Acute tubular necrosis following transurethral resection of the Prostate using Glycine as irrigating fluid.

Transurethral resection of the prostate is currently the gold standard for the surgical treatment of the benign prostatic hyperplasia. This surgery may lead transurethral resection of the prostate (TURP) syndrome and in some cases, acute tubular necrosis can develop. We report a patient who developed hyponatremia, hemolysis and oliguric acute renal failure as a major complication following TURP using glycine as irrigating fluid.A 64-year-old man was admitted for a prostate resection procedure. Physical examination revealed a healthy elderly man. Preoperative laboratory data showed serum sodium 140 mEq/L, blood urea nitrogen (BUN) 0.6 g/L, creatinine 0.7 mg/dL and hemoglobin 12.9 g/dL. Few hours after, the patient becomes incoherent and developed oliguria, nausea and vomiting. The laboratory data revealed rapidly elevating BUN and creatinine levels (BUN 2.4 g/L; creatinine 6.1 mg/dL), the serum sodium concentration decreased by 14 meq/L. A decreased hemoglobin level (7.4 g/dL) with an elevated lactate dehydrogenase level (665 U/L) was observed. Renal ultrasonography was normal. The diagnosis of acute tubular necrosis complicating TURP syndrome was retained. The hyponatremia was slowly corrected to 132 mmol/L by diuresis and fluid restriction. The renal function recovered after four hemodialysis sessions. Using glycine as an irrigant for TURP may cause hyponatremia, hemolysis and also acute renal failure, especially in patients with longer resection time. It is necessary to carry out every effort to shorten resection time and avoid extravasation during surgery.

Readmissions to kidney transplantation department: incidence, causes and risk factors.

Introduction: hospital readmission after kidney transplantation is an important metric for health care quality, which associated with increased morbidity, costs and transition-of-care errors. It is influenced by population demographics and the comprehensiveness of the healthcare system. The aim of this study was to evaluate incidence causes and risk factors associated with hospital readmission within the first year after transplantation. Methods: all patients undergoing kidney transplantation at a single center over a ten-year period were analyzed via retrospective chart review. A multivariable logistic regression analysis was performed to identify associated factors. Results: in 86 patients, the incidence of unplanned readmissions within the first year was 68.6% (n = 59). The main reasons for HR were infection (33%), renal events (32%), surgical complications (16%), and metabolic disturbances (9%). In univariate analyses, hospital readmission was associated with Dyslipidemia p=0.04; OR=2.6; 95% CI= [1.93-13.17], anemia p=0.011; OR=4.5; 95% CI = [1.33-15.6], hemodialysis p=0,012; OR=4.8 ; 95% CI= [1.3-18.5], new onset diabetes after transplantation p=0.05 ; OR=3.5 ; 95% CI= [1.6-13,80], medical history of cardiomyopathy p=0,016 ; OR=6.4 ; 95% CI = [5.4-7.5]. While independent risk factors were: hemodialysis vintage and cardiomyopathy. There was no difference in one-year patient survival and death-censored graft survival in HR group and non-HR group. Conclusion: hospital readmissions severely affect a patient's physical and mental well-being after kidney transplantation, which is also independently associated with morbidity. Our study showed that risk factors associated with hospital readmission often reflect pretransplant comorbidity.

Anti-glomerular basement membrane disease with intense nephrotic syndrome: a new case report.

Anti-glomerular basement membrane (anti-GBM) disease was usually described as a small vessel vasculitis presenting with acute kidney injury, haematuria and non-nephrotic proteinuria. We report a case of anti-GBM disease revealed by an intense nephrotic syndrome. The urinary protein level was 12g/day. Renal biopsy only showed crescent glomerulonephritis with linear staining of IgG in direct immunofluorescence without other glomerulonephritis. Immunoglobulin G (IgG) anti-GBM antibody titer was elevated.

Comparison of changes in pulse wave velocity in patients on peritoneal dialysis and hemodialysis.

Cardiovascular disease is the leading cause of death of dialyzed patients. Aortic stiffness, evaluated by the carotid-femoral pulse wave velocity (cfPWV), is now considered as a prognostic factor for cardiovascular mortality in patients with chronic kidney diseases. The peritoneal dialysis (PD) patients had significantly stiffer arteries. cfPWV was 9.12 ± 2.7 m/s in PD patients without significant correlation compared to hemodialysis (HD) patients (8.97 ± 2.52 m/s). In the univariate study, we found a statistically significant correlation between PWV and age (P = 0), between the pulse wave velocity and phosphorus (P = 0.46), between the VOP and PTH (P = 0.013) and between PWV and dyslipidemia (P = 0.014). Other variables such as phospho-calcic product, hemoglobin, total cholesterol, and KT/V were not significant. To identify the risk factors independently linked to the event, we conducted a multi-varied analysis. A correlation was found between VOP and dyslipidemia (P = 0.008). The other variables were insignificant.

Efficacy of low-dose oral sulodexide in the management of diabetic nephropathy.

BACKGROUND: Diabetic nephropathy (DN) is the single greatest cause of end-stage renal disease (ESRD). Without specific interventions, microalbuminuria (incipient nephropathy) gradually progresses to macroalbuminuria (overt nephropathy) within 10-15 years in about 80% of type 1 and 30% of type 2 diabetic patients, and to ESRD within further 20 years in about 75% and 20%, respectively. A primary alteration in DN consists of decreased concentration of glycosaminoglycans (GAGs) in the glomerular extracellular matrix. This evidence has prompted interest in using exogenous GAGs and specifically sulodexide in DN treatment. PATIENTS AND METHODS: In this uncontrolled multicenter study, diabetic patients with albumin excretion rate (AER) >or=30 mg/24 hours were treated with oral sulodexide 50 mg/day for 6 months, while receiving concomitant medication as required. Two hundred thirty-seven patients (54% males and 46% females, mean age 55 years, mean diabetes duration 11 years) were evaluated; 89% had type 2 and 11% type 1 diabetes mellitus, 67% microalbuminuria and 33% macroalbuminuria. RESULTS: AER was significantly and progressively reduced during sulodexide treatment (p<0.0001): geometric mean after 3 and 6 months was 63.7% (95% confidence interval [95% CI], 59.3%-68.4%) and 42.7% (95% CI, 37.8%-48.2%) of baseline, respectively. The reduction was similar in type 1 and type 2 diabetes and was slightly greater in macroalbuminuric than in microalbuminuric patients. Blood pressure was slightly lowered, while fasting glucose and glycosylated hemoglobin were moderately reduced. Adverse effects were observed in 5.5% of patients, including gastrointestinal in 3.8%. CONCLUSIONS: Sulodexide therapy was shown to reduce AER in patients with DN.

[A rare cause of pruritus in an hemodialysed patient]. / Une Cause Rare de Prurit chez une Hémodialysée Chronique.

BACKGROUND: Uremic pruritus is frequent in patients undergoing hemodialysis. It's multifactorial secondary in most cases to metabolic complications related to uremia. AIM: We report a rare cause of pruritus in an haemodialysed patient. OBSERVATION: It's a 48-year-old woman in periodic haemodialysis during 17 years. She suffered from generalized pruritus associated with psychiatric disturbance without neurologic deficits. CT scan and magnetic resonance imaging revealed extensive, diffuse and bilateral involvement of the white matter. The diagnosis of large low grade B cell lymphoma was confirmed by the histologic examination of stereotactic biopsy which leads to early intracranial hemorrhage and death. CONCLUSION: Before attributing pruritus to renal failure, one should exclude other causes such as the NHL even rarely reported especially when it associated with psychiatric disturbances. CT scan and magnetic resonance imaging contribute to diagnosis.

[Calciphylaxis in chronic renal failure: 3 cases]. / Calciphylaxie au cours de l'insuffisance rénale chronique: etude de 3 cas.

BACKGROUND: Calciphylaxis is a small vessel disease responsible for vascular calcification and skin necrosis. It occurs in association with chronic renal failure and has a poor prognosis. BUT: Report new cases. We report 3 cases of calciphylaxis occurred in patients with chronic renal failure secondary to interstitial nephritis in 1 case, diabetic nephropathy in 1 case and thrombotic microangiopathy in 1 case. CASES: They were 2 females an 1 man aged of 44, 3 years meanly. Hyperphosphoremia and hyperparathyroidism were the essential risk factors. All patients died by sepsis. This course was precipitating by corticotherapy in 2 cases. CONCLUSION: Early recognition and treatment of risk factors is mandatory to reduce mortality in uremic patients with calciphylaxis.

Predictors of renal outcomes in anti-neutrophil cytoplasmic antibody glomerulonephritis.

Glomerulonephritis associated with anti-neutrophil cytoplasmic antibody (ANCA) vasculitis still has a high prevalence of end-stage renal disease (ESRD), particularly in patients with advanced renal failure at presentation. This study aims to evaluate the clinical and histo- pathological features of renal involvement and investigate factors associated with ESRD. Patients with renal biopsy-proven ANCA-associated glomerulonephritis were included retrospectively over a period of nine years (June 2007 to March 2016). The renal survival, defined as time to reach ESRD, was evaluated based on clinical parameters, histopathological classification, and renal risk score. A total of 37 patients with crescentic glomerulonephritis were included in the study. The average age was 54 ± 16 years (range: 17-80) and 51.3% were female. Twenty-two patients were diagnosed with microscopic polyangiitis and 15 had granulomatosis with polyangiitis. The median glomerular filtration rate at presentation was 16.73 mL/min/1.73 m2. Thirty-five patients (94.5%) had renal failure at presentation and 23 patients (62.1%) required initial hemodialysis (HD) therapy. The pattern of glomerular injury was categorized as sclerotic in 48.6% of cases, crescentic in 24.3%, mixed in 24.3%, and focal class in 2.7%. Regarding renal risk score, we had five patients with low risk, 17 with intermediate risk and 15 with high risk. ESRD occurred in 47% of intermediate-risk group and 66% of the high risk group. During follow-up, 17 patients (45.9%) developed ESRD. Tobacco addiction (P = 0.02), alveolar hemorrhage (P = 0.04), hypertension (P = 0.04), initial HD (P = 0.04), and sclerotic class (P = 0.004) were associated with ESRD. In our patients, a sclerotic class was associated with a higher risk of ESRD, suggesting that histo- pathological classification is potentially an important parameter to predict outcomes in renal disease secondary to ANCA-associated vasculitis.

Epstein Syndrome.

Epstein syndrome is characterized by sensorineural hearing impairment, macro- thrombocytopenia without neutrophil inclusion bodies, and hereditary nephritis which can progress to end-stage renal disease (ESRD) in adolescence. The prognosis of Epstein's syndrome depends on the severity of the hematological disorders and renal involvement that can lead to ESRD at an early age. Thrombocytopenia in Epstein syndrome is not an absolute contraindication for major surgical procedures like arteriovenous fistula formation or kidney transplantation. There are no set guidelines for preoperative prophylaxis in a patient with this pathology.

Pellagra Disease in a Hemodialysis Patient.

Pellagra usually results from niacin deficiency and presents with the classic triad of dermatitis, diarrhea, and dementia. It is most commonly associated with malnutrition and poverty. We report a case of pellagra in a hemodialysis (HD) patient with breast neoplasia, aged 68-years, female, on HD unit for seven years. Her original nephropathy was indeterminate. The patient was followed up for homozygous beta-thalassemia and breast neoplasia with hepatic metastases on chemotherapy. The body mass index of the patient was 18.5 kg/m2. Physical examination showed a thickening of the epidermis with a scaly surface, pigmented, and atrophied areas. We noted neuropsychiatric signs (apathy, irritability, anorexia, and depression) and digestive symptomatology (diarrhea). The laboratory tests revealed hypoproteinemia at 55 g/L, hypoalbuminemia at 21 g/L, and hypocholesterolemia at 0.8 g/L. The diagnosis of pellagra disease was made. Vitamin and protein supplementation was initiated, but the patient committed suicide by puncture of her arteriovenous fistula, causing hemorrhagic shock. Pellagra is usually reported to be associated with malnutrition, chronic alcoholism, and some chemotherapeutic agents. In our patient, pellagra was caused by malnutrition and co-morbidities. Pellagra disease requires multidisciplinary care and can be frequently seen in HD patients due to the associated malnutrition.

Evaluation of electrocardiographic findings before and after hemodialysis session.

Dialysis patients have higher rates of sudden cardiac death. The study of the electrocardiogram could identify patients at risk of developing rhythm disorders. The aim of this study was to evaluate the electrocardiographic findings before and after the hemodialysis (HD) session and to examine associations of clinical and serum electrolytes with electrocardiogram findings. We conducted a multicentric transversal study, including chronic HD patients during January 2018. Standard 12-lead electrocardiogram was recorded, before and after the HD session. A medical history was documented. It included age, gender, initial nephropathy, and comorbidities. Serum potassium and total serum calcium were measured before a routine HD session. Serum potassium was measured after HD session. Corrected QT for heart rate was calculated using Bazett's formula. The study included 66 patients. Nineteen patients (28.8%) had hyperkalemia before the HD session and 44 (66.7%) patients had hypokalemia after the HD session. Seventeen patients had prolonged QTc interval (25.7%). On multiple regression analysis, only the prolonged QTc interval was significantly correlated with the serum potassium (P = 0.046).When comparing the mean values of electrocardiogram parameters before and after the HD session, we noted a significant change of heart rate (P = 0.001), R wave (P = 0.016), T wave (P = 0.001), and T/R (P = 0.001) wave. Delta K+ did not correlate with the change in T wave amplitude (r = 0.23, P = 0.59), R wave amplitude (r = -0.16, P = 0.2), T/R wave (r = 0.055, P = 0.65), or QRS duration (r = 0.023, P = 0.85). Delta QTc was correlated to ΔK+. We conclude that usual electrographic manifestations of hyperkalemia are less pronounced in HD patients. Our results confirmed the unstable status of cardiac electrophysiology during HD session.

Thalidomide-induced bronchiolitis obliterans organizing pneumonia in a patient with multiple myeloma.

Thalidomide, which is an angiogenesis inhibitor and immunomodulator that reduces tumor necrosis factor-alpha, has regained value in the treatment of multiple myeloma. Serious pulmonary complications due to thalidomide use remain relatively uncommon. We describe a case of bronchiolitis obliterans organizing pneumonia (BOOP) due to thalidomide. A 51-year-old man with IgG lambda myeloma was treated with thalidomide and dexamethasone. Seven days after the beginning of chemotherapy, the patient presented a fever and a persistent cough. Auscultation revealed crackles in both pulmonary bases. The chest X-ray showed a diffuse bilateral alveolar-interstitial syndrome. Computed tomography scan revealed bilateral pulmonary involvement, with bilateral interstitial alveolar infiltration and ground-glass pattern consolidations. Pulmonary infection, malignant tumor, and lung involvement of multiple myeloma were excluded through various tests. Thalidomide-induced BOOP was suspected, and the drug was withdrawn and replaced by Melphalan. The patient had complete resolution of his symptoms and radiologic pulmonary involvement on discontinuation of the drug. In the absence of other etiologies, physicians should be cognizant of this potential complication in patients receiving thalidomide who present with respiratory symptoms.

[Vascular trombosis of renal graft: 9 cases]. / Thromboses vasculaires du greffon apres transplantation renale: a propos de 9 cas.

BACKGROUND: Allograft renal thrombosis can occur in 1 to 6% of cases. Many predisposing factors has been identified especially alteration of coagulation. AIM: We analyzed in this study frequency and predisposing factors of renal graft thrombosis. METHODS: We report a retrospective study including 319 renal transplant recipients. RESULTS: Nine patients (2.8%) presented veinous graft thrombosis in 5 cases and arterial thombosis in 4 cases. There were 6 men and 3 women aged of 30.6 years meanly (10-56) which developed the thrombosis 6 days (1-48) after the transplantation. All patients were detransplanted after 16.2 days and 1 patient died. CONCLUSION: Thrombosis constitute an important cause of graft loss. A perfect surgical technic and prophylactic treatment in high risk patients are necessary to reduce this complication.

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

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

Determinants of patency of arteriovenous fistula in hemodialysis patients.

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

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

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

[Epidemiology of end-stage renal disease before starting hemodialysis and factors influencing hemodialysis survival]. / Epidemiologie de l'insuffisance renale chronique terminale avant l'initiation de l'hemodialyse et les facteurs influençant la survie en hemodialyse.

BACKGROUND: The incidence of end-stage renal failure is high and it is responsible for the increase of the rate of morbidity and mortality rates among our patients. AIM: The objective is to study patient characteristics before starting hemodialysis and to evaluate factors influencing their short and long term survival. METHODS: This is a prospective study of 127 patients starting hemodialysis between June and December 2001. On May 31, 2005, their survival was analyzed according to different parameters. RESULTS: Patients were 77 males and 50 females. Their mean age was 51.4 +/- 16.1 years (15 to 78 years). Diabetes was observed in 33.9% of cases. Only 70.9% of patients were covered by a social service. Chronic renal failure was diagnosed at the end stage in 34.6% of cases. Before starting hemodialysis, only 4 patients were vaccinated against B hepatitis and arteriovenous fistula were not made in any patients. Pericarditis was observed in 9.4% of patients. Albuminemia was < 35 g/l in 60.5% of patients. First hemodialysis session was programmed in 53.5% of patients and realized urgently in 46.3% of patients. Patients were hemodialysed 4, 8 and 12 hours per week respectively in 16.5%, 15.8% and 67.7% of cases. On May 31, 2005, 35.4% of patients died. Their actuarial survivals at 3 months, 1 year and 4 years were respectively at 87.5%, 79.5% and 64.4%. Acturial survival was bad in patients with pericarditis, diabetes, hemodialysed less than 12 hours/week and when the first hemodialysis session was started urgently. CONCLUSION: The diagnosis of renal failure was frequently made at end-stage. There are no preparations before starting hemodialysis. We have to reinforce prevention programmes and increase the number of nephrologists and nephrology departments.

[Renal involvement in Fabry disease]. / Atteinte renale au cours de la maladie de Fabry.

BACKGROUND: Fabry disease is an X-linked recessive lysosomial storage disorder that is caused by deficient activity of alpha galactosidase A. Renal involvement occurs generally in hemizygous forms. AIM: We report one case of renal involvement in Fabry disease. CASE REPORT: A 47 year-old-man had focal and segmental glomerulosclerosis with moderate renal failure. As the patient presented history of acroparesthesias, hearing loss, left ventricular hypertrophy with arrhythmia and corneal deposits, hemizygous Fabry disease was suspected. This diagnosis was confirmed with low alpha galactosidase activity. After a follow up of 5 years, the renal function remains stable but the patient died by cardiac arrhythmia. CONCLUSION: Occurrence of a glomerulonephritis associated with an hypertrophic cardiopathy without hypertension should advocate Fabry disease.

[A case of preserved fertility in an hemodialyzed patient with systemic lupus erythematosus]. / Cas original d'une fertilité particulièrement conservée chez une patiente lupique en hémodialyse chronique.

BACKGROUND: Pregnancy and child birth in haemodialysis remains a rare event, even more, when pregnancy occurs in patient with systemic lupus erythematosus (SLE). AIM: We report a case of a patient with end stage renal failure secondary to SLE and who carried out 3 pregnancies. CASE REPORT: She was a woman with proliferative and diffuse lupus glomerulonephritis since 1985 treated by corticosteroids and cyclophosphamide. In 1995, she developed chronic renal failure. In 1996, she underwent a 1st full term spontaneous pregnancy with normal birth weight. In 2001, she underwent a second spontaneous pregnancy while she was on periodic haemodialysis. She had a full term baby birth with a birth weight at 1 Kg 700 and who died 4 days later. In 2002, she had a third pregnancy with voluntary abortion at 8 weeks. CONCLUSION: Our patient had conserved fertility despite treatment by cyclophosphamide, chronic renal failure and haemodialysis. The two successful deliveries may be attributed to the control of SLE activity and to the adequacy of haemodialysis.

[Complications of distal tubular acidosis in primary Sjögren's syndrome]. / Complications de l'acidose tubulaire distale au cours du syndrome de gougerot Sjogren primitif.

Renal involvement in primary Sjögren's syndrome occurs in 10-60% of cases. Tubulointerstitial nephritis with distal renal tubular acidosis (DRTA) is the main type of involvement. It's generally asymptomatic and revealed by complications of DRTA. We report 4 cases of GJS complicated by nephrocalcinosis, tetapresic hypokaliemia and osteomalacia. In 2 cases, nephrocalcinosis was diagnosed simultaneously with the GJS. The 2 other cases were diagnosed 3 and 15 years after primary GJS. All patients were treated by coticosteroids at the dose of 0.5 mg/Kg/jour, alkaline solution, K Cl in 2 cases and vitamin D in 2 cases. After a mean follow up of 8.7 years, the renal function remain stable in the 3 cases of nephrocalcinosis and in a patient with osteomalacia, bone lesions progressed. In conclusion, DRTA must be detected by acidification tests in patients with primary Sjögren's syndrome because of their latency and to prevent severe complications.