Gitelman syndrome, hypomagnesemia, and venous thrombosis: An intriguing association

Among salt‐wasting tubulopathies' complications, venous thrombosis is one of the rarest. We report a case of a young woman with Gitelman syndrome (GS). She presented a deep venous thrombosis in her leg and was treated with heparin with favorable outcomes. We retained hypomagnesemia as the cause of the thrombosis.

End-stage renal disease at dialysis initiation: Epidemiology and mortality risks during the first year of hemodialysis

Chronic kidney disease (CKD) treated by hemodialysis (HD) is a worldwide major public health problem. Its incidence is getting higher and higher, leading to an alarming social and economic impact. The survival of these patients is significantly low, especially during the first year of treatment. The purpose of our study was to identify the epidemiological and clinico-biological characteristics of patients at the HD initiation and to reveal the predictive factors of mortality at three months and one year of HD. This is a prospective, analytical, and descriptive study dealing with 229 patients with an end-stage renal disease (ESRD), followed up in the Nephrology Department of Charles Nicolle Hospital and La Rabta Hospital in Tunisia, that was started HD between January and June 2017. A multivariate logistic regression analysis allowed us to identify the independent predictors of mortality at three months and one year. The average age was 60.2 ± 15.3 years, with a gender ratio of 1.41. Seventy-eight percent of patients had more than two comorbidities, 59% had diabetes, and 88% had hypertension. Diabetic nephropathy was the leading etiology of kidney disease (48.9%), while 11% of nephropathies were of unknown etiology. Only 58% were early referred to a nephrologist. The average glomerular filtration rate at HD initiation was 6.06 ± 2.33 mL/min/1.73 m². Hypocalcemia and hyperphosphatemia were noted, respectively, in 60.8% and 84.9% of cases. Anemia was objectified in 98.6% of cases. HD was started in an emergency in 56.8% of cases. One of the most urgent indications was acute pulmonary edema (APE) for 43.8% of patients. Only 10.5% of patients had functional arteriovenous fistula at the dialysis initiation. Patients were hemodialyzed one, two, or three sessions per week, respectively, in 23.2%, 26.6%, and 50.2% of cases. The crude mortality rate was 25% and 13% in, respectively, one year and three months of HD. On multivariate analysis, we identified heart failure and insufficient dialysis dose per week as predictive factors of mortality at the 1^st year of HD. C-reactive protein more than 21 mg/L, insufficient dialysis per week, modified Charlson Comorbidity Index less than 6, and APE at the dialysis initiation were identified as predictive factors of three-month mortality. Despite the short period of study, this work revealed the alarming conditions of patients at HD initiation. This critical situation is due to the delay in CKD diagnosis, the late nephrologist referral, and the lack of preparation before HD initiation.

Encapsulating Peritoneal Sclerosis after kidney Transplantation: Success of Medical Treatment

Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of long-term peritoneal dialysis (PD). EPS may become clinically apparent when patients are on PD (classical EPS) or after undergoing kidney transplantation (post-transplantation EPS). This presentation of EPS seems to occur shortly after kidney transplantation in former PD patients. In this report, we present our experience in our first case of patient diagnosed with EPS after kidney transplantation.

MO231INFECTIVE ENDOCARDITIS IN CHRONIC KIDNEY DISEASE: CLINICAL AND OUTCOME’S FEATURES

Background and Aims

Infective endocarditis complicating chronic kidney disease is associated with high morbidity and mortality among this population particularly exposed to bacteremia.The aim of our study was to study the clinical and evolutionary features of infective endocarditis among patients with chronic renal failure.

Method

It is a retrospective and descriptive study including patients with chronic kidney disease hospitalized in our department, whom presented an infective endocarditis confirmed by modified DUKE criteria

Results

13 patients were included aged meanly of 42.69 years [27-63 years] with a sex-ratio of 0.85. Twelve were in end stage renal disease with an average duration of dialysis of 52 months [1-180 months] and in stage 5 in one case. At the time of diagnosis, vascular access was fistula in one case and a central venous catheter in 11 cases. The catheter was simple in 3 cases and tunnelled in eight cases. The circumstances of discovery were fever in 12 cases associated with an alteration of the general state with asthenia in 10 cases. Low blood pressure was present in seven cases. At biology, the mean hemoglobin level was 8.28 g/dl [6.1-10.8 g/dl]. Leukocytosis was noted in 8 cases. Mean albuminemia was 30.61g/l [24-41g/l]. Albuminemia below 35 g/l was objectified in 6 cases. Major causative organisms were Staphylococcus species in 10 cases. Trans-thoracic echography shows vegetation in 11 cases with an average size of 17.4 mm [6-37 mm] and aortic annular abscess in 2 cases. Antibiotherapy was conducted in all cases. Complications were frequent, including congestive heart failure in 2 cases, secondary septic localisations in 3 cases, hemoptysis in one case and valve perforation in 2 cases. Five patients underwent surgery after a mean delay of 32.75 days [6-47 days]. Death occurred in 8 cases.

Conclusion

Infective endocarditis is severe during chronic kidney failure and more frequent among patients on dialysis by catheter. It is associated with high morbidity and mortality. Management of central venous catheter must be enhanced. Treatment must be early to improve the prognosis of this complication.

MO707MICROBIOLOGY, CLINICAL SPECTRUM AND OUTCOME OF INFECTIOUS PERITONITIS IN PATIENTS ON AUTOMATED PERITONEAL DIALYSIS

Background and Aims

Automated peritoneal dialysis (APD) is a renal replacement therapy that offers patients various advantages such autonomy and comfort. Peritoneal dialysis-related infectious peritonitis (IP) is the most common and severe complication of APD. It is the main cause of technique failure and transfer to hemodialysis and can even be life-threatening. Given the seriousness of this complication, it is necessary to establish preventive strategies and adapt the therapeutic management.The aim of this study was to determine the microbiological and clinical profile of IP, to specify its causes its rate and outcome in patients treated by DPA at the unit of Charles Nicolle hospital in Tunis between January 2000 and December 2018.

Method

We conducted a single-center descriptive retrospective study in the peritoneal dialysis (PD) unit of Charles Nicolle Hospital in Tunis. We identified the episodes of IP occurring in patients treated with APD during the period from January 2000 to December 2018. We studied the clinical, biological and evolutionary aspects of IP.

Results

APD was used in 85% of patients treated at our PD unit during the study period. 322 episodes of IP occurred in 183 patients, that was an IP rate of 0.1 episodes/patient-year. 58% of patients treated with DPA have not presented IP. The mean age of the patients who presented PI was 43 years +/- 15(Extreme: 17-77) with a sex-ratio of 1.23. 74% of patients had a professional activity. 98% of patients had co-morbidities dominated by hypertension (88%), dyslipidemia(73%) and diabetes(16%) with a median Charlson score of 2[2-3] (Extremes: 2-9). Their average Body Mass Index was 24kg/m2+/-5. 33% of the patients were smokers. The average training duration before starting APD was 13days+/-5. The IP were evenly distributed according to seasons (27% occurred in autumn, 26% in spring, 25% in summer and 22% in winter). IP were: a 1st episode in 55% of cases, a new episode in 30% of cases, a relapse in 10% of cases, a recidivism in 3% of cases and a recurrence in 2% of cases. Fever was present in 34% of patients, abdominal pain in 75% of them. The dialysate was cloudy in 98% of cases. The median number of leukocytes in the PD fluid was 380/mm3(Range: 15-8000)with a mean% of neutrophils of 73%+/- 27. Dialysate culture was positive in 60% of cases, negative in 38% of cases and contaminated in 2% of cases. Among the positive cultures, only one was fungal (Candida albicans). Bacterial IP were distributed as follows: 64% Cocci Gram+ dominated by Staphylococcus aureus (48%), 34% Bacillus Gram- (mainly Klebsiella pneumoniae (21%) and Pseudomonas (21%)), 2 cases of Bacillus Gram+ (Corynebacterium afermentans and Lactobacillus) and 2 cases of polymicrobial culture (Cocci Gram+ and Bacillus Gram-).IP was of unknown cause in 48% of cases, related to an asepsis lack in 19% of cases, the orifice infection in 18% of cases and tunnelitis in 2% of cases. The other causes were essentially endogenous. Probabilistic antibiotic therapy was effective in 34% of cases. An adaptation according to the microbiological results was carried out in 19% of cases. Hospitalization was required in 10% of patients. 20% of peritonitis was refractory. Catheter ablation was performed in 14% of patients.IP caused the death of 8 patients and represented 37% of the causes of transfer to hemodialysis.

Conclusion

IPs are a turning point for the survival of the patient and the technique. Knowing the microbiological profile of these infections will make therapeutic interventions precocious and effective in order to preserve the prognosis of patients in APD at the short and long term.

MO719PERITONEAL DIALYSIS IN ELDERLY PATIENTS

Background and Aims

Peritoneal Dialysis (PD) is now often being initiated in older patients. The benefits of this modality of dialysis have been well demonstrated in the literature. The aim of our study was to analyse the epidemiological and clinical profile of the elderly patients and to determine predictive factors of mortality

Method

It was a retrospective study including 51 case defined as patients ≥65-year-old, treated by PD in the Internal Medicine Department of the Charles Nicolle hospital during the period between 1986 and 2020.

Results

Fifty one patients were enrolled in the study. Their mean age was 71,6 ± 5,4 years [65 - 86]. There were 32 men (62, 7%) and 19 women (37,2%) . The method of initiation was the PD in 53, 84%. Diabetic and vascular nephropathy was the first cause of End-Stage Renal Disease in 56% and 19,6%. The mean Charlson score was 5,5 ± 1,4 [3-9]. The mean age when using PD was 70.8 ± 6 years [54-86]. Autonomous and active patients were detected in 29.4%. Diabetes mellitus, hypertension and coronary artery disease was observed in 58,8%, 29,4% and 15.7% of patients. In our study, 82.35% started on automated PD (APD) and 17,6% on continuous ambulatory PD (CAPD). The rate of mortality was 53%.

Switching modality from PD to hemodialysis occurred in 29,4% of cases. A univariate logistic regression identified a coronary artery disease as significantly associated with increased mortality (HR=2,1 [1-2,1, IC 95%](p=0.035)).

Conclusion

Elderly patients on dialysis face many issues but can have continued success with PD when they have adequate care and support. The control of the morbidities such as coronary artery disease is important to decrease the rate of mortality in patients using this modality of dialysis.

MO720SARS-COV2 INFECTION IN THE POPULATION ON PERITONEAL DIALYSIS

Background and Aims

The novel coronavirus disease 2019 (COVID-19) has now spread to the entire world as a highly contagious pandemic. The disease has proved to be more serious in populations with underlying diseases like kidney diseases, diabetes, or cardiovascular diseases. People with end-stage renal disease are known for their weakened immune systems and vulnerability to different types of infections. Recent studies have shown high prevalence and poor prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in hemodialysis patients, but its effect on peritoneal dialysis (PD) patients is still unknown.

The aim of this study was to investigate the clinical, biological, and scannographic particularities and the prognosis of SARS-CoV-2 infection in patients on PD.

Method

We conducted a monocentric descriptive study including all the confirmed cases of SARS-CoV-2 infection in the PD unit of the Nephrology department in Charles Nicolle Hospital. The first confirmed case was in March 2019 and our study period ended in January 2021. We used Real-Time Reverse Transcriptase polymerase chain reaction (RT- PCR) to confirm SARS-CoV-2 infection after nasopharyngeal swabbing.

Results

Eight patients were included: 7 men and 1 woman. The mean age was 40.25 years-old [22-60]. All the patients were hypertensive, 2 of them were diabetics and 3 of them had cardiac pathologies: coronary heart disease in 2 patients and atrial fibrillation in the other patient. One patient had history deep vein thrombosis. All the patients were on automated PD with an average duration of PD of 40.56 months [1-84]. Two of them had history of peritonitis. Regarding the revealing symptoms of COVID-19, all the patients suffered from asthenia, a deterioration of general condition was observed in 7 patients, dry cough was also present in 7 patients, 4 patients described muscle and body aches, 3 patients reported diarrhea and vomiting, dyspnea was observed in 2 patients, only one patient reported loss of taste and smell, and fever was present in only one case.Two patients had low peripheral oxygen saturation (70% and 88%). All the patients had lymphopenia with an average of 557 [900-280]. C-reactive protein was high in 6 patients with an average of 84.7 mg/l. Chest computed tomography (CT) scan was practiced in 3 patients, it was positive in all of them with average extent of damage of 60%. Four patients were admitted in hospital and one of them in the intensive care unit (ICU) for high oxygen needs. All the patients received azithromycin, and vitamin C and D and zinc supplementation. A preventive dose of heparin was prescribed in 5 patients. No patient required intubation. No patient had thromboembolic complications. Six patients fully recovered since more than one month. Regarding the other two patients we have a follow-up of only one week since the beginning of symptoms, one of them is pauci-symptomatic and the other one is still admitted in the ICU.

Conclusion

According to our findings, patients on PD are not at increased risk for severe illness from COVID-19 or other adverse outcomes.

[Emphysematous pyelonephritis and cystitis: An exceptional complication in a kidney transplant recipient]

Emphysematous pyelonephritis is a rare and severe infectious complication characterized by the presence of gas in the renal parenchyma, excretory cavities and surrounded tissues. It is due to the development of non-anaerobic gasifier bacteria. We report a new rare case of emphysematous pyelonephritis in a kidney transplant recipient, particular by its occurrence in a non-functional graft and its exceptional association with emphysematous cystitis.

[Successful treatment with paclitaxel of a visceral relapse of post-transplant Kaposi's sarcoma]

We report the observation of a patient who presented with post-transplant Kaposi's sarcoma after a delay of eight months with a dual cutaneous and palatal localisation. The reduction in immunosuppressive treatment and the introduction of Rapamune® allowed good clinical progress initially with regression of the skin lesions. He subsequently presented later a skin relapse with visceral localisation. Chemotherapy was conducted based on weekly paclitaxel infusions allowing partial remission and maintenance of renal graft function with good clinical tolerance.

P0457MALE LUPUS NEPHRITES: WHAT ABOUT RISK FACTORS FOR RENAL FAILURE ? EXPERIENCE OF ONE DEPARTMENT

Background and Aims

The occurrence of renal involvement during the clinical course of systemic lupus erythematous (SLE) is generally considered to be the most important factor influencing the prognosis in terms of morbidity and mortality. The factors influencing prognosis in lupus nephritis (LN) are variable in literature. The aim of our study was to analyze the clinicopathological correlations, and risk factors associated with renal failure in male patients with LN.

Method

We retrospectively studied all male patients with kidney biopsy-proven lupus nephritis (LN) treated in our department during the period between 1979 and 2016. Looking for predictive factors related to renal prognosis, we analyzed clinical, biological and histological data by multivariate analysis using the comparison of the survival rates by the log-rank test.

Results

We collected 41 native renal biopsies showing LN. Patients were aged 32.17 years (17-65 years) at the time of diagnosis of LN. Diagnosis of SLE was made according to the criteria of the American College of Rheumatology. The most common clinical presentation was nephrotic syndrome (61%), and the most frequent pathological finding in sediment was proteinuria (85%). At the time of diagnosis, 17% of patients had hypertension and 39 % of patients had an eGFR under than 60 ml/min/1.73 m2. LN was of class I, II, III, IV and V in 7.5%, 12.5%, 27.5%, 47.5% and 41.5% of the cases, respectively. Fourteen patients developed end-stage renal failure. The presence of hematuria, renal failure at the time of diagnosis, nephrotic syndrome, low complement, proliferative glomerulonephritis (class IV), high activity index score of LN and thrombotic microangiopathy were significantly associated with poor renal prognosis with (p=0.0053), (p=0.0002), (p=0.0186), (p=0.0287), (p=0.0005), (p=0.058), (p=0.0117), respectively.

Conclusion

Renal failure at the time of diagnosis and active proliferative lesions should be diagnosed and treated as soon as possible because they influence the renal prognosis in lupus man.

P0507ANTI-GLOMERULAR BASEMENT MEMBRANE DISEASE. ABOUT 32 CASES

Background and Aims

Anti-Glomerular basement membrane disease « anti-GBM » is a rare autoimmune disease. It most often results in a rapidly progressive glomerulonephritis syndrome associated with intra-alveolar hemorrhage. The diagnostic confirmation is histological, by the demonstration of linear deposits of immunoglobulins (IgG) along the glomerular basement membrane. The aim of our study was to describe its epidemiological, clinical, biological, immunological, histological, and evolutionary characteristics and to identify the different prognostic factors for predicting patient survival and renal survival.

Method

It was a retrospective, descriptive and analytical study including patients over 16 years old with anti-GBM disease proved by kidney biopsy and followed up over a period of 32 years (January 1985 to July 2017), in Internal Medicine Department of Charles Nicolle Hospital of Tunis.

Results

We collected 32 patients with a sex ratio H/F = 1.13. The mean age at diagnosis was 42 years old with extremes of 18 to 81 years old. The most frequent extra-renal manifestations were pulmonary (53%), neurological (12.5%) and ocular (6%) manifestations. Hematuria associated with proteinuria was constantly found.

The latter was nephritic in 31% of patients. All patients had renal insufficiency on admission, oligo-anuric in 60% of cases. The use of extra-renal treatment at admission was necessary in 75% of patients. On the immunological level, the search for anti-MBG antibodies, performed in 20 patients, was positive in 65% of cases. All our patients had undergone a renal biopsy puncture with direct immunofluorescence study.

Diffuse extra-capillary glomerulonephritis was observed in 93% of patients.

Corticotherapy was initiated in 27 cases, associated with plasma exchange in 21 cases and cyclophosphamide in 17 cases. Nine of our patients died in the first year. Renal outcome was marked by partial remission in 2 cases and end-stage renal failure in 19 cases. In univariate analysis, an age greater than 60 years and the occurrence of respiratory distress were predictors of death.

Oligo-anuria and need dialysis on admission were predictive factors for progression to end-stage renal failure.

Conclusion

Anti-GBM disease is a serious illness. Current therapeutic modalities have significantly improved patient survival. These must be intensive and rapid in order to hope for a favorable renal evolution whose prognosis remains reserved.

P0278CARDIOVASCULAR RISK FACTORS AND THE LONG TERM OUTCOME OF LUPUS NEPHRITIS

Background and Aims

Systemic Lupus Erythematosus (SLE) is associated with an increased risk of cardiovascular morbidity and cardiovascular mortality. The risk of cardiovascular events is 1.3–2.7 times higher in SLE patients than in the general population, and even higher in patients with lupus nephritis (LN). Traditional risk factors as well as SLE-specific and treatment-related factors all contribute to the increased risk of cardiovascular disease. The primary aim of the present study was to evaluate cardiovascular risk factors, morbidity and mortality in patients with LN.

Method

This is a retrospective study of patients over the age of 16, with LN proved by kidney biopsy and followed up in our department over a period of 17 years. The diagnosis of lupus was made according to criteria of The American College of Rheumatology revised in 1997. Demographic, clinical and para-clinical data were collected from medical observations.

Results

We collected 155 women and 19 men with a sex ratio F / H of 8.2. The mean age at the time of the discovery of LN was 32.6 years [15-45 years]. Overall median follow-up time was 81.2 months. Renal symptomatology was dominated by proteinuria noted in all patients with an average proteinuria at 3.3 g / 24h, associated to a nephrotic syndrome in 68% of patients, hematuria was present in 69% of patients and renal failure was present in half of cases with an average serum creatinine of 110 µmol / l. At the time of diagnosis of LN, hypertension was noted in 48.9% of cases, diabetes in 2.8% of cases and obesity in 57.4% of cases with an index average body mass of 28.5 Kg / m2. Smoking was reported in 17.2% of the cases. The average cholesterol level was 5,5±2,1 mmol/l, the average triglycerid level was 2,5±1,1 mmol/. Antiphospholipid syndrome was found in 14.9% of cases. We performed 243 renal biopsies with 174 initial and 69 iterative biopsies. The histological lesions were polymorphic dominated by LN class IV (54.3%), arteriolosclerosis was observed in 47.7% and lesions of thrombotic microangiopathy in 29.8%. Corticosteroid therapy was prescribed in all patients combined with immunosuppressive therapy in 54.6% of cases. The overall survival of the patients at 10 years was 85%. During follow-up, cardiovascular complications found in our series were mainly strokes (6.3%) and coronary insufficiency (5.2%) and transient ischemic attack (6.9%). After a univariate analysis, the additional cardiovascular risk factors identified in our study were antiphospholipid syndrome (p = 0.01), renal failure (p = 0.01), long-term corticosteroid therapy (p = 0.009), the chronicity of the disease (evolution of lupus> 10 years) (p = 0.014), proliferative forms (p=0.001), arteriolosclerosis (p=0.0002) and lesions of thrombotic microangiopathy (p=0.018). Survival in patients without cardiovascular risk factors was better (96% vs 88%).

Conclusion

In conclusion, in addition to traditional risk factors SLE patients have several disease related risk factors that explain increase cardiovascular disease. A careful control for this risk factors is essential to continuously improve survival in SLE.

P1528EPIDEMIOLOGICAL SURVEY OF A POPULATION UNDERGOING URGENT HEMODIALYSIS

Background and Aims

Urgent hemodialysis is a very common situation in nephrology and is burdened with high morbidity and mortality. The aim of this work is to study the epidemiological, etiological, clinico-biological and indications of dialysis emergencies, the parameters of the session and the potential complications.

Method

This is a descriptive study conducted over a period of 12 months (January – December 2017), including all patients who have been admitted to the nephrology department for urgent management in hemodialysis.

Results

Our study collected a total of 318 patients (sex ratio =1.52), the mean age 60.54 ± [18-95 years]. Patients came mainly from the emergency department (69.8%). 40.9 % of the patients were diabetic and 66,4 % hypertensive, 15.1% had coronary artery disease. Among patients, 80.9% had chronic renal insufficiency, of which 29.6% were end-stage (28% hemodialysis and 1.6% peritoneal dialysis). Urgent hemodialysis was undertaken for threatening hyperkalemia in 58.2% of cases, a poorly tolerated uremic syndrome in 50.8% acute pulmonary edema (APO) in 36.5% of cases, and anuria greater than 12h were the indication in 44.4% of cases and a severe metabolic acidosis in 11.3% of cases.

The average duration of the session was 3 hours. Ultrafiltration was necessary in 63.7% of the cases. The blood access was a femoral catheter in 80.6% of the cases. Blood transfusion was indicated in 13.8% of cases. Main complications were dominated by symptomatic arterial hypotension in 12.9% requiring stopping the session in half of cases hypoglycemia in 6.9%, neurological disorder in 6.6% chest pain in 3.5 %. After a year of follow up care, overall mortality was 40% in this population. On multivariate analysis, age (p=0.006) and neurological state according to the glasgow score (p=0.01) were retained as independent factors of mortality in this population.

Conclusion

A greater prevalence of urgent hemodialysis is observed in our country testifying to the accessibility of this method of extrarenal replacement. Hyperkalemia, uremic syndrom and PAO are the main indications for urgent hemodialysis. Early diagnosis, prompt and relevant management of these patients will determine their prognoses in the short and medium term.

P0488IG A NEPHROPATHY: ANALYSIS OF 501 BIOPSY

Background and Aims

Mesangial deposits Ig A was described the first time in 1968 by Berger and Hinglais. It remains the most common primary glomerulonephritis worldwide. It is often idiopathic but can also be secondary. The aim of our study is to describe the epidemiologic characteristics, the incidence and the anatomopathological features of 501 IgA nephropathy (IgA N) patients.

Method

It is a retrospective mono-centric study including patients having IgA N in the renal biopsy done in our department among a period of 17 years.

Results

We analyzed data of 8427 patients who underwent renal biopsy. 81% had glomerular nephropathy with 7.3% (501) IgA N. A male-to-female ratio of 2.27. The average age was 28.7 years. IgA N was primary in 80.2% cases and secondary in 17.8% cases. The most frequent secondary IgA N was rheumatoid purpura (74.8%). There was a male predominance in Berger‘s disease as well as in rheumatoid purpura. Berger’s disease was more common in adults, whereas rheumatoid purpura was more common in children. The main indication of renal biopsy was proteinuria with hematuria in 23.2% of cases and nephrotic syndrome in 23.8%. The association of non-nephrotic proteinuria, hematuria, arterial hypertension and renal injury was found in 9.3% whereas isolated macroscopic hematuria only in 6.4% of cases. According to HAAS classification, HAAS 3 was the most frequent. OXFORD classification used only from 2010, and M1, S1, E0, T0 and M1, S1, E0, T2 were the most frequent. Glomerular lesions were associated to tubulo interstitial and vascular lesions in 48.2% of cases.

Conclusion

IgA nephropathy is the most common glomerular disease and a frequent cause of end stage renal disease. Because of a clear increase of it’s incidence in our country and the delay in the diagnosis, a systematic screening of urines is needed in our country as it’s done in Singapore and Japan.

P0318HYPERKALEMIA: EPIDEMIOLOGY AND MANAGEMENT

Background and Aims

Hyperkalemia is a dreadful biological event that can immediately compromise the vital prognosis. Etiologies are many and varied. The aim of our study is to better characterize the epidemiological and clinical aspects of this disorder in order to establish adequate diagnostic and therapeutic strategies in order to intervene effectively and in the shortest possible time.

Methods

Cross-sectional study carried out over a period of 12 months [January-December 2017] including all emergency calls for hyperkalemia greater than 5.5 mmol / l and undergoing hemodialysis in the nephrology department.

Results

We collected 185 patients (Sex ratio= 1.43) aged on average 61.8 ± 16.1 years [18-94 years].

70.3% had serum potassium between 5.5 and 7 mmol / l and 29.7% greater than 7. Patients mainly came from emergencies in 71.4% of cases. Main symptoms consisted in oligoanuria, vomiting, chest pain, and febrile syndrome in 38.9%, 10.8%, %, and 5.9% of cases, respectively. Of these patients, 76.2% are known to be chronic renal failure whose 29.7% are in chronic dialysis. Acute renal failure (ARF) was diagnosed in 30.3% of patients. Of these, 39.4% were functional AKI, 41% were obstructive and organic AKI in 19.6% of cases. Mean serum potassium was 6.7 ± 0.9mmol / l [5.5-11] associated with metabolic acidosis in 52.4% of cases. Mean serum creatinine was 988umol /l[184-3270]. The electrical signs of hyperkalemia were noted in 40% (n = 74) of patients: large T in 28.6% of cases, atrioventricular block (AVB) in 3.8% of cases including a 3rd BAV degree in 1.6% of cases, QRS wide in 11.4% of cases and sinus bradycardia in 7% of cases, Ventricular Extrasystoles and a branch block found respectively in 3.2% of cases. 30.8% (n = 57) of the patients were under hyperkalaemic treatment. In fact, 27 % of patients took a blocker of the renin-angiotensin system, 7% were on aldoactone, 13.5% of patients on þetabloquant,1.6 % of whom were on kaleoride and / or admitted to intensive care and infused with KCl. Medical treatment was started urgently in 42.7 % of cases and included the administration of twenty ml 10% ca gluconate that was given intravenously over 5-10minutes, insulin with glucose ,sodium polystyrene sulfate (Kayexalete) and salbutamol, sodium bicarbonate indicated for severe metabolic acidosis (pH<7.20). Overall mortality was 21.1% of cases .

Conclusion

Hyperkalemia remains a frequent metabolic disorder. Renal failure and acidosis were the main factors associated to hyperkalemia in our study. The clinical and therapeutic subtleties must be known by any caregiver in order to effectively mitigate the harmful effects of this disorder, mainly in the cardiac function.

P0132DIAGNOSIS OF HYPEROXALURIA FROM RENAL BIOPSY

Background and Aims

Crystal-induced kidney disease refers to kidney injury caused by intratubular crystal deposition. The most common forms of crystalline nephropathy encountered in renal pathology are nephrocalcinosis and oxalate nephropathy. The purpose of our study is to determine the epidemiological and clinical characteristics of hyperoxaluria diagnosed from renal biopsy.

Method

We retrospectively reviewed all kidney biopsy specimens evaluated at renal pathology laboratory, from 1976 to 2019. The biopsy specimens were received from multiple medical department and medical centers. We studied 8900 biopsy specimens and we were focused on patients whose diagnosis of hyperoxaluria was made from renal biopsy

Results

We identified 25 cases (15 children and 10 adults) with a sex ratio H / F of 0.9. Mean age at diagnosis was 17.2 years old [4 months-73 years old]. Most patients were offspring of consanguineous mating (14 of 25) with intermarriage of first-degree cousins being the most common pattern. A family history of chronic kidney disease was found in 13 patients: indeterminated nephropathy (n = 6) and renal stone (n = 5) and primary hyperoxaluria (n=2). Among our patients, five had a history of urolithiasis. One patient had a history of chronic diarrhea related to Crohn's disease and one patient had a history of cephalic pancreatectomy and ileal resection. Initial symptoms and signs were dominated by renal failure (n = 25) with mean creatinine of 789.5 μmol / l [306-1832μmol / l], associated with proteinuria in 10 patients and hematuria in 11 patients. Arterial hypertension was present in 4 patients. Oligo anuria was reported in 4 patients without dilation of the urinary excretory pathways. In our patients, the diagnosis of crystalin nephropathy was revealed by renal biopsy. In one case, the diagnosis was made after renal transplant. In 4 cases the diagnosis was made by postmortem kidney biopsy. In all cases, the kidney biopsy specimen showed extensive intratubular crystal deposition and tubulointerstitial mononuclear cell infiltration with features of tubular injury and interstitial fibrosis. Examination of histologic slides showed colorless refractile crystals of polygonal appearance. Multicolored birefringence under polarized light identified these crystals as calcium oxalate. After different investigations (genetic and biological analysis), the diagnosis of hyperoxaluria was confirmed. Hyperoxaluria was primary in 23 patients and secondary in 2 patients.

Conclusion

Hyperoxaluria is a rare condition, often serious, involving renal prognosis and sometimes life-threatening, especially in early-onset forms. Early diagnosis and treatment should be done as soon as possible to slow the progression to end-stage renal failure. In patients with renal insufficiency, the diagnosis of hyperoxaluria is difficult. Renal biopsy can help when clinical and radiological data are not sufficient.

P0167HYPERTENSION IN PATIENTS WITH LUPUS NEPHRITIS

Background and Aims

Hypertension is a common manifestation during systemic lupus erythematosus (SLE). Its mechanism is multifactorial and microthromboses of renal arterioles seem to be the most important mechanism. The objective of our study is to identify the histological and evolutionary characteristics of patients with lupus nephritis (LN) presenting with hypertension.

Method

A retrospective study of 85 patients followed for LES with lupus nephritis documented by a renal biopsy collected in 17 years and presenting with hypertension.

Results

Among 174 patients with LN, eighty-five (48.58%) are hypertensive. A sex ratio F / H of 6.08. The mean age of LN diagnosis was 36.4 years old [13 -75 years old]. The average time to onset of hypertension was 25.8 months [0-204 months]. Malignant hypertension was present in 12% of patients. Antiphospholipid Antibody Syndrome (APLS) was found in 35.3% of cases. Renal biopsy showed LN class II in 2 cases, class III in 8 cases, class IV in 43 cases, class V isolated in 8 cases and class VI in 3 cases. Vascular lesions were arteriolosclerosis in 40% of cases and thrombotic microangiopathy (TMA) lesions in 17.6% of cases. The treatment was essentially based on blockers of the renin angiotensin system, either as monotherapy or in combination with calcium channel blockers, beta blockers or central antihypertensives. The evolution was marked by the occurrence of cerebrovascular accidents associated in 7 cases with APLS and coronary artery disease in 2 cases. Renal evolution was marked by total and durable remission in 27.5%, chronic renal disease in 31.7%, and end-stage renal failure in 40.8% of cases. Blood pressure was balanced in 40,5 % of cases and unbalanced in 59,5% of cases.

Conclusion

In our lupus patients, hypertension was common, associated with severe glomerular and vascular lesions and a rather severe renal prognosis.

P0435PREDICTORS OF RENAL SURVIVAL IN ELDERLY NEPHROTIC SYNDROME

Background and Aims

With increasing longevity, the numbers of elderly patients presenting with renal diseases including glomerular disease are increasing. Nephrotic syndrome (NS) is a common presentation of glomerular disease in the elderly. We performed this study to assess predictors of renal survival in this population.

Method

A retrospective study including one hundred and six patients aged 65 years or more hospitalized for NS in the Internal Medicine department A of Charles Nicolle hospital at Tunis, between January the 1st, 1975 and December the 31st, 2016.

A multivariate study was carried out, the dependent variable being the evolution towards end-stage renal disease (ESRD).

Results

We studied 106 patients with an average age of 70 ± 4.5years [65-83 years] with a sex ratio (M/F) of 1.7. Twenty-three percent of patients were diabetic. The median proteinuria was 4.6 [3-19.5 g/l], the mean albumin level was 20 ± 5.6g/l and the mean protidemia was 50 ± 6.9 g/l. Nephrotic syndrome was impure in 89.6 % of patients with high blood pressure in 70.5 % of cases, hematuria ≥2 + in 34.7% of cases and renal failure in 88.4 % of cases. The renal biopsy was performed in 41 patients. The most common glomerular lesions were Membranous nephropathy (29 %) followed by amyloidosis (27 %). NS was secondary in 63.2 % of cases mainly to amyloidosis (35.8 %) and diabetes (19.8 %). Idiopathic nephropaty was dominated by membranous nephropathy (11.3 %) and primitive membranoproliferative glomerulonephritis (MPGN) (6.6 %). At the end of follow-up, 35 % of patients achieved complete or partial remission and 58.5 % progressed to ESRD. The multivariate study found as independent risk factors of progression to ESRD uremia ≥ 17 mmol/l (ORa =33.2 [1.3 - 837.7]; p<0.05), phosphoremia ≥ 1.6 mmol/l (ORa=22.1 [1.8-266.5]; p<0.05), potassium concentration ≥ 4.3mmol/l (ORa=24.7 [2.4,251.5]; p<0.01), extra-renal signs (ORa=38,9 [2.4 - 634.3]; p: 0.01), secondary nephropathy (ORa=74 [3.1 - 1788.2]; p<0.01) and MPGN (ORa=48[1.4 - 1675.5]; p<0.05). The protective factors were hemoglobinemia ≥ 9.3g/dl (ORa=0.007 [0 - 0.2]; p<0.01), kidneys well differentiated on ultrasound (ORa=0.032 [0.003 - 0.4]; p<0.01) and treatment with two diuretics (ORa=0.03 [0.003 - 0.4]; p<0.01).

Conclusion

Elderly NS was characterized by a poor prognosis, in particular secondary to delayed and non-uniform treatment strategies, hence the need for rising physician awarness about this decease and consultation on a standardized treatment strategies.

P0465NEPHROTIC SYNDROME IN ELDERLY PATIENTS

Background and Aims

Nephrotic syndrome (NS) is one of the manifestations of acute or chronic glomerular nephropathy in the elderly. Our study objective was to determine the particularities of NS in the elderly.

Method

This is a retrospective study, carried out in the Internal Medicine department A of Charles Nicolle hospital at Tunis, between January the 1st, 1975 and December the 31st, 2016. This study included subjects aged 65 years old or over hospitalized for NS.

Results

We studied 115 patients with an average age of 71 ± 5 years [65-83 years] with a sex ratio (M/F) of 1.7. Twenty-three percent of patients were diabetic. The median proteinuria was 4.7 g/l [3-19.5 g/l], the mean albumin level was 20 ± 6g/l and the mean protidemia was 50.6 ± 6.9 g/l. Nephrotic syndrome was impure in 89.5 % of patients with high blood pressure in 54 % of cases, hematuria ≥2 + in 30% of cases and renal failure in 82.7 % of cases. Renal biopsy was performed in 45 patients. The most common glomerular lesions were Membranous nephropathy (29 %) followed by amyloidosis (24.5 %). NS was secondary in 65.2 % of cases mainly to amyloidosis (35.6 %) and diabetes (19 %). Idiopathic nephropaty was dominated by membranous nephropathy (9.5 %) and primitive primitive (MPGN) (4.3 %). The treatment was symptomatic for 84.4% of patients. Corticosteroids and/or immunosuppressive treatment have been used for 15.6% of patients. At the end of follow-up, 35.3 % of patients achieved complete or partial remission and 56.6 % progressed to ESRD.

Conclusion

Elderly NS was characterized by a poor prognosis due to delayed cosultation and non-uniform treatment strategies. Multicentric study in order to identify different action axes could improve the prognosis of this disease. Multicentric study in order to identify different action axes could improve the prognosis of this disease.

P0418LUPUS NEPHRITIS: A MONOCENTRIC STUDY

Background and Aims

Systemic lupus erythematosus is a multi-visceral autoimmune disease. Renal involvement is one of the most common and serious manifestations of this disease. The histological lesions are highly polymorphic and the renal biopsy remains crucial for the therapeutic management of lupus nephritis (LN). The aim of our investigation was to study the epidemiological, clinical, biological and histological characteristics, outcomes and to evaluate the therapeutic protocols used for lupus nephritis’ treatment and to identify predictive factors of renal prognosis in patients with lupus nephritis.

Method

It was a retrospective study including patients over 16 years old with lupus nephritis proved by kidney biopsy and followed up over a period of 17 years in our department.

Results

We collected 155 women and 19 men with a sex ratio F / H of 8.2. The mean age at the time of the discovery of LN was 32.6 years with a maximum between 15 years and 45 years. The most frequent extra-renal manifestations were articular and dermatological manifestations (79%). Renal symptomatology was dominated by proteinuria noted in all patients, associated to a nephrotic syndrome in 68% of patients. At the time of diagnosis of LN, hematuria was present in 69% of patients and renal failure was present in half of cases. Immunologically, antinuclear antibody were positive in 89.1% of cases, anti DNA positive in 73.4% of cases, anti Sm positive in 79.8% of cases and Antiphospholipids were positive in 50% of cases, associated with an antiphospholipid syndrome in 14.9% of cases. We performed 243 renal biopsies with 174 initial and 69 iterative biopsies. The histological lesions were polymorphic dominated by LN class IV (36.6%) isolated or associated with LN class V (17.7%). All patients received a corticosteroid for induction or maintenance treatment. It was associated with immunosuppressive treatment according to different treatment regimens. The median duration of follow-up was 81.2 months. Renal outcome was marked by complete and sustained remission in 36.7% of cases, incomplete remission with chronic kidney disease in 34.5% of cases, chronic renal failure in 28.7% of cases. At univariate analysis, we identified the young age below 35 years at the time of the discovery of LN, the male sex, increased serum creatinine at the time of biopsy, proliferative forms, the presence of histological signs of chronicity and lesions of thrombotic microangiopathy as predictive factors of poor renal outcomes.

Conclusion

Lupus nephritis is one of the most common and serious manifestations of Systemic lupus erythematosus. The generalization of renal biopsy, the use of early codified therapeutic protocols and regular monitoring and evaluation of disease activity according to the appropriate scores can improve management and survival of patients with renal impairment.

Prevalence and risk factors of hypogonadism in men with chronic renal failure

AIM

To determine the prevalence and the risk factors of hypogonadism in men with chronic renal failure (CRF).

METHODS

We conducted a cross sectional analysis in 48 men with CRF. Total testosterone, prolactin, and gonadotropins were measured in all patients. Hypogonadism was defined by a low level (<10 nmol/l) or a low normal level (10-14 nmol/l) of total testosterone.

RESULTS

The mean age was 53.31±10.22 years. Renal impairment was mild, moderate, severe and at end stage in 9,14,4 and 21 patients, respectively. Nineteen patients had been undergoing extra-renal purification. The average of total testosterone was 13.44±6.17 nmol/L. It was lower in patients with diabetic nephropathy (p=0.004). Hypogonadism was diagnosed in 22 patients (46 %). In this group, gonadotropins were normal in 21 cases and elevated in only one case. Hyperprolactinemia was retained in six patients. Type 2 diabetes (OR: 3.96; p=0.02) and diabetic nephropathy (OR=4.26; p=0.01) were the only risk factors of hypogonadism in our patients.

CONCLUSION

Our results had demonstrated a high prevalence of hypogonadism in males with chronic renal failure. This hormone disorder was associated with type 2 diabetes and diabetic nephropathy.

Monoclonal gammopathy of renal significance with light-chain deposition disease in kidney transplantation

Light-chain deposition disease (LCDD) reoccurs almost invariably after renal transplantation, leading to early graft loss. We report a case of LCDD with monoclonal gammopathy of renal significance diagnosed in the post-transplant period in a 28-year-old male and we discuss the diagnostic and therapeutic challenges in the clinical course.

Mycophenolate Mofetil-induced Oral Ulcerations in a Kidney Transplant Recipient

INTRODUCTION

Mycophenolate Mofetil (MMF) is an immunosuppressive drug usually used in kidney transplants to prevent rejection. It has various adverse effects such as leucopenia, anemia, diarrhea but Mouth ulcers are rarely reported.

METHOD

We present a case report of MMF-induced mouth ulcers in an African patient.

CASE REPORT

A 41-year-old African-male patient has painful oral ulcers which developed 5 months after kidney transplantation. The immunosuppressive maintenance regimen comprised Steroids, Tacrolimus and MMF.

RESULT

These ulcers were firstly related to a fungic or viral infection so the patient was prescribed Fluconazole and Aciclovir without any improvement. Then, Tacrolimus blood level was checked and it was in a therapeutic range. Finally, we decide to stop MMF and the ulcers healed quickly.

DISCUSSION

Oral ulcers are frequently seen complications in immunosuppressant patient but are rarely described with MMF. These ulcers can become large and very painful and degrade patient's life quality. So when infections causes are excluded, we have to keep in mind that these ulcers can be a drug adverse effect.

Peritoneal dialysis in diabetes patients

INTRODUCTION

Peritoneal dialysis (PD) is a renal replacement therapy (RRT) in end stage kidney disease patients with several advantages and disadvantages.

AIM

To evaluate the epidemiological, clinical, biological and outcome of diabetic patients in PD in our service and to determine the factors influencing overall survival and technique.

METHODS

This was a retrospective study that included 90 diabetic patients supported on PD in our Department of Nephrology and Internal Medicine A in Charles Nicolle Hospital of Tunis from 1983 to 2016.

RESULTS

There were 90 patients with mean age of 57 years. The sex ratio M/W was 1.3. Diabetes was type 2 in 84.44%. Complications were decreased ultrafiltration (26.66%), displacement of the catheter (20%), umbilical hernia (3.33%), malnutrition (2.22%) and peritonitis (45.55%). The number of peritonitis was 1 episode every 38.64 patient months. Transfer to hemodialysis was indicated in 37.78% of cases. Death occurred in 33 patients. Causes were cardiovascular (21.11%), septic shock (10%) and complicated peritonitis (5.55%). A statistically significant correlation was found between patient survival and death from cardiovascular events (p = 0.048), type 2 diabetes and high peritoneal permeability (p = 0.033) and technical survival and systolic arterial pressure> 139.5mmHg (p = 0.01). Overall survival at 5 years was 66% and technical survival was 28%.

CONCLUSION

PD is an interesting way of RRT in diabetic patients. Good control of diabetes complications and those of PD technique is essential to increase survival.

Urinary mRNA analysis of biomarkers to epithelial mesenchymal transition of renal allograft

Renal allograft loss is most often a chronic process, irrespective of the mechanism at stake. In this prospective study, we studied the expression of epithelial to mesenchymal transition (EMT) markers vimentin and β-catenin by immunohistochemistry in the surveillance biopsy and measured the mRNA encoding vimentin (VIM), CD45, GAPDH and uroplakin 1a (UPK) by quantitative PCR in urinary cells in 75 renal transplant patients. The aim is to establish a simple screening test for chronic renal allograft dysfunction. We found that the value of the mRNA of vimentin and CD45 relative to the uroplakin 1a (UPK) mRNA is correlated with the score in vimentin immunostaining in routine biopsies. These biomarkers could be used as a noninvasive tool to monitor the renal graft fibrogenesis. This test could be used for early detection of fibrotic diseases of the kidney transplant.

Outcome of Kidney Transplant in Patients with Polycystic Kidney Disease: A Single-Center Study in Tunisia

OBJECTIVES

Autosomal dominant polycystic kidney disease is a common cause of end-stage renal disease and a common indication for renal transplant. This study was undertaken to evaluate the demographics, outcomes, and complications of renal transplant in patients with autosomal dominant polycystic kidney disease compared with other nephropathies.

MATERIALS AND METHODS

In a retrospective case-control design, we reviewed the records of 7 patients with autosomal dominant polycystic kidney disease from a total of 701 renal transplant patients over a 30-year period (1986-2016). For each patient, a matched control was selected based on sex, age, year of transplant, and type of kidney donor. We excluded patients who underwent kidney transplant abroad and those with a follow-up period of less than 2 years.

RESULTS

The number of patients with autosomal dominant polycystic kidney disease requiring transplant at our center was estimated at 0.23 per year, and the condition represented 1.57% of initial nephropathy causes. The mean patient age at transplant was 50.8 ± 8.05 years. There were 5 male and 2 female patients in the case group, with a male-to-female ratio of 2.5. The source of the graft was predominantly a living related donor (5/7). Four patients had extrarenal manifestations, the most common of which were liver cysts (3 patients). Rejection occurred in a single study patient (14.2%) and in 4 control patients (57.1%; P = .51). Two patients did not develop any complications. Complications noted after transplant included infection (3/7 cases vs 2/7 controls; P= .67) and cerebrovascular accidents (2/7 cases vs 0/7 controls).

CONCLUSIONS

Further studies with longer follow-up and greater numbers of patients are needed to compare more precisely the complications and results of transplant between patients with autosomal dominant polycystic kidney disease and other kidney transplant recipients.

Thirty Years of Experience at the First Tunisian Kidney Transplant Center

OBJECTIVES

The aim of this study was to report the results of 30 years of experience at the first kidney transplant center in Tunisia.

MATERIALS AND METHODS

All kidney transplants performed at the center between June 1986 and June 2016 were included. The study period was divided into 3 decades. Recipient and donor data and follow-up information were obtained from a local database and patient medical records. Comparative analyses were performed using the t test for continuous variables and the Χ² test for qualitative variables. Patient and graft survival rates were calculated according to the actuarial method, and comparison of survival curves was performed according to the logrank test.

RESULTS

The mean age of recipients was 32.7 ± 11.5 years (range, 6-65 y) with a gender ratio of 2.2. Duration of prekidney transplant dialysis varied from 2 months to 20 years (median, 27.5 mo); 1.7% of patients underwent transplant preemptively. Kidneys were recovered from deceased donors in 21.2% of cases and from living donors in 78.8%. The proportion of deceased donors dropped from 27.4% during the period 2006-2010 to 12.9% during the period 2011-2015 (P < .04). Patient survival rates at 1, 5, 10, 15, and 20 years were 96%, 89.3%, 79.5%, 71.1%, and 65.4%. Graft survival rates were 95%, 86.5%, 76.2%, 66.3%, and 57.2%. The annual graft loss was 2.9%, with a mortality rate of 2.4% and without significant differences between patients receiving deceased-donor and living-donor organs.

CONCLUSIONS

Kidney transplant activity remains suboptimal in our country. The reduction in deceased-donor organs could be related to the political transformations facing our country with their resulting social and economic consequences. Efforts should be made to increase governmental resources and to improve both public awareness of organ donation and the motivation of transplant teams.

Tuberculosis After Renal Transplant

Tuberculosis is one of the leading infections after renal transplant, particularly in developing countries where the incidence and prevalence in the general population are high. Diagnosis requires bacteriologic and histologic confirmation. Interactions among the antitubercular drugs and the immunosuppressive agents have to be considered while prescribing, and surveillance for adverse effects is required. Although rare, case reports are available on extrapulmonary tuberculosis in allograft recipients. Here, we present a 25-year-old kidney transplant recipient who was diagnosed with lymph node tuberculosis under uncommon circumstances but who had a good outcome. This case report illustrates the difficulties in diagnosis of tuberculosis, changes in therapeutic protocols, and prognostic factors and highlights the effects of infectious complications with immunosuppressive therapy in this particular patient population.