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.

Doppler ultrasound evaluation of hemodialysis vascular access.

Brescia-Cimino arteriovenous fistulas (AVF) ad synthetic grafts are the usual forms of vascular accesses for hemodialysis. Although angiography has been the traditional means of imaging these vascular systems, colour Doppler flow imaging (CDFI) offers a non-invasive method of evaluating AVF dysfunction. We retrospectively evaluated 22 patients with clinical evidence of access dysfunction who were studied by CDFI and of whom 14 also underwent angiography. We analyzed the results of whom the 14 patients who had both CDFI and angiography as angiography was impossible in the remaining eight patients due to difficulty with cannulation. Eight patient had thrombosis on CDFI and angiopraphy in all eight patients confirmed these findings. CDFI showed six stenoses, all of which were proven on angiopraphy. Overall,, CDFI correctly identified all lesions that were seen angiographically ginging a sensitivity and specifificity of 100%. Moreover, CDFI detected two cases of pseudoaneurysms which were missed by angiography. CDFI provides an adequate means of evaluating AVF dysfunction and should be the initial imaging technique of choice.

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.

Neurological disorders in renal transplant recipients.

The charts of 175 renal transplant recipients were retrospectively reviewed. The mean duration of follow up since the transplantation was 4.17 +/- 1.66 years. Apart from cyclosporin induced tremor, which occurred almost in all patients, 22 patients (12.5%) had neurological disorders during their follow up (mean annual incidence of 3%). Eight patients had epileptic seizures, seven had strokes, four had neurological infections, two developed a pseudotumor cerebri syndrome, two neuropathies, one myopathy and one conus medullaris infarction. This study demonstrates that neurological disorders are not uncommon in renal transplant recipients and that their mechanisms are variable and may be related to the underlying diseases such as hypertension and diabetes; to the operation itself; to the side effects of immunosuppression agents or rarely, they can accompany graft rejection.

Pediatric renal transplantation in saudi arabia.

This study was performed to evaluate the short and long-term outcome of pediatric renal transplantation in Saudi Arabia. Four large centers participated in this study and there were 124 patients with evaluable data. They included 79 males and 45 females with ages ranging from 2-18 years with a mean of 12.2 years. There were 69 transplants from living donors and 55 from cadaveric donors. The cause of the original renal disease was unknown in 61.4% of the cases. Re-transplantation rate was 8% and the cause of failure of the first graft was venous thrombosis in 60% of the cases most of whom were transplanted before 1990. Acute rejection occurred in 31% of the patients and did not correlate with age at time of transplantation, sex, nationality, source of donor, place of transplantation or follow-up, year of transplant, or delayed graft function; however, those who eventually lost their grafts had significantly more number of acute rejection episodes. There were 24 cases (19%) of infection related to graft and 43 cases (34%) of extra-renal infection. Medical complications other than rejection and infection occurred in 37% of the study group. The 15 year survival rates of patients and grafts from living donors were 96.7% and 92.2% respectively, while the 11 year survival rates of patients and grafts from cadaver donors were 93% and 58.4% respectively. We conclude that pediatric renal transplantation in Saudi Arabia has been performing well in terms of the quantity and quality and the results are comparable to the reputed programs in other countries.

Reversible uremic deafness: is it correlated with the degree of anemia?

Hearing loss is a common finding in patients with end-stage renal failure. Uremic toxins, ototoxins, and axonal uremic neuropathy appear to be likely pathogenic factors. We analyzed whether an improvement in hearing capacity can be achieved with an improvement of anemia by erythropoietin (EPO) administration. Fifty patients on long-term hemodialysis in a single center were examined audiologically by otoscopy, tympanometry, pure tone audiometry, and the short increment sensitivity index. Twenty-five patients were treated with EPO in a dose of 120 U/kg per week over a period of 5 to 8 months, and the remaining 25 patients were not treated with EPO (controls). Both groups were reexamined audiologically after the study period, and the results were compared. In the group treated with EPO, the hemoglobin level increased from 7 +/- 0.9 to 11 +/- 0.8 g/dL, as against the control group, whose hemoglobin increased from 7.1 +/- 0.9 to 8 +/- g/dL. The audiologic tests were repeated at the end of the study period, and a significant improvement of hearing was found in the patients treated with EPO as compared with the control group (p < .001). Our study suggests that improvement of anemia in patients on long-term hemodialysis by administration of EPO is associated with an improvement in hearing capacity in a significant number of patients. Thus, anemia seems to be an important factor responsible for hearing disorders in patients with end-stage renal failure. Studies with larger numbers of patients are required to confirm this observation.

Prevalence and clinical expression of HCV-genotypes in haemodialysis-patients of two geographically remote countries: Belgium and Saudi-Arabia.

Hepatitis C virus is the leading cause of acute and chronic liver disease in hemodialysis patients. There are at least six major HCV-genotypes, with a well documented geographical distribution in the general population. Moreover, HCV-genotype is one of the major determinants of the therapeutic response to Interferon Alpha in affected patients. Since the therapeutic outcome in HCV-positive hemodialysis patients, especially with regard to the different HCV-genotypes, is of interest, a multicentre epidemiologic study was performed in HCV-antibody positive hemodialysis patients of two geographically remote countries, i.e. in Flanders (Belgium) and in Saudi-Arabia. 184 chronic hemodialysis patients, with a positive second or third generation Elisa assay for HCV, were tested for HCV-viremia and HCV-genotype, using a 5' untranslated region (UR) nested PCR for the detection of HCV-RNA and subsequently type-specific probes to hybridize with HCV-RNA (Inno-Lipa). Additionally, clinical data were collected by means of a standardized questionnaire, thoroughly completed by the nephrologist in charge of each respective patient. Viremia was present in 79% of the patients (146 out of 184). The prevalence of HCV-genotypes differed significantly between Belgian and Saudi-Arabian dialysis-patients. In Belgian dialysis patients HCV-genotype 1b was most prevalent (i.e. 62%), while in Saudi-Arabian patients HCV-genotypes 4, 1b, and la were present in respectively 36,4%, 31,7%, and 25,8% of the HCV-PCR positive patients. Although there were significant differences between Belgian and Saudi-Arabian dialysis patients, no clinical data showed any significant correlation with the HCV-genotype. Transaminases, determined over a six months period, showed normal average values. Doubling of the transaminases, in at least one out of six measurements over a six monthly period, occurred only in 14% (alanine aminotransferase, ALT) and 10% (aspartate aminotransferase, AST) of the patients. In Belgian dialysis patients, HCV-genotype 4 (or HCV-genotype 5) significantly correlated with a more recent start of dialysis treatment. We conclude that there is a significant different geographical prevalence of HCV-genotypes in HCV-affected hemodialysis patients. None of the different HCV-genotypes shows any particular clinical expression. Transaminases are not a sensitive marker for ongoing HCV-replication in hemodialysis patients. In Belgian dialysis patients, a changing pattern of HCV-infection is suggested, with an increasing prevalence of HCV-genotype 4 (or HCV-genotype 5) in more recent years. These data suggest possible implications for the therapeutic strategy in dialysis patients.

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.

Rifampicin-induced acute renal failure: a case report.

Acute oliguric renal failure (ARF) developed in a patient two weeks after he was started on intermittent anti-tuberculous therapy including rifampicin. The clinical picture was compatible with acute allergic interstitial nephritis. Renal histology revealed mainly acute tubular necrosis with mild tubulo-interstitial mononuclear cellular infiltrate. Intermittent therapy, as in our patient, has been the major factor in the development of rifampicin induced ARF in cases reviewed in the literature.

Kidney transplantation in Saudi Arabia: a unique experience.

Kidney transplantation in the kingdom of Saudi Arabia began 16 years ago. In this relatively short period, transplantation has developed so quickly that Saudi Arabia currently has the largest cadaveric kidney transplantation program in the Moslem world. This article illustrates the achievements and progress made through the past and casts a light on differences in the transplantation practice in this part of the world.

Increased silicon levels in dialysis patients due to high silicon content in the drinking water, inadequate water treatment procedures, and concentrate contamination: a multicentre study.

BACKGROUND: Although silicon is considered as an essential element, little is known about the basic effects and clinical significance of increased concentrations of the element in dialysis patients. METHODS AND RESULTS: In a multicentre study we found silicon levels in haemodialysis (HD) patients to be markedly increased. In these patients silicon concentrations were significantly higher than those noted in subjects with normal renal function as well as in patients with chronic renal failure not yet in dialysis and patients treated by continuous ambulatory peritoneal dialysis (CAPD). Moreover we noted that in both HD and CAPD patients mean silicon levels differed from one centre to another. Also, was there in the HD population a significant difference in serum silicon levels among patients from different countries. In HD patients differences in serum silicon levels were either due to the use of silicon contaminated dialysis fluids or an increased oral intake of the element mainly originating from the high silicon content of the drinking water. Silicon contamination of the dialysis fluid was found to be due to either the use of reverse osmosis membranes that insufficiently retain the element during water treatment or by the addition of concentrates containing high amounts of silicon. Using a recently developed high-performance liquid chromatographic/atomic absorption spectrophotometric (HPLC/ETAAS) hybrid technique, we found silicon in serum to be present as a low-molecular-weight non-protein-bound component, which in the presence of a low silicon dialysate is adequately removed during treatment. CONCLUSIONS: The clinical relevance of increased serum silicon levels is not yet known and as such deserves further investigation. In view of the controversy that exists on the element's assumed protective as well as toxic role in the development of some (aluminium-related) neurodegenerative diseases and its vital role in bone formation, monitoring of the silicon levels in serum, tap water, and dialysis fluids might become important.

Intestinal obstruction as a complication of continuous ambulatory peritoneal dialysis: a case report.

Continuous ambulatory peritoneal dialysis (CAPD) has gained in popularity in recent years as a mode of renal replacement therapy. We report a 23 year old patient who was initiated on CAPD using curley Tenckhoff catheter in January 1992. In May 1993, the patient presented with features suggestive of intestinal obstruction. Plain x-ray of the abdomen showed that the CAPD catheter had migrated to the left hypochondrium. During surgery for catheter removal, it was found that the intraperitoneal cuff was adherent to the greater omentum forming a band over which the jejunal loop was kinked causing obstruction. Within 24 hours of removal of the catheter, the intestinal obstruction was relieved. The problem encountered in our patient is unique in illustrating the reversible mechanical intestinal obstruction relieved by catheter removal.

Prevalence of hepatitis C antibodies among hemodialysis patients in the Western province of saudi arabia.

We studied 408 patients on maintenance hemodialysis at four different centers in the Western province of Saudi Arabia to assess the prevalence of antibody against Hepatitis C Virus (HCV) and the possible risk factors. There were 212 males and 196 females with a mean age of 42.9 +/- 13.9 years (range 12 to 75 years). They were on dialysis for a period between 3 to 140 months with a mean of 52.2 + 38 months. Assay for anti-HCV was made by second generation ELISA. A total of 295 patients (72.3%) tested positive. The prevalence rates varied considerably among the four centers studied and were as follows: the center at Jeddah, 62.7%; two centers at Makkah, 87% and 79.7% respectively and one center at Taif, 80.9%. A total of 311 patients had received varying number of blood transfusions. Of these, 230 (74%) were anti-HCV positive as against 97 patients who were never transfused of whom 65 (67%) were positive. This difference did not reach statistical significance (P = 0.22). Similarly, we found no significant correlation between the anti-HCV prevalence rates and serum alanine transaminase levels (P = 0.93). Our study further confirms that there are routes other than blood transfusion involved in the transmission of the HCV and there is a need to determine these routes in order to prevent the spread of this virus.

The annual incidence of seroconversion of antibodies to the hepatitis C virus in the hemodialysis population in saudi arabia.

A mail survey was conducted involving 102 hospital-based active hemodialysis (HD) centers in Saudi Arabia to assess the annual incidence of seroconversion of antibodies against the hepatitis C virus (HCV). Tests for anti-HCV, using second generation ELISA, were performed every three months on the study subjects for a period between January 1993 to December 1994. Response was received from 73 centers (72%) on 1,392 patients and from 61 centers (60%) on 694 staff members. Of the study patients, 733 (52.7%) were males, and 659 (47.3%), females; 1,093 (78.5%) were Saudis, while 299 (21.5%) were Non-Saudis. The mean age of the patients was 44.5 +/- 14.3 years (range 10-75 years). The mean duration on HD was 3.1 + 2.1 years (range 3 months - 10 years). Reuse of the dialyzers was not practiced on any of the study patients. During the study period, 28% of the patients did not receive any blood transfusions while the remaining 72% received varying number of transfusions. The average prevalence of anti-HCV among HD patients was 70%,and among the dialysis staff was 1%. and the annual rate of serconversion was 7% to 9%. The anti-HCV seroconversion rate was significantly lower in the dialysis centers with more than 20 patients compared with the smaller dialysis centers (P< 0.0001). Also, there was a significant correlation between increased rates of seroconversion and duration on HD as well as with history of blood transfusions (P< 0.001). There were no significant differences in the rates of anti-HCV seroconversion related to the sex, age or nationality of the patients. There was no correlation between the elevation of liver enzymes or presence of HBV infection and the annual rate of seroconversion. We conclude that the annual incidence of the seroconversion of anti-HCV in the HD population in Saudi Arabia is 7-9% and isolation of the anti-HCV positive patients may help in decreasing this incidence.

The effect of chemical and heat disinfection of the hemodialysis machines on the spread of hepatitis C virus infection: a prospective study.

Seventeen of our 42 regular hemodialysis (HD) patients (40.5%), and six of our 16 patients on continuous ambulatory peritoneal dialysis (CAPD) (37%) were found to be positive for hepatitis C virus (HCV) antibody in June, 1992. Since the virus was considered susceptible to eradication by the available disinfection methods of the HD machines, the most likely source of transmission was considered to be incomplete application of the universal infection control techniques. These recommendations were strictly applied, but no attempt was made towards designating specific machines for anti-HCV positive patients. Review of data revealed that seven of our 25 previously negative patients (28%) turned positive in the following 12 months. Risk factors such as blood transfusions were excluded in all these patients. A strict protocol of careful chemical disinfection using Citrosteril run at 85 degrees C for 35 minutes after each dialysis session was adopted. Over the following 18 months, six of the remaining 17 negative patients (35.2%) seroconverted. They all had received blood transfusions, 7 to 14 months before (mean 10.5 months). The blood had been screened and had tested negative for anti-HCV antibody. By contrast, none of our CAPD patients who were anti-HCV negative in June 1992, and remained on CAPD, turned positive. The HD machine disinfection techniques were thoroughly reviewed and found to be as prescribed In the absence of other sources of infection with HCV we conclude that the HD machines were the most likely source of transmission of HCV infection and therefore, it is important to assign specific HD machines for anti-HCV positive patients. We have now adopted such a system.

Hepatitis C in dialysis patients.

Hepatitis C virus (HCV) infection is a major health problem in hemodialysis patients. Identified risk factors include duration on dialysis and blood transfusion. A more important risk factor contributing to the high prevalence of anti-HCV, particularly in the developing countries, could be the non-adherence to the known universal infection control precautions. The factors that might help reduce and/or prevent the spread of HCV infection among patients on dialysis include: early screening of patients for anti-HCV, reduction of the number of blood transfusions given, strict application of universal infection control precautions and isolation of patients or machines which ever feasible. The issue regarding isolation of anti-HCV positive patients is controversial and although it is not recommended by the Centers for Disease Control to isolate these patients, it may be advisable to do so, particularly in the developing countries, wherein a high prevalence of anti-HCV exists among the dialysis population.

Effect of short-term use of different non-steroidal anti-inflammatory drugs on renal function during fasting in ramadan.

This study was conducted to determine the combined effect of Ramadan fasting and short-term use of different non-steroidal anti-inflammatory drugs (NSAIDs) on renal function in healthy volunteers. The study subjects were assigned to six different groups, five of whom took different NSAIDs (namely nabumetone, indomethacin, diclofenac, sulindac, tenoxicam) and the sixth was a control group. Data were collected on serum sodium, chloride, potassium, urea, creatinine, bicarbonate and uric acid as well as urinary osmolarity, sodium, potassium, chloride and urea. These measurements were taken before fasting, 10 days into fasting while using NSAIDs, and five days after stopping the use of NSAIDs. The results showed slight changes in serum and urine measurements during fasting while using NSAIDs. These changes, although were significant in some cases, were within the normal range and were noted in all the study groups including the control group. We conclude that short-term use of NSAIDs in healthy subjects during fasting is not associated with any major adverse effects on the renal function.

Is aluminum related bone disease common in hemodialysis units using aluminum based phosphate binders?

The extent of aluminum related bone disease was evaluated in 41 patients on regular maintenance hemodialysis in two dialysis centers in Riyadh, Saudi Arabia. There were 22 males and 19 females aged 20 to 70 years (mean 35.5+11.2 years). Thirty eight of the patients were on aluminum based oral phosphate binders. Investigations performed included serum calcium, magnesium, aluminum and parathormone and radiological investigations including skeletal survey and dual photon absorptiometry. All the patients underwent bone biopsy and the biopsy material was subjected to morphometric studies, including staining for aluminum deposits. The patients were divided into two groups: group 1, (16 patients, 39%) with negative aluminum staining in the bone biopsy tissue, and group 2, (25 patients, 61%) with positive aluminum staining. Bone pain and its distribution as well as fractures were similarly prevalent in both groups. The levels of aluminum in the blood was significantly higher in group 2 (32.9 + 20.2 vs 17.9 + 11.2 ug/L P< 0.05), though it was lower than the lowest accepted toxic level (40 ig/L). There was no significant difference between the two groups in the biochemical or hormonal data, frequency of abnormal radiological signs and pattern of bone histology. Our study indicates that increased aluminum deposition in the bone is prevalent in patients on maintenance hemodialysis using aluminum based phosphate binders, but adynamic bone disease is not prevalent. Further studies may be needed on a larger scale to assess the magnitude of the problem.

Effect of moderately high altitude on the pattern of lung disease.

In high altitude areas, inspired atmosphere oxygen decrease proportionally to the vertical distance from sea level. Population in these areas some adaptive mechanisms to cope with the relatively hypoxic environment. This study compares populations who live in highland areas (2500 meters above sea level) with those in lowland areas (close to sea level). No differences were observed in the prevalence or mortality rate of respiratory diseases between these two groups. It is concluded that even if adaptive mechanisms can be observed in dwellers of moderately high altitude (<3000 m above sea level), such altitude does not adversely affect the pattern of respiratory disease in these populations. However, partial pressure of oxygen (PaO2) tends to be lower in individuals of high altitude areas, leading to marked oxygen desaturation when such individuals encounter a significant respiratory illness. Physicians are advised to introduce early and effective therapeutic measures before such deterioration occurs.