Abdulkareem Alsuwaida

Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution

BACKGROUND AND OBJECTIVES Because there is no recent update on the state of diabetes and its concomitant complications in Saudi Arabia, we undertook a study of the prevalence of health complications in patients with type 2 diabetes mellitus admitted to our institution. METHODS We conducted a retrospective review of medical records of adult Saudi patients with type 2 diabetes who were seen in clinics or admitted to the Security Forces Hospital, Riyadh, Saudi Arabia, between January 1989 and January 2004. RESULTS Of 1952 patients, 943 (48.3%) were males. For the whole study population the mean age at enrollment was 58.4±14.2 years, the mean age at onset of diabetes was 48.1±12.8 years, the mean duration of diabetes was 10.4±7.5 years, and the mean duration of follow-up was 7.9±4.6 years. Nephropathy was the most prevalent complication, occurring in 626 patients (32.1%). Acute coronary syndrome occurred in 451 (23.1%), cataracts in 447 (22.9%), retinopathy in 326 (16.7%), and myocardial infarction in 279 (14.3%), Doubling of serum creatinine was seen in 250 (12.8%) and 79 (4.0%) went into dialysis. Hypertension was present in 1524 (78.1%) and dyslipidemia in 764 (39.1%). Overall mortality was 8.2%. Multiple complications were frequent. Males had higher prevalence of complications than females (P<.05). Mortality was significantly higher in males 92 (9.8%) than females 69 (6.8%) (P=.024). The prevalence of complications significantly increased with duration of diabetes and age (P<.05). CONCLUSION Among Saudis, the prevalence of concomitant diabetic complications is high, with cardiovascular and renal complications the most frequent. Many patients had multiple complications. Early and frequent screenings in the patients with type 2 diabetes are desirable to identify patients at high risk for concomitant complications and to prevent disabilities.

Strategy for second kidney biopsy in patients with lupus nephritis

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.

Interstitial inflammation and long-term renal outcomes in lupus nephritis

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.

Factors affecting the progression of diabetic nephropathy and its complications: a single-center experience in Saudi Arabia.

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 <60 mL/min/1.73m 2 ]. Results: Of 1952 files reviewed, 621 (31.8%) met the criteria for DN, and 294 (47%) were males. The mean (SD) age of the patients at baseline was 66.9 (11.4) years, and mean duration of diabetes was 15.4 (7.5) years. GFR deteriorated from a baseline value of 78.3 (30.3) mL/min/1.73m 2 to 45.1 (24.1) mL/min/1.73m 2 at the last visit, with a mean rate of decline in GFR of 3.3 mL/min/year. Progression of nephropathy was observed in 455 (73.3%) patients, with 250 (40.3%) patients doubling their first-hospital-visit serum creatinine level in a mean of 10.0 (6.0) years. At the end of the study, 16.5% of the cohort developed ESRD and were dialyzed. GFR >90 mL/min/1.73m 2 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.

Recommendations for Fasting in Ramadan for Patients on Peritoneal Dialysis

♦ 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.

Impact of early chronic kidney disease on maternal and fetal outcomes of pregnancy

Background. 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. Methods. We analyzed outcomes of 98 pregnant women with CKD. Women with CKD stage 1 were used as control. Results. 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. Conclusions. Early CKD increases the risk of adverse outcomes in pregnancy. Estimated GFR ranging between 60–89 ml/min/1.73 m2 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.

Glomerular filtration rate estimated by the CKD-EPI formula is a powerful predictor of in-hospital adverse clinical outcomes after an acute coronary syndrome.

The prognostic value of admission estimated glomerular filtration rate (eGFR) calculated by the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula for cardiovascular adverse outcomes in acute coronary syndrome (ACS) was explored. Baseline eGFR was classified as no renal dysfunction (>90 mL/min per 1.73 m2), borderline (90-60.1 mL/min per 1.73 m2), moderate (60-30.1 mL/min per 1.73 m2), or severe (≤30 mL/min per 1.73 m2) renal dysfunction. Of the 5034 patients, 3415 (67.8%) had eGFR <90. Compared to patients with an eGFR ≥60 mL/min per 1.73 m2, patients with <60 mL/min per 1.73 m2 were less likely to be treated with β-blockers, angiotensin-converting enzyme inhibitors, or statins, or to undergo percutaneous coronary interventions. Lower eGFR showed a stepwise association with significantly worse adverse in-hospital outcomes. The adjusted odds ratio of in-hospital death with an eGFR <30 mL/min per 1.73 m2 was 3.1 (95% confidence interval 1.1-8.4, P = .0324), compared with an eGFR >90 mL/min per 1.73 m2. Estimated glomerular filtration rate calculated by the new CKD-EPI is an independent predictor of major adverse cardiac outcomes in patients with ACS.

The prognostic impact of in-hospital worsening of renal function in patients with acute coronary syndrome

BACKGROUND Renal impairment is strongly linked to adverse cardiovascular (CV) events. Baseline renal dysfunction is a strong predictor of CV mortality and morbidity in patients admitted with acute coronary syndrome (ACS). However, the prognostic importance of worsening renal function (WRF) in these patients is not well characterized. METHODS ACS patients enrolled in the SPACE (Saudi Project for Assessment of Coronary Events) registry who had baseline and pre-discharge serum creatinine data available were eligible for this study. WRF was defined as a 25% reduction from admission estimated glomerular filtration rate (eGFR) within 7 days of hospitalization. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared. RESULTS Of the 3583 ACS patients, WRF occurred in 225 patients (6.3%), who were older, had more cardiovascular risk factors, were more likely to be female, have past vascular disease, and presented with more non-ST-segment elevation myocardial infarction than patients without WRF (39.5% vs. 32.8%; p=0.042). WRF was associated with an increased risk of in-hospital death, heart failure, cardiogenic shock, and stroke. After adjusting for potential confounders, WRF was an independent predictor of in-hospital death (adjusted odd ratio 28.02, 95% CI 13.2-60.28, p<0.0001). WRF was more predictive of mortality than baseline eGFR. CONCLUSION These results indicate that WRF is a powerful predictor for in-hospital mortality and CV complications in ACS patients.

Gender Disparities in the Awareness and Control of Hypertension

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.

The clinical significance of serial kidney biopsies in lupus nephritis

Abstract Objectives. 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. Methods. Eleven patients with lupus nephritis and 3 biopsies each were assessed and reclassified based on ISN/RPS classification. Results. 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. Conclusion. My study has shown that lupus nephritis is a shifting disease, and repeated biopsies are a pivotal policy in its management.