Masked Hypertension in Adolescents with Type 1 Diabetes Mellitus: An Exploratory Study

Introduction: Masked hypertension (MHTN) is the finding of elevated out-of-office blood pressure (BP) measurement. This is a pilot study to evaluate the prevalence of MHTN in adolescents with type 1 diabetes mellitus (T1DM). Patients and Methods: Normotensive, adolescents with T1DM were recruited from Tawam Adolescents Diabetes Clinic at Tawam hospital, Al Ain, UAE. They consented to wear the ambulatory BP monitoring (ABPM) device. The heart rate and ambulatory BP were recorded at 15-min intervals for 24 h. Abnormal systolic BP (SBP) and diastolic BP (DBP) were defined as readings above 135 and 85 mm Hg; respectively. Results: Thirteen patients (10 females) were recruited from “Tawam Adolescents Diabetes Clinic.” The median age was 17 (15–19) years, median BMI 21.4 (14.8–29), and median diabetes duration 9 (3–12) years. All patients had normal retinal examination within the past 12 months. Family history of hypertension (HTN) was present in 6/13 (46%) patients. Office BP measurements revealed a mean DBP ± SD of 72 ± 6.9 mm Hg and mean SBP ± SD116 ± 5.5 mm Hg. The median HbA1c was 8.4% (5.6–13.7) and median GFR 125 mL/min/m2 (87–134). Two patients had microalbuminuria. Twenty-four hour ABPM revealed elevated SBP and DBP in 12.2 and 5.8% of the values; respectively. Further analysis confirmed MHTN in 4 (30%) patients, nondipping pattern of BP in 5 (38%) patients, and elevated pulse pressure in 8 (61.5%) patients. Only 4 (30%) patients had normal studies. Conclusions: ABPM uncovered a very high prevalence of MHTN in our patients. Whenever available, ABPM provides an excellent tool for diagnosis and hence early evaluation and management of HTN in adolescents with T1DM. Well-designed large-scale studies are needed to examine the magnitude of MHTN among adolescents with T1DM

Considerations on equity in management of end-stage kidney disease in low- and middle-income countries

Achievement of equity in health requires development of a health system in which everyone has a fair opportunity to attain their full health potential. The current, large country-level variation in the reported incidence and prevalence of treated end-stage kidney disease indicates the existence of system-level inequities. Equitable implementation of kidney replacement therapy (KRT) programs must address issues of availability, affordability, and acceptability. The major structural factors that impact equity in KRT in different countries are the organization of health systems, overall health care spending, funding and delivery models, and nature of KRT prioritization (transplantation, hemodialysis or peritoneal dialysis, and conservative care). Implementation of KRT programs has the potential to exacerbate inequity unless equity is deliberately addressed. In this review, we summarize discussions on equitable provision of KRT in low- and middle-income countries and suggest areas for future research

Increasing access to integrated ESKD care as part of Universal Health Coverage

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle–income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide

Fasting ramadan in kidney transplant patients is safe

Muslims with renal transplant often ask their doctors whether fasting Ramadan is safe. Scanty studies have addressed this question. This prospective study was undertaken to identify any clinical or biological changes with Muslim fasting. 22 kidney transplant patients with stable kidney functions, who were transplanted for more than one year, and voluntarily chose to fast during Ramadan in 1425 H (October-November 2004), were studied. Total of 22 subjects (10 men and 12 women) with a mean age of 47 ± 11.6 years were studied. Full clinical and biological assessment was done before during and after the month of Ramadan fasting. Medications were taken in two divided doses at sunset (time of breaking the fast) and pre dawn (before the fast). None of the patients experienced any undue fatigue, or symptoms. Body weight, blood pressure, kidney function tests, blood sugar, lipid profile, and cyclosporine levels remained stable. In conclusion it is safe for renal transplant recipients of more than one year and having stable graft function to fast during the month of Ramadan; however caution is advised for moderate to severe impaired renal function

Fasting Ramadan in chronic kidney disease patients: Clinical and biochemical effects

Fasting of the month of Ramadan is a pillar of Islam. Muslim patients with chronic kidney disease (CKD) usually fast this month. To determine the effects of fasting on renal function in CKD patients, we prospectively studied 31 (19 males and mean age 54 ±14.2 years) CKD patients during the month of Ramadan 1426 Hijra (4 ^th October - 4 ^th November 2005); 14 patients were in stage III CKD, 12 had stage IV and 5 had stage V. The mean estimated glomerular filtration rate (e-GFR) was 29 ± 16.3 mL/min. Diabetes was the main cause of CKD (19 (61%) patients), and hypertension was present in 22 (71%) patients. Clinical assessment and renal function tests were performed one month prior to fasting then during and a month later. Medications were taken in two divided doses at sunset (time of breaking the fast) and pre dawn (before starting the fast). All patients fasted the whole month of Ramadan with a good tolerance, tendency to weight reduction, and lower systolic and diastolic blood pressure. eGFR showed a significant improvement during the fast and the month after. The blood sugar was high during fasting with an increment in the Hb A1c. There was better lipid profile, reduction of the pro-teinuria and urinary sodium. We conclude that this study demonstrates a good tolerance and safety of fasting Ramadan in CKD patients

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 <u> &#x002B;</u> 13.4 years). The main clinical presenting features were nephrotic syndrome in 68 patients (80&#x0025;), renal insufficiency in 31 (36.5&#x0025;), hypertension in 25 (24&#x0025;) and/or hematuria in 19 (22.4&#x0025;). Histopathology revealed minimal change disease in 25 patients (29&#x0025;), mesangioproliferative glomerulonephritis (GN) in 13 (15.3&#x0025;), focal segmental glomerulosclerosis in 13 (15.3&#x0025;), membranoproliferative GN in seven (8.2&#x0025;), membranous GN in three (3.5&#x0025;), diffuse proliferative GN in five (5.9&#x0025;), crescentic GN in four (4.7&#x0025;), lupus nephritis in 13 (15.3&#x0025;), and amyloidosis in two (2.4&#x0025;). 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

Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians

Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians’ practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians’ practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE. Abbreviations: ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation

Lupus cystitis in an Omani girl

Systemic Lupus Erythematosus (SLE) is an autoimmune disease characterized by multiple organs involvement. Bladder involvement (Lupus cystitis) is a rare manifestation of SLE, and occurs in association with gastrointestinal manifestations. We report a case of lupus inters-titial cystitis with bladder irritation and bilateral hydroureteronephrosis in an adolescent female who was treated with intravenous methylprednisolone pulse therapy followed by oral pred-nisolone and mycofenolate mofetil (MMF). Her symptoms ameliorated, and the hydrouretero-nephrosis improved. She was presented again with systemic flare up of the disease together with hydrouretronephrosis, but without bladder irritation symptoms. The diagnosis of lupus cystitis was confirmed by radiographic abnormalities, cystoscopy and bladder biopsy

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&#x0025;) were males, 33 (50.7&#x0025;) were Saudis with mean age of 37.2 &#x00B1; 11.7 years. Donors were living related (LRD) in 23 (35&#x0025;), living non-related (LNRD) in 27 (42&#x0025;) and cadaveric (CAD) in 15 (23&#x0025;). 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&#x0025;) patients were alive, with functioning graft in 31 (58&#x0025;). Causes of death among 13 patients (11 LNRD &#x0026; 2 CAD) were infections in 7 (54&#x0025;), immediate post transplant in three (22.7&#x0025;), acute myocardial infarction in two (15.7&#x0025;), CVA in one (7.6&#x0025;). Complications encountered were acute rejection (23 episodes) in 18 923.6&#x0025;) patients, infections in 19 (25&#x0025;), chronic rejection in 16 (21.5&#x0025;), surgical in 13 917.1&#x0025;), diabetes mellitus in 5 (6.5&#x0025;) primary non-function in three (3.8&#x0025;) and Kaposi Sarcoma in two (2.4&#x0025;). Twenty-six (81.25&#x0025;) out of 32 transplants performed in Madinah were functioning, four (12.5&#x0025;) patients returned to dialysis and two (6.25&#x0025;) patients died. Among the 21 transplants done in India 11 (52&#x0025;) patients died, six (28.6&#x0025;) returned to dialysis, and four (19.4&#x0025;) 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

Epidemiology and referral patterns of patients with chronic kidney disease in the Emirate of Abu Dhabi

According to estimates, the dialysis prevalence in Abu Dhabi is around 370 per million population. The annual growth is 12-15% and the dialysis population is likely to double in the next five years. Most patients present to dialysis as an emergency and only 2.7% have an arteriovenous fistula at the first dialysis. The prevalence of chronic kidney disease (CKD) in the Emirate is undefined. A study of the epidemiology of CKD and referral patterns was undertaken. SEHA, the Abu Dhabi Health Service delivery company, has a unified computer system containing all measurements made in its laboratories. This study considered all serum creatinine measurements performed between 1 September 2011 and 31 October 2012 from outpatient departments or emergency rooms. The estimated glomerular filtration rate (eGRF) was calculated using the Modification of Diet in Renal Disease formula (the Schwartz formula was used for children). We identified 331,360 samples from 212,314 individuals. The mean serum creatinine was 61 ± 48 μmol/L in females (59 ± 43 μmol/L in Emiratis, 63 ± 54 μmol/L in expatriates) and 87 ± 69 μmol/L in males (80 ± 59 μmol/L in Emiratis, 92 ± 74 μmol/L in expatriates). Among Emiratis, 4.6% of males and 2.8% of females had an eGFR between CKD 3 and 5. Among expatriates, 4.2% of males and 3.2% of females had an eGFR between CKD 3 and 5. On average, eight months elapsed before a patient with CKD 3, and three months for a patient in CKD 5, to attend the nephrology clinic. This study has defined the prevalence of CKD within Abu Dhabi and demonstrated the need to improve identification and referral of CKD patients. Possible solutions include campaigns to increase public and physician awareness of CKD