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There are millions of cancer cases worldwide every year, and breast cancer is one of the most prevalent diseases with the highest mortality rate. The manual effort of pathologists can be significantly reduced by computerized diagnostic systems, which improve the accuracy and reliability of diagnosis. In this paper, we present four novel systems for breast cancer diagnosis in four different scenarios: binary versus multi-class classification and magnification-specific (MS) versus magnification-independent (MI) classification. In each of the proposed systems, we developed an automatic score-level fused CNN model using a pretrained deep neural network and named it the Multi-Level Feature Fusion (MLF2) model. The MLF2-CNN, similar to the conventional CNN models, integrates the feature extraction and classification phases of BC classification into a single automatic learning procedure. Additionally, MLF2-CNN performs an automatic score-level fusion of several classifiers that were trained with multi-level features to make the final decision. A pretrained DenseNet-121 is selected as the backbone of the proposed MLF2-CNN, and several new links are added to the CNN architecture to capture multi-stage features. Several experiments on the publicly available BreakHis dataset demonstrate that the proposed systems capture the best descriptive features and outperform state-of-the-art techniques in most of the scenarios.

Background: The objective is to evaluate the prevalence of acute kidney injury (AKI) as an early complication of the percutaneous nephrolithotomy (PCNL) procedure. Materials and Methods: From May 2022 to October 2022, we conducted a retrospective study on patients undergoing PCNL procedures in two of the tertiary medical centers affiliated with Isfahan University of Medical Sciences. Patients’ baseline characteristics, laboratory values, perioperative data, and stone features were documented. AKI was defined either as a ≥0.3 mg/dL increase in the serum creatinine level within 2 days, or a ≥1.5-fold increase in baseline serum creatinine level within 7 days after the operation. Laboratory values were measured 1 day before PCNL and daily thereafter until discharge. Patients were followed 1 week later to detect all of the possible cases of AKI. Results: The final analysis was performed on 347 individuals. AKI developed in 16 (4.61%) cases. The two groups were comparable regarding age (P = 0.887), gender (P = 0.566), and underlying comorbidities including diabetes mellitus (P = 0.577) and hypertension (P = 0.383). The mean body mass index (BMI) (P < 0.001) and both frequency and severity of hydronephrosis (P < 0.001) were significantly different. A higher mean PCNL duration (P < 0.001), period of hospitalization (P < 0.001), and blood loss volume (P < 0.001) were observed in those who developed AKI. Overall, 56.3% (9) of patients in the AKI group and 2.7% (9) in the non-AKI group required the establishment of more than one access tract, during the procedure (P < 0.001). A lower preoperative hemoglobin level was observed in the AKI group (P < 0.001). Those with AKI had significantly larger stones (3.08 ± 0.46 vs. 2.41 ± 0.23 cm, P < 0.001) and higher Hounsfield units (P < 0.001). In addition, in the AKI group, most of the calculi (81.3%, 13) were of staghorn type, whereas in the non-AKI group, calculi were most frequently located in the middle calyx (30.2%, 100), (P < 0.001). Conclusion: The prevalence of post-PCNL AKI is approximately 4.61%. The mean BMI, preoperative hemoglobin level, PCNL duration, intraoperative blood loss volume, and hospitalization period were significantly higher among patients who developed AKI. Those with AKI had significantly larger stones with higher Hounsfield units and more frequently of staghorn type. The two groups were not statistically different regarding age, gender, and presence of comorbidities (hypertension and diabetes mellitus).

Introduction The mortality of patients on chronic haemodialysis is 10–30 times greater than that of the general population and over 60% of these individuals die within the first 5 years of beginning haemodialysis. Although causes for excessive mortality in haemodialysis patients are not clearly defined, it seems that nutrition, inflammation and oxidative stress play key roles in this regard. Until now, no cohort study has focused on the association between nutritional, inflammatory or oxidative status and risk of complications and adverse outcomes in Iranian haemodialysis patients. Therefore, we sought to fill this gap and designed the Nutritional, Inflammatory, and Oxidative Status in Hemodialysis (NIOS-HD) prospective cohort study to determine the association of dietary factors, malnutrition, anthropometric indices, body composition, inflammation and oxidative stress with quality of life, dialysis access infections, hospitalisation, potential years of life lost and mortality in adults on maintenance haemodialysis in Isfahan, Iran.Methods and analysis The sample size of this cohort was estimated to be 300 participants. At baseline, demographic, medical and dialysis-related data of eligible patients will be recorded. In addition, participants will undergo anthropometric measurements, malnutrition assessment and body composition analysis. Also, their dietary intake and quality of life will be evaluated through interviewer-administered questionnaires. Moreover, their fasting blood samples will be collected and stored for biochemical assays including transthyretin, albumin, serum amyloid A, pentraxin-3, trimethylamine N-oxide, myeloperoxidase, paraoxonase-1 and superoxide dismutase. After baseline evaluation, patients will be followed up to 3 years to update exposure information (except biochemical assays) and measure adverse outcomes. Finally, collected data will be analysed using descriptive and inferential statistics.Ethics and dissemination The NIOS-HD is in agreement with the Declaration of Helsinki and has been approved by the Ethics Committee of Isfahan University of Medical Sciences (reference number: IR.MUI.RESEARCH.REC.1399.605). Findings of this study will be published in academic journals.

Background and purpose: The use of vancomycin, as a key therapeutic choice for treatment of hazardous infections, may be associated with nephrotoxicity. The proposed mechanism is the indirect production of reactive oxygen species and oxidative stress. The purpose of this study was to investigate the effect of vitamin E asan antioxidant agent in the prevention of vancomycin-induced nephrotoxicity. Experimental approach: In a matched-groups interventional study, patients who received vancomycin for any indication were assigned to vitamin E (n = 30) and control (n = 60) groups. The patients in experimental group received 400 units of oral vitamin E per day for 10 days started concurrently with vancomycin, while the patients in control group received vancomycin alone. Serum level of creatinine, blood urea nitrogen (BUN), creatinine clearance (CrCl), and 24-h urine output were determined and recorded before the start of interventions, every other day during therapy, and 12 h after the last dose of vancomycin in 10[th] day of therapy for all patients. Also, the rate of acute kidney injury (AKI) in the two groups was recorded. Finally, the mean values of the measured parameters were compared between the groups. Findings / Results: Treatment with vitamin E for 10 days resulted in a significant reduction of BUN (from 17.5 ± 7.8 mg/dL at baseline to 11.4 ± 4.8mg/dL at the end; P < 0.001) along with slightly non-significant increase of CrCl (from 84.7 ± 18.9 mL/min at baseline to 91.3 ± 19.5 mL/min at the end; P = 0.301) in comparison to the control group. However, CrCl decreased significantly in the control group. Vitamin E had no significant effect on24-h urine output. Regarding vancomycin-induced AKI, 12 cases were observed in the control group, while no case was reported in experimental group (P = 0.041). Conclusion and implications: This study showed the beneficial effect of add-on therapy of vitamin E besides vancomycin in reducing AKI, which could be considered as a new potential prophylactic therapy for vancomycin-induced nephrotoxicity.

Background: Chronic kidney disease (CKD) is an important comorbidity in Coronavirus Disease 2019 (COVID-19) patients considering its high prevalence. We aimed to figure out the relationship between CKD and COVID-19 mortality in this study. Materials and Methods: In total, 116 CKD patients (estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73 m2) and 147 control subjects confirmed with COVID-19 were studied. Data regarding demographics, sign and symptoms, laboratory findings, and chest computed tomography were collected. Association between CKD and in-hospital mortality were analyzed using logistic regression models adjusted for confounders. Results: Mortality rate was significantly higher in CKD than non-CKD (30.17 vs 4.76, P < 0.001) COVID-19 patients. Multivariate logistic regression showed that CKD was significantly correlated with in-hospital mortality in the total sample (Odds ratio (OR) = 8.64, confidence interval (CI): 3.67–20.35) and gender subgroups (females: OR = 4.77, CI: 1.38–16.40, males: OR = 13.43, CI: 3.85–46.87) (P < 0.05) of COVID-19 patients in the crude model. Whereas, the correlation did not remain significant in the fully adjusted model in the total sample (OR = 1.70, CI: 0.35–8.19) and gender subgroups (females: OR = 1.07 CI: 0.06–19.82, males: OR = 0.87, CI: 0.07–10.33) (P > 0.05) of COVID-19 patients. Conclusion: This study suggested an independent association between CKD and in-hospital mortality in COVID-19 patients. Therefore, more intensive surveillance of COVID-19 patients with CKD is to be warranted.

Facial feature extraction algorithms play an important role in many applications of face biometrics such as face recognition for person identification, classification of emotions by facial expression recognition and age estimation using facial images. In this paper, an integration of different type of feature extraction algorithms is applied on facial images for accurate age estimation. This integration is performed by using two-level fusion of features and scores with the help of feature-level and score-level fusion techniques. In our proposed method, the advantage of using different types of features such as biologically inspired features, texture-based features, and appearance-based features is used. Feature-level fusion of biologically inspired and texture-based methods is integrated into the proposed method and their combination is fused with an appearance-based method using score-level fusion. Experiments on the publicly available MORPH and FG-NET databases prove the effectiveness of the proposed method and the proposed method outperforms many of the state-of-the-art systems.

In this study which was conducted in Alzahra University Hospital (Isfahan, I.R. Iran), the therapeutic drug monitoring of vancomycin focused on determining area under the concentration-time curve at dosing interval (τ) at steady state/minimum inhibitory concentration (AUCτ/MIC) was carried out in chronic kidney disease (CKD) patients. The study population was selected from patients with the history of CKD (stages 3 or 4) treated by intravenous vancomycin. To determine vancomycin AUCτ, blood samples were taken at four different occasions (trough-1, peak, random, trough-2) between the fourth and fifth doses of vancomycin. Drug concentration was determined by fluorescence polarization technique, and the E-TEST technique was used to determine the MIC. Nineteen patients were included. For 8 (42%), 7 (37%), and 4 (21%) patients, trough concentration levels were found to be less than 10 mg/L, 10-20 mg/L, and more than 20 mg/L, respectively. The mean value of AUCτ for studied patients was 470.7 ± 228.3 mg.h/L and the mean MIC values was 1.04 ± 0.43 mg/L. Ten patients (53%) and 9 patients (47%) had the AUCτ/MIC ratios above 400 and below 400, respectively, with the average of 519.4 ± 391.3 h. Vancomycin dosing based on patient glomerular filtration rate (GFR), as a traditional method, is not accurate enough to gain the most desired vancomycin concentration in patients with decreased or changing kidney function. Measuring drug concentration and observing its therapeutic effects accordingly is inevitable in susceptible populations receiving vital drugs such as vancomycin.

Background: Recently, renal transplantation has increased worldwide. The incidence of metabolic syndrome is common after renal transplantation that might reduce renal function and increase cardiovascular complications. In this study, we compared renal function after renal transplantation in patients with or without metabolic syndrome. Methods: This cohort prospective study was conducted in 2017 among patients with renal transplantation aged more than 20 years in Isfahan City, Iran. Metabolic syndrome criteria including blood pressure, fasting blood sugar, high- and low-density lipoprotein, triglyceride, and waist circumference, as well as serum creatinine were measured in 30 patients with metabolic syndrome and 30 without metabolic syndrome in one-year follow-up period. Findings: 17 patients were women and 43 were men. The mean serum creatinine changes were not significantly different among the patients with or without metabolic syndrome (P = 0.227) in 1-year follow up. There was no significant association between serum creatinine level with metabolic syndrome criteria such as waist circumference (P = 0.214), diastolic blood pressure (P = 0.061), triglyceride (P = 0.409), high-density lipoprotein (P = 0.315), and fasting blood sugar (P = 0.284) in patients with metabolic syndrome, and only the association between serum creatinine level and systolic blood pressure was significant (P = 0.008). Conclusion: Serum creatinine did not increase significantly in patients with metabolic syndrome. We recommend to consider longer follow-up periods in future studies.

End-stage renal disease is a situation that predisposes the patients to cardiovascular disease, especially myocardial infarction (MI). A valuable biomarker for the diagnosis of this event is cardiac troponin. Although some asymptomatic patients show high plasma levels of cardiac troponin I, it is still the most sensitive variable in MI. All patients more than 18-year-old, on chronic ambulatory peritoneal dialysis (CAPD) for at least three months, and did not have a history of acute myocardial infarction or hospitalization for CVD during last month are included in a cross-sectional descriptive study. Troponin I serum level was measured by VIDAS Troponin I Ultra (TNIU) Assay. Correlation between serum troponin level and cardiovascular risk factors are evaluated. In this study, 52% of patients were male. The mean cTnI level was 0.025±0.044 ng/mL, less than 0.11 ng/mL, and only five patients had cTnI level more than the laboratory threshold. The cut-off level of cTnI for diagnosing cardiovascular disease must be re-evaluated and maybe increase to 0.3 ng/mL. Indeed, the asymptomatic patient may need more close observation for cardiovascular disease.

Surgical resection followed by concurrent radiation therapy and temozolomide (TMZ) chemotherapy is the current standard treatment for glioblastoma multiforme (GBM). The present metaanalysis investigated the impact of prolonged TMZ maintenance therapy (more than 6 cycles) in comparison with standard TMZ maintenance therapy (exactly six cycles) on overall survival (OS) and progression-free survival (PFS) of patients with GBM. A meta-analysis of the literature was conducted using Medline, PubMed, EMBASE and the Cochrane Library in accordance with PRISMA guidelines. Seven articles involving 1018 patients were included. The overall survival was higher in the case group (>6 cycles TMZ) compared to the control group (6 cycles TMZ) (Z=2.375, P=0.018). The lower and upper limits were between 1.002-10.467 months. The case group had higher progression-free survival compared with the control group (Z=3.84; P

A new architecture of deep neural networks, directed acyclic graph convolutional neural networks (DAG-CNNs), is used to classify heartbeats from electrocardiogram (ECG) signals into different subject-based classes. DAG-CNNs not only fuse the feature extraction and classification stages of the ECG classification into a single automated learning procedure, but also utilized multi-scale features and perform score-level fusion of multiple classifiers automatically. Therefore, DAG-CNN negates the necessity to extract hand-crafted features. In most of the current approaches, only the high level features which extracted by the last layer of CNN are used. Instead of performing feature level fusion manually and feeding the results into a classifier, the proposed multi-scale system can automatically learn different level of features, combine them and predict the output label. The results over the MIT-BIH arrhythmia benchmarks database demonstrate that the proposed system achieves a superior classification performance compared to most of the state-of-the-art methods.

A real‐world animal biometric system that detects and describes animal life in image and video data is an emerging subject in machine vision. These systems develop computer vision approaches for the classification of animals. A novel method for animal face classification based on score‐level fusion of recently popular convolutional neural network (CNN) features and appearance‐based descriptor features is presented. This method utilises a score‐level fusion of two different approaches; one uses CNN which can automatically extract features, learn and classify them; and the other one uses kernel Fisher analysis (KFA) for its feature extraction phase. The proposed method may also be used in other areas of image classification and object recognition. The experimental results show that automatic feature extraction in CNN is better than other simple feature extraction techniques (both local‐ and appearance‐based features), and additionally, appropriate score‐level combination of CNN and simple features can achieve even higher accuracy than applying CNN alone. The authors showed that the score‐level fusion of CNN extracted features and appearance‐based KFA method have a positive effect on classification accuracy. The proposed method achieves 95.31% classification rate on animal faces which is significantly better than the other state‐of‐the‐art methods.

Background: This study aimed to identify the efficacy and complications of premicath catheter in patients with renal failure and rejected renal transplant as well. Methods: This descriptive-analytical study included 39 patients who had again undergone premicath catheter insertion due to rejection of renal transplant and 39 patients without renal transplant. Duration of premicath catheter performance and incidence of relevant complications in these two groups were assessed and compared using patients’ records. Findings: The mean duration of catheter performance was 12.9 ± 9.5 and 13.9 ± 11.0 months in groups of with and without renal transplantation, respectively, and there was no significant difference between the two groups (P = 0.690). The mean survival time for the catheter was 25.04 ± 2.57 and 43.43 ± 3.04 months in renal transplant and hemodialysis groups, respectively; which was significantly higher in hemodialysis group, according to the log-rank test (P = 0.020). Conclusion: Survival time of the catheter is less in patients with rejected renal transplant; and due to rejection of the transplant, they should continue hemodialysis in longer time compared to hemodialysis patients who have not received any transplant. Thus, it appears that it is associated with the patient's reactions and their immune system and lack of caring inserted catheter by patient and his/her relatives. Therefore, more care is required in patients undergoing catheter insertion again after renal transplantation. More researches are needed in this field to clarify the conclusion.

Background: Hepatitis E virus (HEV) belongs to the family of Hepeviridae and is the sole member of the genus Hepevirus. HEV infection by genotypes 3 and 4 may tend to chronic infection, especially in immunocompromised patients such as liver and renal transplant patients. This study aimed to assess the frequency of HEV infection in kidney transplant recipients. Methods: This was a cross-sectional study on kidney transplant recipients in Isfahan City, Iran, in 2016. 100 renal transplant recipients were randomly selected and reviewed in Alzahra hospital. Blood samples were obtained from 100 eligible patients. Serum samples were screened for HEV RNA by using real-time polymerase chain reaction (PCR). Findings: Mean age of the patients was 48.2 ± 14.2 years and 63% of them were men. Based on molecular evaluation, all off 100 studied patients had negative results for HEV. Conclusion: HEV infection is not an important problem in renal transplant recipient. It is recommended to check the patients with renal transplant for HEV when liver enzyme is elevated and it is not recommended as a routine lab test.

Objective: Patients on hemodialysis (HD) have a high risk for cardiovascular morbidity and mortality. Cardiac troponins are biomarkers for diagnosing acute myocardial injury or infarction. There is considerable controversy that exists in the frequency and significance of cardiac troponins in predicting cardiac injury and ischemia in HD patients. Methods: In this cross-sectional study, all HD patients more than 18-year-old, who were at least 3 months under HD, and had no sign and symptom of active cardiovascular disease (CVD), in two HD centers were enrolled. One hundred and one patients fulfilled the inclusion criteria. Blood sample for cardiac troponin I (cTnI) was drown before the initiation of HD session during their routine monthly blood testing from patients′ vascular access arterial line. cTnI levels were measured by a high-sensitivity assay, VIDAS troponin I Ultra kit, and correlated with patients′ demographic, clinical, and laboratory results. Findings: The patients′ different demographic and clinical characteristics had no statistically significant correlation with troponin levels except for marginal trend for past medical history of diabetes and hyperlipidemia with corresponding P values of 0.072 and 0.055. Twenty-six patients had cTnI level more than 0.01 ΅g/L and only two patients had cTnI level more than 0.11 ΅g/L. For laboratory results, only fasting blood sugar had statistically significant correlation with patients′ cTnI level (r = 0.357, P = 0.0001). Conclusion: Frequency of significant elevation of cTnI level in our asymptomatic HD patients was very low and if such elevation is found in this population, it may be considered as a sign of active CVD.

Objective: Hypertension and hyperlipidemia are two major risk factors for cardiovascular disease in continuous ambulatory peritoneal dialysis (CAPD) patients. This study was designed to investigate the effect of omega-3 fatty acids on blood pressure (BP) and serum lipids in CAPD patients. Methods: This study was a randomized double-blind clinical trial in which 90 CAPD patients were randomly assigned to either the omega-3 or the placebo group. Patients in omega-3 group received 3 g/day omega-3 for 8 weeks, whereas patients in the control group received placebo. At baseline and at the end of 8 weeks, the patients’ BP was controlled, and serum biochemistry was measured. Findings: Mean systolic BP decreased (–22.2 ± 14.2 mmHg) in the omega-3 group at the end of the study while in the placebo group increased (+0.5 ± 30.2 mmHg) (P < 0.0001). Mean diastolic BP of the omega-3 group decreased more (–11.95 ± 11.9 mmHg) comparing with the placebo group (–1.1 ± 17.3 mmHg) (P = 0.001). There were no significant differences between the two groups in mean changes in serum triglyceride, and total, high-density lipoprotein, and low-density lipoprotein cholesterol. Conclusion: The results of this study indicate that omega-3 reduced BP significantly but had no effect on lipid profile in our CAPD patients.

Background: Detection of latent tuberculosis infection (LTBI) in transplant candidates is very important. The tuberculin skin test (TST) and interferon-gamma release assays (IGRAs) are standard immunologic tools for LTBI detection. The aim of this study was to compare the TST results and T-SPOT® .TB test (a type of IGRAs) in kidney transplant candidates for the screening of LTBI and follow the patients with positive test for an activation of tuberculosis (TB) after transplantation and using anti-TB prophylaxis. Materials and Methods: This study was a prospective study and carried out in 44 renal transplant candidates from March 2010 to February 2011 in the teaching hospitals of Isfahan University of Medical Sciences, Iran. TST and T-SPOT® .TB test were performed and their results evaluated. Patients with a positive skin test and/or T-SPOT® .TB test were started on anti-TB prophylaxis and followed after transplantation for an activation of their LTBI for 1 year. Results: Overall, 8 (18.2%) patients were positive for TST and 6 (13.6%) patients for T-SPOT® .TB test. The agreement between TST and T-SPOT®.TB test was moderate (κ = 0.49, 95% confidence interval 0.145-0.839). The overall agreement between TST and T-SPOT® .TB test was 86%. No relation was found between the underlying diseases and TST or T-SPOT® .TB test positivity. Although isoniazid prophylaxis was used for patients with positive TST and/or T-SPOT® .TB test, one patient had reactivation of TB. Conclusion: In kidney transplant candidates both TST and T-SPOT® .TB test were comparable for the diagnosis of LTBI with reasonable agreement between the tests. However, further studies are needed to determine the ability of T-SPOT® .TB test to detect LTBI and to evaluate the need for prophylaxis in these patients.

Background: Hemodialysis (HD)-associated ocular abnormalities are one of the causes of morbidity among people undergoing HD. This study evaluates the frequency of ocular abnormalities in end-stage renal disease (ESRD) patients undergoing HD and their potential link to HD and demographic parameters. Methods: This cross-sectional study examined 242 eyes of 121 patients with ESRD undergoing regular HD after excluding the ineligible subjects. The study was designed in two parts. Medical histories of each patient including age, gender, family history, medication history, past medical history, and duration of HD collected using a structured check list. All patients underwent complete ophthalmologic examination for evaluation of the best corrected visual acuity (BCVA), intraocular pressure (IOP), and anterior and posterior segments. Results: In total, 121 patients, including 68 (56.2%) males and 53 (43.8%) females, were enrolled in the study. The mean ± SD age of the patients and their mean duration of dialysis were 51.59 ± 16.01 and 3.40 ± 2.75 years, respectively. The most prevalent etiology for HD was diabetes mellitus (39.67%), followed by hypertension (38.84%), and the most common ocular findings included cataract (142 eyes; 58.7%) and ectopic calcification of the conjunctiva and cornea (78 eyes; %32.2). There was at least one abnormal ocular finding in 89.3% of the cases. The BCVA was equal to or less than finger count in 70 eyes (28.92%). There was a significant relationship between conjunctival calcification and the duration of dialysis (P = 0.02). There was significant association between etiology of HD and conjunctival calcification (adjusted odds ratio, 2.44; 95% CI, 1.05–5.67; and P value, 0.03). Such significant associations were present for corneal calcification (P = 0.009), cataract (P = 0.02), and optic atrophy (P = 0.01). Conclusions: Regular ophthalmologic examinations are recommended due to the prevalence of clinical ocular abnormalities in HD patients.

Background: There are a lot of patients with end-stage renal disease in our country and the number is increasing. Some of variables such as patient health and infection control in hemodialysis ward have important role in patients’ hospitalization. Due to access infection or fever of unknown origin, the length of hospital staying may be increased. Also, mortality and hospital cost may be increased too. The aim of this study was determining infection-control status before and after educational intervention in hemodialysis ward of Alzahra hospital, Isfahan, Iran. Methods: This quasi-experiment study was done by a method of assessment 1 month before and after a 2-month educational intervention among patients and staff of hemodialysis ward. The checklist for assessment was achieved from the latest CDC (Centers for diseases control and prevention) guideline. The data were analyzed using chi-square and Fisher’s exact tests. Findings: Before the intervention, 6 employees (46.1%) did hand washing and 8 (61.5%) did aseptic behavior; fistula or graft-site washing before dialysis was done by 13 (76.9%) patients; and disinfection of instruments was done by 10 employees (76.9%). After the intervention, hand washing was done by 13 (100%) and aseptic behavior by 12 employees (92.3%); fistula or graft-site washing was done by 22 patients (63.6%); and disinfection of instruments was done by 12 employees (92.3%). Only doing hand washing by staff was statistically difference after of intervention. Conclusion: According to results of this study, advanced level of education among hemodialysis staff is needed. Improving staff awareness during routine educational programs with practical education must be done, too.

Background: Patients under hemodialysis are exposed to remarkable volume of water. As dialysis water is in direct contact with patients’ blood, absence of regular disinfection of pipes will facilitate the transfer of the endotoxins produced by bacteria in water to the patient's body. Thus, regular control of dialysis system and water disinfectant equipment is compulsory. This study aimed at comparing relative frequency of positive culture for microorganisms in piped water before and after filtration, culture of water after passing from pipes, and culture of dialysis fluid before entering the dialysis filter in hemodialysis section of Alzahra Medical Center (Isfahan, Iran). Methods: During 2010 and 2012, an interventional study was performed in Alzahra Hospital. Samples were taken from piped water before and after filtration and from dialysis fluid before passing from membrane. The obtained samples were cultured in tryptic soy agar (TSA) and the isolated bacteria were then evaluated. Interventions included the disinfection of pipes used for transmission of water and replacement of pipes in hemodialysis section. Findings: Purified water was studied before and after passing the pipes. Dialysis fluid was also assessed before and after the intervention. Bacteria had grown in eight out of 14 samples (57%) before the intervention. In fact, five samples developed Escherichia coli, three had pseudomonas, and one had candida. However, after the intervention, only one out of 14 samples was found to have bacteria (alcaligenes) after filtration and before entering dialysis water pipes. Conclusion: According to the results of this study, the probability of bacterial growth is very high in filtration system of dialysis water. Regular disinfection and microbial sampling and culture are hence crucial. Keywords: Hemodialysis, Dialysis fluid, Microbial contamination

Congestive heart failure (CHF) is frequent in patients with chronic renal failure, and may contribute to high cardiovascular morbidity and mortality. There is little data in the literature about the safety and efficacy of use of spironolactone in patients with end-stage renal disease with heart failure. In this study, we evaluated the safety and efficacy of spironolactone in patients on continuous ambulatory peritoneal dialysis (CAPD) with CHF. This randomized pros-pective double-blind placebo-controlled clinical trial was performed at the St. Al-Zahra peritoneal dialysis center. Eighteen CAPD patients with New York Heart Association (NYHA) class III or IV heart failure, ejection fraction (EF) ≤45%, serum potassium level ≤5.5 mEq/L and who were eligible, were randomly assigned to taking either spironolactone (25 mg every other day) or placebo for six months. The serum potassium was measured monthly and echocardiography was repeated at the end of the study period. The serum potassium levels rose in both groups, and there was no statistically significant difference intragroup and between the groups during the study period. Only in one patient in the spironolactone group did the serum potassium level reach above the critical level (5.70 mEq/L) at the end of the second month of study, necessitating patient exclu-sion. The EF did not change significantly in the placebo group (33.3 ± 11.7 vs. 34.2 ± 11.6, F = 1, P = 0.363), but in the spironolactone group the EF rose significantly (25.7 ± 7.3 vs. 33.3 ± 7.8, F = 27.45, P = 0.002). Our study suggests that spironolactone could be used in CHF patients on CAPD to improve their cardiac function, but close monitoring of their serum potassium level is required.

Kidney transplant recipients are susceptible to various infections due to the use of immunosuppressive drugs. The present study was performed as studies on the prevalence of intes-tinal fungal and parasitic infections in kidney transplant recipients are limited. A total of 150 kidney transplant recipients and 225 matched immunocompetent outpatients, who were referred to the laboratory of Noor Hospital, Isfahan, were studied. After recording demographic characte-ristics, direct test and specific laboratory cultures were carried out on the stool specimens. Patients were instructed on sanitary rules and, during each medical visit, they were reminded of the same. The overall prevalence of intestinal parasitic and fungal infections was 33.3% and 58.7%, respec-tively, in transplant recipients and 20% and 51%, respectively, in the control group; the difference was not statistically significant. The most prevalent intestinal parasite was Entameba coli, which was seen in 9.3% of the study patients and 6.7% of the controls. The most prevalent fungus was Candida sp., which was seen in 22% of the study patients and 24.4% of the control group. Co-existing infection with two or more fungi was seen in 14.8% and 3.4% in the case and control groups, respectively; P

Background: Malnutrition is one of the most common complications among patients under maintenance dialysis which is related to systemic inflammatory processes. Decrease in serum albumin level, following malnutrition, is an independent risk factor for cardio-vascular diseases in patients under dialysis. We aimed to evaluate the effect of oral L-Carnitine supplementation on serum albumin and inflammatory factors (C reactive protein (CRP) and hemosysteine) in patients under peritoneal dialysis. Methods: This randomized, double-blind, placebo-controlled trial was conducted on 48 patients under peritoneal dialysis referring to Isfahan Peritoneal Dialysis Center from 2009-2010. Patients were randomized to carnitine and placebo groups and received oral carnitine (250 mg, 3 tablets /day) or placebo for 9 months. Serum albumin level was checked every 3 months and serum CRP and hemosysteine levels were checked before and after the study and compared between the two groups. Finding: Compared to placebo group, serum albumin level was increased significantly from 3.30 ± 0.51 to 3.70 ± 0.53 mg/dl (P = 0.044). In carnitine group, serum CRP level was increased from 2.35 ± 2.49 to 3.37 ± 4.80 mg/l (P = 0.304) while in the placebo group it was significantly increased from 1.37 ± 1.28 to 2.44 ± 2.68 mg/l (P = 0.039). In contrast, serum hemosysteine level was significantly increased in the carnitine group from 21.40 ± 8.08 to 25.70 ± 6.85 µgr/l (P = 0.019) while its increase in the placebo groop was not significant (P = 0.159). One patient in the carnitine group with history of hypertension experienced an increase in blood pressure that was controlled with a greater dose of anti-hypertensive drugs. Conclusion: In patients under peritoneal dialysis, oral L-carnitine can increase serum albumin level and prevent CRP rising, but has no beneficial effect on hemosysteine. According to several reports on beneficial effects of L-carnitine on anemia and lipid profile in patients under dialysis, its supplementation is recommended for these patients.

Background: Acute phase proteins disorders are common problems in dialysis patients. According to previous studies, carnitine can increase blood albumin levels in these patients. In this study the effect of carnitine on serum albumin level of hemodialysis patients was investigated. Methods: In this blinded placebo controlled randomized clinical trial, 51 hemodialysis patients (16, 17 and 18 patients in the drug (carnitine), placebo and control groups, respectively) aged more than 21 years, were enrolled. L-carnitine (250 mg) and placebo pills were prescribed daily in three divided doses orally for 6 months. The control group received no drug. Serum albumin level in studied patients was measured before the study and every month after intervention. Findings: The mean serum albumin level at baseline in carnitine, placebo, and control groups was 3.87 ± 0.26, 3.88 ± 0.35, and 3.96 ± 0.45 g/dl, respectively. The mean serum albumin level at the end of the study in carnitine, placebo and control groups was 4.39 ± 0.54, 4.44 ± 0.78, and 3.84 ± 0.45, respectively. The mean serum albumin changes in three studied groups were significantly different before and after intervention (P < 0.05) due to the difference of control group with placebo and carnitine groups. There was no significant difference regarding side effects and mortality in carnitine and placebo groups (P > 0.05). Conclusion: Carnitine had not significant effect in serum albumin level. But considering the improvement was observed in carnitine and placebo groups comparing with control group, it could be suggested that it may be attributed to placebo effect and improvement of patients’ mood. Similar studies with higher doses of carnitine are recommended.

• Background: Anemia is one of the major problems of dialysis patients The primary mechanism of anemia in these patients is Erythropoietin insufficient production by kidneys. Often, this kind of anemia is caused by inflammatory reactions. A large number of dialysis patients, despite receiving adequate doses of erythropoietin, are anemic. Therefore it seems the use of a pharmaceutical composition that can control the inflammatory reactions is an appropriate strategy. This study was done to investigate the effect of Pentoxyfilline on hemoglobin level and Erythropoietin dose in these patients • Methods: This study was a clinical trial that performed on anemic peritoneal dialysis patients. Study patients were randomized to two groups of 25 person recipients Pentoxyfilline and control groups. The amount of blood hemoglobin and serum albumin, iron, Total Iron Binding Capacity (TIBC), ferritin and Parathormone (PTH) were measured at the beginning and the end of the study. Collected data were analyzed by SPSS software. • Finding: 45 patients were studied (20 cases and 25 controls). The results of this study have not shown the significant differences in hemoglobin and serum albumin levels changes between two groups. According to results of this study the change of erythropoietin dose was not significant in both goups. • Conclusions: According to the results, conducted another study with higher sample size and longer time for investigation of the effect Pentoxyfilline is recommended.

Background: Post-transplant infection with polyoma viruses (BK and JC viruses) is an important cause of graft loss and nephropathy. The objective of this study was to compare the frequency of BK and JC viruria in renal transplant recipients with and without graft dysfunction. Methods: In a case-control study, we selected 60 kidney transplant patients with and without graft dysfunction in the first two years after transplantation. Each group consisted of 30 patients evaluated for basic demographic and laboratory characteristics. First morning urine samples were sent for BK and JC virus detection with QIAamp DNA Mini Kit and real-time polymerase PCR. Chi-square test with Yates′ correction, Student t-test and Mann-Whitney U test were used as indicated. P value of less than 0.05 was regarded as statistically significant. Results: Both groups were similar in age, gender, and time after transplant and pretransplant dialysis. In both groups, seven patients (23.3%) were JC virus positive whereas in case group 14 patients (46.7%) and in control group 9 patients (30%) were BK virus positive. There were no statistical significant difference between case and control groups for both JC and BK virus infection rate. Conclusions: We concluded that JC and BK virus infection is very prevalent in the first 2 years after transplant and might be monitored appropriately.

PURPOSE: To determine ocular findings in patients with renal transplants and to correlate them with clinical characteristics related to transplantation. METHODS: This cross-sectional study was performed on 150 patients who had received a renal transplant of at least three months' duration with serum creatinine levels < 3 mg/dl. All patients underwent a complete ophthalmologic examination. Clinical variables related to the transplant included cause of renal failure, duration of hemodialysis prior to transplantation and immunosuppressive regimen. RESULTS: Overall, 91 male and 59 female subjects with mean age of 39±17.7 years were included. At least one ocular abnormality could be detected in 89.3% including visual acuity less than 20/25 (48.6%), conjunctival degeneration in the palpebral fissure (36.6%), posterior subcapsular cataracts (24%), pinguecula (17.3%), retinal pigment epitheliopathy (14%), arteriovenous crossing changes (8.6%), proliferative diabetic retinopathy (6%), central serous chorioretinopathy and retinal vein occlusions (each in 3.3%), and non-proliferative diabetic retinopathy, optic nerve atrophy and diabetic macular edema (each in 2.7%). Abnormal ocular findings were not correlated with the underlying renal disorder or use of cyclosporine and prednisolone, however they were positively correlated with transplant duration, pre-transplant dialysis duration and azathioprine or mycophenolate mofetil consumption. CONCLUSION: Ocular disorders are frequent among renal transplant patients especially with older transplants and those with a longer period of pre-transplant hemodialysis.

Bachground: Peritonitis and exit site (ES) infection are two main complications of peritoneal dialysis. There are some controversies regard to preventive strategies for ES care. In this study we compared peritonitis and ES infection rates in patients with and without dressing. Materials and Methods: This historical cohort study carried out on 72 patients under continuous ambulatory peritoneal dialysis treatment, 54 with dressing versus 18 patients without dressing, followed from October 1, 2010 to March 31, 2011 for peritonitis and ES infection. Results: A total of 17 episodes of ES infection occurred in 12 patients in dressing group, but no case was seen in no-dressing group (P = 0.02). Twenty-one episodes of peritonitis occurred in 15 patients in both groups (one episode every 20.6 patient-months). In no-dressing group two episodes occurred in only one patient (one episode every 54 patient-months), and in dressing group, 19 episode in 14 patients (one episode every 17.1 patient-months) (P = 0.03). Peritonitis was significantly more frequent in male versus female in overall patients (38% vs. 14%, P = 0.025) and in dressing group (52% vs. 15%, P = 0.003). In dressing group, peritonitis was more frequent in diabetics versus non-diabetics (48% vs. 11%, P = 0.01). Odds ratio for developing peritonitis was 9.4 in dressing group (95% confidence interval [CI] =1.05 − 84.4; P = 0.045), and 4.4 in men (95% CI = 1.26 − 15.19; P = 0.02). Conclusion: In this study, chronic ES care without dressing was associated with lower risk of peritonitis and ES infection.

Background: Considering the existence of controversies about the predictive value of inflammatory markers for cardiovascular disease (CVD), we aimed to compare the level of high-sensitivity C-reactive protein (hs-CRP) and interlukin-6 (IL-6) level in chronic hemodialysis (HD) patients with and without CVD. Materials and Methods: In this historical cohort study, HD patients with and without CVD disease were enrolled. The presence of CVD risk factors, level of inflammatory factors including IL-6 and hs-CRP as well as lipid levels, fasting blood sugar, and other biochemical factors were compared in two studied groups. Results: During the study, eighty HD patients with (n = 40) and without (n = 40) CVD were enrolled. Diabetes was more prevalent among HD patients with CVD than those without CVD (P < 0.05). The level of IL-6 and hs-CRP were not different in two studied groups (P > 0.05). Univariate analysis of variance test indicated that there was not any significant relationship between hs-CRP and CVD (P > 0.05). Conclusion: The findings indicated that the level of inflammatory factors including hs-CRP and IL-6 are not significantly different in HD patients with and without CVD. However, for obtaining more definite conclusion in this field and evaluation their predicting role in this field, it is recommended to study other novel inflammatory markers as well as the additive effect of the inflammatory factors with traditional ones in larger sample size and longer follow-up.

Background: Hypercoagulable state is a common serious problem in patients with end-stage renal disease (ESRD). ESRD patients are in a condition of chronic inflammation. An increased level of E-selectin, “a key adhesion molecule that regulates leukocyte bindings to endothelium at damaged sites,” accompanies the higher risk of inflammation in ESRD patients. We aimed to investigate the possible correlation among E-selectin as an adhesion molecule, coagulation factors, and inflammatory factors in children with ESRD. Materials and Methods: Thirty-five child patients with ESRD who had been on regular dialysis treatment were registered in our study. Nighteen sex- and age-matched healthy volunteers were used as the control group. Laboratory tests were requested for the evaluation of hematological and biochemical parameters, and parathyroid hormone (PTH), and for coagulation state; fibrinogen, protein C, and protein S were measured. The enzyme-linked immunosorbent assay (ELISA) (Biomerica, CA, and IDS, UK). for serum E-selectin assay was provided by R and D Systems (Abingdon, UK). Results: Hemoglubolin (Hb), blood urea nitrogen (BUN), creatinine, calcium, PTH, triglyceride (TG) concentrations in serum as well as E-selectin showed significant difference between the two study groups, as indeed was expected. Serum E-selectin was significantly higher (P value = 0.033) in dialysis patients than in healthy subjects. E-selectin was positively correlated only with phosphorus in ESRD children (r = 0.398,P = 0.018). No association was found for other parameters. Conclusion: Although in our study circulating E-selectin concentration “as an inflammatory maker” is independently positively associated with limited blood markers, for better evaluation, well-designed cohort studies should be examined in ESRD children.

The purpose of this human study was to investigate the effect of oxygen pretreatment in living kidney donors on early renal function of transplanted kidney. Sixty living kidney donor individuals were assigned to receive either 8–10 L/min oxygen (Group I) by a non-rebreather mask with reservoir bag intermittently for one hour at four times (20, 16, 12, and 1 hours before transplantation) or air (Group II). After kidney transplantation, urine output, blood urea nitrogen (BUN), serum creatinine, need to additional diuretics (NTADs) in the first 24 hours after transplantation, delayed graft function (DGF), the creatinine clearance (CrCL) on 10th day, and duration of hospital stay from the first posttransplant day till normalization of renal function was recorded and compared in two groups. Mean CrCL in posttransplant day 10, NTAD after 24 hours of transplantation, and urine output during 6 hours after operation were significantly better in Group I compared with Group II (𝑃

Background: Excessive body fat is associated with increasing risk of ischemic heart disease (IHD). Some fat cell mediators such as adiponectin and leptin have been recognized as possible new IHD risk factors. We assessed the association of fat cell’s size and number, serum leptin and adiponectin with IHD. Methods: The study was designed as a “case control” study in 40 to 60 years old patients with ischemic heart disease symptoms underwent coronary angiography. The cases had significant stenosis in coronary angiography. The control subjects had normal angiography. Serum lipid levels, adiponectin, leptin, and insulin were examined in all cases and controls by Enzymayic method. The biopsies from abdominal and gluteal fat tissue regions were fixed and stained using the Hematoxilin-eosin method. Slides were photographed with a microscopic digital camera. Fat cell’s size and number were assessed using Image tool V3 software. Data were analyzed with SPSS software. Findings: There were no significant difference between cases and controls in fat cell’s size and number, serum leptin and adiponectin. However, serum leptin was correlated not only to waist circumference (r = 0.31, P = 0.036), but also to body mass index (r = 0.32, P = 0.033). Conclusion: Although Leptin and adiponectin are correlated with obesity and are introduced as IHD risk factors; they showed no association with ischemic heart disease in our study. More investigation is required to confirm this relationship in the Iranian population.

مقدمه: نفروپاتی دیابتی شایع‌ترین علت نارسایی انتهایی کلیه (ESRD) است. در ایجاد نفروپاتی دیابتی علاوه بر عواملی چون آنژیوتانسین II، سیتوکین‌ها و فاکتورهای رشد عروقی (VEGF)، اسید اوریک نیز ممکن است نقش داشته باشد. بنابراین، عوامل کاهش دهنده‌ی اسید اوریک سرم ممکن است در درمان نفروپاتی دیابتی مؤثر باشد. روش‌ها: در یک مطالعه‌ی مورد-شاهد و دوسوکور، 40 بیمار مبتلا به دیابت تیپ دو و نفروپاتی به دو گروه 20 تایی تقسیم شدند. به شرط آن که حداقل mg 500 پروتئین در ادرار 24 ساعته داشته باشند و کراتینین سرم آنان کمتر از mg/dl 3 باشد. در بیماران گروه مورد، روزانه mg 100 آلوپورینول و گروه شاهد دارونما تجویز شد. در هر دو گروه، داروهای ضد فشار خون بالا و داروهای محافظت کننده‌ی کلیه (مهار کننده‌های آنزیم مبدل آنژیوتانسین و مهار کننده‌های گیرنده‌ی آنژیوتانسین) با دوز قبل ادامه یافت و در طول مطالعه تغییر نکرد. یافته‌ها: در هر گروه، 9 مرد و 11 زن وجود داشت. تفاوت قابل توجهی بین سن، شاخص توده‌ی بدنی (BMI)، مدت دیابت، فشارخون سیستولیک و دیاستولیک، FBS، BUN، Cr، K سرم و حجم ادرار بیماران 2 گروه وجود نداشت ( 05/0 < P). پروتئین ادرار 24 ساعته در گروه مورد در ابندای مطالعه 1047 ± 1756و پس از چهار ماه 767 ± 1011 بود و اسید اوریک سرم در ابتدای مطالعه 21/1 ± 91/5 و پس از 4 ماه 79/0 ± 3/5 بود که به طور قابل ملاحظه‌ای نسبت به گروه شاهد کمتر بود (05/0 > P). نتیجه‌گیری: آلوپورینول با دوز پایین (mg 100 روزانه) باعث کاهش پروتئینوری بیماران پس از 4 ماه مصرف شد که احتمال می‌رود با مکانیسم کاهش اسید اوریک سرم بوده است. بنابراین آلوپورینول ممکن است به عنوان یک درمان کمکی، ارزان و کم عارضه در بیماران با نفروپاتی دیابتی مفید باشد. واژگان کلیدی: نفروپاتی دیابتی، اسید اوریک، آلوپورینول، پروتئینوری Results: Each group consisted of 9 men and 11 women. There were no difference between two groups, regarding age, body-mass index (BMI), duration of diabetes, systolic and diastolic blood pressure, fasting blood sugar, serum Blood-urine nitrogen (BUN), serum creatinine (Cr), serum potassium, and urine volume (p>0.05). Serum level of uric acid and 24 hour urine protein were significantly lower in control group, after four months of receiving allopurinol, compared with control group (p

Introduction Although renal transplantation from cadaver is common, living donors continue to be an important source of transplanted kidneys. Recipients of living-donor kidneys demonstrate improved graft survival. In this study, we evaluated the outcomes of renal transplantation from cadaver, related donors and unrelated donors in Isfahan. Methods We evaluated all of the patients who underwent kidney transplantation in hospitals affiliated to Isfahan University of Medical Sciences in 2002. We assessed complications including hypertension, urinary tract infection, fever, transplant rejection, urinary leak, renal failure, renal vessels thrombosis and urinary tract obstruction. Donors (living related, living unrelated, cadaver) were registered and complications were compared in the three groups. Chi-square and Fisher exact tests were used for statistical analysis. Results One-hundred patients were evaluated (22 had received kidneys from cadaver, 10 from living related donors, and 68 from living unrelated donors). Transplant rejection was most common in recipients of kidneys from living unrelated donors (49.7%, P=0.02). Renal failure was most common in recipients of kidneys from cadaver (68%, P=0.02), urinary infection was most common in recipients of kidneys from living unrelated donors (26%, P=0.04). Overall, complications were most common in patients who had received kidneys from cadaver (81%, P=0.04). Conclusions Given the high transplant rejection rate in recipients of kidneys from living unrelated donors, and the complications observed in recipients of kidneys from cadaver, kidney transplant from living related donors seems to be the most favorable option. Keywords Kidney transplantation, Complication, Outcome.

Background: End stage renal disease (ESRD) is a condition that inflammation and oxidative stress plays an important role in damaging to tissues, especially, in the vascular system. The effect of omega-3 fatty acids is well-documented in some inflammatory diseases via eicosapentanoic acid and docosahexanoic acid components of fish oil. The aim of this study was to investigate the effects of dietary omega-3 fatty acid supplementation on levels of lipid peroxidation and oxidative sttress in ESRD patients. Materials and Methods: This randomized controlled double-blind clinical trial consisted of 90 patients on chronic ambulatory peritoneal dialysis (CAPD). One group was treated orally with 3000 mg omega-3, per day for 8 weeks (n = 45) and the other matched group by placebo (n = 45). Serum levels of lipids, iron, ferritin, Protrombin Time, Partial thromboplastin time, superoxide dismutase (SOD), and reduced glutathione (GH) were measured at the beginning and at 8 weeks. Results: Our results showed that SOD and reduced GH were not significantly changed in omega-3 group where lipid profile showed no significant changes too. Erythropoietin requirements also had no significant differences. Conclusion: Incorporation of omega-3 fatty acids to CAPD patients had no beneficial effects on oxidative stress but should evaluate more.

Background: Doppler ultrasonography (DU) and measurement of its indexes, resistive index (RI) and pulsatility index (PI), is used to investigate transplanted kidney hemodynamic status and function. The aim of this study was to determine the correlation between Doppler indexes in the early phase after transplantation with long-term transplanted kidney function. Materials and Methods : In this cross-sectional study on 38 newly kidney transplant patients, we performed DU with assessment of its indexes within 48 hours, 1 week, and 6 months after kidney transplantation. Serum creatinine after stability and 6 months after kidney transplantation were assessed. Cyclosporine level was measured 1 week after kidney transplantation and compared with DU indexes. Results: About 71% of kidney transplanted patients reached their normal initial creatinine level(cr