Faissal A.M Shaheen

Does Repeated Ramadan Fasting Adversely Affect Kidney Function in Renal Transplant Patients

This is a prospective cohort study in renal transplant patients who fasted or who did not fast for three consecutive Ramadans. The baseline estimated glomerular filtration rate (GFR), mean arterial pressure (MAP), and urinary protein excretion before the first Ramadan were compared to those after the third Ramadan in 35 fasters and 33 nonfasters. The effect of age, time after transplantation, presence of diabetes mellitus (DM), and proteinuria on changes in the GFR were studied. The two groups were comparable in gender, age, donor source, time posttransplantation, presence of DM, hypertension, proteinuria, serum creatinine, and MAP. Among the fasters, there was no change in estimated GFR after fasting for three Ramadans (56.4 mL/min versus 55.4 mL/min, P=0.8) even after adjusting for age, DM, baseline GFR, proteinuria, or time after transplantation. There were no significant differences between the fasters and the nonfasters in the changes in GFR, MAP, and urinary protein excretion between baseline and the third Ramadan.

Impact of Recipient and Donor Nonimmunologic Factors on the Outcome of Deceased Donor Kidney Transplantation

OBJECTIVE To study the influence of nonimmunologic factors on the outcome of extended criteria deceased donor (DD) kidney transplants. METHOD This is a retrospective study of DD transplantation carried out from January 1, 2003 to December 31, 2007, to investigate the impact on graft survival and function of donor renal function at retrieval, cold ischemia time (CIT), delayed graft function (DGF), acute rejection episodes (ARE), age, and weight of donors and recipients, transplant center activities, cause of donor death, donor-recipient gender pairing and size of the donating intensive care unit (ICU). RESULTS At retrieval, the frequency of donors with a creatinine clearance <60 mL/min, using the Cockcroft-Gault formula, and age >40 years were 31.7% and 32%, respectively. CIT > 24 hours, DGF, and ARE occurred in 27.1%, 33.4%, and 16.5% of cases, respectively. The overall 1- and 5-year graft and patient survival rates were 88% and 79.8% and 96.6% and 92.3%, respectively. The graft function was inferior with occurrences of ARE (P = .0001), DGF (P = .0001), CIT > 20 hours (P = .005), nontraumatic the donor death (P = .022), and donor ICUs bed capacity <20 (P = .03). The odds ratio (OR) for graft loss with DGF, ARE, and donors right kidneys were 7.74 (95% confidence interval [CI] 6-13.4; P = .0001), 4.47 (95% CI, 2.6-7.6; P = .0001) and 1.7 (95% CI, 1-2.8; P = .045), respectively. Graft function was not influenced by donor renal function at retrieval, donor weight, or donor- recipient gender pairings. CONCLUSION CIT and ARE had an impact on both graft survival and function. DGF and cerebrovascular accidents as the cause of donor death negatively affected graft function during follow-up. ICU center experience had a positive impact on graft survival. Patient survival was affected by recipient age >50 years and female to male donation versus other gender pairings. Neither donor age nor acute terminal rise in the donor serum creatinine affected graft function or survival, or patient mortality.

Reversible uremic deafness : Is it correlated with the degree of anemia?

Hearing loss is a common finding in patients with end-stage renal failure. Uremic toxins, ototoxins, and axonal uremic neuropathy appear to be likely pathogenic factors. We analyzed whether an improvement in hearing capacity can be achieved with an improvement of anemia by erythropoietin (EPO) administration. Fifty patients on long-term hemodialysis in a single center were examined audiologically by otoscopy, tympanometry, pure tone audiometry, and the short increment sensitivity index. Twenty-five patients were treated with EPO in a dose of 120 U/kg per week over a period of 5 to 8 months, and the remaining 25 patients were not treated with EPO (controls). Both groups were reexamined audiologically after the study period, and the results were compared. In the group treated with EPO, the hemoglobin level increased from 7 ± 0.9 to 11 ± 0.8 g/dL, as against the control group, whose hemoglobin increased from 7.1 ± 0.9 to 8 ± 0.8 g/dL. The audiologic tests were repeated at the end of the study period, and a significant improvement of hearing was found in the patients treated with EPO as compared with the control group (p < .001). Our study suggests that improvement of anemia in patients on long-term hemodialysis by administration of EPO is associated with an improvement in hearing capacity in a significant number of patients. Thus, anemia seems to be an important factor responsible for hearing disorders in patients with end-stage renal failure. Studies with larger numbers of patients are required to confirm this observation.

Organ Transplantation in Saudi Arabia.

: Organ transplantation started in the Kingdom of Saudi Arabia (KSA) in 1979 with a kidney transplanted from a live donor. The Saudi Center for Organ Transplantation has been established in 1985 as a governmental agency that supervises all national transplant activities in the KSA. Organ transplantation in the KSA has made great strides since 1985. Saudi Center for Organ Transplantation is playing a central role in all aspects of transplantation including education on all levels, allocation, coordination and procurement. A new initiative has started an ambitious program in 2014 to improve the identification and reporting of organ donors aiming at an annual rate of 15 donors per million populations within 3 years in the KSA.

Adaptation and Implementation of the "Kidney Disease: Improving Global Outcomes (KDIGO)" Guidelines for Evaluation and Management of Mineral and Bone Disorders in Chronic Kidney Disease for Practice in the Middle East Countries

This review presents the views of an expert group of nephrologists from the Middle East along with an international expert on adaptation and implementation of the 2009 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for evaluation and manage-ment of mineral and bone disorders in chronic kidney disease (CKD-MBD) for practice in the Middle East countries. The members of the panel examined the KDIGO guidelines and formulated recommendations that can be implemented practically for the management of CKD-MBD in the Middle East. There was a broad agreement on most of the recommendations made by the KDIGO work-group. However, the panelists commented on specific areas and amplified certain concepts that might help the nephrologists in the Middle East. The final document was reviewed by all participants as well as by members of the Middle East task force implementation group for KDIGO guidelines. Their comments were incorporated. The guideline statements are presented along with detailed rationale and relevant discussion as well as limitations of the evidence. The panel recognized the need to upgrade the suggestion of KDIGO related to lateral abdominal radiograph and echocardiogram in patients with CKD stages 3-5D into a stronger recommendation. The panel underlined the risk of hyper-phosphatemia to CKD-MBD and the importance of prompt initiation or modification of therapy according to rising trends in para-thyroid hormone level. They recommended the use of non-calcium-based phosphate binders as the first-line therapy in CKD patients with signs of vascular calcification. The panel agreed that all aspects of the KDIGO recommendations concerning bone biopsy, evaluation and treatment of bone disease after kidney trans-plantation should be implemented as such.

Cardiovascular and cerebrovascular comorbidities in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcome and practice pattern study phase 5 (2012-2015)

To determine the prevalence of cardiovascular comorbidities and their active risk factors in the selected hemodialysis centers in the Gulf Cooperation Council (GCC) countries, the Dialysis Outcome and Practice Pattern Study (DOPPS) was performed on 40 dialysis centers in the six GCC countries from June 2012 to May 2015. There were 21 dialysis centers from Saudi Arabia, nine from the United Arab Emirates (UAE), four from Kuwait, four from Oman, two from Qatar, and one from Bahrain. There were 922 patients participating in the study; 419 patients from Saudi Arabia, 144 from the UAE, 164 from Kuwait, 89 from Oman, 58 from Qatar, and 25 from Bahrain. Baseline data and laboratory investigations were obtained from every study patient, and the patients with any new events, change of dialysis prescription, or death were reported to the DOPPS main center during follow-up. The median age of the patients in the GCC centers was 55 years (range 32- 80 years), and the median percentage of males was 57%. The most common cause of chronic kidney disease among the study patients was diabetes mellitus (median: 43%) followed by hypertension (median: 29%) and glomerulonephritis (median: 9%). Hypertension (median 90%) and diabetes mellitus (median 52%) were the most common predisposing comorbidities to cardiovascular events in the study patients. The median ratios of patients with coronary artery disease, peripheral vascular disease, and congestive heart failure were 34%, 23%, and 24%, respectively. The median ratio for cerebrovascular comorbidities was 9%. The median prevalence of the factors that may predispose to the cardiovascular and cerebrovascular comorbidities such as gender of the patients, adequacy of dialysis, diabetes, hypertension, hypercholesterolemia, levels of anemia, parathormone levels, and calcium and phosphorus levels in the GCC countries were comparable with those in the previous DOPPS in other countries.

Multinational observational study on clinical practices and therapeutic management of mineral and bone disorders in patients with chronic kidney disease stages 4, 5, and 5D: The OCEANOS study.

Our aim is to assess the current clinical practices in monitoring and treatment patterns of chronic kidney disease (CKD)-mineral bone disorder and the degree to which these practices met the kidney disease improving global outcome (KDIGO) guidelines. This was an international, multi-center, cross-sectional, observational study in adult patients diagnosed with CKD Stages 4, 5, and 5D. Patients were enrolled from Middle East, South Asia, Eurasia, and Africa; patients with estimated glomerular filtration rate ≥30 mL/min/1.73 m(2) or with any medical/surgical conditions precluding their participation were excluded. Frequency of measurements, levels of serum calcium (Ca), phosphorus and parathormone (parathyroid hormone [PTH], and presence vascular/valvular calcification were recorded. Of the 2250 patients enrolled, data on 2247 patients were evaluated. Overall, only a small percentage of patients met all three target KDIGO ranges of serum Ca, phosphorus, and PTH (13.7% [95% confidence interval: 12.0; 15.4], with a higher proportion among CKD Stage 5D patients (14.8%) than CKD Stage 4 and 5 (5.6%) patients. Majority (84.3%) of the patients received treatment with phosphorous binders, of whom 85.5% received Ca-based phosphate binders. Overall, 57.0% of patients received Vitamin D treatment with a similar frequency among patients with CKD Stages 4, 5, and 5D. Over half (65.7%) of the patients were screened for vascular/valvular calcification; of these, 58.8% had ≥1 calcification. Diabetes status, P, PTH, and low density lipoprotein-cholesterol had significant impact on the prescription pattern of phosphorous binders. The current practices for the management of bone and mineral metabolism in CKD patients in the study region fall far short of meeting the KDIGO target range.

Features of Deceased Kidney Transplantation in KSA; 2014-2016

Objectives The existing deceased kidney transplantation program in the Kingdom has different features including pediatric, kidney classification on standard and expanded criteria donors (SCD and ECD), combined and urgent transplantation. As mentioned, of the features, kidneys were placed in classifications, categories, priority and finally distributed to transplant centers according to the protocol. Methods A retrospective study on the allocation, distribution of deceased kidneys in respect to the mentioned features during the years 2014-2016. Results During these period, a total of 313 deceased donors were consented for organ donation of these, 212 (68%) kidney donors were recovered, wherein, 202 donor kidneys were utilized. Qualities of deceased utilized kidneys donors, age ranges from 51 days to 68 years with mean age of 38 years. The causes of death were mainly due to Non-Traumatic causes 125 (62%) and traumatic causes 77 (38%), Mean serum Creatinine is 155 &mgr;mol. Of the 424 recovered cases, 2 kidneys was shared to UAE; 402 (95%) were transplanted and 22(5%) were discarded. There were a total of 68 (17%) kidneys transplanted to pediatric recipients; allocation was based on donor qualities which brings us to the next feature which is the SCD and ECD kidneys. In relation, 67 (99%) of kidneys transplanted to pediatrics were from standard criteria donors per SCOT protocol to allocate 20% of the SCD kidneys for pediatric recipients. Coming back to the kidney classification, there were a total of 290 (72%) SCD and 112 (28%) kidneys transplanted. Kidney Donor Risk Index (KDRI) was also observed with 8 donors having scored <0.8, 86 were between >0.8 – 1.15, 60 were 1.16-1.45 and 58 were >1.45. Combined transplantation such as en-bloc, were performed in 20 kidneys (10 recipients), 4 in kidney-liver, 6 in simultaneous pancreas kidney transplant (SPK) and 1 kidney–heart transplantation was done. Lastly, a total of 45 (11%) kidneys were transplanted to urgent recipients requested by transplant centers in the kingdom. Conclusion The features of deceased kidney transplantation in the kingdom is up to date with the current standards in kidney transplant practice internationally. Although more efforts should be done to further improve the quality of deceased kidney transplants and its features.

Implementation of a Quality Management System on Organ Donation in the Kingdom of Saudi Arabia (KSA)

Introduction World Health Organization (WHO) is advocating for the development of self-sufficiency in Donation and Transplantation (D&T) in all countries, as a practical alternative to combat transplant tourism and commercialism around the world. KSA is a Middle East country with 27.448.000 population. In 2016, 92 deceased donors (3.07 pmp) were reported. Therefore, 265 organ transplantations (9.6 pmp) were performed. Organ shortage represents a major obstacle preventing a further increase of transplantation in KSA. In 2017, the Ministry of Health of KSA launched a 3-year project coordinated by DTI foundation with the support of the Saudi Center for Organ Transplantation (SCOT). The project aims to improve the D&T rates by implementing an organ donation quality management system based on the implementation of the most successful models in organ donation (SEUSA) and quality systems (ODEQUS). Materials and Methods Through the use of SEUSA and ODEQUS methodologies (already described previously by us), as valuable and replicable international collaborative strategies to improve organ donation worldwide, the project methodology includes: a) Competence Authorities involvement; b) Diagnosis of the current situation (national, regional and hospital level) using ODDS (Organ Donation Diagnostic Surveys) and developing in situ expert’s visits; c) Detection of all brain and cardiac deaths in the hospitals implementing the DAS (Decease Alert System); d) implementation of the ODEQUS quality indicators (pilot phase); e) Knowledge exchange activities; f) External hospital audits. Continuous monitoring was performed to allow data collection and analysis. Results and Discussion The pilot phase linked 5 hospitals from different background in Riyadh and Jeddah. D&T healthcare professionals were trained in the application of the quality indicators. An IT tool beta version was created to collect data derived from the clinical donation activity. A 3-year plan was developed to expand the project up to 25 hospitals and to increase the D&T rates of the country. The project allowed to broaden SCOT’s geographical representation with the result of KSA becoming a reference model in D&T in the Middle East region. Conclusion SEUSA and ODEQUS methodologies have shown, to be a good option to consolidate D&T systems. Its use has allowed to homogenize the organ donation process creating a methodology to evaluate the organ procurement performance and defining improvement strategies enhancing the efficiency of transplant systems in KSA.

First Series of Brain Death Organ Donors in United Arab Emirates - SEUSA Program Implementation

Introduction The Middle East region faces some common challenges regarding organ donation and transplantation, like lack integrated approach across (private-public) healthcare systems, poor knowledge and awareness among public and professionals and lack of full regulatory frameworks. In the region deceased donor per million population (pmp) rate is low despite very good medical infrastructure and availability of medical experts compared to European average of donors pmp in 2016 of 21.5 dpmp. Two separate populations studies showed positive public attitudes for donation with 60-68 % surveyed wishing to donate their organs after death. In 2016 UAE issued a new Transplant law and addressed the legal requirement for deceased donation and the Ministry of Health and Prevention issued additional needed guiding documents for its implementation. In order to design a self-sufficient DD program and improve the skills of the health care professionals in the field, the UAE national Transplant committee in UAE and DTI Foundation have been working together to implement SEUSA tools. Methodology The SEUSA methodology is based on application of the tools from the most successful models in organ donation (OD), Spain, Europe and USA, and by implementing specialized trainings for health professionals based on the model of transplant procurement management TPM trainings. Since 2015, 3 yearly intermediate TPM training courses have been conducted for physicians and nurses on every step of the organ donation process. Visits form UAE professionals to Barcelona for educational purposes and experience interchange have also been performed. From 2017, visits from DTI international experts to UAE hospitals have been organized. During the hospital visits, interviews were conducted with local healthcare professionals, recommendations were provided about the establishment of in-hospital organ procurement units and a deceased alert system was defined for possible donor identification. Prior to the visits, ODDS (Organ Donation Diagnostic Surveys) were completed to assess the donor potentiality of each hospital. Results 128 healthcare professionals, mainly from the 10 leading hospitals, have been trained as Transplant Procurement Managers. Between July 2017 and February 2018, a total of 6 potential donors have become actual brain-dead organ donors. 19 organs have been recovered allowing the beginning of deceased cardiac, liver and lung transplantation and expansion of living related kidney transplantation programs in the UAE and full activation of organ sharing model between UAE and the Kingdom of Saudi Arabia. Conclusion Adequate in-hospital structure, organ donation training, and international collaboration alongside institutional and regulatory support from government has proven to be key for the establishment of deceased organ donation in the UAE. SEUSA program continues its implementation in UAE during 2018.