End-stage renal disease at dialysis initiation: Epidemiology and mortality risks during the first year of hemodialysis.

Chronic kidney disease (CKD) treated by hemodialysis (HD) is a worldwide major public health problem. Its incidence is getting higher and higher, leading to an alarming social and economic impact. The survival of these patients is significantly low, especially during the first year of treatment. The purpose of our study was to identify the epidemiological and clinico-biological characteristics of patients at the HD initiation and to reveal the predictive factors of mortality at three months and one year of HD. This is a prospective, analytical, and descriptive study dealing with 229 patients with an end-stage renal disease (ESRD), followed up in the Nephrology Department of Charles Nicolle Hospital and La Rabta Hospital in Tunisia, that was started HD between January and June 2017. A multivariate logistic regression analysis allowed us to identify the independent predictors of mortality at three months and one year. The average age was 60.2 ± 15.3 years, with a gender ratio of 1.41. Seventy-eight percent of patients had more than two comorbidities, 59% had diabetes, and 88% had hypertension. Diabetic nephropathy was the leading etiology of kidney disease (48.9%), while 11% of nephropathies were of unknown etiology. Only 58% were early referred to a nephrologist. The average glomerular filtration rate at HD initiation was 6.06 ± 2.33 mL/min/1.73 m2. Hypocalcemia and hyperphosphatemia were noted, respectively, in 60.8% and 84.9% of cases. Anemia was objectified in 98.6% of cases. HD was started in an emergency in 56.8% of cases. One of the most urgent indications was acute pulmonary edema (APE) for 43.8% of patients. Only 10.5% of patients had functional arteriovenous fistula at the dialysis initiation. Patients were hemodialyzed one, two, or three sessions per week, respectively, in 23.2%, 26.6%, and 50.2% of cases. The crude mortality rate was 25% and 13% in, respectively, one year and three months of HD. On multivariate analysis, we identified heart failure and insufficient dialysis dose per week as predictive factors of mortality at the 1st year of HD. C-reactive protein more than 21 mg/L, insufficient dialysis per week, modified Charlson Comorbidity Index less than 6, and APE at the dialysis initiation were identified as predictive factors of three-month mortality. Despite the short period of study, this work revealed the alarming conditions of patients at HD initiation. This critical situation is due to the delay in CKD diagnosis, the late nephrologist referral, and the lack of preparation before HD initiation.

Urinary tract infections following renal transplantation: a single-center experience.

Urinary tract infection (UTI) is the most frequent infectious complication among renal transplant recipients and a frequent cause of bacteremia, sepsis and acute graft failure. To evaluate the incidence, risk factors, type of pathogens and long-term effect of UTIs on graft and patient survivals in our center, we performed a retrospective cohort study reviewing the medical records of patients who received a renal transplant at our center from June 1986 to December 2009, excluding patients who lost their grafts in the first month due to arterial or veins thrombosis and acute antibody-mediated rejection. We studied 393 kidney-transplanted recipients; at least one UTI occurred in 221 (53.69%) patients during the follow-up period. The most frequent pathogens isolated in urine culture were Escherichia coli (n = 39, 18.4%) and Klebsiella pneumonia (n = 31, 14.6%). When patients with UTIs were compared with those without UTIs, female gender and use of mycophenolate mofetil or azathioprine seemed to be risk factors for UTIs on univariate analysis. However, female gender was the only independent risk factor on multivariate analysis RR = 1.964 (1.202-3.207), P = 0.007. This study confirmed that UTIs remain a major problem in renal transplant recipients, and female gender was the only independent risk factor.

Short- and long-term outcomes of kidney donors: a report from Tunisia.

Kidney transplantation remains the best treatment option of end-stage renal disease. Kidney donations are of particular interest with the currently increasing practice of living-donor transplantation. The purpose of this study was to analyze retrospectively the general health status as well as renal and cardiovascular consequences of living-related kidney donation. A total of 549 living-related kidney donors had donated their kidneys between 1986 and 2007. We attempted to contact all donors to determine short- and long-term outcome following kidney donation. All kidney donors who responded underwent detailed clinical and biochemical evaluation. The data were compared with age-matched health tables of the Tunisian general population. In all, 284 donors (52%) had a complete evaluation. They included 117 men and 167 women with a mean age of 42 ± 12 years. The major peri-operative complications that occurred in these donors included four cases of pneumothorax, six cases of surgical site infection, one case of phlebitis and one case of pulmonary embolism. None of the study cases died. The median length of hospital stay after donor nephrectomy was 6.5 days (range: 3-28 days). The median follow-up period was eight years. The mean creatinine clearance after donation was 90.4 ± 25 mL/min in men and 81.5 ± 27.2 mL/min in women. Proteinuria was >300 mg/24 h in 17 cases (5.9%). Fifty-eight (20.4%) donors became hypertensive and 19.6% of the men and 37.2% of the women became obese. Diabetes mellitus developed in 24 (8.4%), and was more common in patients who had significant weight gain. Our study suggests that kidney donors have minimal adverse effects on overall health status. Regular follow-up identifies at-risk populations and potentially modifiable factors. Creation of a national registry of living donors and their monitoring are an absolute necessity.

The role of generics in kidney transplant: mycophenolate mofetil 500 versus mycophenolate: 2-year results.

OBJECTIVES: The introduction of mycophenolate mofetil has proven itself effective in preventing acute rejection in renal transplant recipients. However, this cost is ineffective with countries with a limited income. This study sought to compare the clinical and therapeutic profiles of a generic formulation with mycophenolate mofetil. MATERIALS AND METHODS: This 2-year, single-center, prospective, randomized, open-label study investigated the efficacy and safety of a new mycophenolate mofetil generic formulation compared with mycophenolate renal transplant recipients. The study divided patients in 2 groups: 8 patients in G1 received mycophenolate mofetil 500 and 10 patients in G2 received mycophenolate. Their demographics were similar: mean age, 36.6±7.1 and 33.3±11.7 years; sex M/F: 2/6 and 5/5; mean donor age, 42.6±11.1 and 43.6±13.9 years; mean HLA mismatches, 2.7±1.2 and 3.3±1.5; deceased donors, 25% and 20%; and warm ischemia time, 40.2±11.9 and 38.7±10.5 minutes. All patients received 2 g daily of mycophenolate mofetil 500 or mycophenolate with initial dosage of 0.1 mg/kg/d and prednisolone. RESULTS: One patient of 7 in the mycophenolate mofetil group and 4 of 6 in the mycophenolate group had 1 episode of acute tubular necrosis, and 1 patient in each group had an acute rejection with no significant differences between the groups. The area under the curve of the mycophenolate mofetil did not show any difference between the 2 groups. The values of serum creatinine were also comparable. Patient survival rate at 6, 12, and 24 months was 100% in the groups. The frequencies of digestive and hematologic adverse effects were comparable in the groups with no significant differences. CONCLUSIONS: Use of mycophenolate mofetil 500 provided safe and effective immunosuppressive therapy compared with mycophenolate. However, as the duration of the study was short, these results need to be confirmed in a long-term study.

Nodular glomerulosclerosis in patients' without history of diabetes mellitus: a case report.

INTRODUCTION: Diabetic nephropathy can occur during the course of both type1 and type 2 diabetes mellitus. The characteristic lesions are diffuse or nodular (Kimmelsteil-Wilson) diabetic glomerulosclerosis. The reported cases represent unusual presentations of diabetes mellitus. CASE PRESENTATION: We report the case of a 49-year-old man without prior history of diabetes mellitus who presented with rapidly progressive renal failure and whose renal biopsy revealed nodular (Kimmelsteil-Wilson) glomerulosclerosis lesions characteristic of diabetes. CONCLUSION: Renal manifestations of diabetes mellitus may antedate other more common presenting symptoms of this disease and we critically review the literature on this subject.

[Treatment of uremic patients by automated peritoneal dialysis: study of 78 cases]. / Prise en charge des patients urémiques en dialyse péritonéale automatisée : a propos de 78 cas.

BACKGROUND: Automated peritoneal dialysis has been increasingly used in recent years. The quality of life is improved in patients on automated peritoneal dialysis with more time for work, family and social activities compared to patients on continuous ambulatory peritoneal dialysis. AIM: We report our experience concerning patients on continuous ambulatory peritoneal dialysis. METHODS: From July 1997 to June 2003, we review retrospectively 78 patients with chronic renal failure treated by automated peritoneal dialysis. Tenckhoff catheter was used for all patients with 1 cuff in 39 cases (35.5%) and 2 cuffs in 71 cases (64.5%). RESULTS: There were 46 males and 32 females. Their mean age was 38.6 +/- 14.5 years. Their main nephropathies were glomerular in 23 patients (29.%), diabetic in 20 patients (25.6%) and vascular in 19 patients (24.4%). Among the 78 patients, 61 (78.2%) were autonomous while 17 (21.8%) were assisted by a member of their family. The mean period of therapy was 25.5 months (3 to 61 months). Peritonitis was the main complication, it was observed in 45 cases after a mean delay of 17 months (1 to 38 months). The mean rate of peritonitis was 36.5 months/patient. Their etiology was identified in 21 (46.7%) cases (8 septic manipulations of catheter and 13 tunnel infections). The principal organism isolated in peritoneal fluid were 18 gram-positive cocci (13 staphylococcus aureus, 4 coagulase-negative staphylococci, 1 streptococcus) and 10 gram-negative bacilli. The outcome of peritonitis was favourable in 39 cases (86.7%). The actuarial technique survival at 1, 3 and 5 years was respectively 94.6%, 80.1% et 49.3%. The actuarial patient survival at 1, 3 and 5 years was respectively 93.3%, 76.8% et 52.2%. At the end of the study, 43 patients (56.4%) left the automated peritoneal dialysis program: 22 (28.2%) were shifted to hemodialysis, 15 (19.3%) died, 6 (7.7%) were transplanted and 1 patient (1.3%) was shifted to continuous ambulatory peritoneal dialysis. CONCLUSION: Our experience concerning automated peritoneal dialysis is recent with a small number of patients. Our results were acceptable and we have to encourage and extend automated peritoneal dialysis to the most new patients with end-stage renal 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.

[Epidemiology of glomerular diseases in Tunisia from 1975 to 2005. Influence of changes in healthcare and society]. / Evolution du spectre des néphropathies glomérulaires en Tunisie de 1975 a 2005. Ses rapports avec l'évolution sanitaire et sociale.

Between April 1975 and March 2005, 4,436 cases of histologically proven glomerulonephritis (GN) were diagnosed by the same team at the Kidney Unit of Charles Nicolle Hospital in Tunis. Respectively 1,510, 1,419 and 1,509 cases were diagnosed in 1975-1985, 1985-1995, and 1995-2005. We compared trends in the incidence rates of the different types of GN and those of Tunisian indicators of health, social and economic status. The following differences were found between 1975-1985 and 1995-2005:--As a proportion of all cases of GN, the frequency of amyloidosis fell from 12,6 % to 6,5 % (p < 0,0001). The 444 cases of amyloidosis observed during the study period were of type AA in 87 % of cases, and were related to chronic infectious diseases in 239 cases (54 %; pulmonary tuberculosis in 114 cases). The frequency of tuberculosis-associated amyloidosis fell during the study period, in parallel with the reduction in the incidence of tuberculosis in the Tunisian population (48,7 cases/100,000 inhabitants in 1983 to 20,17 in 2004). Lupus nephritis accounted for 7.7 % of all cases of GN diagnosed in 1975-1985, compared to 13 % in 1995-2005 (p < 0,00001). Increased exposure to sunlight and use of cosmetics could be involved in this increase.--The incidence of both proliferative endocapillary and membranoproliferative GN (as a proportion of all cases of GN) fell between 1975-1985 and 1995-2005, from 15,9 % and 21,6 % to 6,9 % and 7,7 %, respectively (p < 0,0001). This matched a drop in the incidence of acute rheumatic fever in the Tunisian population, from 7,26/100,000 inhabitants in 1984 to 0,83 in 2004, probably as a result of public health measures and widespread use of antibiotics. The incidence of membranous GN increased from 11,1 to 17,7 % in adults (p < 0,001) whereas it fell from 10,1 to 4,6 % in children (p < 0,01), possibly as a result of a nationwide HBV vaccination program launched in 1995. The incidence of IgA nephropathy increased from 0,9 to 12,9 % in adults (p < 0,0001) and from 0,3 % to 18,4 % in children, but remained relatively stable in elderly adults. This study, conducted in a single center, by the same team, and using the same renal biopsy practices, confirms that the control of infectious diseases in Tunisia has led to a substantial regression of proliferative endocapillary and membranoproliferative GN and renal amyloidosis. Environmental factors, such as the adoption of western lifestyles, could explain the increase in lupus and IgA nephropathies.