High prevalence of and risk factors for hepatitis C in haemodialysis patients in Saudi Arabia: a need for new dialysis strategies

Non-A, non-B is a major form of hepatitis in haemodialysis (HD)patients. Hepatitis C virus (HCV) has been recently identifiedas the leading cause of non-A, non-B hepatitis in HD. A variableprevalence of hepatitis in HD has appeared in the literature,ranging between 1% and 29% in the Western world, and between30% and 54% in Saudi Arabia, but all these reports used first-generationELISA. Using second-generation enzyme immunoassay, we conducteda multi-centre study involving 22 HD centres all over SaudiArabia in order to establish the prevalence and risk factorsfor HCV in HD patients in Saudi Arabia. A total of 1147 patientswere studied, with a mean age of 43.4±15.3 years. Fivehundred and eighty were males and 567 were females. The overallprevalence rate of positive anti-HCV was 68%, with a range fromas low as 14.5%, to 94.7%. To our knowledge, this is the highestvalue reported among dialysis patients world-wide. A positivecorrelation was found between anti-HCV positivity and male sex(P=0.005), longer duration on dialysis (P=0.002) and blood transfusion(P=0.003). However, interestingly 62.6% of the patients whohad not had blood transfusion had anti-HCV antibodies. HCV antibodieswere also found more frequently in Egyptians, Pakistanis andYemenis than in Saudis. A comparison between those centres withlow prevalence of positive HCV and those with high prevalenceregarding risk factors was carried out, and it was found thatthe major difference between them was the adherence of the staffto universal infection precautions. In conclusion, HCV is amajor health problem in HD patients in Saudi Arabia. Identifiablerisk factors are longer duration in dialysis, blood transfusion,male sex, nationality and most importantly the lack of adherenceto universal infection precautions.     

Serum ionic fluoride levels in haemodialysis and continuous ambulatory peritoneal dialysis patients

High serum fluoride (F-) in patients with chronic renal failure (CRF) and end-stage renal disease (ESRD) is associated with risk of renal osteodystrophy and other bone changes. This study was done to determine F- in normal healthy controls and patients with ESRD on haemodialysis (HD) or peritoneal dialysis (PD). Seventeen healthy controls (12 males, 5 females) and 39 ESRD patients on dialysis (17 males, 22 females) were recruited in the study in a community with 47.4 +/- 3.28 microM/l (range 44-51 microM/l) of F- content in drinking water. Control subjects showed a mean serum F- concentration of 1.08 +/- 0.350 microM/l. Males in control group showed slightly higher F- levels (1.15 +/- 0.334, range 0.55-1.9 microM/l) than females (0.92 +/- 0.370, range 0.6-1.5 microM/l). Mean serum F- concentration did not correlate significantly with age and sex among control subjects, whereas such correlation was observed in patients with ESRD on dialysis. Mean serum F- concentration was significantly higher in patients on dialysis (2.67 +/- 1.09, range 0.8-5.2 microM/l) than normal controls. When grouped according to sex, the mean serum F- concentration in males (3.05 +/- 1.04, range 1.8-5.2 microM/l) was significantly higher than females (2.38 +/- 1.08, range 0.8-5.2 microM/l). When patients were grouped according to age, it was observed that F- concentration was significantly higher in patients with age groups 21-70 (2.86 +/- 1.05) than those with age group 13-20 years (1.42 +/- 0.531). Thus F- concentration correlated with age and sex, being higher in males and above 20 years. Despite appreciable clearance of F- (39-90%) across the peritoneum, patients on CAPD showed higher serum F- concentration than those on HD (3.1 +/- 1.97 vs 2.5 +/- 1.137 microM/l). Of the total 39 patients on dialysis 39% had their serum F- concentration above 3.0 microM/l, posing the risk of renal osteodystrophy.      

Sustained virological and histological response with pretransplant interferon therapy in renal transplant patients with chronic viral hepatitis C.

Patients who are anti-HCV positive before renal transplantation (Tx) have a significantly increased risk of posttransplant liver disease. We conducted a prospective, controlled study to evaluate the posttransplant outcome of renal graft candidates with HCV-associated chronic hepatitis (n = 30). Patients were randomly assigned to either of two groups. All patients on enrollment underwent liver biopsy, which showed mild-to-moderate hepatitis activity (mean 4.1, range 2-6). Half the patients received interferon-alpha (IFN-a) administered at a dosage of 3 million units three times weekly for 1 year. Liver biopsy was repeated for treated patients at the end of IFN-a treatment. Of these, 11 patients received renal transplant (group A). The other half did not receive IFN-a and to date 10 patients have been transplanted (group B). Renal transplant recipients were prospectively followed for a period of 12 months and a follow-up liver biopsy was also done at the end of this period (end of study). Biochemical and virological responses were evaluated and the histologic activity index (HAI) scoring according to Knodell was assessed. The mean pretreatment serum HCV RNA level was 1.14 +/- 0.84 and 1.0 +/- 0.89 mEq/ml for groups A and B, respectively (bDNA assay sensitivity threshold is <0.2 mEq/ml). HCV RNA became undetectable in 4 patients of group A. At the end of study period the mean quantitative HCV RNA titers were 1.43 +/- 4.07 and 15.18 +/- 11.08 mEq/ml in groups A and B, respectively (p < 0.0001). In group A, the mean HAI score decreased from 4.27 +/- 1.19 to 1.64 +/- 0.67 after IFN-a treatment (p < 0.0001). This score was maintained till the end of the study period with a mean of 1.82 +/- 0.6. Mean HAI score of group B on enrollment was 3.9 +/- 1.2 and at the end of study increased to 5.5 +/- 1.35 (p = 0.01). There was statistically significant difference (p value less than 0.0001) between the HAI scores at the end of the study period between the two groups. These results demonstrate that interferon therapy while on dialysis is associated with less viremia and decreased progression of chronic liver disease in renal transplant patients with hepatitis C.     

Pattern of renal osteodystrophy in haemodialysis patients in Saudi Arabia

In order to know the pattern of renal osteodystrophy in haemodialysispatients in Saudi Arabia we conducted a multicentre study involving209 patients. The mean age of the patients was 39.4±14(18–70) years, 128 were males and 81 females. All patientswere on acetate dialysate and their mean duration on dialysiswas 3.5 ± 1.5 years. The major symptom was bone and joint pain (25.8%). The meanserum calcium was 2.1 ±0.26 mmol/l, phosphorus 2.0 ±0.36mmol/l, alkaline phosphatase 19.7± 14.6 u/l and parathyroidhormone level was 8.9 ± 3.9mg/ml. The mean serum aluminium(AL) level was 25.4±17.7 µg/l, while that of 1,25vitamin D3 was 8.1±4.2ng/l and of fluoride was 92.2 ±31.4 µg/l. The major radiological finding was osteosclerosis(70%). Dual-photon absorptiometry (DPA) showed low bone mineraldensity (LBM) in 65% of the patients. Forty-one patients had bone biopsies with AL staining of thebiopsies. Of this group, 92% had changes of hyperparathyroidismand 66% of them were pure hyperparathyroidism. Sixty percentof them had variable degrees of AL intoxication. The radiologicalskeletal survey of those patients could detect abnormalitiesin only 46% while 70% of them had abnormal bone mineral density(BMD). In conclusion, osteosclerosis is the commonest radiologicalfinding in our dialysis patients while secondary hyperparathyroidismis the main histopathological diagnosis in bone biopsy, evenin patients with normal skeletal survey. AL intoxication isa significant problem in our population. DPA is more sensitivein detecting bone abnormalities than X-radiography.     

Correlation between skeletal maturation and developmental stages of canines and third molars among Saudi subjects

Aims

The present study was designed to evaluate the efficacy of using the developmental stages of the canines and third molars to predict the timing of skeletal maturity in the Saudi population.

Effect of vitamin-E-modified dialysers on dialyser clotting, erythropoietin and heparin dosage: a comparative crossover study

We performed a crossover study to compare the effects of different dialysis membranes on 20 patients with frequent dialyser clotting and requiring > or = 5,000 units of heparin per dialysis session. Low-flux dialysers are C15NL (cellulose - Terumo) and E15NL (vitamin-E-coated - Terumo) while high-flux dialysers were F60 (polysulphone) and EE15NL (vitamin-E-coated - Terumo). Ten patients underwent dialysis for 2 months with C15NL then switched to E15NL for 2 months. Similarly, the other 10 patients were started on the high-flux dialyser F60 and then switched over to EE15NL for 2 months. The following parameters were measured at the beginning of the study, 2 weeks, 1 month and then at 2 months: hemoglobin, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, protein C, protein S, antithrombin III (ATIII) and factor 12 activity. Dialyser clotting, heparin and erythropoietin requirements were assessed during each dialysis session. There was a significant reduction in clotting with E15NL in comparison to C15NL (22.8 +/- 17 and 44.1 +/- 22.8 (p = 0.0233), respectively). Similarly, heparin requirements were less in the vitamin-E-coated (E15NL) dialysers, 4, 754 +/- 1,427 vs. 6,011 +/- 856 units (p = 0.0281) and erythropoietin usage was also significantly reduced, 4,630 +/- 2,620 vs. 7,850 +/- 4,069 units (p = 0.049). There was a significant increase in hemoglobin with E15NL compared to C15NL, 115 +/- 10.4 vs. 108 +/- 13.1 (p = 0.0343). When the high-flux dialysers were compared there was a tendency towards less dialyser clotting with the EE15NL compared to F60, though this did not achieve statistical significance (p = 0.0561). We could not demonstrate any significant changes between the different dialysers with regards to PT, PTT, fibrinogen factor 12 activity, protein C, protein S and ATIII. In conclusion, we have shown that the use of vitamin-E-modified dialysers is associated with less clotting in patients with persistent clotting problems. In addition, this was associated with less heparin and erythropoietin requirements.     

Comparison of the effects of three haemodialysis membranes on vancomycin disposition

Polysulfone (PSF) and polyacrylonitrile (PAN) were recently introduced haemodialysis (HD) membranes. The effect of each on vancomycin disposition was compared with cuprophan (SCE) in 12 chronic HD patients who received 14 infusions. Vancomycin (1 g) was infused over 1 hour, followed by three 4-hour HD sessions over 5 days, beginning 1 hour after the end of infusion. The intradialytic clearances of vancomycin were 73, 54 and 15 ml/min for PSF, PAN and SCE, respectively. At the end of the third HD session, vancomycin concentration dropped to subtherapeutic level (<7.5 μg/ml) only in patients dialysed with PSF and PAN. The corresponding elimination half-lives (t_1/2β) were 61, 60 and 86 hours for the three membranes, respectively. According to these findings, vancomycin should be given every three HD sessions for PSF and PAN. The dosage interval should be extended up to every 5 HD sessions for patients on SCE. The peak (mean±S.D.) obtained one hour after the end of infusion was 34.2±11.4 μg/ml, which is within the therapeutic range.     

Percutaneous needle biopsy of the transplanted kidney: technique and complications

Over 11 1/2 years, 420 percutaneous needle biopsies were obtained from the transplanted kidneys of 205 patients at one institution. The procedure was performed by one nephrologist and 55 nephrology trainees. No limit was placed on the number of biopsies performed on one kidney, and the highest number was seven. The complications were macroscopic hematuria in 28 biopsies, prolonged hematuria (greater than 24 hours) in eight, transient anuria in five, and prolonged anuria requiring surgical intervention in one. Perinephric hematoma occurred in three patients; retroperitoneal hematoma led to compression of the iliac vein in one. None of these complications led to loss of the transplant. It is suggested that the freedom from serious complication is related to the safety of the technique and the precautions applied to preparation of the patient. These are described in detail.