Pregnancy in patients on dialysis--experience at a referral center.

OBJECTIVE: Pregnancy is infrequent in women with end-stage renal disease. The frequency of conception in dialysis patients has been reported as 0.3% to 1.4% in different studies from different countries. In the present study the frequency and outcome of pregnancies from a referral center in Saudi Arabia from January 1992 to December 2003 is reported. METHODS: All females on maintenance hemodialysis (MHD) and chronic peritoneal dialysis (CPD) were reviewed. Files of the patients in childbearing age (less than 50 years) were analyzed for the frequency of pregnancy, mode of dialysis, complications and outcome. Of the 192 females taken for MHD and CPD, 113 were of the childbearing age. Five patients were already on HD when they became pregnant, the period on HD varied from 7-34 (mean = 24) months and in 4 dialysis was initiated during first pregnancy. (Abortion was defined as termination of pregnancy before 22 weeks of gestation. Perinatal mortality was taken as death of a viable fetus after 22 weeks of gestation or within 4 weeks after delivery. Preterm was defined as delivery before 37 weeks of gestation and low birth weight as a baby weighing less than 2500 gm at birth). RESULTS: Twelve pregnancies were noted in 9 patients (7.9%) with a yearly frequency of 0.66%. All pregnancies were noted in patients on MHD and none on CPD. Seven pregnancies (58%) ended in live births and all were preterm deliveries in the range of 27-36 (mean 31.5) weeks. All babies were low birth weight ranging from 1115-2300 (mean 1700) gram. Three deliveries were spontaneous vaginal and 4 underwent lower segment cesarean sections. Two deliveries ended in perinatal mortality. Three pregnancies ended in spontaneous abortions between 10-20 (mean 12) weeks. One woman had 3 pregnancies, the last one ending in antepartum hemorrhage, hysterotomy and hysterectomy for rupture of uterus. Another patient had 2 pregnancies. No congenital abnormalities were noted in any of the live births. CONCLUSION: Pregnancy though uncommon in women on dialysis can occur. Preterm deliveries with low birth weight are usual though live birth rate of 58% was observed. In view of the need for increased frequency of dialysis for successful outcome, planning the pregnancy and high chances of dangerous complications, early diagnosis of pregnancy in a patient on dialysis essential.

Role of interferon-alpha in the treatment of primary glomerulonephritis.

Interferon-alpha (IFN-alpha) is a naturally occurring cytokine. It was the first cytokine used with clinical benefit in the treatment of viral hepatitis and malignancies. Patients with viral hepatitis B or C may have complications with glomerulonephritis (GN). Improvement in proteinuria with or without clearing of viral markers after IFN-alpha therapy has been reported. This encouraged us to offer IFN-alpha therapy to four patients with GN. These patients refused treatment with steroids and/or cyclophosphamide because of concerns about side effects. One patient with membranous GN and two patients with mesangial GN (MesGN) had a remission of nephrotic syndrome. In one patient with type II diabetes and MesGN, renal insufficiency and proteinuria did not subside; however, renal function remained stable. The mechanism of action of IFN-alpha is discussed, with its possible role in the treatment of primary GN.

Hydatid cyst of the spleen.

Though hydatid disease is quite common in Saudi Arabia, splenic echinococcal cysts are rare. Our experience with the diagnostic problems encountered in three patients seen during a three-year period is presented. The helpful role of ultrasonography and computerized tomography in the preoperative evaluation of this disease also is demonstrated.

Eleven years of experience with dialysis associated tuberculosis.

BACKGROUND: The aim of this retrospective study was to evaluate the incidence of tuberculosis (TB) in dialysis patients and to determine its clinical features and results of short-course (6 months) chemotherapy, mortality and risk factors of mortality. METHODS: The study included 48 TB patients among 330 patients on dialysis of whom 37 were on hemodialysis and 11 were on peritoneal dialysis at Security Forces Hospital in the period from October 1989 to October 2000. The diagnosis of TB was established by a combination of clinical, radiological, biochemical, microbiological and histological examinations. Treatment with anti-TB drugs, the results of therapy and the outcome of patients were noted. RESULTS: There were 32 males and 16 females with age ranges of 18 -89 (mean = 53.4) and 40 - 70 (mean 57.9) years, respectively. Their duration on dialysis ranged from 1 month to 10 years (mean = 26 months). The presenting clinical features were fever (32), cough (16), weight loss (9), and anorexia (7). The organ systems involved were pulmonary (23), peritoneal (15), lymphadenopathy (11), pericardial (4), bone TB (3), bone marrow (2), epididimo-orchitis (1), right infraclavicular chest wall cold abscess (1), right infrascapular cold abscess (1) and right renal mass (1). Single organ system involvement was noted in 36 patients, 2 systems in 10 patients and 3 systems in 2 patients. Two patients were treated empirically with good response. Evidence of tuberculosis was obtained from chest X-rays (23), bone X-rays (3), spinal MRIs (1), AFB (stain and culture) of sputum and fluid (15), ascitic fluid examination with exudate and raised adenine deaminase (ADA) levels (12), lymph node biopsy (8), pleural fluid examination with exudate and raised ADA levels (5), bone marrow aspiration (2), exudative pericardial fluid with raised ADA levels (2), nephrectomy and histopathology (1), dorsal spine biopsy (1) and laparotomy and biopsy ofperitoneum (1). Thirty-two patients received 4 anti-TB drugs: isoniazid (INH), rifampicin (Rif), pyrazinamide (Pyra) and ethambutol (Eth), 10 received 3 drugs (INH, Rif and Pyra or Eth), 2 received 2 drugs (INH + Rif) and a modified regimen was used in 3. The drug toxicities noted were hepatoxicity (5) and INH encephalopathy prior to the routine use of pyridoxine 100 mg daily (3), INH-induced SLE (1) and pyrazinamide-induced thrombocytopenia (1). The outcome of the patients was cured (35), expired (13), and 1 patient expired before starting therapy. Tuberculosis was not the direct cause of death in any of the patients. CONCLUSION: The incidence of TB in dialysis patients is 26 times more common than in the general Saudi population and a high index of suspicion is needed for early diagnosis and treatment. Extrapulmonary TB was noted in 52% of the patients. Short-course (6 months) chemotherapy is effective. INH-induced CNS toxicity is significant.

Percutaneous subclavian vein catheterization for hemodialysis: a report of 57 insertions.

The authors report an analysis of 57 subclavian vein catheterizations for hemodialysis. A total of 51 patients (34 men, 17 women) kept the Cobe single- and double-lumen catheters for 1,726 days. The youngest patient was eighteen and the oldest seventy-two years of age. There were no catheter-related deaths. Complications were encountered in 9 patients. The only life-threatening complication was cardiac arrest, which occurred during flushing of the catheter. The patient was successfully revived. The other complications were pneumothorax and hydrothorax in 1 patient, catheter site infection in 5 patients, and arrhythmias in 2 patients, which stopped after readjustment of the catheter tips. Their experience indicates that percutaneous subclavian vein catheterization is safe and provides quick access for hemodialysis with no morbidity and mortality if done correctly, patiently, and meticulously. The authors believe that this should be the first choice in patients with reversible renal failure and in patients with chronic renal failure, who are usually elderly and medically compromised, till a permanent vascular access is ready for use.

Dual-lumen femoral vein catheterization as vascular access for hemodialysis--a prospective study.

Prospectively from January 1991 to January 1993, the efficacy and complications of 104 polyurethane, double-lumen femoral vein catheterizations (FVC) in 96 renal failure patients were studied. Ambulation was allowed in the hospital as well as at home while the catheter was in. There were 53 males and 43 females, with ages ranging from 13 to 87 (mean, 48.3 +/- 19.7) years. Forty-eight patients had chronic renal failure and 48 had acute renal failure. The catheters were used for 1 to 26 days (mean, 8 +/- 5 days). Fifty-two (50%) of the FVC were used for 2 weeks and 14 (13.5%) for 3 weeks or longer. The various complications encountered were infection (n=31), poor blood flow (n=8), displaced catheter (n=6), thrombosis of the catheter (n=4), hematoma (n=4), bleeding (n=3), exit site infection (n=3), ileofemoral vein thrombosis (n=2), and tear in the catheter wall (n=2). On removal, bacterial colonization was present in 34 out of 93 catheter tips (36.5%); Staphylococcus epidermidis (n=12) was the commonest organism grown. There was no significant difference of infection between diabetic and nondiabetic chronic renal failure patients. The duration of catheterization was found to have no relation with either thrombosis or infection. Femoral vein catheters can be used for hemodialysis for 2 to 3 weeks and ambulation during cannulation may be allowed.

Arteriovenous fistula for hemodialysis. A report of 112 consecutive cases.

Arterio-venous fistula of Brescia was created in 112 consecutive patients during a five year period from May 1983 at King Fahd University Hospital of King Faisal University, Al-Khobar, Saudi Arabia. These fistulae were created for hemodialysis in patients with chronic renal failure. There were 67 males and 45 females. The youngest patient was 13 years and the oldest 75 years. Complications were negligible (0.85%), even-though 31% were diabetics and 24% had sickle cell hemoglobinopathy. The arteriovenous fistula failed in 6 patients and the patency rate was 94.6%. The minimum follow up was three months and the maximum fifty-two months. The end-to-side anastomosis gave better results. For long term dialysis arterio-venous fistula of Brescia should remain as the first choice.

Primary hyperparathyroidism: presentation and management.

164 hypercalcemic patients were examined to determine the co-relation, frequency and mode of presentation of primary hyperparathyroidism. Primary hyperparathyroidism was diagnosed in 11 patients (6.7%). All of them presented late with renal and bony complications. The incidence of primary hyperparathyroidism appears to be lower than that of the western countries, and the introduction of routine serum calcium estimates can be expected to yield more cases of primary hyperparathyroidism especially asymptomatic cases.

Device-day infection rates - a surveillance component system for intensive care units at Security Forces Hospital, Riyadh, Saudi Arabia.

A surveillance component system for Intensive Care Units (ICUs) designed to account for major extrinsic risk factors for nosocomial infections using device days as the denominator has been advocated. A study of the surveillance component system in ICUs was conducted in Security Forces Hospital (SFH), Riyadh, Saudi Arabia, from February 1993 to January 1994 to verify the validity and compare the device-related infection rates with the infection rates based on patient admission and patient days. The standard recommended method was used in data collection. Device-associated infection rates vary by ICU types and device exposure. The surgical ICU (SICU) had the highest pneumonia rate while the pediatric ICU (PICU) had the lowest, being 22.0 and 6.4 per 1000 ventilator days respectively. Bacteremia was highest in the PICU with 20.7/1000 intravascular catheter days. The urinary tract infection rate of 11.4/1000 urinary catheter days was the highest in the medical ICU (MICU). These were statistically significant (P>0.001). The conclusion from the demonstration of these variables is that the use of the surveillance component system gives specific information on the effect of invasive devices in the occurrence of infection related to their use in the various ICUs. It permits the calculation of risk-specific infection rates, being a marker for the unit's invasive practices. Improved handwashing and the wearing of sterile gloves reduced the central intravascular catheter bacteremia rate in PICU from 20.7 to 10.0/1000 catheter days.

Hansen's disease: a cause of lymphadenopathy in endemic areas.

In this paper we report two unusual cases of leprosy, both presenting with lymphadenopathy as the initial manifestation of the disease. Lymphadenopathy was the dominant presenting complaint of the first patient in whom skin lesions were absent. A diagnosis of lepromatous leprosy was made only after a lymph node biopsy. Following this diagnosis neural involvement was evident. In the second patient the lymphadenopathy was associated with polyarthritis leading to a false clinical diagnosis of Still's disease. This unusual presentation in both cases led to a delay in the final diagnosis which was based on histopathological examination of lymph nodes. The clinical and histopathological features of both patients are discussed. Superficial nerves should be palpated in all patients presenting with lymphadenopathy in endemic areas.

Renal granuloma and mesangial proliferative glomerulonephritis in leprosy.

A 17-year-old, Yemeni male patient with borderline lepromatous leprosy and erythema nodosum leprosum (ENL) developed a nephritic range proteinuria. A renal biopsy revealed mesangial proliferative glomerulonephritis and epithelioid granulomas in the interstitium. The presence of granular immunofluorescence for C3 and electron-dense deposits in the glomeruli indicated an immune complex glomerulonephritis. Clinical signs of ENL subsided rapidly under steroid treatment. The unusual combination of proliferative glomerulonephritis and epithelioid granulomas in leprosy is presented and discussed.

Erythropoietin therapy in a pregnant woman on maintenance hemodialysis.

A 25 year old Saudi female, sixth gravida, para four, on renal replacement therapy with regular dialysis for nearly two years, was diagnosed to be pregnant at 12 weeks, with a single viable fetus. She was managed with increased frequency of dialysis and increased doses of anti-hypertensive drugs. For the control of anemia, which was further worsened by the pregnancy, she was treated with r-HuEPO 125 to 150 u/kg 3 times/week along with iron and vitamin supplements to maintain hemoglobin of 90 gm/L. The pregnancy continued to 36 weeks and she had a spontaneous normal delivery of a male baby without any congenital defects, weighing 1605 grams with Apgar score of four at one minute and nine at five minutes.

Liver disease in dialysis patients with antibodies to hepatitis C virus.

Eighty-three patients with chronic end-stage renal failure, including 65 on haemodialysis and 18 on intermittent peritoneal dialysis, were evaluated for hepatitis B virus profile and antibodies to hepatitis C virus (HCV). All those positive for HBsAg were excluded from the study. Nineteen patients were found to be positive for antibodies to HCV by the ELISA II test. Eight cases were already positive for HCV antibody when they started dialysis in our unit, the other 11 became positive during dialysis in our unit. Only one of the patients on peritoneal dialysis was positive for HCV. A liver biopsy was obtained from 17 patients, who consented to the procedure. All the cases were evaluated for the number of blood transfusions received, HIV infection and the approximate time of contracting the HCV infection. Liver enzymes were determined every month. Only three patients had abnormally raised serum aminotransferase at the time of biopsy. The various histopathological lesions detected were chronic active hepatitis (n = 3, including one with changes consistent with cirrhosis), chronic persistent hepatitis (n = 4), non-specific hepatitis (n = 3) and haemosiderosis (n = 3); four biopsy samples were normal. There was no correlation between the biochemical and histopathological changes. Moreover, patients with normal serum aminotransferase levels had abnormal histopathological changes. All were negative for HIV and none of the patients had received a renal graft. Twelve patients had received blood transfusions varying from 2 to 12 units, four had not received any blood, and in one the history of blood transfusion could not be confirmed. The four patients with anti-HCV antibodies who had not received blood transfusion had relatively mild disease--non-specific hepatitis (n = 2) or normal biopsy (n = 2). One patient with cirrhosis died 30 months after liver biopsy from hepatic insufficiency and three received renal transplants. Others are continuing on dialysis and their biochemical tests are within normal limits 12-45 (30 +/- 14) months after biopsy. In conclusion, biochemical tests are poor indicators of liver disease, and liver biopsy is a definitive way of evaluating the patients of dialysis with positive HCV antibodies for prognosis.

Prognosis of radiologically non-functioning obstructed kidneys.

Twenty patients found to have unilateral radiologically non-functioning obstructed kidneys on excretory urography (IVU), and who had normal contralateral kidneys, were further evaluated. Ultrasonography, radionuclide imaging and CT scan were carried out pre-operatively to try to predict which of the kidneys were potentially recoverable after relief of obstruction. Percutaneous nephrostomy was also performed on the last consecutive 7 patients 4 weeks before definitive treatment and the function of the kidneys determined daily. The patients were re-evaluated 2 months after the relief of obstruction. Ultrasonography, radionuclide imaging and CT scan were not found to be reliable in predicting whether these kidneys were potentially recoverable. We consider percutaneous nephrostomy a good procedure for obtaining prognostic information prior to definitive surgery.

Serum ionic fluoride levels in haemodialysis and continuous ambulatory peritoneal dialysis patients.

High serum fluoride (F-) in patients with chronic renal failure (CRF) and end-stage renal disease (ESRD) is associated with risk of renal osteodystrophy and other bone changes. This study was done to determine F- in normal healthy controls and patients with ESRD on haemodialysis (HD) or peritoneal dialysis (PD). Seventeen healthy controls (12 males, 5 females) and 39 ESRD patients on dialysis (17 males, 22 females) were recruited in the study in a community with 47.4 +/- 3.28 microM/l (range 44-51 microM/l) of F- content in drinking water. Control subjects showed a mean serum F- concentration of 1.08 +/- 0.350 microM/l. Males in control group showed slightly higher F- levels (1.15 +/- 0.334, range 0.55-1.9 microM/l) than females (0.92 +/- 0.370, range 0.6-1.5 microM/l). Mean serum F- concentration did not correlate significantly with age and sex among control subjects, whereas such correlation was observed in patients with ESRD on dialysis. Mean serum F- concentration was significantly higher in patients on dialysis (2.67 +/- 1.09, range 0.8-5.2 microM/l) than normal controls. When grouped according to sex, the mean serum F- concentration in males (3.05 +/- 1.04, range 1.8-5.2 microM/l) was significantly higher than females (2.38 +/- 1.08, range 0.8-5.2 microM/l). When patients were grouped according to age, it was observed that F- concentration was significantly higher in patients with age groups 21-70 (2.86 +/- 1.05) than those with age group 13-20 years (1.42 +/- 0.531). Thus F- concentration correlated with age and sex, being higher in males and above 20 years. Despite appreciable clearance of F- (39-90%) across the peritoneum, patients on CAPD showed higher serum F- concentration than those on HD (3.1 +/- 1.97 vs 2.5 +/- 1.137 microM/l). Of the total 39 patients on dialysis 39% had their serum F- concentration above 3.0 microM/l, posing the risk of renal osteodystrophy.

Acute Hydrothorax Complicating continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature.

We describe here hydrothorax that occurred in a patient on continuous ambulatory peritoneal dialysis (CAPD) and highlight the problems of diagnosis and management. A 48 years-old man with history of obstructive uropathy secondary to urolithiasis was stared on CAPD when he reached end-stage renal failure. Two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. Chest examination was suggestive of right sided pleural effusion confusion confirmed by chest X-ray. Radioisotope Technetium 99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued and the patient was switched to hemodialysis. The pleural effusion subsided and has not recurred for the following three years.

The pattern of colonic diseases in the Eastern Province of Saudi Arabia.

The purpose of this paper is to highlight the incidence and scope of lower gastrointestinal tract (GIT) diseases in the Eastern Province of the Kingdom of Saudi Arabia. Between August 1981 and April 1984, 288 patients with significant complaints and physical signs attributable to the lower GIT were prospectively evaluated. A complete patient history was taken in each case followed by physical examination, routine laboratory studies and a sigmoidoscopic examination. In 128 patients (44.5%), sigmoidoscopy and rectal and/or colonic biopsies did not reveal any pathological abnormalities. These patients were considered to have various disorders such as irritable bowel syndrome or parasitic infestation. Eighty-one patients (28%) were found to have mild to moderate non-specific colitis or proctitis. In another 49 patients (17%) the diagnosis of schistosomiasis mansoni was made. Ulcerative colitis and colorectal carcinoma were detected in only 11 (4%) and 4 (1.5%) patients respectively. In the remaining 15 patients (5%), other lower GIT diseases were found. Comparative analysis of the disease pattern in our series has demonstrated some differences from other series from within the Kingdom and also from other countries.

Hepatitis C in chronic renal failure patients.

The occurrence of hepatitis C virus (HCV) infection amongst chronic renal failure (CRF) patients in our Nephrology Unit was investigated over a period of 1 year. A total of 71 patients was studied comprising 26 chronic haemodialysis (CHD) patients, 6 acute haemodialysis patients, 4 peritoneal dialysis patients and 35 CRF patients not on dialysis. Patients were screened before and after haemodialysis, and their baseline and postdialysis values of liver enzymes were determined. Eleven (15.5%) of the total 71 patients were HCV antibody positive. Analysis of the individual patient groups showed that 8 (30.7%) of the 26 CHD patients were positive for HCV. Our data showed a statistically significant relationship between seroconversion and duration of dialysis (p < 0.05). A high statistically significant (p < 0.0001) correlation was observed between the HCV antibodies and CRF. The relative risk of hepatitis C was about 22 times greater for those with CRF compared with the normal controls, which makes CRF an important risk factor. A high proportion of the HCV seroconverters had elevated liver enzyme (serum glutamic pyruvic transaminase). The data presented show a positive correlation between HCV seroconversion, CRF, duration on dialysis and elevated serum liver enzymes.