Ramin Tolouian

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Journals/Publications

• Takamatsu, C., Devis, P., & Tolouian, R. (2021). COVID-19 and renal infarct: To be or not to be on anticoagulation. Clinical nephrology. Case studies, 9, 117-122.
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  We present a unique case of a male veteran with a history of Castleman disease, presenting with multiple arterial and venous vascular thromboses in the setting of recent Coronavirus (COVID-19)-disease diagnosis. We explore this patient's morbidity related to thrombotic complications of his COVID-19 diagnosis that were potentially avoidable with a comprehensive outpatient evaluation of his risk for thrombosis, as well as the initiation of anticoagulation and/or antiplatelet therapy given his high risk. Our case highlights the need for a standardized clinical workup of patients in the outpatient setting for risk assessment of vascular thrombosis associated with COVID-19 infection to direct medical management, in order to minimize adverse outcomes, complications requiring inpatient admission, and the need for additional yet limited medical resources and interventions. We propose a minimum of low-dose aspirin 81 mg daily as a reasonable approach for outpatient clinicians to consider, based on their best clinical judgement, when managing mild COVID-19, while other options, such as novel oral anticoagulants, are undergoing further investigation.
• Ansarin, K., Tolouian, R., Ardalan, M., Taghizadieh, A., Varshochi, M., Teimouri, S., Vaezi, T., Valizadeh, H., Saleh, P., Safiri, S., & Chapman, K. R. (2020). Effect of bromhexine on clinical outcomes and mortality in COVID-19 patients: A randomized clinical trial. BioImpacts : BI, 10(4), 209-215.
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  Bromhexine is a potential therapeutic option in COVID-19, but no data from a randomized clinical trial has been available. The present study aimed to evaluate the efficacy of bromhexine in intensive care unit (ICU) admission, mechanical ventilation, and mortality in patients with COVID-19. An open-label randomized clinical trial study was performed in Tabriz, North-West of Iran. They were randomized to either the treatment with the bromhexine group or the control group, in a 1:1 ratio with 39 patients in each arm. Standard therapy was used in both groups and those patients in the treatment group received oral bromhexine 8 mg three times a day additionally. The primary outcome was a decrease in the rate of ICU admissions, intubation/mechanical ventilation, and mortality. A total of 78 patients with similar demographic and disease characteristics were enrolled. There was a significant reduction in ICU admissions (2 out of 39 vs. 11 out of 39, = 0.006), intubation (1 out of 39 vs. 9 out of 39, = 0.007) and death (0 vs. 5, = 0.027) in the bromhexine treated group compared to the standard group. No patients were withdrawn from the study because of adverse effects. The early administration of oral bromhexine reduces the ICU transfer, intubation, and the mortality rate in patients with COVID-19. This affordable medication can easily be administered everywhere with a huge positive impact(s) on public health and the world economy. Altogether, the verification of our results on a larger scale and different medical centers is strongly recommended. IRCT202003117046797N4; https://irct.ir/trial/46969.
• Mubarak, M., Tolouian, R., Kowalewska, J., & Nasri, H. (2020). Comment: Newly Diagnosed Glomerulonephritis During COVID-19 Infection Undergoing Immunosuppression Therapy, a Case Report. Iranian journal of kidney diseases, 14(4), 323-325.
• Tolouian, R. (2020). . COVID-19 interactions with angiotensin-converting enzyme 2 (ACE2) and the kinin system; looking at a potential treatment.. J Renal Inj Prev..
• Tolouian, R. (2020). Blocking serine protease (TMPRSS2) by Bromhexine; looking at potential treatment to prevent COVID-19 infection. Marshall Journal of Medicine, 6.
• Tolouian, R. (2020). Collapsing glomerulopathy following COVID-19 infection; possible relationship with APOL1 kidney risk alleles in African Americans.. Immunopathol Persa.
• Tolouian, R. (2020). Renal transplantation in a patient with MHY9-Related disease; a case report.. Journal of Nephropathology.
• Tolouian, R. (2020). The footprint of androgen sensitive serine protease (TMPRSS2) in gender mortality with COVID-19.. Immunopathol Persa..
• Tolouian, R., Alhamad, T., Farazmand, M., & Mulla, Z. D. (2020). The correlation of hip fracture and hyponatremia in the elderly. Journal of nephrology, 25(5), 789-93.
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  Increasing age is considered one of the risk factors for hyponatremia. The concept of asymptomatic hyponatremia is not correct anymore as these patients have a greater risk for falls, bone fractures and attention impairment. The combination of old age and a fall is a common recipe for admission to a nursing home.
• Tolouian, R. (2019). APOL1 renal risk alleles in patients on chronic hemodialysis in Northwest of Iran. Journal of renal injury prevention. doi:10.15171/jrip.2019.37.
• Tolouian, R. (2019). Apolipoprotein L1 associated nephropathy; an overview. Journal of renal injury prevention, 311-315. doi:10.15171/jrip
• Tolouian, R. (2019). Tolouian Sign in Hyponatremia. Journal of Nephropathology.
• Tolouian, R. (2019). Tolouian sign in Hyponatremia. Journal of nephropathology, 22.
• Tolouian, R., & Tolouian, R. (2019). Administration of metformin to increase the efficacy of chemotherapy regimen in cancers; a new look to an old drug. Immunopathologia Persa.
• Tolouian, R., Mulla, Z. D., Diaz, J., Aguila, J., & Ramos-Duran, L. (2016). Liver and Cardiac Iron Deposition in Patients on Maintenance Hemodialysis by Magnetic Resonance Imaging T2. Iranian journal of kidney diseases, 10(2), 68-74.
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  Magnetic resonance imaging (MRI) sequence acquisition techniques for iron assessment have revolutionized the study of iron overload in different organs. We hypothesized that MRI can accurately and reliably assess possible iron deposition in the myocardium and liver by measurement of T2* value.
• Tolouian, R., & Vinik, A. I. (2015). Nonblood/urine biomarker of progression of kidney disease in diabetes mellitus. Clinical journal of the American Society of Nephrology : CJASN, 10(7), 1114-6.
• Chandra, A., Biersmith, M., & Tolouian, R. (2014). Obesity and kidney protection. Journal of nephropathology, 3(3), 91-7.
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  Obesity, both directly and indirectly, increases the risk for a variety of disease conditions including diabetes, hypertension, liver disease, and certain cancers, which in turn, decreases the overall lifespan in both men and women. Though the cardiovascular risks of obesity are widely acknowledged, less often identified is the relationship between obesity and renal function.
• Otoukesh, S., Mojtahedzadeh, M., Cooper, C. J., Tolouian, R., Said, S., Ortega, L., Didia, S. C., Behazin, A., Sherzai, D., & Blandon, P. (2014). Lessons from the profile of kidney diseases among Afghan refugees. Medical science monitor : international medical journal of experimental and clinical research, 20, 1621-7.
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  Due to a paucity of research on the profile of kidney diseases among refugee populations, specifically Afghan refugees in Iran, this study aimed to illustrate the pattern of kidney disease among Afghan refugees in Iran and create a database for evaluating the performance of future health services.
• Park, J., Rhee, C. M., Sim, J. J., Kim, Y. L., Ricks, J., Streja, E., Vashistha, T., Tolouian, R., Kovesdy, C. P., & Kalantar-Zadeh, K. (2013). A comparative effectiveness research study of the change in blood pressure during hemodialysis treatment and survival. Kidney international, 84(4), 795-802.
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  It is not clear to what extent changes in blood pressure (BP) during hemodialysis affect or predict survival. Studying comparative outcomes of BP changes during hemodialysis can have major clinical implications including the impact on management strategies in hemodialysis patients. Here we undertook a retrospective cohort study of 113,255 hemodialysis patients over a 5-year period to evaluate an association between change in BP during hemodialysis and mortality. The change in BP was defined as post-hemodialysis minus pre-hemodialysis BP, and mean of BP change values during the hemodialysis session was used as a mortality predictor. The patients' average age was 61 years old and consisted of 45% women, 32% African-Americans and 58% diabetics. Over a median follow-up of 2.2 years, a total of 53,461 (47.2%) all-cause and 21,548 (25.7%) cardiovascular deaths occurred. In a fully adjusted Cox regression model with restricted cubic splines, there was a U-shaped association between change in systolic BP and all-cause mortality. Post-dialytic drops in systolic BP between -30 and 0 mm Hg were associated with greater survival, but large decreases of systolic BP (more than -30 mm Hg) and any increase in systolic BP (over 0 mm Hg) were related to increased mortality. Peak survival was found at a change in systolic BP of -14 mm Hg. The U-shaped association was also found for cardiovascular mortality. Thus, modest declines in BP after hemodialysis are associated with the greatest survival, whereas any rise or large decline in BP is associated with worsened survival.
• Tolouian, R., & T Hernandez, G. (2013). Prediction of diabetic nephropathy: The need for a sweet biomarker. Journal of nephropathology, 2(1), 4-5.
• Tolouian, R., Rajabi, B., Boman, D., Bilbao, J., & Gupta, A. (2013). Iron infusion and deposition in the kidney. Clinical nephrology, 79(3), 237-40.
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  Parenteral iron therapy is the mainstay of treating iron deficiency anemia in chronic kidney disease (CKD) patients.
• Abdi, R., Sandroni, S., & Tolouian, R. (2012). The inception and formation of the theory of hyperfiltration through the ages. Iranian journal of kidney diseases, 6(2), 94-7.
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  With the rising incidence of metabolic syndrome and progressive kidney disease, efforts to halt this progression have become the mainstay of therapies in the era of modern nephrology. The necessity of one versus two kidneys has occupied the minds of leading scientists and philosophers throughout the ages and has laid the foundation for our understanding of progressive kidney disease. This review focuses on the major discoveries of the leading thinkers who with their paradigm shifting ideas and skepticism pushed the boundaries of our knowledge and shaped the theory of hyperfiltration.
• Rambod, M., & Tolouian, R. (2012). Dietary sodium and clinical outcome in hemodialysis: where do we stand and what is next?. Kidney international, 82(2), 130-2.
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  The association of dietary sodium and outcome is widely studied in the general population, but less is known in hemodialysis patients. The evidence supporting daily dietary sodium intake of 2 g on hemodialysis is not strong. Mc Causland et al. found that higher dietary sodium intake was marginally associated with a higher ultrafiltration requirement and mortality, but not with blood pressure. Well-designed clinical trials are needed to examine the association of dietary sodium modification and outcomes in hemodialysis patients.
• Tolouian, R., Connery, S. M., O'Neill, W. C., & Gupta, A. (2012). Using a filtration technique to isolate platelet free plasma for assaying pyrophosphate. Clinical laboratory, 58(11-12), 1129-34.
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  Vascular calcification (VC) is a strong prognostic marker of mortality from cardiovascular disease. Extracellular inorganic pyrophosphate (PPi) is a critical inhibitor of vascular calcification and it has been reported that hemodialysis patients have reduced plasma PPi levels, suggesting that altered PPi metabolism could contribute to VC in hemodialysis patients. Platelets are rich in PPi and release of PPi from platelets during storage or processing of plasma can lead to falsely elevated plasma PPi levels. To prepare plasma samples that are suitable for measuring PPi levels, ultracentrifugation has been used to remove platelets. Consequently, plasma PPi measurements have been limited to research laboratories since the majority of clinical laboratories do not have access to an ultracentrifuge. The purpose of the present study was to test the validity of an improved method of preparing platelet free plasma that uses filtration with a 300,000 Dalton molecular weight cut-off filter to exclude platelets, while minimizing their release of PPi.
• Tolouian, R., & Salameh, H. (2010). Treat the patient not the lab value. NDT plus, 3(1), 81-3.
• Tolouian, R., Hernandez, G. T., Chiang, W. Y., & Gupta, A. (2010). A new approach for evaluating bone turnover in chronic kidney disease. European journal of internal medicine, 21(3), 230-2.
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  The validity of serum parathyroid hormone (PTH) as a surrogate marker of bone turnover in chronic kidney disease (CKD) is limited by several factors such as relative resistance of bone to PTH, hyperphosphatemia, diabetes, gender, age, race and vitamin D analog action on the PTH-bone axis. Urinary collagen N-terminal telopeptide X (NTx), a bone collagen degradation product, expressed as bone collagen equivalents (BCE) per mM of creatinine (NTx/Cr ratio), is routinely used to estimate bone turnover in osteoporosis. The purpose of this study is to evaluate NTx as a marker of bone turnover in CKD.
• Tolouian, R., Rao, D. S., Goggins, M., Bhat, S., & Gupta, A. (2010). Seasonal variation of vitamin D in patients on hemodialysis. Clinical nephrology, 74(1), 19-24.
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  Seasonal and racial differences in serum 25-hydroxyvitamin D levels have been studied extensively in the general population but not in patients with end-stage renal disease (ESRD).
• Tolouian, R., Wild, D., Lashkari, M. H., & Najafi, I. (2005). Oral alkalinizing solution as a potential prophylaxis against myoglobinuric acute renal failure: preliminary data from healthy volunteers. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 20(6), 1228-31.
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  Acute renal failure (ARF) secondary to crush injury is one of the leading causes of hospitalization and death in survivors of massive disasters. The standard therapy for crush injury, intravenous (i.v.) hydration and alkalinization of urine, is often not feasible after a mass disaster; therefore, oral rehydration and urinary alkalinization may be a useful substitute.

Reviews

• Tolouian, R. (2019. Administration of Metformin to increase the efficacy of chemotherapy regimen in cancers; a new look to an old drug.