Peritoneal dialysis: experience of the department of pediatrics of the hospital Charles Nicolle of Tunis

Introduction: Peritoneal dialysis [PD] is still the most common modality used in treatment for children with End Stage Renal Disease [ESRD]. The objective of this study was to identify the epidemiological, clinical, and microbiological factors affecting the outcome of PD

Methods: In this study, we retrospectively reviewed the records of 85 patients who were treated with DP for the last ten years [from January 2004 to December 2013] in the Department of Pediatrics in Charles Nicolle hospital, Tunis

Results: The mean duration of PD was 18.1 +/- 12 months [3.5-75 months]. The average age of PD onset was 9.3 +/- 5.7 years [29 days-23 years]. The sex ratio was 1.5. In a significant number of cases with ESRD, the primary cause is Congenital Anomalies of the Kidneys and Urinary Tract [CAKUT]. Seventy-four of our patients [87%] had been treated with Automated PD. The average time between catheter placement and PD commencement was 3.9 +/- 4.6 days. Catheter change was 1.62 [1-5]. Sixty-one patients [71.8%] had experienced at least one episode of peritonitis. The most frequently isolated organisms was the Gram-positive bacteria [61%]. Survival rates without peritonitis at 12th, 24th and 36th months were 40%, 32% and 18%, respectively. Transition to permanent hemodialysis was required in 66% of patients

Conclusion: Considering the important incidence of peritonitis in our patients, it is imperative to establish a targeted primary prevention

[Impact of the components of metabolic syndrome on survival in a group of hemodialysis]

Background: Metabolic syndrome is defined by the combination of high blood pressure, dyslipidemia, central obesity and a state of insulin resistance. Its prevalence is high in hemodialysis

Aim: The aim of this work is to see the impact of metabolic syndrome on mortality and morbidity in our hemodialysis patients

Methods: This is a retrospective study of 120 chronic hemodialysis patients. The metabolic syndrome was investigated according to the criteria of the National Cholesterol Education Program Adult Treatment Panel III [NCEP ATP III]. Survival was estimated based on each parameter of the metabolic syndrome. A comparison by sex was performed for the following parameters: age, diabetes, hypertension, obesity, waist circumference, dyslipidemia, coronary artery disease and heart failure

Results: Forty chronic hemodialysis patients with metabolic syndrome have been the subject of this study. The mean age was 55.97 years and the sex ratio was 1.88. Seventy percent had diabetes and 90% were hypertensive. Coronary artery disease was present in 57.5% of cases of heart failure in 52.5% of cases. There was no significant difference in 10 years survival depending on the presence of each component of the metabolic syndrome. The study by sex showed no significant difference except for hyper LDL cholesterol

Conclusion: Our study showed no impact of the components of metabolic syndrome on survival. There is a high prevalence of cardiovascular complications but causality with the metabolic syndrome could not be demonstrated

[First case of subcutaneous dematophytosis in a Tunisian renal transplant patient]

Dermatophytes are keratinophilic and usually infect the corneal layer of the epidermis and appendages On the occasion of immunosuppression, such as solid organ transplant, they can invade deeper tissues or cause an infection of the skin and subcutaneous disseminated. To report the first observation of subcutaneous dematophytosis in a Tunisian renal transplant patient. A 29-year-old man had an erythematous lesion of 2 cm at the front of the left leg. He was treated with prednisone and tacrolimus. The skin lesion was has been neglected. The outcome was the occurrence of oozing whose mycological examination showed numerous hyphae and culture was positive for Microsporum canis. Initial treatment was voriconazole, but an interaction with tacrolimus has shortened the duration of treatment to 1 month. Three months later, the lesion became deeper, and then a biopsy was performed. The mycological examination showed the same appearance, previously described. The patient was put on fluconazole by adjusting the doses of tacrolimus and then underwent surgical excision of the lesions. The evolution after 4 months of antifungal treatment was favorable. The increasing incidence of immunosuppressive therapy has given rise to unusual clinical forms of invasive and sometimes serious fungal agents whose pathogenicity is usually limited. Clinicians should be mindful of superficial fungal infections of the skin in a renal transplant patient

[Acute tubular necrosis in kidney transplantation]

The acute tubular necrosis [ATN] is common after kidney transplantation. Acute tubular necrosis [ATN] is multifactorial and represents one of the main causes of the delayed graft function. Its impact on graft and patients survival is documented. To study the prevalence of the ATN in kidney transplanted patients, the acute rejection rate and their impact on the graft and the patient survival. We retrospectively studied the frequency of ATN, its causes and its impact on patient and graft survival in 255 kidney transplanted patients between1986-2006. Thirty-nine patients had ATN [15.29%]. They are 25 men and 14 women with mean age of 30.1 +/- 12.6 years [8-61] followed for an average of 98 +/- 61.76 months. The majority was treated by hemodialysis [79.48%] and half of them were transplanted from kidney of deceased donor. All patients received anti lymphocyte serum and the majority anticalcineurins [69.23%].The outcome was favorable in 26 patients [66.66%] with recovery of diuresis and normalization of renal function after 6 weeks on average. An acute rejection was diagnosed in 21 patients [53.48%]. The mean creatinine at 1, 5 and 10 years was 135.3, 159.9 and 121.4 micromol / l. Eight patients had creatinine

[IL1/IL1 Ra, DTLA-4 and Apol/Fas genes polymorphisms and susceptibility to IgA nephropathy in Tunisian patients]

The IgA nephropathy [IgA-N] is considered the most common form of primary glomerulonephritis and its pathogenic mechanisms are very complex. The study of several genes which encode for immunoregulator molecules in inflammatory and immunological responses during the disease, allowed to describe some number of polymorphisms would be involved in the molecular expression, the road marking, the synthesis and/or the binding to the receptors. So an abnormality of the molecular function associated with its polymorphism would be suggested in the genetic predisposition to the disease. To determine interleukin 1 [IL1], interleukin1 receptor antagonist [IL1 Ra], CTLA-4 and Apol/Fas genespolymorphisms frequencies in IgA-N in order to estimate the impact of these polymorphisms in the disease susceptibility. The polymorphism of a single nucleotide [SNP] at [-889] IL1 alpha of 21 IgA-N patients and 100 healthy blood donors, as controls, was studied by PCRSSP. The SNPs of the IL1 beta [+3954], CTLA-4 [+49] and l'Apol/Fas were analyzed by PCR RFLP and finally the polymorphism of the IL1 Ra gene was determined by a PCR VNTR [variable number tandem repeat]. Investigation of IL1 alpha/beta and Apol/ Fas polymorphisms showed no differences in genotypes and allelesfrequencies between IgA-N patients and controls. However, genotype AA of CTLA-4 exon 1 [+49] was significantly higher in patients [47.62%] than in controls [9,1%] p<0.001. Nevertheless, the clinical histological and biological characteristics of IgA-N were similar in AA CTLA-4 genotype patients compared to AG or GG genotype patients. We fund also, a significant increased frequency of 1/1 IL1 Ra genotype in IgA-N patients [95,24%] compared to controls [54%] [p<0,001] [p<0,001]. We conclude that the susceptibility to IgA-N seems to be associated with the presence of CTLA-4 AA and iL1 Ra 1/1 genotypes in Tunisian population. However, the lack of association between IL1 alpha/ beta and Apol/fas genes polymorphisms should be further investigated by large population based studies

[Hepatitis viral C in kidney transplantation: comparison study between two Maghrebin centers: Casablanca and Tunis]

Hepatitis viral C [HVC] is relatively frequent among kidney transplants. It is responsible for a morbi-mortality that compromises the results of transplantation in the medium and long term. To evaluate and to compare the prevalence of HVC, 172 kidney transplant adult patients were investigated in two Maghrebian centers at Casablanca [G1]: 57 Moroccan patients and Tunisia [G2]:.115 Tunisian patients. The impact of the HVC infection for a morbi-mortality was concerned only the Tunisian recipient patients: 20 kidney recipients having antibodies anti-VHC and positive HVC-RNA [Cases] which were matched in age, sex and date of the kidney graft, to 20 kidney transplant patients anti-HVC and VHCRNA negative [Controls]. The anti-VHC antibodies were detected by ELISA: Innogenetics and their positivity were confirmed by RIBAII. The ARN-VHC was analyzed by RT-PCR INNO-LiPA HCV II amplification of Innogenetics. The prevalence of hepatitis C is similar for the two groups: 19.3% among Moroccan kidney transplants and 20.9% among Tunisians. The infection by the HVC was often active and the detection of viral RNA was found in 91.7% of the G2 patients against 50% among G1 patients. The genotype 1b is the most prevalent; it is found in 59% of the patients. The frequency of HVC among our kidney transplant patients is particularly determined by the duration and the mode of dialysis. In fact, 22.1% of the patients treated by hemodialysis are VHC [+] against 5,6% patients treated by peritoneal dialysis. Also, the average duration of the dialysis is 58,8 months for HVC [+] patients against 33.5 months for HVC [-] [p<0.0001] patients. The frequency of the chronic rejection of the graft is higher in the G2, but it is similar in Tunisian patients with or without antibodies anti-HVC. In the G1, this frequency is statistically higher among positive HVC transplant patients compared to the negative HVC grafted patients [p<0.05]. The case-control study emphasizes the frequency of the proteinuria, the renal insufficiency, the mellitensis diabetes and the polyglobulinemia among patients HCV [+]; however the differences between the two groups remain statistically non significant. The total rate of the hospitalizations is 26 per 100 patients per year in the HCV [+] group against 17 for the HCV [-]. The average duration of hospitalizations is 72 days among HCV [+] patients against 30.2 days for the controls [p<0.05]. The averages of survival of the patients and of the controls were similar 11.6 +/- 5.6 years for transplant patient HCV [+] against 11.2 +/- 5.5 years for the controls. The actuarial curves of the patients were not different for the patients having antibodies anti-HCV positive or negative. The blood and nosocomial modes of contamination of HVC infection explain their higher frequency in this population at risk. The mortality and the morbidity of the renal transplant patients infected by the HCV seem to be higher compared to the uninfected patients. A further study by large population should be carried out to confirm these results

[Calciphilaxis in chronic renal failure: 3 cases]

Calciphylaxis is a small vessel disease responsible for vascular calcification and skin necrosis. It occurs in association with chronic renal failure and has a poor prognosis. Report new cases. We report 3 cases of calciphylaxis occurred in patients with chronic renal failure secondary to interstitial nephritis in 1 case, diabetic nephropathy in 1 case and thrombotic microangiopathy in 1 case. They were 2 females a 1 man aged of 44.3 years meanly. Hyperphosphoremia and hyperparathyroidism were the essential risk factors. All patients died by sepsis. This course was precipitating by corticotherapy in 2 cases. Early recognition and treatment of risk factors is mandatory to reduce mortality in uremic patients with calciphylaxis

[Vascular trombosis of renal graft: 9 cases]

Allograft renal thrombosis can occur in 1 to 6% of cases. Many predisposing factors has been identified especially alteration of coagulation. We analyzed in this study frequency and predisposing factors of renal graft thrombosis. We report a retrospective study including 319 renal transplant recipients. Nine patients [2, 8%] presented veinous graft thrombosis in 5 cases and arterial thombosis in 4 cases. There were 6 men and 3 women aged of 30, 6 years meanly [10-56] which developed the thrombosis 6 days [1-48] after the transplantation. All patients were detransplanted after 16, 2 days and 1 patient died. Thrombosis constitute an important cause of graft loss. A perfect surgical technic and prophylactic treatment in high risk patients are necessary to reduce this complication