Fanconi syndrome induced by tenofovir: A case report.

Tenofovir disoproxil fumarate (TDF) is a nucleotide reverse transcriptase inhibitor discovered in the USA in 2001. It is currently the treatment of choice for patients co-infected with human immunodeficiency virus (HIV) and hepatitis B virus. Its antiretroviral efficacy and good tolerance are responsible for the higher frequency of prescriptions compared with other nucleoside analogs. However, it can induce acute renal toxicity causing impairment of the proximal tubular function of the kidney. This is highly dependent on factors such as associated co-prescription didanosine or a protease inhibitor "boosted" with ritonavir, preexisting renal insufficiency, low body weight, or presence of associated diabetes. In contrast, long-term renal toxicity remains highly debated. Some studies describe a decrease in estimated glomerular filtration rate during prolonged treatment with TDF. Others reported renal safety even during prolonged use. The differences between patients enrolled in the different studies, the measured parameters and their interpretation could explain these discrepancies. We describe a case of a patient infected with HIV, who presented with Fanconi syndrome with acute renal failure six months after starting antiretroviral treatment including tenofovir.

Profile of living related kidney donors: a single center experience.

The living related donor still represents the unique source for renal transplantation in Morocco. Since 1986, 127 living related potential donors have been evaluated and 100 patients have been transplanted at the Ibn Rochd UHC in Casablanca. We retrospectively studied the potential donors and determined their profile and the exclusion criteria. The mean age at the time of donation was 37 ± 11 years (range 18-66 years) and 60% of donors were women. The predominant sources of donors were sisters, brothers and mothers of recipients in 34%, 31% and 24% respectively. Forty three percent of them were married, 20% housewives and 17% unemployed. In addition, 37% were illiterate, 45% school graduates, and 18% university graduates. Donors and recipients were incomplete HLA match in 72.7%, identical in 19% and different in 8.3%. The cross matching test was negative in all cases. The mean plasma creatinine was 0.8 ± 0.1 mg/dL with mean creatinine clearance of 103.16 ± 18.18 mL/min.

[Kidney transplantation in a patient with haemophilia A]. / Transplantation rénale chez un patient hémophile A.

A 37-year-old patient with moderate haemophilia A and end-stage renal disease underwent kidney transplantation in the University Hospital Ibn Rochd of Casablanca (Morocco). He received factor VIII replacement therapy perioperatively and until the 21st day postoperation. So, the activity rates of Factor VIII was higher than or equal to 80 % in the day of intervention and two to three days later, then between 30 and 60 % until healing. The evolution of the patient to 28 months post-transplantation is marked by a good renal function without episode of rejection or bleeding complications. The heavy surgical interventions are possible in patients with haemophilia, but depend on good replacement therapy in peri- and postoperation.

[Surgical treatment of secondary hyperparathyroidism in chronic renal failure. Report of 57 cases]. / Traitement chirurgical de l'hyperparathyroidie secondaire des insuffisants renaux: a propos de 57 cas.

AIM: The aim of this study was to report the experience of the department of general surgery (Aile III) Ibn Rochd Hospital in surgical management of hyperparathyroidism in patients with end-stage renal disease (ESRD). METHODS: Fifty seven patients (24 M, 33F) with hyperparathyroidism underwent surgical parathyroidectomy from 1998 to 2004. Surgical indication was established according to clinical or biological assessment. Fifty nine operations were performed (57 first-hand cervicotomies and resumptions in too cases). RESULTS: Histological examination of parathyroid gland specimens disclosed adenoma in 33 patients and hyperplasia in 14 patients. The follow-up was normal in 52 patients, marqued by cervical hematoma in 2 cases and death was deplored in 4 patients. The post-operative calcium level was in the normal range in 43 cases, low comparatively to the baseline in 12 cases and high in 2 cases. The PTH levelwas normal in 55 patients and high in two patients. Long-term outcome was evaluated in 36 patients mean follow-up (18 months). A good evolution was noted in all patient referring to clinical, biological and radiological investigations. CONCLUSION: That, in our context, surgical parathyroidectomy still an appropriate approach for the treatment of hyperparathyroidism in patients with end-stage renal disease.

Comparison of prevention methods of intradialytic hypotension.

Our study evaluates the effectiveness of the different methods of prevention of intradialytic hypotension (IDH). We studied 16 hemodialysis patients who developed IDH at Ibn Rochd University Hospital. Each patient underwent three standard sessions with cellulose diacetate dialysers and bicarbonate dialysate with calcium concentration of 1.75 mmol/L and sodium (Na) concentration of 140 mmol/L, with dialysate temperature (T) of 37 degrees C. Then the patients were subjected to five successive sessions, each time using one of the following protocols: fixed Na dialysate concentration at 144 mmol/L, Na ramping from 152 to 138 mmol/L, one hour of ultrafiltration (UF) alone followed by three hours of standard dialysis session, dialysis with standard dialysate at T o C, or a combination of Na ramping and cold dialysate. Twelve (78%) patients underwent two sessions of HD per week of five hours each. The mean systolic blood pressure (SAP) in the interdialytic period was 110.7 (100.1-125.5) mmHg; two patients underwent anti-hypertensive treatment. The combination of ramping Na and cold dialysate as well as the cold dialysate were associated with fewer episodes of hypotension in comparison with the standard dialysate. We conclude that the combination modulation of Na and cold dialysate as well as the cold dialysate are the most effective techniques to decrease the number of IDH episodes and the average number of interventions.

Goodpasture's syndrome - four case reports.

Goodpasture's syndrome (GPS) is a rare but severe immunological disease, which is characterised by rapidly progressive glomerulonephritis and intraalveolar hemorrhage (IAH) with the presence of anti-glomerular basement membrane (GBM) antibodies. We report four cases of GP's syndrome referred to the nephrology unit at Ibn Rochd UHC in Casablanca from January 1995 to December 2003. All patients had rapidly progressive glomerulonephritis (RPGN) with proteinuria and microscopic hematuria. Elevated blood pressure was noted in one case. IAH was manifested as hemoptysis in two cases, radiological signs in three cases and confirmed by broncho-alveolar lavage in all cases. Laboratory assessment revealed anemia in all cases. Renal biopsy showed extracapillary glomerulonephritis with linear deposits of IgG along the GBM. Renal failure was severe and hemodialysis was required in all cases. All patients were treated with prednisone and cyclophosphamide and none recovered renal function. Two patients died due to severe lung hemorrhage.

A randomized trial of intermittent versus continuous oral alfacalcidol treatment of hyperparathyroidism in end-stage renal disease.

BACKGROUND: Secondary hyperparathyroidism, a major clinical problem in patients with chronic renal failure, develops in response to phosphate retention and impaired calcitriol [1,25-dihydroxyvitamin D3] synthesis. Vitamin D therapy, particularly alfacalcidol [1 alpha-hydroxyvitamin D3], has been shown to be effective in the treatment of secondary hyperparathyroidism. The aim of this study was to compare the effect of a 12-week course of continuous versus intermittent oral alfacalcidol therapy on parathyroid hormone suppression. PATIENTS AND METHODS: 34 patients were selected and randomly divided into 2 groups to receive either intermittent or continuous oral alfacalcidol. Baseline data were obtained on serum calcium, phosphorus, alkaline phosphatase and PTH. All but the PTH were monitored monthly. PTH levels were measured again until the end of the protocol. The intervention was 2 microg of alfacalcidol given after each dialysis session (intermittent group) or 1 microg given 6 days/week (continuous group). RESULTS: Serum calcium and phosphorus showed a tendency to increase from baseline levels in both groups. Mean PTH levels for both groups showed a progressive reduction over time during the study period. This decrement showed no significant difference with regard to the schedule of alfacalcidol administration when comparing the 2 groups. There also was no difference in the incidence of side effects--hypercalcemia and hyperphosphatemia--between the intermittent and continuous intervention. CONCLUSION: Feedback regulation of PTH with oral alfacalcidol therapy is efficient in the treatment of hyperparathyroidism. However, intermittent and continuous oral administration are equally effective in suppressing an elevated PTH level in hemodialysis patients, with similar safety margins.

Diabetic nephropathy in hemodialysis patients in casablanca.

Diabetes is the main cause of end-stage renal disease (ESRD) in the developed countries and its prevalence and incidence have been constantly increasing over the years. To determine the prevalence and profile of diabetic nephropathy in our ESRD population, we retrospectively studied 564 hemodialysis patients in ten dialysis units in Casablanca. The mean age was 49 +/-16.2 years. The diabetic nephropathy came at the third rank with a prevalence of 13.5% behind chronic glomerulonephritis (21.8%) and hypertensive nephropathy (14.7%). Almost 74% of our diabetics were type 2. From the time of diagnosis the type 2 diabetics reached the ESRD earlier than the type 1 diabetics with a mean period of 15.1 +/- 7 years and 18.8 +/- 5 years, respectively; however, the difference was not statistically significant. There was at least another microangiopathic complication in 95.4% of the patients and macroangiopathic complication in 82%. The median hemoglobin A1C in all patients was higher than normal value. We conclude that ESRD is a serious complication of diabetes, which is constantly increasing. The appropriate management of diabetes and a multidisciplinary approach are necessary to avoid it or at least delay its occurrence.

[Phototherapy and hemodialysis pruritus]. / Photothérapies et prurit des hémodialysés.

The renal failure-related pruritus is frequent (10-30%) and this frequency increases in dialysed patients (60-80%). Its physiopathology remains badly known. The prurit is variable in intensity and surface. It predominates on the forehead, the back and the forearms. The skin is normal on it presents non specific lesions. The best treatment would be the renal graft. When it can't be done, phototherapy represents a good therapeutic alternative. We report the experience of our patients from December 1993 to January 2002. The patients could benefit from a steady treatment and be well followed-up. The mean age of our patients was 51 years with a masculine predominance (12 men to 7 women). The mean duration of hemodialysis was 3 years and the one of prurit was 10 months. Between December 1993 and January 2001, UVB phototherapy with a spectrum was used in 14 cases. After this period a phototherapy with a narrow spectrum was used. The mean dose was 2 Joules with a number of sessions. Eventually, the total body irradiation with UVB was the most regularly effective therapy of the hemodialysed prurit. It allows an important reduction, which is a significant result in comparison with UVA irradiation.

[Sexual dysfunction among 78 Moroccan male hemodialysis patients: clinical and endocrine study]. / Troubles sexuels chez 78 hémodialysés chroniques marocains de sexe masculin: étude clinique et endocrinienne.

PURPOSE: To investigate the correlation between biochemical and endocrine variables with sexual disorders in 78 male patients on chronic hemodialysis at the Ibn Rochd University Hospital (Casablanca-Morocco). METHODS: Seventy-eight male hemodialysis patients with chronic renal failure were evaluated with regard to their sexual function. All patients answered a personal questionnaire on their sexual activity. Hormone (FSH, LH, prolactin, testosterone, and parathyroid hormone) and zinc and ferritin assays were also performed. RESULTS: The men reported erection (44.9%), libido (44.9%), ejaculation (26.8%), and orgasm (21.8%) disorders. Gynecomastia was observed in 17.9% of the patients. There was no correlation with weight nor the nature of the causal nephropathy nor with duration of dialysis. Levels of gonadotropins (FSH, LH), prolactin, and parathyroid hormone were elevated. Testosterone levels were low. Ferritinemia was elevated but there was no significant variation in zincemia. There was a negative curvilinear relationship between serum testosterone and sexual disorders, and between gynecomastia and ferritinemia. LH and prolactin levels were positively correlated with gynecomastia. CONCLUSION: Abnormal hormonal and iron overload could be important factors involved in the complex pathogenesis of sexual dysfunction in chronic renal failure patients undergoning hemodialysis.

[Extramembranous glomerulonephritis and myelodysplastic syndrome]. / Glomérulonéphrite extramembraneuse et syndrome myélodysplasique.

Membranous glomerulonephritis (MGN) is the main cause of nephrotic syndrome in adults and is usually idiopathic. We report a case of nephrotic MGN associated with a myelodysplastic syndrome (MDS) in a 43 year old man. The initial treatment consisted of oral corticosteroids (1 mg/kg/day). Within 3 months proteinuria decreased from 22.4 g/day to 3.96 g/day and the blood cell count was normalized. Renal biopsy disclosed type I MGN. Ponticelli's protocol was started with a favorable effect: negative proteinuria, normal blood cell count and normal bone marrow cellularity. The association between MGN and MDS is quite rate. The possible links between the two conditions are reviewed.

[Primary focal segmental glomerulosclerosis in adults: response to treatment and outcome]. / La hyalinose segmentaire et focale primitive de l'adulte: aspects thérapeutiques et evolutifs.

Response to therapy of primary focal segmental glomerulosclerosis (FSGS) in adults is poor, most studies demonstrated no response at all. We report our experience from a retrospective study about 22 adults patients. All patients presented proteinuria at admission with a nephrotic syndrome in 86 percent of cases. A high blood pressure was noted in 25 percent. A response to corticosteroid was obtained in 8 patients (36%) with complete remission in 5 cases (23%). Three patients were corticosteroid-dependant, two out of them went in remission under cyclophosphamide in one case and under chlorambucil in the other case. Fourteen patients did not respond to corticosteroids. Eight received cyclophosphamide with partial remission in 4 cases and progression to chronic renal failure (CRF) in 4 cases. The six non-responders did not receive immunosuppressive drugs because of severe CRF in 4 cases. The mean duration of follow-up was 39 months (20-55). The response to corticosteroid of primary FSGS in adults remain low (30%). The use of cyclophosphamide has improved the global remission to 50 percent.

[Hemodialysis-related pruritus. A study of 134 Moroccans ]. / Prurit des hémodialyses chroniques. Etude de 134 cas marocains.

The prevalence of pruritus varies from 60% to 90% in patients receiving hemodialysis. The aim to this study was to evaluate the frequency of pruritus and its characteristics among moroccan patients receiving hemodialysis. Pruritus related to primary skin disease or other identified cause than chronic renal failure was excluded. Biological parameters were compared between patients with pruritus and those without. Pruritus occurred in 74.4% of hemodialysis patients and concerned 66 men and 68 women, mean age 44.8 + 14 years. Duration of hemodialysis varied between 5 months to 10 years. Main characteristics of pruritus were a general pattern in 70%, moderate intensity in 50%, appearance after dialysis in 81.2% and severe psychologic repercussion in 20.8%. Antihistamines first-line treatment was rarely effective. UVB radiation used in 7 cases leaded to a marked improvement. This study underlined the high frequency of pruritus in moroccan patients with chronic renal failure on maintenance hemodialysis. Hemodialysis can initiate this symptom as well as improve it. Biological parameters were not different between patients with or without pruritus. It also pointed out on therapeutic challenges. However, UVB radiation seems to be an effective therapy in intractable itching as well as increased frequency of weekly courses of hemodialysis. Long term skin hydratation should be also highly recommended.

[Ossifying fibroma of the face and hyperparathyroidism in a chronic hemodialysis patient]. / Fibrome ossifiant de la face et hyperparathyroïdie chez une hémodialysée chronique.

The bony complications in secondary hyperparathyroidism in chronic renal failure are varied. The ossifying fibroma is a rare manifestation. We report a case of a 40 years old woman with indeterminate nephropathy undergoing hemodialysis since 1982. Since may 1995, the patient had a diffuse and intensive bone pain of the two inferior members inducing functional importance with apparition of endobuccal tumefaction in the hard palate with an important increase of the volume of the maxillo-mandibular complex six months later associated to disturbances of the deglutition and phonation. In december 1995, the serum parathyroid hormone level is measured at 1527.6 pg/ml and the serum alkaline phosphatase level at 1620 UI/l. The bony lesions are disseminated to all the skeleton in the form of a demineralization with an ossifying expansive process affecting the maxillo-mandibular complex. Calcemia was at 2.3 mmol/l and phosphoremia at 2.1 mmol/l. The surgical biopsy of this pseudotumor showed an aspect of ossifying fibroma. The cervical echography showed a left inferior parathyroid nodular. In june 1996, a subtotal parathyroidectomy was done. The 9th day after surgery, the serum parathyroid hormone level was at 103 pg/ml with normal calcemia and phosphoremia. Five years later, the volume of the tumor reduced moderately. This observation induces 3 commentaries: the bony manifestations associated to secondary hyperparathyroidism have sometimes a tumoral aspect, the ossifying fibroma may be for known as well as the brown tumor and the treatment of these tumors in complex justifying furthermore a rigorous prevention of the hyperparathyroidism in hemodialyzed patients.

[Renal involvement in Behçet's disease. About six cases]. / L'atteinte rénale au cours de la maladie de Behçet. A propos de six observations.

PURPOSE: To analyze anatomoclinic and evolutive aspects of the renal involvement associated to the Behçet's disease through 6 observations collected in the nephrology department from 1985 to 2000 and to make a review of the literature. METHODS: Retrospective study, diagnosis of Behçet's disease according to the Classification of the International Group Study on the Behçet's disease and renal damage confirmed by histology. RESULTS: Our patients all male are aged between 25 to 55 years with a mean at 34 years old. The renal damage was revelated by a nephrotic syndrome in 3 cases and by a proteinuria at 1 to 2.7 g/day in 3 cases. Microscopic hematuria was present in 2 cases and arterial hypertension in 2 cases. The renal insufficiency has been noted in 2 cases of which severe in one of them. The renal biopsy showed an amyloidosis AA type in 3 cases, a segmental and focal glomerulonephritis in 2 cases and a thrombotic microangiopathy associated to a moderate tubulo-interstitiel lesions by toxicity of ciclosporine in 1 case. The extrarenal signs were dominated by bipolar aphtosis in all cases, necrotic pseudofolliculitis and the no specific cutaneous hyperreactivity in 5 cases and the erythema nodosum in 1 case. The ocular manifestation has been noted in 4 cases and articular manifestation in 3 cases. The vascular manifestation has been noted in one case. The treatment was colchicine in 4 cases and prednisone and cyclophosphamide in 1 case. Three patients were lost of view and a patient died in hemodialysis. The 2 other patients with amylosis had persistent proteinuria with a normal renal function. CONCLUSION: The kidney is one of organs that can alter the prognosis of the Behçet's disease; so, its screening must be realised in each patient with this disease.

[Surgical complications of nephrectomy in living donors]. / Les complications chirurgicales de la néphrectomie chez le donneur vivant.

Renal transplantation from a living donor is now considered the best treatment for chronic renal failure. We reviewed the operative complications in 38 living related donor nephrectomies performed at our institution over the past 14 years. The mean age of our donors was 30 years old with age range between 18 and 58 years old and female predominance (55.2%). These swabs were realized by a posterolateral lumbar lombotomy with resection of the 11 third. The left kidney was removed in 34 donors (90%), surgical complications were noted in 39.4% of the cases: one case of wound of inferior vena cava (2.6%), one case of release of the renal artery clamp (2.6%), four cases of pleural grap (10.5%), one case of pneumothorax (2.6%), one case of pleurisy (2.6%), three cases of urinary infection (7.8%), three cases of parietal infection (7.8%) and one case of patient pain at the level of the wound (2.6%). There were no mortalities. We conclude that the morbidity of living donor nephrectomy is negligible compared with the advantages for the recipient.