Kidney Diseases and Transplantation

Burden, access, and disparities in kidney disease Deidra C Crews, Aminu K Bello, Gamal Saadi, for the World Kidney Day Steering Committee  Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):281-290 Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage world-wide by 2030 is one of the World Health Organization’s Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.

Therapeutic plasma exchange for children with kidney disorders: Definitions, prescription, indications, and complications Khalid A Alhasan Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):291-298 Therapeutic plasma exchange (TPE) is a procedure that involves the removal of a large volume of plasma that is replaced with a replacement fluid, which is usually 5% albumin or fresh-frozen plasma. This therapeutic modality presents several technical challenges in children but has become increasingly used in pediatric nephrology. Owing to advances in technology, scientists have gained substantial knowledge of the molecular pathogenesis underlying many pediatric renal diseases, supporting the use of TPE in treating these disorders. This review presents a synopsis of the literature as it relates to the accepted indications for TPE in children, the technical aspects of the procedure, and the associated complications. Increased collaboration between pediatric nephrologists will hopefully allow scientists to obtain more data in children to assess the benefits of TPE in various renal disorders and improve the quality of care provided in children with renal disorders.

Birth weight, gestational age, and blood pressure: Early life management strategy and population health perspective Issa Al Salmi, Faisal A M. Shaheen, Suad Hannawi Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):299-308 The incidence of hypertension (HTN) is rising worldwide with an estimated prevalence of 22%, 7.5 million deaths (12.8%). It is a major risk factor for coronary heart diseases and hemorrhagic strokes. In Oman, the crude prevalence of HTN was 33.1%, whereas the age-adjusted prevalence was 38.3%. Among Gulf Cooperation Countries, 47.2% of the individuals were hypertensive, and women were more likely to have HTN than men. Similarly, the prevalence of low-birth-weight (LBW) is also rising globally with the more prevalent incidence in developing countries reaching almost a rate just lower than 20.0/100 births. In Oman, the prevalence of LBW was 4.2% in 1980, which doubled (8.1%) in 2000 and has shown a slow but steady increase reaching 10.2% in 2013. LBW term is the most commonly used surrogate measure of intrauterine growth retardation and has been related to increased cardiovascular mortality, due to increased risk of cardiovascular risk factors, including blood pressure (BP), diabetes, cholesterol level, and other risk factors. The epidemiologic evidence clearly points to an inverse association between birth weight and many hemodynamic cardiovascular risk markers. Possible mechanisms operating in fetal life that might determine BP include the structural development of resistance arteries, the setting of hormone levels, and nephron endowment. Retarded fetal growth leads to permanently reduced cell numbers in the kidney. Patients with high BP had almost 50% less number of glomeruli compared to that of the normotensive individuals, and subsequent accelerated growth may lead to excessive metabolic demand on this limited cell mass. It is not merely a reduced nephron number that is responsible for HTN, but compensatory maladaptive changes that occur internally when nephrogenesis is compromised. The likelihood of an adverse outcome is greatly amplified in those born with LBW who later develop obesity or an increased ponderal index.

Chyluria in pregnancy: Etiology, diagnosis, and management perspective Bimalesh Purkait, Gaurav Garg, Manmeet Singh, Ashish Sharma, Siddharth Pandey, Satya Narayan Sankhwar Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):309-314 Chyluria is clinically described as passage of milky urine. Chyle is absorbed by intestinal lacteals and is composed of emulsified fats, few proteins, and fibrin in varying proportions. Parasitic chyluria is caused mainly by Wuchereria bancrofti infection. The incidence of chyluria in pregnancy is not uncommon in endemic regions. The literature pertaining tomedical management of chyluria in pregnancy is scant. The antifilarial drugs have potential teratogenic risk and are not recommended in pregnant patients. Hence, there is a management dilemma for managing patients with chyluria during pregnancy. In this review, we have tried to highlight the evidence-based diagnosis and management of chyluria in pregnancy.

Association of hepcidin and anemia in early chronic kidney disease Satyendra Kumar Sonkar, Neeraj Kumar Singh, Gyanendra Kumar Sonkar, Sant Pandey, Vivek Bhosale, Anil Kumar, Kauser Usman Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):315-324 Hepcidin is being extensively studied for anemia and inflammation in chronic kidney disease (CKD) patients. Hepcidin is thought to regulate iron metabolism by iron blockade through various mechanisms. Patients with CKD have early cardiac mortality due to anemia and subclinical inflammation; hence, we studied hepcidin as a biomarker in patients with early stage of CKD in relation to anemia and inflammation. In our cross-sectional study, a total of 80 patients were enrolled of whom, there were 25, 26, and 29 patients in CKD stages 1, 2, and 3, respectively. Patients were divided into normal iron level (39), functional iron deficiency (FID) (18), and absolute iron deficiency (AID) (23) based on transferrin saturation and ferritin. We found significantly high level of hepcidin (P <0.05) and high-sensitivity C-reactive protein (hsCRP) (P <0.05) in FID as compared to AID as well as normal iron level. We also found other inflammatory markers such as albumin, transferrin, and ferritin to be significantly associated with FID. In univariate analysis, hemoglobin (Hb) varied significantly with serum total iron-binding capacity (r = 0.40, P <0.001), log hsCRP (r = -0.32, P <0.01), and log ferritin (r = -0.23, P <0.05); however, Hb was not affected significantly with log hepcidin (r = -0.07, P >0.05). The study indicates that among early CKD patients with FID, there was high level of hepcidin along with other inflammatory parameters, which may be associated with poor cardiovascular disease outcome due to increased inflammation.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries Anupma Kaul, Hiral Lal, Prabhakar Mishra, Manoj Jain, Narayan Prasad, Mandakini Pradhan, Manas Ranjan Patel, Amit Gupta, Raj Kumar Sharma Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):325-333 Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient’s median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Seroconversion following hepatitis B vaccination in children with chronic kidney disease Nivedita Kamath, Anil Vasudevan, Arpana Iyengar Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):334-338 Seroconversion following hepatitis B vaccination is low in children with chronic kidney disease (CKD). This study aimed to assess the seroconversion and persistence of protective immunity following hepatitis B vaccination in children with CKD. This prospective observational study was conducted in a tertiary pediatric nephrology centre to assess the seroconversion and maintenance of antibody titers (>10 mIU/mL) at one year following hepatitis B vaccination (10 μg at 0, 1, and 2 months) in children with CKD Stages II to V. Those who did not seroconvert after the schedule were re-vaccinated, and antibody titers were checked. Categorical data were expressed as proportions and analyzed using the Chi-square test. Pearson’s correlation test was used to determine the correlation of antibody titers with other continuous variables. Seroconversion was observed in 72% (n = 26/36) after vaccination. Only 60% (n = 6/10) had seroconversion after the second course of vaccination. Only 60% of children (n = 12/20) who seroconverted had protective antibody titers at one year. Seroconversion following three doses of hepatitis B vaccine is low in children with CKD. Antibody titers should be monitored periodically as the protective immunity wanes rapidly.

Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study Abir Farouk Megahed, Ghada El-Kannishy, Nagy Sayed-Ahmed Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):339-349 There is a paucity of data concerning safety of fasting in Ramadan in chronic kidney disease patients on hemodialysis (HD). The aim of the present study was to assess the frequency of fasting in Ramadan in HD patients in Egypt and the possible effect of fasting on clinical and biochemical variables. This observational multicentric study was carried out during 2016 when fasting duration was around 16 h.

A study of detection and comparison of immunofluorescence on formalin-fixed paraffin-embedded tissue with fresh frozen renal biopsy specimen Ranjana Solanki, Madan Kumar Solanki, Deepika Hemrajani, Jayesh Saha Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):350-358 Direct immunofluorescence on the fresh frozen tissue is established way of demonstrating of immunoglobulins and complement deposition in renal biopsies. IF studies can be done on paraffin-fixed tissue (IF-P) and give comparable results to those obtained on frozen tissue for most pathogenic immunoglobulins and immunoglobulin fragments; although, the detection of C3c may be more problematic. In our study, we used proteinase-K method for antigen retrieval. We aimed to detect immunoglobulins and complements in formalin-fixed paraffin-embedded (FFPE) tissue sections from renal biopsies and have comparison of IF staining intensity on FFPE sections with conventional IF on fresh frozen tissue. Based on our results, we conclude that IF-P can serve as salvage technique and has significant diagnostic utility.

Postoperative complications in living liver donors: A retrospective study, single-center experience in Saudi Arabia Nouf Abdulaziz Althonaian, Alanoud Saleh Alsaiari, Weaam Ahmed Almanea, Norah Jezaa Alsubaie, Awatif Ali Almuharimi, Alaa Althubaiti, Abdulrahman Rashed Altamimi, Khalid Omer Abdullah, Wael Abdulaziz Ohali Saudi Journal of Kidney Diseases and Transplantation 2019 30(2):359-364 Living donor liver transplantation (LDLT) offers life to patients with end-stage liver disease. The balance between the benefit to the recipient and the risk to the donor plays a central role in justifying LDLT. However, the incidence rates of complications posttransplant differ widely. This study is designed to identify postoperative complications in LDLT in a tertiary care center King Abdulaziz Medical City (KAMC). This was a retrospective cohort study. All donors at KAMC between January 2003 and December 2015 were reviewed through a hospital database and patient charts to determine the postoperative complications based on the modified Clavien classification system. All donors were relatives of the recipients and assessed before the surgery. A total of 101 donors underwent LDLT: 75 were male and 26 were female, with a mean age of 27.7 ± 6.6. The breakdown of specific surgical procedures was as follows: 65 (64.3%) donors underwent right hepatic lobectomy, 31 (30.6%) underwent left lateral hepatectomy, three (2.97%) underwent extended right hepatectomy with the inclusion of the middle hepatic vein, and two (1.98%) underwent left hepatectomy. Postoperative complications were determined in 20 patients (19.8%), but no mortality was observed. Complications were reported in 14 (21.5%) right and six (19.4%) left lateral hepatectomy donors. A total of 12 patients had Grade I complications, six patients had Grade II complications, and Grade III complications were reported in two cases. The most frequent complications were upper limb weakness to brachial plexus neuropathy and mild bile leak. Life-threatening complications in our center have not been reported in LDLT; however, some donors may experience postoperative morbidity, which usually were mild and had a good prognosis.