Journal of The Egyptian Society of Nephrology and Transplantation (J Egypt Soc Nephrol Transplant) 2018 | October-December | Volume 18 | Issue 4

Relation of wnt-signaling antagonist sclerostin to valvular calcification and carotid intimal-medial thickness in hemodialysis patients Ghada El-Said, Mohamed AbdAlbary, Ahmed Bahi, Rash R Elzehry, Ghada El-Kannishy Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):103-111 Introduction Sclerostin (Scl) is a Wnt pathway antagonist and is considered to have a role in the bone-vascular axis in patients with chronic kidney disease. However, there is a paucity of data on the relation of circulating serum Scl and valvular calcifications (VCs) in chronic kidney disease and hemodialysis (HD) patients. The present study aimed to evaluate the relationship between serum Scl level and cardiac valve calcification (CVC) as well as carotid intimal-medial thickness (CIMT) in HD patients. Patients and methods This cross-sectional study included 75 HD patients in Mansoura Nephrology and Dialysis Unit. Patients with age older than 75 years, rheumatic valvular disease, cardiomyopathy, prosthetic valves, ischemic heart disease, and carotid artery surgery were excluded. Echocardiogram calcification scores were used to assess the degree of aortic and mitral valve calcification. CIMT was measured using B-mode ultrasonography. Patients’ basic clinical and biochemical data were recorded. Serum Scl level was measured using commercially available enzyme-linked immunosorbent assay kits before HD sessions. Results CIMT (>0.9 mm) was present in 68% of the patients. Double-valve calcification (aortic and mitral) was present in 72% of the patients and 21.3% of the patients had single-valve calcification. Serum Scl level was significantly higher in studied HD patients than normal healthy control (P=0.05). There was a significant negative correlation between serum Scl level and degree of cardiac valve calcification as well as with CIMT. Multiple linear regression analysis revealed that age was the strongest predictor for CIMT in HD patients. Conclusion Cardiac valve calcification and increased CIMT were prevalent in HD patients. Serum Scl level was strongly related to both CVC and CIMT, and it may be considered as one of the calcification modulators in HD patients.

Risk factors, clinical manifestations, and outcomes of Pneumocystis jirovecii infection in post-renal transplant recipients Jitesh Jeswani, Suraj Godara, Chandani Bhagat Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):112-115 Introduction Pneumocystis jirovecii pneumonia (PJP) is a potentially life-threatening infection that occurs in immunocompromised patients. A timely diagnosis of PJP is difficult and relies on clinical features, imaging, and detection of the organism. The aim of this study was to evaluate the risk factors, clinical presentation, and outcomes for 15 patients who developed PJP infection. Patients and methods A retrospective clinical study included all 578 kidney transplant patients who underwent kidney transplantation at the Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. Of the 578 patients, 15 patients developed PJP infection. Results The median age of all recipients was 55.3 years. The mean duration of prophylaxis was 6.9 months (range: 3–9 months). Only one patient had cytomegalovirus infection, and eight patients had a history of graft rejection. Most of our patients had fever and cough as the presenting symptoms, and all patients had breathlessness on admission. Bilateral haziness seen on chest radiograph was present in seven patients, and 10 patients had bilateral ground-glass appearance on high-resolution computed tomography scan. PCR finding for PJP was positive in all patients. Mortality was seen in four patients, where all the four cases had received anti-rejection therapy with ATG. Conclusion We concluded that among renal transplant recipients, PJP can still occur several months after transplantation, late after prophylaxis discontinuation. Treatment with anti-rejection therapy appears to be the major risk factor for PJP in these patients.

Predictive value of novel biomarkers for acute kidney injury in critically ill patients at Assiut University Hospitals Effat A.E Tony, Hatem H.M Maghraby, Shady Y Gayed, Ayat A Sayed Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):116-125 Introduction Acute kidney injury (AKI) is a clinical problem in critically ill patients, which is associated with adverse outcomes. There is a persistent need to find reliable biomarkers for the early diagnosis and prediction of AKI. Many genes are upregulated in the damaged kidneys, with the subsequent protein products appearing in the urine. Urinary liver-type fatty acid-binding protein (uL-FABP) and urinary kidney injury molecule-1 (uKIM-1) are among the promising upregulated biomarkers. Aim To assess the ability of uL-FABP in comparison with kidney injury molecule-1 for early prediction of AKI in adult critically ill patients. Patients and methods A cohort study was conducted enrolling 100 critically ill patients admitted to medical critical care units (CCUs) who had risk factors for developing AKI. Acute Physiology and Chronic Health Evaluation II score was calculated on admission. Serum creatinine was measured on admission and thereafter daily till the seventh day of CCU stay. Urine samples for uL-FABP and uKIM-1 assay were collected at the time of CCU admission, on day 3, and on day 5. Results Among critically ill patients, 60% had AKI diagnosed mostly on the second (53.3%) and third (40%) day of CCU admission. There was a significant difference in Acute Physiology and Chronic Health Evaluation II score (P<0.001), and duration of CCU stay (P<0.01) between AKI and non-AKI groups. The mean baseline of uKIM-1 was significantly higher in patients with AKI (7.17±1.56 ng/ml) compared with those without AKI (3.01±0.85 ng/ml; P=0.01). A significant high baseline uL-FABP level in patients with AKI was 168.51±45.98 (P<0.001). The area under the receiver operating characteristic curves of uKIM-1 and uL-FABP levels at the time of admission for prediction of AKI in critically ill patients within the first 7 days of their stay were 0.95 and 0.78, respectively, with a better predictive performance of uKIM-1 than uL-FABP. Conclusion UKIM-1 was a sensitive and specific biomarker (superior to uL-FABP) for the prediction of AKI in critically ill patients.

Spectrum of biopsy-proven kidney diseases at a tertiary care hospital in South India Sanjeev S Manjunath, Chettypunyam S Chetan, Chaandrashekar Manoj, Satish Suchitha, Krishnamurthy K Kiran, Gangadhar Chirag Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):126-129 Introduction The prevalence of kidney diseases, glomerular and tubulointerstitial, varies with the geographical area, socioeconomic conditions of the people, population demographics, race and ethnicity, access to health care, and also the threshold for doing a renal biopsy. Objective The primary objective was to study the prevalence of biopsy-proven kidney diseases presenting to a tertiary care hospital in Mysore, South India. Patients and methods We have retrospectively analyzed the renal biopsy data from 2005 to 2013. The clinical and laboratory data of patients were collected from biopsy request forms, and histopathology data were recorded. Biopsy specimens were examined by light and immunofluorescence microscopy. As a hospital policy, all biopsies were based on definite indications. A total of 1113 biopsies were considered. Transplant biopsies and those with inadequate specimen were excluded. Results A total of 914 patients had some kind of glomerulopathy. Minimal change disease (n=182/1113) was the commonest histological type among glomerular diseases, followed in order by postinfectious glomerulonephritis, focal segmental glomerular sclerosis, membranous glomerulopathy, and immunoglobulin A nephropathy. Among the secondary glomerular diseases, the commonest was diabetic nephropathy (n=72) followed by lupus nephritis (n= 58) and crescentic glomerulonephritis. Most common indication for renal biopsy was nephrotic syndrome (n=274/1113), chronic kidney disease (n=141), acute glomerulonephritis (n=107), acute kidney injury with unclear etiology or delayed recovery, and rapidly progressive glomerulonephritis. Conclusion Nephrotic syndrome was the commonest indication for renal biopsy, and minimal change nephrotic syndrome (MCNS) was the most common glomerular disease followed by focal segmental glomerular sclerosis. Membranoproliferative glomerulonephritis, the incidence of which has decreased in the developed world, still accounts for a significant number in our population. There is a need for electronic data monitoring in India with nationwide integration for a proper analysis of the changing trends of diseases occurring over an extended time frame.

Cognitive disorders in chronic kidney disease and hemodialysis patients Ahmed S El Belbessi, Iman E El Gohary, Hesham A Sheshtawi, Mona M Abdulmoneim Mohamed Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):130-136 Introduction Cognitive impairment (CI) is common in individuals with chronic kidney disease (CKD) and among those treated with hemodialysis (HD). It may jeopardize treatment adherence by affecting the efficiency of every-day tasks, including correct medication and dietary rules. The severity of CKD is associated with the severity of CI, independent of age, education, and other key confounders. It is important to identify those patients with CI to reduce the considerable morbidity associated with this condition and improve their quality of life. Objectives The aim of the present study is to assess cognitive functions in patients with chronic renal diseases and patients on regular HD and to identify CI in these patients. Patients and methods A total of 30 patients with CKD were recruited from the outpatient clinic of Alamerya General Hospital (group I), and 30 HD patients were enrolled in the dialysis unit of the Alamerya General Hospital (group II). Moreover, 30 sex-matched and age-matched patients were recruited as controls (group III). Montreal Cognitive Assessment (MoCA) and Depression Anxiety Stress scale-21 were used as cognitive and neurological tests. Result The mean executive functions score was significantly lower in group II (2.37±0.67) in comparison with group I (3.33±0.48), with a P value less than 0.001, and it is also significantly lower in groups I and II in comparison with the control group (3.90±0.31), with a P value of 0.002 and less than 0.001, respectively. The mean attention score was significantly lower in group I (4.20±0.81) and group II (4.23±0.94) in comparison with the control group (5.27±0.69), with a P value of less than 0.001. The mean memory score was significantly lower in group I (3.10±0.40) and group II (2.57±0.90) in comparison with the control group (4.47±0.73), with a P value of less than 0.001. The mean total MoCA test score was significantly lower in group II (22.87±1.68) in comparison with group I (24.27±1.26), with a P value of less than 0.017, and it is also significantly lower in groups I and II in comparison with the control group (28.33±1.47), with a P value of less than 0.001. Conclusion Impaired renal function affects total MoCA score in the studied groups.

A study of comparison of clinical assessment of substituted frailty versus performance-based frailty in patients on maintenance hemodialysis program funded by cashless government scheme Priyadarshini John, Manjusha Yadla, Sailaja Singiri Journal of The Egyptian Society of Nephrology and Transplantation 2018 18(4):137-143 Introduction Frailty is common in patients on maintenance dialysis.The common methods used to assess Frailty include questionnaires,Frailty index.SF-36 is a commonly used questionnaire to assess quality of life.SF-36 in modified version may be used as substituted Frailty index.Whether Frailty can be assessed with the substituted frailty index is not clear. We tried to compare the two methods of assessment of Frailty with Performance based Frailty and Substituted Frailty to analyse the better index of assessment in patients on maintenance dialysis. Aim The aims were to compare frailty using two different methods of assessment in patients on maintenance hemodialysis and to determine the utility of substituted frailty as screening tool for assessment of frailty. Patients and methods We studied frailty in patients on maintenance hemodialysis using two different methods of assessment. Fried frailty index is performance based and is inconvenient to assess in every patient. In a search to find an alternative, we came across another method of evaluation using physical function (PF) component in SF-36 score. We studied quality of life in these patients using SF-36 questionnaire. PF in SF-36 scale was used as a substitute for gait speed and grip strength, which are the components in the original frailty index. The other components like unintentional weight loss, physical inactivity and physical exertion were the same in both the methods of assessment. Substituted frailty (Fsubs)=PF score on SF-36, unintentional weight loss greater than 4.5 kg, physical exhaustion, and physical inactivity. Performance-based frailty/measured frailty (Fmeas)=weight loss greater than 4.5 kg, physical exhaustion, low physical activity, handgrip strength assessment, and gait speed. Results A total of 117 (78%) patients reported frailty based on self-assessment (substituted frailty, Fsubs) and 136 (90.6%) patients had frailty on performance-based frailty index using Fried frailty index (Fmeas). Overall, 28 (18.6%) patients had performance-based frailty only and did not report the symptoms suggestive of frailty. Age and sex were not significantly different among the groups. In our study, we observed the sensitivity of Fsubs (substituted frailty) was 79.5%, specificity was 35.7%, and accuracy was 75.3%. Positive predictive value of Fsubs was 92.30% and negative predictive value was 15.15%. Conclusion Substituted frailty may be a useful screening modality to identify frailty in patients on maintenance hemodialysis.