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Background: Simulation allows learning in action, reflection and feedback. All these factors suggest the positive contribution of the simulation to the development of clinical reasoning. The main assessment tool for standardized testing of this skill is the script matching test., Aim: To assess the impact of teaching through high-fidelity clinical simulation on the clinical reasoning of third-year medical students, while assessing their teaching practices, satisfaction and confidence in the learning they received during this session., Methods: We conducted an evaluative bicentric prospective study that included third-year medical students completing their cardiology internship during the first semester of the academic year 2019-2020 in the cardiology departments of Habib Thameur Hospital and Charles Nicolle Hospital, respectively., Results: The study included 48 students. The students who participated in this study liked the teaching practices used in the simulation-assisted lessons. Their interest in these practices is validated by the average of 37,2±5,53 obtained for active learning, 8,04±1,85 for collaboration, 8,5±1,51 for diversity of styles and 8,02±1,72 for high expectations. In our study, the results showed that students were satisfied with the learning they had made during the simulation session. The average for the measurement of satisfaction by the 48 externals was 22,37±2,54. The results of our study indicated that students were confident that their learning would allow them to solve problems similar to those presented in the simulation in a real clinical setting. This is supported by the 31,48±4,63 average student confidence in their learning. Our study showed a progression of the students' clinical reasoning with simulation using a Script Concordance Test. The mark obtained by the students after the simulation session is significantly higher than the one obtained by the students before the simulation session with p=0.008., Conclusion: Simulation is an innovative pedagogical strategy and a contribution to optimizing the clinical reasoning process and improving the quality of care.

Background: Due to the increase in average life expectancy and the higher incidence of cardiovascular disease, more elderly patients present for cardiac surgery nowadays. At the same time, age has been considered a predictor of morbidity and mortality., Aim: To evaluate the short-term outcomes of cardiac surgery in elderly patients., Methods: We conducted a descriptive retrospective study including elderly patients who underwent cardiac surgery from January 2012 to 31st of December 2016. All patients were hospitalized before and after cardiac surgery in the cardiology department of Habib Thameur Hospital., Results: Our study included 55 patients. Average age was 72±6 years old and sex-ratio was two. Eighty-five percent presented with angina, 18% with dyspnea and one patient with an aortic prosthetic valve endocarditis. Mean left ventricular function was 54 ±9 %. Mean EuroSCORE II was 1.91±1.18. Twenty-six per-cent had an urgent surgery. Mean extracorporeal circulation time was of 77±26 min and mean extubation time was 8±6 h. Eighty-four per cent had a coronary artery bybass grafting and 16% a valve replacement. Four per cent had a redux and 4% a combined surgery. Stay in surgical department varied between 3 and 10 days with average of 4.6±1.2 days. Early mortality rate was of 2% and 98% had complications. Ninety-eight complications occurred after surgery: 35 reintervention for mediastinal bleeding or tamponade, 28 bleedings requiring transfusions, eight heart rhythm disorders, an atrioventricular conduction block requiring ventricular, five atrial fibrillation, two ventricular tachycardias, a ventricular fibrillation, eight low cardiac outpout, seven prolonged mechanical ventilation and eight pneumonias. In univariate analysis, recent myocardial infarction and chronic kidney disease were predictive of early complications., Conclusion: Our data shows cardiac surgery is feasible in elderly patients with acceptable risk in terms of mortality and an increased morbidity due to their frailty. Careful patient selection is needed for the success of cardiac surgery in elderly patients.

Introduction: Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization., Aim: To evaluate patients' knowledge about their VKA treatment., Methods: We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment., Results: Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027)., Conclusion: Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

Introduction: Infectious endocarditis (IE) is a rare disease with a high mortality. In 2009, the European society of cardiology restricted antibiotic prophylaxis to a smaller number of cardiac conditions with very high risk for IE. Did these changes in the guidelines have an impact on the epidemiological and bacteriological profile of IE?, Aim: The main aim of our work was to study the evolution of the microbiological profile of IE from 1991 to 2016., Methods: We realized an analytic retrospective study comparing two groups: group 1 included patients admitted for a certain IE before September 2009 and group 2 those admitted after that date., Results: Patients mean age was 46 ± 13 years and sex ratio was of 1.5. Forty percent of the patients were at high risk of IE. Blood cultures were positive in 19 cases. The most frequently isolated germ was Staphylococcus (10 patients). Serology was performed in six patients and was positive for Chlamydia Trachomatis in two cases. Forty-two patients had surgical treatment, 17 had a valve culture that was positive in 3 cases only. Clinical and paraclinic characteristics were comparable among the two groups. Negative blood cultures rates decreased from 72% to 68% between group 1 and 2 (p = 0.789). Staphylococcus positive blood cultures increased from 13% to 21% (p = 0.49). In contrast, Streptococcal positive blood cultures decreased from 11% to 5% in 2009 (p = 0.69)., Conclusion: Our data suggest that there has been no change in the bacteriological profile of IE after the reduction in antibiotic prophylaxis.

Background: Right ventricular (RV) dysfunction is associated with poor prognosis in patients with non-ischemic dilated cardiomyopathy. Several RV echocardiographic parameters have been proposed as sensitive markers to detect patients at risk., Objective: To compare the predictive value of echographic parameters of RV systolic function for adverse outcomes in patients with non-ischemic dilated cardiomyopathy., Methods:    Forty patients with non-ischemic dilated cardiomyopathy were included. Right ventricular systolic function assessed by Doppler echocardiography standard (RV fractional area change, Tei index, TAPSE and dp/dt), tissue Doppler (peak systolic velocity (Sa)) and Strain 2D of the RV. The primary endpoint was the occurrence of a major cardiovascular event. The follow-up extended for 6.2 months ± 2,49., Results: Eighteen patients reached the primary endpoint. TAPSE (HR 0.86 [0.74-0.99], p=0.04), Sa (HR 0.77 [0.62-0.95], p=0.01), Tei index (HR 1.06 [1.01-1.12], p=0.02) and strain of the lateral wall of the RV (HR 1.13 [1.04-1.23], p=0.004) were found to be independent predictors of major cardiovascular event. The cut-off thresholds for TAPSE, Sa, Tei index and strain of the lateral wall of th RV, defined using ROC curves were respectively 12,5mm ; 8,5cm/s ; 0,55 et -12., Conclusion: TAPSE, Sa, Tei index and strain of the lateral wall of the RV are independent predictors of major cardiovascular event in non ischemic dilated cardiomyopathy.

Transurethral resection of the prostate is currently the gold standard for the surgical treatment of the benign prostatic hyperplasia. This surgery may lead transurethral resection of the prostate (TURP) syndrome and in some cases, acute tubular necrosis can develop. We report a patient who developed hyponatremia, hemolysis and oliguric acute renal failure as a major complication following TURP using glycine as irrigating fluid.A 64-year-old man was admitted for a prostate resection procedure. Physical examination revealed a healthy elderly man. Preoperative laboratory data showed serum sodium 140 mEq/L, blood urea nitrogen (BUN) 0.6 g/L, creatinine 0.7 mg/dL and hemoglobin 12.9 g/dL. Few hours after, the patient becomes incoherent and developed oliguria, nausea and vomiting. The laboratory data revealed rapidly elevating BUN and creatinine levels (BUN 2.4 g/L; creatinine 6.1 mg/dL), the serum sodium concentration decreased by 14 meq/L. A decreased hemoglobin level (7.4 g/dL) with an elevated lactate dehydrogenase level (665 U/L) was observed. Renal ultrasonography was normal. The diagnosis of acute tubular necrosis complicating TURP syndrome was retained. The hyponatremia was slowly corrected to 132 mmol/L by diuresis and fluid restriction. The renal function recovered after four hemodialysis sessions. Using glycine as an irrigant for TURP may cause hyponatremia, hemolysis and also acute renal failure, especially in patients with longer resection time. It is necessary to carry out every effort to shorten resection time and avoid extravasation during surgery.

Background: Vascular access is a basic and essential tool required for performing renal replacement therapy in end stage renal disease., Aim: To study the indications of tunneled catheter (KTT) in hemodialysis (HD), identify complications related to the use of KTT and contributing factors, assess the survival and performance of the technique., Introduction: The making of a vascular access is an angular piece for adequate HD and in good conditions. In this context the KTT may be an alternative., Methods: A retrospective study of 52 KTT placed in 49 patients collected in the department of Nephrology Dialysis and Renal Transplantation in RABTA Tunis between 2008 and 2011., Results: The average age of our patients was 55.58 years ± 13.5 years, their Sex ratio was 0.79. The Thirty of our patients were diabetic, 46.2% had hypertension and 21.2% had underlying cardiac disease. The mean duration of HD was 1111.35 days or 37 months. The most common indication of KTT was the absence of arteriovenous fistula in 65.4% of cases, other indications were: short survival (30.7%), the exhaustion of venous capital (34.6%), mediacalcosis (34.6%) and immunosuppression (36.5%). The right internal jugular vein was the choice of insertion site with 78.8%. The overall incidence of immediate complications was 19.2%. Among our patients, 31.4% had a dysfunction. The period of HD represent the risk factor for dysfunction KTT (p = 0.006).An infectious complication was observed in 29% of cases. The median time to onset of infection was 190.83 days. Staphylococcus was isolated in 40% of cases. The average duration of use of KTT was 238 days. The only single factor determining the survival of KTT was the number of KTT put in the same patient., Conclusion: More than a quarter of the population are dialyzed through a catheter. Despite concerted efforts, much remains to be done for the confection at time of a permanent vascular access.

Background: The amyloidosis is one of the histologic lesions the most frequently associated to the aging., Aim: To identify the several etiologies of amyloidosis in elderly patients according to immunohistochemical type., Methods: Retrospective study on 10 years, in Internal medicine and Nephrology department in Charles Nicolle Hospital. Tunis. Tunisia. Diagnosis of amyloidosis was retained after histological confirmation with specific colorations, in patients aged 65 years or more at the diagnose of amyloidosis., Results: The study enrolled 51 patients with amyloidosis. In 67% of cases it was AA amyloidosis. The etiology the most frequently observed with this type was the tuberculosis, followed by chronic pulmonary infections. We retained diagnose of non AA amyloidosis in 21% of patients. The multiple myeloma has been the most frequent etiology observed, but no cause was identified at about half of patients. Twelve per cent of amyloidosis were not typed., Conclusion: From our study, we can remark the high predominance of AA amyloidosis, probably because of frequency of tuberculosis which is still high in our country, this is not in accordance with occidental data, were AL amyloidosis and senile amyloidosis predominate in elderly.

Background: In children, renal biopsy is routinely required in the management of idiopathic steroid-resistant nephrotic syndrome particularly prior to starting nephrotoxic immunosuppressive agents., Aim: To investigate the correlations between the results of initial renal biopsy in Tunisian children with idiopathic steroid-resistant nephrotic syndrome and the subsequent response to cyclosporineprednisolone combination., Methods: We conducted a retrospective study of children with idiopathic steroid-resistant nephrotic syndrome over the period 2002- 2009. Data on clinico-biological features, histological diagnosis and response to cyclosporine-prednisolone were collected., Results: Thirty patients were enrolled, of whom 16 had focal segmental glomerulosclerosis, eight had minimal change disease and six had diffuse mesangial proliferation. Complete Remission was achieved in 15 patients (50%). Nine patients (30%) went into partial remission. Only six patients presented no response (20%). No statistically significant relationship between the different pathological types and the response to CsA-prednisone was found., Conclusion: In our study, two important facts were noted: 1) the predominant histopathological subtype was the focal segmental glomerulosclerosis; 2) a high remission rate was achieved in our patients using a combined cyclosporine-prednisolone treatment regimen. This response is not dependent on the histological type.

Aim: Myocardial ischemia impairs the diastolic left ventricular (LV) function earlier than the systolic function. We evaluated the value of pulse-wave Doppler Tissue Imaging (DTI) in the study of regional myocardial function of LV in patients with coronary artery disease., Methods: We performed a prospective study in 60 patients with coronary artery disease that we compared to 40 healthy individuals in order to assess the value of pulse-wave DTI to study the diastolic LV function . Both groups had a clinical examination, ECG, echocardiography and pulse-wave DTI. Only the patients had a coronary angiography. Pulse-wave DTI was applied to the 16 myocardial segments of the LV, we measured the isovolumetric relaxation time (IVRT), early (Ea) and late diastolic (Aa) velocities., Results: We have demonstrated that compared with healthy subjects, patients with coronary artery disease has a significant increase of IVRT (100.2 +/- 20 ms vs 62.5 +/- 12.2, p <0.001) and lower Ea (7.6 +/- 1.6 vs. 9.2 +/- 2.6) and report Ea / Aa. These anomalies are more pronounced in akinetic segments compared with hypokinetic segments. Relying on data from the coronary angiography, we found in patients that IVRT had increased, Ea and Ea / Aa lowered in most segments hypoperfused than in normally perfused segments. An IVRT > 70ms and Ea <8.3 cm / s emerge as threshold values to identify myocardial ischemia. More coronary lesions are severe more Ea and Ea/Aa decline and IVRT increase. The culprit coronary artery could be identified by pulse- wave DTI since the DTI parameter anomalies are systemized, Conclusion: The pulsed DTI technique seems to be attractive as a non-invasive evaluation method of ischemic heart disease.

Background: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a primary electrical myocardial disease characterized by exercise- and stress-related ventricular lachycardia manifested as syncope and sudden death usually in child and teenager and was rarely described in adults. The management includes betablockade, with the use of implantable cardioverter defibrillators if medical treatment is insufficient., Aim: Report a new case of CPVT., Observation: We report a case of a 43 years old patient in whom CPVT diagnosis was made during his exploration for palpitations occurring with the effort. Registration Holter ECG revealed several episodes of supraventricular tachycardia and episodes of nocturnal sino-atrial block. The patient had an ICD and betablockade treatment., Conclusion: The TVPC in adult can manifest with attenuated symptoms that can be summarized with palpitations with the exertion. The supraventricular arrhythmias and sinus dysfunction may be at the forefront of Electrocardiographic manifestations. The prognosis of this form seems better than the TVPC of the child. Treatment with betablockade appears to be effective but existing dysfunction sinus facilitates decision to implant the ICD.

Background: Uremic pruritus is frequent in patients undergoing hemodialysis. It's multifactorial secondary in most cases to metabolic complications related to uremia., Aim: We report a rare cause of pruritus in an haemodialysed patient., Observation: It's a 48-year-old woman in periodic haemodialysis during 17 years. She suffered from generalized pruritus associated with psychiatric disturbance without neurologic deficits. CT scan and magnetic resonance imaging revealed extensive, diffuse and bilateral involvement of the white matter. The diagnosis of large low grade B cell lymphoma was confirmed by the histologic examination of stereotactic biopsy which leads to early intracranial hemorrhage and death., Conclusion: Before attributing pruritus to renal failure, one should exclude other causes such as the NHL even rarely reported especially when it associated with psychiatric disturbances. CT scan and magnetic resonance imaging contribute to diagnosis.

Background: Calciphylaxis is a small vessel disease responsible for vascular calcification and skin necrosis. It occurs in association with chronic renal failure and has a poor prognosis. BUT: Report new cases. We report 3 cases of calciphylaxis occurred in patients with chronic renal failure secondary to interstitial nephritis in 1 case, diabetic nephropathy in 1 case and thrombotic microangiopathy in 1 case., Cases: They were 2 females an 1 man aged of 44, 3 years meanly. Hyperphosphoremia and hyperparathyroidism were the essential risk factors. All patients died by sepsis. This course was precipitating by corticotherapy in 2 cases., Conclusion: Early recognition and treatment of risk factors is mandatory to reduce mortality in uremic patients with calciphylaxis.

Background: Amyloidosis in Behçet's disease is rare and has a poor outcome., Aim: Report a new case., Case: We report a case of a 38-year-old Tunisian woman who presented with Behçet's disease and nephrotic syndrome. Renal biopsy showed amyloid deposition consistent with AA type. She had not any associated disease that might be an additional cause of secondary amyloidosis. She was treated by colchicine. After 3 years, proteinuria had disappeared and persisted negative 11 years after the diagnosis. A second renal biopsy showed the persistence of amyloidosis., Conclusion: As amyloidosis is one of the prognostic factors affecting survival in Behçet's disease, patients with this disease should be screened for amyloidosis. Administration of colchicine to these patients may be beneficial.

Background: Allograft renal thrombosis can occur in 1 to 6% of cases. Many predisposing factors has been identified especially alteration of coagulation., Aim: We analyzed in this study frequency and predisposing factors of renal graft thrombosis., Methods: We report a retrospective study including 319 renal transplant recipients., Results: Nine patients (2.8%) presented veinous graft thrombosis in 5 cases and arterial thombosis in 4 cases. There were 6 men and 3 women aged of 30.6 years meanly (10-56) which developed the thrombosis 6 days (1-48) after the transplantation. All patients were detransplanted after 16.2 days and 1 patient died., Conclusion: Thrombosis constitute an important cause of graft loss. A perfect surgical technic and prophylactic treatment in high risk patients are necessary to reduce this complication.

Background: The incidence of end-stage renal failure is high and it is responsible for the increase of the rate of morbidity and mortality rates among our patients., Aim: The objective is to study patient characteristics before starting hemodialysis and to evaluate factors influencing their short and long term survival., Methods: This is a prospective study of 127 patients starting hemodialysis between June and December 2001. On May 31, 2005, their survival was analyzed according to different parameters., Results: Patients were 77 males and 50 females. Their mean age was 51.4 +/- 16.1 years (15 to 78 years). Diabetes was observed in 33.9% of cases. Only 70.9% of patients were covered by a social service. Chronic renal failure was diagnosed at the end stage in 34.6% of cases. Before starting hemodialysis, only 4 patients were vaccinated against B hepatitis and arteriovenous fistula were not made in any patients. Pericarditis was observed in 9.4% of patients. Albuminemia was < 35 g/l in 60.5% of patients. First hemodialysis session was programmed in 53.5% of patients and realized urgently in 46.3% of patients. Patients were hemodialysed 4, 8 and 12 hours per week respectively in 16.5%, 15.8% and 67.7% of cases. On May 31, 2005, 35.4% of patients died. Their actuarial survivals at 3 months, 1 year and 4 years were respectively at 87.5%, 79.5% and 64.4%. Acturial survival was bad in patients with pericarditis, diabetes, hemodialysed less than 12 hours/week and when the first hemodialysis session was started urgently., Conclusion: The diagnosis of renal failure was frequently made at end-stage. There are no preparations before starting hemodialysis. We have to reinforce prevention programmes and increase the number of nephrologists and nephrology departments.

Background: The association between Kaposi's sarcoma, Human Herpes Virus 8 infection and multiple myeloma is still controversial especially in hemodialysed patient., Aim: report a new case of this association., Observation: We report the case of a 83 year old man in whom the diagnosis of multiple myeloma of IgA/kappa had been made in December 2003 with end stage renal failure requiring hemodialysis. Initially, it had been treated with Melphalan, Cyclophosphamide, Prednisolone and Vincristine and secondary by Melphalan and Prednisone. Three months later, he had developed extensive porpour lesions in his lower limbs. Skin biopsy had been informed of Kaposi's sarcoma. Human Herpes Virus 8 test was positive., Conclusion: Our observation is another case supporting the hypothesis that Kaposi's sarcoma and multiple myeloma share a common aetiology such as Human Herpes Virus 8. The immunodepressed state related to aging, multiple myeloma, chemotherapy and hemodialysis was the probable factor responsible of rapidly progressive Kaposi's sarcoma in our patient. The association myeloma and Human Herpes Virus 8 infection is still controversial.

Background: Automated peritoneal dialysis has been increasingly used in recent years. The quality of life is improved in patients on automated peritoneal dialysis with more time for work, family and social activities compared to patients on continuous ambulatory peritoneal dialysis., Aim: We report our experience concerning patients on continuous ambulatory peritoneal dialysis., Methods: From July 1997 to June 2003, we review retrospectively 78 patients with chronic renal failure treated by automated peritoneal dialysis. Tenckhoff catheter was used for all patients with 1 cuff in 39 cases (35.5%) and 2 cuffs in 71 cases (64.5%)., Results: There were 46 males and 32 females. Their mean age was 38.6 +/- 14.5 years. Their main nephropathies were glomerular in 23 patients (29.%), diabetic in 20 patients (25.6%) and vascular in 19 patients (24.4%). Among the 78 patients, 61 (78.2%) were autonomous while 17 (21.8%) were assisted by a member of their family. The mean period of therapy was 25.5 months (3 to 61 months). Peritonitis was the main complication, it was observed in 45 cases after a mean delay of 17 months (1 to 38 months). The mean rate of peritonitis was 36.5 months/patient. Their etiology was identified in 21 (46.7%) cases (8 septic manipulations of catheter and 13 tunnel infections). The principal organism isolated in peritoneal fluid were 18 gram-positive cocci (13 staphylococcus aureus, 4 coagulase-negative staphylococci, 1 streptococcus) and 10 gram-negative bacilli. The outcome of peritonitis was favourable in 39 cases (86.7%). The actuarial technique survival at 1, 3 and 5 years was respectively 94.6%, 80.1% et 49.3%. The actuarial patient survival at 1, 3 and 5 years was respectively 93.3%, 76.8% et 52.2%. At the end of the study, 43 patients (56.4%) left the automated peritoneal dialysis program: 22 (28.2%) were shifted to hemodialysis, 15 (19.3%) died, 6 (7.7%) were transplanted and 1 patient (1.3%) was shifted to continuous ambulatory peritoneal dialysis., Conclusion: Our experience concerning automated peritoneal dialysis is recent with a small number of patients. Our results were acceptable and we have to encourage and extend automated peritoneal dialysis to the most new patients with end-stage renal failure.

Background: Membranoproliferative glomerulonephritis in patients with cryoglobulinemia complicating hepatitis C virus have yet been reported. Although, it remains controversial, antiviral treatment seems to be able to improve the outcome of glomerulonephritis., Aim: The objectives of the study were to analyze characteristics of this association and to report literature data and newness treatment., Methods: It's a retrospective study including 11 patients with membranoproliferative glomerulonephritis, hepatitis C virus and mixed cryoglobulinemia. Hepatitis C virus antibodies was identified by ELISA technique. Hepatitis C virus genotype was identified in one patient. Cryoglobulins were isolated from sera of all patients at 37 degrees Celsius., Results: Patients were 3 men and 8 women with a mean age of 51.9 +/- 15.5 years. Between the 11 patients, 7 had hypertension, 9 had nephrotic syndrome and 10 had chronic renal failure. Renal biopsy showed membranoproliferative glomerulonephritis lesions in all cases with fibrinoid thrombi in 8 cases. Six patients had chronic liver disease. Liver biopsy was performed in 4 patients, showing histological feature compatible with chronic active hepatitis in 2 cases. No patient had antiviral therapy. Renal failure was stable in 5 cases and progressed in 6 cases with end stage renal failure in 3 of them. One patient died, 4 months after diagnosis, because of severe pulmonary involvement in cryoglobulinemic vasculitis. In literature, treatment is dominated by antiviral therapy composed first by Interferon Alpha alone. Combination therapy associating Interferon and Ribavirin was recently used in renal involvement; it is clearly more effective than interferon alpha alone., Conclusion: Hepatitis C virus detection should be performed when membranoproliferative glomerulonephritis is associated with cryoglobulinemia. Antiviral treatment should be more widely used in Tunisia to evaluate his effect on renal involvement

Background: Fabry disease is an X-linked recessive lysosomial storage disorder that is caused by deficient activity of alpha galactosidase A. Renal involvement occurs generally in hemizygous forms., Aim: We report one case of renal involvement in Fabry disease., Case Report: A 47 year-old-man had focal and segmental glomerulosclerosis with moderate renal failure. As the patient presented history of acroparesthesias, hearing loss, left ventricular hypertrophy with arrhythmia and corneal deposits, hemizygous Fabry disease was suspected. This diagnosis was confirmed with low alpha galactosidase activity. After a follow up of 5 years, the renal function remains stable but the patient died by cardiac arrhythmia., Conclusion: Occurrence of a glomerulonephritis associated with an hypertrophic cardiopathy without hypertension should advocate Fabry disease.

Background: Pregnancy and child birth in haemodialysis remains a rare event, even more, when pregnancy occurs in patient with systemic lupus erythematosus (SLE)., Aim: We report a case of a patient with end stage renal failure secondary to SLE and who carried out 3 pregnancies., Case Report: She was a woman with proliferative and diffuse lupus glomerulonephritis since 1985 treated by corticosteroids and cyclophosphamide. In 1995, she developed chronic renal failure. In 1996, she underwent a 1st full term spontaneous pregnancy with normal birth weight. In 2001, she underwent a second spontaneous pregnancy while she was on periodic haemodialysis. She had a full term baby birth with a birth weight at 1 Kg 700 and who died 4 days later. In 2002, she had a third pregnancy with voluntary abortion at 8 weeks., Conclusion: Our patient had conserved fertility despite treatment by cyclophosphamide, chronic renal failure and haemodialysis. The two successful deliveries may be attributed to the control of SLE activity and to the adequacy of haemodialysis.

Background: Acute renal failure may occur in varied circumstances. It is potentially reversible spontaneously or after specific treatment. It is rare after hunger strike and fewer cases were reported in the literature. The physiopathological mechanisms are varied and remain incompletely known., Aim: We report the case of a prisoner having presented an acute renal failure after a hunger strike wich was completely reversible., Case: He's a 29 year old man, without a past medical facts, in July 2004 he was incarcereted in prison. In October 2004 he undertake a hunger strike during one month. In November 2004 he was hospitalized for global dehydration and shock. His physical examination showed blood pressure 60/40 mmHg, weight 59 Kg with a loss of weight about 10 Kg, diuresis 800 cc/day. His biological findings showed urea 100 mmol/l, creatinemia 679 (mo/l, natremia 179 mmol/l, kaliemia 5 mmol/l, glycemia 5.2 mmol/l, albuminemia 35 g/l, calcemia 2.35 mmol/l and biological marques of rhabdomyolysis: CPK at 11 times the normal and LDH two times the normal. His treatment consisted on rehydratation, parenteral then enteral refeeding and psychiatric talks. The evolution was favourable, re-establishment of good hydration state with a gain weight of 7 Kg, normalization of renal function, his creatininemia reached 85 (mol/l in three weeks and normalization of muscles enzymes in one month., Conclusion: Hunger strike continue to pose a problem because of it's frequency in penitentiary structures and its organic disorders which can lead to death. A good psychiatric cares may be undertaked in order to prevent a such bad manifestations.

Renal involvement in primary Sjögren's syndrome occurs in 10-60% of cases. Tubulointerstitial nephritis with distal renal tubular acidosis (DRTA) is the main type of involvement. It's generally asymptomatic and revealed by complications of DRTA. We report 4 cases of GJS complicated by nephrocalcinosis, tetapresic hypokaliemia and osteomalacia. In 2 cases, nephrocalcinosis was diagnosed simultaneously with the GJS. The 2 other cases were diagnosed 3 and 15 years after primary GJS. All patients were treated by coticosteroids at the dose of 0.5 mg/Kg/jour, alkaline solution, K Cl in 2 cases and vitamin D in 2 cases. After a mean follow up of 8.7 years, the renal function remain stable in the 3 cases of nephrocalcinosis and in a patient with osteomalacia, bone lesions progressed. In conclusion, DRTA must be detected by acidification tests in patients with primary Sjögren's syndrome because of their latency and to prevent severe complications.

Introduction: Central venous catheters for hemodialysis are very useful as blood accesses when arteriovenous fistulas (AVF) are not available. The aim of this study is to analyse the clinical impact of internal jugular catheters (IJC) in hemodialysed patients and to assess their economic consequences., Patients and Methods: It is a prospective study realised from July 1998 to March 2002 including 533 hemodialysed patients without functional AVF: 280 males and 253 females aged between 17 and 87 years (mean age: 54.1 +/- 15 years). Single lumen polyurethane Vygon were used. All catheters were placed using Seldinger procedure and the posterior route of Jernigan which is more comfortable for patient., Results: Indications of IJC placement were new hemodialysed patients without AVF in 73.5% cases and no functional AVF in 26.5% cases. During the period of the study. IJC was placed in 533 patients. We failed to place the IJC at the first attempt in 42 patients but we succeed in placing it on the controlateral side. During IJC placement, we observed 50 (9.4%) cases of accidental puncture of carotid artery. The median duration use of IJC was 41 days (extreme: 1 to 413 days). IJC were removed mainly because of the use of AVF in 469 (88%) cases and the catheter infection in 41 (77%) cases. Bacteriological analysis were made only for 25 patients: staphylococci were identified in 16 cases and catheter cultures were negative in the 9 other cases. All patients were treated with antibiotics. Outcome was favourable for 39 of them and we had 2 deaths by septicemia. The IJC cost was 44,287 Tunisian Dinars (DT) coresponding to 31.633 Euro including 10125 DT (7,232 Euro) for infectious treatment., Conclusion: The use of IJC is frequent in our center with a high rate of infectious complications which increased the hemodialysis cost. The realisation of AVF, in patients with chronic renal failure before the beginning of hemodialysis, is the best way to limit the use of catheters.

Unlabelled: Acute renal failure (ARF) in patients with diabetes mellitus is frequent. It is caused by several factors notably drugs. Our retrospective study includes 20 cases of ARF induced by drugs in diabetic patients. Eleven men and 9 women with mean age of 55.2 years (17-71 years) were enrolled in the study. Type 2 diabetes mellitus was found in 18 cases and type 1 in 2 cases. Risk factors found are age more than 70 years in 17 cases, pre-existent renal failure in 17 cases, dehydratation in 6 cases, and drug association in 9 cases. In our study diuretics used solely or in association with other drugs were found to be the essential cause of ARF. ACE was noted in 5 cases, gentamycin in 2 cases, non-steroidal antiinflammatory drugs in 1 case, colimycin in 1 case and radiographic contrast media in 4 cases. Symptoms of hypersensitivity are fever in 3 cases, itchiness in 2 case, hepatic dysfunction in 7 case, and hypereosinophilia in 3 cases. Oliguria was observed in 11 patients. Eight patients were dialyzed. Renal function recovery is total in 9 case and partial in 9 others. Two patients having oliguria died., Conclusion: Diuretics are the first cause of drug-induced ARF in diabetic patients. This ARF worsens the renal prognosis for these patients. Oliguria is high risk of mortality.

Post-transplant diabetes mellitus (PTDM) is a frequent complication of renal transplantation. It has a prevalence rate ranging from 3 to 46%. We undertook a retrospective study of 175 nondiabetic renal transplant recipients to determine the prevalence rate, clinical characteristics, and risk factors of PTDM in kidney transplant recipients in our region. Thirty five patients (20%) developed PTDM, 50% were diagnosed by 3 months post transplantation. Eight patients (22.8%) were insulin recurrent. PTDM was independent of kidney source, family history of diabetes, age, sex, incidence of acute rejection, body weight gain, steroid or cyclosporine dose, use of beta-blockers and cytomegalovirus infection. Acturial 5 years survival was 79.4% in the diabetic compared to 80.5% in the control group. Patient survival was similar in the two groups. We conclude that PTDM is frequent in our patients. No significant risk factors of PTDM were identified in this study.