Mucocutaneous Manifestations in Kidney Transplant Patients: Risk Factors.

Introduction Mucocutaneous complications in kidney transplant patients are due to drug toxicity or immunosuppression. The main objective of our study was to determine the risk factors associated with their occurrence. Methods We conducted a prospective analytical study (January 2020- June 2021) including kidney transplant patients seen at the Nephrology Department. We described the characteristics of the patients who presented mucocutaneous complications and then compared them to those who didn't to deduce the risk factors. Statistical analysis was performed using SPSS 20.0 (p<0.05). Results Of the 86 patients recruited, thirty patients had mucocutaneous complications. The mean age was 42.73, with a male predominance (73%). Ten kidney transplants were performed from a living-related donor. All the patients received corticosteroids, Mycophenolate Mofetil, and the Calcineurin Inhibitor: Tacrolimus (76.7%) or Ciclosporin (23.3%). Induction was performed with Thymoglobulin (n=20) or Basiliximab (n=10). Mucocutaneous complications were dominated by infectious manifestations (53.4%): eight cases of fungal infections; six cases of viral infections: warts (n=3), herpes labialis (n=2), intercostal herpes zoster (n=1), and two cases of bacterial infections: atypical mycobacteria and boils. Inflammatory complications (36.6%) included acne (n=4), urticaria (n=3), rosacea (n=1), simple maculopapular exanthema (n=1), aphthous lesion (n=1), and black hairy tongue (n=1). Actinic keratosis, skin xerosis, and bruises were found in one patient respectively. The evolution with a symptomatic treatment was good in all the patients. After statistical analysis, the factors significantly associated with the occurrence of mucocutaneous complications were advanced age, male gender, anemia, HLA non-identical donor, as well as the use of Tacrolimus or Thymoglobulin. Conclusion Infectious mucocutaneous complications are the most common dermatological manifestations among renal transplant recipients. Their occurrence is related to advanced age, male gender, anemia, HLA non-identical donor, and the use of Tacrolimus or Thymoglobulin.

Carbon footprint of a hemodialysis unit in Morocco.

Climate changes have a major influence on the overall health of the population. They are directly linked to the emissions of the greenhouse gases (GHG). The extent of GHG emission in relation to hemodialysis has been measured by several studies all over the world. Up to this date, no similar study has been conducted in Morocco. Therefore, the objective of our study is to conduct a review of the GHG emissions and to evaluate its specificities in order to establish a targeted action plan to reduce the ecological impact of hemodialysis in Morocco. To do this, we sought the help of a certified audit firm. Carbon Footprint tool (L'outil Bilan Carbon), established in Morocco in collaboration with Mohammed VI Foundation for the Protection of the Environment, was used to analyze the results collected for the year 2019. Our unit (conventional hemodialysis 3 × 4 hours, 424 m2 , 24 generators, 80 patients, and 29 nursing staff) generates 408.98 tonnes of CO2 equivalent per year (t CO2-eq per year) or 5.11 TeqCO2 per patient per year. The largest contributors to GHG emissions are electrical energy consumption (28%), equipment purchase and services (27%), and staff and patients travel (22%). The use of renewable energy for the operation of hemodialysis centers can be a realistic solution to reduce the ecological impact of this type of healthcare in Morocco.

Management of pain at arteriovenous fistula puncture: Cryotherapy versus lidocaine/prilocaine.

Pain at arteriovenous fistula (AVF) puncture is common in hemodialysis (HD) patients. The purpose of our work is to determine its frequency, to evaluate the efficiency of two techniques: anesthetic cream (Emla™) and cryotherapy, and to compare their efficiency. A prospective and interventional analytical study of HD patients was conducted in our structure. We included all patients with pain at AVF puncture. We evaluated the pain intensity using a visual analogue scale before and after our intervention: Emla™ cream during three consecutive HD sessions, then cryotherapy (ice cubes placed in latex gloves, during 5 min, directly applied on the puncture sites) during three consecutive HD sessions. The statistical analysis was performed using the Epi Info software. Eighty-four patients are undergoing HD in our structure, of which 32 (38%) report pain at AVF puncture. The mean value of the visual analog scale before the puncture was 7.19 ± 1.95 (4-10). Pain decrease was statistically significant for both techniques. Comparative analysis of the two techniques revealed a significant reduction in pain in favor of cryotherapy (P 0.001). The analgesic effect has been proved for both techniques. Cryotherapy provides higher efficiency, with fewer constraints, and could be proposed for the management of pain at AVF puncture.

An unorthodox pathophysiology of severe cases of COVID-19 the weak heme hypothesis.

Important amount of severe cases is the main concern in COVID-19 pandemic. It could be the running cause of the burn out of the health system in many countries. The aim of this paper is to suggest a pathophysiologic hypothesis to explain the main characteristics of severe cases of COVID-19 and its underlying conditions. In fact, the clinical and biological picture of severe cases of COVID-19 can easily be explained by free heme toxicity exceeding the endogenous antioxidant systems. Severe cases of COVID-19 are comparable to acute porphyria. On the other hand, the geographical distribution of severe cases of COVID-19 is directly associated to how fresh or polluted the air is. Finally, the relatively low rate of severe cases of COVID-19 could be explained by the presence of an unstable hemoglobin variant highly sensitive to the intrinsic conditions resulting from the acute pneumonia secondary to SARS-CoV2 infection. The combination of air pollution and free heme toxicity, resulting from the interaction between an unstable hemoglobin variant and SARS-CoV2 infection, seems to be the best scheme to explain clinical and biological manifestations in severe COVID-19. The arguments to support this hypothesis are detailed. We also propose some strategies to verify the concordance of our hypothesis with the reality and the implications it could have, if verified, either for scientists and decision makers.

Autodialysis in Morocco: how much longer can we wait?

INTRODUCTION: Autodialysis is the dialysis performed by the patient himself at a local center instead of a hemodialysis center. In Morocco, the practice of hemodialysis dates back to 1970; however, an autodialysis center does not yet exist. The objective was to assess the potential medical fitness and adherence of the patients to an autodialysis program. METHODS: Descriptive and analytical multicenter study conducted in March 2015 involving patients from of eight hemodialysis centers in Casablanca (Morocco). The study was conducted in two steps: 1) a transversal assessment of the medical potential to achieve autodialysis that included 556 patients; 2) a survey of the autodialysis membership that included 383 out of 556 patients who were deemed eligible for autodialysis. RESULTS: The average age was 54.63 ± 15.16 years; the average of hemodialysis duration was 85.9 ± 78.1 months. Diabetic nephropathy (22.7%) was the predominant cause of kidney disease. The assessment of medical potential to achieve autodialysis highlighted that almost all of the patients were in good condition (93%), independent (81%), and those without major comorbidities were less than 76 years old. Regarding the potential patients' adherence to autodialysis, among the 383 patients previously deemed suited for autodialysis, 293 (76.5%) responded favorably to the proposal of self-dialysis. CONCLUSION: The practice of hemodialysis should be implemented in a short time in Morocco because our patients' profile is perfectly suitable to this therapeutic method especially when they are young, in good general condition, autonomous, without major comorbidities, and willing to learn.

Why overestimate or underestimate chronic kidney disease when correct estimation is possible?

There is no doubt that the introduction of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 14 years ago, and their subsequent updates, have substantially contributed to the early detection of different stages of chronic kidney disease (CKD). Several recent studies from different parts of the world mention a CKD prevalence of 8-13%. However, some editorials and reviews have begun to describe the weaknesses of a substantial number of studies. Maremar (maladies rénales chroniques au Maroc) is a recently published prevalence study of CKD, hypertension, diabetes and obesity in a randomized, representative and high response rate (85%) sample of the adult population of Morocco that strictly applied the KDIGO guidelines. When adjusted to the actual adult population of Morocco (2015), a rather low prevalence of CKD (2.9%) was found. Several reasons for this low prevalence were identified; the tagine-like population pyramid of the Maremar population was a factor, but even more important were the confirmation of proteinuria found at first screening and the proof of chronicity of decreased estimated glomerular filtration rate (eGFR), eliminating false positive results. In addition, it was found that when an arbitrary single threshold of eGFR (<60 mL/min/1.73 m2) was used to classify CKD stages 3, 4 and 5, it lead to substantial 'overdiagnosis' (false positives) in the elderly (>55 years of age), particularly in those without proteinuria, haematuria or hypertension. It also resulted in a significant 'underdiagnosis' (false negatives) in younger individuals with an eGFR >60 mL/min/1.73 m2 and below the third percentile of their age-/gender-category. The use of the third percentile eGFR level as a cut-off, based on age-gender-specific reference values of eGFR, allows the detection of these false positives and negatives. There is an urgent need for additional quality studies of the prevalence of CKD using the recent KDIGO guidelines in the correct way, to avoid overestimation of the true disease state of CKD by ≥50% with potentially dramatic consequences.

[Valvular calcifications in a patient on hemodialysis in Morocco]. / Calcifications valvulaires chez l'hémodialysé au Maroc.

INTRODUCTION: Valvular calcifications are one of the major cardiovascular complications of hemodialysis because of its prevalence and its predictive indices of morbidity and mortality. There are many risk factors associated with these calcifications. Our study aims to evaluate both the prevalence of valvular calcifications in our patients on hemodialysis and their risk factors. METHODS: This was a single-center cross-sectional descriptive and analytical study of 111 adult patients who were on hemodialysis for more than 6 months at the hemodialysis center CHU Ibn Rushd, Casablanca and who underwent ETT during the year 2013. RESULTS: The average age of our patients was 44 ± 14 years. The average duration of hemodialysis was 146 ± 80 months. Average systolic blood pressure was 123 ± 23 mmHg and average diastolic blood pressure 72 ± 13 mmHg diastolic, average iPTH was 529 ± 460 pg/ml, mean serum calcium was 86 ± 10 mg/l and mean serum phosphate was 40 ± 15 mg/l. Mean CRP level was 11±19,8 mg/L. From the therapeutic point of view, 96% of patients were treated with calcium carbonate, 11% with 25 OH vitamin D, 55,5% with 1 hydroxy-vitamin D3. The prevalence of valvular calcification was 15% with aortic valve location in 41.2% and mitral valve location in 41.2%. In univariate analysis, only hemodialysis duration seems to be associated with the occurrence of calcifications and approaches marginal level of significance (p = 0.09). CONCLUSION: The prevalence of valvular calcification in our hemodialysis patients remains high even if it seems relatively low compared to the literature data. No known risk factor was significantly associated with these calcifications.

Chronic kidney disease, hypertension, diabetes, and obesity in the adult population of Morocco: how to avoid "over"- and "under"-diagnosis of CKD.

The prevalence of hypertension, diabetes, obesity, and chronic kidney disease (CKD) in an adult Arabic-Berber population was investigated according to 2012 KDIGO guidelines. A stratified, randomized, representative sample of 10,524 participants was obtained. Weight, height, blood pressure, proteinuria (dipstick), plasma creatinine, estimated glomerular filtration rate, and fasting glycemia were measured. Abnormal results were controlled within 2 weeks; eGFR was retested at 3, 6, and 12 months. The population adjusted prevalences were 16.7% hypertension, 23.2% obesity, 13.8% glycemia, 1.6% for eGFR under 60 ml/min/1.73 m(2) and confirmed proteinuria 1.9% and hematuria 3.4%. Adjusted prevalence of CKD was 5.1%; distribution over KDIGO stages: CKD1: 17.8%; CKD2: 17.2%; CKD3: 52.5% (3A: 40.2%; 3B: 12.3%); CKD4: 4.4%; CKD5: 7.2%. An eGFR distribution within the sex and age categories was constructed using the third percentile as threshold for decreased eGFR. A single threshold (under 60 ml/min/1.73 m(2)) eGFR classifying CKD3-5 leads to "overdiagnosis" of CKD3A in the elderly, overt "underdiagnosis" in younger individuals with eGFR over 60 ml/min/1.73 m(2), below the third percentile, and no proteinuria. By using the KDIGO guidelines in a correct way, "kidney damage" (confirmed proteinuria, hematuria) and the demonstration of chronicity of decreased eGFR <60 ml/min/1.73 m(2), combined with the third percentile as a cutoff for the normality of eGFR for age and sex, overcome false positives and negatives, substantially decrease CKD3A prevalence, and greatly increase the accuracy of identifying CKD.

Pulmonary hypertension: prevalence and risk factors.

INTRODUCTION: Pulmonary arterial hypertension (PAH), defined as a systolic pulmonary artery pressure above 35 mm Hg, is another vascular disease entity recently described in patients receiving hemodialysis. It is a major problem due to its high prevalence and morbidity and mortality. Its pathophysiological mechanism is just known and the strategies for its supported not yet defined. AIMS: To determine the prevalence of PAH in our hemodialysis patients and its risk factors. METHODOLOGY: Single center descriptive and analytical cross-sectional study, including 111 hemodialysis patients who had benefit from a trans-thoracic cardiac Doppler ultrasound during 2014. A value greater than or equal to 35 mm Hg is considered PAH and classified as follows: mild PAH (35 50 mm Hg), moderate PAH (50 70 mm Hg), and severe pulmonary hypertension (> 70 mm Hg). Patients with a high probability of secondary PAH, especially those with the following history: chronic obstructive pulmonary disease, pulmonary embolism, were not included. RESULTS: The mean age was 44.3 ± 14.2 years. Among the 111 patients, 18 had pulmonary arterial pressure above 35 mm Hg corresponding to 16.22% of PAH prevalence. The average pressure was 45 mm Hg. Of these 18 patients, 11.8% had mild PAH, 3.4% moderate PAH and 0.8% severe PAH. The average hemodialysis duration was significantly associated with PAH (p = 0.003); as well as valvular calcification (p = 0.000), mitral regurgitation (p = 0.001) and tricuspid regurgitation (p = 0.002). CONCLUSION: Primary pulmonary hypertension is a major problem among our hemodialysis because of its high prevalence and its risk factors.

[Falls among hemodialysis patients: Incidence and risk factors]. / Chutes chez l'hémodialysé : incidence et facteurs de risque.

Falls and mineral and bones disorders are both implicated in the occurrence of pathological fractures in patients undergoing chronic dialysis. However, data on falls among this population are rare. We carried out a prospective study during four weeks and included 70 patients on chronic hemodialysis with the main objectives being to evaluate the incidence of falls and factors related to it. At the end of the four weeks, 16 patients (22.86%) fell at least once, with a total of 17 falls during 4 weeks, giving an incidence of 3.2 falls per patient/year. The mean age was 40 ± 16 years. Five patients (31.2%) had a past history of pathological fractures. Ten patients (62.5%) presented intra- and post-dialysis hypotension, six (37.5%) was diagnosed of gait disorders and two (12.5%) had sensory deficit of the lower limbs. Six patients (37.5%) presented frailty. Hypotension (P=0.004), frailty (P=0.047) and sensory deficit (P=0.049) were significantly associated with the occurrence of falls. The incidence of falls is relatively high in our hemodialysis patients and real risk factors exist. Hence, it is important to implement programs for falls prevention to reduce their incidence and impact.

Thrombotic thrombocytopenic purpura and systemic lupus erythematosus: a rare and life-threatening association.

INTRODUCTION: The association between thrombotic thrombocytopenic purpura (TTP) and systemic lupus erythematosus (SLE) is uncommon. Diagnosis is often difficult because of their clinical and biological similarities. The presence of TTP in SLE worsens the prognosis and causes high mortality in the absence of early therapeutic interventions. CASE REPORT: We report the case of a 20 year-old man, admitted with nephrotic range proteinuria, hematuria and rapidly progressive renal failure. He also had anemia, thrombocytopenia and pericardial effusion. The diagnosis of SLE was made based on these clinical findings along with positive antinuclear and anti dsDNA antibodies. Renal biopsy revealed class IV/ V lupus nephritis (LN) with active lesions of thrombotic microangiopathy. The evolution of neurological deficit, persistent thrombocytopenia and active microangiopathic changes suggested the diagnosis of associated TTP. The patient was treated initially with corticosteroids and cyclophosphamide. Plasmapheresis could only be started 16 days later. Mycophenolate mofetil and rituximab were successively tried in the absence of improvement in renal function and persistent thrombocytopenia. The patient's neurological condition deteriorated necessitating transfer to the intensive care unit and mechanical ventilation. There he developed pneumonia and died of septic shock two months after presentation. CONCLUSION: The coexistence of TTP and SLE needs to be considered early in SLE patients with complicated course. It may not respond to the conventional immunosuppressive treatment of SLE.

[Acute postinfectious glomerulonephritis]. / Glomérulonéphrites aiguës postinfectieuses.

Acute postinfectious glomerulonephritis are defined by an acute nonsuppurative inflammatory insult predominantly glomerular. Its current incidence is uncertain because of the frequency of subclinical forms. The most common infectious agent involved is beta hemolytic streptococcus group A. Acute postinfectious glomerulonephritis is uncommon in adults, and its incidence is progressively declining in developed countries. Humoral immunity plays a key role in the pathogenesis of kidney damage. Complement activation by the alternative pathway is the dominant mechanism, but a third way (lectin pathway) has been recently identified. The classic clinical presentation is sudden onset of acute nephritic syndrome after a free interval from a streptococcal infection. Treatment is essentially symptomatic and prevention is possible through improved hygiene and early treatment of infections.

Optimizing hypertension control in hemodialysis patients: a proposed management strategy.

OBJECTIVE: The purpose of the study was to assess the efficiency of a goal-oriented therapeutic strategy in lowering blood pressure and reducing the need for antihypertensive medications in 168 patients undergoing long-term hemodialysis. METHODS: Patients were managed initially by achieving optimal dry weight. After reduction of the dry weight, patients with uncontrolled arterial hypertension were dialyzed using a 1.25 mmol/L calcium concentration buffer. RESULTS: The predialysis mean arterial blood pressure (PDBP) was 127.4/74.2 mmHg for the total population. Fifty (29.76%) of the total study population were hypertensive. Of them, 88% (44 patients) were receiving antihypertensive drugs, while the others were not on such medications. Twenty patients (40% of the hypertensives) were receiving one antihypertensive drug, 17 (34%) were receiving two antihypertensive drugs, while 7 patients (14%) were receiving three or more drugs. There was a significant increase in the number of patients with good control of PDBP in the second data collection [45 patients (90%)] compared to the first data collection of 40 patients (80%). Similarly, there was a significant reduction in the number of patients with uncontrolled PDBP in the second data collection (5 patients (10%) compared to the first data collection of 10 patients (20%). The average blood pressure in the first data collection was 137.2/76.3 and 167.4/87.1 mmHg in the controlled and uncontrolled blood pressure groups respectively. In the second data collection, the average blood pressure was 136.4/75.1 and 161.6/86.3 mmHg in the controlled and uncontrolled groups respectively. CONCLUSION: Therapeutic approach using combination of dry weight reduction and dialysis with low calcium dialysate provides acceptable long-term results in patients with arterial hypertension and reduces the need for antihypertensive medication.

Heart valve calcifications in patients with end-stage renal disease: analysis for risk factors.

BACKGROUND: The prevalence of valve calcification (VC) in end-stage renal disease patients is high and information regarding risk factors is scarce. Our aims were to determine the prevalence of VC in our maintenance haemodialysis (HD) population and to examine some possible aetiologic factors for its occurrence. METHODS: We studied 90 patients (47 women) on maintenance HD for more than 12 months. An M-mode two-dimensional echocardiogram was carried out to evaluate mitral, aortic VC and ventricular geometry. We calculated mean daily calcium intake for the phosphate intestinal chelaing in the previous year to echocardiogram date and also mean values from previous year of Ca, PO4, Ca x PO4, parathyroid hormone, lipide profile, nutritional and inflammatory marquers. Finally consumption of calcium and alfacalcidol was also noted. RESULTS: Thirty-six patients (40%) presented with VC. Patients with VC were older and showed higher levels of serum calcium (92.00 +/- 7.54 vs 89.27 +/- 6.86 mg/L, P = 0.04), phosphorus (69.70 +/- 18.33 vs 44.90 +/- 12.43 mg/L, P < 0.0001), Ca x P product (6164.97 +/- 1797.64 vs 4024.70 +/- 1066.40 mg(2)/L(2), P < 0.0001) and poor ventricular geometry, as compared with patients without VC. Moreover, they required higher doses of alfacalcidol for treating secondary hyperparathyroidism (0.43 +/- 0.60 vs 0.11 +/- 0.46 microg/day, P < 0.0001). CONCLUSION: Findings of the present study are consistent with a role of altered calcium and phosphate metabolism in the pathogenesis of VC in HD patients.

Sexual dysfunction in male patients undergoing hemodialysis in morocco.

Sexual dysfunction impairs the quality of life of patients undergoing hemodialysis (HD). The aim of this study was to evaluate the prevalence and the nature of sexual dysfunction in a Moroccan cohort of patients with chronic renal failure (CRF) on HD. This cross-sectional study was carried out with a questionnaire in 86 patients undergoing hemodialysis. Clinical and biological investigations were done. The mean age of our patients was 46.27 +/- 15.68 years old. 81.4% of the cases suffered from a decrease in sexual activity after the onset of HD. The decrease or the loss of libido was noted in 59.3% of the cases. Total impotence was present in 22.1% of the cases and 36% reported partial impotence. Ejaculation was present in 86% of the cases. The comparison between the group of patients who had no sexual dysfunction (group I) and the group of those who had this problem (group II) showed significant differences of age, social status and sexual life before HD. Other significant differences were found regarding frequency of intercourses and sexual satisfaction. Group II was divided into 2 subgroups: IIA included patients who had sexual dysfunction before HD and IIB: those who developed it after. The comparison of this subgroups showed that differences were significant regarding age, weight and vascular risk factors (diabetes mellitus, atherosclerosis). Sildenafil was more efficient in the patients of the subgroup IIB. This study suggested that HD was one of many factors causing sexual dysfunction in hemodialysed patients. After this clinical evaluation of sexual dysfunction, we emphasize the value of a global approach of this problem. The use of sildenafil seems to be more valuable in young patients with erectile dysfunction which appeared after long dialysis duration.