Data on incidence and prevalence rates of end-stage renal disease (ESRD) from selected countries including Saudi Arabia are provided. Current data from this country suggest that the incidence of treated ESRD (t-ESRD) in the age-group 0-20 years is 14 per million population (PMP) while the combined incidence for all ages is 240 PMP. The cost of management of the patients is staggering. In Japan, it has been estimated that the projected prevalence of t-ESRD will be 1111 PMP needing an estimated budget of US $ 5.8 billion per year for their management. Globally, more than US $ 50 billion would be needed per year with the presently available treatment modalities. This financial liability might make "Health for all by the year 2000" a myth unless some cheaper method of treatment is made available. Vigorous research is needed towards identifying and prioritizing vulnerable groups for ESRD by identifying and properly managing at-risk groups. These include patients with diabetes mellitus and hypertension as well as patients with indicators like proteinuria and obstructive uropathy. Cheaper modes of renal replacement therapy should be sought. Interesting ideas such as induction of diarrhea for amelioration of renal failure need to be explored further as also the use of the patient's own intestine as a medium for molecular exchange.

Continuous ambulatory peritoneal dialysis has become a practical and safe mode of therapy for patients with end-stage renal disease. The creation of a durable, safe and efficient peritoneal access has been made possible through refinements in catheter design. The Tenckhoff catheter and its modifications has remained the most popular peritoneal access devise over the last 25 years. The major objectives' in catheter design include ensuring biocompatibility, ease with which the catheter can be implanted and removed as well as esthetic appeal. The other features in a peritoneal dialysis catheter are those that reduce catheter related complications such as catheter migration, exit-site and tunnel infections, flow restriction and catheter cuff erosion. Although the perfect peritoneal catheter remains elusive as yet, refinements in design and manufacturing materials have facilitated the implantation and maintenance of the catheter resulting in better dialysis technique survival, lesser morbidity and greater patient acceptance.

Maintaining patients with end-stage renal disease (ESRD) on renal replacement therapy is expensive and it is important to increase efforts towards reducing the incidence of ESRD. For this, a sound knowledge of the magnitude of the problem is necessary. This study was undertaken to estimate the incidence of ESRD in two regions of Saudi Arabia namely: Gizan, situated in the Southern area with a population of 654,685; and Al-Madinah, situated in the North Western area with a population of 828,477. All general hospitals and primary care centers under the Ministry of Health in the two regions were included in the study. Those patients in whom two consecutive serum creatinine values above 265 µmol/L were recorded were recruited into the study. There were no non governmental centers offering care for patients with renal failure in the study regions at the time of the study. A total of 108 patients in Al-Madinah region and 187 patients in Gizan fulfilled the criteria of the study. Sex distribution was similar in both regions, 61% male and 39% female. There were 71.3% Saudi and 28.7% Non-Saudi patients in Al-Madinah and 65.2% Saudis and 34.7% Non-Saudi patients in Gizan. Analysis of age distribution showed that the highest prevalence occurred among patients between 41 and 60 years of age in Al-Madinah whereas in Gizan it was between 21 to 50 years. The annual incidence of ESRD in Al-Madinah was 65.2 per million population (PMP) and in Gizan 189 PMP. The higher incidence in Gizan may be due to ethnic, socio-economic and environmental factors. A large scale study covering all parts of the Kingdom is needed to throw more light on such variations in the incidence of ESRD in the Kingdom.

Hair-dye containing paraphenylene diamine (PPD) is widely used and this compound is known to be toxic, when ingested, to several organs including the kidney. In this study, we reviewed 150 cases presenting to Khartoum Teaching Hospital with PPD poisoning over a period of 10 years. The clinical features commonly involved the gastrointestinal tract, skin and eyes. Nearly all the patients had angioneurotic edema and some cases developed flaccid paraplegia or paraperesis. With regards to the renal involvement, we observed that 90 of the 150 study cases (60%) developed acute renal failure (ARF) requiring dialysis. The mean period on dialysis was 15 days (range 1-42 days). All patients recovered normal renal function. In order to exclude permanent glomerular damage following overdose of PPD, 20 patients were subjected to renal biopsy following recovery from ARF. None had evidence of glomerular injury. On the other hand, three patients who had chronic (skin) contact with the dye and one patient who recovered from ARF a year earlier showed evidence of focal segmental glomerulosclerosis on renal biopsy. We conclude that hair-dye containing PPD can cause severe side effects particularly after oral ingestion. Its use should be discouraged and public attention should be drawn in this regard.

Case records of patients aged 13 years or below with chronic renal failure (CRF), seen during the last 10 years at the King Hussein Medical Center, Amman, Jordan were reviewed. There were 46 patients with CRF, (25 males and 21 females), aged 1/2 to 13 years. Chronic pyelonephritis was the major cause of CRF seen in 23 cases (50%), followed by glomerulonephritis in eight (17.4%), congenital hypodysplasia in six (13%), hereditary nephritis in five (10.9%) and unknown etiology in four (8.7%). Of the study patients, 17.3% were below the age of five years at first presentation. Twenty one patients progressed to end-stage renal disease and among them chronic glomerulonephritis was the most common primary renal disease. The higher incidence of chronic pyelonephritis causing CRF in our series in comparison to 23.9% incidence reported in the developed countries shows that our infants and young children probably are not investigated early enough nor do they receive adequate treatment at the time of their first urinary tract infection. Prevention of renal failure, availability of replacement therapy, and extension of treatment opportunities to more children are the main problems concerning CRF in children in our country.

Rhabdomyolysis is a known complication of crush injuries, but is not known to complicate the course of the patients with head injuries without other apparent skeletal muscle injuries. The frequency of renal failure may be high in such group of patients. We conducted a prospective study to evaluate such incidence on twenty patients with head injuries. Ten patients (50%) had other injuries in addition, but none of the patients had crush injury. All the patients were investigated daily for serum electrolytes, urea, creatinine, creatinine phosphokinase (CPK) and myoglobulinuria. All these patients were on a dehydrating protocol to prevent brain edema, including administration of dopamine infusion (1-3 µg/kg/min), intravenous bolus doses of mannitol, and sodium bicarbonate. Nine patients (45%) developed renal impairment, three of them had no other apparent skeletal muscle injuries, but none of them required dialysis. Rhabdomyolysis is not uncommon in head injury patients in the absence of apparent skeletal muscle injuries, and may precipitate renal failure. This may have therapeutic implications to prevent the incidence of acute renal failure in such group of patients.

Anemia is a well recognized complication of chronic renal failure (CRF). Although the use of erythropoietin (EPO) in the treatment of anemia in patients on dialysis is well established, its use in pre-dialysis patients is less well recognized. The preferred route of administration of EPO in pre-dialysis patients is subcutaneous and it is indicated in any patient with CRF who is symptomatic of anemia. Studies have shown that EPO is effective in correcting anemia in these patients with a considerable improvement in quality­of-life scores. There have been no deleterious effects on blood pressure or rate of decline of renal function. However, these two indices should be monitored closely. Common causes of treatment failure include iron deficiency, blood loss and occult sepsis. The available evidence indicates that EPO therapy is safe and effective in the treatment of anemia in pre­dialysis patients.

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

A renal transplant recipient presented with abdominal pain and anuria secondary to multiple radio-opaque obstructing calculi. A ureteroscopy with ultrasonic disintegration was done, and the fragments were spontaneously passed later. The calculi had formed on a non-absorbable suture line. Although ureterolithiasis in the transplanted kidney is amongst the least common of the urological complications following renal transplantation, it is an important reversible cause of obstruction that should always be considered. Also, non-absorbable suture lines should not be used in the urinary tract because they may serve as a nidus for stone formation.

In this report we present the current status of the renal replacement therapy in Sudan. Sudan is a large country with 30 million inhabitants. Peritoneal Dialysis was started in 1968, while hemodialysis was started in 1973. At present, there are only 16 hemodialysis machines serving 56 patients in two centers in Sudan. There are also 15 peritoneal dialysis beds for 70 intermittent peritoneal dialysis patients in three centers. Continuous ambulatory peritoneal dialysis is not being practiced in Sudan. The first renal transplant was in 1974, and till now more than 30 transplants have been performed in two transplant centers. All the transplants have been from living donors. The scholars of Islam in Sudan oppose to donation from cadavers. There are 200 renal transplant patients being followed up in Sudan and the majority had their renal transplants abroad. We conclude that there is a tremendous shortage of renal services in Sudan. There are more efforts being made to improve these services.