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Saudi Journal of Kidney Diseases and Transplantation
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  Citation statistics : Table of Contents
   2007| January-March  | Volume 18 | Issue 1  
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Calcineurin Inhibitor-Free Protocols: Risks and Benefits
AG Barbari, AG Stephan, MA Masri
January-March 2007, 18(1):1-23
The nephrotoxic and extra-renal adverse effects associated with calcineurin inhibitor (CNI) therapies appear to have a negative impact on long-term graft survival. Several CNI minimization protocols have been recently studied. These protocols involve either early CNI avoidance or CNI withdrawal. CNI withdrawal strategies are associated with a significant improvement in renal function and graft survival on both a short and long-term basis. Delayed and progressive withdrawal appears to be safer. Maintaining a high mycophenolate mofetil (MMF) or sirolimus (SIR) exposure minimizes the risk of acute rejection. CNI avoidance regimens using maintenance mono-therapy or combination therapies without induction appear to be immunologically risky and unsafe. In contrast, the combination of SIR + MMF with induction therapy reduces markedly the incidence of acute rejection and chronic allograft nephropathy (CAN). Two year patient and graft survival levels were comparable. CAN as well as the incidence and the risk for cancer in addition to blood pressure profiles and uric acid levels were overall lower in the SIR-based treatment. In contrast, hyperlipidemia, delayed wound healing, lymphocele, arthralgias, thrombocytopenia and study protocol deviations were reported more frequently in the SIR-maintenance protocols. Longer­term follow-ups are definitely needed to determine whether these avoidance strategies will result in a significant improvement in long-term patient and graft survival. Outcome differences among various protocols within the same CNI elimination strategy are probably related to study design, patient selection criteria, immunosuppression monitoring methods, indications for graft biopsies, environmental, and both genetic and ethnic factors. All monitoring techniques are unreliable short of a graft biopsy. Preliminary results on drug lymphocyte binding may offer new guidelines for tailoring immunosuppression. Whether these protocols based on SIR or SIR + MMF can also be extended to high risk patients is currently unknown. These encouraging results allow speculation but with caution that the use of the combination of non-nephrotoxic immunosuppression such as SIR and MMF, might change dramatically the natural course of CAN and may influence long-term patient survival.
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Hepatitis C virus infection in hemodialysis patients in Sudan: Two centers' report
HH El-Amin, EM Osman, MO Mekki, MB Abdelraheem, MO Ismail, MEA Yousif, AM Abass, HS El-haj, HK Ammar
January-March 2007, 18(1):101-106
Prevalence of HCV seropositivity among the hemodialysis population in Sudan is estimated to be around 34%. We undertook a cross sectional study in two major HD centers in Khartoum, Sudan for the prevalence of HCV seropositivity among the hemodialysis patients, during January to -March 2005. Testing for HCV antibodies was performed using 3 rd generation enzyme linked immunoadsorption assay (ELISA). A total of 236 patients were included in the study: 218 adults and 18 children. The mean age was 43.6 ± 15.6 years, and the majority was males: 71.6%. The cause of renal failure was unknown in 168 patients (71.2%). The mean HD duration was 36.6 ± 35.1 months. Prevalence of HCV seropositivity was 23.7%. Among 170 patients who were previously HCV seronegative, 30 (17.1%) seroconverted to positive in one year (estimated incidence: 63 new cases per year). HCV seropositivity was associated with longer duration of dialysis (p < 0.00001), previous surgery (p= 0.026), age of over 30 and years (p = 0.008), and dialysis in multiple centers (p= 0.005). We conclude that although HCV seropositivity in our study was lower than previously reported, it was still high among HD patients in Sudan. Nosocomial transmission of HCV among hemodialysis patients is a contributing factor.
  13 5,216 660
Public Opinion on Organ Donation in Saudi Arabia
Awatif Ali Alam
January-March 2007, 18(1):54-59
To evaluate factors affecting the knowledge and/or attitudes of the Saudi Arabian public with respect to organ donation and transplantation, a cross sectional study was conducted on a random sample of 948 Saudi citizens between 20 -60 years of age during 2005. The collected data included: knowledge about organ donation campaigns, knowledge of the Saudi Center for Organ Transplantation (SCOT), religious knowledge towards related issues, attitudes toward organ donation and self or close-relative experience of organ transplantation. The study revealed that 58.5% of participants heard about the existence of SCOT, 91.1 % knew the need for organ donation, and 92.7 knew that organ donation could save lives. The organ donation campaign was known to 62.3% of the participants. Of these participants, 57.9% were made aware of organ donation campaigns through TV ads, 52.8% from magazines and newspapers and 11.7% from scientific sources. While 23.7% of the participants were unaware of any issued Islamic fatwa regarding organ donation, another 36.1% did not respond to this question revealing a lack of knowledge. Forty-two percent of the respondents agreed to donate their organs after death. Among the various reasons against organ donation, 27.5% feared that the act of organ donation contradicted their religious beliefs, while 3.5% believed that there was no benefit to organ donation. It is concluded that a need for proper information dissemination exists. A multidisciplinary approach is suggested including government support backed by strong recommendations from knowledgeable religious sources.
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The Impact of Polymerase Chain Reaction Assays for the Detection of Hepatitis C Virus Infection in a Hemodialysis Unit
Magdi M Hussein, Jaap M Mooij, Mohamed S Hegazy, Mohammed S Bamaga
January-March 2007, 18(1):107-113
Hepatitis C virus (HCV) infection is most often diagnosed by detection of antibodies against the virus (HCV Ab). However, it has been reported that some HCV Ab negative patients test positive for HCV-RNA. Over a study period of 30 months, all patients on hemodialysis at the Al Hada Armed Forces Hospital in Taif, Saudi Arabia were tested monthly for HCV Ab and twice per year for HCV-RNA. HCV Ab was tested by a third generation microparticle enzyme immunoassay (MEIA), and HCV-RNA by a qualitative hepatitis-RNA assay, second version (COBAS Amplicor ® PCR), which was recently introduced in the Molecular Pathology Laboratory of our hospital. Of the 180 patients studied, 34 (18.9%) had positive HCV Ab, and of the 146 HCV Ab negative patients, five patients tested positive for HCV-RNA (3.42 %). Our study further finds that, when applying HCV Ab testing only, some patients with HCV viremia may be undetected. For better HCV infection control, routine HCV­RNA testing of dialysis patients should be considered, particularly in areas where the infection is common and in units applying isolation policies.
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Organ Donation after Brain-Death: Experience Over Five-Years in a Tertiary Hospital
Abdulaziz Aldawood, Saad Al Qahtani, Ousama Dabbagh, Abdulla A Al-Sayyari
January-March 2007, 18(1):60-64
Organ transplantation is the treatment of choice for end-stage organ failure. The main challenge for organ transplantation continues to be organ shortage. The purpose of our study was to evaluate the success rate of organ donation after brain-death, as documented in a tertiary closed intensive care unit in Saudi Arabia. Data was obtained from a collected database from Jan 2001- Dec 2005. Brain death was documented in 162 patients, most of whom were young (median age was 28 ± 17 years). The group consisted predominantly of males, 149 (92%) and Saudis 109 (67%). Only 24 (17%) positive consents to organ donation were obtained and the majority of them [21 (87%)] were from non-Saudis. Positive consent was obtained from only three percent of Saudi potential organ donors in comparison to the 40% positive rate among non-Saudis (40 %) (p< 0.05). In conclusion, we believe that misconceptions about brain-death are the likely causes behind this unfavorable view towards organ donations among Saudis.
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Comparing Outcomes on Peritoneal and Hemodialysis: A Case Study in the Interpretation of Observational Studies
Simon J Davies
January-March 2007, 18(1):24-30
  5 2,579 592
Cerebral Salt Wasting in a Patient with Head Trauma: Management with Saline Hydration and Fludrocortisone
Akram Askar, Nauman Tarif
January-March 2007, 18(1):95-99
Hyponatremia secondary to the syndrome of inappropriate anti-diuretic hormone secretion is commonly observed in patients with various neurological disorders. Cerebral salt wasting (CSW), although uncommon, has also been reported to frequently result in hyponatremia. Here, we report a case of CSW in a patient with head trauma without evidence of cerebrovascular injury or brain edema. He was diagnosed on the basis of high fractional excretion of urinary sodium and uric acid along with extremely low serum uric acid. Improvements in serum sodium levels after saline hydration and fludrocortisone administration further supported the diagnosis, even in the presence of normal brain and atrial natriuretic peptide levels.
  4 12,318 1,458
Tunneled Femoral Vein Catheterization for Long Term Hemodialysis: A Single Center Experience
Abdulla K Al-Hwiesh, Ibrahiem Saeed Abdul-Rahaman
January-March 2007, 18(1):37-42
Femoral veins have been used for decades to position temporary hemodialysis catheters. Few reports, however, describe its use for permanent vascular access. This study describes the use of tunneled femoral vein catheters as permanent vascular accesses. Fourteen chronic hemodialysis patients (nine males and five females) had tunneled central venous catheters placed in the femoral vein from November 2004 to July 2005. The age of the patients ranged from 21 to 68 years with a mean of 49.8 ± 5.9 years. Placement of a catheter via the internal jugular veins was impossible in 10 patients whose course was complicated by thrombosis or strictures of the superior vena cava. The remaining four patients had exhausted conventional access sites. The insertion of the femoral catheters involved a subcutaneous tunnel that was created by retrograde passage of the catheter through the cannula to the point of exit at a preselected site in the epsilateral thigh away from the groin. The life span of the tunneled femoral catheter ranged between 32-240 days; median time in place was 182 days. There were four incidences of tunnel infection with Pseudomonas aeruginosa, E. coli, and Streptococcus epidermidis, which were treated successfully without the need for catheter removal. Other complications such as bleeding, kinking, migration of the catheter, arterial puncture, retroperitoneal or femoral hematomas were not observed. We conclude that tunneled femoral catheters are suitable alternatives for long-term hemodialysis access. Additional studies with a greater sample size are needed to confirm this conclusion.
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Percutaneous Nephrolithotomy for Complete Staghorn Renal Stones
Abdelmoniem H Koko, Vincent C Onuora, Mohamamed A Al-Turkey, Mohammed Al Moss, Ahmed H Meabed, Nasser A Al Jawani
January-March 2007, 18(1):47-53
To evaluate the effectiveness of percutaneous nephrolithotomy (PNL) in the management of patients with complete staghorn stones, a retrospective study was conducted on 110 patients at the Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia. The study was performed between September 1990 and September 1999. 144 procedures were performed on 119 renal units including 22 units (18.5%) that needed more than one sitting. Of them, 85 units (71.4%) were completely cleared after PNL and 11 units (9.2%) were left with insignificant residual fragments (< 4 mm). This gives a success rate of 78.6% for PNL as a monotherapy. Twelve patients with significant residual fragments required Extracorporal Shock Wave Lithotripsy (SWL) in addition to PNL. The overall success rate after PNL and SWL in 108 renal units was 89.4%. We found PNL useful in the management of patients with complete staghorn stones, either as monotherapy or in combination with SWL. It was associated with little morbidity and the procedure can be instituted even in centers with limited facilities.
  4 4,960 537
Catheter associated infections in hemodialysis patients
Suzan Sanavi, Ahad Ghods, Reza Afshar
January-March 2007, 18(1):43-46
Hemodialysis catheter related infections (HCRI) are one of the major causes of increasing mortality, morbidity and cost of therapy in hemodialysis patients. Prevention of HCRI requires the identification of predisposing risk factors. To determine the frequency of HCRI risk factors, we studied 116 patients (54% male, mean age of 49.5±16 years) patients with HCRI between 2003-2004. Forty one percent of the patients were diabetic. There was a history of previous catheter placement and infection in 41% and 32% of patients,respectively.Pathogenic organisms isolated from blood cultures included Staphylococcus­aureus 42%, Coagulase-negative Staphylococci 20%, E.Coli 19%, Enterococci 7%, Streptococcus D 7%, Pseudomonas aeroginosa 4%, and Klebsiella 1%. Bacterial resistance to vancomycin and amikacin was present in 7% and 4% of the cases, respectively. Hemodialysis catheter related blood borne infections comprised 67% of the total blood­borne infections in our hospital. No significant statistical association was found between HCRI and age, gender, diabetes mellitus, serum albumin level<30 g/L, leukocyte count, erythrocyte sedimentation rate, anatomical location of catheter, mean duration of antibiotic therapy, mean catheter duration, frequency of hemodialysis sessions, pathogenic organisms, and history of previous catheter infection. We conclude that the prevalence of pathogenic organisms of HCRI were similar to previous studies. However, bacterial resistance to antibiotics was low. The mean duration of catheter usage was longer than previously reported.
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Association of White Blood Cell Count with Left Ventricular Hypertrophy and Ejection Fraction in Stable Hemodialysis Patients
Hamid Nasri
January-March 2007, 18(1):31-36
Cardiovascular disease is the principal cause of morbidity and mortality in dialysis patients, and left ventricular hypertrophy (LVH) is an independent risk factor for mortality in hemodialysis (HD) patients. This analysis was undertaken to explore the associations of white blood cell (WBC) count with LVH and also left ventricular (LV) ejection fraction in patients on regular HD. There were 36 patients in the study, of whom 21 were males and 15 females. Their mean (± SD) age was 46 ± 17 years. The median length of the time the patients had been on HD was 19 months. The mean (± SD) WBC count of the patients was 5660 ± 2000 cells/mm 3 (median: 5500 cells/mm 3 ). The mean (± SD) LV ejection fraction of the study patients was 48 ± 11.5 % (median: 52 %). On the basis of septal thickness, the patients were stratified into groups with no, mild, moderate, and severe LVH. In this study, a significant inverse association between WBC count and LV ejection fraction and a significant positive correlation between WBC count and stages of LVH were seen. Our study shows a significant effect of WBC count on LV function and structure. Additional studies are needed to determine whether interventions to decrease inflammation during HD can reduce the risk for LVH associated with elevated WBC count.
  3 5,869 403
Methanol Intoxication with Brain Hemorrhage: Catastrophic outcome of late presentation
Akram Askar, Abdulkarim Al-Suwaida
January-March 2007, 18(1):117-122
  3 7,812 513
Monitoring Iron status in End-Stage Renal Disease Patients on Hemodialysis
Ali Rafi, Ayman Karkar, Mohammed Abdelrahman
January-March 2007, 18(1):73-78
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.
  1 5,834 1,046
Infertility among Kidney Transplant Recipients
Shirin Ghazizadeh, Mahboob Lessan-Pezeshki, Mohammd R Khatami, Mitra Mahdavi-Mazdeh, Mohammad R Abbasi, Jalal Azmandian, Effat Razeghi, Sepideh Seifi, Farrokh Ahmadi, Sima Maziar
January-March 2007, 18(1):79-82
We studied 122 women with a transplanted kidney to evaluate their reproductive performance. 15 of the patients were either post-menopausal or underwent hysterectomy and 33 were unmarried. Of the 76 married reproductive age women, 10 (13.1%) were infertile. Three had male factor infertility, three had ovulatory problems and in four cases, the cause was uncertain. Six of these patients were actively treated by ovulation induction with or without IUI and two of these patients became pregnant. The remaining four patients refused treatment for infertility. We conclude that the incidence of infertility among kidney transplant recipients is similar to the general population, but they are less motivated to be treated for infertility.
  1 3,932 347
Chronic lead poisoning: A "forgotten" cause of renal disease
Meryem Benjelloun, Faissal Tarrass, Khadija Hachim, Ghislaine Medkouri, Mohamed Gharbi Benghanem, Benyounes Ramdani
January-March 2007, 18(1):83-86
Chronic lead nephropathy occurs as a result of years of lead exposure. Nowadays, with the induction of high standards for industrial hygiene, symptomatic lead intoxication has become extremely rare. We report a case of chronic lead nephropathy in a 59­year-old man who worked in a battery-recycling unit and was diagnosed with plumbism during a regular health screening few years ago. The diagnosis was suggested by the following findings: serum creatinine 160 µg/L, creatinine clearance 46 ml/min, daily urine protein excretion 0.1 g, uric acid 9.7 mg/dl, blood lead 9.2 µg/dl, and a urinary excretion of 850 µg lead/72h after a mobilisation test by a Na 2 -Ca-EDTA chelating agent. Renal ultrasound showed bilateral borderline small kidneys. The kidney biopsy revealed moderate focal atrophy, loss of proximal tubules, and prominent interstitial fibrosis. The patient was prescribed angiotensin­converting-enzyme inhibitors to slow the progression of renal insufficiency and control the blood pressure. Hyperuricemia was also treated and controlled. During the regular follow-up, renal function remained stable with no proteinuria. A high index of suspicion for lead intoxication in chronic kidney disease patients should be practiced, especially in patients with hyperuricemia. Chelation of lead urinary excretion is helpful in the diagnosis of this disease.
  1 6,635 810
Attitude of Physicians in Saudi Arabia towards Anemia Treatment Strategies in Patients with Chronic Kidney Disease
Muhammad Ziad Souqiyyeh, Faissal A.M Shaheen
January-March 2007, 18(1):65-72
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.
  1 2,399 377
Prevalence of Acquired Cystic disease in Black Africans on Hemodialysis in West Africa
DA Gnionsahe, DA Lagou, WM Tia
January-March 2007, 18(1):114-116
Acquired cystic kidney disease (ACKD) is a late manifestation of end-stage renal disease. To determine the prevalence of ACKD in black African patients on chronic hemodialysis in West Africa, we examined by ultrasonography the native kidneys of 83 patients from February to August 2002. ACKD was present in 26 patients, with estimated prevalence of 31% that was higher in males. There were 20 (77%) ACKD patients with a duration on dialysis of more than five years. The associated clinical manifestations were lumbar pain (58%), hematuria (23%) and urinary tract infection (23%). No case of renal cancer was detected during this study. We conclude that the prevalence of ACKD and its complications in black African patients on chronic hemodialysis in West Africa is high. We recommend that renal ultrasonography should be performed routinely in patients on hemodialysis for more than 5 years.
  1 1,665 294
Atypical Presentation of Xanthogranulomatous Pyelonephritis: A Case Report
Reda Ghacha, TJ Youmbissi, Ajit K Sinha, Mohammad Abdelrahman, Ayman Karkar
January-March 2007, 18(1):87-90
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 non­functioning hydronephrotic kidney, which is totally distorted, and has enhancing as well as non-enhancing regions on computed tomography.
  - 3,327 359
Recurrence of Focal Segmental Glomerulosclerosis after Renal Transplantation: A Case Report
Nabeel Akash
January-March 2007, 18(1):91-94
Focal segmental glomerulosclerosis (FSGS) may recur following transplantation. Approximately half of the patients with recurrent FSGS lose their grafts. We report a case of a 54-year-old woman with focal segmental glomerulosclerosis (FSGS). She underwent live-related donor kidney transplantation from her 21-year-old son and immunosuppression was maintained with tacrolimus, mycophenolate mofetil and steroids. Eight months after transplantation, the patient presented with increasing lower limbs edema and heavy proteinuria. Allograft biopsy contained 20 glomeruli of which four were totally sclerosed, seven were segmentally sclerotic, and the rest were non-sclerotic, relatively enlarged glomeruli compatible with recurrent FSGS in the graft. Plasmapheresis over a two week period with simultaneous oral cyclophosphamide resulted in a partial response of proteinuria from 12 to 2.2 g/24hrs over 5 weeks.
  - 3,151 424
Letter to the Editor
Attiya Mukhtar, TQ Malik, A Karkar
January-March 2007, 18(1):100-100
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