Sjӧgren's syndrome (SS) is a systemic autoimmune disease affecting mainly the exocrine glands. Tubulointerstitial nephritis (TIN) is the most predominant renal involvement with lymphocyte and plasma cells
infiltration of the interstitium. We report a case of young female with SS presented with renal tubular acidosis (RTA), polyradiculoneuropathy &proteinuria. Renal biopsy revealed granulomatous interstitial nephritis. Granuloma formation is rarely seen in cases of SS.

Background and objectives Despite much research about lupus nephritis, none of the urinary biomarkers has been proven to be truly reflecting lupus nephritis activity, response to treatment, or prognosis. We aimed to study urinary biomarkers in lupus nephritis and test the r relation to kidney damage.
Patients and methods: Forty patients with systemic lupus erythematosus (SLE) were divided into two groups: (1) lupus nephritis group with biopsy-proven proliferative lupus nephritis (classes III and IV) and who did not receive immunosuppressive drugs within the preceding 3 months except for glucocorticoids and (2) lupus non-nephritis group with SLE patients without any renal manifestation. We assessed disease activity by the SLE disease activity index. uNGAL, uKim-1, uNGAL to urinary creatinine excretion (mg/dl), and uKim-1 to urinary creatinine excretion were measured in random spot urine samples at the time of renal biopsy and 6 months after the induction therapy.
Results The LN group before treatment showed higher levels of uNGAL and uKIM-1 (P-value < 0.001). ROC analysis showed that uNGAL at level of > 59 has a 95 % sensitivity, a 100 % specificity, and an AUC = 0.996 in the ability to diagnose LN. While the uKIM-1 ROC showed that at level of > 1.6, it has an 85 % sensitivity, an 80 % specificity, and an AUC = 0.919. uNGAL and uKIM levels were significantly lower after treatment (P-value < 0.001). No significant correlations were found between urinary markers before and after treatment with other clinical, inflammatory, and serological markers of lupus nephritis.
Conclusion uNGAL, uKIM, uNGAL/Creat ratio, and uKIM/Creat ratio can be used as a predictor and a marker of disease activity for lupus nephritis.

Objective
To compare echocardiography‑guided versus clinically guided fluid resuscitation regarding mortality of critically ill patients in ICU.
Patients and methods
This randomized controlled trial was carried out on 120 patients with circulatory shock. Demographic, clinical, and routine laboratory data were recorded. Eligible patients were randomly assigned to either echocardiography‑guided fluid resuscitation or clinically guided fluid resuscitation. Fluid responsiveness was defined as either left ventricular outflow tract‑time velocity integral respiratory variation by 12% or an increase in left ventricular outflow tract‑time velocity integral by 12% after 250 ccs of normal saline challenge.
Results
Echocardiography‑guided resuscitation cases have significantly lower hospital mortality (30 vs. 43% in controls; P = 0.001), intubation and mechanical ventilation rates (7.87 ± 0.63 vs. 4.48 ± 0.38 days in controls; P = 0.01). Moreover, cases have a significantly lower amount of fluid (26 800 vs. 50502 ml in the control group20), with significantly lower net cost [13.4$ (214 EGP) vs. vs 25.11 $ (401 EGP) in the controls; P = 0.000 in controls; P = 0.00].
Conclusions
Echocardiography‑guided fluid resuscitation appears to have lower hospital mortality, hospital morbidities, and ICU cost.

Previous trials evaluated the incidence of critical illness–related corticosteroid insufficiency (CIRCI)
using 250 μg adrenocorticotropic hormone (ACTH). However, this supraphysiological dose could result in false-positive levels.
We aimed to determine the incidence of CIRCI in septic patients using a 1 μg ACTH stress test. Methods: We conducted a prospective cohort study on 39 patients with septic shock. Critical illness–related corticosteroid insufficiency was defined as a Δ max cortisol <9 μg/dL after 1 μg ACTH stress test. The primary outcome of the study was death. Secondary outcomes included days of vasopressors, days of mechanical ventilation (MV), amount of fluid per day, the incidence of acute kidney injury (AKI), and days of intensive care unit (ICU) stay. Results: The incidence of CIRCI in our cohort was 43.6%using 1 μg ACTH. There were no significant differences between groups in terms of ICU scores, laboratory investigations, vasopressors, MV days, amount of
fluid per day, and the ICU stay (P = > 0.05). The CIRCI group had lower median survival and survival probability rates (5 days and 48.4%, respectively) compared with the non-CIRCI group (7 days and 49.5%, respectively). In addition, the CIRCI group had a shorter time to develop AKI and a higher probability of developing AKI (4 days and 44.6%, respectively) in comparison with the non-CIRCI group (6 days and 45.57%, respectively). Conclusion: We concluded that the CIRCI group had a lower mean survival rate and a higher incidence of AKI. We recommend the use of 1 μg ACTH test in septic shock patients to identify this subgroup of patients.

The respiratory variations in mitral valve (MV) Doppler flow in hemodialysis (HD) patients have not been investigated and the normal echocardiographic value is used as a reference for HD patients. The present study evaluated the respiratory variation in MV Doppler flow in HD patients to determine if it has a unique pattern. In this prospective cohort study, echocardiography was performed before and 6 h after dialysis. The transmitral spectral Doppler E wave was measured during inspiratory and expiratory phases. The percent changes in the E wave were calculated pre- and post-dialysis. The means of the percent variation in the MV inspiratory and expiratory E wave pre- and post-dialysis were 56 ± 7% and 44 ± 1.1%, respectively, with a significant
reduction after dialysis (P = .000). There was a significant positive correlation between post-dialysis ΔE wave % change and postdialysis % change in weight (r = .318; P = .000). The respiratory changes in the MV E wave in HD patients were higher than the normal reference values. This marked variation could be explained by fluid overloading in HD patients.

Objective: Aggressive iron substitution in hemodialysis (HD) patients leads to iron overload. The association between liver siderosis and fibrosis is still debatable. We studied the association of liver siderosis with liver fibrosis in HD patients. Furthermore, we studied the performance of liver stiffness measurements (LSMs) in identifying advanced liver fibrosis. We investigated the performance of biochemical indicators of iron status in identifying advanced liver fibrosis.
Methods: Fifty-five HD patients (average HD duration 6 6 2 years) with hyperferritinemia secondary to intravenous iron supplementation (weakly iron dose 252.7 6 63 mg; median blood transfusions 3 [2-5]) were recruited. The liver fibrosis grade was determined with Fibroscan, aminotransferase-to-platelet ratio index (APRI), and Fib-4 index. Liver iron concentration (LIC) was estimated with magnetic resonance imaging (MRI). Iron parameters and liver function biochemical indicators were also assessed.
Results: The median serum ferritin and transferrin saturation (TSAT) were 3531 mg/L and 77%, respectively. 34.5%, 20%, and 45.5% of the patients showed mild, moderate, or severe liver siderosis, respectively. All patients with severe liver siderosis showed advanced liver fibrosis. Patients with severe liver siderosis and advanced liver stiffness showed higher serum iron, TSAT, aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum bilirubin, APRI, and Fib-4 index scores than those with mild liver siderosis. Serum iron and TSAT showed good utility in identifying advanced liver fibrosis determined with Fibroscan, APRI, and Fib-4 index. Liver stiffness
exhibited good utility in identifying advanced liver fibrosis diagnosed with APRI and Fib-4 index.
Conclusions: High weekly intravenous iron dose associated with severe hyperferritinemia, high serum iron, and TSAT might lead to severe liver siderosis and concomitant liver fibrosis in HD patients. Serum iron, TSAT, Fibroscan, Fib-4, and APRI scores might offer noninvasive tools for identifying advanced liver fibrosis in those patients.

Objective:
The aim was to assess diffusion‑weighted magnetic resonance imaging (DW‑MRI) and apparent diffusion coefficient (ADC) of the renal parenchyma role in evaluation of different chronic kidney disease stages.
Introduction: 
MRI has a special ability to evaluate both renal structure and function objectively without any radiation hazards.
Patients and methods:
This study enrolled 38 patients with chronic kidney disease (CKD) and 30 participants as healthy volunteers (sex and age matched). Abdominal MRIs with DWI results were compared with the level of estimated glomerular filtration rate.
Results:
There were no significant differences in the ADC values of our studied patients between the right and left kidneys or between male and female. The entire control group had facilitated diffusion, whereas 70 and 30% patients with CKD had facilitated and restricted diffusion, respectively. Patients with CKD had significantly lower ADC in comparison with control group. The mean ADC was significantly decreasing with advancing stage of CKD, where stage I CKD had the highest mean ADC, whereas stage V CKD had lowest mean ADC. The ADC had a
negative weak correlation with serum creatinine (r = −0.30; P = 0.04) but a positive moderate correlation with creatinine clearance (r = 0.56; P = 0.01).
Conclusion
The renal ADC had 86% sensitivity and 100% specificity in diagnosing chronic kidney disease, so the authors can depend on DWI and ADC in diagnosis and differentiating CKD stages.

Background: A high incidence of thromboembolic events is observed in thalassemia patients. This study investigated the relationship between carotid intima-media thickness (CIMT) and lipid profile, iron metabolic indices (IMI), and inflammatory markers in β-thalassemia intermedia (β- TI) patients.
Patients and methods: Forty-five β-TI patients at Assiut University Hospital and 34 healthy individuals
were enrolled in the study. We measured Lipid profile, IMI, highly sensitive CRP (Hs-CRP), and interleukin-
6 (IL-6) and compared the results between both groups. We used CIMT measurement as a marker for
subclinical atherosclerosis. We used both univariate and multivariate analyses to test relations and
independent predictors of CIMT.
Results: β-TI patients had higher CIMT (P = 0.000). CIMT was positively correlated with absolute neutrophil count (ANC) (r = 0.320, p = 0.032), ferritin (r = 0.544, p = 0.000), Hs-CRP (r = 0.603, p= 0.000), and IL-6 (r = 0.520, p = 0.000). Hs-CRP was an independent predictor of CIMT (p = 0.000). Hs-CRP cut off value of 60.4 ug/dl has sensitivity of 63.3% and specificity of 93.3% in predicting premature atherosclerosis.
Conclusion: β-TI patients had higher CIMT despite the protective lipid profile. Hs-CRP was an independent
predictor of CIMT.