chronic hemodialysis patients. The metabolic syndrome was investigated according to the criteria of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). Survival was estimated based on each parameter of the metabolic syndrome. A comparison by sex was performed for the following parameters: age, diabetes, hypertension, obesity, waist circumference, dyslipidemia, coronary artery disease and heart failure. RESULTS: Forty chronic hemodialysis patients with metabolic syndrome have been the subject of this study. The mean age was 55.97 years and the sex ratio was 1.88. Seventy percent had diabetes and 90% were hypertensive. Coronary artery disease was present in 57.5% of cases of heart failure in 52.5% of cases. There was no significant difference in 10 years survival depending on the presence of each component of the metabolic syndrome. The study by sex showed no significant difference except for hyper LDL cholesterol. CONCLUSION: Our study showed no impact of the components of metabolic syndrome on survival. There is a high prevalence of cardiovascular complications but causality with the metabolic syndrome could not be demonstrated.