|Year : 2016 | Volume
| Issue : 7 | Page : 42-50
|Hemodialysis delivery, dialysis dose achievement, and vascular access types in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015)
Anas AlYousef1, Sumaya AlGhareeb2, Jamal Al Wakeel3, Saeed M. G. Al-Ghamdi4, Brian A Bieber5, Mohamad Hassan6, Yacoub Al Maimani7, Naser Alkandari8, Haroun Z Ahmed9, Ashraf Fawzy10, Ronald L Pisoni5, GCC-DOPPS 5 Study Group11
1 Nephrology Division, Farwaniya Hospital, Kuwait City, Kuwait
2 Nephrology Department, Salmaniya Medical Complex, Manama, Bahrain
3 Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
4 Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
5 Arbor Research Collaborative for Health, Ann Arbor, MI, USA
6 Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
7 Department of Medicine, Royal Hospital, Muscat, Oman
8 Nephrology Division, Mubarak Alkabeer Hospital, Kuwait City, Kuwait
9 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
10 Department of Medicine, Hamad General Hospital, Doha, Qatar
11 List of Study Group in Acknowledgment
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|Date of Web Publication||1-Dec-2016|
| Abstract|| |
The prospective observational Dialysis Outcomes and Practice Patterns Study (DOPPS) was initiated in late 2012 in national samples of hemodialysis (HD) units (n = 41 study sites) in all six Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For many years, guidelines have recommended single pool Kt/V ≥1.2 as the minimum adequate dose for chronic HD patients. Here, we report initial DOPPS results regarding HD practices related to dialysis dose achievement in the GCC. A total of 928 adult HD patients were included in this analysis from 41 centers representing all six GCC countries. Baseline descriptive statistics (e.g., mean, standard deviation, median, interquartile range, or percentage) were calculated for the study sample. Results were weighted according to the fraction of HD patients sampled within each participating study site. Mean age varied between 51 years in Bahrain, Oman, and Saudi Arabia, 55 years in the United Arab Emirates (UAE) and Kuwait, and 62 years in Qatar. Mean body mass index (BMI) was the lowest in Oman patients (23.9 kg/m 2 , but the remaining GCC countries had mean BMIs of 25.7-28.9 kg/m 2 and substantial fractions of overweight patients. Median dialysis vintage ranged from 1.52 years in Kuwait to 3.52 years in Oman. Mean treatment time per session varied from 202 min in Saudi Arabia to 230 min in Qatar while mean blood flow rate (BFR) ranged between 267 mL/min in Oman and 310 mL/min in Saudi Arabia. Interdialytic weight gain varied considerably among GCC countries between 3.1 and 4.0 kg. Central venous catheter use was high among GCC countries, ranging from 29% in Oman to 56% in Kuwait, with other countries averaging 30-40% catheter use. Data were available only for 50-76% of patients in four GCC countries (Kuwait, Qatar, Saudi Arabia, and UAE) for calculating single pool Kt/V to indicate dialysis adequacy. When calculated for patients with vintage >1 year and dialyzing three times per week, mean single pool Kt/V was highest in Qatar and the UAE (1.50-1.51), intermediate in Kuwait (1.35), and lowest in Saudi Arabia (1.29). A higher risk of mortality was observed for patients having a single pool Kt/V <1.2 (vs. ≥1.2) [hazard ratio (HR) = 1.71, 95% confidence interval [CI]: 1.01-2.92]. Achievement of Kt/V in the GCC, although lower than in other DOPPS regions such as Europe/ANZ and North America, was similar to that in Japan. Japan and the GCC also share the practice of having a lower blood volume filtered per HD session per kg body weight. These findings suggest that increasing mean BFR and treatment time in the GCC, along with reducing catheter use, would substantially increase overall achievement of Kt/V >1.2 in the GCC, and hence, may improve survival. These mortality findings will need to be confirmed with up-coming GCC-DOPPS 6 analysis.
|How to cite this article:|
AlYousef A, AlGhareeb S, Al Wakeel J, Al-Ghamdi SM, Bieber BA, Hassan M, Al Maimani Y, Alkandari N, Ahmed HZ, Fawzy A, Pisoni RL, GD. Hemodialysis delivery, dialysis dose achievement, and vascular access types in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015). Saudi J Kidney Dis Transpl 2016;27, Suppl S1:42-50
|How to cite this URL:|
AlYousef A, AlGhareeb S, Al Wakeel J, Al-Ghamdi SM, Bieber BA, Hassan M, Al Maimani Y, Alkandari N, Ahmed HZ, Fawzy A, Pisoni RL, GD. Hemodialysis delivery, dialysis dose achievement, and vascular access types in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcomes and practice patterns study phase 5 (2012-2015). Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2017 Mar 30];27, Suppl S1:42-50. Available from: http://www.sjkdt.org/text.asp?2016/27/7/42/194889
| Introduction|| |
Patients with end-stage renal disease (ESRD) are dependent on dialysis for survival with the great majority receiving hemodialysis (HD). HD has been commonly used as an ESRD therapy for several decades with the first case of successful HD described in North America in 1949.  Dialysis adequacy was introduced later to achieve a dialysis prescription that would be sufficient for ESRD patients for their quality of life and, to some extent, prolong survival. ESRD is prevalent worldwide, and the numbers of newly diagnosed patients have been rising annually across most countries. ,, ESRD carries great morbidity and mortality, in addition to a huge expenditure of resources to maintain such therapy. 
In managing regular HD patients, we need to ensure the optimal dialysis prescription for each patient and quantify the amount of dialysis actually delivered to the patient. Dialysis adequacy refers to what 'dose' of HD is required to maintain a patient's health and functionality which is most commonly assessed through measures of urea clearance during an HD session.  The most widely accepted measures of urea clearance are Kt/V, the ratio between the product of urea clearance (K, in mL/min) and dialysis session duration (t, in minutes) divided by the volume of distribution of urea in the body (V, in mL) and urea reduction ratio, which is derived solely from the percentage fall in serum urea during a dialysis treatment. Kt/V is the most tested measure of the dialyzer effect on HD patient survival and is the most frequently applied measure of the delivered dialysis dose.  Kt/V has been expressed in several different ways. 
The international, prospective, observational Dialysis Outcomes and Practice Patterns Study (DOPPS), ongoing since 1996, was initiated in the late 2012 in national samples of HD units (n = 41 study sites) in all six Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For many years, guidelines have recommended a single pool Kt/V ≥1.2 as the minimum adequate achieved dose for chronic HD patients. Here, we report our initial DOPPS results regarding HD practices related to dialysis dose achievement in the GCC.
| Methods|| |
Data were from phase 5 of the DOPPS, an international prospective cohort study in 21 countries. DOPPS is based on nationally representative samples of randomly selected dialysis facilities and patients. Within each participating facility, 20-30 patients were randomly selected, depending on facility size. Institutional review boards in each country approved the study, and informed patient consent was obtained in accordance with local requirements. The main analyses were based on 928 adult chronic HD patients who were enrolled at the start of the GCC-DOPPS phase 5 from 41 GCC HD units participating in DOPPS 5. All six of the GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) were represented in this DOPPS phase 5 study. All study HD patients were ≥18 years old at the time of study entry into DOPPS. Further details of the GCC-DOPPS study design are provided in the "The DOPPS Phase 5 Study in the GCC Countries: Design and Study Methods" paper by Pisoni et al in this special Supplement issue of the Saudi Journal of Kidney Disease and Transplantation.
Baseline descriptive statistics (e.g., mean, standard deviation, median, interquartile range, or percentage) were calculated for the study sample, and results by country were weighted according to the fraction of HD patients sampled within each participating study site. The relationship of all-cause mortality for patients having a baseline single pool Kt/V <1.2 versus ≥1.2 was analyzed using Cox proportional hazards regression stratified by GCC country, adjusted for patient age, and accounted for facility clustering effects (through the sandwich estimator). The Kt/V measurement used for the mortality analyses was the closest measured value for the patient on or before the date of study enrollment. Time at risk for mortality analyses began at the time of study entry and continued throughout the study follow-up but censored if patients departed the study for any non-death-related reason (e.g., switched to peritoneal dialysis or to a different dialysis unit, received a kidney transplant, or recovered renal function). Mortality analyses were restricted to patients with dialysis vintage >1 year and prescribed thrice weekly HD since this was required for a patient's Kt/V measurement to be suitable in the analysis.
All statistical analyses were performed using SAS software, version 9.4.
| Results|| |
Out of the 41 DOPPS centers in the GCC, Saudi Arabia had the highest number of participating centers (N=21 HD facilities), from which 419 patients were studied. Bahrain, the smallest country within the GCC, had one participating HD center contributing data from 25 enrolled patients, followed by 58 patients from Qatar, 89 patients from Oman, 116 patients from Kuwait, and 221 patients enrolled from the United Arab Emirates (UAE) for a total number of patients of 928 [Table 1]. Mean age varied from 51 years in Bahrain, Oman, and Saudi Arabia, 55 years in the UAE and Kuwait, and 62 years in Qatar. Males comprised approximately 56% of the patients in GCC which is similar to other regions where there is a slight male predominance. Median dialysis vintage ranged from 1.82 years in Kuwait to 3.52 years in Oman. Substantial variability was seen across GCC countries in the mean body mass index (BMI) ranging from 23.9 kg/m 2 in Oman to 25.7-27.2 kg/m 2 in Saudi Arabia, the UAE, Qatar, and Bahrain, with the largest mean BMI reported for HD patients in Kuwait (28.9 kg/m 2.
The number of HD treatments prescribed per week varied considerably across GCC countries, with 98% of patients prescribed thrice weekly HD in Kuwait, 92-95% in Saudi Arabia and Qatar, and 79-82% prescribed thrice weekly HD in the UAE and Oman. In the UAE and Oman, 21% and 19% of patients were prescribed twice weekly HD, respectively. In Qatar, 7% of HD patients were prescribed >3 HD treatments per week. Mean treatment time varied from 202 min per HD session in Saudi Arabia, 213-219 min per HD session in Oman, Bahrain, and Kuwait, and 226-230 min per HD session in the UAE and Qatar.
At study entry, data were requested for each patient to calculate single pool Kt/V for each of the first four months preceding the study entry date. However, for the data reported for the study, there were large fractions of patients in each country for whom a single pool Kt/V could not be calculated. Thus, Kt/V data reporting was missing for 100% of study patients in Bahrain, 72% in Oman, 50% in the UAE, 33- 37% in Kuwait and Saudi Arabia, and 24% in Qatar. Consequently, nationally representative results by GCC country for Kt/V were not possible to calculate. However, to get a sense of Kt/V achievement in several of the GCC countries, we restricted analyses to 27 of the 41 study sites which provided Kt/V for at least some of their patients. Among patients on dialysis >1 year in this subset of 27 facilities, the percentage missingness by country in Kt/V reporting was: 33% in the UAE, 28% in Saudi Arabia, 28% in Kuwait, and 20% in Qatar. Based on these restricted data, a mean single pool Kt/V was highest in Qatar and the UAE (1.50-1.51), intermediate in Kuwait (1.35), and lowest in Saudi Arabia (1.29). Within this subset of data for patients on dialysis >1.0 years, the percentage of patients with single pool Kt/V <1.2 varied from 14% in Qatar and the UAE to 32% in Kuwait, and 38% in Saudi Arabia. Using this subset of data in the above 4 GCC countries for patients on dialysis >1.0 years, a Cox regression mortality model was used to investigate the relationship of mortality with having a low single pool Kt/V <1.2 while adjusting for patient age. A higher risk of mortality was observed for patients having a single pool Kt/V <1.2 (vs. ≥1.2) (HR = 1.71, 95% CI: 1.01-2.92). These Kt/V levels by country and the association of low Kt/V with mortality should be viewed as preliminary findings to be confirmed with hopefully improved Kt/V reporting for GCC-DOPPS patients in DOPPS 6.
Blood flow rates (BFRs) used for HD displayed relatively small variation across the GCC countries. The median BFR was 300 mL/min across all GCC countries except Oman where the median BFR was 250 mL/min, and mean BFRs ranged from 267 mL/min in Oman to 310 mL/min in Saudi Arabia. With regard to mode of HD, the great majority of patients (>89%) were prescribed conventional HD in all GCC countries except in Kuwait, where 38% of patients were prescribed hemodialfiltration (HDF). Prescription of HDF was reported for 11% of patients in the UAE and 4% in Saudi Arabia.
Vascular access use varied considerably across GCC countries. Bahrain had the highest percentage of patients receiving HD with an arteriovenous fistula (AVF) (68%), which is the vascular access type recommended as the preferred access by most guidelines when feasible to achieve for a patient. , Saudi Arabia reported 63% of patients using an AVF and 6% using an arteriovenous graft (AVG), which is the second best choice of vascular access type for HD patients after an AVF. Kuwait displayed the lowest percentage of patients or dialysis having an AVF (41%). Overall, central venous catheter (CVC) use was quite high across GCC countries in comparison to other DOPPS countries.  Within the GCC, CVC use ranged from 29- 32% in Oman, Saudi Arabia, and Bahrain, 40- 41% CVC use in Qatar and the UAE, whereas Kuwait reported the highest CVC use with 56% of patients dialyzing with a catheter. However, despite Kuwait having the highest CVC use, Kuwaiti HD patients had the lowest percentage of bacteremia reported over a four month study period (4.4%), compared with 7-9% in Saudi Arabia, Bahrain, and the UAE, and 11-14% in Oman and Qatar [Figure 1].
|Figure 1: Percentage of patients with a bacteremia in the 4 months before Dialysis Outcomes and Practice Patterns Study enrollment, by Gulf Cooperation Council Dialysis Outcomes and Practice Patterns Study region (2012–2015).|
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Mean weight gain between dialysis sessions varied across GCC countries from 3.1 to 4 kg. Dialysate calcium (Ca) varied considerably across the GCC countries. In Kuwait, it was distributed as 47% of patients were prescribed 3.5 mEq/L, 20% prescribed 3.0 mEq/L, and 33% prescribed 2.5 mEq/L, whereas in Qatar 71% of patients were prescribed dialysate Ca of 2.5 mEq/L and 29% with 3.5 mEq/L. In Saudi Arabia, the majority of patients were prescribed 3 mEq/L dialysate calcium (67%), whereas in the UAE, 80% of patients were nearly split between being prescribed either 2.5 or 3.0 mEq/L dialysate Ca. Dialysate Ca data were not reported for >50% of patients in Oman. For those patients with reported data in Oman, largely coming from two HD units, approximately 90% were being prescribed a dialysate Ca of 3.5 mEq/L.
A mean pre-dialysis serum sodium of 136-138 mEq/L was seen across four of the six GCC countries, with the lowest in Bahrain (135 mEq/L) and highest in Qatar (140 mEq/L). Predialysis serum potassium ranged between 4.63 mEq/L as the lowest in Bahrain and 5.21 mEq/L as the highest in Oman.
| Discussion|| |
Cardiovascular diseases are the most common cause of morbidity and mortality in dialysis patients.  Anemia, hypertension, and vascular calcifications resulting from hyperphosphatemia and secondary hyperparathyroidism are main contributors to cardiovascular morbidity and mortality of chronic kidney disease patients.  Clearance of small-middle molecules in addition to correction of the metabolic abnormalities through HD is of paramount importance in prolonging survival of HD patients. , Dialysis adequacy as defined earlier involves measurement of small solute and urea clearance. The delivered dose of HD depends on certain factors that include duration and frequency of dialysis sessions, dialyzer size and characteristics, dialysate and BFR, and vascular access, in addition to patients' BMI, protein intake, physical activity, and hematocrit. 
Our results indicate an overall single pool Kt/V of 1.37 across the GCC countries, which is comparable to that in Japan 1.42 despite their lower BFR. However, in Japan, the majority of HD patients dialyze with AVF (91%) compared to 57% of GCC HD patients using an AVF. Residual kidney function plays a major part in clearance of middle molecules and hence improves both dialysis adequacy and patients' morbidity/mortality.  To illustrate this, North American patients had a BFR close to 400 mL/min compared to 326 mL/min in European patients, while both had similar numbers of patients with AVF/AVG vascular access, yet they have almost identical single pool Kt/V. The difference, in our opinion, was made by the residual renal function where 72% of European patients had daily urine output more than 200 mL per day compared to only 47% of North American patients (lowest among the 4 groups).
Among GCC countries, Oman reported the highest mean single pool Kt/V of 1.72 despite their patients being prescribed the lowest BFR. However, pertinent to this is the fact that Omani HD patients also were seen to have a considerably lower mean BMI than in other GCC countries. The HEMO study, a prospective randomized clinical trial on the clinical impact of HDs dose, did not find any improvement either in survival or in the rate of hospitalization overall in patients randomized to a higher dialysis dose (single-pool Kt/V 1.65) compared with those randomized to a more conventional dialysis dose (single-pool Kt/V 1.25).  However, it did not incorporate residual kidney function into dialysis dosing, which was shown to have a great impact on mortality and a higher dialysis dose was related to improved survival for females in the HEMO trial.  In Kuwait, despite high use of HDF (38%) and high use of high-flux dialyzers (94%) in general, a comparably low single pool Kt/V was observed, which may in part be related to the high prevalence of catheter use among HD patients, and the actual low dose delivered of HDF. Does it mean that HDF is not different than HD? Recent studies have suggested that HDF if delivered in a certain dose has a positive impact on cardiovascular diseases and all-cause mortality. ,,
With regard to types of membranes used in GCC countries, about 54% of patients were using high-flux dialyzers. Our results indicate an associated high mortality in patients with Kt/V <1.2, and there is a substantial number of patients with this low Kt/V level among GCC countries ranging between 14% and 38%, however, the data collection was lacking in some centers yielding only 27 out of the 41 centers to provide Kt/V results for the majority of their patients. This preliminary data should be interpreted carefully and acted on by improving dialysis adequacy in our patients, with one major factor to be stressed in particular, which is vascular access.
Another issue that will be of major impact in our next analysis is the measurement of Kt/V. In GCC-DOPPS 5, we had no data on Kt/V from Bahrain and from the great majority of Oman patients despite the relative ease of measuring Kt/V given the advancement in technology of HD machines. Recently, there have been more voices against Kt/V as a sole measure for dialysis adequacy due to some negative aspects associated with its measurement and results. Whether Kt/V is still to be used as an indicator of dialysis adequacy is beyond the scope of this paper. However, by all means, we need to maintain at least the minimum standard - that is Kt/V ≥1.2 as a target of dialysis adequacy for the current HD patients as recommended by most international guidelines. It has to be a standard of care in our facilities to measure Kt/V for most, if not all, patients on regular HD that would help provide better quality of care to our patients. HDF prescription, on the other hand, needs to be improved and actual dose delivered should be checked regularly to get the most of such therapy, in accordance with the most recent international body of evidence.
| Conclusion|| |
Achievement of Kt/V in the GCC, although lower than in Europe and North America, was similar to that in Japan. Japan and the GCC also share the practice of having a lower blood volume filtered per HD session per kg body weight. These findings suggest that increasing mean BFR and/or treatment time in the GCC, along with reducing catheter use, likely would substantially increase overall achievement of Kt/V>1.2 in the GCC. Higher mortality risk was seen for patients having a single pool Kt/V <1.2. However, the mortality data we presented have to be confirmed in the upcoming analysis of GCC-DOPPS 6 once those data have been collected during the next three years - and hopefully with improved reporting of Kt/V.
| Acknowledgments|| |
We wish to thank the devoted efforts of GCCDOPPS 5 Study Group members for their numerous contributions to this study including Country Investigators (Dr. Sameer Al-Arrayed, Dr. Sumaya Al Ghareeb, Dr. Bassam Al Helal, Dr. Naser Alkandari, Dr. Ali Alsahow, Dr. Anas AlYousef, Dr. Mohammad AlAzmi, Dr. Yaqob Ahmed Almaimani, Dr. Issa Alsalmi, Dr. Nabil Salmeen Mohsin, Dr. Fadwa Al Ali, Dr. Mohamed El-Sayed Abdel Fatah, Dr. Ashraf Fawzy, Dr. Abdulla Hamad, Dr. Saeed M. G. Al-Ghamdi, Dr. Mohammed Al Ghonaim, Dr. Jamal Al Wakeel, Dr. Fayez Hejaili, Dr. Ayman Karkar, Dr. Faissal Shaheen, Dr. Samra Abouchacra, Dr. Ali Abdulkarim Al Obaidli, Dr. Mohamed Hassan, Dr. Mona Nasir Al Rukhaimi and Dr. Abdul Kareem Saleh, Dr. Sylvia Ramirez, Dr. Bruce Robinson, Dr. Ronald L. Pisoni), Clinical Research Associates and Project Coordinators/Managers (Dr. Amgad El-Baz El-Agroudy, Dr. Balaji Dandi, Ms. Cherry Flores, Mrs. Ph. Fatma Al Raisi, Ms. Ibtisam Al-Hasni, Dr. Ashraf Fawzy, Dr. Haroun Zakaria Ahmed and Mr. Dan Santiago from the Saudi Center for Organ Transplantation, Mr. Muhammad Awwad, Ms. Roberta Al HousaniBlakely, Christina Pustulka, Anne Vandermade, Melissa Fava, Anna Hogan, Michelle Maxim, Justin Albert), Biostatisticians (Brian A. Bieber), and Study Site Medical Directors, and Study Coordinators: Dr. Hamid Ali Alyousif, Ms. Sohair Abdulroof Albably, Dr. Ahmed Eid Alkady, Dr. Samir Al Muielo, MD, Dr. Fakreldein Elamien Ali, Dr. Ayman El Monger, Dr. Sameh Mohammed Al-sammad, Dr. Baraa Rajab, Dr. Atif Hanan, Tarek Abdelfattah Ahmed Ali, Dr. Ayman Karkar, Dr. Mohammed Abdelrahman, Dr. Mohammed Hussein, Dr. Wael Abdlah, Dr. Faisal Mushtaq, Dr. Salah Eldin El Sheik Beshir, Dr. Medhat Abdelmonem Shalaby, Dr. Mustafa Khaleel Al Obeid, Dr. Mohamad El Hadary, Dr. Alaa Al Shamy; Dr. Aboud Mamari, Dr. Mohammed Raily, Dr. Mustafa Ahmed; Ramzi Abou-Ayache, Dr. Hormoz Dastoor, Dr. Mohamed Hassan, Dr. Bassam Bernieh, Dr. Hareth Muthanna Mohammed Saaed, Dr. Mustafa Kamel, Prof. Abdel Basset Hassan, MD, PhD, FASN, Dr. Hassan Khammas, Dr. Balaji Dandi, Dr. Sumaya AlGhareeb, Dr. Fadwa Al Ali, Dr. Anas Alyousef, Dr. Nasser AlKandari, Dr. Ali Alsahow, Dr. Bassam AlHelal, Dr. Ahmed Mandour, Dr. Yaqob Ahmed Almaimani, Dr. Amer Ahmed Alaamri, Dr. Ibrahim Sayed Ibrahim, Dr. El Badri Abdelgadir, Dr. Mohammed Al-Sayed Seleem, Dr. Ali Hassan Hakami; Dr. Samir Beshay, Dr. Nayer Morsy, Mr. Menwer Al-ofi, Ms. Sohair Abdulroof Albably, Dr. Huda Mohammed Saeed Ahmed, Ola Al-Marhoon; Dr. Samir Al Muielo, Ms. Joynalyn Barrios, Ms. Fatima Cruza; Ligaya Battad, Mr. Abdullah A. K. Al Harbi, Dr. Sameh Mohammed Alsammad, Ms. Manal Ahmed Hamdan, Jennifer Samson, Mr. Ahmed Mousa Khawaji, Ms. Eman Al-Hejji, Ms. Rosalinda Lamis, Ms. Lagrimas Codotco, Dr. Wael Abdlah, Mrs. Priyanka Prasad, RN, Mr. Bander Faisal Justinia, Mr. Faisal Al Enazy, Sarah Brazil, Dr. Naemah Abdullah, Dr. Alaa Al Shamy, Dr. Aboud Mamari, Mely Gari Piling, Dr. Fakhriya Al Alwai, Rusmina Binti Sudin, Dr. Chandra Mauli Jha, MD; Katheryn Jamilano, Basima Khaddah, Hilal Al Rasbi, Muhy Eddin Hashem Hasan, Sr. Ekram Awadh Salem, Walid Gouiaa, Mini Issac, Jiby Mammen, Mary Ellen Monday, Mrs. Afrah Al Jamri, Mr. Yasser Khalil Abbas, Mrs. Rania Abd El-Aziz, Rania Abd El-Aziz, Cherry Flores, Mini Kumari Ramakrishnan, Shanty Mannaraprayil, Maria Charisse Bernardo, Bassam AlHelal, Evangeline Valdez, Rosily Joseph, Mrs. Ghaniyaal Shukaili, Adel Mohamed Bayoumy, Hamid Alshahri, Amira Balkhair, Amina Said Al Shezawi, Sultan Saif Ali Alroshdi, Dr. Shaninaz Faisal Bashir, Dr. Ahmed Mousa Dawood, Keirin Porras, Dr. Anthonimuthu Victor, Mr. Sultan Al-Toqi.
| Source of Support|| |
The DOPPS Phase 5 Study in the GCC has been supported by Amgen without restrictions on publications. The DOPPS Program is supported by Amgen, Kyowa Hakko Kirin, AbbVie Inc, Sanofi Renal, Baxter Healthcare, and Vifor Fresenius Medical Care Renal Pharma, Ltd. Additional support for specific projects and countries is also provided by Amgen, BHC Medical, Janssen, Takeda, and Kidney Foundation of Canada (for logistics support) in Canada; Hexal, Deutsche Gesellschaft fur Nephrologie (DGfN), Shire, and WiNe Institute in Germany; and the Japanese Society for Peritoneal Dialysis for Peritoneal Dialysis Outcomes and Practice Patterns Study in Japan. Funding for the DOPPS Program is provided without restrictions on publications.
Conflict of interest: None declared.
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Nephrology Division, Farwaniya Hospital, P. O. Box 1981, Qurtoba 73770