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Background and Aims Acute kidney injury (AKI) is common in the elderly due to physiologic renal aging and underlying pathologies. Few studies focused on AKI in Tunisian elderly. The aim of our study was to highlight the epidemiological, clinical, etiological, therapeutic, and progressive characteristics of AKI in elderly. Method We conducted a descriptive retrospective study of AKI in patients admitted to our department over a period of 04 years from 01/01/2014 to 31/12/2017. Results We collected 40 patients including 25 women and 15 men with a sex ratio of 1.66. The mean age was 74 [65-87] years. We noted the presence of pre-existing chronic kidney disease in 58% of cases, diabetes in 50% of cases and hypertension in 73% of cases. Polypharmacy was found in 40% of cases. AKI was symptomatic in 80% of cases and found on a routine check-up in 20% of cases. Mean creatinine was 612+/-334 µmol/l. AKI was pre-renal in 37% and parenchymal in 63% of cases. Iatrogenic origin was found in 33% of cases. Renal biopsy was performed for diagnostic purposes in 6 cases. Haemodialysis was necessary in 50% of cases. Etiopathogenic treatment was initiated in 73% of cases. Intra-hospital mortality was 10%, recovery of renal function (RF) was partial in 40 % of cases and total in 20 % of cases. Follow-up time was 16 +/- 23.2 months. And at the last news, recovery of renal function (RF) was partial in 7 cases and total in 10 cases, 6 patients kept a chronic renal failure (CRF), among them 3 cases had and end-stage of CRF. Conclusion AKI is a frequent pathology in the elderly and its severity is linked to mortality and the transition to chronicity. Iatrogenic causes are frequent and preventable in this population, hence the major interest of prevention.

Background and Aims The B cells have a central role in the pathogenesis of several renal pathologies. Rituximab, a monoclonal antibody directed against the CD20 receptor expressed on the surface of B cells is an interesting alternative to conventional treatments of kidney pathologies. Method We conducted a descriptive retrospective study of the use of rituximab in nephrology patients. Results We collected 25 patients including 12 women and 13 men. The mean age was 33,5 [16-55] years. The rituximab was indicated for an extramembranous glomerulopathy in 6 patients, a focal segmental glomerulosclerosis in 4 patients, a minimal change disease in 4 patients, a lupus nephritis in 5 patients, and a granulomatosis with polyangiitis in 2 patients. Four kidney transplant patient received rituximab for the treatment of antibody mediated rejection in 3 cases and large cell lymphoma in 1 case. The average time between the diagnosis of the renal disease and starting treatment with rituximab was of 76 +/- 46,5 months. And it was of 16 [ 0,7 ; 59,8] months after transplantation in kidney transplant recipients. Side effects have been observed in 11 cases (44%). A favorable response has been obtained in 10 cases (40 %), within an average of 2,27 months, with at least one relapse in 4 cases. The follow-up time was 36,33 +/- 31,67 months. Conclusion Rituximab has been shown to be helpful in several cases of kidney disease. It may reduce the need for maintenance immunosuppression and help in some cases that are refractory to other therapies.

Background and Aims Hyperkalemia is a dreadful biological event that can immediately compromise the vital prognosis. Etiologies are many and varied. The aim of our study is to better characterize the epidemiological and clinical aspects of this disorder in order to establish adequate diagnostic and therapeutic strategies in order to intervene effectively and in the shortest possible time. Methods Cross-sectional study carried out over a period of 12 months [January-December 2017] including all emergency calls for hyperkalemia greater than 5.5 mmol / l and undergoing hemodialysis in the nephrology department. Results We collected 185 patients (Sex ratio= 1.43) aged on average 61.8 ± 16.1 years [18-94 years]. 70.3% had serum potassium between 5.5 and 7 mmol / l and 29.7% greater than 7. Patients mainly came from emergencies in 71.4% of cases. Main symptoms consisted in oligoanuria, vomiting, chest pain, and febrile syndrome in 38.9%, 10.8%, %, and 5.9% of cases, respectively. Of these patients, 76.2% are known to be chronic renal failure whose 29.7% are in chronic dialysis. Acute renal failure (ARF) was diagnosed in 30.3% of patients. Of these, 39.4% were functional AKI, 41% were obstructive and organic AKI in 19.6% of cases. Mean serum potassium was 6.7 ± 0.9mmol / l [5.5-11] associated with metabolic acidosis in 52.4% of cases. Mean serum creatinine was 988umol /l[184-3270]. The electrical signs of hyperkalemia were noted in 40% (n = 74) of patients: large T in 28.6% of cases, atrioventricular block (AVB) in 3.8% of cases including a 3rd BAV degree in 1.6% of cases, QRS wide in 11.4% of cases and sinus bradycardia in 7% of cases, Ventricular Extrasystoles and a branch block found respectively in 3.2% of cases. 30.8% (n = 57) of the patients were under hyperkalaemic treatment. In fact, 27 % of patients took a blocker of the renin-angiotensin system, 7% were on aldoactone, 13.5% of patients on þetabloquant,1.6 % of whom were on kaleoride and / or admitted to intensive care and infused with KCl. Medical treatment was started urgently in 42.7 % of cases and included the administration of twenty ml 10% ca gluconate that was given intravenously over 5-10minutes, insulin with glucose ,sodium polystyrene sulfate (Kayexalete) and salbutamol, sodium bicarbonate indicated for severe metabolic acidosis (pH Conclusion Hyperkalemia remains a frequent metabolic disorder. Renal failure and acidosis were the main factors associated to hyperkalemia in our study. The clinical and therapeutic subtleties must be known by any caregiver in order to effectively mitigate the harmful effects of this disorder, mainly in the cardiac function.

Background and Aims Urgent hemodialysis is a very common situation in nephrology and is burdened with high morbidity and mortality. The aim of this work is to study the epidemiological, etiological, clinico-biological and indications of dialysis emergencies, the parameters of the session and the potential complications. Method This is a descriptive study conducted over a period of 12 months (January – December 2017), including all patients who have been admitted to the nephrology department for urgent management in hemodialysis. Results Our study collected a total of 318 patients (sex ratio =1.52), the mean age 60.54 ± [18-95 years]. Patients came mainly from the emergency department (69.8%). 40.9 % of the patients were diabetic and 66,4 % hypertensive, 15.1% had coronary artery disease. Among patients, 80.9% had chronic renal insufficiency, of which 29.6% were end-stage (28% hemodialysis and 1.6% peritoneal dialysis). Urgent hemodialysis was undertaken for threatening hyperkalemia in 58.2% of cases, a poorly tolerated uremic syndrome in 50.8% acute pulmonary edema (APO) in 36.5% of cases, and anuria greater than 12h were the indication in 44.4% of cases and a severe metabolic acidosis in 11.3% of cases. The average duration of the session was 3 hours. Ultrafiltration was necessary in 63.7% of the cases. The blood access was a femoral catheter in 80.6% of the cases. Blood transfusion was indicated in 13.8% of cases. Main complications were dominated by symptomatic arterial hypotension in 12.9% requiring stopping the session in half of cases hypoglycemia in 6.9%, neurological disorder in 6.6% chest pain in 3.5 %. After a year of follow up care, overall mortality was 40% in this population. On multivariate analysis, age (p=0.006) and neurological state according to the glasgow score (p=0.01) were retained as independent factors of mortality in this population. Conclusion A greater prevalence of urgent hemodialysis is observed in our country testifying to the accessibility of this method of extrarenal replacement. Hyperkalemia, uremic syndrom and PAO are the main indications for urgent hemodialysis. Early diagnosis, prompt and relevant management of these patients will determine their prognoses in the short and medium term.

Secondary renal amyloidosis (RA) is the most common type of renal involvement in ankylosing spondylitis (AS). We assessed the epidemiologic and clinico-biological profile of AS patients with RA, to analyze treatment modalities and prognostic aspects, and to determine predictive factors of RA during AS. This was a retrospective study including 13 cases of RA among 212 cases who presented with AS, during the period from 1978 to 2006. The median age of the patients at the time of diagnosing AS was 47 years (range: 19-67). There were 11 males and two females. RA onset was diagnosed after a mean follow-up of 144.6 months (range: 10-505) from the AS diagnosis. We noted erosive peripheral arthritis, lumbar stiffness with bamboo spine, and coxitis in 23.1%, 76.9%, and 30.8% of cases, respectively. Nephrotic syndrome was found in eight patients (61.5%). At the time of diagnosing RA, six patients had renal failure. Amyloid deposits were histologically proven by salivary gland biopsy in six cases (46.1%) and by renal biopsy in seven cases (53.8%). Four patients received a long-course treatment with colchicine but with a good outcome only in two cases. In our series, AS was more severe among patients with RA. Four predictive factors of RA were identified: smoking (P = 0.04), erosive peripheral arthritis (P = 0.002), bamboo spine (P = 0.001), and biologic indicators of inflammation (P = 0.0001). High erythrocyte sedimentation rate was identified as the only independent risk factor of RA during AS (P = 0.0001). Renal function as well as urinalysis should be monitored at regular intervals to detect early renal involvement during AS.

BackgroundPrimary membranous nephritis (PMN) is an autoimmune disease induced by the deposit of antibodies (Ab) to the phospholipase receptor A2 receptor (PLA2R) on podocytes. In this context, we aimed to assess the relationships between anti-PLA2R Ab, PLA2R rs4664308 SNP, PLA2R mRNA levels and PMN susceptibility and outcome.MethodsSixty-eight PMN patients, 30 systemic lupus erythematosus (SLE) patients with secondary MN and 30 healthy control subjects served for anti-PLA2R Ab measurement by ELISA and PLA2R rs4664308 SNP genotyping by a commercial real-time PCR. Twenty patients with tubulo-interstitial nephritis (TIN) were used as controls for renal PLA2R mRNA quantification in PMN patients from kidney biopsies. PLA2R mRNA quantification was carried-out by real-time PCR after RNA extraction.ResultsForty-three (63.2%) PMN patients received initial therapy consisting of alternating monthly cycles of corticosteroids and cyclophosphamide. Twelve (17.6%) patients had resistant PMN to initial therapy and were consecutively treated by cyclosporine or tacrolimus. Anti-PLA2R Ab were positive in 54 (79.4%) PMN patients, while all SLE patients and controls were negative, pConclusionAnti-PLA2R Ab and renal PLA2R mRNA could be useful markers for PMN outcome predicting. The PLA2R rs6446308 SNP is associated with PMN susceptibility in Tunisians.

Light chain deposition disease (LCDD) is characterized by the tissue deposition of monotypic immunoglobulin light chains of either kappa or lambda isotype. It is the archetypal systemic disease that is most frequently diagnosed on a kidney biopsy, although the deposits may involve several other organs. This brief review focuses on the clinicopathological features of LCDD-associated nephropathy with an emphasis on the diagnostic and therapeutic difficulties related to this elusive condition.

The sarcoidosis was rarely associated to IgA nephropathy. We report a 38-year-old man presented decreased visual acuity and xerostomia. He had two axillary lymphadenopathies and pitting edema of legs in physical examination. The ophthalmological examination revealed a right posterior uveitis. Biological investigations showed a mild renal insufficiency and elevated serum level of angiotensin-converting enzyme, β2 microglobulin and IgA. He had a proteinuria and a microscopic hematuria. The kidney echography was without abnormalities. Histological study of the renal biopsy found results in favor to IgA nephropathy. Biopsies performed in accessory salivary gland and lymph nodes revealed non-necrotising epitheloid and gigantocellular granulomatous inflammation suggesting a sarcoidosis. The diagnosis of a sarcoidosis associated to IgA nephropathy was posed. The treatment was based on oral prednisolone with gradual tapering doses. He regained normal vision. The renal function had not worsened. No relapse of sarcoidosis was noted during our follow up.

The sarcoidosis is a systemic granulomatosis affecting most frequently the lungs and the mediastinum. An acute renal failure reveals exceptionally this disease. It’s a retrospective study implicating 13 cases of sarcoidosis complicated of acute renal failure. The aim of this study is to determine epidemiological, clinical, biological and histological profile in these cases and the interest of considering sarcoidosis diagnosis in case of unexplained renal failure. Extra-renal complications, therapeutic modalities and the outcome were determined in all patients. Our series involved 13 women with an average age of 41 years. Biological investigations showed an abnormal normocalcemia in 8 cases, a hypercalcemia in 5 cases, a hypercalciuria in 11 cases and polyclonal hypergammaglobulinemia in 7 cases. An acute renal failure was found in all patients with a median creatinin of 540 umol/L. The renal echography was normal in all patients. The kidney biopsy performed in all patients showed tubulo-interstitial nephritis. The extra-renal signs were: pulmonary interstitial syndrome in 5 cases, a sicca syndrome in 4 cases, mediastinal lymphadenopathy in 2 cases, a lymphocytic alveolitis in 3 cases, an anterior granulomatous uveitis in 3 cases and a polyarthritis in 6 cases. Six patients benefited from hemodialysis. The treatment consisted of corticosteroid in all cases. The follow up was marked by complete resolution of clinical and biological signs. The diagnosis of renal sarcoidosis should be made rapidly in order to avoid end stage renal failure.

Euphorbia paralias is known in traditional medicine as an anti-inflammatory agent, a purgative and for its local anesthetic property. To the best our knowledge, renal toxicity of this substance has not been previously reported. In this paper, we report the case of a 29-year-old male who developed renal damage following ingestion of Euphorbia paralias. He had been on follow-up for nephrotic syndrome since 1986, although irregularly, with several relapses but each responding well to steroid therapy. A kidney biopsy had not been performed earlier due to refusal by the patient. He was off steroids since April 2008 because the patient developed osteoporosis. He was admitted with general malaise and oliguria to our department in May 2009, following repeated vomiting and watery diarrhea for three days. On examination, he was edematous but had normal vital signs except for a pulse rate of 120/min. Hemoglobin was only 5.5 g/dL but with normal white cell and platelet counts. Blood biochemistry showed evidence of advanced renal failure with a serum creatinine level of 1835 μmol/L and urea at 44.6 mmol/L, sodium of 132 μmol/L and potassium at 4.3 mmol/L. He had features of nephrotic syndrome with severe hypoproteinamia and 24-h urinary protein of 10.45 g. Ultrasonography revealed enlarged kidneys with a reduced echogenecity of the medulla and the papillae. Subsequently, after hemodialysis with blood transfusion, a kidney biopsy was performed that showed focal segmental glomerulosclerosis associated with an acute tubular injury. On intensive interrogation, the patient gave a history of ingesting boiled Euphorbia paralias as a native treatment for edema, ten days prior to the onset of the current illness. A diagnosis of acute renal failure (ARF) resulting from the possible nephrotoxic effect of Euphorbia paralias poisoning was made. He was treated with intermittent hemodialysis and corticosteroids. Serum creatinine values improved after 48 days. At six months following the intoxication, serum creatinine of the patient was 240 μmol/L. In cases of unexplained ARF, a toxic mechanism should always be considered and acute renal failure caused by Euphorbia paralias should be included as a cause if renal toxicity is suspected in those places where it is being used as a native medicine.

We will study the epidemiologic, clinical, biological, therapeutic, prognostic characteristics and predictive factors of development of nephropathy in ankylosing spondylitis patients. We retrospectively reviewed the medical record of 32 cases with renal involvement among 212 cases of ankylosing spondylitis followed in our service during the period spread out between 1978 and 2006. The renal involvement occurred in all patients a mean of 12 years after the clinical onset of the rheumatic disease. Thirty-two patients presented one or more signs of renal involvement: microscopic hematuria in 22 patients, proteinuria in 23 patients, nephrotic syndrome in 11 patients and decreased renal function in 24 patients (75%). Secondary renal amyloidosis (13 patients), which corresponds to a prevalence of 6,1% and tubulointerstitial nephropathy (7 patients) were the most common cause of renal involvement in ankylosing spondylitis followed by IgA nephropathy (4 patients). Seventeen patients evolved to the end stage renal disease after an average time of 29.8 ± 46 months. The average follow-up of the patients was 4,4 years. By comparing the 32 patients presenting a SPA and renal disease to 88 with SPA and without nephropathy, we detected the predictive factors of occurred of nephropathy: tobacco, intense inflammatory syndrome, sacroileite stage 3 or 4 and presence of column bamboo. The finding of 75% of the patients presented a renal failure at the time of the diagnosis of renal involvement suggests that evidence of renal abnormality involvement should be actively sought in this disease.

Le syndrome de Behçet est une vascularite qui peut s'accompagner de plusieurs atteintes systémiques. Une atteinte rénale peut compliquer cette maladie. Les lésions rénales sont variées, les plus fréquentes sont l'amylose et la néphropathie à IgA. Patient âgé de 33 ans suivi pour un syndrome de Behçet depuis 10 ans et dont le diagnostic a été retenu devant l'association d'une aphtose bipolaire récidivante, des lésions de pseudofolliculite et un test pathergique positif. Il avait un typage HLA B 51. L'examen ophtalmologique était normal. Il a présenté une hématurie microscopique. L'examen cytobactériologique des urines était négatif. L'évolution était marquée par la survenue d'une hématurie macroscopique, un syndrome néphrotique avec une protéinurie à 3,8 g/24h et une albuminémie à 25 g/l ; la fonction rénale était normale. Il n'avait pas de lithiases urinaires. L'uréthro-cystographie rétrograde, l'uro-scanner et l'échographie doppler rénale étaient sans anomalies. Une origine lithiasique, infectieuse ou tumorale a été éliminée. Le dosage des IgA était élevé. La ponction biopsie rénale a objectivé une néphropathie glomérulaire avec des dépôts mésangiaux diffus d'IgA . Un traitement par l'azthioprine et la colchicine a été instauré. Le patient n'a pas présenté de récidive de l'hématurie sur un recul de 2 ans avec disparition du syndrome néphrotique. La réalisation d'analyses urinaires systématiques à la recherche d'une hématurie et/ou d'une protéinurie au cours d'un syndrome de Behçet permet de faire le diagnostic précoce d'une néphropathie à Ig A.

Between April 1975 and March 2005, 4,436 cases of histologically proven glomerulonephritis (GN) were diagnosed by the same team at the Kidney Unit of Charles Nicolle Hospital in Tunis. Respectively 1,510, 1,419 and 1,509 cases were diagnosed in 1975-1985, 1985-1995, and 1995-2005. We compared trends in the incidence rates of the different types of GN and those of Tunisian indicators of health, social and economic status. The following differences were found between 1975-1985 and 1995-2005:--As a proportion of all cases of GN, the frequency of amyloidosis fell from 12,6 % to 6,5 % (p < 0,0001). The 444 cases of amyloidosis observed during the study period were of type AA in 87 % of cases, and were related to chronic infectious diseases in 239 cases (54 %; pulmonary tuberculosis in 114 cases). The frequency of tuberculosis-associated amyloidosis fell during the study period, in parallel with the reduction in the incidence of tuberculosis in the Tunisian population (48,7 cases/100,000 inhabitants in 1983 to 20,17 in 2004). Lupus nephritis accounted for 7.7 % of all cases of GN diagnosed in 1975-1985, compared to 13 % in 1995-2005 (p < 0,00001). Increased exposure to sunlight and use of cosmetics could be involved in this increase.--The incidence of both proliferative endocapillary and membranoproliferative GN (as a proportion of all cases of GN) fell between 1975-1985 and 1995-2005, from 15,9 % and 21,6 % to 6,9 % and 7,7 %, respectively (p < 0,0001). This matched a drop in the incidence of acute rheumatic fever in the Tunisian population, from 7,26/100,000 inhabitants in 1984 to 0,83 in 2004, probably as a result of public health measures and widespread use of antibiotics. The incidence of membranous GN increased from 11,1 to 17,7 % in adults (p < 0,001) whereas it fell from 10,1 to 4,6 % in children (p < 0,01), possibly as a result of a nationwide HBV vaccination program launched in 1995. The incidence of IgA nephropathy increased from 0,9 to 12,9 % in adults (p < 0,0001) and from 0,3 % to 18,4 % in children, but remained relatively stable in elderly adults. This study, conducted in a single center, by the same team, and using the same renal biopsy practices, confirms that the control of infectious diseases in Tunisia has led to a substantial regression of proliferative endocapillary and membranoproliferative GN and renal amyloidosis. Environmental factors, such as the adoption of western lifestyles, could explain the increase in lupus and IgA nephropathies.

The impact of delayed graft function (DGF) on the outcome of renal transplantation remains controversial. We analyzed the risk factors for DGF and its impact on graft and patient survival. A total of 354 renal transplants performed between June 1986 and April 2000 were analyzed. Variables analyzed included donor and recipient age, method and duration of renal replacement therapy, HLA mismatch, cold and warm ischemia times, biopsy-confirmed acute rejection, length of stay in the hospital, serum creatinine at the end of first hospitalization as well as graft and patient survival at one, three, five and ten years. The study patients were divided into two groups: patients with DGF (G1) and those without DGF (G2). DGF occurred in 50 patients (14.1%), and it was seen more frequently in patients transplanted from deceased donors (60% vs. 40%, P

Introduction Diabetic nephropathy can occur during the course of both type1 and type 2 diabetes mellitus. The characteristic lesions are diffuse or nodular (Kimmelsteil-Wilson) diabetic glomerulosclerosis. The reported cases represent unusual presentations of diabetes mellitus. Case presentation We report the case of a 49-year-old man without prior history of diabetes mellitus who presented with rapidly progressive renal failure and whose renal biopsy revealed nodular (Kimmelsteil-Wilson) glomerulosclerosis lesions characteristic of diabetes. Conclusion Renal manifestations of diabetes mellitus may antedate other more common presenting symptoms of this disease and we critically review the literature on this subject.