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.

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.

Pattern of acute renal failure in a tertiary hospital in the United Arab Emirates.

Acute renal failure (ARF) is a challenging problem in nephrology. To evaluate the pattern, management and outcome of ARF in our tertiary hospital, we analyzed the data of all 81 patients admitted with or developing ARF in hospital between January 2002 and June 2003. The 45 men and 36 women of mean age 56.2 +/- 21 (range 13 to 91) years were managed either on the ward (n = 48; 59%) and or in the ICU (n = 33; 41%) 10% were direct admissions to the nephrology service with ARF, and 90% developed ARF in hospital. Thirty percent were referred by oncology services and 15% by general medicine. Sepsis was the cause of ARF in 36 (44%) patients, followed by drug nephrotoxicity in 11 (14%), and obstructive uropathy in 9 (11%). Comorbid conditions were hypertension in 28 (35%); diabetes in 27 (33%); chronic renal failure, 19 (23%); ischemic heart disease 19 (23%); and liver disease 12 (15%). The most common predisposing factor was hypotension in 42 (52%), dehydration in 32 (40%), and drug nephrotoxicity in 20 (25%). Sixty patients (74%) were managed conservatively, and 21 (26%) required renal replacement therapy. The length of hospital stay was 29.5 +/- 38.4 (range 2 to 279) days. Patient survival for those managed on the ward was 71% compared to 33% for ICU patients (P <.00001). Renal survival was 83% for ward patients, compared to 48% for those in the ICU (P <.001). This study showed that majority of ARF developed in-hospital with oncology patients constituting the greatest proportion. Sepsis was the leading cause of ARF and hypotension, the main predisposing factor. Patients treated in the ICU showed a worse prognosis for both patient and renal survival.

Outcome and predictive factors of acute renal failure in the intensive care unit.

The development of acute renal failure (ARF) in the ICU setting carries a high morbidity and mortality. To assess the outcomes and its predictive factors in our ICU, we analyzed the data of patients with ARF treated during 18 months. The 33 patients included 21 men and 12 women of mean age 51 +/- 21.7 years (13 to 87). Sepsis with multi-organ dysfunction (MOD) was the leading cause of ARF (58%). Comorbid conditions were malignancy in 30% of patients, diabetes mellitus in 24%, hypertension in 21%, ischemic heart disease in 21%, liver disease in 15%, and chronic renal failure in 15%. Predisposing factors were hypotension in 67% of cases, dehydration in 36%, drug related in 33%, congestive heart failure in 24%, and liver cirrhosis in 6%. Twenty-five (76%) patients needed mechanical ventilation, 22 (67%) were anuric, 18 (55%) had MODS, and 15 (45%) needed inotropic support. Length of stay in hospital was 27.2 +/- 28.0 days (2 to 94). Nineteen patients (58%) were managed conservatively and 14 (42%) by renal replacement therapy. Patient mortality was 67% and renal mortality 52%. The impact of the following factor: was assessed on patient and renal outcome was assessed ventilation support, presence of oliguria, need for inotropes, and presence of MOD. Patient mortality was significantly influenced by an elevated odds ratios (OR) (95% CI): mechanical ventilation [OR = 34 (95% CI 1.95 to 538)], and presence of MODS [OR = 12.3 (95% CI 2 to 75)]. Renal mortality was influenced by mechanical ventilation [OR = 12.3 (95% CI 1.6 to 119)], oliguria [OR = 12 (95% CI 2 to 72)], inotrope support [OR = 10 (95% CI 2 to 52), and MOD [OR = 35 (95% CI 3.5 to 35.0)]. This study confirms the high patient and renal mortality of ARF among patients to ICU. The four parameters were excellent predictors of renal outcome, while only the need for mechanical ventilation and the presence of MOD were predictors for patient survival.

Late cytomegalovirus disease with atypical presentation in renal transplant patients: case reports.

Cytomegalovirus (CMV) disease typically occurs 1 to 4 months (median 35 days) after solid organ transplantation. Recent reports documented that the natural history of CMV disease associated with solid organ transplantation has been modified as a result of the widespread use of potent immunosuppressents and antiviral prophylaxis. We herein report three pretransplant CMV seropositive recipients (with unknown donor status) who were diagnosed recently to display late and atypical CMV disease. Two men and one woman included two patients who presented with allograft dysfunction at 12 years and at 3 years after transplantation. Both patients showed increased serum creatinine approximately from baseline 200 to >400 micromol/L over 3 months in the absence of features of rejection or cyclosporine toxicity. A renal biopsy was refused by both patients. Two of the three patients presented with symptoms of enterocolitis (diarrhea, nausea, weight loss), which had persisted for more than 6 months. Other symptoms and signs of overt CMV disease (fever, leukopenia) were absent. None had pulmonary, hepatic, or other major organ involvement. In all patients IgG antibodies and CMV DNA by polymerase chain reaction were positive with negative IgM antibodies. The immunosuppressive regimen consisted of mycophenolate mofetil (MMF), steroids, and calcineurin inhibitors. The kidney function significantly improved in both patients with renal dysfunction. Gastrointestinal symptoms resolved completely with gradual weight gain. The recognition and early diagnosis of late atypical CMV disease in kidney transplant patients presenting with allograft dysfunction and/or other organ systems is important. The MMF has a red herring effect in our cases due to its GI side effects.

An atypical course of Caroli's disease in a renal transplant patient--case report and review of the literature.

This is a rare case of Caroli's disease, diagnosed following renal transplantation in a patient with autosomal recessive polycystic kidneys. Despite advanced cystic transformation of the biliary tree with striking architectural changes, there was no evidence of portal hypertension or hepatic fibrosis. Moreover, the patient did not suffer a single episode of cholangitis, a most interesting feature of this case. Her clinical course was punctuated by repeated episodes of gastrointestinal and urinary tract infections with resistant organisms; but fortunately, she had no evidence of septicemia. Recurrent Salmonella gastroenteritis indicated a chronic carrier state with the dilated bile ducts possibly acting as a potential reservoir. This has significant implications considering the immune suppression associated with renal transplantation. In general, Caroli's disease is rare. Therefore, a high index of suspicion for the diagnosis of Caroli's disease is warranted especially in patients with ARPKD or ADPKD. Once confirmed, affected patients with end-stage renal disease such as our patient, should ideally undergo combined liver-kidney transplantation.

Patients on hemodialysis visiting madina munawarah: communication between nephrologists.

Two hundred and thirteen patients who were already on hemodialysis (HD) at other locations visited Al-Madina Al-Munawarah, Saudi Arabia, during the year 1996. These patients were accepted for temporary HD at the King Fahad hospital during their stay in the city. Only 29 (13.6%) patients had detailed medical reports with them. Forty-one (19.2%) patients had full serology reports with them. Those coming from within Saudi Arabia were comparable to those from other countries. Hemodialysis per se should not deter patients from leading as normal a life as possible, including visiting places for leisure or religious purposes. Full cooperation and communication between HD units would give appropriate and timesaving services to those patients at place of visit and would limit possible problems.

The spectrum of glomerulonephritis in adults in madinah munawarah region.

To evaluate the patterns of glomerular diseases in the Madinah region in Saudi Arabia we reviewed 85 biopsies from native kidneys of adult patients presenting with clinical and or biological features suggestive of glomerular disease. Only light microscopy was used to evaluate these biopsies. There were 62 males and 23 females with age ranging from 12 to 80 years (mean 28 + 13.4 years). The main clinical presenting features were nephrotic syndrome in 68 patients (80%), renal insufficiency in 31 (36.5%), hypertension in 25 (24%) and/or hematuria in 19 (22.4%). Histopathology revealed minimal change disease in 25 patients (29%), mesangioproliferative glomerulonephritis (GN) in 13 (15.3%), focal segmental glomerulosclerosis in 13 (15.3%), membranoproliferative GN in seven (8.2%), membranous GN in three (3.5%), diffuse proliferative GN in five (5.9%), crescentic GN in four (4.7%), lupus nephritis in 13 (15.3%), and amyloidosis in two (2.4%). In conclusion, Minimal change disease was the most common type of primary GN in our patients. The mean age for this group was 27.2 (range 13-43 years). Lupus nephritis was the commonest secondary GN in the Madinah region.

Viral hepatitis in renal transplant patients.

Hepatitis is emerging as a common serious problem in renal transplant patients. To determine the prevalence of viral hepatic in our transplant population, we screened the patients who received renal transplants in the period from 1979-1997, inclusive, for hepatitis B virus (HBV) and for hepatitis C virus (HCV) infection. Of those patients screened for HBV infection, seven o f101 recipients (6.9%) were found positive for HbsAg. During the follow up, one patient cleared HbsAg and one from the negative group acquired it. Of the recipients screened for HCV antibodies 32 of 78 patients (41%) had positive tests. Higher incidence of chronic liver disease (37.5%) was found in the HCV positive group, compared to zero in the negative group. However, no difference in the short-term graft loss (25%), was noted between these two groups. We conclude that prevalence of hepatitis C in our transplant patients is high and may have an impact on their long-term outcome.

Short-tem Post Renal Trasplant Follow-up at Madinah Al Munawarah.

We reviewed the records of the renal transplant patients followed at our hospital to determine short-term outcome and complications. Sixty-five renal transplant patients, follow-up for two years were included in this study. Of these patients 40 (61.5%) were males, 33 (50.7%) were Saudis with mean age of 37.2 +/- 11.7 years. Donors were living related (LRD) in 23 (35%), living non-related (LNRD) in 27 (42%) and cadaveric (CAD) in 15 (23%). Thirty-two transplants were carried out at Medinah, 21 in India and the rest in other centers inside Saudi Arabia. Immunosuppression was based on a triple therapy (Cyclosporin, Azathioprine, and Prednisone). At two years, 52 (80%) patients were alive, with functioning graft in 31 (58%). Causes of death among 13 patients (11 LNRD & 2 CAD) were infections in 7 (54%), immediate post transplant in three (22.7%), acute myocardial infarction in two (15.7%), CVA in one (7.6%). Complications encountered were acute rejection (23 episodes) in 18 923.6%) patients, infections in 19 (25%), chronic rejection in 16 (21.5%), surgical in 13 917.1%), diabetes mellitus in 5 (6.5%) primary non-function in three (3.8%) and Kaposi Sarcoma in two (2.4%). Twenty-six (81.25%) out of 32 transplants performed in Madinah were functioning, four (12.5%) patients returned to dialysis and two (6.25%) patients died. Among the 21 transplants done in India 11 (52%) patients died, six (28.6%) returned to dialysis, and four (19.4%) had function deteriorated in all patients. We conclude that despite limitations, results of renal transplantation carried out at Madinah are encouraging on short-term basis. Live related transplant has a very good outcome, while commercial transplantation carries poor prognosis.

CAPD: Experience at Al Madinah Al Munawarah.

CAPD is not as popular mode of renal replacement therapy (RRT) in this country as it is in the west and hence the experience with CAPD is limited. At our center 16 patients (8 Males, 8 Females) with ESRD with a mean age of 46.3 +/- 15.6 years were managed by CAPD during 1990-1994. CAPD was the first option as a renal replacement therapy (RRT) in seven (44%) and second option in nine (56%) patients. Indications for CAPD were: Vascular access problems in 10 (62.5%), cardiovascular instability in three (19%), patient preference in two (12.5%) and non-availability of nearby HD center in one (6%) patient. Standard safe leur-lock system was used for dialysis. All patients were well dialyzed with good quality of life. Peritonitis was the main complication encountered (one episode/eight patient months), cause of hospital admission and reason for returning back to hemodialysis (HD). Other complications encountered were intraperitoneal bleeding in three, accidental cutting of outline in two, leakage in one and exit site infection in one. Average survival of this method was 15 + 10.5 months (range 1-37 months). At the time of reporting this study seven patients continued to be on CAPD, six were transferred back to hemodialysis, one was transplanted and two died due to other reasons. We conclude that CAPD is an acceptable mode of RRT in this part of the world.

Once Weekly Low Dose Subcutaneous Erythropoietin: An Economic Solution for the Management of Anemia of End-stage Renal Disease.

Forty patients with end-stage renal disease on maintenance hemodialysis were categorized into three groups depending upon the route of administration of erythropoietin (EPO). Eighteen of these patients received i.v. EPO (group A), 11 were switched from i.v. to s.c. route (group B), and 11 other patients were started on s.c. EPO from the beginning of treatment (group C). They were studied to evaluate the efficacy of EPO and its dosage. The target hemoglobin was decided to be between 9 and 10.5 g/L. The hemogram of all these patients showed considerable improvement after EPO treatment. Mean hemoglobin level increased from 7.0 +/- 1.0 in all the groups to 9.0 + 1.0, 9.1 +/- 0.9 and 9.0 + 0.9 g/dl in groups A,B, and C respectively. Mean dose of EPO to achieve target hemoglobin was 120 +/- 42.2, 42.6 + 16.2 and 36.6 + 11.1 U/Kg/week in groups A, B, and C respectively. Our observation illustrates that once weekly s.c. EPO is equally effective as i.v. EPO albeit at reduced dose and hence saving costs substantially without compromising patient care. Also, it maintains hemoglobin in target range in patients already stabilized on i.v. EPO.

Rhabdomyolysis and acute renal failure in head injury patients.

Rhabdomyolysis is a known complication of crush injuries, but is not known to complicate the course of the patients with head injuries without other apparent skeletal muscle injuries. The frequency of renal failure may be high in such group of patients. We conducted a prospective study to evaluate such incidence on twenty patients with head injuries. Ten patients (50%) had other injuries in addition, but none of the patients had crush injury. All the patients were investigated daily for serum electrolytes, urea, creatinine, creatinine phosphokinase (CPK) and myoglobulinuria. All these patients were on a dehydrating protocol to prevent brain edema, including administration of dopamine infusion (1-3 microg/kg/min), intravenous bolus doses of mannitol, and sodium bicarbonate. Nine patients (45%) developed renal impairment, three of them had no other apparent skeletal muscle injuries, but none of them required dialysis. Rhabdomyolysis is not uncommon in head injury patients in the absence of apparent skeletal muscle injuries, and may precipitate renal failure. This may have therapeutic implications to prevent the incidence of acute renal failure in such group of patients.

Prevalence of hepatitis C virus antibodies in hemodialysis patients in madinah Al munawarah.

This study was carried out to evaluate the prevalence of antibodies against hepatitis C virus (HCV) in our hemodialysis (HD) unit at Madinah Al Munawarah in Saudi Arabia. Fifty six of the 94 patients (60%) studied were positive for HCV, while none of the thirty staff members working in the same unit were positive. The positivity of HCV correlated significantly with duration on HD. No significant correlation was found with the number of blood transfusions, hepatitis B markers or liver enzymes.

Ramadan fasting and renal transplant recipients: Clinical and biochemical effects.

Eleven renal transplant recipients were studied while fasting during the month of Ramadan. All were asymptomatic. The serum and urinary bichemical analysis showed no significant changes. Also, there were no adverse effects on the allograft and the cyclosporine A levels did not change significantly. There was a significant elevation of serum potassium levels during fasting, but the levels always remained within normal limits. Our study indicates that fasting during Ramadan does not seem to be associated with any significant ill effects in renal transplant recipients. However, studies involving larger numbers of patients are needed to confirm this observation.

Early and late occurrences of destructive spondyloarthropathy in haemodialysed patients.

In a series of 100 patients dialysed for 3 months to 17 years destructive spondyloarthropathy was diagnosed in 11 cases. Lower cervical spine was involved in ten and dorsal spine in one. When compared to patients without arthropathy, spinal involvement was associated with longer duration of dialysis and greater prevalence of parathyroidectomy. The patients with destructive spondyloarthropathy were divided into two groups: Group 1, four patients, in whom arthropathy occurred within the first 41 months of dialysis, and Group 2, seven patients, in whom arthropathy occurred after 106 months of dialysis. Group 1 was associated with greater age, chondrocalcinosis (2 of 4), absence of overt osteoarticular bone defects, and absence of carpal-tunnel syndrome. Parathyroidectomy (PTx) was performed in one patient. Amyloidosis was not found in one patient who came to autopsy. Group 2 was associated with presence of shoulder pain (6 of 7), juxtaarticular bone cysts (6 of 7) and CTS (6 of 7), and absence of radiological chondrocalcinosis. PTx was performed in six of seven patients and amyloidosis was found in three. In conclusion, destructive spondyloarthropathy may be seen early in the course of dialysis, apart from general amyloid involvement of accelereted hyperparathyroidism. A specific finding of this study was the discovery of radiological chondrocalcinosis in association with early arthropathy, which is a well-recognised feature in non-uraemic subjects.