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Rationale & Objective The Kidney Failure Risk Equation (KFRE) is a simple widely validated prediction model using age, sex, estimated glomerular filtration rate, and urinary albumin-creatinine ratio to predict the risk for end-stage kidney disease. Data are limited for its applicability to kidney transplant recipients. Study Design Validation study of the KFRE as a post hoc analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. Setting & Participants Adult kidney transplant recipients with functioning kidney allografts at least 6 months posttransplantation from 30 centers in the United States, Canada, and Brazil. Participants with estimated glomerular filtration rates, Graphical abstract

Tularemia is a zoonotic disease caused by Francisella tularensis that can be transmitted to humans when they handle rabbits, receive tick bites, consume contaminated water, or inhale aerosolized particles. We present the case of a 51-year-old white man with rheumatoid arthritis who was taking immunosuppressive medications and presented with tularemia. Our patient acquired the typhoidal form of tularemia, which is a severe systemic illness that manifests with fevers, headaches, myalgias, vomiting, diarrhea, and neurological symptoms, due to his immunocompromised state. The diagnosis was made through biopsy of a pulmonary nodule found incidentally on computed tomography scan.

Levamisole as an immunomodulator drug has been demonstrated to improve the immune response to hepatitis B virus vaccination in haemodialysis patients. The aim of this randomized double-blind placebo-controlled trial was to evaluate the effect of levamisole supplementation on tetanus-diphtheria (Td) vaccine response rates in haemodialysis patients. Forty haemodialysis patients who had not received tetanus vaccination in a year before investigation and had unprotective anti-tetanus immunoglobulin G (IgG) levels (

There is an expanding prevalence pool of heart failure (HF) due to the increasing prevalence of survivors of myocardial infarction, diabetes, hypertension, chronic kidney disease, and obesity. There is increasing interest in the role of nutrition in all forms of HF, given observations concerning micro- and macronutrient deficiencies, loss of lean body mass or sarcopenia, and their relationships with hospitalization and death. This review examines the relationships among loss of lean body mass, macro- and micronutrient intake, and the natural history of HF, particularly in the elderly, in whom the risks for all-cause rehospitalization, infection, falls, and mortality are increased. These risks are potentially modifiable through strategies that improve nutrition in this vulnerable population.

Background: Although there are some animal models for biomarkers of contrast-induced acute kidney injury (CI-AKI), for cardiorenal syndrome (CRS) and for acute renal failure, the interplay between CI-AKI and CRS has yet to be evaluated. Insight into the pathogenesis of CRS is urgently needed from animal models in order to foster the discovery and implementation of novel biomarkers for this disease. Specially designed animal models for type 1 and 3 CRS, particularly CI-AKI, have not yet emerged. Summary: We hypothesize that the aging male spontaneously hypertensive rat (SHR) is likely to be a suitable model. The SHR model is able to mimic risk factors for preclinical CRS that appears in the clinical setting, specifically hypertension, age, preexisting damage and dysfunction of the heart and kidney, endothelial dysfunction, increased level of reactive oxygen species, decreased level and bioavailability of nitric oxide (NO), impairment of the L-arginine-NO pathway, and insulin resistance. In the SHR, CI-AKI results in a different profile of AKI biomarkers than is seen with preexisting chronic kidney injury. Key Messages: The SHR model can be used to evaluate the interaction between CI-AKI and CRS type 1 and 3 and to verify neutrophil gelatinase-associated lipocalin (NGAL) as a reliable CI-AKI biomarker for clinical application. Further research is warranted with a large number of aging male SHRs to prove NGAL as a sensitive, specific, highly predictive, early biomarker for CI-AKI.

Background A large proportion of patients with type 2 diabetes mellitus have diabetic nephropathy. Despite current therapies including renin-angiotensin system inhibitors, diabetic nephropathy progresses to end-stage renal disease in most of these patients. Therefore, there is an urgent need to find new treatments for such patients. The aim of this study was to evaluate the efficacy of silymarin, an herbal drug with antioxidant and anti-inflammatory properties, in preventing the progression of diabetic nephropathy. Study Design Randomized, double-blind, placebo-controlled, 2-arm parallel trial. Setting & Participants 60 patients with type 2 diabetes with macroalbuminuria (urinary albumin excretion >300 mg/24 h) despite treatment with the maximum dose of a renin-angiotensin system inhibitor for more than 6 months and estimated glomerular filtration rate >30 mL/min/1.73 m 2 . Intervention Patients were randomly assigned to 2 equal groups to receive three 140-mg tablets of silymarin or 3 tablets of placebo daily for 3 months. Outcomes The primary outcome was absolute change in urinary albumin-creatinine ratio (UACR) from baseline to the end of the treatment phase. Measurements UACR and urinary and serum levels of TNF-α (tumor necrosis factor α; an inflammatory marker), malondialdehyde (MDA; an oxidative stress marker), and TGFβ (transforming growth factor β; a marker of fibrosis) at baseline and the end of the treatment phase. Results Although UACR decreased in both groups, this decrement was significantly higher in the silymarin compared with the placebo group; mean difference in change in UACR between the 2 groups was −347 (95% CI, −690 to −4) mg/g. Urinary levels of TNF-α and urinary and serum levels of MDA also decreased significantly in the silymarin compared with the placebo group. Limitations Small sample size and short duration of the treatment phase. Conclusions Silymarin reduces urinary excretion of albumin, TNF-α, and MDA in patients with diabetic nephropathy and may be considered as a novel addition to the anti–diabetic nephropathy armamentarium.

Background: Restless legs syndrome (RLS) is a common disorder in hemodialysis patients that leads to insomnia and impaired quality of life. Because high oxidative stress has been implicated in the pathogenesis of RLS, we sought to evaluate the efficacy of vitamins C and E and their combination in reducing the severity of RLS symptoms in hemodialysis patients in this randomized, double-blind, placebo-controlled, four-arm parallel trial. Methods: Sixty stable hemodialysis patients who had all four diagnostic criteria for RLS developed by the International Restless Legs Syndrome Group with no acute illness or history of renal stone were randomly allocated to four fifteen-patient parallel groups to receive vitamin C (200 mg) and vitamin E (400 mg), vitamin C (200 mg) and placebo, vitamin E (400 mg) and placebo, and double placebo daily for eight weeks. International Restless Legs Scale (IRLS) scores were measured for all patients at baseline and at the end of treatment phase. The primary outcome was absolute change in IRLS sum score from baseline to the end of treatment phase. Results: Means of IRLS sum score decreased significantly in the vitamins C and E (10.3 ± 5.3, 95% CI: 7.4– 13.3), vitamin C and placebo (10 ± 3.5, 95% CI: 8.1–11.9), and vitamin E and placebo groups (10.1 ± 6, 95% CI: 6.8–13.5) compared with the double placebo group (3.1 ± 3, 95% CI: 1.5–4.8), (P < 0.001); however, no differences were observed between these treatment groups. Conclusions: Vitamins C and E and their combination are safe and effective treatments for reducing the severity of RLS in hemodialysis patients over the short-term.

Background. Uremic pruritus (UP) is still a common tormenting symptom among patients on hemodialysis (HD). The pathogenesis of UP is complex and not fully clarified. Some preliminary studies indicate that UP is a systemic inflammatory disease with a deranged balance of T helper (TH) cell differentiation toward TH1 predominance. The aim of this study was to further elucidate the potential contribution of TH1 cytokines to the pathogenesis of UP. Methods. In this study, 112 HD patients were screened for UP. After meeting the required criteria, 31 HD patients with UP were included in the study as case group and 30 age- and sex-matched HD patients without UP were enrolled as controls. The serum levels of interleukin (IL)-2 and interferon-c (as TH1 cytokines), IL-4 (as a TH-2 cytokine), high-sensitive C-reactive protein (as an inflammatory marker), parathyroid hormone, calcium, phosphate, albumin and ferritin were measured in all patients. Moreover, blood variables including hemoglobin and mean corpuscular volume were also determined. The correlations of measured factors with UP severity were determined as well. Results. Except for the serum levels of IL-2, which were significantly higher in HD patients with itch versus those without it [0.544 6 0.126 (U/mL) versus 0.318 6 0.145 (U/mL); P < 0.0001], no statistically significant difference was observed in the levels of each of the above-mentioned factors between the two groups. Additionally, no correlation was detected between the levels of measured factors and UP severity. Conclusions. The results of our study, for the first time, point to the potential important role of IL-2 in UP and further support the notion of TH1 overactivity in its pathogenesis. Our study paves the way for further studies focusing on the contribution of IL-2 to the UP, such as the experimental use of anti-IL-2 receptor antibodies.

Fetal wound healing occurs rapidly and without scar formation early in gestation. Studying the mechanisms of scarless repair can lead to novel scar-preventive approaches. In fetal wounds, collagen is deposited early and is fine and reticular with less cross-linking. Several important differences of fetal vs. postgestational wound-healing response have been determined, such as the presence of less inflammation, higher hyaluronic acid concentration and a greater ratio of collagen type III to type I. Compared with typical wounds, there are also altered ratios of signaling molecules, such as higher ratios of transforming growth factor (TGF)-β3 to TGF-β1 and -β2, and matrix metalloproteinases to tissue inhibitors of metalloproteinases. Furthermore, fetal fibroblasts do not exhibit TGF-β1-induced collagen production compared with their mature counterparts. Patterning genes (homeobox genes) involved in organogenesis are more active in the fetal period and are believed to be the "first domino" in the fetal cutaneous wound repair regulatory cascade. The recommended scar-preventive agents, such as Scarguard MD®, silicone gel and sheet, Seprafilm® Bioresorbable Membrane, topical hyaluronan, onion extract, oral tamoxifen and 585-nm pulsed dye laser are reviewed in this study. Despite the lack of supporting evidence, there is a widespread false presumption that the acceleration of healing with the widely assumed scar-preventive commercial agents is associated with decreased scar formation. Humans are erroneously inclined to make a negative correlation between the healing rate and the degree of scar formation, while such a correlation does not exist in reality. Despite the importance of scar prevention, no FDA-approved therapy for this purpose is available in the 21st century, which reflects the important challenges, such as the presence of redundant pathways, that these approaches are facing.

Background Nephrotic edema is considered refractory if it does not respond to maximum or near-maximum doses of loop diuretics. This condition can be treated with loop diuretics and thiazides. However, animal studies show that the simultaneous downregulation of pendrin with acetazolamide and inhibition of the sodium-chloride cotransporter with hydrochlorothiazide generates significant diuresis, and furosemide administration following a pendrin inhibitor potentiates furosemide's diuretic effect. Therefore, we performed this study to compare the efficacy of acetazolamide and hydrochlorothiazide followed by furosemide versus furosemide and hydrochlorothiazide followed by furosemide for treatment of refractory nephrotic edema. Study Design Randomized, double-blind, 2-arm, parallel trial. Setting & Participants 20 patients with refractory nephrotic edema despite treatment with 80mg of furosemide daily and creatinine clearance > 60mL/min. Intervention Patients were randomly assigned to 2 groups: group 1 (n=10) received 250mg of acetazolamide and 50mg of hydrochlorothiazide daily and group 2 (n=10) received 40mg of furosemide and 50mg of hydrochlorothiazide daily for 1 week in phase 1. In phase 2, both groups received 40mg of furosemide daily for 2 weeks. Outcomes The primary outcome was absolute change in weight before and at the end of each phase. Measurements Weight and 24-hour urine volume at baseline and the end of each phase. Results The mean weight decrease was of significantly larger magnitude in group 1 compared with group 2 at the end of phase 1 (−1.4±0.52 [SD] vs −0.65±0.41kg; P=0.001) and phase 2 (−1.6±0.84 vs −0.5±0.47kg; P=0.005). The increase in 24-hour urine volume was also significantly higher in group 1 at the end of phase 2. Limitations Small sample size, short follow-up duration, and lack of serum bicarbonate and chloride measurement. Conclusions Acetazolamide and hydrochlorothiazide followed by furosemide is more effective than furosemide and hydrochlorothiazide followed by furosemide for the treatment of refractory nephrotic edema.

There has been considerable advancement in catheters, wires, balloons, stents, and adjunctive strategies for procedures performed in the cardiac catheterization laboratory. Despite these improvements, angiographic procedures remain dependent on the use of water-soluble iodinated contrast that has

Despite recent advances, iatrogenic bile duct injury remains one of the most common complications of laparoscopic cholecystectomy. Aberrant biliary tract anatomy is one of the major risk factors for iatrogenic bile duct injury. In this case report, for the first time, we report a case of aberrant left main bile duct draining directly into the cystic duct or gallbladder that presented with bile duct injury after laparoscopic cholecystectomy. We hope that the diagnostic and management approach used in this case will help physicians to identify and manage their patients should they face such a rare anatomy.

The aim of this study is to report our six-year experience with portal-endocrine and gastric-exocrine drainage technique of pancreatic transplantation, which was first developed and implemented at our center in 2007.In this study, the outcomes of all patients at our center who had pancreas transplantation with portal-endocrine and gastric-exocrine drainage technique were evaluated.From October 2007 to November 2013, 38 patients had pancreas transplantation with this technique - 31 simultaneous kidney pancreas and seven pancreas alone. Median duration of follow-up was 3.8 years. One-, three-, and five-year patient and graft survival rates were 94%, 87%, 70% and 83%, 65%, 49%, respectively. For pancreas allograft dysfunction evaluation, 51 upper endoscopies were performed in 14 patients; donor duodenal biopsies were successfully obtained in 45 (88%). We detected nine episodes of acute rejection (eight patients) and seven episodes of cytomegalovirus (CMV) duodenitis (six patients). No patient developed any complication due to upper endoscopy.Portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation provides lifelong easy access to the transplanted duodenum for evaluation of pancreatic allograft dysfunction.

Introduction:: Due to its immunosuppressive properties, local graft irradiation (LGI) has been proposed as a second line therapy for treatment of acute kidney rejection. Case Presentation:: In this case-series we report 6 patients with biopsy proven acute kidney allograft rejection refractory to conventional antirejection therapy who underwent LGI for treatment of acute rejection at our center. Three of these patients had living donor transplants, 2 had deceased donor transplants, and one had received a simultaneous kidney/pancreas transplant. All patients were treated with anti thymocyte-globulin or muromonab-CD3, and intravenous steroids for initial treatment of rejection. Three patients also received intravenous immunoglobulin. LGI was tried as a last resort and was well tolerated and resulted in either improvement or stabilization of renal function in 5 patients. One patient could not be given the complete course of chemical immunosuppression for treatment of rejection due to concomitant cryptococcal meningitis and was switched to LGI with good short-term response. Discussion:: Our results suggest that LGI could be considered a second line therapy to the conventional anti-rejection therapy for patients with refractory acute kidney allograft rejection, or for patients who cannot receive systemic immunosuppression due to severe infection.

Sirs,Vitiligo is a common, recalcitrant, psychologically devastating skin disorder with a complex and enigmatic etiopathogenesis (1). Autoimmune, autocytotoxic and neurogenic phenomena are consider...

Vascular damage and immunological events leading to generation of fibrogenic fibroblasts are the main components of systemic sclerosis (SSc) pathogenesis. Superoxide anions play a role in endothelial damage by oxidizing circulating low-density lipoproteins. IL-1 plays a key role in the pathophysiology of SSc by inducing upregulation of adhesion molecules, inflammatory damage of the endothelium and tissue fibrosis. Elevated levels of proTh2 cytokines such as IL-6 in the early stages of SSc lead to enhanced fibroblast collagen production. Taurine, a semi-essential amino acid, is an antioxidant, inhibits the production of proinflammatory cytokines such as IL-1 and IL-6 and also inhibits production of TGF-beta, a major fibrogenic cytokine. Therefore, we conclude that taurine may be a novel addition to the treatment armamentarium of this disabling disorder.

Background: High fasting plasma glucose (FPG) levels before fluorodeoxyglucose (FDG) administration for positron emission tomography/computed tomography (PET/CT) might affect the accuracy of 18-fluoro-deoxy-glucose-positron emission tomography-computed tomography (FDG-PET/CT) in diagnosis of pancreatic lesions. Current guidelines require FPG levels of < 200 mg/dL before FDG administration; however, the literature on the effect of FPG levels of < 200 mg/dL on the accuracy of FDG-PET/CT is scarce. Objectives: The aim of this study was to evaluate the effect of FPG levels of < 200 mg/dL on the accuracy of FDG-PET/CT in diagnosis of pancreatic lesions. Patients and Methods: In this retrospective study, 161 patients who had FDG-PET/CT for initial diagnosis of pancreatic lesions were included. Fasting plasma glucose levels before FDG administration were recorded. Accuracy of FDG-PET/CT in diagnosis of pancreatic lesions was compared between patients who were non diabetic (FPG < 126 mg/dL) and hyperglycemic (126 ≤ FPG < 200 mg/dL). Results: Thirty-four patients were hyperglycemic and 127 non diabetic. Sensitivity, specificity, positive predictive value and negative predictive value of FDG-PET/CT were 90%, 88%, 87% and 91% in non diabetic and 82%, 92%, 95% and 73% in hyperglycemic patients, respectively. Overall, the accuracy was higher in non diabetic than hyperglycemic patients (89% vs. 85%). Conclusions: Accuracy of FDG-PET/CT for primary diagnosis of pancreatic lesions is higher in patients with FPG levels < 126 mg/dL than in patients with FPG levels between 126 and 200 mg/dL.

Accessory spleen is estimated to occur in 1 in 10 people in the general population, usually in the tail of the pancreas. Epidermoid cysts arising from ectopic spleen tissue in the tail of the pancreas are a benign and extremely rare pathology. Only 27 cases with such pathology have been reported in the English literature. Differentiating this pathology from other pancreatic pathologies, especially in the presence of a history of recent cancer, is almost impossible. In this article, we report a 36-year-old African-American woman with a history of colon cancer and hemicolectomy who was incidentally found to have a cystic lesion in the tail of her pancreas during surveillance abdominal imaging. After a distal pancreatectomy, the lesion was diagnosed to be an epidermoid cyst in an intrapancreatic accessory spleen. This is the first report of such pathology in a patient with a recent history of cancer. We propose that this pathology be considered as a differential diagnosis when assessing patients with cystic lesions in their pancreas, even when they have a history of previous malignancies.

Systemic lupus erythematosus (SLE) is uncommon in young children and unusual in infancy. Although a variety of liver pathologies have been reported in SLE, presentation of this disease with granulomatous liver involvement is very rare. In this article, for the first time, we report an infant girl presenting with unexplained hepatosplenomegaly and non-necrotizing granulomatous liver involvement at the age of six months who later developed pancytopenia and proteinuria and was finally diagnosed with SLE at the age of three years. Therefore, we suggest that SLE could be considered as one of the possible differential diagnoses when infants or children present with unexplained granulomatous liver involvement.

Dear Editor, The correct estimation of renal function in patients with liver cirrhosis and chronic kidney disease (CKD) is difficult (1, 2). Direct measurement of glomerular filtration rate (GFR) using exogenous markers (iohexol or iothalamate) is considered the reference to assess renal function in cirrhotic patients (1, 2). However, direct measurement of GFR is not available at all transplant centers. The 24 hour urine creatinine clearance (CrCl) is widely used to measure GFR, and is calculated by multiplying the ratio of urine creatinine (Cr) to plasma Cr by 24 hours urine volume. However CrCl has several limitations. Besides the problem with accurately timed urine collection, CrCl is reported to overestimate the true GFR in liver cirrhosis patients compared with the direct measurement of GFR (1, 2). A low plasma Cr secondary to liver disease and poor muscle mass may overestimate GFR using CrCl. In addition, the GFR overestimation is also reported to be due to over-secretion of Cr from renal tubules in proportion to glomerular filtration, especially at low GFR (1, 2). Conversely, we have found that the total amount of Cr excreted in cirrhotic patients is lower than the minimum expected Cr excretion in 24 hours urine (20 mg/kg/day in males and 15 mg/kg/day in females). Hence, when urine Cr excretion is low, CrCl may also on the contrary underestimate the true GFR. In a retrospective study, we evaluated the charts of 160 consecutive patients who underwent liver transplantation alone (LTA) at our center from January 2002 to December 2012. Out of these, 25 patients had CKD with pre-transplant estimated GFR values ≤ 60 ml/min/ 1.73 m2 calculated using 4-variable and 6-variable modification of diet in renal disease (MDRD) equations. The 24-hour urine CrCl was available in all 25 patients within a month pre-transplant. Ten patients were excluded from analysis as their collected urine volumes were either 3000 ml suggesting under- or over- collection of urine. In remaining 15 patients, mean observed urine Cr excretion was significantly lower than the minimum expected Cr excretion in 24 hour urine (1.28 ± 0.62 grams/day vs. 1.69 ± 0.43 grams/day; P = 0.04). In these 15 patients with CKD, there was no significant difference between CrCl and MDRD-4 (49.6 ± 23.5 vs. 41.7 ± 11.6 respectively, P = 0.63), and between CrCl and MDRD-6 (49.6 ± 23.5 vs. 37.2 ± 9.5, respectively, P = 0.19) pre-transplant. However, GFR values at three months post-transplant were significantly higher compared with their corresponding values pre-transplant (see Table 1). The lower urine Cr excretion in these patients is probably secondary to decreased Cr production due to poor muscle mass and liver disease. The improvement in e-GFR early post-transplant suggests that there is likely some hemodynamic component to CKD pre-transplant. It is reported that the CKD eventually gets worse overtime post-LTA due to calcineurin inhibitor therapy and other risk factors (3, 4). In our study, although we did not measure GFR directly, the improved GFR values early post-LTA likely reflect true pre-transplant GFR values. In conclusion, although CrCl has been reported to overestimate GFR in liver cirrhosis patients with CKD, a lower than expected 24 hour urine creatinine excretion may also cause underestimation of GFR. Table 1. Pre- and Post-Liver Transplant (LT) e-GFR Values in 25 Study Patients

Background Population based studies on prevalence and risk factors of NAFLD in Iranian population are few. The prevalence of NAFLD and non alcoholic steatohepatitis (NASH) in Iranians varies from 2.9% to 7.1% in general population and 55.8% in patients with type 2 diabetes mellitus. Objectives To determine the prevalence and determinants of non alcoholic fatty liver disease (NAFLD) in a sample of adult Iranian general population. Patients and Methods This was a cross-sectional study being performed in Shiraz, southern Iran during a 10-month period from November 2010 to September 2011 through cluster random sampling of Iranian general population in Shiraz region. All individuals undergone anthropometric, blood pressure measurements, thorough medical history and physical examinations. Laboratory measurements included fasting blood glucose (FBS), lipid profile, complete blood count (CBC) and liver function tests. NAFLD was diagnosed by transabdominal ultrasonography. Results 819 subjects were included in this study among which were 340 males (41.5%) and 479 females (58.5%) with the mean age of 43.1 ± 14.1 years. NAFLD was diagnosed in 176 (21.5%) subjects. Patients with NAFLD were significantly older (P < 0.001), had higher proportion of male gender (P = 0.004) and had higher BMI (P < 0.001). They also had higher prevalence of hypertension (P < 0.001), high FBS (P < 0.001), high cholesterol (P = 0.026), high triglyceride (P < 0.001) and high waist circumference (P < 0.001). Taking all these together, patients with NAFLD had significantly higher prevalence of metabolic syndrome when compared to healthy subjects (P < 0.001). Conclusion The prevalence of NAFLD in this group of Iranian adult general population is 21.5%. NAFLD in Iranian population is associated with male gender, old age, obesity, and features of metabolic syndrome.

The aim of this cross-sectional study was to assess the health status and quality of life (QOL) of paid unrelated versus related living kidney donors postdonation at Shiraz Transplant Center in Iran. We invited all donors (n = 580, 347 paid unrelated, 233 related) who underwent donor nephrectomy at our center from 2004 to 2010 to participate in a health survey and physical examination. Of 580 donors, 144 consented to participate; participation of paid unrelated donors was significantly lower than related (52/347 vs. 92/233; p

Malnutrition is highly prevalent in hemodialysis (HD) patients. These patients have high levels of oxidative stress and inflammation which can subsequently induce malnutrition. Selenium levels have been found to be decreased in HD patients. As selenium deficiency leads to oxidative stress and inflammatory response, the aim of this study was to evaluate the effects of selenium supplementation on oxidative and inflammatory markers and the nutritional status of HD patients.In this randomized double-blind placebo-controlled trial, 80 patients on stable HD for at least 3 months without any acute illness or active infections were randomly allocated to two equal groups to receive one selenium (200 µg) or placebo capsule daily for 12 weeks. Serum levels of lipoproteins, malondialdehyde (MDA), interleukin-6 (IL-6), high-sensitivity C-reactive protein (HSCRP), homocysteine, ferritin and transferrin as well as the subjective global assessment (SGA) score, malnutrition-inflammation score (MIS) and hemoglobin (Hb) levels were measured at the baseline and at the end of the treatment phase. The primary outcome was a change in the nutritional status measured by the SGA score from the baseline towards the end of the treatment phase of the study.The SGA score and MIS decreased significantly in the selenium group compared to the placebo group (P0.001 for both). Moreover, serum levels of MDA decreased significantly in the selenium group compared with increasing levels in the placebo group (P0.001). Selenium supplementation also hindered an increase in IL-6 levels compared with the placebo group (P = 0.016). There were no significant differences between the selenium and placebo groups in terms of changes in serum levels of lipoproteins, HSCRP, homocysteine, ferritin and transferrin or Hb levels.This study shows that selenium may be an effective complementary supplement for reducing the severity of malnutrition in HD patients through alleviating oxidative stress and inflammation.

The pathophysiology of urolithiasis in infancy is not well known. The aim of this study was to investigate whether infants with urolithiasis have higher serum levels of vitamin D, as a possible risk factor for urolithiasis, compared to infants without urinary calculi.In this case-control study, 36 infants with urolithiasis (age range, 2.5 to 24 months) were enrolled as well as 36 age- and sex-matched infants without urolithiasis. Random urine samples were tested for calcium, phosphorous, oxalate, citrate, uric acid, sodium, potassium, magnesium, and creatinine levels, and also nitroprusside test was done on the samples. Serum levels of potassium, urea nitrogen, creatinine, 25-hydroxyvitamin D3, parathyroid hormone, calcium, phosphorous, and uric acid were measured in all of the infants with urolithiasis. Serum levels of 25-hydroxyvitamin D3 were also measured in the control group.Serum levels of 25-hydroxyvitamin D3 were significantly higher in the infants with urolithiasis than in the controls (33.85 ± 14.78 ng/mL versus 18.26 ± 7.43 ng/mL, P.001). Nine infants in the urolithiasis group (25%) were found to have hypercalcemia; 3 of these cases also had hypervitaminosis D. Hypercalciuria was detected in 10 infants with urolithiasis (27.8%), hypocitraturia in 6 (16.7%), hypomagnesiuria in 3 (8.3%), and hyperoxaluria in 1 (2.8%). Nineteen infants with urolithiasis had at least one metabolic disorder.High serum levels of vitamin D may play an important role in the pathogenesis of urolithiasis in infants with hypercalcemia. We recommend evaluation of vitamin D levels in these infants.

Urinary tract infection (UTI) is common after pediatric kidney transplantation. The purpose of this study was to evaluate the prevalence of UTI and its risk factors in children and adolescents with kidney transplantation in Shiraz Transplant Center.All children with kidney transplantation from 1992 to 2008 who were under regular follow-up were included in this retrospective study. Confirmed episodes of UTI after the 1st month of kidney transplantation were reviewed.Of the 216 patients younger than 19 years at the time of transplantation, 138 were included. The mean age at the time of kidney transplantation was 13.6 ± 3.5 years. Urinary tract infection was documented in 24 patients (15 girls and 9 boys), of whom 12 experienced 1 episode, 4 had 2 episodes, and 8 had more than 2 episodes, during a median follow-up period of 54 months. Of the patients with UTI, 14 (58%) had urinary reflux-obstruction disorders as the primary kidney disease, 6 (25%) had suffered hereditary diseases, 3 (12.5%) had glomerular disease, and 1 (4.5%) had a urinary calculus. Occurrence of UTI was not significantly different among children with different primary kidney disease (P = .22). Despite using prophylactic antibiotics after the 1st month of kidney transplantation in all 5 patients with neurogenic bladder, they all experienced recurrent UTI.Despite discontinuation of antibiotic therapy, UTI was uncommon in children after the first month of transplantation. Two significant risk factors for UTI were female gender and neurogenic bladder in this transplant population.

The abnormal processing of amyloid-beta peptide (A beta) and resultant formation of fibrillar A beta (fA beta) are major events in the pathogenesis of Alzheimer disease (AD). Microglia as the phagocytic cells of the brain can engulf and digest fA beta within their acidic lysosomes. The lysosomes of AD patients are less acidic and therefore less capable of clearance of fA beta. Vacuolar proton pumps (V-ATPases) which are found abundantly in microglia and macrophages, acidify lysosomes by pumping protons into these structures. Proton pump inhibitors (PPIs) can inhibit V-ATPases of the lysosomes. These drugs are shown to penetrate the blood-brain barrier in animals. PPIs are consumed for long periods in conditions such as gastroesophageal reflux disease, with the resultant exposure of the human brain to the substantial amounts of PPIs. We hypothesize that by blocking the V-ATPases on microglial lysosomes, PPIs may basify lysosomes and hamper degradation of fA beta. Chronic consumption of PPIs may thus be a risk factor for AD.

Our information about renal involvement in beta-thalassemia major is limited. Recently, few studies have reported proteinuria, hypercalcuria, phosphaturia, and oversecretion of tubular damage markers; however, hematuria has not yet been meticulously studied in these patients. We investigated hematuria in patients with beta-thalassemia major.Urinalysis was performed in 500 patients with beta-thalassemia major under a regular blood transfusion program. In those with hematuria (at least 3 to 5 erythrocytes per high-power field) a second urinalysis was done at the next transfusion time.The patients ranged in age from 6 months to 32 years. The male-female ratio was 1.05:1. Hematuria was detected in 55 (10.6%), including 9.8% of those younger than 20 years and 20.0% of those older than 20 years. Hematuria was persistent in 79.2% of the second urinalyses. Sixty-four percent of the patients with hematuria were females. A blood transfusion program had been started during the first year of life in 81% percent of the patients with hematuria. Sterile pyuria was detected in 4% and proteinuria in 16% of the patients with hematuria, while these figures in patients without hematuria were 2.1% (P = .56) and 1.4% (P = .002), respectively.We found that in patients with beta-thalassemia major, the risk of hematuria rises with age. Moreover, proteinuria seems to be more common in those with hematuria. Further studies are needed to ascertain the importance of these findings.

A 60-year-old, otherwise healthy, male farmer presented to our Dermatology Department with a large ulcer on his lower right leg. The lesion had started as a small papule 6 months before, which became eroded and transformed into a rather rapidly progressive ulcer. On careful inspection, numerous larvae were found moving within the wound. The larvae were analyzed and found to be Lucilia sericata (the green bottle blowfly). The lesion was diagnosed histopathologically as squamous cell carcinoma. The myiasis was treated by submerging the wound in a dilute permanganate potassium solution.

Background There is ample evidence for involvement of macrophage migration inhibitory factor (MIF) in autoimmune and inflammatory diseases. Objective The aim of this study was to determine whether MIF levels were raised in the sera of patients with pemphigus vulgaris (PV). Methods Serum MIF levels were measured using ELISA method in 22 patients with active PV and 21 age- and sex-matched healthy controls and the results were compared with each other. Results The mean serum MIF levels was significantly higher in PV patients than in control subjects (11.99 ± 1.63 pg/m vs. 1.83 ± 0.22 pg/ml; P-value = 0.0001). Conclusions Elevated MIF levels in the sera of PV patients could participate in disease induction by activation of T cells as well as induction of autoantibody production by B cells. Given that MIF counter-regulates the effects of steroids, MIF antagonists may prove to be very effective, novel steroid-sparing agents for this life-threatening conundrum.