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BackgroundEarly diagnosis and treatment of Polyomavirus BK Nephropathy (PVBKN) is a challenging issue in the management of patients with kidney transplantation. Currently, histopathologic diagnosis is the gold standard method for diagnosis of PVBKN. However, typical viral inclusions may not be found in early stages of the PVBKN and should, instead, be diagnosed using immunohistochemistry (IHC) study. There is no clear consensus about routine IHC tests in the pathologic evaluation of transplanted kidney biopsy samples.Material and methodsThe current study was conducted on transplanted kidney biopsy samples, since 2016 to 2019. The patients who have presented with new onset of allograft dysfunction, at least 2 weeks after transplantation surgery, were included in our study. All these biopsy samples were evaluated with routine renal biopsy stains as well as IHC for SV40 (Simvian Virus 40) antigen. The identification of typical nuclear virus inclusion body and any nuclear positive staining on IHC (≥1+ positive result) were considered as definite evidence of PVBKN. Sensitivity, specificity, Positive Predictive and Negative Predictive Values (PPV and NPV) of histopathologic assessment without IHC study were evaluated.ResultsAmong 275 included cases, 18 (6.5%) patients with PVBKN were diagnosed. In patients with PVBKN, typical viral inclusions were detected in 14 samples (77.7%), on primary histopathological examination. However, virus-infected cells were identified just after IHC study in 4 (22.2%) of patients. Sensitivity, Specifity, PPV and NPV of morphologic histopathological assay without IHC for detection of PVBKN was 77.7, 100, 100 and 98.4% respectively.ConclusionRoutine IHC study for SV40 in all transplanted kidney biopsy samples with new onset of allograft dysfunction, will enhance the diagnostic sensitivity of early stage disease detection.

Estimating glomerular filtration rate (eGFR) using different formulas is common clinical practice for evaluating kidney function and drug dosing. But, the performance of available eGFR equations is questionable during early days after kidney transplantation.This study compared the performance of three common eGFR equations (Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)) in relation with measured GFR (mGFR) using clearance of Tc-99m-diethylenetriaminepentaacetic acid, 7 to 10 days post kidney transplantation. Agreement of mGFR and different eGFR equations in the staging of kidney function and dosing of 8 common antimicrobials were assessed.Thirty kidney and 5 simultaneous pancreas-kidney transplant recipients were included. CG applying total body weight (CGTBW) had the lowest bias (-12 mL/min/ 1.73 m2) and the highest percentage of estimation within 30% of mGFR (71.4%). MDRD showed the best precision (13.14 mL/min/ 1.73m2) and linear correlation with mGFR. CKD-EPI and MDRD acted better than CG for staging the level of kidney function. CGTBW had the lowest discordance rate with mGFR for antimicrobials dosing (33.6%). Discordance rates of drug dosing between mGFR and eGFR formulas were greater for drugs that have higher dosing levels such as (val)-ganciclovir (≥ 54.3%).Until developing more accurate methods for estimating kidney function during first 1 to 2 weeks after kidney transplantation, CGTBW method is suggested for drug dose adjustment and MDRD or CKD-EPI equation for the staging of kidney function in these patients, keeping in mind that these formulas underestimate the level of kidney function in new transplant recipients.

Background/Aims: Renal artery stenosis (RAS) is a known cause of secondary hypertension and renal failure. Although renal artery angiography is the gold standard for diagnosing RAS, a simple method to estimate if patients will develop RAS is required. The aim of this retrospective study was to develop a simple risk score to predict significant RAS. Methods: Four thousand one hundred seventy-seven patients who underwent renal angiography between 2002 and 2016 at Tehran Heart Center were included. Significant RAS was defined as narrowing of the renal artery by at least 70%. Multiple predictors of the RAS were determined using multivariable logistic regression with a backward elimination method. The scoring system obtained from the final model was presented as nomogram. The possible nonlinear effect of continuous variables was evaluated using restricted cubic splines. Overfitting of the final model was assessed applying the tenfold cross-validation method. Model performance was checked using calibration plot as well as Hosmer-Lemeshow goodness of fit test, and area under the receiver operating characteristics (ROC) curve. Results: The prevalence of RAS was 14.1%. Female sex (OR [95% CI]: 1.53 [1.26–1.85]), hypertension (OR [95% CI]: 1.38 [1.08–1.77]), estimated glomerular filtration rate (OR [95% CI]: 0.98 [0.97–0.98]), body mass index (OR [95% CI]: 0.97 [0.95–0.99]), and age (OR [95% CI]: 1.01 [1.00–1.02]) were determined as the multiple predictors of RAS. The area under the ROC curve of the final predictive model was 0.702 (95% CI: 0.679–0.725). Conclusion: This model assesses the risk of RAS using available information. This model can be used for both clinical and research purposes.

Introduction: Both scleroderma renal crisis and severe pericardial effusion are rare and life-threatening complications of systemic sclerosis. This article describes a case of scleroderma renal crisis heralded by severe pericardial effusion. Case Presentation: The patient was a 39-year-old woman with a history of 8 years diffuse cutaneous scleroderma and extensive skin involvement who referred to Imam Khomeini Hospital Complex, Tehran, Iran, with worsening dyspnea and pleuritic chest pain. Echocardiography revealed severe pericardial effusion, which was drained by the pericardial window. Thereafter, the patient became gradually anuric and her blood pressure was uncontrolled despite maximum doses of antihypertensive agents, including captopril. The serum creatinine level was increased progressively; thus, hemodialysis started. Concomitantly, microangiopathic hemolytic anemia complicated the course of the disease, which responded to plasma exchange. Kidney biopsy revealed pieces of evidence indicating thrombotic microangiopathy. Conclusions: This case report denotes to a probable association between scleroderma the renal crisis and severe pericardial effusion. Therefore, physicians should be vigilant about the renal crisis in patients with systemic sclerosis and pericardial effusion.

Tacrolimus is the cornerstone of immunosuppressive therapy in organ transplantation with variable inter-individual pharmacokinetics. This study assessed the relationship between CYP3A5/3A4 polymorphisms and tacrolimus dose requirement as well as 6-month transplant outcomes in Iranian kidney transplant recipients.In this prospective study, 110 adult kidney transplant recipients treated with tacrolimus were genotyped for the presence of common SNPs: rs776746: AG (CYP3A5*3). Patients who carried at least one CYP3A5*1 allele were known as CYP3A5 expressers while those who were CYP3A5*3/*3 homozygotes were classified as CYP3A5 non-expressers.The daily tacrolimus dose was significantly higher and tacrolimus dose adjusted trough levels (C/D ratio) was significantly lower in CYP3A5 expressers compared with non-expressers (P.05). Although the incidence of clinically suggested acute allograft rejection was significantly higher (OR = 0.365 [95% CI: 0.14 - 0.93]; P.05) and median time to first acute rejection was sooner among CYP3A5 expressers compared with non-expressers (12.17 vs. 26.83 days, P.05); however, estimated glomerular filtration rate, incidence of biopsy proven acute rejection and delayed graft function and 6-month patients' and grafts' survival did not differ between the two groups.CYP3A5 genetic polymorphism is significantly associated with required tacrolimus dose. After achieving desired tacrolimus blood level, although some transplant outcomes such as the incidence of clinically suggested acute rejection and time to first rejection were different between CYP3A5 expressers and non-expressers, however, other clinical outcomes did not differ between groups. Therefore, it is not the time to routinely assess kidney transplant recipients for CYP3A5 genetic polymorphism before transplantation.

Introduction: Despite high rates of morbidity and mortality in patients with contrast-induced nephropathy (CIN), there is no consensus regarding prevention of this well-known complication of contrast media use. One agent that has been widely used in this regard is N-acetyl cysteine (NAC). Nevertheless, its efficacy is still controversial. The aim of this study was to assess the efficacy of NAC, both in the oral and intravenous forms, for the prevention of CIN. Methods: This study is a double-blind randomized placebo controlled clinical trial. We randomized 434 adult patients with chronic kidney disease (constant serum creatinine ≥1.5 mg/dL) who were candidates for coronary angiography/plasty. The patients were categorized into three groups. One group received 1,200 mg NAC intravenously half an hour before the procedure and oral placebo starting 3 days before angiography. The second group received oral NAC 600 mg twice daily for 3 days, starting the day before the intervention and intravenous placebo half an hour before intervention. The third group received both oral and intravenous placebo. CIN was defined as a 25% relative increase in serum creatinine from baseline value, 48 h after use of contrast medium. Results: Of the 434 patients, 149 received intravenous NAC, 145 received oral NAC, and the remaining 140 received placebo. The incidence of CIN in the three groups was 6.1%, 7.6%, and 10.8%, respectively (p = 0.34). Conclusion: In patients with chronic kidney disease, neither intravenous nor oral NAC is superior to placebo for preventing CIN.

Fibroblast growth factor 23 is likely to be the most important regulator of phosphate homeostasis, which mediates its functions through fibroblast growth factor receptors and the coreceptor Klotho. In addition to reducing expression of the sodium-phosphate cotransporters NPT2a and NPT2c in the proximal tubules, fibroblast growth factor 23 inhibits renal 1α-hydroxylase and stimulates 24-hydroxylase and appears to reduce parathyroid hormone secretion in short-term studies. Fibroblast growth factor 23 synthesis and secretion by osteocytes and osteoblasts are upregulated through 1,25-dihydroxyvitamin D3 and through an increased dietary phosphate intake. Recent studies have indicated that a low-protein diet and calcium deficiency reduce circulating fibroblast growth factor 23 levels, but magnesium deficiency increases fibroblast growth factor levels. Drugs such as phosphate binders, bisphosphonate, and estrogens have various effects on circulating fibroblast growth factor 23 levels. The high cardiovascular disease event rates and mortality associated with elevated levels of this hormone may be due to various effects on the cardiovascular system, including left ventricular hypertrophy, arterial stiffness, vascular calcifications, endothelial dysfunction, and increased levels of inflammatory markers. In addition, elevated levels of this hormone may contribute to mineral bone metabolism disorders and to patient and allograft survival after renal transplant. Here, we discuss the effects of fibroblast growth factor 23 on adverse renal, bone, and cardiovascular outcomes after kidney transplant.

Kidney transplant is a new area for use of rituximab, which is being used to treat acute antibody-mediated rejection or as an induction agent in ABO- or HLA-incompatible grafts. We report on late-onset neutropenia in rituximab-treated kidney transplant recipients with antibody-mediated rejection.This observational prospective study was performed on kidney transplant recipients with clinically suspicious or biopsy-proven antibody-mediated rejection treated with plasmapheresis plus intravenous immunoglobulin with (cases) or without (controls) rituximab.Compared with none of the controls, 4 of 6 patients (66.7%) in the rituximab-treated group experienced late-onset neutropenia 35 to 93 days after the last dose of rituximab. The course of neutropenia was complicated by endocarditis in 1 patient, resulting in his death just because of a lack of valvular surgery.Increased use of rituximab to treat antibody-mediated rejection among kidney transplant recipients requires attention to its late-onset adverse event, neutropenia. Although asymptomatic in some patients, kidney transplant recipients treated concomitantly with plasmapheresis and mycophenolate mofetil are predisposed to hypogammaglobulinemia, and monitoring of patients for infections is required.

Background: The effect of kidney transplantation on improvement of survival rate and post-transplant-medical health is dramatic. Transplantation is associated with various emotions such as loss, grief and bereavement. Therefore, any psychiatric intervention that can improve the psychological aspects of these patients is valuable. Objectives: Due to the specific medical and psychiatric conditions of Kidney transplant recipients, researchers have designed expressive emotion psychotherapy as a simple, feasible and time limited brief psychotherapy for these patients. The aim was the assessment of this psychotherapy on quality of life and general health of kidney transplant recipients. Methods: This 12-week randomized double-blind clinical trial took place at the Kidney transplant department of Imam Khomeini hospital, an academic and governmental hospital affiliated with Tehran University of Medical Sciences (TUMS) from November 2015 to February 2016 (Iran). From a total of 82 patients screened for this study, 64 patients (34 in the intervention group and 30 in the control group) completed the trial. Participants were divided to two groups: the first received expressive emotion intervention and the second received fact recording education as the control group. Outcomes were assessed by the kidney transplant questionnaire (KTQ) and general health questionnaire (GHQ-28) at baseline and at weeks four and twelve. Results: Baseline demographic characters of patients in both groups were similar. The mean age of patients that participated in the study were respectively 39.26 ± 12.98 and 40.83 ± 14.37 for intervention and control groups. The results of this study indicated that patients in the “intervention” group had a statistically significant enhancement in total KTQ score (P = 0.001) and total GHQ score (P = 0.001). Regarding every domain of GHQ, this group had a better condition than the “control” group (P = 0.000). The intervention had a significant effect on certain domains of KTQ such as “uncertainty/fear” and “emotion”. Conclusions: Expressive emotion brief psychotherapy that focuses on the instructions of expression about one’s living and dealing with a diagnosis of chronic medical condition is recommended for kidney transplant recipients.

Background/Aims: Coronary artery bypass grafting (CABG) is associated with an increased risk of morbidity and mortality in patients with pre-existing renal dysfunction. Numerous measures have been implemented to overcome this problem; however, no improvement in outcomes has been achieved. This study was aimed at investigating the effects of prophylactic dialysis on mortality and morbidity in these patients. Methods: This randomized-controlled clinical trial enrolled 88 non-dialysis-dependent patients with chronic kidney disease awaiting CABG surgery. Thirty-nine randomly selected patients received dialysis 3 times prior to surgery, and 49 patients formed the control group. Kaplan-Meier analysis and Cox proportional-hazards models were used to identify factors associated with survival. Results: There was no significant difference in the development of morbidities between the groups (p = 0.413). A significant difference was evident in the average survival time (p = 0.037). Cox proportional-hazards models determined that the hazard ratio of death after surgery was 10.854-fold greater in non-dialysis patients than in patients who received dialysis (hazard ratio = 2). Conclusion: Prophylactic dialysis prior to CABG decreases mortality, but does not affect morbidity, in patients with renal insufficiency.

With an increased incidence of living-donor kidney transplants, in response to increasing unmet needs for renal transplant, a clear understanding of determinants of posttransplant outcomes is essential. The importance of delayed graft function in deceased-donor kidney transplant is now part of conventional medical wisdom, due to the large amount of evidence focused on this aspect. However, the same is not true for living-donor kidney transplant, partly due to lack of evidence on this crucial clinical question and partly due to lack of awareness about this issue. The current review aims to highlight the importance of delayed graft function as a crucial determinant of outcomes in living-donor kidney transplant. An exhaustive search of online medical databases was performed with appropriate search criteria to collect evidence about delayed graft function after living-donor kidney transplant, with a special focus on studies from the Middle East. Data on incidence, impact, risk factors, and possible prevention modalities of delayed graft function in patients undergoing living-donor kidney transplant are presented. A key finding of this review is that contemporary incidence rates reported from the Middle East are comparatively higher than those reported from outside the region. Although in absolute terms the incidence is lower than deceased donor kidney transplant, the effects of delayed graft function on graft rejection and graft and patient survival are sufficiently large to warrant the formulation of specific treatment protocols. Key to formulating prevention and treatment strategies is identifying discrete risk factors for delayed graft function. Although this evidence is scant, an overview has been provided. Further studies examining different aspects of delayed graft function incidence after living-donor kidney transplant are urgently needed to address a so far little known clinical question.

Nephrogenic systemic fibrosis (NSF) is a rare disease that is mostly reported in patients with chronic kidney disease (CKD) who have received gadolinium as a contrast in imaging techniques. The exact pathogenetic role of renal failure or gadolinium is not known. The aim of this study is to show whether mild-to-moderate renal failure is a risk for NSF as it is described in severe renal failure. In this cross-sectional study, we enrolled 164 patients with serum creatinine levels >1.5 mg/dL who were in different stages of CKD and had received gadolinium (gadopentetate). The average lag time between the gadolinium administration and the study was 4 months. The most prevalent skin symptom was itching (19%) and the least frequent was induration and papules (

Plasma oxidative stress (OS) including total homocysteine (tHcy) and malondialdehyde (MDA) concentrations is usually elevated and antioxidant enzymes activities are decreased in patients suffering from chronic kidney disease. It is thought that OS in these patients may have a role in the pathophysiology of cardiovascular events. It has been suggested that N-acetylcysteine (NAC) may be effective to lower OS. This study was designed to evaluate the possible effect of 4-week treatment with oral NAC on plasma tHcy and MDA concentrations and status of antioxidant enzymes in chronic hemodialysis (HD) patients who were receiving vitamin B group at least from the onset of dialysis program. Twenty patients were enrolled in this study. All subjects were treated with oral NAC (600 mg twice daily) for 4 weeks. Predialysis plasma tHcy and MDA concentrations and activities of glutathione peroxidase, catalase, and superoxide dismutase were assessed before the initiation of NAC and after 4-week NAC therapy. At baseline, moderately severe hyperhomocysteinemia was present in about 63% of patients. The results showed significant (19%) decline in plasma tHcy concentration after NAC therapy. However, moderately severe hyperhomocysteinemia was persistently seen in about 50% of the patients. NAC did not affect concentration of MDA and antioxidant enzymes activities. Because of the proposed relationship between cardiovascular morbidity and hyperhomocysteinemia in patients on HD, daily supplementation of patients with NAC may be recommended as adjunct to vitamins in those subjects who did not respond adequately to group B vitamins alone.

Background Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic renal disorder caused by mutation in 2 genes PKD1 and PKD2. Thus far, no mutation is identified in approximately 10% of ADPKD families, which can suggest further locus heterogeneity. Owing to the complexity of direct mutation detection, linkage analysis can initially identify the responsible gene in appropriate affected families. Here, we evaluated an Iranian ADPKD family apparently unlinked to both PKD1 and PKD2 genes. This is one of the pioneer studies in genetic analysis of ADPKD in Iranian population. Methods Linkage reanalysis was performed by regenotyping of flanking microsatellite markers in 8 individuals of the ADPKD family. Direct mutation analysis was performed by Sanger sequencing. Results Mutation analysis revealed a pathogenic mutation (c.1094+1G>A) in the PKD2 gene in the proband. Analyzing 2 healthy and 4 clinically affected members confirmed the correct segregation of the mutation within the family and also ruled out the disease in 1 suspected individual. Misinterpretation of the linkage data was due to the occurrence of 1 crossing over between the PKD2 intragenic and the nearest downstream marker (D4S2929). Homozygosity of upstream markers caused the recombination indistinguishable. Conclusion Although analysis of additive informative polymorphic markers can overcome the misleading haplotype data, it is limited because of the lack of other highly polymorphic microsatellite markers closer to the gene. Direct mutation screening can identify the causative mutation in the apparently unlinked pedigree; moreover, it is the only approach to achieve the confirmed diagnosis in individuals with equivocal imaging results.

Insulin resistance (IR), a risk factor for cardiovascular disease and all-cause mortality, is prevalent among maintenance hemodialysis patients. Effects of omega-3 fatty acids on IR in hemodialysis patients have not been well understood. This study aimed to determine the effects of omega-3 fatty acids on IR and serum lipids of hemodialysis patients.Fifty-four adult patients on hemodialysis were randomly assigned to receive either 1800 mg of omega-3 fatty acids or placebo daily for 4 months. Serum concentrations of glucose, triglyceride, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, C-reactive protein, insulin, leptin, and adiponectin were measured at baseline and after 4 months of the intervention. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance and 2 adipokine-based measures of IR, including the leptin-adiponectin ratio and homeostasis model assessment corrected by adiponectin.Mean differences of serum C-reactive protein, insulin, leptin, and adiponectin concentrations did not show significant difference between the two groups following 4 months of intervention. Fasting serum glucose and low-density lipoprotein cholesterol were not significantly influenced by omega-3 supplementation, either. Serum triglyceride, total cholesterol, and high-density lipoprotein cholesterol levels significantly decreased in the omega-3 group (P = .02, P = .03, and P.001, respectively). None of the indirect indexes of IR showed significant changes at the end of the study in either the omega-3 or placebo group.Supplemental use of omega-3 fatty acids showed some beneficial effects on lipid profile of hemodialysis patients without any improvement in IR.

Background: Staphylococcus aureus is one of the most important microorganisms that causes various human diseases by secreting virulence factors known as staphylococcal super antigens (SAgs). Staphylococcal Enterotoxin B (SEB) is a bacterial antigen that is responsible for food poisoning in humans. Among SEB detection methods, a lateral flow device (LFD) is ideal for rapid immunochromatographic tests because it is easy to use, requires minimal time to produce results, and does not require personnel training. Objectives: In our laboratory, the production of an immunochromatographic test strip, for the detection of SEB using a sandwich assay and a competitive method, was described; the test can detect SEB with high sensitivity. Materials and Methods: The strip assays were compared with PCR, a valid method for detection. For PCR, a specific sequence for SEB production was detected using primers designed according to GenBank sequences. Results: In total, 80 food samples suspected of SEB contamination were assessed using the two methods. Fifty-four samples were contaminated based on the PCR technique and twenty-six of those were confirmed using the strip assay. Conclusions: The sensitivity of the sandwich method was approximately 10 ng/mL and that of the competitive method was approximately 250 ng/mL. In the LFD, a highly specific monoclonal antibody used for both the sandwich and competitive methods resulted in an increased sensitivity and accuracy for the detection of a minimal SEB concentration.

Iminoral is the generic microemulsion of cyclosporine. We performed a randomized double-blind multicenter trial to evaluate its efficacy and safety compared with the innovator medication Neoral for preventing acute rejection episodes in adult patients during the first year after renal transplant.We used 221 de novo renal transplant recipients from 6 transplant centers in Iran enrolled between April 2008, and January 2010. They were randomized to receive either Iminoral or Neoral as the calcineurin inhibitor component of the immunosuppressive regimen in addition to mycophenolate mofetil and oral corticosteroids. They were followed-up for 1 year. The primary endpoint was the rate of acute allograft rejection. Secondary endpoints consisted of 1-year graft survival rates, daily dosages of cyclosporine, trough and C2 cyclosporine blood level, serum creatinine levels, patient death rates, discontinuing the study drug, tolerability, and adverse events.The risk of acute rejection episode during the first month after transplant was 9% for Iminoral and 10% for Neoral; these declined to 4% and 2% during next 11 months. One-year graft survival rate was 0.86 for both groups. Renal function stabilized during the first month. Declination of the creatinine levels was similar between the 2 groups and reached a stable value of 114.9 μmol/L five months after the transplant. The frequency of clinical complications was similar between the groups.Iminoral is safe and effective when used in de novo kidney transplant patients as an immunosuppressive medication.

Background: Antibody mediated rejection (AMR) and thrombotic microangiopathy (TMA) after kidney transplantation are difficult to differentiate most of the times and both play important roles in kidney allograft loss. Common treatment strategies of these two conditions include plasmapheresis, intravenous immunoglobulin (IVIG) and rituximab. Objectives: This study was designed to assess the efficacy of routine treatment of AMR/TMA in Iranian kidney transplant recipients, which comprises of plasmapheresis and IVIG. Patients and Methods: This one-year cross-sectional study was performed in the Kidney Transplantation Ward of Imam-Khomeini Hospital Complex, Tehran, Iran. All kidney transplant recipients who were administered plasmapheresis and IVIG to treat definite or suggested AMR or TMA were assessed clinically and also evaluated on laboratory data. Results: During 2014, we encountered five patients with suspicious AMR or TMA at our kidney transplant center. Renal biopsy was performed for two of them, suggesting AMR for one patient and TMA for another patient. All patients were treated with plasmapheresis plus IVIG. In this center, as a routine practice, the cumulative dose of 2 g/kg of IVIG was divided to 300 - 400 mg/kg after each plasmapheresis. Only one out of the five patients showed response, albeit not completely. Conclusions: Due to daily plasmapheresis within the first several days after AMR or TMA, administering high amounts of the cumulative dose of IVIG after plasmapheresis may result in high amounts of IVIG withdrawal by plasmapheresis and response failure. Our suggestion is to reduce the IVIG dose after each plasmapheresis to 100 mg/kg (i.e. replacement dose) to reach a cumulative dose of 2 g/ Kg. If plasmapheresis treatment is initiated sooner than the completion of the IVIG cumulative dose of 2 g/kg, the remaining dose can be administered during one injection.

Hyperphosphatemia is a significant risk factor for the development of ectopic calcification and coronary artery diseases in patients on hemodialysis (HD), and must be controlled with the use of phosphate binders. Studies comparing the effects of sevelamer and nicotinic acid, both similar non-calcium and non-aluminum phosphate binders, are not available. In this study, 40 patients on HD with a serum phosphorus level of more than 6 mg/dL were enrolled. After a two week washout period without phosphate binders, the patients were randomly divided into two equal groups (n = 20) and were started on nicotinic acid or sevelamer for a period of four weeks. The dose of nicotinic acid used was 500 mg and that of sevelamer was 1600 mg daily. Blood samples were drawn for the measurement of the total calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), triglyceride (TG), total cholesterol (Chol), high-density lipoprotein (HDL), low-density lipoprotein (LDL), uric acid and parathyroid hormone (PTH). Patients receiving sevelamer showed a significant reduction in serum P level (2.2 ± 0.69 mg/dL; P

Renal artery stenosis in elderly patients is mainly caused by atherosclerosis. The prevalence of this disorder in patients with chronic kidney diseases is reported to be 0.5% to 5.5%. However, because the patients with atherosclerotic renal artery disease are mostly asymptomatic, the true prevalence is expected to be higher. Renovascular hypertension and ischemic nephropathy are two main consequences of this disease, but it is difficult to determine in which patient the progress of stenosis may cause these syndromes. The big challenge in renal artery stenosis is how to manage the patients. In the past 70 years, it has been believed that simply maintaining of kidney perfusion by opening the stenosis could control blood pressure and preserve kidney function. Nowadays, the blood pressure can be controlled well by medical treatment without the need for revascularization; however, management of ischemic nephropathy remains a dilemma. With advancements in understanding the pathophysiology of changes in the parenchyma of the kidney after stenosis, it is now generally accepted that only a minority of patients with ischemic nephropathy will benefit from revascularization. Nonetheless, finding these patients is critical and need more randomized trials to show who mostly benefit from revascularization and when it may save the kidney.

Since Wilhelm Rontgen reported his novel discovery of the XRay in 1895(Rontgen, 1898 as cited in Weinmann etal., 2005), the Diagnostic imaging has been an integral part of medicine. He was decorated by the second class of Prussian crown medal and he was also awarded the first physic Nobel Prize at 1901. LevyDorn was another pioneer in radiology who understood the potential importance of X-ray in medicine and opened a daily private office for medical examination with X-ray in 1896 just one year after innovation of X-ray by Rontgen. He pointed to the danger of this method to the living organism very early (Hierholzer K & Hierholzer J 1997; Nitze, 1895; as cited in Hierholzer K & Hierholzer J, 2002) Since X-rays are not sufficiently absorbed by soft tissue, contrast media (CM) is used to highlight organs or pathologies. Osborne etal reported that inorganic Iodine enhanced the urinary tracts X-ray images (Osborn etal., 1923). But the most important contributor to the field of urological imaging came from the field of agriculture when A Binz and C Rath, two scientists from the Berlin agricultural college synthesized a new organic iodinated molecule "Selectan"(Binz & Rath 1928 as cited in Hierholzer K & Hierholzer J, 2002), and a research fellow used this agent in clinical investigations. (Swick 1929a, 1929b as cited in Hierholzer K & Hierholzer J, 2002; Weinmann etal., 2005). In 1928 an urologist, Forssmann, used one of these agents in his own coronary arteries (Hricak & Barbarive 1984).This was an unexpected methodological contribution of urological research to cardiology. From 1929 on, serial production of Uroselectan was established. This agent was a big step forward in safety, because ionic iodide (Sodium Iodide and Lithium Iodide) cannot be used in a clinical setting. In the early 1950s, a new generation of iodinated agents was launched, which were derivatives of triiodinated benzoic acid, e.g. diatrizoate (Urografin etc.). These agents became standard in diagnostic imaging for the next 30 years and are still widely used in many countries. Almen suggested that non-ionic molecules could reduce osmolality (Almen, 1969, as cited in Weinmann etal., 2005), an idea that was the basis of safer compounds that entered routine clinical use in the 1980s. Water-soluble, non-ionic iodinated contrast agents are now the workhorses in contrast based imagings. More than 90% of contrasts media are used in western countries are non-ionic CM. There are two main complications of contrast media. The aim of this chapter is to discuss these two major side effects of CM. the most important of these two complication is contrast induced nephropathy (CIN) which will be described in details and the other is anaphylaxis reactions to the CM which will be mentioned briefly at the end of the chapter.

Background Based on Acute Kidney Injury Network (AKIN) criteria, we considered acute kidney injury (AKI) as an absolute increase in the serum creatinine (sCr) level of more than or equal to 0.3 mg/dl or 50%. The introduction of Urinary neutrophil gelatinase-associated lipocalin (UNGAL) has conferred earlier diagnosis of AKI. Pentoxifylline (PTX), a non-specific phosphodiesterase inhibitor, can suppress the production of some factors of inflammatory response and presumably prevent AKI. We examined the PTX on the development of AKI in cardiac surgery patients by measuring the levels of UNGAL. Materials and methods We performed a double blind randomized clinical trial, enrolling 28 consecutive patients undergoing elective coronary artery bypass graft (CABG) surgery. Patients were divided into two groups, one to receive PTX 5 mg/kg intravenous bolus injection, followed by 1.5 mg/kg/h continuous intravenous infusion until 3 hours after cessation of CPB and the other group received placebo. UNGAL was measured before, 3 and 24 hours after surgery. In addition serum creatinine was measured before and 24, 48, 72 and 96 hours after surgery and C-reactive protein (CRP) only 24 hours postoperatively. Results Both groups did not differ in demographic and baseline characteristics. 12 patients developed AKI 48 hours after surgery; 5 of them were in the intervention group and 7 in the control group (p= 0.445). There was an increase of UNGAL in both groups postoperatively, although not significant. Mean sCr was significantly increased in the control group at 24 and 48 hours after surgery (24-h mean: 0.79 ± 0.18 mg/dl vs. 1.03 ± 0.43 mg/dl, P value = 0.02; 48-h mean: 1.17 ± 0.24 mg/dl vs. 0.98 ± 0.20 mg/dl, P value = 0.03, respectively). PTX had a positive effect in preventing AKI reflecting in changes in sCr, and the increase of UNGAL was consistent with the emergence of AKI (Pearson's correlation = 0.30). Conclusion Our study demonstrates a weak correlation between UNGAL and sCr after cardiac surgery. The rise of UNGAL in these patients may be reduced by administration of PTX although we did not show significance. PTX could reduce the occurrence of AKI as determined by attenuation of sCr rise without causing hemodynamic instability or increased bleeding. Overall, we suggest future studies with larger sample sizes to elucidate this effect and determine the different aspects of administrating PTX. Trial Registration ISRCTN: IRCT138807302622N1

Sodium bicarbonate has been recently proposed as a prophylactic measure for the prevention of contrast-induced nephropathy (CIN). We aimed to compare the efficacy of the combination of sodium bicarbonate with half saline, and half saline alone in preventing CIN in patients having uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema.Seventy-two patients undergoing elective coronary angiography with a serum creatinine levelor =1.5 mg/dL who had uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema were prospectively enrolled in a single-center, double-blind, randomized, controlled trial from August 2007 to July 2008 and were assigned to either an infusion of sodium bicarbonate plus half saline (n=36) or half saline alone (n=36). The primary end point was an absolute (or =0.5 mg/dL) or relative (or =25%) increase in serum creatinine 48 hours after the procedure (CIN).There were no significant differences between the groups regarding their baseline demographic and biochemical characteristics, as well as the underlying disease. A total of 6.1% of the patients receiving sodium bicarbonate plus half saline developed CIN as opposed to 6.3% of the patients in the half saline group, which was not statistically different (odds ratio = 0.97; 95% confidence interval, 0.13-7.3; p=1.0).The combination therapy of sodium bicarbonate plus half saline does not offer additional benefits over hydration with half saline alone in the prevention of CIN.

Central vein catheterization is a routine and relatively safe procedure in critically ill patients. Complications with this procedure depend to the site of catheterization and the skill of the operator. In addition to the common complications with femoral vein catheterization there are some rare usually preventable side effects related to guide wire and catheter. In our patient who underwent femoral catheterization for acute hemodialysis, we report migration of guide wire through the systemic circulation from the femoral vein to the jugular vein. This is a very rare complication that is a human error and is totally preventable by doing the procedure by a skilled doctor and considering the standards described for central vein catheter insertion.

High serum levels of lipoprotein(a) and homocysteine are risk factors of cardiovascular disease which are prevalent in patients on hemodialysis. Controversy exists about the effects of hydroxymethylglutaryl-CoA reductase inhibitors on serum lipoprotein(a) levels in patients on hemodialysis. Also, deficiency of some water soluble vitamins and administration of statins may raise serum levels of homocysteine in these patients. This study was designed to investigate serum levels of lipoprotein(a) and homocysteine in patients on hemodialysis who were taking a statin, vitamin B6, and folic acid.We investigated on 152 patients with maintenance hemodialysis who were taking atorvastatin or lovastatin, vitamin B6, and folic acid for at least 6 months. Their serum levels were obtained to measure lipoprotein(a) and homocysteine levels, as well as triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol.The mean serum values of total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol and triglyceride were significantly less than the maximum reference values (P.001). The mean serum level of lipoprotein(a) was also less than the reference value (P = .009), but homocysteine level was 33% higher on average than the reference value (P.001).Our study demonstrated that in our patients on hemodialysis, the mean serum level of homocysteine was about 30% higher than the reference value although they were receiving vitamin B6 and folic acid. Hence, they were still exposed to the risk of cardiovascular disease.

Background There is controversy about the prophylactic measures proposed for the prevention of contrast-induced nephropathy (CIN). We aim to compare the efficacy of the combination of sodium bicarbonate and isotonic saline and that of isotonic saline alone in preventing CIN. Study Design Randomized double-blind controlled trial. Setting & Participants 265 consecutive patients 18 years or older with a serum creatinine level of 1.5 mg/dL or greater undergoing elective coronary angiography from August 2007 to June 2008 in Tehran Heart Center, Tehran, Iran. Intervention Study participants were randomly assigned to receive either 75 mL of 8.4% sodium bicarbonate added to 1 L of isotonic saline (n = 135) or isotonic saline alone (n = 130) as a bolus of 3 mL/kg for 1 hour before contrast injection, followed by an infusion of 1 mL/kg/h for 6 hours after the procedure. Outcomes & Measurements The primary end point was an absolute (≥0.5 mg/dL) or relative (≥25%) increase in serum creatinine level 48 hours after the procedure (CIN). Results There were no significant differences between the bicarbonate and saline groups regarding baseline demographic and biochemical characteristics, including baseline serum creatinine level (1.63 ± 0.32 [SD] versus 1.66 ± 0.50 mg/dL), baseline glomerular filtration rate (46.4 ± 12 versus 45.4 ± 12 mL/min/1.73 m 2 ), and baseline urine pH (5.42 ± 0.6 versus 5.46 ± 0.8). Nine patients (7.4%) receiving sodium bicarbonate developed CIN as opposed to 7 patients (5.9%) in the saline group, which was not statistically different (odds ratio, 1.26; 95% confidence interval, 0.45 to 3.50; P = 0.6). Limitations The trial did not follow up participants to assess need for dialysis and mortality rate. Conclusion The combination therapy of sodium bicarbonate plus saline does not offer additional benefits over hydration with saline alone in the prevention of CIN.

Post-transplant erythrocytosis (PTE) is characterized by persistently elevated hematocrit levelor= 51%. This complication is reported to develop in 10-20% of renal allografts recipients, mostly 2 years after kidney transplantation. PTE is self-limited in 25% of the patients; however it may persist in patients with an increased susceptibility for thrombosis and potential fatal outcome. To evaluate the prevalence and risk factors of PTE in our center, we reviewed the records of 235 patients who received renal allografts from 1999 to 2004. Polycythemia was found in 45 (19%) patients. There was no significant correlation of polycythemia and age, history of hypertension, diabetes, pre-transplant hematocrit level, pre-transplant history of transfusion, graft's function, and source of kidney. A significantly higher proportion of PTE patients were males, patients with history of polycystic kidney disease, and patients with glomerulonephritis. We conclude that PTE is an important complication of kidney transplantation. There are several risk factors that should be addressed to prevent this complication.

Contrast-induced nephropathy (CIN) is the third leading cause of acute kidney injury in hospitalized patients. The prevalence of CIN is reported to range from 0% to 50%, depending not only on patient condition and the procedure used but also the definition of CIN applied. We aimed to determine the best diagnostic indicator of CIN in patients with normal serum creatinine. This study included 206 patients with normal serum creatinine who underwent coronary angiography/angioplasty. Serum creatinine level and glomerular filtration rate (GFR) were measured before and on the second and fifth days after contrast administration. The incidence of CIN based on a 25% increase in serum creatinine was calculated and compared with the incidence based on a 25% decrease in GFR or an increase of at least 0.5 mg/dL in serum creatinine. Of 206 patients, 127 were male (61.7%) and 79 were female (38.3%); the mean age was 59.56 ± 10.3 years. The prevalence of CIN was 30% based on a 25% increase in serum creatinine, 23% based on a 25% decrease in GFR (P

Neutrophil-gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury. The aim of this study was to define a cut-off for NGAL in the early diagnosis of contrast-induced nephropathy (CIN) in patients with normal kidney function. We enrolled 121 patients with normal serum creatinine who underwent coronary angiography. NGAL was measured in urine before the procedure and 12 and 24 h afterward. CIN was defined as a 0.3 mg/dl increase in serum creatinine within 48 h after the procedure. Seven of 121 patients had CIN (5.8%). The NGAL levels in the 12- and 24-h urine samples of these patients were 30 (5-45) and 20 (15-40) ng/ml, respectively, whereas those in patients without CIN were 15 (5-45) and 15 (10-51) ng/ml, respectively (P = 0.8). In patients with CIN, the sensitivity and specificity of NGAL with a cut-off of 22.5 ng/ml were 71.4% and 57.9% in 12-h urine samples, with the negative predictive values (NPV) and positive predictive values (PPV) of 97.1% and 9.4%, respectively. In conclusion, we suggest that urine NGAL with cut-off point of 22.5 ng/ml has acceptable sensitivity and specificity for early diagnosis of CIN in patients with normal serum creatinine, but regarding NPV and PPV the best performance of this value is to rule out the CIN in patients at risk who received contrast media.