The Prevalence of Peritonitis among Pediatric Peritoneal Dialysis Patients at Large Saudi Center.

Peritonitis is a common and serious complication of peritoneal dialysis (PD) and it is a direct or major contributing cause of death in around 16% of PD patients. Severe or prolonged peritonitis leads to structural and functional alterations of the peritoneal membrane, eventually leading to membrane failure, PD technique failure, and conversion to long-term hemodialysis (HD). This is cross-sectional record-based study in which the records of all children aged <14 years with end-stage renal disease on PD either on coiled or straight PD catheter had been reviewed at pediatric nephrology department in a tertiary care hospital, Riyadh, over the period of three years from 2017 to 2019. All information was collected using a structured data collection form. Our study had 30 patients on automated PD with 10 females (33.3%) and 20 males (66.7%) during the study period. The age ranged from 11 months to 14 years with a median 5.5 years, all of them were new to dialysis. A total of 11 out of 30 patients had multiple episodes of PD-associated peritonitis and the prevalence of peritonitis among the 30 patients was 37%. Peritoneal fluid cultures were positive in 100% episodes. Gram-positive, Gram-negative, and fungal organisms were identified in 72.7%, 18.1%, and 9.0% episodes, respectively. The analysis showed the exit-site infection (ESI) to be a risk factor to develop peritonitis, where 21 patients out of 30 had at least one ESI, 52% end by peritonitis in coiled catheter group. No mortality among our cohort of patients was noted, even removal of or changing PD catheter and transfer to HD. Our data showed that the prevalence of peritonitis secondary to ESI with Gram-positive organisms was significantly high, especially in coiled catheter group.

Experience with second line drugs in frequently relapsing and steroid dependent childhood nephrotic syndrome in a large Saudi center.

BACKGROUND AND OBJECTIVES: To assess the efficacy and safety of second line drugs used at our center in frequently relapsing and steroid dependant (FR/SD) childhood nephrotic syndrome. PATIENTS AND METHODS: This was a retrospective study over a period of 3 years (July 2012 to July 2015) on the use of 4 second line drugs in FR/SD nephrotic syndrome in children treated at our center. These drugs were Levamisole, Mycophenolate Mofetil (MMF), Cyclophosphamide, and Cyclosporine. We studied the relapse rate per year, cumulative dose of steroids, success, failure, and side effects of these drugs. Statistical analyses were done with the help of a statistician using the T-test and the "N-1"Chi-Square test. RESULTS: We reviewed the charts of 60 children. All had FR/SD nephrotic syndrome and received a 3 month protocol of prednisolone. 20 received Levamisole (33%), 12 received Cyclophosphamide (20%), 20 received MMF (25%), and 13 received Cyclosporine (22%).All the four drugs significantly reduced the relapse rate and the cumulative dose of steroids (P < .0001). Treatment success was best with Cyclosporine (69.2%), and treatment failure was the least with Cyclosporine (7.6%). However, treatment success and failure with Cyclosporine when compared to other three drugs was not statistically significant. No dangerous side effects were seen with any of the 4 drugs in the observation period. CONCLUSION: All the second line drugs in our study were equally effective. However, we recommend that the initial treatment of FR/SD nephrotic syndrome should be chosen with the least toxic yet equally efficacious drug Levamisole.

The level of C-reactive protein in chronic hemodialysis patients: a comparative study between patients with noninfected catheters and arteriovenous fistula in two large Gulf hemodialysis centers.

Hemodialysis (HD) patients have greater morbidity and mortality when they have a central venous catheter (CVC) rather than an arteriovenous fistula (AVF) access. Inflammation associated with dialysis catheter use and resultant higher C-reactive protein (CRP) levels could have an independent adverse effect on patient outcomes. In this prospective study, we investigated whether HD catheters induce inflammation independent of infection. We compared the mean levels of the inflammatory marker (CRP) in 67 patients on maintenance HD using noninfected catheters with 86 HD patients using AVFs at Prince Salman Center for Kidney Diseases, Saudi Arabia (KSA), and Jahra Hospital, Kuwait, who met our inclusion criteria. C-reactive protein levels were measured every 2 months over a period of 6 months using immunoturbidimetric assay. One hundred fifty-three patients on maintenance HD for more than 6 months were included in the study, with mean age of 52.19 ± 16.06 years; 66% were males and 34% were females. Serial levels of mean CRP were statistically and significantly higher in group with noninfected catheters (1.33, 1.24, and 1.10 mg/dL) compared to those with AVFs (0.65, 0.59, and 0.68 mg/dL) with P value of 0.000. In our study, we found no relation between CRP level and age, sex, hemoglobin, albumin, calcium, phosphorus, and iPTH level in both groups. Hemodialysis patients with a catheter have a heightened state of inflammation independent of infection, and thus our study supports the avoidance of catheters and a timely conversion to AVFs with catheter removal.

Treatment of chronic hepatitis C with peginterferon alfa-2b, plus ribavirin in end stage renal disease patients treated by hemodialysis: single Saudi center experience.

INTRODUCTION: Hepatitis C virus (HCV) infection is a global health problem, common worldwide, leading to acute and chronic hepatitis and its consequences of hepatic cirrhosis and hepatocellular carcinoma. Antiviral therapy of HCV+ in dialysis patients with interferon-α (INF-α) gives slightly better results than in the general population, but is poorly tolerated and associated with side effects. Although, Ribavirin in not recommended for dialysis patients, the addition of small doses of this medication to pegylated INF is discussed. PURPOSE: The aim of this study is to assess the efficacy and safety of peginterferon alfa-2b (12 kDa) plus Ribavirin in hemodialysis chronic HCV patients. METHODS: Fourteen end-stage renal disease patients (ESRD) on regular hemodialysis (HD) in Prince Salman Center for Kidney Diseases (PSCKD), ten males (71.4%) and four females (28.6) were enrolled in a prospective study. All the patients have Hepatitis C Virus infection; were treated by pegylated interferon alpha-2b (peginterferon alfa-2b) 1 mcg/kg/week subcutaneously with Ribavirin 200 mg three times weekly; for 48 weeks. Two patients were non responsive to previous course of 24 weeks peginterferon alfa-2a. HCV -RNA PCR qualitative and quantitative were tested before, 12, 48 weeks of treatment and 24 weeks after for sustained virologic response (SVR) results. α-fetoprotein level was measured in all the 14 patients before starting treatment to exclude any evidence of hepatocellular carcinoma. RESULTS: One patient (7.1%) refused to complete the treatment because he could not tolerate the side effects and treatment was stopped after the third dose. After 12 weeks, three of 14 patients (21.4%) were still HCV-RNA PCR positive and there were not two log decrees in quantitative PCR, so treatment was stopped in this group of patients. One patient of the remaining had more than two log decrees in quantitative PCR, while nine were seroconverted to HCV-RNA PCR negative, so the treatment was completed for 48 weeks in 10 patients. After 48 weeks of treatment, qualitative and quantitative HCV-RNA PCR were done for 10 patients and the results were still negative (71.4%). Results of qualitative and quantitative HCV-RNA PCR done 24 weeks later showed that 10 patients still negative and SVR was (64%). Their mean ALT and AST dropped from 54.36 ± 36.79 IU/dL and 31.52 ± 17.02 IU/dL before starting therapy to 37.26 ± 36.53 IU/dL and 25.37 ± 23.72 IU/dL, respectively, after termination. Their mean hemoglobin (Hb) level dropped from 11.31 ± 0.86 to 10.06 ± 1.06 g/dL; (p < 0.001), and white blood cell count (WBC) dropped from 6.14 ± 0.65 × 10(3)/mm(3) to 4.51 ± 0.95 × 10(3)/mm(3); (p < 0.001). Platelet count fell from 130.11 ± 48.06 × 10(3)/mm(3) to 63.03 ± 23.19 × 10(3)/mm(3); (p < 0.001), also erythropoietin dose increased from 182.14 ± 39.30 IU/kg/w to 253.93 ± 83.07 IU/kg/w, (p = 0.776). CONCLUSION: Peginterferon alfa-2b (12 kDa) plus Ribavirin therapy in hemodialysis chronic HCV patients is safe, well tolerated and effective with accepted rates of sustained virological response up to 64%.

Intravenous alfacalcidol once versus twice or thrice weekly in hemodialysis patients.

Secondary hyperparathyroidism remains a serious problem in hemodialysis patients. The use of vitamin D analogs still constitutes a basis for its treatment. This study was carried out to evaluate the efficacy of intravenous administration of alfacalcidol once versus twice or thrice weekly in hemodialysis patients with secondary hyperparathyroidism. Twenty-nine end-stage renal disease patients maintained on hemodialysis for more than one year were included in this prospective study after signing the consent. These patients with secondary hyperparathyroidism had been on intravenous alfacalcidol twice or thrice per week and were followed up to 4 months (stage 1). Then they were shifted to intravenous alfacalcidol once weekly starting with the last total weekly intravenous dose for another 4 months (stage 2). The dose of alfacalcidol was adjusted according to intact parathyroid hormone, serum calcium and phosphorus levels, and calcium-phosphorus product. Intact parathyroid hormone, calcium, phosphorus, calcium-phosphorus product were measured monthly. Parathyroid ultrasound was done as a baseline and then repeated at the end of stage 1 and stage 2. The intact parathyroid hormone was reduced from 49.72 ± 2.72 pmol/L (mean ± standard error of the mean [SEM] during stage 1 to 42.13 ± 2.15 pmol/L during stage 2 (P = 0.005). Dose of alfacalcidol was reduced from 18.80 ± 1.15 µg/month (mean ± SEM) in stage 1 to 15.18 ± 1.27 µg/month in stage 2 (P = 0.008), and consequently the cost of alfacalcidol was reduced from 21.05 ± 1.25 US$/month (mean ± SEM) during stage 1 to 16.87 ± 1.40 US$/month during stage 2 (P = 0.008). Although the phosphorus level increased from 1.56 ± 0.36 mmol/L (mean ± SD) in stage 1 to 1.70 ± 0.46 mmol/ L in stage 2 (P = 0.003), and calcium-phosphorus product increased from 3.48 ± 0.82 mmol(2)/L(2) (mean ± SD) in stage 1 to 3.76 ± 1.00 mmol(2) /L(2) in stage 2 (P = 0.017), they remained in the target levels recommended by the Kidney Disease Outcomes Quality Initiative guidelines. No serious effects were observed during stage 1 and stage 2, respectively. Intravenous alfacalcidol once weekly is effective, safe and less costly in suppressing intact parathyroid hormone compared to twice or thrice weekly administration in chronic hemodialysis patients.

Appropriateness of anemia management in hemodialysis patients.

UNLABELLED: The anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration. AIMS: To investigate current practice of anemia management in hemodialysis patients and to assess the appropriateness of anemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations. SETTINGS AND DESIGN: The study was conducted at two hemodialysis centers in Riyadh, Saudi Arabia. Data on anemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data were collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing hemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy. RESULTS: Data were collected from 87 patients. Mean Hgb value for those patients was 11.16 ± 0.97 g/dL. Thirty-nine patients (45%) had mean Hgb values between 11.0 and 12.0 g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099 ± 5946 IU/Week (135 ± 99 IU/kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693 ± 420.5 ng/mL. Fifty-two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5 ± 19.7%. CONCLUSIONS: There is an opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron status.

Cinacalcet hydrochloride therapy for secondary hyperparathyroidism in hemodialysis patients.

This study compared the efficacy of a cinacalcet-based regimen with unrestricted conventional therapy (vitamin D and phosphate binders) for achieving Kidney Disease Outcome Quality Initiative (K/DOQI) targets for dialysis patients. In this multicenter, prospective study, hemodialysis patients with poorly controlled secondary hyperparathyroidism (SHPT) were randomized to receive a cinacalcet-based regimen (n=55) or a conventional therapy (n=27). Doses of cinacalcet, vitamin D sterols, and phosphate binders were adjusted during a 12-week dose-titration phase to achieve intact parathyroid hormone (iPTH) levels ≤ 31.8 pmol/L. The primary end point was the percentage of patients with values in this range during a 24-week efficacy-assessment phase. The clinical response to 36-week cinacalcet treatment was evaluated. A dual energy X-ray absorptiometry was performed before and after 36 weeks of cinacalcet therapy. Fifty-eight percent of the cinacalcet group reached the primary end point, as compared with 19% of the conventional therapy group (P=0.001). A higher percentage of patients receiving the cinacalcet-based regimen versus conventional therapy achieved the targets for calcium, phosphorus and Ca×P. Achievement of targets was greatest in patients with less severe disease (intact PTH range, 31.8 to 53 pmol/L). Cinacalcet therapy increased proximal femur bone mineral density (BMD), but did not affect the lumbar spine. Itching intensity decreased significantly. Cinacalcet based treatment facilitates achievement of the K/DOQI targets for iPTH and bone mineral metabolism compared with conventional therapy in hemodialysis patients. Suppression of iPTH with cinacalcet reverses bone loss in the proximal femur. Cinacalcet alleviated itching.

Free thyroxine, free triiodothyronine and thyroid-stimulating hormone before and after hemodialysis in Saudi patients with end-stage renal disease: is there any difference?

Patients on regular hemodialysis (HD) suffer from a chronic illness that is believed not to involve the thyroid gland. However, they may have low levels of serum thyroxine (T4) and tri-iodothyronine (T3). It was found earlier that serum total T3 and free T4 concentrations were significantly higher immediately after a HD session than before. In this single-center prospective study, we evaluated the difference between free T3 (FT3), free T4 (FT4) and thyroid-stimulating hormone (TSH) levels before and immediately after HD sessions in 40 Saudi patients with end-stage renal disease undergoing regular HD at the Prince Salman Center for Kidney Disease, Riyadh, Saudi Arabia. The study involved 23 female and 17 male patients with a mean age of 49.65 ± 16.20 years. None of the study patients had any known thyroid disease. We measured the thyroid hormones monthly for three successive months using the electrochemiluminescence technique both before and after HD sessions. At the end of our study, we found a statistically significant difference between pre-HD and post-HD levels for FT3; in the first month, it was 4.47 ± 1.01 versus 4.86 ± 1.03 pmol/L, (P = 0.004); in the second month, it was 4.48 ± 1.37 versus 4.83 ± 1.64 pmol/L, (P = 0.008); and in the third month, it was 3.84 ± 0.88 versus 4.04 ± 0.84 pmol/L, (P = 0.003). The FT4 in the first month was 15.42 ± 2.75 pmol/L versus 17.20 ± 2.85 pmol/L, P = 0.000, in the second month it was 14.86 ± 2.66 versus 16.74 ± 3.27 pmol/L, P = 0.000 and in the third month it was 14.86 ± 3.93 versus 16.70 ± 4.00 pmol/L, P = 0.000, respectively. However, the pre- and post-HD levels of TSH did not show any statistically significant difference; in the first month it was 3.17 ± 1.47 versus 3.32 ± 1.39 pmol/L, P = 0.254, in the second month it was 2.57 ± 1.36 versus 2.49 ± 1.29 pmol/L, P = 0.299 and in the third month it was 2.36 ± 1.17 versus 2.44 ± 1.22 pmol/L, P = 0.238, respectively. Thus, there was a statistically significant increase in the post-HD levels of FT3 and FT4 although the TSH levels did not show any significant change. Our study suggests that measurement of TSH alone might be more reliable in the assessment of thyroid function in patients on regular HD than FT3 and FT4.

Pegylated interferon alpha-2a for treatment of chronic HCV infection in hemodialysis patients: a single Saudi center experience.

INTRODUCTION: Chronic hepatitis C infection is common among patients on dialysis. While the associated liver disease is usually relatively mild during dialysis, disease progression can accelerate due to immunosuppression following kidney transplantation, and interferon therapy after transplantation stimulates graft rejection. Pegylated interferon and ribavirin are now the recommended treatment for chronic hepatitis C virus in patients without renal failure. However, until now, there has been relatively little information on the efficacy and tolerability of pegylated interferon in dialysis patients. AIM OF THE WORK: To evaluate the response to pegylated interferon alpha-2a in chronic hepatitis C-infected patients on chronic hemodialysis. PATIENTS AND METHODS: This controlled study included 28 patients with end-stage renal disease who had been on dialysis in the Prince Salman Center for Kidney Disease for more than 6 months and tested positive for HCV RNA on repeated occasions. Thirteen patients were treated with pegylated interferon alpha-2a therapy (of which three were also receiving ribavirin), and the remaining fifteen served as controls. Viral genotyping and both qualitative and quantitative PCR were carried out before starting therapy. Treatment was continued for 48 weeks. After 24 weeks of treatment, the biochemical and virological responses were evaluated. Biochemical response was evaluated at the end of the treatment, with sustained virological response (SVR) being evaluated 24 weeks later. The side effects were monitored throughout the treatment period. RESULTS: All patients in the treatment group completed 48 weeks of therapy without any drop out. Their mean age was 43.38 ± 11.62 years. After 24 weeks of therapy, 10 patients (76%) were initial responders, while 3 patients (24%) were resistant. Six months after termination of therapy, 9 patients (69%) were sustained responders, while one patient relapsed. Their ALT and AST dropped from 55.78 ± 33.79 IU/dl and 34.04 ± 19.58 IU/dl before starting therapy to 27.22 ± 16.54 IU/dl and 18.88 ± 12.28 IU/dl after termination (P = .06 and .08, respectively). Their mean hemoglobin (Hb) level dropped from 11.05 ± 1.43 to 9.48 ± 1.24 g/dl (P = 0.3), and white blood cell count (WBC) dropped from 6.82 ± 2.6 × 10(3)/mm(3) to 4.1 ± 2.34 × 10(3)/mm(3); (P = 0.57). Platelet count fell from 194.56 ± 129.78 × 10(3)/mm(3) to (152.33 ± 107.66 × 10(3)/mm(3); P = 0.39). When initial responders (n = 10) were compared to resistant patients (n = 3), the only observable difference was higher ALT and AST levels in resistant patients. Pegylated interferon alpha-2a was well tolerated, and none of the patients stopped interferon because of hematological side effects while dose modification was carried out in most of the patients. All three patients who received combination therapy from the start were sustained responders. None of the patients in the control group seroconverted to HCV negative status during the study period. CONCLUSION: Pegylated interferon alpha-2a was well tolerated among our hemodialysis patients. Hematological disturbances appeared to be the most important adverse effects. At the end of therapy a response rate of up to 76%, with 69% sustained response, can be obtained with pegylated interferon alpha-2a therapy.

Effect of hepatitis C virus on hemoglobin and hematocrit levels in saudi hemodialysis patients.

BACKGROUND: Hepatitis C virus infection is common among patients undergoing hemodialysis, and HD patients are at high risk for infection with such virus. Recently, some studies and case reports indicated attenuated anemia in HD patients with HCV infection, and they previously considered this to be related to increased erythropoietin production after hepatic stimulation by chronic infection with hepatitis virus. AIM: The aim of our study is to investigate whether HCV-positive HD patients have higher hemoglobin (Hb) and hematocrit (HCT) values compared to HCV-negative patients. METHODS: We retrospectively studied 83 chronic HD patients from Prince Salman Center for Kidney Disease, and monthly samples were collected between July 2007 and July 2008. The HCV status was determined by anti-HCV antibodies and confirmed with RNA polymerase chain reaction (PCR). Those with a history of blood transfusion or massive blood loss during the last six months were excluded from the study. RESULTS: Thirty-three percent of our patients tested positive for anti-HCV antibody (51.8% were male). The mean age for HCV-positive group was 54.92 +/- 15.61 years, while it was 51.01 +/- 14.81 years for the HCV-negative group (p = 0.27). Mean Hb in the HCV-positive group was 11.18 +/- 1.41 gm/dL compared to 10.87 +/- 1.29 gm/dL for the HCV-negative group (p = 0.05). Mean HTC values for the HCV-positive group was 34.4 +/- 3.9, compared to 32.41 +/- 3.41 for the HCV-negative group 12 months after starting hemodialysis. Eighty-one patients (27 HCV-positive and 54 HCV-negative) received erythropoietin (EPO) therapy. Seventy-two patients (25 HCV-positive and 47 HCV-negative) received IV iron (p = 0.28). Mean erythropoietin dose was (114.83 +/- 84.92 IU/kg/week) for HCV-positive compared to (122.2 +/- 91.46 IU/kg/week) for HCV-negative group (p = 0.74). Liver function tests were normal except for higher bilirubin level in the HCV-positive group, 7.74 +/- 4.03 Umol/L compared to 5.47 +/- 3.71 Umol/L in the HCV-negative group (p = 0.01). CONCLUSION: Our study showed that ESRD patients on HD with HCV infection have higher Hb and HCT levels compared with HCV-negative patients.

Anticoagulation therapy during haemodialysis: a comparative study between two heparin regimens.

Low-molecular-weight heparins have been suggested as providing well tolerated, efficient, convenient and possibly more cost-effective anticoagulation for haemodialysis than unfractionated heparins (UFHs). A single-bolus dose at the start of haemodialysis effectively prevents clot formation in the dialyser and air trap with fewer side effects and possible benefits on uraemic dyslipidaemia. The safety, clinical efficacy and cost of two anticoagulation regimens in 23 haemodialysis patients were compared over 12-month period. The study comprised two stages: the first stage in which UFH was used for 6 months and the second stage in which UFH was replaced by tinzaparin sodium. The relationship between the anticoagulant effect of tinzaparin sodium and clinical clotting during haemodialysis was recorded. Clinical clotting (grades 1-4) was evaluated by visual inspection after blood draining of the air trap every hour and by inspection of the dialyser after each session. The costs and effects of both anticoagulant protocols on the lipid profile were also compared. Anticoagulation with tinzaparin sodium resulted in less frequent dialyser and air-trap clotting compared with UFH (P = 0.001 and 0.04, respectively). Over 24 weeks, no changes in standard serum lipid profiles were observed. There was statistically significant improvement in dialysis adequacy - evidenced by improved single-pool Kt/V 6 months after tinzaparin sodium use (1.40 +/- 0.28 tinzaparin sodium versus 1.23 +/- 0.28 for UFH) without any change in the haemodialysis prescription. The total cost of 24-week use of tinzaparin sodium was 23% more expensive compared with that of UFH. Tinzaparin sodium should be considered as an effective, well tolerated and may be a superior alternative to conventional heparin anticoagulation in haemodialysis. However, at least - on the short term - tinzaparin sodium therapy did not affect lipid profile in haemodialysis patients. Currently, the direct cost in Saudi Arabia is a little more than standard heparin by about 23%.