Impact of therapeutic education on the choice of renal replacement therapy. Moroccan monocentric experience / Impact de l'éducation thérapeutique sur le choix du traitement de suppléance. Expérience monocentrique marocaine

Introduction: Therapeutic patient education (TPE) is gaining importance in the management of patients with chronic kidney disease (CKD). The objective of this study is to assess the interest of TPE in the acquisition of knowledge concerning CKD and renal replacement therapy, as well as the orientation of the patients towards a personalized choice of treatment. Materials and methods: Patients with a minimum stage 4 CKD were prospectively included between November 2016 and February 2020. We proposed TPE sessions on CKD and its treatment to all patients. We explained the theoretical part through a slideshow about the definition of end-stage renal disease, its symptoms and the various methods of renal replacement therapy. A "basket" of essential material to illustrate a session of hemodialysis (HD) or peritoneal dialysis (PD) was used to achieve the practical part of the study. Data was collected using two questionnaires: the first one, at the start of the session, included the socio-demographic and clinical characteristics of the patients and evaluated their level of basic knowledge, and the second one, at the end of the session, assessed the evolution of knowledge after TPE, leading to a therapeutic choice. Results: The mean age of the 211 included patients was 55.59 years old (SD = 15.47). Male to female ratio was 0.73. The level of education was low in 69% of the cases of whom 23.7% were employees. The glomerular filtration rate (GFR) was between 15 and 30 mL/min in 56.8% of the cases. Initial nephropathy was known in 60% of patients while the stage of CKD was unknown in 66.4%. Before TPE, patients with a good level of overall knowledge were around 29%, rising to 73% after TPE. A significant correlation was found between the level of education of the patients and their knowledge score before and after TPE. The choice of renal replacement therapy was taken for PD, TR and HD respectively in 36%, 19% and 11.8% of the cases, while 33.2% asked for time to think. Elderly and/or low educated patients most often remained undecided; moreover those who are young and/or educated prefer TR. During the follow-up period, 46% of patients started renal replacement therapy (36.5% started HD, 8.1% PD and 1.4% KT). The choice made by our patients was respected in 42% of the cases: in all the patients who chose HD; in 36% of those who chose PD, and 19% of those who chose kidney transplantation (KT). The final therapeutic modality was strongly linked to the following parameters: age, GFR and level of education. Conclusion: This study highlighted the insufficient level of patients' information about CKD and its treatment and allowed the patients to express their choice of their replacement therapy, which is a complicated process that must ­integrate the opinion of the nephrologist and the patient's preference to lead to an ­optimal organization of the therapeutic modality.

Introduction: L'éducation thérapeutique du patient (ETP) en néphrologie est incontournable dans l'intégration du patient dans la prise en charge de sa maladie rénale chronique. L'objectif de notre étude est d'évaluer l'intérêt de l'ETP dans l'acquisition des connaissances relatives à l'insuffisance rénale chronique (IRC) et aux méthodes de suppléance rénale, ainsi que dans l'orientation vers un choix thérapeutique personnalisé. Matériels et méthodes: Il s'agit d'une étude prospective réalisée entre novembre 2016 et février 2020, incluant les patients en IRC à partir du stade 4, à qui nous avons proposé une séance d'ETP sur l'IRC et ses moyens de suppléance. Ces séances, tenues tous les quinze jours, comportent un volet théorique accompli à l'aide d'un diaporama traitant les rôles des reins, la définition de l'insuffisance rénale chronique terminale (IRCT), ses symptômes et les différentes méthodes de suppléance. Concernant le volet pratique, nous avons utilisé « un panier ¼ comportant le matériel essentiel pour illustrer une séance d'hémodialyse (HD) ou de dialyse péritonéale (DP). Le recueil des données est effectué grâce à deux questionnaires : un au début de séance notant les données sociodémographiques et cliniques du patient et évaluant son niveau de connaissances de base, et un deuxième en fin de séance pour évaluer l'évolution des connaissances après ETP et pour exprimer un choix thérapeutique. Résultats: Nous avons recensé 211 patients avec un âge moyen de 55,59 ans ± 15,47 et un sexe-ratio H/F de 0,73. Le niveau d'instruction était bas dans 69 % des cas ; 23,7 % de nos patients avaient un emploi ; le débit de filtration glomérulaire (DFG) était compris entre 15 et 30 mL/min dans 56,8 % des cas. La néphropathie initiale était connue chez 60 % des patients alors que le stade de l'IRC était méconnu chez 66,4 %. Avant ETP, les patients ayant un bon niveau de connaissances globales étaient de l'ordre de 29 %, passant à 73 % après ETP. L'analyse statistique a mis en évidence une corrélation significative entre le niveau d'instruction des patients et leur score de connaissances avant et après ETP. Le choix de la méthode de suppléance rénale a été porté sur la DP, la transplantation rénale (TR) et l'HD respectivement dans 36 %, 19 % et 11,8 % des cas, alors que 33,2 % ont réclamé un temps de réflexion. Les patients âgés et/ou à bas niveau d'instruction restent le plus souvent indécis ; par ailleurs, les jeunes et/ou instruits choisissent plutôt la TR. La DP est choisie indépendamment de ces critères. Durant la période de suivi, 46 % des patients ont démarré une suppléance rénale (36,5 % ont démarré l'HD, 8,1 % la DP et 1,4 % la TR). Le choix émis par nos patients a été respecté dans 42 % des cas : chez tous les patients qui ont choisi l'HD ; chez 36 % de ceux qui ont choisi la DP ; et chez 19 % de ceux qui ont choisi la TR. La modalité thérapeutique finale était fortement liée aux paramètres suivants : l'âge, le DFG et le niveau d'instruction. Conclusion: Les résultats de notre étude ont soulevé l'insuffisance du niveau d'information des patients concernant l'IRC et son traitement, et ont permis aux patients d'exprimer un choix de traitement avec une congruence adéquate par rapport à ce qui a été précédemment publié. Le choix du traitement de suppléance rénale est un processus compliqué qui doit intégrer l'avis du néphrologue, la préférence du patient et l'organisation de la modalité thérapeutique.

Pregnancy after kidney transplantation: Ibn Sina Rabat University hospital experience / Grossesse après transplantation rénale : expérience du service de transplantation rénale du CHU Ibn Sina de Rabat (Maroc)

Introduction: Kidney transplantation (KT) restores the fertility of women with end-stage kidney disease (ESKD), thus offering them the possibility of having children. However, pregnancy after kidney transplantation is associated with high maternal-fetal morbidity. The purpose of this work is to report the experience of our service in pregnancies in kidney transplant recipients. Materials and methods: We retrospectively studied the records of transplant recipients who had one or more pregnancies after KT. We analyzed clinical (blood pressure, weight gain, oedema, duration of pregnancy, obstetric complication) and biological (creatinine, urinary albumin excretion) parameters. Results: Between 1998 and 2020, twenty-one pregnancies occurred in 12 transplant recipients. The average age of patients at the time of conception was 29 ± 5 years with a delay between KT and pregnancy of 43 ± 29 months. Seven pregnancies began with arterial hypertension (HTA) controlled under treatment, proteinuria before conception was negative in all pregnancies and renal function was normal with an average creatinine level of 10.1 ± 1,27 mg/L. Prior to pregnancy, immunosuppression regimens were based on anticalcineurin (n = 21) combined either with mycophenolate mofetil (MMF) (n = 10) or azathioprine (n = 8) or alone (n = 3). Immunosuppression regimens were all associated with corticosteroid therapy. Three months before conception, MMF was relayed by azathioprine in seven pregnancies, on the other hand three other unplanned pregnancies, started under MMF. During pregnancy, the appearance of proteinuria greater than 0,5 g/24 h was noted in three pregnancies in the third trimester. Pregnancy hypertension was found in three pregnancies, one of which progressed to pre-eclampsia. As for renal function, it remained stable with an average creatinine level of 10,3 mg/l in the 3rd trimester. Two cases of acute pyelonephritis were noted. No episode of acute rejection was noted during and 3 months after pregnancy. The delivery was performed by caesarean section in 44.4 %, after an average term of 37 week of amenorrhea ± 2.04 with three cases of prematurity. The average birth weight was 3 110 g ± 450 g. There was one case of spontaneous abortion and two cases of fetal death in utero. After post--partum, renal function remained stable in five patients. In six cases, there was impaired renal function either by acute rejection or secondary to chronic allograft nephropathy. Conclusion: In our department, a quarter of transplant recipients were able to carry a pregnancy with a rate of 89 % of successful pregnancies. Pregnancy after KT requires special planning and monitoring. A multidisciplinary collaboration between transplant nephrologist, gynecologist and pediatrician is necessary by referring to the recommendations.

Introduction: La transplantation rénale (TR) permet de restaurer la fertilité des femmes en insuffisance rénale chronique terminale (IRCT), leur offrant ainsi la possibilité d'avoir des enfants. Toutefois, la grossesse après greffe rénale est associée à une morbidité materno-fœtale élevée. Le but de ce travail est de rapporter l'expérience de notre service dans les grossesses chez les transplantées rénales. Matériels et méthodes: Nous avons étudié rétrospectivement les dossiers de transplantées ayant eu une ou plusieurs grossesses après TR. Nous avons analysé des paramètres cliniques (tension artérielle, prise de poids, œdèmes, durée de grossesse, complications obstétricales) et biologiques (créatininémie, excrétion urinaire d'albumine). Résultats: Entre 1998 et 2020, 21 grossesses ont eu lieu chez 12 transplantées. L'âge moyen des patientes au moment de la conception était de 29 ± 5 ans avec un délai entre la TR et la grossesse de 43 ± 29 mois. Sept grossesses ont débuté avec une hypertension artérielle (HTA) contrôlée sous traitement, la protéinurie avant conception était négative dans toutes les grossesses et la fonction rénale était normale avec une créatininémie moyenne de 10,1 ± 1,27 mg/L. Avant les grossesses, les régimes d'immunosuppression étaient à base d'anticalcineurine (n = 21), associé soit à du mycophénolate mofétil (MMF) (n = 10) soit à de l'azathioprine (n = 8), ou seul (n = 3). Les régimes d'immunosuppression ont tous été associés à une corticothérapie. Trois mois avant la conception, le MMF a été ­relayé par l'azathioprine dans sept grossesses, et trois autres grossesses non programmées ont débuté sous MMF. Au cours des grossesses, on a noté l'apparition d'une protéinurie supérieure à 0,5 g/24 h dans trois grossesses au troisième trimestre. L'HTA gravidique a été retrouvée dans trois grossesses, dont une a évolué vers une pré-éclampsie. Quant à la fonction rénale, elle est restée stable avec une créatininémie moyenne de 10,3 mg/L au troisième trimestre. Deux cas de pyélonéphrite aiguë ont été notés. Aucun épisode de rejet aigu n'a été noté au cours et trois mois après la grossesse. L'accouchement a été réalisé par césarienne dans 44,4 %, après un terme moyen de 37 semaines d'aménorrhée, ± 2,04 avec trois cas de prématurité. Le poids de naissance moyen était de 3 110 g ± 450 g. On a noté un cas d'avortement spontané et deux cas de mort fœtale in utero. Après le post-partum, la fonction rénale est restée stable chez cinq patientes. Dans six cas, on a assisté à une altération de la fonction rénale par un rejet aigu ou secondaire à une néphropathie chronique d'allogreffe. Conclusion: Dans notre service, un quart des transplantées a pu mener une grossesse avec une productivité de 89 % de ces grossesses. La grossesse après la TR nécessite une planification et une surveillance particulière. Une collaboration multidisciplinaire entre néphrologue transplanteur, gynécologue et pédiatre est nécessaire en se référant aux recommandations.

Pregnancy after kidney transplantation: Ibn Sina Rabat University hospital experience / Grossesse après transplantation rénale : expérience du service de transplantation rénale du CHU Ibn Sina de Rabat (Maroc)

Introduction: Kidney transplantation (KT) restores the fertility of women with end-stage kidney disease (ESKD), thus offering them the possibility of having children. However, pregnancy after kidney transplantation is associated with high maternal-fetal morbidity. The purpose of this work is to report the experience of our service in pregnancies in kidney transplant recipients. Materials and methods: We retrospectively studied the records of transplant recipients who had one or more pregnancies after KT. We analyzed clinical (blood pressure, weight gain, oedema, duration of pregnancy, obstetric complication) and biological (creatinine, urinary albumin excretion) parameters. Results: Between 1998 and 2020, twenty-one pregnancies occurred in 12 transplant recipients. The average age of patients at the time of conception was 29 ± 5 years with a delay between KT and pregnancy of 43 ± 29 months. Seven pregnancies began with arterial hypertension (HTA) controlled under treatment, proteinuria before conception was negative in all pregnancies and renal function was normal with an average creatinine level of 10.1 ± 1,27 mg/L. Prior to pregnancy, immunosuppression regimens were based on anticalcineurin (n = 21) combined either with mycophenolate mofetil (MMF) (n = 10) or azathioprine (n = 8) or alone (n = 3). Immunosuppression regimens were all associated with corticosteroid therapy. Three months before conception, MMF was relayed by azathioprine in seven pregnancies, on the other hand three other unplanned pregnancies, started under MMF. During pregnancy, the appearance of proteinuria greater than 0,5 g/24 h was noted in three pregnancies in the third trimester. Pregnancy hypertension was found in three pregnancies, one of which progressed to pre-eclampsia. As for renal function, it remained stable with an average creatinine level of 10,3 mg/l in the 3rd trimester. Two cases of acute pyelonephritis were noted. No episode of acute rejection was noted during and 3 months after pregnancy. The delivery was performed by caesarean section in 44.4 %, after an average term of 37 week of amenorrhea ± 2.04 with three cases of prematurity. The average birth weight was 3 110 g ± 450 g. There was one case of spontaneous abortion and two cases of fetal death in utero. After post-partum, renal function remained stable in five patients. In six cases, there was impaired renal function either by acute rejection or secondary to chronic allograft nephropathy. Conclusion: In our department, a quarter of transplant recipients were able to carry a pregnancy with a rate of 89 % of successful pregnancies. Pregnancy after KT requires special planning and monitoring. A multidisciplinary collaboration between transplant nephrologist, gynecologist and pediatrician is necessary by referring to the recommendations.

Introduction: La transplantation rénale (TR) permet de restaurer la fertilité des femmes en insuffisance rénale chronique terminale (IRCT), leur offrant ainsi la possibilité d'avoir des enfants. Toutefois, la grossesse après greffe rénale est associée à une morbidité materno-fœtale élevée. Le but de ce travail est de rapporter l'expérience de notre service dans les grossesses chez les transplantées rénales. Matériels et méthodes: Nous avons étudié rétrospectivement les dossiers de transplantées ayant eu une ou plusieurs grossesses après TR. Nous avons analysé des paramètres cliniques (tension artérielle, prise de poids, œdèmes, durée de grossesse, complications obstétricales) et biologiques (créatininémie, excrétion urinaire d'albumine). Résultats: Entre 1998 et 2020, 21 grossesses ont eu lieu chez 12 transplantées. L'âge moyen des patientes au moment de la conception était de 29 ± 5 ans avec un délai entre la TR et la grossesse de 43 ± 29 mois. Sept grossesses ont débuté avec une hypertension artérielle (HTA) contrôlée sous traitement, la protéinurie avant conception était négative dans toutes les grossesses et la fonction rénale était normale avec une créatininémie moyenne de 10,1 ± 1,27 mg/L. Avant les grossesses, les régimes d'immunosuppression étaient à base d'anticalcineurine (n = 21), associé soit à du mycophénolate mofétil (MMF) (n = 10) soit à de l'azathioprine (n = 8), ou seul (n = 3). Les régimes d'immunosuppression ont tous été associés à une corticothérapie. Trois mois avant la conception, le MMF a été relayé par l'azathioprine dans sept grossesses, et trois autres grossesses non programmées ont débuté sous MMF. Au cours des grossesses, on a noté l'apparition d'une protéinurie supérieure à 0,5 g/24 h dans trois grossesses au troisième trimestre. L'HTA gravidique a été retrouvée dans trois grossesses, dont une a évolué vers une pré-éclampsie. Quant à la fonction rénale, elle est restée stable avec une créatininémie moyenne de 10,3 mg/L au troisième trimestre. Deux cas de pyélonéphrite aiguë ont été notés. Aucun épisode de rejet aigu n'a été noté au cours et trois mois après la grossesse. L'accouchement a été réalisé par césarienne dans 44,4 %, après un terme moyen de 37 semaines d'aménorrhée, ± 2,04 avec trois cas de prématurité. Le poids de naissance moyen était de 3 110 g ± 450 g. On a noté un cas d'avortement spontané et deux cas de mort fœtale in utero. Après le post-partum, la fonction rénale est restée stable chez cinq patientes. Dans six cas, on a assisté à une altération de la fonction rénale par un rejet aigu ou secondaire à une néphropathie chronique d'allogreffe. Conclusion: Dans notre service, un quart des transplantées a pu mener une grossesse avec une productivité de 89 % de ces grossesses. La grossesse après la TR nécessite une planification et une surveillance particulière. Une collaboration multidisciplinaire entre néphrologue transplanteur, gynécologue et pédiatre est nécessaire en se référant aux recommandations.

[Bladder AA amyloidosis: A rare location. About a case]. / Amylose AA vésicale : une localisation rare. À propos d'un cas.

INTRODUCTION: Bladder localization of AA amyloidosis is rare. It can be responsible for massive and recurrent hematuria. We report a case of bladder AA amyloidosis secondary to Crohn's disease in a renal transplant patient. CLINICAL OBSERVATION: A 62-year-old man, suffering from Crohn's disease since 1991 complicated by renal AA amyloidosis. He received a kidney transplant since 20 years from an HLA identical donor. After an 18-year period of clinical remission, the patient was admitted for a flare-up of his Crohn's disease in the form of intermittent diarrhoea. Treatment with corticosteroids allowed a good evolution. A year later, he was rehospitalized for massive macroscopic haematuria. Histological examination of the bladder biopsy revealed AA amyloidosis. The patient fully recovered but died 6 weeks later from septic shock of urinary origin. CONCLUSION: The treatment of bladder localization of AA amyloidosis is based on treating the cause. Hematuria is sometimes massive, exceptionally requiring emergency cystectomy for haemostasis.

[Thymoglobulin as induction treatment in kidney transplantants with low immunological risk: a Moroccan experience]. / La thymoglobuline en traitement d'induction chez les transplantés rénaux à faible risque immunologique: une expérience marocaine.

Introduction: Thymoglobulin® is a polyclonal antibody indicated for induction treatment in kidney transplantation. The purpose of this study is to estimate the effectiveness of Thymoglobulin® as induction treatment in kidney transplant patients with low immune risk. Methods: we conducted a retrospective study between January 2012 and September 2017. Patients with low immunological risk, defined as the absence of previous transplantation and donor-specific antibodies (DSA), were included and received Thymoglobulin® induction therapy. Demographic and clinical characteristics, biological parameters and post-renal transplant complications were studied. Results: we enrolled 55 kidney transplant patients with an average follow-up period of 38 ± 16 months. The average age of patients was 39,1 ± 12,1 years with a male predominance (58.2%). No patient had DSA prior to transplant. Cumulative dose of Thymoglobulin® was 4,26 ± 0,87 mg/kg, with an average duration of 5 ± 0,82 days. Lymphocyte depletion was maximal on the first day of infusion. Three patients had delayed graft function, at least one episode of bacterial infection in 56,4% of patients, 7 cases of CMV infections (12,7%) and 2 cases of CMV disease (3,6%). Graft survival rate was calculated for all patients with an average serum creatinine of 11,7 ± 3,6 mg/l during the last visit. Conclusion: although it is not indicated for first line treatment in patients with low immunological risk, Thymoglobulin® can nevertheless be prescribed at a lower dose, with similar efficacy and without exposure to a higher risk of rejection.

HLA-identical living related kidney transplantation: Outcomes of a national multicenter study.

OBJECTIVES: The kidney prognosis of HLA-identical seems theoretically very interesting with the lowest risk of acute rejection after that of identical twins. Objectives were to determine the prevalence of acute rejection and various complications in a cohort of HLA-identical living-related kidney transplant. METHODS: A retrospective, multicenter study was conducted in seven university centers in Morocco, which included all recipients of an HLA-identical living-related kidney transplant performed between 1990 and 2019. RESULTS: Data on 68 HLA-identical living-related kidney transplants were collected. The donors were siblings in 89.7%, the parents in 7.3%, and identical twins in 3% of cases. 53.6% of all recipients were under 35 years old, and 59.4% of them were male. 39.7% of all donors were under 35 years old, and 47% of them were male. 48.5% of HLA-identical living-related kidney transplants were performed before the year 2000. 18 kidney transplant biopsies were performed on 16 kidney transplant recipients. Seven episodes of acute rejection occurred in six patients, 8.8% of the whole cohort (n = 68). Two cases of acute rejection among the seven were related to poor adherence, cessation of immunosuppressive therapy, and loss of medical follow-up by these patients. These two patients were 20 years old at the time of kidney transplantation. The global kidney transplant survival was 66.7% versus 91.9% (P = 0.04) in the two patient groups having developed acute rejection and not having developed acute rejection, respectively. CONCLUSIONS: Acute rejection is a real threat to HLA-identical kidney transplant recipients. Therefore, it seems very important to codify the immunosuppressive regimen and to adopt a minimal and effective treatment.

[Microscopic polyangiitis induced by a serotonin reuptake inhibitor. Case report]. / Polyangéite microscopique induite par un inhibiteur de la recapture de la sérotonine. À propos d'un cas.

Microscopic polyangiitis is an ANCA-associated vasculitis and affects small sized vessels. We report a case of microscopic polyangiitis, in a 31 year old patient with renal, skin and neurologic manifestations, which was probably triggered by a selective serotonin reuptake inhibitor. Under induction therapy with corticosteroids and cyclophosphamide, the kidney recovery is complete, neurological is slow but satisfactory.

Management of gout by Moroccan rheumatologists: a Moroccan Society for Rheumatology National Survey.

To assess the modalities and current practices in gout management reported by Moroccan rheumatologists. We performed a cross-sectional online survey using a questionnaire e-mailed to 360 rheumatologists included 30 multiple-choice questions. 105 rheumatologists responded to the survey with 29% of response rate. The number of gout patients seen per month was five (3-9); they were referred in 58.7% by a general practitioner. The clinical presentation of gout patients was dominated by gout crisis in 71%, and the association gout crisis and gouty arthropathy accounted for 19% of severe forms. 40% of rheumatologists apply the 2015ACR/EULAR classification criteria. Obesity accounted for 85.7% of the associated comorbidities. The most commonly prescribed Urate-lowering therapy (ULT) was allopurinol in 81.3% (± 12). 48% of rheumatologists reported starting allopurinol at 200 mg daily and associated it with colchicine during the first 6 months by 33.3%. The determination of uric acid levels was monitoring in 76.2% every 3 months. Administration of ULT to asymptomatic hyperuricemia was found in 69.5% when patients had renal complications, while only 14.3% recommended dietary and lifestyle measures. The median duration for therapeutic education was 15 min (10, 20). In 96.2%, the education of the patient was done orally. 93.3% of rheumatologists inform their patients on how to manage a gout attack, and 96.2% on the measures of hygiene and diet has adopted. Our survey gives an insight into the elements that should be improved in the management of gout by the Moroccan rheumatologists. It highlights the need to standardize the management of gout, hence the importance of developing Moroccan recommendations on gout.

Calciphylaxis: Successful Management of a Rare Complication of Chronic Kidney Disease in Two Patients.

Calciphylaxis, or calcification uremic arteriolopathy, is a rare disease thought to occur due to arteriolar calcifications of the dermis and is responsible for ischemia with cutaneous necrosis and painful panniculitis. Its mechanism remains poorly understood which makes its management challenging and difficult to standardize. We report our management of two patients diagnosed with calciphylaxis. In one patient, calciphylaxis was mentioned upon admission given the context of preexisting secondary hyperparathyroidism and the existence of multiple risk factors. In both patients, the diagnosis was confirmed histologically. Our two observations highlight the difficulty of the diagnosis and the complexity of the therapeutic management that has been personalized according to patient characteristics and clinical evolution. Several therapeutic means can be implemented once the diagnosis is made; nevertheless, its prognosis remains pejorative despite the therapeutic advances. Broad debridement, good phosphocalcic balance control, and the correction of the risk factors top the list of any therapeutic strategy. One of the major challenges of the therapy is normalizing the calcium-phosphate balance. Thus, Cinacalcet and sodium thiosulfate appear to be promising treatments.

HLA Class II with Lupus Nephritis in Moroccan Patients.

Lupus nephritis (LN) is a disease with a poor prognosis. The association between LN and the Human leukocyte antigen (HLA) genes has never been studied on a Moroccan population. The aim of this work was to evaluate the distribution of the HLA class II alleles in patients with LN and to determine susceptible and protective HLA alleles/haplotypes in LN. The association between these alleles, disease severity of LN, and age at onset were also investigated. Seventy-five patients with LN were compared with 169 healthy unrelated controls. HLA class II alleles typing was performed by polymerase chain reaction-sequence-specific primers (PCR-SSP). A significant increase of HLA-DRB1*15 allele frequency (p = 0.001) and a significant decrease of the HLA-DRB1*04 allele (p = 0.04) were observed in LN patients. The frequency of HLA-DRB1*15-DQB1*06 haplotype (p = 0.003) was increased in the patients while that of HLA-DRB1*04-DQB1*03 (p = 0.027) was decreased. A significant increase of HLA-DRB1*15 allele frequency (p = 0.0001) and HLA-DRB1*15-DQB1*06 haplotype (p = 0.002) was observed in patients with class IV LN. In the Moroccan population we demonstrated the positive association of HLA class II alleles and haplotypes with LN and with a severe form of nephritis. HLA-DRB1*15 allele does not determine the age of disease onset in LN.

Attitudes toward organ donation among personnel from the University Hospital of Rabat.

The medical staff could play a major role in promoting for organ donation. The aim of our study was to assess the attitudes of the medical staff toward organ donation. It is a prospective study conducted over a period of six months. A questionnaire was distributed and explained to the medical staff in our institute. Fifteen questions were designed to include four main themes: sociodemographic information, attitude toward organ donation, perceived knowledge about organ donation, and reasons for refusal or acceptance of organ donation. Among the 245 respondents, 36.3% had prior knowledge about organ transplantation, 31.8% knew about the law of organ donation, 43.2% had already donated blood sometimes, 65.7% expressed their consent to organ donation during their lifetime, and 82.8% expressed their agreement to donation after their death. The grounds for refusal were generally: a misunderstanding of risks, desire for respect of corpse. The religious and the ethical motive were present too as a ground for decision making. The medical staff is the key for organ donation. To promote organ transplantation, personnel should be well informed about ethical, moral, and religious dimensions of organ donation and transplantation.

Mixed cryoglobulinemia-associated Sjögren's syndrome leading to spontaneous rupture of the kidney: a case report.

BACKGROUND: Spontaneous rupture of the kidney is uncommon and is mainly caused by renal tumors. Only a few cases are caused by vasculitis. We report here the first case of spontaneous rupture of kidney resulting from mixed cryoglobulinemia. CASE PRESENTATION: A 44-year-old man presented with sudden onset of fever, acute pulmonary edema, left flank abdominal pain unassociated with trauma, and rapidly progressive renal failure requiring dialysis. Computed tomography of the abdomen revealed a large perirenal hematoma of the left kidney. During conservative surgery, the patient underwent renal biopsy that showed renal vasculitis and membranoproliferative glomerulonephritis with intracapillary microthrombi. Tests were positive for mixed cryoglobulinemia caused by Sjögren's syndrome. The patient was better after immunosuppressive therapy, with the disappearance of clinical symptoms and the recovery of baseline renal function. CONCLUSION: We report on this case and discuss a possible link between spontaneous rupture of kidney and mixed cryoglobulinemia-associated Sjögren's syndrome.

Pregnancy after renal transplantation: Effects on mother, child, and renal graft function.

The aim of this study was to report our experience of pregnancy in renal transplant (RT) patients and its medium and long-term effects on the renal graft as well as the maternal fetal complications. We studied 21 pregnancies in 12 RT patients with mean age of 29.9 ± 5.3 years. The mean duration of RT to 1 st pregnancy was 42 (21-68.5) months and the median follow-up period was 112.5 (138-165) months. The pregnancy was planned in 28.6% of the cases. At the time of the diagnosis of the pregnancy, all the patients were maintained on corticosteroids and cyclosporine, 14.3% of the patients were on mycophenolate mofetil, and 71.4% of the patients were on azathioprine. The high blood pressure was present before the pregnancy in 33.3% of the patients. During pregnancy, proteinuria appeared in 20% of the cases, urinary tract infection in 33.3%, and preeclampsia in 5%. Anemia was present in all the patients during pregnancy. The doses of cyclosporine were increased during pregnancy. The mean term of delivery was 37 ± 2 weeks. Premature delivery was observed in 19% of the cases, fetal death in utero in 10%, and abortion in 15%. The number of living children was 16, with a mean birth weight of 3014 ± 515 g; the weight was lower than 2500 g in three (15%) cases. In the long-term follow-up, we noticed two cases of acute rejection related to patients' noncompliance, and four cases of chronic allograft nephropathy, without a switch to dialysis. We conclude that pregnancy in RT patients requires multidisciplinary care because of the increased risks of maternal and fetal complications. Each pregnancy needs to be planned; all parameters have to be studied and evaluated in order to allow for optimization of outcome and minimization of complications.

Mechanical complications of continuous ambulatory peritoneal dialysis: Experience at the Ibn Sina University Hospital.

Peritoneal dialysis is a new renal replacement therapy recently introduced in Morocco since 2006. Continuous ambulatory peritoneal dialysis has proven to be as effective as hemodialysis. However, it is associated with several complications. The aim of this study was to evaluate the outcome of complications in patients treated with peritoneal dialysis at our center. The nature of non-infectious complications was noted during follow-up in these patients. Fiftyseven complications were noted among 34 patients between June 2006 and June 2014. Catheter migration was the most common complication (36.8%), followed by obstruction (14%), dialysate leaks (14%), hemorrhagic complications (10.5%) and, finally, hernia (12.2%), catheter perforation (5.2%) and externalization (3.5%).

[Pathological and clinical correlations in renal AA amyloidosis: A Moroccan series of 30 cases]. / Amyloses rénales AA : corrélations anatomocliniques dans une série marocaine de 30 cas.

OBJECTIVE: Study of histological and clinical correlations of 30 cases of renal amyloidosis AA diagnosed between November 2010 and December 2012. RESULTS: The main causes associated with amyloidosis AA were represented by chronic infectious diseases (60%). Nephrotic syndrome and renal failure were observed in 94% and 73% respectively. The distribution of amyloid deposits: 90% of patients had a glomerular form and 10% had a vascular form. Inflammatory reaction associated with AA renal amyloidosis was present in 50% of cases. This inflammation was observed near amyloid deposits associated with a deposition of immunoglobulin chains and/or complement factors. CONCLUSION: Our study confirms the predominance of AA amyloidosis complicating chronic infectious diseases, especially tuberculosis. Our data point out a relationship between the morphology of renal AA amyloidosis, its clinical presentation and prognosis.

Infectious peritonitis profile in peritoneal dialysis at Ibn Sina University Hospital: a 6-year data report.

BACKGROUND: Infectious peritonitis (IP) is the most common complication in peritoneal dialysis (PD). The purpose of this study is to assess the prevalence of IP and to determine its clinical, biological, and evolutive characteristics. PATIENTS AND METHODS: We conducted a five year, five months retrospective study from July 2006 to December 2011. All patients on peritoneal dialysis that have been followed on PD for a minimum of 3 months and who presented IP during follow-up were included. Data were analyzed using SPSS 17.0. RESULTS: The 76 episodes of IP were identified in 36 patients. The peritonitis rate (months × patients/peritonitis), as calculated by the Registre de Dialyse Péritonéale de Langue Française (RDPLF Registry) [French peritoneal dialysis registry] in December 2011, was 18.59. Time to occurrence of peritonitis from the start of peritoneal exchange was 15.44±10 months. The mean age of our patients was 49.1±16.8 years [10-80]: the youngest patient's age was 10, while the oldest was 80 years old (male to female: sex ratio M/F=1,66). Also, 22% of our patients were diabetic. The mean follow-up in PD was 22.6±14 months. Abdominal pain was present in 79% of the cases. Fever and vomiting were noted in 42% and 38% of cases, respectively. The C-reactive protein rate was elevated in 77% of cases, and leukocytosis was found in 27% of cases. Bacteriological proof was present in 73.68% of cases. Gram-positive cocci were involved in 56.6% of microbiologically proven IP cases. Gram-negative bacilli were represented in 37.7%. The outcome was favorable in 89.4%. The PD catheter was removed in 2.63% of the cases. In addition, 7.89% of our patients were transferred to hemodialysis. DISCUSSION: The rate of IP remains high in our series. More than one-half of the peritonitis cases with positive cultures (56.6%) were caused by Gram-positive cocci. Gram-negative bacilli ranked second (27.7%). These results agree with data in the literature. Moreover, the rate of culture-negative IP in our series is high (26%). Evolution is good in most cases (89%). CONCLUSION: Despite the gradual decrease of its rate, peritonitis remains frequent in our center and calls for optimization of means of prevention. The high frequency of negative culture IP in our study urges us toward better collaboration with biologists to target antibiotic therapy and improve IP management.

Viral hepatitis C and B among dialysis patients at the Rabat University Hospital: prevalence and risk factors.

The aim of this study is to investigate the prevalence of hepatitis C virus (HCV) and hepatitis B virus (HBV) in maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis patients at the Rabat University Hospital and to identify the major risk factors for transmission. A retrospective study was performed in 67 chronic HD and 36 peritoneal dialysis patients. For the screening of viral infections, we tested for anti-HCV antibodies and HBs antigen (Hbs Ag). We compared infected and non-infected patients in order to determine the risk factors for contamination. In the HD unit, the prevalence of anti-HCV was 60% and the prevalence of HBs Ag was 6%. Duration of dialysis (P = 0.001) was the only risk factor in our HD patients. In peritoneal dialysis (PD), the prevalence of anti-HCV was 8%. Hbs Ag was detected in 2.6% of our PD patients. Viral hepatitis C is the main viral infection in our HD unit. The duration of dialysis is the main risk factor for infection in our study. The transmission is essentially nosocomial, requiring a strict adherence to infection control procedures.

Features and outcomes of lupus nephritis in Morocco: analysis of 114 patients.

BACKGROUND: There is wide variation in clinical presentation and outcome of lupus nephritis (LN) among different ethnic groups. Few data for LN exist on North Africans, especially those from Morocco. The aim of our study was to review retrospectively the features and outcome of LN in Moroccan patients. PATIENTS AND METHODS: We performed a single-center retrospective study. A total of 114 patients with LN were included. All patients met American Rheumatism Association criteria. LN was classified according to the International Society of Nephrology/Renal Pathology Society classification. We adopted previously defined outcome criteria for LN. RESULTS: There were 101 females and 13 males, with a mean age of 29.9 years. At first presentation, we noted hypertension in 33%, hematuria in 76%, nephrotic syndrome in 53%, and renal failure in 60% of cases. Renal biopsy revealed predominant proliferative classes in more than 80% of patients. Patients received different regimens mainly based on intravenous cyclophosphamide. After a mean follow-up of 22 months, remission occurred in 45.5%, relapses in 82%, end-stage renal failure in 21%, and death in 16% of cases. Infection and neurological and cardiovascular diseases were the most frequent causes of death. CONCLUSION: LN seems to be severe in our study, with a predominance of proliferative forms, severe renal manifestations, and poor renal and overall survival.