Bassam Bernieh

Gonadal dysfunction and infertility in kidney transplant patients receiving sirolimus

Sirolimus is an immunosupressor of the mammalian target of rapamycin inhibitors (mTOR-I) group. Recent studies have emphasized a potential impact of sirolimus on male gonadal function. We report our clinical experience with sirolimus-induced gonadal dysfunction and infertility in both male and female kidney transplant patients. Of the 170 kidney transplant patients, nine (5.3%) patients (six males and three females) were receiving sirolimus. Follow-up data for two male patients were not available. The one unmarried female patient developed amenorrhea post-transplantation and had resumption of her menstrual cycles after discontinuation of sirolimus. The remaining six married patients (four males and two females), who all had fathered or conceived children in the pre-transplantation period, developed gonadal dysfunction and infertility on average 5–12 months after transplantation. Sirolimus was discontinued in all four male patients with full recovery of the oligo/azospermia and restoration of fertility. Both married female patients developed amenorrhea post-transplantation. Sirolimus was discontinued in one female patient with resumption of her menstrual cycles. In this small population of patients treated with sirolimus, the prevalence rate of reversible gonadal dysfunction and infertility was significant in both males and females. Infertility secondary to sirolimus is under-diagnosed and should be studied further.

Plasma BNP in patients on maintenance haemodialysis: a guide to management?

The number of patients requiring long-term haemodialysis is increasing throughout the world. Cardiovascular disease is much more common in these patients than in the general population and accounts for the majority of deaths. New approaches to management are clearly needed to reduce this excessive cardiovascular burden. We propose that circulating levels of the cardiac natriuretic peptides, B-type natriuretic peptide (BNP) in particular, might provide a useful, objective guide to the management of their hydration status and pharmacotherapy. An overview of the literature shows that plasma levels of the cardiac natriuretic peptides are increased in this patient population and reflect cardiac preload and afterload along with cardiac pathology, thereby providing an index of cardiovascular (especially cardiac) stress and distress. Circulating levels of the cardiac peptides change in parallel with cardiac load, especially across haemodialysis. Furthermore, there is robust evidence that natriuretic peptide levels are predictive of cardiovascular outcome in these patients. Accordingly, we hypothesize that management of their haemodialysis, and pharmacotherapy designed specifically to lower plasma BNP levels to, or close to, the normal range, will reduce the excessive burden on the cardiovascular system and thereby ultimately lower the incidence of cardiovascular disease. We outline, in broad terms, how a trial to test this hypothesis might be designed.

GFR estimation in the morbidly obese pre- and postbariatric surgery: one size does not fit all

BackgroundGlomerular hyperfiltration commonly associated with obesity is expected to improve postbariatric surgery. However, formula-based glomerular filtration rate (GFR) estimation in these patients is limited by body size confounders necessitating use of modified equations, the reliability of which remains uncertain.MethodsIn this study, various GFR-estimating formulae were compared in morbidly obese patients at baseline and postbariatric surgery. Through a retrospective chart review, we identified 220 patients who had undergone this procedure, with over 6-month follow-up, during which major weight reduction was achieved.ResultsA significant decrease in BP and glomerular hyperfiltration was observed, though there was large variability in GFR estimation using the different formulae. Gross over and underestimation was observed which improved with correction for body size confounders especially lean body weight (LBW). Postoperatively, significant attenuation in estimated GFR was demonstrated when LBW or body surface area-adjusted versions were used. In a subgroup of patients with chronic kidney disease, a significant improvement in GFR was seen postoperatively with the LBW-modified formula but there were again inconsistencies when using other equations.ConclusionThough clinicians must be critical in the application of GFR estimates to patient care, LBW adjustment appears to be the most practical solution to its estimation in the obese patients. This is particularly true for patients with normal renal function but appears to be also applicable to those with compromised kidney function. Future studies are needed to compare these equations with a gold standard GFR measure as well as to explore whether the renal benefits from bariatric surgery are sustained or seen in more advanced CKD stages.

Long-term use of low-molecular-weight heparin in hemodialysis patients: a 7-year experience.

Background: Low-molecular-weight-heparin (LMWH) is not routinely used as anticoagulant in hemodialysis (HD). The ideal dose and the safety of long-term use are not known. Methods: A prospective three-phase interventional study. Phase 1 involved dose titration, phase 2 safety and efficacy and phase 3 routine practice. Results: During 7 years of the use of the LMWH enoxaparin (EN), 236 patients were treated with a total number of 60,987 HD sessions. The mean dose used during the titration phase was 0.43 ± 0.16 mg/kg/session, which was subsequently reduced in phase 3 to 0.36 ± 0.14 mg/kg/session. The long-term effects of EN on the platelet count and lipid profile were comparable to unfractionated heparin. Conclusion: The long-term use of LMWH (EN) with a reduced dose in HD is practical and safe.

Prevalence of Polyomavirus Among United Arab Emirates Kidney Transplant Recipients: Results From a Single Center

BACKGROUND BK viremia and nephropathy are increasing problems in renal transplant recipients. The absence of a safe and effective antiviral therapy made screening-based prevention a recommended strategy. The prevalence of its reactivation among recipients of kidney transplants in the Middle East has not been well established. Our objective was to determine the prevalence of BK virus (BKV) infection for renal transplant recipients at our medical center. METHODS All renal transplant recipients followed up in our transplantation clinic between 2012 and 2013 (n = 116) were screened. Urine and blood quantitative real-time polymerase chain reaction (PCR) for the BKV were performed in all of the study patients. Renal biopsy was performed only in patients with deteriorating renal function associated with positive PCR. Patients who showed positive BKV PCR were followed up for 6 to 12 months. This included clinical and kidney function assessment along with BKV PCR viral load. RESULTS Among the 116 kidney transplant recipients studied, 65 (56%) were male, age 51 ± 15 years, with a transplantation vintage of 131 ± 61 months; 17 (14.7%) were positive for BKV PCR. Three (2.7%) showed viremia; 2 of them had deterioration of kidney function, renal biopsy confirmed the diagnosis of BK nephropathy (NP) in both cases. The 3 cases were managed by reducing the immunosuppressive treatment with stabilization of their kidney function. Cases with stable renal function and positive urine for BKV cleared the virus spontaneously during follow-up after minor reduction of the immunosuppressive treatment or without any intervention. None of our patients lost the graft due to BK NP. CONCLUSION Our study suggests that BKV is not uncommon in our kidney transplant recipients. Routine screening suggested by the KDIGO Guidelines could help minimize its detrimental impact on the transplant outcome.

Epidemiology and referral patterns of patients with chronic kidney disease in the Emirate of Abu Dhabi.

According to estimates, the dialysis prevalence in Abu Dhabi is around 370 per million population. The annual growth is 12-15% and the dialysis population is likely to double in the next five years. Most patients present to dialysis as an emergency and only 2.7% have an arteriovenous fistula at the first dialysis. The prevalence of chronic kidney disease (CKD) in the Emirate is undefined. A study of the epidemiology of CKD and referral patterns was undertaken. SEHA, the Abu Dhabi Health Service delivery company, has a unified computer system containing all measurements made in its laboratories. This study considered all serum creatinine measurements performed between 1 September 2011 and 31 October 2012 from outpatient departments or emergency rooms. The estimated glomerular filtration rate (eGRF) was calculated using the Modification of Diet in Renal Disease formula (the Schwartz formula was used for children). We identified 331,360 samples from 212,314 individuals. The mean serum creatinine was 61 ± 48 μmol/L in females (59 ± 43 μmol/L in Emiratis, 63 ± 54 μmol/L in expatriates) and 87 ± 69 μmol/L in males (80 ± 59 μmol/L in Emiratis, 92 ± 74 μmol/L in expatriates). Among Emiratis, 4.6% of males and 2.8% of females had an eGFR between CKD 3 and 5. Among expatriates, 4.2% of males and 3.2% of females had an eGFR between CKD 3 and 5. On average, eight months elapsed before a patient with CKD 3, and three months for a patient in CKD 5, to attend the nephrology clinic. This study has defined the prevalence of CKD within Abu Dhabi and demonstrated the need to improve identification and referral of CKD patients. Possible solutions include campaigns to increase public and physician awareness of CKD.

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

ABSTRACT Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians’ practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians’ practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE. Abbreviations: ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.

Renal replacement therapy for metformin and sitagliptin overdose

Metformin and sitagliptin are widely used in the management of type 2 diabetes mellitus. We present a case who reported ingestion of an overdose of metformin and sitagliptin in a suicidal attempt. The patient presented with severe lactic acidosis, hypotension, and hyperglycemic acute kidney injury, successfully treated medically with intravenous infusion of fluids and sodium bicarbonate, and prompt convection hemodialysis.

Differences in albumin levels among different ethnicities

Estimation of serum albumin is part of the monthly routine monitoring process for dialysis patients. Albumin data were collated from 505 haemodialysis patients from within the Emirate of Abu Dhabi and 2315 patients from the UK along with age, gender, nationality and the presence or absence of diabetes for the month of August. The data were analyzed by Chi Squared, Bonferroni and ANOVA where appropriate and logistic regression was undertaken using the variables, gender, age, nationality and the presence of diabetes. P<0.05 was taken as statistically significant.