Dialyzer reuse impact on dialyzer efficiency, patient morbidity and mortality and cost effectiveness.

Since the introduction of dialyzer reuse more than three decades ago, several studies have reported its safety, efficacy and cost effectiveness. Reuse of hemodialyzer was prospectively studied in ten chronic hemodialysis (HD) patients recruited from the renal unit, the King Khalid University Hospital, Riyadh, Saudi Arabia, for three months. During the study period, 66 dialyzers were used for 408 sessions of HD, with a mean reuse of 6.2 +/- 5.3 episodes per dialyser, the mean of maximum reuse episodes being 13.7 +/- 8.0. The urea reduction ratio was maintained between 73 +/- 5% at baseline to 71.2 +/- 9.03% (p=0.53) at the maximum reuse. Similarly phosphate reduction with each HD session was maintained; mean decrease in phosphate levels was 0.67 mmol/L. Significant increase in heparin requirement was noted; however, the risk of bleeding was not increased. Hematocrit levels increased from 30.4 +/- 4.1% to 33.2 +/- 3.6% at the end of the study (p=0.6). Albumin leak in dialysate decreased with each reuse; baseline 8.27 +/- 7.93 mg/L to 2.8 +/- 0.4 mg/L at maximum reuse (p=0.04). Serum albumin levels remained stable. No short-term adverse effects on patients' morbidity and mortality were noted. Total cost savings of 53% was achieved with the reuse of dialyzers, excluding capital equipment used for preparation for reuse. In conclusion, dialyzer reuse seems to be safe and may provide an economical and efficient dialysis. Studies involving larger number of patients is required to validate this observation.

Effect of intravenous cyclophosphamide pulse therapy on renal functions and histopathology in patients with severe lupus nephritis.

Despite the wide use of intravenous cyclophosphamide (IC) in lupus nephritis (LN), there are few published studies showing the effect of this treatment on renal histology. In this prospective study, we report the effect of IC on the evolution of histopathologic features in successive renal biopsies in patients with LN. Thirty patients with class IV or V LN were started on IC (10-15 mg/kg) administered once every month for six months followed by three monthly for another six doses making a total of two years of therapy. The clinical course of the disease, serum creatinine and 24 hours urinary protein and creatinine clearance were tested at entry and subsequently during each follow-up visit. Repeat renal biopsy was performed after completion of two years of therapy. The mean serum creatinine of the study patients was 166.3 + 42 tmol/L at entry which decreased to 104 + 46.4 tmol/L at two years (P + 2.4 g at entry to 1.39 + 1.54 g at two years (P + 31 ml/min at the start of treatment to 64 + 32 ml/min at two years of therapy (P 200 tmol/L, of whom six progressed to variable degrees of chronic renal failure. Repeat renal biopsy was performed in 21 patients. The original biopsy of these patients showed class IV in 17 and class V in four patients. On repeat biopsy, five of class IV disease had progressed to advanced sclerosis, four to class V, and five remained unchanged. The remaining three patients with class IV LN changed to one each of class I, II and III. Of the four patients with class V, one progressed to advanced sclerosis, one changed to class III and two remained the same. There was a significant decrease (P < 0.05) in the activity index although there was a significant increase in the chronicity index (P < 0.001). Multivariat analysis for possible risk factors for progression to chronic renal failure showed initial high serum creatinine to be a powerful predictor of renal failure. In conclusion, IC pulse therapy is effective in improving or stabilizing renal function in patients with class IV or V LN. The only poor prognostic determinant observed was higher initial serum creatinine value.

Prevalence of glomerular diseases: king khalid university hospital, saudi arabia.

To obtain a more recent and comprehensive insight into the prevalence of glomerular diseases in our patient population, medical records of 200 patients with biopsy proven glomerulonephritis (GN), between January 1994 and June 1999, at the King Khalid University Hospital, Riyadh, Saudi Arabia were analyzed. Primary glomerular disease was found to be the most prevalent, accounting for 63.5% of all glomerular diseases. Among primary glomerular diseases, focal and segmental glomerulosclerosis (FSGS) was the most common histological lesion (34.6%) and was associated with a high prevalence of hypertension (86.4%), nephrotic syndrome (68.18%), hematuria (63.6%) and renal functional impairment (27.3%). Mesangioproliferative GN was the second most common lesion (25.1%) followed by mesangiocapillary GN (15.7%), IgA nephropathy (10.2%), and minimal change disease (8.5%). Amongst secondary glomerular diseases, lupus nephritis was the most prevalent (24.5%). In conclusion, primary glomerular diseases constituted the commonest group encountered and the prevalence of FSGS was quite high with male sex and young adults predominating. FSGS was also associated with a high prevalence of end-stage renal disease. Further collaborative studies are necessary to explore the predisposing factors and associations of glomerular disease, especially FSGS.

The spectrum of glomerulonephritis in saudi arabia: the results of the saudi registry.

Only few studies regarding glomerulonephritis, with relatively small numbers of patients, have so far been published from different centers in Saudi Arabia, and have reported conflicting results regarding the patterns, even in the same city. The possible reasons for these differences include the small number of patients in the different studies, differences in the indications for renal biopsies, referral bias, geographical differences, and, sometimes, the non-availability of the necessary diagnostic facilities in the reporting centers. In order to overcome these problems, a registry for glomerulonephropathy was attempted in Saudi Arabia. Six large referral hospitals from different regions of Saudi Arabia participated in this registry. Biopsy reports and clinical information of 1294 renal biopsies were obtained. There were 782 renal biopsies due to glomerulonephritis (GN) accounting for 77.2% of the total biopsies. Five hundred eighty seven (72.6%) were primary glomerulonephritidis. Focal and segmental glomerulosclerosis (FSGS) (21.3%) and membrano-proliferative glomerulonephritis (MPGN) (20.7%) were the most common types found in the primary glomerulonephritidis. Membranous glomerulonephritis (MGN) was present in only 10.6% of the cases. IgA nephropathy was found in 6.5% of the cases. Of the secondary glomerulo-nephritides, systemic lupus erythematosus (SLE) was the most common indication for biopsy (57.0%) and amyloidosis was found in only 3.2% of the biopsies. In conclusion, FSGS and MPGN were the most common forms of primary glomerulonephritis in adult patients in Saudi Arabia. MGN was not as common as in the western world. SLE was the commonest cause of secondary GN. Amyloidosis was not as common as in other Arab countries. There is a need for more centers from Saudi Arabia to join this national GN registry. Similar registries can be established in different Arab countries, which all would, hopefully, lead to a Pan-Arab GN registry.

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.

Peritonitis in Patients on CAPD at King Khalid University Hospital: Less Infection-rate with More Center-experience.

Continuous ambulatory peritoneal dialysis (CAPD) was started at the King Khalid University Hospital in 1986. Peritonitis remains the most significant complication of the procedure. Earlier rates of peritonitis were high, but after gaining sufficient experience, the rates are declining. To evaluate the change in peritonitis trend, 55 new patients who were recruited to our CAPD program between the periods October 1993-October 1996 were analyzed for the development of peritonitis on annual basis. There were 37 (67%) males and 18 (33%) females with a mean age of 43.3 years (range 12-72 years). A total of 34 episodes of peritonitis were recorded with a rate of 1.5 episode/patients year in 1993, 0.5 episode/patient year in 1994 and 0.8 in 1995. only 40% of episodes showed positive cultures whereas 60% remained culture-negative despite use of recommended modified culture techniques. Organisms causing peritonitis included staphylococcus eipdermides (6.7%), E. coli (3.3%), Streptococcus fecalis (3.3%) and pseudomonas (6.7%). Out of 34 episodes of peritonitis, 29 (85.3%) showed response to treatment and five episodes could only be treated after removal of catheter. Of the 29 episodes that responded to treatment, three relapsed and one had recurrent infection . However, all were successfully treated though one responded only after removal of catheter. Thus, a total of six catheters (20%) necessitated removal and replacement. In spite of high diabetic patients population in our series (27.2%) only one died of peritonitis related sepsis and another died of myocardial infarction after clearing the infection. Thus mortality remains low in spite of potential risk. Although we still use straight system CAPD rather than Y system peritonitis rates have declined considerable and we hope that the procedure will gain more acceptability amongst patients with ESRD in Saudi Arabia.

Sarcoidosis with partial reversibility of renal failure: two case reports with review of literature.

Sarcoidosis is one of the granulomatus disorders affecting many organ systems of the body. Renal impairment in sarcoidosis is rare and occurs usually as a result of long standing hypercalcemia or hypercalciuria with nephrocalcinosis or renal stones. Sarcoid glomerulopathy and tubulo-interstitial granulomatus involvement have been described. We report two cases of sarcoidosis, the first with interstitial nephritis and anterior uveitis without evidence of granuloma. The patient was normocalcemic and normocalciuric. The second case presented with nephritic range proteinuria and severe renal insufficiency with a history of recurrent parotid swelling seven years before diagnosis. Renal biopsy showed non-caseating granulomas in the tubulo-interstitial region. Both patients showed good response to steroid therapy, however, there is still residual renal insufficiency six months after therapy. In conclusion, renal sarcoidosis although a rare presentation, should be considered in the presence of extra-renal manifestation of sarcoidosis as it is amenable to treatment.

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.

Effect of recombinant human erythropoietin on lymphocyte phenotyping and phagocyte activity in hemodialysis patients.

The effect of recombinant human erythropoietin (rHmEPO) on lymphocytic phenotyping as well as on the phagocyte activity of polymorphonuclear cells and monocytes was evaluated in 16 patients on maintenance hemodialysis. The mean age of the patients was 38.2 +/- 16.2 years. There were seven men and nine women. All patients were started on 50 U/kg of rHmEPO intravenously three times per week, and the dosage was increased gradually to achieve target haemoglobin of 12 g/dL. Predialysis blood samples were taken monthly for 3 months, and phagocyte respiratory burst as well as lymphocyte subsets were studied. Healthy blood donors were taken as controls. By 3 months of rHmEPO treatment, there was no significant increase in total T and B cells, but there was a significant increase in both CD4 (P < 0.001) and CD8 (P < 0.005): however, there was no significant change in the CD4/CD8 ratio. There was significant reduction in the natural killer cells (P < 0.005). The phagocyte activity studies showed a significant increase in the respiratory burst in whole blood (P < 0.001) and opsonized zymosan (P < 0.001) as well as improvement in the suppressed polymorphonuclear cell and monocyte activity by uremia. Phagocytosis studied by yeast uptake showed significant improvement from the pretreatment suppressed phagocytes to normal activity posttreatment. In conclusion, treatment with rHmEPO increases CD4 and CD8 cell counts without affecting the CD4/CD8 ratio, decreases the natural killer cells, and improves the impaired phagocyte activity in hemodialysis patients.

Central vein stenosis in patients with prior subclavian vein catheterization for maintenance dialysis.

We evaluated the prevalence of central vein stenosis in patients with prior central vein catheterization for vascular access for hemodialysis. A total of 36 patients with end-stage renal disease (ESRD) who were referred to the division of vascular surgery at King Khalid University Hospital in Riyadh were evaluated. Bilateral ascending venogram was performed in all cases. The patients were divided into three groups: Group I included 38 extremities in 32 patients who were referred for construction of an arteriovenous fistula. All these patients had previous history of subclavian vein catheterization. This included six patients who had bilateral catheter insertion. Venography demonstrated greater than 50% central vein lesions in 13 of the 38 extremities yielding a prevalence of 34%. Group II included four extremities in four patients who were on hemodialysis for many years all of whom presented with features suggestive of venous obstruction in their already existing arteriovenous fistulae. All four patients gave history of prior subclavian vein catheterization for dialysis. Three of these patients had > 50% subclavian vein stenosis while one showed complete occlusion of the vein. Group III included 30 extremities without history of prior central vein cannulation and none of them showed any lesions on venography. Our study further confirms previous reports that show a high prevalence of central vein stenosis following use of subclavian catheter as vascular access. We suggest that the subclavian route should be abandoned in patients with ESRD and temporary venous cannulation, if needed, should be performed in the femoral or internal jugular veins. Also, in individuals with history of prior central vein cannulation, venography is strongly recommended before an arteriovenous fistula is made.

Long-term effect of intravenous calcitriol on the treatment of severe hyperparathyroidism, parathyroid gland mass and bone mineral density in haemodialysis patients.

We conducted this study on 15 chronic haemodialysis patients to evaluate the efficacy of i.v. calcitriol over a 1-year period in the treatment of severe secondary hyperparathyroidism (HPT), in particular its effect on bone mineral density (BMD) and parathyroid gland mass. Mean age was 39 +/- 11.9 (20-65) years and dialysis duration was 58 +/- 3 (19-130) months. i.v. calcitriol was given at a dose of 1 microg post-dialysis 3 times/week for 3 weeks; the dose was then adjusted to maintain the total serum calcium at less than 2.88 mmol/l. The maximum dose was 3 microg 3 times/week. Serum calcium (Ca) and phosphorus (P) were determined prior to treatment, then weekly for 6 weeks and every 2 weeks thereafter. Skeletal survey, dual photon densitometry and parathyroid ultrasound (US) were done prior to treatment and after 1 year. Bone biopsy was done in 10 patients at the beginning of treatment. There was a significant reduction (p < 0.01) in pre-treatment mid-region serum parathyroid hormone (PTH) from 1,476 +/- 895 to 489 +/- 485 P mol/l, as well as alkaline phosphatase (p < 0.04) from 236.5 +/- 221 to 116.3 +/- 49 U/l. This was without a significant increase in serum Ca (2.15 +/- 0.25 to 2.44 +/- 0.26 mmol/l, p = 0.08). Three patients had recurrent hypercalcaemia which responded to reduction of Ca in dialysate. There was a significant increase in BMD over the spine from 1.071 +/- 0.25 to 1.159 +/- 0.22 g/cm2 (p < 0.003) with a percent increase of 9.3 +/- 8.9% as well as over the femoral neck from 0.834 +/- 0.002 to 0.89 +/- 0.09 g/cm2 (p < 0.001) with a percent increase of 7.45 +/- 6.81%. Five patients had enlarged parathyroid glands by US and in 3 of these, there was a significant reduction to normal with treatment. Bone biopsy was done in 10 patients. Six patients had predominant hyperparathyroid bone disease and 4 had mixed uraemic osteodystrophy. In conclusion, long-term i.v. treatment with calcitriol is effective in the treatment of severe secondary HPT. PTH decreased without a significant increase in serum Ca. BMD also increases during this therapy.

Efficacy and safety of once-daily amikacin in combination with ceftazidime in critically ill adults with severe gram-negative infections.

Forty critically ill adult patients with severe Gram-negative infection were treated with once-daily amikacin combined with ceftazidime. The mean age was 56.6 +/- 19 years and mean APACHE II score was 22.7 +/- 6.6. Forty percent of patients required mechanical ventilation. The mean creatinine clearance at onset of therapy was 59.4 +/- 28 ml/min. All bacterial isolates were sensitive to amikacin. Fixed doses of amikacin 15 mg/kg, 12 mg/kg, and 8 mg/kg body weight were given once daily to patients with estimated creatinine clearance of > 80 ml/min., 50-80 ml/min., and < 50 ml/min, respectively. Forty-two causative gram-negative bacteria were isolated from 40 patients. The most common bacteria were Pseudomonas aeruginosa (18), and Escherichia coli (10). Overall clinical success and bacteriological eradication occurred in 85% and 87.5% of patients; 78.9% and 79% of patients with hospital-acquired infections; 90.5% and 95.2% of patients with community-acquired infections; and 62.5% and 81.3% of patients requiring mechanical ventilation, respectively. Therapeutic failure was documented in 15% of patients. Death due to infection was scored in two patients. The remaining were all due to persistence of the initial causative bacteria in patients with hospital-acquired infections. Persistence was documented with Ps. aeruginosa (2), Serratia spp. (1), and Acinetobacter spp. (1). Overall mortality occurred in 22.5% patients. Death unrelated to infection occurred in 7 patients. There was no clinical evidence of ototoxicity in any of our patients, however, nephrotoxicity was documented in 5%. In conclusion, once-daily amikacin combined with ceftazidime is practical, efficacious and probably safe in critically ill infected patients.

Pattern of glomerular disease in Saudi Arabia.

Clinical data and renal biopsy study of 186 adult patients found to have nephropathy and seen at the Security Forces Hospital, Riyadh, over a 5-year period (1989 to 1994) were reviewed. Primary glomerular disease accounted for more than three fourths of all patients (79%), and the most common histological lesion was focal segmental glomerulosclerosis (40.8%) associated with a high incidence of hypertension (86.7%), nephrotic syndrome (61.7%), hematuria (48.8%), and renal impairment (33.3%). Mesangioproliferative glomerulonephritis was the second most common lesion (21.1%), followed by membreous glomerulonephritis (13.6%), immunoglobulin A nephropathy (IgAN) (13.6%), membranoproliferative glomerulonephritis (9.5%), and minimal change disease (1.4%). Although not as common as in most other developed countries, IgAN is being increasingly recognized in Saudis. Lupus nephritis remained the commonest cause of secondary glomerulonephritis (48.5%), whereas amyloidosis was conspicuously absent. There is no evidence, at least in this series, that chronic infection such as hepatitis B virus infection has a major role in the development of glomerulonephritis.

Coagulation inhibitors and fibrinolytic parameters in patients on peritoneal dialysis and haemodialysis.

Coagulation inhibitors and fibrinolytic parameters were studied in twelve patients on continuous ambulatory peritoneal dialysis (CAPD) and ten patients on haemodialysis (HD). Patients on CAPD exhibited higher levels of ATIII and proteins C and S than those on HD. No significant differences were noted in tPA and PAI levels. Both groups of patients showed higher levels of tPA than controls. Besides, patients on HD had significantly lower levels of ATIII and protein C than controls. PAI levels in both patient groups were similar to those of the controls, but tPA levels were higher in patients than in controls. These results indicate that HD is associated with marked diminution in the circulating levels of coagulation inhibitors. This is in contrast to CAPD patients who showed elevated levels of these inhibitors, despite their significant loss in the dialysate. The finding of enhanced fibrinolysis in both patient groups may be a natural protective mechanism against the development of a thrombotic tendency.

One-year experience of very low doses of subcutaneous erythropoietin in continuous ambulatory peritoneal dialysis and its effect on haemostasis.

Recombinant human erythropoietin (rHuEpo) is now well established in the management of the anaemia associated with chronic renal failure. The aim of this study was to assess the efficacy and safety of low doses of subcutaneous (s.c.) erythropoietin in continuous ambulatory peritoneal dialysis (CAPD) patients and particularly its effects on haemostasis. Seven CAPD patients were given s.c. erythropoietin for more than 1 year. Their mean age was 36.2 +/- 9.2 years and their mean pretreatment haemoglobin (Hb) was 7.05 +/- 0.53 g/dl. All patients were started on 20 U/kg, 3 times/week, to be doubled every 4 weeks if no response was obtained. Five patients had a good response and attained the target Hb of 10-12 g/dl and were maintained on low doses of rHuEpo (20 U/kg s.c., twice a week). A marked improvement in haemostatic function was noted when comparing the pre- with the post-treatment measurements. There was a significant reduction in the bleeding time, significant increases in fibrinogen and factor VIII clotting activity but not in von Willebrand factor antigen or ristocetin cofactor. There was also simultaneous enhancement of the platelet aggregation responses to adrenalin, collagen, arachidonic acid and ADP. In conclusion, long-term treatment with small doses of s.c. rHuEpo is safe, convenient and effective in correcting anaemia in patients on CAPD, rHuEpo caused significant improvement of bleeding time which can be explained partly through the correction of anaemia and in part by the improvement in haemostatic function.

Non-peritonitis complications of continuous ambulatory peritoneal dialysis in Saudi Arabia.

Although peritonitis is the major complication and leading cause of morbidity in patients undergoing continuous ambulatory peritoneal dialysis (CAPD), there are other complications of this long-term renal replacement therapy (RRT) modality. In order to evaluate the non-peritonitis complications, we retrospectively studied 60 new patients who were accepted in our CAPD program over a period of eight years from 1984 to 1993. Out of the 60 patients, 31 were females and 29 were males, with a mean age of 37.0 +/- 18 years. Tenckhoff's catheter was implanted by surgeons under direct vision in the operating theater through a midline incision. Nine of our patients had previous abdominal surgery and 11 females had pregnancies before CAPD, ranging from one to 10 with a mean of four. A total of 49 episodes of complications were observed, 32 early and 17 late. Early complications were defined if they occurred within three months from starting the procedure and late complications were defined as occurring after this period. There were 15 catheter blocks (25%), nine dialysate leaks (15%) and five hemoperitoneums (8.3%). Two serious and unusual complications were observed. In one of our patients, a mesenteric blood vessel injury occurred during catheter insertion, which necessitated massive blood transfusions and laparotomy. The other patient developed intestinal obstruction due to obstruction of intestinal loops around the catheter; this was corrected by removal of the catheter without the need for laparotomy. The late complications included six hernias, three hydroceles, three exit site infections, three tunnel infections and one case of loss of ultrafiltration.