Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Prescription of CRRT: a pathway to optimize therapy

Severe acute kidney injury (AKI), especially when caused or accompanied by sepsis, is associated with prolonged hospitalization, progression to chronic kidney disease (CKD), financial burden, and high mortality rate. Continuous renal replacement therapy (CRRT) is a predominant form of renal replacement therapy (RRT) in the intensive care unit (ICU) due to its accurate volume control, steady acid-base and electrolyte correction, and achievement of hemodynamic stability. This manuscript reviews the different aspects of CRRT prescription in critically ill patients with severe AKI, sepsis, and multiorgan failure in ICU. These include the choice of CRRT versus Intermittent and extended hemodialysis (HD), life of the filter/dialyzer including assessment of filtration fraction, anticoagulation including regional citrate anticoagulation (RCA), prescribed versus delivered CRRT dose, vascular access management, timing of initiation and termination of CRRT, and prescription in AKI/sepsis including adsorptive methods of removing endotoxins and cytokines.

Continuous renal replacement therapy: Principles, modalities, and prescription

The mortality rate of critically ill patients with severe acute kidney injury (AKI) remains high. The associated sepsis and septic shock, as well as the presence of multiorgan failure, further increase the risk of death. Renal replacement therapy (RRT) represents the cornerstone of the management of severe AKI. Continuous RRT (CRRT) has been considered the predominant form of dialysis in the intensive care unit due to its accurate volume control, steady acid-base, and electrolyte correction and achievement of hemodynamic stability. This narrative review covers an introduction to CRRT, its physiologic principles, modalities, requirements, indications, and different elements of adequate prescription.

The dialysis outcomes and practice patterns study phase 5 in the Gulf Cooperation Council countries: Design and study methods

The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international prospective cohort study of the relationships between hemodialysis (HD) care practices and HD patient outcomes. The DOPPS began in 1996, in the United States, and has since expanded to 21 countries, collecting detailed data from >75,000 HD patients, with >200 scientific publications, focused on describing HD practices associated with improved HD patient outcomes. The goal of DOPPS is to help HD patients "live better and live longer." Starting in 2012, the DOPPS was able to expand to all six of the Gulf Cooperation Council (GCC) countries, namely, Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. The DOPPS study design consists of selecting HD facilities for study participation in each country to represent the different types of HD facilities and geographic regions within each GCC country. Within each study site, HD patients were randomly selected for detailed data collection to represent the HD practices within each participating HD facility. Altogether, 41 HD facilities have participated in the GCC-DOPPS Phase 5 study including 20 facilities from Saudi Arabia, nine from the United Arab Emirates, four each from Kuwait and Oman, two from Qatar, and one from Bahrain. Herein, we provide a detailed description of the study design and methods, data collection, study management, scientific investigator oversight and guidance, and study governance and support for the GCCDOPPS Phase 5 study.

Changes in biochemical, hemodynamic, and dialysis adherence parameters in hemodialysis patients during Ramadan

This paper aimed to study the effect of Ramadan fasting on biochemical and clinical parameters and compliance for dialysis. A prospective multicenter observational cross-sectional study comparing fasting with a non-fasting stable adult hemodialysis patients for demographic and biochemical parameters, compliance with dialysis, inter-dialytic weight gain, pre- and post-blood pressure, and frequency of intradialytic hypotensive episodes was carried out. Six hundred thirty-five patients, of whom 64.1% fasted, were studied. The fasters were younger (53.3 ± 16.2 vs. 58.4 ± 16.1 years; P = 0.001) but had similar duration on dialysis (P = 0.35). More fasters worked (22.0% vs. 14.6%; P = 0.001) and missed dialysis sessions during Ramadan. No differences were noted between groups in sex, diabetic status, or dialysis shift or day. There were no differences in the pre- and post-dialysis blood pressure; serum potassium, albumin or weight gain; diabetic status; sex; and dialysis shift time or days. However, serum phosphorous was significantly higher in the fasting group (2.78 ± 1.8 vs. 2.45 ± 1.6 mmol/L; P = 0.045). There were no intragroup differences in any of the parameters studied when comparing the findings during Ramadan with those in the month before Ramadan. Fasters were significantly younger and more likely to be working, to miss dialysis sessions, and to have higher serum phosphorous levels. No other differences were observed.

A Randomized Trial on Health-Related Patient Satisfaction Level with High-Efficiency Online Hemodiafiltration versus High-Flux Dialysis

Background/Aim: Our aim was to investigate the effect of on-line HDF versus high-flux (HF) hemodialysis (HD) on a patient's health-related satisfaction level. Methods: Overall, 72 patients, on regular low-flux HD for 51 ± 26 month mean age of 54 ± 12 years, were randomized to HF (group 1, n = 36) and to HDF (group 2, n = 36) and followed up for 24 months. Assessment was based on the patient's satisfaction level using modified questionnaires of the validated Kidney Disease Quality of Life-Short Form (KDQOL-SF) version 1.3. Results: The HDF group achieved a higher satisfaction level than the HF group (p < 0.0001) with less cramps (3 ± 5 vs. 55 ± 8), itching (9 ± 10 vs. 48 ± 10), joint pain and stiffness (24 ± 10 vs. 83 ± 8), and improvement in general mood (94 ± 9 vs. 28 ± 16), sexual performance (57 ± 10 vs. 5 ± 5), and social activity (82 ± 9 vs. 15 ± 8). Conclusion: High-efficiency postdilution on-line HDF versus high-flux HD significantly improved patients' satisfaction and quality of life, including social, physical, and professional activities.

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.

Stress and burnout among hemodialysis nurses: a single-center, prospective survey study

Stress is a well known and identified problem within the nursing profession. Dialysis nurses are exposed to high level of stress. Increasing workload can aggravate stress and cause burnout and exhaustion. Stress and burnout are capable of having a detrimental impact on organizational productivity and pose serious health and safety hazards on the job. We aimed in this study to determine the type and level of stress and the amount of burnout among our dialysis nurses, and to evaluate the managing skills and the impact of stress on their work performance. There were 93 nurses (19 national and 74 expatriate nurses) who answered modified questionnaires to the aims of our prospective and descriptive correlational study. Our results show that most nurses involved in the study (national and expatriate) experienced a mild level of stress (79% and 68%, respectively) and moderate level of burnout (42% and 38%, respectively). The most common stressor among the national nurses was technical breakdowns of machines (15.9%) and that among expatriates was job insecurity (16.9%). The majority of the national nurses (21%) coped with this by increased sick leaves, whereas the majority (25%) of the expatriates responded by becoming easily frustrated. The most utilized coping skill among both groups was the relaxation methods (20.8% versus 24.9%) and the least utilized was denial (3.9% versus 0.5%). In conclusion, our results suggest the exposure of dialysis nurses to different types of stress and demonstrate the different experienced coping skills. These results may have implications for nursing management and hospital administration.

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.

Infection control in hemodialysis units: a quick access to essential elements

Infection is the most common cause of hospitalization and the second most common cause of mortality among hemodialysis (HD) patients, after cardiovascular disease. HD patients as well as the dialysis staff are vulnerable to contracting health-care-associated infections (HAIs) due to frequent and prolonged exposure to many possible contaminants in the dialysis environment. The extracorporeal nature of the therapy, the associated common environmental conditions and the immune compromised status of HD patients are major predisposing factors. The evident increased potential for transmission of infections in the HD settings led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions. Different international organizations have generated guidelines and recommendations on infection prevention and control for implementation in the HD settings. These include the Centers for Disease Control and Prevention (CDC), the Association of Professionals in Infection Control (APIC), the Kidney Disease Outcomes Quality Initiative (K/DOQI), the European Best Practice Guidelines/European Renal Best Practice (EBPG/ERBP) and the Kidney Disease: Improving Global Outcomes (KDIGO). However, these guidelines are extensive and sometimes vary among different guideline-producing bodies. Our aim in this review is to facilitate the access, increase the awareness and encourage implementation among dialysis providers by reviewing, extracting and comparing the essential elements of guidelines and recommendations on infection prevention and control in HD units.

Modalities of hemodialysis: quality improvement

Hemodialysis (HD) treatment had, over many years, improved the survival rate of patients with end-stage renal disease. However, standard or conventional HD prescription is far from being optimal in replacing the function of normal kidneys. Its unphysiologic clearance pattern and inability to remove all types and sizes of uremic toxins results in inter- and intra-dialysis complications and an unacceptably high rate of cardiovascular morbidity and mortality. Efficiency of HD can be improved by increasing blood and dialysate flow rates, dialyzer size and surface area and duration and frequency of dialysis sessions. Home HD, where short daily or long slow nocturnal HD sessions can conveniently be performed, provides an excellent option for quality of life improvement and reduction in morbidity and mortality. Recent innovations in the specifications of HD machines and improvement in dialysis membranes characteristics and water treatment technology paved the way for achieving quality HD. These advancements have resulted in efficient implementation of adsorption, diffusion and/or convection principles using adsorption HD, hemofiltration, hemodiafiltration (HDF) and online HDF modalities in order to achieve optimum HD. Implementation of these innovations resulted in better quality care achievements in clinical practice and reduction in morbidity and mortality rates among HD patients.

The value of pre-dialysis care

Chronic kidney disease (CKD) is one of the major health care burdens worldwide, with a significant increase in the number of patients and a huge increase in the financial demands in recent years. Patients with CKD usually progress through different stages before they reach end-stage renal disease. The rate and speed of renal function deterioration are variable, but uncontrolled hypertension and diabetes mellitus are major risk factors. Pre-dialysis care, with change of life style, blood pressure and glycemic control, the use of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers, lipid-lowering agents and management of anemia and mineral bone disorder can improve quality of life, preserve functioning nephrons and reduce cardiovascular morbidity and mortality with significant reduction in management costs. Early referral of patients with CKD to the nephrologist allows for adequate exposure to educational programs, psychosocial preparation, participation in the decision of type of renal replacement therapy (RRT), pre-emptive kidney transplantation, early creation of dialysis access and adequate training in selected modality of RRT. The degree of involvement and interaction must be individualized according to the needs of the patient and the type of RRT planned. A multi-disciplinary team is crucial for the implementation of a variety of strategies and to intervene more effectively in meeting the health care needs of CKD patients.

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.

Caring for Patients with CRF: Rewards and Benefits

Patients with CRF usually progress through different stages before they reach ESRD and require special medical, social and psychological care and support during the pre-ESRD and following renal replacement therapy (RRT). Early referral of patients with CRF has the advantage of receiving adequate management and regular followup, with significant reduction in cardiovascular morbidity and mortality, attending an education program, prepared psychologically, participate in the decision of type of RRT, preemptive kidney transplantation, early creation of dialysis access, and adequate training in selected modality of RRT. During the early stages of commencement of RRT, psychological support and social care with rehabilitation program are mandatory. The degree of involvement and interaction must be individualized according to the needs of patient and type of RRT. A multidisciplinary team is crucial for implementation of a variety of strategies to help staff intervene more effectively in meeting the care needs of CRF patients.

Outcome of patients treated with automated peritoneal dialysis: effects of selection of patients

To determine the effect of selection of peritoneal dialysis patients who used auto-mated PD (APD) as a first renal replacement therapy (RRT) option, we studied two groups of adult chronic kidney disease (CKD) patients treated with APD over a period of 4 years: group 1 included 30 patients in whom APD was the first choice for RRT and group 2 included 40 patients transferred from failed hemodialysis (HD) treatment. Both groups were matched for the original causes of CKD and comorbid conditions. However, group 1 had significantly higher residual renal function (RRF) than group 2 [glomerular filtration rate (GFR) 11.85 ± 4 mL/min and urine output 995 ± 465 mL/day vs. 3.69 ± 3.7 mL/min and 340 ± 447 mL/day, respectively, P = 0.0001] and Kt/v (2.7 ± 0.7 vs. 1.9 ± 0.4, respectively, P = 0.006). Most of the patients were compliant with their APD prescription, performed ideal PD techniques, achieved adequate dialysis and fluid ultra-filtration, and experienced much less than average infectious and non-infectious complications. However, group 1 achieved better clinical outcome than group 2, including relatively higher survival rate and kidney transplantation, significantly fewer episodes of peritonitis per year (0.09 vs. 0.14, respectively, P = 0.0001), higher serum albumin (2.95 ± 0.3 vs. 2.7 ± 0.27 g/dL, respectively, P = 0.035), hemoglobin (11.5 ± 0.9 vs. 10.6 ± 0.7 g/dL, respectively, P = 0.022) and lower parathormone levels (283 ± 117 vs. 389 ± 269 pg/mL, respectively, P = 0.02). They also maintained significantly higher total fluid removal compared to group 2 (1120 ± 330 vs. 560 ± 300 mL/day, respectively, P = 0.004), higher RRF (GFR 8 ± 2.6 mL/min vs. 1.8 ± 2.4 mL/min, respectively, P = 0.0001), and urine output (556 ± 447 mL/day vs. 240 ± 347 mL/day, respectively, P = 0.004), and significantly higher Kt/v (2.8 ± 0.7 vs. 1.9 ± 0.4, respectively, P = 0.2). In conclusion, in CKD patients, PD is a viable initial modality of RRT, and with better RRF may have a better outcome than as a secondary choice.

Factors affecting hemodialysis patients' satisfaction with their dialysis therapy

Aim. To assess the degree of satisfaction among hemodialysis patients and the factors influencing this satisfaction. Methods. Patients were recruited from 3 Saudi dialysis centers. Demographic data was collected. Using 1 to 10 Likert scale, the patients were asked to rate the overall satisfaction with, and the overall impact of, their dialysis therapy on their lives and to rate the effect of the dialysis therapy on 15 qualities of life domains. Results. 322 patients were recruited (72.6% of the total eligible patients). The mean age was 51.7 years (±15.4); 58% have been on dialysis for >3 years. The mean Charlson Comorbidity Index was 3.2 (±2), and Kt/V was 1.3 (±0.44). The mean satisfaction score was (7.41 ± 2.75) and the mean score of the impact of the dialysis on the patients' lives was 5.32 ± 2.55. Male patients reported worse effect of dialysis on family life, social life, energy, and appetite. Longer period since the commencement of dialysis was associated with adverse effect on finances and energy. Lower level of education was associated with worse dialysis effect on stress, overall health, sexual life, hobbies, and exercise ability. Conclusion. The level of satisfaction is affected by gender, duration on dialysis, educational level, and standard of care given.

H1N1 in dialysis units: prevention and management

Dialysis patients are at increased risk of contracting influenza A H1N1 and developing serious illness. Increasing the awareness of dialysis patients and continuous education and training of medical staff on early recognition and management of influenza A H1N1 can help in saving the life of patients. Antiviral drugs and influenza vaccines are effective in providing adequate immunity in dialysis patients with strict implementation of infection control policies and procedures can help in preventing and controlling the dissemination of influenza A H1N1 in dia-lysis units. We report a case of a patient who presented with H1N1 influenza and developed acute kidney injury during his hospitalization and his course with disease.

Pregnancy and contraceptive issues in renal transplant recipients

Fertility is improved within months and conception is achieved within one to six years after kidney transplantation. Pregnancy is safe and has little effect on long-term graft survival, but has increased maternal and fetal risks. Pregnancy is contraindicated in the first two years post-kidney transplantation due to increased risk of acute rejections and higher doses of immunosuppressive drugs. Poor renal function, uncontrolled diabetes mellitus and hypertension are other contraindications. Family planning and counseling, and consideration of a suitable contraceptive method are essential before transplantation. Tubal ligation and vasectomy are permanent contraceptives with the least failure results. Combined pills are highly effective and are among the lowest failure rate contraceptives, but they interact with cyclosporine, and are contraindicated in patients with thromboembolism and deep vein thrombosis. Progesterone-only minipill has the advantage of avoiding the risks associated with estrogen, but has a higher failure rate than the combined pills. The barrier methods (condom and diaphragm) are effective and safe contraceptives and can prevent sexually transmitted diseases, but require motivated couples. Intra uterine devices are convenient contraceptives, but have higher failure rate and are associated with increased incidence of pelvic infection. Pregnancy in renal transplant recipients should be managed by a multidisciplinary approach in a tertiary centre.

Modulation of renal inflammation: therapeutic strategies

Inflammation is a complex process that reflects the local and systemic responses to different immunological and non-immunological stimuli, enable resistance to disease, repair of tissue damage, and restoration of normal function with the least possible tissue damage. This is achieved by intact regulatory immune system, which includes pro- and anti-inflammatory cytokines, chemokines, growth factors, complement cascade system, renin-angiotensin system, and different sets of adhesion molecules expressed on leukocytes and vascular endothelium, in addition to neutrophils, monocytes/macrophages, and different subsets of T-lymphocytes. Once imbalance occurs in the different factors of the inflammatory response to injurious stimuli, inflammation will proceed and exacerbate tissue damage. Inflammation can be initiated by different stimuli such as deposition or formation of antibody-antigen immune complexes, sensitized T-cells, trauma, tissue necrosis, or infection. It is characterized by activation of acute phase response and release of reactants/markers such as C-reactive protein. Renal inflammation can occur either as an isolated local acute inflammatory reaction or as part of a systemic inflammatory disorder. Recently, there have been tremendous advancements in the fields of immunology and molecular biology that helped in exploring the mechanisms of renal inflammation. This has been accompanied by extensive in vitro and in vivo studies that led to a better understanding of phenotypic changes and multifunctional potentials of local and infiltrating cells, role and control of different inflammatory mediators, adhesion molecules, and the rennin-angiotensin system within the site of inflammation. These achievements helped in researching into ways to modulate renal inflammation, control the severity of renal injury, promote regeneration and tissue repair, and induce tolerance.

Hepatitis C in dialysis units: the Saudi experience

Hepatitis C virus (HCV) infection is a significant health problem, as it can lead to chronic active hepatitis, liver cirrhosis, and hepatic carcinoma. Patients undergoing hemodialysis treatment are at increased risk of contracting HCV and other viral infections. This is primarily due to their impaired cellular immunity, underlying diseases, and blood exposure for a prolonged period. Transmission of viral hepatitis, and in particular HCV in dialysis units, has been showing a progressive increase worldwide, ranging between 5% in some western countries and up to 70% in some developing countries. The annual rate of HCV seroconversion in Saudi Arabia is 7% to 9%, while its prevalence is variable between 15% and 80%. This prevalence remained at almost 50% in recent years, despite the further increase in number of patients with end-stage renal disease and the expansion of dialysis services. The most prevalent genotypes in Saudi Arabia are genotype 4 followed by genotypes 1a and 1b, whereas genotypes 2a/2b, 3, 5, and 6 are rare. Genotypes 1 and 4 were associated with different histological grades of liver disease. Mixed infections with more than one genotype were observed in some studies. Isolation of dialysis machines and infected patients, together with strict application of infection-control policies and procedures and continuous education and training of nursing staff, remain the cornerstone in prevention and control of the spread of HCV infection in dialysis units. Interferon (INF)-alpha or pegylated INF, alone or in combination with ribavirin, have shown great promise in the treatment of chronic HCV in dialysis patients.

Monitoring iron status in end-stage renal disease patients on hemodialysis

Body iron stores should be assessed regularly and accurately during erythropoietin (r-HuEPO) replacement therapy. To evaluate the accuracy of the current tests, transferrin saturation (TSAT) and serum ferritin levels, in assessing and monitoring body iron stores, we studied 24 regular hemodialysis patients (19 males, mean age 47+/-18 years, and mean duration on hemodialysis 15+/-13 months) on regular erythropoietin therapy over a 12 month period. Patients were classified as having normal, deficient, indeterminate, or overload status depending on the values of TSAT and serum ferritin. Using TSAT and serum ferritin, iron status could be determined in 16 (67%) patients only; 12 (50%) had adequate (or normal) iron status, 3 (12.5%) had iron deficiency, and one (4.2%) had iron overload. In the remaining 8 patients, iron status was indeterminate; six patients had high serum ferritin with low TSAT (functional iron deficiency), and two patients had high TSAT values and low serum ferritin. Serum ferritin alone had very low specificity in diagnosing iron overload. In conclusion, when used together, TSAT and serum ferritin have a low sensitivity for diagnosing the iron status of CKD patients on HD. When TSAT and serum ferritin values diverge, they become unreliable in guiding iron therapy, and this set of findings generally indicates functional iron deficiency. There is a clear need to use the newer indices, like reticulocyte hemoglobin concentration and percentage of hypochromic red cells, which are more sensitive. This is likely to make the diagnosis of iron status more accurate and may reduce the requirements and frequency of iron and r-HuEPO administration.

Atypical presentation of xanthogranulomatous pyelonephritis: a case report

Xanthogranulomatous pyelonephritis (XPN) is a rare form of chronic pyelonephritis, which is usually caused by calculous obstructive uropathy. We present a previously healthy 45-year-old housewife, who was admitted to The Dammam Central Hospital, Dammam, Saudi Arabia with left loin pain and increased frequency of micturition of four days duration. She also had icterus and features of disseminated intravascular coagulation. Abdominal ultrasound and computed tomography of the abdomen was suggestive of XPN. She responded well to treatment with antibiotics and nephrectomy. Histology of the resected kidney confirmed a diagnosis of XPN. Our case suggests that the diagnosis of XPN should be kept in mind when a middle-aged female patient presents with unilateral non-functioning hydronephrotic kidney, which is totally distorted, and has enhancing as well as non-enhancing regions on computed tomography.

Tuberculosis in end-stage renal disease patients on hemodialysis

Recent studies have shown that there is an increase in the incidence of mycobacterium tuberculosis (MBT). This is more prevalent among immune compromised patients (those on dialysis) and recipients of organ transplants. Furthermore, extra-pulmonary presentation appears to be more common and difficult to diagnose. We aimed in this study to assess and evaluate the presentation of MBT in a retrospective study conducted among 256 hemodialysis (HD) patients where 18 of them were diagnosed and managed for tuberculosis over a 10-year period between 1990 and 2000. The mean age of the patients was 38 years (21-75 years). The mean interval between the onset of HD and the time of diagnosis was about 24 months (1-120 months). The diagnosis of tuberculosis was made either by isolation of acid-fast bacilli (AFB), the typical caseating granuloma on biopsy, or by recovery of tubercle bacilli from the culture of the biopsy material. Extra-pulmonary tuberculosis was more common (77.8%) than pulmonary tuberculosis (22.2%). The various extra-pulmonary tuberculosis sites noted were cervical lymphadenitis (16.7%), gastrointestinal (16.7%), genitourinary (11.1%), peritonitis (11.1%), pleural effusion (5.6%), pericardial effusion (5.6%), miliary tuberculosis (5.6%), and pyrexia of unknown origin (5.6%). None of the patients with extra-pulmonary tuberculosis had evidence of pulmonary tuberculosis. The atypical presentation with insidious onset was quite common. Anergy to tuberculin skin test was noticed in 56% of cases. All of our patients received modified antituberculosis treatment for 1 year with adequate response, and without undue side effects. We conclude that a high index of suspicion is required especially in the diagnosis of extra-pulmonary tuberculosis, and when there is a high percentage of anergy to tuberculin skin test. Tissue biopsy both for characteristic histology and demonstration of MTB, either by staining or culture, remains the main criteria for the diagnosis of extra-pulmonary tuberculosis.

The renal allograft donor with isolated microhematuria

Recently, there has been extensive debate about extending the criteria for accepting living donors to include the presence of mild renal abnormalities such as isolated microhematuria. Hematuria defined as the detection of greater than five red blood cells per high power field can be associated with abnormalities throughout the urinary tract. Detection of casts or dysmorphic red blood cells in the urine sediment with or without proteinuria could indicate underlying intrinsic renal disease. Anatomic causes, such as stones and tumors, should be excluded; cystoscopy may be indicated to exclude bladder pathology. Obviously, urinary tract infection, uncontrolled hypertension and latent diabetes mellitus must be excluded. Microscopic hematuria could be associated with mesangial IgA deposits; as 10% of first-degree relatives of patients with IgA glomerulonephritis suffer from microhematuria and/or proteinuria that may require consideration of renal biopsy. Microhematuria could also be associated with other known hereditary renal diseases such as C3 deposits disease, IgM nephropathy, autosomal dominant polycystic kidney disease, Alport's syndrome or thin basement membrane disease. In conclusion, careful assessment of isolated microhematuria, in the context of living kidney donation, is mandatory as results may reveal occult renal disease that may contraindicate kidney donation.

Prevention of viral transmission in HD units: the value of isolation

We have investigated the influence of isolation of patients with different viral serology status on the transmission of viral hepatitis among patients on hemodialysis (HD). Our kidney center was designed to facilitate isolation of infected patients and implement infection control pre-cautions. These included separate rooms, separate entrances and exit sites, and designated HD machines for patients with hepatitis B, hepatitis C, and sero-negative patients. In addition, universal infection control polices and procedures were implemented. These included proper chemical and heat disinfection of all HD machines following each HD session. These measures were complemented with education and training of the nursing staff detailing strict adherence to all infection control policies and procedures. All of our patients and staff were vaccinated against hepatitis B. Our results showed that after four years of follow-up, there was a decrease in the annual incidence of hepatitis C seroconversion from an average of 2.4% to 0.2%. The current prevalence of hepatitis C is 29% compared to 57% at the start of the study. In addition, there have been no reported sero-conversion cases of hepatitis B. Furthermore, our data also confirmed that the prevalence of hepatitis C (as well as hepatitis B) is more frequent in HD (29%) than peritoneal dialysis (5%) units. Surgical procedures, blood transfusion, and frequent visits to different dialysis units remain the major risk factors for contracting viral hepatitis. In conclusion, these results clearly show that isolation of patients and machines, together with strict adherence to infection control policies and procedures, result in a significant decline in the incidence and prevalence and better control of viral hepatitis transmission among HD patients.

Idiopathic reversible renal failure in a young woman with minimal change glomerulonephritis

We report a 19-year-old Saudi female with nephrotic syndrome whose renal biopsy revealed findings suggestive of minimal change glomerulonephritis (MCGN). She developed oliguric renal failure requiring hemodialysis. She remained dialysis dependent for five weeks and subsequently renal function recovered fully. She remained nephrotic and responded to a six week course of corticosteroids. She was followed for two years during which she had two relapses, which responded to steroids. Acute renal failure is uncommon in MCGN and is due to acute tubular necrosis induced by hypovolemia or drugs. This patient did not have any obvious precipitating factor, which led to acute reversible renal failure.

Post-transplant erythrocytosis: a disease with multifactorial etiology

Post-transplant erythrocytosis (PTE) is defined as an increase in hematocrit greater than 51%. This phenomenon affects 5 to 17% of renal transplant patients within two years of transplantation. Its etiology is not clearly known, but several factors have been implicated in its pathogenesis. We report on a 50-year-old male, known to have autosomal dominant polycystic kidney disease, diabetes mellitus and hypertension for 20 years, who underwent a living unrelated donor transplantation. Three years following renal transplan-tation, he was noted to have high hemogloblin and hematocrit (18.3 gm%, 53.8%). This erythrocytosis persisted for nine months during which period he underwent multiple phlebotomies before undergoing spontaneous remission. He did not develop any compli-cations of erythrocytosis. Our patient had multiple factors to account for occurrence of PTE: diabetes mellitus, hypertension, mild allograft dysfunction, polycystic kidney disease and cyclosporin therapy. Our case suggests that multiple factors may be operative in a given patient leading to the development of PTE.

End-stage renal failure as a complication of acute tubulo-interstitial nephritis

Acute tubulo-interstitial nephritis (ATIN) is an important cause of acute renal failure, where renal impairment tends to be variable but recovery is the rule. End-stage renal failure (ESRF) has been rarely reported as a complication of ATIN. We report here a case of idiopathic ATIN that resulted in severe acute renal failure. The patient developed ESRF, which required permanent renal replacement therapy.

Post-transplant erythrocytosis: a review of 47 renal transplant recipients

Post-transplant erythrocytosis (PTE) is a well known phenomenon occurring in 5-17% of renal transplant recipients (RTR). In this retrospective study, we studied 47 RTR which included 39 males and eight females. They were divided into two groups according to the presence or absence of PTE, which was defined as a hematocrit of more than 51%. Nine of the 47 patients (19%) developed PTE all of whom were males. The mean age of patients with PTE was 44 +/- 9 years versus 40 +/-11 years for patients without PTE. The mean follow-up period was 113 +/- 26 months and 93 +/- 58 months for the PTE and non-PTE groups respectively. The mean period after transplant when PTE developed was 9.8 +/- 9 months and it lasted for 37 +/- 3 months. Thromboembolic complications in the form of lower limb deep vein thrombosis occurred in one patient. Most patients were treated with phlebotomies, and one received an angiotensin converting enzyme inhibitor. There were no apparent predisposing factors in any but one patient, who had autosomal dominant polycystic kidney disease and developed hydronephrosis of the transplanted kidney. This might have caused excessive production of erythropoietin resulting in PTE. The serum creatinine values were higher, although statistically insignificant in patients with PTE. Chronic rejection was more commonly seen in patients with PTE (44%) than those without PTE (11%). Our findings suggest that PTE is a benign condition affecting males more than females. It may have an association with chronic rejection. Most cases can be controlled using phlebotomy.

Spectrum of tuberculosis in dialysis patients in saudi arabia

Data from different regional hospitals of Saudi Arabia were collected to know the prevalence, clinical features and results of therapy of tuberculosis, in patients on dialysis. Eight hospitals located in five different provinces of Saudi Arabia were involved. There were 132 patients with TB on dialysis of whom 75 were males (mean ages in different hospitals ranging 42-58 years) and 57 were females (mean ages ranging 38-58 years). The prevalence of TB in these patients varied from 2.4 to 14.5% with an average of 7%, which is 12 times commoner than in the general population of Saudi Arabia. The presenting clinical features were fever (65%), cough (17%), weight loss (59%) and anorexia (58%). The organs/systems involved by TB were pulmonary in 73 (55.3%), lymphadenopathy in 30 (22.7%) peritoneal in 27 (20.4%) and bone in seven (5.3%). The diagnosis of TB was made by X-ray chest in 73, positive acid fast bacilli in sputum in 38, lymph node biopsy in 30, ascitic fluid examination in 20 and other tests in 17 patients. Four anti-TB drugs namely, isoniazid (INH), rifampicin (Rif), ethambutol (Eth) and pyrazinamide (Pyra) were used in 58 patients (44%) for six months; three drugs namely, INH, Rif, and Eth or Pyra were used in 61 patients (46%) for a variable period of six to 12 months. A total of 28 (21%) patients expired, eight while on therapy, one before starting the therapy and 19 after they were cured of TB. The main causes of death were sepsis in eight (28.5%), cardiovascular in seven (25%) and sudden death in six (21%). TB was not the direct cause of death in any of the patients except one, in whom it could be contributory.

Atypical presentation of Churg-Strauss syndrome: another "forme fruste" of the disease?

Vasculitis is a clinicopathologic process characterized by inflammation and damage to blood vessels. A broad and heterogenous group of syndromes may result from this process, because any type, size, and location of blood vessel may be involved. The cause of these conditions remains unclear, but an autoimmune inflammatory process, characterized by involvement of both neutrophils and endothelial cells, seems to play an important role. In 1951, Churg and Strauss described a clinical syndrome of severe asthma, hypereosinophilia with eosinophilic infiltrates, eosinophilic vasculitis, and granulomata in various organs. Asthma may precede this vasculitis by many years. We report a case of anti-neutrophil cytoplasmic antibody-positive, pauci-immune, crescentic, necrotizing glomerulonephritis with peripheral and interstitial eosinophilia but without asthma. This is very unusual in Churg-Strauss syndrome.

Hyperuricemia and gout in renal transplant recipients

Hyperuricemia, unlike clinical gout, is extremely common in renal transplant patients. The high prevalence of hyperuricemia is related to prolonged exposure to cyclosporine rather than to its dose or serum concentration. Serum creatinine levels do not show significant correlation with hyperuricemia, behaving more like a surrogate marker for cyclosporine dose and trough level. The low incidence of gout in renal transplant patients, despite the hyperuricemia, may be related to the prolonged immunosuppression effect.

CAPD in dammam central hospital, saudi arabia: a five-year experience

Thirty-one patients with end-stage renal disease (ESRD) were offered continuous ambulatory peritoneal dialysis (CAPD) at the Dammam Central Hospital, Dammam, Saudi Arabia over a period of five years. The group included 21 women and 10 men with a mean age of 41.3 +/- 17.2 years. The main indication for CAPD was poor or failed vascular access (51.4%). Peritonitis remained the major complication with an overall incidence of 0.62 episode per patient year. Staphylococcus epidermidis was the main causative organism. Therapy with CAPD lasted a mean of 26 +/- 7.4 months. Our results, showing good technique survival and low peritonitis rate, suggest that CAPD should be promoted to become a full arm of the integrated care of ESRD in Saudi Arabia.