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OBJECTIVE To evaluate surgical outcomes and renal functions after cystectomy + MAINZ Pouch II and epispadias repair as a staged procedure in adult patients with exstrophy epispadias complex (EEC). STUDY DESIGN Descriptive study. PLACE AND DURATION OF STUDY Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2004 to December 2020. METHODOLOGY A total of 33 patients with EEC were treated. Out of which, 20 underwent cystectomy + MAINZ Pouch II with epispadias repair as a staged procedure. Out of these, 17 had a follow-up period of more than a year and were included in the study. The patients were followed up after 6 weeks of surgery, at 6 months, one year, and at the end of follow-up. The assessed variables included the patients' renal function tests, malignancy potential, morning erections, ejaculations, night emissions, day-and-night-time urinary frequency, and overall happiness of patients at the end of follow-up. RESULTS The mean age was 25.1 ± 7.5 years and mean follow-up duration was 7.8 ± 5.2 years. Postoperatively, there was a rise in blood urea from 27.8 to 35.08 mg/dl with a concurrent fall in serum bicarbonate from a mean of 23.5 to 20.2 mEq/dl. All patients were continent during the day-time postoperatively; whereas, two patients experienced nocturnal enuresis. All male patients exhibited good erections and ejaculations, but there was persistence of dorsal chordae in 4 (23.3%) patients. All were delighted, happy and pleased with the surgical outcomes and had returned to normal life. No rectal or sigmoid malignancy was observed. CONCLUSION In adult EEC patients, cystectomy + MAINZ Pouch II and epispadias repair is safe and effective. Key Words: Adults, Exstrophy epispadias complex, MAINZ pouch II, Pakistan.

OBJECTIVE To determine the outcomes of urethroplasty and its complications from a large cohort of patients managed in a single centre. STUDY DESIGN Descriptive study. PLACE AND DURATION OF STUDY Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from January 2010 to December 2016. METHODOLOGY A total of 546 patients with stricture urethra at different locations underwent urethroplasty from January 2010 to December 2016 were included. All patients had an ascending urethrogram followed by retrograde ± antegrade urethroscopy to assess the location and length of the stricture. Technique of urethroplasty was chosen according to the site, length and etiology. Following appropriate procedure, patients were followed up in the dedicated urethral stricture clinic. Procedure was considered successful if either no further therapeutic intervention was required and the maximum flow rate (Qmax) was >20 ml/sec with a voided volume of at least 200 mls. The procedure was regarded as unsuccessful, if further treatment was required or Qmax was

Background and objectives In regenerative medicine, mesenchymal stem cells derived from adipose tissues (Ad-MSCs) are a very attractive target to treat many diseases. In relation to nephrology, the aim of the current study is to investigate the effects of Ad-MSCs for the amelioration of acute kidney injury and to explore the mechanism of renal parenchymal changes in response to allogeneic transplantation of Ad-MSCs. Methods and results The nephrotoxicity was induced by cisplatin (CP) in balb/c mice according to RIFLE Class and AKIN Stage 3. PCR, qRT-PCR and fluorescent labeled cells infusion, histopathology, immunohistochemistry, functional analyses were used for genes and proteins expressions data acquisition respectively. We demonstrated that single intravenous infusion of 2.5×107/kg mAd-MSCs in mice pre-injected with CP recruited to the kidney, restored the renal structure, and function, which resulted in progressive survival of mice. The renal tissue morphology was recovered in terms of diminished necrosis or epithelial cells damage, protein casts formation, infiltration of inflammatory cells, tubular dilatation, and restoration of brush border protein; Megalin and decreased Kim-1 expressions in mAd-MSCs transplanted mice. Significant reduction in serum creatinine with slashed urea and urinary protein levels were observed. Anti-BrdU staining displayed enhanced tubular cells proliferation. Predominantly, downgrade expressions of TNF-α and TGF-β1 were observed post seven days in mAd-MSCs transplanted mice. Conclusions Ad-MSCs exerts pro-proliferative, anti-inflammatory, and anti-fibrotic effects. Ad-MSCs transplantation without any chemical or genetic manipulation can provide the evidence of therapeutic strategy for the origin of regeneration and overall an improved survival of the system in functionally deprived failed kidneys.

Pediatric urolithiasis remains endemic in low-resource countries where infants constitute 17–40% of all children with urolithiasis. This study reports socio-economic factors, medical history and chemical composition of urinary stones in 976 infants of up to 2 years of age. Between 1992 and 2016, 976 infants presented to our institute with 1038 stones. Chemical composition of stones was analyzed by Fourier transformation infrared spectroscopy (FTIR). The mean age of infants was 19.5 ± 5.74 months with a M:F ratio of 5.5:1. Half (50%) of the infants were rural dwellers, 90% belonged to low socio-economic class and 70% were malnourished. A history of chronic diarrhoea was reported in 13% and urinary tract infections in 5%. The anatomic location was bladder in 487 (46.9%), kidney in 246 (23.6%), ureter in 142 (13.6%), urethra in 2 (0.2%) and 161 (15.5%) were passed spontaneously. Overall frequency of compounds in stones showed ammonium acid urate (AAU) in 772 (74.37%), calcium oxalate (CaOx) in 410 (39.5%). Uric acid (UA) in 119 (11.46%), calcium phosphate apatite (CaP) in 96 (9.25%), magnesium ammonium phosphate (Struvite) in 45 (4.34%), cystine in 12 (1.16%) and xanthine in 40 (3.85%). Frequency of compounds was similar in genders. Infants of age 0–6 months had higher frequency of UA (28%), CaOx (50%) and low AAU (61%) as compared to 11, 39 and 75%, respectively, in 7–24 months (p

Interferon-gamma inducible protein-10 (IP-10/CXCL10) is a chemokine involved in the alloimmune response against kidney allograft. We aimed to investigate the association of urinary CXCL10 protein levels with rejection in renal transplant patients.A total of 273 urine samples from (biopsy-proven) rejection and non-rejection patients and controls were included in this study. CXCL10 levels were analyzed for association with rejection.The data showed statistically significant differences in the CXCL10 levels between rejection vs. non-rejection (p 0.001). Among the rejection groups, statistically significant differences for CXCL10 levels were found between ACR vs. NAD (p 0.001), ACR vs. BLR (p = 0.019) and AVR vs. NAD (p = 0.009). Receiver Operating Characteristic (ROC) curve analysis of CXCL10 showed an area under the curve (AUC) of 0.74 with 72% sensitivity and 71% specificity at 27.5 pg/ml between rejection and non-rejection group. Kaplan-Meier curve analysis among different levels of CXCL10 showed a better rejection-free graft survival in patients with100 pg/ml when compared to200 pg/ml (38 ± 6 vs. 12 ± 1.0 weeks; log-rank p 0.001) and 100-200 pg/ml (38 ± 6 vs. 22 ± 9 weeks; log-rank p = 0.442) concentration.The results indicate significantly increased levels of CXCL10 protein in the urine at the time of allograft rejection. This association of urinary CXCL10 protein levels with rejection could provide an additional tool for the non-invasive monitoring of allograft rejection.

Urolithiasis has always been a fascinating disease, even more so in children. There are many intriguing facets to this pathology. This article is a nonsystematic review to provide an update on the surgical management of pediatric urolithiasis. It highlights the pros and cons of various minimally invasive surgical options such as extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), laparoscopy, and robotics. This article also describes the various intracorporeal disintegration technologies available to fragment the stone, including the newer advancements in laser technology. It also emphasizes the cost considerations especially with reference to the emerging economies. Thus, this manuscript guides how to select the least-invasive option for an individual patient, considering age and gender; stone size, location, and composition; and facilities and expertise available.

CCL2 is a chemoattractant for monocytes/macrophages, T cells, and natural killer cells. It is shown to be involved in the immunological responses against renal allograft. This study was conducted to access the role of urinary CCL2 expression in predicting the rejection episodes in renal transplant patients.A total of 409 urine samples included in this study. The samples were consisted of (a) biopsy-proven graft rejection (n = 165); (b) non-rejection (n = 93); (c) non-biopsy stable-graft (n = 42), and (d) healthy renal donors (n = 109). The samples were quantified for the CCL2 using the MCP-1/CCL2 ELISA kit. The data were analyzed using the Statistical Package for Social Sciences (SPSSResults showed that the CCL2 levels were significantly increased in rejection group when compared with the non-rejection, stable-graft, and control, P0.05. The receiver operating curve's characteristics illustrated that the urinary CCL2 level is a good predictor for graft rejection, with an area under the curve of 0.81 ± 0.03 with optimum sensitivity and specificity of 87% and 62%, respectively, at a cut-off value of 198 pg/mL. Kaplan-Meier curve also showed better cumulative rejection-free graft survival time in group with less than 198 pg/mL of CCL2 as compared to those with expression levels of more than 198 pg/mL (30 weeks vs. 3 weeks; log-rank test, P0.001).In our study, noninvasive investigation of CCL2 levels in urine has showed potential to predict rejection episodes. It is suggested that the CCL2, with others markers, may help in early detection and monitoring of graft rejection episodes.

The goal of this study was to investigate metabolic risk factors in pediatric stone formers in an emerging economy. A prospective, data collection enrolled 250 children age

Chemical composition of stones is one of the important diagnostic criteria for aetiology of stone formation and treatment to prevent recurrence. This paper reports composition of stones in children at a tertiary hospital by Fourier Transformation Infrared Spectroscopy (FTIR).Between January-June 2015, 412 urinary stones from children were analysed by FTIR. Chi-square tests were used for the comparison of categorical measurements between groups. All reported values were 2-sided and statistical significance was considered at p-value ≤0.05.Of the 412 stones, 263 (63.8%) were renal, 101(24.5%) bladder and 48 (11.7%) ureteric. The mean age of children was 7.15±4.13 years with a M:F ratio 2.4:1. Of the 412 stones, 144(34.9%) were pure stones composed of one compound and 268(65.1%) were mixtures. Frequency of compound in stones was Ammonium Acid Urate (AAU) (65%), Calcium Oxalate (CaOx) (76.9%), Uric Acid (5%), Calcium Phosphate Apatite (7%), Whitlockite (8.4%), Struvite (4%), Cystine (0.72%) and Xanthine (2.11%). Frequency of compounds analysed in three ages groups 0-5, 6-10 and 11-15 years showed high frequency of AAU (73%) in 0-5 years as compared to (60%) in 11-15 years (p0.018). CaOx (90%) in 11-15 as compared to (62.5%) in 0-5 years (p0.001). Bladder stones were more prevalent in children 0-5 years (32%) vs 19% in 11-15 years (p0.004) while renal were 75% in 11-15 years and 54% in 0-5 years (p0.04).AAU stones known to be associated with malnutrition and chronic diarrhoea are highly prevalent in paediatric stones formers in our population in the kidney, bladder and ureter.

AIM: We report here, case series of patients with acute kidney injury (AKI) after ingestion of Paraphenylene diamine (PPD) a derivative of analine. It is used as coloring agent to dye hair, fur and plastic and in photographic films. PATIENTS AND METHODS: subjects for the study reported here comprised a cohort of100 patients coming to this institution with AKI following PPD poisoning. AKI was defined according to RIFLE criteria and PPD poisoning on basis of history and presenting features. All patients had normal size kidneys on ultrasonography and no previous co- morbidity. RESULTS: One hundred patients with AKI after PPD exposure were brought to this institute between May 2010- February.2015, among these 56 were females, with mean age of 23.11 ± 7.94 years. Cause of AKI was toxic rhabdomyolysis as indicated by marked rise in muscle enzymes with mean LDH and CK levels of 6665.22±6272.04 and 194486.66±301905.80 respectively. Hepatotoxicity with raised AST and ALT was a main feature of the studied population. Renal replacement was required in 97 % patients. Complete renal recovery was observed in 77 patients, while 16 died during acute phase of illness. Respiratory failure and recurrent hyperkalemia were main causes of mortality. CONCLUSION: Easy availability and low cost of PPD, lead to remarkable increase in use of the substance, especially for suicidal purpose. Awareness among health professionals and at society as well as government level is need of time. Language: en

Objective To report our experience of a series of percutaneous nephrolithotomy (PCNL) procedures in a single centre over 18 years in terms of patient and stone characteristics, indications, stone clearance and complications, along with the results of chemical analysis of stones in a subgroup. Patients and Methods We retrospectively analysed the outcomes of PCNL in 3402 patients, who underwent the procedure between 1997 and 2014, obtained from a prospectively maintained database. Data analysis included patients’ age and sex, laboratory investigations, imaging, punctured calyx, duration of operation, volume of irrigation fluid, radiation exposure time, blood transfusion, complications and stone-free status at 1-month follow-up. For the present analysis, outcomes in relation to complications and success were divided in two eras, 1997–2005 and 2006–2014, to study the differences. Results Of the 3402 patients, 2501 (73.5%) were male and 901 (26.5%) were female, giving a male:female ratio of 2.8:1. Staghorn (partial or complete) calculi were found in 27.5% of patients, while 72.5% had non-staghorn calculi. Intracorporeal energy sources used for stone fragmentation included ultrasonography in 917 patients (26.9%), pneumatic lithoclast in 1820 (53.5%), holmium laser in 141 (4.1%) and Lithoclast® master in 524 (15.4%). In the majority of patients (97.4%) a 18–22-F nephrostomy tube was placed after the procedure, while 69 patients (2.03%) underwent tubeless PCNL. The volume of the irrigation fluid used ranged from 7 to 37 L, with a mean of 28.4 L. The stone-free rate after PCNL in the first era studied was 78%, vs 83.2% in the second era, as assessed by combination of ultrasonography and plain abdominal film of the kidney, ureter and bladder. The complication rate in the first era was 21.3% as compared with 10.3% in the second era, and this difference was statistically significant. Stone analysis showed pure stones in 41% and mixed stones in 58% of patients. The majority of stones consisted of calcium oxalate. Conclusions This is the largest series of PCNL reported from any single centre in Pakistan, where there is a high prevalence of stone disease associated with infective and obstructive complications, including renal failure. PCNL as a treatment method offers an economic and effective option in the management of renal stone disease with acceptable stone clearance rates in a resource-constrained healthcare system.

The prevalence of end-stage renal disease is increasing worldwide. It is also one of the main health problems in Pakistan. Currently, hemodialysis represents the main mode of treatment for patients with end-stage renal disease in this country. Despite 24-hour free dialysis at the Sindh Institute of Urology and Transplantation (Karachi, Pakistan), a significant number of patients do not turn up for regular dialysis or miss regular sessions of dialysis. We conducted this study to identify and highlight the factors leading to poor compliance with regular hemodialysis treatment despite free dialysis treatment offered at our center.In 2014, 4565 patients with end-stage renal disease were registered at the Sindh Institute of Urology and Transplantation. Among these, 610 patients (13.4%) missed more than 2 sessions of dialysis and were included in the present study. Patients provided written informed consent before study participation. Data were collected from a questionnaire survey and analyzed by SPSS software (SPSS: An IBM Company, version 20.0, Chicago, IL, USA).Despite 24-hour dialysis facilities, the patient drop-out rate (779; 18%) was high. In addition, a significant minority of patients (610; 13.4%) was erratic in adherence to maintenance hemodialysis schedules, with2 missed appointments. The mean age of these 610 patients was 33.4 ± 7.4 years, and 345 patients (57%) were males. The main factors leading to poor compliance included cost of travel (33.2%), lack of affordable lodging and boarding facilities near dialysis center (30.9%), long distances from dialysis center (20.1%), and lack of family support (15.6%).This study shows that there is significant drop-out and poor compliance rates for regular dialysis despite free dialysis facilities.

Kidney paired exchange is an established method of overcoming incompatibility in donor-recipient pairs and expanding the living-donor pool. It is infrequently performed in developing countries. We report the first kidney paired exchange in Pakistan, successfully performed at our center. One donor-recipient pair consisted of a 38-year-old female recipient (blood type, B positive) and her 40-year-old husband (A positive) as the potential donor. The second pair consisted of a 30-year-old male recipient (A positive) and his 30-year-old wife (B positive) as the potential donor. The donors were exchanged with the recipients, and both pairs were antigen matched for human leukocyte antigen A and human leukocyte antigen DR. Luminex antibody screening was negative, as were the crossmatches for T and B cells and for IgG and IgM. The transplant procedures and recoveries proceeded uneventfully. The recipients are maintaining serum creatinine levels around 0.78 mg/dL and 0.90 mg/dL, 1 year after transplant. Kidney paired exchange is a relatively low-cost option for overcoming the barrier of incompatibility in a resource-constrained setting.

Our aim was to determine the clinical significance of borderline lymphocytic infiltrates on indicated renal allograft biopsies in a living related renal transplant setting.The study was conducted at the histopathology department of Sindh Institute of Urology and Transplantation. A retrospective review of 421 renal transplant patients was conducted from October 2007 to September 2008 to identify patients in whom a histologic diagnosis of borderline changes was made on dysfunctional renal allograft biopsies. Demographic, clinical, and laboratory data; biopsy findings; treatments given; and responses to treatment were collected and analyzed. Standard biopsy indications determined the need for graft biopsies. Biopsies were reported according to Banff criteria.Mean age was 26.92 ± 9.14 years (range, 10-45) for recipients and 38.46 ± 9.16 years (range, 19-50) for donors. Males were predominant among recipients (84.6% vs 15.4%), and females were predominant among donors (57.7% vs 42.3%). The best serum creatinine levels were 1.79 ± 1.15 mg/dL (range, 0.83-6.12). These were achieved after a median of 3 days (interquartile range, 2-7.25). Dysfunctional biopsies exhibiting borderline infiltrates were performed at a median duration of 5.5 days (interquartile range, 3-14.25). Mean serum creatinine at the time of biopsy was 2.34 ± 1.43 mg/dL (range, 1.25-8.25). The biopsies showed borderline cellular infiltrates (interstitial inflammation 1 [i1] and tubulitis 1 and [t1] lesions). All recipients except one received antirejection treatment (antithymocyte globulin, n = 5; escalation of mycophenolate mofetil dosage, n = 1; pulse steroids, n = 19); all recipients responded with a decline in serum creatinine toward baseline, with a mean serum creatinine of 1.31 ± 0.42 mg/dL (range, 0.40-2.71). This response was achieved at a median duration of 9.73 ± 5.32 days (range, 1-23) after starting treatment.The borderline cellular infiltrates on dysfunctional renal allograft biopsies signify evolving phases of acute cellular rejection. These infiltrates responded favorably to antirejection treatment in our setting.

Co-existence of angiomyolipoma (AML) and renal cell carcinoma (RCC) in the same tumor mass is very rare and only eight cases have been reported. We present a case of a young female with tuberous sclerosis complex (TSC) with bilateral huge renal AMLs. Both tumors were removed, one of which revealed co-incidental RCC. She was subsequently successfully transplanted a kidney from her brother and is maintaining normal graft function eight months post-transplant. No recurrence or metastases of RCC has been detected till the last follow-up.

Vascular endothelial growth factor (VEGF) protein plays an important role in tumor development and progression. Polymorphisms in the VEGF gene may lead to over- or underexpression of the protein and may be associated with either risk or progression of malignancy. The aim of this case-control study is to identify and quantify the correlation between VEGF polymorphisms and renal cell carcinoma (RCC).Restriction fragment length polymorphism methods were used for the analysis of VEGF polymorphisms at -2578 and +936 positions in the promoter and 3'-untranslated regions, respectively. The VEGF -2578 A-allele was associated with an increased risk of RCC (odds ratio: 1.6; 95% CI: 1.2-2.3) and A-carrier genotypes were strongly correlated (odds ratio: 2.7; 95% CI: 1.5-4.7) with higher risk. Comparison of VEGF +936 C/T polymorphism between patient and control groups revealed no association with renal carcinoma. Both VEGF -2578 C/A and VEGF +936 C/T polymorphisms showed no significant association with the histopathological parameters of RCC.This study shows that VEGF -2578 A-allele and A-carrier genotypes are associated with an increased risk of RCC. In groups with higher incidence of RCC, a screening test for this polymorphism may be recommended in conjunction with other established markers.

Aim: In the absence of a national renal biopsy registry, there is a paucity of information on the pattern of renal disease observed in native renal biopsies in adults in Pakistan. Methods: A retrospective review of native renal biopsies performed in adult patients was undertaken at the Sindh Institute of Urology and Transplantation (SIUT) during the period from July 1995 to December 2008. Renal biopsies were studied by light, immunoflourescence and electron microscopy. The renal biopsy diagnoses were categorized into the following groups: glomerulopathies (GN), tubulointerstitial diseases (TID), renal vascular diseases (VD), and hereditary diseases (HD). Results: A total of 1793 adult patients were included in the study. GN was the commonest diagnosis representing 83.9% of all biopsies. Primary GN (PGN) accounted for 86.9% and secondary GN (SGN) for 13%. When PGN was further analyzed, focal segmental glomerulosclerosis (FSGS) was the leading histopathological diagnosis, found in 29% of PGN, followed by membranous GN (MGN), seen in 23.5% of cases. Among SGN, lupus nephritis (44.1%) was the commonest, followed by amyloidosis (42.1%) and diabetic nephropathy (8.1%). TID comprised 11.6% of all renal biopsy diagnoses. VD and HD were less frequent, found in 3.9% and 0.4%, respectively. Conclusion: The pattern of biopsied renal pathology is similar to that reported recently from other parts of the world with similar biopsy indications.

Objectives : To describe decision factors and outcome of open surgical procedures in the management of children with stone. Materials and Methods : Between January 2004 and December 2008, 3969 surgical procedures were performed in 3053 children with stone disease. Procedures employed included minimally invasive techniques shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopy (URS), perurethral cystolithotripsy (PUCL), percutaneous cystolithotripsy (PCCL), and open surgery. From sociomedical records demographics, clinical history, operative procedures, complications, and outcome were recorded for all patients. Results : Of 3969 surgeries, 2794 (70%) were minimally invasive surgery (MIS) techniques to include SWL 19%, PCNL 16%, URS 18.9%, and PUCL+PCCL 16% and 1175 (30%) were open surgeries. The main factors necessitating open surgery were large stone burden 37%, anatomical abnormalities 16%, stones with renal failure 34%, gross hydronephrosis with thin cortex 58%, urinary tract infection (UTI) 25%, and failed MIS 18%. Nearly 50% of the surgeries were necessitated by economic constraints and long distance from center where one-time treatment was preferred by the patient. Stone-free rates by open surgeries were pyelolithotomy 91%, ureterolithotomy 100%, and cystolithotomy 100% with complication rate of upto 3%. Conclusions : In developing countries, large stone burden, neglected stones with renal failure, paucity of urological facilities, residence of poor patients away from tertiary centers necessitate open surgical procedures as the therapy of choice in about 1/3rd of the patients. Open surgery provides comparable success rates to MIS although the burden and nature of disease is more complex. The scope of open surgery will remain much wide for a large population for considered time in developing countries.

Donor shortage and absence of transplant law lead to unrelated commercial transplants in Pakistan. We report the socio-economic and outcome parameters of 126 local recipients of unrelated kidney vendor transplants presenting to our institute between 1997 and 2007. Their outcome was compared with 180 recipients of living-related donor transplants matched for age, gender and transplant duration as controls. Age of commercial recipients was 35.63 +/- 11.57 years with an M:F ratio of 2.4:1. Majority (92%) were transplanted in northern Pakistan paying US$7271 +/- 2198. All were educated with 50% being graduates or above and rich earning a monthly salary of US$517 +/- 518 with 44% earning >US$500. Comparison of commercial recipients with controls showed high comorbidities 35 (28%) vs. 14 (8%) (P = 0.0001) with diabetes, hepatitis-C and cardiovascular diseases. Donor age was 29.97 +/- 6.16 vs. 32.63 +/- 9.3 years (P = 0.035). Biologic agents induction in 101 (80%) vs. 14 (8%) (P = 0.0001), acute rejections in 42 (33%) vs. 31 (17%) (P = 0.005), 1-year creatinine 1.84 +/- 1.28 vs. 1.27 +/- 0.4 mg/dl (P = 0.0001), surgical complications 28 (22%) vs. 14 (8%) (P = 0.001), tuberculosis 14 (11%) vs. 6 (6%) (P = 0.007), acute hepatitis 20 (16%) vs. 3 (2%) (P = 0.0001), cytomegalovirus 33 (26%) vs. 21 (11%) (P = 0.001) and recurrent urinary tract infection 35 (28%) vs. 30 (16%) (P = 0.034). Overall 1- and 5-year graft survival was 86% and 45% vs. 94% and 80%, respectively (P = 0.00001). Total deaths were 34 (27%) vs. 12 (6.0%) (P = 0.001). In conclusion, recipients of the vended kidneys are poor candidates, educated, rich and often self-selecting. Their outcome is poor, which will leave them poorer still and back to dialysis if not death.

Background Acute rejections (ARs) with plasma cell-rich infiltrates (PCARs) are associated with poor outcomes. Patients and methods Between February 2012 and December 2013, 1630 dysfunctional renal graft biopsies were performed. Of these, 50 (3%) showed PCAR. ARs with >10% plasma cells were defined as PCAR. Human leukocyte antigen (HLA) antibodies were tested in historic sera and at the time of PCAR. Treatment for PCAR comprised methylprednisolone, antithymocyte globulin, plasmapheresis, and anti-CD20 antibody. Results Of the 1630 dysfunctional biopsies, 50 (3%) had PCAR which occurred 3.1 ± 2.55 yr after transplant. The percentage of plasma cells was 28.8 ± 11.7, and CD138, 29.0 ± 12.4. Donor-specific antibodies (DSAs) were found in 32 (64%) overall, Class I in 15% and Class II in 65%. Post-treatment serum creatinine improved from 3.80 ± 2.59 to 2.66 ± 1.59 mg/dL in DSA positive (p

We report here, a case series of patients with acute kidney injury (AKI) after ingestion of paraphenylene diamine (PPD) a derivative of analine. It is used as a colouring agent to dye hair, fur and plastic and in photographic films.Subjects for the study reported here comprised a cohort of 100 patients coming to this institution with AKI following PPD poisoning. AKI was defined according to RIFLE criteria and PPD poisoning on the basis of history and presenting features. All patients had normal sized kidneys on ultrasonography and no previous co- morbidity.One hundred patients with AKI after PPD exposure were brought to this institute between May 2010 and February 2015. Among these, 56 were females, with mean age of 23.11 ± 7.94 years. Cause of AKI was toxic rhabdomyolysis as indicated by marked rise in muscle enzymes with mean lactate dehydrogenase and creatinine phosphokinase levels of 6665.22 ± 6272.04 and 194 486.66 ± 301 905.80, respectively. Hepatotoxicity with raised aspartate aminotransferase and alanine aminotransferase was a main feature of the studied population. Renal replacement was required in 97% of patients. Complete renal recovery was observed in 77 patients, while 16 died during the acute phase of illness. Respiratory failure and recurrent hyperkalaemia were the main causes of mortality.Easy availability and low cost of PPD has lead to a remarkable increase in the use of this substance, especially for suicidal purposes. Awareness of its effects among health professionals, as well as at a societal and government level, is needed at this time.

Pakistan is a low-resource country with a population of 185 million where expenditure on health is 1.3% of the gross national product. The estimated incidence of end-stage renal disease (ESRD) is 100 per million of the population. The paucity and high costs of renal replacement therapy render more than 90% of the ESRD population disenfranchised from replacement therapy. Our center, which is a government sector organization, established as an integrated dialysis and living related renal transplant program in the 1980s, where all services were provided free of cost to all patients with life-long follow-up care including medications. The model was based on a concept of community/government partnership where the contributions to funds vary between 40% and 60% for each partner. The model has been self sustaining for 25 years, with an annual budget of $28 million in 2010. Presently, over 600 patients are dialyzed each day and each week, 7–10 patients have received live related transplants. The overall 1- and 5-year graft survival rate of 3150 transplants is 92% and 85%, respectively. Free dialysis and transplantation established our institute as a focus of transplantation in the country. This model therefore allowed the institute to have a vital role in the campaign against transplant tourism and in the promulgation of the transplant law. It shows that in low-resource countries, specialized centers in the government sector can, with community support, provide high-quality ESRD care to the disenfranchised population.

To evaluate the experience of 37 years regarding etiology, complications and evolving practice of the management of stricture urethra patients at the Sindh Institute of Urology and Transplantation, Karachi.The retrospective descriptive study included 1600 cases of stricture urethra admitted to the Urology Section of the institute from 1972 to 2009. Files of all patients were reviewed; age, gender, site of stricture, etiology, diagnostic methods, clinical symptoms and management, as well trends and patterns were noted.There were 1600 patients of whom 1595 (99.4%) were males and 5 (0.4%) were females with age ranging from 14-80 years. Pelvic fracture urethral disfraction defects (n = 655; 49.5%) and fall astride (n = 123; 9.2%) were the commonest causes. Of the total, 92 percent presented with retention of urine. In the first decade, rail-road and dilatation was the mainstay of treatment. In the second decade, rail-road, dilatation and direct visual internal urethrectomy were the mainstay, but in the last 5 years, urethroplasty replaced the old methods.Trauma is the main cause of stricture. Over the years, urethroplasty and direct visual internal urethrotomy are the mainstay of management. Stricture clinic plays an important role in the early diagnosis of complications of stricture urethra and in the rehabilitation of these patients.

Background The Glutathione S-transferases ( GST s) genes deletion polymorphisms have been associated with the progression of several cancers. The association studies between the 2 GST s ( GSTM1 and GSTT1 ) null polymorphisms with the susceptibility to renal cell carcinoma (RCC) have been inconclusive. Therefore, with the inclusion of our own data, we performed a comprehensive meta-analysis to assess the association between these 2 polymorphisms and the risk of RCC. Methods A systematic literature search was carried out for studies published in the PubMed, EMBASE, Cochrane library, and Google Scholar from 1997 to December 2014. Results were stated as pooled odds ratios (ORs) for nonparametric data after heterogeneity analysis with 95% CI using fixed effect or random effect model. Results We systematically selected 13 relevant studies after thorough searches from the databases. Data showed no association between the GSTM1 and the GSTT1 null genotypes and the risk of RCC (OR = 1.01; CI: 0.92–1.11; P = 0.89 for GSTM1 and OR = 1.14; CI: 0.91–1.42; P = 0.25 for GSTT1 ). No association was found when the data were stratified according to the geographical/ethnic basis, source of control, and the risk factor evaluation. Subgroup analysis of occupational exposure to pesticides showed an inverse association of the active genotypes of both GSTM1 and GSTT1 polymorphisms with the exposed group of RCC ( P P GSTM1/GSTT1 significantly increased the susceptibility to RCC by 1.4-fold ( P = 0.001). This association remained significant for the Asian populations in subgroup analysis (OR = 1.8; CI: 1.30–2.49; P = 0.0004). Conclusion In conclusion, this meta-analysis suggests that the 2 GST s deletion polymorphisms independently have no association with the risk of RCC. However, combination of both deletions increases the risk of developing the RCC.

To evaluate the efficacy and long-term results of laser urethrotomy as minimally invasive treatment for traumatic stricture urethra.Between January 2006 and June 2008, 78 male patients were treated with Holmium Laser urethrotomy. 16 Fr urethroscope was used through which 600um laser fiber was introduced through side channel. Stricture was visualized and incised at 12 o'clock position with energy set at 1500-2000 MJ at pulse rate of 10-12. Two other incisions were given at 2 and 10 o'clock positions. Further ablation was done till 16Fr Foley's catheter was passed. Patients were followed in a stricture clinic.Patients age ranged from 15-73 years. All strictures were due to trauma, Road traffic accident in 40 (52%) post catheter trauma 4 (5%), fall as ride 27 (35%) and failed urethroplasty 7 (8%). Site of stricture was bulbar 57 (73%), bulbomembranous 16 (20%) and membranoprostatic 5 (2.5%). Length of stricture ranged from 0.8-2.5 cms. At 3 months follow-up, 60 (77%) patients remained catheter and symptoms free while 18 (23%) developed recurrence of stricture but at the end of 36 months follow-up success rate decreased to 47 (60%). Among those who developed re-strictures, 6 ( 7.6%) had 2nd sitting laser while 4 (5.1%) had urethroplasty, and others were on intermittent dilatation. Immediate complications were sepsis 10 (13%), extravasation 2 (4%), failed urethrotomy 2 (4%) and mild haematuria 3 (5.8%). Hospital stay ranged from day care to 3 days.Laser urethrotomy is minimally invasive and an effective treatment for short strictures in bulbarurethra. The recurrence rate is 40% in the long-term follow-up and is more commonly seen in completely obliterated strictures.

To review 17 years experience of the stone clinic with incorporating the changes in practice over the years and to report the benefits of stone clinic in a developing country.The SIUT Stone clinic was established in 1990 with installation of HM4 Lithotriptor. This clinic is run jointly by a Urologist, Dietitian, Nephrologist, Biochemist and Radiologist. From 1990 - 2007, about 38,749 stone patients received treatment with ESWL (55%), PCNL (6.0%), URS (15.5%), litholopaxy 4.0% and open surgery 19.7%. These patients after treatment were followed in the stone clinic with stone analysis and 24 hours urine metabolic studies where indicated. Dietary and oral hydration programme combined with medical therapy was also instituted. Recurrence rate was noted in those patients who were advised diet modification, oral hydration and medical treatment. Complications of stone disease were documented during the follow-up period.In ESWL group 8226 patients were followed in the stone clinic for 5 years. In this group, 185 (2.2%) had recurrence of renal calculi. In PCNL group 1306 patients were followed, and 16 (1.1%) had recurrence. In the open surgery group of 1294 patients, 17 (1.3%) had recurrence of renal calculi. The complications of stone disease noted were renal failure and infections in 162 (1.5%) patients, during the follow-up period.This study shows the beneficial effect of a stone clinic in a developing country and positive effect on the reduction of recurrence and complications of stone disease. Our experience promotes the need to open more specialized stone clinics in areas where stone disease is highly prevalent.

To compare the outcome of Extra corporeal shockwave lithotripsy for a renal pelvic stone with and without JJ stent.A comparative cross sectional study was carried out at Sindh Institute of Urology and Transplantation from January 2007 to January 2008. Eighty patients with renal pelvic stone measuring 2cm +/- 2mm were selected for treatment with Extra Corporeal Shockwave Lithotripsy (ESWL). All of these patients were adults with normal renal function and had unilateral renal stones with negative urine cultures. Patients with renal failure and children were excluded. They were divided into two groups of 40 each. Group A patients underwent ESWL without a JJ stent and in Group B a JJ stent was placed before ESWL. SLX F2 electromagnetic ESWL machine was used to impart shock waves. 3000 shockwaves were given in a session. Both the groups were compared for renal colic, steinstrasse, fever, lower urinary tract symptoms (LUTS) emergency room visits and hospital admissions, stone clearance, number of ESWL sessions, auxilliary procedures, (percutaneous nephrostomy or ureterorenoscopy) and cost.Ureteric colic occurred in 13 (32.5%) patients in group A and in 3 (7.5%) patient in group B. Steinstrasse developed in 4 (10%) patients with out JJ stent and in 3 (7.5%) patients with JJ stent. Fever was encountered in 1 (2.5%) patient in group A and in 3 (7.5%) patient in group B. Mean emergency room visits were 2.1 per patient in group A and 0.7 per patient in group B. Stone clearance occurred in 33 (82.5%) patients in group A and 31 (77.5%) in group B. In group B lower urinary tract symptoms were found in 50% versus 20% in group A. Auxillary procedure was performed in one (2.5%) patient each in both groups.Pre ESWL JJ stenting for a 2 cm +/- 2 mm renal stone was not beneficial in terms of steinstrasse, fever, stone clearance and number of ESWL sessions. However ureteric colic was significantly less in the stented group. Lower urinary tract symptoms (LUTS) was also significantly high in the patients having a JJ stent. The cost of the treatment doubled in the stented group which is an important factor in our country. JJ stenting does not prove to be a cost effective procedure when compared to the reduction in complications.

To compare the efficacy of Holmium: YAG laser and pneumatic lithoclast in treating ureteric calculi.The study included total of 100 patients divided into two equal groups of laser lithotripsy (LL) and pneumatic lithoclast (PL). Study was conducted between September 2006 and February 2007. Inclusion criteria were patients with a ureteric stone of size 1-2 cm and negative urine culture. An x-ray KUB was mandatory. IVU and CT pyelogram were also done when required. Procedures were done under general anaesthesia after a single dose of pre-operative antibiotic. A 7.5 Fr semi rigid ureteroscope was used for ureteroscopy in all cases. Holmium: YAG laser with 365 microm wide probe was employed in laser group and frequency was set between 5 and 10 Hz at a power of 10 to 15 W. Swiss lithoclast with single or multiple fire technique was used accordingly in PL group. Postoperatively patients underwent radiography and helical CT as required at 4th week of follow up to asses stone clearance.The mean patient age in LL and PL group was 38 +/- 10 and 40 +/- 10 years respectively. The male to female ratio and stone size were similar between the groups. Stone migration up in pelvicalyceal system occurred in two patients of LL group while in eight patients of PL group. JJ Stent was placed in 5(10%) patients in laser group where as 13 (26%) patients required it in pneumatic lithoclast group. Stone free rate at 4 weeks was 92% in laser group as compared to 82% in pneumatic lithoclast group. Hospital stay was more than 24 hours in 2 patients of laser group as compared to 5 patients of pneumatic lithoclast group. Complication rate was 4% in LL group whereas it was 14% in PL group.Holmium: YAG laser lithotripsy is a superior technology compared to pneumatic lithoclast in terms of rate of stone clearance and complications, especially in upper ureteric stones.

To compare holmium Yag laser with lithoclast in patients with renal stones undergoing percutaneous nephrolithotomy (PCNL).A comparative cross sectional study was performed on 60 patients undergoing PCNL. Patients with a 2.5 cm stone in renal pelvis, having preoperative negative urine culture, no coagulopathy and fit for general anaesthesia were included, pregnant females were excluded. They were randomly divided into 2 groups of 30 cases each depending on the energy source used. Group A included cases of PCNL subjected to laser treatment and group B had patients undergoing PCNL with pneumatic lithoclast. For each group duration of procedure, any per operative or postoperative complication, residual stone, duration of hospital stay and cost of each procedure were recorded.The average operative time was 125.7 +/- 31.1 minutes in group A and 98.5 +/- 18.7 minutes in group B (P = 0.0001). The overall complication rate was similar in both groups being 13.3% in group A and 23.3% in group B. Residual stone was observed in 17% cases in group A and 13% cases in group B (P = 0.5). The mean postoperative hospital stay was 3.17 +/- 1.6 days in group A and 4 +/- 2.3 days in group B (P = 0.4). Cost analysis showed that the initial capital cost of equipment was 40,000 Euro in laser and 24,000 Euro in pneumatic lithoclast. However because of reuse of fiber the per procedure cost was 60 Euro in laser and 50 Euro in lithoclast group.In our experience we found that Holmium: YAG laser and pneumatic lithoclast are both effective and safe lithotriptors for percutaneous stone removal. More operating time was required in laser, more complications encountered with pneumatic lithoclast and a high initial cost of laser. However with increasing experience with laser, more promising results are expected with this new technology. The cost can be compensated by using it in other procedures especially at a public sector hospital.

In recent years, Pakistan has emerged as one of the largest centres for commerce and tourism in renal transplantation. Kidney vendors belong to Punjab in eastern Pakistan, the agricultural heartland, where 34% people live below poverty line. We report results of a socioeconomic and health survey of 239 kidney vendors. The mean age was 33.6 +/- 7.2 years (M:F 3.5:1). Mean nephrectomy period was 4.8 +/- 2.3 years. Ninety per cent of the vendors were illiterate. Sixty-nine per cent were bonded labourers who were virtual slaves to landlords, labourers 12%, housewives 8.5% and unemployed 11%. Monthly income was $US15.4 +/- 8.9 with 2-11 dependents per family. Majority (93%), vended for debt repayment with mean debt of $1311.4 +/- 819. The mean agreed sale price was $1737 +/- 262. However, they received $1377 +/- 196 after deduction for hospital and travel expenses. Postvending 88% had no economic improvement in their lives and 98% reported deterioration in general health status. Future vending was encouraged by 35% to pay off debts and freedom from bondage. This study gives a snapshot of kidney vendors from Pakistan. These impoverished people, many in bondage, are examples of modern day slavery. They will remain exploited until law against bondage is implemented and new laws are introduced to ban commerce and transplant tourism in Pakistan.

To find the relationship between human leukocyte antigens (HLA) and cryoglobulin positivity in hepatitis C virus (HCV) infected individuals.Eligible individuals selected from pre and post renal transplant settings were divided into three groups. Group A (n = 301) consisted of normal controls, while group B (n = 200) comprised of pathological controls that were HCV antibody (anti-HCV) positive but negative for cryoglobulins. Group C comprised of 56 anti-HCV positive, cryoglobulin positive patients. HLA-A, -B and -DRB1 loci were typed by polymerase chain reaction (PCR) method and relationship between HLA antigens, anti-HCV status and cryoglobulinaemia was analyzed.HLA-A*02, -B*57 and -DRB1*03 were more frequently found among group C members as compared to groups A and B. Only HLA-B* 57 occurrence reached statistical significance (14.3% versus 6% and 4%, corrected P-value = 0.045 and 0.012 and OR = 2.6 and 4 respectively) No differences in the distribution of HLA antigens were seen among healthy and pathological controls.The presence of HLA-B*57 confers susceptibility to cryoglobulinaemia in HCV infected patients in our population. HCV positive renal transplant recipients with these alleles should be monitored for cryoglobulin formation).

To determine the pattern of excretion of total bilirubin IXa and IXb in the first meconium of newborn infants.First two newborns of varying gestational age were selected every week through random sampling from the neonatal unit. Of the 41 newborn infants selected 8 expired before meconium passage, hence the results are from 33 newborns. Meconium was collected and stored at -20 degrees C, protected by aluminium foil. Samples were defrosted, vortex mixed with equal amount of dimethyl-sulfoxide, centrifuged, and analyzed by HPLC.Unconjugated Bilirubin-IXalpha and -IXbeta were identified and quantitative estimation of Bilirubin-IXa done. Bilirubin-IXb was greater than 50% of the total, in the first meconium of the newborn. Amount of bilirubin excreted in meconium was 29.2 - 90.8 mg [0.051 - 0.155 mmol] per sample of meconium passed. Amount was 9.7 mg/ Kg of body weight in term newborn and 12 mg/kg in preterm.The amount of bilirubin -IXb decreases and bilirubin-IXa increases with increasing gestational age. Newborns with birth asphyxia (BA) had significantly greater quantity of bilirubin in meconium, compared to infants without BA.

To evaluate the effect of cyclosporine (CSA) on serum magnesium and its fractional excretion in renal transplant recipients.A cross sectional comparative study on 50 live related renal transplant recipients on CSA therapy with serum creatinine2.0 mg/dl and 30 healthy controls. Serum creatinine, magnesium and its fractional excretion and CSA levels were monitored. Patients were followed at 6 months.The mean serum creatinine in patients was 1.41 +/- 0.42 mg/dl, cyclosporine 210 +/- 66 ng/ml at a dose of 4.8 +/- 1.4 mg/kg/day. The serum magnesium was 1.77 +/- 0.32 mg/dl vs 1.98 +/- 0.17 mg/dl in healthy controls (p0.05). Fractional excretion was 5.05 +/- 2.53% in patients vs 2.8 +/- 1.05% in controls (p0.05). No correlation was found between CSA levels (100-400 ng/ml) and serum magnesium (r = 0.053) or FEMg% (r = 0.215). Of the 50 recipients 27 (54%) had FEMg% in the control range. At 6 months follow up no difference in CSA levels was found between recipients with FEMg% in the normal range vs those with FEMg5%. However, serum creatinine increased from 1.42 +/- 0.30 mg/dl to 1.68 +/- 0.82 mg/dl (p0.05).CSA therapy lowers serum magnesium as compared to healthy controls and there is marked increase in FEMg% in 50% of the patients. Patients with FEMg5% developed renal function deterioration. FEMg percent can thus be a good follow up marker of CSA chronic toxicity in stable transplant recipients.