Multinational observational study on clinical practices and therapeutic management of mineral and bone disorders in patients with chronic kidney disease stages 4, 5, and 5D: The OCEANOS study.

Our aim is to assess the current clinical practices in monitoring and treatment patterns of chronic kidney disease (CKD)-mineral bone disorder and the degree to which these practices met the kidney disease improving global outcome (KDIGO) guidelines. This was an international, multi-center, cross-sectional, observational study in adult patients diagnosed with CKD Stages 4, 5, and 5D. Patients were enrolled from Middle East, South Asia, Eurasia, and Africa; patients with estimated glomerular filtration rate ≥30 mL/min/1.73 m(2) or with any medical/surgical conditions precluding their participation were excluded. Frequency of measurements, levels of serum calcium (Ca), phosphorus and parathormone (parathyroid hormone [PTH], and presence vascular/valvular calcification were recorded. Of the 2250 patients enrolled, data on 2247 patients were evaluated. Overall, only a small percentage of patients met all three target KDIGO ranges of serum Ca, phosphorus, and PTH (13.7% [95% confidence interval: 12.0; 15.4], with a higher proportion among CKD Stage 5D patients (14.8%) than CKD Stage 4 and 5 (5.6%) patients. Majority (84.3%) of the patients received treatment with phosphorous binders, of whom 85.5% received Ca-based phosphate binders. Overall, 57.0% of patients received Vitamin D treatment with a similar frequency among patients with CKD Stages 4, 5, and 5D. Over half (65.7%) of the patients were screened for vascular/valvular calcification; of these, 58.8% had ≥1 calcification. Diabetes status, P, PTH, and low density lipoprotein-cholesterol had significant impact on the prescription pattern of phosphorous binders. The current practices for the management of bone and mineral metabolism in CKD patients in the study region fall far short of meeting the KDIGO target range.

Current obstacles to organ transplant in Middle Eastern countries.

The Middle Eastern map includes all the Arab countries, Iran, Turkey, Pakistan, and countries of Central Asia. There are common features of organ transplant in these countries such as inadequate preventive medicine, uneven health infrastructure, poor awareness of the medical community and public about the importance of organ donation and transplant, high level of ethnicity, poor government support of organ transplant, and political unrest. In addition, there is inadequate team spirit among transplant physicians, lack of planning for organ procurement and transplant centers, and lack of effective health insurance. Living-donor organ transplant is the most widely practiced type of transplant in the Middle East. Deceased-donor organ donation is not used properly because of continued debate in the medical community about the concept of death according to neurologic criteria (brain death) and inadequate awareness of the public about the importance of organ donation and transplant in many countries in this region. Continuous work is needed to provide solutions to overcome the current obstacles.

Organ Donation From Deceased Donors: A Proactive Detection Program in Saudi Arabia.

Several challenging obstacles remain to increasing the number of organ donations from deceased patients in a hospital setting. These include medical, administrative, and ethical issues. Possible medical obstacles include the failure of early recognition of possible donors and inadequate care of potential and actual donors. To maximize the use of donated organs, proper care of the donors and expedited donor consent cannot be overemphasized. The care rendered to patients should ensure appropriate perfusion and nutrition of the organs, with meticulous follow-up until organ recovery. For example, patients involved in accidents are presumed to be healthy, but many have no available medical history on file. At the time of organ recovery, unexpected infections or malignancies can be minimized by raising the index of suspicion of the presence of serious conditions in donors, especially in donors with unknown medical history. A careful physical examination and an appropriate and aggressive laboratory investigation may disclose the cause of suspected clinical conditions in these potential donors. Individuals who work in intensive care units are the main group of health care providers directly involved in the process of organ donation. Appointing a donor coordinator in each intensive care unit could improve all aspects of organ donation. Such coordination could harmonize efforts toward the goals mentioned above and surmount the obstacles encountered during deceased-donor organ donation. Here, we describe the preliminary results of the Proactive Detection Program, a collaboration between the Saudi Center for Organ Transplantation (the national organ donation and transplant supervising center) and intensive care units of donating hospitals. With its success in Saudi Arabia, it is hoped that it will be widely adopted in other regions.

Rituximab as a rescue therapy in patients with glomerulonephritis.

To evaluate the use of rituximab in the treatment of severe glomerulonephritis (GN) in order to prevent progression of kidney disease toward the end stage, we designed a multicenter, retrospective study in Saudi Arabia about the efficacy and safety of the use of "off label" rituximab in a variety of severe refractory GN to conventional treatment and the progression of kidney disease for at least one year of follow-up. All the patients had kidney biopsies before treatment with rituximab, and proteinuria and glomerular filtration rate (GFR) were followed-up for the period of the study. The immediate side-effect at the time of administration of rituximab included itching in three patients, hypotension in one patient and anaphylaxis in one patient (dropped out from the study). After the administration of rituximab in 42 patients and during the first six months of therapy, 16 (38%) patients had complete remission (CR), 13 (31%) patients had partial remission (PR) and 13 (31%) patients had no remission. The mean follow-up period for the patients was 19.0 ± 6.97 months (median 18.0 months). The long-term follow-up during the study period disclosed a good hospitalization record for almost all of the patients. Membranous GN (MGN) was the largest group in the cohort (58% of the patients), and we observed CR and PR in 40% and 28% of them, respectively, which was comparable with the previous experience with rituximab in MGN patients with more CR than PR in our cohort. We conclude that our study suggests the safety and efficacy of the use of rituximab in patients with refractory GN and that larger and long-term prospective studies are required to define the role of rituximab in the different categories of these diseases.

How to improve organ donation in the MESOT countries.

There are more than 29 countries that have membership of the Middle East Society for Organ Transplantation (MESOT) with more than 600 million populations. These include all Arab countries, Iran, Turkey, Pakistan and countries of Central Asia. There are common features of organ transplantation in the Middle East Countries that include inadequate preventive medicine, uneven health infrastructure, poor awareness of the medical community and public at large of the importance of the organ donation and transplantation, high level of ethnicity and poor government support of organ transplantation. In addition, there is lack of team spirit among transplant physicians, lack of planning for organ procurement and transplant centers and lack of effective health insurance. Patients seek commercial transplantation most of the time. Patients on waiting lists for organ transplantation increase with time and there is a considerably growing gap between supply and demand of organs in the MESOT countries. Living organ donation is the most widely practiced type of donation in the Middle East and includes kidney and partial liver. Cadaver organ donation has a great potential in the Middle East. Nevertheless, this source is still not utilized properly due to the continued debate in the medical community about the concept of brain death and inadequate awareness of the public of the importance of organ donation and transplantation in many countries in this region.. There are three dominant and distinctive models for practice including the Saudi, Iranian and Pakistani models. The Saudi model includes the presence of a national organ procurement center as a governmental agency to supervise organ donation and transplantation. The Iranian model consists of renal grafts donation from the living genetically unrelated persons to the benefit of patients with end-stage renal disease. The Pakistani model is an interesting funding model for management of end-stage organ failure in the developing countries. We conclude that organ donation and transplantation are hampered with obstacles in the MESOT countries. Solutions need continuous work on many fronts. Local experiences can be implemented into new improved models that can help overcoming current obstacles.

Liver donation and transplantation in Saudi Arabia.

OBJECTIVES: The aim of the study was to evaluate and analyze the results of liver transplants from living and deceased donors in Saudi Arabia. MATERIALS AND METHODS: We performed a retrospective study from the National Registry reported to the Saudi Center for Organ Transplantation on 616 living donors and deceased donors between 2004 and 2010. Data included donors ' characteristics and acceptance rates of livers from deceased donors, recipient's status posttransplant, follow-ups, and patient survival. RESULTS: A total of 612 cases from deceased donors consented for liver donation of whom 402 cases (65.7%) were retrieved; 332 of them (82.3%) were transplanted. The mean age of the deceased donors was 33.2 years. Regarding living-donor liver transplants, 285 transplants were performed mostly from parent to offspring or offspring to parent. The mean age of the donors was 26.6 years and male/female ratio was 3/1. The mean follow-up was 745 days, and the mean posttransplant stay in hospital was 28.2 days. There were 11 cases with primary nonfunctioning grafts. At the end of the follow-up, 532 patients were alive (88%) and 58 patients died (10%). The patient survival at 3 years and the estimated 5-year survival were 87.2% and 77.1%. CONCLUSIONS: The outcome of liver transplanting in Saudi Arabia is comparable to international levels. However, the need to increase the acceptance rate and the use of procured livers requires more effort in managing deceased donors. Both living-donor and deceased-donor liver transplants should be continued in Saudi Arabia to meet the ever-increasing demand of patients with end-stage liver disease.

Trends of elevated parathormone serum titers in hemodialysis patients on intensive therapy for bone disease: a multicenter study.

To determine the prevalence of controlled parathyroid hormone (PTH) serum levels with intensified therapy for chronic kidney disease mineral and bone disorder (CKD-MBD) in the dialysis population, we studied 563 chronic hemodialysis patients recruited from three different dialysis centers from three different major cities in the Kingdom of Saudi Arabia. The trend of the routine monthly chemistries related to CKD-MBD was evaluated besides the whole-molecule PTH serum levels over 28 months (January 2011 to April 2013). The cost ratios of the medications to the estimated dialysis total cost were calculated. There were 323 (57.4%) males in the study, and the mean age of the patients was 50.2±15.2 years; 371 (65.9%) patients were initiated on dialysis before 2011. The causes of the original kidney disease included diabetes mellitus in 163 (29%) patients. Parathyroidectomy was performed in 23 (4.1%) patients and only six (23%) patients underwent the operation during the study period; most of the parathyroidectomies (69%) were performed before 2011. The trend of the medians of monthly serum levels of calcium, phosphorus, albumin, bicarbonate, alkaline phosphatase, serum levels of PTH and vitamin D25 assays showed better control of the levels with time. The added cost of cinacalcet was more significant than the other drugs, including vitamin D and phosphate binders, but the cost was minimal in comparison with the whole dialysis bill. The ratios of the discontinuation rates to the total patient-months of treatment for the different drugs were in the range of 3-4% and mostly due to transient overdosing of medications. We conclude that the trends of the median serum levels of PTH and related minerals in the CKD patients in our dialysis patients suggested a good inclination toward control and prevention of the vascular calcifications prevalent in the CKD-MBD. The popularity of use of new drugs such as cinacalcet is promising and does not seem to add much to the current out-patient cost of chronic dialysis.

Attitude of physicians towards the evaluation and treatment of the glomerulonephritis patients.

To survey the attitude of the physicians in Saudi Arabia toward the evaluation and treatment of glomerulonephritis (GN) patients, a questionnaire was sent to the medical directors of 175 dialysis centers in the KSA. The study was performed from July to November 2010. A total of 171 (97.7%) medical directors of dialysis centers answered the questionnaire. There were 131 (77%) respondents who followed up hospitalized or out-patients with nephrological problems other than dialysis at their corresponding hospitals. Only 111 (65%) of the respondents attended general nephrology clinics. Furthermore, 115 (80%) respondents followed up GN patients at their corresponding hospitals, with an average of more than 6 patients/year reported by 70 (61%) respondents. The availability of the specific serologic tests, performance of kidney biopsies and a pathologist to read them were disclosed by 55 (32%), 50 (29%), and 46 (27%) respondents, respectively. There were 46 (27%) respondents who encountered very often minimal change disease in the patients they followed up in their corresponding hospitals, 26 (15%) encountered it sometimes, and 21 (12%) encountered the disease rarely, while 78 (46%) never encountered this disease. Similar patterns were stated by the respondents for the rest of the primary and secondary GN; IgAN was the least encountered among the other types of GN. For the steroids and immunosuppressive agents use in the treatment of GN, the respondents were close in frequency to the current practice for the different types of this disease. There were 52 (30%) respondents who believed that the current protocols for treatment of GN are satisfactory, with a minimal room for improvement, while 74 (43%) had no idea about this issue. Moreover, there were only 44-49 (26-29%) respondents who answered the questions about the use of rituximab in the different types of GN and believed that the indications of it could cover most GN with variable degrees; the most popular use of rituximab in GN included MGN and lupus nephritis. We conclude that the set-up for the evaluation and treatment of GN patients is restricted in Saudi Arabia. The exposure and expertise in treatment of the GN is limited and needs better addressing through more availability of nephrologists and performance of kidney biopsies. The quest for innovative effective therapy, such as rituximab, to prevent progression of CKD secondary to GN is still warranted.

Prevalence of anemia in predialysis chronic kidney disease patients.

To evaluate the prevalence of anemia in a large cohort that comprises patients in different stages of chronic kidney disease (CKD) in the kingdom of Saudi Arabia (KSA), we conducted a multi-center cross-sectional study of a cohort of CKD patients who have not started dialysis. The study patients were recruited from the nephrology clinics in 11 different medical centers distributed all over the regions of the KSA. For the estimated glomerular filtration rate (GFR), we used the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation. There were 250 study patients who fulfilled the criteria for the study. The patients were stratified according to their GFR as follows: stage 1: 19 patients, stage 2: 35 patients, stage 3: 67 patients, stage 4: 68 patients, and stage 5: 61 patients. The composite of proteinuria and abnormal imaging in stages 1 and 2 was satisfied in 100% of the cases. The prevalence of anemia was elevated for the hemoglobin levels below 12 g/dL (the level at which the evaluation of anemia in CKD should be initiated) in the different stages of CKD, that is, 42%, 33%, 48%, 71%, and 82% in the stages from 1 to 5, respectively. The prevalence was also elevated for the hemoglobin levels below 11 g/dL (the minimum hemoglobin level at which therapy should be initiated with erythropoietin), that is, 21%, 17%, 31%, 49%, and 72%, respectively for stages from 1 to 5. In conclusion, we found a large prevalence of anemia among the CKD population in Saudi Arabia, and the burden of patients who require treatment with erythropoietin is considerably large. However, the response to therapy will not require large doses according to the availability of long-acting erythropoiesis stimulating agents, which will render the therapy more convenient and less expensive.

Survey of attitudes of physicians toward the current evaluation and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD).

We aimed in this study to determine the opinion of the medical directors of dialysis centers in the Kingdom of Saudi Arabia (KSA) about the updates of strategies for evaluation and treatment of chronic kidney disease-mineral and bone Disorder (CKD-MBD). A questionnaire was sent to medical directors of 174 dialysis centers in the KSA between July and November 2009. The questionnaire was opinion based and comprised the prevalence of the CKD-MBD, strategies of therapy and indications of cinacalcet, a new therapy in the CKD patients. A total of 154 medical directors of the 174 (88.5%), who are the therapeutic decision-makers for 10100 (89%) dialysis patients, answered the questionnaire. There were 84 respondents (54%) who believed that the parathormone (PTH) blood levels initially increase at a glomerular filtration rate (GFR) < 30%. There were 80 (53%) respondents who believed that changes of phosphorus (PO4) and calcium (Ca) blood levels are initially observed at GFR < 30 mL/min. The majority of respondents, 115 (77%), 116 (80%), 95 (66%), and 134 (90%) currently have observed increased prevalence of vascular calcifications, adynamic bone disease, PTH > 500 pmol/L, and elevated Ca blood levels, respectively, only in the minority of advanced CKD. However, 88 (58%) respondents observed increased prevalence of elevated PO4 blood levels in the majority of new dialysis and advanced CKD patients. There were 137 (89%) respondents who believed from the current published evi-dence that CKD-MBD may result in increased morbidity (e.g. fractures) and mortality (e.g. cardiovascular) in advanced CKD and new dialysis patients. However, only 41 (27%) respondents follow the PTH levels in their patients every 2-3 months, while 81(53%) follow it every 6 months. There were 127 (83%), 129 (84%), 114 (75%) respondents who would start vitamin D (vit D) in dialysis and CKD patients for hypocalcemia, high PTH, and vit D 1,25 deficiency, respectively. However, only 51 (34%) respondents would start vit D therapy for vit D 25 deficiency. There were 98 (75%), 73 (57%) 74 (59%), and 88 (68%) respondents who claimed that they could achieve control of calcium levels alone, control of PO4 levels alone PTH levels alone , and all parameters of CKD-MBD in > 50% of their patients, respectively. There were 126 (82%) and 126 (82%) respondents who agreed to the indications of the cinacalcet that include refractory secondary hyperparathyroidism of dialysis patients to vit D and diet and phosphate binders together, and when surgical parathyroidectomy is contraindicated or fail in this population, respectively. However, 127 (83%) and 139 (91%) respondents disagreed to the indications that include indiscriminate prescription to all CKD patients or off label to some early CKD patients, respectively. We conclude that the medical directors of the active dialysis centers in Saudi Arabia are well aware of the morbidity and mortality caused by the CKD-MBD in addition to the indications of vit D and phosphate binders and cinacalcet therapy. However, the study suggests inadequate assessment of the prevalence, patterns of CKD-MBD, and results of intervention in the CKD patients such as treatment of vit D 25 deficiency, and knowledge of the availability of cinacalcet for the treatment of CKD-MBD. More local studies and guidelines are required to disseminate information about the current patterns of CKD-MBD for better approach to the management of this disorder in the kidney centers in this country.

Survey of attitude of physicians on updates in the management of anemia in chronic kidney disease patients.

We aimed in this study to assess the opinion of medical directors of dialysis centers in the Kingdom of Saudi Arabia (KSA) about updates of strategies for treatment of anemia in patients with chronic kidney disease (CKD). A questionnaire was sent to the medical directors of the 174 active dialysis centers in the KSA including centers under the Ministry of Health (MOH) (67 %), the governmental non-MOH sector (12%) and private hospitals (21 %) that together care for a population of more than 11,300 chronic dialysis patients. The study was performed between November 2008 and March 2009. A total of 143 of the 174 (82.1%) medical directors answered the questionnaire. This covered 9563 (84%) dialysis patients in the KSA. There were 95 (68.8%) respondents who believed that the mechanism of action of ESAs is due to both blood concentration and direct action on the stem cells that form red cells. Only 81 (57%) respondents believed that the half-life of the short-acting ESAs is less than one day, 67 (46.9%) believed the half-life of darbepoetin is 2-4 days, and 52 (36.6%) believed the half-life of CERA is 5-10 days; 79 (55.6%) respondents believed that the interval of dosing of darbepoetin is once biweekly, and 92 (71.9%) believed that the interval of dosing of CERA is once a month. There were 110 (76.9%) respondents who believed the CKD should receive a long-acting than short-acting ESAs for the more stable hemoglobin levels, 64 (44.8%) believed that pharmacodynamics of the CERA are better than other ESAs and warrant its use over all of them, and 115 (80.6%) believed that the target hemoglobin is 11-13 g/dL in CKD patients is well established. Finally, 65 (51.5%) respondents would request more than 30% of the stock of ESAs in the future as short-acting ESAs vs 71 (55%) for darbepoetin and 40 (37.4%) for CERA. There were no statistically significant differences among the respondents according to their affiliations (MOH, non MOH and private sector) on any of the issues in the questionnaire. We conclude that our results showed inadequate awareness of the medical directors of the dialysis centers in the KSA of the mechanisms of action of ESAs and the new agents such as the CERA. However, they were well informed about the limits of the targeted hemoglobin levels and showed a trend toward using the long-acting ESAs.

Effectiveness of a separate training center for peritoneal dialysis patients.

The aim of this study is to analyze the patients' database of the Baxter's Training Peritoneal Dialysis Program (BTPDP) adopted at the Baxter Renal Education Center (BREC), Riyadh, Saudi Arabia in order to determine its effectiveness in the management, compliance, and outcome of the trained peritoneal dialysis (PD) patients. The study analyzes the database of the BTPDP, which includes the demographic data, duration of follow-up, complications, and outcome of the patients trained on PD between September 2003 and November 2007. Records of 376 patients with a mean age of 46.0+/-22.6 years were available in the database for analysis. Of them, 187 (49.7%) were males, 312 (82.9%) were trained at the BREC, 315 (83.8%) were new PD patients, and 298 (79.3%) were trained on automated PD (APD). The dropouts during the study period included 172 patients (46%); 42 (24.4%) were transplanted, 45 (26.2%) switched to hemodialysis, 57 (33.1%) died and 28 (16.3%) were lost to follow-up. A comparison was made between the group trained at the BREC and the group trained at the hospital. There was an overwhelming adoption of BTPDP by the different hospitals during the study period (p<0.00001). There were 264 (84.6%) patients trained on APD at the BREC vs. 34 (53.1%) at the hospital (p<0.00001), and the patients trained at the BREC had significantly less dropouts than those trained at the hospital during the study period 135 (43.3%) vs. 38 (59.4%) respectively (p<0.02). The mean period of follow-up was significantly different between the patients trained at the BREC and those trained at the referring hospital (390+/-461 days vs. 679+/-779 days respectively (p<00000.8). Also, there was a trend for better technique survival after the second year, among the patients trained at the BREC. We conclude that the BREC model has increased the recruitment to PD, and helped in spreading this method of renal replacement therapy among patients. This model emphasizes the role of a designated training course by an expert team, and unifies the training standards. Furthermore, application of this model can be expanded nationwide and even to other countries.

Attitude of physicians in Saudi Arabia towards anemia treatment strategies in patients with chronic kidney disease.

We aimed in this study to evaluate the attitude of physicians in the Kingdom of Saudi Arabia (KSA) towards strategies for treatment of anemia in patients with chronic kidney disease (CKD). A questionnaire was sent to 153 physicians in 148 active dialysis units in the KSA including centers under the Ministry of Health (MOH) (73.6%), centers in the governmental non-MOH sector (12.2%) and centers in private hospitals (14.2%) that together care for a population of more than 7900 chronic dialysis patients. The study was performed between April and June 2006. A total of 137 physicians (89.5%) answered the questionnaire from 129 (87.1%) dialysis centers that catered to 7052 (89.2%) dialysis patients. There were 104 respondents (75.9%) who staged their CKD patients according to the level of glomerular filtration rate (GFR). The estimated mean prevalence of each stage of CKD in the respondents' clinics was 15%, 19%, 29%, 22%, and 29% for the stages 1, 2, 3, 4, and 5, respectively. The estimated prevalence of anemia [hemoglobin (Hb) < 110 g/L] in the different stages of CKD were 11%, 17%, 38%, 59%, and 78% in stages 1, 2, 3, 4, and 5, respectively. However, only 69 respondents (48%) answered these two questions. Sixty-seven respondents (50.4 %) believed that any patient with Hb < 110 g/L should receive r-HuEPO irrespective of the CKD stage, and 133 (99.3%) believed that correction of anemia in the CKD patients has documented impact on morbidity and mortality. In case of availability of a long acting r-HuEPO such as darbepoetin, 88 (66.2%) respondents would use it as their first choice other than the current short acting drug. Our survey suggests that the current practices concerning anemia management in CKD patients in the KSA may not be satisfactory. There are many centers that do not have data on the prevalence of CKD or anemia in their units. More studies are required to explore the quality of services rendered to the CKD patients and guidelines need to be outlined for the management of anemia in the CKD patients.

Attitude of physicians towards the follow-up of renal transplant patients: a questionnaire survey in Saudi Arabia.

The goal of this study was to evaluate the attitude of the physicians towards the follow-up of the renal transplant patients in the Kingdom of Saudi Arabia (KSA). We sent a questionnaire to 168 physicians working in 148 active dialysis centers in the KSA. The study was conducted from June-October 2005. There were 140 physicians (83.3%) who answered the questionnaire; they represented 136 (91.9%) dialysis centers. There were 43 (31.2%) respondents who had a transplant clinic for follow-up of transplant recipients. Of the 96 (69.1%) who did not have a clinic, 29 (30.2%) claimed expertise for follow-up of transplant recipients, six (6.2%) had a laboratory set-up to monitor the immunosuppressive drug levels and 40 (44.4%) felt the need for one. There were 121 (89%) respondents who would consider the chronic renal failure (CRF) patients for transplantation because it is the best form of therapy. Seventy-seven respondents (55%) had a protocol for work-up of the CRF patients for transplantation, 31 (22.3%) had a coordinator for the work-up of the transplant candidates, 34 (24.5%) had regular meetings to decide on the waiting list for transplantation, and 51 (37.8%) had affiliation with, or worked at a transplant center. Nevertheless, 127 (90.7%) respondents believed that the results of renal transplantation were good enough to recommend the procedure to all patients as early as possible. There were 133 (97.1%) respondents who believed that organ shortage was the major factor for the low percentage of renal transplantation. Only 52 (37.1%) respondents knew about the recent regulations established by the World Health Organization (WHO) for organ donation. There were 63 (48.1%) respondents who believed that seeking commercial renal transplantation outside the KSA to be unacceptable because of the medical and ethical complications involved. Many respondents (71.4%) from non-MOH hospitals, and those who had transplant clinics believed that the tacrolimus + mycophenolate combination was the most popular immunosuppressive regimen for renal transplant patients. Our survey suggests that the current practices concerning the work-up and follow-up of transplant patients in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit.

Attitude of transplant centers in the Middle East towards the follow-up of renal allograft live donors.

In an attempt to survey the attitude of the heads of some distinguished transplant programs in the Middle East countries towards the follow-up and complications that may ensue in the live renal allograft donors, we sent a questionnaire to 29 active renal transplant centers in the Kingdom of Saud Arabia (KSA) and some other Middle East countries, which together perform about 1500 living renal transplantations annually. The study was performed during November-December, 2005. Th questionnaire was intended to evaluate the presence of a protocol that guides the physicians in their selection, work-up and follow-up of the live renal allograft donors, the presence of regular time schedule for follow-up of the donors during the first year and thereafter, and the tests performed during these clinic visits, the physicians' perception towards the life-long health insurance of the live donors as well as the physicians' estimates of the major complications that may occur in the live donors such a hypertension, proteinuria, chronic renal failure, early surgical complications and depression. There were 20 responses (69%) from transplant centers that together perform about 1200 (80%) living rena transplantations annually. There were 18 (90%) respondents who had a protocol to guide the selection o the live renal allograft donors, 10 (52.6%) had a written policy for post-donation follow-up of live renal allograft donors, 15 (83.3%) would see the donors for the first time within three months post-discharge, 10 (66.7%) would see the donors every three months thereafter during the first year and 11 (68.8%) would see them once a year after the first year. There was a consensus among the respondents to monitor the renal function tests that include plasma urea creatinine and urinalysis. The post donation incidence of hypertension, proteinuria, chronic renal failure, early surgical complications and psychological problems such as depression was estimated by more than 80% of the respondents as 1-5%. We conclud that the current practices concerning the follow-up of renal allograft live donors by the dialysis centers i the Middle East seem promising. However, this being a questionnaire survey, results may not be totall accurate. Prospective studies are required to ensure that protocols for follow-up are abided by.

The attitude of physicians towards education and rehabilitation of patients on chronic dialysis: a questionnaire survey.

In this study, we aimed to evaluate the attitude of physicians in the Kingdom of Saudi Arabia (KSA) towards the education and rehabilitation of chronic dialysis patients Questionnaires were sent to 155 physicians working in 148 dialysis centers. They included 109 centers (73.6 %) in the Ministry of Health (MOH), 18 (12.2%) in governmental non-MOH sector and 21 centers (14.2 %) in private hospitals that together care for a population of more than 7,900 chronic dialysis patients. The study was performed between January and March 2006. Responses were received from 141 physicians (90.9%) from 140 (94.5%) dialysis centers. There were 134 (97.1%) respondents who believed that the ideal ratio of patients per dialysis nurse should be < or = 3, 132 (97.1%) believed that the ideal ratio of patients per physician should be < or = 25, 120 (88.9%) believed that the ideal ratio of patients per dietitian should be < or = 50, and 102 respondents (81.0%) believed that the ideal ratio of patients per social worker should be < or =50. There were 46 respondents (32.6%) who always and 53 (37.6%) who mostly found time to educate the patients about the various options available for renal failure treatment. Educational tools, such as reading materials and audiovisuals, were only available to 56 respondents (42.7%). There were 88 (63.3%) respondents who always discussed results of laboratory tests in detail with their dialysis patients, while 48 (34.5%) informed patients when any abnormality was discovered. There were 130 respondents (94.9%) who believed that their patients were satisfied with services of the physicians, 53 (39.0%) with the dietitian's, 57 (42.5%) with the social worker's, and 131 (94.9%) with the nurses' services. Our survey suggests that that the current practices concerning education and rehabilitation of patients in the dialysis centers in the KSA may not be satisfactory. More studies are needed to explore these issues.

Attitude of Physicians towards the Management of Bone Disease in Hemodialysis Patients: A Questionnaire Based Survey.

This study is aimed at evaluating the attitude of physicians in dialysis centers in the Kingdom of Saudi Arabia (KSA) towards the management of bone disease. We sent a questionnaire to 168 physicians who jointly cared for 7214 chronic hemodialysis (HD) patients. A total of 134 physicians (79.8%) answered the questionnaire from 134 dialysis centers (91.7%) that cumulatively catered to 7030 dialysis patients (97.6%). Of them, 71 (53.4%) had a protocol for management of bone disease at their centers, while 87 (67.4%) believed that the current results of management of bone disease were satisfactory. About 84.2% and 82.7% of the physicians checked serum calcium and phosphorus levels respectively monthly, while only 24.6% would check parathormone (PTH) once every three months; 32.8% did not have this latter test available in their centers. Bone x-rays of the hands and clavicles were being performed once every year by 47.4%, while 38.4% would perform the x-rays as indicated by the clinical status. Therapy would be aimed to achieve mid-normal calcium and phosphorus levels by 64.9% and 56.8 % of the respondents respectively, while only 29.3% would try to achieve three times the normal level of the PTH. Only 43.3% of the respondents believed that sevelamer would be a safer phosphate binder than calcium or metal based one. Almost all the respondents used vitamin D, mostly by daily oral administration. Fifty-nine respondents (44.4%) believed that sevelamer plus vitamin D was better to control PTH than calcium-based phosphate binder plus vitamin D, while 51 (38.3%) had no idea about this issue. There were 57 respondents (42.5%) who believed that high intake of calcium would increase the risk of vascular and metastatic calcifications without hypercalcemia, while 43 (32.1%) had no idea. There were a significantly lower percentage of MOH centers having a protocol for management of bone disease in the dialysis patients. Also, there was a higher percentage of non-availability of PTH assay, lower tendency of the physicians to target low normal level of phosphorus and higher percentage to target normal levels of PTH in MOH centers. In addition, MOH physicians had significantly lesser tendency to consider sevelamer the best phosphate binder for the dialysis patients. Our study suggests that the current practices concerning the management of bone disease in dialysis centers in the KSA require refinement and a protocol to guide the management is required.

Survey of the attitude of physicians towards establishing and maintaining a peritoneal dialysis program.

In an attempt to evaluate the attitude of physicians towards establishing and maintaining a peritoneal dialysis (PD) program in the Kingdom of Saudi Arabia (KSA), we sent a questionnaire to 160 physicians; the heads of the 148 active dialysis centers in the KSA and 12 other consultants working in these centers. This covered decision makers in 109 centers (73.6%) in the Ministry of Health (MOH), 18 (12.2%) in Governmental-non-MOH centers, and 21 (14.2%) in private hospitals that, together, care for a population of more than 7300 patients on chronic hemodialysis (HD) and 559 on PD. The study was performed between September and December 2005. A total of 145 of the 160 physicians (90.6%) from 141 dialysis centers (95.2%) answered the questionnaire. There were 81 respondents (56.3%) who believed that follow-up of the PD patients should be available in all the dialysis centers, 80 (55.2%) would like to have a PD clinic at their centers, and only 20 (13.8%) had PD clinics in their centers. However, 93 (66.4%) respondents did not request from the administration of their hospitals to open a PD clinic and 62 (44.6%) admitted to having no expertise in managing the patients on PD, while 53 (38.1%) claimed that they did not have enough space in their dialysis centers to start a PD program. Regarding training and expertise, 57 (40.7%), 58 (43.3%), 48 (35.6%) and 72 (52.9%) physicians had training in continuous ambulatory PD (CAPD), intermittent peritoneal dialysis (IPD), automated peritoneal dialysis (APD) or continuous cyclic peritoneal dialysis (CCPD), and acute PD, respectively. The comparisons between the health sectors in the KSA showed that MOH had significantly less active PD programs, and this reflected tremendously on the knowledge of the staff. Our survey indicates that the current practices concerning the PD programs in the KSA are modest, and that a new strategy is required to spread this modality of therapy horizontally in all the dialysis centers, and vertically by introducing the latest technologies in the field of PD, such as automated PD machines and connectology. There is also a need to increase the awareness of physicians about the benefits and applicability of PD. National guidelines and training are indispensable and cannot be overemphasized to improve this service, especially in the MOH hospitals.

Attitude of Physicians toward the Use of Erythropoietin in Hemodialysis Patients.

We attempted in this study to evaluate the attitude of the physicians in The Kingdom of Saudi Arabia (KSA) towards the use of recombinant human erythropoietin (r-HuEPO) in patients on hemodialysis (HD). We sent a questionnaire to 181 physicians in the 147 active dialysis centers in KSA; 110 (74.9 %) of them were under the Ministry of Health (MOH), 14 (9.5%) in Governmental non-MOH hospitals and 23 (15.6 %) were in private hospitals. This covered a population of more than 7300 chronic HD patients. The study was conducted from October to December 2004. Response was obtained from 144 physicians (79.5%), working in 135 dialysis centers (92.5%) that totally treated 7107 (97%) HD patients in the KSA. Of the 144 respondents, 99 (72.8%) responded that they would use r-HuEPO therapy for all new HD patients not guided by hemoglobin (Hb) level. Almost all the respondents would start the patients on a weekly dose of 70% of the dialysis patients with the drug in comparison with the non-MOH and private sector centers (81% vs 100%, respectively P< 0.04). There was a significantly less percentage of MOH than the non-MOH centers to have a written protocol for administration of r-HuEPO (49.1% vs 95% respectively, P< 0.0002). In conclusion, a protocol to guide the r-HuEPO therapy in HD patients is lacking in many centers of the KSA and there is a need for increased awareness of the physicians working in those centers in the practical aspects of the use of this drug in the treatment of anemia in this population.

Post-renal transplant proteinuria: the saudi experience.

We conducted this study to evaluate the risk factors for proteinuria in renal transplant patients. We reviewed the records of the active renal transplant patients at two large transplant centers in Riyadh and Jeddah in Saudi Arabia, transplanted between January 1979 and November 1998. The recipients were grouped according to the presence and magnitude of proteinuria: group I; from zero-0.3 g/L, group II; from 0.4-1.0 g/L, group III; more than one g/L. The records of 340 patients were reviewed in this study. The mean age of the study patients was 39.7 years and the mean duration following transplantation was 82.2 months. There were 209 (61.5%) patients in group I, 92 (27.1%) patients in group II and 39 (11.5%) patients in group III. There was no significant difference among the three groups in terms of mean age, mean duration after transplantation, type of donor (living-related and unrelated, or cadaver), rate of re-transplantation (8.2%), prevalence of hypertension while on dialysis (66.6%), etiology of original renal disease, incidence of acute rejection in the first year, occurrence of diabetes after transplantation (30.6%), or mean serum level of cholesterol (5.9 mmol/L). In comparison to the other groups, group I had significantly more females (44.5 %), more patients with blood pressure within normal limits with or without treatment (56% versus 38% and 17% respectively), lower mean serum creatinine (125 micromol/L versus 149 and 173 micromol/L respectively), higher mean cyclosporine dose (3.28 versus 2.7 and 2.73 mg/kg/day respectively), higher mean prednisolone dose (0.15 mg/kg/day) and less frequency of abnormal electrocardiogram (10% versus 22% and 25% respectively). We conclude that the prevalence of post-transplant proteinuria is high in our study patients. Also, our study suggests that proteinuria may be a marker of renal dysfunction and cardiovascular disease in this group of patients. Further studies are required including allograft histology to delineate better the causes and consequences of post-transplant proteinuria.