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.

Utility of a blood volume monitor in the management of anemia in dialysis by computing the total hemoglobin mass.

INTRODUCTION: The degree of interdialytic weight gain and ultrafiltration may influence anemia results in dialysis. The purpose of this study is to evaluate the utility of a blood volume monitor (BVM) in the management of renal anemia and its ability to avoid the variability of hematocrit (Hct) and hemoglobin values (Hb) depending on plasma volume through a simple method of monitoring the total hemoglobin mass (MtHb ). METHODS: Predialysis blood samples for measurement were drawn at both the midweek treatment and the beginning-of-the-dialysis-week treatment in 30 patients. The MtHb was calculated as MtHb = Vb × Hb, where Vb is the absolute blood volume determined by online dialysate dilution using an online hemodiafiltration machine incorporating a relative BVM. FINDINGS: The MtHb and the total red cell volume (VRBC ) as measured with the bolus method at the starting of the treatment were 540 ± 148 grams and 1544 ± 339 mL, respectively. There were significant differences between the Hb levels and between the hematocrit levels according to the time of dialysis. However, the MtHb remained constant. There was also an excellent correlation between the Hb measurements by the BVM and the blood sampling method (R = 0.89, P value <0.001). CONCLUSION: Our study suggests that BVM could be very useful in the management of anemia in dialysis by computing the total Hb mass in clinical practice and may support better and more appropriate assessments of the factors influencing circulating Hb.

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.

Effects of lowering dialysate calcium concentration on mineral metabolism and hemodynamic parameters in hemodialysis patients.

INTRODUCTION: It has been suggested that a dialysate calcium concentration of 1.5 mmol/L is a compromise between bone protection and cardiovascular risk. This study aimed to investigate the effect of reducing dialysate calcium concentration to 1.5 mmol/L on mineral metabolism and hemodynamic parameters. MATERIALS AND METHODS: Dialysate calcium concentration was changed from 1.75 mmol/L to 1.5 mmol/L for 9 months and observed the effects on mineral metabolism and dialysis outcome parameters in 52 hemodialysis patients. RESULTS: The results at 9 months demonstrated that postdialytic serum calcium level decreased significantly from 109 ± 7 mg/L to 102 ± 6 mg/L, intact parathyroid hormone (PTH) increased from 372 ± 52 pg/mL to 606 ± 80 pg/mL, and the oral alfacalcidol increased from 1.4 ± 0.3 µg/w to 3.3 ± 0.4 µg/w. In patients with low PTH levels, continuous increase of PTH was observed. There were no significant variation in the oral calcium carbonate dose and serum levels of alkaline phosphatase, predialytic calcium, and pre- and postdialytic phosphorus. The ultrafiltration rate and postdialysis systolic blood pressure were significantly lower after reducing the dialysate calcium concentration to 1.5 mmol/L. Intradialytic hypotension and cramps were more frequent with this dialysate calcium concentration. CONCLUSIONS: These findings demonstrated that a decrease in dialysate calcium concentration from 1.75 mmol/L to 1.5 mmol/L improved mineral metabolism by prevention of postdialytic hypercalcemia and releasing oversuppression of PTH, but it was associated with more use of oral alfacalcidol and more hemodynamic impairment.

Experience in using thermal disinfection to remove viable bacteria and endotoxins in centraly distributed reverse osmosis water.

INTRODUCTION: The water used for dilution of hemodialysis concentrates has to meet official quality recommendations regarding microbiology and chemical parameters. To avoid chemical use and to simplify treatments, hot water has been used to control microbial contamination of water distribution systems. In this study we evaluated the efficacy of heat disinfection in maintaining the quality of dialysis water generated by reverse osmosis (RO). METHODS: During the first part of the study, we consecutively used (1) continuous water circulation, (2) daily heat disinfection and (3) a combination of daily heat disinfection and weekly chemical disinfection while checking bacterial count and endotoxin level every 4-5 weeks. During the second part of the study, we continued using daily heat disinfection while checking bacterial count and endotoxin level on weekly basis. RESULTS: The endotoxin levels at all sampling points of the water treatment system were lower than 0.005/ ml throughout the study. The application of heat disinfection alone reduced bacterial levels but an escape phenomenon occurred. After an interval of 21 days, an exponential increase of bacterial count was noted and cultures from the RO unit revealed growth of Pseudomonas fluorescence. The addition of chemical disinfection was successful in eliminating micro-organisms. Throughout this study, micro-organisms and endotoxins were not detectable in dialysate fluid and substitution fluid in dialysis monitors. CONCLUSION: The isolation of a thermo-sensitive organism from the RO unit after a period of relying on thermal disinfection suggests the existence of dead space in the RO unit that is not adequately exposed to heat but is accessible to chemical disinfection. .

Lupus nephritis emerging during remission of minimal change disease.

INTRODUCTION: Rare cases of association between lupus nephritis (LN) and minimal changes nephrotic syndrome (MCNS) were described. Some authors suggest that this association, taking into account the low prevalence of both diseases, may not be a simple coincidence. Several pathophysiological hypotheses have been proposed to explain this association, including a potential central role of T lymphocytes. CASE REPORT: We describe the case of a 21 years-old female patient who initially presented with isolated nephrotic range proteinuria. She had no evidence of systemic involvement and Immunological tests were negative, including anti-neutrophil antibodies (ANA) and anti-double-stranded DNA antibodies (Anti-dsDNA). Renal biopsy showed normal glomeruli under light microscopy and no significant deposits were found in immunofluorescence studies. She was diagnosed to have MCNS and responded to a short course of steroids. She remained in remission for three years, after which she presented again with nephrotic-range proteinuria accompanied by clinical signs of systemic involvement. During her second presentation, she fulfilled the diagnostic criteria of systemic lupus erythematosus (SLE) and another kidney biopsy showed class-V lupus nephritis. She was treated with pulse steroids followed by oral prednisolone and mycophenolate mofetil, with good clinical response. CONCLUSION: This case indicates that relapses of MCNS should be carefully investigated in the right setting to avoid missing a systemic disease such as SLE.

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.

[Predilution online hemodiafiltration: which dose of anticoagulation?]. / L'hémodiafiltration online en mode prédilutionnel : quelle dose d'anticoagulation ?

INTRODUCTION: Patients in end stage renal disease on hemodialysis are in higher risk of bleeding related to the anticoagulation used during a session, so only the lowest effective dose of anticoagulation must be used. The aim of this study was to evaluate the efficacy of predilution in hemodiafiltration with reduced dose of anticoagulation compared to hemodialysis in preventing coagulation of circuits. PATIENTS AND METHODS: This study was conducted in stable hemodialysis patients without high bleeding risk. All patients were treated by two different treatments: (A) conventional hemodialysis, (B) predilution hemodiafiltration with the half dose of anticoagulation used during treatment (A). Other confounding parameters were kept constant during the study. The primary endpoint was the incidence of major thrombotic events judged on a subjective visual score. RESULTS: Twenty-one patients were included (105 sessions for each treatment). Major incidents are occurring more frequently in predilution hemodiafiltration with reduced dose of anticoagulation (P=0.03). The premature discontinuation of sessions was more frequent in predilution hemodiafiltration, this difference was not significant (P=0.07). Duration of sessions was significantly shorter in predilution hemodiafiltration (P=0.03). The higher frequency of thrombotic events in predilution hemodiafiltration has no effect on net ultrafiltration volume achieved in both treatments. CONCLUSION: Predilution hemodiafiltration with a lower dose of anticoagulation did not prevent major clotting of extracorporeal circuit manner at least equivalent to a reference method.

Applying sodium profile with or without ultrafiltration profile failed to show beneficial effects on the incidence of intradialytic hypotension in susceptible hemodilaysis patients.

INTRODUCTION: Intra-dialytic hypotension (IDH) is a common complication during hemodialysis (HD) treatment. Previous studies have reported that modulating dialysate sodium concentration combined or not with modulation of ultrafiltration (UF) rate may reduce the incidence of IDH. The aim of the present study was to evaluate the effect of sodium and UF profiles on the occurrence of intra-dialytic complications and dialysis quality. METHODS: From a total of 64 patients, we selected 18 patients who suffered from recurrent IDH. Every patient received ten HD sessions utilizing each of the following treatments: (1) CONTROL: constant sodium concentration and UF rates. (2) Sodium and UF profiles: a linearly decreasing sodium concentration combined with a linearly decreasing UF rate. (3) Sodium profile: decreasing sodium concentration with constant UF rate. RESULTS: Fourteen patients completed the study protocol. The incidence of IDH, mean inter-dialytic weight gain and the delivered dialysis dose were not different between the three treatments. However, symptomatic episodes of IDH were more commonand pre-dialysis systolic blood pressure was higher during the second and third treatment modalities compared to controls. Isolated sodium profile was associated with more malaise and less achievement of target session duration compared to the other two treatments. Isolated sodium profile was associated with less achievement of target UF while combined sodium and UF profiles were associated with more achievement of target UF compared to controls. CONCLUSION: Our results indicate that sodium profile with or without UF profile does not have a beneficial effect on the incidence of IDH, achievement of target session duration or the delivered dialysis dose. Keywords : Sodium Profile; Ultrafiltration; Intradialytic Complications.

Scleroderma renal crisis precipitated by steroid treatment in systemic lupus erythematosus and scleroderma overlap syndrome.

INTRODUCTION: Connective tissue disorders can overlap in various ways. Patients may present with features of more than one specific disease without satisfying the diagnostic criteria and thereafter evolve into a specific disease entity. Occasionally, patients may fulfil simultaneously the diagnostic criteria of two or more diseases. Several cases of systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) overlap syndrome have been reported. SLE patients often develop lupus nephritis, the treatment of which is based on immunosuppression with corticosteroids (CS) and cytotoxic drugs. However, the use of high dose of CS has been associated with scleroderma renal crisis (SRC) in patient with SSc. CASE REPORT: a 43-year-old woman presented to the nephrology department of the Military hospital in Rabat, Morocco, in August 2011 with progressive dyspnea and oliguria. She was diagnosed as SLE and scleroderma overlap syndrome based on clinical and serological markers. Renal biopsy showed lupus nephritis. Immunosuppression consisting of high-dose steroid and cyclophosphamide pulses was given. There was response to treatment but 15 days later the course of the disease was complicated by scleroderma renal crisis evidenced by elevated blood pressure, deteriorating kidney function, hemolysis and thrombocytopenia. The patient was treated with perindopril and rapid reduction of steroid doses. This was followed by correction of hemolysis and thrombocytopenia. Two months later, the patient was off dialysis, but had chronic renal insufficiency with an estimated GFR of 25 ml/minute. CONCLUSION: This report describes the occurrence of SRC in a patient with lupus nephritis and SSc/ SLE overlap syndrome who was treated by CS and cyclophosphamide.

A model to calculate cardiac output in hemodialysis patients by thermodilution.

The Blood Temperature Monitor module (BTM) is used to measure recirculation by thermodilution in dialysis. Numerous studies have confirmed its interest in the measuring of the vascular access flow. In this letter we describe a model to calculate cardiac output in dialysis by the BTM.

A model to predict optimal dialysate flow.

Diffusive clearance depends on blood (Qb) and dialysate flow (Qd) rates and the overall mass transfer area coefficient (KoA) of the dialyzer. In this article we describe a model to predict an appropriated AutoFlow (AF) factor (AF factor = Ratio Qd/Qb), that is able to provide adequate Kt/V for hemodialysis patients (HDP), while consuming lower amounts of dialysate, water and energy during the treatment. We studied in vivo the effects of three various Qd on the delivered dose of dialysis in 33 stable HDP. Hemodialysis was performed at Qd of 700 mL/mn, 500 mL/mn, and with AF, whereas specific dialysis prescriptions (treatment time, blood flow rate [Qb], and type and size of dialyzer) were kept constant. The results showed that increasing the dialysate flow rate more than the model of AF predicted had a small effect on the delivered dose of dialysis. The Kt/V (mean ± SD) was 1.52 ± 0.16 at Qd 700, 1.50 ± 0.16 at Qd 500, and 1.49 ± 0.15 with AF. The use of the AF function leads to a significant saving of dialysate fluid. The model predicts the appropriate AF factor that automatically adjusts the dialysate flow rate according to the effective blood flow rate of the patient to achieve an appreciable increase in dialysis dose at the lowest additional cost.

[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.

Pregnancy during hemodialysis: a single center experience.

Successful pregnancy outcome is an uncommon occurrence in women requiring chronic dialysis treatment. We reviewed the course and outcome of 9 pregnancies occurred in women on chronic hemodialysis in our center from 1999-2007; 5 of them ended with delivery of alive newborns, 2 with fetal deaths in-utero, and 2 with abortions. The average age of patients was 34 years. The etiology of the original kidney disease was unknown in 44.4% of the cases, and only 22.2% of the patients maintained diuresis. Dialysis started in 8 cases before the diagnosis of pregnancy. The average gestational age at diagnosis was 14 weeks. We modified the prescription of dialysis in 4 patients by increasing the frequency of the dialysis sessions to 6 per week and in 3 by increasing the duration of each session to 6 hours. Anemia was present in all the cases; 3 patients received erythropoietin and 4 patients required transfusion. The pregnancy was com-plicated in 44% of the cases by a polyhydramnios. The average time at delivery was 33 weeks and it was achieved in 80% of pregnancies through vaginal route. The average weight of newborns was to 2380 g. We conclude that pregnancy in women on hemodialysis is possible. The success of pregnancy may be influenced by the residual diuresis and early diagnosis to improve the quality of dialysis by increasing the dialysis dose.

[Clinical case of acute renal failure revealing an autoimmune hypothyroidism]. / Insuffisance rénale aiguë révélant une hypothyroïdie auto-immune.

Although the clinic picture is often indicative of muscle manifestations in patients with hypothyroidism, signs and symptoms of this condition are variable from simple elevation of serum muscle enzymes with myalgia, muscle weakness, cramps to rhabdomyolysis with acute renal failure which remains a rare event. Thyroid hormones affect the function of almost every body organ, and thyroid dysfunction produces a wide range of metabolic disturbances. Hypothyroidism is associated with significant effects on the kidney which the pathophysiology seems to be multifactorial, but the exact mechanisms remain poorly understood. Hypothyroidism as a cause of renal impairment is usually overlooked, leading to unnecessary diagnostic procedures. The main objective of our observation is to report a case of acute renal failure revealing an autoimmune hypothyroidism in which thyroid hormone substitution led to a significant improvement in muscular, thyroid and renal disorders.