Wael El-Reshaid

Comparison of the Efficacy of Two Injectable Forms of Vitamin D3 and Oral One-Alpha in Treatment of Secondary Hyperparathyroidism in Patients on Maintenance Hemodialysis

In the present study, we compared the efficacy of two intravenous forms of vitamin D3[Calcijex: 1,25(OH)2D3 and One-Alpha: 1(OH)D3] and that of oral One-Alpha in the treatment of secondary hyperparathyroidism in patients receiving maintenance hemodialysis. Twenty patients were assigned to 1 of 2 treatment groups (A and B) which were matched for age, sex, and duration of maintenance hemodialysis. None of the patients included had chronic liver disease or had received drugs known to interfere with hepatic enzymes. All patients had received a stable dose of oral calcium and One-Alpha for a minimum period of 1 year, which maintained corrected serum calcium at the upper limit of the normal range. At the start of the study, oral One-Alpha was replaced by Calcijex in group A and injectable One-Alpha in group B. Treatment was maintained for 3 months (phase I). Subsequently, injectable vitamin D3 was discontinued and all patients received their previous dose of oral One-Alpha for a period of 1 month. Finally, oral One-Alpha was discontinued again and the injectable forms of vitamin D3 were crossed over in the 2 treatment groups for another 3 months (phase II). The results showed that the serum concentrations of 1,25(OH)2D3, measured 48 h after intravenous injection of One-Alpha, were not different from that produced by an equivalent dose of Calcijex in the same group of patients. Furthermore, overall analysis of intact parathyroid levels during the cross-over, using ANOVA with repeated responses, indicated that the two analogues were equipotent as regards suppression of PTH secretion. In our study, treatment with intravenous vitamin D3 led to significant suppression of PTH secretion. These results were achieved by a lower drug dosage of vitamin D3 and at lower trough blood levels of 1,25(OH)2D3 as compared to those of oral One-Alpha. Our findings are in favor of the early use of either forms of injectable vitamin D3 in the treatment of secondary hyperparathyroidism.

Combination of Immunosuppressive Agents in Treatment of Steroid-Resistant Minimal Change Disease and Primary Focal Segmental Glomerulosclerosis

Background. Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are the most prevalent histopathological lesions in idiopathic nephrotic syndrome (INS). The latter is associated with high morbidity and mortality due to symptomatic anasarca, bacterial infections, venous and arterial thromboembolism, and potential progression to end-stage renal disease in the case of FSGS. Traditionally, most patients are treated with corticosteroids, cyclophosphamide (CTX) or calcineurin-inhibitors (C-I). Unfortunately, many patients become steroid or C-I dependent, with the inherent risk of long-term side effects, or are resistant to both. The aim of this paper is to report on our experience with a new protocol of a combination of immunosuppressive agents added sequentially to improve the response of steroid and C-I refractory or resistant-INS and to minimize the long-term side-effects of single-agent treatment. Methods. Twenty-one patients with corticosteroid-resistant and C-I refractory INS (6 with MCD and 15 with FSGS) were treated prospectively over 6 and a half years. Our protocol consisted of an initial regimen of C-I followed by the addition of mycophenolate mofetil (MMF) and then by monthly intravenous CTX for 3 consecutive months. Dose reduction of C-I or/and MMF was attempted afterwards at 4-months intervals. Patients who remained refractory to the previously mentioned protocol were treated with an additional course of pulse Solu-Medrol given for 3 days followed by oral corticosteroids tapered over 6 months in addition to a second course of intravenous CTX given for 3 consecutive months. Results. With the initial regimen, two patients with MCD, remained in complete remission (CR) without any therapy after the course of CTX. Fifteen patients had variable response to C-I and MMF, but they achieved CR after CTX and their initial dosage of C-I and MMF were reduced to nearly one half. The remaining four patients had refractory form of FSGS even after the initial regimen, yet responded with CR to the additional course of steroid/CTX. However, no success with dose-reduction, in C-I and MMF, was achieved in the latter four patients. Conclusion. Our study represents the first clinical trial with prospective and adequate follow-up of combination therapy of immunosuppressive agents in INS. This method is effective and safe for treatment of patients who are refractory to the conventional single-agent therapy.

Glomerulopathy in Kuwait: the spectrum over the past 7 years.

There are few studies that examine, prospectively, the epidemiological profile of glomerulopathy (GP) and its clinicopathological correlation. All patients referred to Al-Amiri renal center in Kuwait from 01 1st, 1995 to 12 31st, 2001 were screened for GP. Detailed clinical data were collected and serological markers were done. Renal biopsy was performed whenever indicated. During those 7 years, a total of 584 patients were diagnosed, on histological basis, to have GP, 315 of whom were Kuwaiti nationals. During the same period of the study, 26 patients presented with bilateral small kidneys, history of proteinuria >2 g/day and lacked systemic manifestations of autoimmune disease. Furthermore, 164 patients with clinical manifestations of diabetic glomerulosclerosis were not subjected to kidney biopsy. Hence, the calculated annual incidence rate of GP in Kuwaiti nationals was 34.5 per 100,000 population (PTP). The calculated rate of diabetic glomerulosclerosis was 13.4 PTP and that of non-diabetic 21.1 PTP. The calculated incidence rates of GP increased with age and were twice as high in males compared to females. Vasculitis was more common in elderly males while SLE nephritis was a disease of adults, 88.7% of whom were females. In the subgroup of primary GP, focal segmental glomerulosclerosis was the most common histological lesion accounting for 18.0% of the total biopsies in Kuwaiti patients, yet only 36.8% of those who fulfilled the criteria of primary type. Minimal change disease was the second primary GP (13.0%), followed by immunoglobulin A deposition disease (7.9%) and membranous glomerulonephritis (5%). Autoimmune diseases such as systemic lupus erythematosus (SLE) and vasculitis were common. Interestingly, only 44 of 72 (61.1%) of patients with SLE and 11 of the 62 (17.7%) of patients with vasculitis presented with rapidly progressive glomerulonephritis. On the other hand, 10 of 58 (17.2%) patients with nephroangiosclerosis presented with renal failure and protein excretion >2 g/day simulating primary GP. Furthermore, only 21 of 40 (52.5%) patients with IgA nephropathy presented with “benign disease”. Prospective studies are essential to ascertain the actual incidence and etiology of GP. The loose clinicopathological correlation in GP dictates an aggressive diagnostic approach in its study and management.

Chronic Renal Disease in Kuwaiti Nationals: A Prospective Study During the Past 4 Years

Our study is a prospective one conducted at Al-Amiri Hospital and including all new cases of chronic renal disease (CRD) seen at the capital area of Kuwait between 1 January 1999 and 30 December 2003. Diagnosis of CRD was based on clinical, laboratory, and radiological features. Kidney biopsies were done when indicated. A total of 271 cases of chronic renal failure (CRF) were diagnosed, of whom 143 were women. The median age was 40 years (range, 5 to 80 years; mean ± SD: 40 ± 14). The most common cause of CRF was glomerulonephritis (32%), of which systemic lupus erythematosis and vasculitis constituted 5% and 4%, respectively. Diabetic glomerulosclerosis was the second leading cause of CRD (24%), followed by tubulointerstitial disease (11%) and nephroangiosclerosis (10%). Less frequent causes included renovascular/ischemic disease (6%), obstructive nephropathy (3%), and adult polycystic kidney disease (3%). One hundred and seven patients had 121 incidents of acute deterioration of underlying renal disease. This was mostly due to drugs (22%), infection (21%), and volume depletion (13%). Antiinflammatory drugs were the most common drugs (63%) responsible for the acute decline in renal function. By the end of the study, 18 (7%) patients died, 55 (20%) required maintenance dialysis, and 40 (15%) had received a kidney allograft. Diabetic patients did not differ from nondiabetic with regard mortality, although had more renal replacement therapy (p = .002). Using the Cox regression model, analysis of the relative risk factors likely to contribute to mortality, viz. age, gender, original kidney disease, fitness for transplantation, and mode of presentation, did not show significant factors except for less hazard to death in those diagnosed early with CRD (i.e., on routine testing; relative risk 0.06, p = .01). In conclusion, our study indicates that early diagnosis and management of CRD can improve the patients quality of life and decrease the cost of frequent hospitalization, morbidity, and even mortality associated with end-stage renal disease.

Postmortem Biopsies: The Experience in Kuwait

Objective: To report our 4-year experience in postmortem needle biopsy of liver, heart, kidney and lung tissues when formal autopsy could not be performed. Subjects and Methods: In the period from January 2000 to December 2003, postmortem biopsies were done at Al-Amiri Hospital, Kuwait, in 19 cases where the original diagnosis or cause of death was not clear. The procedure was performed by a dedicated trained medical team using a biopsy needle or limited incisions guided by the knowledge of the clinical presentation and results of laboratory and radiological investigations. Results: The actual diagnosis was established in 8 cases by postmortem histological findings and corrected in another 9 cases. In the remaining 2 cases with systemic sepsis, autopsy only confirmed the antemortem clinical diagnosis. Conclusion: Our study shows that needle biopsy is an adequate technique for postmortem examination and should be considered as the minimum alternative to conventional autopsy.

Sonographic Assessment of Renal Size in Healthy Adults

Objective: To assess the normal sonographic values of renal length and cortical thickness in healthy adults and establish reference ranges in our population for comparison when examining renal disease. Subjects and Methods: Sonographic assessment of renal length and cortical thickness were performed from January 2006 to December 2011 in 252 healthy individuals who were self-referred to the El-Reshaid Renal Clinic in Kuwait. They were screened for the absence of renal abnormalities. Weight and height were measured, and body mass index (BMI) and body surface area calculated. Patients were divided into 5 age groups: 18-30, 31-40, 41-50, 51-60 and 61 -80 years, in order to generate reference graphs for renal length and cortical thickness. Results: The mean renal lengths for the right and left kidney were 10.68 ± 1.4 and 10.71 ± 1.0 cm, respectively (p = 0.56) without a significant change with age. The minimum cortical thickness was 0.6 cm. The renal length correlated with the weight of the patients (p < 0.01) and their BMI (p < 0.01) but not with their height. There was no difference in renal size or cortical thickness in patients older than 60 years despite an age-related decline in the glomerular filtration rate (p < 0.001). Conclusions: Renal length and cortical thickness did not vary significantly with age. Renal length correlated well with weight and BMI but not with height. Hence, establishing normal ranges of renal parameters is essential for comparison in situations where possible renal disease is being investigated.

Pediatric dialysis and renal transplantation in Kuwait over the past 11 years

Abstract Data on end-stage renal disease (ESRD) patients and their renal replacement therapy (RRT) were collected retrospectively from the three dialysis centers, the pediatric urology unit, and the organ transplant center of Kuwait. The study period was from 1 January 1986 to 31 December 1996. A total of 61 children, 50 of whom were Kuwaiti nationals, required RRT for ESRD during those 11 years. This gave an average annual incidence rate of 18 per million Kuwaiti children. Glomerulonephritis was the most-frequent underlying disease and accounted for 44% of total cases, while pyelonephritis (including urinary tract anomalies and dysplastic kidneys) was responsible for 30%. Multisystem disease was responsible for ESRD in 7 patients (14%), 2 of whom had lupus nephritis, 2 vasculitis, 2 Henoch-Schönlein purpura, and 1 hemolytic uremic syndrome. Continuous ambulatory peritoneal dialysis and home intermittent peritoneal dialysis, using cycler machines, were not favored dialysis techniques by most parents, especially for those <6 years old. The actuarial survival on dialysis was 75%±7% at 12 months. Of the 8 patients who died, 7 were <6 years old. Thirty-eight patients received 46 kidney transplants, 13 of which were performed on a pre-emptive basis. The actuarial patient survivals at 12 months for those receiving first live and cadaveric kidney transplants were 90%±5% and 85%±2%, respectively, while those for grafts were 76%±8% and 66%±2%, respectively. This is the first nationwide long-term study of the incidence and etiology of pediatric ESRD in our area and the RRT in a country with adequate treatment facilities.

Complementary bodybuilding: A potential risk for permanent kidney disease

We report our experience of renal disease associated with bodybuilders who had been on high-protein diet, anabolic androgenic steroids (AASs), and growth hormone (GH) for years. A total of 22 adult males who volunteered information about use of high protein diet and AAS or GH were seen over a six-year period with renal disease. Kidney biopsy revealed focal segmental glomerulosclerosis (FSGS) in eight, nephroangiosclerosis in four, chronic interstitial nephritis in three, acute interstitial nephritis in two, nephrocalcinosis with chronic interstitial nephritis in two, and single patients with membranous glomerulopathy, crescentic glomerulopathy, and sclerosing glomerulonephritis. Patients with FSGS had a longer duration of exposure, late presentation, and worse prognosis. Those with interstitial disease had shorter exposure time and earlier presentation and had improved or stabilized after discontinuation of their practice. There is a need for health education for athletes and bodybuilders to inform them about the risks of renal disease involved with the use of high-protein diet, AAS, and GH.

Comparison of peritonitis rates and patient survival in automated and continuous ambulatory peritoneal dialysis: a 10-year single center experience

Abstract Peritonitis is a common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). In this retrospective study, peritonitis rates and patient survival of 180 patients on CAPD and 128 patients on APD were compared in the period from January 2005 to December 2014 at Al-Nafisi Center in Kuwait. All patients had prophylactic topical mupirocin at catheter exit site. Patients on CAPD had twin bag system with Y transfer set. The peritonitis rates were 1 in 29 months in CAPD and 1 in 38 months in APD (p < 0.05). Percentage of peritonitis free patients over 10-year period in CAPD and APD were 49 and 60%, respectively (p < 0.05). Time to develop peritonitis was 10.25 ± 3.1 months in CAPD compared to 16.1 ± 4 months in APD (p < 0.001). Relapse and recurrence rates were similar in both groups. Median patient survival in CAPD and APD groups with peritonitis was 13.1 ± 1 and 14 ± 1.4 months respectively (p = 0.3) whereas in peritonitis free patients it was 15 ± 1.4 months in CAPD and 23 ± 3.1 months in APD (p = 0.025). APD had lower incidence rate of peritonitis than CAPD. Patient survival was better in APD than CAPD in peritonitis free patients but was similar in patients who had peritonitis.

Consultants for the American Journal of Nephrology 1997

Consultants for the American Journal of Nephrology 1997 Abrass, Christine Adler, Sharon Agodoa, Lawrence Akmal, Mohammad Anderson, Sharon Andreucci, Vittorio Avram, Morel Bakris, George Balow, James Bennette, William Boswell, William Breyer, Julia Langman, Craig Levin, Nathan Limb, Victoria Maroni, Bradley Martinez-Maldonado, Manuel Matthew, Weir R. Mitch, William Mushnick, Robert Nissenson, Allan Nolph, Karl Nosrati, Saeid