Sexual function and associated factors in Iranian patients with chronic low back pain.

STUDY DESIGN: Case-control study. OBJECTIVES: (i) To describe the prevalence of sexual dysfunction in chronic low back pain (CLBP) patients, (ii) to compare the range of sexual function outcomes between patients with CLBP and healthy controls and (iii) to investigate which factors are associated with sexual function within the cohort of individuals with CLBP. SETTING: Low back pain (LBP) clinic of Qazvin University of Medical Sciences, Qazvin, Iran. METHODS: A total of 702 patients with CLBP and 888 healthy controls participated in the study. The Female Sexual Function Index (FSFI), International Index of Erectile Function (IIEF) and Premature Ejaculation Diagnostic Tool (PEDT) were used to evaluate sexual function. In addition, quality of life, anxiety, functional status and pain intensity were assessed in patients. Univariate and multiple linear regression analyses were performed for the identification of factors associated with sexual function. RESULTS: The prevalence of sexual problems in female patients with CLBP was 71.1% (n=177) while the corresponding figure for healthy women was 36.8% (n=161). Erectile dysfunction was present in 59.5% of male patients and in 24.5% of healthy males. Higher sexual function in both male and female patients with CLBP were being younger, lower duration of back pain, lower BMI, higher education level, being unemployed, physically active shorter sick leave, lower level of pain intensity, lower disability, higher family income, lower levels of depressive and anxiety symptoms, and higher psychical functioning and mental functioning. CONCLUSIONS: CLBP patients report considerably higher prevalences of sexual problems compared with healthy controls. Sex therapy and sexual management should be added to routine care and treatment of patients with CLBP.

Doppler ultrasonographic assessment of early changes in kidney graft size and resistive index and their predictive role on 1-year graft function.

INTRODUCTION: Doppler ultrasonography is a simple, noninvasive diagnostic tool for assessment and follow-up studies in renal transplantation. The aim of this study was to investigate the correlation between early changes in graft size and resistive index (RI) and 1-year graft function. METHOD: We recorded graft size, RI, and serum creatinine level in 25 living kidney donors (before transplantation) as well as early (1-week), and 1-year after transplantation (in kidney recipients). Then we assessed the correlation between early changes in graft size and RI and 1-year Scr. RESULTS: Repeated measurement tests showed a significant increase in graft size including length (initial, 107.6 ± 5.8 mm; average increase, 8.48 ± 5.61 mm; P < 0.001), anterior-posterior diameter (initial, 46.3 ± 4.7 mm; average increase, 6.16 ± 4.08 mm; P < 0.001), and parenchymal thickness (initial, 14.96 ± 2.1 mm; average increase, 3.04 ± 1.98 mm; P < 0.001) 1 week after transplantation. However, during the 1-year follow-up examinations the increase in graft size was not significant in contrast with 1-week follow-up values (P > 0.47). Pearson correlations showed significant correlation between early changes in graft size (eg, anterior-posterior diameter, r = -0.492; P = 0.013); and 1-year Scr levels. There was no significant correlation between graft size changes and RI or RI and Scr early or 1-year after transplantation. CONCLUSION: There was a significant increase in kidney size (including length, anterior-posterior diameter, and cortical thickness) early after transplantation. The amount of increase in size significantly correlated with Scr level 1-year after transplantation. There was no correlation between RI and Scr.

Efficacy and morbidity following PCNL in patients with renal anomalies: the outcome from a randomized study comparing different imaging modalities for assessment.

AIM: The aim of this paper was to assess outcome of totally tubeless percutaneous nephrolithotomy (TPCNL) performing with and without preoperative computed tomography (CT) scan, in anomalous kidneys. METHODS: A total of 50 patients with renal anomaly were randomly divided into two groups. Exclusion criteria was stone size >3.5 cm. Twenty six had malrotation, 21 had horseshoe kidney and 3 had ectopic pelvic kidneys. For 25 patients, TPCNL was performed with preoperative CT scan and in the remnant only intravenous urography and renal ultrasonography were done, preoperatively. The incidence of complications and outcomes were compared between two groups in a 1 month period. RESULTS: In the group with preoperative CT scan, the mean (SD) stone size was 2.9 (0.75) vs. 2.7 (0.95) cm2. Between the two groups, there were not statistical differences in the mean (SD) analgesic requirement, hemoglobin drop, operation time, hospital stay, and return to normal activity. They were 7.5 (1.7) vs. 6.1 (1.9) mg of morphine, 1.20 (0.36) vs. 1.52 (0.27) mg/dl, 64 (13.2) vs. 59 (13.3) minutes, 1.9 (0.4) vs. 1.7 (0.45) and 12.4(2.9) vs. 10 (3.5) days, respectively. Only 2 patients required blood transfusion and one patient had postoperative pneumothorax in the group with CT while in the other group, three patients required postoperative transfusion and one showed postoperative fever. A successful outcome at the first attempt was 88% in group with CT vs. 80% in the other group. CONCLUSION: It seems that TPCNL could be done with safety in renal anomalies by omitting preoperative CT scan.

Evaluation of Epstein-Barr virus load in saliva before and after renal transplantation.

INTRODUCTION: Posttransplant lymphoproliferative disorders (PTLD) arising in solid organ transplant patients show a strong correlation with Epstein-Barr virus (EBV) infection. The aim of our study was to evaluate the frequency of EBV DNA levels before and after transplantation among saliva samples of Iranian kidney transplant patients. MATERIALS AND METHODS: In 40 kidney transplant recipients and their healthy donors, we evaluated the EBV DNA levels in saliva samples by quantitative polymerase chain reaction method using samples obtained 1 hour before transplantation surgery. In addition, 3 months after transplantation we evaluated EBV DNA levels in recipients for comparison with preoperative levels. Exclusion criteria included hepatitis B, hepatitis C, and human T-cell leukemia virus infections before transplantation as well as HIV-positive patients under highly active antiretroviral therapy, graft rejection requiring dialysis and active viral infection of oral cavity. RESULTS: Before renal transplantation, there was no significant difference in saliva EBV DNA levels between kidney donor and recipient patients (P=.8). The levels increased significantly to 67.6% in the recipient group after transplantation (P=.01). CONCLUSION: We observed that EBV was more frequently present in the oral mucosa after renal transplantation. Thus, we can follow these patients for EBV infection using saliva examinations as a simple screening method.

Should post kidney transplantation hyperlipidemia considered a risk factor for graft function?

BACKGROUND: Hyperlipidemia is a common problem after kidney transplantation. OBJECTIVE: To uncover the real impact of post kidney transplantation hyperlipidemia on graft function and survival, and to determine whether it is just a biochemical phenomenon after using immunosuppressant or a part of disease pathology. METHODS: 330 kidney transplants were managed in Sina Hospital Kidney Transplantation Unit affiliated to Tehran University of Medical Sciences, Tehran, Iran from September 1994 till February 2010. The demographic characteristics of the patients, causes of chronic kidney diseases, history of pretransplantation dialysis, pretransplantation comorbidities (e.g., hypertension, diabetes mellitus [DM], hyperlipidemia and coronary artery disease), rejection episodes, status of infection with cytomegalous virus [CMV], post-transplantation DM, hyperlipidemia, ischemic heart disease [IHD], and graft and patient survival were recorded. A serum creatinine level >2 mg/dL was considered as "graft deterioration," and return to dialysis as "graft loss." According to the presence or absence of post kidney transplantation hypercholesterolemia (>200 mg/dL) or hypertriglyceridemia (>200 mg/dL), the patients were classified into "hyperlipidemic" or "non-hyperlipidemic." The presence of clinical or paraclinical coronary artery disease was also determined in both groups. RESULTS: The incidence of hyperlipidemia elevated from 8% to 50% before and after transplantation. 2.7% developed clinical IHD. 13% of hyperlipidemics and 22% of non-hyperlipidemics developed graft deterioration. Among hyperlipidemics with deteriorated grafts 40% had premorbid diseases, 68% had CMV infection and 82% had hypertension. Only 22% had previous acute rejection and 27% received deceased kidney transplant. CONCLUSIONS: post kidney transplantation hyperlipidemia is just an associated phenomenon secondary to the use of immunosuppressant medications, which have no obvious impact on renal graft function and can be easily controlled by instituting dietary modifications and use of modern antilipid medications. Post kidney transplantation CMV infection and hypertension are considered as the main threatening risk for renal graft-even more dangerous than acute or chronic rejections.

Could prophylactic monoclonal antibody improve kidney graft survival?

OBJECTIVES: This study was designed to evaluate the impact of daclizumab monoclonal antibody on early and late kidney graft survival. MATERIALS AND METHODS: From 2007 to 2008, 57 kidney transplant recipients were followed for a mean of 9.3 months. Twenty-three patients received 1 mg/kg daclizumab 24 hours before and 14 days after transplantation. In contrast, 34 patients (controls) did not receive daclizumab. The same immunosuppressive protocol was administered to all participants: oral prednisolone, mycophenolate mofetil, and cyclosporine. Delayed graft function (DGF), acute rejection, prednisolone pulses and/or antithymoglobulin (ATG), cytomegalovirus (CMV) infection, urinary tract infection (UTI), as well as early and late graft function were compared between the two groups. RESULTS: The mean age in cases and controls was 39.7 and 37.1 years, respectively. The occurrence of DGF was 4% versus 3%; reversible acute rejection, 16% versus 14.5%, and irreversible acute rejection 0% versus 9% (P < .05) for treated versus control groups, respectively. ATG was used in 21% versus 23%, and pulse prednisolone 26% versus 20%, respectively. In case and control groups, the mean creatinine levels were 1.4 mg/dL versus 1.35 mg/dL at discharge. At last follow-up, it was 1.35 mg/dL versus 1.2 mg/dL, respectively. CMV infection occurred in 30% versus 35%, and UTI in 17% versus 19% of treated versus controls, respectively. CONCLUSION: The prophylactic administration of daclizumab improved early graft survival and prevented irreversible acute rejection.

Role of resistive index measurement in diagnosis of acute rejection episodes following successful kidney transplantation.

OBJECTIVE: This study was performed to evaluate the role of resistive index (RI) in the diagnosis of rejection episodes following successful kidney transplantation. MATERIALS AND METHODS: One hundred and one unrelated living first kidney allograft adult recipients (75 males and 26 females) of overall mean age of 39 years were enrolled and prospectively followed for 6 months. The measurement of RI by Doppler ultrasonography was performed in all patients on days 3 and 7 as well as at months 1, 3, and 6 in addition to when there was graft dysfunction. We determined serum creatinine and cyclosporine levels. RESULTS: Twenty-seven patients (26.7%) experienced 33 acute rejection episodes during the follow-up. There were significant differences between mean RI among patients with normal function vs rejection: 0.606 +/- 0.065 vs 0.866 +/- 0.083 (P < .05), respectively. Overall, elevated levels of cyclosporine, ischemic acute tubular necrosis (ATN), and renal artery thrombosis were observed in 8, 5, and 3 patients, respectively. No association was observed between these factors and RI. CONCLUSIONS: RI was significantly higher in patients with acute rejection episodes. It had no association with ATN or cyclosporine toxicity. Hence, RI may be useful to diagnose acute renal allograft rejection following renal transplantation.

Does donor nephron mass have any impact on graft survival?

OBJECTIVES: Functioning nephron mass namely, the number of nephrons in the grafted kidney, is one of the nonimmunologic factors that may have some impact on long-term graft survival. The aim of this study was to assess the impact of donor nephron mass on graft outcome in the recipient. MATERIALS AND METHODS: From 1989 to 2005, 1000 renal transplants were performed at our center. The 217 studied cases were followed for an average of 8 years. All patients received grafts from living donors. The weight of the grafted kidney (donor nephron mass) as well as the recipient's body mass index (BMI) were measured at the time of operation. Nephron mass index (NMI) was defined as the ratio of donor nephron mass to recipient BMI. Associations between variables were tested by logistic regression and Pearson correlation using the SAS system and S-plus statistical software. To evaluate graft function, we determined serum creatinine values, acute rejection episodes and chronic nephropathy. RESULTS: Mean NMI was 8.07 +/- 0.2 and mean creatinine level was 1.43 +/- 0.4 mg/dL. There were 32 cases (14.7%) of acute rejection, who were managed successfully with antithymocyte globulin (ATG) in 28 cases. Four patients lost their grafts. There were 15 cases (7%) of graft loss due to chronic rejection. Using Pearson correlation, we observed no association between NMI and mean serum creatinine level. Logistic regression showed a significant relation between NMI and acute rejection (P<.05) with an odds ratio of 2.0. There was no significant correlation between NMI and chronic rejection. CONCLUSIONS: The lower the NMI, the greater the short-term graft loss. However, in the long term, no significant correlation was found between graft survival and NMI. Also, mean creatinine level was not significantly different among patients regardless of NMI.

Microchimerism and renal transplantation: doubt still persists.

OBJECTIVE: We sought to study microchimerism in a group of kidney transplant recipients. MATERIALS AND METHODS: In this study, the peripheral blood microchimerism (PBM) after renal transplantation was retrospectively evaluated in 32 male-to-female recipients of living unrelated or cadaveric donor renal transplants. Using a nested polymerase chain reaction (PCR) amplification specific for SRY region of the Y chromosome, microchimerism was detected with a sensitivity of 1:1,000,000. Recipients were compared according to the presence of PBM, acute and chronic rejection episodes, type of allotransplant, recipient and donor age at transplantation, previous male labor or blood transfusion, allograft function (serum creatinine level), and body mass index. RESULTS: Among 32 recipients, 7 (21.9%) were positive for PBM upon multiple testing at various posttransplant times. All microchimeric recipients had received kidneys from living unrelated donors. No significant difference was observed with regard to other parameters. In addition the acute rejection rate in the microchimeric group was 3 (42%) versus 4 (16%) in the nonmicrochimeric recipients (not significant). CONCLUSION: Our results suggested better establishment of microchimerism after living donor kidney transplantation. However, doubt persists concerning the true effect of microchimerism after renal transplantation. It seems that microchimerism alone has no major protective role upon renal allograft survival.

Does renal transplantation improve erectile dysfunction in hemodialysed patients? What is the role of associated factors?

OBJECTIVE: To assess the effect of successful renal transplantation on improvement of erectile function in hemodialysis (HD) patients and the relationship between the degree of patient response and other factors. MATERIALS AND METHODS: From September 2002 to November 2005, erectile function of 64 patients on HD for at least 6 months was evaluated pretransplantation and 6 months posttransplantation by International Index of Erectile Function, version 5 (IIEF-5). Sixty four age-matched persons without renal impairment were enrolled as control group to compare erectile dysfunction (ED) prevalence with the HD group. We evaluated duration of HD, age, and site of arterial anastomosis. In an attempt to find predictors of improvement of ED, after kidney transplantation, we performed linear regression analysis with a backward method. RESULTS: The prevalence of ED in HD patients was 87.5%. Although there were some differences in the prevalence of ED between patients older versus younger than 50 years, the difference was not statistically significant. There was no relationship between the duration of dialysis and the severity of ED in HD group. Compared to the pretransplant IIEF-5 score (13.59), there was significant improvement (19.16). In an attempt to find predictors of ED improvement, we used a linear regression analysis with backward method. Pretransplant IIEF-5 score, age at the time of transplant, and anastomosis to the common iliac artery showed significant associations with improvement, but the duration of dialysis and anastomosis to internal iliac or external iliac artery did not. CONCLUSION: The incidence of ED among hemodialyzed patients is high. Kidney transplantation is the key treatment for this complaint. ED has a major negative impact on the quality of life and family relations. Its treatment is associated with improvement of psychogenic factors. ED is a sensitive topic and many patients will not spontaneously discuss it with their physician, so better to include potency evaluation in posttransplantation list evaluations.

Pelvic nerve neuropathy after kidney transplantation.

OBJECTIVES: We examined the relation of various age, gender, diabetes, hypertension, and graft function with the prevalence of femoral and lateral cutaneous nerves sensory and/or motor disturbances after kidney transplantation. MATERIALS AND METHODS: Among 129 patients who underwent kidney transplantation from April 2001 to March 2002. We excluded, 10 due to preoperative sensory disturbances. We evaluated the prevalence of sensory and/or motor disturbances preoperatively by physical examination and postoperatively by both physical and electromyography examinations. The clinical findings were correlated with the following risk factors: age, gender, preoperative dialysis duration, background diseases. (e.g., diabetes, hypertension), graft weight, nephron mass index, operative and retraction time, and rejection episodes. RESULTS: At 1 to 9 days postoperatively, 31 ng (26%) patients, suffered neuropathy of the lateral cutaneous nerve and 4 (3.3%), femoral neuropathy. No meaningful relation was detected between the incidence of neuropathy and these risk factors. The probability of neuropathy was greater among diabetics, hypertensives, women, and those with graft rejection episodes. All of these complaints were temporary. CONCLUSIONS: Post-kidney transplant femoral and/or lateral cutaneous nerve neuropathy is a prevalent complication particularly in diabetic, hypertensive, and female patients. Neuropathy is also more evident after graft rejection.

Ureteroscopic management of urological complications after renal transplantation.

OBJECTIVE: To determine the feasibility, safety and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. MATERIAL AND METHODS: We reviewed 1560 consecutive renal allografts performed between June 1989 and February 2002. A total of 28 patients (1.8%) had indications for an endoscopic procedure on the allograft ureter, as follows: obstructive ureteral calculi with a history of failed extracorporeal shock-wave lithotripsy, n=6; suspected ureteral stricture, n=3; upwardly migrated ureteral stents, n=9; and ureteral stricture at the ureteroneocystostomy site, n=10. Ureters were anastomosed to the bladder using the Leadbetter-Politano and Lich-Gregoire methods in six and 22 cases, respectively. Ureteroscopies were performed with a semi-rigid 9.8 F Wolf ureteroscope. RESULTS: Identification of the ureteral orifice and insertion of a guide-wire into it was successful in 19 cases (68%). If we exclude the 10 patients with ureteral stricture, ureteroscopy was successful in 13/18 cases (72%). Four ureteral calculi (67%) were removed with the ureteroscope. Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at the ureteroneocystostomy site (40%) underwent successful ureteral dilatation and double-J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications (one urinary leakage and one symptomatic urinary tract infection) occurred and were managed conservatively. CONCLUSIONS: Ureteral endoscopy is a safe and effective method for the management of urological complications after renal transplantation. This procedure can be considered the first choice, in preference to percutaneous and antegrade modalities.

The relationship between lipid profile and erectile dysfunction.

The objective of this study is to investigate the relation between serum lipids (cholesterol, LDL, HDL, triglyceride (TG)) and erectile dysfunction (ED). The experimental methods involved comparison of 100 patients with organic ED (mean age of 43.59+/-10.51 y), with 100 healthy individuals (mean age of 43.72+/-9.76 y) regarding their lipid profile from January 2000 to June 2003 (cholesterol, TG, HDL, LDL). The results showed that there was a significant difference between mean plasma cholesterol and LDL levels in the individuals suffering from ED and the control group (P=0.04 and 0.02, respectively). The TG and HDL mean plasma level differences were not significant (P=0.583 and 0.299, respectively). Odds ratios for high plasma cholesterol level (>240 mg/dl) and high plasma LDL level (>160 mg/dl) were 1.74 and 1.97. The R2 was 0.04 for both cholesterol and LDL. Applying linear regression, the coefficient for cholesterol and LDL reduced the International Index of Erectile Function questionnaire scores by -0.036 and -0.035. In conclusion, this study, the correlation of cholesterol and LDL levels with ED strongly supports the role of hyperlipidemia treatment in both the prevention and management of ED.

Management of Peyronie's disease by dermal grafting.

PURPOSE: To evaluate the results of plaque excision and dermal grafting in Peyronie's disease. MATERIALS AND METHODS: Twenty seven patients were scheduled to undergo plaque excision and dermal grafting for Peyronie's disease. Potency, bending of erected penis, and having painful erection were evaluated in patients before and after operation. To evaluate erectile dysfunction, we used International Index of Erectile Function (IIEF) by interviewing the patients and filling questionnaires by their partners. Doppler ultrasonography was used to determine the vascular competence of penis before and after operation in 15 patients. RESULTS: The disease was more prevalent between the ages of 40 and 60 years. Plaques were located as follows: dorsal in 18, right lateral in 6 and left lateral in 3. Mean plaque size was 11 (range 5 to 18) mm. After plaque excision and dermal grafting, penile deformity, erectile dysfunction, and painful erection had remained yet in 4 (15%) out of 27, 3 (16%) out of 19, and 3 (14%) out of 22, respectively. Doppler ultrasonographic study in 15 patients revealed improvement in peak systolic velocity (p<0.01). In addition, a decrease in end diastolic velocity was noted also that was not significant statistically (p=0.26). Resistive index did not improve after operation. CONCLUSION: This procedure showed significant improvement in penile deformity (85% of cases), erectile dysfunction (84% of cases) and painful erection (86% of cases). We recommend plaque excision and dermal grafting as an effective procedure in treating Peyronie's disease.

Epidemiologic study of 284 patients with urogenital trauma in three trauma center in Tehran.

PURPOSE: To perform an epidemiologic study of urogenital injuries in traumatic patients who were referred to three traumatic centers in Tehran during one year. MATERIALS AND METHODS: This study included a part of data of National Trauma Registries, which was performed within one year. Questionnaires were completed by trained staff in three different geographical regions of Tehran: Shohada-e-Tajrish hospital (north of Tehran), Sina hospital (south of Tehran), and Shaheed Faiazbakhsh (west of Tehran). RESULTS: Two hundred and eighty four (5%) out of 57367 patients who were referred to the above mentioned centers had genitourinary trauma, of whom, 145 (42%) were hospitalized. Males with a frequency of 92% (258 patients) were the most injured group. Patients mean age was 25+/-14 years, mostly between 20 and 29 years (33.6%) followed by 10-19 years age group with a frequency of 25.6%. Non-penetrating trauma with a frequency of 96% was the most common type and accident was the most mechanism of trauma. One hundred and one patients out of the studied population had associated injuries. The most frequent injuries were occurred in extremities (40%) and the less in head and neck (7%). There were 22 (21.7%) intra-abdominal organ injuries. Sixty nine percent of patients developed mild injury (ISS<7), 20% developed severe injury and (ISS>12), and 4.2% of patients died. The most common injured organ was kidney (3.3%) and the least one was ureter, as no ureteral injury was reported. CONCLUSION: Although a low percentage of traumatic patients develop urogenital injuries, disregarding these injuries may lead to serious complications and it is recommended to consider these injuries while dealing with such patients. Considering the fact that these complications which could be preventable, are mostly developed in the youth, making solution for such problem is recommended.