Survey of attitude of physicians on updates in the management of anemia in chronic kidney disease patients

We aimed in this study to assess the opinion of medical directors of dialysis centers in the Kingdom of Saudi Arabia (KSA) about updates of strategies for treatment of anemia in patients with chronic kidney disease (CKD). A questionnaire was sent to the medical directors of the 174 active dialysis centers in the KSA including centers under the Ministry of Health (MOH) (67 %), the governmental non-MOH sector (12%) and private hospitals (21 %) that together care for a population of more than 11,300 chronic dialysis patients. The study was performed between November 2008 and March 2009. A total of 143 of the 174 (82.1%) medical directors answered the questionnaire. This covered 9563 (84%) dialysis patients in the KSA. There were 95 (68.8%) respondents who believed that the mechanism of action of ESAs is due to both blood concentration and direct action on the stem cells that form red cells. Only 81 (57%) respondents believed that the half-life of the short-acting ESAs is less than one day, 67 (46.9%) believed the half-life of darbepoetin is 2-4 days, and 52 (36.6%) believed the half-life of CERA is 5-10 days; 79 (55.6%) respondents believed that the interval of dosing of darbepoetin is once biweekly, and 92 (71.9%) believed that the interval of dosing of CERA is once a month. There were 110 (76.9%) respondents who believed the CKD should receive a long-acting than short-acting ESAs for the more stable hemoglobin levels, 64 (44.8%) believed that pharmacodynamics of the CERA are better than other ESAs and warrant its use over all of them, and 115 (80.6%) believed that the target hemoglobin is 11-13 g/dL in CKD patients is well established. Finally, 65 (51.5%) respondents would request more than 30% of the stock of ESAs in the future as short-acting ESAs vs 71 (55%) for darbepoetin and 40 (37.4%) for CERA. There were no statistically significant differences among the respondents according to their affiliations (MOH, non MOH and private sector) on any of the issues in the questionnaire. We conclude that our results showed inadequate awareness of the medical directors of the dialysis centers in the KSA of the mechanisms of action of ESAs and the new agents such as the CERA. However, they were well informed about the limits of the targeted hemoglobin levels and showed a trend toward using the long-acting ESAs

Attitude of Physicians towards the Follow-up of Renal Transplant Patients: A Questionnaire Survey in Saudi Arabia

The goal of this study was to evaluate the attitude of the physicians towards the follow-up of the renal transplant patients in the Kingdom of Saudi Arabia (KSA). We sent a questionnaire to 168 physicians working in 148 active dialysis centers in the KSA. The study was conducted from June-October 2005. There were 140 physicians (83.3%) who answered the questionnaire; they represented 136 (91.9%) dialysis centers. There were 43 (31.2%) respondents who had a transplant clinic for follow-up of transplant recipients. Of the 96 (69.1%) who did not have a clinic, 29 (30.2%) claimed expertise for follow-up of transplant recipients, six (6.2%) had a laboratory set-up to monitor the immunosuppressive drug levels and 40 (44.4%) felt the need for one. There were 121 (89%) respondents who would consider the chronic renal failure (CRF) patients for transplantation because it is the best form of therapy. Seventy-seven respondents (55%) had a protocol for work-up of the CRF patients for transplantation, 31 (22.3%) had a coordinator for the work-up of the transplant candidates, 34 (24.5%) had regular meetings to decide on the waiting list for transplantation, and 51 (37.8%) had affiliation with, or worked at a transplant center. Nevertheless, 127 (90.7%) respondents believed that the results of renal transplantation were good enough to recommend the procedure to all patients as early as possible. There were 133 (97.1%) respondents who believed that organ shortage was the major factor for the low percentage of renal transplantation. Only 52 (37.1%) respondents knew about the recent regulations established by the World Health Organization (WHO) for organ donation. There were 63 (48.1%) respondents who believed that seeking commercial renal transplantation outside the KSA to be unacceptable because of the medical and ethical complications involved. Many respondents (71.4%) from non-MOH hospitals, and those who had transplant clinics believed that the tacrolimus + mycophenolate combination was the most popular immunosuppressive regimen for renal transplant patients. Our survey suggests that the current practices concerning the work-up and follow-up of transplant patients in the dialysis centers in the KSA require refinement in terms of the need to enforce the use of a protocol to guide evaluation and therapy in each dialysis unit

Dialysis Centers in the Kingdom of Saudi Arabia

To help future planning of the dialysis services in the different geographical regions and health sectors in Saudi Arabia, we surveyed its 130 active hemodialysis (HD) centers using a questionnaire about their manpower, hemodialysis equipment, as well as, peritoneal dialysis and transplant patients at the end of the year 2000. Almost all the dialysis centers were on hospital campus but of variable sizes with an average ratio of 14.8 dialysis machines per center (range 2-113 machines per center). The distribution of the dialysis centers according to the geographical regions of Saudi Arabia included 18(14%) in the northern, 25(19%) in the southern, 13(10%) in the eastern, 35(27%) in the western and 39(30%) in the central region. There was a total of 6,694 dialysis patients served on 1,918 hemodialysis machines. There were 1,793(93%) HD machines capable of performing bicarbonate dialysis. There was an average ratio of 3.5 patients per one HD machine. In addition to the hemodialysis, there were 28(22%) centers engaged in peritoneal dialysis (PD) and 56(43%) centers in the follow-up of post transplant patients. The total number of the nephrologists, regardless of their expertise was 212 of whom 180(84%) spoke Arabic; the average ratio was 32 patients per nephrologist (range of 14-58). There were 1320 hemodialysis nurses of whom only 465(35%) spoke Arabic. The average ratio of patients to nurses was five patients per nurse (range of 4-6). There were 72(55%) social workers and 70(54%)dietitians with average patients ratios to these supporting services of 1:93 patients (range of 1:58-137) and 1:96 patients (range of 1:53-137), respectively. The study HD patients had a mean age of 47.8 ± 17.1 years (range: 2-92 years); of them, 52.5% were males and 12% had non-Saudi nationality. Of the hemodialysis patients, 1,815(27%) were diabetics. The calculated net increase of dialysis population was 988 patients per year (14.8%). There were 5,700(85%) patients on regular bicarbonate dialysate. Chronic viral infection were noted in more than half of all the dialysis population: thus 3,380(50%) were positive for hepatitis C viral (HCV) serology, 448(7%) had positive hepatitis B (HBV) antigenemia and six(0.1%) had the human acquired immunodeficiency syndrome. In conclusion, our findings demonstrated a satisfactory advancement achieved in many Saudi dialysis centers in terms of equipment, personnel and patients′ care. However, there should be more emphasis in the future on quality care through better self-assessment of the performance of these centers

Chronic Kidney Disease of Unknown Etiology: A Single-center Cross-sectional Study

Globally, chronic kidney disease of unknown etiology (CKDu) has been recognized as an emerging cause contributing to the rise in chronic kidney disease (CKD). Nevertheless, in the Kingdom of Saudi Arabia, the epidemiology of CKDu remains understudied. The aim of this study was to assess the epidemiological, clinical, and laboratory characteristics of the CKDu population. From May 2021 to May 2022, a retrospective cross-sectional study was conducted on patients with Stage 4–5 CKD who presented to King Fahd Hospital in Jeddah. On the basis of the cause of CKD, patients were categorized into two groups: those with traditional risk factors for CKD (CKDt) and those without a recognizable cause of CKD (CKDu). Out of a total of 500 patients with Stage 4–5 CKD who were enrolled in the study, 100 patients were found to have CKDu. Compared with the 400 patients with CKDt, the patients in the CKDu group were younger (a mean age of 52.3 years vs. 66.1 years, P <0.001), with the majority in the middle age group of 40–65 years old (68% vs. 43%, P <0.001). They were predominantly males (72% vs. 56%, P = 0.003), with less hyperkalemia (4.29 vs. 5.13, P <0.043), and presented without a previous history of CKD (57% vs. 31%, P = 0.001). Among the 500 patients who were studied, 100 patients (20%) presented with CKDu who were predominantly younger males without a known history of CKD. Further studies on a nationwide scale are warranted

Darbepoetin Use for the Treatment of Anemia in Hemodialysis Patients in Saudi Arabia

Erythropoietin replacing proteins have improved patient outcomes and quality of life. Darbepoetin has a 3-fold longer half-life than recombinant human erythropoietin (rHuEPO). In this study, we investigate the efficacy and safety of the conversion of stable hemodialysis patients from the current short-acting r-HuEPO (EPO alfa or beta) to the long-acting darbepoetin. In addition, we verified the appropriateness of the current ratio of conversion of the short acting to the long-acting erythropoietin in an open label prospective multi-center study. The study design included 12 weeks darbepoetin administration. The conversion ratio was 200 IU of short acting r-HuEPO to 1 microgram of darbepoetin. We adjusted the dose of darbepoetin to maintain hemoglobin levels between 110-120 g/L. There were 33 patients who satisfied the entry criteria. The study was conducted from January-June, 2005. The study patients included 18 men and 15 women, the mean age was 50.4 &#x00B1; 12.3 years and the mean duration on HD was 323 &#x00B1; 51.9 days. There was a significant decrease in the mean dose of darbepoetin from 37.3 &#x00B1; 12.9 ug/week at week 1 of the study to 20.8 &#x00B1; 16.6 ug/week by the end of week 12 (p&lt; 0.00003) while the hemoglobin level was maintained within the previously defined range. The initial conversion ratio from short-acting erythropoietin to darbepoetin was 200 IU to 1 microgram. However, at the end of week 12, the mean dose of darbepoetin decreased to an equivalent conversion ratio to 361 IU: 1 microgram. This may reflect great savings in the cost of treatment. Our experience with darbepoetin reveals that darbepoetin is effective and safe for the treatment of anemia in hemodialysis patients and has a more convenient dosing schedule than short-acting erythropoietin. The darbepoetin dosage decreases over time and savings are expected to greater with darbepoetin more than with short-acting erythropoietin with time

The Effect of Vitamin E-Modified Dialyzers on Acute Intra-dialytic Symptoms: A Comparative Crossover Study

We performed a crossover study to compare the effect of vitamin E-modified dialyzers on acute intra-dialytic symptoms, with other membranes. Twenty patients on hemodialysis were studied. They were divided into two equal groups of low-flux (C15NL, E15NL) and high-flux (F60, EE15NL) membrane dialyzers. Within each group, a vitamin E-modified dialyzer was compared with another dialyzer in a crossover design over a two-month period. All study patients were seen during each dialysis session by a physician and the occurrence of intra-dialytic symptoms were recorded. There was a significant overall improvement in the incidence of acute intra-dialytic symptoms with the use of vitamin E-modified dialyzers as compared with the other membranes. This effect was more for cuprophane than polysulfone. The occurrence of hypotensive episodes did not differ. Our study indicates that we can achieve a reduction in the incidence of acute intra-dialytic symptoms with the use of vitamin E-modified membrane as compared to cuprophane and polysulfone

Initiation of darbepoetin for management of anemia in non-dialysis-dependent patients with chronic kidney disease

The anemia of chronic kidney disease (CKD) is a common comorbidity seen in kidney diseases. It is also associated with increased cardiovascular morbidity and mortality and diminished quality of life. Often, patients with CKD of different stages require erythropoiesis-stimulating agents (ESAs) to maintain their hemoglobin (Hb) within the target range. Darbepoetin alfa is a newer ESA with a longer half-life than recombinant human erythropoietin (EPO). The objective of this study is to assess the efficacy and safety profile of twice-monthly (Q2W) and once a month (1QM) darbepoetin alfa in CKD patients, not on dialysis. The secondary objective was to assess the appropriate dose conversion from EPO to darbepoetin. Patients with CKD not on dialysis, receiving darbepoetin alfa every other week, or once every month, and with stable Hb levels between 10 and 12 g/dL, were enrolled in this single-center, open-label, single-arm study. In this study, 36 patients (21 female, 15 male) were enrolled with a mean age of 46.4 ± 20.12 years. About 56% of the patients (n = 20) received darbepoetin alfa 40 μg Q2W for more than three months and 36% (n = 13) were on once-monthly doses, whereas the other 8% (n = 3) were on variable doses ranging from 20 to 60 μg every two weeks. More than 80% of the patients were converted from short-acting EPO to darbepoetin corresponding to a conversion ratio of 672.2 IU:1 μg (standard deviation = 488.5). Hb levels ≥10 g/dL were maintained in 77.78% of the patients. The safety profile of darbepoetin alfa in this study was recorded, and no significant adverse effects were noted. Our study suggests that darbepoetin alfa, administered in fixed small doses and frequency of Q2W or Q1M, maintained Hb levels ≥10 g/dL in patients with CKD, not on dialysis

Early clinical manifestations and laboratory findings before and after treatment of cytomegalovirus infection in kidney transplant patients

Cytomegalovirus (CMV) is one of the most frequently encountered opportunistic viral pathogens in kidney transplant recipients. In this study, we retrospectively reviewed all living related and unrelated kidney transplant recipients on regular follow-up from January 2006 to June 2015, who were suspected to have CMV clinically and confirmed by DNA polymerase chain reaction (PCR). CMV PCR was detected in 102 kidney transplant recipients. The median time of detection after kidney transplant was 21 months, ranging from 15 days to 84 months. There were 58 male and 44 female patients. The induction immunosuppression in living related kidney transplants was with antithymocyte globulin or basiliximab, whereas the most common maintenance immunosuppressive regimen was with cyclosporine, mycophenolate mofetil, and prednisolone. Most of the transplant recipients were asymptomatic at the time of detection of CMV PCR (67%). Fever, mainly low grade, was the main presentation in 16% of patients, followed by diarrhea (15%) and pneumonitis (2%). The most common hematological abnormality was lymphopenia seen in 46% of patients, followed by anemia (40%) and thrombocytopenia (14%). The common biochemical abnormalities found were elevated alanine aminotransaminase (18%) and hyperbilirubinemia (9%). The serum creatinine was found to be above baseline in 72% of patients. All patients with CMV infection were treated with intravenous ganciclovir, 2.5–5 mg/kg q 12 hourly, according to creatinine clearance, for 21 days. The treatment was successful in all but two patients, who died during the treatment period. There was a significant improvement in the kidney and liver functions after successful treatment of CMV infection. Our study shows that CMV infection should be considered in a patient presenting with unexplained rise in serum creatinine, low-grade fever, diarrhea, or anemia. A significant improvement in kidney and liver functions was observed after successful treatment of the infection

Epidemiology of human leukocyte antigens among omani population

Oman is located on the Southeastern coast of the Arabian Peninsula, and its population has high levels of consanguinity. Human leukocytic antigen (HLA) typing analysis in human population holds unexploited potential for elucidating the genetic causes of human disease and possibly leads to personalized medicine. This is a retrospective, descriptive study evaluating HLA frequencies of Omani individuals who underwent workup for kidney transplantation at the Royal Hospital (RH) from 2005 to 2016. Data on 870 subjects were collected from the Oman kidney transplant registry at RH as well from electronic medical record system. The mean age (standard deviation) years for the cohort were 33.2 (13.0). Males constituted 56.3% (490) while females constituted 43.7% (380). Seven HLA-A alleles accounted for more than 70% of the total alleles. Of which, HLA-A2 contributed the highest frequency (24%), followed by HLA A11 (9.4%), and A32 (8.1%). Ten alleles accounted for 70% of HLA-B alleles. Of which, HLA-B51 was the most common (18.9%), followed by HLA-B-35 (13.6%), and HLA-B8 (7.9%). Seven HLA-DRB1 alleles accounted for more than 70% of the total HLA DRB1 alleles, of which HLA- DRB1*16 contributed the highest frequency (29.56%). This was followed by HLA-DRB1*03 (14.57%) and HLA-DRB1*11 (9.48%). While three alleles accounted for more than 75% of the total HLA DQB1alleles. Of which, HLA-DQB1*05 contributed the highest frequency (37.56%). This was followed by allele HLA-DQB1*02 (26.48%) and HLA-DQB1*03 (17.18%). This study showed considerable heterogeneity in both HLA Class I and Class II antigens, which reflects admixture of our population with rest of old world countries. Despite the high levels of consanguinity, this population is genetically highly heterogeneous. These findings may be useful for transplantation programs, noncommunicable diseases, epidemiology of HLA linked diseases, pharmacogenomics, and anthropology