A case of PRES in an active lupus nephritis patient after treatment of corticosteroid and cyclophosphamide.

Posterior reversible encephalopathy syndrome (PRES) is primarily a radiological diagnosis. The syndrome is characterized by headache, altered mental status, seizures, and bilateral posterior white matter edema in a nonvascular distribution on neuroimaging with resolution of findings usually in 7-14 days (Casey et al. in AJNR Am J Neuroradiol 21:1199-1206, 2000). In most cases, computed tomography of the brain will show hypodense lesions in the parieto-occipital lobe. Although this syndrome is uncommon, prompt and accurate recognition allows early treatment, which has been shown to produce favorable outcomes. It is hypothesized that the dysfunction can be caused by a failure of autoregulation systemic hypertension or by the cytotoxic effects of vasculitides and immunosuppressive drugs. The present report is a possible second case of cyclophosphamide-induced PRES in a 16-year-old girl with systemic lupus erythematous and lupus nephritis. The initial suspected diagnosis was an ischemic stroke, but it was later changed, with resolution of symptoms after management of the underlying cause.

Prevalence and risk factors of cognitive dysfunction in chronic hemodialysis patients.

OBJECTIVES: There is growing evidence for cognitive dysfunction in chronic hemodialysis patients as the age and the prevalence of comorbidities increase in this population. The aim of the present study was to assess cognitive performance in hemodialysis patients and determine the variables associated with poor cognitive function. METHODS: Cross-sectional cohort of 108 maintenance hemodialysis patients in the Marrakech area. Cognitive performance was assessed through the mini mental state examination (MMSE). Cognitive impairment was defined as a score of less than 24. Univariate and multivariate analyses were performed to determine the variables associated with MMSE score. RESULTS: We found that 25% of the subjects were cognitively impaired. After adjusting for demographic and medical variables, low MMSE scores were independently associated with educational level (odd ratio: 0.564; p = 0.031) and anemia (odd ratio: 0.743; p = 0.046). CONCLUSION: There is a high prevalence of cognitive dysfunction among hemodialysis patients and many causative factors have been evoked. Effective identification of this trouble allows adequate psychological interventions to improve the quality of life of these patients.

University hospital doctors: what are their beliefs about organ donation?

INTRODUCTION: Organ and human tissue donation is not well developed in Morocco. This is due in part to the refusal of families, but also to a lack of awareness. We conducted a survey of a representative sample of doctors more exposed to the donation process to assess their knowledge and attitudes toward organ donation and their training needs. METHODS: This is a cross-sectional study of physicians in Marrakech University Hospital. An anonymous questionnaire adapted to Moroccan context, assessing the knowledge, opinions, attitudes, and needs regarding organ donation was given to doctors. RESULTS: Among 130 distributed questionnaires, we collected 115 completely answered surveys. Respondees were as follows: 60.8% were females, 87 were residents and 28 interns, 80% were aged from 25 to 34 years, and 60% had practiced their profession for 1 to 5 years. Results showed that 28% don't know that tissue and organ donation from a cadaver is authorized in Morocco, 6% are aware of the organs and tissues that can be taken, 76% know the definition of brain death, 35% don't believe in this concept, 88% were favorable for the removal of organs and tissue of deceased persons, 10% ignore that Islam allows organ donation, 62% will give their organs and tissues after death, 25% refuse organ donation of a parent, and 30% refuse it of their children after death. CONCLUSIONS: Our findings show that there is discordance between knowledge and attitudes of doctors in our hospital toward organ donation. The promotion of organ donation requires good training of our teams to sensitize the population.

Knowledge and attitudes of Moroccan hemodialysis patients toward renal transplantation: did we inform our patients enough?

BACKGROUND: Chronic kidney disease is a worldwide public health problem. It is essential to offer patients all appropriate and available treatment options. However, it seems that nephrologists do not talk enough about renal transplantation to their patients. AIM: This pilot study assessed the knowledge, attitudes, and beliefs of hemodialysis patients related to renal transplantation. METHODS: The research included 120 hemodialysis patients from three centers. The instrument was a structured questionnaire completed in individual interviews. None of the respondents had been transplanted. The subjects addressed in the document were sociocultural status, willingness to be transplanted, ability to identify major benefits and risks of renal transplantation, and knowledge of religious attitudes toward living and cadaveric organ donation and transplantation. RESULTS: Among the 120 patients were 53.3% women with an overall mean age of 50.5±10.3 years. The mean duration of hemodialysis was 7.7±5.8 years. Only 15% were highly educated, and 55% had a moderate economic status. Of the 120 respondents, 76% stated that they were willing to be transplanted. However, 41.7% thought that transplantation was more expensive than hemodialysis. Only 65.8% believed that renal transplantation offered a better quality of life. They were afraid of multiple complications and return to dialysis. Of the 120 respondents, 65.9% believed that Islam is adverse to cadaveric donation, a rate that fell to 35.8% concerning living donors. Fifty-four percent of respondents stated that they wanted to obtain more information about renal transplantation. CONCLUSION: There is a need to increase awareness about organ donation and transplantation among hemodialysis patients and their families.

Early pulse pressure and low-grade proteinuria as independent long-term risk factors for new-onset diabetes mellitus after kidney transplantation.

Risk factors for new-onset diabetes after transplantation (NODAT) need to be assessed in large cohorts. We retrospectively evaluated the impact of early (3 and 6 months after transplantation) proteinuria, urinary albumin excretion (UAE) and arterial pressure on NODAT in 828 Caucasian renal transplant recipients (median follow-up: 5.3 years; 5832 patient-years). The 10- and 20-year incidence of NODAT was 15.0% and 22.0%, respectively. Low-grade (<1 g/day) (HR: 2.04 [1.25-3.33], p = 0.0042) and very low-grade (<0.3 g/day) (HR: 2.21 [1.32-3.70], p = 0.0025) proteinuria were independent risk factors for NODAT. There was a dose-dependent relationship across UAE categories (increasing risk from normoalbuminuria to macroalbuminuria) with NODAT. Tacrolimus, sirolimus and beta-blockers (HR: 1.86 [1.07-3.22], p = 0.0277) were significantly associated with NODAT even after multiple adjustments, but not diuretics, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Systolic arterial pressure (HR per 10 mmHg: 1.16 [1.03-1.29], p = 0.0126) and pulse pressure (HR: 1.26 [1.12-1.43], p = 0.0002) were associated with NODAT. Only pulse pressure remained significant after adjustments. Patients at highest risks had early proteinuria and pulse pressure >60 mmHg. Early low-grade proteinuria and pulse pressure (in addition to beta-blockers) constitute independent risk factors for NODAT; they may be markers of the metabolic syndrome and/or vascular damage in renal transplant recipients.

Urinary albumin excretion and the risk of graft loss and death in proteinuric and non-proteinuric renal transplant recipients.

BACKGROUND: Microalbuminuria and macroalbuminuria constitute risk factors for ESRD and death in non-transplanted populations. Whether microalbuminuria (especially in non-proteinuric patients) and macroalbuminuria constitute risk factors for graft loss and death is presently unknown in renal transplantation. METHODS: We retrospectively assessed the association between urinary albumin excretion (UAE) and ESRD and death in renal transplantation. RESULTS: UAE was measured in 616 (397 proteinuric; 219 non-proteinuric patients) renal transplant recipients. They were grafted for 62 months (range: 6-192). During the 40 months (3.7-99) thereafter, 31 patients underwent dialysis and 32 died. Microalbuminuria (vs. normoalbuminuria) and macroalbuminuria (vs. microalbuminuria) were powerful risk factors for graft loss [OR: 14.25 (2.88-52.3) and 16.41 (7.46-36.0), respectively, both p < 0.0001], even after adjustments on renal function and diabetes. Among the 219 non-proteinuric patients, microalbuminuria (vs. normoalbuminuria) was a significant risk factor for graft loss [OR: 23.09 (1.93-276.4), p = 0.0132]. Both microalbuminuria (vs. normoalbuminuria) [OR: 5.55 (2.43-12.66), p < 0.0001] and macroalbuminuria (vs. microalbuminuria) [OR: 4.12 (1.65-10.29), p = 0.0024] were predictive of death. CONCLUSIONS: Microalbuminuria and macroalbuminuria are powerful independent predictors of ESRD and death. Microalbuminuria is a risk factor for graft loss even in non-proteinuric patients. UAE provides additional information on renal and patient prognosis as compared to proteinuria and renal function.

Early proteinuria is a strong indicator of donor renal lesions, ischemia-reperfusion injury and immunological aggression.

BACKGROUND: Early proteinuria is associated with reduced long-term graft survival. However, the determinants and mechanisms of proteinuria early after transplantation have not been identified. METHODS: Parameters associated with proteinuria within the first 3 months following transplantation were retrospectively assessed among 484 renal transplant recipients. RESULTS: Proteinuria was more abundant in patients with a history of two or more rejection episodes (0.42 +/- 0.68 vs 0.18 +/- 0.39 g/d; P = .02). Proteinuria was greater when donor age was 60 or more (OR: 4.43; P = .003), when recipient death was due to cardiovascular causes (OR: 1.98; P = .002), or when cold (OR: 1.77; P = .006) or warm (1.21; P = .09) ischemia times were prolonged. CONCLUSIONS: Proteinuria early after transplantation was related to pretransplant renal lesions, ischemia-reperfusion, and immunologic injuries.

Renal artery aneurysm secondary to Candida albicans in four kidney allograft recipients.

INTRODUCTION: Infection is a frequent cause of morbidity and mortality in solid organ transplant recipients. It may occur at different periods after transplantation. We report four cases of mycotic aneurysms due to Candida albicans (CA) in renal transplant recipients occurring early after kidney transplantation. CASE REPORTS: Four patients (three men, one woman) aged from 24 to 55 years who underwent cadaveric renal transplantation from three different donors developed a mycotic aneurysm at 9 to 90 days after transplantation. In all cases aneurysms were located at the anastomosis between the renal graft artery and the iliac axis. The clinical presentations were fever in three cases, including endocarditis in one patient or deterioration of graft function in two cases and hemorrhagic shock secondary to a ruptured renal artery in the fourth case, which led to death. The arterial aneurysm was discovered at autopsy. The diagnosis of a mycotic aneurysm was based on morphological investigations: echotomography, spiral computed tomography, and arteriography. In all cases bacteriological studies (blood culture, culture of the aneurysmal wall and content) isolated CA. In three patients CA was isolated from the preservation solution; it was of the same phenotype as the one isolated from the aneurysm in one recipient. Antifungal therapy was started in patients who lived, but all kidney transplants had to be removed. Anatomical results of arterial reconstructions were satisfactory in all cases and remained so during the follow-up. CONCLUSION: The insidious presentation and clinical course of mycotic aneurysms due to CA require a high degree of suspicion to make the correct diagnosis.

[Cardiovascular calcifications in hemodialysis patients. Prevalence and risk factors]. / Calcifications cardiovasculaires chez l'hémodialysé chronique. Prévalence et facteurs de risque.

OBJECTIVES: Cardiovascular diseases are the leading cause of morbidity and mortality in chronic hemodialysed patients. The aim of our study was to determine the prevalence of cardiovascular calcifications in dialysed patients and to evaluate their risk factors. METHODS: We did a transversal study in 86 chronically hemodialysed patients in the hemodialysis department, Ibn Sina university hospital (Rabat). All patients, 44 men and 42 females, mean age 42 +/- 15.5 years were hemodialysed for more than one year. FINDINGS: The prevalence of cardiovascular calcifications was 24.5%. Chronic hemodialysed patients with cardiovascular calcifications were older (50.5 years +/- 15.4 vs 39 years +/- 14.6; p = 0.003). They had a long hemodialysis duration (81 months +/- 51 vs 59 months +/- 43; p = 0.05) and a higher calcium plasmatic concentration (2.27 +/- 0.15 vs 2.1 +/- 0.19 mmol/l; p = 0.03). We noted a male gender predominance (sex ratio M/W = 18/3 vs 26/39; p = 0.0002). Multivariate analysis showed, as an independent predictor of cardiovascular calcifications, the old age (p = 0.01). Cardiovascular calcifications seem uncommon in our hemodialysis patients. Older age, longer hemodialysis duration and male gender are risk factors. The use of low doses of calcium carbonate, vitamin D and low milk products diet may explain this low prevalence.

[Nephroprotection in young type 1 diabetic patients treated with converting enzyme inhibitor]. / Néphroprotection chez le jeune diabétique de type 1 traité par inhibiteur d'enzyme de conversion. Résultats préliminaires d'une étude prospective.

CONTEXT: Diabetic nephritis is a renal microangiopathy that represents a major cause of morbidity and mortality in diabetic patients. It is expressed either by microalbunuria, proteinuria or renal failure, depending on the stage of the diabetes. In this context, angiotensin converting enzyme inhibitors (ACEI) slow down the progression of renal damage. OBJECTIVE: To assess the nephroprotector effects of ACEI in young type 1 Moroccan diabetics with varying stages of renal damage. Methods Prospective study including 29 patients exhibiting a diabetic nephropathy and/or hypertension having been followed-up for 1 year and treated with ACEI. The following parameters were analysed on inclusion, at six months and after 1 year of treatment: systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), urinary excretion of albumin, 24-hour proteinuria, creatininemia, creatinine clearance, glycosylated haemoglobin, kalemia, total cholesterol and triglycerides. RESULTS: The mean age of our patients was of 23.6 +/- 5.5 years, the age at onset of diabetes was of 9.3 +/- 2.6 years. According to the renal damage, we determined 4 groups of patients: Group I: microalbuminuria (10 patients), Group II: proteinuria (7 patients), Group III: renal failure (6 patients), Group IV: isolated hypertension (6 patients). Study of the progression of the clinical and biological parameters, during treatment with converting enzyme inhibitors (combined with diuretics in Groups II and III) revealed: In Group I: a decrease in urinary excretion of albumin, which returned to normal in 3 cases, in Group II: a decrease in the proteinuria, which became a microalbuminuria in 4 cases, in Group III: a stabilisation of renal function concomitant to a reduction in proteinuria, in Group IV: a significant reduction in mean arterial pressure. CONCLUSION: One year of treatment with ACEI appears effective on reducing proteinuria levels and stabilising the renal function in young type 1 diabetic patients.