Chronic diarrhea due to duodenal candidiasis in a patient with a history of kidney transplantation.

Candida infection in the small intestine is uncommon. We report an unusual case of duodenal candidiasis that presented as chronic diarrhea in a patient who had previously undergone kidney transplantation. A 60-year-old man presented with profuse watery diarrhea that had lasted 6 months 13 years after kidney transplantation. Upper gastrointestinal endoscopy results indicated candidiasis within the esophagus and duodenum. Biopsy results revealed active duodenitis with hyphal and yeast forms of Candida overlying the duodenal epithelium in periodic acid Schiff staining. The patient was successfully treated with fluconazole. After 6 months of follow-up, the patient had no complaint of diarrhea. Duodenal candidiasis may be the result of chronic diarrhea in patients with a history of kidney transplantation.

A workshop on urinalysis and a survey on urine microscopy among kidney centers of Iran.

Urinalysis is a mandatory diagnostic tool for the evaluation of patients with kidney diseases. A workshop on urinalysis was held for nephrologists in Isfahan, Iran, on October 11-12, 2012. After the presentation of the results of a survey of the nephrology centers of Iran on urine microscopy, the most important aspects of urinalysis were presented and discussed. These included the following: (1) urinalysis by dipstick, which provides results in a few seconds, is simple to use, has a low cost, and is used worldwide for screening purposes, in spite of some limitations; (2) measurement of proteinuria by 24-hour urine collection, which still represents the reference method in spite of limitations due to frequent over or under collection errors; (3) protein-creatinine ratio in a random urine sample, which is recommended by international guidelines as an alternative to the measurement of 24-hour protein excretion; (4) microalbuminuria, which is seen as a marker of systemic endothelial damage; and (5) the urinary sediment, which is underused even among nephrologists in spite of the relevant diagnostic information it can supply in a wide spectrum of kidney diseases.

Two decades of experience in mucormycosis after kidney transplantation.

BACKGROUND: Invasive mucormycosis is a very rare infection after kidney transplantation. Here, we report 25 renal transplant recipients with mucormycosis; to our knowledge, this is the largest reported population of mucormycosis in these patients. MATERIAL/METHODS: In a retrospective study, we collected all kidney transplants with mucormycosis from 9 Transplant Centers of Iran from 1990 to 2010. The definitive diagnosis of mucormycosis was established by obtaining a biopsy specimen of the involved tissue. RESULTS: The most form of disease was rhino-cerebral (n =13), followed by pulmonary (n=7). Overall mortality rate was 52% (n=13), particularly in recipients with pulmonary infection (100%); however, the mortality rate in rhino-cerebral form of disease was low (30.8%). There was no statistically significant difference in mortality rate between male and female (P=0.8). In addition, no significant differences were seen in mortality rate with age of patients (p=0.8) and time of diagnosis since transplantation (p=0.3). Pulmonary infection was more seen in recipients received azathioprine compared to those on mycophenolate mofetil (p=0.006). CONCLUSIONS: Mucormycosis after renal transplantation has a poor prognosis, particularly patients with pulmonary involvement.

Epidemiology of culture-negative peritonitis in Iranian patients on continuous ambulatory peritoneal dialysis.

INTRODUCTION: Culture-negative peritonitis is a major challenge in the treatment of peritonitis in continuous ambulatory peritoneal dialysis (CAPD). This study aimed to evaluate the culture-negative peritonitis in patients from the Iranian CAPD Registry. MATERIALS AND METHODS: Data of 1472 patients from 26 CAPD centers were analysed. Peritonitis was defined as any clinical suspicion together with peritoneal leukocyte count of 100/mL and more. RESULTS: The patients had been on PD for a mean of 500 ± 402 days. There were a total of 660 episodes of peritonitis observed among 299 patients (peritonitis rate of 1 episode in 34.1 patient-months). Excluding patients with both negative and positive culture results, there were 391 episodes of peritonitis in 220 patients (174 culture-positive episodes in 97 patients and 217 culture-negative episodes in 123). The 1- to 4-year patient survival rates were 85%, 75%, 69%, and 59% for the patients with culture-positive peritonitis, and 92%, 78%, 73% and 63% for the patients with culture-negative peritonitis, respectively (P = .34). The technique survival rates were 90%, 57%, 42%, and 27% and 95%, 85%, 74%, and 40%, respectively (P = .001). On follow-up, there were higher rates of active PD patients, lower rates of PD dropouts, and higher rates of kidney transplantation in patients with culture-negative peritonitis compared to those with culture-positive peritonitis. CONCLUSIONS: In our patients, the prevalence of culture-negative peritonitis was high (55.9%). Patient survival with culture-negative peritonitis was comparable to those with culture-positive peritonitis and technique survival was higher among those with culture-negative peritonitis.

Impaired kidney allograft function following ezetimibe therapy.

Although ezetimibe therapy has been shown to be effective in lowering serum cholesterol level, it has not been reported to affect serum cyclosporine level in transplant recipients. Here, we describe a kidney transplant recipient who experienced acute kidney allograft dysfunction after ezetimibe prescription. Our patient showed an increase in serum creatinine level as well as a decrease in serum cyclosporine levels 1 month after taking ezetimibe. This suggests that ezetimibe may interact with cyclosporine and decrease its serum level resulting in allograft dysfunction. In this regard, careful monitoring of kidney function along with the serum cyclosporine level in kidney allograft recipients is recommended when cyclosporine is co-administered with ezetimibe.

Lung contusion and cavitation with exudative plural effusion following extracorporeal shock wave lithotripsy in an adult: a case report.

INTRODUCTION: Among the complications of extracorporeal shock wave lithotripsy are perinephric bleeding and hypertension. CASE PRESENTATION: We describe the case of a 31-year-old Asian man with an unusual case of hemoptysis and lung contusion and cavitation with exudative plural effusion due to pulmonary trauma following false positioning of extracorporeal shock wave lithotripsy. Differential diagnoses included pneumonia and pulmonary emboli, but these diagnoses were ruled out by the uniformly negative results of a lung perfusion scan, Doppler ultrasound, and culture of bronchoalveolar lavage and plural effusion, and because our patient showed spontaneous improvement. CONCLUSIONS: False positioning of extracorporeal shock wave lithotripsy can cause lung trauma presenting as pulmonary contusion and cavitation with plural effusion.

The story of continuous ambulatory peritoneal dialysis in Iran.

Iran, a developing country with a population of approximately 71,000,000, is the most populous country in the Middle East and the 16th most populous in the world. Gross domestic product (GDP) per capita is US$8900 and total health expenditure is approximately 6% of GDP. The total number of end-stage renal disease (ESRD) patients reported by the Management Center for Transplantation and Special Diseases (MCTSD) was 32,686 in 2007, which denotes a prevalence of 466 per million population (pmp) in Iran. Considering the growth rate of 12%, the expected number of ESRD patients in 2010 is 40,000; incidence of ESRD is expected to be 63.8 pmp. These numbers are lower compared to developed countries, which may suggest poor referral and under-diagnosis of ESRD. In Iran at present, hemodialysis (HD) and renal transplantation are the most common renal replacement therapy (RRT) modalities, accounting for 47.7% and 48.8% of prevalent RRT patients respectively. Based on the Iran Dialysis Center report of 2001, approximately 1% of ESRD patients were being treated with continuous ambulatory peritoneal dialysis (CAPD); this number increased to approximately 3.5% (6.8% of total dialysis patients) in 2006. In the present article, reasons for underutilization of peritoneal dialysis (PD) and improvements in PD within the past 5 years will be reviewed.

Metabolic abnormalities in patients with recurrent stone formation in a hot territory.

OBJECTIVE: This was a cross-sectional study of 150 consecutive patients (105 males and 44 females) with nephrolithiasis. Serum and urine metabolic evaluations were preformed. RESULTS: 70 percent (n=105) of patients were males. Sixty patients (40%) had hypertension. The urine volume of 114 subjects (76%) was less than 1 liter/day. There was an inverse correlation between urine pH and weight of patients (r=-0.48, p=0.001). The prevalence of hypophosphatemia, hypokalemia, hyperuricemia and hypercalcemia was 11% (n=17), 12.6% (n=19), 20% (n=30), and 5% (n=8), respectively. The prevalence of hypercalciuria and hyperuricosuria was 24% (n=36) and 14% (n=21), respectively. The urine calcium significantly correlated with urine sodium (r=0.3, p<0.001) and uric acid (r=0.43, p<0.001). Serum phosphate concentrations were inversely correlated with urine calcium concentrations (r=-0.37, p=0.016). CONCLUSION: Our findings suggest that lower urine volume has an important role in nephrolithiasis in hot areas. Higher urine sodium and uric acid and lower serum phosphor correlate with higher urine calcium in stone formers. However, further cohort studies should be performed to establish these findings (Tab. 2, Fig. 3, Ref. 26). Full Text (Free, PDF) www.bmj.sk.

Description of an outbreak of acute sterile peritonitis in Iran.

BACKGROUND: Outbreaks of sterile or chemical peritonitis are uncommon and often not well documented. It is therefore important to describe the characteristics of sterile peritonitis in continuous peritoneal dialysis (PD) patients. METHODS: Characteristics of acute chemical peritonitis (ACP) are described in 20 patients (5 males, 15 females; mean age 50 +/- 15 years; range 29 - 72 years). Cultures and Gram stains were negative for micro-organisms. All patients with symptoms of peritonitis were using glucose bags with the same lot number and resolution of peritonitis occurred only after changing the suspicious bags. The first measurements of dialysate-to-plasma creatinine (D/P creat) and glomerular filtration rate (GFR) before and after ACP were compared in 14 patients with no separate episode of bacterial peritonitis during that time. RESULTS: Cloudy dialysate was observed in 19 patients and 13 experienced abdominal pain. Mean dialysate white blood cell count and percentage neutrophils were 520/mm(3) (range 100 - 1600/mm(3)) and 65% (range 14% - 98%) respectively. Analysis of the unused PD solution showed that endotoxin (0.06 endotoxin unit/mL), 5-hydroxymethyl furaldehyde (8 microg/mL), and acetaldehyde (0.4 microg/mL) concentrations were within acceptable ranges. In 14 patients without episodes of bacterial peritonitis, D/P creat was significantly higher after than before ACP (0.77 +/- 0.07 vs 0.55 +/- 0.1, p = 0.036), whereas GFR was not (4.5 +/- 2.9 vs 4.9 +/- 2.53 mL/minute, p = 0.62). CONCLUSION: Although chemical peritonitis in glucose-based PD solution is uncommon, it should be distinguished from bacterial peritonitis in outbreaks of peritonitis. Facilities to measure glucose degradation products are required, especially in developing countries. Acute chemical peritonitis increases small-molecule transport in the short term.

Effects of allopurinol and vitamin E on renal function in patients with cardiac coronary artery bypass grafts.

BACKGROUND: Acute renal failure is a common complication of cardiac surgery, with oxidants found to play an important role in renal injury. We therefore assessed whether the supplemental antioxidant vitamin E and the inhibitor of xanthine oxidase allopurinol could prevent renal dysfunction after coronary artery bypass graft (CABG) surgery. METHODS: Of 60 patients with glomerular filtration rate (GFR) < 60 mL/min scheduled to undergo CABG surgery, 30 were randomized to treatment with vitamin E and allopurinol for 3-5 days before surgery and 30 to no treatment. Serum creatinine levels and potassium and creatinine clearances were measured preoperatively and daily until day 5 after surgery. RESULTS: The patients consisted of 31 males and 29 females, with a mean age of 63 +/- 9 years. After surgery, there were no significant differences in mean serum creatinine (1.2 +/- 0.33 vs 1.2 +/- 0.4 mg/dL; p = 0.43) concentrations, or creatinine clearance (52 +/- 12.8 vs 52 +/- 12.8 mL/min; p = 0.9). The frequency of acute renal failure did not differ in treatment group compared with control (16% vs 13%; p = 0.5). Length of stay in the intensive care unit (ICU) was significantly longer in the control than in the treated group (3.9 +/- 1.5 vs 2.6 +/- 0.7 days; p < 0.001). CONCLUSION: Prophylactic treatment with vitamin E and allopurinol had no renoprotective effects in patients with pre-existing renal failure undergoing CABG surgery. Treatment with these agents, however, reduces the duration of ICU stay.

Effect of losartan on Doppler sonography indices in kidney transplant patients: a randomized clinical trial.

BACKGROUND: Color Doppler sonography indices, such as resistive index (RI) and pulsatility index (PI), can predict arteriosclerosis of internal renal vessels after kidney transplantation. Angiotensin II receptor antagonists, however, may have antiatherogenic effects. We therefore assessed the effects of losartan on RIs of renal allografts. METHODS: We compared duplex sonographic measurements in renal allograft recipients (30 males, 20 females) from living donors randomized to a losartan (25 mg twice daily) or a control group. RESULTS: The patients in the two groups had similar baseline characteristics, and 49 (24 in the losartan and 25 in the control group) completed 12 months of follow-up. After 12 months, the losartan and control groups did not differ significantly in mean RI (0.71 +/- 0.06 vs 0.69 +/- 0.07, P = 0.4) or PI (1.3 +/- 0.25 vs 1.29 +/- 0.28, P = 0.8) of the intrarenal artery and mean RI (0.74 +/- 0.07 vs 0.72 +/- 0.07, P = 0.3) and PI (1.5 +/- 0.3 vs 1.4 +/- 0.34, P = 0.3) of the main artery. CONCLUSIONS: Losartan had no effect on Doppler sonography indices. Longer follow-up, however, may be needed to confirm this finding.

Skin mucormycosis presenting as an erythema-nodosum-like rash in a renal transplant recipient: a case report.

INTRODUCTION: Cutaneous mucormycosis is a rare entity related to kidney transplantation. It usually presents with ecthyma-like lesions and black necrotic cellulitis. We report an unusual case of primary cutaneous mucormycosis presenting as erythema-nodosum-like lesions in a woman who had received a renal transplant. CASE PRESENTATION: A 49-year-old woman with diabetes received a living-unrelated kidney transplant. Her clinical course was uneventful for the first six months after transplantation. She then developed multiple, painful, erythema-nodosum-like lesions on her right leg and thigh following an episode of minor trauma. Mucormycosis was diagnosed by skin biopsy. Microscopic examination also showed panniculitis. The patient was treated successfully with amphotericin B and surgical resection. To our knowledge, this is the first description of primary cutaneous mucormycosis with erythema-nodosum-like lesions and panniculitis after renal transplantation. CONCLUSION: Cutaneous mucormycosis should be considered in the differential diagnosis when a kidney transplant recipient develops erythema-nodosum-like lesions with panniculitis.

Bone mineral density in kidney transplant recipients and patients on hemodialysis: a comparison with healthy individuals.

INTRODUCTION: We measured bone mineral density (BMD) before and after transplantation to determine the frequency and severity of preoperative and postoperative osteoporosis and compare them with the BMD in healthy individuals. MATERIALS AND METHODS: We determined the BMD at the lumbar spine and femoral levels in 22 men and 18 women who were on long-term dialysis in Yazd, Iran, and a group of kidney transplant recipients including 43 men and 18 women. They were compared with each other and healthy individuals studied in a recent study in Iran. Factors potentially associated with alterations of the BMD were studied in each group. RESULTS: The frequency of osteoporosis in the vertebrae and femoral neck was higher in the kidney transplant recipients than the healthy population (21.3% versus 4.9%; P = .001; odds ratio, 5 and 9.8% versus 2.4%; P = .02; odds ratio, 5.4, respectively) but not significantly different from those in the patients on dialysis (17.9% and 17.5%, respectively). In transplantation group, multivariate analysis showed that there was a significant negative correlation between the lumbar BMD and the cumulative prednisolone dose (r = -0.36, P = .003). No correlation was found between BMD of lumbar or femoral neck and the body mass index, age, and cumulative cyclosporine level. CONCLUSIONS: Osteoporosis is more frequent in patients on dialysis and kidney transplant recipient than in general population. However, there is no difference in osteoporosis frequency between transplanted patients and those on dialysis. In the lumbar spine, a higher cumulative prednisolone dose results in decreased BMD among kidney transplant recipients.