Hospitalization patterns in HD patients in the Kingdom of Saudi Arabia: A comprehensive cohort study.

INTRODUCTION: The rate of hospitalization represents a morbidity indicator in HD patients. The study aimed to evaluate hospitalization patterns in a large HD cohort. METHODS: All DaVita-KSA HD patients from October 2014 to December 2019 were included. Demographical and clinical characteristics and hospitalization data were recorded. Less than 24 h admission was excluded. Overall and cause-specific hospitalization rates were calculated. RESULTS: During the follow-up period, 3982 patients with a mean age of 52.5 ± 16.8 years, 2667 hospitalizations were recorded in 34.1% of the patients and 45.6% had repeated admissions. Infectious causes accounted for 26.6% of all recorded causes vs. 15.6% for cardiovascular complications. The median hospital stay length was 11 days, while the overall annual hospitalization rate of 34.9% and the annual duration of 3.7 days per patient. Hospitalized patients had a higher risk of mortality (p < 0.001). CONCLUSION: Infectious complications were the leading cause of hospitalization and had the longest hospital stay.

Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience.

BACKGROUND: The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis. METHODS: We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis. RESULTS: Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets. Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets. CONCLUSION: This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.

Exome capture and massively parallel sequencing identifies a novel HPSE2 mutation in a Saudi Arabian child with Ochoa (urofacial) syndrome.

We describe a child of Middle Eastern descent by first-cousin coupling with idiopathic neurogenic bladder and high-grade vesicoureteral reflux at 1 year of age, whose characteristic facial grimace led to the diagnosis of Ochoa (urofacial) syndrome at age 5 years. We used homozygosity mapping, exome capture and paired-end sequencing to identify the disease causing mutation in the proband. We reviewed the literature with respect to the urologic manifestations of Ochoa syndrome. A large region of marker homozygosity was observed at 10q24, consistent with known autosomal recessive inheritance, family consanguinity and previous genetic mapping in other families with Ochoa syndrome. A homozygous mutation was identified in the proband in HPSE2: c.1374_1378delTGTGC, a deletion of 5 nucleotides in exon 10 that is predicted to lead to a frameshift followed by replacement of 132 C-terminal amino acids with 153 novel amino acids (p.Ala458Alafsdel132ins153). This mutation is novel relative to very recently published mutations in HPSE2 in other families. Early intervention and recognition of Ochoa syndrome with control of risk factors and close surveillance will decrease complications and renal failure.

Role of bone biopsy in renal osteodystrophy.

Renal osteodystrophy (ROD), the abnormal bone histology that occurs in the context of kidney disease, is a disease spectrum and not a uniform progressive bone disease. It is an important component of the broad disturbances of bone and mineral metabolism associated with chronic kidney disease (CKD). There are multiple pathogenetic factors which contribute to the histological abnormalities seen on bone biopsy. The patients with ROD are rarely symp-tomatic in the early stages of CKD. It is also noteworthy that the clinical manifestations are usually preceded by biochemical changes that are insidious and subtle. This makes it difficult for the clinician to suspect the presence of bone and mineral metabolism abnormalities without direct testing. The serum calcium, phosphorus, and alkaline phosphatase levels are usually normal until late in the course of CKD. The main screening test for abnormal bone and mineral metabolism is the measurement of parathyroid hormone which is also somewhat delayed. The clinical signs and symptoms are also challenging to interpret because of their slow and non-specific nature which may include vague, ill-defined, bone aches and pains, and muscle weakness. The gold standard for diagnosis of ROD is bone biopsy with mineralized bone histology after double tetracycline labeling, iron staining and aluminum staining. The currently used histomorphometric descriptions of bone histology are not well integrated clinically and a new nomenclature that is clinically more relevant and useful has been proposed. Additional studies are required to define the spectrum of ROD in the current therapeutic era, and to find clinically useful non-invasive biomarkers to improve the treatment and monitoring of the abnormal bone in the setting of CKD.

A retrospective review of the outcome of plasma exchange and aggressive medical therapy in antibody mediated rejection of renal allografts: a single center experience.

UNLABELLED: Antibody-mediated rejection (AMR) has been recognized as a major cause of renal allograft loss. Protocols using plasma exchange (PE) to reverse rejection have mixed results. METHODS: A retrospective chart review was performed to determine the clinical response to PE inpatients with AMR of renal allograft. A good response to treatment was defined as a decline in serum creatinine (SCr) to within 25% above the prerejection value or discontinuation of dialysis with a SCr <2 mg/dl within 3 months of discharge from the hospital and disappearance of donor-specific alloantibodies (DSA). RESULTS: Twenty-two patients, treated with PE for biopsy proven AMR with or without acute-cellular rejection (ACR), were included in the study. Sixty-four percent of patients had concurrent AMR and ACR. Fifty-two percent of all patients had a good response to antirejection therapy, whereas 63% of patients with only AMR and 46% of patients with both AMR and ACR had a good response. Good response to PE did not correlate with the number of plasma volumes exchanged (P = 0.09), but correlated with a shorter period from transplantation to the rejection episode (P = 0.002). CONCLUSION: Only a shorter interval between transplantation and the acute rejection episode correlated with a good response to PE.

Vitamin D and kidney disease.

Abnormalities in vitamin D metabolism play a major role in the pathogenesis of secondary hyperparathyroidism in chronic kidney disease. The gradual and progressive decline in 1,25-dihydroxyvitamin D in the course of chronic kidney disease is the result of several mechanisms that limit the ability of the failing kidney to maintain the levels of 1,25-dihydroxyvitamin D despite increasing levels of parathyroid hormone. Recent observations have indicated that chronic kidney disease seems to be associated with a high incidence of nutritional vitamin D insufficiency or deficiency as manifested by decreased levels of 25-hydroxyvitamin D. This contributes to the inability to maintain the levels of 1,25-dihydroxyvitamin D; therefore, current practice guidelines suggest repleting vitamin D status by the administration of native vitamin D as a first step in the therapy of the abnormalities of bone and mineral metabolism in chronic kidney disease. The efficacy of this therapy is extremely variable, and active vitamin D sterols may be required, especially as kidney disease progresses. The importance of the abnormal vitamin D metabolism is being investigated vigorously in view of the observations that vitamin D may have important biologic actions in many tissues in addition to bone and parathyroid. Thus, observational data have suggested potential survival benefits of vitamin D sterol administration in this clinical setting, and experimental data have suggested a potential beneficial effect of vitamin D sterols on the progression of kidney disease. Further work is required to define the mechanisms involved and to examine the effects of vitamin D therapy on outcomes in randomized, controlled trials.

Euglycemic diabetic ketoacidosis in pregnancy.

Diabetic ketoacidosis (DKA) can be a catastrophic event during pregnancy, complicating almost nine percent of diabetics in pregnancy. It induces both maternal and fetal mortality. Ketosis has been implicated in fetal distress and causes adverse neurological outcome. DKA with a relatively low blood sugar levels is called euglycemic DKA, which is a rare entity and reported usually in type I diabetic patients. A 37-year-old Saudi female patient known to have type II diabetes developed euglycemic [blood glucose level 4.3 mmol/L (78 mg/dl)] DKA while in her fifth pregnancy. She responded to intravenous dextrose and insulin with gradual improvement. Euglycemic DKA should be considered in type II diabetics during pregnancy and treated promptly.

Clinical association between renal insufficiency and positive troponin I in patients with acute coronary syndrome.

BACKGROUND: Whether renal insufficiency (RI) influences troponin levels in patients with acute coronary syndromes (ACS) is controversial. We attempted to determine whether there is an association between RI and troponin I (TnI) elevation in patients presenting with ACS. METHODS: We studied 764 consecutive patients with ACS admitted to our institution from January 1999 to June 2000. Patients were identified prospectively and data were collected through chart review of all cases with an admission diagnosis of ACS. In order to assess the relationship of TnI and RI, we calculated the creatinine clearance (Cr-Cl) for all patients. We conducted an analysis of variance comparing TnI in quintiles of patients with lowest to highest Cr-Cl. RESULTS: Among 764 patients, 173 patients had a discharge diagnosis of ST elevation myocardial infarction and 591 had non-ST elevation myocardial infarction. There was no correlation between peak TnI levels and renal function as measured by Cr-Cl in the entire cohort with ACS and in the subgroups with ST elevation myocardial infarction and non ST elevation myocardial infarction. CONCLUSIONS: This large cohort study demonstrates that there appears to be no association between RI and positive TnI in patients with ACS.

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors.

OBJECTIVES: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function. BACKGROUND: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction. METHODS: Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events. RESULTS: Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl. CONCLUSIONS: Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.

The new definition of myocardial infarction: diagnostic and prognostic implications in patients with acute coronary syndromes.

BACKGROUND: The clinical implications of the recently revised criteria for diagnosis of acute myocardial infarction (AMI) in patients with suspected acute coronary syndromes are unknown. METHODS: To evaluate the prognostic implications of the new diagnostic criteria for AMI, we studied 493 consecutive patients with suspected acute coronary syndromes admitted to University of Michigan, Ann Arbor, between May 1, 1999, and January 1, 2000. Patients with positive cardiac enzymes and symptoms suggestive of coronary ischemia (n = 275) were divided into 2 groups: group A, with elevated peak creatine kinase-MB fraction and/or new electrocardiographic changes suggestive of AMI regardless of troponin status (diagnosed as AMI by old criteria), and group B, with normal peak creatine kinase-MB fraction but elevated troponin I level (additional patients diagnosed as having AMI by new criteria). RESULTS: As compared with group A (n = 224), patients in group B (n = 51) were older women, with increased comorbidities such as previous stroke or aortic stenosis, and had fewer in-hospital procedures. In-hospital adverse events (reinfarction, heart failure, shock, and mortality) were similar between the groups, whereas 6-month mortality was higher among group B patients (16.3% vs 5.8%; P =.03). This difference was not statistically significant after adjustment for differences in baseline characteristics between the groups (odds ratio, 1.6; 95% confidence interval, 0.5-5.9). CONCLUSIONS: The new criteria result in a substantial increase in the diagnosis of AMI. Furthermore, they help to identify patients with acute coronary syndromes who have greater comorbidities and worse 6-month outcomes who are otherwise missed by the old criteria. Additional studies are needed to confirm these preliminary findings and to determine the financial implications of the new criteria.