The water used for dilution of hemodialysis concentrates has to meet official quality recommendations regarding microbiology and chemical parameters. To avoid chemical use and to simplify treatments, hot water has been used to control microbial contamination of water distribution systems. In this study we evaluated the efficacy of heat disinfection in maintaining the quality of dialysis water generated by reverse osmosis (RO). During the first part of the study, we consecutively used (1) continuous water circulation, (2) daily heat disinfection and (3) a combination of daily heat disinfection and weekly chemical disinfection while checking bacterial count and endotoxin level every 4-5 weeks. During the second part of the study, we continued using daily heat disinfection while checking bacterial count and endotoxin level on weekly basis. The endotoxin levels at all sampling points of the water treatment system were lower than 0.005/ ml throughout the study. The application of heat disinfection alone reduced bacterial levels but an escape phenomenon occurred. After an interval of 21 days, an exponential increase of bacterial count was noted and cultures from the RO unit revealed growth of Pseudomonas fluorescence. The addition of chemical disinfection was successful in eliminating micro-organisms. Throughout this study, micro-organisms and endotoxins were not detectable in dialysate fluid and substitution fluid in dialysis monitors. The isolation of a thermo-sensitive organism from the RO unit after a period of relying on thermal disinfection suggests the existence of dead space in the RO unit that is not adequately exposed to heat but is accessible to chemical disinfection. .

Systemic lupus erythematosus (SLE) is an unpredictable autoimmune systemic disorder that often involves the kidney. In this study, we aimed to assess the clinical characteristics, pathological findings, and therapeutic response of children presenting with lupus nephritis (LN). We retrospectively studied 50 children with SLE admitted to the pediatric nephrology departments of four teaching hospitals in Baghdad between December 2009 and December 2011. The female to male ratio was 5:3. The median age was 11 years with a range of 5 -17 years. The commonest presenting features were weight loss (92%), fever (90%), edema (88%), arthritis (70%), hair loss (70%) and malar rash (60%). Examination revealed hepatosplenomegaly/lymphadenopathy in 20% of patients. Anti-dsDNA was positive in 92% of patients. Pathological examination revealed LN class I in 4%, class II (10%), class III (8%), class IV (74%) and class V (4%). All patients in class I, II and III achieved full remission after treatment with prednisolone. Thirty-one patients in class IV and V received induction treatment with cyclophosphamide followed by maintenance with cyclophosphamide (16 patients), mycophenolatemofetil (13 patients) or azathioprine (2 patients). Twenty-four of those patients achieved remission, four patients developed chronic kidney disease and three patients died. Five patients in class IV/V were treated with mycophenolate mofetil and three of them achieved remission, whilst three patients were treated with azathioprine and all of them achieved remission. Diffuse proliferative glomerulonephritis (class IV) was the most common pattern of LN encountered in our study.

Hypertension (HTN), diabetes mellitus (DM) and chronic kidney disease (CKD) are important health problems worldwide, and it is possible to reduce their burden through effective HTN screening and treatment programs. It may be feasible to incorporate such programs in the community outreach activities of nursing and medical schools in Sudan. Village inhabitants in the Northern state of Sudan were invited to attend a free clinic for screening of hypertension as well as for follow up and treatment of persons with previously diagnosed hypertension. Fourth year nursing students from the National Ribat University were asked to record demographic data and blood pressure measurements for the attendants of the clinic. A total of 389 adults were screened, their mean age was 41±15 years and 83.8% of them were females. Family history of HTN, DM and CKD was reported by 52.7%, 40.4% and 12.9% respectively. Personal history of HTN, DM and CKD was reported by 28.5%, 17% and 6.4% respectively. The overall prevalence of HTN was 39.6%. Among persons previously diagnosed as hypertensive, 80.2% were on antihypertensive medication but only 48.6% had blood pressure > 140/90 mmHg. Among the 278 persons with no personal history of HTN, 19.1% had blood pressure ≥ 140/90 mmHg. Variables significantly and independently associated with the presence of HTN were family history of HTN (OR: 6.4, P: 0.005), less than 10 years of formal education (OR: 3.5, P: 0.000) and age ≥ 40 years (OR: 2.4, P: 0.005). With proper coordination, nursing and medical students can effectively contribute to the implementation of hypertension screening programs.

Affective disorders, particularly depression, are the commonest and probably the most important psychopathological complication of end stage renal disease (ESRD). Depression has the potential to alter adversely the medical outcome of ESRD patients and the psychological stress can affect patient's adherence to medication regimen. In Iraq as well as many other Arab countries, the true prevalence of depression among ESRD patients is unknown. The objective of this study was to determine the prevalence of depression among a cohort of Iraqi hemodialysis (HD) patients and relate it to their socio-demographic characteristics. We recruited patients from two HD centers in Baghdad, excluding patients with history of depression or other psychiatric disorders prior to the initiation of HD. The Arabic version of diagnostic and statistical manual of mental disorders fourth edition (DSM-IV) was used to diagnose depression. Beck's Depression Inventory was used to grade its severity. Clinical and laboratory data of the study group were documented and related to the diagnosis of depression. Seventy-five Iraqi patients on maintenance HD were included in the study. Patients' duration on HD ranged from six months to five years. The prevalence of depression among this cohort of HD patients was 80%. The prevalence of severe, moderate and mild depression was 25%, 50% and 25% respectively. The mean depression score was 17.1. Female gender, unemployment, and marital status had statistically significant associations with depression. Depression is common in this group of Iraqi HD patients and its prevalence is comparable to the results of similar studies in other societies.

In view of the conflicting evidence of helper T cell type 1 (Th1) or type 2 (Th2) pattern of cytokine synthesis in steroid sensitive nephrotic syndrome (SSNS), this study aimed to assess type-1/type-2 cytokines level in different stages of SSNS and to evaluate the role of IL-18. We prospectively studied thirty children with SSNS, aged 2-12 years. The children were evaluated in the active stage before treatment initiation and re-evaluated again during remission while still on steroid treatment. A subgroup of children (21/30) was also evaluated during remission after steroid withdrawal. The control group included 30 healthy age- and sex-matched siblings. Serum levels of IL-2, IFN-γ, ΙL-4, IL-13 and IL-18 were measured by ELISA. IL-2 levels were not significantly different between children in different stages of SSNS and controls (p>0.05). Levels of IL-4, IL-13 and IL-18 were significantly higher during the active stage of SSNS compared to remission and controls (p<0.05). Serum IFN-γ was significantly lower in children with active disease compared to remission stages and controls (p<0.05). In children with SSNS, serum levels of IL-18 correlated significantly with both IL-4 and IL-13 during all stages (r=0.72 and p<0.0001, r=0.82 and p<0.0001, respectively). Children with active SSNS seem to have a shift to type-2 cytokine production, and IL-18 expression is significantly correlated with this type-2 immune response.

The Saharan horned viper (Cerastes cerastes) is a common snake in the sandy and rocky regions in the south of Morocco. Although nearly all snakes with medical relevance can induce acute renal failure (ARF), it's unusual except with bites by some viper species. ARF has very rarely been reported following Cerastes cerastes bite. A 55-year-old Moroccan man was bitten on his right hand by a Saharan horned viper, Cerastes cerastes. He presented 24 hours later in a state of confusion, agitation and hypotension with marked swelling of his right hand. Investigations revealed evidence of disseminated intravascular coagulation (DIC) and rhabdomyolysis. The appropriate antivenom was not available. Despite adequate hydration, he developed acute renal failure necessitating prolonged hemodialysis. He subsequently improved and was discharged from the hospital after four weeks with normal renal function. Although uncommon, the bite of Cerastes cerastes can result in ARF due to DIC and rhabdomyolysis. The appropriate antivenom should be made available in areas where this snake is prevalent.

Informed consent is a critical issue especially in conducting clinical trials that expose human life to medical or surgical interventions. It necessitates a long and complex process through which the participant is presented with all potential favorable and non-favorable consequences upon getting enrolled in the study. The process of taking informed consent is well-understood in developed countries, with every effort taken to enhance and maintain the autonomy of patients and their right to make an informed choice of whether to participate or not. This may not be the case in the developing world.The information given to patients before the trial might not be properly developed and presented, an issue that can result in serious threat to the decision-making process. On the other hand, investigators should remember that enrolling people into a trial with no potential benefit for themselves cannot be considered ethical. In the current debate, we aim to address the issue of how respectfully and ethically clinical research trials can be done on human subjects and what we can do to enhance the practice in an ethical context. Development of a system through which we could warrant all rights of study participants in all cases around the world seems far from view. However, if we are in doubt about the ethics of a clinical trial, we can ask ourselves: "what would we do, if we were in the same position our patients are in now?"

Delayed Graft Function (DGF) is a common complication of renal transplants and the long-term relation between DGF and survival of patients and grafts is not well established. This is a historical cohort study of transplanted patients in Taleghani Hospital of Shahid Beheshti University in Iran between 1994 and 2010. Patients who required dialysis during the first week after transplantation were considered to have DGF. The patients' conditions were updated to determine existing graft function, graft loss or patients' death at one year and five years post transplantation in relation to the presence or absence of DGF. DGF complicated 67/385 transplants (17.4%). Causes included acute tubular necrosis (58.2%), accelerated rejection (29.9%), transplant renal artery thrombosis (9%) and renal vein thrombosis (3%). More kidneys in the DGF group were procured from cadaveric donors (6% versus 0.9%, P = 0.02). At hospital discharge, patients with DGF had significantly higher mean creatinine level (4.4 ± 2.8 versus 2.0 ± 1.7; P = 0.001) compared to other patients. They also had more early acute rejection episodes and more late acute rejection episodes (34.3% versus 2% and 16.4% versus 3%, respectively; P = 0.0001) compared to other patients. The proportion of functioning grafts was significantly lower in the DGF group at 1-year (53.7% versus 95.3%, P = 0.0001) and 5-years (22.4% versus 61.6%, P = 0.001) compared to patients without DGF. The DGF group had a significantly higher acute rejection rate and an increased risk of graft loss at one and five years.

Despite increased utilization of marginal organs, there is still a marked disparity between organ supply and demand for transplantation. To maximize resources, it is imperative that procured organs are in good condition. Surgical damage at organ recovery can happen and organs are sometimes discarded as a result. We describe a damaged recovered kidney with high ureteric transection that was successfully transplanted using a primary Boari flap ureterocystostomy. The donor kidney was procured form a deceased donor and sustained damage by transection of the ureter just distal to the pelvi-ureteric junction at organ recovery. The recipient had been on the transplant waiting list for eight years and not accepting this kidney would have seriously jeopardized her chance of future transplantation. Several centers rejected the donor kidney. We assessed the kidney and decided to proceed with transplantation. The kidney was successfully transplanted. A primary Boari flap was constructed and the transplant ureter implanted onto the bladder. The post-operative course was complicated by urine leak that settled down after management by nephrostomy insertion and bladder catheterization. The patient made a good recovery and remained well at six monthly follow up with a serum creatinine of 1.7 mg/dl. Primary Boari flap ureterocystostomy is a viable option when the transplant surgeon is faced with a high ureteric injury in the procured kidney. Since most patients wait years for a suitable graft and some may never find an adequate match, every effort should be made to effectively utilize the scarce available resources to the fullest.

Our aim was to investigate the possibility of a significant relationship between chemokines and chemokine receptor genes polymorphisms and the spontaneous clearance or the persistence of HCV infection. A total of 96 hemodialysis (HD) patients infected with HCV were classified into two groups: G1 included 73 patients with persistently positive HCV-RNA and G2 included 23 HD patients who have spontaneously eliminated the virus. The control group consisted of 170 healthy blood donors. All subjects were genotyped for CCR5 ?32, CCR5 (-59029) A/G, CCR2 (64Ile) and MCP-1(-2518) A/G gene polymorphisms. Our results showed a statistically significant increased frequencies of the CCR2 (64Ile) and the (-59029) CCR5 A alleles in patients infected with HCV (22.1% and 35.9%) compared to G1 (24.3% and 40.6%) and compared to controls (14.4% and 20%). We also observed a lower frequency of the MCP-1 G allele and a greater frequency of the CCR5?32 variant in G2 (15.2% and 6.5%) compared to G1 (22.6% and 1.4%) that was not statistically significant. However, adjustment for known covariates (age, gender and HCV genotypes) didn't confirm the results of univariate analysis. In conclusion, our study suggests a possible role for some of the studied chemokines polymorphisms in the spontaneous clearance or persistence of HCV infection in Tunisian population. These results should be further investigated by a prospective cohort studies and large population-based studies.