Vascular access surgery is a permanent challenge for the vascular surgeon and is a very dynamic, inter-disciplinary field in modern medicine. High technical skill, extreme care and continuity to gain as much experience as possible are required. Priority should be given to the patients' native vessels. Nevertheless, grafts do have a place provided special attention is paid to the restricted indications. Close co-operation of the vascular surgeon, the nephrologist and the radiologist is essential. The nephrologist is responsible for access surveillance and for early detection of fistula dysfunction. Dialysis related parameters should be observed routinely; clinical examination and if necessary ultrasonographic and angiographic technique will give further information. Recently introduced methods such as permanent central venous catheters and an increasing variety of interventional procedures must be critically evaluated in the future.

We evaluated the prevalence of central vein stenosis in patients with prior central vein catheterization for vascular access for hemodialysis. A total of 36 patients with end-stage renal disease (ESRD) who were referred to the division of vascular surgery at King Khalid University Hospital in Riyadh were evaluated. Bilateral ascending venogram was performed in all cases. The patients were divided into three groups: Group I included 38 extremities in 32 patients who were referred for construction of an arteriovenous fistula. All these patients had previous history of subclavian vein catheterization. This included six patients who had bilateral catheter insertion. Venography demonstrated greater than 50% central vein lesions in 13 of the 38 extremities yielding a prevalence of 34%. Group II included four extremities in four patients who were on hemodialysis for many years all of whom presented with features suggestive of venous obstruction in their already existing arteriovenous fistulae. All four patients gave history of prior subclavian vein catheterization for dialysis. Three of these patients had > 50% subclavian vein stenosis while one showed complete occlusion of the vein. Group III included 30 extremities without history of prior central vein cannulation and none of them showed any lesions on venography. Our study further confirms previous reports that show a high prevalence of central vein stenosis following use of subclavian catheter as vascular access. We suggest that the subclavian route should be abandoned in patients with ESRD and temporary venous cannulation, if needed, should be performed in the femoral or internal jugular veins. Also, in individuals with history of prior central vein cannulation, venography is strongly recommended before an arteriovenous fistula is made.

Eighteen children with biopsy-proven Wilm's tumor were diagnosed and treated between 1985-1994 at the King Fahd Hospital of the University, Alkhobar, Saudi Arabia. There were eight males and 10 females. The median age at diagnosis was 2.5 years. Two patients (11%) had stage I, six patients (33%) stage II, eight patients (44%) stage III and one patient each (6%) had stages IV and V respectively. Seventeen patients (94%) had favorable histology and one (6%) had anaplastic type. One patient had bilateral tumor and one had associated aniridia. Follow-up was from 2 to 10 years (mean:5 years). The treatment administered was according to the recommendations of the National Wilm's Tumor Study II and III. Two patients died resulting in an overall disease-free survival of 88.8%. Our study further confirms that Wilm's tumor is a curable malignancy even in advanced stage.

CAPD is not as popular mode of renal replacement therapy (RRT) in this country as it is in the west and hence the experience with CAPD is limited. At our center 16 patients (8 Males, 8 Females) with ESRD with a mean age of 46.3 ± 15.6 years were managed by CAPD during 1990-1994. CAPD was the first option as a renal replacement therapy (RRT) in seven (44%) and second option in nine (56%) patients. Indications for CAPD were: Vascular access problems in 10 (62.5%), cardiovascular instability in three (19%), patient preference in two (12.5%) and non-availability of nearby HD center in one (6%) patient. Standard safe leur-lock system was used for dialysis. All patients were well dialyzed with good quality of life. Peritonitis was the main complication encountered (one episode/eight patient months), cause of hospital admission and reason for returning back to hemodialysis (HD). Other complications encountered were intraperitoneal bleeding in three, accidental cutting of outline in two, leakage in one and exit site infection in one. Average survival of this method was 15 + 10.5 months (range 1-37 months). At the time of reporting this study seven patients continued to be on CAPD, six were transferred back to hemodialysis, one was transplanted and two died due to other reasons. We conclude that CAPD is an acceptable mode of RRT in this part of the world.

We have studied 26 patients with rhabdomyolysis complicated with acute renal failure. The causes of rhabdomyolysis were dominated by paraphenylene diamine intoxication (PPD) (13 cases). The other etiologies were: crush syndrome (6 cases), eclampsia (3 cases), intense physical effort (1 case), butane intoxication (1 case), postural rhabdomyolysis induced by a prolonged surgical operation for pheochromocytoma (1 case). None of the patients had any past medical history of muscle or renal disease. Serum level of creatinine phosphokinase varied from 1200 to 5400 IU/L. The mean peak of serum creatinine level was 620 umol/1. Therapy included forced alkaline diuresis in all cases. Hemodialysis was required in 18 cases. All but eight patients survived. We conclude that rahabdomyolysis could be caused by intoxication, which was a prime cause in this study. Prevention may be possible with restriction of use of toxic products.

Forty seven patients with end-stage renal disease (ESRD) on maintenance hemodialysis at the Najran General Hospital, Najran, Saudi Arabia were studied for prevalence of hepatitis C virus (HCV) infection. A total of 24 patients (51.1%) were found to be positive for anti-HCV antibodies. Duration of hemodialysis was longer (p = < 0.025) in anti-HCV positive patients (4.9 ± 2.9 years) as compared to anti-HCV negative subjects (1.7 + 1.4 years). No significant relationship was found between blood transfusions and anti-HCV positivity. Ten (41.7%) of the anti-HCV positive patients showed elevated liver enzymes in comparison with two (8.7%) of the seronegative patients. This difference was statistically significant (p = <0.05). Liver biopsies from eight of the anti-HCV positive patients demonstrated cirrhosis in one, chronic active hepatitis in three, chronic persistent hepatitis in three and normal histology in one patient. There was no correlation between liver enzymes and the severity of histopathological findings on liver biopsy.

Transplantation of organs is becoming increasingly successful. What was once an experimental and life-saving emergency procedure has now been transformed into a life-enhancing and technologically advanced form of therapy. Histocompatibility testing between the donor and recipient consist of identification of HLA antigens known as tissue typing, and testing for pre-formed antibodies in the recipient against the donor HLA antigens, known as crossmatching. The importance of matching of HLA antigens has been debated ever since the first successful renal transplant was performed in 1954. Powerful and newer immunosuppressive drugs have not been able to establish an operational state of long-term organ tolerance. In this article, an attempt is made to show the clear and obvious effect of HLA antigen matching on the long-term graft survival. Also, the merits and demerits of different crossmatching methods and their proper interpretation and application to improve the overall graft survival are discussed.

We report a four-year old Saudi boy who was on continuous ambulatory peritoneal dialysis using a Y-connector system. He developed peritonitis without associated exit-site infection. Xanthomonas maltophilia was grown from the dialysis effluent. The organism was sensitive to netalmycin, tetracycline and co-trimoxazole. The patient responded to treatment with co-trimoxazole given for a total of ten days. However, he presented with a second episode of peritonitis and the same organism was grown again from the dialysis effluent. Due to intractable infection, the PD catheter had to be removed during the second episode of peritonitis.

Crossed renal ectopia is an unusual anomaly, 90% of which is fused to the ipsilateral kidney. Multicystic dysplasia in association with crossed non-fused renal ectopia is a very rare phenomenon and can produce a palpable abdominal mass. We report a 2-year old girl who presented with a mass in the abdomen. Detailed evaluation including laparotomy confirmed a diagnosis of multicystic dysplasia in a crossed non-fused ectopic kidney. This diagnostic entity should be considered, when a mass is found in the abdomen or pelvis, and when no kidney can be found in it's normal ipsilateral position.