Prevalence of chronic kidney disease in Tunisian diabetics: the TUN-CKDD survey.

BACKGROUND: In Tunisia, the prevalence of diabetes mellitus increased from 15.5% on 2016 to 23% by 2023. While Chronic Kidney Disease (CKD) stills the most dreaded complications of diabetes, studies on the prevalence of chronic kidney disease non-dialysis diet are scarce. The aim of this study was to assess the prevalence of chronic kidney disease among the Tunisian diabetic population based on investigators' specialty, demographic criteria (gender, age, duration of diabetes and geographic distribution) and diagnosis criteria (albuminuria and/or eGFR). METHODS: This observational, multicentric, and cross-sectional study enrolled all diabetic subjects from all regions of Tunisia with at least 3 months of follow-up before the inclusion date, from 09 January to 08 February 2023. CKD diagnosis was established based on the KDIGO guidelines. The study was carried out at medical departments and ambulatory clinics of different healthcare providers. Baseline data were collected by investigators using an electronic case report form (eCRF). Continuous variables were described by means, median, standard deviation, and quartiles. Categorical data were tabulated in frequencies and percentages. RESULTS: The overall prevalence of CKD among the 10,145 enrolled patients with diabetes mellitus was 38.7% with a 95%CI [37.8-39.6%]. 50.9% were male, with a mean age of 67.5 (± 11.3) years. The mean diabetes duration was 16.1 years (± 8.9). The highest CKD prevalence was noted among nephrologists (82.2%), while it was similar between the cardiologists and the primary care physicians (30.0%). CKD prevalence was highest among males (43.0% versus 35.1%) and increased proportionally with patients' age and diabetes duration. CKD was more frequent in the Mid-East Area when compared to other regions (49.9% versus 25.3 to 40.1% in other regions). Albuminuria was present within 6.6% of subjects with CKD, and it was found an estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² within 13.3% of subjects wit h CKD. 18.9% had both criteria. CONCLUSIONS: In Tunisia, CKD among diabetics had a prevalence of 38.7%, approaching European prevalence. The prevalence discrepancy worldwide of CKD can be improved with a larger population size and by implementing standardized practices.

Renal AA amyloidosis revealing extramedullary plasmocytoma / Amylose rénale AA révélant un plasmocytome extra-médullaire : étude de cas

Introduction: Solitary plasmacytoma is a rare, localized malignancy. Bone localizations are the most common. Extramedullary plasmacytomas are much rarer. They are most often in the upper respiratory tract and can be complicated by amyloidosis. Here is an original report of a mediastinal extramedullary plasmacytoma revealed by type AA renal amyloidosis. Case presentation: We present the case of a 52-year-old patient with mediastinal extramedullary plasmocytoma diagnosed by renal failure due to type AA renal amyloidosis. Treatment was based on surgery with chemotherapy based on prednisone and melphalan. The patient presented end-stage renal failure that required hemodialysis at discharge. Conclusion: Extramedullary plasmacytoma is a rare tumour that may be associated with amyloidosis, usually type AL. To our knowledge, its association with AA amyloidosis has not been reported in the literature. Treatment is based on surgery combined with radiotherapy or chemotherapy.

Introduction: Le plasmocytome solitaire est une tumeur maligne rare localisée. Les localisations osseuses sont les plus fréquentes. Les plasmocytomes extra­médullaires (PEM) sont beaucoup plus rares, localisés le plus souvent au niveau des voies respiratoires supérieures. Présentation du cas: Nous rapportons une observation de PEM médiastinal révélé par une insuffisance rénale en rapport avec amylose rénale de type AA chez un patient âgé de 52 ans. Le traitement a comporté une tumorectomie de la masse associée à une chimiothérapie. Sur le plan rénal, le patient était au stade d'insuffisance rénale terminale nécessitant le recours à l'hémodialyse chronique. Conclusion: Le PEM est une tumeur rare pouvant se compliquer d'une amylose le plus souvent de type AL. Son association à une amylose AA n'a pas été rapportée auparavant à notre connaissance. Le traitement est basé surtout sur la chirurgie associée à une radiothérapie ou chimiothérapie.

Renal Amyloidosis: Epidemiological, Clinical, and Laboratory Profile in Adults from One Nephrology Center.

Background: Renal amyloidosis is one of the main differential diagnoses of nephrotic proteinuria in adults and the elderly. The aim of this study with the most important series in our country is to contribute to the epidemiological, clinical, and etiological study of the renal amyloidosis. Methods: In a retrospective study carried out between 1975 and 2019, 310 cases of histologically proven and typed renal amyloidosis were selected for this study. Results: There were 209 men and 101 women with a mean age of 53.8 ± 15.4 years (range, 17-84 years). Of the 310 cases, 255 (82.3%) were diagnosed with AA renal amyloidosis and 55 (17.7%) with non-AA amyloidosis. Infections were the main cause of AA amyloidosis, and tuberculosis was the most frequent etiology. The period from the onset of the underlying disease to diagnosis of the renal amyloidosis was an average of 177 months. The most frequent manifestations at the time of diagnosis were nephrotic syndrome (84%), chronic renal failure (30.3%), and end-stage renal disease (37.8%). After a medium follow-up of 16 months (range, 0-68 months), mortality occurred in 60 cases. Conclusions: Given the high frequency of AA amyloidosis in our country, awareness of the proper management of infectious and chronic inflammatory diseases remains a priority in reducing the occurrence of this serious disease.

Gitelman syndrome, hypomagnesemia, and venous thrombosis: An intriguing association.

Among salt-wasting tubulopathies' complications, venous thrombosis is one of the rarest. We report a case of a young woman with Gitelman syndrome (GS). She presented a deep venous thrombosis in her leg and was treated with heparin with favorable outcomes. We retained hypomagnesemia as the cause of the thrombosis.

[Left ventricular hypertrophy in hemodialysis patient: Prevalence, electrocardiographic, echocardiographic study and associated risk factors]. / Hypertrophie ventriculaire gauche chez les hémodialysés : prévalence, étude électrique, échographique et facteurs de risque.

BACKGROUND: Left ventricular hypertrophy is the most prevalent cardiac abnormality in hemodialysis patients. The diagnosis of this abnormality is possible by electrocardiogram and/or echocardiography. Our study aimed to assess the prevalence of left ventricular hypertrophy in hemodialysis patients and the accuracy of different electrocardiographic criteria. METHODS: This was a cross-sectional retrospective study including 60 hemodialysis patients between 2017 and 2018. A left ventricular mass index higher than 115g/m2 and 95g/m2 respectively in men and women defines echocardiographic left ventricular hypertrophy. We assessed left ventricular hypertrophy prevalence, sensitivity, specificity, and area under the receiver-operating characteristics (ROC) curve of fourteen different electrocardiographic criteria for identification of left ventricular hypertrophy. RESULTS: This was a cohort of 60 patients composed of 27 men and 33 women with a mean age 52.6±15,8years. Hypertension was the most common cardiovascular risk factor (82 %). The prevalence of left ventricular hypertrophy at echography was 65 %. Prevalence of left ventricular hypertrophy at electrocardiographic varied across the different criteria ranging from 5 % (R wave in DI) to 32 % (Perugia score). The highest left ventricular hypertrophy prevalence at electrocardiographic was found with the five following criteria: Perugia score (32 %), Peguero-Lo Presti index (28 %), Sokolow-Lyon index, Cornell index, Framingham-adjusted Cornell voltage (17 %). Sensitivity was ranged from 5 % (R in DI, Gubner-Ungerleider index, and product) to 41 % (Perugia score). The specificity of most criteria was ≥90 % except for the Perugia score (85 %). The sensitivity, specificity, postitive and negative productive values and left ventricular hypertrophy prevalence using the five most accurate criteria combined were respectively 48, 90, 70.28, 77.85 and 33 %. Hypertension, duration of HD, arteriovenous fistula, interdialytic weight gain, systolic blood pressure, hemoglobin <9g/dL and hyperparathyroidism were significantly associated with left ventricular hypertrophy. CONCLUSION: The prevalence of left ventricular hypertrophy detected by echocardiography was high. All electrocardiographic criteria had a low sensibility and a high specificity in the diagnostic of echocardiographic left ventricular hypertrophy. To improve the accuracy of electrocardiographic criteria, it is necessary to combine several electrocardiographic criteria and not often focused on a single classic electrocardiographic index.

Overall of kidney transplant recipients with a pretransplantation cancer history.

No significant morbidity from recurrence cancer and no development of secondary type of cancers in pre-existing malignancies. We must be careful about risk of rejection.

Subacute right ventricle perforation: a pacemaker lead complication.

Myocardial perforation is an uncommon but potentially life-threatening complication of pacemaker and implantable cardioverter-defibrillator. Myocardial perforation may be acute, subacute or chronic when it occurs within 24 hours of the device insertion; between 1 day and 30 days; and more than 30 days after implantation. This complication may occur in 1.7%-7% of patients. However, subacute myocardial perforation is rare and affects 0.5%-1.2% of patients. We report the case of an 85-year-old patient with a pacemaker failure 10 days after implantation due to a subacute myocardial perforation caused by an active fixation ventricular lead. Transthoracic echocardiography showed penetration of the ventricular lead through the right ventricular apex into the pericardium without any pericardial effusion. We confirmed myocardial perforation by a CT scan. We referred her to the surgery ward where she was successfully managed.

Proliferative glomerulonephritis and mantle cell lymphoma: a rare association.

Renal involvement in mantle cell lymphoma (MCL) is rare. We present the case of a man followed for MCL presented with acute kidney injury and positive antineutrophil cytoplasmic antibody (ANCA) type anti proteinase 3 (PR3). He was treated as for a rapidly progressing glomerulonephritis with cyclophosphamide and methylprednisolone followed by oral prednisone. Renal biopsy revealed diffuse endocapillary proliferation and segmental extracapillary proliferation in four glomeruli. Immunohistochemistry confirmed the renal invasion of lymphomatous cells. He started improving his renal function shortly after starting treatment. The coexistence of renal MCL infiltration, extracapillary proliferation and ANCA positive is exceptional.

[Successful treatment with paclitaxel of a visceral relapse of post-transplant Kaposi's sarcoma]. / Succès du traitement par paclitaxel d'une rechute viscérale d'un sarcome de Kaposi après transplantation rénale.

We report the observation of a patient who presented with post-transplant Kaposi's sarcoma after a delay of eight months with a dual cutaneous and palatal localisation. The reduction in immunosuppressive treatment and the introduction of Rapamune® allowed good clinical progress initially with regression of the skin lesions. He subsequently presented later a skin relapse with visceral localisation. Chemotherapy was conducted based on weekly paclitaxel infusions allowing partial remission and maintenance of renal graft function with good clinical tolerance.

[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.

[Exhaustion of vascular capital in patients on hemodialysis: what will be the outcome?] / Epuisement du capital vasculaire en hémodialyse: quelle issue?

Despite advances in the treatment of chronic renal failure, vascular access remains the weakest link in renal replacement therapy (RRT) and the leading cause of morbidity in patients on hemodialysis We report the case of a young female patient with chronic renal insufficiency secondary to vascular nephropathy on periodic hemodialysis and whose vascular capital was early exhausted due to iterative thromboses in arteriovenous fistulas and failure in peritoneal dialysis. Protein C deficiency was objectified. The patient underwent tunneled hemodialysis catheter insertion at the level of the right atrium via a right anterolateral thoracotomy with cannulation of the inferior vena cava, with poor functional outcome after three months of use. Since then she has been dialyzed using puncture of the external jugular veins.

Retroperitoneal fibrosis: A retrospective review of clinical presentation, treatment and outcomes.

Retroperitoneal fibrosis (RPF) is a rare disease and has a high risk of developing chronic kidney disease (CKD). This retrospective study was carried out with the objective to study the epidemiological, clinical and therapeutic characteristics of RPF and identify the risk factors associated with its progression to CKD. All 30 cases (24 males and five females) of RPF admitted from January 1985 to December 2013 in the Military Hospital of Tunis were included in this study. The mean age was 50.5 years. Presentation was with lower back pain, acute renal failure and inflammatory syndrome in 93%, 56% and 43% of the cases, respectively. Sixteen patients (54%) had a creatinine clearance <60 mL/min at the time of diagnosis. Erythrocyte sedimentation rate and C-reactive protein of >30 mm/h and 10 mg/L were observed in 56% and 53% of cases, respectively. The abdominal computed tomography scan showed ureterohydronephrosis in 63% of the cases. Classes I, II and III according to Scheel's radiological classification were found in, respectively, 16%, 13% and 70% of cases. Biopsy of RPF was performed in 20% of the cases, and all showed an inflammatory infiltrate without signs of vasculitis. RPF was idiopathic in 85% of the cases. Oral corticosteroid therapy was started for all patients. After a mean follow-up time of 53.2 months, an initial favorable response was noted in 76% of the cases. Fifty-three percent of the patients have presented one or more relapses during follow-up and 20% progressed to CKD. Most relapses were successfully treated by corticosteroids; only five patients had required additional immunosuppressive therapy. Two patients died. Elevated creatinine at diagnosis, high urea, clearance of creatinine lower than 60 mL/min and the use of ureteral stents were identified as risk factors for development of CKD.