Nephro-Urology Monthly
Volume:11 Issue: 1, Feb 2019

Nowadays, the demand for a kidney allograft is increasing in Iran as well as the rest of the world, which is growing the wait list. The Iranian model of a kidney transplant was initiated for solving organ shortage and has been extremely controversial both inside and outside of Iran. This narrative review was done by using Iranian and international databases to retrieve literature dealing with the Iranian model of kidney transplantation. All publications up until January 2018 were included. It has drawn out the weaknesses and strengths as well as the advantages and disadvantages, then, it provides some suggestion for better functioning of the Iranian model. Overall, 61 publications were retrieved and selected. After exclusion of unsuitable and duplicate articles, 17 were included. The main strengths of the Iranian model were having a lawful structure, supporting health centers and patients financially by government and charity funds, as well as reducing the waiting list. The main weaknesses include inadequate public awareness regarding the concept of brain death, the absence of a well-defined kidney registry system, need for renewing existing laws, regulations, and guidelines, the absence of permanent health insurance and follow-up for donors, as well as absence of a comprehensive network organ bank. The transplant authorities in Iran should work on reinforcement of the model by solving and overcoming some challenges. Preventing organ failure, as well as its risk factors, public education and encouraging organ donation from individuals who are brain dead, improving the outcomes of circulatory death donation, and investment in tissue engineering could significantly reduce organ shortage. The final solution is living unrelated renal donation (LURD).

Acute kidney injury (AKI) or acute renal failure is a clinical manifestation in which the kidneys are unable to preserve the normal homeostasis of water and electrolytes. To evaluate the effects of low dose dopamine to improve the renal functions in children, 3 µg/kg/min, IV infusion of dopamine was prescribed. The results of this study showed that low dose dopamine improved the serum creatinine concentration and corrected the time of appropriate urine volume, however, it was not effective on the serum electrolytes (Na, K, Bicarbonates, BUN) and the glomerular filtration rate (GFR).

To determine whether tadalafil, a PDE5i, is effective on stent-associated symptoms. In this double-blind randomized clinical trial, 80 consecutive male patients with unilateral double J stents were randomly assigned to intervention and placebo groups (n = 40 per group). The patients received 10 mg of tadalafil or placebo once a day for four weeks. The Ureteral Stent Symptom Questionnaire (USSQ) was selected as the primary outcome assessment tool. Complications were recorded as secondary outcomes. Data were analyzed using STATA 11 statistical software. Relative risk (RR) and risk difference (RD) were calculated for appropriately dichotomized endpoints. Of the 80 patients who provided consent, 72 patients successfully completed the study. The mean urinary symptom index score was 30.94 in the placebo group and 26.59 in the tadalafil group (P = 0.0003). Stent-related pain was reported by 80% of the patients in the placebo group and by 67.6% of the patients in the tadalafil group. The mean pain index score was 20.77 in the placebo group and 16.41 in the tadalafil group (P = 0.039). The mean sexual matters score in the placebo and tadalafil groups was 6.20 and 3.73, respectively (P = 0.0007). There was no significant difference in other domains between the groups. The tadalafil group showed no increase in major side effects compared to the placebo group. Tadalafil improved stent-related urinary symptoms, pain, sexual status, and overall score; it can also be used as a novel treatment modality in the alleviation of lower urinary tract symptoms and improve the quality of life in these patients.

No consensus management is available for the bladder neck contracture (BNC) secondary to radical retropubic prostatectomy (RRP). We present our experience of a technique in which holmium: YAG surgical laser was utilized transurethrally to incise the stenotic area. Incisions with holmium: YAG surgical laser were made in 34 subjects with BNC between January 2012 and May 2018. Medical charts were reviewed to evaluate related data including medical history, international prostate symptoms score, uroflowmetry, and recurrence of the stricture. The mean length of operation was 34 ± 4.06 minutes. No significant postoperative or perioperative complications were noted. The median length of hospital stay after surgery was two days. Five subjects (13.8%) required endoscopic holmium: YAG laser retreatment. After the first treatment with holmium: YAG surgical laser, the mean duration for recurrence was 4.3 months. In addition, significant improvements were observed in Qmax, residual urine volume, and the total IPSS score. BNC after RRP is relatively frequent but it can be safely and effectively managed by transurethral holmium: YAG laser incision

Thirty-six people per one million have end-stage renal disease (ESRD). ESRD has the indication of kidney transplantation; or hemodialysis and it is one of the causes of infertility in men. A high prevalence of sperm DNA damage is reported in men's semen with ESRD; therefore, the aim of this study was to evaluate sperm DNA damage in men with ESRD before and after kidney transplantation. This study evaluated 15 men with chronic renal failure and were candidates for kidney transplantation. DNA damage and semen parameters were investigated in the semen of these patients before and after the transplantation. Aniline blue and toluidine blue staining were used to evaluate the sperm chromatin structure and condensation. The slides were analyzed by light microscope to determine the percentage of DNA damage in sperms. The percentage of positive aniline blue and toluidine blue significantly decreased after kidney transplantation (40% versus 29%, P = 0.01 for aniline blue and 45% versus 35%, P = 0.01 for toluidine blue). Sperm morphology, count, motility, and sperm volume were improved after the transplantation; except for the morphology, all of them were statically significant. These findings support that the kidney transplantation in patients with renal failure could improve chromatin structure and condensation and sperm parameters. Additionally both toluidine blue and aniline blue staining are simple and suitable techniques to evaluate DNA damage.

Delayed graft function (DGF) and slow graft function (SGF) are complications after kidney transplantation that resulted in poor short-term outcome. In this study, we evaluate a new model for deceased kidney transplantation to reduce the cold ischemia time and its effect on DGF and SGF as short-term outcomes. We have included 814 deceased kidney transplanted patients in this study. All of the donors were local, while the recipients were both local and nonlocal. Kidney recipient’s outcomes (included mortality rate as well as DGF and SGF), age, gender, BMI, blood group, Rh, allograft renal function, transplantation date, kidney transplantation history, PPD, positive history of rheumatologic disorders, the distance between home of recipient and the transplantation center, cardiovascular disease, and dialysis duration was evaluated for all patients. The incidence of DGF and SGF were 24.8% and 20.5%, respectively. There were no statistical differences in the rate of DGF and SGF between local and distant recipients (P > 0.21). The rate of DGF was significantly higher in females as well as 40 - 65 year old recipients (P < 0.05). In logistic regression multivariate analysis, DGF and SGF were significantly correlated with BMI, blood group, the history of kidney transplantation, and dialysis duration. This study showed the feasibility of using a local donor for a distant recipient as well as reduction of cold ischemia time and lower rate of DGF. It is obvious that the shorter CIT, which resulted from usage of local donor, can lead to better kidney transplant outcomes.

Asymptomatic persistent microscopic hematuria is one of the common symptoms in children with kidney disorders and may be one of the most important signs of glomerular damage. Vesicoureteral reflux (VUR) also is one of the common disorders in children that causes scarring, secondary lesions, and subsequent problems, including hypertension, chronic renal failure, and end-stage renal disease (ESRD). This is a case-control study that was conducted on 100 children with VUR (50 children with reflux nephropathy as the case group and 50 children without reflux nephropathy as the control group) at Amirkabir Hospital, Arak, Iran. The frequency of asymptomatic persistent microscopic hematuria was evaluated in both groups of children. The mean age of the children in the case group was 2.93 ± 2.30 and in the control group was 3.46 ± 2.68 years old (P = 0.268). Thirty-four percent of the case group and 14% of the control group were males (P = 0.019). In addition, 22% of children in the case group and only 8% of children in the control group showed asymptomatic persistent microscopic hematuria (P = 0.049). According to the results of this study, it seems that the asymptomatic persistent microscopic hematuria is more in children with reflux nephropathy.

Bartter syndrome (BS) is a rare metabolic disorder causing defect in sodium and chloride absorption in the thick ascending limb of Henle’s loop and increased urinary loss of sodium chloride (Na), chloride (Cl), and prostaglandins. We present the case of a 1-year-old girl with BS presenting with vomiting, poor feeding, and agitation. Physical examination revealed muscle weakness, developmental delay, and failure to thrive. Laboratory investigations revealed hypokalemia, metabolic alkalosis, hyponatremia, and hypokalemia. Urinary investigations revealed raised urinary chloride, sodium, potassium, and calcium levels. Renal ultrasound revealed a renal calculus in the lower calyx of the right kidney with hydronephrosis. The basic defect in BS is the loss of one of the transporters involved in sodium reabsorption in the thick ascending limb on the Henle’s loop or apical K channel. BS is characterized by severe hypokalemia, metabolic alkalosis, hyponatremia, hypochloremia, and hyperaldosteronism. In BS, increased urinary loss of sodium, potassium, and chloride is observed.

Oxalate nephropathy after RYGB, albeit rare, has a poor prognosis with a rapid progression to kidney failure. Oxalate nephropathy has many etiologies and is one of the rare causes of renal failure. A 39-year-old diabetic woman came to our nephrology clinic because of a progressive increase in serum creatinine from 1 to 4.2. She had a history of Roux-en-Y gastric bypass (RYGB) surgery six months earlier. In view of the unexplained progressive increase in creatinine, a kidney biopsy was done. The histological diagnosis of oxalate nephropathy with diabetic nephropathy class 2b was made. Oxalate nephropathy is a rare and most severe renal complication after bariatric surgery that is reported in some patients after jejunoileal bypass and RYGB surgery. Oxalate nephropathy is progressive in nature and has a poor prognosis. In our case, oxalate nephropathy and kidney failure occurred six months after RYGB surgery. Since the histological finding in our patient revealed oxalate nephropathy with diabetic nephropathy class 2b, it seems diabetic nephropathy can probably facilitate calcium oxalate crystals formation. This important point should be considered that oxalate nephropathy could rapidly progress to renal failure; so, patients who undergo Roux-en-Y gastric bypass surgery should have regular follow-ups.