مرکز تحقیقات نفرولوژی و پیوندکلیه

پيش زمينه و هدف: ويروس BKمتعلق به خانواده پوليوما ويريده می‌باشد که اغلب در دوران کودکی باعث الودگی در انسان می‌شود. اين ويروس در کليه‌ها به صورت نهفته باقی می‌ماند. حضورBKVدر ادرار بيماران پيوند کليه 57-35درصد و در سرم اين بيماران 29-6 درصد تخمين زده شده است. حضور تيتر بالایويروس BKدر خون اين بيماران عامل اصلی نفروپاتی و در نتيجه باعث اختلال عملکرد بافت پيوندی شده و می‌تواند منجر به دفع آن گردد. هدف از اين مطالعه بررسی ميزان فعاليت مجدد ويروس BKبا روش مولکولی در بيماران کليوی و ارتباط شيوع آن با ريسک فاکتورهای سن، جنس، مدت زمان بعد از پيوند، مدت زمان دياليز، داروهای ايمنوساپرسيو، دوره رد حاد پيوند و ديابت در اين بيماران است.

مواد و روش‌ها: اين مطالعه بر روی 130 بيمار پيوند کليه مراجعه کننده به درمانگاه نفرولوژی بيمارستان امام خمينی (ره) اروميه انجام گرفت. دفع ادراری ويروسBK در نمونه‌های ادراری اين بيماران با روش واکنش زنجيره‌ای پلی مرازی (PCR) مورد تشخيص قرار گرفت.

يافته‌ها:از 130 نمونه ادرار بيماران پيوند ويروس BKدر 26 (20درصد) نمونه از بيماران مثبت بود. ميانگين مدت زمان تشخيص ويروس BKدر بيماران مثبت در 30 ماه نخست پيوند می‌باشد (01/0=P). رابطه معنی‌داری مابِين فراوانی دفع ويروس BKدر ادرار با سن، جنس، مدت زمان بعد از پيوند، مدت زمان دياليز, داروهای ايمنوساپرسيو، دوره رد حاد پيوند، ميزان کراتنين و ديابت مشاهده نگرديد.

بحث و نتيجه گيری: نتايج اين تحقيق نشان دهنده فعاليت ويروس BKدر يک پنجم بيماران پيوند کليه مراجعه کننده به درمانگاه نفرولوژی بيمارستان امام خمينی (ره) اروميه می‌باشد. تشخيص ويروس BKبا روش مولکولی می‌تواند ضمن تشخيص سريع‌تر موجبات پيشگيری از نفروپاتی حاصل از ويروس BKو از دست دادن بافت پيوندی را فراهم آورد.

پیش زمينه و هدف: سرطان پروستات شايع­ترين سرطان شناخته شده مردان است . در حال حاضر DRE, PSA روش­های SCREENING بيماران بوده و در صورت بالا بودن PSA يا DRE مشکوک از TRUS بيوپسی پروستات که روشی تهاجمی است جهت تشخيص قطعی استفاده مي­شود. عوامل متعددی باعث افزايش PSA مي­شود. ما در اين مطالعه سعی داريم اثرات BCG تراپی داخل مثانه­ای بر سطح سرمی PSA را بررسی کنيم.

  مواد و روش کار: مطالعه فوق از نوع Clinical trial مي­باشد. از بين بيماران مبتلا به تومور سطحی مثانه که تحت TUR تومور قرار گرفته و 2 هفته بعد
BCG تراپی داخل مثانه­ای مي­شدند و قبل از عمل PSA>4ng/ml يا DRE غيرطبيعی نداشتند 66 نفر وارد مطالعه شدند. BCG تراپی به طور هفتگی
به مدت 6 هفته انجام شد. PSA قبل از شروع BCG تراپی و سپس قبل از هر جلسه BCG تراپی و 3 ماه بعد از اتمام BCG تراپی چک شد در صورتي­که PSA بيشتر از 2 برابر حد پايه افزايش مي­يافت يا PSA>4ng/ml مي­شد، significant در نظر گرفته شده، و از گروه دارای PSA>4ng/ml بيوپسی پروستات تحت گايد سونوگرافی بعمل می آمد.

  يافته­ها: در 15 نفر (22%) PSA افزايش قابل توجه ديده شد از 3/10-1/. (متوسط ng/ml 3/2). در10 نفر (1/15%) PSA به بالاتر از 4ng/ml رسيد و در تمامی آنها در عرض 3 ماه از قطع درمان به حد پايه برگشت. در 5 نفر از بيماران PSA در 2 نمونه متوالی به بيش از 2 برابر حد پايه رسيد. در اينها PSA به حد پايه برنگشت در 3 نفر همچنان بالاتر از 2 برابر حد پايه باقی ماند و در 2 نفر به کمتر از 2 برابر حد پايه رسيد. در 10 نفر با PSA>4ng/ml زمان متوسط رسيدن به بالاتر 4ng/ml ، 8/1 هفته با range 3-1 هفته بود. DRE در 7 نفر از بيماران با PSA>4ng/ml و نيز در 5 نفر با افزايش PSA به بيش از 2 برابر پايه طبيعی بود. در 1 نفر از 10 نفر ندول لوب راست و در 2 نفر پروستات بزرگتر از حد طبيعی بود. در 6 نفر از 10 نفر بيوپسی guided TRUS پروستات
بعمل آمد که در 2 نفر پروستاتيت گرانولوماتوزو در 4 نفر بافت طبيعی پروستات گزارش شد.

  نتيجه­ گيری: BCG تراپی باعث افزايش PSA مي­شود و تا 3 ماه بعد از قطع BCG تراپی قابل برگشت است و در صورتي­که بعد از 3 ماه بالای ng/ml 4 باشد بيوپسی پروستات پيشنهاد مي­شود

 چكيده

  پيش زمينه و هدف: اختلال عملكرد مزمن كليه پيوندي از شايع­ترين علل از دست رفتن كليه پيوندي است. در اين مقاله زمان انتظار و بقاء پيوند با حذف موارد فوت در بيماران با اختلال عملكرد مزمن كليه مطالعه گرديد. همچنين ارتباط بين عملكرد كوتاه مدت و طولاني مدت آن مطالعه شد.

  مواد و روش كار: در يك مطالعه تك مركزي گذشته نگر، 214 بيمار با اختلال عملكرد مزمن كليه پيوندي كه طي سال­هاي 1376 تا 1384 به درمانگاه 
فوق تخصصي نفرولوژي بيمارستان­هاي دانشگاه علوم پزشكي اروميه جهت پيگيري و مراقبت­هاي بعد از پيوند مراجعه كردند، بررسي شد. عملكرد كليه با استفاده از شاخص GFR ارزيابي شد و در هر ويزيت، بر مبناي راهنماي باليني NKF و KDOQI طبقه بندي گرديد. داده­ها با روش كاپلان ماير تحليل بقاء و آزمون لگاريتم رتبه­اي آناليز شدند.

  يافته­ها: ميزان خام از دست رفتن كليه پيوندي با حذف موارد فوت 6/26 درصد طي متوسط زماني انتظار 7/81 ماه است. بيماراني كه در زمان شروع فرآيند كاهشي در مرحله 3 از GFR قرار دارند به­طور معني­داري، سريع­تر از رتبه­هاي 1 و 2 كليه پيوندي را از دست مي­دهند.

  بحث ونتيجه گيري: نتايج اين مطالعه نشان دادوضعيت بيمارطي سال اول بعداز پيونديكي ازعوامل مهم وتعيين كننده براي رد كليه پيوندي با حذف مواردفوت مي­باشد.اقدامات درماني درجهت جلوگيري ازتخريب عملكرددريكسال اول باعث بقاطولاني مدت پيوند مي­گردد.

  كليد واژه­ها : اختلال عملكرد مزمن، رد پيوند با حذف موارد فوت، نارسايي طولاني مدت عملكردكليه، تحليل بقا

چكيده

  خانم 53 ساله با سابقه پيوند كليه از شش سال قبل به علت سردرد، تاري ديد و تب در بيمارستان بستري شد. وي به علت ابتلاء به ديابت مليتوس بعد از پيوند از پنج سال قبل تحت درمان با انسولين بود. در معاينات فيزيكي در زمان بستري، تب خفيف، ادم و اريتم پري اربيت، كموزيس و تندرنس در استخوان ماگزيلري داشت. نسج به دست آمده از طريق انسزيون زيرلب كالدول حاوي مخاط سينوس و پوست محتوي بافت گرانولاسيون، جهت آسيب شناسي ارسال شد. بررسي آسيب شناسي بافت مويد تهاجم هايفي­هاي بدون انشعاب قارچي، منطبق بر موكورمايكوزيس مهاجم بود. با وجود دبريدمان جراحي و درمان با آمفوتريسين ب با دوز بيش از 1mg/kg براي بيش از پنج هفته، متاسفانه بهبودي حاصل نشد. موكورمايكوزيس در بيماران داراي ضعف سيستم ايمني به­خصوص افراد ديابتي با درصد مرگ و مير بالايي همراه است. موفقيت درمان و بهبود بقاء بيمار مستلزم مداخله زودرس و وسيع جراحي علاوه بر درمان با داروهاي ضد قارچ به مدت طولاني مي­باشد.

مقدمه: لوپوس اريتماتوسيستميك يك بيماري اتوايميون است كه زنان را در سنين باروري مبتلا مي¬كند. به همين علت متخصصان به بسياري از مشكلات حاملگي در مبتلايان به لوپوس شامل تاثير لوپوس بر پيامد هاي جنيني و همچنين حاملگي بر لوپوس توجه مي كنند. اين مطالعه جهت بررسي نتايج مرتبط با مادر و جنين در زنان حامله مبتلا به لوپوس طراحي شده است. مواي و روش كار: اين يك مطالعه گذشته نگر بر روي 20 حاملگي در 13 زن مبتلا به لوپوس اريتماتو سيستميك دردپارتمان نفرولوژي دانشگاه علوم پزشكي اروميه مي باشد. نتايج: متوسط سن بيماران 24 سال (حد فاصل 19-37 سال) بود. 7 بيمار نولي¬پار بودند. 15 حاملگي از20 حاملگي در فاز رميسيون و مابقي در فاز فعال بيماري اتفاق افتاده بود. در 5 بيمار بيوپسي كليه قبل از حاملگي انجام شده بود. يك بيمار در مرحله 2، سه بيمار در مرحله 3 و يك بيمار در مرحله 4 نفريت لوپوسي قرار داشتند. عملكرد كليه در تمام بيماران قبل از حاملگي طبيعي بود. 2 از 13 بيمار داراي تيترآنتي فسفوليپيد آنتي بادي مثبت (APA) بودند اما فقط يكي از آنها سابقه سقط¬هاي مكرر و ترومبوزوريدهاي عمقي اندام تحتاني را داشت. در تمام بيماران APA مثبت از آسپرين و هپارين استفاده شد. در 7 مورد پروتيينوري در حد غيرنفروتيك در طي حاملگي مشاهده شد اما با اختلال در عملكرد كليه، افزايش فشار خون و مورتاليتي مادر همراه نبود. تشديد بيماري در 3 مورد مشاهده شد كه تاثيري بر پيش آگهي مادر و جنين نداشت. متوسط سن حاملگي 37 هفته (بين 34-39 هفته) با 5 مورد زايمان پره ترم بود. مرگ داخل رحمي جنين (IUFD) در2 مورد و سقط در يك مورد وجود داشت. متوسط وزن زمان تولد نوزادان 2160 گرم و آپگار 8 در زمان تولد بود. يك مورد اختلال رشد داخل رحمي (IUGR) و 3 مورد تولد نوزاد با وزن كم (LBW) گزارش شد. فقط يك مورد نوزاد LBW از مادر داراي بيماري فعال قبل از حاملگي متولد شده بود. تنها يك مورد از 5 حاملگي با تيتر مثبت آنتي فسفوليپيد آنتي بادي ناموفق بود. غير از يك مورد، كليه بيماران در زمان لقاح تحت درمان با استروييد بودند. بحث: احتمال پيامدهاي مطلوب مادر و جنين در حاملگي زنان مبتلا به لوپوس كه مدت طولاني در رميسيون كامل بوده، عملكرد كليه نرمال و فشارخون طبيعي و تيتر منفي APA دارند زياد است. اگرچه ريسك از دست رفتن جنين و / يا اختلال عملكرد كليه در لوپوس فعال و/ يا نارسايي كليه زياد است.

پيش زمينه و هدف: به منظور مشخص كردن شيوع ضايعات ارتوپديك در بيماران نارسايي كليه كه تحت عمل جراحي پيوند كليه در بيمارستان امام خميني دانشگاه اروميه قرار گرفته اند مطالعه انجام شد.

مواد و روش كار: 500 بيمار كه تحت عمل جراحي پيوند كليه قرار گرفته بودند و به درمانگاه نفرولوژي مراجعه كرده بودند براي وجود درد در اندام، دفورميتي، شكستگي، محدوديت حركتي، تاريخچه درد حاد استخوان و عفونت دستگاه اسكلتي عضلاني مورد بررسي قرار گرفتند. هركدام از بيماراني كه داراي يكي از اين شكايات يا علائم بودند جهت معاينه ارتوپديك به درمانگاه ارتوپدي ارجاع مي شدند و در صورت لزوم راديوگرافي و MRI  از آنها به عمل مي آمد.

يافته ها: 4 مورد نكرورآواسكولار، يك مورد سندرم درد حاد و 2 مورد شكستگي مينور وجود داشت يكي از بيماران داراي استئومليت انگشت بود وسه تن از بيماران داراي كوتاهي قد با ژنووالگوم بودند.

نتيجه: شيوع نكروز آواسكو لار در بيماران مورد مطالعه كمتر از گزارشات ليترچراست . شكستگي و عفونت مشكل بزرگي در بين بيماران ما نبودند.

كلمات كليدي: پيوند كليه ، نكرورآواسكولار، درد حاد استخوان

زمينه و اهداف: پيوند کليه درمان انتخابي براي نارسايي مزمن کليه است. بکارگيري تکنيک آناستوموز مناسب يورترووزيکال مناسب ميتواند از اکثر خطرهاي تهديد کنندهي کليه پيوندي جلوگيري کند. به علت ميزان عوارض پايين و آسان بودن، تکنيک يورترونئوسيستوستومي اکستراوزيکال در پيوند کليه محبوبيت پيدا کرده است. اين کاهش در عوارض به علت محدود بودن ديسکسيون مثانه و نياز به حالب کوتاهتري از دهنده، ميباشد. ما عوارض ارولوژيک باري و باري تاگوچي را گروهي از بيماران پيوند کليه، ارزيابي و مقايسه کرديم.روش بررسي: ما يورترونئوسيستوستومهاي باري و باري تاگوچي را که تصادفي انتخاب ميشدند، از سپتامبر 2004 تا مارس 2007 (متوسط پيگيري 12 ماه) ثبت کرديم. عوارض ارولوژيک شامل هماچوري عارضه دار، فيستول ادراري، تنگي حالب و ريفلاكس بودند.يافته ها: از کل 198 بيمار، 100 مورد تحت آناستوموزباري - تاگوچي و 998 مورد تحت آناستوموز باري قرار گرفتند. ميزان عوارض ارولوِژيک در تکنيک ايمپلانتاسيون مجدد باري تاگوچي4 مورد (4%) و در باري 5 مورد (1/5%) بود. اين ميزان عوارض قابل توجه نبود (71/=p ) و شامل، يک ليک ادراري و3 تنگي حالب در گروه باري- تاگوچي و 4 تنگي و يک ليک در گروه باري بودند، که اين بيماران، نياز به عمل مجدد پيدا کردند. هماچوري عارضه دار و ريفلاکس علامت دار، در مطالعه ما رويت نشد. مدت زمان آناستوموز حالب 16-4 دقيقه (متوسط78/2 ± 26/8 دقيقه) در باري تاگوچي و 20-5 دقيقه (متوسط34/3±9/9 دقيقه) در باري ثبت شد. اختلاف معنيدار بود )0001/= p)در پنجاه بيمار باري - تاگوچي که به صورت تصادفي انتخاب و (Voiding cystourethrography, VCUG) شدند. 2 بيمار (4%) (II، (I ريفلاکس خفيف تا متوسط داشتند. اين بيماران نياز به درمان اندوسکوپيک يا جراحي مجدد پيدا نکردند.نتيجهگيري: مطالعه ما نشان داد که يوترونئوسيستوستومي اکستراوزيکال باري- تاگوچي بدون افزايش در عوارض اورلوژيک، روش آسان و سريع است. اين تکنيک با عوارض قابل قبول يکي از تکنيک هاي انتخابي در مرکز ما است .

There are several ways of performing vesico-ureteral anastomosis in kidney trans-plantation (Tx); they are broadly classified into two categories: extra-vesical and intra-vesical. Extra-vesical methods are preferred in kidney transplantation. In this study, we attempt to integrate two extra-vesical techniques of Barry and Taguchi and to evaluate the frequency of occurrence of vesico-ureteral reflux (VUR) with this technique. Also, an attempt is made to compare the results with other techniques reported in the literature. Fifty consecutive transplant recipients, who underwent uretero-neo-cystostomy (uretero-vesical anastomosis) by the new technique of Barry-Taguchi were evaluated for VUR by sonography and cystoureterography, six months after Tx. The mean age of the study subjects was 34.8 years; there were 33 males and 17 females. The mean time between Tx and evaluating for VUR was 6.6 months. Two cases of asymptomatic VUR (4%) were detected at the end of the study period. The occurrence of 4% asymptomatic VUR suggests that this technique is more acceptable compared to others. Because of the simple nature of the procedure as well as the short time required, this technique could be a suitable choice in kidney transplantation.

Renal transplantation recipients are at a high risk of developing tuberculosis (TB) following transplantation, especially in developing countries, with high incidences of morbidity and mortality. In this report, we examined the risk factors and impact of TB on the outcome of kidney transplantation.

PATIENTS AND METHODS:

Among 1350 living donor Iranian kidney transplantations, 52 (3.9%) had TB diagnosed in various organs. Of these, 7 (13.5%) had TB pretransplantation and 40 (76.9%) were men. The overall mean age was 32.6 +/- 10.5 years.

RESULTS:

The interval between transplantation and diagnosis was 54.6 +/- 48.23 (range 4 to 140) months. In 34 (65.6%) patients TB was diagnosed after the first year posttransplantation. Pleuro/pulmonary TB was the most common form (68%). All posttransplant TB patients received a quadriple antituberculosis therapy; pyrazinamide, rifampicin, ethambutol, and isoniazide). Hepatotoxicity was seen in 16 (30%) patients, including 12 mild cases with normalization after temporary withdrawal of isoniazide and rifampicin, and four were severe, but mortality was not attributable to hepatocellular failure. Twelve patients (23%) died. Chronic allograft dysfunction occurred in 34 (65%) patients, 19 (37%) with graft loss. Pre-TB patients showed comparable posttransplant courses.

CONCLUSION:

TB is a common infection among renal transplant recipients in developing countries. The peak incidence is after the first year of transplantation and mortality is considerable. Hepatoxicity is a considerable risk of treatment, possibly as a result of additive toxic effects of immunosuppressive drugs. Chronic allograft nephropathy is a serious complication that has a negative impact on the graft survival.

The treatment of choice for patients with end-stage renal disease is renal transplantation. Urinary tract reconstruction is usually done by anti-reflux ureteroneocystostomy, of which there are several techniques. In this study, a comparison of previous studies related to complications and outcome of various extra-vesical uereteroneocystostomy techniques that were used in our center was made. From the year 1988, when renal transplantation was first performed in our center, we utilized many ureteroneocystostomy techniques including Lich-Grigoir, Barry, Tagochi, and finally Barry-Tagochi. With each conversion, we compared the results of the earlier technique with the new one. In addition, we collected the results of four previous studies conducted by our surgeons and analyzed the complications seen with ureteroneocystostomy. A total of 717 renal transplant recipients were included in our study; 214 of these patients were reimplanted by the Barry-Tagochi technique, 155 cases by the Barry technique, 44 cases by the Tagochi technique, and finally, 304 cases by the Lich-Grigor technique. There was no significant difference in the overall complications, urinary leakage and ureteral stenosis, and obstruction between the four groups. However, complicated hematuria was significantly more frequently seen in the Tagochi group (P = 0.002). Also, the mean time taken for ureteroneocystostomy was longer in the Lich-Grigor group (P = 0.001). We found that the Barry-Tagochi technique had an overall incidence of urological complications similar to that of the other extravesical techniques and was less time consuming.

Renal transplantation has been advocated as the treatment of choice for end-stage renal disease. Immunosuppression increases the incidence of cancer and promotes the growth of neoplasms in solid organ recipients. There have been a few reports on the incidence of cancer from transplant registries. It is difficult to precisely compare the incidence with that in the general population using data from small, single-center studies. Thus, we sought to study the prevalence of genitourinary cancer development in Iranian renal transplant recipients. We collected data from 5 kidney transplant centers in Iran between 1984 and 2008, seeking to detect the incidence, type, and outcome of cancers after kidney transplantation. Only histologically confirmed tumors, which occurred after renal transplantation, were included in the analysis. Of the 5532 patients who underwent kidney transplantation, genitourinary tumors were detected in 21 subjects (0.38%), namely, 12 males and 9 females. Transitional cell carcinoma (TCC) of the bladder, the most common genitourinary cancer (n = 7) was followed by renal cell carcinoma (RCC; n = 5), ovarian cancer (n = 3), breast cancer (n = 3), prostate cancer (n = 1), seminoma (n = 1), and uterine cancer (n = 1). The overall mean age of the patients was 46 +/- 12 years (range, 19-72 years) and the median time to diagnosis after transplantation was 72 months (range, 4-240 months). Seven patients died during the follow-up. There was a male predominance among TCC of the bladder and RCC (5:2 and 4:1, respectively). In conclusion, TCC of the bladder was the most common genitourinary tumor following kidney transplantation. It was predominant in male patients.

Despite numerous studies, the precise role of Th1/Th2 cytokines in acute renal allograft rejection remains unclear. To provide insight into the role of cytokines in acute allograft rejection, we measured serum T-cell cytokine concentrations for correlation with clinical events after renal transplantation in adults. Serum Th1 (interleukin-2 [IL-2] and interferon-gamma [IFN gamma] and Th2 (IL-4, IL-10) cytokine concentrations were measured in 60 consecutive living donor kidney transplant recipients namely, 40 males, overall mean age 38.82 years), on the day before as well as 7 and 14 days posttransplantation using ELISA. Patients were stratified based upon acute rejection episode (ARE) in the first month after transplantation. Immunosuppression consisted of cyclosporine, mycophenolate mofetil, and prednisolone. ARE was diagnosed based on an increased plasma creatinine of more than 50%, sonographic analysis, radioisotope scan, pathologic findings, or measured cyclosporine blood levels. Twelve ARE were diagnosed among patients (20%). There was no significant difference between the 2 groups with respect to the mean serum concentration values of IL-2, IL-10, IL-4, and IFN gamma on the day before or 7 or 14 days after transplantation. This study showed that there was no correlation between the Th1/Th2 serum cytokine profiles and early ARE in living donor kidney transplantation.

Erectile dysfunction (ED) is common among patients with end-stage renal disease (ESRD), who undergo hemodialysis (HD). The aim of this study was to evaluate the safety and effectiveness of sildenafil in male HD patients with ED. Twenty-seven HD patients were recruited for this prospective, randomized, double-blind, placebo-controlled, clinical trial study of sildenafil during a period of 1 week. Efficacy was assessed by using the International Index of Erectile Function (IIEF) before and 1 week after treatment. Baseline demographic and clinical features were similar in both the groups. There was a weak correlation between ED and duration of undergoing dialysis (P = 0.073). There was significant relationship between sildenafil usage and improvement in erectile function (P < 0.0001). Placebo improved significantly the erectile function (P = 0.016), perhaps by psychological way. However, sildenafil had a more significant effect than placebo in increasing IIEF score among HD patients (P = 0.00 compared to 0.016). Sildenafil is effective and safe for treating ED among HD patients.

BACKGROUND:

Helicobacter pylori (HP), a small gram-negative spiral bacillus living in the mucus layer of the human stomach, mediates some gastrointestinal disorders. Considering the immunocompromised nature of transplant recipients due to immunosuppression, they are generally prone to viral and bacterial infectious diseases. In this study we sought to investigate the seroprevalence of HP infection among Iranian kidney transplant recipients.

METHODS:

We selected randomly 91 kidney transplant patients who were examined for anti- HP Immunoglobulin G (IgG) using an enzyme-linked immunosorbent assay method (Lake Success, NY, USA).

RESULTS:

Forty-three subjects (47.3%) were seropositive for anti-HEV IgG. There was no difference by age (P=.49), sex (P=.22), blood transfusion history (P=.19), or hemodialysis history (P=.46) between seropositive and seronegative groups, but there was a significant difference regarding the educational status of the subjects (P=.03), The difference was not confirmed by considering diploma as the cut point to categorize subjects (P>.05). Comparing age groups, Pearson chi-square analysis revealed no significant correlation between HP seropositivity and increasing age (P=.963), even when controlled for sex, educational status, history of blood transfusion, or hemodialysis.

CONCLUSION:

The frequency of transplant recipients with anti-HP IgG antibodies in our institution (47.3%) was not higher than that in the general population (almost 60% in Urmia). This rate was lower than reports from developing countries possibly due to better health and sanitation.

BACKGROUND:

Incidence and risk factors for skin tumors following renal transplantation can vary geographically; therefore, a retrospective study was performed to determine the incidence of and potential risk factors for skin cancer at 14 Transplant Centers in Iran between 1984 and 2008.

MATERIAL/METHODS:

We enrolled 11,255 kidney transplant recipients who were examined for all skin tumors. All skin cancers were established by histological examination. The data collection included the patient's age and sex, immunosuppressive regimen before and after diagnosis of tumor, rejection episodes, post-transplant latency period, other concurrent neoplastic problems, renal allograft function and outcome.

RESULTS:

One hundred and twenty-eight (1.14%) renal recipients had skin tumor, representing half of all post-transplant malignancies (128 out of 245 cases). Kaposi's sarcoma was the most common post-transplant cancer compared with other skin tumors. Male recipients had more tumors than did females (P=0.04); the male-to-female ratio in the affected patients was 2.5:1. The age at transplantation of patients with skin tumor was higher compared to RTRs without skin tumor (47±11 vs. 38±15 years, P=0.000), and individuals older than 45 years were at higher risk (odds ratio=3.8, 95%CI 2.6-5.5) of skin cancers. Patients consuming azathioprine were at risk more of skin cancer compared with those were on MMF (odds ratio =2.9, 95%, CI 2.0-4.2). The overall mortality was low (7.8%) in cases with skin cancer.

CONCLUSIONS:

This study showed that male sex, increased age, prolonged immunosuppression and azathioprine increased the risk of skin tumors after renal transplantation.

INTRODUCTION. Screening programs for chronic kidney disease (CKD) are deemed to be cost effective only when they are limited to high-risk groups. We screened a sample of high-risk population of Urima, Iran. MATERIALS AND METHODS. As a pilot study for a national project, we enrolled 905 participants who had at least one risk factor for CKD (including hypertension, diabetes mellitus, or a family history of CKD). The study population was selected from among patients with Dm or hypertension and family members of those with CKD in Urima urban area and 2 randomly selected neighbor rural areas. Urine dipstick tests were done and blood sample was obtained to detect proteinuria and measure serum creatinine concentration, respectively. RESULTS. A total of 607 participants (67.1%) were enrolled from rural areas and 298 (32.9%) from the urban area. The mean serum creatinine level was 1.27 ± 0.60 mg/dL. A high serum creatinine level was demonstrated in 343 participants (37.9%), and 212 (23.4%) were demonstrated to have proteinuria. There was a significant correlation between serum creatinine level and urinary protein excretion (P = .001). There were no significant differences between rural and urban subgroups in terms of proteinuria (P = .42) and serum creatinine level (P = .08). CONCLUSIONS. The prevalence of a high creatinine level (37.9%) is so high in the high-risk population of Urmia. Our most important goal of implementing this preliminary study was to assess probable limitations and problems of performing an extensive national screening program for CKD in the future.

INTRODUCTION:

Gingival enlargement is one of the most cumbersome complications of cyclosporine A. It affects patient's life style by impairing the appearance and function of masticatory tract. This study was conducted on a sample of Iranian kidney transplant recipients to determine the frequency and risk factors of cyclosporine-induced gingival enlargement.

MATERIALS AND METHODS:

A total of 200 kidney transplant recipients (mean age, 39.7 +/- 13.2 years) were enrolled in this study. All of the participants were receiving cyclosporine for at least 12 months prior to the study. Factors including age, gender, cyclosporine dose, serum concentration of cyclosporine, duration of immunosuppressive administration, plaque, and gingival indexes were evaluated.

RESULTS:

Seventy kidney transplant recipients (35%) showed various degrees of gingival enlargement. Serum cyclosporine concentration and the intensity of gingival enlargement (McGraw index) had a significant correlation (r = 0.35, P < .001). Multiple regression analysis revealed an independent association between gingival enlargement and either serum concentrations of cyclosporine and plaque index (P < .05). The other variables failed to show a significant relationship with gingival enlargement.

CONCLUSIONS:

The prevalence of cyclosporine-induced gingival enlargement in our patients seems to be almost greater than the prevalence reported in previous studies. There was a significant relationship between cyclosporine immunosuppressive treatment and gingival overgrowth in Iranian kidney transplant recipients.

Several years after the initial usage of continuous ambulatory peritoneal dialysis (CAPD), the percentage of patients using this continues to be very low constituting about 15% of all patients with end-stage renal disease (ESRD). In this study, we attempt to define the impact of an educational program for improving the use of CAPD. This is a quasi-experimental study (before-after) conducted with educational materials including workshop, teaching by booklet and showing educational films, performed in Urmia, Iran. We designed a questionnaire for data collection and enrolled 160 patients with an aim-based sampling method. We used descriptive statistics and Friedman test for analysis in SPSS software version 11.5. The overall patients' information about CAPD defined by total scoring was as follows: 75% had little information; 19% had moderate information and 6% of patients were well informed. All the information levels increased after intervention. Our study suggests that the poor utilization of CAPD is due to relative un-awareness about PD and/or lack of adequate facilities.

Decreased bone mineral density is a common problem after kidney transplantation. Osteoporosis has a major role in morbidity in these patients. We evaluated the incidence of osteoporosis and determined risk factors in 77 patients aged 17 to 50 years who had undergone renal transplantation 6 months to 2 years previously. Bone mineral densitometry was performed using dual-energy x-ray absorptiometry. The incidence of osteoporosis was 26% (20 of 77 patients). Mean (SD) age of affected patients was 34.6 (8.7) years. The most common sites of osteoporosis were the hip (osteoporotic in 19 patients [24.7%] and osteopenic in 42 [54.5%]) and the spine (osteoporotic in 6 patients [7.8%] and osteopenic in 52 [67.5%]). There was a significant relationship between posttransplantation creatinine concentration and hip osteoporosis (P = .01). No relationship was observed between osteoporosis and age, sex, body mass index, duration of hemodialysis therapy, cumulative dosage of any drugs, or use of pulsed methylprednisolone therapy. A hip or spine z score of 1 or less had no relationship to the number of steroid pulse sessions but was significantly related to the total dosage of cyclosporine (P < .001), prednisolone (P < .001), and mycophenolate mofetil (P < .05). A hip z score of less than 1 was related to the posttransplantation period (P = .02). In conclusion, osteoporosis is a frequent complication that requires detection and treatment to reduce morbidity.

OBJECTIVES:

Full activation of T cells requires 2 distinct but synergistic signals. The first is the T-cell antigen receptor, which is antigen specific, and the second is activation of co-stimulatory signals. Active vitamin D (1, 25-dihydroxyvitamin D3) decreases T-cell activation and proliferation, inhibits differentiation and maturation of dendritic cells, and induces tolerogenic dendritic cells. These immunoregulatory effects may be due, at least in part, to changes in cytokine secretion and expression of co-stimulatory molecules. The use of active vitamin D has been reported to improve allograft survival, decelerate loss of allograft function, and prevent acute rejection. This study was conducted to assess the effect of active vitamin D on the expression of co-stimulatory molecules and HLA-DR in renal transplant recipients.

MATERIALS AND METHODS:

In this prospective study, we enrolled 24 renal transplant recipients who had undergone a transplant 6 to 18 months earlier, had stable allograft function, and were without episodes of allograft dysfunction or febrile illness in the previous 2 months. Participants were administered oral calcitriol 0.5 micrograms daily for 4 weeks. Expression of HLA-DR, CD28, CD86, and CD40 in peripheral blood leukocytes was assessed by flow cytometry before and after calcitriol administration.

RESULTS:

Compared to baseline levels, expression of HLA-DR decreased by 16.8%; expression of CD28, by 30%; of CD40, by 31.2%; and of CD86, by 36.7%.

CONCLUSIONS:

In renal transplant recipients, decreased expression of co-stimulatory and HLA-DR molecules occurred after treatment with active vitamin D. Such changes may be involved in increasing allograft survival.

INTRODUCTION:

Limited data with adequate sample size exist on the development of posttransplant lymphoproliferative disorder (PTLD) in living donor kidney recipients. We conducted a retrospective cohort study on the data of 10 transplant centers to identify the incidence of PTLD in Iran.

MATERIALS AND METHODS:

Data of 9917 kidney transplant recipients who received their kidneys between 1984 and 2008 were reviewed. Fifty-one recipients (0.5%) who developed PTLD were evaluated with a median follow-up of 47.5 months (range, 1 to 211) months.

RESULTS:

Patients with PTLD represented 24% of all posttransplant malignancies (51 out of 211 cases). There was no relationship between PTLD and sex (P = .20). There were no statistically significance differences considering the age at transplantation between patients with and without PTLD. The late-onset PTLD (70.6%) occurred more frequently compared to the early form. There was no signification relationship between early-onset and late-onset groups in terms of clinical course and outcome. In patients who received azathioprine, PTLD was more frequent when compared to those who received mycophenolate mofetil (P < .001). The lymph nodes were the predominantly involved site (35.3%), followed by the gastrointestinal tract, brain, kidney allograft, lung, ovary, vertebrae, and palatine. Age at diagnosis and the time from transplantation to diagnosis were comparable for various involvement sites of PTLDs. The overall mortality in this series of patients was 51.0%.

CONCLUSIONS:

Posttransplant lymphoproliferative disorder is a rare but devastating complication and long-term prognosis can be improved with early recognition and appropriate therapy.

INTRODUCTION:

Kaposi's sarcoma (KS) is one of the most common tumors to occur in kidney recipients, especially in the Middle East countries. Limited data with adequate sample size exist about the development of KS in living kidney recipients.

METHODS:

Therefore, we made a plan for a multicenter study, accounting for up to 36% (n = 7,939) of all kidney transplantation in Iran, to determine the incidence of KS after kidney transplantation between 1984 and 2007.

RESULTS:

Fifty-five (0.69%) recipients who developed KS after kidney transplantation were retrospectively evaluated with a median follow-up of 24 (1-180) months. KS occurred more often in older age when compared to patients without KS (49 +/- 12 vs. 38 +/- 15 years, P = 0.000). KS was frequently found during the first 2 years after transplantation (72.7%). Skin involvement was universal. Furthermore, overall mortality rate was 18%, and it was higher in patients with visceral involvement compared to those with mucocutaneous lesions (P = 0.01). However, KS had no adverse affect on patient and graft survival rates compared to those without KS. Forty-four patients with limited mucocutaneous disease and four with visceral disease responded to withdrawal or reduction of immunosuppression with or without other treatment modalities. Renal function was preserved when immunosuppression was reduced instead of withdrawn in patients with and without visceral involvement (P = 0.001 and 0.008, respectively).

CONCLUSION:

The high incidence of KS in this large population studied, as compared to that reported in other transplant patient groups, suggests that genetic predisposition may play a pathogenetic role.

PMID:

18592392

[PubMed - indexed for MEDLINE]

Abstract

Objectives: The process of kidney failure in renal transplant recipients with chronic allograft dysfunction is characterized by a progressive decline in glomerular filtration rate over time that it is determined by the 5-stage model. This study used stage-based statistical survival analysis to predict graft survival in renal transplant recipients with chronic allograft dysfunction. Materials and Methods: In a single-center, retrospective study, 214 renal transplant recipients with chronic allograft dysfunction were investigated at a university hospital in Iran from 1997 to 2005. At each patient visit, kidney function was assessed using glomerular filtration rate and stage of disease. Results: The estimated stage-specific hazard rates of disease progression are stage one, 453.936; stage two, 485.040; stage three, 545.808; and stage four; 649.488 per 1000 person-years. The estimated mean times in each stage were as follows: kidney damage with normal or increased glomerular filtration rate, 26.43 months; kidney damage with mildly decreased glomerular filtration rate, 24.74 months; moderate kidney disease, 21.98 months; and severe kidney disease; 18.48 months. These estimates yield a mean time from stage 1 to kidney failure of 91.63 months. The probability of graft survival was predicted using estimated stage-specific hazard rates. The 18th, 58th, 118th, and 155th months death-censored graft survival probabilities were 0.99, 0.75, 0.25, and 0.10. Conclusions: In this method of survival analysis, we can determine a statistical model according to a real clinical model in renal transplant recipients with chronic allograft dysfunction. It enables us to determine the stage-specific hazard rates of disease progression. These findings can help nephrologists to understand the kidney disease process and better predict graft survival.

Abstract

OBJECTIVES:

Graft loss owing to chronic allograft dysfunction is a major concern in renal transplant recipients. We assessed the affect of immune and nonimmune risk factors on death-censored graft loss in renal transplant recipients with chronic allograft dysfunction.

MATERIALS AND METHODS:

We performed a retrospective, single-center study on 214 renal transplant recipients with chronic allograft dysfunction among 1534 renal transplant recipients at the Urmia University Hospital from 1997 to 2005. Data registry includes details from all renal transplants. The renal transplant recipient information is regularly updated to determine current graft function, graft loss, or renal transplant recipient's death. The selection criteria were a functional renal allograft for at least 1 year and a progressive decline in allograft function.

RESULTS:

Increasing donor age (RR=1.066; P < .001), recipient age (RR=1.021, P = .00), recipient weight (RR=1.024; P = .029), and waiting time on dialysis to transplant (RR=1.047; P = .006), pretransplant hypertension (RR=3.126; P < .001), pretransplant diabetes (RR=5.787; P < .001), delayed graft function (RR=6.087; P < .001), proteinuria (RR=2.663; P = .001), posttransplant diabetes (RR=2.285; P = .015), posttransplant hypertension (RR=2.047; P = .017), and AR (RR=3.125; P < .001). Patients in stage 2 at the beginning of chronic allograft dysfunction relative to stage 1 (RR=4.823; P < .001) and patients in stage 3 at the beginning of chronic allograft dysfunction relative to stage 1 (RR=123.06; P < .001) were significant risk factors for death-censored graft loss. Using mycophenolate mofetil versus azathioprine reduced death-censored graft loss (RR=0.499; P = .001).

CONCLUSION:

We found that age of donor, pretransplant hypertension, pretransplant diabetes, type of immunosuppression (mycophenolate mofetil vs azathioprine), delayed graft function, proteinuria, and stage of allograft dysfunction at the start of chronic allograft dysfunction are the major risk factors for late renal allograft dysfunction.

Abstract

Steroid-resistant nephrotic syndrome (SRNS) in children carries a significant risk of progression to end-stage renal failure (ESRF). We report a two-step protocol adapted in children with SRNS. Thirty-seven SRNS were treated with cyclosporine A (CyA) in association with prednisolone (alternate day) for 6 months (first-step treatment). Twelve patients (32.4%) went into complete remission, and 2 (5.4%) got partial remission. The other 23 cases who were steroid and CyA resistant entered a second-step treatment with withdrawing steroids, with CyA (5 mg/kg/day) in association with mycophenolate mofetil (MMF) 30 mg/kg/day for 6 months. Complete remission was observed in 11 cases (47.82%) and partial remission in 2 cases (8.7%). After two steps of treatment, 27/37 children went into total remission. In steroid and CyA-resistant INS, the association of MMF with CyA was able to induce remission in about half cases without relevant side effects.

Abstract

Background. Henoch-Schönlein purpura (HSP) is the most common childhood vasculitis with an incidence of approximately 10 per 100 000 children. There is some evidence to support steroid therapy in the treatment of severe abdominal pain, severe nephritis, and central nervous system involvement. However, the routine use of corticosteroids is controversial. Frequent relapses, lack of response to steroid, steroid dependency, and steroid side effects may occur in some patients. Mycophenolate mofetil (MMF) gains increasing popularity in the treatment of autoimmune disorders, but hitherto, the available evidence to support the use of MMF in HSP is limited to some case study reports. Case Presentation. We report six children with HSP who failed to respond to systemic steroid therapy, whereas MMF successfully treated the manifestations of the disease. Conclusion. The manifestations of HSP disappeared mainly during the first week of treatment with MMF and all the patients were in a complete remission at the end and after discontinuation of the therapy. In our experience, MMF appeared to be safe and effective for the maintenance of remission in the HSP patients.

Abstract

The outcome of pediatric renal transplantation was previously reported by a single-center study at the year 2006. Therefore, we aimed to evaluate and report the characteristics and outcome of renal pediatric renal transplantation in a multi-center nationwide study. In this nationwide report, medical records of 907 children (≤18yr) with renal transplantation in eight major pediatric transplant centers of Iran were recorded. These 907 patients received a total of 922 transplants. All children who failed to follow-up were excluded. Rather than baseline characteristics, graft and patient outcomes were considered for survival analysis. For further analysis, they were divided into two groups: patients who had graft survival time more than 10yr (n=91) and the ones with graft survival time of equal or less than 10yr (n=831). Of 922 recipients, 515 (55.8%) were boys and 407 (44.2%) were girls with the mean age of 13.10 (s.d.=3.54) yr. DGF and AR were occurred in 10% and 39.5% of the transplanted children, respectively. Transplantation year, dialyzing status before transplantation, DGF, and AR were significant enough to predict graft survival in cox regression model (overall model: p<0.001). Nowadays, there is a successful live donor pediatric renal transplantation in Iran. Graft survival has improved in our recipients and now the graft survival rates are near to international standards.

Abstract

PURPOSE:

Our aim was to determine association of vesicoureteral reflux (VUR) and idiopathic hypercalciuria in children with recurrent and single episode of urinary tract infection (UTI).

MATERIALS AND METHODS:

The study group consisted of 45 children with VUR and recurrent UTI, and 2 control groups: 45 normal healthy children (control group 1) and 45 children with VUR and single episode of UTI (control group 2). Idiopathic hypercalciuria was defined as urine calcium to creatinine ratio more than 0.8 (mg/mg) in infants younger than 1 year old, and more than 0.2 (mg/mg) in older children (without any detectable causes for hypercalciuria).

RESULTS:

The study group consisted of 26 (57.8%) girls and 19 (42.2%) boys, with the mean age of 41.14 +/- 22.1 months. Nine (20%) subjects had hypercalciuria. The control group 1 composed of 22 (48.9%) girls and 23 (51.1%) boys, with the mean age of 43.98 +/- 16.23 months. In this group, 6 subjects (13.3%) with hypercalciuria were detected. The control group 2 composed of 23 (51.1%) girls and 22 (48.9%) boys, with the mean age of 39.96 +/- 24.2 months. In group 2, 7 subjects (15.6%) with hypercalciuria were detected.

CONCLUSION:

Comparison between such results was not statistically significant. Despite reports of different studies about accompanying of hypercalciuria with recurrent UTI with or without anatomical abnormalities, according to the present study, idiopathic hypercalciuria is not a major contributing factor to recurrent UTI in children with VUR.

Abstract

INTRODUCTION:

The aim of this study was to evaluate the accuracy of Technetium Tc 99m dimercaptosuccinic acid (99mTc-DMSA) renal scintigraphy in the diagnosis of urinary tract infection (UTI) in children with suspected infection but with a negative urine culture.

MATERIALS AND METHODS:

The records of all children with suspected or definite diagnosis of UTI presented during a 2-year period were reviewed in this study. Abnormal findings on renal scintigraphy, voiding cystourethrography (VCUG), and ultrasonography were evaluated and compared between the patients with the definite diagnosis of UTI and those with suspected UTI and negative urine cultures.

RESULTS:

Of 210 patients, 86 had a definite diagnosis of UTI (group 1) and 124 had suspected UTI without a positive culture (group 2). Abnormal findings on DMSA scans were seen in 76 patients (88.4%) in group 1 and 84 (67.7%) in group 2. Vesicoureteral reflux was detected by VCUG in 50% and 32.3% of the patients in groups 1 and 2, respectively. In group 2, vesicoureteral reflux was seen in 40.5% of the patients with abnormal DMSA scan. Ultrasonography findings were abnormal in 51.3% and 39.8% of the patients with abnormal DMSA scan findings in groups 1 and 2, respectively.

CONCLUSION:

According to our findings, in children with a negative urine culture and abnormal urinalysis, 99mTc-DMSA renal scintigraphy is helpful in diagnosing UTI and vesicoureteral reflux; we recommend VCUG when DMSA scan supports UTI despite a negative urine culture and a normal ultrasonography.