Mortality due to bleeding, myocardial infarction and stroke in dialysis patients.

Essentials Mortality due to bleeding vs. arterial thrombosis in dialysis patients is unknown. We compared death causes of 201 918 dialysis patients with the general population. Dialysis was associated with increased mortality risks of bleeding and arterial thrombosis. Clinicians should be aware of the increased bleeding and thrombosis risks. SUMMARY: Background Dialysis has been associated with both bleeding and thrombotic events. However, there is limited information on bleeding as a cause of death versus arterial thrombosis as a cause of death. Objectives To investigate the occurrence of bleeding, myocardial infarction and stroke as causes of death in the dialysis population as compared with the general population. Methods We included 201 918 patients from 11 countries providing data to the ERA-EDTA Registry who started dialysis treatment between 1994 and 2011, and followed them for 3 years. Age-standardized and sex-standardized mortality rate ratios for bleeding, myocardial infarction and stroke as causes of death were calculated in dialysis patients as compared with the European general population. Associations between potential risk factors and these causes of death in dialysis patients were investigated by calculating hazard ratios (HRs) with 95% confidence intervals (CIs) by the use of Cox proportional-hazards regression. Results As compared with the general population, the age-standardized and sex-standardized mortality rate ratios in dialysis patients were 12.8 (95% CI 11.9-13.7) for bleeding as a cause of death (6.2 per 1000 person-years among dialysis patients versus 0.3 per 1000 person-years in the general population), 13.4 (95% CI 13.0-13.9) for myocardial infarction (22.5 versus 0.9 per 1000 person-years), and 12.4 (95% CI 11.9-12.9) for stroke (14.3 versus 0.7 per 1000 person-years). Conclusion Dialysis patients have highly increased risks of death caused by bleeding and arterial thrombosis as compared with the general population. Clinicians should be aware of the increased mortality risks caused by these conditions.

Crystalline Nephropathy in Renal Transplant: A Series of 4 Cases.

Crystals are particles of endogenous inorganic or organic composition that can trigger kidney injury when deposited or formed inside the kidney. The most common forms of crystalline nephropathies (CNs) are nephrocalcinosis and oxalate nephropathy. The causes of early allograft dysfunction are changing constantly, and recently calcium oxalate (CaOx) crystal deposition has been added to this list. CaOx deposition in renal allograft is important and probably under-recognized cause of delayed graft function that requires adequate awareness with early intervention to improve the allograft outcome. Here, we describe four cases of irreversible renal graft injury due to CNs.

Survival in dialysis patients is different between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition.

AIMS/HYPOTHESIS: A previous study in Dutch dialysis patients showed no survival difference between patients with diabetes as primary renal disease and those with diabetes as a co-morbid condition. As this was not in line with our hypothesis, we aimed to verify these results in a larger international cohort of dialysis patients. METHODS: For the present prospective study, we used data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry. Incident dialysis patients with data on co-morbidities (n = 15,419) were monitored until kidney transplantation, death or end of the study period (5 years). Cox regression was performed to compare survival for patients with diabetes as primary renal disease, patients with diabetes as a co-morbid condition and non-diabetic patients. RESULTS: Of the study population, 3,624 patients (24%) had diabetes as primary renal disease and 1,193 (11%) had diabetes as a co-morbid condition whereas the majority had no diabetes (n = 10,602). During follow-up, 7,584 (49%) patients died. In both groups of diabetic patients mortality was higher compared with the non-diabetic patients. Mortality was higher in patients with diabetes as primary renal disease than in patients with diabetes as a co-morbid condition, adjusted for age, sex, country and malignancy (HR 1.20, 95% CI 1.10, 1.30). An analysis stratified by dialysis modality yielded similar results. CONCLUSIONS/INTERPRETATION: Overall mortality was significantly higher in patients with diabetes as primary renal disease compared with those with diabetes as a co-morbid condition. This suggests that survival in diabetic dialysis patients is affected by the extent to which diabetes has induced organ damage.

Sirolimus for the treatment of Kaposi sarcoma after renal transplantation: a series of 10 cases.

The incidence of Kaposi sarcoma (KS) has substantially increased among immunocompromised patients, suggesting a role for immunosuppressive drugs. The aim of this study was to evaluate the incidence, features, and outcome of KS among 307 kidney transplantation patients at our center between January 1994 and June 2010. During the study period, the 10 patients who developed KS (3.25%) showed a mean age at transplantation of 35.8 ± 8.7 years (range, 22 to 49 years). The mean interval between transplantation and occurrence of KS was 24.7 ± 21.36 months (range, 6 to 64 months). The mean time of antithymocyte globulin induction was 9.5 days (range, 6 to 13 days). KS was restricted to the skin in 7 cases, among which, one presented with associated Hodgkin lymphoma. Visceral involvement (one lung and one colon) was observed in two cases. One patient presented with a gastric KS without skin lesions. Immunosuppressive treatment was reduced, then withdrawn in three cases, resulting in regression of KS a few weeks later, but with graft loss requiring hemodialysis at 1, 3 and 4 months. Among the remaining 7 cases, we stopped mycophenalate mofetil (MMF) and switched from calcineurin inhibitors to sirolimus. Allograft function remained stable after the switch. Only one patient who already had allograft dysfunction due to biopsy-proven chronic allograft nephropathy. Deteriorated progressively, undergoing hemodialysis at 2 years after KS diagnosis. In conclusion, we observed a relatively high incidence of KS among our cases. The introduction of sirolimus resulted in complete regression of KS lesions with preserved graft function.

Atypical presentation of a brown tumor in a kidney transplant recipient: a case report.

Brown tumor is a rare complication of secondary hyperparathyroidism. It is exceptionally encountered after kidney transplantation. We here report on a 54-year-old male recipient who developed a brown tumor localized in the right forearm, and whose initial presentation was atypical, mimicking a bone tumor. Hence, diagnosis of brown tumors should be suggested by clinicians in a context of hyperparathyroidism.

[Management of arterial hypertension in Tunisia: the challenge of a developing country]. / Prise en charge de l'hypertension artérielle en Tunisie: le défi d'un pays en voie de développement.

Tunisia is a north-African country where epidemiological and socio-economical transition lead cardio-metabolic diseases at the forefront of health concerns. Cardiovascular disease becomes the leading cause of death. Epidemiological studies noted that 30,6% of adults are hypertensive. Only 38,8% from those diagnosed with hypertension were aware about their disease. From those, 84% take antihypertensive treatment. Tunisian health authorities developed in 1993 a national program for diabetes and hypertension care. Hypertension benefits from a full support by the social security fund for policyholders and the state for the poor. Thus, hypertension followed by public health centers is controlled in 42.9% of cases.

[Microalbuminuria and left ventricular geometry in essential arterial hypertension]. / Microalbuminurie et geometrie ventriculaire gauche dans l'hypertension arterielle essentielle.

The association between left ventricular hypertrophy and microalbuminuria is actually admitted. Recent studies shown that patients with microalbuminuria have higher left ventricular mass index, worst systolic function and often concentric geometric kind of left ventricular hypertrophy. The efficiency of an adapted and early therapeutic on a potential relationship between reduction of microalbuminuria and improvement of target organ injury, principally heart and kidney, is still to evaluate. The aim of our study is to review geometric and hemodynamic aspect of left ventricular hypertrophy in hypertensive micro-albuminuria patients.

Risk genotypes and haplotypes of the GLUT1 gene for type 2 diabetic nephropathy in the Tunisian population.

OBJECTIVE: Diabetic nephropathy (DN) is a long-term complication of both type 1 and type 2 diabetes. Genetic studies on DN have been of little help so far, since several genetic association studies have shown conflicting results. Here we report the findings of a case-control study on five SNPs in the glucose transporter 1 (GLUT1) gene. The study investigated the association of five GLUT1 genotypes and haplotypes with DN. RESEARCH DESIGN AND METHODS: All subjects, 126 DN (cases) and 273 type 2 diabetes (controls), were genotyped using the polymerase chain reaction restriction fragment length polymorphism. RESULTS: The TT and the AA genotypes of the Haell and Enh2 SNP1, increased the risk of DN. The study also identified CGT as the highest risk haplotype (4.4-fold) followed by CAT with an increased risk of DN of 2.6-fold. CONCLUSIONS: The GLUT1 gene confers susceptibility to DN in type 2 diabetes patients in the Tunisian population.

Free-living amoebae (FLA): detection, morphological and molecular identification of Acanthamoeba genus in the hydraulic system of an haemodialysis unit in Tunisia.

UNLABELLED: The free-living amoebae (FLA) are ubiquitous and opportunistic protozoa. They can induce human and animal diseases. The aim of our study was to detect the FLA and Acanthamoeba genus in the hydraulic system of an hemodialysis unit. It was a prospective study of 46 water samples. The first collect (23) was before cleaning and after the haemodialysis sessions and the second (23) after cleaning and before the hemodialysis sessions. RESULTS: the morphological study enabled us to detect morphotypic diversity. The predominant morphotypes were the acanthopodial forms (29%). At the entrance of hemodialysis unit there were acanthopodial (44%) and monotactic (25%) forms; at the outlet, acanthopodial and fan-shaped forms (25% each). In addition, Acanthamoeba genus was present in 39% (1st collect) and 18% (2nd collect). The amplification of the FLA 18S rDNA gene was negative in only one sample localized in the last stage of water treatment unit (WTU). The amplification of the 18S rDNA (ASA.A1) Acanthamoeba gene was positive in 15 samples. CONCLUSIONS: we noted that, in the hemodialysis unit, the purification techniques used in the WTU were effective, but there is a problem of water stagnation in the drain, which constitutes an appropriate condition for the biofilms formation. It is then necessary to use a filter with a low porosity (0.2 microm) at the entrance of the hemodialysis unit and if possible to change the drain.

Association of glucose transporter 1 polymorphisms with type 2 diabetes in the Tunisian population.

BACKGROUND: T2DM is a complex metabolic disease. Genetic studies on T2DM have been of little help so far because several genetic association studies have shown conflicting results. In this study, we report the findings of a case-control study on three SNPs in the GLUT1 gene. For this, we investigated the association of GLUT1 genotypes and haplotypes with T2DM. RESEARCH DESIGN AND METHODS: All 273 T2DM subjects (cases) and 343 healthy subjects (controls) were genotyped using the polymerase chain reaction restriction fragment length polymorphism. RESULTS: Results showed that the GT genotype of XbaI SNP could increase the risk of susceptibility to T2DM to 2.4 and that TAT is a 'risk haplotype' conferring a risk of 3.4 to T2DM. CONCLUSION: The TAT haplotype of the GLUT1 gene confers susceptibility to T2DM in the Tunisian population.

Association of calpain-10 polymorphisms with type 2 diabetes in the Tunisian population.

BACKGROUND: Genome-wide analyses of the genetic predisposition to type 2 diabetes mellitus (T2DM) in different isolates and populations have identified regions of interest called non insulin-dependent diabetes mellitus (NIDDM) 1, 2, 3 and 4. At the NIDDM1 locus (2q37.3), calpain-10 (CAPN10) encodes for a ubiquitously expressed protease implicated in the two fundamental pathophysiological aspects of T2DM. This is a report of the results of a study of the association of four CAPN10 polymorphisms with T2DM in the Tunisian population. PARTICIPANTS AND METHODS: A total of 222 T2DM patients with a diabetes duration of 10 years or more and 206 healthy controls were enrolled to analyze the frequency distribution of four CAPN10 polymorphisms (UCSNP-43, UCSNP-19, UCSNP-110 and UCSNP-63) using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) in the Tunisian population. We also investigated the association of T2DM with different haplotypes and haplotype combinations. RESULTS: Only the A allele of UCSNP-43 showed an association with T2DM (odds ratio, OR=1.86). We also identified a novel combination of haplotypes (121/221) defined by three polymorphisms (UCNSP-43, -19 and -63) that is associated with an increased risk of T2DM (OR=2.38). CONCLUSION: In this study involving the Tunisian population, we identified genetic variants within CAPN10 that are linked with T2DM and a novel haplotype combination, 121/221, associated with an increased susceptibility to T2DM.

[Evaluation of plasmatic homocysteine determination by gas chromatography-mass spectrometry]. / Evaluation d'un transfert de méthode : dosage de l'homocystéine plasmatique par chromatographie en phase gazeuse couplée à la spectrométrie de masse.

Total plasma homocysteine emerged in the past few years as an independent risk factor for cardiovascular diseases. This test is now currently prescribed for the diagnosis of unexplained thrombosis in young adults or recurrent thrombosis in patients with arteriopathy. This sulphured amino-acid is an important intermediate in transsulfuration and remethylation pathways of methionine metabolism. Within the context of a collaboration between Monastir and Grenoble Universities and because a gas chromatograph mass spectrometer (GC-MS) instrument was available in Monastir, we proposed to transpose a GC-MS method previously developed in Grenoble's hospital for this parameter and to validate it by comparison with the liquid chromatography tandem mass spectrometry (LC-MS-MS) method, used at present. Analytical performances were good: detection limit 0.4 micromol/L and linear range up to 4 mg/L (29.6 micromol/L), and between-run and within-run precision with coefficients of variation < 5% and < 8 %, respectively. The comparison with LC-MS-MS method showed a good correlation (y = 0.9874 x -0.208; r(2) = 0.84). Mean difference from LC-MS-MS was -0.4 micromol/L. Plasma concentrations of homocysteine (mean + SD) determined among Tunisian adults, 29 men, 27 women, of the same age were respectively: 11.6 +/- 2.4 micromol/L and 10.1 +/- 2.7 micromol/L, p = 0.025. This method is now currently used to evaluate tHcy concentration in patients with risk factors for cardiovascular disease.

Autosomal dominant Alport's syndrome: study of a large Tunisian family.

Alport's syndrome is a hereditary nephritis that may lead to end-stage renal disease (ESRD) in early adult life. It is a clinically and genetically heterogeneous nephropathy. Alport's syndrome is often associated with sensorineural deafness and/or ocular abnormalities. In contrast with the well-known X-linked phenotype, very little is known about the autosomal dominant form caused by mutations in COL4A3 and COL4A4 in the chromosome region 2q35-q37. We describe a Tunisian family with autosomal dominant Alport's syndrome in which males and females were equally affected. Two members reached ESRD at age 40 and 53 years, respectively. Three members experienced isolated microhematuria and one member experienced sensorineural deafness. No eye abnormalities were observed. Immunohistochemical studies showed a normal distribution of the alpha5 (type IV collagen) chain in the epidermal basement membrane. Genetic analysis demonstrated that a common haplotype co-segregated with the disease in the heterozygous state in all affected patients, thereby, confirming an autosomal dominant mode of inheritance. The same haplotype was observed in two asymptomatic children. We conclude that autosomal dominant Alport's syndrome, follows a rare mode of inheritance and exhibits a milder phenotype than usually observed in classic X-linked Alport's syndrome. The frequency of this mode of inheritance should be confirmed by a larger study.

Infectious complications in kidney transplant recipients: a single-center experience.

To determine the patterns of infectious complications in renal transplant recipients in our center, we evaluated 48 patients (29 men and 19 women) who were transplanted between 1994 and 2003. The average age of the patients was 29 years. Thirty (62.5%) and 18 (37.5%) transplants were from living related and cadaveric donors, respectively. Posttransplant immunosuppression consisted of azathioprine or mycophenolate mofetil (MMF), prednisone, antithymocyte globulin (ATG), and cyclosporine or tacrolimus. The acute rejection episodes were treated with pulse doses of methylprednisolone; steroid-resistant rejection was treated with ATG or muromonab (OKT3). All patients received prophylaxis with sulfadoxine-pyrimethamine; none received prophylaxis against cytomegalovirus (CMV) infection. Thirty-nine (81%) recipients developed 77 confirmed episodes of infection; 35 (46%) episodes occurred in the early postoperative period, 28 (36%) in the first month and 14 (18%) after 6 months. According to the type of infection, there were 24 urinary tract, 16 CMV, seven herpetic, nine general septic, six fungal, four pneumonia, one disseminated nocardial, and 10 miscellaneous episodes. All 26 (100%) patients who had acute rejection episodes developed infections compared with 13/22 (59%) who did not have rejection (P < .01). There was a significant correlation between CMV disease and acute rejection and/or tacrolimus or MMF use. CMV infection occurred after the additional immunosuppressive treatment for acute rejection in 10 patients or during the use of tacrolimus or MMF in six patients. We conclude that CMV infection was the most frequent opportunistic pathogen in our renal transplant population and related to the intensive antirejection therapy, followed by urinary tract infections within 3 months after surgery.

[Association of distal tubular acidosis, Hashimoto's thyroiditis and Gougerot-Sjögren's syndrome]. / Association d'une acidose tubulaire distale, d'une thyroïdite de Hashimoto et d'un syndrome de Gougerot-Sjögren.

INTRODUCTION: Distal tubular acidosis is associated with auto-immune diseases not specific to organ. The coexistence of distal tubular acidosis and auto-immune thyroid affection is very rare. OBSERVATION: A 36-year-old woman exhibiting primary hypothyroidism, Gougerot-Sjögren's syndrome and hypergammaglobulinemia, presented distal tubular acidosis revealed by severe hypokaliemia and complicated by quadriplegia and circulatory arrest. Correcting the thyroid defect did not appear to influence the progression of acidosis. COMMENTS: Based on this observation, one can discuss the pathogenesis of distal tubular acidosis during auto-immune diseases (hypothyroidism, Gougerot-Sjögren's syndrome and monoclonal hypergammaglobulinemia) and its impact on therapy.

Asymptomatic gastric angiodysplasia in chronic hemodialysis patients: case reports.

Gastrointestinal (GI) angiodysplasia is a vascular lesion. It is a common cause of GI bleeding in chronic renal failure (CRF). We report three adult chronic hemodialysis patients with asymptomatic angiodysplasia. Over a period of four years, the hemoglobin level was stable and none of our patients received iron supplementation or erythropoietin (EPO) therapy. Incidence of angiodysplasia may be underestimated in the CRF patients. Further studies may be needed.