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Hemodiafiltration (HDF) is not associated with lower mortality risk compared to standard hemodialysis (HD). However, there are many critical clinical outcomes in dialysis patients in addition to mortality; the impact of HDF on these other outcomes is not clear. This retrospective study included all patients referred to DaVita Clinics in the Kingdom of Saudi Arabia. High-flux HD was the initial modality in all patients. Those who did not achieve adequacy targets or those with poorly controlled phosphorus were switched to postdilution HDF using 18 to 23 L exchange per treatment. Patients dialyzing with a central venous catheter, patients who dialyzed less than 90 days at DaVita, and those with interrupted HDF were excluded. Of the 1115 patients, 215 (19%) were on HDF and 900 on high-flux HD; the median follow-up was 6 months for all patients. The HDF group showed a significant reduction in serum phosphate (P < .001), a significant increase in serum calcium (P < .012) and a significant improvement in Kt/V (P < .0001). The HDF group had significantly higher hemoglobin levels than the HD group (P = .024), with a significant reduction in weekly erythropoiesis-stimulating agent dose after starting HDF (P < .001). A modified protocol that included prolonged dialysis duration, larger-sized dialyzer, faster blood flow rates, and adding hemofiltration fluid may be helpful in achieving the recommended targets. Thus, HDF can enable the achievement of adequate dialysis care in some patients. Randomized-controlled clinical trials are necessary to confirm these findings.

BackgroundWomen of all ages and elderly patients of both genders comprise an increasing proportion of the haemodialysis population. Worldwide, significant differences in practice patterns and treatment results exist between genders and among younger versus older patients. Although efforts to mitigate sex-based differences have been attempted, significant disparities still exist.MethodsThis retrospective cohort study included all 1247 prevalent haemodialysis patients in DaVita units in Portugal (five dialysis centres, n = 730) and Poland (seven centres, n = 517). Demographic data, dialysis practice patterns, vascular access prevalence and the achievement of a variety of Kidney Disease: Improving Global Outcomes (KDIGO) treatment targets were evaluated in relation to gender and age groups.ResultsBody weight and the prescribed dialysis blood flow rate were lower in women (P 80 years of age.ConclusionsThis large, multicentre real-world analysis indicates that haemodialysis practices and treatment targets are similar for women and men, including the most elderly, in DaVita haemodialysis clinics in Europe.

BACKGROUND: Recent international reports have shown significant changes in the incidence of different glomerular diseases. OBJECTIVE: Examine temporal and demographic trends of biopsy-diagnosed glomerular diseases in the adult population of Saudi Arabia over the last two decades. DESIGN: Medical record review. SETTINGS: Four tertiary medical centers in Saudi Arabia. PATIENTS AND METHODS: We identified all patients that underwent native kidney biopsy between 1998 and 2017. MAIN OUTCOME MEASURES: The frequency and the disease trends in four biopsy eras (1998–2002, 2003–2007, 2008–2011, and 2012–2017) for different glomerular diseases. SAMPLE SIZE AND CHARACTERISTICS: 1070 patients, 18-65 years of age; 54.1% female. RESULTS: Of 1760 patients who underwent native kidney biopsies, 1070 met inclusion criteria. Focal segmental glomerulosclerosis was the most common biopsy-diagnosed disease, with comparable frequencies over the four eras (23.6%, 19.8%, 24.1%, and 17.1, respectively [P value for trend=.07]). The frequency of immunoglobulin A nephropathy increased progressively. The incidence of membranoproliferative glomerulonephritis declined significantly. Among the secondary types of glomerular diseases, systemic lupus erythematosus-associated lupus nephritis was the most common, followed by diabetic nephropathy. The prevalence of diabetic nephropathy increased from 1.4% in the first era to 10.2% in the last one. CONCLUSIONS: Trends in biopsy-diagnosed glomerular disease have changed. While focal segmental glomerulosclerosis remains the most common glomerular disease, there has been a significant rise in the prevalence of immunoglobulin A nephropathy and diabetic nephropathy. In contrast, membranoproliferative glomerulonephritis has declined. LIMITATIONS: Retrospective methodologies are vulnerable to lost data. CONFLICT OF INTEREST: None.

Background The optimal treatment algorithm for iron therapy and the use of erythropoiesis-stimulating agents (ESA) in anemic hemodialysis (HD) patients has not been established. Hemoglobin (Hb) target levels can be achieved through more frequent intravenous (IV) iron use with lower ESA dose, or with less iron dosing but higher ESA. ESA therapy to correct anemia may result in severe arterial and venous thrombotic complications and the evidence base evaluating hard clinical outcomes related to the use of IV iron is sparse. Methods A total of 1247 maintenance HD patients from 12 dialysis centers in Portugal (n = 730) and Poland (n = 517) were considered. We assessed achievement of KDIGO renal anemia targets with focus on treatment strategies, which typically differ between countries. In Poland the use and dose of IV iron was 35–72% higher than that in Portugal (p 20 and > 50% were both significantly higher in patients in Poland (88.8 and 14.6%) than in Portugal (76.3 and 5.7% respectively, p 800 μg/L (35.6%) compared to Portugal (15.8%, p

Focal segmental glomerulosclerosis (FSGS) is a common progressive chronic renal disease. Podocyte injury and loss are the postulated pivotal events that trigger FSGS. In this study, the authors aim to examine the evolution of FSGS in murine models histologically, ultrastructurally and immunohistochemically with special emphasis on podocytes and parietal epithelial cells (PECs).FSGS resembling primary FSGS in humans was initiated in Wistar rats using intravenous Adriamycin injections. Blood and urine analysis were performed at 0, 8, and 12 weeks. Both the control kidneys and the test kidneys were harvested at 8 and 12 weeks, examined histologically and ultrastructurally and the findings correlated with the glomerular expression of immunostains specific for podocytes (WT-1) and for activated PECs (CD44).FSGS developed in both 8 and 12 weeks test groups showing progressive proteinuria, podocytopathy and segmental glomerular scarring. There was a decrease in the glomerular expression of WT-1 with a concurrent increase in the glomerular expression of CD44, indicating podocyte loss with synchronous increase in activated PECs. The evolving FSGS correlated negatively with podocytes and positively with activated PECs.Our study shows that with podocyte injury there is podocyte effacement and loss, proteinuria, glomerular segmental adhesion and scarring, all culminating in FSGS. In addition, there is activation, hyperplasia and hypertrophy of PECs. This demonstrates that both podocyte loss and PEC activation promote FSGS. Our findings are consistent with recent investigations. More studies are required to further understand the role of these cells in the evolution of FSGS and subsequently introduce new targeted treatment modalities.

Objectives: To examined the short and long-term outcome of class II lupus nephritis (LN). Methods : This retrospective study included patients with class II LN at their first renal biopsy between January 1996 and December 2016 in King Khaled University Hospital, Riyadh, Saudi Arabia. The rate of complete remission, worsening renal function, and histological transformation in the second biopsy were examined. Results: The study included 32 female patients with class II LN. The most frequent presentation (62.5% of patients) was hematuria with subnephrotic range proteinuria. The clinical presentation included acute kidney injury in 22% of patients, and 9.4% had nephrotic range proteinuria. Management with steroid monotherapy in 25 patients resulted in complete remission for 92% of these patients at 6 months. After a median follow up of 8 years, 2 patients had a doubling of their serum creatinine. During the follow up 17 patients (53%) needed a second biopsy, which revealed transformation to other classes (65%). Conclusions : Daily steroid monotherapy may be an appropriate first-line treatment for class II LN that presents with subnephrotic range proteinuria and normal kidney function. Patients with acute kidney injury and/or nephrotic range proteinuria may warrant more aggressive immunosuppressive regimens. Saudi Med J 2018; Vol. 39 (10): 990-993 doi: 10.15537/smj.2018.10.22435 How to cite this article: Alsuwaida AO, Bakhit AA, Alsuwaida FA, Wadera JJ, Kfoury HM, Husain S. The long-term outcomes and histological transformation in class II lupus nephritis. Saudi Med J . 2018 Oct;39(10):990-993. doi: 10.15537/smj.2018.10.22435.

Lupus nephritis (LN) is characterized by a highly variable clinical course. It has been reported that histopathologic lesions are risk factors for the progression of LN. The aim of this study is to investigate the relationship among the co-deposition of C1q, clinicopathological features, and renal outcomes in patients with LN. The clinical and histological parameters were studied in patients with International Society of Nephrology/Renal Pathology Society Class III or IV LN, who underwent two kidney biopsies. The patients were divided into two groups based on the glomerular C1q deposits: C1q-positive and C1q-negative. The impact of C1q status and longterm renal outcome on the doubling of serum creatinine and the rate of remission in the two groups were further investigated. Fifty-three patients had pure proliferative nephritis and 37.7% of these had a co-deposition of C1q. Doubling of serum creatinine was observed in 25% of patients with C1q-positive and 24.2% of patients with C1q-negative deposits. There was no difference between the two groups in terms of achieving complete or partial remission. The renal survival in the two groups was similar (P = 0.75). Upon repeat biopsy, the persistence of C1q positivity was associated with a poor outcome (P = 0.007). C1q deposition in the glomerulus in the baseline biopsy was not associated with a poor renal outcome or severe pathologic features in patients with proliferative LN. However, the persistence of C1q positivity in repeat kidney biopsy is associated with a poor renal outcome.

Despite the fact that many of the medical outcome data of peritoneal dialysis (PD) have been improving over the past few years, PD remains an underutilized modality in many countries worldwide. Most nephrologists in those countries report a high rate of patients’ refusal. We conducted this survey-based study to determine the obstacles behind underutilization of PD in Saudi Arabia from patients’ perspectives and to understand the reasons for their refusal. Nine-hundred and twenty hemodialysis (HD) patients, who had never been on PD before, participated in this study. Responses obtained from patients indicate that their refusal of PD could be because they had not received proper counseling and education about PD from their treating nephrologists throughout the course of their disease.

Introduction: Glomerular diseases in the elderly population are a challenging clinical dilemma, and kidney biopsy is of paramount importance to clarify the morphological changes. The aim of this study was to evaluate the prevalence of major glomerulopathies that affect older adults. Methods: This retrospective study included 70 adults aged >65 years and was performed at four tertiary centres in Saudi Arabia between January 2001 and December 2017. Results: There were 74 native kidney biopsies, which accounted for 7.2% of all native renal biopsies that were performed in the 16-year period. Furthermore, 64% of the native biopsied patients were men. The most common clinical presentations were nephrotic syndrome (40%) and acute kidney injury (20%). In older adults with primary glomerular diseases, IgA nephropathy was the most frequent pathological type (36.4%), whereas diabetes mellitus was the most frequent etiology (37.5%) for secondary glomerular diseases. Women were more likely to develop diabetic nephropathy. Conclusion: The prevalence of IgA is progressively increasing and is currently the most frequent type of primary glomerular disease diagnosed in senior adult. Diabetes has become the leading cause of secondary glomerular disease. Renal biopsy is therefore of paramount importance because an accurate diagnosis will help clinicians establish the diagnosis and guide therapy for both younger and older adults.

Introduction Medication non-adherence is an important cause of treatment failure among patients with systemic lupus erythematosus (SLE). Depression is a common neuropsychiatric disorder associated with SLE. The aims of this study are to assess the prevalence of both medication non-adherence and depressed mood among Saudi patients with SLE by using validated tools and to explore the impact of both depressive symptoms and disease activity on medication non-adherence. Methods A cross-sectional study was conducted in outpatients with SLE. Medication non-adherence was assessed by using the Morisky Medication Adherence Scale, and the severity of depressed mood was evaluated with the Beck's Depression Inventory. Disease activity was measured using the SLE Disease Activity Index (SLEDAI). Multiple logistic regression models were used to identify the multivariate predictors of medication non-adherence. Results Out of 140 patients, 134 (95.7%) were females with a mean (±SD) age of 35.6 (±11.3) years and a disease duration of 8.8 (±6.7) years. Medication non-adherence and depressed mood were detected in 62.1% and 35% of the patients, respectively. A moderate or severe depressed mood was significantly associated with medication non-adherence ( p = 0.04). There was a significant correlation between disease activity and the severity of depressed mood ( r = 0.31, p = 0.003). Disease activity did not correlate with medication non-adherence. Logistic regression demonstrated that moderate-to-severe depressed mood increased the probability of medication non-adherence (OR 2.62; 1.02-6.71). Conclusion Medication non-adherence and depressive symptoms are highly prevalent among Saudi SLE patients. Routine screening could facilitate the early detection and management of depression and medication adherence.

Objectives: To examin the effect of Ramadan fasting on worsening of renal function (WRF). Method: This was a single-arm prospective observational study including 65 patients with stage 3 or higher chronic kidney disease (CKD). By definition, WRF was considered to have occurred when serum creatinine levels increased by 0.3 mg/dL (26.5 µmol/l) from baseline during or within 3 months after Ramadan. The study was conducted in the Nephrology Clinic of King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia during the month of Ramadan 1436 AH (Hijiri), which corresponded to June 18-July 17, 2015. Results: This study included 65 adults with a mean age of 53 years. Overall, 33% of patients developed WRF. In the multivariate analysis, more advanced CKD stage, higher baseline systolic blood pressure and younger age were independently associated with WRF. Underlying cause of CKD, use of diuretics, use of renin angiotensin blockers, gender, and smoking status were not associated with WRF. Conclusion: In patients with stage 3 or higher CKD, Ramadan fasting during the summer months was associated with worsening of renal function. Clinicians need to warn CKD patients against Ramadan fasting. Saudi Med J 2017; Vol. 37 (1): 48-52 doi: 10.15537/smj.2017.1.17566 How to cite this article: Bakhit AA, Kurdi AM, Wadera JJ, Alsuwaida AO. Effects of Ramadan fasting on moderate to severe chronic kidney disease. A prospective observational study. Saudi Med J . 2017 Jan;38(1):48-52. doi: 10.15537/smj.2017.1.17566.

Background: The concurrence of diabetes and nephritogenic infections may have a tremendous impact on the kidney. The approach to the two concurrent diseases is based on histological, immunofluorescence findings and most importantly on ultrastructural features. In this experiment our aim was to compare the pattern of injury seen in the kidney in animals with induced post-infectious glomerulonephritis with and without associated diabetes. Methods: We divided 48 Wistar species rats into four groups comprising twelve rats each. Group I is the normal control, group II includes the rats with induced diabetes, group III are the rats with acute post-infectious glomerulonephritis (APIG), while group IV includes the rats with induced diabetes and APIG. Streptozocin was used to induce diabetes in groups II and IV while neutral phosphatase toxin (NPTase) of Staphylococcus strain was used in groups III and IV. Groups III and IV were sacrificed three and ten days after infection. Routine, immunofluorescence and ultrastructural stains and studies were performed on the kidneys of all rats. Serum urea and creatinine and urinary protein were estimated in all groups. Results: Out of the forty-eight rats initially included in the study, only twenty-four survived the experiment: three in Group I, five in Group II, five in Group III and eleven in Group IV. The most relevant and distinguishing findings in cases of APIG with associated diabetes are the earlier and more prominent infiltration by polymorphonuclear cells, the stronger positivity for IgG and the earlier and more extensive presence of dense deposits which were confirmed by the electron microscopy study. Conclusions: This experiment ascertains the adverse effects of diabetes in cases of acute post-infectious glomerulonephritis, in terms of onset and severity of the disease. The necessity of a better control of the glucose level may not only decrease the incidence of acute post-infectious glomerulonephritis but may also contribute to the development of a milder form of the disease.

Summary Background/purpose The validity of the Oxford classification of immunoglobulin (Ig)A nephropathy has not been fully explored in the Arab population. The aim of this study was to assess the validity of this classification in a cohort of adult Saudi patients with histologically proven IgA nephropathy. Methods A retrospective review of clinical and histological data of patients with biopsy-proven IgA nephropathy diagnosed between May 1998 and May 2011 was undertaken. The study was conducted at two institutions in Riyadh, Saudi Arabia. A total of 70 patients (46% females) with primary IgA nephropathy were included, with a mean age of 32.2 ± 12.9 years. The median follow-up was 3.5 years. The primary endpoint was decreased renal function, which was defined as 50% decrease in estimated glomerular filtration rate from baseline at last follow up. Results Higher mesangial score and later stage of segmental glomerulosclerosis showed trends towards correlations with a higher degree of proteinuria and lower estimated glomerular filtration rate at presentation and a higher rate of worsening of renal function, but these trends did not reach statistical significance (p > 0.05). However, endocapillary hypercellularity and tubular atrophy/interstitial fibrosis were significantly associated with reduced initial estimated glomerular filtration rate and higher initial proteinuria. In multivariate logistic regression, the worsening of renal function was not predicted by any histologic class. Conclusion The Oxford classification system is a useful tool that reflects the severity of the initial clinical presentation in Arabs with IgA nephropathy. However, it did not predict long-term renal outcomes. 背景 在阿拉伯人群中，IgA 腎病變的牛津分類法尚未通過充分的驗證。本研究以經過組織學驗證為 IgA 腎病變的沙烏地阿拉伯成年患者為對象，對此分類法的效度進行了評估。 方法 是次分析所涉及的個案，是從 1998 年 5 月至 2011 年 5 月間，經切片證實為原發性 IgA 腎病變的 70 位患者，女性佔 46%，平均年齡 32.2 ± 12.9 歲，均來自沙烏地阿拉伯利雅得的兩家院所。追蹤期間中位數為 3.5 年，首要終點為腎功能下降，其定義為腎小球濾過速率 (GFR) 估算值降幅達 50% (相對於基線)。 結果 分析顯示，環間膜評分偏高、與較晚期節段性腎小球硬化症，均與以下呈現相關的傾向：基線較嚴重的蛋白尿、基線較低的 GFR 估算值、及追蹤期間較明顯的腎功能惡化，雖然未達統計學意義 (p > 0.05)。然而，微血管內細胞過多、及腎小管萎縮/間質纖維化，則與基線較嚴重的蛋白尿、及基線較低的 GFR 估算值呈明顯關聯。在多變項邏輯迴歸分析中，組織學分類並未能預測腎功能惡化的發生。 結論 對於阿拉伯的 IgA 腎病變成年患者，牛津分類法可有效反映初期的病情嚴重性，但未能預測腎功能的長期變化。

Background and Aim Physicians' attitudes towards disease prevention are crucial. The purposes of this study are to examine the prevalence of cardiovascular risk factors and adherence to international preventive screening programmes by a group of physicians. Methods Online and paper format questionnaires were completed by a sample of 650 physicians from November 2010 to March 2011. The collected data included the main components of screening programmes, which are recommended in international guidelines. Results The data show that 30.5% of male physicians currently smoke, 19.4 % are obese, 15.2% have hypertension, 38% are physically inactive and 10.9% have diabetes. Nearly all (95%) of the female participants and most (83%) of the male participants older than 45 years had never had a colonoscopy. Of the male physicians older than 55 years, 36.4% had never had prostate-specific antigen testing, and only 10.9% had undergone a digital rectal examination. Among the female physicians, 27.4% were obese, and 42% had never had a mammogram. Conclusion The prevalence of behavioural risk factors for cardiovascular disease is high among physicians. A substantial percentage of the practising physicians did not adhere to the age-specified preventive screening measures recommended in international guidelines.

Objectives: To assess the prognostic value of IgG4 reactivity in biopsy-proven cases of idiopathic membranous nephropathy (iMN) and to outline its potential in guiding therapy. Methods: A retrospective study of biopsy-proven iMN cases from January 1997 to August 2013 was undertaken. Patients were identified, and an extensive analysis of the clinical and histological parameters were performed. The primary endpoint was a worse renal outcome, which was defined as doubling of the serum creatinine baseline value. Results: The study included 52 patients, with mean age of 38.0 years. The median baseline creatinine was 112.7 ± 36.3 umol/l among those with positive staining for IgG4 and 67.4 ± 19.3 umol/l among those with negative staining for IgG4 (P=0.5). There was no significant difference in the 24 hr urine protein between IgG4 positive and IgG4 negative staining cases (P=0.375). The probability of doubling serum creatinine was similar among those with or without IgG4 deposition. Follow up of the patients revealed that 23.4% of those with positive IgG4 and 14% of those with negative IgG4 had deterioration of the renal function. The prevalence and severity of tubulo-interstitial inflammation was not statistically different between the two groups. Conclusion: There was no relationship between IgG4 positivity and the severity of clinical and/or histological parameters in patients with iMN. IgG4 reactivity had no impact on the long-term outcome of the patients. Further studies are needed to outline the potential use of targeted therapy against IgG4 auto-antibody in a certain category of patients with membranous nephropathy.

Background. Standard clinical and laboratory parameters have limited predictive values for discriminating between active lupus nephritis and chronic disease. The objective of this study was to examine the predictive utility of a second kidney biopsy in patients with lupus nephritis. Methods. Patients with lupus nephritis were advised to have second kidney biopsies at the end of the maintenance phase of their therapies. Baseline and second renal biopsies were re-classified by pathologists blinded to the clinical data. The relationships between remission status and histological parameters were examined. Results. Included in this study were 77 patients followed up for a median duration of 8.7 years (interquartile range, 5.3– 10.1 years). Their renal survival rates were 93% for those in complete remission (CR), 69% for partial remission (PR) and 41% for no remission (NR). One-third of the patients with PR and 14% of patients with NR had no histological evidence of active disease on second biopsy. At the second biopsy, but not at the baseline biopsy, activity index was predictive of survival. The 10-year renal survival rate was 100% for those with an activity index of 0, 80% for those with an activity index of 1 or 2 on the second biopsy and 44% for those with an index of >2, regardless of remission status. Conclusion. Second kidney biopsy at the end of maintenance phase of therapy is an important diagnostic and prognostic tool that could guide physicians to safer practices with better outcomes.

Hypertension is an important risk factor for the commonest cause of death among men, namely, cardiovascular diseases. The purpose of this study was to provide data concerning gender difference in the awareness, treatment, and control of hypertension in adults. We conducted a cross-sectional study in Riyadh, the capital city of Saudi Arabia. Subjects were asked if they had been told by a physician that they had hypertension or were on blood pressure (BP) medication. Blood pressure was measured using standardized Joint National Committee (JNC) protocol. The study sample consisted of 814 adults who were at least 18 years old. Of the estimated 27.6% people with hypertension, 38.6% were unaware of their hypertension, 29.8% were aware of their condition but were not being treated, and among those who had been treated 40.8% remained uncontrolled. Independent predictors of a lack of awareness of hypertension were an age of at least 45 years, male gender, and BMI greater than 30. The extent of awareness and control of hypertension did not differ significantly by monthly income, educational level, physical activities, or smoking status. Awareness and control of hypertension is low in men, making them public health priorities. Achieving more stringent BP control will require increased attention by physicians and public education to improve the awareness and control of hypertension.

BACKGROUND AND OBJECTIVES: One out of five Saudi diabetics develops end-stage renal disease (ESRD). Factors associated with progressive loss of renal function have not been extensively studied and reported in our community. We sought to evaluate the pattern and progression in glomerular filtration rate (GFR) and investigate the potential risk factors associated with progression to diabetic nephropathy (DN) among Saudi patients. DESIGN AND SETTING: Hospital-based retrospective analysis of type 2 diabetic patients seen between January 1989 and January 2004 at Security Forces Hospital and King Saud University in Riyadh, Saudi Arabia. PATIENTS AND METHODS: DN was defined as persistent proteinuria assessed by urine dipstick [at least twice for at least two consecutive years and/or serum creatinine >130 μmol/L; and/or GFR 90 mL/min/1.73m2 at the first hospital visit; duration of diabetes >10 years; persistent proteinuria; systolic blood pressure >130 mm Hg; and presence of retinopathy were significant markers associated with progression of nephropathy. CONCLUSION: Diabetic nephropathy tends to be progressive among Saudis, with GFR deteriorating at a rate of 3.3 mL/year and with a doubling of serum creatinine level in 40.3% of patients in 9.9 years.

Carbonic anhydrase II (CAII) deficiency is an autosomal recessive disorder characterized by renal tubular acidosis, osteopetrosis, recurrent bone fractures, renal stones, growth failure, and mental retardation. Several cases have been reported in Saudi Arabia with homozygous mutations in CA2 consistent with a high degree of consanguinity. We report a case of carbonic anhydrase II deficiency with short stature, mixed renal tubular acidosis, recurrent bone fractures due to trivial trauma, recurrent renal stones and cerebral calcification. This patient was compound heterozygous for a novel CA2 mutation and a previously reported mutation in Arabs.

To evaluate the use of rituximab in the treatment of severe glomerulonephritis (GN) in order to prevent progression of kidney disease toward the end stage, we designed a multicenter, retrospective study in Saudi Arabia about the efficacy and safety of the use of "off label" rituximab in a variety of severe refractory GN to conventional treatment and the progression of kidney disease for at least one year of follow-up. All the patients had kidney biopsies before treatment with rituximab, and proteinuria and glomerular filtration rate (GFR) were followed-up for the period of the study. The immediate side-effect at the time of administration of rituximab included itching in three patients, hypotension in one patient and anaphylaxis in one patient (dropped out from the study). After the administration of rituximab in 42 patients and during the first six months of therapy, 16 (38%) patients had complete remission (CR), 13 (31%) patients had partial remission (PR) and 13 (31%) patients had no remission. The mean follow-up period for the patients was 19.0 ± 6.97 months (median 18.0 months). The long-term follow-up during the study period disclosed a good hospitalization record for almost all of the patients. Membranous GN (MGN) was the largest group in the cohort (58% of the patients), and we observed CR and PR in 40% and 28% of them, respectively, which was comparable with the previous experience with rituximab in MGN patients with more CR than PR in our cohort. We conclude that our study suggests the safety and efficacy of the use of rituximab in patients with refractory GN and that larger and long-term prospective studies are required to define the role of rituximab in the different categories of these diseases.

Brain natriuretic peptide (BNP) levels increase in patients with congestive heart failure. Theoretically, BNP levels can be helpful in the determination of the "dry weight" of hemodialysis patients. To evaluate the effect of hemodialysis on the plasma concentration of BNP and to determine the factors that affect BNP levels during hemodialysis in patients with chronic renal failure, we studied five stable patients with chronic renal failure. A total of 15 blood samples were obtained for BNP levels at 24, 48 and 72 hours after the last hemodialysis session. The plasma BNP levels did not change significantly either with ultrafiltration volume or with time since last dialysis. However, the BNP levels correlated positively with the erythropoietin (EPO) dose (r=0.98, P< 0.001) and negatively with the serum albumin levels (r = 0.94, P=0.02). Univariate analysis showed that the EPO dose (P=0.001) and the albumin level (P=0.02) were significant predictors of BNP level. Adjusted multivariate analysis showed significant interaction between the EPO dose and the albumin level (P=0.01, P=0.03 respectively. In conclusion: the plasma BNP levels were not significantly influenced by ultrafiltration volume or time since last dialysis. However, the BNP levels may be a useful prognostic parameter for assessing the risk of cardiovascular morbidity and mortality in hemodialysis patients.

This study was undertaken to determine whether self-measured home blood pressure (BP) readings were comparable to clinic visit BP readings in hypertensive type II diabetic patients. We measured the BP of 27 hypertensive patients at home and during the clinic visits over a three week period. The BP readings were analyzed using a mixed linear model with mean daytime ambulatory measure as a covariate. We found that, although there was no significant difference in the mean systolic BP between home and clinic readings (0.6 mm Hg), the mean home BP readings were significantly higher (difference = 6.8 mm p< 0.0006). The proportion of masked hypertension, defined as elevated home systolic or diastolic BP (or both) values despite normal clinic visit BP values, was 40.7%. Three diastolic and one systolic BP measurement at home achieved a reliability coefficient of 0.8. Self-measurement of BP gave highly reliable readings when they were compared with blind readings taken by a trained professional using a mercury sphygmomanometer. We conclude that self-measured BP at home identifies a high prevalence of masked hypertension in treated hypertensive type 2 diabetic patients and that it represents a valuable management adjunct to ensure maximum benefit from antihypertensive drug therapy.

Repeated kidney biopsies are increasingly recognized to be pivotal in the management of various phases of lupus nephritis. The aim of this retrospective study was to examine the shift in activity index and chronicity index among International Society of Nephrology/Renal Pathology Society (ISN/RPS) class patients with lupus nephritis who undergo a triple kidney biopsy.Eleven patients with lupus nephritis and 3 biopsies each were assessed and reclassified based on ISN/RPS classification.The mean creatinine level increased from 74 (± 38) μmol/l at baseline to 129 (± 116) μmol/l at the second biopsy and to 204 (± 200) μmol/l at the last biopsy. Among 11 kidney biopsies, 7 (63.7%) had a different ISN/RPS class in the second biopsy. The third biopsy showed that six kidney biopsies had a different ISN/RPS class compared to the second biopsy. Even among patients who stayed in the same ISN/RPS class, the second and third biopsies gave a different activity and/or chronicity index. The median activity index (range) was 3.1 (0-14), 4 (0-13) and 3 (0-14) for the first, second and third biopsies, respectively. The median chronicity indices (range) were 2.5 (0-8), 7 (0-8) and 5 (0-10), respectively.My study has shown that lupus nephritis is a shifting disease, and repeated biopsies are a pivotal policy in its management.

BACKGROUND AND OBJECTIVES: To evaluate differences in erythropoietin requirements between diabetic and non-diabetic patients on hemodialysis and peritoneal dialysis. DESIGN AND SETTINGS: This was a retrospective, cross-sectional study conducted between January 2010 and December 2011, at King Khalid University Hospital Riyadh, Saudi Arabia, with 47 peritoneal and 57 hemodialysis patients. METHODS: A total of 24 (51%) peritoneal dialysis and 30 (52.6%) hemodialysis patients were suffering from diabetes. We compared demographics, hemoglobin, ferritin, transferrin saturation, C-reactive protein, parathyroid hormone, and weekly erythropoietin dose. RESULTS: The mean weekly dose of erythropoietin was 5391.3 (4692.7) units in peritoneal dialysis (diabetic and non-diabetic) patients compared to 9869.7 (5631.7) units in hemodialysis (diabetic and non-diabetic) patients, with a difference of 4478.3 (6615) units (P=.001). The mean weekly dose in diabetic peritoneal dialysis patients was 3818.2 (4489.5) units, compared to 8814.8 (5121.9) units in hemodialysis (P=.001) patients. The mean weekly dose in non-diabetic peritoneal dialysis patients was 6545.4 (3863.5) units compared to 12 222 (6210) units in non-diabetic hemodialysis patients (P=.02). Diabetic peritoneal dialysis patients required a lower dose of erythropoietin compared to non-diabetic peritoneal dialysis patients (3818.2 [4489.5] units vs 6545.4 [3863.5] units per week) (P=.036). In hemodialysis patients, the mean erythropoietin dose was lower in diabetic patients compared to non-diabetic patients (8814.8 [5121.9] units vs 12 222 [6210] units per week) (P=.043). CONCLUSION: The diabetic patients in both groups (hemodialysis and peritoneal dialysis) required less erythropoietin than non-diabetic patients. Diabetic patients on peritoneal dialysis required less erythropoietin diabetic patients on hemodialysis.

Introduction The International Society of Nephrology/Renal Pathology Society (ISN/RPS) pathological classification criteria of lupus nephritis are limited to glomerular injury. Although the tubulointerstitium is commonly involved, the importance of such involvement is not well defined. The major objective of this study was to evaluate the association of interstitial inflammation with the long-term outcomes of patients with lupus nephritis. Patients and methods A total of 73 patients who were diagnosed with lupus nephritis between 1996 and 2012 were analyzed. The follow-up data were obtained, and the analysis was conducted to determine the effect of interstitial inflammation on the rate of the doubling of serum creatinine or end-stage renal disease (ESRD) in patients with lupus nephritis. Of the patients included in the cohort, 63 underwent a second biopsy. Results The degree of interstitial inflammation was positively correlated with the serum creatinine level at the time of biopsy ( p = 0.005) but not at the end of the follow-up period ( p = 0.9). The complements level, anti-dsDNA, ANA, and proteinuria were not related to the degree of interstitial inflammation. There was no relationship between the probability of remission and the severity of interstitial infiltrate. The rate of no remission was 40% among those without interstitial infiltrate, 34.6% in those with mild infiltrate and 23.5% among those with moderate-to-severe infiltrate ( p = 0.6). There was no relationship between interstitial inflammation at the baseline biopsy and worsening of renal function ( p = 0.17). There was a strong relationship between interstitial inflammation at the repeat biopsy and renal survival ( p = 0.005). The recovery of interstitial inflammation in lupus nephritis correlated with a favorable outcome in the patients with interstitial inflammation at baseline that had resolved at the repeated biopsy ( p = 0.047). Conclusion The persistence of interstitial inflammation is associated with poor renal outcome among patients with lupus nephritis. A comprehensive histological assessment of inflammation in lupus nephritis including interstitial inflammation may provide better prognostic information.

♦Introduction The month of Ramadan holds great religious and social significance for Muslims all over the world. The aim of the present study was to provide a modified dialysis schedule for peritoneal dialysis (PD) patients that allows for fasting and that minimizes the effect on the patient's general health and volume status. ♦Methods We observed 31 patients under treatment at the PD unit of King Khalid University Hospital, King Saud University, Riyadh. During the 3 - 4 weeks before the start of Ramadan, all patients were counseled individually and in detail about the possibility of fasting. They were also provided with clear instructions about fluid intake (up to 1 L daily) and avoiding a high-potassium diet. Of the 31 patients, 18 (10 women, 8 men) elected to fast during the month of Ramadan. The mean duration of fast in the study year (2009) in Riyadh, Saudi Arabia, was about 14 hours: from 0415 h (before sunrise) to 1800 h (after sunset). Depending on membrane type and patient preference, the fasting group was shifted to one of two regimens: • Modified continuous ambulatory PD (8 patients): 3 exchanges during the night (1.36% or 2.27%), and icodextrin for a long dwell during the day. The first dialysis exchange was performed immediately after breaking the fast (1900 h), and the next at 2300 h. The final exchange was performed in the early morning before sunrise (0300 h), when the icodextrin was infused. • Modified continuous cycling PD (10 patients): exchanges (1.36% or 2.27%) were performed over 6 - 7 hours, and icodextrin was infused for a long dwell during the day. The patient connected to the cycler at 2000 h or 2100 h, and therapy finished at nearly 0300 h, with icodextrin as the last fill. ♦Results Of the study patients, 2 were admitted because of peritonitis (1 in each modality group), and the modified therapy was discontinued. In the modified CCPD group, 1 patient (on PD for 1 month before Ramadan) developed PD-related pleural effusion (proved by pleural fluid analysis), and PD was consequently discontinued. Hypotension developed in 2 patients of the CAPD group and 1 of the CCPD group during the first 2 weeks. In the CCPD group, 1 patient presented with lower limb edema and mild fluid overload. Overall, PD patients that opted to fast during Ramadan did not experience any serious morbidity or deterioration in renal function during their period of observance. No biochemical parameters or clearance studies showed a statistically significant p value. ♦Conclusions In view of the study findings, we conclude that most stable patients on PD can fast, provided that they strictly adhere to their medications and dialysis therapy in addition to the dietary restrictions. These patients should be followed closely to detect any complications and to ensure that adequate fluid and electrolyte balance are maintained.

Elevated serum creatinine is associated with higher maternal and fetal risks; however, the influence of milder degree of renal impairment diagnosed on basis on estimated glomerular filtration rate (eGFR) is less well defined. This study assesses the impact of early chronic kidney disease (CKD) utilizing eGFR in predicting adverse outcomes in women with CKD.We analyzed outcomes of 98 pregnant women with CKD. Women with CKD stage 1 were used as control.Women with eGFR of 60?89 ml/min were at an increased risk for deterioration of renal function, preeclampsia, and cesarean section. The odd ratios for composite maternal complication of worsening of renal function or preeclampsia were 6.75 (95% confidence interval (CI), 1.84-24.80) in women with eGFR of 60?89. Similarly, women with an eGFR of 60?89 had a significantly increased risk for intrauterine growth restriction (38.5%), preterm birth (31.2%), and intrauterine fetal death (15.8%). The odds for composite fetal adverse outcomes were 2.91 (95% CI, 1.19-7.09) in women with eGFR of 60?89.Early CKD increases the risk of adverse outcomes in pregnancy. Estimated GFR ranging between 60?89 ml/min/1.73 m(2) is associated with significant maternal and fetal complications. The risk of adverse outcomes in pregnant women with early CKD can be more accurately stratified by using estimated GFR than the serum creatinine alone.

Systemic lupus erythematosus (SLE) is one of the common autoimmune disorders that affect women during their childbearing years. Disease activity frequently increases during pregnancy and the postpartum period, representing a challenge for both the patient and the treating physician(s). We report a case of successful management of lupus nephritis flare in the first trimester. The patient developed bilateral leg edema and nephrotic-range proteinuria of 5 g/day. She was treated with steroids and tacrolimus, which resulted in the induction of remission during pregnancy. The patient reached full-term with no maternal or fetal complications. This case indicates that tacrolimus, which is convenient to use and has limited adverse effects, may represent a potential safe and effective treatment option for SLE nephritis during pregnancy.

To understand the impact of salt intake on blood pressure and to assess the application of international management guidelines in Saudi diabetic hypertensive patients.We recruited 112 consecutive diabetic hypertensive patients visiting the diabetic and nephrology clinic at the King Khalid University Hospital between July 2005 and January 2006. Participants received complete medical assessment and their 24 hours urine sodium was measured. Patients on diuretics were excluded from the study.A significant correlation between 24 hours urine sodium and diastolic blood pressure concentration was observed (r = 0.25, p=0.04) but not with systolic blood pressure (r =0.06, p=0.6) or 24 hours urine protein (r =0.06, p=0.63). Approximately 15% of the patients had an glycosylated hemoglobin (A1C) of between 7-8% while 41.2% had an A1C of8 (suboptimal group for glycemic control). Low-density lipoprotein (LDL) cholesterol in only 37.5% of the patients was within the desired goal (2.4 mmol/l). Whereas only 24.8% of the patients achieved the goal of systolic and diastolic BP of130/80 mm Hg.Modest salt restriction has possible adjuvant effect to pharmacologic treatment to enhance blood pressure control. However, a majority of the Saudi diabetic patients with hypertension and hyperlipidemia are inadequately treated.

Hyperoxaluria can result in the deposition of oxalate in bones, arteries, eyes, heart, nerves, kidneys and other structures when there is a reduction in glomerular filtration rate. Liver and kidney transplantation is curative for patients with Type I primary hyperoxaluria. Here we report a case of recurrent oxalosis in a post-transplant kidney with early graft failure in an adult male.

There is overwhelming evidence that individuals with Major Depressive Disorder (MDD) are being seriously under diagnosed and under treated. The Self-Reporting Questionnaire (SRQ) is a good screening instrument for the detection of psychiatric disorders. However, the clinical significance of SRQ as a screening test for MDD in patients on hemodialysis (HD) has yet to be elucidated. The purpose of this study was to evaluate the diagnostic utility of the SRQ in detecting MDD in a cohort of patients with end-stage renal disease (ESRD) on maintenance HD. Twenty-six patients on maintenance HD were randomly recruited and were asked to complete the SRQ. The participants were, in addition, interviewed by a psychiatrist, who had been blinded to the SRQ score. We examined the ability of SRQ to detect patients who were diagnosed to have MDD based on psychiatric assessment. Among the 26 patients assessed, four patients were diagnosed to have MDD based on current diagnostic criteria. Logistic regression analysis showed that SRQ could predict patients with MDD with adjusted odds ratio of 1.9 (CI, 1.06- 3.42). Being a female was the most important variable for having a high SRQ (F=16.9, P=0.0004). The limitations of this study include a relatively small sample size and a high rate of somatic symptoms reported in the non-depressed population that limited the positive predictive value of the SRQ. Thus, although the SRQ has a high sensitivity, the positive predictive value of the SRQ is poor at low cut offs. In conclusion, our study suggests that an ideal screening tool in patients on HD should have minimal emphasis on the somatic symptoms of MDD. Until such a tool is available, clinical assessment remains the best screening tool for MDD.

Peritoneal dialysis (PD) patients have a high risk of developing vitamin D deficiency as 25(OH) vitamin D, the precursor of active vitamin D, is lost during dialysis. This cross-sectional study was conducted to investigate the prevalence of vitamin D deficiency among adult Saudi patients on regular PD The data was collected in the summer of 2010 from patients who were on PD for more than six months at the King Khalid University Hospital, Riyadh. We recorded the demographic and clinical parameters for all patients. Blood samples were taken for serum vitamin D level (25 OH), serum parathyroid hormone (PTH) levels and other necessary biochemical parameters. There were 27 patients (11 males and 16 females) with a mean age of 46 (15-78 ± 21) years. Five patients were on continuous ambulatory PD and 22 patients were using automated PD. The average time on PD was 27.5 (6-84 ± 18.5) months. The mean serum vitamin D 25 (OH) level was 16.1 (4.9-41.5 ± 8.23) nmol/L. Sixteen (59.2%) of the patients had levels below 15 nmol/L, while another eight patients (29.6%) had vitamin D levels between 15 and 25 nmol/L, indicating a marked deficiency. The mean serum calcium was 2.2 (1.7-2.6 ± 0.2) mmol/L and the mean serum phosphorous was 1.48 (0.64-2.22 ± 0.37) mmol/L. Fifteen patients (55.5%) had significant hyperparathyroidism (serum PTH levels above 30 pmol/L). Majority of the PD patients in our center had vitamin D deficiency. The possible reasons include chronic renal failure, dietary restrictions, loss of vitamin D and decreased exposure to sunlight.