Etiological Factors Affecting Single Versus Multiple Tunneled Hemodialysis Catheter Cuff Extrusions in the Saudi Population.

OBJECTIVE: To identify underlying factors associated with single versus multiple expulsions of tunneled hemodialysis catheter cuffs and their associated complications. MATERIALS AND METHODS: A multicenter, five-year retrospective data analysis was conducted on hemodialysis patients with tunneled catheters. Patient data included age, gender, BMI, and associated comorbidities. The type of procedure (new tunnel insertion vs. exchange), exit site infection, and catheter-related bloodstream infection (CRBSI) were also included. RESULTS: The data of 122 patients was analyzed. Seventy-eight patients had diabetes mellitus, 102 patients had hypertension, and 24 had ischemic heart disease. Fifty-one patients were on antiplatelet therapy, and nine patients were on oral steroids. The access site for 98 patients was the right internal jugular; for 19 patients, it was the left internal jugular; five patients had a femoral dialysis catheter. Patients were grouped into two categories: those with single cuff extrusion episodes and those with multiple cuff-out episodes. Sixty-three patients had one cuff extrusion, and 59 had multiple cuff-out episodes during the study period. Patients who had CRBSI and hypertension and were aged between 61 and 95 had multiple episodes of cuff extrusion and reached statistical significance. Exit-site infection, diabetes mellitus, antiplatelet therapy, gender, catheter site, and BMI had no statistical significance between the two groups. CONCLUSION: Tunneled catheter cuff extrusion is a frequent phenomenon. Catheter-related bloodstream infection, hypertension, and age of 61 to 95 years are high-risk factors for multiple episodes of cuff extrusion.

Multicenter Study to Validate a Hospitalization Risk Assessment Tool in Hemodialysis Patients.

Introduction Protein-energy wasting is a prevalent condition in patients with chronic kidney disease. Our goal was to validate the risk assessment tool (Hashmi's tool) in multiple centers, developed in 2018, as it was easily applicable and cost-effective. Methods The following variables were scored as 0, 1, 2, or 3 as per severity: body mass index, HD vintage in years, functional capacity, serum albumin, serum ferritin, and the number of co-morbid conditions (diabetes mellitus, hypertension, ischemic heart disease, and cerebrovascular disease). This scoring system was applied to maintenance hemodialysis patients in six different centers. The patient's record was evaluated for two years. Patients were divided into low-risk (score <6) and high-risk (score ≥6). We compared the two groups using the chi-square test for the difference in hospitalization and mortality. Results A total of 868 patients' records were analyzed, and the maximum score was 13 with the application of Hashmi's tool. Four hundred twenty-nine patients were in the low-risk group, and 439 patients fell into the high-risk group. Four hundred sixty-seven patients were male, and 401 were females; 84% had hypertension, and 54% had diabetes mellitus. In the high-risk group, we identified more females. Patients' likelihood of being in the high-risk group was higher if they had diabetes mellitus, hypertension, or ischemic heart disease. Hospitalization due to vascular or non-vascular etiologies was more common in the high-risk group (p=0.036 and p<0.001, respectively). A total of 123 patients died during the study period, 92 from the high-risk group as compared to 31 from the low-risk group. This was three times higher and statistically significant (p<0.001). Conclusion Using a simple and cost-effective tool, we have identified malnourished patients who are at risk of hospitalization and mortality. This study has validated the previous work at a single center, which has now been reflected in six dialysis units across Saudi Arabia.

Analysis of chronic kidney disease patients by targeted next-generation sequencing identifies novel variants in kidney-related genes.

Despite the enormous economic and societal burden of chronic kidney disease (CKD), its pathogenesis remains elusive, impeding specific diagnosis and targeted therapy. Herein, we sought to elucidate the genetic causes of end-stage renal disease (ESRD) and identify genetic variants associated with CKD and related traits in Saudi kidney disease patients. We applied a genetic testing approach using a targeted next-generation sequencing gene panel including 102 genes causative or associated with CKD. A total of 1,098 Saudi participants were recruited for the study, including 534 patients with ESRD and 564 healthy controls. The pre-validated NGS panel was utilized to screen for genetic variants, and then, statistical analysis was conducted to test for associations. The NGS panel revealed 7,225 variants in 102 sequenced genes. Cases had a significantly higher number of confirmed pathogenic variants as classified by the ClinVar database than controls (i.e., individuals with at least one allele of a confirmed pathogenic variant that is associated with CKD; 279 (0.52) vs. 258 (0.45); p-value = 0.03). A total of 13 genetic variants were found to be significantly associated with ESRD in PLCE1, CLCN5, ATP6V1B1, LAMB2, INVS, FRAS1, C5orf42, SLC12A3, COL4A6, SLC3A1, RET, WNK1, and BICC1, including four novel variants that were not previously reported in any other population. Furthermore, studies are necessary to validate these associations in a larger sample size and among individuals of different ethnic groups.

Paclitaxel-Coated Balloons Compared to Plain Balloon Angioplasty in the Management of Dysfunctional Arteriovenous Fistulae: A Single-Center Randomized Clinical Trial.

The study aimed to compare paclitaxel-coated balloons (PCB) to percutaneous transluminal plain balloon angioplasty (PTA) in the management of dysfunctional arteriovenous fistulae. This single institution randomized controlled trial was approved by the institutional and local review boards and is registered in the ClinicalTrials.gov website. The study was initially designed to recruit a total of 92 patients. However, recruitment was terminated after the release of the meta-analysis that raised concerns about the potential increased risk of death associated with PCB. A total of 23 patients with nonthrombosed dysfunctional fistulae (mean age 67 years, 12 females) were recruited (PCB = 12) from October 2017 to September 2018. The fistulae were radiocephalic (n = 5), brachiocephalic (n = 12), brachiobasilic (n = 6), and seven immature fistulae. After a 2-min predilatation of the target lesions, patients were randomized to receive an additional 2-min of angioplasty with either a plain balloon or PCB (Lutonix). The primary endpoint was fistula patency at 12 months. The secondary endpoints included technical and clinical success, time-to-reintervention, survival at 12 months, and complications. The primary endpoint of fistula patency at 12 months was met in three patients treated with PCB and two patients treated with PTA. The all-cause mortality at one year was 8% (n = 2), both were in the PTA group. Treatment failed in restoring adequate fistula function in four patients [2 PCB with immature arteriovenous fistula (AVF) and two PTA with mature AVF]. Three patients were lost to follow-up (1 PCB, 2 PTA). Of the remaining patients (6 PCB and 4 PTA), there was no significant difference in the median time-to-reintervention between the two groups (148 vs. 174 days). Two minor complications were recorded which did not require any additional treatment. Although this trial was terminated prematurely, there appears to be no significant difference between PCB and PTA in maintaining fistula patency and reducing the time-to-reintervention. No mortality was recorded in the PCB group during the study period.

Parathyroid Hormone Serum Levels and Mortality among Hemodialysis Patients in the Gulf Cooperation Council Countries: Results from the DOPPS (2012-2018).

Background: The prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) has collected data since 2012 in all six Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates). We report the relationship of PTH with mortality in this largest GCC cohort of patients on hemodialysis studied to date. Methods: Data were from randomly selected national samples of hemodialysis facilities in GCC-DOPPS phases 5 and 6 (2012-2018). PTH descriptive findings and case mix-adjusted PTH/mortality Cox regression analyses were based on 1825 and 1422 randomly selected patients on hemodialysis, respectively. Results: Mean patient age was 55 years (median dialysis vintage, 2.1 years). Median PTH ranged from 259 pg/ml (UAE) to 437 pg/ml (Kuwait), with 22% having PTH <150 pg/ml, 24% with PTH of 150-300 pg/ml, 34% with PTH 301-700 pg/ml, and 20% with PTH >700 pg/ml. Patients with PTH >700 pg/ml were younger; on dialysis longer; less likely to be diabetic; have urine >200 ml/d; be prescribed 3.5 mEq/L dialysate calcium; had higher mean serum creatinine and phosphate levels; lower white blood cell counts; and more likely to be prescribed cinacalcet, phosphate binders, or IV vitamin D. A U-shaped PTH/mortality relationship was observed with more than two- and 1.5-fold higher adjusted HR of death at PTH >700 pg/ml and <300 pg/ml, respectively, compared with PTH of 301-450 pg/ml. Conclusions: Secondary hyperparathyroidism is highly prevalent among GCC patients on hemodialysis, with a strong U-shaped PTH/mortality relationship seen at PTH <300 and >450 pg/ml. Future studies are encouraged for further understanding this PTH/mortality pattern in relationship to unique aspects of the GCC hemodialysis population.

Effect of Fasting the Whole Month of Ramadan on Renal Function Among Muslim Patients With Kidney Transplant: A Meta-Analysis.

OBJECTIVES: Muslim renal transplant patients often ask whether fasting during Ramadan would be harmful to their kidneys. We performed a meta-analysis on relevant studies to answer this question. MATERIALS AND METHODS: We searched 4 databases using comprehensive search terms with predefined eligibility criteria. Two reviewers (FH and RA) independently assessed the relevance of studies obtained during the search. If disagreement occurred, a consensus would be sought; if disagreement persisted, the arbitration would be left to a third author (AAS). RESULTS: Eight studies (549 patients) were identified as eligible; these studies measured renal function before and after Ramadan with patients acting as their own controls in 5 studies. Our pooled analyses showed no significant changes after fasting with regard to estimated glomerular filtration rate (70.1 ± 9.1 vs 68.5 ± 7.5 mL/min, respectively; P = .6) or in serum creatinine levels (105.3 ± 8.8 and 106.1 ± 6.0 µmol/L, respectively; P = .47). In 4 self-controlled studies (148 patients) that had analyzed changes in systolic and diastolic blood pressure before versus after fasting, no significant differences were shown. However, in 3 studies that assessed changes in glomerular filtration rate in fasting (n = 358) versus nonfasting patients (n = 355), there was a significant difference in change in glomerular filtration rate following Ramadan fasting (-0.13 ± 1.2 mL/min in those who fasted versus 4.2 ± 4.6 mL/min in those who did not fast; P = .039); however, these results were associated with significant publication bias (systematic heterogeneity). CONCLUSIONS: Fasting during Ramadan did not result in significant changes in kidney function or blood pressure in posttransplant patients with good baseline kidney function when patients acted as their own controls.

Effect of thyroid function status in hemodialysis patients on erythropoietin resistance and interdialytic weight gain.

Thyroid function abnormalities are common in hemodialysis (HD) patients. Here, we investigated their frequency and impact on intradialytic hemodynamics and erythropoietin resistance index (ERI). Demographic and laboratory data including thyroid-stimulating hormone (TSH), interdialytic weight gain, and intradialytic blood pressure (BP) changes were measured, and ERI was calculated. The prevalence and causes of abnormities in TSH and free thyroxine (FT4) and their effects on ERI and intradialytic hemodynamics were then assessed. One hundred and thirty patients (mean age, 57.1 ± 19.2 years; 66.4% diabetic, 86.7% hypertensive) were enrolled. Among them, 16.7% had hypothyroidism, 2.3% had hyperthyroidism, and 10.9% had subclinical hypothyroidism. TSH level was significantly associated with higher BP (P <0.05), lower albumin (3.6 ± 4.4 and 2.6 ± 1.8, respectively; P = 0.05), lower dialysis hours (3.9 ± 5.3 and 2.6 ± 1.8, respectively), and lower ERI (3.7 ± 4.4 and 2.4 ± 1.9, respectively; P = 0.05). FT4 was significantly associated with higher interdialytic weight gain (13.4 ± 4.3 and 11.8 ± 2.2 pmol/L, respectively; P = 0.009) and higher pre-HD diastolic BP (13.2 ± 4.0 and 12.0 ± 2.9 pmol/L, respectively; P = 0.05). A negative correlation was seen between TSH level and urea reduction ratio (r = 0.29, P = 0.002), serum albumin (r = 0.304, P = 0.001), hemoglobin level (r = 0.26, P = 0.005), and ERI (r = 0.2, P = 0.002). A higher TSH level was associated with hypertension, lower albumin level, fewer dialysis hours, and increased resistance to erythropoietin. TSH level was negatively correlated with dialytic adequacy, serum albumin level, hemoglobin level, and ERI.

A Simple and Cheap Hospitalization Risk Assessment Tool for Use in Hemodialysis Patients.

OBJECTIVE: To develop a simple, objective, cheap scoring tool incorporating nutritional parameters and other variables to predict hospitalization and mortality among hemodialysis patients - a tool that could be utilized in low resource countries. METHODS: The following variables were scored according to severity into 0, 1, 2 or 3: BMI, functional capacity, HD vintage in years, serum albumin, serum ferritin, and the number of comorbid conditions (diabetes mellitus, hypertension, ischemic heart disease, cerebrovascular disease). This tool was evaluated on our regular hemodialysis patients who were followed up for 24 months (June 2015 till July 2017). In our study population, the maximum score recorded was 12; accordingly, a score of 6 was used to differentiate between a low-risk group (score < 6) or a high-risk group (score ≥6). The 2 groups were compared (using the Chi square test) for possible differences in mortality and hospitalization rates during the follow-up period. RESULTS: One hundred and forty adult hemodialysis patients were monitored over 2 years; 83 were males and 57 females; 59% of the patients had diabetes mellitus. Twenty-nine patients (30.7%) were found to be in the high-risk group and 111 (79.3%) in the low-risk group. The high-risk patients were almost one and a half times more likely to be hospitalized for vascular access issues than the low-risk group (p = 0.056) and 3 times more likely to be hospitalized for non-vascular access issues than the low-risk group (p = 0.0001). The mortality rate in the high-risk group was 3.1 times that in the low-risk group, but this was not statistically significant. CONCLUSION: Using a simple and cheap assessment tool in hemodialysis patients, we have identified patients at high risk for hospitalization rates and mortality. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=490544.

Improvement in dialysis-related adverse events with use of body composition monitoring.

This study aims to utilize body composition monitor (BCM) device to achieve euvolemic status in problematic dialysis patients and to evaluate its clinical outcome. One hundred and five hemodialysis (HD) patients were enrolled based on difficulty in achieving dry weight. The reasons for enrollment in the study were (a) recurrent intradialytic hypotension, (b) intradialytic hypertension, (c) intradialytic muscle cramps, or (d) the presence of comorbid conditions that make clinical assessment of dry weight difficult (e.g., cirrhosis of liver, heart failure, severe malnutrition, or morbid obesity). Following initial assessment of hydration status using BCM device, dry weight for each patient was adjusted accordingly (upward, downward, or unchanged). The patients were, thereafter, monitored over a 15-week period for possible resultant change in the clinical and hemodynamic parameters. Forty-two patients were monitored due to hypertension, 18 due to hypotension, 10 due to hypotension and cramps, and 35 due to comorbid conditions that make clinical assessment of dry weight difficult. At the conclusion of study period, there was improvement in the monitored parameters. Hypertension improved in 79% of the patient with hypertension, hypotension in 90%, and hypotension with cramps in 90%. In the comorbid group, BCM monitoring provided better insight to clinical problem management in 80% cases. Overall quality of BCM assessments was 96.1%. In the hypertension group, mean blood pressure decreased by 10.9 mm Hg in the whole group (P = 0.0006), the drop was 3 mm Hg in the patients dialyzing with HD (P = 0.0006) and 8.6 mm Hg in those on hemodiafiltration (HDF) (P = 0.08). In the comorbid conditions group, the mean blood pressure rose by 22.5 mm Hg in the whole group (P 0.00001), 21.5 mm Hg in the patients dialyzing with HD (P = 0.00001) and 21.5 mm Hg in those on HDF (P = 0.0004). BCM monitoring together with clinical assessment is a useful tool which when appropriately applied reduces the incidence of dialysis-related complications.

Let Us Listen to Patients: Underutilization of Peritoneal Dialysis from Patients' Perspectives.

Despite the fact that many of the medical outcome data of peritoneal dialysis (PD) have been improving over the past few years, PD remains an underutilized modality in many countries worldwide. Most nephrologists in those countries report a high rate of patients' refusal. We conducted this survey-based study to determine the obstacles behind underutilization of PD in Saudi Arabia from patients' perspectives and to understand the reasons for their refusal. Nine-hundred and twenty hemodialysis (HD) patients, who had never been on PD before, participated in this study. Responses obtained from patients indicate that their refusal of PD could be because they had not received proper counseling and education about PD from their treating nephrologists throughout the course of their disease.

Trends in Deceased Donor Kidney Availability and Utilization in the Kingdom of Saudi Arabia.

OBJECTIVES: We investigated trends in deceased donor kidney availability and utilization in Saudi Arabia, wait list changes, and recipient characteristics. MATERIALS AND METHODS: Ten-year registry data from the Saudi Center for Organ Transplantation were analyzed, including consent/discard rates, numbers of kidneys from deceased donors versus expanded criteria and standard criteria donors, wait list characteristics, dialysis characteristics, and causes of chronic kidney disease. RESULTS: Annual mean number of deceased donor transplants remained almost constant over the 10-year period (mean of 129). Use of kidneys from expanded criteria donors increased (from 16%-28%), which was associated with higher frequency of delayed graft function (36.2% vs 16%; P = .002) and acute rejection (5.4% vs 19.6%; P = .001) versus kidneys from standard criteria donors. Donor consent rate (34%) and cold ischemic time (12.3 hours) remained constant. Numbers of patients on wait lists remained fairly constant (mean of 2825), although those on dialysis on wait lists decreased from 24% to 17% (P < .0001). Overall wait list numbers remained level or even dropped despite increased patients on dialysis (from 7%-10% annually). Between 2008 and 2016, prevalence of patients > 65 and > 75 years rose by 4.2% and 2.4% and prevalence of diabetes mellitus in patients on dialysis increased by 59.2%. Of kidneys consented in 2016, 14.7% were not recovered, mainly because of sudden cardiac arrest (60%). Of total transplanted kidneys, proportion from deceased donors decreased from 51% (2008-2010) to 22.1% (2014-2016). Only 13% of recipients were older than 55 years, although they comprised 25% of the dialysis population, with patients < 18 years (comprising 2.2% of the dialysis population) receiving 15% of kidneys. CONCLUSIONS: Deceased donor transplants remained almost constant; however, their proportion of total transplanted kidneys decreased, while transplants with extended criteria kidneys increased. Wait list totals decreased, with relatively less elderly patients and more children being transplanted.

Variables affecting darbepoetin resistance index in hemodialysis patients.

Erythropoietin resistance index calculation has been used as a tool to evaluate anemia response to erythropoietin therapy. Very little has been reported in its use when using darbepoetin and factors influencing in Arab patients. Darbepoetin resistance index (DRI) was calculated in all our patients using darbepoetin. This was correlated to demographic, clinical, and laboratory parameters. Of the 250 patients, 40.4% were diabetic, 71.1% on hemodialysis, and 28.6% on hemodiafiltration), 23.9% with PermCaths (PC), and 76.1 % with arteriovenous fistula (AVF). The mean DRI was 10.96 ± 12.9 I. Females had 45% higher DRI than males (P = 0.005), and patients with PC had a 66% higher DRI than those with AVF (P = 0.029). Patients with Vitamin D level below the 50th percentile had 55.9% higher DRI than those above it (P = 0.05). DRI was negatively correlated with age (P = 0.018), dialysis vintage (P = 0.039), interdialytic weight gain P = 0.007), Vitamin D level, and serum albumin (P = 0.005) and positively correlate with parathyroid hormone (PTH) level (P = 0.000). No impact was seen by the mode of dialysis, being diabetic, using anti-hypertensive therapy, body mass index, Kt/V, serum iron, total iron binding capacity, transferrin saturation, ferritin, C-reactive protein, Ca, or P. DRI in our Arab patients was comparable to erythropoietin resistance indices reported in other communities. Higher DRI was observed in females, PC users, lower serum albumin, lower Vitamin D, and shorter dialysis vintage. A negative correlation existed between DRI and age, dialysis vintage, interdialytic weight, and serum albumin and a positive correlation with PTH level.

Predictability and Risk Factors for Development of New-Onset Type 2 Diabetes Mellitus After Transplant in the Saudi Population.

OBJECTIVES: The study objective was to investigate the predictability and risk factors for the development of new-onset type 2 diabetes mellitus after transplant in the Saudi population. MATERIALS AND METHODS: This was a retrospective observational cohort study in adult kidney transplant recipients who developed new-onset type 2 diabetes mellitus after transplant. Patients with and without new-onset type 2 diabetes mellitus after transplant were compared for demographic factors, blood glucose levels at 4-hour intervals for 24 hours after transplant, and serum creatinine levels at 6 and 12 months after transplant. RESULTS: Of 279 patients included in our study, 15.5% developed new-onset type 2 diabetes mellitus after a mean follow-up of 4.6 ± 2.1 years after transplant. Patients with new-onset type 2 diabetes mellitus after transplant were significant older (P = .001), had a higher body mass index (P = .001), and had higher fasting blood glucose levels 24 hours after transplant (P = .03). No significant differences were observed regarding sex, transplant type, or serum creatinine levels at 6 and 12 months. Risk factors for new-onset type 2 diabetes mellitus after transplant are body mass index (P = .001; relative risk of 1.26), fasting blood glucose at 24 hours (P = .001; relative risk of 1.3), age (P = .001; relative risk of 1.44), and family history of diabetes mellitus (P = .001; relative risk of 31.3). CONCLUSIONS: Risk factors for developing new-onset type 2 diabetes mellitus were age, heavier weight, body mass index, family history of diabetes mellitus, and having higher fasting blood glucose levels 24 hours after transplant, with family history of diabetes mellitus being an especially very high significant risk factor.

Changes in biochemical, hemodynamic, and dialysis adherence parameters in hemodialysis patients during Ramadan.

This paper aimed to study the effect of Ramadan fasting on biochemical and clinical parameters and compliance for dialysis. A prospective multicenter observational cross-sectional study comparing fasting with a non-fasting stable adult hemodialysis patients for demographic and biochemical parameters, compliance with dialysis, inter-dialytic weight gain, pre- and post-blood pressure, and frequency of intradialytic hypotensive episodes was carried out. Six hundred thirty-five patients, of whom 64.1% fasted, were studied. The fasters were younger (53.3 ± 16.2 vs. 58.4 ± 16.1 years; P = 0.001) but had similar duration on dialysis (P = 0.35). More fasters worked (22.0% vs. 14.6%; P = 0.001) and missed dialysis sessions during Ramadan. No differences were noted between groups in sex, diabetic status, or dialysis shift or day. There were no differences in the pre- and post-dialysis blood pressure; serum potassium, albumin or weight gain; diabetic status; sex; and dialysis shift time or days. However, serum phosphorous was significantly higher in the fasting group (2.78 ± 1.8 vs. 2.45 ± 1.6 mmol/L; P = 0.045). There were no intragroup differences in any of the parameters studied when comparing the findings during Ramadan with those in the month before Ramadan. Fasters were significantly younger and more likely to be working, to miss dialysis sessions, and to have higher serum phosphorous levels. No other differences were observed.

Erythrocyte sedimentation rate in stable patients on chronic hemodiaysis.

The objective of this study was to assess the value and determinants of erythrocyte sedimentation rate (ESR) in stable patients on regular hemodialysis (HD). Pre-dialysis and post-dialysis ESR was measured in a group of stable adult patients on regular HD and the results were compared. The results were also correlated with the patients' demographic and laboratory data. Only stable patents were included in the study. Patients with evidence of current infection, active inflammatory processor malignancy and severe anemia were excluded. We recruited 161 patients in the study of whom 44.1% were males, 53.4% had diabetes mellitus and 40.4% had an episode of sepsis previously. Only 15.5% of the patients had less than one year of dialysis and 54.3% were over the age of 60 years. The mean post-dialysis ESR was significantly higher than the pre-dialysis ESR (55.6 ± 30.4 and 49.8 ± 28.5, respectively; P = 0.003). Pre-dialysis, 79.5% of the patients had raised ESR. ESR was significantly correlated with C-reactive protein, serum ferritin, plasma albumin and fibrinogen (P <0.05). Patient factors (age, gender, duration of dialysis, previous renal transplantation, type of dialysis access and sepsis or thrombosis of dialysis access site) and blood laboratory parameters (hemoglobin, serum creatinine and serum parathormone) had no statistically significant correlation with ESR ( P ≥ 0.05). Post-dialysis the ESR was raised in most of the stable patients on regular HD and was significantly higher than the pre-dialysis ESR (by, on average, 5.8 mm/h). ESR had variable correlation with different blood factors.

Level of dietary awareness among Saudi dialysis patients and the influence of various factors.

Our objective was to investigate the degree of dietary awareness of Saudi patients on chronic hemodialysis and influencing factors on this awareness. This is an interviewadministered survey-based cross-sectional study carried out on adult dialysis patients at the King Abdulaziz Medical City, Riyadh. The first part of the survey consisted of the collection of demographic data and the second part consisted of questions in the areas of awareness on the dietary influence of sodium, potassium, fluid intake and calcium/phosphorous and lipids. The questions are simply answered as "yes" or "no." The overall awareness score was 79%. The awareness scores were highest in the area of lipids (86.5%) and lowest in the fluid intake area (71.3%). The scores for sodium, phosphorous/calcium and potassium were 80%, 79.6% and 73%, respectively. The degree of awareness was influenced by the number of visits by the dietitian (P = 0.008) and the educational level of the patients (P = 0.02), but not by age, duration on dialysis or gender. In conclusion, our findings suggest that there is a need for better of awareness among our dialysis patients. The highest score for awareness was seen in the cholesterol-related questions and the lowest score was seen in the fluid intake questions area. This is influenced by the number of visits by the dietitian and the educational level of the patients, but not by age, duration on dialysis or gender.

Stroke-free status and depression scores among Saudi dialysis patients.

BACKGROUND: To assess the prevalence of stroke symptoms and depression among Saudi dialysis patients and related factors. METHODS: This is a cross-sectional multicentre study of Saudi dialysis patients. Demographics, clinical and laboratory's data were collected. Freedom from stroke symptoms was assessed using the Questionnaire for Verifying Stroke-Free Status and depression using the Geriatric Depression Scale. RESULTS: Five-hundred and forty-nine patients (77.3% response rate); 94.6% were receiving hemodialysis and 5.4% peritoneal dialysis were included in the study. Freedom from stroke was reported in 76.6% of patients, was higher in females (p = 0.07), and was not affected by the presence of diabetes mellitus coronary artery disease or peripheral vascular disease. However, it was significantly lower in hypertensive patients (p = 0.035) and was not affected by age, dialysis duration, Kt/V, albumin or hemoglobin levels. It was, however, more prevalent in the non-depressed patients compared to depressed patients (p = 0.036). Mild and major depression scores were noted in 45.2% and 6.1%, respectively; the depression score being significantly higher in HD than in PD patients (6.3 ± 3.4 vs. 5.0 ± 3.2 p = 0.049) but was not related to sex, employment, vascular access type, age, dialysis duration, Kt/V or serum albumin or hemoglobin levels. CONCLUSION: A quarter of the patients were not stroke symptom-free and these were more likely the depressed patients, in females, but significantly less in hypertensive patients. Almost half of the patients were depressed with 6.1% having major depression. The depression score was significantly higher in HD than in PD patients.

Safety climate in dialysis centers in Saudi Arabia: a multicenter study.

OBJECTIVE: The aim of this study was to assess the safety climate as perceived by nurses and physicians in the dialysis units in Saudi Arabia. METHODS: This is a cross-sectional survey-based multicenter study using the Safety Climate Scale, which assesses the perception by staff of the prevailing climate of safety. We used 17 items in this survey. These could be further divided into 3 summative categories: (a) handling of errors and safety concerns (9 items), (b) leadership emphasis of safety (7 items), and (c) overall safety recommendation (1 item). The survey uses 5 Likert scale options (1, disagree strongly; 2, disagree slightly; 3, neutral; 4, agree slightly; and 5, agree strongly). RESULTS: There were 509 respondents--a response rate of 76.6% and 53.3% among nurses and physicians, respectively. The internal consistency using Cronbach α was 0.899. The overall mean (SD) of satisfaction with safety climate was higher among the nurses than the physicians (4.13 [1.1] and 4.05 [1.7], respectively; P = 0.029). The overall agreement rate was 73.8%, with more nurses than physicians agreeing that safety climate prevails the dialysis center (75.4% versus 72.1%, respectively; P = 0.047).The respondents perceived a stronger commitment to safety from their clinical area leaders than from senior leaders in the organization (76.2% and 72.4%, respectively). In addition, the physicians gave lower scores to more questions than the nurses particularly in 3 areas, namely, "leadership is driving us to be a safety-centered institution" (71.5% versus 76.5%; P = 0.037), "I am encouraged by my colleagues to report any patient safety concerns I may have" (67.4% versus 84.7%; P = 0.03), and "I know proper channels to ask questions about safety" (69.6% versus 87.2%; P = 0.002).The scores by the physicians in all the 3 summative categories were again less than the scores by the nurses, but this did not reach a statistical significance. CONCLUSIONS: The nurses had higher perceptions of a prevailing safety climate than the physicians. There was a perception of a stronger commitment to safety from their clinical area leaders than from senior leaders in the organization. Senior management needs to relay their commitments to safety more effectively especially to physicians and to open clear and easily accessible channels for communication for safety issues.

Posterior reversible encephalopathy syndrome with tactile hallucinations secondary to dialysis disequilibrium syndrome.

We report what we believe is the first case of posterior reversible encephalopathy syndrome (PRES) secondary to dialysis disequilibrium syndrome (DDS) in patients in whom all other possible causes of PRES were excluded and in whom a transient episode of tactile hallucination also occurred. We believe that this case of DDS was particularly severe, leading to PRES because of the late institution of dialysis therapy and the concomitant severe degree of metabolic acidosis on presentation.

Effect of repeated ramadan fasting in the hottest months of the year on renal graft function.

BACKGROUND: Adult Moslems are required to fast during the lunar month of Ramadan every year. Although the sick and travelers, as well as some other specified groups, are exempted from this requirement. OBJECTIVES: To investigate the effect of repeated Ramadan fasting during the hottest months of the year on renal graft functions. PATIENTS AND METHODS: This was a prospective cohort study comparing two groups of renal transplant receivers; one group had fasted for two consecutive Ramadan months during 2011 and 2012, while the other group had not fasted. The baseline eGFR (estimated glomerular filtration rate) was compared to the eGFR carried out 19.6 ± 1.3 months later, within and between groups. Further subgroup analysis was done according to eGFR baseline; low (< 45 mL/min/1.73 m(2)), moderate 45-75 (mL/min/1.73 m(2)), and high (> 75 mL/min/1.73 m(2)). RESULTS: There were 43 fasting and 37 non-fasting participants with comparable; ages, gender, type of transplant, and baseline eGFR and serum creatinine (SCr). The fasting participants, however, had a longer elapsed time since their transplantation. In the fasting group, SCr and eGFR did not change from baseline after a mean follow-up period of 19.6 ± 1.3 months; SCr of 105.1 ± 55.4 and 114.2 ± 71.5 µmol/L, respectively (P-value = 0.8), and eGFR 75.6 ± 29.2 and 70.2 ± 28.1 mL/min/1.73 m(2), respectively (P-value = 0.09). Similarly, no significant changes were observed in the non-fasting group; Sr of 123.1 ± 67 and 115.8 ± 65.2 µmol/L, respectively (P-value = 0.6), and eGFR of 65.9 ± 25.9 and 68.8 ± 24.6 mL/min/1.73 m(2), respectively (P-value = 0.6). On subgroup analysis, according to the eGFR level, we found no significant differences in the eGFR, before and after 19.6 ± 1.3 months, in the severe and moderate subgroups. However, a significant but similar drop was noted in the high GFR subgroups in both the fasting subgroup (96.4 ± 15 to 84.9 ± 20.7 mL/min/1.73 m(2); P = 0.17) and in the non-fasting subgroup (92.9 ± 15.8 to 82.3 ± 18.2 mL/min/1.73 m(2); P = 0.019). CONCLUSIONS: Fasting in the month of Ramadan in two consecutive years, and during the hottest months, in Riyadh, Saudi Arabia, did not adversely affect kidney graft function.