Nephro-Urology Monthly
Volume:3 Issue: 1, Jan 2011

Only few small studies have evaluated efficacy of ribavirin in combination with pegylated interferon or standard interferon in hemodialysis patients. In current review, we aim to determine the efficacy and safety of ribavirin-containing regimen in these patients. Medline, Scopus, ISI web of knowledge and Proquest were searched for prospective studies of IFN and PEG-IFN combined with ribavirin in IFN-naive dialysis patients with chronic Hepatitis C infection. Reporting of HCV RNA results at least 6 months after treatment using a PCR assay was mandatory. From 17 relevant studies, six studies met our inclusion criteria. Because of high level of heterogeneity and low number of studies, we discarded meta-analysis. Two studies investigated standard interferon plus ribavirin. One reported 66% of Sustained Viral Response and zero treatment discontinuation. In contrast, another study reported just 16% of Sustained Viral Response and 33% of treatment discontinuation. Four studies investigated pegylated interferon plus ribavirin. One study reported amazing Sustained Viral Response rate of 97%, however, another study reported Sustained Viral Response rate of just 28.6% and treatment discontinuation rate of 71.4%. Other reported Sustained Viral Response and treatment discontinuation rates were 50%, 70% and 16%, respectively. Individuals on dialysis with chronic hepatitis C who were treated with interferon or pegylated interferon plus ribavirin can have higher Sustained Viral Response rate than dialysis patients treated with interferon or pegylated interferon alone. Administration of ribavirin with close monitoring of CBC and serum ribavirin concentration can be safe.

Helicobacter pylori (H. pylori) has been reported to play an important role in the development of gastritis and gastric ulcer. Here we report the prevalence of H. pylori infection in 87 hemodialysis (HD) patients. In the present study we investigated the prevalence of H. pylori infection in 87 HD patients by three serum anti-H. pylori IgG, H. pylori stool antigen (HpSAg) and Urease Breath Test (UBT). All the three methods confirmed each other and when 2 out of the 3 methods showed positive findings, patients were regarded as H. pylori -positive. We also assessed the relationship between clinical factors, serum urea nitrogen, creatinine levels, and duration of dialysis, age and gender with the prevalence H. pylori in these patients. Eighty seven HD patients (48 male and 39 female) with the mean age of 54.4±16.7 years old and mean dialysis duration of 36.2±33.5 months were assessed. Fifty five (63.2%) of them had dyspepsia. The prevalence of H. pylori infection was 44.8%. Multivariate logistic regression analysis revealed the serum urea nitrogen level was significantly associated with H. pylori prevalence (P=0.03, 95% CI: 1.4-35.8). High serum urea nitrogen seems to correlate with a high prevalence of H. pylori infection. The prevalence of H. pylori infection was low in young patients, but high in elderly patients (P=0.04, 95%CI: 0.97-10.3). There was no significant correlation between gender, duration of dialysis, serum Cholesterol, Triglyceride, creatinine, Hemoglobin, albumin, calcium and phosphor and H. pylori infection in these patients. Among dialysis patients, the proportion of H. pylori-positive patients was not low. Dialysis treatment may influence H. pylori infection.

Overweight and obesity are significant risk factors for chronic kidney disease (CKD). Glomerular filtration rate (GFR) is the best index of renal function. We evaluated the accuracy of the Cockroft-Gault, MDRD and modified MDRD formulae in predicting GFR in overweight and obese subjects and also determined the relationship between Body Mass Index (BMI), weight and GFR. Healthy volunteers with BMI ≥23kg/m² were recruited and subjected to blood and urine investigations, renal ultrasonography and 99mTc-DTPA renal scan. The correlation, accuracy and precision of the eGFR derived from each formula were compared with reference GFR as determined by 99mTc-DTPA. A total of 101 subjects with a median weight of 74.0kg (68.0-84.7) and median BMI of 29.6 kg/m² (27.2-33.2) were recruited. Their mean GFR 99mTc-DTPA was 120.3± 24.5ml/mm/1.73m². Although the eGFRs derived from all formulae correlated with GFR 99mTc-DTPA, only those derived from the MDRD and modified MDRD had small biases and better precision in estimating GFR. While GFR significantly correlated with the subject's weight (p=0.036), it didnt with their BMI (p=0.302). The MDRD-based formulae were better in estimating GFR in overweight and obese Malaysian subjects. GFR correlated with subject's weight rather than BMI.

Potential role of L-carnitine in anemia adjuvant treatment is still a matter of concern. The aim of the study was to determine the influence of L-carnitine on renal anemia and erythrocyte metabolism in haemodialyzed (HD) patients. We studied 26 patients (13 male and 13 female) aged from 13 to 65, (mean age 38) and 30 healthy volunteers (12 male, 18 female) aged from 25 to 65, (mean age 40). HD patients showed stable hemoglobin (Hb) levels and low plasma free carnitine (FC) levels. Laboratory markers of: carnitine metabolism, hematological status, iron stores as well as erythrocyte metabolism were measured. L-carnitine (500 mg/day) was administered orally for 12 months (dose from 5.3 to 16.7 mg/kg of body weight, mean dose 9 mg/kg). After six months of oral low doses administration of L-carnitine, plasma total (TC) and FC levels increased and reached a plateau (at almost two times the initial levels) being at 12 months significantly higher than in the controls. During L-carnitine treatment a significant increase of mean Hb concentration was observed. Patients who responded (14/26) to L-carnitine differed from those who did not respond, with significantly longer dialysis time and lower both initial FC concentrations and FC/TC ratio. The following changes in erythrocyte metabolism were noticed: 1) glycolytic enzymes: significant increase of erythrocyte sodium, potassium ATPase, hexokinase and lactate dehydrogenase activities, 2) glycolytic intermediates: increase of 2,3-diphosphoglycerate and decrease of adenosine triphosphate concentrations, 3) decrease of the glucose uptake and lactate production by erythrocytes. 1. L-carnitine may ameliorate anemia in some hemodialysis patients. 2. L-carnitine induces metabolic changes in erythrocytes. 3. Long-term maintenance hemodialysis patients may benefit most from L-carnitine supplementation. 4. Low doses of L-carnitine are effective in restoring the plasma carnitine pool.

Dialysis catheter-related infections (CRI) remain a significant cause for morbidity and mortality in hemodialysis patients. We studied factors that predispose hemodialysis patients to CRI. This a retrospective case controlled study of hemodialysis patients with a cuffed permanent catheter access conducted over a 12-month period. Those developing CRI acted as the study group and those who remained free of CRI acted as controls.Patients and catheter variables that were documented included: Chronic Comorbidity Index (CCI), serum albumin level, Kt/V, number of CRI, organism/s isolated, and whether the catheter had to be removed. Significance of differences between the two groups was assessed using two tailed independent test for continuous variables and Chi square for categorical variables. Fifty-seven study patients and 39 controls were included. There were 107 episodes CRIs. The number of episodes of infection/catheter patients was 1.1 after a mean follow up period of 933 (± 255) days. Number of episodes of infection per 1000 catheter/days was 1.2 and per 100 dialysis sessions was 0.714.Catheter duration was shorter (1040 ± 198 days) in the infected group compared to the control group (1139 ± 275 days, p=0.042). The commonest organism isolated was Staph aureus (35%) followed by Enterobacter cloacae (14.8%). The commonest antibiotic used was vancomycin, followed by gentamycin and ceftazidime. The actuarial catheter survival was markedly less with multiple episodes of infection compared to single episode (p=0.029). A single episode of infection was associated with 9.5% chance of catheter losses as opposed to a 43.3% chance in multiple infections (p=0.0001). Risk of infection was increased with femoral placement and number of dialysis sessions. The risk of catheter loss with multiple infections is more. The demographic characteristics are not a risk factor for developing infection.

A tendency to metabolic acidosis with use of amino acid-based peritoneal dialysis solution, especially when two exchanges are performed with the solutions. In the present study, we aimed to investigate whether metabolic acidosis is a considerable problem in patients on continuous ambulatory peritoneal dialysis (CAPD) used amino acid-based peritoneal dialysis solution. The cross-sectional study included 119 PD (62 female, 57 male) patients. The first group consisted of 47 patients who had used amino acid-based PD solution once a day. The second group included 72 patients who had not used the solution. Mean age was 47 ± 13 years. Blood bicarbonate concentration and serum albumin level were significantly lower in first group than that of the second group (25.12 ± 3.38 mmol/L vs. 26.91 ± 4.32 mmol/L, P: 0.018 and 2.82 ± 0.46 g/dL vs. 3.15 ± 0.50 g/dL, P: 0.001, respectively). On the other hand, blood urea nitrogen concentration and use of essential amino acid preparation were meaningfully higher in the first group than those of the second group (66.17 ± 13.70 mg/dL vs. 52.79 ± 16.55 mg/dL, P: 0.001 and 33 (47.8%) patients vs. 14 (28%) patients, P: 0.022, respectively). However, there was no meaningfully difference between these groups for serum pH value and presence of metabolic acidosis. Although mean blood bicarbonate concentration was significantly lower in amino acid-based PD solution group than that of the control group, it was in normal range in both groups and there was no significant difference between both groups for pH value and presence of metabolic acidosis. Therefore, metabolic acidosis is not a considerable problem in PD patients used amino acid-based peritoneal dialysis solution.

Percutaneous insertion of peritoneal dialysis catheters (PDC) by nephrologists is gradually gaining favour due to its convenience for patients and financial benefits. This study was carried out to determine the outcomes of this procedure and to compare it with catheters inserted by surgeons during the same period. A retrospective review of PDC insertion by percutaneous (medical) and open (surgical) techniques was carried out in a Renal Unit at a University Teaching Hospital serving a population of 450,000. All patients going onto peritoneal dialysis were considered for medical insertion of PDC, except for those with previous PDC insertions, abdominal operations or obesity. All patients who had PDC insertions for peritoneal dialysis between January 2005 and September 2008 were included and followed up to the completion of the study. The main outcome measures were technique success, primary failure (failure within the first month) and complications beyond the first month. One hundred and twenty PDCs were inserted (69 medical, 51 surgical) in 97 patients. The primary failure rate for first insertions was 16.7% for medical and 10.5% for surgical insertions, but the difference was not significant (P = 0.72). Peritonitis, the most common complication, was treated successfully in 25 of 30 patients. Secondary blockage was similar for medical (13%) and surgical insertions (12%). Exit site infections were significantly higher in the surgical group (P = 0.04), while PD peritonitis was more common with medical group (P = 0.47). The number of PDC removed due to complications was higher in the medical (23%) than the surgical group (16%), but not significantly (P = 0.38). Median survival of PDC was similar in both groups. Percutaneous insertion of a PDC by a motivated and suitably experienced nephrologist offers significant advantages provided careful patient selection is applied. Medical insertion of PDC is safe and reduces pressure on precious operating theatre time.

Although perforation of the uterus by an intrauterine contraceptive device is not uncommon, intravesical migration and secondary stone formation is a very rare complication. We report a series of 10 women in whom an intrauterine contraceptive Copper-T device migrated from the uterus to the bladder and resulted in formation of a stone. Between May 1995 and January 2009, ten women were treated for bladder stones because of migrated intrauterine contraceptive device. Diagnosis was established after performing pelvic ultrasonography and/or intravenous urogram. We describe history, clinical course, diagnostic workup and treatment data obtained from the hospital charts. The mean age was 42.6 ys (33-59). Persistent lower urinary tract symptoms were the main complaint in almost all cases, while four patients presented with macroscopic hematuria. The interval between insertion of intrauterine contraceptive device and onset of symptoms ranged from 2 to 12 ys. Cystoscopy revealed partial intravesical position of the intrauterine contraceptive device in 9 cases and an entire intravesical intrauterine contraceptive device in one case with calculus formation in all cases. All patients underwent endoscopic lithotripsy of the stone with extraction of intrauterine contraceptive device. Procedures went well with no complications. Patients received urinary drainage for 10 days. Postoperative course was uneventful with a 2 years follow-up. intrauterine contraceptive device perforation to the bladder, with stone formation, is a rare event. Persistent lower urinary tract symptoms in women with intrauterine contraceptive device should raise the suspicion of intravesical migration. Ultrasonography permitted excellent depiction of intravesical migrated intrauterine contraceptive device. Endoscopic retrieval is feasible and safe procedure.

Tamsulosin has been used in several current medical expulsion therapy experiments but the results of studies are variable. Therefore, we conducted a study to evaluate the role of tamsulosin on stone clearance in patients with lower ureteric stone with extracorporeal shock wave lithotripsy (SWL). A prospective randomized open label study was performed in 119 patients with single lower ureteric calculus undergoing shock wave lithotripsy. The study group received 0.4 mg tamsulosin daily and control group received hydration and analgesic on demand for a maximum of 30 days. Follow up visits were performed at 1, 2, 3 & 4 weeks after ESWL. Efficacy of tamsulosin was evaluated in term of success rate, time for expulsion of fragment & analgesic requirement. The clearance rate was 93% in tamsulosin group and 90% in control group, when stone size was in the range of 4-7 mm and difference was statistically not significant (p=0.6). When stone size was in the range of 8-12 mm, the clearance was 80% in tamsulosin group and 52% in control group and difference in statistically significant (p=0.021). The mean time to expulsion of the fragments was 12.9 days (±7.5) in tamsulosin group and 14.2days (±7.9) in control group and difference was statistically insignificant (p=0.561). The mean dose of analgesic used in tamsulosin group was 65.83 mg (±48.26) and 116.10 mg (±55) in control group. The difference was statistically significant (p=0.000). Treatment with tamsulosin appears to be beneficial in lower ureteric stone clearance after ESWL, particularly in larger stone with less need of analgesic.

Properly functioning angioaccess is essential for the provision of adequate dialysis. We present and discuss a unique vascular access experience in a Saudi Arabian Center, lasting for more than ten years. We prospectively studied all patients with end stage kidney disease, who underwent any of three vascular access procedures (cuffed central venous catheter, arteriovenous graft, or arteriovenous fistula) from 1993 to 2004 with the objective of assessing the relative rates among these three forms of angioaccess and the survival rates of arteriovenous fistula and its relation with patient's gender, weight or nationality. The survival rate of the AVF as defined by the fistula patency rate was divided into three categories: short-term patency (early AVF failure in: less than 6 weeks), medium-term patency (6 to 52 weeks) and long-term patency (more than 52 weeks). There were 603 patients (386 males and 217 females). The mean age was 48.5 years (SD ± 18.6). 326 patients were Saudis. The cause of ESRD was diabetes mellitus in 2 75 patients, glomerulonephritides in 170 patients and hypertension in 158 patients. The mean BMI was 29 (SD ± 3.7). 580 of the patients had arteriovenous fistula (AVF), 44 had arteriovenous graft (AVG), and 35 patients received only central venous catheter. There was a high early failure rate of AVF 46.4%, particularly in females (61.5%, p =0.0001) and non Saudis (55%, p=0.0008). The long-term patency rate (> 52 weeks) was 38.8 % with no differences seen between genders or nationalities. BMI did not have an effect on AVF survival. The incidence of other complications combined was only 5.3%. The vast majority of angioaccess was AVF in keeping with NKF-DOQI guidelines. There was a high early AVF failure rate in women and non-Saudis. Diabetes mellitus seems to be a strong contributing factor but not other renal disease etiologies. Further research is needed in this field in Saudi Arabia.

Osteitis fibrosa is a well documented complication of hyperparathyroidism secondary to chronic renal failure. It preferentially affects the long bones, the spine and the ribs. Maxillofacial bones are rarely affected and leads to facial deformities. We report the case of a 15-year-old female patient who developed hyperparathyroidism secondary to end-stage renal disease that manifested as unilateral jaw enlargement. Histological appearance is that of a fibrous dysplasia.

To describe and report a case of an episodic painless hematuria, in a middle aged gentleman whose initial radiological work up and cystoscopic findings suggested localized carcinoma of the urinary bladder. Nuclear matrix protein and urine cytology were negative for urotheilal tumor. Transurethral resection of bladder wall mass and pathology confirmed amyloidoma (vesical amyloidosis). Absence of clinical stigmata of secondary disease and appropriate histopathology confirmed the diagnosis of primary vesical amyloidosis. Diagnosis of vesical amyloidosis was based on the awareness of the existence of this entity and the use of appropriate histopathology and surgical resection was performed. We conclude that early diagnosis and prompt resection is necessary for localized vesical amyloidosis presenting primarily with hematuria.