New Markers of Bone Fragility in Hemodialysis Patients: A Monocentric Study

INTRODUCTION

Mechanisms underlying bone fragility in patients under dialysis are various. The assessment of bone disorder is not yet codified in these patients. Our study aimed to determine the relationship between the serum fibroblast growth factor 23 (FGF23) level and bone fragility. We also aimed to assess the bone alkaline phosphatase (bAP) to the C-terminal telopeptide of type I (CTX) ratio and the FGF23*bAP product to CTX ratio in patients under hemodialysis.

METHODOLOGY

We conducted a cross-sectional study, including 76 patients under hemodialysis. To assess bone fragility, we measured bAP, CTX, and FGF 23. We calculated the bAP to the CTX ratio (bAP/CTX) and the FGF23*bAP product to the CTX ratio (FGF23*bAP/CTX). We defined bone fragility as the existence of osteoporosis or fragility fractures. Receiver operating characteristic (ROC) curves were evaluated for each biological using the existence of osteoporosis or fragility fracture as the gold standard for bone fragility.

RESULTS

There were 51 men. The mean age was 53.36 ± 14.27 years. Bone fragility was noted in 25 cases. Patients with osteoporosis had higher FGF*bAP/CTX and bAP/CTX ratios. The ability of the ratio (bAP/CTX) to distinguish patients with osteoporosis from those without osteoporosis was good, with a ROC AUC of 0.707. The optimal ratio cut-off value with the highest accuracy was 9.72. The ability of the ratio (FGF23*bAP/CTX) to distinguish patients with bone fragility was good, with a ROC AUC of 0.701. The optimal ratio cut-off value with the highest accuracy was 1621.89 (sensitivity 60%, specificity 78.4%).

CONCLUSION

Our study showed FGF23, FGF23*bAP product to CTX ratio, and the bAP to CTX ratio can be used as markers of bone fragility in hemodialysis patients. Therefore, these noninvasive and relatively inexpensive methods may serve to diagnose bone fragility in patients under hemodialysis.

Mineral bone disorder and osteoporosis in hemodialysis patients

BACKGROUND

Bone disease is common in patients undergoing hemodialysis. It is the result of bone turnover abnormalities and the decrease of bone mineral density (BMD). We aimed to determine the usefulness of serum bone turnover markers and BMD measurement by dual-energy x-ray absorptiometry (DXA) in hemodialysis patients.

METHODS

We conducted a cross-sectional study including 90 hemodialysis for more than 12 months. Bone mineral density was assessed by DXA. Peripheral blood samples were obtained from each patient before dialysis in a fasting state within a week of the DXA. Biochemical variables of calcium and phosphate were measured. One bone formation marker (bone-specific alkaline phosphatase (bAP), one bone resorption marker (carboxy-terminal telopeptides of type 1 collagen (CTX)) were measured. Total alkaline phosphatase (TAP), intact parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) which is a bone-derived hormone were also measured.

RESULTS

CTX values were 6.25 times higher than the normal limit of the assay. Bone alkaline phosphatase levels were less than 10 ng/mL in 28.8% of cases. 23% of patients have osteoporosis and 45% have osteopenia. Femoral BMD had negative correlations with age and PTH levels. FGF23 levels were significantly increased in patients with osteoporosis affecting the lumbar. The levels of bAP and CTX showed a positive correlation. Both circulating bAP and CTX levels showed also positive correlations with PTH levels. Fractures, observed in 12.2% of cases, were associated with low PTH values and the existence of osteoporosis.

CONCLUSIONS

Our study showed that osteoporosis and fracture are common in dialysis patients. The reduced BMD was associated with advanced age and elevated levels of PTH. Markers of bone turnover and FGF23 may play a role in the diagnosis of bone disease in hemodialysis patients. DXA measurement is necessary for the monitoring for bone loss.

Determinants of patency of arteriovenous fistula in hemodialysis patients

The arteriovenous fistula (AVF) is the vascular access of the first choice for hemodialysis (HD). Studies on patency of AVF and its affecting factors reveal a high risk for access failure. The aim of this study was to assess the primary and secondary AVF patency and their determinant factors. It was a retrospective, descriptive study conducted in the HD facility of the Nephrology Department in Rabta University Hospital. We included AVF created before December 2009 in end-stage renal disease (ESRD) patients. The end of the follow-up was fixed in December 2013. We included 126 AVFs created in 111 patients; 22.5% were aged >65 years, 39.6% were diabetic, 68.5% were hypertensive, and 26.1% had peripheral vascular disease. The primary patency rates were 78% at one year and 42% at five years. The secondary patency rates were 80% at one year and 69% at five years. Multivariate analysis revealed that the factors affecting the primary patency of AVF were: the use of jugular catheter for longer than three months (odds ratio (OR):1.91, P = 0.044) and a C-reactive protein >5 mg/L (OR: 1.7, P = 0.049). Aging (>65 years) (OR: 2.46, P = 0.042), referral time to a nephrologist <6 months before onset of ESRD (OR: 2.87, P = 0.015), absence of an antiplatelet therapy (OR: 4.47, P = 0.005), and serum phosphorus <45 mg/L (OR: 2.07, P = 0.045) were the significant impairing risk factors for secondary AVF patency. Our study suggests that early referral and creation of AVF and maturation before ESRD as well as its adequate monitoring are essential for maintaining patency.

Renal Involvement in 2 Siblings With Cockayne Syndrome

Renal involvement in Cockayne syndrome is rare and its pathogenesis is yet unknown. We report herein 2 cases (siblings) with Cockayne syndrome type A confirmed by biochemical and molecular assays. The first case was a 13-year-old girl who presented with nephritic syndrome and a rapidly progressive kidney failure. Her younger sister, 7 years old, exhibited hypertension, hyperfiltration, and microalbuminuria. She had hyperreninemia and hyperaldosteronemia without kidney failure or renal arterial stenosis. Renal biopsy, performed the older sister, revealed cystic focal segmental glomerulosclerosis, arteriosclerosis, tubulointerstitial fibrosis, and tubular atrophy. The different clinical phenotypes in the two siblings support the absence of an obvious genotype-phenotype correlation in Cockayne syndrome type A patients. In the older sister, the particular focal glomerular sclerosis and senile lesions assume that kidney disease in Cockayne syndrome may be related to prematurely aging secondary to a defective nucleotide repair.

Acute tubular necrosis following transurethral resection of the Prostate using Glycine as irrigating fluid

Transurethral resection of the prostate is currently the gold standard for the surgical treatment of the benign prostatic hyperplasia. This surgery may lead transurethral resection of the prostate (TURP) syndrome and in some cases, acute tubular necrosis can develop. We report a patient who developed hyponatremia, hemolysis and oliguric acute renal failure as a major complication following TURP using glycine as irrigating fluid.A 64-year-old man was admitted for a prostate resection procedure. Physical examination revealed a healthy elderly man. Preoperative laboratory data showed serum sodium 140 mEq/L, blood urea nitrogen (BUN) 0.6 g/L, creatinine 0.7 mg/dL and hemoglobin 12.9 g/dL. Few hours after, the patient becomes incoherent and developed oliguria, nausea and vomiting. The laboratory data revealed rapidly elevating BUN and creatinine levels (BUN 2.4 g/L; creatinine 6.1 mg/dL), the serum sodium concentration decreased by 14 meq/L. A decreased hemoglobin level (7.4 g/dL) with an elevated lactate dehydrogenase level (665 U/L) was observed. Renal ultrasonography was normal. The diagnosis of acute tubular necrosis complicating TURP syndrome was retained. The hyponatremia was slowly corrected to 132 mmol/L by diuresis and fluid restriction. The renal function recovered after four hemodialysis sessions. Using glycine as an irrigant for TURP may cause hyponatremia, hemolysis and also acute renal failure, especially in patients with longer resection time. It is necessary to carry out every effort to shorten resection time and avoid extravasation during surgery.

Malignant hypertension-associated thrombotic microangiopathy following cocaine use

Cocaine is one of the most commonly used illicit drugs with distribution and consumption throughout the world. Acute renal failure associated with rhabdomyolysis, direct vasoconstriction and hemodynamic alteration is well described in patients with cocaine intoxication. Cocaine use is associated with high blood pressure and may rarely induce malignant hypertension associated with thrombotic microangiopathy. We report the case of a patient who developed malignant hypertension associated with thrombotic microangiopathy after chronic consumption of cocaine. A kidney biopsy revealed thrombotic microangiopathy with fibrinoid necrosis of arterioles and glomerular tufts. He required dialysis sessions. Cocaine-mediated endothelial injury and platelet activation may play important pathogenetic roles in cocaine abusers who develop malignant hypertension associated with thrombotic microangiopathy. Clinicians need to be aware of this rare feature of cocaine intoxication.

The tunneled catheter for haemodialysis: about 52 cases

BACKGROUND

Vascular access is a basic and essential tool required for performing renal replacement therapy in end stage renal disease.

AIM

To study the indications of tunneled catheter (KTT) in hemodialysis (HD), identify complications related to the use of KTT and contributing factors, assess the survival and performance of the technique.

INTRODUCTION

The making of a vascular access is an angular piece for adequate HD and in good conditions. In this context the KTT may be an alternative.

METHODS

A retrospective study of 52 KTT placed in 49 patients collected in the department of Nephrology Dialysis and Renal Transplantation in RABTA Tunis between 2008 and 2011.

RESULTS

The average age of our patients was 55.58 years ± 13.5 years, their Sex ratio was 0.79. The Thirty of our patients were diabetic, 46.2% had hypertension and 21.2% had underlying cardiac disease. The mean duration of HD was 1111.35 days or 37 months. The most common indication of KTT was the absence of arteriovenous fistula in 65.4% of cases, other indications were: short survival (30.7%), the exhaustion of venous capital (34.6%), mediacalcosis (34.6%) and immunosuppression (36.5%). The right internal jugular vein was the choice of insertion site with 78.8%. The overall incidence of immediate complications was 19.2%. Among our patients, 31.4% had a dysfunction. The period of HD represent the risk factor for dysfunction KTT (p = 0.006).An infectious complication was observed in 29% of cases. The median time to onset of infection was 190.83 days. Staphylococcus was isolated in 40% of cases. The average duration of use of KTT was 238 days. The only single factor determining the survival of KTT was the number of KTT put in the same patient.

CONCLUSION

More than a quarter of the population are dialyzed through a catheter. Despite concerted efforts, much remains to be done for the confection at time of a permanent vascular access.

Kidney involvement in Crow-Fukase syndrome

Crow-Fukase syndrome, also known as POEMS syndrome, is a rare plasma dyscrasia characterized by monoclonal gammopathy and various combinations of polyneuropathy, organomegaly, endocrinopathy and dermatological changes, and their initials stand for the acronym POEMS. Substantial kidney involvement is rarely related to this disease. Our report is about five patients suffering from the POEMS syndrome with kidney involvement that rapidly progressed to end-stage renal disease. Our report is about three females and two males with a mean age of 60.6 years. Neuropathy was noted in all the cases. Endocrinopathy included hypothyroidism and/or diabetes. Skin changes were noted in one case, and included peri-orbital hyperpigmentation. Monoclonal gammopathy was present in all the cases and was related to multiple myeloma in three cases. Kidney involvement presented in all the five cases. Treatment included Melphalan, Thalidomid, steroids and hemodialysis. Survival was short for three patients, from five to 34 months.

Therapeutic efficacy of a biosimilar epoetin alfa in hemodialysis patients

Anemia is a frequent complication in patients with chronic kidney disease. However, human recombinant erythropoietin (rHu-EPO) has revolutionized the management of anemia in chronically dialyzed patients. Epomax ® is a new rHu-EPO alfa manufactured in Tunisia (Medis Laboratories). The aim of this study was to evaluate the efficacy and tolerance of Epomax ® in chronic hemodialysis (HD) patients in a phase-III, multicenter, clinical trial. Fiftythree HD patients (mean age 47.7 ± 13 years) who received a stable dose of rHu-EPO (Hemax ® , a rHu-EPO alfa manufactured by Biosidus Laboratories) subcutaneously were switched to Epomax ® via the same route of administration. At baseline, the mean systolic pressure was 132 ± 18 mm Hg and the mean diastolic pressure was 79 ± 8 mm Hg. The mean blood hemoglobin was 10.2 g/dL and the median ferritin level was 667 ng/mL. After a follow-up of 43 days, the mean blood hemoglobin was 10.5 g/dL under the effect of Epomax ® . There was no significant difference in the mean hemoglobin levels between the treatments with both drugs. Few adverse events were reported during the study. We conclude that Epomax ® was effective at maintaining the hemoglobin levels at target concentrations and was well tolerated in HD patients.

Osteomalacia complicating renal tubular acidosis in association with Sjogren's syndrome

Renal involvement in Sjogren's syndrome (SS) is not uncommon and may precede other complaints. Tubulointerstitial nephritis is the most common renal disease in SS and may lead to renal tubular acidosis (RTA), which in turn may cause osteomalacia. Nevertheless, osteomalacia rarely occurs as the first manifestation of a renal tubule disorder due to SS. We herewith describe a 43-year-old woman who was admitted to our hospital for weakness, lumbago and inability to walk. X-ray of the long bones showed extensive demineralization of the bones. Laboratory investigations revealed chronic kidney disease with serum creatinine of 2.3 mg/dL and creatinine clearance of 40 mL/min, hypokalemia (3.2 mmol/L), hypophosphatemia (0.4 mmol/L), hypocalcemia (2.14 mmol/L) and hyperchloremic metabolic acidosis (chlorine: 114 mmol/L; alkaline reserve: 14 mmol/L). The serum alkaline phosphatase levels were elevated. The serum levels of 25-hydroxyvitamin D and 1,25-dihydroxy vitamin D were low and borderline low, respectively, and the parathyroid hormone level was 70 pg/L. Urinalysis showed inappropriate alkaline urine (urinary PH: 7), glycosuria with normal blood glucose, phosphaturia and uricosuria. These values indicated the presence of both distal and proximal RTA. Our patient reported dryness of the mouth and eyes and Schirmer's test showed xerophthalmia. An accessory salivary gland biopsy showed changes corresponding to stage IV of Chisholm and Masson score. Kidney biopsy showed diffuse and severe tubulo-interstitial nephritis with dense lymphoplasmocyte infiltrates. Sicca syndrome and renal interstitial infiltrates indicated SS as the underlying cause of the RTA and osteomalacia. The patient received alkalinization, vitamin D (Sterogyl ®), calcium supplements and steroids in an initial dose of 1 mg/kg/day, tapered to 10 mg daily. The prognosis was favorable and the serum creatinine level was 1.7 mg/dL, calcium was 2.2 mmol/L and serum phosphate was 0.9 mmol/L.

Renal paraneoplastic vasculitis complicating lung adenocarcinoma

Renal paraneoplastic vasculitis (RNPV) is rare. It can be revealed by glomerulonephritis, microaneurysms or renal failure. RPNV may precede the onset of the primary tumor, and treatment and prognosis depend on the etiology (primary tumor). A 54-year-old man who had a primary lung adenocarcinoma was admitted for nephrotic syndrome. The investigations revealed RNPV. The patient was treated with corticosteroids at high dose and cyclophosphamide with improvement of the renal condition; however, the patient died from worsening of his pulmonary neoplasia.

Subcutis calcinosis caused by injection of calcium-containing heparin in a chronic kidney injury patient

Subcutis calcinosis, characterized by abnormal calcium deposits in the skin, is a rare complication of using calcium-containing heparin occurring in patients with advanced renal failure. We report the case of an 83-year-old female, a known case of chronic kidney disease (CKD) for four years with recent worsening of renal failure requiring hospitalization and hemodialysis. She developed subcutis calcinosis following injection of calcium-containing heparin. Biochemical tests showed serum parathormone level at 400 pg/dL, hypercalcemia, elevated calcium-phosphate product and monoclonal gammopathy related to multiple myeloma. She developed firm subcutaneous nodules in the abdomen and the thighs, the injection sites of Calciparin ® (calcium nadroparin) that was given as a preventive measure against deep vein thrombosis. The diagnosis of subcutis calcinosis was confirmed by the histological examination showing calcium deposit in the dermis and hypodermis. These lesions completely disappeared after discontinuing calcium nadroparin injections. Subcutis calcinosis caused by injections of calcium-containing heparin is rare, and, to the best our knowledge, not more than 12 cases have been reported in the literature. Pathogenesis is not well established but is attributed to the calcium disorders usually seen in advanced renal failure. Diagnosis is confirmed by histological tests. Outcome is mostly favorable. The main differential diagnosis is calciphylaxis, which has a poor prognosis. Even though rarely reported, we should be aware that CKD patients with elevated calcium-phosphorus product can develop subcutis calcinosis induced by calcium-containing heparin. When it occurs, fortunately and unlike calciphylaxis, outcome is favorable.

Kaposi's sarcoma with HHV8 infection and ANCA-associated vasculitis in a hemodialysis patient

The association between Kaposi's sarcoma (KS) and human herpes virus eight (HHV-8) infection is rarely reported in hemodialysis (HD) patients. We report here the rare association of KS, HHV-8 and hepatitis C virus (HCV) infection as well as syphilis in a HD patient. We report the case of a 72-year-old woman who presented with microscopic polyangiitis with alveolar hemorrhage and pauci-immune necrosing and crescentic glomerulonephritis as well as renal failure requiring HD. Biological tests showed positive HCV and syphilis tests. The patient was treated by HD and intravenous pulse, followed by oral corticosteroids and six cyclophosphamide monthly pulses with remission of the alveolar hemorrhage, but without renal functional recovery as the patient remained HD dependent. Five months after the first treatment administration, she developed extensive purpuric lesions on her lower limbs, abdomen face and neck. A skin biopsy showed KS. The HHV-8 test was positive, with positive polymerase chain reaction-HHV8 in the serum and skin. After immunosuppression withdrawal, the KS skin lesions regressed rapidly without relapse after 12 months of follow-up, but alveolar hemorrhage relapsed after 16 months of follow-up. Our case showed that the immunosuppressed state related to multiple factors such as aging, vasculitis, HHV-8, HCV, syphilis, immunosuppressive therapy and HD may all have contributed to the development of KS in our patient.

Alveolar hemorrhage and kidney disease: characteristics and therapy

Anti-neutrophil cytoplasmic antibody-associated vasculitis and Goodpasture's glomerular basement membrane disease are the most common causes of diffuse alveolar hemorrhage, a life-threatening disease. Systemic lupus erythematosus and the antiphospholipid syndrome are also causes of alveolar hemorrhage. We retrospectively reviewed 15 cases of diffuse alveolar hemorrhage (DAH) associated with renal diseases. Diagnosis of DAH was based on the presence of bloody bronchoalveolar lavage fluid. There were three men and 12 women, with a mean age of 50.5 years (extremes: 24-74 years). Proteinuria and hematuria were observed, respectively, in 15 and 14 cases. Six patients revealed arterial hypertension. Crescentic glomerulonephritis was diagnosed with kidney biopsies in ten cases. The etiology of renal disease was microscopic polyangiitis (MPA) in seven cases, Wegener disease in four cases, systemic lupus erythematous in one case, cryoglobulinemia in one case, myeloma in one case and propyl-thiouracil-induced MPA in one case. Hemoptysis occurred in 14 cases. The mean serum level of hemoglobin was 7.1 g/dL (5.1-10 g/dL). The mean serum creatinine concentration was 7.07 mg/dL (2.4-13.7 mg/dL). Gas exchange was severely compromised, with an oxygenation index <80 mmHg in 14 patients and <60 mmHg in seven patients. Bronchoalveolar lavage was performed in 11 cases, and had positive findings for hemorrhage in all. Methylprednisolone pulses and cyclophosphamide were used in 14 patients. Plasmapheresis was performed in three cases. One patient received cycles of Dexamethasome-Melphalan. Three patients died as a result of DAH. The mortality rate in our study was 20%.

The pattern of histologically-proven acute post-infectious glomerulonephritis in Tunisian adults seen in 1976-2004

INTRODUCTION

Acute post-infectious glomerulonephritis (APIGN) is uncommon in adults. It is widely recognized that the prognosis of APIGN is good in children. There is however little information about its long-term prognosis in adults.

METHODS

Between December 1976 and October 2004, 148 adult cases of APIGN were managed in our center. We retrospectively reviewed these patients' records and evaluated their clinical course and outcome.

RESULTS

The mean age of studied patients was 36 ± 15 years, and the male to female ratio was 2.3. The most common site of preceding infection was the respiratory tract (68.8%). At presentation, 89.2% had nephritic syndrome and 9.4% had rapidly progressive glomerulonephritis. Proteinuria was observed in 99.3%, hematuria in 95.3%, peripheral edema in 89.2% and hypertension in 81.8%. Most patients (60.7%) had acute kidney injury and four patients (2.7%) required dialysis. Renal biopsy showed diffuse endocapillary proliferative glomerulonephritis in 88.8% of patients, associated with extracapillary proliferation in 12%. After a median follow-up of 2.5 year, only two patients died and 16.12% of patients had persistent clinical and/or biological abnormality. Chronic kidney disease was noted in 10 patients (6.75%) including four patients (2.7%) who progressed to end-stage renal disease. Poor prognostic factors included nephrotic range proteinuria, extracapillary proliferation in renal biopsy, acute kidney injury and the need for dialysis.

CONCLUSION

In this cohort of patients, APIGN progressed to chronic kidney disease in less than 10% of patients.

[Etiologic profile of amyloidosis of the elderly in Tunisia]

BACKGROUND

The amyloidosis is one of the histologic lesions the most frequently associated to the aging.

AIM

To identify the several etiologies of amyloidosis in elderly patients according to immunohistochemical type.

METHODS

Retrospective study on 10 years, in Internal medicine and Nephrology department in Charles Nicolle Hospital. Tunis. Tunisia. Diagnosis of amyloidosis was retained after histological confirmation with specific colorations, in patients aged 65 years or more at the diagnose of amyloidosis.

RESULTS

The study enrolled 51 patients with amyloidosis. In 67% of cases it was AA amyloidosis. The etiology the most frequently observed with this type was the tuberculosis, followed by chronic pulmonary infections. We retained diagnose of non AA amyloidosis in 21% of patients. The multiple myeloma has been the most frequent etiology observed, but no cause was identified at about half of patients. Twelve per cent of amyloidosis were not typed.

CONCLUSION

From our study, we can remark the high predominance of AA amyloidosis, probably because of frequency of tuberculosis which is still high in our country, this is not in accordance with occidental data, were AL amyloidosis and senile amyloidosis predominate in elderly.

Histopathological spectrum of childhood idiopathic steroid-resistant nephrotic syndrome in Tunisia

BACKGROUND

In children, renal biopsy is routinely required in the management of idiopathic steroid-resistant nephrotic syndrome particularly prior to starting nephrotoxic immunosuppressive agents.

AIM

To investigate the correlations between the results of initial renal biopsy in Tunisian children with idiopathic steroid-resistant nephrotic syndrome and the subsequent response to cyclosporineprednisolone combination.

METHODS

We conducted a retrospective study of children with idiopathic steroid-resistant nephrotic syndrome over the period 2002- 2009. Data on clinico-biological features, histological diagnosis and response to cyclosporine-prednisolone were collected.

RESULTS

Thirty patients were enrolled, of whom 16 had focal segmental glomerulosclerosis, eight had minimal change disease and six had diffuse mesangial proliferation. Complete Remission was achieved in 15 patients (50%). Nine patients (30%) went into partial remission. Only six patients presented no response (20%). No statistically significant relationship between the different pathological types and the response to CsA-prednisone was found.

CONCLUSION

In our study, two important facts were noted: 1) the predominant histopathological subtype was the focal segmental glomerulosclerosis; 2) a high remission rate was achieved in our patients using a combined cyclosporine-prednisolone treatment regimen. This response is not dependent on the histological type.

[A rare cause of pruritus in an hemodialysed patient]

BACKGROUND

Uremic pruritus is frequent in patients undergoing hemodialysis. It's multifactorial secondary in most cases to metabolic complications related to uremia.

AIM

We report a rare cause of pruritus in an haemodialysed patient.

OBSERVATION

It's a 48-year-old woman in periodic haemodialysis during 17 years. She suffered from generalized pruritus associated with psychiatric disturbance without neurologic deficits. CT scan and magnetic resonance imaging revealed extensive, diffuse and bilateral involvement of the white matter. The diagnosis of large low grade B cell lymphoma was confirmed by the histologic examination of stereotactic biopsy which leads to early intracranial hemorrhage and death.

CONCLUSION

Before attributing pruritus to renal failure, one should exclude other causes such as the NHL even rarely reported especially when it associated with psychiatric disturbances. CT scan and magnetic resonance imaging contribute to diagnosis.

[Calciphylaxis in chronic renal failure: 3 cases]

BACKGROUND

Calciphylaxis is a small vessel disease responsible for vascular calcification and skin necrosis. It occurs in association with chronic renal failure and has a poor prognosis. BUT: Report new cases. We report 3 cases of calciphylaxis occurred in patients with chronic renal failure secondary to interstitial nephritis in 1 case, diabetic nephropathy in 1 case and thrombotic microangiopathy in 1 case.

CASES

They were 2 females an 1 man aged of 44, 3 years meanly. Hyperphosphoremia and hyperparathyroidism were the essential risk factors. All patients died by sepsis. This course was precipitating by corticotherapy in 2 cases.

CONCLUSION

Early recognition and treatment of risk factors is mandatory to reduce mortality in uremic patients with calciphylaxis.

[Renal amyloidosis during Behçet's disease. Study of one case]

BACKGROUND

Amyloidosis in Behçet's disease is rare and has a poor outcome.

AIM

Report a new case.

CASE

We report a case of a 38-year-old Tunisian woman who presented with Behçet's disease and nephrotic syndrome. Renal biopsy showed amyloid deposition consistent with AA type. She had not any associated disease that might be an additional cause of secondary amyloidosis. She was treated by colchicine. After 3 years, proteinuria had disappeared and persisted negative 11 years after the diagnosis. A second renal biopsy showed the persistence of amyloidosis.

CONCLUSION

As amyloidosis is one of the prognostic factors affecting survival in Behçet's disease, patients with this disease should be screened for amyloidosis. Administration of colchicine to these patients may be beneficial.

[Vascular trombosis of renal graft: 9 cases]

BACKGROUND

Allograft renal thrombosis can occur in 1 to 6% of cases. Many predisposing factors has been identified especially alteration of coagulation.

AIM

We analyzed in this study frequency and predisposing factors of renal graft thrombosis.

METHODS

We report a retrospective study including 319 renal transplant recipients.

RESULTS

Nine patients (2.8%) presented veinous graft thrombosis in 5 cases and arterial thombosis in 4 cases. There were 6 men and 3 women aged of 30.6 years meanly (10-56) which developed the thrombosis 6 days (1-48) after the transplantation. All patients were detransplanted after 16.2 days and 1 patient died.

CONCLUSION

Thrombosis constitute an important cause of graft loss. A perfect surgical technic and prophylactic treatment in high risk patients are necessary to reduce this complication.

Bleeding and thrombosis in a patient with secondary antiphospholipid syndrome

Antiphospholipid antibodies have been associated with occurrence of arterial and venous thrombotic events and fetal loss, which together constitute the antiphospholipid syndrome (APS). However, bleeding is rare in this syndrome. We report a case of systemic lupus erythematosus (SLE) with APS complicated simultaneously by thrombotic and hemorrhagic events. A 34-year-old woman was a known case of diffuse proliferative lupus nephritis associated with APS, on treatment with corticosteroids, cyclophosphamide and anticoagulants. She presented in February 2004 with severe anemia, menorrhagia, gingival bleeding and acute loss of vision in the left eye. Investigations revealed a hematoma in the psoas muscle with thrombosis of the inferior vena cava and occlusion of the retinal vein. Blood tests revealed a strongly positive lupus anticoagulant, factor XI deficiency (35%) and decrease of free protein S (44%). Factor XI inhibitor, anti-prothrombin, and anti-protein S antibodies were absent. The patient was treated with corticosteroids and six pulses of cyclophosphamide, which resulted in a rapid disappearance of bleeding, reduction of hematoma and normalization of hematological abnormalities. She was maintained on corticosteroids, azathioprine and anticoagulant agents were introduced. After a follow-up of 28 months, there was no recurrence of bleeding, the thrombosis had resolved, and there was a decrease in the levels of circulating anticoagulant as well as anticardiolipin antibodies.

Interstitial and glomerular renal involvement in sarcoidosis

Sarcoidosis is a systemic disease characterized by chronic granulomatous inflammation. Chronic kidney disease (CKD) was reported in less than 1% of patients of sarcoidosis. The prevalence of tubulo-interstitial nephritis (TIN) in sarcoidosis varies from 7 to 27%. In this retrospective study, we present 15 patients with interstitial or glomerular renal involvement secondary to sarcoidosis diagnosed in our center from 1975 to 2006. Patients were 13 (96.6%) females and two males with a mean age of 56.5 years. CKD was present in 14(93.3%) patients, proteinuria in 13(96.6%), and nephrotic syndrome in one. Pulmonary involvement was present in 10 (66.6%) patients. Renal biopsy performed in 12 (80%) patients revealed TIN lesions in 10 (66.6%) patients, extracapillary proliferative glomerulonephritis (GN) in one, and membranous GN type 2 in another. Corticosteroid therapy using prednisolone 0.5 to 1 mg/kg per day was used in 12(80%) patients. Ten (66.6%) patients were followed up for a mean period of 25 months (ranged from 2 to 48 months). The outcome was favorable with 7 (46.6%) patients improved their renal function, 6 (40%) remained with a moderate CKD, one normalized his renal function, and one died suddenly after 2 months of initiating the treatment corticosteroids. We conclude that corticosteroid treatment is efficient in TIN and variably efficient in GN. Patients with sarcoidosis may cause advanced renal failure, which renders it a serious nephrological condition.

MEFV Mutations in Tunisian Patients Suffering from Familial Mediterranean Fever

OBJECTIVES

To identify the frequency and distribution of familial Mediterranean fever (FMF) gene (MEFV) mutations in Tunisian patients.

PATIENTS AND METHODS

This study was performed in the Genetic Department of Tunis University Hospital. A clinical diagnosis of FMF was made according to published criteria. Mutation screening of the MEFV gene was performed in the Human Genetic Laboratory of the "Faculté de Medecine de Tunis" for 8 mutations including the 5 most common known mutations M694V, V726A, M694l, M680l, and E148Q. The tests performed were polymerase chain reaction (PCR) restriction-digestion for M694V, V726A, M680l, R761H, E148Q; amplification refractory mutation system for A744S, M694l; and PCR-electrophoresis assay for l692del.

RESULTS

Of the 139 unrelated patients investigated, 61 (44%) had 1 or 2 mutations. In 78 (56%) probands no mutation was identified: 28 patients were homozygous; 16 were compound-heterozygous; 2 had complex alleles; and 17 had only 1 identifiable mutation. Of the mutations, M680l, M694V, M694l, V726A, A744S, R761H, l692DEL, and E148Q accounted for 32, 27, 13, 5, 3, 1, 1, and 18%, respectively.

CONCLUSION

The profile of the MEFV gene mutations in the Tunisian population is concordant with other Arab populations but with some differences. M680l is the most common mutation, while V726A, the commonest mutation among Arabs, is rare in our population.

[A case of preserved fertility in an hemodialyzed patient with systemic lupus erythematosus]

BACKGROUND

Pregnancy and child birth in haemodialysis remains a rare event, even more, when pregnancy occurs in patient with systemic lupus erythematosus (SLE).

AIM

We report a case of a patient with end stage renal failure secondary to SLE and who carried out 3 pregnancies.

CASE REPORT

She was a woman with proliferative and diffuse lupus glomerulonephritis since 1985 treated by corticosteroids and cyclophosphamide. In 1995, she developed chronic renal failure. In 1996, she underwent a 1st full term spontaneous pregnancy with normal birth weight. In 2001, she underwent a second spontaneous pregnancy while she was on periodic haemodialysis. She had a full term baby birth with a birth weight at 1 Kg 700 and who died 4 days later. In 2002, she had a third pregnancy with voluntary abortion at 8 weeks.

CONCLUSION

Our patient had conserved fertility despite treatment by cyclophosphamide, chronic renal failure and haemodialysis. The two successful deliveries may be attributed to the control of SLE activity and to the adequacy of haemodialysis.

[Acute renal failure in a prisoner after hunger strike]

BACKGROUND

Acute renal failure may occur in varied circumstances. It is potentially reversible spontaneously or after specific treatment. It is rare after hunger strike and fewer cases were reported in the literature. The physiopathological mechanisms are varied and remain incompletely known.

AIM

We report the case of a prisoner having presented an acute renal failure after a hunger strike wich was completely reversible.

CASE

He's a 29 year old man, without a past medical facts, in July 2004 he was incarcereted in prison. In October 2004 he undertake a hunger strike during one month. In November 2004 he was hospitalized for global dehydration and shock. His physical examination showed blood pressure 60/40 mmHg, weight 59 Kg with a loss of weight about 10 Kg, diuresis 800 cc/day. His biological findings showed urea 100 mmol/l, creatinemia 679 (mo/l, natremia 179 mmol/l, kaliemia 5 mmol/l, glycemia 5.2 mmol/l, albuminemia 35 g/l, calcemia 2.35 mmol/l and biological marques of rhabdomyolysis: CPK at 11 times the normal and LDH two times the normal. His treatment consisted on rehydratation, parenteral then enteral refeeding and psychiatric talks. The evolution was favourable, re-establishment of good hydration state with a gain weight of 7 Kg, normalization of renal function, his creatininemia reached 85 (mol/l in three weeks and normalization of muscles enzymes in one month.

CONCLUSION

Hunger strike continue to pose a problem because of it's frequency in penitentiary structures and its organic disorders which can lead to death. A good psychiatric cares may be undertaked in order to prevent a such bad manifestations.

[Renal involvement in Fabry disease]

BACKGROUND

Fabry disease is an X-linked recessive lysosomial storage disorder that is caused by deficient activity of alpha galactosidase A. Renal involvement occurs generally in hemizygous forms.

AIM

We report one case of renal involvement in Fabry disease.

CASE REPORT

A 47 year-old-man had focal and segmental glomerulosclerosis with moderate renal failure. As the patient presented history of acroparesthesias, hearing loss, left ventricular hypertrophy with arrhythmia and corneal deposits, hemizygous Fabry disease was suspected. This diagnosis was confirmed with low alpha galactosidase activity. After a follow up of 5 years, the renal function remains stable but the patient died by cardiac arrhythmia.

CONCLUSION

Occurrence of a glomerulonephritis associated with an hypertrophic cardiopathy without hypertension should advocate Fabry disease.

[Treatment of uremic patients by automated peritoneal dialysis: study of 78 cases]

BACKGROUND

Automated peritoneal dialysis has been increasingly used in recent years. The quality of life is improved in patients on automated peritoneal dialysis with more time for work, family and social activities compared to patients on continuous ambulatory peritoneal dialysis.

AIM

We report our experience concerning patients on continuous ambulatory peritoneal dialysis.

METHODS

From July 1997 to June 2003, we review retrospectively 78 patients with chronic renal failure treated by automated peritoneal dialysis. Tenckhoff catheter was used for all patients with 1 cuff in 39 cases (35.5%) and 2 cuffs in 71 cases (64.5%).

RESULTS

There were 46 males and 32 females. Their mean age was 38.6 +/- 14.5 years. Their main nephropathies were glomerular in 23 patients (29.%), diabetic in 20 patients (25.6%) and vascular in 19 patients (24.4%). Among the 78 patients, 61 (78.2%) were autonomous while 17 (21.8%) were assisted by a member of their family. The mean period of therapy was 25.5 months (3 to 61 months). Peritonitis was the main complication, it was observed in 45 cases after a mean delay of 17 months (1 to 38 months). The mean rate of peritonitis was 36.5 months/patient. Their etiology was identified in 21 (46.7%) cases (8 septic manipulations of catheter and 13 tunnel infections). The principal organism isolated in peritoneal fluid were 18 gram-positive cocci (13 staphylococcus aureus, 4 coagulase-negative staphylococci, 1 streptococcus) and 10 gram-negative bacilli. The outcome of peritonitis was favourable in 39 cases (86.7%). The actuarial technique survival at 1, 3 and 5 years was respectively 94.6%, 80.1% et 49.3%. The actuarial patient survival at 1, 3 and 5 years was respectively 93.3%, 76.8% et 52.2%. At the end of the study, 43 patients (56.4%) left the automated peritoneal dialysis program: 22 (28.2%) were shifted to hemodialysis, 15 (19.3%) died, 6 (7.7%) were transplanted and 1 patient (1.3%) was shifted to continuous ambulatory peritoneal dialysis.

CONCLUSION

Our experience concerning automated peritoneal dialysis is recent with a small number of patients. Our results were acceptable and we have to encourage and extend automated peritoneal dialysis to the most new patients with end-stage renal failure.

[Myeloma, Kaposi's sarcoma and HHV8 infection in hemodialyzed patient]

BACKGROUND

The association between Kaposi's sarcoma, Human Herpes Virus 8 infection and multiple myeloma is still controversial especially in hemodialysed patient.

AIM

report a new case of this association.

OBSERVATION

We report the case of a 83 year old man in whom the diagnosis of multiple myeloma of IgA/kappa had been made in December 2003 with end stage renal failure requiring hemodialysis. Initially, it had been treated with Melphalan, Cyclophosphamide, Prednisolone and Vincristine and secondary by Melphalan and Prednisone. Three months later, he had developed extensive porpour lesions in his lower limbs. Skin biopsy had been informed of Kaposi's sarcoma. Human Herpes Virus 8 test was positive.

CONCLUSION

Our observation is another case supporting the hypothesis that Kaposi's sarcoma and multiple myeloma share a common aetiology such as Human Herpes Virus 8. The immunodepressed state related to aging, multiple myeloma, chemotherapy and hemodialysis was the probable factor responsible of rapidly progressive Kaposi's sarcoma in our patient. The association myeloma and Human Herpes Virus 8 infection is still controversial.

[Complications of distal tubular acidosis in primary Sjögren's syndrome]

Renal involvement in primary Sjögren's syndrome occurs in 10-60% of cases. Tubulointerstitial nephritis with distal renal tubular acidosis (DRTA) is the main type of involvement. It's generally asymptomatic and revealed by complications of DRTA. We report 4 cases of GJS complicated by nephrocalcinosis, tetapresic hypokaliemia and osteomalacia. In 2 cases, nephrocalcinosis was diagnosed simultaneously with the GJS. The 2 other cases were diagnosed 3 and 15 years after primary GJS. All patients were treated by coticosteroids at the dose of 0.5 mg/Kg/jour, alkaline solution, K Cl in 2 cases and vitamin D in 2 cases. After a mean follow up of 8.7 years, the renal function remain stable in the 3 cases of nephrocalcinosis and in a patient with osteomalacia, bone lesions progressed. In conclusion, DRTA must be detected by acidification tests in patients with primary Sjögren's syndrome because of their latency and to prevent severe complications.

[Epidemiology of end-stage renal disease before starting hemodialysis and factors influencing hemodialysis survival]

BACKGROUND

The incidence of end-stage renal failure is high and it is responsible for the increase of the rate of morbidity and mortality rates among our patients.

AIM

The objective is to study patient characteristics before starting hemodialysis and to evaluate factors influencing their short and long term survival.

METHODS

This is a prospective study of 127 patients starting hemodialysis between June and December 2001. On May 31, 2005, their survival was analyzed according to different parameters.

RESULTS

Patients were 77 males and 50 females. Their mean age was 51.4 +/- 16.1 years (15 to 78 years). Diabetes was observed in 33.9% of cases. Only 70.9% of patients were covered by a social service. Chronic renal failure was diagnosed at the end stage in 34.6% of cases. Before starting hemodialysis, only 4 patients were vaccinated against B hepatitis and arteriovenous fistula were not made in any patients. Pericarditis was observed in 9.4% of patients. Albuminemia was < 35 g/l in 60.5% of patients. First hemodialysis session was programmed in 53.5% of patients and realized urgently in 46.3% of patients. Patients were hemodialysed 4, 8 and 12 hours per week respectively in 16.5%, 15.8% and 67.7% of cases. On May 31, 2005, 35.4% of patients died. Their actuarial survivals at 3 months, 1 year and 4 years were respectively at 87.5%, 79.5% and 64.4%. Acturial survival was bad in patients with pericarditis, diabetes, hemodialysed less than 12 hours/week and when the first hemodialysis session was started urgently.

CONCLUSION

The diagnosis of renal failure was frequently made at end-stage. There are no preparations before starting hemodialysis. We have to reinforce prevention programmes and increase the number of nephrologists and nephrology departments.

[Membranoproliferative glomerulonephritis in patients with cryoglobulinemia complicating hepatitis C virus: report of 11 cases]

BACKGROUND

Membranoproliferative glomerulonephritis in patients with cryoglobulinemia complicating hepatitis C virus have yet been reported. Although, it remains controversial, antiviral treatment seems to be able to improve the outcome of glomerulonephritis.

AIM

The objectives of the study were to analyze characteristics of this association and to report literature data and newness treatment.

METHODS

It's a retrospective study including 11 patients with membranoproliferative glomerulonephritis, hepatitis C virus and mixed cryoglobulinemia. Hepatitis C virus antibodies was identified by ELISA technique. Hepatitis C virus genotype was identified in one patient. Cryoglobulins were isolated from sera of all patients at 37 degrees Celsius.

RESULTS

Patients were 3 men and 8 women with a mean age of 51.9 +/- 15.5 years. Between the 11 patients, 7 had hypertension, 9 had nephrotic syndrome and 10 had chronic renal failure. Renal biopsy showed membranoproliferative glomerulonephritis lesions in all cases with fibrinoid thrombi in 8 cases. Six patients had chronic liver disease. Liver biopsy was performed in 4 patients, showing histological feature compatible with chronic active hepatitis in 2 cases. No patient had antiviral therapy. Renal failure was stable in 5 cases and progressed in 6 cases with end stage renal failure in 3 of them. One patient died, 4 months after diagnosis, because of severe pulmonary involvement in cryoglobulinemic vasculitis. In literature, treatment is dominated by antiviral therapy composed first by Interferon Alpha alone. Combination therapy associating Interferon and Ribavirin was recently used in renal involvement; it is clearly more effective than interferon alpha alone.

CONCLUSION

Hepatitis C virus detection should be performed when membranoproliferative glomerulonephritis is associated with cryoglobulinemia. Antiviral treatment should be more widely used in Tunisia to evaluate his effect on renal involvement

[Epidemiology of glomerular diseases in Tunisia from 1975 to 2005. Influence of changes in healthcare and society]

Between April 1975 and March 2005, 4,436 cases of histologically proven glomerulonephritis (GN) were diagnosed by the same team at the Kidney Unit of Charles Nicolle Hospital in Tunis. Respectively 1,510, 1,419 and 1,509 cases were diagnosed in 1975-1985, 1985-1995, and 1995-2005. We compared trends in the incidence rates of the different types of GN and those of Tunisian indicators of health, social and economic status. The following differences were found between 1975-1985 and 1995-2005:--As a proportion of all cases of GN, the frequency of amyloidosis fell from 12,6 % to 6,5 % (p < 0,0001). The 444 cases of amyloidosis observed during the study period were of type AA in 87 % of cases, and were related to chronic infectious diseases in 239 cases (54 %; pulmonary tuberculosis in 114 cases). The frequency of tuberculosis-associated amyloidosis fell during the study period, in parallel with the reduction in the incidence of tuberculosis in the Tunisian population (48,7 cases/100,000 inhabitants in 1983 to 20,17 in 2004). Lupus nephritis accounted for 7.7 % of all cases of GN diagnosed in 1975-1985, compared to 13 % in 1995-2005 (p < 0,00001). Increased exposure to sunlight and use of cosmetics could be involved in this increase.--The incidence of both proliferative endocapillary and membranoproliferative GN (as a proportion of all cases of GN) fell between 1975-1985 and 1995-2005, from 15,9 % and 21,6 % to 6,9 % and 7,7 %, respectively (p < 0,0001). This matched a drop in the incidence of acute rheumatic fever in the Tunisian population, from 7,26/100,000 inhabitants in 1984 to 0,83 in 2004, probably as a result of public health measures and widespread use of antibiotics. The incidence of membranous GN increased from 11,1 to 17,7 % in adults (p < 0,001) whereas it fell from 10,1 to 4,6 % in children (p < 0,01), possibly as a result of a nationwide HBV vaccination program launched in 1995. The incidence of IgA nephropathy increased from 0,9 to 12,9 % in adults (p < 0,0001) and from 0,3 % to 18,4 % in children, but remained relatively stable in elderly adults. This study, conducted in a single center, by the same team, and using the same renal biopsy practices, confirms that the control of infectious diseases in Tunisia has led to a substantial regression of proliferative endocapillary and membranoproliferative GN and renal amyloidosis. Environmental factors, such as the adoption of western lifestyles, could explain the increase in lupus and IgA nephropathies.

Insuffisance rénale aiguë secondaire à la povidone iodée

INTRODUCTION

Povidone iodine is a widely-used antiseptic agent, especially for cutaneous lesions. Despite its apparent innocuousness, some cases of acute renal failure are reportedly due to iodine toxicity.

CASE

We report a case of an acute renal failure secondary to povidone iodine exposure in a 37-year-old woman. She underwent a hysteroscopy for diagnosis of primary sterility, and povidone iodine was used as the contrast agent. She developed acute renal failure with oliguria during the postoperative period. Treatment with diuretics and hemodialysis led to a favorable outcome and return of normal kidney function.

DISCUSSION

Mucosal administration of povidone iodine appears to lead to greater iodine toxicity than cutaneous administration. The clinical feature of our patient suggested tubular necrosis caused by iodine, after the other possible causes of acute renal failure were ruled out.

CONCLUSION

Acute renal failure secondary to povidone iodine administration is possible, especially through mucosal surfaces. Outcome is favorable after the conclusion of exposure and symptomatic treatment.

La pyélonéphrite emphysémateuse

The emphysematous pyelonephritis is a rare and severe renal infection characterized by the presence of gas in renal parenchyma and its perirenal spaces. We report two cases of emphysematous pyelonephritis in two diabetic women (53 and 50 years old respectively). In the first case, the treatment was based on nephrectomy because of the presence of a septic shock and three risk factors, which are acute renal failure, hematuria and thrombopenia. In the second case, the treatment was only medical. The evolution was favorable in the two cases. We insist in this article that this diagnosis should be considered in every female diabetic patient having severe acute pyelonephritis resistant to a well-conducted medical treatment.

Case Report. Chronic subdural haematoma and autosomal polycystic kidney disease: Report of two new cases

Chronic subdural haematoma (SDH) was recently described in some patients who were suffering from autosomic dominant polycystic kidney disease (ADPKD). It results in various neurological symptoms mimicking those related to intracranial aneurysms, which are relatively frequent in such patients. The authors report two cases of chronic SDH observed in two patients known to have advanced renal failure attributed to ADPKD. Medical imaging failed to reveal features of associated intracranial abnormalities such as aneurysms or arachnoid cysts. Surgical drainage resulted in a good recovery without relapse during a long period of follow up that exceeded 10 years in the first case.

Amylose rénale compliquant l’évolution de colites inflammatoires chroniques

INTRODUCTION

In 4 patients we observed the association of an amyloid nephropathy and a chronic inflammatory bowel disease (Crohn's' disease in 3 cases and ulcerative rectocolitis in 1 case).

OBSERVATIONS

These patients, aged a mean of 37 years (range: 28-48 years), had been admitted for exploration of a nephrotic syndrome associated with renal failure in 2 cases. The investigations lead to the diagnosis of AA type amyloidosis in the 4 cases. One patient was lost from follow-up. One patient was treated with salazopyrine, one with corticosteroids and one with colchicine. After a mean follow-up of 16 months (5-30 months), all the patients had persistent nephrotic syndrome, with end stage renal failure in one case, persistence of normal renal function in one case and improved renal function in one case. None of the patients exhibited remission in the nephrotic syndrome. The response of amyloidosis to the treatment of the chronic inflammatory bowel disease varied. Corticosteroids and colchicine stabilised renal function in 2 of our patients but without remission in the nephrotic syndrome.

DISCUSSION

AA amyloidosis is a rare complication of inflammatory bowel disease. The indication for colchicine is important to consider particularly since the response of amyloidosis to the treatment of the causal disease does not, in the majority of cases, lead to the remission of the amyloidosis, the prognosis of which is determined by the extent of renal involvement.

[Acute renal failure due to drugs in diabetics patients]

Acute renal failure (ARF) in patients with diabetes mellitus is frequent. It is caused by several factors notably drugs. Our retrospective study includes 20 cases of ARF induced by drugs in diabetic patients. Eleven men and 9 women with mean age of 55.2 years (17-71 years) were enrolled in the study. Type 2 diabetes mellitus was found in 18 cases and type 1 in 2 cases. Risk factors found are age more than 70 years in 17 cases, pre-existent renal failure in 17 cases, dehydratation in 6 cases, and drug association in 9 cases. In our study diuretics used solely or in association with other drugs were found to be the essential cause of ARF. ACE was noted in 5 cases, gentamycin in 2 cases, non-steroidal antiinflammatory drugs in 1 case, colimycin in 1 case and radiographic contrast media in 4 cases. Symptoms of hypersensitivity are fever in 3 cases, itchiness in 2 case, hepatic dysfunction in 7 case, and hypereosinophilia in 3 cases. Oliguria was observed in 11 patients. Eight patients were dialyzed. Renal function recovery is total in 9 case and partial in 9 others. Two patients having oliguria died.

CONCLUSION

Diuretics are the first cause of drug-induced ARF in diabetic patients. This ARF worsens the renal prognosis for these patients. Oliguria is high risk of mortality.

[Diabetes following kidney transplantation. Report of 35 cases]

Post-transplant diabetes mellitus (PTDM) is a frequent complication of renal transplantation. It has a prevalence rate ranging from 3 to 46%. We undertook a retrospective study of 175 nondiabetic renal transplant recipients to determine the prevalence rate, clinical characteristics, and risk factors of PTDM in kidney transplant recipients in our region. Thirty five patients (20%) developed PTDM, 50% were diagnosed by 3 months post transplantation. Eight patients (22.8%) were insulin recurrent. PTDM was independent of kidney source, family history of diabetes, age, sex, incidence of acute rejection, body weight gain, steroid or cyclosporine dose, use of beta-blockers and cytomegalovirus infection. Acturial 5 years survival was 79.4% in the diabetic compared to 80.5% in the control group. Patient survival was similar in the two groups. We conclude that PTDM is frequent in our patients. No significant risk factors of PTDM were identified in this study.