Ali Al-Harbi

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.

Eleven years of experience with dialysis associated tuberculosis.

BACKGROUND The aim of this retrospective study was to evaluate the incidence of tuberculosis (TB) in dialysis patients and to determine its clinical features and results of short-course (6 months) chemotherapy, mortality and risk factors of mortality. METHODS The study included 48 TB patients among 330 patients on dialysis of whom 37 were on hemodialysis and 11 were on peritoneal dialysis at Security Forces Hospital in the period from October 1989 to October 2000. The diagnosis of TB was established by a combination of clinical, radiological, biochemical, microbiological and histological examinations. Treatment with anti-TB drugs, the results of therapy and the outcome of patients were noted. RESULTS There were 32 males and 16 females with age ranges of 18 -89 (mean = 53.4) and 40 - 70 (mean 57.9) years, respectively. Their duration on dialysis ranged from 1 month to 10 years (mean = 26 months). The presenting clinical features were fever (32), cough (16), weight loss (9), and anorexia (7). The organ systems involved were pulmonary (23), peritoneal (15), lymphadenopathy (11), pericardial (4), bone TB (3), bone marrow (2), epididimo-orchitis (1), right infraclavicular chest wall cold abscess (1), right infrascapular cold abscess (1) and right renal mass (1). Single organ system involvement was noted in 36 patients, 2 systems in 10 patients and 3 systems in 2 patients. Two patients were treated empirically with good response. Evidence of tuberculosis was obtained from chest X-rays (23), bone X-rays (3), spinal MRIs (1), AFB (stain and culture) of sputum and fluid (15), ascitic fluid examination with exudate and raised adenine deaminase (ADA) levels (12), lymph node biopsy (8), pleural fluid examination with exudate and raised ADA levels (5), bone marrow aspiration (2), exudative pericardial fluid with raised ADA levels (2), nephrectomy and histopathology (1), dorsal spine biopsy (1) and laparotomy and biopsy ofperitoneum (1). Thirty-two patients received 4 anti-TB drugs: isoniazid (INH), rifampicin (Rif), pyrazinamide (Pyra) and ethambutol (Eth), 10 received 3 drugs (INH, Rif and Pyra or Eth), 2 received 2 drugs (INH + Rif) and a modified regimen was used in 3. The drug toxicities noted were hepatoxicity (5) and INH encephalopathy prior to the routine use of pyridoxine 100 mg daily (3), INH-induced SLE (1) and pyrazinamide-induced thrombocytopenia (1). The outcome of the patients was cured (35), expired (13), and 1 patient expired before starting therapy. Tuberculosis was not the direct cause of death in any of the patients. CONCLUSION The incidence of TB in dialysis patients is 26 times more common than in the general Saudi population and a high index of suspicion is needed for early diagnosis and treatment. Extrapulmonary TB was noted in 52% of the patients. Short-course (6 months) chemotherapy is effective. INH-induced CNS toxicity is significant.

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.

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.

Repeated Pregnancies in Patients with Primary Membranous Glomerulonephritis

This retrospective study was carried out in patients with membranous glomerulonephritis (MGN) and repeated pregnancies, the aim being to see how one influences the other. Patients with two or more pregnancies after MGN were included in the study. Nine patients underwent 51 pregnancies (range 2–12, mean 5.6) and 30 were post-MGN (range 2–5, mean 3.2). Their ages were 27–44 (32 ± 5.7) years. The duration of follow-up was 2–10 (5.6 ± 2.5) years. The pregnancy outcome, i.e., number of full-term deliveries (FT), spontaneous abortion, preterm deliveries (PT), perinatal mortality (PM), low-birth-weight babies (LBW) and cesarean section (CS), was noted. In the pre-MGN group (n = 21), there were 20 (95.2%) live births and 1 (4.7%) abortion; none had PT, PM, LBW or CS. In the post-MGN group (n = 30), there were 27 (90%) live births, 2 (6.6%) PT, 1 (3.3%) abortion, 1 (3.3%) PM, 3 (10.0%) LBW baries and 3 (10.3%) CS. However, in comparison, there was no statistically significant difference in the pregnancy outcome between the two groups (p > 0.05 in all). Comparing the incidence of hypertension, proteinuria and serum creatinine levels between the first and the last post-MGN pregnancies, there was no statistically significant difference between the two groups. Only 1 patient developed renal insufficiency (serum creatinine 220 µmol/l) after undergoing 5 pregnancies and follow-up of 6 years. In conclusion, the outcome of repeated pregnancies in patients with MGN is good with 90% live births. Repeated pregnancies do not influence the course of MGN.