Alport's syndrome with focal segmental glomerulosclerosis lesion - Pattern to recognize.

The association between Alport's syndrome (AS) and focal segmental glomerulosclerosis (FSGS) in the same patient is complex and rarely reported. We report a case of a 42-year-old male presenting with proteinuria, microscopic hematuria, elevated serum creatinine and hypertension with unremarkable physical examination apart from obesity. The renal biopsy showed well-established FSGS pattern of injury with mild interstitial fibrosis and tubular atrophy, while the electron microscopic examination demonstrated glomerular basement membranes (GBM) changes compatible with AS. AS can be complicated by segmental glomerular scarring, which can mimic primary FSGS, while familial FSGS can result from mutations in collagen IV network of the GBM. This overlap can complicate histopathological interpretation of renal biopsy, which should be accompanied by mutational analysis for accurate diagnosis and proper therapeutic intervention.

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.

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?

For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. METHODS: This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. RESULTS: During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). CONCLUSIONS: We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate.

Barriers to Peritoneal Dialysis in Saudi Arabia: Nephrologists' Perspectives.

In Saudi Arabia, only 9% of dialysis patients are on peritoneal dialysis (PD), and this has been the case for years. A number of centers around the world have sought to understand the underutilization of PD by asking nephrologists directly. In this study, we aimed to gather information that will answer the question "Why is PD underutilized in Saudi Arabia?" hoping that a roadmap may be developed to overcome the hurdles the study underscores, allowing for more patients to utilize this valuable modality.

Comparison of the tuberculin skin test and Quanti-FERON-TB Gold In-Tube (QFT-G) test for the diagnosis of latent tuberculosis infection in dialysis patients.

Dialysis patients are more likely than the general population to develop active tuberculosis (TB). In these patients, the availability of a highly sensitive and specific test to diagnose latent TB will ensure earlier treatment and decreased progression to active disease. In the current study, the Quanti-FERON-TB Gold In-Tube (QFT-G) test was compared with the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) among 200 hemodialysis patients and 15 confirmed TB disease cases in a tertiary care center in Saudi Arabia. Among the LTBI cases, 26 (13%) were TST positive, and 65 (32.5%) were positive by the QTF-G test, with an overall agreement between the 2 tests of 75.5% (k=0.34) being observed. Among the confirmed tuberculosis disease cases, none were positive by TST, and 10 (66.7%) were positive by the QTF-G test, resulting in an overall agreement of 33.3% (k=0). A comparison between the TST and the QTF-G test was performed based on the sensitivity, specificity, and area under the curve (AUC) obtained for the tests. The QTF-G test was more sensitive and less specific than the TST in predicting the confirmed TB disease cases. When we tested the correspondence of the AUC values between the 2 diagnostic modalities, the obtained p-value was 0.0003. In conclusion, the AUCs of the examined diagnostic modalities are significantly different in predicting LTBI and tuberculosis.

Insomnia in chronic renal patients on dialysis in Saudi Arabia.

BACKGROUND: Studies have shown that insomnia is a common sleep disorder among patients with end-stage renal disease (ESRD). This study aimed to assess the prevalence of insomnia in Saudi patients with ESRD who are on maintenance dialysis. METHODS: This was an observational cross-sectional study carried out over a period of five months in two hemodialysis centers in Saudi Arabia. To assess the prevalence of insomnia, we used the ICSD-2 definition. We also examined the association between insomnia and other sleep disorders, the underlying causes of renal failure, dialysis duration, dialysis shift, and other demographic data. RESULTS: Out of 227 enrolled patients, insomnia was reported by 60.8%. The mean patient age was 55.7 +/- 17.2 years; 53.7% were male and 46.3% were female. Insomnia was significantly associated with female gender, afternoon hemodialysis, Restless Legs Syndrome, high risk for obstructive Sleep Apnea Syndrome and excessive daytime sleepiness (P-values: 0.05, 0.01, < 0.0001, < 0.0001, and < 0.0001, respectively). No significant association was found between insomnia and other variables, including BMI, smoking habits, underlying etiology of renal failure, dialysis duration, association with hemoglobin, ferritin, and phosphorus or dialysis adequacy as measured by the Kt/V index. CONCLUSION: Insomnia is common in dialysis patients and was significantly associated with other sleep disorders. Greater attention needs to be given to the care of dialysis patients with regard to the diagnosis and management of insomnia and associated sleep disorders.

Factors associated with decision-making about end-of-life care by hemodialysis patients.

The current cross sectional study is based on a questionnaire database on patients with end-stage renal disease (ESRD) to determine their preferences about end-of-life care and differences of certainty regarding the application of cardiopulmonary resuscitation and life sustaining measures in case of cardiac arrest. The study was performed on 100 patients on hemodialysis for at least 2 years and not on the transplant list in two tertiary hospitals in Saudi Arabia; King Fahad National Guard in Riyadh and King Faisal Specialist Hospital in Jeddah in March 2007. More than two thirds of the surveyed patients were willing to make decisive decisions. Having more than 5 children was the only factor significantly associated with the ability to make decisive decisions; there was an insignificant association with factors such as marital status or non-Saudi nationality. Factors such as self-perception or disease curability, previous admissions to hospital or intensive care units, prior knowledge of mechanical ventilation, or cardiopulmonary resuscitation did not have any influence on making certain decisions on end-of-life care. There was a significant lack of knowledge in our study patients of cardiopulmonary resuscitation, mechanical ventilation, and disease outcome.

Restless legs syndrome in patients on dialysis.

Restless legs syndrome (RLS) is an extremely distressing problem experienced by patients on dialysis; the prevalence appears to be greater than in the general population, with a wide variation from 6.6% to 80%. The diagnosis of RLS is a clinical one, and its definition has been clarified and standardized by internationally recognized diagnostic criteria, published in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). This study was designed to find out the prevalence of RLS in Saudi patients with end-stage renal disease (ESRD) on maintenance dialysis. This is a cross sectional study carried out between May and Sept 2007 at two centers, King Abdulaziz Medical City-King Fahad National Guard Hospital (KAMC-KFNGH), Riyadh and King Faisal Specialist Hospital and Research Centre (KFHRC), Jeddah, Saudi Arabia. Data were gathered on 227 Saudi patients on chronic maintenance hemodialysis or chronic peritoneal dialysis. The prevalence of RLS was measured using IRLSSG's RLS Questionnaire (RLSQ). Potential risk factors for RLS including other sleep disorders, underlying cause of chronic renal failure, duration on dialysis, dialysis shift, biochemical tests and demographic data were also evaluated. The overall prevalence of RLS was 50.22% including 53.7% males and 46.3% females. Their mean age was 55.7 +/- 17.2 years and mean duration on dialysis 40.4 +/- 37.8 months. Significant predictors of RLS were history of diabetes mellitus (DM), coffee intake, afternoon dialysis, gender and type of dialysis (P= 0.03, 0.01, < 0.001, 0.05 and 0.009 respectively). Patients with RLS were found to be at increased risk of having insomnia and excessive daytime sleepiness (EDS) (P= < 0.001 and 0.001, respectively). Our study suggests that RLS is a very common problem in dialysis population and was significantly associated with other sleep disorders, particularly insomnia, and EDS. Optimal care of dialysis patient should include particular attention to the diagnosis and management of sleep disorders.

Advance care planning preferences among dialysis patients and factors influencing their decisions.

To determine the resuscitation preferences of hemodialysis (HD) Saudi patients, we con-ducted a cross-sectional, observational descriptive questionnaire study in two major tertiary hospitals in Saudi Arabia from March to December 2007. We enrolled all the patients on HD for two years or more, and excluded the patients who were transplant candidates, confused, or demented. The questionnaire was com-posed of 4 sections. The first 3 sections were concerned with demographic data, education levels, employ-ment, family size, number of children, and functionality status besides knowledge about cardiopulmonary resuscitation (CPR), mechanical ventilation, and ICU admission. The fourth section contained different sce-narios and questions on personal and preferences such as end of life decisions, medical interventions, CPR, ICU admission, and the decision maker in these events. A total of 100 patients (53% males, 67% Saudis, and 85% married) were enrolled in the study. The mean duration on dialysis was 6.0 years (+/- 4.1). More than 70% of the patients viewed themselves as above average in the religiosity score, and 44% disclosed a good life quality. More than 95% had little or no knowledge about cardiac resuscitation, intubation, and mechanical ventilation. The majority of the patients authorized their treating physician to decide for them about cardiac resuscitation in case they did not make advanced directives and only 22% believed that this decision should be made by their family members. If their physician believed their condition was hopeless, 77% preferred to stay at home. We conclude that the majority of our patients had limited awareness about cardiac resuscitation measures. The majority of the patients trust their physicians to decide about the futility of resuscitation. Patients were able to decide reasonably well when they are well informed.

Diagnostic decision making in medicine.

Medical diagnostic decision making, like all decision making instances, involves a cognitive process. It starts with internalizing data, structuring it and generating hypotheses. In simple cases very often the experienced physician utilizes pattern recognition, intuition and retrieval in reaching a diagnostic decision. In more complicated cases more complex cognitive process takes place including the balancing of probabilities and the weighing of evidence. Apart from knowledge and experience, personal traits and perceptions and prejudices play some part in some situations.