Ahmed H Mitwalli

Tuberculosis in Patients on Maintenance Dialysis

Tuberculosis was diagnosed in 7 of 25 patients who underwent maintenance dialysis, an incidence of 28%, five of the patients (71.4%) were females. It was characterized clinically by an insidious onset, the main symptoms being anorexia, loss of weight, and a low-grade fever. There were extrapulmonary presentations in 5 of the 7 patients. Tuberculous lymphadenitis predominated in the extrapulmonary form (5 patients, 57%). Pulmonary tuberculosis was noted in one patient (21.7%) who presented with pleural effusion. One patient had a tuberculous abscess involving the seventh rib. Total white cell and differential count was normal in all patients examined. All of the patients were diagnosed at the beginning of their dialysis treatment and early therapy was initiated. Treatment led to recovery in all seven patients, and no recurrence was observed. Despite earlier reports of high mortality in similar groups of patients, it is suggested that awareness of the increased incidence of tuberculosis in dialysis patients, together with recognition of its unusual presentation and consequent early diagnosis, results in a good prognosis.

Pattern of glomerular disease in Saudi Arabia

Clinical data and renal biopsy study of 186 adult patients found to have nephropathy and seen at the Security Forces Hospital, Riyadh, over a 5-year period (1989 to 1994) were reviewed. Primary glomerular disease accounted for more than three fourths of all patients (79%), and the most common histological lesion was focal segmental glomerulosclerosis (40.8%) associated with a high incidence of hypertension (86.7%), nephrotic syndrome (61.7%), hematuria (48.8%), and renal impairment (33.3%). Mesangioproliferative glomerulonephritis was the second most common lesion (21.1%), followed by membreous glomerulonephritis (13.6%), immunoglobulin A nephropathy (IgAN) (13.6%), membranoproliferative glomerulonephritis (9.5%), and minimal change disease (1.4%). Although not as common as in most other developed countries, IgAN is being increasingly recognized in Saudis. Lupus nephritis remained the commonest cause of secondary glomerulonephritis (48.5%), whereas amyloidosis was conspicuously absent. There is no evidence, at least in this series, that chronic infection such as hepatitis B virus infection has a major role in the development of glomerulonephritis.

Liver disease in dialysis patients with antibodies to hepatitis C virus

Eighty-three patients with chronic end-stage renal failure, including 65 on haemodialysis and 18 on intermittent peritoneal dialysis, were evaluated for hepatitis B virus profile and antibodies to hepatitis C virus (HCV). All those positive for HBsAg were excluded from the study. Nineteen patients were found to be positive for antibodies to HCV by the ELISA II test. Eight cases were already positive for HCV antibody when they started dialysis in our unit, the other 11 became positive during dialysis in our unit. Only one of the patients on peritoneal dialysis was positive for HCV. A liver biopsy was obtained from 17 patients, who consented to the procedure. All the cases were evaluated for the number of blood transfusions received, HIV infection and the approximate time of contracting the HCV infection. Liver enzymes were determined every month. Only three patients had abnormally raised serum aminotransferase at the time of biopsy. The various histopathological lesions detected were chronic active hepatitis (n = 3, including one with changes consistent with cirrhosis), chronic persistent hepatitis (n = 4), non-specific hepatitis (n = 3) and haemosiderosis (n = 3); four biopsy samples were normal. There was no correlation between the biochemical and histopathological changes. Moreover, patients with normal serum aminotransferase levels had abnormal histopathological changes. All were negative for HIV and none of the patients had received a renal graft. Twelve patients had received blood transfusions varying from 2 to 12 units, four had not received any blood, and in one the history of blood transfusion could not be confirmed. The four patients with anti-HCV antibodies who had not received blood transfusion had relatively mild disease--non-specific hepatitis (n = 2) or normal biopsy (n = 2). One patient with cirrhosis died 30 months after liver biopsy from hepatic insufficiency and three received renal transplants. Others are continuing on dialysis and their biochemical tests are within normal limits 12-45 (30 +/- 14) months after biopsy. In conclusion, biochemical tests are poor indicators of liver disease, and liver biopsy is a definitive way of evaluating the patients of dialysis with positive HCV antibodies for prognosis.

Effect of Chronic Viral Hepatitis on Graft Survival in Saudi Renal Transplant Patients

Background: In Saudi Arabia the prevalence of hepatitis C among hemodialysis patients is very high ranging from 60 to 80%. A large number of these dialysis patients go for renal transplant, resulting into a higher prevalence of hepatitis C virus (HCV) infection in renal transplant patients. Yet no current systematic report is available on the influence of hepatitis C status on patient and graft survival. The present study was therefore undertaken to address this objective. Methods: Retrospective analysis of data of 448 renal transplantation subjects was undertaken. The mean follow-up period was 5.85 ± 2.7 (median 5.3) years. The factors associated with renal graft survival were reviewed and these include: age, sex, and type of donor, immunosuppressive medication, episodes of infection, blood pressure, serum creatinine, and status of hepatitis. The primary end-points were renal graft function and patient survival. Logistic regression, COX regression analysis, and Kaplan-Meier survival estimates were used to evaluate the influence of hepatitis C on the above parameters. Results: Among 448 recipients of first kidney transplant patients, 286 (63.8%) were positive for HCV infection. In the HCV-positive group, 204 (71.32%) were males. Kaplan-Meier survival analysis showed a significantly better graft survival for HCV-negative patients than HCV-positive patients (p < 0.001; log-rank test). Logistic regression analysis and COX regression analysis have shown different grades of graft dysfunction were present in HCV-positive patients after adjustment for covariates: age, sex, blood pressure, type of donor, and immunosuppressive medication; the presence of HCV was a major predictor of bad outcome and significantly influenced graft survival (odds ratio = 4.37; 95% Cl = 1.81–4.77). Significant deterioration of liver function was noted in HCV-positive patients at the last follow-up, taking ALT as a marker (ALT level 80.6 ± 5.8 U/l at the last follow-up versus 49.5 ± 32 U/l at baseline p ≤ 0.0001). Sixteen patients had a chronic active course and 1 patient developed biopsy-proven liver cirrhosis and portal hypertension. A serious and significantly greater incidence of fatal chest infections was seen in HCV-positive patients. Although mortality was greater in HCV-positive versus HCV-negative patients (20 vs. 7), the difference did not attain statistical significance (p = 0.23) and none of the patients died as a result of hepatic failure. Conclusion: The presence of HCV infection greatly influenced graft survival in renal transplant patients and a higher proportion of infected patients had renal and hepatic dysfunction. A significant increase in fatal chest infections was noted in HCV-positive patients. Overall mortality was higher in HCV-positive patients, but it was not statistically significant. All measures should be taken to prevent HCV transmission in the dialysis population. Renal transplant recipients with HCV infection need close monitoring for both graft and liver function.

Coagulation inhibitors and fibrinolytic parameters in patients on peritoneal dialysis and haemodialysis

Coagulation inhibitors and fibrinolytic parameters were studied in twelve patients on continuous ambulatory peritoneal dialysis (CAPD) and ten patients on haemodialysis (HD). Patients on CAPD exhibited higher levels of ATIII and proteins C and S than those on HD. No significant differences were noted in tPA and PAI levels. Both groups of patients showed higher levels of tPA than controls. Besides, patients on HD had significantly lower levels of ATIII and protein C than controls. PAI levels in both patients groups were similar to those of the controls, but tPA levels were higher in patients than in controls. These results indicate that HD is associated with marked diminution in the circulating levels of coagulation inhibitors. This is in contrast to CAPD patients who showed elevated levels of these inhibitors, despite their significant loss in the dialysate. The finding of enhanced fibrinolysis in both patient groups may be a natural protective mechanism against the development of a thrombotic tendency.

Effects of concomitant hepatitis C virus infection in patients with underlying lupus nephritis on long-term renal outcome

BACKGROUND Despite recent advances in the management of lupus nephritis (LN), these unfortunate patients are at a higher risk of developing chronic kidney disease (CKD). Concomitant chronic hepatitis C virus (HCV) infection is associated with adverse outcome in patients with LN and further compounds the risk as some of these patients choose to undergo kidney transplantation in the near future. Objectives. The aim of the present study is to evaluate the long-term impact of chronic HCV infection in patients with underlying Class IV LN on renal function, progression to end-stage renal disease (ESRD) and patient survival. METHODS Retrospective analysis of the medical records of 134 nondialysis-dependent patients with biopsy-proven World Health Organization Class IV LN with chronic HCV infection was done from January 1995 to January 2008 at King Khalid University Hospital, Riyadh, Saudi Arabia. Primary and the secondary end points were death or the development of ESRD. The patients were followed over a period of 6.7 ± 3.3 (1-14.4) years. RESULTS From a total of 134 biopsy-proven Class IV LN patients, 15 (11.2%) patients were HCV positive of which 2 (13.3%) patients were male and 13 (86.7%) patients were female. One hundred and nineteen (88.8%) patients were HCV negative of which 17 (14.3%) were male and 102 (85.7%) were female. The mean age was 32.47 ± 11.8 years. Eight (53.3%) patients in the HCV-positive group versus 19 (22.6%) patients in the HCV-negative group progressed to severe renal impairment with serum creatinine >350 μmol/L (P = 0.024). A total of 8 (53.3%) patients in the HCV-positive group versus 18 (17.3%) in HCV-negative group progressed to ESRD (P = 0.005). The mean creatinine clearance was higher (43.3 ± 33 mL/min) in the HCV-negative LN group at last follow-up than in the HCV-positive patients (25 ± 34.9 mL/min) with a statistically significant P-value of 0.0463. Five patients (33.3%) with HCV-positive LN died in comparison to eight (7.6%) patients who were HCV negative P = 0.03; however, the cause of hospital mortality was mainly cardiovascular disease (CVD) and infection and none of the patients died of chronic liver disease, although there was significant deterioration of the liver function at the end of the study. Kaplan-Meier survival estimates showed a significantly inferior renal function and rapid deterioration to ESRD in LN patients with concomitant HCV infection, with a dialysis free survival of 95 and 80% for the HCV-negative group and 90 and 65% for the HCV-positive groups at the end of 5 and 10 years respectively, with a highly significant P-value of <0.05 at the end of 10 years. CONCLUSION The present study highlights that concomitant HCV infection in patients with LN is associated with worse renal outcome, higher rate of progression to ESRD and reduced patient survival.

Bone mineral content and bone mineral density values measured by single photon absorptiometry among healthy Saudi population.

Several noninvasive methods for assessing bone mass have emerged over the last two decades, namely, single photon absorptiometry (SPA), dual photon absorptiometry, and quantitative computerized tomography. These techniques have proved to be sensitive and reproducible, with absorptiometry causing minimal radiation exposure. Several studies on osteoporosis have shown that its frequency varies in different racial groups; for example, Hispanics and Blacks in the USA appear to be the least affected by osteoporosis. It was therefore important to establish the normal standard of measurements of bone mass among healthy Saudi population using SPA to be used for clinical applications such as predicting the risk of fractures, monitoring the response to therapy, and quantitating the severity of metabolic bone disease.

Comparison between Continuous Ambulatory Peritoneal Dialysis and in Center Hemodialysis

The data on 39 patients on hemodialysis and 19 on continuous ambulatory peritoneal dialysis (CAPD) were compared in terms of correction of metabolic abnormalities, types of complications necessitat...

Intermittent peritoneal dialysis (IPD) in the elderly

Twenty-one elderly patients with end-stage renal disease (ESRD) secondary to various etiologies received IPD at our unit. It was done manually by trained staff nurses. Each patient received 20-24 one hour exchanges of 2 liters PD solution twice a week through a permanent Tenckhoff catheter. Mean age of patients was 63 years (range 60–96),12 were male and 9 female. Mean duration of stay on IPD was 23 months (range 18–41). The etiologies of ESRD were: diabetes mellitus (9 patients), unknown etiology (7), hypertension (3), glomerulonephritis and liver cirrhosis (hepatitis C) (2). The peritonitis rate was one episode per 16.3 patient/month. The causative organisms were staphylococcus, coliforms, acinobacter and pseudomonas. Six patients died due to each of the following: 2 septicemia not related to PD; 2 hepatic failure; 2 massive myocardial infarction. Two patients were changed to hemodialysis due to recurrent peritonitis. We observed 7 episodes of catheter exit-site infection; causative organisms were staphylococcus (4), and pseudomonas (3). Staphylococcus cases of exit-site infection responded to local fucidin ointment and oral antibiotic, while in the pseudomonas cases the catheter had to be removed. All patients received erythropoietin and have maintained good hemoglobin levels (10.1 ± 1.2 gm%). They also had adequate control of their serum creatinine and urea level. As the patients improved, they became less dependent on their relatives.

Utilization and Limitations of Various Modalities of Long-Term Peritoneal Dialysis in King Khalid University Hospital: Six-Year Experience

ABSTRACT In 1982, we started the first long-term peritoneal dialysis program in Saudi Arabia for the management of end-stage renal failure in adults. Over the next 6 years, we accepted 54 adult pat...