Iranian Journal of Kidney Diseases
Volume:15 Issue: 1, Jan 2021

Coronavirus disease (COVID-19), declared as a pandemic has affected millions of people and caused unprecedented number of death. The disease is caused by a severe acute respiratory syndrome related coronaviruses-2 virus which enters cells by binding with the host angiotensin converting enzyme-2 and CD147 protein. Among COVID-19 patients admitted to a hospital, hypertension, diabetes and obesity are the most common co-morbidities. A majority of COVID-19 hospitalized patients are found to have proteinuria and hematuria which is associated with higher risk of in-hospital mortality. Studies have reported high incidence of acute kidney injury (AKI) among COVID-19 patients admitted to hospital (10 to 43%) and intensive care unit (43-75%). These patients with AKI have much higher need for mechanical ventilation, vasopressor use and critical care. In addition, proportion of patients with AKI who require renal replacement (RRT) therapy is greatly increased. Acute tubular injury, cytokine storm induced systemic inflammatory response, endothelial injury and dysfunction are the main mechanisms of AKI. In addition, direct viral invasion of tubules, lymphocytic infiltration and complement mediated (C5b9) related injury is also seen. Mortality risk among patients with AKI and those in need of RRT is greatly amplified. Appropriate timing and choice of RRT for these patients is not well defined but will need to take in account the clinical condition, anticipation of their clinical course and availability of dialysis resources. Risk of AKI and death is also increased among kidney recipients and patients with chronic kidney disease.

Dyslipidemia is a common metabolic abnormality in Type 2 diabetic Mellitus (T2DM) patients with kidney dysfunction. Therefore, the current study was conducted to assess the association between serum lipid levels and estimated glomerular filtration rate (eGFR) in T2DM patients.

This cross-sectional study was performed on 802 participants, aged 40 years or more who had referred to the Abu Reyhan Clinic of Shahid Mohammadi Hospital in Bandar Abbas, Hormozgan province, Iran. Biochemical variables including FBS, triglycerides, total cholestrol, LDL-C, and HDL-C levels were measured using the enzymatic method. The association between serum lipid profile and eGFR was assessed using the Spearman correlation coefficient test and linear regression model.

Mean ± SD age of the subjects (72.3% females) was 53.55 ± 5.56 years old. Mean ± SD of eGFR-EPI and eGFR-MDRD was 86.30 ± 17.48 and 86.80 ± 23.29, respectively for all the subjects. In the current study, a negative association was observed between eGFR-EPI and FBS (r = -0.123, β = -0.172) and TGs (r = -0.080, β = -0.096) (P < .01). Also, there was an inverse association between the eGFR-MDRD and FBS (r = -0.123, β = -0.172) and TGs levels (r = -0.074, β = -0.086) (P < .05). However, the concentration of other lipid profiles was not associated with the eGFR level (estimated by EPI and MDRD methods).

Our findings suggested that the patients with reduced eGFR level are more likely to have greater TG serum level. Therefore, high TG levels can be considered as a potential biomarker for predicting renal complications in the patients with T2DM.

Introduction. Chronic Kidney Disease (CKD) is of high clinical importance due to cost of outcomes such as kidney transplantation. However, CKD is an overlooked disorder among commercial drivers. The present study aimed to evaluate hypertension and Glomerular Filtration Rate (GFR) among commercial drivers. Methods. In this cross-sectional study, a total of 903 commercial drivers referred for obtaining their health license were recruited. After obtaining informed consent, a questionnaire consisted of demographic characteristics was completed. Blood pressure, level of lipid profile, blood sugar, blood urea nitrogen, and plasma creatinine were measured. Chi-square and independent T-test were used for data analysis. Results. All participants were male. The mean ( ± SD) age and Body mass index were 42 ± (10) years and 27 ± (4) kg/m2, respectively. Of 903 studied cases 40 (4%) had GFR < 60. Increased age and high blood pressure had a significant association with reduced GFR (P < .0001). The ones with sleep apnea were more likely to have GFR < 60, however, the association was not statistically significant after adjusting for related risk factors. Conclusion. Older age and hypertension are considered as risk factors for CKD among commercial drivers. Obstructive sleep apnea also should be kept in mind as a possible risk factor that requires further elucidation and management.

Introduction. Data on the effects of melatonin administration on metabolic parameters in patients with diabetic nephropathy (DN) is limited and controversial. This study was performed to analyze the effects of melatonin administration on metabolic status in patients with DN. Methods. This randomized, double blind, placebo-controlled clinical trial was performed on 60 patients with DN. Patients were randomly assigned into two groups to take either 10 mg/d of melatonin (n = 30) or placebo (n = 30) for 12 weeks. Fasting blood samples were taken at baseline and 12 weeks after intervention to quantify metabolic parameters. Results. Melatonin administration significantly reduced plasma fasting glucose (β = -10.64 mg/dL; 95% CI: -20.37 to -0.90; P < .05), insulin (β = -2.37 µIU/mL, 95% CI: -3.33 to -1.41; P < .001), insulin resistance (β = -0.67, 95% CI: -0.98 to -0.35; P < .001), significantly increased insulin sensitivity (β = 0.01, 95% CI: 0.006 to 0.01; P < .05), and plasma HDL-cholesterol levels (β = 2.75 mg/dL, 95% CI: 0.75 to 4.75; P < .05) when compared with the placebo. Melatonin also caused a significant increase in total antioxidant capacity (TAC) (β = 140.45 mmol/L; 95% CI: 80.48 to 200.41; P < .001), and glutathione (GSH) levels (β = 50.36 µmol/L, 95% CI: 94.08 to 0.02; P < .05) when compared with placebo. Ultimately, melatonin could upregulate gene expression of peroxisome proliferator-activated receptor gamma (PPAR-γ) (P < .05) in comparison with placebo. Conclusion. Results of this study indicated that melatonin administration for 12 weeks in DN patients had beneficial effects on glycemic control, HDL-cholesterol, TAC and GSH levels, and gene expression of PPAR-γ, but did not affect other metabolic parameters.

Dysregulated vitamin D metabolism is one of the most important issues in chronic kidney disease- mineral and bone disorder (CKD-MBD). Patients with end-stage kidney disease (ESKD) receive large amounts of calcitriol, i.e., 1,25 –dihydroxy vitamin D [1-25(OH)2D], for suppression of parathyroid hormone (PTH). The aim of this study was to evaluate the 1-25(OH)2D status in maintenance hemodialysis patients and its correlation with 25(OH) D level and calcitriol consumption and to determine whether the usual practice of administrating large amounts of calcitriol for suppression of PTH may lead to toxic serum levels.

One hundred and fifty-six maintenance hemodialysis patients were enrolled. Demographic data, comorbid conditions and history of medication use (cumulative and current doses) were retrieved from Hemodialysis Data Processor Software previously designed for our center. Predialysis serum samples were measured for serum levels of 25(OH)D and 1-25(OH)2D accompanying by markers of mineral bone metabolism and inflammation.

Of 156 patients, 66% were male and the mean age was 56.5 ± 16.3 years. There was no significant correlation between serum level of 25(OH)D and 1,25(OH)2D (r = 0.12, P > .05). Only current ingestion of vitamin D was correlated with both 25(OH) D (r = 0.324, P < .001) and 1,25(OH)2D serum levels (r = 0.334, P < .001). There was no significant relationship between current or cumulative calcitriol consumption and 1,25(OH)2D serum level. 1,25(OH)2D/25(OH)D ratio which, represents the degree of vitamin D hydroxylation efficiency was 0.9 pg/ng (expected value in no CKD > 2.2 pg/ng).

Calcitriol consumption was not correlated with increased serum 1,25(OH)2D level and the practice of hyperparathyroidism treatment with calcitriol may be safely continued, though we are not yet aware of the 1,25(OH)2D status at the cellular level.

Uremic pruritus (UP) is one of the major complaints in hemodialysis patients without specific treatment. Considering the antipruritic effect of melatonin in atopic dermatitis (AD) and similarities in mechanism between pruritus in AD and UP, this randomized clinical trial designed to evaluate the antipruritic effect of melatonin on hemodialysis patients with UP.

This multicenter double-blind randomized clinical trial was conducted among the hemodialysis patients with UP. Adult patients were randomly assigned to receive two capsules of melatonin 5 mg /d for a 2 weeks period, undergoing a 1 week washout period, and then two capsules of placebo for another 2 weeks period, or the reverse sequence. Visual Analogue Scale (VAS), % affected Body Surface Area (%BSA) and 12-Pruritus Severity Scale questionnaire (12-PSS) were measured before and after each of the three periods. A crossover analysis of variance adjusted by treatment, period and carryover effect was performed by STATA 14.

Thirty-nine patients under hemodialysis (mean age of 55.08 ± 12.34 years) completed the study. Mean changes in VAS, 12-PSS, and %BSA after the interventions (melatonin vs. placebo, mean ± SD) were as follows, respectively: -3.21 ± 3.33 vs. -1.38 ± 2.23, -4.59 ± 5.22 vs. -2.08 ± 4.35, and -19.10 ± 30.31 vs. 4.64 ± 29.11 (P < .05). However, the statistical significance of the treatment effect from melatonin was observed, carryover and period effects were not significant (P > .05) for any of the main variables.

Based on to the preliminary results of this study, melatonin can be introduced as an effective drug for management of pruritus in uremic patients.

Hyperphosphatemia is an important symptom of chronic kidney disease-mineral bone disorder (CKD-MBD). Various oral phosphate binders have been used, but have not been very effective, especially for severe secondary hyperparathyroidism (SHPT) in patients undergoing maintenance dialysis. Maintenance dialysis patients with severe SHPT can develop hypophosphatemia for several months after parathyroidectomy without elevated alkaline phosphatase. Based on these clinical phenomena, we hypothesized that high levels of parathyroid hormone (PTH) might inhibit intestinal phosphorus absorption which mediated by sodium-dependent phosphorus transporters.

Forty BALB/c mice were divided into four groups. Mice in group 1 were given an intravenous injection of normal saline as the control group. Mice in groups 2, 3, and 4 were given PTH(1- 34) in doses of 40 μg/100 g, 200 μg/100 g, and 400 μg/100 g body weight intravenously, respectively. All mice were euthanized 8 hours after the injection. The mRNA and protein expression of sodium-dependent phosphorus transporter NPT-2b and Pit-1 on the membrane of the intestinal epithelial cells was detected by real-time polymerase chain reaction (PCR) and western blot analysis, respectively.

In group 4, intestinal epithelial NPT-2b and Pit-1 protein expression was significantly decreased, whereas in groups 2 and 3, no significant changes were found.

A high PTH level decreases the protein expression of NPT-2b and Pit-1 in the intestinal mucosa.

To explore the risk factors for development of peripheral arterial disease (PAD) in patients with maintenance peritoneal dialysis and the relationship between osteoprotegerin (OPG) and PAD.

In China, 108 patients with PD were selected as the research subjects. General information such as age, gender, height, weight, BMI, blood pressure, and smoking history were collected. Serum albumin, fasting glucose, calcium, phosphorus, blood urea nitrogen, creatinine, total cholesterol, triglyceride, LDL-c, HDL-c and CRP, OPG levels were detected. Urea clearance index (Kt/V) and ankle brachial index (ABI) were measured.

There were 19 patients with PAD, accounting for 17.60%. Compared with the non-PAD group, the PAD group was older, female, lower BMI, a longer duration of PD, a higher proportion of diabetic patients, lower albumin and creatinine levels, lower Kt/V (renal), and higher CRP and OPG levels (P < .05); Multivariate Logistic regression analysis showed that elderly (OR = 1.262, 95% CI: 1.021 to 2.015), patients with diabetes (OR = 1.710, 95% CI: 1.054 to 2.651), low serum albumin (OR = 0.786, 95% CI: 0.651 to 0.962) and Kt/V (renal) (OR = 0.547, 95% CI: 0.366 to 0.812), high levels of CRP (OR = 1.303, 95% CI: 1.028 to 2.052) and OPG (OR = 1.125, 95% CI: 1.011 to 1.386)were independent risk factors for PAD in patients with PD; Pearson correlation analysis showed a negative correlation between OPG level and ABI (r = -0.267, P < .01).

Old age, malnutrition, high levels of CRP and OPG, and lower Kt/V are related to the occurrence of PAD in peritoneal dialysis patients. OPG levels may be predictive indicators of PAD.

Renal lymphangiomatosis is an unusual disorder. It may develop due to the abnormality of the intrarenal, peripelvic and perirenal lymphatics. The differential diagnosis contains renal lymphoma, polycystic kidney disease, multicystic dysplasia and renal tumors. We report a case of renal lymphangiomatosis, previously diagnosed as autosomal dominant polycystic kidney disease, to emphasize that these two diseases can be easily confused. It should be kept in mind that RL is in the differential diagnosis of polycystic renal disease to prevent overtreatment.

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Renal involvement in sarcoidosis patients is occurred, but the incidence and prevalence is uncertain. The most common renal involvement of systemic sarcoidosis is nephrocalcinosis and interstitial nephritis. After sarcoidosis was diagnosed in a 31-year-old male patient, we performed a renal biopsy because of nephrotic range proteinuria and renal dysfunction. The collapsing variant of focal segmental glomerulosclerosis (FSGS) secondary to sarcoidosis was diagnosed by kidney biopsy.

The objective of our paper is to reemphasize the importance of critical thinking in clinical practice and education in the field of internal medicine using the example of edema. We provide an in-depth and interactive investigation of physiological concepts as a foundation for the understanding of body fluid dynamics. Four fundamental concepts described are the hydrostatic and oncotic pressure gradients, capillary permeability, and lymphatic drainage. Furthermore, we visit the causes of edema in nephrotic syndrome. Traditional teaching considers hypoalbuminemia as a primary cause of edema formation in nephrotic syndrome. It has been proven that other etiologies causing edema include salt and water retention by the kidneys and a possible increase in capillary permeability are more important causes in the development of edema in nephrotic syndrome.