Saudi Journal of Kidney Diseases and Transplantation最新文献

Acute kidney injury (AKI) caused by rhabdomyolysis following a single episode of seizure is a rare entity. We report a rare case of food poisoning contaminated with pesticides, complicated by a seizure episode. This was followed by rhabdomyolysis and AKI in two members of the same family. The diagnosis of rhabdomyolysis was supported by a markedly elevated level of serum creatinine phosphokinase. Both patients underwent hemodialysis and subsequently made a rapid and complete recovery. Under further investigations, the contaminated source of food was identified. Toxicological screening led to the identification of the pesticide endrin as the cause of the seizure and rhabdomyolysis-associated AKI. The cause of AKI in both cases was attributed to acute rhabdomyolysis. Endrin is known to cause renal insufficiency by various mechanisms, including direct acute tubular injury, interstitial edema, and impaired autoregulation of renal blood flow. The temporal relationship between ingestion of the endrin-contaminated food and the development of seizures preceding acute rhabdomyolysis supported this fact. As endrin is known to cause seizures, especially in the absence of other etiologies for rhabdomyolysis, our cases supported the occurrence of endrin-induced rhabdomyolysis following seizures.

The immunogenicity of COVID-19 vaccines in maintenance hemodialysis (MHD) and kidney transplant recipients (KTR) are suboptimal. However, there are no data on the durability of the humoral response with the ChAdOx1 nCoV-19 vaccine in these groups. This was a multicenter, prospective cohort study of MHD patients (n = 73), KTR (n = 62), and controls (n = 22) who received the ChAdOx1 nCoV-19 vaccine between February 2021 and April 2022. The vaccine response was measured at 1 and 6 months after the second dose. The antibody response in the MHD group compared with the controls was statistically lower at both 1 and 6 months. However, only six (8.2%) cases showed negative seroresponses at 1 month, and five (6.84%) had negative responses at 6 months. For the KTR group, overall, 26 (35.61%) cases had no seroresponse, and 36 (64.39%) seroconverted at6 months. In this group, antibody levels were lower at 6 months; however, there was no significant difference compared with 1 month. In a comparison of the MHD group and KTR, the antibody levels were significantly lower in the KTR group. The risk factors for no response at 6 months in the KTR group were a greater age, a recent history of antirejection, and being in the early transplant period, whereas only age was linked with a low response in the MHD group. Our report highlights the consistent and durable response of the COVID-19 vaccine in both groups of patients, despite them having an attenuated response compared with the controls.

Hepatitis B virus (HBV)-associated vasculitis manifests as vasculitis of the medium vessel and polyarteritis nodosa (PAN). HBV-associated PAN (HBV-PAN) is negative for antineutrophilic cytoplasmic antibodies (ANCA), without glomerulonephritis (GN) or pulmonary involvement; relapse does not occur after successful HBV seroconversion. We describe a case of HBV-associated vasculitis characterized by small and medium overlapping vasculitis and an atypical long-term course in a 60-year-old male with hypertension and HBV who initially presented with abdominal pain and scrotal swelling. The abdominal angiogram revealed a beaded morphology and aneurysms involving the mesenteric, hepatic, and intraparenchymal renal arteries. Tests for the HBV core antibody, cANCA, PR3, and rheumatoid factor were positive. He received pulse steroids and cytoxan for PAN and entecavir for HBV, which resolved the symptoms. Serum creatinine (SCr) rose and then remained stable. Multiple urinalysis measurements were negative. Two years later, the patient developed abdominal pain, orchitis, hemoptysis, and acute kidney injury (SCr = 11 mg/dL). The viral load of HBV was negative. Urinalysis showed 3+ blood and 3+ protein. The renal biopsy displayed pauci-immune crescentic GN with active crescents involving ~50% of the glomeruli. Two arteries had evidence of past arteritis with elastic lamina disruption. Acute necrotizing arteritis was absent. The patient recovered renal function after receiving pulse steroids, plasma exchange, rituximab, and cytoxan. Although the initial trigger may have been HBV, the vasculitis became self-perpetuating, as it recurred without HBV viremia. Patients with HBV-PAN who are ANCA+ should be closely followed because they could be at a higher risk of relapsing vasculitis.

Peritonitis is one of the most serious complications of peritoneal dialysis (PD). The most common microbial causes of PD-associated peritonitis are Gram-positive pathogens. However, unusual microorganisms may be involved in this type of infection, such as Campylobacter fetus. Here, we report a case of C. fetus peritonitis in a 60-year-old woman undergoing continuous ambulatory PD. This patient was admitted to the nephrology department with a history of fatigue, abdominal pain, diarrhea, vomiting, and fever. A bacteriological examination of the PD effluent revealed a cloudy liquid containing 900 leukocytes/mm3 with 75% polymorphonuclear neutrophils. C. fetus was obtained in a pure culture. Antibiotic susceptibility testing was performed. A favorable outcome was noted after treatment with amoxicillin or clavulanic acid and amikacin. Thus, an accurate bacteriological diagnosis of PD-associated peritonitis requires optimal culture methods to improve the isolation of fastidious microorganisms such as Campylobacter and therefore guide appropriate antibiotic therapy.

Bartonella henselae is the causative agent of cat-scratch disease, which is characterized by self-limited regional lymphadenopathy with fever. However, visceral manifestations are possible, especially in immunocompromised patients. Here, we report a case of bartonellosis in a kidney transplant (KT) recipient complicated by glomerulonephritis (GN) associated with the infection. A 52-year-old male who received a deceased-donor KT a year earlier presented to the emergency department with fever, malaise, and abdominal pain. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil, and prednisone. Inguinal lymphadenopathy was found, along with generalized intra-abdominal lymphadenopathy was found. A microscopic examination of the inguinal node demonstrated necrotizing granulomas. His kidney function deteriorated, and an allograft biopsy was performed. The finding was diffuse endocapillary proliferative GN with immune complexes. The B. henselae serology results came back positive, and doxycycline and rifampin were initiated. Given the severity of the kidney injury and the imminent loss of the graft, it was decided that the patient should be treated with steroid pulses. On completion of the antibiotic therapy, his lymphadenopathy resolved. His kidney function gradually recovered, and the patient was no longer dependent on dialysis. Bartonellosis is rare in KT recipients. To our knowledge, there are no other reports of infection-associated GN caused by bartonellosis in KT recipients. Nevertheless, numerous parainfectious immune disorders have been reported in association with Bartonella infections. B. henselae infections should be considered in KT recipients presenting with fever and lymphadenopathy, and also in those presenting with cryptogenic parainfectious manifestations like GN.

Postinfectious glomerulonephritis (PIGN) is one of the most common causes of acute kidney injury in children worldwide. In most cases, there is complete clinical and morphological recovery. Rarely, patients present with persistent abnormal renal function for a few months or years after an episode of PIGN, some even progressing to renal failure. Here, we describe a case of an 11-year-old boy with biopsy-diagnosed PIGN, demonstrating persistent proteinuria, hematuria, and hypertension even 1 year after being treated for PIGN. A second follow-up biopsy showed chronic glomerulopathy in the form of focal and segmental glomerulosclerosis (FSGS) and mesangial hypercellularity. The journey of this patient from PIGN to FSGS is detailed in this case report.

There is a definite paucity of data about the safety and immunogenicity of the Oxford-AstraZeneca vaccine among patients with maintenance hemodialysis (MHD). We aimed to assess the humoral response following this vaccine in a single center of India. In this prospective study, a total of 31 MHD cases were recruited and analyzed. The response was compared with a control group composed of 23 health-care workers. All participants had received two doses of the Oxford-AstraZeneca (COVISHIELD) vaccine. The serology testing was done with severe acute respiratory syndrome coronavirus 2 spike protein antibody assay using indirect chemiluminescence immunoassay after 1 month of the second dose. A cutoff of 15 arbitrary unit (AU)/mL was considered a positive seropositive response. The median age of the patients was 44 (36-52.5) years. Five cases were pretransplant and three were posttransplant with graft failures. Fourteen (45.1%) cases had a 4-week gap between the two doses whereas 17 (54.9%) had an 8-week gap. The median (interquartile range) antibody levels of the MHD and control groups were 400 (315-400) and 398 (367-400) AU/mL, respectively (P = 0.37). All MHD and control groups developed a positive seroresponse. There was no difference in antibody response concerning age, sex, dialysis vintage, or dosing schedule. However, there was a significant difference in the level of antibody response for the MHD cases on immunosuppressive drugs (P = 0.02). The humoral response in maintenance dialysis patients with Oxford-AstraZeneca was comparable to general patients in our report, and immunosuppressive medications were associated with a decreased seroresponse.

Clinical practice guidelines (CPGs) based on evidence and expert opinions ensure that patients with chronic kidney disease (CKD) receive the most up to date care. We aimed to assess and evaluate the most recent and approved international CPGs and compare them via the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Four independent reviewers appraised the selected guidelines with the AGREE II instrument. We considered five eligible CPGs for critical appraisal: the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) CPGs for CKD, the National Institute for Health and Care Excellence (NICE) guidelines for assessing and managing CKD, the Academy of Nutrition and Dietetics' CKD evidence-based nutrition practice guidelines, the CPGs of the Ministry of Public Health in Qatar (MOPH/QA), and the Scottish Intercollegiate Guidelines Network's guidelines for the diagnosis and management of CKD. The overall assessments of three CPGs (NICE, NKF-K/DOQI, and MOPH/QA) scored greater than 85%; the results were congruent with higher scores in the six AGREE II domains: 80%, 67%, and 86% for Domain 3; 47%, 43%, and 86% for Domain 5; and 60%, 48%, and 86% for Domain 6, respectively. Generally, the clinical recommendations were significantly better for the NICE CPGs. All evidence-based CPGs had relatively low methodological quality. The NICE CPGs demonstrated the highest quality, followed by the MOPH/QA and NKF-K/DOQI CPGs, and all five CPGs were recommended for use in practice but with improvements. Saudi Arabia has to formulate its own national CPGs for the diagnosis and management of CKD based on those published by the NICE.

Renal disorders in pregnancy include pregnancy-related acute kidney injury (AKI) and pre-existing chronic kidney disease (CKD), which are risky for both the mother and the fetus. Here, we present the epidemiology and outcomes of pregnancy-related acute kidney injury and CKD in pregnancy at our tertiary care center. We studied the maternal and fetal outcomes of AKI and CKD in pregnancy. Pregnant females and women up to 6 weeks postpartum with AKI or CKD were included in the study; those aged <18 years were excluded. Of 70 cases, 55 had AKI, 10 had AKI and CKD, and 5 had CKD (two were at CKD Stage 5D). The mean age was 27.5 ± 5.4 years, and the mean gestational age was 28.6 ± 8.2 weeks. Sepsis was the most common cause of AKI, followed by pre-eclampsia (21/65). Of the mothers, 48 out of 68 recovered completely (two were already on maintenance hemodialysis), and 10 died. Twenty patients required hemodialysis, nine of whom recovered completely, one progressed to CKD, four became dependent on dialysis, and six died. Regarding the fetal outcomes, 28 were normal-term deliveries, seven were medically terminated, and 35 died. Hypertension, sepsis, metabolic acidosis, raised bilirubin, and the need for hemodialysis were significantly associated with poor maternal outcomes. Raised bilirubin was the only maternal factor significantly associated with poor fetal outcomes. AKI and CKD in pregnancy are associated with higher morbidity and mortality in both the mother and fetus; hence, the focus must be on prevention through regular antenatal checkups.

Lithium-associated hyperparathyroidism is one of the most common causes of hypercalcemia in patients taking lithium. We present an elderly patient who developed hypercalcemia secondary to chronic lithium therapy-induced hyperparathyroidism. He presented with tremors and myoclonus. It was precipitated by a concomitant intake of diuretics, leading to dehydration. Extracorporeal therapy for lithium removal was not given even though he had neurological symptoms, and he was managed with intravenous fluids. He promptly recovered and lithium was stopped. Lithium-related endocrinological manifestations should be investigated for, in any suspected case of lithium toxicity.