Challenges of Retrograde Ureteroscopic Procedures in Overweight Patients.

BACKGROUND: Obesity and urolithiasis are both prevalent conditions that have an impact on the healthcare system. The ureteric diameter and accessibility play a crucial role in the management of urolithiasis in both overweight and normal weight patients. Studies have shown that obesity can lead to changes in ureter diameter where excessive body fat can exert pressure on the kidneys, causing them to enlarge in size and this enlargement can result in a compression of the adjacent structures, including the ureter. The aim of this study is to assess the incidence of intraoperative challenges faced during retrograde ureteroscopic procedures in overweight patients with ureteric and renal calculi. METHODS: We retrospectively reviewed patients who underwent retrograde ureteroscopic surgery (RURS) for urolithiasis from 1st January 2021 until 30th August 2023. The outcome and any complications were documented and compared with the patient's Body Mass Index (BMI). All patients who undergo RURS in our facility have to have a Non-Contrast CT scan prior to surgery. Procedural success was determined by the ability to obtain access to the stone site intraoperatively and stone-free status in kidney, ureter, and bladder (KUB) X-ray post-operatively. Post-operative complications were recorded up to two weeks post-operatively and classified according to the Calvein Dindo Classification. RESULTS: Our total sample size was 146 patients out of which 75 were overweight and 71 were normal weight patients. In 34 (45%) of overweight patients' access to the ureter was restricted due to a narrow ureteric orifice with ureteroscopy not successful; on the contrary 13 (18%) of normal weight patients faced this same issue. This was statistically significant with a p-value of .004. The stone clearance rates were 91% and 95% in overweight and normal weight patients respectively, which is higher in normal weight patients however this difference was not found to be a statistically significant finding (p-value .028). Overweight patients had 12% Grade I and 8% Grade II complications whereas normal weight patients had 11% Grade I complications and 1.4% Grade II with no higher-grade complications. CONCLUSION: Retrograde ureteroscopic procedures are a safe treatment modality for patients with urolithiasis in both overweight and normal weight populations. They are shown to have similar success rates between both populations once ureteric access is obtained. However, access failure rates are shown to be slightly higher in overweight patients. Hence, further preoperative patient counselling and technical considerations should be undertaken.

Peritoneal dialysis in the Arabian Gulf countries: Challenges and opportunities.

The Gulf Cooperation Council (GCC) is a regional organisation, consisting of six Arab countries that share common objectives and cultural identities, with a total population of 57.3 million. The prevalence of patients requiring dialysis in GCC countries is increasing, with a current mean prevalence of 551 per million population. Despite the several patient-level and healthcare system benefits of peritoneal dialysis (PD) compared to in-centre haemodialysis, the growth in PD utilisation has been limited. This is related to several factors, including deficiencies in modality education for chronic kidney disease patients, nephrology training and governmental policies advocating for this dialysis modality. Establishing a detailed PD registry in GCC countries is an important step towards understanding our patients' characteristics, outcomes, current PD practices and challenges in order to increase the use of PD and to facilitate future initiatives aimed at optimising the management of PD patients in this part of the world. This article reviews common challenges around PD practices and utilisation in GCC countries and provides possible solutions to overcome these challenges. It should be noted that the literature on PD patients, outcomes and treatment practices in GCC countries is limited, and as a result, many of our recommendations and discussion are based on clinical observations, experience and data when available.

Degrees of Testicular Atrophy Following Orchidopexy for Testicular Torsion.

Introduction Testicular torsion is an urological emergency. It is a time-sensitive condition in which twisting of the spermatic cord and testicular blood supply occurs, causing acute onset severe scrotal pain. The incidence of testicular torsion is highest amongst prepubertal males; however, it can occur at any age. Every hour that passes from the onset of symptoms has been shown to decrease the salvageability rate of the torted testis. Another significant factor that impacts testicular salvage is the degree of torsion. Prompt surgical exploration of the scrotum and orchidopexy, if the testis is salvageable, is the mainstay of treatment. A major sequela following orchidopexy for torsion is the decrease in testicular volume. The aim of this study is to assess testicular volume loss post orchidopexy in patients who presented with testicular torsion, as well as to identify the significance of the degree of rotation and duration of torsion in post-fixation volume loss. Methods This is a retrospective study in which all patients who underwent scrotal exploration for a primary diagnosis of testicular torsion between June 1, 2016, to January 15, 2023, were reviewed. The information obtained included the patients' demographics such as age, duration of symptoms, and laterality. Ultrasound images were reviewed for pre- and postoperative findings which included confirmation of testicular torsion as well as testicular volume measurements. Patients were excluded if they underwent an orchidectomy, had a diagnosis other than testicular torsion once scrotal exploration was done, or did not perform a follow-up scrotal ultrasound. Additionally, patients who underwent an orchidopexy for undescended testis earlier in life were also excluded. For statistical analysis purposes, degrees of testicular torsion and time to surgery were classified into mild, moderate, and severe. Results A total of 109 patient records were reviewed within the specific time frame. Of these, 47 patients were excluded as per the exclusion criteria mentioned previously, which gave us a sample size of 62 patients. Our findings showed that increasing severity of the degree of torsion as well as the time for surgery have statistically significant (p-value <0.05) effects on postoperative testicular volume loss. However, it was noted that time to surgery has a more pronounced effect on the mean volume loss than the degree of torsion. Moreover, the analysis also showed that, on average, with every additional hour from the onset of symptoms to surgery, the approximate volume loss is 0.15 ml. However, once time exceeds the 4.5-hour mark, the mean volume loss is 0.4 ml for each additional hour. Conclusion The current study indicates that earlier surgical intervention and correction of torsion are associated with enhanced preservation of postoperative testicular volume. Both the degree of torsion and time to surgery influence mean volume loss; however, time to surgery has a greater impact on the mean volume loss. These results highlight the importance of early diagnosis and intervention in cases of testicular torsion to minimize the risk of long-term testicular volume loss.

Kt/V: achievement, predictors and relationship to mortality in hemodialysis patients in the Gulf Cooperation Council countries: results from DOPPS (2012-18).

BACKGROUND: Dialysis adequacy, as measured by single pool Kt/V, is an important parameter for assessing hemodialysis (HD) patients' health. Guidelines have recommended Kt/V of 1.2 as the minimum dose for thrice-weekly HD. We describe Kt/V achievement, its predictors and its relationship with mortality in the Gulf Cooperation Council (GCC) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates). METHODS: We analyzed data (2012-18) from the prospective cohort Dialysis Outcomes and Practice Patterns Study for 1544 GCC patients ≥18 years old and on dialysis >180 days. RESULTS: Thirty-four percent of GCC HD patients had low Kt/V (<1.2) versus 5%-17% in Canada, Europe, Japan and the USA. Across the GCC countries, low Kt/V prevalence ranged from 10% to 54%. In multivariable logistic regression, low Kt/V was more common (P < 0.05) with larger body weight and height, being male, shorter treatment time (TT), lower blood flow rate (BFR), greater comorbidity burden and using HD versus hemodiafiltration. In adjusted Cox models, low Kt/V was strongly related to higher mortality in women [hazard ratio (HR) = 1.91, 95% confidence interval (CI) 1.09-3.34] but not in men (HR = 1.16, 95% CI 0.70-1.92). Low BFR (<350 mL/min) and TT (<4 h) were common; 41% of low Kt/V cases were attributable to low BFR or TT (52% for women and 36% for men). CONCLUSION: Relatively large proportions of GCC HD patients have low Kt/V. Increasing BFR to ≥350 mL/min and TT to ≥4 h thrice weekly will reduce low Kt/V prevalence and may improve survival in GCC HD patients-particularly among women.

Current Status and Future of End-Stage Kidney Disease in Gulf Cooperation Council Countries: Challenges and Opportunities.

There is a paucity of data on epidemiology along with an incomplete registry of end-stage kidney disease (ESKD), nephrologist workforce, and variability among the countries of Gulf Cooperation Council (GCC). The study is an observation, descriptive study which aimed to describe current ESKD burden, nephrologist density, and kidney care infrastructure in GCC. Responses to a questionnaire-based survey obtained from representatives of the Nephrology Societies of GCC countries were analyzed. The categorical variables were compared using Chi-square test. A P = 5% was considered as significant. The mean prevalence of ESKD per million populations (pmp) was 551, highest in Oman (1000/pmp), least in Qatar (347/pmp). Predominant etiology in GCC was diabetes mellitus (DM) and hypertension (HTN) (100%, each), followed by chronic glomerulonephritis (66.7%). A transplant registry was maintained by all GCC countries. Hemodialysis (HD) (67.2%) was the most opted modality of kidney replacement therapy (KRT), followed by kidney transplantation (22%) and peritoneal dialysis (9.6%); 1.0% of patients opted for conservative management. Unplanned initiation of HD was three times more common. The access distribution among incident and prevalent HD patients respectively was (i) nontunneled central catheter (nTCC) (58.7 ± 36.6 vs. 1.5 ± 1.5), (ii) tunneled central catheter (23.5 ± 29.9 vs. 33.6 ± 10.0), and (iii) arteriovenous fistula (17.3± 14.4 vs. 57.8 ± 11.86). Death and transplantation were the reasons for dropout from HD. GCC has adequate kidney care infrastructure. There are 1686 nephrologists [range: Bahrain 9, Kingdom of Saudi Arabia (KSA) 1279]. Qatar, KSA, and Kuwait provide training in kidney biopsy; all countries except Bahrain have formal training programs for nTCC placement. ESKD prevalence is high, DM, HTN; glome-rulonephritis (GN) is the most common causes. The need for KRT is expected to rise in GCC. HD is the predominant KRT modality with a high prevalence of dialysis catheters as vascular access.

Sirolimus-based calcineurin inhibitor withdrawal immunosuppressive regimen in kidney transplantation: a single center experience.

BACKGROUND/AIM: This observational study was conducted to evaluate the safety and efficacy of the conversion from calcineurin inhibitors (CNIs) to sirolimus (SRL)-based immunosuppressive therapy in kidney transplantation. MATERIALS AND METHODS: Sixty-four kidney recipients of mean age 38.3 +/- 14.6 years were converted to SRL. The main reasons for conversion were elective in 45 (70.3%) and biopsy-proven chronic allograft nephropathy in 11 (17.2%). The primary CNI used was cyclosporine A in 51 patients. Mean time to conversion was 50.5 months. After conversion, 61 patients received mycophenolate mofetil. We evaluated the impact of conversion on renal function for 5 years post-conversion. The overall mean follow-up time was 72.8 months. RESULTS: The analysis showed significant improvement in renal function at month 3 post-conversion (P < 0.05) with stabilization thereafter. Lipid parameters and blood sugar levels were similar pre- and post-conversion. Abnormal liver function test was transient in 12.8%. Reasons for SRL discontinuation were nephrotic range proteinuria in two patients and mouth ulceration in one. We compared patients with serum creatinine <140 micromol/l and those with serum creatinine > or = 140 micromol/l, and found that serum creatinine was an independent risk factor for chronic allograft dysfunction (P = 0.02). Graft loss occurred in three patients because of cardiovascular death in two and an acute rejection episode in one. CONCLUSIONS: We concluded that conversion from CNIs to SRL is an option and of benefit without significant acute rejection episodes or chronic allograft dysfunction especially in well-selected kidney transplant recipients with good graft function.