Use of Sodium-glucose Cotransporter 2 Inhibitors in Patients with Chronic Kidney Disease.

Chronic kidney disease (CKD) is a common complication in patients with diabetes mellitus. Recently, the class of sodium-glucose cotransporter 2 inhibitors (SGLT2-Is) has been shown to have cardiovascular and renal benefits. The extent of the use of SGLT2-Is in patients with CKD is unknown. The objective of this study was to describe the prescription pattern of empagliflozin (the only available agent) in patients with CKD at Johns Hopkins Aramco Healthcare. This was a retrospective single-center analysis of patients with CKD over 2 years between January 1, 2020, and December 31, 2021. The prescription pattern of empagliflozin for adults (≥18 years) with CKD was determined quarterly. Among 2528 patients with CKD, 119 (5%) patients were prescribed empagliflozin during the first quarter of 2020. The number of patients steadily increased and reached 16% by the end of the study period. Despite the overwhelming evidence of their benefits, the overall utilization of SGLT2-Is was poor. Physicians' education is paramount to increase awareness about the benefits of SGLT2-Is as renoprotective and lifesaving medications.

COVID-19 in patients with end stage kidney disease at a large community hospital in Eastern Saudi Arabia. A prospective study.

OBJECTIVES: To report the outcome of patients with end stage kidney disease (ESKD) who were diagnosed with COVID-19 at a large community hospital in Eastern Saudi Arabia. METHODS: A single center, prospective observational study at Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia. Patients with ESKD who were maintained on dialysis and developed COVID-19 between June 15, 2020 and October 31, 2021 were enrolled. RESULTS: In total, 30 patients with ESKD were diagnosed with severe acute respiratory syndrome coronavirus 2 infection. Twenty two (73%) patients developed the disease prior to COVID-19 vaccine rollout. The median age of the cohort was 63 (55-75) years. Most patients were diabetic (73%), hypertensive (97%) and had a median body mass index of 28 kg/m2. Twenty seven (90%) patients required admission, 16 (52%) patients developed pneumonia, and 5 (17%) patients required mechanical ventilation. Patients who developed pneumonia were older, and the majority had diabetes mellitus and coronary artery disease. Five patients died with a total mortality of 17%. CONCLUSION: Patients with ESKD who developed COVID-19 had a poor outcome with high mortality compared to the general population. Presence of diabetes mellitus, coronary artery disease and older age were associated with a higher risk of severe disease. There was a sharp decline in the number of positive cases following implementation of the vaccination program.

Effect of Ramadan on Clinical and Biochemical Parameters among Non-fasting Hemodialysis Patients.

The holy month of Ramadan brings many changes to the lifestyle of Muslims. The effect of these changes on patients with end-stage renal disease (ESRD) is not well studied. The purpose of this study was to investigate the effect of Ramadan on the clinical and metabolic profile of non-fasting patients with ESRD who were maintained on hemodialysis (HD) in the eastern region of Saudi Arabia. A single-center prospective longitudinal study of patients with ESRD who were maintained on HD at a major community hospital in Eastern Saudi Arabia. The patients adopted the lifestyle and dietary changes typically associated with Ramadan in Eastern Saudi Arabia. Measurements included body weight, blood pressure, interdialytic weight gain, serum potassium, serum phosphorus, and serum albumin at the beginning and the end of Ramadan. The development of fluid overload and hyperkalemia was monitored. Seventy patients with ESRD who were maintained on HD were screened and 18 patients were identified to meet the inclusion criteria. There were no differences in patients' weight, interdialytic weight gain, or blood pressure at the beginning and end of Ramadan. Laboratory parameters, including serum potassium, serum phosphorus, and serum albumin, showed no significant changes either; and there were no emergency encounters for fluid overload or hyperkalemia. Lifestyle and dietary changes during the fasting month of Ramadan did not result in significant clinical or laboratory differences among non-fasting HD patients in Eastern Saudi Arabia.

Hemodialysis during Lockdown Due to Coronavirus Disease 2019 Pandemic in Eastern Saudi Arabia.

The first case of Coronavirus disease-2019 (COVID-19) in the Kingdom of Saudi Arabia was confirmed in the city of Qatif in March 2020. As a result, Qatif was placed under lockdown for two months in an attempt to prevent the widespread of COVID-19. Doing hemodialysis (HD) during lockdown was a new and challenging experience that we recently have faced. Swift arrangements were made to accommodate patients with end-stage renal disease in need for HD. The challenges to healthcare facilities, healthcare providers, and patients are discussed with the hope that this experience would help mitigate some of the difficulties healthcare providers may face in a similar situation.

In-hospital acute kidney injury.

BACKGROUND: Hospital-acquired acute kidney injury is associated with increased mortality and has major public health implications. The incidence of in-hospital AKI in Eastern Saudi Arabia is not known. AIMS: To determine the incidence of in-hospital acute kidney injury in Eastern Saudi Arabia. METHODS: A single centre, retrospective cohort study at a major community hospital between July 2015 and July 2017. RESULTS: A total of 26 383 patients were hospitalized and 293 (1.11%) were diagnosed with acute kidney injury. Drug-induced AKI was diagnosed in 38 (13%) patients, while 255 (87%) patients had acute kidney injury not attributed to drugs. Full recovery of renal function was observed in 39% and 44% in the drug induced and non-drug induced acute kidney injury groups, respectively. CONCLUSIONS: acute kidney injury is a serious complication in hospitalized patients. Full recovery of renal function was observed in a minority of patients.

Sirolimus-induced interstitial lung disease and resolution after conversion to everolimus.

Mammalian target of rapamycin inhibitors (mTORi) are used to treat a variety of malignancies and have an established role in organ transplantation. Interstitial lung disease (ILD) is one of the complications of mTORi and is believed to be a class effect. More cases of ILD have been reported with sirolimus than with everolimus in the literature, possibly due to earlier introduction and wider use of sirolimus. We report the case of a kidney transplant recipient who developed ILD secondary to sirolimus and improved rapidly after switching to everolimus.

Chronic idiopathic systemic capillary leak syndrome: a case report.

BACKGROUND: Idiopathic systemic capillary leak syndrome (ISCLS), is a rare disorder characterized by recurrent attacks of varying severity of hypovolemic shock and generalized edema in association with hemoconcentration and hypoalbuminemia in the absence of albuminuria. The chronic form of ISCLS is extremely rare with only a few cases reported in the literature. CASE PRESENTATION: Here we report the case of a young woman who developed chronic ISCLS characterized by massive, generalized and persistent edema. The work up confirmed the presence of monoclonal gammopathy. She was treated with several agents with no response. CONCLUSION: Chronic ISCLS is a very rare disease of unknown etiology and results in devastating complications. The medical community should be aware of this disease with the hope that targeted therapy will become available in the future.

Fusarium Infection in a Kidney Transplant Recipient Successfully Treated with Voriconazole.

Fusarium infections in solid-organ transplant recipients are rare and carry high mortality. We report a case of a kidney transplant recipient who developed infection with Fusarium species. The patient received treatment with oral voriconazole for five months with good response.

Prevalence of Microalbuminuria in Adult Patients with Sickle Cell Disease in Eastern Saudi Arabia.

BACKGROUND: Proteinuria is a common feature of sickle cell nephropathy (SCN) that can progress to renal insufficiency and end stage renal disease. Microalbuminuria (MA) is the earliest manifestation of SCN and precedes the development of overt proteinuria. In addition to the renal consequences, MA is linked to cardiovascular complications. Periodic screening and early detection of MA allow early intervention that may reduce the risk of progression to advanced renal failure and cardiovascular diseases. OBJECTIVE: The aim of this study was to investigate the prevalence of MA in patients with SCD in the eastern region of Saudi Arabia. METHODS: A prospective cross-sectional observational study was conducted at Johns Hopkins Aramco Healthcare (JHAH). Urine samples of SCD patients 18 years old and older were tested for the presence of MA using urinary albumin over creatinine ratio (ACR). Correlation was tested with multiple variables including age, gender, body mass index (BMI), hemoglobin level, blood pressure, blood transfusion history, pain episodes, and use of hydroxyurea. RESULTS: Urine samples were tested on 72 patients. The mean age of the study cohort was 35 ± 16.9 years. Microalbuminuria was detected in 18 patients (25%). No correlation was found with any of the tested variables. CONCLUSION: Microalbuminuria is a common finding in patients with SCD in eastern Saudi Arabia. Patients with SCD should be screened for MA, and those with positive tests should probably be treated with antiproteinuric agents that may slow the progression to advanced stages of renal failure and decrease the risk of cardiovascular diseases.

Dense deposit disease associated with multiple myeloma
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Dense deposit disease (DDD) is a very rare pathological finding associated with activation of the final complement pathway. DDD has been rarely found in association with multiple myeloma (MM). Here we report a patient with MM presenting with renal failure, anemia, and bone pain. The renal biopsy showed DDD. The patient received anti-myeloma treatment and responded well. The case is discussed and literature reviewed.
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Negative Staining for COL4A5 Correlates With Worse Prognosis and More Severe Ultrastructural Alterations in Males With Alport Syndrome.

INTRODUCTION: Alport syndrome (AS) is a genetic disorder characterized by progressive hematuric nephropathy with or without sensorineural hearing loss and ocular lesions. Previous studies on AS included mostly children. METHODS: To determine the prognostic value of loss of staining for collagen type IV alpha 5 (COL4A5) and its relationship with the ultrastructural glomerular basement membrane alterations, we performed direct immunofluorescence using a mixture of fluorescein isothiocyanate-conjugated and Texas-red conjugated antibodies against COL4A5 and COL4A2, respectively, on renal biopsies of 25 males with AS (including 16 who were diagnosed in adulthood). RESULTS: All patients showed normal positive staining of glomerular basement membranes and tubular basement membranes for COL4A2. Of the 25 patients, 10 (40%) patients showed loss of staining for COL4A5 (including 89% of children and 13% of adults) and the remaining 15 (60%) had intact staining for COL4A5. Compared with patients with intact staining for COL4A5, those with loss of staining had more prominent ultrastructural glomerular basement membrane alterations and were younger at the time of biopsy. By Kaplan-Meier survival analysis and Cox regression analysis, loss of staining for COL4A5 predicted earlier progression to overt proteinuria and stage 2 chronic kidney disease or worse. By multivariate Cox regression analysis, loss of staining for COL4A5 was an independent predictor of the development of overt proteinuria and stage 2 chronic kidney disease or worse. DISCUSSION: Thus, the COL4A5 expression pattern has an important prognostic value and it correlates with the severity of ultrastructural glomerular basement membrane alterations in males with AS. Loss of COL4A5 staining is uncommon in patients with AS diagnosed in their adulthood.

End-stage renal disease in patients with sickle cell disease.

Sickle cell nephropathy is a severe complication of sickle cell disease (SCD) that has a wide range of manifestations, from asymptomatic microalbuminuria to end-stage renal disease (ESRD). The data on patients with SCD who develop ESRD are scarce. The aim of this study was to explore the course of patients with SCD who developed ESRD and received renal replacement therapy (RRT). The course of patients with SCD who developed ESRD and started dialysis at two centers in the Eastern Province of Saudi Arabia was retrospectively analyzed. Parameters included age at initiation of dialysis, survival until death or kidney transplantation, hospitalization due to pain crisis, disease-related parameters, and requirement for blood transfusion. Sixteen patients with SCD developed ESRD and started RRT with either hemodialysis or peritoneal dialysis. The mean age at initiation of dialysis was 46.6 years. The majority of patients (10 out of 16) were resistant to erythropoiesis-stimulating agents (ESA) and required blood transfusion repeatedly. Pain crises were infrequently encountered. Median survival was 54 months. Four patients received kidney transplantation with good outcome. In conclusion, most patients with SCD who developed ESRD were resistant to ESA and required repeated blood transfusion. The rate of hospitalization due to pain crisis was relatively low. Survival on dialysis was comparable to that of patients with no SCD, and the post-transplant course was relatively benign.

Angiosarcoma at the site of nonfunctioning arteriovenous fistula in a kidney transplant recipient.

Angiosarcoma is a rare malignant neoplasm of the endothelial cells of blood vessels or lymphatics. We report a case of a 46-year-old male patient with a kidney transplant who developed epithelioid angiosarcoma at the site of a nonfunctioning arteriovenous fistula in the antecubital fossa 3 years after renal transplantation. The patient had skin, soft tissue, and bone metastasis on presentation. He died of systemic metastasis with respiratory failure.

Acute bile nephropathy secondary to anabolic steroids.

Renal dysfunction in cholestatic liver disease is multifactorial. Acute kidney injury may develop secondary to renal vasoconstriction in the setting of peripheral vasodilation and relative hypovolemia, tubular obstruction by bile casts, and direct tubular toxicity from bile. Anabolic steroids are frequently used by athletes to boost endurance and increase muscle mass. These agents are a recently recognized cause of hepatotoxicity and jaundice and may lead to acute kidney injury. To increase awareness about this growing problem and to characterize the pathology of acute kidney injury in this setting, we report on a young male who developed acute kidney injury in the setting of severe cholestatic jaundice related to ingestion of anabolic steroids used for bodybuilding. Kidney biopsy showed bile casts within distal tubular lumina, filamentous bile inclusions within tubular cells, and signs of acute tubular injury. This report supports the recently re-emerged concept of bile nephropathy cholemic nephrosis.

Vancomycin-induced acute tubular necrosis.

OBJECTIVES: To report nephrotoxicity in the form of acute tubular necrosis (ATN) related to vancomycin. METHODS: This study was conducted at Johns Hopkins Aramco Healthcare, Saudi Aramco, Dharan, Saudi Arabia between June and August 2013. All patients who received intravenous vancomycin as a part of the hospital's vancomycin stewardship program were monitored for the development of ATN. RESULTS: A total of 89 patients received vancomycin over a 3-month period. Three patients developed ATN attributed to high levels of vancomycin, with an incidence of 3.4%. CONCLUSION: Intravenous vancomycin is nephrotoxic and can lead to ATN. The medical community must be aware of the potential risks of vancomycin associated nephrotoxicity. Renal function and vanomycin drug levels should be closely monitored.

Proteinuria in patients with sickle cell disease.

Proteinuria is a complication of sickle cell nephropathy that can progress to renal insufficiency and end-stage renal disease. The magnitude of proteinuria among patients with sickle cell disease (SCD) has been reported with variable prevalence. The aim of this study was to determine the prevalence of proteinuria in a large number of patients with SCD in Eastern Saudi Arabia. The urinalyses of 940 non-diabetic patients with SCD were tested for the presence of proteinuria. The glomerular filtration rate (e-GFR) of all patients was estimated using the Cockcroft- Gault equation. Proteinuria was found in 79 of 940 patients with SCD (prevalence 8.4%). The mean age of the affected patients with proteinuria was 33 ± 15.4 years (10-76). The mean GFR was 118 mL/min/1.73 m 2 . This study indicates that patients with SCD in Eastern Saudi Arabia have a low prevalence of proteinuria and preserved GFR.

Acanthamoeba encephalitis in a patient with systemic lupus treated with rituximab.

Acanthamoeba species are free-living protozoa that can infect humans and animals. Acanthamoeba can cause serious central nervous system infections in immunocompromised hosts. Here we report a case of Acanthamoeba encephalitis in a patient with lupus nephritis, 1 month after completing a course of rituximab, an anti-CD20 chimeric antibody.