Health Care Access, Socioeconomic Status, and Acute Kidney Injury Outcomes: A Prospective National Study.

Rationale & Objectives: Acute kidney injury (AKI) incidence and outcome in Kuwait are unknown. Moreover, non-Kuwaitis, who represent 66% of the population, have lower income, and their access to public health services is restricted compared with Kuwaitis who have free full access. Study Design: Observational prospective multicenter cohort study. Setting & Participants: Adult inpatients with AKI in 7 public hospitals from January 1 to December 31, 2021. Exposure: AKI identified using Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Outcomes: For hospitalized patients with AKI, the outcomes included 30-day outcomes of mortality, need for dialysis, kidney recovery rates, and differences in outcomes between Kuwaitis and non-Kuwaitis. Analytical Approach: A backward stepwise multiple logistic regression analysis was performed to assess possible independent risk factors for the outcomes. Results: We recruited 3,744 patients (mean age: 63 years; mean baseline estimated glomerular filtration rate [eGFR]: 66.7 mL/min; non-Kuwaitis: 42.3%), representing 3.2% of hospitalizations and 19.5% of intensive care unit (ICU) admissions. Non-Kuwaitis were significantly younger (57.6 vs 66.9 years), with higher baseline eGFR (73.1 vs. 62 mL/min), more frequent community acquired AKI (53.8% vs 46.7%), and AKI in summer (34.7% vs 26.9%). Dialysis was provided to 33.5% of patients, with a higher need for non-Kuwaitis (35.5% vs 32.1%). At 30 days, 34.4% of patients died, representing 24.8% of hospital mortality and 59.8% of ICU mortality. No differences in mortality or kidney recovery were noted between Kuwaitis and non-Kuwaitis. Low eGFR did not affect the mortality rate. Limitations: Observational nature and short follow-up period of 30 days only. Conclusions: AKI was associated with high dialysis need and mortality. Non-Kuwaitis accounted for less cases despite representing 66% of the population because they were younger with higher baseline eGFR and fewer comorbid conditions. Non-Kuwaitis had higher rates of community acquired AKI and AKI in summer and a higher need for dialysis but had similar mortality and complete kidney recovery rates.

Incidences of acute kidney injury (AKI), its management, and its outcomes are unknown in Kuwait. In addition, Kuwait has a large population of ethnically diverse expatriates who have lower income and do not enjoy the same level of access to public hospital services. We recruited hospitalized adults who have a diagnosis of AKI in several public hospitals in Kuwait. We analyzed characteristics, management, and outcomes data for more than 3,700 patients and found that AKI affects 3.2% of hospitalized patients. AKI leads to high dialysis utilization rates and causes high mortality rates. Although more Kuwaitis were affected by AKI, the mortality rates for Kuwaitis and non-Kuwaitis were similar. Non-Kuwaitis were younger with better baseline kidney function and fewer chronic diseases than Kuwaitis.

Impact of COVID-19 infection on the dialysis population prospective, observational, nationwide study.

INTRODUCTION: Hemodialysis (HD) patients are at increased risk of severe COVID-19 infection but infection rates vary. Our objectives are to describe COVID-19 positive HD patients' characteristics, infection rates, and factors associated with mortality in HD COVID-19 cases in Kuwait. METHODS: Data on demographics, comorbidities, and treatments received, as well as mortality for HD patients admitted to hospitals for COVID-19, from 1/March to 31/July 2020, prospectively collected and analyzed. RESULTS: A total of 141 infected HD patients were admitted (Mean age 58 ± 16.1; Males 56%), representing 7% of the total HD population and 0.2% of all COVID-19 cases during the study period. Of those 141 infected HD patients, 27 (19%) died, and this represents 6% of total COVID-19-related mortality and 27% of the total HD mortality. In contrast, total covid-19-related mortality of all positive cases was only 0.7%, and total HD mortality during the study period was only 5%. COVID-19-positive HD patients who died were older and 59% were males. However, the differences were not statistically significant. Of the 61 infected HD patients who needed to be switched to continuous kidney replacement therapy (CKRT), 34% died, and of the 29 infected HD patients who needed admission to intensive care, 65% died. CONCLUSION: HD population represents a small fraction of the total population; however, positive HD COVID-19 cases represent a sizable proportion of COVID-19 cases and a significant percentage of total COVID-19-related mortality, and total HD mortality.

Safety of Intravenous Iron in CKD Stage 3-5 Patients Not on Dialysis: A Retrospective Cohort Study.

Background: Iron deficiency is common in chronic kidney disease (CKD) patients not on dialysis (ND). Restoring depleted iron stores through intravenous (IV) route is faster and associated with less side effects. There is conflicting data regarding intravenous iron use and its impact on clinical outcomes in this population. Objective: This study aims at evaluating any negative clinical impact associated with IV iron use in CKD patients at stages (3-5) before dialysis. Design: Retrospective chart review. Setting and Population: Chart analysis of ND CKD 3-5 (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) patients who received IV iron between January 2013 and January 2018 in 3 major hospitals in Kuwait. Methods: Outcomes analyzed were rates of all-cause hospitalizations, infection-related hospitalizations, mortality rates, and eGFR decline over 12 months after IV iron infusion in this population divided into 3 groups according to CKD stage. Results: A total of 738 patients were included in our analysis. Mean initial hemoglobin concentration was 111.5 ± 15.0 g/L in group 1 (CKD 3: eGFR 30-59 mL/min/1.73 m2), 103.6 ± 17.7 g/L in group 2 (CKD 4: eGFR 15-29 mL/min/1.73 m2), and 99.4 ± 14.5 g/L in group 3 (CKD 5: eGFR < 15 mL/min/1.73 m2 but not on dialysis). All-cause hospitalization and infection-related hospitalization were more common among group 3 subjects (adjusted odds ratio =2.12 [95% confidence interval, CI: 1.32-3.41] and 2.02 [95% CI: 1.15-3.55]), respectively. No deaths occurred during 12 months of follow-up. Limitations: Lack of control group, retrospective study. Conclusion: Intravenous iron use in CKD 3-5 ND is generally safe. Higher hospitalization rates in patients with eGFR <30 mL/min are possibly associated with lower baseline hemoglobin, lower baseline eGFR, and higher comorbidity burden, and not related to iron infusion.

Contexte: La carence en fer est fréquente chez les patients atteints d'insuffisance rénale chronique (IRC) qui ne sont pas sous dialyse (ND). Le rétablissement des réserves de fer par voie intraveineuse (IV) est plus rapide et associé à moins d'effets secondaires. Les données sur l'administration du fer par intraveineuse et son incidence sur les résultats cliniques dans cette population demeurent toutefois contradictoires. Objectif: Cette étude vise à évaluer tout effet clinique négatif associé à l'administration de fer IV chez les patients atteints d'IRC de stade 3 à 5 avant la dialyse. Type d'étude: Examen rétrospectif des dossiers médicaux. Cadre et population: Analyse des dossiers médicaux de patients atteints d'IRC de stade 3 à 5 (DFGe < 60 ml/min/1,73 m2) ND ayant reçu du fer IV entre janvier 2013 et janvier 2018 dans trois grands hôpitaux du Koweït. Méthodologie: Les taux d'hospitalisations toutes causes confondues et d'hospitalisations liées à une infection, le taux de mortalité et le déclin du DFGe ont été mesurés sur une période de 12 mois après la perfusion de fer. La population était divisée en trois groupes selon le stade de l'IRC. Résultats: L'analyse porte sur un total de 738 patients. La concentration initiale moyenne d'hémoglobine était de 111,5 ± 15,0 g/L dans le groupe IRC 3 (DFGe: 30-59 ml/min/1,73 m2), de 103,6 ± 17,7 g/L dans le groupe IRC 4 (DFGe: 15-29 ml/min/1,73 m2) et de 99,4 ± 14,5 g/L dans le groupe IRC 5 (DFGe < 15 ml/min/1,73 m2 sans dialyse). Les hospitalisations toutes causes confondues et les hospitalisations liées à une infection étaient plus fréquentes chez les sujets du groupe IRC 3 (rapport de cotes ajusté = 2,12 [IC à 95 %: 1,32-3,41] et 2,02 [IC 95 %: 1,15-3,55] respectivement). Aucun décès n'est survenu pendant les 12 mois de suivi. Limites: Absence de groupe témoin, étude rétrospective. Conclusion: L'administration de fer IV chez les patients atteints d'IRC de stade 3 à 5 ND est généralement sûre. Le taux d'hospitalisation plus élevé observé chez les patients présentant un DFGe < 30 ml/min est probablement attribuable à des mesures initiales plus faibles pour l'hémoglobine et le DFGe, de même qu'à une charge de comorbidité plus élevée, plutôt qu'à la perfusion de fer.

Use of Rituximab as an Off-Label Medication in Glomerular Diseases: Clinical Perspective.

OBJECTIVES: The aim of this study was to review the use rituximab (RTX) and outcomes in immune-mediated glomerular diseases (glomerulonephritis [GN]) and to compare it to the established literature. METHODS: Adult GN patients who received RTX between January 2014 and January 2018 in three public hospitals were reviewed. Membranous nephropathy (MN) and minimal change disease (MCD) were considered diseases with the literature supporting RTX use. Lupus nephritis (LN), primary focal segmental glomerulosclerosis (1o FSGS), IgA nephropathy, IgG4-related disease (IgG4-RD), and C3GN had insufficient literature support for RTX use. Clinical remission was assessed 6 months after receiving RTX. RESULTS: A total of 61 cases were analyzed. RTX was an add-on therapy in 87%. The remission rate was 95% in the MCD and MN versus 56% in the off-label group (p = 0.002). LN patients had a mean initial estimated glomerular filtration rate (eGFR) of 69 mL/min. All class III LN achieved remission, and 11 of 21 class IV achieved remission. The mean initial eGFR for 1o FSGS was 33 mL/min, and it did not improve, and only 2 of 5 had partial resolution of proteinuria. Proteinuria improved in 3 of 5 IgG4-RD cases with eGFR stabilization but failed to improve in C3GN cases with eGFR deterioration. Vasculitis cases (6 ANCA-associated vasculitis and 2 IgA vasculitis) were analyzed separately. Remission was achieved in only 2 ANCA-associated vasculitis cases, and none in IgA vasculitis cases. CONCLUSIONS: Our data support the use of RTX in resistant MCD and MN. RTX showed success in LN and IgG4-RD but not FSGS or C3GN. The small number of cases of vasculitis does not allow drawing a conclusion on RTX effectiveness.

Response to and outcomes of the Pfizer BNT162B2 vaccine in hemodialysis patients-A prospective observational study.

INTRODUCTION: COVID-19 infection is associated with high mortality among hemodialysis patients. Standard vaccine response is generally lower among these patients. The adequate antibody titer response and the outcome of COVID-19 vaccine responders versus non-responders are unknown. METHODS: Hemodialysis patients on maintenance hemodialysis who have received two doses of Pfizer BNT162B2 vaccine were studied. Antibody response was tested after 14 days of the second dose. LIAISON SARS-CoV2 S1/S2 IgG test by DiaSorin (Italy) was used to assess antibody response. Patients were followed between 3 and 7 months after vaccination for COVID-19 infection, hospitalization and death related to COVID-19. FINDINGS: A total of 138 patients received two doses of Pfizer BNT162B2 vaccine. One hundred and twenty-seven patients had adequate response to the vaccine with IgG level ≥ 15 AU/ml versus 11 patients had poor response with IgG level ≤ 15 AU/ml. The response was 92% (127/138). Patient with history of prior COVID-19 infection had higher antibody titer mean of 339 ± 113 versus 157 ± 140 for patient with no prior history of COVID-19. Seven patients in both groups had COVID-19 infection post vaccine. Among the responders, five patients had COIVD-19 infection and two were hospitalized. These two patients had lower antibody titer of 23.9 and 75.2 AU/ml. In comparison, three patients who were not hospitalized had higher antibody titer 96.3, 118, and 319 AU/ml, respectively. In the non-responders one patient was hospitalized and one death occurred with rate of infection of 18%. DISCUSSION: Seropositive patients with low antibody titer might be associated with worse outcome among responders. The ideal antibody titer level among dialysis patient is not known. Also, prior COVID-19 infection is associated with higher response to vaccine with higher antibody titer. All non-responders did not have prior COVID-19 infection. More research is required to further evaluated protective antibody titer.

Renal Data from the Arab World Dialysis in Kuwait: 2013-2019.

The total number of end-stage kidney disease patients treated with dialysis in 2019 in Kuwait was 2230, with a 6% increase from the year before. Dialysis prevalence was 465 per million population (PMP) and dialysis incidence was100 PMP. Kuwaiti nationals represented 70% of the dialysis population and males represented 52%. Of the same population, 59% had diabetes. Hepatitis C virus affected <4% and hepatitis B virus affected <2% of the dialysis population. The annual mortality rate was stable at around 12%. Hemodialysis (HD) share was 89%, with 48% of HD patients getting HD via catheter, 54% on hemodiafiltration (HDF), and 50% dialyzing against a calcium bath of 1.75. Patients getting <3 times/week of HD constituted 10% and patients spending <3.5 h/session constituted 11%. We had only 20 dialysis patients under the age of 12 years (12 on HD). The major challenges faced included poor peritoneal dialysis penetration, the unacceptable high rates of catheters as primary HD vascular access, partly due to lack of chronic kidney disease (CKD) clinics and lack of vascular access coordinators, and the unexplained high rates of use of calcium bath of 1.75. There is also a need for a national campaign for early detection and prevention of CKD to reduce rates of end-stage renal disease.

Glomerulonephritis Histopathological Pattern Change.

BACKGROUND: Glomerulonephritides (GN) are relatively rare kidney diseases with substantial morbidity and mortality. They are often difficult to treat, sometimes with no cure, and can lead to chronic kidney disease (CKD) and end stage kidney disease (ESKD). Kidney biopsy is the diagnostic procedure of choice with variable indications from center to center. It helps in identifying the exact specific diagnosis, assessing the level of disease activity and severity, and hence aids in proper therapy and helps predicting prognosis. There is a global change of pattern of glomerular disease over the last five decades. METHODS: Retrospective analysis of all kidney biopsies (545 cases) that were done in patients over 12 year-old over last six years in four major hospitals in Kuwait. The indications for kidney biopsy were categorized into six clinical syndromes: nephrotic syndrome, sub-nephrotic proteinuria, nephrotic syndrome plus acute kidney injury (AKI), sub-nephrotic proteinuria plus AKI, isolated hematuria, and Unexplained renal impairment. We calculated the incidence of each type of kidney disease and indication of biopsy. RESULTS: most common indication of kidney biopsy was sub-nephrotic proteinuria associated with AKI in 179 cases (32.8%). Primary Glomerulonephritis was the main diagnosis that was reported in 356 cases (65.3%). Immunoglobulin A Nephropathy (IgAN) was the commonest lesion in primary glomerulonephritis in 85 (23.9%) cases. Secondary Glomerulonephritis was diagnosed in 134 cases (24.6%), 56 (41.8%) of them were reported as lupus nephritis cases. In young adults (below 18 years of age) there were 31 cases reviews, 35.5% were found to have minimal change disease (MCD). CONCLUSION: IgAN is the commonest glomerulonephritis in primary nephrotic syndromes in Kuwait over the past six years. Lupus nephritis is the leading secondary glomerulonephritis diagnosis.

Basic description of the dialysis population of Kuwait: The 2015 data.

Kuwait has a small, relatively young population plagued with diabetes, hypertension, and obesity, making the risk of development and progression of chronic kidney disease (CKD) very high. The total dialysis population of Kuwait in 2015 was 1720. The Ministry of Health (MOH) has divided the country into six health regions. The total number of dialysis population has been increasing slowly from 1600 in 2013 to 1650 in 2014 to 1720 in 2015, with 4% increase from 2014 to 2015. We describe some salient features among the dialysis population in Kuwait.

Cardiovascular and cerebrovascular comorbidities in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcome and practice pattern study phase 5 (2012-2015).

To determine the prevalence of cardiovascular comorbidities and their active risk factors in the selected hemodialysis centers in the Gulf Cooperation Council (GCC) countries, the Dialysis Outcome and Practice Pattern Study (DOPPS) was performed on 40 dialysis centers in the six GCC countries from June 2012 to May 2015. There were 21 dialysis centers from Saudi Arabia, nine from the United Arab Emirates (UAE), four from Kuwait, four from Oman, two from Qatar, and one from Bahrain. There were 922 patients participating in the study; 419 patients from Saudi Arabia, 144 from the UAE, 164 from Kuwait, 89 from Oman, 58 from Qatar, and 25 from Bahrain. Baseline data and laboratory investigations were obtained from every study patient, and the patients with any new events, change of dialysis prescription, or death were reported to the DOPPS main center during follow-up. The median age of the patients in the GCC centers was 55 years (range 32- 80 years), and the median percentage of males was 57%. The most common cause of chronic kidney disease among the study patients was diabetes mellitus (median: 43%) followed by hypertension (median: 29%) and glomerulonephritis (median: 9%). Hypertension (median 90%) and diabetes mellitus (median 52%) were the most common predisposing comorbidities to cardiovascular events in the study patients. The median ratios of patients with coronary artery disease, peripheral vascular disease, and congestive heart failure were 34%, 23%, and 24%, respectively. The median ratio for cerebrovascular comorbidities was 9%. The median prevalence of the factors that may predispose to the cardiovascular and cerebrovascular comorbidities such as gender of the patients, adequacy of dialysis, diabetes, hypertension, hypercholesterolemia, levels of anemia, parathormone levels, and calcium and phosphorus levels in the GCC countries were comparable with those in the previous DOPPS in other countries.