Epidemiological Study of Acute Kidney Injury in Intensive Care Unit: Evolution and Prognosis.

Acute kidney injury (AKI) is very common in intensive care units (ICUs). Its complications are often fatal, life-threatening, and may lead to kidney impairment. This is a multicentric, prospective, and descriptive study, spread over a period of six months, from January 1, 2017 to June 30, 2017, including incident cases of AKI defined according to the AKI Network criteria seen in the ICUs of Ibn Rochd University Hospital of Casablanca. Their evolution was studied during the hospital stay at three, six, 12, and 24 months. A total of 102 patients were included, 52% of whom were female. The median age was 45.2 ±0 22.93 years (10 days-87 years). Clinically, 28.4% were oligo-anuric and 54.8% had a multivisceral failure, mainly neurological and respiratory. The median creatinine level was 37.6 mg/L ± 19.82 (8-230). AKI was mainly organic and functional in 43.1% and 40.2% of cases, respectively, and the main etiologies were dehydration, sepsis, and tumor obstruction. Dialysis was required in 25.5% of cases. When discharged from the hospital, mortality occurs in 35% of cases, total recovery of renal function was observed in 22%, progression to chronicity in 38%, and end-stage renal disease (ESRD) in 5% of cases. The progression to chronicity and ESRD increased in the 1st and 2nd year of followup after the first episode of AKI. The risk factors for progression to chronicity were as follows: age, hypertension, the presence of comorbidities, the presence of multivisceral failure and the severity of AKI. AKI is now considered a risk factor for chronic kidney disease and longterm mortality, hence the interest and importance of nephrological monitoring.

Autodialysis in Morocco: how much longer can we wait?

INTRODUCTION: Autodialysis is the dialysis performed by the patient himself at a local center instead of a hemodialysis center. In Morocco, the practice of hemodialysis dates back to 1970; however, an autodialysis center does not yet exist. The objective was to assess the potential medical fitness and adherence of the patients to an autodialysis program. METHODS: Descriptive and analytical multicenter study conducted in March 2015 involving patients from of eight hemodialysis centers in Casablanca (Morocco). The study was conducted in two steps: 1) a transversal assessment of the medical potential to achieve autodialysis that included 556 patients; 2) a survey of the autodialysis membership that included 383 out of 556 patients who were deemed eligible for autodialysis. RESULTS: The average age was 54.63 ± 15.16 years; the average of hemodialysis duration was 85.9 ± 78.1 months. Diabetic nephropathy (22.7%) was the predominant cause of kidney disease. The assessment of medical potential to achieve autodialysis highlighted that almost all of the patients were in good condition (93%), independent (81%), and those without major comorbidities were less than 76 years old. Regarding the potential patients' adherence to autodialysis, among the 383 patients previously deemed suited for autodialysis, 293 (76.5%) responded favorably to the proposal of self-dialysis. CONCLUSION: The practice of hemodialysis should be implemented in a short time in Morocco because our patients' profile is perfectly suitable to this therapeutic method especially when they are young, in good general condition, autonomous, without major comorbidities, and willing to learn.

Pulmonary hypertension: prevalence and risk factors.

INTRODUCTION: Pulmonary arterial hypertension (PAH), defined as a systolic pulmonary artery pressure above 35 mm Hg, is another vascular disease entity recently described in patients receiving hemodialysis. It is a major problem due to its high prevalence and morbidity and mortality. Its pathophysiological mechanism is just known and the strategies for its supported not yet defined. AIMS: To determine the prevalence of PAH in our hemodialysis patients and its risk factors. METHODOLOGY: Single center descriptive and analytical cross-sectional study, including 111 hemodialysis patients who had benefit from a trans-thoracic cardiac Doppler ultrasound during 2014. A value greater than or equal to 35 mm Hg is considered PAH and classified as follows: mild PAH (35 50 mm Hg), moderate PAH (50 70 mm Hg), and severe pulmonary hypertension (> 70 mm Hg). Patients with a high probability of secondary PAH, especially those with the following history: chronic obstructive pulmonary disease, pulmonary embolism, were not included. RESULTS: The mean age was 44.3 ± 14.2 years. Among the 111 patients, 18 had pulmonary arterial pressure above 35 mm Hg corresponding to 16.22% of PAH prevalence. The average pressure was 45 mm Hg. Of these 18 patients, 11.8% had mild PAH, 3.4% moderate PAH and 0.8% severe PAH. The average hemodialysis duration was significantly associated with PAH (p = 0.003); as well as valvular calcification (p = 0.000), mitral regurgitation (p = 0.001) and tricuspid regurgitation (p = 0.002). CONCLUSION: Primary pulmonary hypertension is a major problem among our hemodialysis because of its high prevalence and its risk factors.

[Falls among hemodialysis patients: Incidence and risk factors]. / Chutes chez l'hémodialysé : incidence et facteurs de risque.

Falls and mineral and bones disorders are both implicated in the occurrence of pathological fractures in patients undergoing chronic dialysis. However, data on falls among this population are rare. We carried out a prospective study during four weeks and included 70 patients on chronic hemodialysis with the main objectives being to evaluate the incidence of falls and factors related to it. At the end of the four weeks, 16 patients (22.86%) fell at least once, with a total of 17 falls during 4 weeks, giving an incidence of 3.2 falls per patient/year. The mean age was 40 ± 16 years. Five patients (31.2%) had a past history of pathological fractures. Ten patients (62.5%) presented intra- and post-dialysis hypotension, six (37.5%) was diagnosed of gait disorders and two (12.5%) had sensory deficit of the lower limbs. Six patients (37.5%) presented frailty. Hypotension (P=0.004), frailty (P=0.047) and sensory deficit (P=0.049) were significantly associated with the occurrence of falls. The incidence of falls is relatively high in our hemodialysis patients and real risk factors exist. Hence, it is important to implement programs for falls prevention to reduce their incidence and impact.

[Acute postinfectious glomerulonephritis]. / Glomérulonéphrites aiguës postinfectieuses.

Acute postinfectious glomerulonephritis are defined by an acute nonsuppurative inflammatory insult predominantly glomerular. Its current incidence is uncertain because of the frequency of subclinical forms. The most common infectious agent involved is beta hemolytic streptococcus group A. Acute postinfectious glomerulonephritis is uncommon in adults, and its incidence is progressively declining in developed countries. Humoral immunity plays a key role in the pathogenesis of kidney damage. Complement activation by the alternative pathway is the dominant mechanism, but a third way (lectin pathway) has been recently identified. The classic clinical presentation is sudden onset of acute nephritic syndrome after a free interval from a streptococcal infection. Treatment is essentially symptomatic and prevention is possible through improved hygiene and early treatment of infections.

Optimizing hypertension control in hemodialysis patients: a proposed management strategy.

OBJECTIVE: The purpose of the study was to assess the efficiency of a goal-oriented therapeutic strategy in lowering blood pressure and reducing the need for antihypertensive medications in 168 patients undergoing long-term hemodialysis. METHODS: Patients were managed initially by achieving optimal dry weight. After reduction of the dry weight, patients with uncontrolled arterial hypertension were dialyzed using a 1.25 mmol/L calcium concentration buffer. RESULTS: The predialysis mean arterial blood pressure (PDBP) was 127.4/74.2 mmHg for the total population. Fifty (29.76%) of the total study population were hypertensive. Of them, 88% (44 patients) were receiving antihypertensive drugs, while the others were not on such medications. Twenty patients (40% of the hypertensives) were receiving one antihypertensive drug, 17 (34%) were receiving two antihypertensive drugs, while 7 patients (14%) were receiving three or more drugs. There was a significant increase in the number of patients with good control of PDBP in the second data collection [45 patients (90%)] compared to the first data collection of 40 patients (80%). Similarly, there was a significant reduction in the number of patients with uncontrolled PDBP in the second data collection (5 patients (10%) compared to the first data collection of 10 patients (20%). The average blood pressure in the first data collection was 137.2/76.3 and 167.4/87.1 mmHg in the controlled and uncontrolled blood pressure groups respectively. In the second data collection, the average blood pressure was 136.4/75.1 and 161.6/86.3 mmHg in the controlled and uncontrolled groups respectively. CONCLUSION: Therapeutic approach using combination of dry weight reduction and dialysis with low calcium dialysate provides acceptable long-term results in patients with arterial hypertension and reduces the need for antihypertensive medication.

[Acute renal failure secondary to the transurethral resection of the prostate syndrome]. / Insuficiencia renal aguda secundaria al síndrome de resección transuretral de próstata.

OBJECTIVE: Complications of transurethral resection of the prostate (TURP) related to hypotonicity and hypervolemia were well described in the literature. However acute renal failure, known to be a clinical presentation of some TURP syndromes was less discussed. METHODS: We report a case of oliguric acute renal failure as a major complication after TURP, with a discussion of a possible mechanism for the disorder. RESULTS: The mechanism by which renal failure developed in our patient is not entirely clear, but most likely is due to hemolysis. Other factors such as hemodynamic alterations, hypotension and rabdomyolisis are also suspected based on analysed data. CONCLUSION: We believe that a detailed evaluation before and after TURP will allow to reduce the incidence of this abnormality and to prevent its occurrence.

Chronic lead poisoning: a "forgotten" cause of renal disease.

Chronic lead nephropathy occurs as a result of years of lead exposure. Nowadays, with the induction of high standards for industrial hygiene, symptomatic lead intoxication has become extremely rare. We report a case of chronic lead nephropathy in a 59-year-old man who worked in a battery-recycling unit and was diagnosed with plumbism during a regular health screening few years ago. The diagnosis was suggested by the following findings: serum creatinine 160 microg/L, creatinine clearance 46 ml/min, daily urine protein excretion 0.1 g, uric acid 9.7 mg/dl, blood lead 9.2 microg/dl, and a urinary excretion of 850 microg lead/72 h after a mobilisation test by a Na2-Ca-EDTA chelating agent. Renal ultrasound showed bilateral borderline small kidneys. The kidney biopsy revealed moderate focal atrophy, loss of proximal tubules, and prominent interstitial fibrosis. The patient was prescribed angiotensin-converting-enzyme inhibitors to slow the progression of renal insufficiency and control the blood pressure. Hyperuricemia was also treated and controlled. During the regular follow-up, renal function remained stable with no proteinuria. A high index of suspicion for lead intoxication in chronic kidney disease patients should be practiced, especially in patients with hyperuricemia. Chelation of lead urinary excretion is helpful in the diagnosis of this disease.

Doppler echocardiograph evaluation of pulmonary hypertension in patients undergoing hemodialysis.

Pulmonary hypertension (PH) has been reported in hemodialysis (HD) patients, but data regarding its incidence and mechanisms are scarce. The aims of this study was to evaluate the prevalence of unexplained PH in long-term HD patients, and to examine some possible etiologic factors for its occurrence. The prevalence of PH was estimated by Doppler echocardiography in a cohort of 86 stable patients on HD via arteriovenous access for more than 12 months. All the patients underwent full clinical evaluation, chest radiography, and a standard 12-lead echocardiograph. Laboratory investigation included a mean of 12 months (serum calcium, phosphorus, parathormone (PTH), alkaline phosphatase, lipids, and hemoglobin). Pulmonary hypertension was defined as pulmonary artery systolic pressure >35 mmHg as determined by Doppler echocardiography using the modified Bernoulli equation. Pulmonary hypertension was detected in 23 patients (26.74%). Of those with PH, left ventricular hypertrophy was seen in 13 patients (56.52%), and valvular calcifications in 6 patients (26.08%). There were no significant differences between both groups with regard to age, sex, duration of dialysis, shunt location, and all the biological parameters of the study. The presence of PH was not related to the level of PTH, or the severity of other metabolic abnormalities. This study demonstrates a high prevalence of PH among patients with ESRD receiving long-term HD via surgical arteriovenous access. The role of the vascular access, anemia, or secondary hyperparathyroidism as the etiology of PH in HD patients did not hold in this study.

Cauda equina compression revealing brown tumor of the spine in a long-term hemodialysis patient.

Brown tumors, or osteoclastomas, are erosive bony lesions arising as a complication of hyperparathyroidism (HPT). In patients with end-stage renal disease (ESRD), brown tumors are classic skeletal manifestations usually seen in severe forms of secondary HPT. However, involvement of the spine is considered extremely rare. We report a long-term hemodialysis case, in which cauda equina compression developed due to a sacral brown tumor. A decompressive surgery and subtotal parathyroidectomy were indicated to preserve neurologic function, and to ensure remineralization of the lesion. This case illustrates that, though rare, brown tumors should be considered in uremic patients with neurological symptoms. Emergent decompressive surgery is required to remove pressure on neurological structures and to stabilize the spine.

Heart valve calcifications in patients with end-stage renal disease: analysis for risk factors.

BACKGROUND: The prevalence of valve calcification (VC) in end-stage renal disease patients is high and information regarding risk factors is scarce. Our aims were to determine the prevalence of VC in our maintenance haemodialysis (HD) population and to examine some possible aetiologic factors for its occurrence. METHODS: We studied 90 patients (47 women) on maintenance HD for more than 12 months. An M-mode two-dimensional echocardiogram was carried out to evaluate mitral, aortic VC and ventricular geometry. We calculated mean daily calcium intake for the phosphate intestinal chelaing in the previous year to echocardiogram date and also mean values from previous year of Ca, PO4, Ca x PO4, parathyroid hormone, lipide profile, nutritional and inflammatory marquers. Finally consumption of calcium and alfacalcidol was also noted. RESULTS: Thirty-six patients (40%) presented with VC. Patients with VC were older and showed higher levels of serum calcium (92.00 +/- 7.54 vs 89.27 +/- 6.86 mg/L, P = 0.04), phosphorus (69.70 +/- 18.33 vs 44.90 +/- 12.43 mg/L, P < 0.0001), Ca x P product (6164.97 +/- 1797.64 vs 4024.70 +/- 1066.40 mg(2)/L(2), P < 0.0001) and poor ventricular geometry, as compared with patients without VC. Moreover, they required higher doses of alfacalcidol for treating secondary hyperparathyroidism (0.43 +/- 0.60 vs 0.11 +/- 0.46 microg/day, P < 0.0001). CONCLUSION: Findings of the present study are consistent with a role of altered calcium and phosphate metabolism in the pathogenesis of VC in HD patients.

Renal manifestations of tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is an autosomal-dominant neurocutaneous disorder involving the skin, brain, kidney, heart and other organs. Renal manifestations are mainly angiomyolipomas, renal cysts and cancer. We report three female patients, mean aged of 31 years (range: 22-37), with a family history of TSC in one case. Cutaneous and nervous symptoms were found in all patients. Clinical complaints were mainly abdominal pain (3 cases), hematuria (2 cases), right flank palpable mass (1 case). Angiomyolipomas (AML) were diagnosed by ultrasonography in all patients, associated to renal cysts in one case. A patient underwent total right nephrectomy without any event during the follow-up. In a second patient, a selective arterial embolization of AML was indicated. Total left nephrectomy was performed due to the persistence of hematuria and the increased flank mass. Pathological examination of the kidney revealed a clear cell carcinoma. The third patient with small AML, associated with renal cysts, required careful monitoring. Renal manifestations in TSC are frequent and serious, they are the second leading cause of death after nervous lesions. Clinical and morphological aspects are variable and different therapeutic indications must be discussed.

[Calcium needs in hemodialyzed-parathyroidectomized patients]. / Les besoins en calcium chez les hémodialysés parathyroïdectomisés.

Parathyroidectomy changes the homeostasis of calcium balance in patients under dialysis for kidney failure. The aim of this work is to value calcium needs in 20 hemodialysed patients who underwent parathyroidectomy, in the department of nephrology of UHC Ibn Rochd of Casablanca from January 1994 to June 1999. These patients, 12 women (60%) and 8 men (40%), aged between 14 and 70 years (mean=46.10+/-13.62 years). Hungry bone syndrome was noted in 8 patients and postoperative hypocalcemia in 15 (75%). Mean minimal serum calcium was 196+/-0.21 mmol/l, with clinical signs in 6 patients. Mean calcium supplement the first postoperative week was 18.1+/-0,54 g/day in the 8 patients with hungry bone syndrome and 14.28+/-0,86 g/day in the 12 remaining patients. Between 6 and 18 months postoperatively, required calcium supplementation was 4.5 to 12 g/day in patients with hungry bone syndrome compared with 3 to 6g/day at the remaining patients. Mean serum calcium remained stable between 2.16 mmol/l to the 3(rd) month and 2.48 mmol/l to the 36(th) month. Postoperative hypocalcemia remains a major concern after parathyroidectomy requiring massive substitution with calcium and active vitamin D metabolite under close supervision to spare these patients from hypercalcemia resulting from parathyroid dysfunction.