Hypertensive Encephalopathy and Renal Failure in a Young Man

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Concomitant macro and microvascular complications in diabetic nephropathy

To determine the prevalence of concomitant microvascular and macrovascular complica-tions of diabetic nephropathy we retrospectively reviewed the medical records of all 1,952 type 2 dia-betic patients followed-up at Security Forces Hospital, Riyadh, Saudi Arabia from January 1989 to December 2004. There were 626 (32.1%) patients (294 (47%) were males) who developed diabetic nephropathy. Their mean age was 66.9 ± 11.4 years, mean duration of diabetes was 15.4 ± 7.5 years, mean age at the onset of nephropathy was 61.5 ± 12.4 years, and mean duration of nephropathy was 3.9 ± 3.8 years. Concomitant diabetic complications included cataract (38.2%), acute coronary syndrome (36.1%), peripheral neuropathy (24.9%), myocardial infarction (24.1%), background retinopathy (22.4%), stroke (17.6%), proliferative retinopathy (11.7%), foot infection (7.3%), limb amputation (3.7%) and blindness (3%). Hypertension was documented in 577 (92.2%) patients, dyslipidemia in 266 (42.5%) and mortality from all causes in 86 (13.7%). There were 148 (23.6%) patients with one complication, 81 (12.9%) with two, 83 (13.3%) with three, and 61 (9.7%) with four or more. Dete-rioration of glomerular filtration rate was observed in 464 (74%) patients and doubling of serum creatinine in 250 (39.9%), while 95 (15.2%) developed end-stage renal disease (ESRD) at the end of study and 79 (12.6%) required dialysis. Complications were significantly more prevalent among males with greater number reaching ESRD level than females (P< 0.05). Relative risks of developing com-plications were significant after the onset of nephropathy; ACS (1.41), MI (1.49), stroke (1.48), diabetic foot (1.6), amputation (1.58) and death (1.93). We conclude that complications of diabetes are aggre-ssive and progressive including high prevalence of diabetic nephropathy. Careful monitoring and proper institution of management protocols should be implemented to identify diabetic patients at high risk for complications and mitigate progression into ESRD

Prevalence of vitamin D deficiency in peritoneal dialysis patients

Peritoneal dialysis (PD) patients have a high risk of developing vitamin D deficiency as 25(OH) vitamin D, the precursor of active vitamin D, is lost during dialysis. This crosssectional study was conducted to investigate the prevalence of vitamin D deficiency among adult Saudi patients on regular PD The data was collected in the summer of 2010 from patients who were on PD for more than six months at the King Khalid University Hospital, Riyadh. We recorded the demographic and clinical parameters for all patients. Blood samples were taken for serum vitamin D level (25 OH), serum parathyroid hormone (PTH) levels and other necessary biochemical parameters. There were 27 patients (11 males and 16 females) with a mean age of 46 (15-78 ± 21) years. Five patients were on continuous ambulatory PD and 22 patients were using automated PD. The average time on PD was 27.5 (6-84 ± 18.5) months. The mean serum vitamin D 25 (OH) level was 16.1 (4.9-41.5 ± 8.23) nmol/L. Sixteen (59.2%) of the patients had levels below 15 nmol/L, while another eight patients (29.6%) had vitamin D levels between 15 and 25 nmol/L, indicating a marked deficiency. The mean serum calcium was 2.2 (1.7-2.6 ± 0.2) mmol/L and the mean serum phosphorous was 1.48 (0.64-2.22 ± 0.37) mmol/L. Fifteen patients (55.5%) had significant hyperparathyroidism (serum PTH levels above 30 pmol/L). Majority of the PD patients in our center had vitamin D deficiency. The possible reasons include chronic renal failure, dietary restrictions, loss of vitamin D and decreased exposure to sunlight

Factors affecting the progression of diabetic nephropathy and its complications: A single-center experience in Saudi Arabia

<b>Background and Objectives:</b> One out of five Saudi diabetics develops end-stage renal disease (ESRD). Factors associated with progressive loss of renal function have not been extensively studied and reported in our community. We sought to evaluate the pattern and progression in glomerular filtration rate (GFR) and investigate the potential risk factors associated with progression to diabetic nephropathy (DN) among Saudi patients. <b>Design and Setting:</b> Hospital-based retrospective analysis of type 2 diabetic patients seen between January 1989 and January 2004 at Security Forces Hospital and King Saud University in Riyadh, Saudi Arabia. <b>Patients and Methods:</b> DN was defined as persistent proteinuria assessed by urine dipstick [at least twice for at least two consecutive years and/or serum creatinine &gt;130 &#956;mol/L; and/or GFR &lt;60 mL/min/1.73m ² ]. <b>Results:</b> Of 1952 files reviewed, 621 (31.8&#x0025;) met the criteria for DN, and 294 (47&#x0025;) were males. The mean (SD) age of the patients at baseline was 66.9 (11.4) years, and mean duration of diabetes was 15.4 (7.5) years. GFR deteriorated from a baseline value of 78.3 (30.3) mL/min/1.73m ² to 45.1 (24.1) mL/min/1.73m ² at the last visit, with a mean rate of decline in GFR of 3.3 mL/min/year. Progression of nephropathy was observed in 455 (73.3&#x0025;) patients, with 250 (40.3&#x0025;) patients doubling their first-hospital-visit serum creatinine level in a mean of 10.0 (6.0) years. At the end of the study, 16.5&#x0025; of the cohort developed ESRD and were dialyzed. GFR &gt;90 mL/min/1.73m ² at the first hospital visit; duration of diabetes &gt;10 years; persistent proteinuria; systolic blood pressure &gt;130 mm Hg; and presence of retinopathy were significant markers associated with progression of nephropathy. <b>Conclusion:</b> Diabetic nephropathy tends to be progressive among Saudis, with GFR deteriorating at a rate of 3.3 mL/year and with a doubling of serum creatinine level in 40.3&#x0025; of patients in 9.9 years

Appropriateness of anemia management in hemodialysis patients

AbstractThe anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration.AimsTo investigate current practice of anemia management in hemodialysis patients and to assess the appropriateness of anemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations.Settings and designThe study was conducted at two hemodialysis centers in Riyadh, Saudi Arabia. Data on anemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data were collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing hemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy.ResultsData were collected from 87 patients. Mean Hgb value for those patients was 11.16±0.97g/dL. Thirty-nine patients (45%) had mean Hgb values between 11.0 and 12.0g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099±5946IU/Week (135±99IU/kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693±420.5ng/mL. Fifty-two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5±19.7%. Conclusions: There is an opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron status

Appropriateness of Anaemia management in haemodialysis patients

The anemia of end stage renal disease (ESRD) is common and often severe complication that can be managed successfully by erythropoiesis-stimulating agents (ESA) administration. Aim: to investigate current practice of anaemia management in haemodialysis patients and to assess the appropriateness of anaemia management by comparing observed practice to the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommendations. Setting and design: The study was conducted at two haemodialysis centers in Riyadh, Saudi Arabia. Data on anaemia parameters, comorbidities, ESA dosing and iron supplementation were collected. The data was collected for 7 months retrospectively from April to the end of May 2008 and prospectively from June to October 2008. Patients who were over 18 years of age with ESRD undergoing haemodialysis were included. Patients were excluded if they have cancer or receiving chemotherapy or radiotherapy. Results: Data were collected for 87 patients. Mean Hgb value for those patients was 11.16± 0.97 g/dL. Thirty nine of patients (45%) had mean Hgb values between 11.0 and 12.0 g/dL the target range recommended by KDOQI guideline. The mean weekly prescribed dose of erythropoietin was 8099± 5946 IU/Week (135 ±99 IU/Kg/Week). Information on ferritin concentrations was available for 48 (55%) patients. The mean serum ferritin concentration for those patients was 693 ±420.5 ng/mL. Fifty two patients had transferrin saturation (TSAT) values recorded. The mean TSAT value was 38.5% ±19.7. Conclusions: there is opportunity to improve anemia management in hemodialysis patients particularly thorough evaluation of causes of inadequate response rate and better monitoring and management of iron statusKing Saud Universit

Outcome and complications in peritoneal dialysis patients: A five-year single center experience

Peritoneal dialysis (PD) is one of the modes of renal replacement therapy being utilized for the management of end-stage renal failure in King Khalid University Hospital, King Saud Uni-versity, Riyadh, for more than two decades. The aim of this study was to evaluate the complications related to PD as well as its outcome in patients on this mode of therapy during the period between January 2004 and December 2008. There were 72 patients included in the study, of whom 43 were females. The average age was 50.7 ± 30.1 years (14-88 years). Diabetes was the leading cause of end-stage renal disease (ESRD) seen in 40.2% of the study patients. Twenty-eight patients (38.9%) were on continuous ambulatory peritoneal dialysis (CAPD) and 44 (61.1%) were on automated PD (nocturnal intermittent peritoneal dialysis, NIPD or continuous cycler peritoneal dialysis, CCPD). The mean du-ration on PD of the study patients was 25.5 ± 16.58 months (1-60 months). The peritonitis rate was one episode per 24.51 patient-months or one episode per 2.04 patient-years. The incidence of peritonitis per person-year was calculated as 0.42. The leading causative agent for peritonitis was Staphylococcus (32%). Exit-site infection (ESI) rate was one episode per 56.21 patient-months. The incidence of ESI was 0.214 per person-years. The most common infective organism for ESI was Pseudomonas aeru-ginosa (58.8%). At the end of 5 years, 35 patients were continuing on PD, 13 patients were shifted to hemodialysis (HD), nine patients underwent renal transplantation, and six patients were transferred to other centers. Among the 13 patients who were shifted to HD, four patients had refractory peritonitis, four others had catheter malfunction, three patients had inadequate clearance on PD and two patients had lack of compliance. A total of 11 patients died during the study period, giving an overall mortality rate of 15.27% for the five-year period. Our study suggests that there has been considerable improvement in overall outcome and mortality in patients on PD. Additionally, a marked reduction in the infectious and non-infectious complications was noted with the peritonitis and ESI rates in our center being comparable to other studies and international guidelines

Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution

Background and Objectives: Because there is no recent update on the state of diabetes and its concomi--tant complications in Saudi Arabia , we undertook a study of the prevalence of health complications in patients with type 2 diabetes mellitus admitted to our institution. Methods: We conducted a retrospective review of medical records of adult Saudi patients with type 2 diabetes who were seen in clinics or admitted to the Security Forces Hospital , Riyadh , Saudi Arabia , between January 1989 and January 2004. Results: Of 1952 patients , 943 (48.3&#x0025;) were males. For the whole study population the mean age at enrollment was 58.4&#x00B1;14.2 years , the mean age at onset of diabetes was 48.1&#x00B1;12.8 years , the mean duration of diabetes was 10.4&#x00B1;7.5 years , and the mean duration of follow-up was 7.9&#x00B1;4.6 years. Nephropathy was the most prevalent complication , occurring in 626 patients (32.1&#x0025;). Acute coronary syndrome occurred in 451 (23 .1 &#x0025;), cataracts in 447 (22.9&#x0025;) , retinopathy in 326 (16.7&#x0025;) , and myocardial infarction in 279 (14.3&#x0025;) , Doubling of serum creatinine was seen in 250 (12.8&#x0025;) and 79 (4.0&#x0025;) went into dialysis. Hypertension was present in 1524 (78.1&#x0025;) and dyslipidemia in 764 (39.1&#x0025;). Overall mortality was 8.2&#x0025;. Multiple complications were frequent. Males had higher prevalence of complications than females (P&#60; .05). Mortality was significantly higher in males 92 (9.8&#x0025;) than females 69 (6.8&#x0025;) (P=.024). The prevalence of complications significantly increased with dura--tion of diabetes and age (P&#60; .05). Conclusion: Among Saudis, the prevalence of concomitant diabetic complications is high, with cardiovas--cular and renal complications the most frequent. Many patients had multiple complications. Early and frequent screenings in the patients with type 2 diabetes are desirable to identify patients at high risk for concomitant complications and to prevent disabilities