Anxiety and Depression Disorders in Adults on Chronic Hemodialysis.

Mood disorders are common in end-stage renal disease (ESRD) and may increase morbidity and mortality in adults on chronic hemodialysis (HD), affecting their quality of life (QOL). We aimed to investigate the prevalence of and factors associated with anxiety and depression in ESRD patients on chronic HD. Thirty-nine HD patients were assessed for anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) questionnaire. The HADS scores were correlated with demographic, clinical, and laboratory parameters. According to the HADS scores, depression and anxiety were found, respectively, in 11 (28.2%) and in nine (23.1%) patients. Both depression and anxiety were found in four (10.3%) patients. The average depression score was 7.4 ± 4.2; the average anxiety score was 7.7 ± 4.6. The depression score correlated significantly with the number of medications (r = 0.46, P = 0.003) and phosphatase alcalin (r = -0.37; P = 0.022); the anxiety score correlated significantly with the number of medications only (r = 0.36, P = 0.022). The risk factors associated with anxiety were age [odds ratio (OR) = 1.12; 95% confidence interval (CI): 1.01-1.2; P = 0.025] and sleep disturbances (OR = 6.74; 95% CI: 1.49-30.4; P = 0.016), and only diabetes was a risk factor associated with depression (OR = 4.4; 95% CI: 1.94-16.9; P = 0.009). The screening and management of depression and anxiety would improve the QOL of patients on chronic HD.

Granulomatous interstitial nephritis in the military hospital of Morocco: Causes and outcomes.

Granulomatous interstitial nephritis (GIN) is a rare cause of renal failure. Most frequent etiologies are sarcoidosis, drugs, granulomatosis with polyangiitis, and infections agents (particularly renal tuberculosis). The aim of this retrospective study was to evaluate the clinical features, causes, and outcomes of patients with GIN in adult patients in a region of Morocco. All native renal biopsy (January 2008 to December 2017) were reviewed, but only cases of GIN were analyzed. Eleven cases of GIN were identified in this study, constituting 2.7 % of all native renal biopsies performed on this period (n = 407). There were 7 (63.6%) women, and the average age was 44.2 ± 13.9 years. The mean serum creatinine level at the renal biopsy was 39.1 ± 20.7 mg/L. The most common etiology was sarcoidosis (45.4%, n = 5) followed by drug-induced GIN (27.2%, n = 3). A good renal outcome was reported in patients with drug-induced GIN and sarcoidosis. However, no renal recovery was described in patients with other etiologies. One information from our report and the previously studies is that better data collection systems such as biopsy registries are needed to provide data on the epidemiology and treatment of rare kidney diseases.

Renal Histology in Diabetic Patients.

BACKGROUND: The diagnosis of diabetic nephropathy is based on the course of clinical manifestations and renal biopsy. Renal biopsy is usually performed in patients with atypical presentations. OBJECTIVES: This study was performed to analyze various renal histopathological lesions in diabetic patients and to establish a clinicopathological correlation. MATERIALS AND METHODS: In this retrospective study, the authors analyzed renal histology of 40 patients with type 2 diabetes mellitus who presented with atypical features of diabetic renal involvement and underwent renal biopsy at the Military Hospital Mohammed V, Rabat, Morocco, between January 2008 and December 2016. RESULTS: About 60% of the patients had isolated diabetic nephropathy, 35% had isolated nondiabetic renal diseases and 5% had both. Patients with nondiabetic renal diseases had significantly higher hematuria (P = 0.02), shorter duration of diabetes (P = 0.009), higher mean estimated glomerular filtration rate (P = 0.04) and lower prevalence of diabetic retinopathy (P < 0.001). The most common histological lesion in patients with nondiabetic renal diseases was IgA nephropathy (25%). In patients with diabetic nephropathy, the most common histological class was Class III (42.3%). Furthermore, higher histological classes were associated with lower estimated glomerular filtration rate (P < 0.001) as well as higher prevalence of diabetic retinopathy (P = 0.009) and nephrotic proteinuria (P = 0.04). CONCLUSIONS: This study found that in Rabat, Morocco, the most common histopathological lesion in patients with diabetes was diabetic nephropathy. Hematuria, shorter duration of diabetes, higher mean estimated glomerular filtration rate and lower prevalence of diabetic retinopathy were reported among those with nondiabetic renal diseases. These findings are in accord with that of studies from other countries. However, large sample size and long-term follow-up clinical studies are needed to demonstrate the renal pathological implications and renal outcomes in type 2 diabetes mellitus patients with renal involvement.

Acute interstitial nephritis in the military hospital of Morocco: Clinical features and renal outcomes.

Acute interstitial nephritis (AIN) is a common cause of acute kidney injury, possibly with increasing incidence over recent years; therefore, epidemiological studies provide important information for clinical practice and investigations. The aim of this retrospective study was to describe the clinical features and outcome of patients with biopsy-proven AIN in a region of Morocco. All native renal biopsies (January 2008 to December 2017) on adults were reviewed, but only AIN cases were analyzed. Of the 407 renal biopsies performed in this period, 30 patients were included. The mean age of the patients was 47.1 ± 16.7 years; female gender was preponderant (60%). At the time of biopsy, the serum creatinine level was 33.9 ± 11.8 mg/L. The classic triad of fever, skin rash, and eosinophilia occurred in three (10%) patients. The common causes of AIN were drugs in 13 (43.3%) patients followed by autoimmune diseases in 11 (33.3%) patients. At six months postbiopsy, 26.7%, 33.3%, and 40% had partial, complete, and no recovery, respectively. In this study, a good outcome was associated with autoimmune diseases (P = 0.02) and with a higher intensity of interstitial edema (P = 0.01). However, a presence of a granuloma (P = 0.04), a higher percentage of interstitial fibrosis (P <0.01), and glomerulo-sclerosis (P <0.01) were associated with no recovery and steroids seem to have no effect in the recovery (P = 0.14).This information provides a contribution toward understanding the epidemiology of acute renal failure in Africa, with implications in planning future prospective studies.

The impact of blood flow rate on dialysis dose and phosphate removal in hemodialysis patients.

The inadequacy of dialysis and hyperphosphatemia are both associated with morbidity and mortality in chronic hemodialysis (HD) patients. Blood flow rate (BFR) during HD is one of the important determinants of increasing dialysis dose. The aim of this study was to determine the effect of increasing BFR on dialysis dose and phosphate removal. Forty-four patients were included in a cross-sectional study. Each patient received six consecutive dialysis sessions as follows: three consecutive sessions with a BFR of 250 mL/min, followed by three others with BFR of 350 mL/min without changing the other dialysis parameters. Patients' body weight was recorded, and blood samples (serum urea and phosphate) were collected before and after each dialysis session. For assessing the efficacy of dialysis, urea reduction ratio (URR), Kt/VDiascan (Kt by Diascan and V by Watson), Kt/V Daugirdas (Daugirdas 2nd generation), equilibrated Kt/V, and phosphate reduction rate (PRR) were used. The increase of BFR by 100 mL/min resulted in a significant increase of URR, Kt/V Diascan, Kt/VDaugirdas, equilibrated Kt/V, and PRR: URR; 75.41 ± 5.60; 83.51 ± 6.12; P <0.001), (Kt/VDiascan; 1.28 ± 0.25; 1.55 ± 0.15; P <0.001), (Kt/VDaugirdas; 1.55 ± 0.26; 2.10 ± 0.61; P = 0.001), equilibrated Kt/V; 1.40 ± 0.19; 1.91 ± 0.52; P = 0.001), and (PRR; 50.32 ± 12.22; 63.66 ± 13.10; P = 0.010). Adequate dialysis, defined by single-pool Kt/V ≥1.4, was achieved using two different BFRs: 250 and 350 mL/min, respectively, in 73% and 100% of the cases. Increasing the BFR by 40% is effective in increasing dialysis dose and phosphate reduction rate during high-flux HD. The future prospective studies are needed to evaluate the impact of increasing BFR on phosphate removal using the total amount of phosphate removed, and also evaluate the cardiovascular outcome of phosphate reduction and dialysis improvement.

Histopathological study of nephrotic syndrome in adults: A Moroccan report.

The reported causes of nephrotic syndrome (NS) varies between different countries. In this retrospective study, we aimed to evaluate the underlying causes of NS in adult patients who underwent renal biopsy in a region of Morocco and we also determined the distribution of histopathological diagnoses with regard to the age subgroups and genders from January 2007 to December 2016. Patients were divided into four groups according to age at the time of renal biopsy. A total of the 257 patients with NS were included in this study. The mean age of the patients was 40.9 ± 16.7 years; male gender was preponderant (61.9%). One hundred and sixty-six (64.6 %) and 81 (35.4%) patients were diagnosed as primary and secondary glomerulonephritis, respectively. The most common diagnosis in NS was membranous nephropathy (MN) (22.2%), followed by minimal change disease (MCD) (20.6%), and lupus nephritis (LN) (13.6%). Among the patients aged 15-30, 31-45, 46-60, and >61 years, the most common cause of NS was MCD (32.1%), MN (29.6 %), MN (26.1%), and amyloidosis (AM) (28.2%), respectively. The proportion of patients with MCD and LN decreased in parallel with patient age and the proportion of patients with renal AM increased in parallel with patient age. Among the female patients aged 15-30 and 31-45 years, LN was the leading cause of NS (41.5 and 36.7%, respectively). Among the male patients aged 15-30 years, MCD was the leading cause of NS (43.2%). Our study over 10 years represents an important data of regional variations of glomerular diseases presenting with adult-onset NS.

The influence of hemodialysis membrane permeability on serum procalcitonin values in patients on maintenance hemodialysis.

BACKGROUND: Procalcitonin (PCT) has emerged as a marker of infection and it could be useful for detection of systemic bacterial infections in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD). The aim of this study was to assess the influence of HD membrane permeability to PCT serum levels in noninfected HD patients on maintenance HD. METHODS: In a prospective comparative study, we measured PCT serum levels and C reactive protein (CRP) before and after HD in 36 sessions (18 sessions of HD with low-flux = Group L; and 18 sessions with high flux membranes = Group H), in 18 chronic HD patients without history of infection. RESULTS: Sessions of HD by high-flux membranes (Group H) displayed median PCT values that were significantly decreased after dialysis (0.21 ng/mL [0.13-0.41] vs. 0.18 ng/mL [0.10-0.24], p <0.001) but median PCT significantly increased after HD sessions by low-flux membranes (Group L) (0.21 ng/mL [0.14-0.33] vs. 0.25 ng/mL [0.14-0.36]; p = 0.008). CRP values were significantly increased after HD in both groups. CRP correlated with PCT values only in group H before HD (r = 0.49; p = 0.36). CONCLUSIONS: PCT represents a useful diagnostic marker for systemic bacterial infection. However, there is a need for specific reference ranges to be developed in patients with renal failure undergoing HD; also, PCT serum levels must be interpreted according to the HD membrane permeability.

Gastrointestinal bleeding due to angiodysplasia in patients on hemodialysis: A single-center study.

Gastrointestinal (GI) bleeding due to angiodysplastic lesions is a common problem among patients receiving hemodialysis (HD). We studied 22 HD patients (5 females and 17 males) who had GI bleeding due to angiodysplasia; the mean age of whom was 54 ± 10 years. All patients had upper and lower GI endoscopy. The most common site for the lesion was the right colon in seven cases (31.8%), followed by stomach in 4 cases (18.1%). In eight (36.3%) patients, there were multiple lesions located in the stomach, duodenum, and the right colon. All patients were treated with coagulation; with argon plasma in 14 (63.6%) patients, bipolar coagulation in five (22.7%) patients, and hot clip in three (13.6%) patients. One patient who presented with persistent bleeding despite endoscopic therapy was well-benefited of a complementary treatment, thalidomide. Hemostasis was obtained in all patients after an average of 6.8 sessions of endoscopic coagulation procedure. We conclude that angiodysplasia is a frequent cause of hemorrhage in chronic renal failure that can be managed in most patients by argon plasma and bipolar coagulation.

Kidney biopsy in the Military Hospital of Morocco: Complications and histopathological findings.

Epidemiological studies on renal biopsies are necessary to establish the pattern and trends of renal diseases in a particular geographic area. In this retrospective study, we reviewed the medical records, histopathology findings and complications of renal biopsy in a region of Morocco. We studied a total of 130 native kidney biopsies taken between January 2008 and January 2012. All biopsies were examined by light microscopy and immunofluorescence microscopy. There were 86 males (66.2%) and 44 females (33.8%), with a mean patient age of 44.82 ± 17.86 (range 8-86) years. The most common indications of renal biopsy was nephritic syndrome (61.5%), followed by renal failure of unknown etiology (30.8%) and asymptomatic urinary abnormalities (5.4%). Primary glomerulonephritis (PGN) was found in 60 (46.2%) of the patients. Among the PGN cases, the most common one was membranous nephropathy (MN) (12.3%). Secondary glomerular disease (SGN) accounted for 48 (36.9%) of the cases. The most common SGN was lupus nephritis (LN) (10%). Tubulointerstitial disease [13 (10%)] and vascular disease [9 (6.9%)] were less common. The most common complications of the procedure were pain at the biopsy site in 12.3%, gross hematuria in 12.3%, perirenal hematoma in 7.7% and hematuria requiring nephrectomy in 0.8% of the patients. The most common indication for renal biopsy was nephrotic syndrome, MN was the most frequent PGN and LN was the most frequent SGN in our report.

Commentary: the practice of dialysis in the intensive care unit in a developing country.

INTRODUCTION AND AIMS: In developing countries, little is known about renal replacement therapy (RRT) for acute kidney injury (AKI) in critically ill patients. The aim of this study is to describe characteristics of patients, clinical practice of renal support and outcomes in intensive care units (ICU) in a developing country. METHODS: Patients who underwent RRT for AKI from May 2003 to July 2008, in four ICUs in our institution were included in this retrospective study. Patients with end stage renal disease or younger than aged 18 years were exclueded. We have considered: patient demographics, indications of RRT, number of dialysis session, comorbidities, APACH II score for illness severity, mechanical ventilation, use of vasoactive drugs, and mortality rate. RESULTS: 105 critically ill patients admitted during the study period were treated with RRT, with a mean age of 56.13 +/- 16.8 (19-85) years. Sixty five were male and 40 female; all received intermittent hemodialysis. The total number of dialysis sessions was 284, and the mean number was 3.7 +/- 2.9; mean length of session was 225.22 +/- 75.16 (60-290) min. The majority of the cases (67%) were from medical ICU, followed by 30.2% from surgical ICUs (including cardiothoracic surgery ICU) and 2.8% were from burn ICU. The most common comorbidities were type 2 diabetes mellitus in 46 (44%) and hypertension in 35 (33.4%). Sepsis was a contributing factor to AKI in 60 patients (57.14%), hypovolemia in 30 (28.5%), and cardiogenic shock in 9 (8.5%). The APACHE II score was 25.86 +/- 11.8; the majority of patients (66.7%) were ventilated; 63 (60%) were under vasoactive drugs and 88 (83.8%) were oliguric. The most common indication for initiation of dialysis was hyperkalemia in 51 (48.5%) of the cases, followed by severe acidosis in 35 (33.3%) and acute pulmonary edema for 20 (19%). ICU mortality was 68.5% and increased to 95.2% when more than two organs were involved. CONCLUSIONS: Our experience suggests that indications for initiation of RRT in ICU are not greatly different from that in industrialized countries; yet, the big difference is in a high mortality rate among our patients.

Quantification of hemodialysis dose: what Kt/V to choose?

BACKGROUND: Quantification of hemodialysis became more accurate and easier after the advent of ionic dialysance and the use of methods for estimating urea distribution volume (V). The aim of this study was to compare different methods of hemodialysis dose assessment: Kt/VDau (Daugirdas 2nd generation), Kt/VOCM (Kt by OCM (Online Clearance Monitor) and V by Watson), and Kt/VBCM (Kt by OCM and V by bio-impedance); and to assess the dialysis adequacy, defined by a Kt/V>1.4. DESIGN: Prospective, observational study. METHODS: 35 hemodialysis sessions were evaluated in 35 chronic hemodialysis patients. During each session, we measured simultaneously, Kt/VOCM, Kt/VBCM and calculated Kt/VDau by performing blood samples before and after each session. RESULTS: 35 patients, gender (M/F: 19/16), mean age of 50.49 years, were evaluated. We noted a difference between the three methods of evaluating Kt/V index: Kt/VDau, Kt/VOCM and Kt/VBCM (1.82 ± 0.29; 1.45 ± 0.23; 1.8 ± 0.33, p<0.001). Comparison of Kt/VOCM with Kt/VDau and Kt/VBCM leads to a significant systematic underestimate of Kt/V by 22% and 20.5% respectively. Better agreement between Kt/VDau and Kt/VBCM was observed. The adequate hemodialysis was achieved, according to three methods: Kt/VDau, Kt/VOCM and Kt/VBCM respectively in 100%, 57,1% and 88.6% of the cases. CONCLUSIONS: The Kt/V index is different depending on the method used for its evaluation. The three methods can be used for quantification of hemodialysis with a better agreement between Kt/VDau and Kt/VBCM. In this study, Kt/VOCM results underestimate hemodialysis efficiency. This difference has to be considered when applying quantification of hemodialysis to clinical practice.

Parameters to assess nutritional status in a Moroccan hemodialysis cohort.

INTRODUCTION: Malnutrition is common in maintenance hemodialysis (HD) and is associated with increased mortality and morbidity in affected patients. The aim of this study was to determine the prevalence of malnutrition and correlate the methods of nutritional assessment. METHODS: We evaluated the nutritional status of 40 prevalent HD patients by subjective global assessment (SGA) score, anthropometrics [body mass index (BMI), arm circumference (AC), triceps skin-fold thicknesses (TSF), arm muscle circumference (AMC)], biochemical tests [normalized protein equivalent to total nitrogen appearance (nPNA), and pre-dialysis serum albumin and serum prealbumin levels] and bio-electrical impedance (BEI) analysis to estimate body composition [lean tissue index (LTI) and fat tissue index (FTI)]. RESULTS: The study assessed 40 patients (20 males and 20 females) with a mean age of 50.7±16.5 years. The prevalence of malnutrition according to the different methods ranged from 5 % to 65%. There were highly significant gender-specific differences in AMC (p<0.001) and TSF (p<0.001). The BEI revealed a highly significant difference in LTI (p<0.001) but no difference in FTI (p=0.14) according to gender. There was a positive correlation between LTI and both serum albumin (r=0.37; p=0.018) and serum prealbumin (r=0.53; p<0.001). Also, there was a significant positive correlation between FTI and BMI (r=0.59; p<0.001), AC (r=0.44; p=0.004) and TSF (r=0.61; p<0.001). CONCLUSION: Our data suggest that BEI analysis provides a useful means of assessing nutritional status and was correlated with anthropometrics and biochemical findings.

Assessment of dialysis adequacy guidelines implementation in a developing country.

Dialysis adequacy has been shown to have a significant impact on patient survival, but there are few data concerning the adequacy of the delivered hemodialysis dose in developing countries. To describe the level of implementation of dialysis practice guidelines in a dialysis center in Morocco, we retrospectively reviewed our 1-year experience of managing chronic hemodialysis patients (CHP), from May 2009 to May 2010. Demographic and biochemical data were collected, and the percentage of patients achieving targets recommended by the NKF-KDOQI guidelines were calculated. Our data suggests that dialysis units in a developing country can achieve current guidelines targets for dialysis adequacy, however, our results are not generalizable to all dialysis centers in Morocco.

[Acute renal failure as a complication of Mediterranean spotted fever]. / Fièvre boutonneuse méditerranéenne compliquée d'insuffisance rénale aiguë.

The Mediterranean spotted fever is a bacterial infection caused by Rickettsia Conorii mainly around Mediterranean basin. It is often considered like a trivial infection. However, severe forms with a high morbidity and high mortality risk have been described. These forms often associate with impaired consciousness, abnormal liver function, impaired homeostasis, pneumonia and acute renal failure. Several mechanisms of renal damage during the Mediterranean spotted fever have been reported, their pathogenesis remains speculative and the prognosis is determined by the type of renal disease and on early treatment. Thus, rickettsiosis should be considered in combination of acute renal, hepatic cytolysis and thrombocytopenia, allowing rapid achievement of a specific treatment.