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Objectives: Muslim renal transplant patients often ask whether fasting during Ramadan would be harmful to their kidneys. We performed a meta-analysis on relevant studies to answer this question., Materials and Methods: We searched 4 databases using comprehensive search terms with predefined eligibility criteria. Two reviewers (FH and RA) independently assessed the relevance of studies obtained during the search. If disagreement occurred, a consensus would be sought; if disagreement persisted, the arbitration would be left to a third author (AAS)., Results: Eight studies (549 patients) were identified as eligible; these studies measured renal function before and after Ramadan with patients acting as their own controls in 5 studies. Our pooled analyses showed no significant changes after fasting with regard to estimated glomerular filtration rate (70.1 ± 9.1 vs 68.5 ± 7.5 mL/min, respectively; P = .6) or in serum creatinine levels (105.3 ± 8.8 and 106.1 ± 6.0 μmol/L, respectively; P = .47). In 4 self-controlled studies (148 patients) that had analyzed changes in systolic and diastolic blood pressure before versus after fasting, no significant differences were shown. However, in 3 studies that assessed changes in glomerular filtration rate in fasting (n = 358) versus nonfasting patients (n = 355), there was a significant difference in change in glomerular filtration rate following Ramadan fasting (-0.13 ± 1.2 mL/min in those who fasted versus 4.2 ± 4.6 mL/min in those who did not fast; P = .039); however, these results were associated with significant publication bias (systematic heterogeneity)., Conclusions: Fasting during Ramadan did not result in significant changes in kidney function or blood pressure in posttransplant patients with good baseline kidney function when patients acted as their own controls.

Thyroid function abnormalities are common in hemodialysis (HD) patients. Here, we investigated their frequency and impact on intradialytic hemodynamics and erythropoietin resistance index (ERI). Demographic and laboratory data including thyroid-stimulating hormone (TSH), interdialytic weight gain, and intradialytic blood pressure (BP) changes were measured, and ERI was calculated. The prevalence and causes of abnormities in TSH and free thyroxine (FT4) and their effects on ERI and intradialytic hemodynamics were then assessed. One hundred and thirty patients (mean age, 57.1 ± 19.2 years; 66.4% diabetic, 86.7% hypertensive) were enrolled. Among them, 16.7% had hypothyroidism, 2.3% had hyperthyroidism, and 10.9% had subclinical hypothyroidism. TSH level was significantly associated with higher BP (P <0.05), lower albumin (3.6 ± 4.4 and 2.6 ± 1.8, respectively; P = 0.05), lower dialysis hours (3.9 ± 5.3 and 2.6 ± 1.8, respectively), and lower ERI (3.7 ± 4.4 and 2.4 ± 1.9, respectively; P = 0.05). FT4 was significantly associated with higher interdialytic weight gain (13.4 ± 4.3 and 11.8 ± 2.2 pmol/L, respectively; P = 0.009) and higher pre-HD diastolic BP (13.2 ± 4.0 and 12.0 ± 2.9 pmol/L, respectively; P = 0.05). A negative correlation was seen between TSH level and urea reduction ratio (r = 0.29, P = 0.002), serum albumin (r = 0.304, P = 0.001), hemoglobin level (r = 0.26, P = 0.005), and ERI (r = 0.2, P = 0.002). A higher TSH level was associated with hypertension, lower albumin level, fewer dialysis hours, and increased resistance to erythropoietin. TSH level was negatively correlated with dialytic adequacy, serum albumin level, hemoglobin level, and ERI., Competing Interests: None

Background: To assess the prevalence of stroke symptoms and depression among Saudi dialysis patients and related factors., Methods: This is a cross-sectional multicentre study of Saudi dialysis patients. Demographics, clinical and laboratory's data were collected. Freedom from stroke symptoms was assessed using the Questionnaire for Verifying Stroke-Free Status and depression using the Geriatric Depression Scale., Results: Five-hundred and forty-nine patients (77.3% response rate); 94.6% were receiving hemodialysis and 5.4% peritoneal dialysis were included in the study. Freedom from stroke was reported in 76.6% of patients, was higher in females (p = 0.07), and was not affected by the presence of diabetes mellitus coronary artery disease or peripheral vascular disease. However, it was significantly lower in hypertensive patients (p = 0.035) and was not affected by age, dialysis duration, Kt/V, albumin or hemoglobin levels. It was, however, more prevalent in the non-depressed patients compared to depressed patients (p = 0.036). Mild and major depression scores were noted in 45.2% and 6.1%, respectively; the depression score being significantly higher in HD than in PD patients (6.3 ± 3.4 vs. 5.0 ± 3.2 p = 0.049) but was not related to sex, employment, vascular access type, age, dialysis duration, Kt/V or serum albumin or hemoglobin levels., Conclusion: A quarter of the patients were not stroke symptom-free and these were more likely the depressed patients, in females, but significantly less in hypertensive patients. Almost half of the patients were depressed with 6.1% having major depression. The depression score was significantly higher in HD than in PD patients.

We report what we believe is the first case of posterior reversible encephalopathy syndrome (PRES) secondary to dialysis disequilibrium syndrome (DDS) in patients in whom all other possible causes of PRES were excluded and in whom a transient episode of tactile hallucination also occurred. We believe that this case of DDS was particularly severe, leading to PRES because of the late institution of dialysis therapy and the concomitant severe degree of metabolic acidosis on presentation.

Dialysis patients are more likely than the general population to develop active tuberculosis (TB). In these patients, the availability of a highly sensitive and specific test to diagnose latent TB will ensure earlier treatment and decreased progression to active disease. In the current study, the Quanti-FERON-TB Gold In-Tube (QFT-G) test was compared with the tuberculin skin test (TST) for the diagnosis of latent tuberculosis infection (LTBI) among 200 hemodialysis patients and 15 confirmed TB disease cases in a tertiary care center in Saudi Arabia. Among the LTBI cases, 26 (13%) were TST positive, and 65 (32.5%) were positive by the QTF-G test, with an overall agreement between the 2 tests of 75.5% (k=0.34) being observed. Among the confirmed tuberculosis disease cases, none were positive by TST, and 10 (66.7%) were positive by the QTF-G test, resulting in an overall agreement of 33.3% (k=0). A comparison between the TST and the QTF-G test was performed based on the sensitivity, specificity, and area under the curve (AUC) obtained for the tests. The QTF-G test was more sensitive and less specific than the TST in predicting the confirmed TB disease cases. When we tested the correspondence of the AUC values between the 2 diagnostic modalities, the obtained p-value was 0.0003. In conclusion, the AUCs of the examined diagnostic modalities are significantly different in predicting LTBI and tuberculosis., (Copyright © 2013 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.)

Aim: To assess the efficacy and safety of combined pegylated interferon and ribavirin therapy in hepatitis C virus (HCV) infection in renal transplant recipients., Methods: This is a retrospective chart review of post renal transplant patients who were positive for anti-HCV and HCV-RNA, and who have received treatment with combination of pegylated interferon and ribavirin between October 2003 and December 2008. Only patients with stable graft function and absence of evidence of cirrhosis and who received the therapy for continuous 48 wk were included. Nineteen patients (13 male and 6 female) were identified and included. The patient's complete blood count, liver and kidney profile, and calculated glomerular filtration rate (GFR) were monitored every 6-8 wk while on treatment. HCV-RNA was tested at 12 wk for early virological response, at 48 wk for end of treatment response (ETR), and then retested at 24, and 48 wk after completion of therapy for sustained virological response (SVR). Liver biopsies were obtained before treatment from all patients and graft kidney biopsies were performed as required., Results: Of the entire cohort, 9 patients (47.4%) showed an ETR and 8 had SVR (42.1%). Of the 8 patients with abnormal alanine aminotransferase (ALT) levels at baseline, 78.9% had their ALT normalized (including the virological non responders). ALT was normal in all responders at the end of therapy and at 24 wk post therapy (100%). Only one patient (5.3%) developed an increase in creatinine and decline in GFR from baseline towards the end of treatment. This patient's kidney biopsy revealed borderline rejection. There was no impact on response by HCV-genotype, initial HCV RNA load, age or sex of the patient or duration post transplant before commencement of therapy. All patients tolerated treatment in the same way as non-transplant with no unusual or increased occurrence of side effects., Conclusion: The combination of pegylated interferon and ribavirin is effective in suppressing HCV-RNA, with a low risk of graft rejection or failure in HCV infected renal transplant recipients.

Background: Studies have shown that insomnia is a common sleep disorder among patients with end-stage renal disease (ESRD). This study aimed to assess the prevalence of insomnia in Saudi patients with ESRD who are on maintenance dialysis., Methods: This was an observational cross-sectional study carried out over a period of five months in two hemodialysis centers in Saudi Arabia. To assess the prevalence of insomnia, we used the ICSD-2 definition. We also examined the association between insomnia and other sleep disorders, the underlying causes of renal failure, dialysis duration, dialysis shift, and other demographic data., Results: Out of 227 enrolled patients, insomnia was reported by 60.8%. The mean patient age was 55.7 +/- 17.2 years; 53.7% were male and 46.3% were female. Insomnia was significantly associated with female gender, afternoon hemodialysis, Restless Legs Syndrome, high risk for obstructive Sleep Apnea Syndrome and excessive daytime sleepiness (P-values: 0.05, 0.01, < 0.0001, < 0.0001, and < 0.0001, respectively). No significant association was found between insomnia and other variables, including BMI, smoking habits, underlying etiology of renal failure, dialysis duration, association with hemoglobin, ferritin, and phosphorus or dialysis adequacy as measured by the Kt/V index., Conclusion: Insomnia is common in dialysis patients and was significantly associated with other sleep disorders. Greater attention needs to be given to the care of dialysis patients with regard to the diagnosis and management of insomnia and associated sleep disorders.

Restless legs syndrome (RLS) is an extremely distressing problem experienced by patients on dialysis; the prevalence appears to be greater than in the general population, with a wide variation from 6.6% to 80%. The diagnosis of RLS is a clinical one, and its definition has been clarified and standardized by internationally recognized diagnostic criteria, published in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). This study was designed to find out the prevalence of RLS in Saudi patients with end-stage renal disease (ESRD) on maintenance dialysis. This is a cross sectional study carried out between May and Sept 2007 at two centers, King Abdulaziz Medical City-King Fahad National Guard Hospital (KAMC-KFNGH), Riyadh and King Faisal Specialist Hospital and Research Centre (KFHRC), Jeddah, Saudi Arabia. Data were gathered on 227 Saudi patients on chronic maintenance hemodialysis or chronic peritoneal dialysis. The prevalence of RLS was measured using IRLSSG's RLS Questionnaire (RLSQ). Potential risk factors for RLS including other sleep disorders, underlying cause of chronic renal failure, duration on dialysis, dialysis shift, biochemical tests and demographic data were also evaluated. The overall prevalence of RLS was 50.22% including 53.7% males and 46.3% females. Their mean age was 55.7 +/- 17.2 years and mean duration on dialysis 40.4 +/- 37.8 months. Significant predictors of RLS were history of diabetes mellitus (DM), coffee intake, afternoon dialysis, gender and type of dialysis (P= 0.03, 0.01, < 0.001, 0.05 and 0.009 respectively). Patients with RLS were found to be at increased risk of having insomnia and excessive daytime sleepiness (EDS) (P= < 0.001 and 0.001, respectively). Our study suggests that RLS is a very common problem in dialysis population and was significantly associated with other sleep disorders, particularly insomnia, and EDS. Optimal care of dialysis patient should include particular attention to the diagnosis and management of sleep disorders.

Objective: To compare service expectations between Arab and Austrian patients., Methods: We used a Kano model-based questionnaire with 20 service attributes of relevance to the dialysis patient. We analyzed 530, 172, 60, and 68 responses from Saudi, Austrian, Syrian, and UAE patients, respectively. We compared the customer satisfaction coefficient and the frequencies of response categories ("must be," "attractive," "one-dimensional," and "indifferent") for each of the 20 service attributes and in each of the 3 national groups of patients. We also investigated whether any differences seen were related to sex, age, literacy rate, or duration on dialysis., Results: We observed higher satisfaction coefficients and "one-directional" responses among Arab patients and higher dissatisfaction coefficients and "must be" and "attractive" responses among Austrian patients. These were not related to age or duration on dialysis but were related to literacy rate., Conclusion: We speculate that these discrepancies between Austrian and Arab patients might be related to underdeveloped sophistication in market competitive forces and to cultural influences.

Background: In clinical practice, the glomerular filtration rate (GFR) is often estimated by the Modification of Diet in Renal Disease (MDRD) or Cockcroft-Gault (CG) formulae. No data are available, however, on the performance of these formulae in Arab individuals., Methods: Plasma creatinine samples were obtained from 90 consecutive normal Arab kidney donors for the estimation of GFR (eGFR) using the simplified MDRD and CG formulae. The GFR was measured in these donors with chromium labelled EDTA {[51Cr] EDTA). Bias was assessed by calculating the difference between the measured GFR and the calculated GFR using each of the two formulae; precision was calculated using the r value of the regression analysis., Results: The group studied consisted of 90 donors, of whom 64 were males (71%). The mean age was 30.8 years (+/- 9.8) and mean BMI was 25.7 (+/- 5.7). The measured GFR (mean 112.4 +/- 17.5) correlated better with the calculated GFR by CG formula (mean 107.7 +/- 29.7) and showed poor correlation with the GFR estimated by the MDRD (mean 89.2 +/- 13.8); bias = 4.8 and 23.3, respectively (p = 0.1 and < 0.0001, respectively). The correlation with CG formula was better in males (bias = 2, p = 0.5) and those under 30 years of age (bias = 1.0, p = 0.9). Based on our data, we calculated a correction factor to the CG formula to improve the correlation with the measured GFR in Arab individuals. By multiplying the CG formula by 1.0446, the bias was reduced from 4.8 (p = 0.1) to 0.0 (p = 0.5) with an increase in precision from 0.2 (p = 0.05) to 0.43 (p = 0.0001). Using CG formula, the frequency for values within 30% of the mean of the measured value was 75%, which improved to 80% using the revised formula., Conclusions: CG formula was found to be the most appropriate for calculation of GFR in Arab individuals. It is possible to reduce the bias and improve precision in Arab individuals with normal renal function by multiplying the result obtained by CG formula by 1.0446.

Objective: To assess health awareness in patients on renal replacement therapy (RRT) in Saudi Arabia., Methods: This is a cross-sectional survey using a 22-item questionnaire in 143 randomly selected adult RRT patients [40 on hemodialysis (HD), 61 on peritoneal dialysis (PD) and 42 with renal transplant (TX)]. The study was carried out at King Abdul-Aziz Medical City, Riyadh in April 2006. The questionnaire was designed to evaluate patients' knowledge in 5 areas: 1. causes of renal failure, 2. biology of the kidneys, 3. symptoms of kidney disease, 4. therapeutic options available, 5. national kidney patients support facilities. The association between the level of awareness (the percentage of correct answers) to different demographic factors was assessed., Results: Three fifths of the patients had less than secondary education. The average mark for correct responses of all patients was 45.9% with a highest (58%) for the category on biology of the kidney and lowest (36.8%) for national kidney patients support facilities. The PD group had the highest score (54.4%) followed by HD (44.3%) and finally TX (35.1%)., Conclusion: The level of our patients; health awareness is lower than satisfactory. Level of education seems to be a contributory factor.

Renal involvement in systemic lupus erythematosus (SLE) is a serious complication of the disease. However, the prognosis of patients with lupus nephritis is continually improving with 10-year survival rates now greater than 75%. This improvement reflects earlier diagnosis due to more sensitive and specific diagnostic tests, better clinical appreciation of the natural history, and improved treatment of SLE and its manifestations. This review of the treatment of lupus nephritis has graded the level of evidence of specific treatment using the guidelines of the US Preventive Service Task Force. Although many new treatments have been advocated, the best evidence for treating proliferative lupus nephritis relies on a strategy combining specific treatment of the SLE as well as generalised treatment of the associated comorbidities. This strategy involves a combination of corticosteroids and cytotoxic agents plus or minus the adjunctive use of antimalarials, coordinated aggressive management of hypertension, proteinuria, infections, dyslipidaemia, thrombotic coagulopathy and potential renal replacement therapies.