Assessing physical inactivity as a risk factor for chronic kidney diseases in Iranian population.

OBJECTIVES: Physical inactivity is a major adjustable lifestyle risk factor in renal patients; nevertheless, research on the association of physical activity (PA) with chronic kidney disease (CKD) is unclear. DESIGN: Cross-sectional. SETTING: We evaluated the secondary care related to the nephrology specialists. PARTICIPANTS: We evaluated PA in 3374 Iranian patients with CKD aged ≥18 years. Exclusion criteria were current or prior kidney transplantation, dementia, institutionalisation, expected to start renal replacement therapy or leave the area within study duration, participation in a clinical trial or inability to undergo the informed consent process. PRIMARY AND SECONDARY OUTCOME: The renal function parameters were measured and compared with PA, assessed by the Baecke questionnaire. Estimated glomerular filtration rate, haematuria and/or albuminuria were used to estimate decreased kidney function and the incidence of CKD. To estimate the relationship between PA and CKD, we used the multinomial adjusted regression models. RESULTS: In the first model, findings indicate that the patients with the lowest PA score had significantly higher odds of CKD (OR 1.44, 95% CI 1.16 to 1.78; p=0.01), adjustment for age and sex attenuated this relationship (OR 1.25, 95% CI 1.56 to 1.78, p=0.04). Furthermore, adjusting for low-density lipoprotein, high-density lipoprotein, triglyceride, fasting blood glucose, body mass index, waist circumference, waist/hip ratio, coexisting diseases and smoking made this relationship insignificant (OR 1.23, 95% CI 0.97 to 1.55; p=0.076). After adjusting for potential confounders, we found that patients with lower PA have higher odds of CKD stage 2 (OR 1.62, 95% CI 1.13 to 2.32; p=0.008), no association with other CKD stages. CONCLUSION: These data suggest that physical inactivity contributes to the risk of early CKD, so encouraging patients with CKD to maintain higher PA levels could be used as a simple and useful tool to decrease the risk of disease progression and its related burden.

Chronic Kidney Disease in Isfahan Province, Action Plan for Screening in A Population-based Study.

INTRODUCTION: We intended to explore the prevalence of chronic kidney disease (CKD) and its different stages, as well as CKD associated variables in the adult population in Isfahan province, Iran. METHODS: Adults aged ≥ 18 were recruited in a cross-sectional study from 2017 to 2019. Data including demographics, anthropometrics, and laboratory findings were collected from each subject. The equation of chronic kidney disease- Epidemiology Collaboration (CKD-EPI) was used to estimate glomerular filtration rate (eGFR), and eGFR and UACR values were utilized to determine the stages of CKD. RESULTS: Data from a total of 3374 subjects was analyzed. The mean age of participants was 49.3 ± 14.09 years and 59.3% were female. The prevalence of CKD was 18.5%. Only 0.25 and 3.5% of the population were in CKD stage 3 and 4, while most of the patients were in CKD stage 2 (7.6%) and stage 1 (7.1%). CKD patients were mostly on refined grains diet and used lesser dairy products compared to healthy participants. Variables including systolic blood pressure (OR = 1.018; P < .001), diastolic blood pressure (OR = 1.005; P < .05), fasting blood sugar (OR = 1.011; P < .001), female sex (OR = 1.319; P < .05), body mass index (OR = 1.030; P < .05), married status (OR = 1.335; P < .05), and smoking (OR = 1.529; P < .05) were significantly associated with increased risk of CKD in the logistic regression analysis. CONCLUSION: According to our results, the prevalence of CKD, especially stages 1 and 2, is quite high in central part of Iran. These findings help us to improve the screening for CKD patients and perform larger scale studies to identify the challenges ahead.  DOI: 10.52547/ijkd.7201.

Designing, implementing, and evaluating the process of training advisor and teaching assistant at Isfahan medical school.

INTRODUCTION: The study aimed to design, implement, and evaluate the process of advisor and teaching assistant (TA) to increase the quality of cascade training in principal educational groups, presenting the obstacles and problems of this educational intervention and introducing them to educational planners. METHODOLOGY: This applied developmental research was conducted in Isfahan University of Medical Sciences in 2017-2018 in principal educational groups (internal medicine, surgery, pediatrics, gynecology, and cardiology). For this purpose, a working party called TAs was composed of managers, faculty members, and active and interested assistants, including 24 people. The action plan, bylaws, job description, and logbooks were completed by the method of the focus group. Getting the report, monitoring the activity, exchanging the ideas, and drawing up the various plans were continuously done through bi-monthly in-person meetings, and the virtual group was organized for monitoring, starting a training logbook, and doing semi-organized interviews to evaluate. RESULTS: In a total of 1131 h, various educational activities were conducted such as cooperating with the advisor, teaching some part of a class, holding a workshop, contributing to question design, preparing the educational resources, and organizing an educational round. CONCLUSION: Improving the knowledge, attitude, and practice of assistants in cascade training, regulating their activities, learning the teaching skills, and exercising them with the teacher were some of the most significant opportunities of this study.

Survival of Post-Transplant Lymphoproliferative Disorder after Kidney Transplantation in Patients under Rapamycin Treatment.

Background: One of the important causes of mortality and morbidity in kidney transplanted patients is Post Transplant Lymphoproliferative Disease (PTLD), which is due to immunosuppression therapy and viral activity. It seems that Rapamycin, with dual antineoplastic and immunosuppressive effects, may have a pivotal role in the treatment of PTLD patients and preserving transplanted kidneys. Methods and Materials: Twenty patients with PTLD were enrolled. Immunosuppressive therapy was reduced or ceased, and Rapamycin was initiated at the time of PTLD diagnosis. We evaluated the effects of switching immunosuppressive drugs to Rapamycin on graft status, the response of tumor, and 6, 12 months, and 5-year survival in patients. Results: PTLD remission was achieved in 14 patients, while six patients died; no relapse was detected in recovered patients. The median of PTLD free time was 25 months, and the mean overall survival in patients with PTLD treated by Rapamycin was 84.8 (95% CI=61.3-108.23).The five-year survival rate was 67%, 12 months survival was 73.8%, and six months' survival was 80%. The response rate to Rapamycin and immunosuppression reduction alone was 46.6%. Four out of 13 Diffuse Large B-Cell Lymphoma patients achieved a complete response just only after the reduction of immunosuppressive drugs and the consumption of Rapamycin. Conclusion: The present study demonstrated the effectiveness of conversion from immunosuppressive medication, particularly of Calcineurin inhibitors to Rapamycin in PTLD patients. However, more research is needed to confirm the Rapamycin effect on patients with PTLD.

Newly Diagnosed Glomerulonephritis During COVID-19 Infection Undergoing Immunosuppression Therapy, a Case Report.

During the COVID-19 pandemic, we had a 25 years old male case without any underlying disease or history of autoimmune disease in COVID-19 Clinic, Isfahan, Iran. He presented with arthralgia and weakness so we started COVID-19 therapeutic regimen. In his hospitalization, creatinine increases and abnormalities in random urine sediment was seen. Methylprednisolone and cyclophosphamide were prescribed due to suspected glomerulonephritis. After renal biopsy the diagnose was confirmed as crescentic proliferative glomerulonephritis. The patient also, underwent plasmapheresis and intravenous immunoglobulin injection. He was discharged healthy without development of new pulmonary symptoms despite immunosuppressive treatment.

Incidence of nonmelanoma skin cancer in renal transplant recipients: A systematic review and meta-analysis.

BACKGROUND: Nonmelanoma skin cancer (NMSC) in renal transplant recipients is common and associated with significant morbidity and mortality. The aim of the present systematic review and meta-analysis was to estimate the incidence of NMSC among renal transplant recipients. MATERIALS AND METHODS: We systematically searched PubMed, Medline, Scopus, and Web of Science databases for studies that assessed the incidence of NMSC in renal transplant recipients using a combination of relevant keywords. Two independent investigators included studies and extracted necessary information. Random effect meta-analysis was used to estimate pooled incidence of NMSC with 95% confidence intervals (CIs). RESULTS: Twenty-nine studies comprising 36,021 patients meet the criteria for the systematic review. The pooled incidence of NMSC in renal transplant recipients was 12.6% (95% CI: 12%-14%) with a majority of squamous cell carcinoma (SCC) 55% (95% CI: 47%-63%). The pooled estimate of the incidence rates of SCC and basal cell carcinoma was 2.7% (95% CI: 2%-3.4%) and 2.2% (95% CI: 1.5%-2.8%), respectively. Subgroup analysis per geographic location showed that pooled incidence of NMSC was 39.1% (95% CI: 26.3%-51.8%), 12.4% (95% CI: 8.8%-16%), and 1.2% (95% CI: 0.4%-2%) in Australia and New Zealand, Europe, and Middle East, respectively. CONCLUSION: The results of the current meta-analysis demonstrated that the incidence of NMSC in renal transplant recipients varies widely. Regarding the high incidence of NMSC among renal transplant recipients, awareness of associated risk factors and early diagnosis of the malignancy in the population is a major clinical need.

Outcome of rapamycin therapy for post-transplant-lymphoproliferative disorder after kidney transplantation: case series.

BACKGROUND: Post-transplant lymphoproliferative disorders (PTLD) are a complication of chronic immunosuppressive therapy in solid organ transplantation with a high mortality rate. Alternative treatments such as rapamycin have been explored. METHODS: A detailed retrospective analysis was performed according to data collected from 13 patients with PTLD. At the time of PTLD diagnosis, immunosuppressive therapy was decreased and rapamycin administered. Overall survival, disease-free survival of patients and graft survival were determined. RESULTS: Among 590 kidney transplant recipients, 13 adult patients with PTLD were included in this study. The mean age of the patients was 42.15 (range: 25-58) years at the time of PTLD diagnosis, and 9 patients were male. Histology was distributed in 9 diffuse large B cell, 1 Malt lymphoma, 1 Burkitt lymphoma, 2 Hodgkin-like PTLD. The response rate to rapamycin alone was 30.8%. The mean overall survival period was 23.38 months and 11 patients are still alive. In total, 10 patients (76.9%) achieved a complete remission with functioning graft in 11 (84.6%) patients. CONCLUSION: Despite the retrospective focus and limited number of patients, this study provides promising results regarding the effectiveness of stopping calcineurin inhibitors and switching to rapamycin for patients with PTLD.

Effect of magnesium supplementation on carotid intima-media thickness and flow-mediated dilatation among hemodialysis patients: a double-blind, randomized, placebo-controlled trial.

OBJECTIVES: The aim of the present study was to determine the efficacy of oral magnesium (Mg) supplementation on endothelial function through evaluation of carotid intima-media thickness (cIMT), brachial artery flow-mediated dilatation (FMD), and C-reactive protein (CRP) among hemodialysis (HD) patients. METHODS: This randomized, controlled, double-blind clinical trial consisted of 54 patients on HD. One group was treated orally with 440 mg of Mg oxide 3 times per week for 6 months (n = 29). The control group (n = 25) was given placebo using the same administration protocol. cIMT, FMD, serum calcium levels, phosphorus, lipid, CRP, and bicarbonate were measured at baseline and at 6 months in both groups. RESULTS: At 6 months, cIMT was significantly decreased in the Mg group (0.84 ± 0.13 mm at baseline and 0.76 ± 0.13 mm at 6 months, p = 0.001). However, in the placebo group, cIMT was significantly increased (0.73 ± 0.13 and 0.79 ± 0.12 mm, respectively, p = 0.003). When hypertension, diabetes mellitus, smoking, hyperlipidemia, and systemic lupus erythematosus were controlled for in the analysis, the effect of Mg remained significant in both groups (p = 0.000). CONCLUSION: Our results indicate that Mg might not improve endothelial function (CRP level and FMD) and that a decreased cIMT as a marker of atherosclerosis may be due to the inhibition of calcification through the regulation parathormone, calcium, and phosphorus.

Incidence of malignancy after living kidney transplantation: a multicenter study from iran.

Malignancy is a common complication after renal transplantation. However, limited data are available on post-transplant malignancy in living kidney transplantation. Therefore, we made a plan to evaluate the incidence and types of malignancies, association with the main risk factors and patient survival in a large population of living kidney transplantation. We conducted a large retrospective multicenter study on 12525 renal recipients, accounting for up to 59% of all kidney transplantation in Iran during 22 years follow up period. All information was collected from observation of individual notes or computerized records for transplant patients. Two hundred and sixty-six biopsy-proven malignancies were collected from 16 Transplant Centers in Iran; 26 different type of malignancy categorized in 5 groups were detected. The mean age of patients was 46.2±12.9 years, mean age at tumor diagnosis was 50.8±13.2 years and average time between transplantation and detection of malignancy was 50.0±48.4 months. Overall tumor incidence in recipients was 2%. Kaposis' sarcoma was the most common type of tumor. The overall mean survival time was 117.1 months (95% CI: 104.9-129.3). In multivariate analysis, the only independent risk factor associated with mortality was type of malignancy. This study revealed the lowest malignancy incidence in living unrelated kidney transplantation.

Metabolic evaluation in patients with nephrolithiasis: A report from Isfahan, Iran.

BACKGROUND: Nephrolithiasis is a major public health problem worldwide. In recent years, growing evidence suggest that this disease may originate from underlying metabolic disorders. This is the first study that reports the frequency of different metabolic abnormalities among patients with nephrolithiasis in Isfahan, a large central province of Iran. MATERIALS AND METHODS: From the time period between March 2009 and August 2010, 437 nephrolithiasis patients in Isfahan province enrolled in this study. Metabolic evaluation was performed by obtaining a 24-hours urine sample and fasting venous blood draw. We analyzed urine samples for volume, creatinine, calcium, citrate, oxalate, uric acid, sodium, and cystine. Fasting blood samples were assessed for serum calcium, phosphorus, sodium, potassium, uric acid, albumin, creatinine and blood urea nitrogen. RESULTS: The mean age was 46 ± 13.8 years (rang: 18-87). Nearly 50% were first time stone formers. The most common metabolic abnormalities were hypocitraturia (40.5%) and hypernatriuria (31.8%) that was followed by hyperoxaluria (28.8%). Hypercalciuria was detected only in 9.2% of the cases. CONCLUSION: Although, high calcium excretion was the most frequent metabolic derangement in several similar studies, in our province with considerably high prevalence of vitamin D deficiency, it is not frequent among nephrolithiasis patients. Instead, other metabolic risk factors were in higher frequencies.

Sirolimus-based immunosuppression for treatment of cutaneous warts in kidney transplant recipients.

Dermatological complications, especially skin infections, are very common following organ transplantation, and result in a lot of distress in the recipient. Herpes zoster, herpes simplex, and human papillomavirus infections are common infections in kidney transplant recipients, and therapeutic management is usually disappointing in immunosuppression state. We report here 2 cases of kidney transplant recipients who developed diffuse human papillomavirus-induced cutaneous warts with no response to conventional treatments. According to similar reports in organ transplant recipients, we modified the immunosuppressive regimen by converting to sirolimus, which led to a rapid relief from cutaneous warts in both patients. This evidence along with other case reports suggest that conversion to sirolimus may be considered as an effective strategy in cases of giant or multiple viral warts in kidney and perhaps other transplant recipients.

Trend of indications for therapeutic plasma exchange at an Iranian university hospital.

BACKGROUND: There is neither a registry system nor center-by-center reports on therapeutic plasma exchange in Iran. We evaluated the trend of indications as well as techniques and safety of plasma exchange in a single center in Iran. METHODS: All registered cases in the plasma exchange unit of Al-Zahra hospital between 1996 and 2005 accounting for 560 patients (260 men, 300 women; median age 29, range 1-95 years) who underwent a total of 3985 procedures were included. Data collection was performed using the official questionnaire of the International Apheresis Registry System. RESULTS: The total number of procedures per year has remained stable corresponding to a median of 9 treatments per 100,000 inhabitants. Of the 560 patients, the majority had neurologic (62.8%), followed by hematologic disorders (16.9%). The three most common indications were: Guillain-Barré syndrome (27.8%), myasthenia gravis (23.0%) and thrombotic thrombocytopenic purpura (11.4%). Three hundred and seventy-nine patients (67.7%) belonged to category I of the ASFA indication classification, 28 (5%) to category II, 104 (18.5%) to category III, and five (0.9%) to category IV. Forty-four cases (7.8%) were unclassified. All plasma exchanges were performed with a discontinuous flow centrifugation method. Normal saline+albumin (5%) was the main liquid of replacement (77.9%). CONCLUSION: The trend of indications in our center is comparable to international data. However, the average number of procedures in our population is lower than world statistics and the method of plasma exchange has not been modified.

Comparison of polyomavirus (BK virus and JC viruses) viruria in renal transplant recipients with and without kidney dysfunction.

BACKGROUND: Post-transplant infection with polyoma viruses (BK and JC viruses) is an important cause of graft loss and nephropathy. The objective of this study was to compare the frequency of BK and JC viruria in renal transplant recipients with and without graft dysfunction. METHODS: In a case-control study, we selected 60 kidney transplant patients with and without graft dysfunction in the first two years after transplantation. Each group consisted of 30 patients evaluated for basic demographic and laboratory characteristics. First morning urine samples were sent for BK and JC virus detection with QIAamp DNA Mini Kit and real-time polymerase PCR. Chi-square test with Yates' correction, Student t-test and Mann-Whitney U test were used as indicated. P value of less than 0.05 was regarded as statistically significant. RESULTS: Both groups were similar in age, gender, and time after transplant and pretransplant dialysis. In both groups, seven patients (23.3%) were JC virus positive whereas in case group 14 patients (46.7%) and in control group 9 patients (30%) were BK virus positive. There were no statistical significant difference between case and control groups for both JC and BK virus infection rate. CONCLUSIONS: We concluded that JC and BK virus infection is very prevalent in the first 2 years after transplant and might be monitored appropriately.

Skin cancer after renal transplantation: Results of a multicenter study in Iran.

BACKGROUND: Incidence and risk factors for skin tumors following renal transplantation can vary geographically; therefore, a retrospective study was performed to determine the incidence of and potential risk factors for skin cancer at 14 Transplant Centers in Iran between 1984 and 2008. MATERIAL/METHODS: We enrolled 11,255 kidney transplant recipients who were examined for all skin tumors. All skin cancers were established by histological examination. The data collection included the patient's age and sex, immunosuppressive regimen before and after diagnosis of tumor, rejection episodes, post-transplant latency period, other concurrent neoplastic problems, renal allograft function and outcome. RESULTS: One hundred and twenty-eight (1.14%) renal recipients had skin tumor, representing half of all post-transplant malignancies (128 out of 245 cases). Kaposi's sarcoma was the most common post-transplant cancer compared with other skin tumors. Male recipients had more tumors than did females (P=0.04); the male-to-female ratio in the affected patients was 2.5:1. The age at transplantation of patients with skin tumor was higher compared to RTRs without skin tumor (47±11 vs. 38±15 years, P=0.000), and individuals older than 45 years were at higher risk (odds ratio=3.8, 95%CI 2.6-5.5) of skin cancers. Patients consuming azathioprine were at risk more of skin cancer compared with those were on MMF (odds ratio =2.9, 95%, CI 2.0-4.2). The overall mortality was low (7.8%) in cases with skin cancer. CONCLUSIONS: This study showed that male sex, increased age, prolonged immunosuppression and azathioprine increased the risk of skin tumors after renal transplantation.

Effect of allopurinol in decreasing proteinuria in type 2 diabetic patients.

INTRODUCTION: Diabetic nephropathy is the most prevalent cause of end-stage renal disease. Besides factors such as angiotensin II, cytokines, and vascular endothelial growth factor, uric acid may play a role as the underlying cause of diabetic nephropathy. We evaluated allopurinol effects on proteinuria in diabetic patients with nephropathy. MATERIALS AND METHODS: In a double-blinded randomized controlled trial on 40 patients with type 2 diabetes mellitus and diabetic nephropathy (proteinuria, at least 500 mg/24 h and a serum creatinine level less than 3 mg/dL), allopurinol (100 mg/d) was compared with placebo. Administration of antihypertensive and renoprotective drugs (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers continued for both groups, without changes in dosage. Proteinuria was compared at baseline and 2 and 4 months between the two groups. RESULTS: Each group consisted of 9 men and 11 women. There were no difference between two groups regarding age, body mass index, duration of diabetes mellitus, systolic and diastolic blood pressure, fasting blood glucose, blood urea nitrogen, serum creatinine, serum potassium, and urine volume. Serum levels of uric acid (P = .02) and 24-hour urine protein (P = .049) were significantly lower in the patients on allopurinol, after 4 months of receiving allopurinol, compared with the control group. CONCLUSIONS: Low-dose allopurinol can reduce severity of proteinuria after 4 months of drug administration, which is probably due to decreasing the serum level of uric acid. Thus, allopurinol can be administered as an adjuvant cost-effective therapy for patients with diabetic nephropathy.

Histopathology of skin lesions with warty appearance in renal allograft recipients.

Warts are common in renal allograft recipients, with a reported incidence of warts ranging from 24% to 100%. These patients also demonstrate an accelerated course from wart to carcinoma. Although the histologic appearance of common warts is predictable in immunocompetent patients, this has not been shown in renal allograft recipients. The purpose of the study was to evaluate the histopathologic findings of warty lesions in renal allograft recipients and to determine the degree of dysplasia or malignant transformation in such lesions. We examined 55 renal allograft recipients for warty lesions. We obtained biopsy specimens from 50 lesions that appeared on clinical examination to be common warts and evaluated their histopathologic features. Median time from transplantation was 49 months (<5 years). All patients were treated with cyclosporine, azathioprine, and prednisolone. Among 55 renal allograft recipients, 17 patients (30.9%) had warty lesions. Forty-seven lesions (94%) showed changes of verruca vulgaris on histologic examination, and only three lesions (6%) showed warts with mild dysplasia. No malignant transformation was reported. Our findings were in contrast to a previous, similar study. This may be attributable to the relatively short period from transplantation to biopsy in our patients.