Iranian Journal of Kidney Diseases
Volume:7 Issue: 3, May 2013

Leakage of small amounts of proteins in urine has been considered since 1980s a crucial sign of early kidney disease, especially in diabetic patients. An increasing interest in microalbuminuria as a cardiovascular risk marker has been more recently considered. Many studies linked microalbuminuria to early cardiovascular disease, as a marker of endothelial dysfunction, not only in diabetic patients, but also in hypertensive patients and in general population. Microalbuminuria is considered nowadays by guidelines as a cost-effective marker of subclinical organ damage in hypertensive patients and should be checked routinely in hypertensive patients. Assessing subclinical organ damage is recommended not only at the level of screening, but also during treatment. Microalbuminuria is also considered as a treatment outcome marker and useful for understanding the ability of a given therapeutic intervention to regress organ damage or slow down its progression.

Human T-cell lymphotropic virus 1 (HTLV1) is a lymphotropic virus which can be transmitted through unprotected sexual activity, breast feeding, and blood transfusion. Although most of HTLV1-infected individuals remain asymptomatic carriers, 1% to 5% and 3% to 5% develop adult T-cell leukemia and HTLV1-associated myelopathy/tropical spastic paraparesis, respectively. The aim of this study was to determine the prevalence of HTLV1 infection in hemodialysis patients in Sari and Ghaemshahr. This cross-sectional study was conducted on160 patients using random samples selection, and included 80 men and 80 women (mean age, 59.1 ± 14.7 years). All the samples were screened for HTLV1 antibody by enzyme-linked immunosorbent assay and positive samples were confirmed by Western blot assay. Only 1 patient had a positive anti-HTLV1 enzyme-linked immunosorbent assay test, which was confirmed by Western blot. The overall prevalence of HTLV1 seropositivity was 0.6%. The patient was a 21-year-old woman with a history of multiple blood transfusions. She had a history of unsuccessful kidney transplantation and had been on hemodialysis before transplant, too. This study suggests that HTLV1 infection may not be prevalent in high-risk patients in Mazandaran province, and there is no need for HTLV1 screening of blood samples.

Microalbuminuria and left ventricular hypertrophy (LVH) have both been shown to predict increased cardiovascular morbidity and mortality, especially in diabetic patients. The present study investigated the relationship between microalbuminuria and LVH in patients with essential hypertension. After a primary workup to rule out secondary hypertension, 110 essential hypertensive patients with LVH (mean age, 62.97 ± 11.02 years) and 10 essential hypertensive patients without LVH (mean age, 65.13 ± 10.15 years) were enrolled in this case-control study. Spot urine sample was collected for the assessment of microalbuminuria and creatinine concentrations in the two groups. Smoking status, blood pressure, and serum levels of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and creatinine were evaluated. Patients with LVH had significantly higher microalbuminuria level compared with those without LVH (mean urine albumin-creatinine ratio, 54.4 ± 39.48 μg/mg versus 33.56 ± 21.73 μg/mg; P <. 001). Multivariable regression analysis showed that the patients with a higher urine albumin-creatinine ratio were more likely to have LVH (OR, 1.028; 95% CI, 1.015 to 1.041; P <. 001). Other significant predictive factors for LVH in the model were diastolic blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and serum creatinine. Left ventricular hypertrophy is associated with microalbuminuria in patients with essential hypertension. These data are strengthening the role of microalbuminuria as an indicator of high cardiovascular risk.

Systemic lupus erythematosus is an autoimmune disease that may affect almost all organ systems. Renal involvement is the most significant prognostic factor. Renal biopsy findings play an important role in treatment decision. Ki-67 is a monoclonal antibody that is only found in proliferative cells. This study aimed to investigate the proliferative activity in renal biopsy specimens of patients with lupus nephritis using the Ki-67 monoclonal antibody, and to compare the proliferative index between different subgroups of patients. Renal biopsy specimens of 29 patients with systemic lupus erythematosus were retrospectively evaluated. Type of lupus nephritis and activity and chronicity indexes were determined. Ki-67 immunostaining was performed. For each patient, 1000 cells were counted and the number of Ki-67 positive cells was determined. The Ki-67 activity index was compared between different subgroups of lupus nephritis and correlated with systemic lupus erythematosus disease activity index, serum creatinine, proteinuria, anticardiolipin antibodies, and complement levels. A positive correlation between Ki-67 proliferation index, serum creatinine levels, and systemic lupus erythematosus disease activity index were found. Although conventional activity indexes were low, in 3 of 9 patients with class II lupus nephritis, Ki-67 proliferation indexes were high, indicating proliferation. Ki-67 can be used as a proliferation marker in renal biopsy specimens for patients diagnosed with systemic lupus erythematosus.

Microalbuminuria is a reliable marker of diabetic nephropathy. Establishment of peripheral vascular complications leads to early diagnosis, prevention, and treatment of renal and cardiovascular complications. This study investigated the value of ankle-brachial index (ABI) for prediction of microalbuminuria in type 2 diabetic patients. Measurement of ABI with color Doppler ultrasonography was carried out for 206 patients with type 2 diabetes mellitus. An ABI Index less than 0.9 was defined as a predictive marker for atherosclerosis. Microalbuminuria and risk factors of atherosclerosis were compared between the patients categorized based on the ABI values. The mean ABI was 1.1 ± 0.2 (range, 0.052 to 1.6), and 41 (20%) had an abnormal ABI (< 0.9). The correlations were significant between abnormal ABI and duration of disease (P =. 04), cardiovascular event and cardiac care unit admission (P =. 001), hypertension (P =. 01), and dyslipidemia (P =. 01). There was a significant correlation between ABI and microalbuminuria (odds ratio, 0.05; 95% confidence interval, 0.038 to 0.630; P <. 001). A cutoff point of an ABI less than or equal to 1.04 had a sensitivity of 71.6% and a specificity of 64.2% for prediction of microalbuminuria. The ABI is a noninvasive and reliable assay for detection of peripheral and cardiovascular complications, and also early stage of nephropathy in diabetic patients. In patients with an abnormal ABI, long-term follow-up for earlier detection and prevention of complications is helpful.

Calcium and vitamin D are essential structural components of the skeletal system, which prevent osteoporosis after menopause. However, there is a controversial debate on the association between the intake of calcium and vitamin D supplements and the increased risk of formation of kidney calculi in postmenopausal women. which yet have to be confirmed. This study aimed to compare the metabolic changes after supplementation of calcium and vitamin D and examine the risk of stone formation. Fifty-three postmenopausal women referred to rheumatology clinic who had no history of kidney calculi, bone diseases (apart from osteoporosis), metabolic, and rheumatic disorders and had not been receiving calcium, diuretics and calcitonin were investigated. Renal ultrasonography and blood tests were performed and the urine calcium levels were measured for a period of 24 hours for all patients. The examinations were repeated after a 1- year period of treatment with supplemental calcium (100 mg/d) and vitamin D (400 IU/d) and compared with the data before the treatment. After 1 year, asymptomatic lithiasis was confirmed in 1 of 53 patients (1.9%) using ultrasonographic examination. No significant differences were found between the 24-hour urine and blood calcium levels before and after the treatment. Our findings showed that oral intake of calcium and vitamin D after 1 year has no effect on the urinary calcium excretion rate and the formation of kidney calculi in postmenopausal women.

There is no data specifically on the clinical and immunopathologic features of Immunoglobulin M nephropathy (IgMN) in adults with kidney diseases in Pakistan. We retrospectively reviewed our adult native renal biopsy records from May 2001 to April 2010 and identified 57 cases out of a total of 1753 records labeled as IgMN on final histopathological analysis. Among these, 41 cases were included in the present analysis. Their relevant data items were collected from the case files and biopsy reports. The mean age of this cohort was 30.21 ± 10.12 years. The male-female ratio was 1.15:1. The most common presentation was idiopathic nephrotic syndrome. Hematuria and hypertension at presentation were noted in 24 (58.5%) and 10 (24.4%) patients, respectively. The most common morphologic change was glomerular mesangial cell proliferation, found in 28 biopsies (68.3%). Mesangial matrix expansion was noted in 16 (39%). Minor glomerular alterations were noted in 5 cases (12.2%) and focal segmental glomerulosclerosis in 4 (9.8%). Immunofluorescence microscopy showed diffuse mesangial positivity of IgM in all specimens. Subdominant IgA was noted in 6 cases (14.6%). Complements C3 and C1q were found in 28 (68.3%) and 21 (51.2%) patients, respectively. Our results show that IgMN is not very common in adults. Its clinicopathological spectrum is similar to that described from the neighboring countries, showing a spectrum of morphologic changes ranging from minor changes to FSGS.

Anemia is among the most important complications of chronic kidney disease (CKD) and a lot of symptoms and signs are due to this problem. Erythropoietin injection may improve anemia, but it may cause hypertension in these patients. The aim of this study is to evaluate erythropoietin injection effects on blood pressure of hemodialysis and predialysis patients. Forty hemodialysis patients and 40 predialysis patients with end-stage renal disease were enrolled in the study. The studied patients were comparable in terms of age, sex, hemoglobin, serum calcium, and baseline blood pressure. Erythropoietin was injected for all of the patients with anemia (4000 U, twice weekly). The effect of erythropoietin on their blood pressure was evaluated for each group by comparison of systolic, diastolic, and mean arterial blood pressure values before and 1 hour after the injection. After erythropoietin injection, systolic, diastolic, and mean arterial blood pressure values increased significantly in the hemodialysis group, and the increases were significantly greater in this group than the predialysis group (P =. 02, P =. 01, and P =. 02, respectively). Blood pressure increase was significant only for the systolic component in the predialysis group. Erythropoietin injection increases blood pressure levels in both groups. However, this is more significant in the hemodialysis patients as compared with patients with end-stage renal disease who have not started dialysis. Monitoring of blood pressure after erythropoietin injection is recommended.

Kidney transplantation and its conventional treatment can lead to increased risk of diabetes mellitus outbreak in normoglycemic recipients. Also, uncontrolled hyperglycemia may increase allograft loss and decrease patient survival. We aimed to assess the frequency of hyperglycemia in transplant patients and its risk factors. A retrospective study was performed on 3342 adult kidney transplant recipients between 2008 and 2010. Demographic and laboratory data were collected. All laboratory tests were done in a one laboratory, and hyperglycemia was defined as a fasting plasma glucose level greater than 125 mg/dL. Univariable and multivariable logistic regression analyses were used to determine the risk factors of hyperglycemia following kidney transplantation. There were 2120 men (63.4%) and 1212 women (36.3%) included in the study. The prevalence of hyperglycemia was 22.5%. Hyperglycemia was significantly higher in patients with cytomegalovirus infection (P =. 001), elevated serum creatinine (P <. 001), low high-density lipoprotein cholesterol (P =. 01), and increased blood levels of cyclosporine (P <. 001). After adjusting for covariates by multivariate logistic regression, the hyperglycemia rate was significantly higher for patients with a cyclosporine trough level greater than 250 ng/mL (P <. 001), a serum creatinine level greater than 1.5 mg/dL (P <. 001), and a high-density lipoprotein cholesterol less than 45 mg/dL (P =. 03). This study indicated that hyperglycemia is a common metabolic disorder in Iranian kidney transplant patients. Risk factors for hyperglycemia were higher cyclosporine level, impaired kidney function, and reduced high-density lipoprotein cholesterol values.

The association between nephrotic syndrome and juvenile idiopathic arthritis have rarely been described in pediatric patients. We report a child with steroid-responsive nephrotic syndrome, with frequent relapses, who presented with a new relapse of nephrotic syndrome associated with arthritis and uveitis at 21 months in remission after treatment with chlorambucil. Juvenile idiopathic arthritis was diagnosed and kidney biopsy examination showed mesangial glomerulonephritis with immunoglobulin M deposits. To our knowledge, only 2 cases of nephrotic syndrome preceding juvenile idiopathic arthritis have been reported, one without histopathology assessment and the other with minimal change disease. Although mesangial glomerulonephritis with nephrotic syndrome and juvenile idiopathic arthritis could have been coincidental, the immune pathogenic mechanism accepted for both diseases suggests they could be related.

Ketoacidosis can occur most often as a result of uncontrolled diabetes mellitus. However, it can be seen with fasting and alcohol consumption, as well. Ketoacidosis in association with fasting has less severity, and ketoacid levels do not exceed 10 mEq/L. In the literature, there are a few reports about severe high anion gap acidosis that were associated with fasting. We report a case of pregnancy associated with high anion gap acidosis as a result of fasting.

Kidney transplantation is generally considered the best option for most patients with end-stage renal disease requiring renal replacement therapy, even for patients with graft failure. Here, we describe a case of a 49-year-old man who received his 1st kidney transplant the United Kingdom from his brother when he was 18 years old in. Thirty-one year after the first transplant, he underwent successful 4th living-unrelated kidney transplantation with no serious complications at our transplant center. He continued to have excellent allograft function and his latest serum creatinine 33 months after his 4th transplant was 1.2 mg/dL. To our knowledge, this is the first case of 4th kidney transplantation from Iran.