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Background: Autosomal dominant polycystic kidney disease (ADPKD), one of the common inherited disorders in humans, is characterized by the development and enlargement of renal cysts, often leading to end-stage renal disease (ESRD). In this study, Iranian ADPKD families were subjected to high-throughput DNA sequencing to find potential causative variants facilitating the way toward risk assessment and targeted therapy. Methods: Our protocol was based on the targeted next generation sequencing (NGS) panel previously developed in our center comprising 12 genes involved in PKD. This panel has been applied to investigate the genetic causes of 32 patients with a clinical suspicion of ADPKD. Results: We identified a total of 31 variants for 32 individuals, two of which were each detected in two individuals. Twenty-seven out of 31 detected variants were interpreted as pathogenic/likely pathogenic and the remaining 4 of uncertain significance with a molecular diagnostic success rate of 87.5%. Among these variants, 25 PKD1/2 pathogenic/likely pathogenic variants were detected in 32 index patients (78.1%), and variants of uncertain significance in four individuals (12.5% in PKD1/2). The majority of variants was identified in PKD1 (74.2%). Autosomal recessive PKD was identified in one patient, indicating the similarities between recessive and dominant PKD. In concordance with earlier studies, this biallelic PKD1 variant, p.Arg3277Cys, leads to rapidly progressive and severe disease with very early-onset ADPKD. Conclusion: Our findings suggest that targeted gene panel sequencing is expected to be the method of choice to improve diagnostic and prognostic accuracy in PKD patients with heterogeneity in genetic background.

Kidney failure is the permanent impairment of kidney function associated with increased morbidity, hospitalization, and requirement for kidney replacement therapy. A total of 11 countries in the Middle East region (84.6%) responded to the survey. The prevalence of chronic kidney disease in the region ranged from 5.2% to 10.6%, whereas prevalence of treated kidney failure ranged from 152 to 826 per million population. Overall, the incidence of kidney transplantation was highest in Iran (30.9 per million population) and lowest in Oman and the United Arab Emirates (2.2 and 3.0 per million population, respectively). Long-term hemodialysis services were available in all countries, long-term peritoneal dialysis services were available in 9 (69.2%) countries, and transplantation services were available in most countries of the region. Public funding covered the costs of nondialysis chronic kidney disease care in two-thirds of countries, and kidney replacement therapy in nearly all countries. More than half of the countries had dialysis registries; however, national noncommunicable disease strategies were lacking in most countries. The Middle East is a region with high burden of kidney disease and needs cost-effective measures through effective health care funding to be available to improve kidney care in the region. Furthermore, well-designed and sustainable health information systems are needed in the region to address current gaps in kidney care in the region.

Kidney transplant provides superior outcomes to dialysis as a treatment for end-stage kidney disease. Therefore, it is essential that kidney transplantation be part of an integrated treatment and management plan for chronic kidney disease (CKD). Developing an effective national program of transplantation is challenging because of the requirement for kidney donors and the need for a multidisciplinary team to provide expert care for both donors and recipients. This article outlines the steps necessary to establish a national kidney transplant program, starting with the requirement for effective legislation that provides the legal framework for transplantation whilst protecting organ donors, their families, recipients, and staff and is an essential requirement to combat organ trafficking. The next steps involve capacity building with the development of a multiskilled workforce, the credentialing of transplant centers, and the reporting of outcomes through national or regional registries. Although it is accepted that most transplant programs will begin with living related kidney donation, it is essential to aspire to and develop a deceased donor program. This requires engagement with multiple stakeholders, especially the patients, the general community, intensivists, and health departments. Development of transplant centers should be undertaken in concert with the development of a dialysis program. Both are essential components of integrated care for CKD and both should be viewed as part of the World Health Organization’s initiative for universal health coverage. Provisions to cover the costs of treatment for patients need to be developed taking into account the state of development of the overall health framework in each country.

Background Kidney transplantation (KT) is the optimal treatment for kidney failure and is associated with better quality of life and survival relative to dialysis. However, knowledge of the current capacity of countries to deliver KT is limited. This study reports on findings from the 2018 International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) survey, specifically addressing the availability, accessibility, and quality of KT across countries and regions. Methods Data were collected from published online sources and a survey was administered online to key stakeholders. All country-level data were analyzed by ISN region and World Bank income classification. Results Data were collected via a survey in 182 countries of which 155 answered questions pertaining to KT. Of these, 74% stated that KT was available, with a median incidence of 14 pmp (range: 0.04 to 70) and median prevalence of 255 pmp (range: 3 to 693). Accessibility of KT varied widely; even within high income countries, it was disproportionately lower for ethnic minorities. Universal health coverage of all KT treatment costs was available in 31% and 57% had a KT registry. Conclusions There are substantial variations in KT incidence, prevalence, availability, accessibility, and quality worldwide, with the lowest rates evident in low- and lower-middle income countries. Understanding these disparities will inform efforts to increase awareness and the adoption of practices that will ensure high quality KT care is provided around the world.Supplemental Visual Abstract; http://links.lww.com/TP/C288.

Background Health information systems (HIS) are fundamental tools for the surveillance of health services, estimation of disease burden and prioritization of health resources. Several gaps in the availability of HIS for kidney disease were highlighted by the first iteration of the Global Kidney Health Atlas. Methods As part of its second iteration, the International Society of Nephrology conducted a cross-sectional global survey between July and October 2018 to explore the coverage and scope of HIS for kidney disease, with a focus on kidney replacement therapy (KRT). Results Out of a total of 182 invited countries, 154 countries responded to questions on HIS (85% response rate). KRT registries were available in almost all high-income countries, but few low-income countries, while registries for non-dialysis chronic kidney disease (CKD) or acute kidney injury (AKI) were rare. Registries in high-income countries tended to be national, in contrast to registries in low-income countries, which often operated at local or regional levels. Although cause of end-stage kidney disease, modality of KRT and source of kidney transplant donors were frequently reported, few countries collected data on patient-reported outcome measures and only half of low-income countries recorded process-based measures. Almost no countries had programs to detect AKI and practices to identify CKD-targeted individuals with diabetes, hypertension and cardiovascular disease, rather than members of high-risk ethnic groups. Conclusions These findings confirm significant heterogeneity in the global availability of HIS for kidney disease and highlight important gaps in their coverage and scope, especially in low-income countries and across the domains of AKI, non-dialysis CKD, patient-reported outcomes, process-based measures and quality indicators for KRT service delivery.

Crescents (C) have been recently added to the Oxford classification of IgA nephropathy (IgAN) consisting of mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental sclerosis (S) and tubular atrophy/ interstitial fibrosis (T) (MEST). The aim of the study was to assess the added impact of crescents, on development of end-stage kidney disease (ESKD) in IgAN patients Methods. On-hundred fifteen IgAN patients (76% male, mean age: 37 ± 13 years, mean serum creatinine: 4.0 ± 4.3 mg/dL, mean proteinuria: 3.4 ± 2.5 g/d) were followed for 43 ± 29 months. MEST score was defined according to Oxford classification (M0/M1, E0/ E1, S0/S1). To increase the power, T was defined as T0 ≤ 25% and T125%. Crescents were defined as C0, "absence" and C1 "at least one" crescent. In sensitivity analysis, the risk of ESKD was estimated at different cut-off levels of at least 10, 20, and 30% crescents.Forty patients (35%) developed ESKD. Among those 14% with at least one crescent, 21 patients (46%) developed ESKD. In 11 patients with C ≥ 30%, 66% and among 57 patients with T1, 60% and in 27 patients with T1 + C1 74% developed ESKD. In adjusted model, only C ≥ 30% (HR = 3.15, 95% CI: 1.15 to 11.00; P = 0.027) and the presence of T1+ C1 (HR = 7.18, 95% CI: 1.90 to 27.10, P = 0.004) were associated with increased risk of ESKD. The median kidney survival was 78.0 months (95% CI: 70.5 to 85.6 months), in patients with T0 + C0 and 32.3 months (95% CI: 19.3 to 45.3 months) in patients with T1 + C1.In this study T ≥ 25%, and the presence of crescents ≥ 30%, were independently associated with increased risk of ESKD. This risk was strongly increased in the combined presence of at least one crescent and T1 ≥ 25%, that predicted a high ESKD rate. DOI: 10.52547/ijkd.6685.

Focal segmental glomerulosclerosis (FSGS) is one of the important causes of end stage kidney disease (ESKD). We evaluated the progression risk factors of primary FSGS to chronic kidney disease (CKD) or ESKD with a predictive model including clinical and histological predictors.201 patients with primary FSGS (59% male, mean age: 38 ± 15 years), were studied. Time-dependent Cox model and C statistics were used for the predictive model. Interaction and correlation between independent variables were estimated.During 55 ± 27 months of follow-up, 82 patients (41%) developed CKD (46) or ESKD (36) patients. In adjusted model, 1 unit of higher serum creatinine (SCr) at baseline (HR = 1.39, 95% CI: 1.15 to 1.70) and 1% increase in glomeruli with segmental glomerulosclerosis (SGS) (HR = 1.03, 95% CI: 1.02 to 1.04) or interstitial fibrosis/tubular atrophy (IF/TA) (HR = 1.03, 95% CI: 1.01 to 1.05) increased the risk of CKD/ESKD. In adjusted model, higher baseline proteinuria and collapsing variant were not associated with risk of CKD/ESKD. By adding SGS and IF/TA scores to baseline SCr in the model, discrimination by C statistics was 0.83 (95% CI: 0.77 to 0.90). Median renal survival was 3.1 years (95% CI: 2.2 to 4.1 years) in patients with highest risk score (baseline eGFR25 mL/min/1.73m2 + IF/TA/SGS50%), and 8.1 years (95% CI: 7.7 to 8.6 years).in those with lowest score (baseline eGFR75 mL/ min/1.73m2 + IF/TA/SGS5%).In primary FSGS, higher baseline SCr, increased SGS and IF/TA, but not baseline proteinuria and collapsing pathology, were the predictors for CKD/ESKD. These findings indicated the importance of timely detection and referral in prognosis of primary FSGS. DOI: 10.52547/ijkd.6442.

Despite significant improvement in End Stage Kidney Disease (ESKD) patient's management, and better availability of dialysis for caregivers, mortality among these patients is unacceptably high.We collected the data of 751 incident hemodialysis patients from March 2004 to November 2018. Survival curves was created by using the Kaplan-Meier method. Comorbidities, as well as time-dependent values of laboratory findings, were examined as independent factors by three models of Cox regression analysis.The median follow-up period was 31.7 months (1.08 to 169.28). Patient survival rates were 88%, 77%, 56%, 32%, 26% ,16% and 12%, at 1, 2, 4,6, 8, 10, 12 and 14 years of follow-up, respectively. The most common cause of mortality was cardiovascular disease. We observed lower survival rates in patients ≥ 65 years (HR = 2.684, 95% CI: 1.133 to 3.377; P.001), diabetes mellitus (HR = 1.729, 95% CI: 1.484 to 2.014; P.001) and walking disability (HR = 2.505; 95% CI: 2.104 to 2.983; P.001). Low hemoglobin level (HR = 1.496; 95% CI: 1.257 to 1.779; P.001), hyperphosphatemia (HR = 1.305, 95% CI: 1.104 to 1.542; P = 0.002) and high low-density lipoprotein cholesterol level (HR = 1.933; 95% CI: 1.431 to 2.611; P.001) were predictors of mortality. A single pool Kt/V1.2 (HR = 0.743, 95% CI: 0.635 to 0.870; P.001) and high serum creatinine level (HR = 0.842, 95% CI: 0.811 to 0.874; P.001) showed protective effects.Our study showed a high survival rate in a single center cohort of hemodialysis patients in Iran. Traditional risk factors of mortality in general population, as well as indices of dialysis efficacy and general health status were the main predictors of mortality. Nationwide registries are necessary to investigate the dialysis survival rates and their predictors in our country. DOI: 10.52547/ijkd.6435.

Background: People with kidney failure typically receive kidney replacement therapy (KRT) in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy, which focuses on symptom management, psychological health, spiritual care and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that impact its uptake and quality. Methods: The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology (ISN), which aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, uptake and quality of conservative kidney management. Results: Respondents from 160 countries completed the survey and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%), shared decision-making (32%), or provided psychological, cultural, or spiritual support (36%). One quarter provided relevant healthcare providers with training on conservative kidney management delivery.Conclusions: Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.

Rationale & Objective: Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe. Study Design: A cross-sectional survey. Setting & Participants: Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September 2018. Outcomes: PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures. Analytical Approach: Descriptive statistics. Results: Responses were received from 88% (n = 160) of countries and there were 313 participants (257 nephrologists [82%], 22 non-nephrologist physicians [7%], 6 other health professionals [2%], 17 administrators/policy makers/civil servants [5%], and 11 others [4%]). 85% (n = 156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for ≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes. Limitations: Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data. Conclusions: Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.

© 2020 International Society of NephrologyThere is a huge gap between the number of patients worldwide requiring versus those actually receiving safe, sustainable, and equitable care for kidney failure. To address this, the International Society of Nephrology coordinated the development of a Strategic Plan for Integrated Care of Patients with Kidney Failure. Implementation of the plan will require engagement of the whole kidney community over the next 5–10 years.

Seven months after the emergence of SARS-COV-2 virus, there is paucity of data regarding the epidemiology of the virus in hemodialysis patients. We aim to present the results of the screening program implied after outbreak of COVID-19 in a referral hemodialysis ward.We started clinical screening and obligatory mask wearing for dialysis patients and personnel on 20-Feb-2020. However 11 symptomatic COVID-19 patients emerged till day +36. On days +39 and +40 a screening program was implied including measurement of SARS-COV-2 PCR and immunoglobulin G and M (IgG/IgM) and chest computerized tomography (CCT) scan. The results of CCT scan, classified according to the coronavirus disease 2019 (COVID-19) Reporting and Data System (CO-RADS) classification; as with very low (grade 1-normal), low, indeterminate, high, and very high likelihood of COVID-19 (grades 2, 3, 4, and 5; respectively), were used for compartmentalization of patients.Among 178 patients (68.2% male, mean age = 58.7 ± 16.6 years), 11 got COVID-19 before screening, two of whom died. CCT scans were normal in 71.3% and grade 2, 3, 4, and 5 in 7.9%, 4.5%, 5.6%, and 10.7%; respectively. PCR and IgG and/or IgM were positive in 27 and 32 patients. Eighty-three patients had evidence of COVID-19 infection, who were significantly older (62.2 ± 16.6 vs. 56.1 ± 16.02, P.05). There was no difference in the rate of infection considering gender, diabetes mellitus, hypertension and different blood groups.Asymptomatic SARS- COV 2 infection may affect a large number of dialysis patients. We highly recommend a screening strategy whenever the number of patients is increasing.

Background and Aims Several studies have reported the results of renal biopsies from different registries and single centres. In most series focal and segmental glomerulosclerosis (FSGS), IgA nephropathy (IgAN), membranous glomerulopathy (MG) and lupus nephritis (LN) have been reported as the most common primary and secondary glomerulonephritis (GN). This study was conducted to update the reports of our hospital, as the main referral kidney centre of the country. Method Data from 4713 patients, who had undergone renal biopsy between Sept-1999 to Sept.-2019 were extracted from the GN data registry of our centre. Demographic data, renal syndrome at presentation and laboratory findings were studied. Almost all kidney specimens had been studied with light and immunofluoroscent microscopes and in selected cases with electron microscope. Nephrotic syndrome (NS) was defined as proteinuria >3.5 g/day or >3 g/day, if associated with hyperlipidemia, hypoalbuminemia and edema. Nephritic syndrome was defined as proteinuria >500 mg/day and hematuria, with or without hypertension and/or serum Cr (SCr) ≥1.4 mg/dl. Subnephrotic (SN) proteinuria was defined as proteinuria of 200 -3000 mg/day. Acute kidney injury (AKI) was defined as increase in SCr >1.4 during the past few days to weeks before admission. Results The most frequent type of renal pathology was MG (25.2%) followed by FSGS (13.6%), IgAN (12%), LN (8.9%), minimal change disease (MCD) (7%), crescentic GN (6.2%) and paraprotein associated GN (4.3%). The prevalence of different renal pathologies changed significantly over time (p-value:0.000) (figure).The most common clinical presentation was NS (60.2%), followed by SN proteinuria (15.2%), nephritic syndrome (12%) and AKI (7.5%). Age, sex, clinical syndrome at presentation and hypertension were significantly different between major pathological diagnostic groups (p=0.000). Table shows the detailed clinical features of the most important glomerulonephritides in our centre. Figure shows the changes in prevalence of each pathologic diagnosis over 21 years. Conclusion In our series the most common types of GN were MG, FSGS and IgAN, which are the most frequent glomerulonephritides in other biopsy series with various orders. Most of our patients presented with NS, followed by SN proteinuria. The relative frequency of MPGN and LN have reduced and FSGS has increased over time.

Background and Aims Oxford classification of IgA nephropathy (IgAN) consists of the presence of four key pathologic features: mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental sclerosis (S) and tubular atrophy and interstitial fibrosis (T). The association between MEST score and renal outcome has been evaluated in previous studies. More recently crescents (C) were added to Oxford classification but the additive effect of the crescents on prediction of renal outcome is less well studied. The aim of the study was to assess the added impact of crescents, as an independent variable, on development of end stage kidney disease (ESKD) in combination with other pathological features of Oxford classification, in patients with IgAN. Method One- hundred fifteen patients with IgAN (76% male, mean age: 37±13 years, mean serum creatinine: 4.0±4.3 mg/dl and mean proteinuria: 3.4±2.5 g/24 hours) were followed for 43±29 months. MEST score was defined according to Oxford classification (M0/M1, E0/E1, S0/S1). To increase the power of the study, T was defined as T0 Association between Oxford Classification score and risk of ESKD was examined by time-dependent Cox model to estimate hazard ratio, through univariate and multivariate analyses, adjusted for demographics, laboratory and pathological findings. Kaplan–Meier and the log-rank tests were used to estimate kidney survival. Results During follow-up 40 patients (35%) developed ESKD (dialysis or kidney transplantation). Forty- six patients (40%) had at least one crescent and among them 25 (46%) developed ESKD. In sub- analysis in 11 patients with C≥30%, 7 (66%) developed ESKD. Among 57 patients with T1, 34 (60%) developed ESKD. Twenty- seven patients had both T1 and C1 and among them 20 (74%) developed ESKD. In adjusted model, among patients with crescents, only C≥30% (HR: 3.15, 95% CI 1.15-11.00,P=0.027) and the presence of T1+ C1 (HR: 7.18, 95% CI 1.90-27.10,P=0.004) were associated with increased risk of ESKD and the combinations of M1+C1, E1+C1 or S1+C1 were not significantly associated with increased risk of ESKD (P=0.067, P=0.450, P=0.035, respectively). The median kidney survival was 78.0 months (95% CI, 70.5-85.6 months) with T0+C0 and 32.3 months (95% CI, 19.3-45.3 months) with T1+C1. Conclusion In this study based on Oxford classification, tubular atrophy and interstitial fibrosis≥25%, and presence of crescents≥ 30%, were independently associated with increased risk of ESKD. This risk was strongly increased in combined presence of at least one crescent and T1≥25% and 74% of such patients developed ESKD within a mean interval of 27 months.

Background: Focal segmental glomerulosclerosis (FSGS) is one of the important causes of end stage kidney disease (ESKD). We evaluated the risk factors of progression of primary FSGS to chronic kidney disease (CKD) or ESKD with a predictive model including clinical and histological predictors.Methods: 201 patients with primary FSGS (59% male, mean age: 38±15 years), were studied. Time-dependent Cox model and C statistics were used for the predictive model. Interaction and correlation between independent variables were estimated.Results: During 55±27 months of follow-up, 82 patients (41%) developed CKD (46) or ESKD (36) patients. In adjusted model, 1 unit of higher serum creatinine (SCr) at baseline (HR:1.39, 95%CI: 1.15-1.70) and 1% increase in glomeruli with segmental glomerulosclerosis (SGS) (HR: 1.03, 95% CI: 1.02-1.04) or interstitial fibrosis/tubular atrophy (IF/TA) (HR: 1.03, 95% CI: 1.01-1.05) increased the risk of CKD/ESKD. In adjusted model, higher baseline proteinuria and collapsing variant were not associated with risk of CKD/ESKD. By adding SGS and IF/TA scores to baseline SCr in the model, discrimination by C statistics was 0.83 (95%CI: 0.77-0.90). Median renal survival was 3.1 years (95% CI: 2.2-4.1 years) in patients with highest risks score (baseline eGFR2+ IF/TA/SGS> 50%), and 8.1 years (95% CI: 7.7-8.6 years).in those with lowest score (baseline eGFR>75 ml/min/1.73 m2+ IF/TA/SGS Conclusion: In primary FSGS, higher baseline SCr, increased SGS and IF/TA, but not baseline proteinuria and collapsing pathology, were the predictors for CKD/ESKD. These findings indicated the importance of timely detection and referral in prognosis of primary FSGS.

Background: Anemia is one of the most prevalent complications in patients with chronic kidney disease, which is believed to be caused by the insufficient synthesis of erythropoietin by the kidney. This phase III study aimed to compare the efficacy and safety of CinnaPoietin® (epoetin beta, CinnaGen) with Eprex® (epoetin alfa, Janssen Cilag) in the treatment of anemia in ESRD hemodialysis patients. Methods: In this randomized, active-controlled, double-blind, parallel, and non-inferiority trial, patients were randomized to receive either CinnaPoietin® or Eprex® for a 26-week period. The primary endpoints of this study were to assess the mean hemoglobin (Hb) change during the last 4 weeks of treatment from baseline along with the evaluation of the mean weekly epoetin dosage per kilogram of body weight that was necessary to maintain the Hb level within 10–12 g/dL during the last 4 weeks of treatment. As the secondary objective, safety was assessed along with other efficacy endpoints. Results: A total of 156 patients were included in this clinical trial. There was no statistically significant difference between treatment groups regarding the mean Hb change (p = 0.21). In addition, the mean weekly epoetin dosage per kg of body weight for maintaining the Hb level within 10–12 g/dL showed no statistically significant difference between treatment arms (p = 0.63). Moreover, both products had comparable safety profiles. However, the incidence of Hb levels above 13 g/dL was significantly lower in the CinnaPoietin® group. Conclusion: CinnaPoietin® was proved to be non-inferior to Eprex® in the treatment of anemia in ESRD hemodialysis patients. The trial was registered in Clinicaltrials.gov (NCT03408639).

Background: Focal segmental glomerulosclerosis (FSGS) is one of the important causes of end stage kidney disease (ESKD). We evaluated the risk factors of progression of primary FSGS to chronic kidney disease (CKD) or ESKD with a predictive model including clinical and histological predictors. Methods: 201 patients with primary FSGS (59% male, mean age: 38±15 years), were studied. Time-dependent Cox model and C statistics were used for the predictive model. Interaction and correlation between independent variables were estimated. Results: During 55±27 months of follow-up, 82 patients (41%) developed CKD (46) or ESKD (36) patients. In adjusted model, 1 unit of higher serum creatinine (SCr) at baseline (HR:1.39, 95%CI: 1.15-1.70) and 1% increase in glomeruli with segmental glomerulosclerosis (SGS) (HR: 1.03, 95% CI: 1.02-1.04) or interstitial fibrosis/tubular atrophy (IF/TA) (HR: 1.03, 95% CI: 1.01-1.05) increased the risk of CKD/ESKD. In adjusted model, higher baseline proteinuria and collapsing variant were not associated with risk of CKD/ESKD. By adding SGS and IF/TA scores to baseline SCr in the model, discrimination by C statistics was 0.83 (95%CI: 0.77-0.90) for prediction of CKD/ESKD . Median renal survival was 3.1 years (95% CI: 2.2-4.1 years) in patients with highest risks score (baseline eGFR 50%), and 8.1 years (95% CI: 7.7-8.6 years).in those with lowest score (baseline eGFR>75 ml/min/1.73 m 2 + IF/TA/SGS

Dysregulated vitamin D metabolism is one of the most important issues in chronic kidney disease- mineral and bone disorder (CKD-MBD). Patients with end-stage kidney disease (ESKD) receive large amounts of calcitriol, i.e., 1,25 -dihydroxy vitamin D [1-25(OH)2D], for suppression of parathyroid hormone (PTH). The aim of this study was to evaluate the 1-25(OH)2D status in maintenance hemodialysis patients and its correlation with 25(OH) D level and calcitriol consumption and to determine whether the usual practice of administrating large amounts of calcitriol for suppression of PTH may lead to toxic serum levels.One hundred and fifty-six maintenance hemodialysis patients were enrolled. Demographic data, comorbid conditions and history of medication use (cumulative and current doses) were retrieved from Hemodialysis Data Processor Software previously designed for our center. Predialysis serum samples were measured for serum levels of 25(OH)D and 1-25(OH)2D accompanying by markers of mineral bone metabolism and inflammation.Of 156 patients, 66% were male and the mean age was 56.5 ± 16.3 years. There was no significant correlation between serum level of 25(OH)D and 1,25(OH)2D (r = 0.12, P.05). Only current ingestion of vitamin D was correlated with both 25(OH) D (r = 0.324, P.001) and 1,25(OH)2D serum levels (r = 0.334, P.001). There was no significant relationship between current or cumulative calcitriol consumption and 1,25(OH)2D serum level. 1,25(OH)2D/25(OH)D ratio which, represents the degree of vitamin D hydroxylation efficiency was 0.9 pg/ng (expected value in no CKD2.2 pg/ng).Calcitriol consumption was not correlated with increased serum 1,25(OH)2D level and the practice of hyperparathyroidism treatment with calcitriol may be safely continued, though we are not yet aware of the 1,25(OH)2D status at the cellular levels.

Atherosclerosis is associated with increased intima- media thickness (IMT) and vascular calcification (VC) in maintenance hemodialysis (MHD) patients. Fetuin-A is a serum protein, which inhibits vascular calcification. The aim of this study was to investigate the association between fetuin-A and VC, in a group of MHD patients.One hundred and forty-three MHD patients were included and followed for 3 years. Blood samples were studied for calcification and inflammation markers and fetuin-A was checked 3 times at the start, middle and the end of the study. We used common carotid doppler sonography for assessment of indices of VC, which were performed at baseline and at the end of the study. Vascular calcification was defined as a common carotid intima media thickness ≥ 0.8 mm on either side or the existence of any plaque or stenosis ≥ 50% on either side.From 143 patients (mean age 57.5 ± 15.9, 60.1% male), 104 patients (75.4%) had VC at baseline. The mean age and the prevalence of DM were significantly higher in patients with VC (P.001 for both). There was no significant difference in the levels of Pi, PTH, and fetuin-A between the two groups. In a multiple logistic regression model at baseline only age (OR = 1.09, P.001), and diabetes mellitus (OR = 4.59, P.05) were associated with VC and dialysis vintage had a marginal association (OR = 1.20, P = .09). At the end of the study only age (OR = 1.12, P.001), and CRP (OR = 1.14, P.05) were associated with VC. The mean survival of patients with VC was significantly lower than the patients without VC (31.87 ± 0.95 vs. 33.73 ± 1.29, P.05), however the mortality was not affected by fetuin-A level.Survival rate of patients without VC was higher than the patients with VC. We didn't find any correlation between the level of fetuin-A and VC. It seems that the traditional risk factors of VC, including age and diabetes mellitus are the main predictors of VC in MHD patients.

Secular increases in the burden of kidney failure is a major challenge for health systems worldwide, especially in low- and middle-income countries (LMICs) due to growing demand for expensive kidney replacement therapies. In LMICs with limited resources, the priority of providing kidney replacement therapies must be weighed against the prevention and treatment of chronic kidney disease, other kidney disorders such as acute kidney injury, and other noncommunicable diseases, as well as other urgent public health needs. Kidney failure is potentially preventable—not just through primary prevention of risk factors for kidney disease such as hypertension and diabetes, but also by timely management of established chronic kidney disease. Among people with established or incipient kidney failure, there are 3 key treatment strategies—conservative care, kidney transplantation, and dialysis—each of which has its own benefits. Joining up preventive care for people with or at risk for milder forms of chronic kidney disease with all 3 therapies for kidney failure (and developing synergistic links between the different treatment options) is termed “integrated kidney care” and has potential benefits for patients, families, and providers. In addition, because integrated kidney care implicitly considers resource use, it should facilitate a more sustainable approach to managing kidney failure than providing one or more of its components separately. There is currently no agreed framework that LMIC governments can use to establish and/or scale up programs to prevent and treat kidney failure or join up these programs to provide integrated kidney care. This review presents a suggested framework for establishing integrated kidney care programs, focusing on the anticipated needs of policy makers in LMICs.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle–income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

RATIONALE & OBJECTIVE Hemodialysis (HD) is the most common form of kidney replacement therapy. This study aimed to examine the use, availability, accessibility, affordability, and quality of HD care worldwide. STUDY DESIGN A cross-sectional survey. SETTING & PARTICIPANTS Stakeholders (clinicians, policy makers, and consumer representatives) in 182 countries were convened by the International Society of Nephrology from July to September 2018. OUTCOMES Use, availability, accessibility, affordability, and quality of HD care. ANALYTICAL APPROACH Descriptive statistics. RESULTS Overall, representatives from 160 (88%) countries participated. Median country-specific use of maintenance HD was 298.4 (IQR, 80.5-599.4) per million population (pmp). Global median HD use among incident patients with kidney failure was 98.0 (IQR, 81.5-140.8) pmp and median number of HD centers was 4.5 (IQR, 1.2-9.9) pmp. Adequate HD services (3-4 hours 3 times weekly) were generally available in 27% of low-income countries. Home HD was generally available in 36% of high-income countries. 32% of countries performed monitoring of patient-reported outcomes; 61%, monitoring of small-solute clearance; 60%, monitoring of bone mineral markers; 51%, monitoring of technique survival; and 60%, monitoring of patient survival. At initiation of maintenance dialysis, only 5% of countries used an arteriovenous access in almost all patients. Vascular access education was suboptimal, funding for vascular access procedures was not uniform, and copayments were greater in countries with lower levels of income. Patients in 23% of the low-income countries had to pay >75% of HD costs compared with patients in only 4% of high-income countries. LIMITATIONS A cross-sectional survey with possibility of response bias, social desirability bias, and limited data collection preventing in-depth analysis. CONCLUSIONS In summary, findings reveal substantial variations in global HD use, availability, accessibility, quality, and affordability worldwide, with the lowest use evident in low- and lower-middle-income countries.

Objective To determine the global capacity (availability, accessibility, quality, and affordability) to deliver kidney replacement therapy (dialysis and transplantation) and conservative kidney management. Design International cross sectional survey. Setting International Society of Nephrology (ISN) survey of 182 countries from July to September 2018. Participants Key stakeholders identified by ISN’s national and regional leaders. Main outcome measures Markers of national capacity to deliver core components of kidney replacement therapy and conservative kidney management. Results Responses were received from 160 (87.9%) of 182 countries, comprising 97.8% (7338.5 million of 7501.3 million) of the world’s population. A wide variation was found in capacity and structures for kidney replacement therapy and conservative kidney management—namely, funding mechanisms, health workforce, service delivery, and available technologies. Information on the prevalence of treated end stage kidney disease was available in 91 (42%) of 218 countries worldwide. Estimates varied more than 800-fold from 4 to 3392 per million population. Rwanda was the only low income country to report data on the prevalence of treated disease; 5 ( Conclusions These comprehensive data show the capacity of countries (including low income countries) to provide optimal care for patients with end stage kidney disease. They demonstrate substantial variability in the burden of such disease and capacity for kidney replacement therapy and conservative kidney management, which have implications for policy.

Background: The aim of this study was to evaluate the management of mineral and bone disorders (MBD) in patients with chronic kidney disease (CKD) in Iran and the extent to which KDIGO goals were met. Methods: This multi-centre observational studywasconductedonpatients withCKDstages 4, 5, and5D. Data were collectedfroma total of 209patients withnosurgical or medical conditions that precluded their participation. This study assessed the frequency of measurements, serum levels of phosphorus (P), calcium (Ca), and parathyroid hormone (PTH), the achievement of the targets recommended by the 2009 KDIGO guidelines, and the presence of vascular/valvular calcification. Results: The KDIGO targets for P, Ca, and iPTH, were achieved in 47, 51, and 18 of the patients with stage 4 + 5 and in 63, 50, and 44 of the patients with stage 5D, respectively. The serum PTH level of 18 of the patients with CKD stage 4 + 5 was within the recommended range, while it was higher than the recommended level in other patients. Among patients with CKD stage 5D, the serum PTH level was within, below, and above the recommended range in 44, 39, and 17 of the patients, respectively. The frequency of the measurement of the blood levels of Ca, P, and PTH were based on the 2009 KDIGO guidelines in 88 of patients. Forty-six percent of cases were screened for vascular/valvular calcification, 30 of whom had calcification at least in one site. Conclusions: The current status is far from the targets recommended by the current guidelines in the management of CKD-MBD. © 2017, Nephro-Urology Monthly.

Background: As hypophosphatemia is a common multifactorial problem of kidney transplantation (Tx), this research aimed at studying the frequency of posttransparent hypophosphatemia in the early postkidney Tx period and investigating the risk components associated with the situation. Materials and Methods: In this study, 50 renal transplant recipients on the day before (−1) and on days 10 (+10) and 30 (+30) days after kidney Tx were examined for the levels of serum phosphate (Pi). Levels of serum creatinine (Cr), Pi, 25-hydroxyvitamin D (25[OH] D), intact parathyroid hormone (iPTH) and fibroblast growth factor 23 (FGF-23), the 24 h urinary excretion of Pi and Cr, estimated glomerular filtration rate (eGFR), and the ratio of transport maximum of Pi (TMP) to eGFR (TMP/GFR) were evaluated on the same days. Results: Hypophosphatemia (serum Pi

Objectives The immunologic status of kidney allograft recipients affects transplant outcome. High levels of pretransplant serum soluble CD30 correlate with an increased risk of acute rejection. Studies show conflicting results. We evaluated the relation between pretransplant serum sCD30 levels with the risk of posttransplant acute kidney rejection in renal transplant recipients. Materials and methods This prospective cohort study was performed between March 2010 and March 2011 on 77 kidney transplant recipients (53 men [68.8%], 24 women [31.2%]; mean age, 41 ± 14 y). Serum samples were collected 24 hours before transplant and analyzed for soluble CD30 levels by enzyme-linked immunosorbent assay. Patients were followed for 6 months after transplant. Acute biopsy-proven rejection episodes were recorded, serum creatinine levels were measured, and glomerular filtration rates were calculated at the first and sixth months after transplant. Preoperative serum soluble CD30 levels were compared in patients with and without rejection. Results The mean pretransplant serum soluble CD30 level was 92.1 ± 47.3 ng/mL. At 6 months' follow-up, 10 patients experienced acute rejection. Mean pretransplant soluble CD30 levels were 128.5 ± 84 ng/mL versus 86.7 ± 37 ng/mL in patients with and without acute rejection episodes (P = .008). At 100 ng/mL, the sensitivity, specificity, and positive and negative predictive values of pretransplant serum soluble CD30 level to predict acute rejection were 70%, 73.6%, 29.1%, and 94.3%. Conclusions We showed a significant relation between pretransplant serum soluble CD30 levels and acute allograft rejection. High pretransplant levels of serum soluble CD30 can be a risk factor for kidney transplant rejection, and its high negative predictive value at various cutoffs make it useful to find candidates with a low risk of acute rejection after transplant.

BackgroundArteriovenous fistula (AVF) is the optimal vascular access in hemodialysis (HD) patients because of its lower complication rates and better longevity compared to arteriovenous graft (AVG) and central venous catheter (CVC).MethodsA cohort of 532 HD patients from nine HD facilities were recruited in September 2012 and prospectively followed for a median of 28 months. Unadjusted and fully adjusted hazard ratios (HR) of mortality for vascular access were calculated using Cox proportional hazards model.ResultsSeventy-two percent of patients had AVF, 7% AVG, 21% CVC. Overall, AVF failure was 43 per 1000 patient-years and AVF creation 19 per 1000 patient-years. In logistic regression analysis, odds ratio of having non-AVF access for age was 1.02 (95% CI: 1.01-1.03), female gender 1.97 (95% CI: 1.30-3.01), and Charlson comorbidity index (CCI) 1.17 (95% CI: 1.02-1.36). Total number of deaths was 17 per 100 patient-years. Two percent of death was because of pure catheter infection and 10.5% more mortality happened due to catheter infection complicated by underlying cardiovascular diseases. In unadjusted and full adjustment Cox models, HR of death for patients with CVC (reference: AVF patients) was, respectively, 2.17 (95% CI: 1.51-3.11) and 1.58 (95% CI: 1.01-2.51). Access problems of insertion-repair accounted for 24% of hospitalization, and catheter infection explained 10% of total admissions.ConclusionsCatheter use in HD patients was associated with higher mortality and morbidity despite extensive adjustment for covariates. Risk factors for higher usage of non-AVF access are older age, female gender, and underlying comorbidities.

This study aimed to evaluate the outcome and predictors of survival in hemodialysis patients of Hasheminejad Kidney Center where a comprehensive dialysis care program has been placed since 2004.Data of 560 hemodialysis patients were used to evaluate 9-year survival rates and predictors of mortality. Cox regression models included comorbidities as well as averaged and 6-month-averaged time-dependent values of laboratory findings as independent factors.Survival rates were 91.9%, 66.0%, 46.3%, and 28.5%, at 1, 3, 5, and 9 years, respectively, in all patients and 90.8%, 61.6%, 42.1%, and 28.0% in 395 incident patients starting hemodialysis after 2004. Adjusted survival models demonstrated age, male sex, diabetes mellitus, cardiovascular disease, and high-risk vascular access as baseline predictors of mortality, as well as averaged low hemoglobin level (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.36 to 2.90) and a single-pool KT/V1.2 (HR, 2.28; 95% CI, 1.60 to 3.26). The averaged high-density lipoprotein cholesterol (HR, 0.67; 95% CI, 0.55 to 0.81) and serum creatinine (HR, 0.71; 95% CI, 0.64 to 0.79) levels demonstrated protective effects. The adjusted time-dependent model further revealed the significant association of hypocalcemia (HR, 1.63; 95% CI, 1.13 to 2.34), hypercalcemia (HR, 1.50; 95% CI, 1.02 to 2.21), and hyperphosphatemia (HR, 1.68; 95% CI, 1.20 to 2.37) with death.Our patients have relatively comparable survival rates with high-profile dialysis centers. Aiming to better achieve the recommended targets, especially hemoglobin and nutritional and bone metabolism factors, should be considered for optimal dialysis outcomes.

Transplant tourism is one of the main unacceptable aspects of medical tourism, implicating travel to another country to receive an allograft. Organ shortages in wealthier countries have persuaded patients to preclude organ waiting lists and travel to other countries for getting organs especially kidneys. On the other hand, in many countries, there is no transplant program, and hemodialysis is expensive. Hence, patients with end-stage kidney disease may have to travel to get a kidney allograft for the sake of their lives. In Iran, a legal compensated and regulated living unrelated donor kidney transplant program has been adopted since 1988, in which recipients are matched with liveunrelated donors through the Iran Kidney Foundation and the recipients are compensated dually by the government and the recipient. In this model regulations were adopted to prevent transplant tourism: foreigners were not allowed to receive a kidney from Iranian donors or donate a kidney to Iranian patients; however, they could be transplanted from donors of their own nationality, after full medical workup, with the authorization of the Ministry of Health. This was first considered as a humanitarian assistance to patients of the countries with no transplant program and limited and low quality dialysis. However, the policy of "foreign nationality transplant" gradually established a spot where residents of many countries, where living-unrelated donor transplant was illegal, could bring their donors and be transplanted mainly in private hospitals, with high incentives for the transplant teams. By June 2014, six hundred eight foreign nationality kidney transplants were authorized by Ministry of Health for citizens for 17 countries. In this review, we examine the negative aspects of transplant for foreign citizens in Iran and the reasons that changed "travel for transplant" to "transplant tourism " in our country and finally led us to stop the program after more than 10 years.

Catheter-related infections, exit-site-tunnel infections and peritonitis remain the Achilles heel of peritoneal dialysis. Although the overall incidence of peritoneal-dialysis-related infectious complications has been reduced since the introduction of the Y-set and double bag system, approximately one-fifth of peritonitis episodes are associated with catheter exit-site and tunnel infections. Since its development in 1968, the Tenckhoff catheter has become one of the most widely used peritoneal catheters, and many have proposed that a number of modifications have made it a better choice. Controversies concerning the effect on exit-site infections of catheter(s) with one or two cuffs, with straight, coiled, Swan-Neck, or other modifications led to the randomized controlled studies that are reviewed in this paper. Several studies have confirmed that mupirocin, applied at the exit-site as part of regular exit-site care, reduces the risk of S. aureus exit-site and tunnel infections. Recently, the emergence on a world-wide basis of mupirocin-resistant S. aureus (MuRSA) in peritoneal dialysis patients has brought this prophylactic strategy into question. However the low frequency of resistant organisms after four years of mupirocin prophylaxis suggests that we can continue its use with annual surveillance. Once established, exit-site infections may respond to appropriate treatment, but if not the only option may be catheter removal and replacement. Although peritonitis risk has decreased over the past decade, mainly due to improvements in connection technology, exit-site and tunnel infections have not (1, 2). An exit-site infection that does not respond to treatment may lead to tunnel infection and to persistent peritonitis, which may require catheter removal and occasionally discontinuation of the peritoneal dialysis. Therefore it is important to be familiar with these factors that predispose to exit-site infection and to know how to prevent and to treat such infections. This review will discuss factors that predispose to catheter-related exit-site infections, techniques of exit-site care, and ways to prevent exit-site infection, with emphasis on S. aureus infections and their treatment (3, 4).

Fatigue is a common complaint in long term dialysis patients that may influence their quality of life. The present study was carried out in order to evaluate the prevalence and course of fatigue in a group of chronic PD patients and to find the possible factor(s) related to its development. We retrospectively reviewed 100 charts of the patients previously on PD. The presence or absence of fatigue in the 1st and last clinic visits and the 1st and 2nd changes in fatigue state were studied according to the monthly clinical records of the primary nurses. Data regarding dialysate volume, urine volume, weekly erythropoietin (EPO) dose, hemoglobin, hematocrit, blood urea, serum creatinine, residual renal creatinine and urea clearances, dialysate to peritoneal creatinine ratio (D/P Cr), total weekly Kt/V and total creatinine clearance/1.73 m2 body surface area (TCrCl) were collected. Fifty-five patients were male and 45 female. The mean age at the 1st clinic visit was 61.3 +/- 16 years. At the 1st visit 55 patients had fatigue and 45 did not. In 32 of the 55 patients fatigue disappeared after a mean duration of 7.9 +/- 8.4 months and in 31 of the 45 patients fatigue appeared after a mean duration of 8 +/- 6.8 months. So at the last visit the frequency of fatigue increased significantly from 55% to 67% (p < 0.001). In patients with fatigue the mean age and female percentage were higher (64.2 +/- 14.1 vs 57.8 +/- 17.6, p = 0.05 and 1.2 vs 0.5, p < 0.05 respectively), mean hemoglobin concentration was lower (104.4 +/- 14.7 vs 110.6 +/- 14.2 g/L, p < 0.04) and mean EPO dose was higher (6379.6 +/- 7142 vs 3395.4 +/- 4337.8 units/week, p < 0.02) at the 1st clinic visit. EPO dose was also higher in patients with fatigue at the last visit (8253.7 +/- 10317.3 units/wk vs 4736.4 +/- 5432.5, p < 0.03). No correlation was found between dialysis adequacy according to either weekly Kt/V or TCrCl and nutritional state according to nPCR and frequency of fatigue. We conclude that fatigue is a common symptom in PD patients and it's prevalence increases over time. Anemia seems to be the most important factor associated with fatigue. Dialysis adequacy and nutritional state did not show any correlation with the frequency of fatigue in our study.

Phosphate control is still a great challenge in chronic kidney disease (CKD), and in spite of the great improvements in dialysis techniques, achievement of the goals for mineral metabolism control is still far from ideal. Aluminum hydroxide has been largely abandoned due to the high risk of aluminum toxicity, while the use of calcium-based phosphate binders may cause hypercalcemia, overzealous parathyroid suppression, and extraskeletal calcification. Sevelamer hydrochloride has been introduced as an efficient medication for phosphate control, with a lower risk of hypercalcemia and parathyroid suppression. Various clinical trials have compared the risk of vascular calcification between sevelamer and calcium salts with inconsistent results. In spite of these inconsistencies, the Kidney Disease Outcomes Quality Initiative (KDOQI) suggests non-calcium phosphate binders as the preferred phosphate binder in dialysis patients with severe vascular and/or other soft-tissue calcifications and in those with hypercalcemia or parathyroid hormone (PTH)

Living unrelated kidney donation (LURD) is increasing worldwide due to the shortage of cadaveric kidneys. In our country an LURD program has been practiced since 1988. This study sought to evaluate the attitude of Iranian nephrologists towards various aspects of the program. Questionnaires including 20 queries were sent to nephrologists. Among 100 randomly selected nephrologists, 50 completed and returned the questionnaires. Forty six (92%) and 45 (90%) believed that LURD has potential minor short- and long-term complications, respectively. Forty two percent assumed renal failure was a potential complication. Ninety two percent used to inform donors about the complications, all verbally. Thirty four percent and 72% assumed inhalational opium addiction and heroin addiction were contraindications to LURD, respectively. Twenty eight percent and 68% believed that the amount of recipients' gift and the governmental award are not sufficient, respectively. Thirty two percent believed that all compensation should be paid by the government. Sixty six percent believed that donors should be given social advantages, and 26% believed that they should not, in order to not enhance persuasion of nonaltruistic donation. Eighty eight percent claimed that donor follow-up is not regularly done and should be organized. Finally, 30 agreed and 19 disagreed with LURD. We conclude that despite the success of our LURD program in elimination of the transplant waiting list, most Iranian nephrologists believe that there should be some revisions. Verbal information about complications may not be sufficient to help the donors to make a correct decision. We should reconsider the method and amount of financial compensation and organize a regular follow-up program.

This study was designed to evaluate the adherence of maintenance hemodialysis patients to medications and its correlation with quality of life and depressive symptoms.A total of 150 maintenance hemodialysis patients with a mean age of 56.4 ± 16.4 years (52.7% women) were included. Medication adherence was evaluated via the Simplified Medication Adherence Questionnaire, based on which nonadherent patients were identified. Specifically, the Drug-Intake Percentage Questionnaire was used for evaluation of adherence to phosphate binders, quality of life was assessed with short Form-36 and depression by the Beck Depression Inventory (BDI).A BDI score of 15 and greater was documented in 40.7%, and nonadherence in 24.7% of the patients. Adherent patients were significantly older than nonadherent ones, had a lower mean parathyroid hormone level, and had lower BDI scores. The quality of life scores were not significantly different between adherent and nonadherent patients. Multivariable analysis demonstrated that BDI score was a significant predictor of nonadherence (odds ratio for each unit increase, 1.11; 95% confidence interval, 1.04 to 1.18; P = .001). Overall, 55.5% of patients were taking more than 66% of their prescribed dose of calcium carbonate, while 10.3% and 53.8% of patients were taking more than 66% of their prescribed dose of aluminum hydroxide and sevelamer, respectively.Adherence to medication was mainly associated with hemodialysis patients' depressive symptom scores. Control of depression may significantly improve adherence to medications and patient management.