Massive Bilateral Hydroureteronephrosis and End-Stage Renal Disease Ensuing From Chronic Schistosomiasis: A Case Report.

Globally, schistosomal infections affect over 200 million people resulting in the loss of 70 million disability-adjusted life years. In the sub-Saharan Africa region, where over 85% of the global schistosomal infections are found, it is estimated that about 120 million people become symptomatic, over 20 million have severe disease, and nearly 200 000 die every year. Renal impairment is a severe consequence of schistosomiasis occurring in about 6% of all infected individuals and in 15% of those with the hepatosplenic form. We present a case of massive bilateral hydroureteronephrosis and end-stage renal disease resulting from chronic schistosomiasis in a 38-year-old male of African origin. A 38-year-old male rice farmer of African origin presented with a history of elevated blood pressure, abdominal swelling, and reduced urinary output for about 10 months. Abdominal examination revealed an intraabdominal mass measuring 30 cm × 17 cm extending from the right hypochrondrium region downward to right inguinal outward to umbilicus crossing the midline. He had an estimated glomerular filtration rate of 3.9 mL/min, hemoglobin of 6.78 g/dL, and had multiple electrolyte abnormalities. A computed tomography intravenous urogram scan of the abdomen revealed hepatomegaly (18 cm), bilateral renal enlargement with hydroureteronephrosis, and multiple calcifications on the urinary bladder. A rectal biopsy isolated haematobium eggs and confirmed the diagnosis. Urinary schistosomiasis can have distressing effects on the urinary system in particular and survival prospects in general. In view of this, extensive evaluation of the genitourinary system is pivotal for timely diagnosis and prompt management particularly in residents of schistosoma-endemic communities presenting with obstructive uropathy.

Markers of mineral metabolism and vascular access complications: The Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study.

INTRODUCTION: Vascular access dysfunction is a major cause of morbidity in patients with end-stage renal disease (ESRD) on chronic hemodialysis. The effects of abnormalities in mineral metabolism on vascular access are unclear. In this study, we evaluated the association of mineral metabolites, including 25-hydroxy vitamin D (25(OH)D) and fibroblast growth factor-23 (FGF-23), with vascular access complications. METHODS: We included participants from the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study who were using an arteriovenous fistula (AVF; n = 103) or arteriovenous graft (AVG; n = 116). Serum levels of 25(OH)D, FGF-23, parathyroid hormone (PTH), calcium, phosphorus, C-reactive protein (CRP) and interleukin-6 (IL-6) were assessed from stored samples. Participants were followed for up to 1 year or until a vascular access intervention or replacement. FINDINGS: A total of 24 participants using an AVF and 43 participants using an AVG experienced access intervention. Those with 25(OH)D level in the lowest tertile (<11 ng/mL) had an increased risk of AVF intervention compared to those with higher 25(OH)D levels (adjusted relative hazard [aHR] = 3.28; 95% confidence interval [CI]: 1.31, 8.20). The highest tertile of FGF-23 (>3750 RU/mL) was associated with greater risk of AVF intervention (aHR = 2.56; 95% CI: 1.06, 6.18). Higher PTH was associated with higher risk of AVF intervention (aHR = 1.64 per SD of log(PTH); 95% CI: 1.02, 2.62). These associations were not observed in participants using an AVG. None of the other analytes were significantly associated with AVF or AVG intervention. DISCUSSION: Low levels of 25(OH)D and high levels of FGF-23 and PTH are associated with increased risk of AVF intervention. Abnormalities in mineral metabolism are risk factors for vascular access dysfunction and potential therapeutic targets to improve outcomes.

Immunodiagnosis and molecular validation of Toxoplasma gondii infection among patients with end-stage renal disease undergoing haemodialysis.

Infection is a significant cause of morbidity and mortality in patients with chronic kidney disease, especially who were under dialysis due to their depressed immunity. Toxoplasma gondii is a ubiquitous parasite that causes severe manifestations in immunocompromised patients. This case-control study was conducted to the immunodiagnosis and molecular validation of T. gondii infection among patients with end-stage renal disease undergoing haemodialysis. The study population consisted of 260 haemodialysis patients and 259 healthy controls referred to the main dialysis centres of Tehran, Iran during 2016. Anti-T. gondii immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies were assessed using enzyme-linked immunosorbent assay. As well, the T. gondii genomic DNA in whole blood samples of IgM-positive patients and healthy controls was evaluated using GRA6-polymerase chain reaction (PCR) and SAG1-loop-mediated isothermal amplification (LAMP) assays. The anti-T. gondii IgG and IgM antibodies were detected in 175 (67.3%) and 18 (7%) of haemodialysis patients and 122 (47%) and 4 (1.5%) of controls, respectively. Two of the 18 blood samples from IgM-positive patients and none of the IgM-positive control subjects were positive by GRA6-PCR. Whereas, nine and two blood samples of IgM-positive patients and controls were positive for Toxoplasma DNA by a SAG1-LAMP technique respectively. The seropositivity of the Toxoplasma IgM antibody was significantly different between haemodialysis patients and healthy controls which was confirmed by PCR and LAMP. The higher prevalence of T. gondii infection in haemodialysis patients compared with the controls proposes that these patients can be a group at risk for toxoplasmosis and screening for toxoplasmosis before dialysis is necessary for the patients.

Pathologic mechanisms underlying the clinical findings in canine leishmaniasis due to Leishmania infantum/chagasi.

In dogs with symptomatic or asymptomatic leishmaniasis, Leishmania infantum appears to induce a mixed Th1/Th2 immune response that in the sick dog may eventually result in tissue damage via different pathomechanisms, notably granulomatous inflammation (eg, nodular dermatitis, osteomyelitis), immune complex deposition (eg, glomerulonephritis), and/or autoantibody production (eg, polymyositis). This is a compensatory but detrimental mechanism generated mainly because of the insufficient killing capacity of macrophages against the parasite in the susceptible dog. Clinical disease is typically exemplified as exfoliative and/or ulcerative dermatitis, with or without nasodigital hyperkeratosis and onychogryphosis, glomerulonephritis, atrophic myositis of masticatory muscles, anterior uveitis, keratoconjunctivitis sicca, epistaxis, and/or polyarthritis, appearing alone or in various combinations. The pathogenesis of these clinical conditions has recently been highlighted, to a greater or lesser extent. The usually subclinical conditions expressed as chronic colitis, chronic hepatitis, vasculitis, myocarditis, osteomyelitis, orchiepididymitis, and meningoencephalomyelitis, though uncommon, are of pathologic importance from a differential point of view. The leading cause of death among canine leishmaniasis patients is chronic proteinuric nephritis that may progress to end-stage kidney disease, nephrotic syndrome, and/or systemic hypertension. However, even the asymptomatic proteinuria, when profuse, may be a serious problem because it predisposes to arterial thromboembolism and eventually contributes to the deterioration of the body condition.

The unacknowledged impact of urinary schistosomiasis in children: 5 cases from Kumasi, Ghana.

Urinary schistosomiasis is a parasitic disease caused by Shistosoma haematobium. It is prevalent in several parts of Africa particularly in areas where there are large water bodies. In most affected communities, the condition is often accepted as normal since to them, all growing children pass blood in their urine and "grow out of it". Mass treatment of school children has been a regular exercise often undertaken by stake holders to decrease the disease burden and reduce transmission in selected communities. Urinary schistosomiasis can have devastating impact on the urinary tract which is often unacknowledged and unevaluated. Such omission could have implication for progressive renal damage which, if not detected and treated, could lead to end stage renal failure and death. We present five (5) cases of urinary schistosomiasis with severe obstructive uropathy seen at the paediatric nephrology/urology units of Komfo Anokye Teaching Hospital, Ghana. All five cases had some degree of anaemia and hypertension. Two of the five cases presented with end stage renal failure and died subsequently whilst two underwent successful surgery. One made a spontaneous recovery from the urinary obstruction though still has significant renal impairment. This potential devastating effect of urinary schistosomiasis on the kidneys calls for thorough evaluation and assessment of each confirmed case to include blood pressure measurement, full blood count, and ultrasonography of the urinary system. Mass screening programmes should be combined with portable ultrasonography of the kidneys, ureters and bladder.

Prevalence of intestinal parasitism and associated symptomatology among hemodialysis patients.

Intestinal parasites are an important cause of morbidity and mortality. Immunocompromised individuals may develop more severe forms of these infections. Taking into account the immunity impairment in patients suffering from chronic renal failure (CRF), we will determine the prevalence and associated symptoms of intestinal parasites in these patients. Controls without CRF were used for comparison. Stool samples were collected and processed for microscopic identification of parasites using the Formalin-ether concentration method. For Cryptosporidium diagnosis, the ELISA technique was used. One hundred and ten fecal samples from hemodialysis patients were analyzed, as well as 86 from a community group used as control group. A result of 51.6% of intestinal parasites was observed in hemodialysis patients and 61.6% in the control group. Cryptosporidium and Blastocystis were the most common infections in patients with CRF (26.4% and 24.5%, respectively). Blastocystis was the most common infection in the control group (41.9%), however no individual was found positive for Cryptosporidium. Among the CRF patients, 73.6% were symptomatic, 54.3% of these tested positive for at least one parasite, in contrast to 44.8% in asymptomatic patients (p = 0.38). The most common symptoms in this group were flatulence (36.4%), asthenia (30.0%) and weight loss (30.0%). In the control group, 91.9% were symptomatic, 60.8% of these tested positive for at least one parasite, in contrast to 71.4% in asymptomatic patients (p = 0.703). A significant difference between the two groups was observed with regard to symptoms, with bloating, postprandial fullness, and abdominal pain being more frequent in the control group than in the hemodialysis group (all p < 0.05). Comparing symptomatic with asymptomatic, there was no association in either group between symptoms or the prevalence of parasitic infection, nor with the type of parasite or with multiple parasitic infections. Patients with chronic renal failure are frequent targets for renal transplantation, which as well as the inherent immunological impairment of the disease itself, results in immunosuppression by medication. For this reason, carriers of intestinal parasites with pathogenic potential can develop serious clinical complications influencing the success of transplantation. This fact, coupled with the high prevalence of intestinal parasites and the dissociation between symptoms and infection in CRF patients, suggests that the stool test should be incorporated in routine propedeutics. Furthermore, preventive measures for the acquisition of parasites through the fecal-oral contamination route should be introduced.

Prevalence of ittestinal parasitism and associated symptomatology among hemodialysis patients / Prevalência de parasitismo intestinal e sintomatologia associada em pacientes hemodialíticos

Intestinal parasites are an important cause of morbidity and mortality. Immunocompromised individuals may develop more severe forms of these infections. Taking into account the immunity impairment in patients suffering from chronic renal failure (CRF), we will determine the prevalence and associated symptoms of intestinal parasites in these patients. Controls without CRF were used for comparison. Stool samples were collected and processed for microscopic identification of parasites using the Formalin-ether concentration method. For Cryptosporidium diagnosis, the ELISA technique was used. One hundred and ten fecal samples from hemodialysis patients were analyzed, as well as 86 from a community group used as control group. A result of 51.6% of intestinal parasites was observed in hemodialysis patients and 61.6% in the control group. Cryptosporidium and Blastocystis were the most common infections in patients with CRF (26.4% and 24.5%, respectively). Blastocystis was the most common infection in the control group (41.9%), however no individual was found positive for Cryptosporidium. Among the CRF patients, 73.6% were symptomatic, 54.3% of these tested positive for at least one parasite, in contrast to 44.8% in asymptomatic patients (p = 0.38). The most common symptoms in this group were flatulence (36.4%), asthenia (30.0%) and weight loss (30.0%). In the control group, 91.9% were symptomatic, 60.8% of these tested positive for at least one parasite, in contrast to 71.4% in asymptomatic patients (p = 0.703). A significant difference between the two groups was observed with regard to symptoms, with bloating, postprandial fullness, and abdominal pain being more frequent in the control group than in the hemodialysis group (all p < 0.05). Comparing symptomatic with asymptomatic, there was no association in either group between symptoms or the prevalence of parasitic infection, nor with the type of parasite or with multiple parasitic infections. Patients with chronic renal failure are frequent targets for renal transplantation, which as well as the inherent immunological impairment of the disease itself, results in immunosuppression by medication. For this reason, carriers of intestinal parasites with pathogenic potential can develop serious clinical complications influencing the success of transplantation. This fact, coupled with the high prevalence of intestinal parasites and the dissociation between symptoms and infection in CRF patients, suggests that the stool test should be incorporated in routine propedeutics. Furthermore, preventive measures for the acquisition of parasites through the fecal-oral contamination route should be introduced.

Doenças parasitárias infectam grande número de indivíduos em todo o mundo. Manifestações clínicas mais severas podem se apresentar em pacientes imunocomprometidos. Considerando o importante comprometimento imunológico observado em pacientes com insuficiência renal crônica (IRC), foi determinada a prevalência e sintomas associados a parasitoses intestinais nesses pacientes em comparação a controles saudáveis. Foram coletadas amostras fecais de cada participante e processadas para identificação microscópica dos parasitas pelo método de concentração por formol-éter. Foi utilizada a técnica de ELISA para identificar coproantígenos de Cryptosporidium. Foram analisadas 110 amostras fecais de pacientes em hemodiálise e 86 de um grupo controle comunitário. Cryptosporidium e Blastocystis foram as infecções mais freqüentes nos pacientes em hemodiálise (26,4% e 24,5%, respectivamente). Blastocystis foi a infecção mais freqüente no grupo controle (41,9%), entretanto nenhum indivíduo positivo para Cryptosporidium foi identificado. Considerando os pacientes com IRC, 73,6% eram sintomáticos, sendo 54,3% positivos para algum parasita, contra 44,8% nos assintomáticos (p = 0,38). Os sintomas mais frequentes neste grupo foram flatulência (36,4%), adinamia (30,0%) e perda de peso (30,0%). No grupo controle, 91,9% eram sintomáticos, sendo 60,8% positivos para algum parasita, contra 71,4% nos assintomáticos (p = 0,703). Em relação aos sintomas, houve diferença significativa entre os dois grupos, sendo que flatulência, plenitude pós-prandial, e dor abdominal foram mais freqüentes no grupo controle que nos pacientes em hemodiálise (todos p < 0,05). Comparando-se sintomáticos com assintomáticos, não houve associação entre a sintomatologia e a prevalência de parasitose, nem com o tipo de parasita, e nem com o poliparasitismo, nos dois grupos. Considerando que pacientes com IRC são frequentes alvos de transplante renal, resultando em imunossupressão por medicamentos, que é somada à deficiência imunológica inerente à própria doença. Os portadores de parasitas intestinais com potencial patogênico podem desenvolver sérias complicações clínicas que influenciam o sucesso do transplante. Este fato, aliado a alta prevalência de parasitas intestinais e dissociação entre os sintomas e infecção nesses pacientes, sugerem a incorporação do exame de fezes na propedêutica de rotina dos mesmos, juntamente com medidas preventivas para a aquisição de parasitas com rota de contaminação fecal-oral.

Malaria induced acute renal failure: a single center experience.

Malaria has protean clinical manifestations and renal complications, particularly acute renal failure that could be life threatening. To evaluate the incidence, clinical profile, out-come and predictors of mortality in patients with malarial acute renal failure, we retrospectively studied the last two years records of malaria induced acute renal failure in patients with peripheral smear positive for malarial parasites. One hundred (10.4%) (63 males, 37 females) malaria induced acute renal failure amongst 958 cases of acute renal failure were evaluated. Plasmodium (P). falciparum was reported in 85%, P. vivax in 2%, and both in 13% patients. The mean serum creatinine was 9.2 ± 4.2 mg%, and oligo/anuria was present in 82%; 78% of the patients required hemodialysis. Sixty four percent of the patients recovered completely, 10% incompletely, and 5% developed chronic kidney failure; mortality occurred in 21% of the patients. Low hemoglobin, oligo/anuria on admission, hyperbilirubinemia, cerebral malaria, disseminated intravascular coa-gulation, and high serum creatinine were the main predictors of mortality. We conclude that malaria is associated with acute renal failure, which occurs most commonly in plasmodium falciparum infected patients. Early diagnosis and prompt dialysis with supportive management can reduce morality and enhance recovery of renal function.

Presence of antibodies against Leishmania chagasi in haemodialysed patients.

In the last decades there has been an increase in cases of visceral leishmaniasis complicating the post-transplant phase, mainly following kidney transplantation. The aim of this study was to evaluate the reactivity of haemodialysed patients using IFAT. Blood samples of 310 individuals from Natal, RN, Brazil, were collected and analysed. Data regarding blood transfusion, cause of end-stage renal disease and duration of haemodialysis were also analysed. In total, 69 patients (22.3%) were positive by IFAT. This study suggests that antibody detection should be performed in this group of patients since they are possible candidates for kidney transplantation.

Risk factors predisposing to toxoplasmosis in chronic renal failure patients and renal transplant recipients.

This work evaluated risk factors predisposing to toxoplasmosis in chronic renal failure patients and renal transplant recipients. The present study included 91 cases classified according to their renal status into four groups; control group, renal failure patients not on haemodialysis, renal failure patients on regular haemodialysis and renal transplant recipients group. The age groups (< 20) and (30-) had the highest positivity for anti-Toxoplasma IgG & IgM antibodies in comparison to the other age groups. The results showed no sex difference in positivity rate for anti-Toxoplasma IgG & IgM in groups. There was no significant difference between groups regarding risk factors for contracting toxoplasmosis, clinical presentation suggestive of toxoplasmosis and diabetes mellitus. There was significant difference between all groups as regarding intake of immunosuppressive drugs and blood transfusion.

The role of renal proximal tubular cells in diabetic nephropathy.

We now know that the rate of progression of diabetic nephropathy, like all progressive renal disease, correlates with the degree of corticointerstitial fibrosis. Therefore, much interest has focused on the contribution of the resident cells in the renal cortex to this process. This article reviews the evidence that the epithelial cells of the proximal tubule are major players in orchestrating events in the corticointerstitium in diabetic nephropathy. More specifically, it addresses their role in extracellular matrix turnover, generation of cytokines, and recruitment of inflammatory cells, as well as examining the concept that they are the source of the interstitial myofibroblasts, which are the principal mediators of the fibrotic process.

Intestinal spore-forming protozoa among patients suffering from chronic renal failure.

Cryptosporidium parvum, Isospora belli, Cyclospora cayetanensis and Microsporidia are four intestinal spore-forming protozoa that cause diarrhoea in immuno-competent individuals and immuno-suppressed patients. Fresh stool samples were obtained from 120 patients suffering from CRF and attending the Dialysis Unit of Zagazig University Hospital. Also, stool samples were obtained from 40 immuno-competent individuals complaining of diarrhoea (control group). The stool samples were examined by direct smear and formol-ether concentration methods then stained by Giemsa, Modified Ziehl Neelsen (MZN) and Aniline carbol methyl violet stains. The four intestinal spore-forming protozoa were detected in 40/120 (33.3%) of patients with CRF and in 2/40 (5.0%) of the control group with a statistically highly significant difference (P < 0.001). C. parvum, Microsporidia, C. cayetanensis and I. belli were detected in 18/120 (15%), 10/120 (8.3%), 9/120 (7.5%) and 3/120 (2.5%), respectively. The four protozoa were found as mixed infections with other pathogens or as single infections confirming their role alone as a cause of diarrhoea. MZN stain was the most efficient simple, and not expensive.

[Hemodialysis and strongyloidiasis: a presumed cause of eosinophilia able to mask the other]. / Hémodialyse et strongyloïdose: une cause présumée d'hyperéosinophilie peut en cacher une autre.

The authors report a case of recurrent strongyloidiasis in a former French soldier of the Indochina colonial war (1946-54). Strongyloidiasis was associated with inaugural renal failure (acute steroid-resistant interstitial-type), requiring permanent hemodialysis. Despite antiparasitic treatment, relapse with digestive and pulmonary symptoms occurred 10 years later, following chronic eosinophilia. This observation emphasises that in dialysed subjects, eosinophilia should always stimulate a search for parasitic etiologies before incriminating dialysis-material allergy. Strongyloidiasis is a self-perpetuating helminthiasis whose distribution area is far greater than the intertropical zone. It can be completely asymptomatic, appear as late digestive complications and be responsible for bacteraemic peaks with septic visceral localizations. It causes a chronic oscillating eosinophilia. Diagnosis is usually performed by iterative stool examinations by Baermann technique in order to detect Strongyloides stercoralis rhabditoid larvae. In dialysed patients with unexplained eosinophilia awaiting renal transplant, the options of systematic thiabendazole (50 mg/kg) or ivermectine (0.2 mg/kg) single-dose to overcame the risk of disseminated strongyloidiasis induced by immunosuppressive post-transplantation therapy could be debated.

Infection by Cryptosporidium parvum in renal patients submitted to renal transplant or hemodialysis.

The frequency of infection by Cryptosporidium parvum was determined in two groups of renal patients submitted to immunosuppression. One group consisted of 23 renal transplanted individuals, and the other consisted of 32 patients with chronic renal insufficiency, periodically submitted to hemodialysis. A third group of 27 patients with systemic arterial hypertension, not immunosuppressed, was used as control. During a period of 18 months all the patients were submitted to faecal examination to detect C. parvum oocysts, for a total of 1 to 6 tests per patient. The results showed frequencies of C. parvum infection of 34.8%, 25% and 17.4%, respectively, for the renal transplanted group, the patients submitted to hemodialysis and the control group. Statistical analysis showed no significant differences among the three groups even though the frequency of C. parvum infection was higher in the transplanted group. However, when the number of fecal samples containing C. parvum oocysts was taken in account, a significantly higher frequency was found in the renal transplanted group.

Dihydropteridine reductase activity: lack of association with serum aluminum levels and cognitive functioning in patients with end-stage renal disease.

Although increased levels of aluminum (Al) are present in patients with dialysis encephalopathy (DE), it is unclear if the association is causal. The enzyme dihydropteridine reductase (DHPR) plays a critical role in neurotransmitter formation and its activity. Elevated levels of Al are reported to decrease DHPR activity, which would alter neurotransmitter metabolism, thus producing DE. We examined the association between erythrocyte DHPR activity and Al levels, attention/psychomotor skills, and depression in a group of 21 patients with end-stage renal disease. DHPR activity was not related to Al level, mental status, psychomotor ability, or depression score. After administration of deferoxamine (an Al chelating agent), Al level increased significantly but DHPR activity remained the same. Our results suggest that the mechanism for the development for DE does not involve alterations of neurotransmitter metabolism caused by Al-mediated reductions in DHPR activity.