Effects of direct acting antiviral therapy on liver stiffness measured by using fibro scan in Egyptian patients with chronic hepatitis C

Aim Egypt has the highest incidence of hepatitis C virus (HCV) infection in the world. Fibrosis development is common in HCV cases, and it is important in disease prediction. The aim of this study was to demonstrate the role of fibro scan in assessment of changes in hepatic stiffness in patients with chronic HCV infection following direct acting antiviral treatment (DAAT). Methods This prospective observational research included 120 patients with compensated HCV infection. All patients were subjected to fibro scan before and after receiving DAAT. Patients' history, clinical examination, laboratory parameters (red - RBCs, and white blood cells - WBCs, hepatic function test, renal function test, coagulation profile, HBsAg, AFP - alpha feto protein, HbA1C, HCVAb) and fibro scan were done for all patients. Results Stiffness may differentiate F0-2 minimal fibrosis from F3-4 massive fibrosis using ROC-curve analysis, with 77.5% sensitivity, 90% specificity, 88.57% positive predictive value (PPV), and 80% negative predictive value (NPV). With sensitivity, specificity, PPV, and NPV of 71.4%, 44.5%, 43.48%, and 71.43%, respectively, the APRI-score can discriminate F0-2 from F3-4 at cutoff of 0.314. At a cutoff of 1.18, Fib4 calculation can discriminate F0-2 from F3-4, with sensitivity, specificity, PPV, and NPV of 78.6%, 64.1%, 63.04%, and 78.57%, respectively. Conclusion Hepatic fibrosis measurements such as fibro scan and non-invasive fibrosis scores (FIB-4) and aspartate aminotransferase (AST) to platelet ratio index (APRI) showed a significant improvement after direct-acting antiviral therapy. Improvements in hepatic function tests, serum creatinine level, and platelet count are also seen.

Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study

Glomerular diseases continue to be the leading cause of end-stage renal disease (ESRD) globally. Hence, it is important to recognize the pattern of glomerular diseases in different geographical areas in order to understand the patho-biology, incidence and progression of the disorder. Published studies from different centers in Saudi Arabia have reported contradicting results. In this retrospective study, we report our experience at the Armed Forces Hospital, Riyadh, Saudi Arabia. A total of 348 native renal biopsies performed at our center on patients with proteinuria >1 g, hematuria and/or renal impairment during a period of 5 years (between January 2005 and December 2009) were studied by a histopathologist using light microscopy, immunofluorescence and electron microscopy, and were categorized. Results showed that primary glomerular disease accounted for 55.1% of all renal biopsies. The most common histological lesion was focal and segmental glomerulosclerosis (FSGS) (27.6%), followed by minimal change disease (MCD) (17.7%) and membrano-proliferative glomerulonephritis (MPGN) (13.0%). Secondary glomerular disease accounted for 37.9% of the glomerular diseases, with lupus nephritis (LN) being the most common lesion (54.5%), followed by hypertensive nephrosclerosis (22%), post-infectious glomerulonephritis (7.5%), diabetic nephropathy (DN) (6.8%) and vasculitides (4.5%). Four percent of all biopsies turned out to be ESRD while biopsy was inadequate in 2.8% of the cases. In conclusion, our study showed that FSGS was the most common primary GN encountered, while LN was the most common secondary GN. We encountered 14 cases of crescentic glomerulonephritis. Also, the prevalence of MPGN, MCD, IgA nephropathy and membranous GN was many folds higher in males when compared with the Western data. We believe that it is mandatory to maintain a Saudi Arabian Renal Biopsy Registry to understand better the pattern of glomerular disease in the Saudi population and to follow any change in trend.

Hypercholesterolemia in renal transplantation

OBJECTIVES

We conducted this study to evaluate the prevalence, and risk factors of hypercholesterolemia (HC) in renal transplant population.

METHODS

We reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia transplanted between 1979 and November 1998. The patients were grouped according to the measurement of serum cholesterol level; group I (normal): below or equal 5.2 mmol/L, group II (mild HC): from 5.3-6.0 mmol/L, group III (moderate HC): from 6.1-8.0 mmol/L group IV (severe HC): above 8.0 mmol/L.

RESULTS

There were 1096 patients' records included in the study. According to the level of measured serum cholesterol, there were 421 (38.4%) patients is group I, 256 (23.3%) patients in group II, 363 (33.1%) patients in group III and 57 (5.2%) patients group IV. We found no significant difference between the study groups in terms of gender (60% males, 40% females), mean duration of transplantation (66.9 months), between those transplanted before 1990 and those transplanted after 1990, donor type, prevalence of hypertension (85%), history of hypertension on dialysis, original kidney disease, frequency of rejections in the first year (28%), mean serum creatinine (220 mumol/L), cyclosporine mean dose (3.2 mg/kg/day) mean prednisone dose (0.15 mg/kg/day), number of patients on azathioprine (65%), the mean proteinuria (0.6 G/L) or number of antihypertensives. In comparison with the group with normal serum cholesterol level, the group with severe hypercholesterolemia had significantly higher mean age (40.6 versus 37.4 years), higher mean weight (72 versus 65.8 kg), rate of retransplantation (8.8% versus 3.1%), higher frequency of diabetics (35% versus 20%) and higher frequency of abnormal electrocardiogram (18.2% versus 5.2%).

CONCLUSION

That hypercholesterolemia is a significant problem in the renal transplant population in Saudi Arabia. Risk factors for the development of hypercholesterolemia are mainly related to weight, age, diabetes and retransplantation.

Total plasma clearance of 51Cr-EDTA: variation with age and sex in normal adults

Although inulin clearance measured during constant infusion is still considered the reference method, single-injection of 51Cr-EDTA with subsequent plasma sampling has become the most popular technique for the routine assessment of glomerular filtration rate. Despite the fact that the technique has been in use for 30 years, there are only a few reports of normal values calculated directly from 51Cr-EDTA data and normal ranges have generally been produced by conversions of inulin data. The aim of this study was to measure the variation in total plasma clearance, calculated directly from 51Cr-EDTA measurements, in normal males and females, of Saudi Arabian origin, over a wide range. Altogether, 201 potential kidney donors aged 16-60 years were studied. No statistically significant association of total plasma clearance with age or sex could be demonstrated; however, predictive equations suggesting a small decline in total plasma clearance with age were developed. The figures presented suggest that the reduction in total plasma clearance of 51Cr-EDTA with age is relatively shallow up to the age of at least 60 years and that normal ranges produced by conversion of inulin data may overestimate the decline with age.

Diabetes and renal transplantation: saudi experience

We conducted this study to evaluate the prevalence and risk factors of diabetes mellitus (DM) in our renal transplant population. We retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia, transplanted between 1979 and November 1998. The recipients were grouped according to the diagnosis of diabetes; group I: diabetes developed before transplantation (BTDM), group II: diabetes developed only after transplantation (ATDM) and group III: did not have diabetes (NDM). There were 1112 patients' records included in the study. The mean age was 38.2 years and the mean duration of transplantation was 66.9 months. There were 113(10.2%) patients in BTDM group, 134 (12.1%) patients in the ATDM group and 865 (77.8%) patients in the NDM group. There was no significant difference in the prevalence of hypertension among the study groups. In comparison to the other groups, the BTDM group had significantly more males (78.8%), more patients who were transplanted after 1990 (pre-cyclosporin era), more patients with grafts from living non-related donors (46%), higher incidence of acute rejection episodes (39%), higher mean serum creatinine and more patients treated with azathioprine (71%). The ATDM group had significantly higher mean age (46.4 years), higher mean duration of transplantation (91.5 months), higher rate of retransplantation (8.2%), higher mean serum cholesterol level (6.0mmol/L) and more frequently abnormal electrocardiogram (24.6%) than the other two groups. The ATDM group had comparable mean weight (70.2 kg) to the BTDM group but significantly higher than the NDM group (66.1kg). The NDM group had significantly higher mean dose of cyclosporine (3.3 mg/kg/day) and higher mean dose of prednisone (0.16 mg/kg/day) than the other groups. The only independent risk factor for developing DM after transplantation was advancing age. The currently used low-dose steroid therapy was not significantly associated with development of DM after renal transplantation. Nevertheless DM is an important co-morbid condition in the transplant population and is associated with increased risk for cardiovascular and cerebrovascular events.

Hypertension in renal transplantation: saudi arabian experience

To evaluate the prevalence, etiologic factors and therapy of hypertension in actively followed up transplant population in Saudi Arabia; we retrospectively reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia. These subjects were transplanted between January 1979 and November 1998. The patients were grouped according to the measurement of blood pressure; group 1 (considered normo-tensive): blood pressure below 140/90 mmHg, group2: blood pressure between 140-159/90-99, group 3: blood pressure 160-179/100-109 group 4: equal to or above 180/110. There were 1115 patients' records included in the study. The mean duration of transplantation was 66.9 +/- 50.1 months. According to the level of measured blood pressure, there were 641 (57.5%) patients in the normotensive group (group 1), 404 (36.3%) patients in the mildly hypertensive group (group 2) 64 (5.7%) patients in the moderately severe hypertension group (group 3) and only six (0.5%) patients in the severe hypertension group (group 4). The estimated prevalence of hypertension in this study was almost 85%. We found no significant difference in the prevalence of hypertension in terms of gender, year of transplantation, duration of transplantation, type of donor, number of previous transplants, diagnosis of renal artery stenosis, etiology of kidney disease, diagnosis of diabetes after transplantation, diagnosis of cerebrovascular accidents, or mean dose of prednisolone and cyclosporine. There was a statistically significant association between increased level of blood pressure and old age (above 50 years), original disease associated with hypertension, history of hypertension on dialysis, acute rejection (once or more), presence of protienuria (more than 0.3 mg/day), abnormality of ECG, or serum creatinine above 300 micromol/L. We conclude that hypertension is highly prevalent in the renal transplant population in Saudi Arabia. Risk factors for the development of hypertension or its complication should be more aggressively approached in order to protect the patients and their grafts alike.

A new treatment forInterdialytic hyperkalemia - the use of fosinopril sodium

Fosinopril sodium is the first of the phosphinic acid class of angiotensin-converting enzyme inhibitors (ACEI). It is used as an antihypertensive agent, but differs from other ACEI in its dual routes of excretion (liver and kidney), and less incidence of hyperkalemia and cough. We conducted a study in known chronic hemodialysis patients who developed interdialytic hyperkalemia in spite of other treatments to control hyperkalemia. We used fosinopril in this group of patients to assess the effect of fosinopril on serum potassium (K) levels. Twenty-four patients were given fosinopril 10 mg at 18:00 h daily for 8 weeks. K levels were measured before and after each dialysis treatment. Interdialytic weight gains were recorded. The average pretrial potassium level was 6.57 mmol/l (+/- 0.47), and the posttrial level was 5.34 (+/- 0.76); p </= 0.0001. No statistically significant interdialytic weight gain or reduction occurred. No first dose hypertensive effect or cough were reported. We have found the use of fosinopril to be successful in lowering predialysis serum K levels in hyperkalemic dialysis patients.

The diagnosis of segmental transplant renal artery stenosis by captopril renography

The captopril renogram test has been shown to be a sensitive test for the diagnosis of renal artery stenosis in native and transplanted kidneys. Most reports have involved only stenosis of the main renal artery. Although segmental renal artery stenosis has been diagnosed successfully in native kidneys, it is not clear whether the captopril renogram test can diagnose segmental renal artery stenosis in a transplanted kidney. The authors report two cases of successful identification, by the captopril renogram test, of functionally significant stenosis in an intrarenal branch of a single transplant renal artery.

Interpretation of captopril transplant renography using a feed forward neural network

Severe renal artery stenosis (RAS) is a relatively uncommon complication after renal transplantation but is a curable cause of hypertension, which demands reliable early diagnosis to reduce morbidity, mortality and graft loss. Captopril renography has been used for a number of years as a method of detecting RAS but controversy still exists as to the diagnostic accuracy of this test and as to the most appropriate interpretation criteria with which to establish a positive result.

METHODS

This report presents the results of using artificial neural networks to impartially assess these interpretation criteria. Data comprised 31 99mTc-MAG3 captopril renography investigations undertaken on hypertensive renal transplant patients with a suspected diagnosis of RAS. Each renogram study was correlated with an arteriogram as the "gold standard". Training of the network was performed using the round-robin technique.

RESULTS

An accuracy of 95% could be achieved by considering perfusion index, time-to-peak activity, accumulation index and excretion index for both pre- and post-challenge studies. This varied as the parameters were either included or excluded.

CONCLUSION

Artificial neural network analysis is a useful technique to evaluate the most appropriate criteria for interpreting captopril transplant renography investigations.

Serum parathyroid hormone suppression by intravenous 1,25-dihydroxyvitamin D3 in patients on maintenance haemodialysis

Secondary hyperparathyroidism in patients with end-stage renal disease is characterised by elevated circulating levels of parathyroid hormone, due to inadequate synthesis of calcitriol, the active metabolite of vitamin D. Recent studies suggest that administration of calcitriol may directly suppress parathyroid (PTH) secretion independent of changes in serum calcium. We have studied the effect of intravenous calcitriol administration on the PTH level in 14 patients on maintenance haemodialysis with serum PTH levels above 2,000 pmol/l over a 16-week period. There was a significant reduction in the PTH level (65%) and a rise of serum calcium to the normal range. There was a significant reduction in serum PTH levels before the serum calcium concentrations increased, suggesting that calcitriol directly inhibits PTH release. In conclusion, intravenous treatment with calcitriol is of clinical importance, because it suppresses hypersecretion of PTH in uraemic patients, with minimal side effects.

The importance of the perfusion index in the evaluation of captopril renography for transplant renal artery stenosis

Severe renal artery stenosis (RAS) is a relatively uncommon complication following renal transplantation but is a curable cause of hypertension which demands reliable early diagnosis to reduce morbidity, mortality and graft loss. Captopril renography has been used for a number of years as a method of detecting RAS mainly in native kidneys, with only a few studies concerning the transplant situation. Controversy still exists as to the diagnostic accuracy of this test and as to the most appropriate interpretation criteria with which to establish a positive result. This paper reports the evaluation of 26 captopril renography investigations on hypertensive renal transplant patients with a suspected diagnosis of RAS. Each renogram study was correlated with an arteriogram as the 'gold standard' which was undertaken within 28 days of the renography. A sensitivity of 92%, a specificity of 86% and an accuracy of 88% were achieved by including a consideration of the change in perfusion to the kidney between pre- and post-challenge studies. It is concluded that captopril renography is a useful screening test for the detection of transplant renal artery stenosis (TRAS).