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Treatment of focal segmental glomerulosclerosis (FSGS) is frustrating, especially for steroid-resistant FSGS. Different immunosuppressive agents have been used with inconsistent outcome. We analyzed the data in our FSGS patients who, in addition to steroid, were treated with cyclosporine (CYA), cyclophosphamide (CYP), and mycophenolate mofetil (MMF) along with the long-term follow-up. This is a retrospective analysis of 113 patients diagnosed to have FSGS with 11 years' follow-up carried out at The Kidney Center Post Graduate Training institute. Among 113 patients, 51.3% were male with a mean age of 34.4 ± 11.8 standard deviation. Patients who achieved complete remission with steroid alone and steroid with combination of CYA, CYP, and MMF were 38 (26%), 19 (16.8%), and six (5.3%), respectively, similarly those who got partial remission were three (3.6%), five (4.4%), three (2.6%), and eight (7.0%), respectively. The factors which affected the outcome were serum creatinine (SCr), tubulointerstitial fibrosis (TIF), and the treatment. In adjusted analysis, increase in 1 mg of SCr reduces the patient recovery by 56%, while the absence of TIF increases recovery by 80.75%. Taking steroid as reference category, steroid + CYA found 2.03 times more effective as compared with steroid alone. Seven patients developed end-stage renal disease (ESRD) and three died due to disease during the follow-up. CYA comes out as the most effective treatment for steroid-resistant FSGS followed by MMF and CYP. The long-term outcome of all modalities is the same in terms of mortality and developing ESRD. The degree of TIF and renal failure has strong influence on the course of the disease., Competing Interests: None

Objective: To compare adequacy of dialysis between single-use and reused dialyzer in order to ascertain whether reuse of dialyzers provides adequate dialysis and thereby enable provision of effective yet affordable renal replacement therapy in resource-limited countries., Study Design: Observational cross-sectional study., Place and Duration of Study: Department of Nephrology, The Kidney Centre, Postgraduate Training Institute (TKC-PGTI), Karachi, from December 2017 to February 2018., Methodology: Equal number of patients on thrice weekly hemodialysis with either single-use (group A; n=33) or reuse (group B; n=33) dialyzer for at least six months were reviewed. Both groups were compared for dialysis adequacy measured as urea reduction ratio (URR); as well as adequacy of patient care in terms of anemia, bone-mineral control and nutritional status. Serum hemoglobin and erythropoietin stimulating agent (ESA) dose were taken as markers for anemia management, serum calcium, phosphate and intact parathyroid hormone (iPTH) for bone-mineral control and serum albumin as index for nutritional status., Results: The mean age of patients in Group A was 51.36 +13.9 years and in Group B was 54.78 +15.4 years. Female to male ratio was 1.75:1. The mean number of dialyzer reused in group B was 47.5±27.8. There was no significant difference between the study groups in terms of URR (p=0.362), hemoglobin (p=0.347), ESA dose (p-=0.556), serum calcium, phosphorus and iPTH (p=0.868, p=0.138 and p=0.323, respectively), and serum albumin (p=0.777). All the parameters were in accordance with KDOQI guidelines., Conclusion: Reuse of dialyzer does not affect dialysis efficiency. Adequate dialysis therapy can be provided economically through reprocessed dialyzers in at least resource-poor countries.

Objective: To study the clinical characteristics of patients on hemodialysis for more than ten years in order to highlight the modifiable factors that may improve survival in low socioeconomic status., Study Design: Observational cross-sectional study., Place and Duration of Study: Department of Nephrology, The Kidney Centre Postgraduate Training Institute (TKCPGTI), Karachi, from November 2017 to January 2018., Methodology: Clinical records of 38 patients, who have been on thrice weekly hemodialysis for more than ten years at the study centre with registration period from 1989 to 2018, were reviewed. The participants were placed in three groups according to duration of hemodialysis: 10 to 15 years; 15 to 20 years, and >20 years. Background information (age, gender, age at initiation of hemodialysis, cause of renal failure), dialysis dose (urea reduction ratio), anemia (hemoglobin), bone-mineral metabolism (calcium, phosphate and iPTH), and nutrition (albumin) were evaluated. The parameters were compared among the groups and with respect to K/DOQI and EBPG guidelines., Results: Mean age at institution of hemodialysis was 33.5 years. The most common cause of End Stage Renal Disease (ESRD) was of unknown etiology (bilateral small shrunken kidneys). Chronic sclerosing glomerulonephritis was the second most common cause. The mean hemoglobin level was 10.98 +1.4 g/dL. Mean phosphate, calcium and iPTH were 4.75 ±1.34 mg/dL, 9.62 ±0.64 mg/dL and 281.5 pg/ml, respectively. Serum albumin was 3.66 ±0.39 mg/dL. These indexes were comparable to recommended guidelines., Conclusion: Clinical characteristics and other profiles of patients on hemodialysis for more than 10 years are comparable to the standard K/DOQI and EPBG guidelines. We believe that complying the standard guidelines for management of patients on chronic hemodialysis can result in better long-term outcome and survival in our population.

Objective: To study the pattern of dyslipidaemia in patients with stage-V chronic kidney disease on conservative management and those on maintenance haemodialysis., Methods: This comparative observational study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, from February to July, 2008, and comprised stage-V chronic kidney disease patients. The patients were divided in two groups. Those who were on conservative management were placed in Group A, and those who were on maintenance haemodialysis were in Group B. Serum total lipid, cholesterol, triglycerides and high-density lipoprotein for both groups were assayed on chemical analyser and low-density lipoprotein was calculated by Friedwald equation. SPSS 17 was used for data analysis., Results: Of the 120 patients, there were 60(50%) in each group. The mean age of patients in Group A was 46.33±14.56 years and in Group B was 43.4±14.1years. Of all, 64(53.3%) were men and 56(46.7%) were women. Mean systolic and diastolic blood pressure was 134±19.58mmHg and 83.6±14.14mmHg in Group A and 129±19.7mmHg and 79.7±12.1mmHg in Group B. Mean serum total lipid was significantly higher (p<0.01) whereas mean serum cholesterol was significantly lower (p<0.01) in Group B. Comparison of mean serum triglycerides between the groups was also statistically significant (p<0.01) and was high in Group B. Mean serum high-density lipoprotein was lower in Group B (p<0.01). The difference between serum low-density lipoprotein levels was statistically insignificant between the groups (p=0.11)., Conclusions: Pattern of dyslipidaemia in patients on maintenance haemodialysis was more hostile than those on conservative management, and posed increased risk of coronary heart disease.

Reusing dialyzers is almost universal in developing countries to reduce the cost of hemodialysis (HD). Economic benefits of dialyzer reuse, when estimated only on the basis of the dialyzer and its consumables are very significant and attractive. In this study, we compared the cost of mechanical reuse of dialyzer considering all of the direct costs (medications, dialyzer, and its consumables, disinfection fluid, and hospitalization if any) in HD treatment, which if significantly different between single use and reuse, can nullify the obvious cost benefits. A total of 70 adult patients of any gender on maintenance HD at The Kidney Centre Post Graduate Training Institute for more than three months were included. Equal numbers of patients were on single use (Group A) and reuse of dialyzer (Group B). Both groups were compared for total direct costs of HD over a six months period. Average six monthly total direct cost per patient of Group A was significantly high as compared to Group B, the United States Dollar (USD) 1750.67 ± 135.31$ vs. USD 1488.50 ± 132.23$); difference USD 262.18$ (P <0.001). The total cost saving being 14.97% in Group B. Our study shows that dialyzer reuse provides a significant economic benefit and remains a means of reducing the cost of HD.

Introduction: Month of Ramadan bring many changes in life style, especially the diet of Muslims all over the world among both fasting and nonfasting individuals. Hemodialysis patients are kept on restricted diet because of fluid and electrolytes imbalance. The aim of this study was to compare changes in the clinical and biochemical parameters in fasting and nonfasting hemodialysis patients during the Ramadan., Materials and Methods: In a longitudinal study, we recruited 282 patients who were on maintenance dialysis for more than 3 months. Measurements included body weight, blood pressure, serum potassium, serum albumin, and serum phosphorus at the beginning and during the last week of Ramadan., Results: There were 252 patients who were not fasted while 34 patients were those who fasted during the Ramadan. In the nonfasting hemodialysis patients, serum albumin significantly increased at the end of Ramadan (P < .001), while serum phosphorus levels (P = .004) and diastolic blood pressure (P = .002) showed a decrease as compared with the measurements before Ramadan. In the fasting group, only serum albumin had a significant increase (P < .001) during Ramadan, while other parameters were not significantly different between the two measurements., Conclusions: Changes in dietary pattern and content during the Ramadan is safe in terms of electrolyte balance and blood pressure changes for patients on hemodialysis. It is also safe for those patients who want to fast during this month.

Objective: The effect of month of Ramadan on the mortality in hemodialysis patients, and to compare it with that in all other Islamic months., Study Design: A descriptive study., Place and Duration of Study: Hemodialysis Unit, The Kidney Center, Karachi, from January 1989 to December 2012., Methodology: All those patients who were diagnosed to have end stage kidney disease and on maintenance hemodialysis for more than 3 months, regardless of underlying cause of kidney failure were included. Patients with acute kidney injury were excluded. Status of the patients was recorded at the end of the study period. The fasting status of the patients was not mentioned. The deaths of the patients were further evaluated and frequencies of death in all twelve Islamic months were calculated., Results: A total of 1,841 patients were registered, out of whom 897 (48.7%) died, and 269 (14.6%) survived till the end of the study. One thousand and fifty six (57.3%) were males, 651 (35.4%) were diabetic. Total number of 143 (7.76%) events occurred in Ramadan, out of which 94 patients died which make nearly 11% of the total deaths distributed in 12 Islamic months. Frequency of death was higher in Ramadan when compared with other months., Conclusion: Ramadan reflected a higher frequency of death. Therefore, there is a need to evaluate the risk factors in a prospective study so that the dialysis patients can be better managed during this period.

In spite of controversies, dialyzer reuse has remained an integral part of hemodialysis because of lower cost, good overall safety record, and improved membrane biocompatibility. Reuse declined in developed countries from the beginning of this century because of mass production of hemodialyzers at favourable price with better biocompatible membrane. Abandoning dialyzer reuse became challenging in South Asian region, where more than 40% of the population live below the International Poverty Line of $1.25 per day, less than 10% of end stage renal disease patients receive renal replacement therapy, and upto 70% of those starting dialysis stop treatment due to cost within the first 3 months. Dialyzer reuse is an efficient cost-saving method that allows the use of more efficient and expensive biocompatible synthetic membranes, thereby providing high-quality dialysis to individuals living in countries with limited medical resources without compromising the safety or effectiveness of the treatment.