To avoid renal allograft rejection and loss, human leucocyte antigen compatibility and lymphocytotoxic cross-matching of renal donors against prospective renal allograft recipients are obligatory and fundamental steps in pretransplant evaluation. The complement-dependent cytotoxicity assay has been the mainstay technique for ascertaining the presence of donor-specific antibodies since the 1970s. Improvement in the performance of cross-matching has seen the introduction of more sensitive and specific techniques such as flow cytometry, and highly sensitive enzyme-linked immunosorbent assay, Luminex platforms and virtual cross-match. This review article is an in-depth comparison of the advantages and disadvantages of each of the cross-match techniques. We demonstrate the application of these techniques through a clinical case scenario. A step-by-step analysis and interpretation of cross-match modalities of varying levels of sensitivity and specificity is needed to arrive at a pragmatic decision, which will lead to better transplantation outcome. In some patients with immunologically complex issues, a spectrum of cross-match techniques may be required for a safe outcome of transplant.

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Background Many maintenance hemodialysis (MHD) patients exhibit erythropoietin (EPO) hyporesponsiveness. An inverse association has been found between vitamin D levels and EPO requirements in patients with chronic kidney disease. Vitamin D supplementation may improve response to EPO by either suppression of the chronic inflammatory status, control of hyperparathyroidism, or direct stimulation of erythroid progenitors. Aim A prospective clinical study is needed to assess the potential therapeutic role of vitamin D supplementation on EPO resistance index (ERI) in MHD patients. Methods A total of 30 patients with anemia on MHD for more than 6 months were included. They were on standard anemia therapy with subcutaneous (SC) EPO 4000 U and intravenous iron sucrose 100 mg once or twice weekly. A total of 20 age- and sex-matched healthy individuals were included as controls. Baseline laboratory studies included complete blood picture, calculation of ERI [weekly EPO dose/body weight in kg/hemoglobin (Hb) level], serum iron, total iron-binding capacity, ferritin, hepcidin, calcium, phosphorus, alkaline phosphatase (ALP), intact parathyroid hormone, 25(OH) vitamin D (vitamin D₃), C-reactive protein, and interleukin (IL)-6. The studies were repeated after 3 months of oral α-calcidol therapy (2 µg thrice weekly, with each dialysis session). Results Hb increased significantly from 8.34±0.9 to 9.48±0.9 g/dl (P=0.000), and ERI decreased significantly from 7.39±1.13 to 6.61±1.2 IU/kg/g/dl (P=0.000). Inflammatory markers (serum C-reactive protein, IL-6, ferritin, and hepcidin) decreased significantly (P=0.000 for all). Serum intact parathyroid hormone and ALP decreased significantly (P=0.007 and 0.000, respectively). At the start of the study, there was a significant positive correlation between ERI and serum ferritin (P=0.026), and a significant negative correlation between serum vitamin D3 level and ALP (P=0.004). At the end of the study, there was a significant negative correlation between serum vitamin D3 level and each of serum ferritin (P=0.005) and IL-6 (P=0.019). Conclusion A 3-month course of oral α-calcidol significantly ameliorates hyperparathyroidism and inflammatory markers, increases Hb, and decreases ERI in MHD patients.

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Objectives We aimed to study the association of fibroblast growth factor-23 (FGF-23) with conventional cardiovascular risk factors in hemodialysis (HD) patients. Patients and methods This is a cross-sectional study, which was carried out on 90 HD patients. Demographic data were recorded in predefined data sheets. The blood samples for FGF-23 and other laboratory variables were collected and measured using the standard methods. The results and their relationships with FGF-23 were analyzed. Results In our study, there were insignificant correlations between FGF-23 and all clinical cardiovascular variables apart from a significant positive correlation between FGF-23 and systolic blood pressure (r=−0.546, P=0.004). Multivariate analysis failed to show any significant association between FGF-23 and systolic blood pressure (B=0.749, T=1.659, P=0.067). Conclusion Multiple linear regression analysis failed to show any significant association between FGF-23 and other conventional cardiovascular risk factors. We recommend using FGF-23 as an independent risk factor of cardiovascular morbidity and mortality, and searching for agents that control its level in HD patients.

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Background The optimal timing to start continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) in critically ill ICU patients has not been accurately estimated. The proposed risk, injury, failure, loss, end-stage kidney disease (RIFLE) criteria for diagnosis of AKI may provide a method for nephrologists to decide the ‘optimal timing’ for starting dialysis. Objective Our study aimed to analyze the correlation between RIFLE stages at the start of CRRT and 90-day survival rate and to detect the effect of the timing of CRRT on poor kidney outcome in 90-day survivors. Patients and methods A retrospective cohort analysis was performed on the data of 96 critically ill patients with AKI in ICU treated with CRRT during a 2-year period in international extended care hospital, Jeddah, Saudi Arabia, from January 2015 to January 2017. Information such as age, sex, RIFLE stage, sepsis, sepsis-related organ failure assessment score, number of organ failures before CRRT, CRRT time, survival, and kidney outcome conditions at 90 days after CRRT started was collected. According to their baseline severity of AKI at the start of CRRT, the patients were assigned to three groups according to the increasing severity of RIFLE stages, group I (risk of renal dysfunction, R), group II (injury to the kidney, I), and group III (failure of kidney function, F), using RIFLE criteria. The poor kidney outcome was classified as RIFLE-L (loss of kidney function, L) or RIFLE-E (end-stage kidney disease, E) using RIFLE criteria. The correlation between RIFLE stage and 90-day survival rate was analyzed among these three groups. Additionally, the association between RIFLE stage and the poor kidney outcome (RIFLE-L+RIFLF-E) in the 90-day survivors was analyzed. Results Of the overall 96 patients, 48 survived to 90 days after the start of CRRT. There were 14, 20, and 62 patients in group I, II, and III, respectively, with corresponding 90-day survival rate of 78.5% (11/14), 60% (12/20), and 40.3% (25/62) (P<0.01, compared among groups). The percentage of the poor kidney outcome of 90-day survivors in the three groups was 18.18% (2/11), 25% (3/12), and 56% (14/25), respectively (P<0.01). After adjustment for other baseline risk factors, the relative risk for the 90-day mortality significantly increased with baseline RIFLE stage. Conclusion The RIFLE classification may be used to predict 90-day survival after starting CRRT and the poor kidney outcome of 90-day survivors in the critically ill patients with AKI treated with CRRT. Early versus late initiation of dialysis before RIFLE-F stage may be the optimal timing.

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Background There is an increased risk of acquiring hepatitis C virus (HCV) infection among hemodialysis (HD) patients. HCV prevalence varies considerably among different HD centers throughout the world. In Egypt, the prevalence of HCV in HD patients could reach 50.7%. Aim The aim of this study were to measure the rate of HCV seroconversion for patients at the HD Unit in Assiut University Hospitals and to assess the diagnostic utility of routine laboratory test of anti-HCV antibodies used in those patients. Patients and methods This study was performed at the HD Unit, in the Internal Medicine Department, Assiut University Hospital. We included patients on regular HD between 2011 and 2014 who were negative for anti-HCV and hepatitis B surface antigen with normal liver enzyme level. Follow up after 3 and 6 months was done by testing for liver enzymes and anti-HCV using third-generation enzyme-linked immunosorbent assay and cases with positive results had qualitative real-time PCR to confirm the result. Results We recruited 63 patients, seroconversion for anti-HCV was found in 21 (33.3%) patients; seven patients develop this seroconversion after 3 months follow-up transiently and 14 patients develop it after 6 months follow-up. However, all patients lack HCV viremia as confirmed by testing for HCV RNA using real-time PCR. Conclusion In our study, seroconversion for anti HCV among the HD patients was found in 33.3% but they lack HCV viremia. Screening in HD units is better to be done using PCR testing to avoid transient anti HCV seroconversion particularly in units with high prevalence of anti HCV.

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