Why are serum magnesium levels lower in Saudi dialysis patients?

OBJECTIVES: Serum magnesium (Mg) levels are often altered in dialysis patients. This study was conducted to ascertain the trends in Mg levels in patients on dialysis treatment. METHODS: A retrospective study was performed in the Dialysis Unit of King Khalid University Hospital, King Saud University, Riyadh, on patients undergoing regular dialysis. Patient demographic data, including body mass index (BMI), serum calcium (Ca), Mg, parathyroid hormone (PTH), cholesterol, and triglycerides were documented. RESULTS: Of a total of 115 patients, 70 (60.9%) were on haemodialysis (HD), and 45 (39.1%) were on peritoneal dialysis (PD). Of these, 10 patients (8.7%) had Mg levels of <0.7 mmol/L, 13 (11.3%) had 0.7 mmol/L, 24 (20.9%) had 0.8 mmol/L, 26 (22.6%) had 0.9 mmol/L, 16 (13.9%) 1.0 mmol/L, and 26 (23.9%) showed levels of ≥1.1 mmol/L. Approximately 93.0% had increased PTH levels, 43 (37.4%) had decreased serum Ca, 24 (20.9%) had low serum cholesterol, and 60 (52.2%) had low serum triglyceride. PD patients had significantly lower Mg and higher PTH levels compared to HD patients. CONCLUSION: Patients with chronic kidney disease are generally considered at risk of developing hypermagnesaemia due to reduced renal excretion. However, a considerable number of dialysis patients in our unit had hypomagnesaemia (or low levels) instead. In addition to other factors, PTH secretion is affected by serum Mg levels. We found a significant correlation between serum Mg and Ca as well as PTH levels. Consequently, optimizing Mg concentration in patients on dialysate is essential to reduce risk of dyslipidaemia, arrhythmias, hyperparathyroidism, or adynamic bone disease.

Awareness, attitude, and distribution of high blood pressure among health professionals.

BACKGROUND: BP control is suboptimal Worldwide. Little is known about attitudes of health professionals toward their BP status. AIM: To estimate awareness, attitudes, and distribution of blood pressure among health professionals. STUDY DESIGN: Prospective cross-sectional survey. METHODS: Study was conducted among health professionals in two tertiary hospitals in Riyadh, KSA during December 2010. Socio-demographics, risk factors for high BP, awareness, and adherence to treatment were recorded. RESULTS: Six hundred and seventy-two subjects, 66.6% females, mean age 36.2 + 13.9 years. Prevalence of Hypertension (HTN) was 28%. 114 (60.6%) patients had self reported HTN in HTN group while 74 (11%) of total study population, were not aware that they have HTN which was detected on screening. Stress and lack of formal exercise were prevalent risk factors for HTN, present in 44.1% and 36.1%, of patients, respectively, while obesity was present in 19.4%. Many participants were not aware of recently recommended target value of blood pressure. 22.3% patients were irregular for their follow-up. 12.2% patients were not adherent to the treatment. Isolated systolic hypertension was more common in men. A point of serious concern was that relatively young health professionals, who were not known to be hypertensive did not monitor their BP, found to have HTN. CONCLUSION: Suboptimal awareness and lack of adherence to the treatment for BP among health professionals is of serious concern, for increased chances of cardiovascular events. Physical exercise, correction of obesity and compliance with treatment may reduce the risk of HTN-related adverse outcome in this special subset of the population.

Recommendations for fasting in Ramadan for patients on peritoneal dialysis.

INTRODUCTION: The month of Ramadan holds great religious and social significance for Muslims all over the world. The aim of the present study was to provide a modified dialysis schedule for peritoneal dialysis (PD) patients that allows for fasting and that minimizes the effect on the patient's general health and volume status. METHODS: We observed 31 patients under treatment at the PD unit of King Khalid University Hospital, King Saud University, Riyadh. During the 3 - 4 weeks before the start of Ramadan, all patients were counseled individually and in detail about the possibility of fasting. They were also provided with clear instructions about fluid intake (up to 1 L daily) and avoiding a high-potassium diet. Of the 31 patients, 18 (10 women, 8 men) elected to fast during the month of Ramadan. The mean duration of fast in the study year (2009) in Riyadh, Saudi Arabia, was about 14 hours: from 0415 h (before sunrise) to 1800 h (after sunset). Depending on membrane type and patient preference, the fasting group was shifted to one of two regimens: Modified continuous ambulatory PD (8 patients): 3 exchanges during the night (1.36% or 2.27%), and icodextrin for a long dwell during the day. The first dialysis exchange was performed immediately after breaking the fast (1900 h), and the next at 2300 h. The final exchange was performed in the early morning before sunrise (0300 h), when the icodextrin was infused. Modified continuous cycling PD (10 patients): exchanges (1.36% or 2.27%) were performed over 6 - 7 hours, and icodextrin was infused for a long dwell during the day. The patient connected to the cycler at 2000 h or 2100 h, and therapy finished at nearly 0300 h, with icodextrin as the last fill. RESULTS: Of the study patients, 2 were admitted because of peritonitis (1 in each modality group), and the modified therapy was discontinued. In the modified CCPD group, 1 patient (on PD for 1 month before Ramadan) developed PD-related pleural effusion (proved by pleural fluid analysis), and PD was consequently discontinued. Hypotension developed in 2 patients of the CAPD group and 1 of the CCPD group during the first 2 weeks. In the CCPD group, 1 patient presented with lower limb edema and mild fluid overload. Overall, PD patients that opted to fast during Ramadan did not experience any serious morbidity or deterioration in renal function during their period of observance. No biochemical parameters or clearance studies showed a statistically significant p value. CONCLUSIONS: In view of the study findings, we conclude that most stable patients on PD can fast, provided that they strictly adhere to their medications and dialysis therapy in addition to the dietary restrictions. These patients should be followed closely to detect any complications and to ensure that adequate fluid and electrolyte balance are maintained.

Cytomegalovirus disease in a renal transplant recipient: the importance of pre-transplant screening of the donor and recipient.

A 16-year-old female patient who was born with a single kidney developed chronic kidney disease during her early childhood due to reflux nephropathy and recurrent urinary tract infection. She progressed to end-stage renal disease (ESRD) and was commenced on renal replacement therapy in the form of peritoneal dialysis in May 2011. Subsequently, she underwent living unrelated donor kidney transplantation in China. She was hospitalized soon after returning to Saudi Arabia for management of high-grade fever, shortness of breath, and deterioration of renal function, which was found to be due to cytomegalovirus (CMV) disease, proved by kidney biopsy and presence of high level of anti-CMV immunoglobulins. Allograft biopsy showed mature viral particles sized between 120 and 149 nm in the nuclei of the glomerular endothelial cells. The patient was treated with valgancyclovir and specific CMV immunoglobulin, as well as by reducing and even stopping the dose of tacrolimus and mycophenolate. Despite all these measures, her condition continued to deteriorate and she finally died. Our study emphasizes that unrelated renal transplantation, especially if unplanned and improperly prepared, is a very risky procedure that might transfer dangerous diseases and increase the morbidity and mortality of the patients. We strongly stress the need for mandatory and proper screening for CMV carrier status among donors as well as recipients prior to transplantation. Also, a recommendation is made to reject CMV-positive donors.

Effects of concomitant hepatitis C virus infection in patients with underlying lupus nephritis on long-term renal outcome.

BACKGROUND: Despite recent advances in the management of lupus nephritis (LN), these unfortunate patients are at a higher risk of developing chronic kidney disease (CKD). Concomitant chronic hepatitis C virus (HCV) infection is associated with adverse outcome in patients with LN and further compounds the risk as some of these patients choose to undergo kidney transplantation in the near future. Objectives. The aim of the present study is to evaluate the long-term impact of chronic HCV infection in patients with underlying Class IV LN on renal function, progression to end-stage renal disease (ESRD) and patient survival. METHODS: Retrospective analysis of the medical records of 134 nondialysis-dependent patients with biopsy-proven World Health Organization Class IV LN with chronic HCV infection was done from January 1995 to January 2008 at King Khalid University Hospital, Riyadh, Saudi Arabia. Primary and the secondary end points were death or the development of ESRD. The patients were followed over a period of 6.7 ± 3.3 (1-14.4) years. RESULTS: From a total of 134 biopsy-proven Class IV LN patients, 15 (11.2%) patients were HCV positive of which 2 (13.3%) patients were male and 13 (86.7%) patients were female. One hundred and nineteen (88.8%) patients were HCV negative of which 17 (14.3%) were male and 102 (85.7%) were female. The mean age was 32.47 ± 11.8 years. Eight (53.3%) patients in the HCV-positive group versus 19 (22.6%) patients in the HCV-negative group progressed to severe renal impairment with serum creatinine >350 µmol/L (P = 0.024). A total of 8 (53.3%) patients in the HCV-positive group versus 18 (17.3%) in HCV-negative group progressed to ESRD (P = 0.005). The mean creatinine clearance was higher (43.3 ± 33 mL/min) in the HCV-negative LN group at last follow-up than in the HCV-positive patients (25 ± 34.9 mL/min) with a statistically significant P-value of 0.0463. Five patients (33.3%) with HCV-positive LN died in comparison to eight (7.6%) patients who were HCV negative P = 0.03; however, the cause of hospital mortality was mainly cardiovascular disease (CVD) and infection and none of the patients died of chronic liver disease, although there was significant deterioration of the liver function at the end of the study. Kaplan-Meier survival estimates showed a significantly inferior renal function and rapid deterioration to ESRD in LN patients with concomitant HCV infection, with a dialysis free survival of 95 and 80% for the HCV-negative group and 90 and 65% for the HCV-positive groups at the end of 5 and 10 years respectively, with a highly significant P-value of <0.05 at the end of 10 years. CONCLUSION: The present study highlights that concomitant HCV infection in patients with LN is associated with worse renal outcome, higher rate of progression to ESRD and reduced patient survival.

Comparison of high and low dose of cyclophosphamide in lupus nephritis patients: a long-term randomized controlled trial.

To evaluate the outcome of low doses of cyclophosphamide (Cyclo) therapy in lupus nephritis (LN) patients, we studied 117 biopsy-proven, de novo LN WHO class IV patients double-blinded and randomized in December 1997 to receive Cyclo in different doses; Group I (n=73) received Cyclo 10 mg/kg monthly for six months then every two months for 12 months. Group II (n=44) received Cyclo 5 mg/kg monthly for six months then every two months for 36 months. The patients were followed-up till January 2007. Six months post-induction values for creatinine clearance were significantly higher in Group I (67.7 ± 28.6 mL/min) compared with Group II (55.1 ± 30.1 mL/min), P = 0.026. Serum C4 and ANA were not significantly different between the groups (P > 0.05). At the mean follow-up of 6.77 ± 3.3 years, the mean creatinine clearance was 44.74 ± 31.7 mL/min in Group I vs. 49.3 ± 38.8 in Group II. Urinary protein was 1.65 ± 1.8 g/dL in Group I vs. 1.02 ± 1.01 in Group II (P = 0.03). The survival curve showed that kidney survival overtime was comparable in both groups (P = 0.2). Complete remission was observed in 25 (34.2%) patients in Group I vs. 11 (25%) in Group II (P = 0.288), while partial remission was similar in both groups; 43 (58.9%) patients in Group I vs. 26 (59%) patients in Group II. End-stage renal disease was observed in 10 (13.7%) patients in Group I vs. 9 (20.4%) patients in Group II (P = 0.359). Side-effects were more frequent in Group I patients than in Group II patients; gonadal toxicity and malignancy were lower in Group II patients (P = 0.0000). Moreover, different infections occurred in 23 (31.3%) patients vs. six (13.6%), digital infarcts occurred in 1.35% vs. 0%, diabetes in 4.1% vs. 2.27%, and vasculitis in 4.1% vs. 2.27% in Group I vs. Group II, respectively. Sustained amenorrhea without pregnancy was observed in both groups; however, significantly more in Group I patients, P ≤ 0.05. We conclude that low-dose Cyclo therapy is sufficiently effective for WHO class IV LN patients with lower side-effects compared with standard dose.

Dyslipidemia in dialysis patients.

In order to evaluate the lipid profiles of dialysis patients, we retrospectively reviewed all the chronic kidney disease (CKD) patients on chronic hemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD), followed up between June 2004 and May 2005, in two tertiary hospitals in Riyadh, Saudi Arabia. There were 380 patients including 206 (54.2%) females and the mean age of the patients was 45.9 ± 15.8 years. The mean dialysis duration was 65.0 ± 58.3 months. Diabetes was present in 97 (25.5%) of the patients and hypertension in 84 (22.1%). Younger patients had more disturbed lipid profile than elderly patients, and females had higher lipid values than males. The CAPD patients had worse lipid profile than those on HD, irrespective of age, sex and duration of dialysis. The presence of diabetes, hypertension, smoking and cardiovascular disease (CVD) all contributed to the worsening of lipid profiles of our patients. Dialysis patients showed improvement in lipid profile initially followed by gradual deterioration. We conclude that dyslipidemia, which increases the risk of CVD by increasing atherogenesis, progresses over time in dialysis patients and becomes worse in CAPD patients.

Effect of chronic viral hepatitis on graft survival in Saudi renal transplant patients.

BACKGROUND: In Saudi Arabia the prevalence of hepatitis C among hemodialysis patients is very high ranging from 60 to 80%. A large number of these dialysis patients go for renal transplant, resulting into a higher prevalence of hepatitis C virus (HCV) infection in renal transplant patients. Yet no current systematic report is available on the influence of hepatitis C status on patient and graft survival. The present study was therefore undertaken to address this objective. METHODS: Retrospective analysis of data of 448 renal transplantation subjects was undertaken. The mean follow-up period was 5.85 +/- 2.7 (median 5.3) years. The factors associated with renal graft survival were reviewed and these include: age, sex, and type of donor, immunosuppressive medication, episodes of infection, blood pressure, serum creatinine, and status of hepatitis. The primary end-points were renal graft function and patient survival. Logistic regression, COX regression analysis, and Kaplan-Meier survival estimates were used to evaluate the influence of hepatitis C on the above parameters. RESULTS: Among 448 recipients of first kidney transplant patients, 286 (63.8%) were positive for HCV infection. In the HCV-positive group, 204 (71.32%) were males. Kaplan-Meier survival analysis showed a significantly better graft survival for HCV-negative patients than HCV-positive patients (p < 0.001; log-rank test). Logistic regression analysis and COX regression analysis have shown different grades of graft dysfunction were present in HCV-positive patients after adjustment for covariates: age, sex, blood pressure, type of donor, and immunosuppressive medication; the presence of HCV was a major predictor of bad outcome and significantly influenced graft survival (odds ratio = 4.37; 95% Cl = 1.81-4.77). Significant deterioration of liver function was noted in HCV-positive patients at the last follow-up, taking ALT as a marker (ALT level 80.6 +/- 5.8 U/l at the last follow-up versus 49.5 +/- 32 U/l at baseline p < or = 0.0001). Sixteen patients had a chronic active course and 1 patient developed biopsy-proven liver cirrhosis and portal hypertension. A serious and significantly greater incidence of fatal chest infections was seen in HCV-positive patients. Although mortality was greater in HCV-positive versus HCV-negative patients (20 vs. 7), the difference did not attain statistical significance (p = 0.23) and none of the patients died as a result of hepatic failure. CONCLUSION: The presence of HCV infection greatly influenced graft survival in renal transplant patients and a higher proportion of infected patients had renal and hepatic dysfunction. A significant increase in fatal chest infections was noted in HCV-positive patients. Overall mortality was higher in HCV-positive patients, but it was not statistically significant. All measures should be taken to prevent HCV transmission in the dialysis population. Renal transplant recipients with HCV infection need close monitoring for both graft and liver function.

Complications of CAPD: A Single Center Experience.

To evaluate the complications of CAPD and their contributing factors in order to improve the patients' survival and reduce morbidity and mortality, we studied records of 65 CAPD patients treated at our hospital from October 1996 to January 2002. There were 32 (49%) males and the mean age of the patients was 48 +/- 16 years. All the patients were on the twin bag CAPD system. The mean duration of follow-up on CAPD was 29 +/- 20 months. There were 75 episodes of complications occurring in the patients with a rate of 0.41 episodes/patient years. Peritonitis was the most frequent and serious complication accounting for 55 episodes with a rate of 0.35 episodes/patient years. Only 51% of the episodes showed positive culture; the organisms included Staphylococcus epidermidis (18.2%), Staphylococcus aureus (3.6%), Pseudomonas (16.4%), E. coli (1.8%), Azadobacter (5.45%) and Serratia (3.6%). All the episodes of infection, except one, responded to treatment but 10 patients had recurrent infection; one patient was cured only after removal of the catheter. There were 12 exit site infection episodes and five catheters were removed due to mechanical and infectious reasons. Three patients were switched to hemodialysis (HD), nine patients were transplanted and 11 patients expired; none died due to peritonitis. We conclude that the mortality rate of the complications on CAPD has declined in the present study compared to our previous report early in the 1990s due mostly to the adoption of the twin bag CAPD system.

Plasma fibrinogen and its correlates in adult Saudi population.

OBJECTIVE: To determine plasma fibrinogen and its correlates in the adult Saudi population and to investigate hyperfibrinogenemia as a possible risk factor for cardiovascular diseases (CVD). METHODS: A cross-sectional survey was designed and carried out through multi-stage stratified cluster random sampling of every third house in 6 heterogeneously populated districts of Riyadh, Kingdom of Saudi Arabia, during the period 1999 to 2002. Demographic and clinical data of 2263 adult Saudi subjects, consisting of 1934 (85.5%) men and 329 (14.5%) women, was collected through a standard questionnaire. Body mass index (BMI), blood pressure (BP) and history of smoking were recorded. Plasma fibrinogen, total serum cholesterol, triglycerides, high density lipoproteins (HDL) and blood sugar were determined in fasting blood samples. RESULTS: The majority (84.6%) of the subjects were between 20-50 years of age. The mean plasma fibrinogen was 336 +/- 115 mg/dl, and was increasing with age both in men and women. The mean +/- SD fibrinogen in women (357 +/- 118 mg/dl) was significantly higher (p value of 0.03) than men (332 +/- 114 mg/dl). Hyperfibrinogenemia (>400 mg/dl) was indicated in 554 (24.6%) of the total subjects. Among hyperfibrinogenemic Saudi adults, the prevalence of hypercholesterolemia was 14.3%, hypertriglyceridemia 24%, obesity 26.3%, systolic/diastolic hypertension 11.5% and 11% and hyperglycemia 26% (in women only). A reciprocal relation was observed between HDL and plasm fibrinogen. Significant positive correlation was seen between fibrinogen and BMI, systolic and diastolic BP and total cholesterol. There was no significant difference in the distribution of plasma fibrinogen between smokers and non-smokers (p value of 0.864). The difference in the magnitude of metabolic as well as modifiable CVD risk factors between smokers and non-smokers was not significant, except serum triglyceride which was significantly higher in smokers than non-smokers (p value of 0.020). CONCLUSION: A significant positive correlation was observed between hyperfibrinogenemia and obesity, systolic/diastolic hypertension and hypercholesterolemia. Our results thus support the earlier reports that hyperfibrinogenemia is a potential CVD risk factor. Unlike other reports, we could not find any correlation between smoking and plasma fibrinogen in our studied subjects. The value of hyperfibrinogenemia as a definite risk factor for CVD has to be quantified in future case-control studies comparing its significance between CVD subjects and normal controls.

Spectrum and outcome of primary glomerulonephritis.

Glomerulonephritis (GN) is a major cause of chronic renal failure (CRF). To evaluate the trends and outcome with modern improved treatment strategies, we retrospectively reviewed the clinical records of 120 patients with biopsy proven primary GN at our center from January 1990 to June 2001. All the biopsy specimens were subjected to light, electron and immunofluorescent microscopy. The recorded clinical parameters included the presenting symptoms, blood pressure readings, complete blood count, urinalysis, 24-hr urinary protein excretion, creatinine clearance besides rendered therapy and the outcome. Focal segmental glomerulosclerosis was the most common GN and accounted for 56 (47.6%) cases. The frequency of other GN cases in our study included IgA GN in 21 (17.5%) patients, membranous GN in 20 (16.7%), minimal change disease (MCD) in 13 (10.8%), membranoproliferative GN in 4 (3.3%), post infection in 4 (3.3%) and rapidly progressive glomerulonephritis (RPGN) in 2 (1.7%). The type of nephropathy had great influence on outcome and response to therapy. The deterioration of patients with FSGS was the fastest of the glomerulopathies, and nine (16.1%) patients developed end-stage renal failure (ESRD). MCD and post infection GN had the best outcome. Corticosteroids alone along with supportive medication conferred good results in MCD, while combined therapies of mycophenolate mofetil (MMF) and/or cyclophosphamide with corticosteroids provided better outcomes in the rest of the GN. RPGN responded well to the cyclophosphamide and the patients did not develop ESRD. Hyperuricemia, high serum creatinine and hypertension predicted worse outcomes. The control of blood pressure and glucose, and treatment of hyperuricemia and hypoalbuminemia had salutary effect on the outcome. We conclude that due to the better delivered care the outcome of primary GN has improved over the years. However, FSGS is still the most frequently encountered primary GN and has the worst outcome. In the present study, combined therapies with corticosteroids and cytotoxic drugs and supportive therapy were associated with better outcome.

Hepatitis C virus seroprevalence rate among Saudis.

OBJECTIVE: The aim of the study is to determine the seroprevalence of hepatitis C virus (HCV) in blood donors, children, pregnant women, hemodialysis patients and drug addicts in Saudi Arabia. METHODS: Using third generation enzyme immunoassay kits, we have screened Saudi cohorts of all ages and sexes, namely infants, pre-school, school children, young adults and adults (blood donors and antenatals) for antibodies to HCV. We have also reviewed HCV seroprevalence data among high risk groups from 1998 to 2002. RESULTS: An overall 1.1% (6313 out of 557813) seroprevalence rate was determined among Saudi blood donors; 0.1% (5 out of 3854) in Saudi children; and 0.7% (22 out of 3127) among pregnant women. Hemodialysis patients remain at highest risk of infection at 55.7% whereas intravenous drug addicts have 14% exposure rate. CONCLUSION: We conclude that the present public health schemes have been effective in reducing hepatitis C infection in the general community in the Kingdom of Saudi Arabia but the infection among high risk groups remain a major problem that needs to be actively addressed.

Morbidity and mortality in ESRD patients on dialysis.

End-stage renal disease (ESRD), due to its high morbidity and mortality as well as social and financial implications, is a major public health problem. Outcome depends not only on different modalities of treatment like hemodialysis and peritoneal dialysis, but also on existing co-morbidities, age, duration on dialysis, supportive therapies and infection control strategies. Thus, a detailed study becomes necessary to improve health care delivery, provide medical care and to establish a geographical reference. The present study was undertaken to characterize the ESRD patients by their demographic and co-morbid conditions and relate this to the morbidity and mortality trends. The medical records of 110 ESRD patients seen over a five-year period (June 1995 to December 1999) in two tertiary-care hospitals in Riyadh, Saudi Arabia were studied retrospectively. There were 79 (64.5%) males and 31 (35.5%) females; their age ranged from 17 to 92 years (mean age 53.8 +/- 17.8 years). Diabetes was the commonest cause of ESRD seen in 26 (26.6%) followed by nephrosclerosis, unknown etiology, lupus nephritis, pyelonephritis and primary glomerulonephritis. Diabetes mellitus was the most prevalent co-morbidity seen during the study period and occurred in 65 patients (59%) followed by heart disease in 36 (32.7%), liver disease in 30 (27.3%), cerebrovascular accidents in 13 (11.8%) and neoplasm in 11 (10%). Seven (6.3%) patients only were smokers. Hemodialysis was the most frequent treatment choice as renal replacement therapy. Among the causes of hospitalization, cardiovascular conditions were the leading single cause (19.1%), followed by access related reasons and infections (11.5% each). The overall hospitalization rate was 11.2 days/year. The overall mortality rate was 8.07 deaths/year. The leading cause of death was cardiovascular in 15 (51.7%) followed by unknown/sudden death in eight (27.5%). Other causes of death included fluid overload, gastrointestinal hemorrhage, septicemia, liver disease and pulmonary embolism. Diabetes was the commonest co-morbid cause among the deceased. Old age, diabetes mellitus, prolonged duration on dialysis and cardiac diseases were the common causes of mortality. Our findings are consistent with worldwide reports. The study provides a reference data and will hopefully be helpful in improving the medical care.

Transverse myelitis in a patient with severe lupus nephritis: a case report.

We report here a case of severe lupus nephritis, Raynaud's phenomenon, digital gangrene and optic neuritis who, developed acute transverse myelitis (ATM). SLE can present virtually with any complication in the central nervous system (CNS) and ATM is a rare but serious manifestation. It is noteworthy that ATM developed in this patient while she was on intravenous cyclophosphamide (IVC) therapy having already finished six doses of monthly infusions of 10 mg/kg body weight. The patient responded well to methyl-prednisolone pulse therapy, IVC and plasmapheresis. She recovered fully and is doing well after nine months of follow-up.

Single Center Experience with Pre-dialysis Patients.

The objective of this study was to evaluate the effect of the management of factors accelerating renal injury such as hypertension and diabetes on progression of chronic renal failure (CRF). For this end, the records of 112 CRF patients with serum creatinine (SCr) level of 150- 850 micromol/L were retrospectively studied at King Khaled University Hospital in Riyadh, Saudi Arabia. The leading causes of CRF in the study patients were diabetes in 52 (46.4%) patients, glomerulonephritis in 25 (22.4%) and hypertension in 17 (15.2%). Progressive elevation of SCr level was recorded at 92 micromol/L/year in 62 (55.4%) patients with initial SCr level of 150-300 micromol/L; they progressed to end stage renal disease (ESRD) in a mean duration of 4 (1/2) years. Forty-three (38.4%) patients with SCr level of 300-450 micromol/L had an increase of SCr at 136 micromol/L/year and progressed to ESRD in a mean period of four years. Seven (6.2%) patients who had initial SCr level of > 450 micromol/L had an increase of 136 micromol/L/year and progressed to ESRD in a mean duration of 2 (1/2) years. Sixty-two (55.4%) patients had initial blood pressure (BP) readings above the recommended level of 130/80 mm Hg. Antihypertensive management stabilized 47 (75.8%) of these patients using multiple drug regimens such as an angiotensin converting enzyme (ACE) inhibitor and diuretics (20.5%). Though this center did not use erythropoietin (EPO) in these patients, the control of the levels of hemoglobin and hematocrit was obtained by aggressive iron supplementation including intravenous administration. In conclusion, the present management of CRF patients, which attempts to comply with the international standards, still needs refining in order to reach better outcome.