Glomerular diseases in the Military Hospital of Morocco: Review of a single centre renal biopsy database on adults.

Epidemiological studies provide useful information for clinical practice and investigations. This report aimed to determine glomerular diseases frequencies in a region of Morocco. All native renal biopsies (January 2000 to December 2007) on adults were reviewed, but only glomerular diseases were analyzed. The diagnosis of each case was based on histological, immunopathological and clinical features. We have performed 171 renal biopsies in 161 patients (101 males and 60 females), the mean age was (range) 40.4 ±15 years (16-72). Clinical indications that lead to renal biopsy were: nephrotic syndrome (60.3%), renal failure of unknown aetiology (31.6%), asymptomatic urinary abnormalities (6.2%) and nephritic syndrome(1.9%). Primary glomerular diseases were reported in 84 patients (52%). The most common histological lesion was minimal change disease (26%). Idiopathic membranous glomerulopathy was the second most common lesion (23%) followed by membranoproliferative glomerulonephritis (17%), IgA nephropathy (12%), focal and segmental glomerulosclerosis (9.4%) and crescentic glomerulonephritis (6%). Secondary glomerular diseases were reported in 53 patients (33%). Lupus nephritis was the secondary glomerular disease most frequent (45%) followed by amyloïdosis (19%), diabetic nephropathy (15%), and Good pasture's syndrome (7.6%). The most common complications of the procedure were pain at biopsy site in 4%, gross hematuria in 11.1%, perirenal hematoma in 5% and hematuria requiring nephrectomy in 0.6% patients. Minimal change disease was the most frequent primary glomerulopathy and lupus nephritis was the most frequent secondary glomerulopathy in our group. The reasons for these findings are unclear. This information is an important contribution to the understanding the prevalence of renal diseases in North Africa.

Bisalbuminemia during remission of nephrotic syndrome.

The bisalbuminemia acquired outside of the long-term antibiotic treatment is an exceptional event. It is a rare condition characterised by the presence of two distinct fractions of serum albumin on electrophoresis. This anomaly reflects the presence, at the same time, of a normal albumin and a modified albumin. These changes of albumin may be related to various causes. Their association with nephrotic syndrome is exceptional. We report a case of bisalbuminemia during a period of remission of nephrotic syndrome.

[Benign intracranial hypertension in a hemodialysis patient: consider the fistula]. / Hypertension intracrânienne bénigne chez un hémodialysé : penser à la fistule.

UNLABELLED: Benign intracranial hypertension (BIH) is a syndrome characterized by the abnormal elevation of the intracranial pressure in the absence of a mass lesion or hydrocephalus, and with normal composition of the cerebrospinal fluid. We report a case of BIH in a chronic hemodialysis patient with no signs of intraocular inflammation or neurologic abnormalities. Treatment with acetazolamide followed by corticosteroids failed to improve the signs of BIH. However, after correction of the radiocephalic arteriovenous fistula of the left upper extremity, which demonstrated excessive flow, BIH symptoms completely disappeared. CONCLUSION: When managing BIH in a hemodialysis patient, consider the fistula.

[Non-diabetic renal disease in type II diabetes mellitus patients in Mohammed V Military Hospital, Rabat, Morocco]. / La néphropathie non diabétique chez les patients diabétiques de type 2 à l'hôpital militaire Mohammed V de Rabat (Maroc).

The distinction between diabetic nephropathy lesions and non-diabetic renal lesions is not always obvious and is often based on renal biopsy. This study evaluated the prevalence and predictors of nondiabetic renal disease in people with type 2 diabetes. The study was conducted between January 2008 and October 2010 in the nephrology department of the military hospital in Rabat. The study included 16 patients with type 2 diabetes in whom renal biopsy was indicated. Non-diabetic renal disease was found in 6 of the patients (37.5%); IgA nephropathy was the most frequent non-diabetic renal disease (half of non-diabetic renal diseases). Hypertension was significantly less frequent in the non-diabetic renal disease group than the diabetic nephropathy group (16.7% versus 80.0%, P = 0024), duration of diabetes was a shorter (4.5 versus 15.5 years, P = 0.022) and diabetic retinopathy was absent (100% versus 40%, P = 0.026). There were no statistically significant differences between the 2 groups in relation to age, sex, creatinine level, 24-hour proteinuria, nephrotic syndrome and microscopic haematuria.

Predictors of early vascular-access failure in patients on hemodialysis.

Vascular access management is key and critical in the successful management of hemodialysis patients, and an arteriovenous fistula (AVF) is considered the access of choice. This study was conducted between January 2007 and October 2009 at the Military Hospital in Rabat. Data on 115 patients who underwent 138 AVFs were retrospectively studied. Wrist AVF was the most common site of use. The primary course was uncomplicated in 63% of the patients, while primary failure occurred in 23.9% of the patients. Presence of diabetes was the most important risk factor for primary failure.

The Kt/V by ionic dialysance: Interpretation limits.

The availability of hemodialysis machines equipped with online clearance monitoring (OCM) allows frequent assessment of dialysis efficiency and adequacy without the need for blood samples. Accurate estimation of the urea distribution volume (V) is required for Kt/V calculated from OCM to be consistent with conventional blood sample-based methods. A total of 35 patients were studied. Ionic dialysance was measured by conductivity monitoring. The second-generation Daugirdas formula was used to calculate the Kt/V single-pool (Kt/VD). Values of V to allow comparison between OCM and blood-based Kt/V were determined using Watson formula (VWa), bioimpedance spectroscopy (Vimp), and blood-based kinetic data (Vukm). Comparison of Kt/Vw ocm calculated by the ionic dialysance and Vw (Kt/Vw ocm) with Kt/VD shows that using VW leads to significant systematic underestimation of dialysis dose by 24%. Better agreement between Kt/V ocm and Kt/VD was observed when using Vimp and Vukm. Bio-impedancemetry and the indirect method using the second-generation Daugirdas equation are two methods of clinical interest for estimating V to ensure greater agreement between OCM and blood-based Kt/V.

Non-diabetic renal disease in type II diabetes mellitus patients in Mohammed V military hospital, Rabat, Morocco

The distinction between diabetic nephropathy lesions and non-diabetic renal lesions is not always obvious and is often based on renal biopsy. This study evaluated the prevalence and predictors of nondiabetic renal disease in people with type 2 diabetes. The study was conducted between January 2008 and October 2010 in the nephrology department of the military hospital in Rabat. The study included 16 patients with type 2 diabetes in whom renal biopsy was indicated. Non-diabetic renal disease was found in 6 of the patients [37.5%]; IgA nephropathy was the most frequent non-diabetic renal disease [half of non-diabetic renal diseases]. Hypertension was significantly less frequent in the non-diabetic renal disease group than the diabetic nephropathy group [16.7% versus 80.0%, P = 0024], duration of diabetes was a shorter [4.5 versus 15.5 years, P = 0.022] and diabetic retinopathy was absent [100% versus 40%, P = 0.026]. There were no statistically significant differences between the 2 groups in relation to age, sex, creatinine level, 24-hour proteinuria, nephritic syndrome and microscopic haematuria

[Prevalence of metabolic syndrome in chronic haemodialysis patients in Morocco]. / Prevalence du syndrome métabolique chez les hemodialyses chroniques au Maroc.

We determined the prevalence of metabolic syndrome in 25 chronic haemodialysis patients in the haemodialysis centre of the Mohammed V military teaching hospital in Rabat. The mean age of the patient as was 46.5 (SD 14.8) years and mean haemodialysis duration 62.9 (SD 38.4) months. We evaluated the 5 parameters of metabolic syndrome: waist circumference, hypertriglyceridaemia, high-density lipoprotein (HDL) cholesterol, blood pressure and blood glucose. In all, 11 (44%) patients had metabolic syndrome: 7 women and 4 men. Low HDL cholesterol was found in 100% of the patients, hypertriglyceridaemia in 90.9% and hypertension in 63.6%. There were significant differences between patients with and without metabolic syndrome with regard to levels of hypertriglyceridaemia and HDL cholesterol, and waist circumference. Factors significantly associated with the presence of metabolic syndrome were abdominal obesity, and systolic hypertension and aypertriglyceri daemia.

Effect of the quality of water used for dialysis on the efficacy of hemodialysis: a single-center experience from Morocco.

The quality of the water used for dialysis has been suggested as a factor causing inflammation in patients on hemodialysis (HD). We therefore conducted this study to identify the effect of quality of the water on nutritional state, inflammation and need for human recombinant erythropoietin (EPO) in patients undergoing HD at Agadir, Morocco. This prospective study included patients on HD for at least one year. The water treatment was done according to the standard protocol, which was followed by additional enhancement of ultrafiltration using an additional polysulfone filter (diasafe, Fresenius, Bad Homburg, Germany) before the dialyser. Water was monitored regularly during the study period to ensure acceptable levels of bacterial count as well as endotoxin levels. Various parameters including dry weight, systolic and diastolic blood pressure (PA) before and after an HD session, need for human recombinant EPO, levels of hemoglobin (Hb), albumin, ferritin, C-reactive protein (CRP), and the dose of dialysis delivered (Kt/V) were measured first at the beginning of the study and thereafter, in the third, sixth and 12 th months of the study. The study involved 47 patients, and after 12 months of the study, an improvement in median dry weight (1.2 kg, P = 0017) and a simultaneous median reduction of 20.7 IU/kg/week of EPO, with an in-crease of the median level of Hb, was noted. The results of our study suggest that by improving the biocompatibility of HD with the use of good quality water, patients acquire a better nutritional, inflammatory and hematologic status.

Prevalence of metabolic syndrome in chronic haemodialysis patients in Morocco

We determined the prevalence of metabolic syndrome in 25 chronic haemodialysis patients in the haemodialysis centre of the Mohammed V military teaching hospital in Rabat. The mean age of the patients was 46.5 [SD 14.8] years and mean haemodialysis duration 62.9 [SD 38.4] months. We evaluated the 5 parameters of metabolic syndrome: waist circumference, hypertriglyceridaemia, high-density lipoprotein [HDL] cholesterol, blood pressure and blood glucose, In all, 11 [44%] patients had metabolic syndrome: 7 women and 4 men. Low HDL cholesterol was found in 100% of the patients, hypertriglyceridaemia in 90.9% and hypertension in 63.6%. There were significant differences between patients with and without metabolic syndrome with regard to levels of hypertriglyceridaemia and HDL cholesterol, and waist circumference. Factors significantly associated with the presence of metabolic syndrome were abdominal obesity, and systolic hypertension and hypertriglyceridaemia

Characteristics of intradialytic hypotension: experience of Agadir Center-Morocco.

We report in this retrospective study the experience of our hemodialysis (HD) center in the incidence of intradialytic hypotension (IDH) over 18 months. We first studied the demographic, clinical, biological and morphological data of our 52 HD patients and compared the characteristics of patients with frequent IDH and those without. We found that factors significantly associated with IDH include diabetes, left ventricular hypertrophy, impaired diastolic function, weight gain and high ultrafiltration rates. Despite these results, further larger studies are required to confirm them.

[Bacteremia on femoral catheter infection: an unusual cause of orbital cellulitis]. / Bactériémie sur infection du cathéter fémoral: une cause inhabituelle de cellulite orbitaire.

The authors report a case of orbital cellulitis complicating bacteremia on central catheter infection. A 51-year-old man, with a history of diabetes and end-stage renal disease, was admitted for left exophthalmos with inflammatory chemosis, fever, and worsening of his general state. The CT scan showed exophthalmos with thickening of soft tissues and infiltration of the ocular fat without collection or sinus impairment. Orbital cellulitis was diagnosed. The etiological investigations showed Staphylococcus aureus bacteremia on femoral catheter infection. Progression was favorable with antibiotics and nursing care. The authors discuss the compromised prognosis of this disease and the need for rapid diagnosis and prompt therapeutic management.

[Non-secreting myeloma associated with nephrotic syndrome]. / Myélome non excrétant révélé par un syndrome néphrotique.

The non-secreting myeloma is a rare form of myeloma. Its association with a nephrotic syndrome is exceptional. The observation which we report below described the history of a 66 years old patient who presents a non-secreting myeloma revealed by a nephrotic syndrome. Various assumptions on the mechanism of no excretion were put forth. Nevertheless, several points are to be elucidated as for the pathogenesis of the association non-secreting myeloma and nephrotic syndrome.

[Biermer's disease and venous thrombosis. Report of two cases]. / Maladie de Biermer et thrombose veineuse. A propos de deux observations.

INTRODUCTION: The main issue in venous thrombotic events is their etiology. Several clinical and/or biological data can be helpful in that research. In the two cases we report here, a macrocytic anemia led to the diagnosis of probably acquired hyperhomocysteinemia. FIRST CASE: a 24-year-old man was admitted for severe anemia and a superior vena cava syndrome. Biological data showed megaloblastic anemia and mild features of blood destruction that were explained by a pernicious anemia. Second case: a 35-year-old man had two deep venous thrombotic events in one year (involving the right leg, then the left leg); biological findings showed a macrocytic mild anemia that was diagnosed as a pernicious anemia. In both of the patients, deep venous thrombosis was mainly explained by a hyperhomocysteinemia that was a consequence of vitamin B12 deficiency. The two patients improved under anticoagulant treatment combined with subcutaneous vitamin B12. CONCLUSION: Pernicious anemia can cause acquired hyperhomocysteinemia, which is considered a risk factor for deep venous thrombosis. Thus, the connectivity of these conditions should remain in the practitioner's mind, especially when thrombosis occurs along with a macrocytic anemia.

Beneficial influence of recombinant human erythropoietin therapy on the rate of progression of chronic renal failure in predialysis patients.

BACKGROUND: Partial correction of anaemia with recombinant human erythropoietin (rHuEpo) has been shown to markedly improve the general condition and quality of life of predialysis patients, but the effects of rHuEpo therapy on blood pressure and the rate of progression of chronic renal failure (CRF) are still disputed. In particular, no study evaluated the time duration until the start of maintenance dialysis in treated patients, compared to untreated predialysis patients. METHODS: We retrospectively evaluated the rate of decline of creatinine clearance (Delta Ccr) and the duration of the predialysis period in 20 patients with advanced CRF treated with rHuEpo (Epo+ group), and in 43 patients with a similar degree of CRF but with less marked, asymptomatic anaemia, not requiring rHuEpo therapy (Epo- group). All patients were submitted to identical clinical and laboratory surveillance. All received similar oral supplementation with B(6), B(9), and B(12) vitamins and oral iron supplementation. Maintenance dose of subcutaneous epoetin was 54.3+/-16.5 U/kg/week (median dose 3300 U/week). RESULTS: Initial and final haemoglobin (Hb) levels were 8.8+/-0.7 and 11.3+/-0.9 g/dl in the Epo+ group, vs 10.9+/-1.2 and 9.5+/-0.9 g/dl in the Epo- group. In the Epo+ group, Delta Ccr declined from 0.36+/-0.16 during the preceding 24 months to 0.26+/-0.15 ml/min/ 1.73 m(2)/month after the start of rHuEpo therapy (P<0.05). No significant variation was observed in the Epo- group. Time duration until the start of dialysis was 16.2+/-11.9 in the Epo+ group, compared to 10.6+/-6.1 months in the Epo- group (P<0.01). Slowing of progression was observed in 10 Epo+ patients, whereas no significant variation in Delta Ccr occurred in the other 10. There was no difference in previous Delta Ccr rate, nor in Hb or blood pressure levels while on rHuEpo therapy between the two subgroups. CONCLUSIONS: Our study affords conclusive evidence that rHuEpo therapy did not result in accelerated progression of CRF in any treated predialysis patients, nor deleterious increase in blood pressure, but instead resulted in significant slowing of progression and substantial retardation of maintenance dialysis. Such encouraging results remain to be validated in a large prospective, randomized study.

[Genetics of kidney diseases and renal fibrosis]. / Génétique des maladies rénales et de la fibrose rénale.

Renal fibrosis is found in genetic kidney diseases. In some of them, fibrosis may be due to mechanisms not dependent on the gene defect. In other cases, fibrosis depends more specifically on the gene defect: e.g. in juvenile nephronophthisis where interstitial fibrosis predominates, or in Alport's syndrome where glomerulosclerosis is triggered probably by unbalanced distribution of alpha chains of type IV collagen in glomerular basement membrane. Study of genes predisposing to renal fibrosis and progression is more complex. Genes regulating the renin-angiotensin system have been considered. The DD polymorphism of the converting enzyme gene may be associated with a more rapid progression rate of renal failure in glomerular and non-glomerular diseases. This remains, however, to be confirmed in more appropriate studies.

Polycystic kidney disease: <<30 ans après>>.

Major progress has been achieved in autosomal dominant polycystic kidney disease in the last 30 years; Progress in imaging procedures has been decisive for diagnosis (by ultasonography), management of kidney and liver complications (by CT scan), and investigation and sometimes management of intracranial aneurysms (by MRI-angiography and endovascular treatment procedures). On the other hand, progress in molecular genetics has led to the identification of PKD1 and PDK2 genes, and their respective gene products, polycystin 1 and 2. A two-hit model for cyst formation has recently been put forward. The link between the gene defects and cyst fluid formation and progression is still unknown. In addition, cystic and non-cystic lesions coexist in the disease, underlining that the primary molecular defect is located upstream of the mechanism of cyst formation.

Role of calcium carbonate administration timing in relation to food intake on its efficiency in controlling hyperphosphatemia in patients on maintenance dialysis.

A study has claimed that at an equal elemental calcium dose, CaCO3 was not less but equally as efficient in controlling predialysis hyperphosphatemia as calcium acetate, provided both calcium salts were ingested 5 min before meals instead of during meals because the higher acidity of the fasting gastric juice would allow for better dissociation of CaCO3. However, this study did not directly demonstrate that the efficiency of CaCO3 in controlling hyperphosphatemia was actually greater when it was administered before a meal than during a meal. To examine this point, we performed a 3 month randomized crossover trial in 12 reliable and stable patients maintained on chronic hemodialysis. Their plasma concentrations of calcium, protein, phosphate, bicarbonate, urea, and creatinine were measured before the first dialysis of each week and the amount of intact parathyroid hormone (PTH) at the beginning and at the end of each of the 3 months. Comparison of the plasma concentrations measured during the 2 modes of administration showed no significant differences in creatinine, urea, bicarbonate, or intact PTH. The mean (+/-SD) plasma concentration of PO4 was not significantly lower (1.88+/-0.50 vs. 1.74+/-0.41 mM) whereas the corrected level of plasma Ca was significantly lower (2.30+/-0.17 vs. 2.38+/-0.16 mM; p < 0.04) when CaCO3 was given before meals than during meals. In conclusion, the administration of CaCO3 before a meal does not increase its efficiency in controlling hyperphosphatemia because the level of plasma PO4 was actually slightly higher with this timing of administration whereas the comparison of the creatinine and urea levels suggested a stability of phosphate intake and the comparison of the PTH and bicarbonate levels suggested the stability of osteolysis and of the transcellular membrane shift of phosphate. Also, administration of CaCO3 before a meal is associated with significantly lower plasma corrected calcium, suggesting less absorption of calcium, which may be an advantage but only in hypercalcemic patients. There is no reason other than the prevention of its hypercalcemic effect to recommend the administration of CaCO3 just before meals rather than during meals.