The problem of pulmonary arterial hypertension in end-stage renal disease: can peritoneal dialysis be the solution.

BACKGROUND: Pulmonary arterial hypertension (PAH) in the setting of end-stage renal disease (ESRD) has important prognostic and therapeutic consequences. We estimated the prevalence of PAH among patients with ESRD treated with automated peritoneal dialysis (APD), investigated the effect of different variables and compared pulmonary artery pressure and cardiac function at the beginning and end of the study. METHODS: This is a 5-year study in which 31 ESRD patients on APD were recruited after fulfilling inclusion criteria. Blood samples were collected from all patients for the biochemical and hematological data at the beginning of the study and every month and at the study termination. Total body water (TBW) and extracellular water (ECW) were calculated using Watson's and Bird's calculation methods. All patients were followed-up at 3-month interval for cardiac evaluation. Logistic regression analysis was used to assess the relation between different variables and PAH. RESULTS: The mean age of the study population (n = 31) was 51.23 ± 15.24 years. PAH was found in 24.2% of the patients. Mean systolic pulmonary artery pressure (sPAP) and mean pulmonary artery pressure (mPAP) were significantly higher in the APD patients at study initiation than at the end of the study (40.75 + 10.61 vs 23.55 + 9.20 and 29.66 + 11.35 vs 18.24 + 6.75 mmHg respectively, p = 0.001). The median ejection fraction was significantly lower in patients with PAH at zero point than at study termination [31% (27-34) vs 50% (46-52), p = 0.002]. Hypervolemia decreased significantly at the end of study (p <  0.001) and correlated positively with the PAP (r = 0.371 and r = 0.369), p = 0.002). sPAP correlated with left ventricular mass index, hemoglobin level, and duration on APD. CONCLUSIONS: Long term APD (> 1 years) seemed to decrease pulmonary arterial pressure, right atrial pressure and improve left ventricular ejection fraction (LVEF). Risk factors for PAH in ESRD were hypervolemia, abnormal ECHO findings and low hemoglobin levels. Clinical and echocardiographic abnormalities and complications are not uncommon among ESRD patients with PAH. Identification of those patients on transthoracic echocardiography may warrant further attention to treatment with APD.

Outsourcing Dialysis Program: Implementation and Challenges.

The demand for dialysis treatment has exceeded supply over the last decade in Saudi Arabia in line with other countries in the region and hence the Ministry of Health (MOH) to outsource dialysis care on a fee-for-service basis. The main objective of this review article is to examine and understand the challenges and strategies devised for the successful implementation, the good operation, and the guaranteed efficiency of outsourcing dialysis program in order to achieve the set clinical performance indicators and quality standards. The outsourcing program has largely helped the MOH in Saudi Arabia to improve the adequacy of dialysis care and the quality of life of dialysis patients and might be cost-effective.

The Effectiveness of Alternate-day Cinacalcet Therapy for Secondary Hyperparathyroidism in Noncompliant Hemodialysis Patients.

Chronic kidney disease (CKD) is defined as an abnormality of the kidney's structure or function that is present for more than 3 months. Secondary hyperparathyroidism is a consequence of CKD, which eventuates with a decrease in the glomerular filtration rate. This study aimed to evaluate the effectiveness of alternate-day cinacalcet in noncompliant dialysis patients compared with a daily dose. The effects on the levels of intact parathyroid hormone (iPTH), calcium, and phosphorus were measured, and the compliance of patients with our protocol was observed. We followed the patients' (n = 134) iPTH levels every 3 months and their serum calcium and phosphorous monthly for 6 months and compared the results with 6 months of data from patients receiving daily doses of cinacalcet. The patients' mean age was 49.54 ± 16.17 years, the mean duration of dialysis was 6.44 ± 5.10 years, and 37.3% had diabetic nephropathy. The mean dose of alternate-day cinacalcet was 61.92 ± 26.59 mg. The level of iPTH before and after the change was 924.63 ± 474.132 pg/mL and 787.87 ± 496.49 pg/mL, respectively (P = 0.001), and the mean serum calcium level before and after was 8.56 ± 1.91 mg/dL and 8.85 ± 1.25 mg/dL, respectively (P = 0.035). The level of serum phosphorous before and after the change was 4.81 ± 1.32 mg/dL and 5.08 ± 2.3 mg/dL, respectively (P = 0.204). Cinacalcet produced significant reductions in iPTH with intermittent (three times per week) doses and thus was more cost-effective and had better compliance.

Iatrogenic Hypothermia during Hemodialysis Can Induce Serious Cardiac Arrhythmias in Diabetic Patient.

Cardiovascular diseases are the main cause of morbidity and mortality in end-stage renal disease (ESRD) patients. Cardiac arrhythmias are prevalent in patients undergoing hemodialysis (HD), however, dialysis treatment per se can be considered as an arrhythmogenic stimulus. Uremic patients are characterized by a "pro-arrhythmic substrate" because of the high prevalence of ischemic heart disease, left ventricular hypertrophy, and autonomic neuropathy. The incidence of hypothermia in HD patient is unknown. The severity of hypothermia correlated to cardiac arrhythmias. Here, we report a 50-year-old Saudi lady known case of long-standing diabetes mellitus with diabetic retinopathy, nephropathy and neuropathy, ESRD on HD, coronary artery disease developed transient third-degree heart block secondary to iatrogenic hypothermia during HD session, which was completely resolved after adjusting temperature of dialysis machine. To the best of our knowledge, the association of third-degree atrioventricular block and hypothermia induced by HD session has not been previously reported.

Meropenem at recommended dose is a potential risk for seizure in hemodialysis patient.

Dosage adjustment of meropenem is usually recommended in hemodialysis (HD) patients and about 30% of meropenem is cleared during regular HD sessions. However, most of the published trials excluded patients on regular HD. Little is known about the accurate dosage of meropenem needed to avoid central nervous system toxicity. Herein, we report a 65-year-old Saudi female, a known case of end-stage renal disease on regular HD, who was admitted because of pyelonephritis and started on meropenem in the recommended dose according to cultures and sensitivity. She developed tonic-clonic convulsions after the 7th dose. Seizures were completely aborted after discontinuation of the offending drug. The recommended dosage of 500 mg daily in HD patients may still be too high particularly in Asian patients owing to their relatively small body mass index.

Practical recommendations for the early use of m-TOR inhibitors (sirolimus) in renal transplantation.

m-TOR inhibitors (e.g. sirolimus) are well-tolerated immunosuppressants used in renal transplantation for prophylaxis of organ rejection, and are associated with long-term graft survival. Early use of sirolimus is often advocated by clinicians, but this may be associated with a number of side-effects including impaired wound-healing, lymphoceles and delayed graft function. As transplant clinicians with experience in the use of sirolimus, we believe such side-effects can be limited by tailored clinical management. We present recommendations based on published literature and our clinical experience. Furthermore, guidance is provided on sirolimus use during surgery, both at transplantation and for subsequent operations.

Pattern of renal diseases and the need for establishment of renal biopsy registry in Saudi Arabia.

Renal disease is a common medical problem in Saudi Arabia. Varieties of renal lesions if not treated properly or not discovered early will lead to a chronic kidney disease. Identifying the types of renal lesions can help in identifying the high-risk patients and appropriate treatment can be provided. Glomerulonephritis (GN) is considered one of the leading causes of end-stage renal disease in Saudi Arabia. The prevalence of different renal lesions were identified by different reports; however, these reports showed inconsistency. One important reason for such differences is related to the lack of unified methods in diagnosing and processing renal tissues and to the fact that different reports were reported by different pathologists. In addition, the differences in the reported results may reflect patient selection biases for renal biopsy or to the different policies and protocols adopted by different nephrologists. This is a prospective, multicenter study that involves different patients from different institutes and from different regions in Saudi Arabia to delineate the pattern of renal diseases based on renal biopsies. Four hundred and five cases were selected and studied over two years. This preliminary report shows that the most common primary renal lesion in Saudi Arabia is focal segmental glomerulosclerosis in 24.1%, followed by IgA nephropathy (15.2%), mesangioproliferative non-IgA, (13.2%), and membranoproliferative GN (12.4%). Lupus nephritis was the most common cause of secondary GN in 66% of the secondary causes.

Comparative crossover controlled study using polysulphone and vitamin E coated dialyzers.

OBJECTIVE: There is relatively little clinical experience reported on the use of the vitamin E coated dialyzer (CL-EE12, Terumo). This study compares its efficacy and intradialytic symptoms with a polysulphone dialyzer in 2 groups of patients in a controlled crossover trial design. METHODS: This study was carried out at the Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia, during the time period January to March 2002. In group A, 34 patients were dialyzed for 4 weeks with vitamin E dialyzer then switched over to Fresenius 60 (F60) for 4 weeks. In group B, 41 patients were dialyzed with F60 for 4 weeks then switched to vitamin E coated dilayzers for 4 weeks. The following parameters were measured weekly, hemoglobin level, urea reduction ratio (URR), urea clearance ratio (Kt/V), pre and post dialysis diastolic blood pressure (DBP) and systolic blood pressure (SBP), interdialytic weight gain. The patients were observed for interdialytic hypotension or symptoms. RESULTS: No significant findings were found in any of the parameters except more dialyzer clotting was observed with vitamin E dialyzer than in F60 dialyzers (1.6% of dialysis sessions versus 0.1% P<0.03). The interdialytic weight gain tended to be less in the vitamin E group but did not reach statistically significant difference. The Kt/V and URR were slightly higher when using the vitamin E dialyzer only in the second and third weeks. hypotensive episodes (P<.007) less leg cramp (P<.31) and less itching (P<.02) in the vitamin E coated treated group within group B. CONCLUSION: There were only minor differences noted between the 2 dialyzers in the parameters measured.

Prevalence of vitamin D deficiency in Saudi adults.

OBJECTIVE: To determine the prevalence of vitamin D deficiency in healthy Saudi adults. METHODS: A cross-sectional study carried out as part of the screening and early evaluation of kidney disease project. Vitamin D was measured in subjects recruited at 2 screening camps in Riyadh, Saudi Arabia, between March to May 2008. Subjects from the 2 large commercial centers in Riyadh aged ≥18 years and Saudi nationals were invited. RESULTS: The study sample comprised of 488 subjects. The mean age of the subjects was 37.43 (11.32) years, of which 50.2% (n=245) were males. Twenty-nine percent of subjects were in the vitamin D deficiency group, 22.7% were in the relative insufficiency group, and 47.5% had normal levels of 25-hydroxy vitamin D. We observed that female gender was an independent predictor of vitamin D deficiency or insufficiency (odds ratio [OR]: 2.992; 95% confidence intervals [CI] 2.069-4.327). Anemia was also a predictor for vitamin D deficiency or insufficiency (OR: 3.16; 95% CI 2.02-4.92). Age was positively correlated with vitamin D levels (Pearson correlation=0.183, p<0.000). CONCLUSION: Vitamin D deficiency is common in healthy Saudi adults. This is more pronounced in females and in the younger age groups. Wearing of traditional clothes, deliberate avoidance of the sun, and inadequate dietary intake are likely to be the principal causes of low vitamin D levels.

Impact of early chronic kidney disease on maternal and fetal outcomes of pregnancy.

BACKGROUND: Elevated serum creatinine is associated with higher maternal and fetal risks; however, the influence of milder degree of renal impairment diagnosed on basis on estimated glomerular filtration rate (eGFR) is less well defined. This study assesses the impact of early chronic kidney disease (CKD) utilizing eGFR in predicting adverse outcomes in women with CKD. METHODS: We analyzed outcomes of 98 pregnant women with CKD. Women with CKD stage 1 were used as control. RESULTS: Women with eGFR of 60?89 ml/min were at an increased risk for deterioration of renal function, preeclampsia, and cesarean section. The odd ratios for composite maternal complication of worsening of renal function or preeclampsia were 6.75 (95% confidence interval (CI), 1.84-24.80) in women with eGFR of 60?89. Similarly, women with an eGFR of 60?89 had a significantly increased risk for intrauterine growth restriction (38.5%), preterm birth (31.2%), and intrauterine fetal death (15.8%). The odds for composite fetal adverse outcomes were 2.91 (95% CI, 1.19-7.09) in women with eGFR of 60?89. CONCLUSIONS: Early CKD increases the risk of adverse outcomes in pregnancy. Estimated GFR ranging between 60?89 ml/min/1.73 m(2) is associated with significant maternal and fetal complications. The risk of adverse outcomes in pregnant women with early CKD can be more accurately stratified by using estimated GFR than the serum creatinine alone.

Epidemiology of chronic kidney disease in the Kingdom of Saudi Arabia (SEEK-Saudi investigators) - a pilot study.

There are no available data about the prevalence of chronic kidney disease (CKD) and its risk factors in the general population of the kingdom of Saudi Arabia. To estimate the prevalence of CKD and its associated risk factors in the Saudi population, we conducted a pilot community-based screening program in commercial centers in Riyadh, Saudi Arabia. Candidates were interviewed and blood and urine samples were collected. Participants were categorized to their CKD stage according to their estimated Modification of Diet in Renal Disease (MDRD3)-based, the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the presence of albuminuria. The sample comprised 491 (49.9% were males) adult Saudi nationals. The mean age was 37.4 ± 11.3 years. The over-all prevalence of CKD was 5.7% and 5.3% using the MDRD-3 and CKD-EPI glomerular filtration equations, respectively. Gender, age, smoking status, body mass index, hypertension and diabetes mel-litus were not significant predictors of CKD in our cohort. However, CKD was significantly higher in the older age groups, higher serum glucose, waist/hip ratio and blood pressure. Only 7.1% of the CKD patients were aware of their CKD status, while 32.1% were told that they had protein or blood in their urine and 10.7% had known kidney stones in the past. We conclude that prevalence of CKD in the young Saudi population is around 5.7%. Our pilot study demonstrated the feasibility of screening for CKD. Screening of high-risk individuals is likely to be the most cost-effective strategy to detect CKD patients.

Dilemma of renal disease in elderly.

The aging process results in profound anatomic and functional changes in a number of human body systems. Changes in kidney function with normal aging are the most dramatic of any human organ or organ system. These include anatomical, physiological, hemodynamic and immunological changes. Increased propensities of systemic diseases and exposure to poly-pharmacy of the aged group have an additive deleterious effect. The aforementioned changes have its implications on clinical presentations, management and prognosis of all renal diseases in elderly. Atypical presentation, more frequent and longer course are the characteristics of acute renal failure in this age group. Also, presentation of glomerular diseases, clinical course, prognosis, decision of performing a renal biopsy and use of immunosuppressive drugs in elderly specially those subgroup above 80 years of age are still a big challenges that needs a consensus and standardization.