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Background and aim. Asymptomatic bacteriuria (ASB) is a frequent finding in allograft kidney transplant recipients and may be associated with a higher incidence of urinary tract infections in this population. We aimed to investigate the potential utility of serum procalcitonin (PCT) concentrations, an early marker of infection, for ASB diagnosis. We also compared its diagnostic performance with white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and highly sensitive C-reactive protein (hsCRP). Methods. In a single-center, cross-sectional study, 37 kidney transplant recipients with no clinical signs or symptoms of urinary tract infections were included. ASB was assessed by means of urine culture. Serum PCT concentrations were determined by the electrochemiluminescence immunoassay technique. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic performance of PCT and other classifiers. Results. Seventeen patients (46%) had ASB. Serum PCT concentrations were significantly higher in ASB+ patients (0.14 vs. 0.08 ng/ml, p=0.009). PCT concentrations significantly correlated with serum creatinine (r=0.408, p=0.012) and ESR (r=0.466, p=0.004). Of the four tested classifiers (PCT, WBC count, ESR, and hsCRP), only PCT was able to significantly distinguish between ASB+ and ASB- patients [area under the curve: 0.74, (95% CI: 057-0.91) p=0.012]. Adjustment of the ROC model for serum creatinine showed that the ability of PCT in classifying patients by ASB status is not affected by creatinine concentrations (crude vs. adjusted area under the curve: 0.74 vs. 0.72, test of AUC difference: p=0.891). A cut-point of 0.10 ng/ml of PCT correctly classified ASB+ patients with a sensitivity and specificity of 64.7% and 80.0%, respectively. Conclusion. PCT might be a useful surrogate marker for ASB diagnosis among kidney transplant recipients. Diagnostic performance of PCT is superior to that of WBC count, ESR, and hsCRP. Further, diagnostic ability of PCT appears to be independent of renal function.

Introduction: Delayed graft function (DGF) is associated with significant adverse outcomes in deceased donor kidney transplantation (KT) including lower graft survival. However, risk factors and potential preventive strategies like intraoperative rabbit antithymocyte globulin (rATG; thymoglobulin) have not yet been fully evaluated. Objectives: The aim of this study was to investigate DGF risk factors and determine the association of intraoperative rATG with the risk of DGF in deceased donor kidney recipients. Patients and Methods: We retrospectively examined medical records of 163 first time deceased donor kidney transplant recipients at two major kidney transplant centers from 2014 to 2016. All the donors were standard heart-beating, brain death donors. Risk factors for DGF in recipients were evaluated using multivariate logistic regression analysis. Results: The mean recipients’ age was 43±13 years and the majority of participants were male (64%). The overall rate of DGF was 27%. Intraoperative rATG was significantly associated with a lower rate of DGF (adjusted odds ratio [AOR], 0.33, 95% CI, 0.11-0.95). Intraoperative transfusion (AOR, 3.7, 95% CI, 1.4-9.9) and diabetes mellitus (AOR, 3.7, 95% CI, 1.5-8.9) were significantly associated with higher risk of DGF. Conclusion: This study showed that intraoperative blood transfusion and diabetes mellitus were associated with increased risk of DGF. Meanwhile, administration of intraoperative rATG was associated with reduced odds ratio of DGF. Future studies are needed to evaluate the potential role of rATG in DGF-related renal outcomes.

Background: Chronic renal failure (CRF) and end-stage renal disease (ESRD) are among the underlying reasons for the hospitalization of expeditionary pilgrims to Mecca. This study aimed to evaluate the reasons and consequences of sending the patients with CRF and ESRD to Mecca to perform rites of pilgrimage. Methods: This retrospective cross-sectional study assessed the profiles of all pilgrims in 2012 and 2013. The independent variables were awareness and unawareness of the patients with CRF and patients on dialysis; moreover, the dependent variables were reasons for referral and hospitalization in hospital, probable death rate, and indications of dialysis in an emergency. Results: Out of all Pilgrims, 2416 (1.76% of the total pilgrims’ population) cases had CRF, out of whom 1.15%, 10.47%, and 88.36% of the patients were on dialysis, aware, and unaware of their disease, respectively. Furthermore, 93 (3.9%) patients with CRF were hospitalized during Hajj. Cardiovascular disease (41%) and respiratory diseases (20%) were the most common reasons for patients’ hospitalization. Conclusion: It is suggested that the glomerular filtration rate of the pilgrims be calculated before sending them to Hajj; moreover, the patients with CRF should be screened accurately. Proper vaccination and cardio check-up are necessary before the Hajj expedition. Considering low-salt diet and adequate fluid intake in patients with CRF during Hajj can minimize patients' referral to hospitals.

Background and Aims Preeclampsia (PE) is a complex disorder that is characterized by hypertension and proteinuria after the 20th week of pregnancy, and it causes most neonatal morbidity and perinatal mortality. Despite many efforts, the knowledge acquired regarding its pathogenesis and pathophysiology does not allow us to treat it efficiently. It is not possible to arrest its progressive nature, and the available therapies are limited to symptomatic treatment. MicroRNAs (miRNAs) are small non-coding RNAs of approximately 19–23 nucleotides that can bind to the 3’ untranslated region of target mRNAs resulting in the degradation and translation inhibition of the mRNA, thereby regulating gene expression at the post-transcriptional level. Many studies have confirmed deregulated miRNA in pregnant patients with PE, and the function and mechanism of these differentially expressed miRNA are gradually being revealed. Method Sample collection Among the patients in the maternity ward, Department of Obstetrics and Gynecology. pregnant women who carried fetuses from 26 to 40 weeks of gestation were selected for study. Plasma samples were obtained from a total of 90 women in two groups; 48 being preeclamptic and 42 being healthy pregnancies, forming the control group. None of these subjects had undergone an invasive procedure. A volume of 5 mL maternal venous blood was drawn and collected in an ethylenediamine tetraacetic acid (EDTA) tube. The blood samples were centrifuged initially at 1200 g for 10 min and a second time at 10,000 g for 10 min, and 500 mL from the supernatant layer were used. The supernatant layer of the plasma was taken to Department of Molecular Biology and Genetics, Molecular Diagnosis Laboratory for storage at -80°C until the time of study. Total RNA extraction Total RNA was isolated from plasma using Trizol (Invitrogen, Carlsbad, CA) following the manufacturer protocol. Total RNA was analyzed using the commercially available Bioanalyzer Agilent RNA 6000 picoassay. MicroRNA isolation from maternal plasma MicroRNAs were obtained with the High-Specificity miRNA QRT-PCR detection kit (Stratagene-an Agilent Technologies Company, USA-Canada) according to manufacturer recommendations. Micro RNAs were subjected to a polyadenylation reaction as previously described. Next, using an oligo dT primer harboring a consensus sequence, reverse transcription was performed using an Affinity Script RT/RNase Block Enzyme mixture (Stratagene). miRNA was anayzed using the Bioanalyzer 2100- Agilent Small RNA assay. QRT-PCR platform The cDNA was amplified by real-time PCR. The real-time PCR analysis was performed on a Stratagene Mx3005P. This reaction contained a microRNA-specific forward primer, a TaqMan probe complementary to the 3ꞌ of the specific microRNA sequence, as well as part of the polyA adaptor sequence, and a universal reverse primer complementary to the consensus 3ꞌ sequence of the oligodT tail. Results were recorded in clinic sheets and were analyzed using SPss version 22. Results G1 consist of 48 and G2 42 pts. There were no differences in two group in respect to age (mean age was 28± 9.5 and 27± 5.23 in G1 and G2 respectively). Micro RNA155, 210 and 494 were significantly higher in plasma of G1 (Pv 0.001, 0.0001, 0.005 respectively). Micro RNA 29b was significantly lower in G1 (Pv 003). And there was no difference between two groups in respect to Micro RNA 34a (Pv 0.09). And also PE patients with higher plasma creatinine have more plasma level of Micro RNA155 and 210. There was a significant correlation between Micro RNA 494 and anemia in PE patients Conclusion In this study we showed that Micro RNA155, 210 and 494 increased and Micro RNA 29b decreased in PE and after clarifying by further studies may use as a predictor in clinical practice.

Objective Delayed graft function (DGF) is an early complication after deceased donor kidney transplantation with significant adverse effects on graft outcomes. Ischemia-reperfusion injury during transplantation is a major cause of DGF. Tissue concentrations of carnitine, an antioxidant and regulator of cellular energy supply, decrease in the kidney following ischemia-reperfusion insult. Based on promising animal data, this study evaluated the possible protective effect of L-carnitine against DGF. Design This study is a pilot, randomized, double-blind, placebo-controlled clinical trial that was conducted on kidney transplantation patients in kidney transplant ward of Imam Khomeini hospital complex affiliated to Tehran University of Medical Sciences, Tehran, Iran. Subjects Patients older than 14 years old undergoing their first kidney transplantation from a deceased donor were evaluated for eligibility to take part in this study. Fifty-six patients were randomly assigned to L-carnitine or placebo groups. Intervention During this trial, 3 g of oral L-carnitine or placebo was administered in 3 divided doses each day for 4 consecutive days starting the day before kidney transplantation (i.e., days −1, 0, 1, and 2). Main Outcome Measure The need for dialysis within the first week after transplantation, serum creatinine and urine output were assessed daily. After hospital discharge, patients were followed for 3 months regarding organ function. Results DGF incidence did not differ between the L-carnitine and placebo groups (18.51% vs. 23.8%, respectively; P = .68). Total allograft failure within 3 months after kidney transplantation happened in 6 patients in the placebo and 1 patient in the L-carnitine group ( P = .05). Conclusion This study showed no protective effects of oral L-carnitine supplementation against DGF occurrence recipients; however, 3-month graft loss was lower in the L-carnitine supplemented group.

Introduction: Mineral and bone disorders are common in patients with chronic kidney disease (CKD). Vitamin D plays an important role in calcium-phosphorus balance. Objectives: The main aim of this investigation is to assess the relation between circulating levels of 25(OH) vitamin D and parathyroid hormone (PTH) and estimating the best threshold of vitamin D which may prevent secondary hyperparathyroidism. Patients and Methods: This cross-sectional study was conducted between January 2014 to September 2015. Adult patients with CKD who were not on routine peritoneal dialysis or hemodialysis and did not receive any kidney transplantation, enrolled to this study. Patients who were pregnant or who were on vitamin D supplementation therapy were excluded. Basic demographic and laboratory information were measured. Results: Around 254 patient enrolled in this study (55.1% men). The prevalence of vitamin D deficiency and insufficiency were significantly high, 12.6% and 53.9%, respectively. Serum PTH level increased significantly as circulating plasma level of 25(OH) vitamin D decreased (P = 0.003). Serum total calcium increased significantly with high levels of plasma 25(OH) vitamin D (P < 0.001) and hypercalcemia was seen in 2.8% of patients. Piecewise linear regression modeling of PTH for 25(OH) vitamin D estimated the best threshold for 25(OH) vitamin D of 13.00 ng/mL (95% CI: 2.55-23.44 ng/mL) (P = 0.015). Conclusion: This study again confirms this fact that sufficient level of serum 25(OH) vitamin D is mandatory in patients with CKD in order to prevent secondary hyperparathyroidism. Although this study recommends level of serum 25(OH) vitamin D to be above 13 ng/mL for this purpose.

Background: Delayed graft function (DGF) and slow graft function (SGF) are complications after kidney transplantation that resulted in poor short-term outcome. Objectives: In this study, we evaluate a new model for deceased kidney transplantation to reduce the cold ischemia time and its effect on DGF and SGF as short-term outcomes. Methods: We have included 814 deceased kidney transplanted patients in this study. All of the donors were local, while the recipients were both local and nonlocal. Kidney recipient’s outcomes (included mortality rate as well as DGF and SGF), age, gender, BMI, blood group, Rh, allograft renal function, transplantation date, kidney transplantation history, PPD, positive history of rheumatologic disorders, the distance between home of recipient and the transplantation center, cardiovascular disease, and dialysis duration was evaluated for all patients. Results: The incidence of DGF and SGF were 24.8% and 20.5%, respectively. There were no statistical differences in the rate of DGF and SGF between local and distant recipients (P > 0.21). The rate of DGF was significantly higher in females as well as 40 - 65 year old recipients (P < 0.05). In logistic regression multivariate analysis, DGF and SGF were significantly correlated with BMI, blood group, the history of kidney transplantation, and dialysis duration. Conclusions: This study showed the feasibility of using a local donor for a distant recipient as well as reduction of cold ischemia time and lower rate of DGF. It is obvious that the shorter CIT, which resulted from usage of local donor, can lead to better kidney transplant outcomes.

To investigate the efficacy and safety of oral N-acetylcysteine (NAC) for preserving residual renal function in patients undergoing hemodialysis. Randomized, multi-center, parallel-group, open-label clinical trial (Registration No. IRCT 2014071418482N1). 54 patients who have been undergoing hemodialysis for at least 3 months and had residual urine volume >100 ml/24 h were randomly allocated to NAC or no medication. Residual renal function evaluated by (1) estimated glomerular filtration rate (GFR), (2) 24 h urine volume, and (3) renal Kt/V. GFR and Kt/V was determined at baseline and after 3 months. 24 h urine volume was measured at baseline, after 1, 2, and 3 months. Intention-to-treat analysis was performed on 47 patients (NAC = 26, control = 21). GFR in patients receiving NAC improved, whereas in the control arm a decline of 1.0 ml/min/1.73 m2 was recorded (3.59 vs. 2.11 ml/min/1.73 m2, effect size = 17.0 %, p = 0.004). For 24 h urine volume, the between-group difference after 1 month was significant (669 vs. 533 ml/24 h, effect size = 15.4 %, p = 0.004). After 3 months, 24 h urine volume in the NAC arm was on average 137 ml higher than in the control group, and the difference reached near significance (673 vs. 536 ml/24 h, p = 0.072). In the follow-up visit, Kt/V was higher in the NAC arm but the difference did not reach statistical significance (0.81 vs. 0.54, p = 0.152). Three months treatment with NAC appears to be effective in preserving renal function in patients undergoing hemodialysis and the medication is generally well-tolerated.

The purpose of this study was to evaluate T-cell immunity markers using serial post-transplantation monitoring of cytokine-producing cells during the first post-transplant months for the prediction of acute rejection and potentially chronic rejection of kidney allograft. We followed 57 kidney allograft recipients for meanly 3 years post-transplantation. Blood samples were collected pre-transplant, 2, 4 and 12 weeks post-transplant. The frequencies of IL-10-, IL-17- and IFN-γ-producing cells were determined in all time-points using ELISPOT assay. The results of ELISpot monitoring and levels of IL-23 and TGF-β were compared between recipients with acute (n = 12) or chronic rejection episodes and patients with stable graft function (n = 45). In all post-transplant time-points, significantly high frequencies of IFN-γ- and IL-17-producing cells and low frequency of IL-10-producing cells were observed in rejection group versus patients with stable graft function (P 0.0001). The ROC curve analysis for determining the reliability of cytokine-producing cells for the prediction of acute rejection revealed that AUC was 0.046 for IL-10 (P 0.001), 0.927 for IL-17 (P 0.001) and 0.929 for INF-γ-producing cells (P 0.001). Our results indicate that analyzing the frequencies of INF-γ/IL-10/IL-17-producing cells may define a reliable panel for the prediction of acute rejection within the first post-transplant year which could also be applicable for the prediction of chronic rejection episodes.

Low vitamin D levels have been linked to metabolic syndrome in the general population. In the present study, the relationship between inadequate serum concentrations of vitamin D and metabolic syndrome in patients with end-stage renal disease undergoing hemodialysis was explored. In a cross-sectional setting, 145 patients undergoing maintenance hemodialysis were enrolled. Metabolic syndrome was defined using the International Diabetes Federation criteria. Serum concentration of 25(OH) vitamin D was determined by a commercially available enzyme immunosorbent assay method. The prevalence of metabolic syndrome was 53.1%. The prevalence rate of severe vitamin D deficiency ( 30 ng/mL) 29.0%. With the increasing number of metabolic abnormalities, vitamin D levels significantly decreased (P for trend = 0.028). Among the components of metabolic syndrome, vitamin D deficiency was significantly associated with central obesity (odds ratio [OR], 95% confident interval [CI] = 2.80, 1.11-7.04, P = 0.028). A positive, but nonsignificant association between vitamin D deficiency and raised fasting plasma glucose was noted (OR, 95% CI = 2.40, 0.94-6.11, P = 0.067). Both vitamin D deficiency and insufficiency were significantly associated with an increased likelihood of having metabolic syndrome (P < 0.05). In a final model controlling for age, sex, and parathyroid hormone levels, vitamin D deficiency increased the odds of having metabolic syndrome by more than threefold (OR, 95% CI = 3.26, 1.30-8.20, P = 0.012). Low levels of vitamin D are frequent among hemodialysis patients and are associated with the metabolic syndrome.

Controlling blood pressure in hemodialysis patients is crucial but not always easy. The most common blood pressure measurement method is peri-dialysis measurement, but due to interdialytic blood pressure fluctuations, we are unsure if it is the proper way for evaluating blood pressure. Some studies have shown the superiority of 24-h ambulatory blood pressure monitoring over peri-dialysis blood pressure measurement. We aimed to compare the consistency of these methods in determining hypertension among hemodialysis patients. We studied 50 patients (mean age: 55.8 years) on regular hemodialysis in Imam Khomeini University Hospital, Tehran, Iran. Peri-dialysis blood pressure and interdialytic 24-h ambulatory blood pressure monitoring were recorded for each patient. Patients' demographic data and peri-dialysis weight were recorded too. All data were analyzed using the PASW Statistics 18.0, SPSS Inc. (Chicago, IL). There was a significant difference between pre-dialysis mean systolic blood pressure (146.1 ± 23.3 mmHg) and mean systolic blood pressure recorded by ambulatory blood pressure monitoring (135.3 ± 19.3 mmHg) (p = 0.001). There was also a significant difference between pre-dialysis mean diastolic blood pressure (83 ± 14 mmHg) and mean diastolic blood pressure recorded by ambulatory blood pressure monitoring (77.3 ± 10 mmHg) (p = 0.003). But the frequencies of hypertension measured with both methods were significantly consistent and the Kappa agreement coefficient was 0.525 (p = 0.001). Considering ambulatory blood pressure monitoring as the gold standard for blood pressure measurement, our recommendation for the best cutoff point to diagnose hypertension, with the highest sensitivity and specificity would be 135/80 mmHg for pre-dialysis blood pressure and 115/70 mmHg for post-dialysis blood pressure.

Kidney transplant is a new area for use of rituximab, which is being used to treat acute antibody-mediated rejection or as an induction agent in ABO- or HLA-incompatible grafts. We report on late-onset neutropenia in rituximab-treated kidney transplant recipients with antibody-mediated rejection.This observational prospective study was performed on kidney transplant recipients with clinically suspicious or biopsy-proven antibody-mediated rejection treated with plasmapheresis plus intravenous immunoglobulin with (cases) or without (controls) rituximab.Compared with none of the controls, 4 of 6 patients (66.7%) in the rituximab-treated group experienced late-onset neutropenia 35 to 93 days after the last dose of rituximab. The course of neutropenia was complicated by endocarditis in 1 patient, resulting in his death just because of a lack of valvular surgery.Increased use of rituximab to treat antibody-mediated rejection among kidney transplant recipients requires attention to its late-onset adverse event, neutropenia. Although asymptomatic in some patients, kidney transplant recipients treated concomitantly with plasmapheresis and mycophenolate mofetil are predisposed to hypogammaglobulinemia, and monitoring of patients for infections is required.

Drug-induced nephrotoxicity is one of the most common side effects of medications and accounts for about 20 % of hospital admissions for acute kidney injury (AKI). Some possible pharmacologic mechanisms of pentoxifylline (PTX) that suggest it as a candidate to ameliorate AKI include interaction at the level of the adenosine receptors, increase in erythrocyte deformability, stimulation of vasodilatory prostaglandins production and prevention of vascular congestion, and suppression of tumor necrosis factor alpha (TNF-α) and apoptosis. This manuscript reviews all clinical and animal studies on the use of PTX as a renoprotective agent against a number of nephrotoxic drugs. Data were collected by searching MEDLINE, PubMed, Scopus, Cochrane central register of controlled trials, and Cochrane database systematic reviews. Key words used as search terms were pentoxifylline, nephroprotective, renoprotective, drug-induced renal diseases, drug-induced nephrotoxicity, drug-induced renal toxicity, and drug-induced nephropathy. This search was performed without time limitation. Most greatest number of studies and human clinical trials on the renoprotective effect of PTX against drug-induced nephrotoxicity involves cyclosporine (Cyc). It seems that despite encouraging results from animal studies, there is insufficient evidence to support the renoprotective effect of PTX against Cyc-induced nephrotoxicity in humans. Although some available animal studies show protective effects of PTX against renal toxicity of some antimicrobial and cytotoxic agents, designing clinical trials to approve these nephroprotective effects requires prior confirmation of no reducing antimicrobial or antitumor action of these medications by PTX.

The aim of the study was to investigate the efficacy of nasal oxygen as a supplementation to hydration therapy in reducing the risk of developing contrast-induced nephropathy (CIN).In a randomized controlled trial, 348 patients scheduled to undergo elective coronary angiography were randomly allocated to standard hydration plus 2 L/min to 3 L/min nasal oxygen (from 10 minutes before the procedure until the end of the procedure) (n = 176) or standard hydration alone (n = 176). The primary outcome measure was development of CIN defined as either an increase of 25% or more in serum creatinine concentrations or an increment of at least 0.5 mg/dL in serum creatinine concentrations 48 hours after catheterization.Of the 348 patients who completed the study, 105 developed CIN (30.2%; 95% confidence interval, 25.4% to 35.0%). A diagnosis of CIN was made in 32 (18.6%) and 73 (41.5%) patients in the nasal oxygen and control arms, respectively (P.001). In the intervention arm, creatinine concentrations postcontrast remained relatively constant (average change, 2.7%), whereas a significant increase of 17.3% was recorded in the control arm (P.001; effect size, 11.8%).Supplementation with nasal oxygen in addition to standard hydration appears to be an effective strategy in reducing CIN. The effect size for this intervention seems to be moderate.

Insulin resistance (IR), a risk factor for cardiovascular disease and all-cause mortality, is prevalent among maintenance hemodialysis patients. Effects of omega-3 fatty acids on IR in hemodialysis patients have not been well understood. This study aimed to determine the effects of omega-3 fatty acids on IR and serum lipids of hemodialysis patients.Fifty-four adult patients on hemodialysis were randomly assigned to receive either 1800 mg of omega-3 fatty acids or placebo daily for 4 months. Serum concentrations of glucose, triglyceride, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, C-reactive protein, insulin, leptin, and adiponectin were measured at baseline and after 4 months of the intervention. Insulin resistance was assessed using the homeostasis model assessment of insulin resistance and 2 adipokine-based measures of IR, including the leptin-adiponectin ratio and homeostasis model assessment corrected by adiponectin.Mean differences of serum C-reactive protein, insulin, leptin, and adiponectin concentrations did not show significant difference between the two groups following 4 months of intervention. Fasting serum glucose and low-density lipoprotein cholesterol were not significantly influenced by omega-3 supplementation, either. Serum triglyceride, total cholesterol, and high-density lipoprotein cholesterol levels significantly decreased in the omega-3 group (P = .02, P = .03, and P.001, respectively). None of the indirect indexes of IR showed significant changes at the end of the study in either the omega-3 or placebo group.Supplemental use of omega-3 fatty acids showed some beneficial effects on lipid profile of hemodialysis patients without any improvement in IR.

Background: Some studies have hypothesized the protective role of vitamin C against cardiovascular disorders (CVD) in patients with end-stage renal disease (ESRD). This study was designed to assess plasma vitamin C concentration and its relationship to hemodialysis (HD) patients’ morbidity and mortality. Methods: Plasma vitamin C concentrations were assessed in HD patients using spectrophotometry and subjects were prospectively followed for up eighteen months for all-cause mortality. Any association between vitamin C concentration and patients’ demographic data, co-morbidities, or the cause of ESRD were investigated using the Chi-square test. Results: Ninety-one patients with a mean age of 56.7 ± 15.7 years were included in this study. The most frequent cause of ESRD was simultaneous hypertension and diabetes in 30 % of patients, followed by hypertension in 25.6 %, and diabetes in 11.1 %, respectively. About 34 % of patients had CVD as the most prevalent co-morbidity. Forty-nine patients (53.8 %) had low levels of vitamin C concentration. There was a significant relationship between vitamin C insufficiency and presence of any co-morbidity in HD patients (p < 0.05). There was a significant difference in vitamin C concentrations between patients without co-morbidities and those with cardiovascular ones (F[2,88]=3.447, p = 0.036). Twenty-two (24.2 %) patients died over a median duration of 227 days. There was a significant difference in time to death of patients with and without low levels of vitamin C concentration (p = 0.04). Conclusions: The results showed lower plasma vitamin C levels in HD patients who suffered any co-morbidity and sooner time to death in these patients.

Zinc (Zn) deficiency has been reported in 40-78% of hemodialysis (HD) patients and may be associated with anemia and pruritus and probably limiting the expression of renal osteodystrophy. This study was designed to explore possible correlation between serum zinc concentration and anemia, intact parathyroid hormone (iPTH) concentration and pruritus severity in HD patients. During a case-control study, the serum Zn concentration of patients on main-tenance HD was compared with those of the healthy controls and with the cut-off point of 70 mcg/dL as the risk of Zn deficiency. The mean serum Zn concentration in patients on main-tenance HD was significantly lower than that of the control group; however, it was not different with the cut-off point of 70 μg/dL. No correlation between serum Zn concentration and hema-tologic indices was detected. A significant positive correlation between serum Zn concentration and erythropoietn dose was noted. No correlation was found between serum Zn concentration and PTH level or pruritus severity. In conclusion the results of this study showed that zinc concentrations were lower in HD patients compared to controls, however, the effects of routine supplementation of zinc to control anemia, serum PTH level or pruritus severity are yet doubtful.

Plasma oxidative stress (OS) including total homocysteine (tHcy) and malondialdehyde (MDA) concentrations is usually elevated and antioxidant enzymes activities are decreased in patients suffering from chronic kidney disease. It is thought that OS in these patients may have a role in the pathophysiology of cardiovascular events. It has been suggested that N-acetylcysteine (NAC) may be effective to lower OS. This study was designed to evaluate the possible effect of 4-week treatment with oral NAC on plasma tHcy and MDA concentrations and status of antioxidant enzymes in chronic hemodialysis (HD) patients who were receiving vitamin B group at least from the onset of dialysis program. Twenty patients were enrolled in this study. All subjects were treated with oral NAC (600 mg twice daily) for 4 weeks. Predialysis plasma tHcy and MDA concentrations and activities of glutathione peroxidase, catalase, and superoxide dismutase were assessed before the initiation of NAC and after 4-week NAC therapy. At baseline, moderately severe hyperhomocysteinemia was present in about 63% of patients. The results showed significant (19%) decline in plasma tHcy concentration after NAC therapy. However, moderately severe hyperhomocysteinemia was persistently seen in about 50% of the patients. NAC did not affect concentration of MDA and antioxidant enzymes activities. Because of the proposed relationship between cardiovascular morbidity and hyperhomocysteinemia in patients on HD, daily supplementation of patients with NAC may be recommended as adjunct to vitamins in those subjects who did not respond adequately to group B vitamins alone.

Background. Upper gastrointestinal (UGI) symptoms are common in uremic patients, and higher serum levels of urea have been suggested to be related to Helicobacter pylori (HP) colonization and UGI mucosal inflammation. Aim. The aim of this study was to compare HP infection and UGI endoscopic findings between uremic patients, renal transplant (RT) recipients, and controls. Methods. A total of 474 subjects (71 chronic renal failure [CRF], 73 hemodialysis [HD], 25 Tx, and 305 controls) from Baqyiatallah Hospital, Tehran, Iran were recruited between April 2002 and March 2004 for evaluation of dyspepsia, excluding those receiving any HP-eradication therapy. All subjects were examined for esophagus, stomach and duodenum mucosa, and infection with HP on 2 distinct tissue samples of the anthral region. Results. Four groups of subjects (mean ± 2 se; age, 45 ± 1.6 years; 62.9% male) were studied. Duodenal ulcer in the uremic patients (CRF, 16.1%; HD, 13.7%) was more common than that in the RT-recipients (8%) and controls (6.5%); P = .038. Erosive gastritis and duodenal bulb deformity were also more common in the uremic subjects (CRF, 23.9%, 36.9%; HD, 30.1%, 20.5%, respectively) than those in the other subjects (RT recipients, 16%, 8%; controls, 8.2%; 0%, respectively); P

Background That hypertension (HTN) as a leading cause of end-stage renal disease (ESRD) is linked to sleep disorders in the general population can be the basis of a hypothesis that HTN may be a contributing factor to the poor quality of sleep in some kidney transplant recipients. This study was designed to investigate the correlation between ESRD secondary to HTN and sleep quality among kidney transplant recipients. Methods In this case control study, 201 kidney transplant recipients were divided into group I (ESRD) secondary to HTN, ( n = 82) and group II (ESRD secondary to other causes, n = 119). The groups were matched for medical comorbidities, demographic and clinical data, and symptoms of anxiety and depression. Sleep quality assessed by means of the Pittsburgh Sleep Quality Index (PSQI) was compared between the study groups. Results The mean (SD) of the total PSQI score was significantly high in group I compared with group II (7.42 ± 2.36 vs 6.60 ± 3.07, P = .042). Similar results were observed for the sleep duration scores in the groups (1.22 ± 1.12 vs 0.86 ± 1.12, P = .026). In group I, all the other PSQI components were higher than those in group II, difference that were statistically significant. Conclusion Sleep quality and duration was poorer among our kidney transplant recipients with ESRD secondary to HTN compared with the controls. Further studies, however, are required to investigate whether HTN is responsible for the reported poor quality of sleep in some kidney transplant recipients.

Low vitamin D levels have been linked to metabolic syndrome in the general population. In the present study, the relationship between inadequate serum concentrations of vitamin D and metabolic syndrome in patients with end-stage renal disease undergoing hemodialysis was explored. In a cross-sectional setting, 145 patients undergoing maintenance hemodialysis were enrolled. Metabolic syndrome was defined using the International Diabetes Federation criteria. Serum concentration of 25(OH) vitamin D was determined by a commercially available enzyme immunosorbent assay method. The prevalence of metabolic syndrome was 53.1%. The prevalence rate of severe vitamin D deficiency (5 ng/mL) was 3.4%, mild vitamin D deficiency (5-15 ng/mL) 31.0%, vitamin D insufficiency (16-30 ng/mL) 36.6%, and vitamin D sufficiency (30 ng/mL) 29.0%. With the increasing number of metabolic abnormalities, vitamin D levels significantly decreased (P for trend = 0.028). Among the components of metabolic syndrome, vitamin D deficiency was significantly associated with central obesity (odds ratio [OR], 95% confident interval [CI] = 2.80, 1.11-7.04, P = 0.028). A positive, but nonsignificant association between vitamin D deficiency and raised fasting plasma glucose was noted (OR, 95% CI = 2.40, 0.94-6.11, P = 0.067). Both vitamin D deficiency and insufficiency were significantly associated with an increased likelihood of having metabolic syndrome (P 0.05). In a final model controlling for age, sex, and parathyroid hormone levels, vitamin D deficiency increased the odds of having metabolic syndrome by more than threefold (OR, 95% CI = 3.26, 1.30-8.20, P = 0.012). Low levels of vitamin D are frequent among hemodialysis patients and are associated with the metabolic syndrome.

The purpose of this study is to investigate the possible correlation between corrected flow time (FTc) in carotid artery and changes in volume status.Ninety-three patients with end-stage renal failure who underwent fluid removal via hemodialysis were enrolled prospectively. The volume of fluid removed as well as prehemodialysis and posthemodialysis measures of FTc in the carotid artery, heart rate, and mean arterial pressure was evaluated. All imaging measurements were performed with patients at supine position, 15 minutes before and after the hemodialysis session, by evaluating the right common carotid artery at the level of the lower border of thyroid cartilage.The mean FTc before fluid removal was 345.07±37.19 milliseconds. This measure decreased significantly after the volume removal with a posthemodialysis mean of 307.77±31.76 milliseconds (P.0001). There was a statistically significant and negative association between the volume of fluid removed by hemodialysis and the changes in FTc (Pearson correlation, -0.39; P.0001).The assessment of changes in FTc of carotid artery via Doppler waveform analysis may predict the changes in intravascular volume. The use of this diagnostic modality may be an accurate and noninvasive alternative to currently available methods.

Regulatory T cells have been suggested to have a protective role against acute rejection in allograft recipients. However, there is little information available about their contribution to chronic rejection process. The role of transforming growth factor-beta 1 (TGF-β1) as a profibrogenic and/or immunoregulatory cytokine in renal allografts is also controversial.To evaluate the frequency of CD4+CD25+CD127- and CD3+CD8+CD28- regulatory T cells in chronic allograft dysfunction (CAD) and to investigate the expression of TGF-β1 in renal allografts.Thirty biopsy-proven CAD patients were pair-matched with 30 stable graft function patients and a third group of healthy volunteers. Flowcytometry was performed on PBMCs to determine the frequency of CD3+CD8+CD28- and CD4+CD25+CD127- regulatory T cells in lymphocyt population. TGF-β1 gene expression was assessed by Real Time PCR.The percentages of CD3+CD8+CD28- Tregs among renal allograft recipients was higher than healthy controls (p0.001) since stable graft patients showed the most rates. The frequency of CD4+CD25+CD127- Tregs was lower in CAD patients than stable recipients (p=0.024) and healthy group (p=0.015). TGF-β1 gene expression was greater in CAD patients compared to healthy group (p=0.03) but there was no significant difference between gene expression of stable graft patients and healthy volunteers.The negative association between the frequency of regulatory T cell subtypes and chronic allograft dysfunction proposes these cells as probable candidates for promoting allograft survival. Moreover, despite the immunoregulatory capacity of TGF-β1, it is likely to be implicated in chronic damages of allograft tissue.

Objective To determine the correlation between cyclosporine blood concentration at 2 hours after dosing (C2) and renal allograft function. Materials and Methods From 2008 to 2010, 1191 kidney transplant recipients (718 male and 473 female patients) were studied. The correlation between serum creatinine concentration and C2 blood concentration was stratified as 400, 600, 800, and 1000 ng/mL. Results The mean (SD) C2 was 620 (235) ng/mL, and serum creatinine concentration was 1.49 (0.68) mg/dL. At multivariate regression analysis, no significant correlation was observed between serum creatinine concentration and C2 blood concentrations of 600, 800, or 1000 ng/mL ( P = .18, .57, and .76, respectively); however, it was associated at 400 ng/mL ( P = .03). Moreover, 36.1% of 3159 samples demonstrated satisfactory renal allograft function despite low C2 blood concentration between 400 and 600 ng/mL. Conclusion During maintenance therapy, C2 blood concentration between 400 and 600 ng/mL is effective and safe for providing prophylaxis against rejection, and can improve long-term survival by decreasing cyclosporine toxicity.

Objective To evaluate the prevalence of anemia and appraise its risk factors at 6 months after renal transplantation. Materials and Methods This retrospective study was performed between 2008 and 2010 in 2713 adult kidney transplant recipients to determine the prevalence of posttransplantation anemia. Anemia was defined as hemoglobin concentration of 12 g/dL or less in women and 13 g/dL or less in men. Results The prevalence of posttransplantation anemia was 52.7%, with severe anemia (hemoglobin ≤11 g/dL) detected in 24.4% of patients. Impaired renal function was the only risk factor associated with anemia (odds ratio, 3.6; P = .047). However, severe anemia after kidney transplantation was correlated with female sex ( P = .001), renal allograft dysfunction ( P = .00), and cytomegalovirus infection ( P = .002). Conclusion The present study demonstrated a quite high prevalence of posttransplantation anemia, in particular associated with impaired renal allograft function. Severe anemia was correlated with female sex, degree of kidney graft dysfunction, and cytomegalovirus infection.

Background: Significant impairment in health-related quality of life (HRQOL) among dialysis patients could be partly explained by some co-morbid disorders, such as chronic kidney disease-mineral and bone disorder (CKD-MBD). Also disturbance in calcium and phosphorus metabolism would increase mortality and morbidity. Therefore, further efforts to treat these abnormalities may improve the survival. Objectives: We designed a large multicenter population-based study in Iran to describe and assess the relation between HRQOL, hospitalization, and bone metabolism markers. Patients and Methods: We enrolled a total of 5820 dialysis patients from 132 dialysis centers in different parts of the country whom were volunteers to cooperate between October 2010 and August 2011. The Iranian adapted version of the Kidney disease quality of life-short form (KDQOL-SF TM ) version 1.3 questionnaire was used to assess the health related quality of life. The clinical and demographic characteristics were gathered from patients’ data files. Results: The mean (SD) age of patients was 54.88 (16.36) years, and the range was 2 to 99 years. Of all patients, 43.1% were female. The scores of kidney disease component summary (KDCS), physical component summary, mental component summary, and total quality of life were significantly higher in the lower quartile of corrected serum calcium and higher quartile of serum parathyroid hormone (PTH) levels (P < 0.05). In a regression analysis of multilevel data, while corrected serum calcium level was associated with total KDCS and short form health survey (SF-36) scores after adjusting for other variables, hospitalization was directly correlated with serum phosphorus level and had reverse correlation with dialysis duration and quality of life. Conclusions: In the current study, quality of life was correlated with serum calcium level, calcium-phosphate product, and serum PTH level, while hospitalization was correlated only with serum phosphorus level. However, quality of life was inversely correlated with hospitalization.

Background: Infective endocarditis (IE) is a serious complication in immunosuppressive patients that has adverse effects. Objectives: The aim of this study was to define the characteristics, outcomes, and correlating factors of mortality in renal transplant recipients. Patients and Methods: Infective endocarditis was diagnosed in 22 patients from three renal transplant centers in Iran between 2000 and 2010. Modified Duke criteria were applied to confirm the diagnosis. Results: Twenty-two renal transplant patients with IE were evaluated. Blood culture results were positive in 81%. Enteroccous and group D non-enterococcal were the causative microorganisms in 31% and 25% of patients, respectively. In-hospital and 12-month mortality was 41% and the mortality rate was higher in older patients in comparison to younger patients. Overall, the rates of one-year disease-free patient and graft survival were 49% and 88%, respectively. Conclusions: Despite the availability of different and potent antibiotics, the mortality caused by IE remains considerably high. These patients are significantly prone to endovascular infections that affect the mortality and survival.

There are wide individual differences in pharmacokinetic parameters of mycophenolate mofetil (MMF) among transplanted patients. Some studies have shown that single nucleotide polymorphisms (SNPs) of the Uridine Diphosphate Glucuronosyl Transferase1A9 (UGT1A9) are responsible for these differences in early days after transplantation. Therefore it was decided to evaluate the influence of UGT polymorphism on MMF pharmacokinetics among stable Iranian transplant patients. This was a cross sectional study from March 2008 through December 2008 in Imam Khomeini Hospital affiliated to the Tehran University of Medical Sciences in Iran. Blood samples were taken from 40 de novo stable Iranian renal transplant patients taking 2 g MMF daily with SrCr≤1.4 mg/dL with at least 3 months history of transplantation. Appropriate PCR and HPLC methods were used for the determination of SNPs and their impact on MPA pharmacokinetics. T-275A polymorphism occurred in 15% of patients, UGT1A9*3 occurred in 2.5% of patients. Carriers of T-275A polymorphism had significant lower MPA AUC 0-12 in comparison with non-carriers or wild type (73.3±17.8 g/h/mL vs. 110.8±31.1 μg/h/mL, p = 0.006). There was no significant difference in AUC 6-12 between the two groups although carriers of T-275A SNP had lower MPA AUC 6-12 (22.4±4.5 μg/h/mL vs. 26.8±10.2 μg/h/mL, p = 0.24). Cmax was lower in the carriers of (20.2±9.0 μg/mL vs. 37.2±12.5 μg/mL, p=0.004). There was no significant difference in C0 between two groups. (3.0±1.2 μg/mL vs. 3.9±1.6 μg/mL, p = 0.1). This study in Iranian stable transplanted patients shows that carriers of T-275A polymorphism had significantly lower MPA exposure compared to non-carriers.

Drug-induced nephrotoxicity (DIN) accounts for up to 60% of hospital acquired acute kidney injury with considerable morbidity and mortality. Several efforts have been made to reduce drug-induced nephrotoxicity; however, DIN remains a matter of concern. Statins with their antioxidant, anti-inflammatory and anti-apoptotic effects may have the potential to protect kidney against DIN. The present review evaluated all of the available in vitro and in vivo studies that examined the use of statins as renoprotective agents against nephrotoxic drugs. Materials for this review were obtained by searching Medline, PubMed, Scopus, Cochrane central register of controlled trials, and Cochrane database of systematic reviews. Key words used as search terms included “statin”, “3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, “HMG-CoA reductase inhibitors”, “nephroprotective”, “renoprotective”, “drug-induced renal diseases”, “drug-induced nephrotoxicity”, “drug-induced renal toxicity”, “drug-induced nephropathy”, “drug-induced renal side effects”, and “contrast-induced nephropathy”. This search was performed without time limitation. Only English language articles were included in this review. This review concluded that chronic statin user may be less prone to contrast-induced nephropathy (CIN) compared with statin non-users. Short-term high dose statin administration may also reduce the incidence of CIN in statin naïve patients. This renoprotective effect of statins against CIN is seen in low risk patients with normal kidney function or mild kidney dysfunction, but probably not in patients with moderate to severe renal dysfunction. Based on available animal data, statins may protect kidney against gentamicin-, cisplatin- and cyclosporine-induced nephrotoxicity, however, theses animal results have not yet been confirmed by human data. This article is open to POST-PUBLICATION REVIEW. Registered readers (see “For Readers”) may comment by clicking on ABSTRACT on the issue’s contents page.

Background There is still controversy over whether pregnancy adversely affects renal transplantation outcomes. We, thus, compared two groups of kidney transplant recipients in terms of patient survival and allograft function: those who did versus did not conceive posttransplant. Methods This historical cohort study conducted between 1996 and 2002, divided female kidney transplant recipients of reproductive age into group I ( n = 86, at least one posttransplant pregnancy) and group II ( n = 125, no posttransplant pregnancy). The two groups were matched for age, cause of end-stage renal disease (ESRD), treatment protocol, and first creatinine (Cr). All patients received a first transplant and all had a Cr less than 1.5 mg/dL on entry into the study. The subjects were followed for 45.4 ± 22.0 and 46.3 ± 19.8 months, respectively ( P > .05). Five-year patient and graft survivals and Cr were considered to be the main outcome measures. Results Mean (SD) age in groups I and II was 26.6 ± 6.6 and 26.9 ± 8.1 years, respectively ( P > .05). Five-year patient and graft survival rates were not significantly different between the study groups. Of the women in group 1, only 9 (10.5%) subjects displayed elevated serum Cr levels (>1.5 mg/dL) at the end of follow-up, while the serum Cr levels in 35 (28%) group II patients were above 1.5 mg/dL ( P = .024). Conclusion Our results indicates pregnancy did not seem to adversely affect patient and graft survival among kidney transplant recipients. Renal transplantation in stable women of childbearing age should not be a contraindication to pregnancy.

Differentiation between rejection (the most common cause) and many other possibilities for detrimental effects on graft function represents a difficult issue to diagnose the cause of renal allograft dysfunction. This study was designed to determine whether technetium-99m sulfur colloid (TSC) accumulation predicted graft rejection. We prospectively studied 54 episodes of allograft dysfunction in 53 kidney transplant recipients who underwent TSC scintiscanning and graft biopsy. Visual analysis of TSC uptake compared uptake, in the allograft with that in the marrow of the fifth lumbar vertebra (L5). A 3+ result meant that allograft uptake was greater than L5 marrow uptake; 2+, the same; 1+, less and finally 0, no allograft uptake. Transplant accumulation of 2+ or more was considered consistent with rejection (P = .01). Allograft biopsies interpreted based on the Banff Working Classification showed rejection in 45 of 54 renal biopsies with 42 the biopsy-proven rejection episodes showing at least 2+ graft uptake. Furthermore, this nuclear medicine technique had a sensitivity of 93.3%, a specificity of 44.4%, a positive predictive value of 89.3%, a negative value of 57.1% and an efficiency of 83.3% for the diagnosis of renal allograft rejection.

The pretransplant cytokine profile of donor and recipient blood and tissues may be associated with transplant outcome. A Th1 response is generally associated with transplant rejection, while a Th2 response may lead to tolerance and stable graft survival. A total of 56 (37 male and 19 female) patients of mean 36 +/- 5 years were candidates for living unrelated kidney transplantation. Serum samples were collected 24 hours pretransplantation as well as at 1 and 2 weeks posttransplantation. Immunosuppression consisted of cyclosporine, prednisolone, and mycophenolate mofetil. Among the transplanted patients, 19 (33.9%) individuals experienced an acute rejection episode, as proven by biopsy, as well as an increased serum creatinine and blood urea nitrogen, within 14 days after transplantation. We determined serum concentrations of interleukin (IL) 2 and interferon (IFN)-gamma for Th1 and IL4 and IL10 for Th2 by an enzyme-linked immunosorbent assay method (Bender med system kits, Germany). Among Th1 cytokines, the mean concentration levels for groups with versus without acute rejection were: IL-2 pretransplant 15 pg/mL vs 6.8 pg/mL, respectively (P = .005); IL-2 at 1 week, 19 pg/mL vs 4.85 pg/mL, respectively (P = .001); IL-2 at 2 weeks, 21.1 pg/mL vs 4.65 pg/mL, respectively (P = .0001); IFN-gamma pretransplant 161.1 pg/mL vs 65.2 pg/mL, respectively (P = .001); IFN-gamma at 1 week, 175.6 pg/mL vs 66.5 pg/mL, respectively (P = .001); and IFN-gamma at 2 weeks, 173.7 pg/mL vs 77.1 pg/mL (P = .001). IL-2 and IFN-gamma levels were significantly higher in the group with acute rejection versus those without acute rejection. In conclusion, these data suggest that cytokine analysis, especially of Th1 cytokines, might be a valuable prognotic index of kidney transplant outcome.

Background There are surprisingly a few studies that evaluate the impact of chronic viral hepatitis, which is common in HD (hemodialysis) patients, on HRQOL (health related quality of life). Objectives We conducted a study to evaluate the impact of chronic viral hepatitis on HRQOL and to compare their HRQOL with non-infected HD patients via a HRQOL questionnaire. Patients and Methods The Iranian adapted version of the Kidney Disease Quality of Life Short Form (KDQOL-SF) version 1.3 questionnaires were filled out by the HD patients. In all HD patients, serum HBsAg, HBS Abs, and HCV Abs [enzyme-linked immunosorbant assay (ELISA)] were routinely checked every six months. Patients were considered to have chronic HBV infection if HBsAg was positive for more than six months. In all HD patients, third generation assay was used to detect HCV infection. Furthermore, serum HCV-RNA (PCR) was examined in anti-HCV-positive patients for confirmation of HCV infection. Results in this cross sectional study 4101 patients from 103 dialysis units in Iran between October 2010 and August 2011 were included. Prevalence of hepatitis B and hepatitis C infection was 2.1% and 1.3% respectively. Almost all KDQOL items for viral hepatitis patients had equivalent or better scores than those without viral hepatitis. In the logistic regression after adjustment for age, sex, educational level, marital status, dialysis vintage, HBs Ag positivity and HCV Ab positivity, only age (P < 0.001) and educational level (P = 0.015) had negative impact on quality of life. Conclusions Our data show that not only general health and physical activity were preserved but also health perception may be better among HD patients with viral hepatitis.

Background: The effectiveness of health care and health policy developments are often determined by health-related quality of life (HRQOL) assessment. Objectives: The objective of this study was to explore the potential corresponding factors and traditional biomarkers of HRQOL in a large number of Iranian hemodialysis patients. Patients and Methods: A total of 6,930 chronic hemodialysis (HD) patients enrolled. KDCS-SF version 1.3 questionnaire was used to assess the health related quality of life (HRQOL). We pooled PCS, MCS and KDCS scores with random effect model from 19 similar studies performed between 1996 and 2010 Results: The mean age was 54.4 ± 17.1 years. Mean PCS, MCS and KDCS scores obtained for the study cohort were 40.79 ± 20.10, 47.79 ± 18.31 and 57.97 ± 11.70, respectively; the total score of SF-36 plus KDCS was 51.12 ± 13.41 as well. The most common primary known disease was hypertension (31.9%) and the second etiology was diabetes (25.5%). In multilevel logistic regression, Kt/V between 1 and 1.2 and PCS, KDCS more than 50 were considered as a significant reduction in the risk of hospitalization. Conclusions: This study showed that PCS and MCS score were slightly more than overall results while KDCS was slightly less than overall results. In addition, dialysis adequacy with Kt/V between 1 and 1.2 is associated with lower rate of hospitalization.

Antikaliuretic action of trimethoprim is minimized by raising urine pH. This study was designed to test the hypothesis that the antikaliuresis caused by trimethoprim could be diminished by alkalinizing the luminal fluid in the CCD, thereby converting trimethoprim from its cationic, active form to an electroneutral, inactive form. Timethoprim-induced inhibition of transepithelial Na + transport was examined in A6 distal nephron cells by analysis of short circuit current. The voltage-dependence of the trimethoprim-induced block of Na + channels was examined with patch clamp recordings of A6 cells. The antikaliuretic effect of trimethoprim was examined in vivo in rats pretreated with desoxycorticosterone and with NH 4 Cl to lower urine pH, and in rats also receiving acetazolamide to raise urine pH. We found that the concentration of trimethoprim required to inhibit the amiloride sensitive component of short circuit current by 50% (IC 50 ) was 340 µ m (at pH 8.2) and 50 µ m (at pH 6.3). The IC 50 s of protonated trimethoprim were similar (34 µ m at pH 8.2 and 45 µ m at pH 6.3). The mean time open for the high selectivity, Na + channel was reduced from 1679 ± 387msec to 502 ± 98msec with addition of 10 -5 m trimethoprim to patch pipette solution at the resting membrane potential (-V pipette = 0 mV). Further decreases in mean time open were observed as -V pipette was reduced (that is, apical membrane hyperpolarization) to -40mV (mean time open=217 ± 85 msec) and to -80mV (mean time open=69 ± 13 msec). In vivo , trimethoprim caused a > 50% reduction in potassium (K + ) excretion due primarily to a fall in the [K + ] in the lumen of the terminal CCD. This effect of trimethoprim was markedly attenuated in an alkaline urine induced by acetazolamide. We conclude that it is the charged, protonated species of trimethoprim which blocks epithelial Na + channels. Increasing urinary pH decreases the concentration of the charged species of trimethoprim and minimizes its antikaliuretic effect.

Cardiovascular diseases are the most common causes of death in chronic kidney disease (CKD) and kidney transplant patients. This study aimed to evaluate cardiac troponins in transplant recipients and CKD patients without cardiac symptoms.Two groups of patients (CKD and kidney transplant recipients) were evaluated for troponins T and I levels. These values were associated with renal replacement therapy and demographic and clinical characteristics of the patients.Eighty CKD patients and 80 kidney transplant recipients were studied. There was a significant difference in Troponins T and I levels were significantly higher in the CKD group than in the transplant recipients. In the CKD group, 14 patients (17.5%) had an elevated troponin T level and 8 (10.0%) had an elevated troponin I, all of whom were in stage 4 of CKD. None of the kidney transplant patients had a positive troponin. Among CKD patients, decreased glomerular filtration rate was associated with elevated troponin I level. Elevated troponin T level was significantly associated with age and decreased glomerular filtration rate. In multivariable analysis, significant associations were found between troponin T level and age, serum creatinine, and glomerular filtration rate. A significant relationship was also found between troponin I and cholesterol and glomerular filtration rate.The assessment of troponin T and I in CKD and kidney transplant patients shows that in patients with CKD and without any symptoms of acute coronary syndrome, serum level of cardiac troponins increase and it is linked to serum creatinine and GFR.

Background Invasive mucormycosis is a very rare infection after kidney transplantation. Here, we report 25 renal transplant recipients with mucormycosis; to our knowledge, this is the largest reported population of mucormycosis in these patients. Material/methods In a retrospective study, we collected all kidney transplants with mucormycosis from 9 Transplant Centers of Iran from 1990 to 2010. The definitive diagnosis of mucormycosis was established by obtaining a biopsy specimen of the involved tissue. Results The most form of disease was rhino-cerebral (n =13), followed by pulmonary (n=7). Overall mortality rate was 52% (n=13), particularly in recipients with pulmonary infection (100%); however, the mortality rate in rhino-cerebral form of disease was low (30.8%). There was no statistically significant difference in mortality rate between male and female (P=0.8). In addition, no significant differences were seen in mortality rate with age of patients (p=0.8) and time of diagnosis since transplantation (p=0.3). Pulmonary infection was more seen in recipients received azathioprine compared to those on mycophenolate mofetil (p=0.006). Conclusions Mucormycosis after renal transplantation has a poor prognosis, particularly patients with pulmonary involvement.

Chronic renal failure has been known to be associated with impotence and loss of libido in men and for many women, infertility and menstrual irregularities. There have been ongoing improvements in survival and quality of life after renal transplantation. These have been accompanied by an improvement in reproductive function and reversal of the relative infertility that occurs despite maintenance hemodialysis. One of the most impressive aspects of successful renal transplantation in the young person is the ability of the male patient to father a child and the female patient to give birth to a healthy baby. Pregnancy does not appear to have any adverse effect on the long-term survival of renal allografts. Because the outcome of pregnancy in transplantation are so different than those in chronic dialysis, it is advisable to treat end-stage renal disease patients with transplantation and wait until renal function has been stable before undertaking a planned pregnancy. Women are usually advised to wait at least 1 year after living-related kidney Transplantation, and 2 years after cadaveric kidney transplantation; however, waits of 5 years or more have been associated with impaired renal function post-partum. All women of child-bearing age should be counseled about the possibility and risks of pregnancy after kidney transplantation. Types of immunosuppressive regimens and assessment of graft function should be considered during preconception counseling. Contraceptive counseling should be provided before transplantation surgery, because ovulatory cycles may begin within 1 to 2 months after transplantation in women with grafts that are functioning well. It is strongly advised that every sexually active transplant recipient attend a family-planning counseling session, ideally before transplantation is performed. Breastfeeding is discouraged for patients taking any immunosuppressive drugs. In this chapter we will first have a short review on reproductive physiology in male and female and irregularities caused by end stage renal disease and then we will review the experience of women undergoing child birth after transplantation, with a focus on outcomes and suggested management strategies including contraception counseling.

Malignancy is a common complication after renal transplantation. However, limited data are available on post-transplant malignancy in living kidney transplantation. Therefore, we made a plan to evaluate the incidence and types of malignancies, association with the main risk factors and patient survival in a large population of living kidney transplantation. We conducted a large retrospective multicenter study on 12525 renal recipients, accounting for up to 59% of all kidney transplantation in Iran during 22 years follow up period. All information was collected from observation of individual notes or computerized records for transplant patients. Two hundred and sixty-six biopsy-proven malignancies were collected from 16 Transplant Centers in Iran; 26 different type of malignancy categorized in 5 groups were detected. The mean age of patients was 46.2±12.9 years, mean age at tumor diagnosis was 50.8±13.2 years and average time between transplantation and detection of malignancy was 50.0±48.4 months. Overall tumor incidence in recipients was 2%. Kaposis' sarcoma was the most common type of tumor. The overall mean survival time was 117.1 months (95% CI: 104.9-129.3). In multivariate analysis, the only independent risk factor associated with mortality was type of malignancy. This study revealed the lowest malignancy incidence in living unrelated kidney transplantation.

Poor sleep quality is very common among maintenance hemodialysis patients and has negative impacts on patients' quality of life. Benzodiazepines have traditionally been used in this population; however, they may induce physical dependence and sleep apnea. Nonbenzodiazepine hypnotic medications with less side effects are introduced as alternatives. This study was designed to compare the effect of zolpidem and clonazepam on sleep quality of hemodialysis patients.In a randomized crossover study on 23 hemodialysis patients, sleep quality was assessed using the Pittsburgh Sleep Quality Index at baseline, at the initiation of a 1-week washout period after a 2-week treatment with zolpidem (1 mg) and clonazepam (5 mg to 10 mg), and after the second 2 weeks of treatment. Patients who suffer from any concurrent situations that may affect sleep quality or psychiatric disorders and those on medications affecting sleep quality were excluded.The prevalence of poor sleep quality was 87.8% of the 88 hemodialysis patients who were initially approached. There was a significant negative correlation between iron deficiency and poor sleep quality. Both clonazepam and zolpidem significantly improved sleep quality; however, clonazepam was more effective in decreasing the Pittsburgh Sleep Quality Index scores (P = .03). Zolpidem was better tolerated in the hemodialysis patients.Clonazepam was more effective than zolpidem in the improvement of sleep quality of hemodialysis patients, while zolpidem was better tolerated in these patients.

The latent nature of chronic kidney disease (CKD) in primary stages precludes early diagnosis. This necessitates plans such as screening, but we should first introduce CKD as a public health problem. This study was designed to define the burden of CKD in Iran.We calculated disability-adjusted life years (DALYs) according to the World Health Organization's practical guidelines for national burden of disease studies. The sum of years of life lost and years lived with disability were estimated for CKD stages 1 to 4 and end-stage renal disease (ESRD) based on the national registry data and the published reports about CKD in Iran in 2004.Over 700 000 people were estimated to have CKD in Iran in 2004 and 61 000 new cases of CKD were anticipated. The prevalence rate of CKD was estimated to be 1083 and its incidence rate was 173.5 per 100 000 population. Chronic kidney disease was responsible for 1 145 654 DALYs. The highest DALYs for stages 1 to 4 of CKD were due to unknown etiology, diabetes mellitus, and hypertension (382 000 years, 347 400 years, and 311 800 years, respectively). The DALY for ESRD and CKD stages 1 to 4 were 21 490 years and 1 124 164 years, respectively.The present study provides an estimate of the burden of CKD in Iran. As CKD can be controlled by practical cost-effective plans, we strongly recommend the information given by this study be considered for future action plans.

Kidney transplant recipients are at increased risk of cancers, most frequently skin cancers, and in some regions, Kaposi sarcoma and non-Hodgkin lymphoma. We sought to investigate the associate of the most frequent malignancies among our patients with human leukocyte antigens (HLAs).We performed a retrospective study on 44 kidney allograft recipients who had posttransplant malignancy and 44 kidney allograft recipients without malignant lesions (control group). All of the patients had been treated by immunosuppressive regimens including cyclosporine plus prednisolone or cyclosporine, prednisolone, and mycophenolate mofetil. Data on HLA typing were achieved from their transplant records.There were 15 patients (34.1%) with Kaposi sarcoma; 13 (29.6%) with non-Hodgkin lymphoma, 6 (13.6%) with skin cancer, 2 (4.5%) with ovary cyst adenocarcinoma, and 8 (18.2%) with other tumors. The mean interval from transplantation to diagnosis of malignancy was 15.3 month. Twelve patients died of cancer during the follow-up (mean, 12.3 years). No significant difference was noted in the age, sex, and time of transplantation between these patients and those in the control group. Kaposi sarcoma was associated with HLA-CW4 (P = .03) with an odds ratio of 4.96 (95% confidence interval, 2.90 to 8.12).We found HLA-CW4 as a risk factor of Kaposi sarcoma in kidney allograft recipients. Screening for malignancies after kidney transplantation sounds very important with special attention to the specific environmental and genetic factors in each population.

To investigate the oxidative stress and its association with antioxidants in patients on hemodialysis, we evaluated the levels of albumin, C-reactive protein (CRP), ferritin, vitamin E, glutathione, and total antioxidant capacity in these patients.In a cross-sectional study, we enrolled 25 patients on maintenance hemodialysis and measured the inflammatory and oxidative stress indicators consisting of the plasma concentrations of glutathione, vitamin E, and total antioxidant capacity. The acute-phase inflammatory response was assessed by determining the serum levels of CRP and albumin as well as the plasma level of ferritin. Antioxidants and acute-phase reactants in men and women and their association with age and their correlations with each other were analyzed.The mean age of the patients was 53.6 +/- 14.1 years (range, 29 to 70 years). They had been on hemodialysis for a mean duration of 4.66 +/- 5.08 years. There were no association of sex or age with the levels of antioxidants and acute-phase reactants. Plasma level of glutathione significantly correlated with CRP (r = 0.48; P = .01) and serum albumin (r = 0.42; P = .04). Duration of dialysis did not correlate with the antioxidants or acute-phase reactants.Although it is reasonable to see an association between acute-phase reactants and levels of antioxidants in patients on hemodialysis, we failed to show such a relation. It is recommended that other biomarkers of oxidative stress and their relation in patients with kidney failure be investigated.