Cutaneous manifestations in patients with end-stage renal disease on hemodialysis.

Background: End-stage renal disease (ESRD) is a serious chronic disease that affects many organ systems. Skin manifestations that are commonly seen in ESRD can significantly impair the quality of life in these patients. Early recognition and management of mucocutaneous disorders can improve quality of life and decrease morbidity. This study aimed to evaluate the skin manifestations in ESRD patients undergoing hemodialysis. Methods: In this cross-sectional study 150 patients undergoing hemodialysis in the Nephrology Department of Shahid-Beheshti Hospital in Babol were enrolled. The demographic and clinical data were assessed. Analysis was done by SPSS 22 and significance level was under 0.05. Results: The mean duration of hemodialysis was 8.7 months. The most common skin findings in patients include xerosis 84.7%, pallor 82.7%, pruritus 67.3%, hyperpigmentation 40%, purpura 28%. Skin infections were detected in 36% of patients (fungal 28%, bacterial 10.7%, and viral 5.3%). Nail, hair and mucosal changes were observed among 65.3%, 38% and 17.3% of patients respectively. No significant correlation was detected between skin findings and duration of dialysis. Conclusion: The findings of the present study showed that skin manifestations are highly prevalent among patients with ESRD. Prompt diagnosis and management of the dermatological disorders may improve the quality of life in the affected patients.

Modeling Factors Associated with Dialysis Adequacy Using Longitudinal Data Analysis: Generalized Estimating Equation Versus Quadratic Inference Function.

BACKGROUND: In hemodialysis patients, changes in dialysis adequacy (DA) are examined longitudinally. The aim of this study was to determine factors affecting DA using the generalized estimating equation (GEE) and to compare them with the quadratic inference function (QIF). STUDY DESIGN: A longitudinal study. METHODS: This longitudinal study examined the records of 153 end-stage renal disease (ESRD) patients. The longitudinal data on the DA and baseline demographic and clinical characteristics were obtained from patients' files. The GEE1, GEE2, and QIF models were fitted with different correlation structures, and then the best correlation structure was selected using the quasi-likelihood information criterion (QIC), Akaike information criterion (AIC), and Bayes information criterion (BIC) fitting criteria. RESULTS: The majority of patients (59.5%) had unfavorable DA (KT/V<1.2). Women and patients<60 years had more favorable DA. In the GEE model, the coefficients of female gender (ß=0.079, 95% confidence interval [CI]: 0.032, 0.062), age at starting dialysis (ß=-0.002, 95% CI: -0.004, -0.0001), hypertension (HTN, ß=-0.055, 95% CI: -0.007, -0.103), diabetes (ß=-0.088,95% CI: -0.021, -0.155), dialysis duration (ß=0.132, 95% CI: 0.085, 0.178), and weight (ß=-0.004, 95% CI: -0.006, -0.003) demonstrated a significant relationship with DA. The three models resulted in a similar estimate of regression coefficients. The relative efficiencies of QIF versus GEE1, QIF versus GEE2, and GEE2 versus GEE1 were 1.175, 1.056, and 1.113, respectively. CONCLUSION: DA is not optimal in most hemodialysis patients, and gender, age at the start of dialysis, HTN, diabetes, dialysis duration, and weight had a significant association with DA. The three different models yielded quite similar coefficient estimates, but the QIF model resulted more efficient than GEE1 and GEE2.

Relationship between fatigue and quality of life and related factors in family caregivers of patients on hemodialysis.

BACKGROUND: The incessant and stressful nature of providing care to patients with chronic diseases can cause fatigue in caregivers. Caregivers' fatigue and reduced quality of life can reduce the patient's quality of care. Since it is important to pay attention to the mental health of family caregivers, this study investigated the relationship between fatigue and quality of life and their related factors in family caregivers of patients on hemodialysis. METHODS: This cross-sectional descriptive-analytical study was performed in 2020-2021. One hundred seventy family caregivers were recruited by convenience sampling from two hemodialysis referral centers in the east of Mazandaran province, Iran. The data collection tools were the Family Caregiver Quality of Life questionnaire and Krupp's fatigue severity scale. RESULTS: The majority (88%) of caregivers had moderate to severe fatigue. Caregivers' fatigue was a major factor influencing their quality of life. There was a significant fatigue difference between some categories of kinship and the caregiver's income level (P < 0.05). Caregivers with lower income and education levels, those who were the patient's spouse, and those who could not leave the patient alone had significantly worse quality of life than other caregivers (P < 0.05). Also, caregivers living with the patient in the same house had a worse quality of life than those living separately (P = 0.05). CONCLUSION: Considering the high prevalence of fatigue among family caregivers of patients on hemodialysis and its adverse effect on their quality of life, it is recommended to perform routine screenings and implement fatigue alleviation interventions for these caregivers.

Increased frequency of CD39+CD73+ regulatory T cells and Deltex-1 gene expression level in kidney transplant recipients with excellent long-term graft function.

BACKGROUND: The ability of regulatory T cells (Tregs) to limit inflammatory responses has been demonstrated. However, different subpopulations of this cell have varying abilities to suppress alloreactive immune responses. The primary goal of this study was to assess the frequency of CD4+FOXP3+CD39+CD73+ Tregs and Deltex-1 gene expression on long-term renal transplant function. METHODS: A total of 49 subjects were divided into 3 groups: (i) the excellent long-term graft function (ELTGF) group, (ii) the chronic graft dysfunction (CGD) group, and (iii) the healthy control (HC) group. Following sample collection, peripheral blood mononuclear cells (PBMCs) were isolated, and the Deltex-1 gene expression level and the frequency of CD4+FOXP3+CD39+CD73+ Tregs were evaluated. RESULTS: The ELTGF group had more CD4+FOXP3+ Tregs than the CGD group, but the difference was not statistically significant (P = 0.07). However, the frequency of CD4+FOXP3+CD39+CD73+ Tregs and the ratio of these cells to total CD4+ lymphocytes significantly increased in the ELTGF group than in the CGD group (P = 0.04 and P = 0.02 respectively). In addition, the expression level of the Deltex-1 gene was significantly lower in the CGD group than in the other 2 groups (P = 0.01 and P = 0.04 respectively). CONCLUSIONS: Given the increased frequency of CD4+FOXP3+CD39+CD73+ Tregs and the expression level of the Deltex-1 gene in the ELTGF group, it appears that these factors probably improved function and long-term survival of the transplanted organ through the suppression of alloreactive responses and reduction of inflammation. In other words, one of the immunological mechanisms involved in the CGD group may be a deficiency in Tregs.

Ten-year incidence of post-transplant Diabetes Mellitus in renal transplant patients.

BACKGROUND: Kidney transplantation is the treatment of choice for renal failure. Development of New-Onset Diabetes After Transplantation (NODAT) significantly increases kidney graft loss and mortality. This study aimed to evaluate the 10-years prevalence of NODAT in renal transplant patients. METHODS: In this cross-sectional study, medical records of non-diabetic patients undergoing kidney transplant in Shahid-Beheshti Hospital of Babol, between March 2009-2019 were retrospectively reviewed. RESULTS: Totally 284 patients with the mean age of 40.83 ± 12.94 years were included. New-Onset Diabetes After Transplantation was identified in 57 (20.1%) patients and 92.98% developed NODAT during the first month after transplantation. New-Onset Diabetes After Transplantation and non-NODAT patients were 43.8% and 34.38% female. Graft rejection occurred in 18 (31%) of NODAT and 78 (34%) of non-NODAT patients (p = .69). Patients with NODAT were about 10 years older (47.88 ± 11.06 vs 38.96 ± 13.12 years; p = .002). The pre-transplant Fasting Blood Sugar (FBS) was higher in the NODAT group (93.78 ± 13.78 vs 87.07 ± 11.56, p = .001) and post-transplantation cytomegalovirus (CMV) infection was higher in NODAT group (56% vs 40%, p = .021). New-Onset Diabetes After Transplantation patients had significantly higher BMI (27.16 ± 5.39 vs 23.94 ± 4.71, p < .001). CONCLUSION: New-Onset Diabetes After Transplantation is more prevalent in subjects with older age, higher BMI, post-transplant CMV infection, and higher pre-transplant FBS but gender, pre-transplant CMV infection, type of dialysis and smoking were not associated with it. So, these patients should be followed-up more diligently.

Rare case of aspergillus brain abscess in an immunocompromised patient.

We present a case of aspergillus brain abscess in a 48-year-old woman with a history of kidney transplantation and no underlying central nervous system (CNS) disease. Follow-up of the patient for 4 years shows normal findings. Early diagnosis and aggressive treatment could improve the prognosis of this fatal complication.

Increased frequency of activated regulatory T cells in patients with lupus nephritis.

BACKGROUND AND OBJECTIVE: Lupus nephritis (LN) is one of the common manifestations of systemic lupus erythematosus (SLE), affecting the quality of life of patients. Abnormality in the adaptive immune response, such as T cell response, plays the main role in the pathogenesis of SLE and LN. In this study, we aimed to evaluate the role of different subpopulations of regulatory T cells (Tregs) and effector T cells (Teff) in LN patients and compare them with SLE patients. MATERIALS AND METHODS: A total of 48 participants were enrolled in this study and divided into 3 groups: (i) patients with SLE; (ii) patients with LN; and (iii) healthy controls (HCs). The frequencies of CD4+ CD25++ CD45RA- Foxp3hi activated Tregs (aTregs), CD4+ CD25+ CD45RA+ Foxp3lo resting Tregs (rTregs), CD4+ CD25+ CD45RA- Foxp3lo non-Tregs, CD4+ CD25+ Foxp3- Teff, and Tregs were analyzed in all subjects using a flow cytometer. RESULTS: LN patients had a significantly increased frequency of aTregs and Tregs compared with SLE patients (standardized mean difference [SMD] = 0.50; 95% CI [-0.26, 1.25]; p > 0.05 and SMD = 0.60; 95% CI [-0.16, 1.36]; p > 0.05, respectively). Patients with LN had a significantly increased frequency of Teff compared with SLE patients (SMD = 0.49; 95% CI [-0.26, 1.24]; p > 0.05). However, an increased ratio of Tregs/Teff was observed in LN patients compared with SLE patients (SMD = -0.25; 95% CI [-0.97, 0.48]; p > 0.05). CONCLUSION: Patients with LN showed immunoregulatory properties, in which both aTregs and Tregs had increased frequencies.

ß-Thalassemia minor & renal tubular dysfunction: is there any association?

OBJECTIVE: Beta(ß)-thalassemia is one of the most common hereditary hematologic disorders. Patients with thalassemia minor (TM) are often asymptomatic and the rate of renal dysfunction is unknown in these patients. Due to the high prevalence of renal dysfunction in Iran, the current study aimed to determine renal tubular dysfunction in patients with beta-TM. METHODS: In this case-control study, 40 patients with TM and 20 healthy subjects were enrolled and urinary and blood biochemical analysis was done on their samples. Renal tubular function indices were determined and compared in both groups. Data was analyzed by SPSS software, version 20.0. RESULTS: The fraction excretion (FE) of uric acid was 8.31 ± 3.98% in the case and 6.2 ± 34.71% in the control group (p = 0.048). Also, FE of potassium was significantly higher in patients with TM (3.22 ± 3.13 vs. 1.91 ± 0.81; p = 0.036). The mean Plasma NGAL level was 133.78 ± 120.28 ng/mL in patients with thalassemia and 84.55 ± 45.50 ng/mL in the control group (p = 0.083). At least one parameter of tubular dysfunction was found in 45% of patients with thalassemia. CONCLUSION: Based on the results of this study, the prevalence of tubular dysfunction in beta-thalassemia minor patients is high. Due to the lack of knowledge of patients about this disorder, periodic evaluation of renal function in TM patients can prevent renal failure by early diagnosis.

Investigating the relationship between quality of life and hope in family caregivers of hemodialysis patients and related factors.

BACKGROUND: Family caregivers of hemodialysis patients are the first and most crucial source of care at home. They experience many problems in the care of hemodialysis patients, which can affect their quality of life and hope, affecting the quality of care provided to patients. This study aimed to determine the relationship between quality of life and hope in family caregivers of hemodialysis patients. METHODS: A cross-sectional (descriptive-analytical) study performed on 300 family caregivers in the east of Mazandaran province in Iran. Data were collected using the Family Caregiver Quality of Life (FQOL), SF8 and adult hope scale. Data analysis was performed in SPSS version 16, and a P-value of below 0.05 was considered statistically significant. RESULTS: The results showed that, there was a direct and significant relationship between hope and quality of life. However, the quality of life was significantly lower in suburban residents, the unemployed, spouses, people with lower education and income levels, caregivers who cannot leave their patients alone, those living with their patients in the same house, and those taking care of male patients, compared to other participants (P < 0.05). Suburban residents, the unemployed, people with an insufficient level of income, and those living with their patients in the same house had significantly lower hope, compared to other subjects. CONCLUSION: Since an increase of hope and quality of life of caregivers can cause improved quality of patient care, it is recommended that hope-based educational programs and interventions be implemented for caregivers.

Psychological consequences for family caregivers of patients receiving hemodialysis: threat or opportunity?

BACKGROUND: Family caregivers of patients receiving hemodialysis experience physical and psychological disorders. They are unfortunately neglected. The aim of this study was to explain the psychological consequences for family caregivers of patients receiving hemodialysis. METHODS: This qualitative inductive conventional content analysis research approach was conducted in Tehran, Iran. Nineteen hemodialysis patient caregivers were enrolled via purposive sampling. Data collection was conducted through in-depth and semi-structured interviews until reaching data saturation. All interviews were recorded, transcribed, imported into the Open Code Software, and analyzed using the Graneheim and Lundman methods. RESULTS: The results included two main categories: (1) threats to the psychological integrity; (2) development of capabilities. The first main category comprised the sub-categories of "care-related negative feelings and emotions," care-related stress and its behavioral impacts on care, "psychological disorders arising from care provision," and "impaired quality and quantity of sleep." The second main category comprised of the sub-categories of "care-related positive feelings and emotions" and "coping strategies." CONCLUSIONS: The present study showed that though caring for hemodialysis patients threatens the caregiver's psychological integrity, it provides the opportunity of development capabilities.

TIM-3 as a potential exhaustion marker in CD4+ T cells of COVID-19 patients.

BACKGROUND: COVID-19 causes a range of clinical symptoms from mild to critical and can be life-threatening. Up to now, it has led to many deaths. We aimed to evaluate exhausted markers on CD4+ T cells of COVID-19 patients. METHODS: In this study, we evaluated 44 patients with confirmed COVID-19 disease and 16 healthy individuals. Patients were divided into moderate/severe and critical groups. Peripheral blood mononuclear cells (PBMCs) were isolated and stained by anti-human CD39, PD-1, TIM-3, and anti-human CD4. The percentage of each CD4+  subpopulation was calculated by flow cytometry. Furthermore, we collected clinical information and laboratory data of both control and patient groups. RESULTS: We detected overexpression of TIM-3 on CD4+  T cells in both critical and moderate/severe patients than in healthy individuals (HIs; p < .01 and p < .0001, respectively). CD4+  TIM-3+ CD39+  lymphocytes were significantly higher in the critical patients than in HI (p < .05). Both Patient groups showed lymphopenia in comparison with HI, but CD4+  lymphocytes did not show any significant difference between study subjects. The increased amount of C-reactive protein, erythrocyte sedimentation rate, creatinine, blood urea nitrogen, and neutrophil count was observed in patients compared to HI. CONCLUSION: T cell exhaustion occurs during COVID-19 disease and TIM-3 is the most important exhausted marker on CD4+ T cells.

The Clinical Course and Prognostic Factors of COVID-19 in Patients with Chronic Kidney Disease, A Study in Six Centers.

INTRODUCTION: Coronavirus disease 19 (COVID-19), has recently emerged as a great health challenge. The novel corona virus may affect the kidneys mainly as acute kidney injury (AKI). Also, the outcome of COVID-19 may be different in patients with underlying kidney disease. The aim of this study was to compare the outcome of COVID-19 in patients with and without underlying kidney disease. METHODS: This was a retrospective study on 659 hospitalized COVID-19 patients in six centers of Iran. Patients were classified into kidney (chronic kidney disease (CKD), end-stage kidney disease (ESKD) or kidney transplantation) and non-kidney groups. The clinical conditions and laboratory data were extracted from the charts. Outcome was defined as death during hospitalization or within 30 days of discharge. RESULTS: Among 659 COVID-19 patients (mean age: 60.7 ± 16.4, 56% male), 208 were in the kidney group (86 ESKD, 35 kidney transplants, and 87 CKD patients). AKI occurred in 41.8%. Incidence of AKI was 34.7% in non-kidney, 74.7% in CKD, and 51.4% in kidney transplant patients (P < .001). Totally 178 patients (27%) died and mortality rate was significantly higher in CKD patients (50.6 vs. 23.4%, P < .001). AKI was associated with increased mortality rate (OR = 2.588, CI: 1.707 to 3.925). Initial glomerular filtration rate (GFR) < 44.2 mL/min and elevated lactate dehydrogenase (LDH) and C-reactive protein (CRP) had significant association with mortality. CONCLUSION: We showed a higher mortality rate in COVID-19 patients with AKI and CKD. Low initial GFR and elevated LDH and CRP were associated with high mortality in COVID-19 patients.

Effectiveness of extracorporeal blood purification (hemoadsorption) in patients with severe coronavirus disease 2019 (COVID-19).

BACKGROUND: Extracorporeal blood purification has been proposed as one of the therapeutic approaches in patients with coronavirus infection, because of its beneficial impact on elimination of inflammatory cytokines. METHODS: This controlled trial has been conducted on critically ill COVID-19 patients admitted in the state hospital affiliated to Babol University of Medical Sciences, Iran who received different antiviral and antibacterial drugs, and different modalities of respiratory treatments and did not have positive clinical improvement. No randomization and blindness was considered. All of the participants underwent three sessions of resin-directed hemoperfusion using continuous renal replacement therapy with a mode of continuous venovenous hemofiltration (CVVH). RESULTS: Five men and five women with a mean age of 57.30 ± 18.07 years have been enrolled in the study; and six of them have improved after the intervention. Peripheral capillary oxygen saturation (SpO2) changed after each session. Mean SpO2 before the three sessions of hemoperfusion was 89.60% ± 3.94% and increased to 92.13% ± 3.28% after them (p < 0.001). Serum IL-6 showed a reduction from 139.70 ± 105.62 to 72.06 ± 65.87 pg/mL (p = 0.073); and c-reactive protein decreased from 136.25 ± 84.39 to 78.25 ± 38.67 mg/L (P = 0.016). CONCLUSIONS: Extracorporeal hemoadsorption could improve the general condition in most of recruited patients with severe coronavirus disease; however, large prospective multicenter trials in carefully selected patients are needed to definitely evaluate the efficacy of hemoperfusion in COVID-19 patients. TRIAL REGISTRATION: The research protocol has been registered in the website of Iranian Registry of Clinical Trials with the reference number IRCT20150704023055N2 .

Designing and Validation of Health-Related Quality of Life Inventory for Family Caregivers of Hemodialysis Patients.

BACKGROUND: Family caregivers are important sources of care for hemodialysis patients. Although caring for a family member is a pleasant feeling, experiencing lots of physical and psychological caregiving burden influences the quality of life among family caregivers of hemodialysis patients. This study aimed to design and validate the quality of life inventory for family caregivers of patients on hemodialysis. METHODS: A sequential-exploratory mixed method was conducted in Tehran, Iran, in 2017-2018. In the qualitative phase, the researcher conducted in-depth semi-structured interviews with 19 participants. Finally, a pool of 93 items was extracted from this phase. Then, psychometric properties such as face validity (Impact Score>1.5), content validity ratio (CVR>0.63), content validity index (Item Content Validity Index: ICVI>0.78 , Scale Content Validity Index/Average: SCVI/Ave>0.8) and Kappa value (Kappa>0.7, internal consistency (Cronbach's alpha>0.7), relative reliability (ICC: interclass correlation coefficient), absolute reliability (Standard Error of Measurement: SEM and Minimal Detectable Changes: MDC), convergent validity (Correlation Coefficient between 0.4-0.7), interpretability, responsiveness, feasibility, and ceiling and floor effects were assesse. RESULTS: The quality of life inventory for family caregivers of hemodialysis patients was developed with 34 items and five factors (namely patient care burden, conflict, positive perception of situations, self-actualization, fear, and concern). The findings confirm that the scale is acceptable regarding validity, reliability and other measurement features. CONCLUSIONS: This inventory is consistent with the health care status in Iran. Therefore, it can be used to measure the quality of life among family caregivers of hemodialysis patients.

Reduced CD4+ CD25++ CD45RA- Foxp3hi activated regulatory T cells and its association with acute rejection in patients with kidney transplantation.

BACKGROUND: It was found that regulatory T cells (Tregs) importantly affect the maintenance of the kidney graft. However, Tregs are a heterogeneous population with less to more suppressive activity. The aim of this study was to determine the effects of different subsets of Tregs, as well as their ratio to effector T cells (Teff), on kidney transplantation outcomes. METHODS: A total of 58 participants were enrolled in this study and divided into four groups: (i) first kidney transplant recipients (stable 1); (ii) second kidney transplant recipients (stable 2); (iii) transplant recipients with acute rejection (AR); and (iv) healthy control subjects. By using flow cytometer, the frequencies of CD4+ CD25++ CD45RA- Foxp3hi activated Tregs (aTregs), CD4+ CD25+ CD45RA+ Foxp3lo resting Tregs (rTregs), CD4+ CD25+ CD45RA- Foxp3lo non-suppressive T cells, CD4+ CD25+ Foxp3- cells Teff, and total Tregs were analyzed in all subjects. RESULTS: The frequency of aTregs (as well as the ratio of aTregs/Tregs) was significantly lower in the AR patients than the other three groups. In contrast to AR patients, stables 1 and 2 had a higher aTreg/Treg ratio than those in the control group. Although patients with AR had a significantly lower total Tregs than the other three groups, the balance of total Tregs and Teff was similar between patients with and without AR. CONCLUSION: Patients with AR had poorer immunoregulatory properties than those with normal graft functioning, as well as those in the control group. These reduced immunoregulatory properties in patients with AR could lead to graft rejection.

Soluble CD30, the Immune Response, and Acute Rejection in Human Kidney Transplantation: A Systematic Review and Meta-Analysis.

Soluble CD30 (sCD30) is considered to be a marker for the activated immune system in which T cells can damage the allograft. Some studies reported that post-transplant sCD30 can predict early acute rejection and can thereby be used as a biomarker to detect acute rejection. However, several other studies found no relation between post-transplant sCD30 and acute rejection. This meta-analysis study aims to answer this main question of whether sCD30 can help clinicians to monitor transplant recipients. The electronic databases, including PubMed, Web of Science, ProQuest, Embase, Scopus, Google Scholar, the gray literature, and the key journals, were searched for observational studies from 1 January 1990 up to 30 April 2018. Eighteen studies, with a total of 1,453 patients, were included in this paper. With regard to the different measurement times, post-transplant sCD30 was separately analyzed and divided into five groups (i.e., 1, 2, 3, 4 week, and 1 month post-transplant sCD30). All groups indicated a strong association between sCD30 and the acute rejection. The standardized mean difference (SMD) is 1.22 in 1 week, 0.77 in 2 week, 1.11 in 3 week, 1.27 in 4 week, and 0.71 in 1 month groups. The association between sCD30 and acute rejection was consistent across all the subgroup analyses. We found that post-transplant sCD30 had a strong association with acute kidney rejection. We also found that the deceased donors had more association with the high amount of sCD30 than living donors in patients with acute rejection. Finally, we realized that donor type was an important factor leading to the heterogeneous results in the primary studies.

The role of immune response in initiation and progression of chronic kidney disease.

Chronic kidney disease (CKD) is a common disease in the world that has adverse outcomes.  Immune systems and its components have important roles in the initiation, progression and complications of this disease by systemic inflammation.  Regarding the role of kidneys in the body's natural homeostasis and its relationship with other organs, CKD causes impairments in other organs. Patients with chronic renal failure have variety of complications, such as cardiovascular disease, anemia, bone disorders, immune dysfunction and etc., which together culminate in the morbidity and mortality of these patients. Immune dysfunction is one of the most important and serious complications in CKD patients. These patients often suffer from immune suppression and are susceptible to some infections. In this review, we describe some major findings about interactions between the kidney and immune system in CKD.

Acute renal failure due to IgA nephropathy in sarcoidosis.

Sarcoidosis is a systemic disorder affecting multiple organs. We presented a 56-year-old woman with renal impairment who was diagnosed with sarcoidosis accompanied by IgA nephropathy. Treatment with methylprednisolone was started for the patient. After treatment, the patient was discharged with good general condition and resolved proteinuria.

Combination of different clinical reasoning tests in a national exam.

INTRODUCTION: Clinical reasoning as a critical and high level of clinical competency should be acquired during medical education, and medical educators should attempt to assess this ability in medical students. Nowadays, there are several ways to evaluate medical students' clinical reasoning ability in different countries worldwide. There are some well-known clinical reasoning tests such as Key Feature (KF), Clinical Reasoning Problem (CRP), Script Concordance Test (SCT), and Comprehensive Integrative Puzzle (CIP). Each of these tests has its advantages and disadvantages. In this study, we evaluated the reliability of combination of clinical reasoning tests SCT, KF, CIP, and CRP in one national exam and the correlation between the subtest scores of these tests together with the total score of the exam. METHODS: In this cross sectional study, a total number of 339 high ranked medical students from 60 medical schools in Iran participated in a national exam named "Medical Olympiad". The ninth Medical Olympiad was held in Shahid Beheshti University of Medical Sciences, Tehran, Iran, under the direct supervision of the Ministry of Health and Medical Education in summer 2017. The expert group designed a combination of four types of clinical reasoning tests to assess both analytical and non-analytical clinical reasoning. Mean scores of SCT, CRP, KF, and CIP were measured using descriptive statistics. Reliability was calculated for each test and the combination of tests using Cronbach's alpha. Spearman's correlation coefficient was used to evaluate the correlation between the score of each subtest and the total score. SPSS version 21 was used for data analysis and the level of significance was considered <0.05. RESULTS: The reliability of the combination of tests was 0.815. The reliability of KF was 0.81 and 0.76, 0.80, and 0.92 for SCT, CRP, and CIP, respectively. The mean total score was 169.921±41.54 from 240. All correlations between each clinical reasoning test and total score were significant (P<0.001). The highest correlation (0.887) was seen between CIP score and total score. CONCLUSION: The study showed that combining different clinical reasoning tests can be a reliable way of measuring this ability.

Measurement of serum irisin in the different stages of chronic kidney disease.

BACKGROUND: Irisin is a myokine that regulates energy metabolism by inducing browning of adipose tissue. The aim of this study was to evaluate the relationship between irisin level and biochemical parameters of chronic kidney disease (CKD) patients in stage 2 and stage 4. METHODS: The research was a cross-sectional study; the study population included patients with CKD who were over 18 years of age, included 90 individuals with CKD, of these participants, 45 were in the second stage of the CKD while the other 45 subjects were in the fourth stage. Serum irisin concentration plus the level of glucose (Glu), urea, creatinine (Cr) and hemoglobin (Hb) were measured. RESULTS: In the present study, the serum irisin level of patients in stage 4 was significantly reduced (13.00 ng / ml) compared with patients in stage 2(21.41 ng / ml). CONCLUSION: With the progression of CKD from stage 2 to stage 4, parameters such as serum Cr, TG, LDL, FBS, BUN and urea levels significantly increased. Inversely, factors such as irisin, GFR, Alb, HDL and Hb levels significantly decreased. These findings suggest that irisin may be involved in the regulation of biochemical factor levels in CKD patients through the progression from stage 2 to stage 4.