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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2016  |  Volume : 27  |  Issue : 7  |  Page : 31-41
Nutritional status and outcomes in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcome and practice patterns study phase 5 (2012-2015)


1 Department of Nephrology, Hamad General Hospital, Doha, Qatar
2 Arbor Research Collaborative for Health, Ann Arbor, MI, USA
3 Department of Nephrology, King Khalid University Hospital, Riyadh, Saudi Arabia
4 Department of Nephrology, King Saud University for Health Sciences, Riyadh, Saudi Arabia
5 Department of Nephrology, Salmaniya Medical Complex, Manama, Bahrain
6 Department of Nephrology, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
7 Royal Hospital, Muscat, Oman
8 Department of Nephrology, Farwaniya Hospital, Kuwait City, Kuwait
9 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
10 List of Study Group in Acknowledgment

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Date of Web Publication1-Dec-2016
 

   Abstract 

Nutrition is an important factor in maintaining good health of hemodialysis (HD) patients, affecting their morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) is an international observational study assessing differences in dialysis practices and outcomes across >20 countries. Here, we present the results for the Gulf Cooperation Council (GCC) countries regarding nutrition data and its relationship with outcomes as a part of the DOPPS Phase 5 study (2012-2015). Data were from Phase 5 of the DOPPS. Main analyses were based on 927 adult chronic HD patients enrolled at the start of the GCC-DOPPS Phase 5 study from each of the 40 randomly selected GCC HD facilities from Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. Within each participating facility, 20-30 patients were randomly selected, depending on facility size. Analysis showed minor differences across GCC countries in age, albumin levels, nutrition supplement use, and being bothered by the lack of appetite. Elderly (>60 years old) and diabetic HD patients displayed poorer nutritional parameters than young and nondiabetic patients. A low albumin level (<3.2 g/dL) was associated with the highest risk of mortality with a hazard ratio (HR) of 2.47 (P <0.0001) followed by diabetes with HR 1.57 (P <0.04) and older age [HR= 1.27/10 years older (P <0.01)]. Quality of life measures physical component summary and mental component summary correlated negatively with albumin <3.2 g/dL (−2.18 and −5.5, respectively, P <0.05 for each), and with serum creatinine level <7.5 mg/dL (−2.29 and −2.1 respectively, P <0.05 for each. We are presenting the first study of the nutrition status and outcomes for HD patients in the GCC countries in DOPPS. Our results were mostly comparable to findings in previous trials in other countries. Although the data are observational, our study provides good insight into aspects of nutrition in the GCC countries and can be compared to the rest of the world to better understand trends and practice differences.

How to cite this article:
Al-Ali FS, Bieber BA, Pisoni RL, Ezzat H, AlGhonaim M, AlHejaili F, AlGhareeb S, Saleh A, Al Maimani Y, Alyousef A, Ahmed HZ, Hamad A, GD. Nutritional status and outcomes in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcome and practice patterns study phase 5 (2012-2015). Saudi J Kidney Dis Transpl 2016;27, Suppl S1:31-41

How to cite this URL:
Al-Ali FS, Bieber BA, Pisoni RL, Ezzat H, AlGhonaim M, AlHejaili F, AlGhareeb S, Saleh A, Al Maimani Y, Alyousef A, Ahmed HZ, Hamad A, GD. Nutritional status and outcomes in hemodialysis patients from the Gulf Cooperation Council countries enrolled in the dialysis outcome and practice patterns study phase 5 (2012-2015). Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2017 Mar 30];27, Suppl S1:31-41. Available from: http://www.sjkdt.org/text.asp?2016/27/7/31/194888

   Introduction Top


Patients with end-stage renal disease (ESRD) on hemodialysis (HD) have increased morbidity and mortality. Nutrition is an important factor in maintaining good health in HD patients. Malnutrition is common among patients with ESRD and is associated with higher rates of morbidity and mortality. [1],[2],[3] There are many indicators to evaluate nutritional status in HD patients including modified subjective global assessment, body mass index (BMI), serum albumin, serum creatinine, normalized protein catabolic rate (nPCR), and lymphocyte count. Nutritional indicators correlate with morbidity and mortality. [3],[4] Older age and comorbid conditions such as diabetes mellitus (DM) and coronary artery disease have been linked to higher risks of mortality in HD patients. [5],[6],[7] Abnormalities in laboratory measures related to hyperkalemia and hyperphosphatemia also have been linked to greater risks of mortality. [8],[9],[10] Due to the low intake of protein in HD patients, it has been suggested that nutritional supplementation is used in HD patients on a routine basis. [11] The Dialysis Outcome and Practice Patterns Study (DOPPS) is an international observational study that compares the dialysis outcomes and practices in different countries. There have been multiple papers by the DOPPS describing nutrition and outcomes in the USA, Europe, and other countries [3],[12],[13] but none in the Gulf Corporation Council (GCC) countries. Here, we present the first GCC nutrition data as a part of the DOPPS study.


   Methods Top


Data were from Phase 5 of the DOPPS (2012- 2015), an International Prospective Cohort Study in 21 countries. DOPPS is based on nationally representative samples of randomly selected dialysis facilities and patients. Within each participating facility, 20-30 patients were randomly selected, depending on facility size. Institutional Review Boards in each country approved the study, and informed patient consent was obtained in accordance with local requirements. The main analyses were based on 927 adult chronic HD patients who were enrolled at the start of the GCC-DOPPS Phase 5 study from 40 of the GCC HD units participating in DOPPS Phase 5. All six of the GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates [UAE] were represented in this DOPPS Phase 5 study. All study HD patients were ≥18 years old at the time of study entry into DOPPS. Further details of the GCC-DOPPS study design are provided in the "The DOPPS Phase 5 Study in the GCC Countries: Design and Study Methods" paper by Pisoni et al in this special supplement issue of the Saudi Journal of Kidney Disease and Transplantation. [14]

Baseline descriptive statistics (e.g., mean, median, or percentage) weighted by facility sampling fraction were calculated for the study sample and by patient age group (<60 years vs. ≥60 years old) and by diabetes status. Logistic regression was used to calculate the odds of several different outcomes as noted in the results section. Patient responses to the 36-item version of the Kidney Disease Quality of Life (KDQOLTM-36) were used to calculate two health-related quality of life (QOL) summary scores, i.e., the physical component summary (PCS) and mental component summary (MCS). [15],[16] Higher PCS and MCS scores indicate better physical and mental QOL, respectively. Linear mixed models were used to analyze associations of nutritional measures with patient PCS and MCS. The above logistic and linear mixed models were based on the use of generalized estimating equations, which were adjusted for GCC country, patient age category (<60 years vs. ≥60 years old), sex, and whether the patient was diagnosed with DM. Models accounted for clustering of participants within facilities, assuming an exchangeable working correlation matrix.

The relationship of all-cause mortality with patient level nutritional measures and the extent to which patients were bothered by a lack of appetite and were analyzed using Cox proportional hazards regression stratified by GCC country, adjusted for patient age category (<60 years vs. ≥60 years old), sex, and whether the patient was diagnosed with DM. These Cox regression models also included the sandwich estimator to account for facility clustering effects. Furthermore, for the purposes of the Cox survival models, the extent to which a patient was bothered by a lack of appetite during the prior 30 days was dichotomized into the two groups of whether a patient was extremely or very much bothered by lack of appetite compared with patients who were not at all, somewhat, or moderately bothered by lack of appetite.

All statistical analyses were performed using the SAS software, version 9.4. (SAS Institute Inc., 100 SAS Campus Drive. Cary, NC 27513 USA).


   Results Top


[Table 1] shows the number of HD patients from each GCC country included in our analyses with the percentage of patients according to demographics, comorbid conditions, selected nutrition-related laboratory tests, and patient self-reported appetite information. The total number of patients was 927. Saudi Arabia had the highest number (419 patients), while Bahrain had the lowest (25 patients). Large differences are seen across GCC countries in age and sex of the study HD patients. Mean age ranged from 51 years old in Bahrain, Oman, and Saudi Arabia to nearly 62 years old in Qatar. As commonly seen internationally (United States Renal Data System: 2015 USRDS Annual Data Report: Volume 2 ESRD: Chapter 13 International Comparisons pp25) males predominated in the HD patient population in each GCC country, varying from 52% in Oman to 61% in the UAE and Qatar. The median number of years on dialysis (vintage) also varied nearly 2fold across GCC countries in this study sample from 1.82 years in Kuwait to 3.52 years on Oman. Large differences also were observed across the six GCC countries in the prevalence of reported cardiovascular disease and diabetes among HD patients [Table 1].
Table 1: Patient characteristics by GCC country (2012–2015).

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Similar to the above variation in patient characteristics, mean levels of nutritional measures also differed substantially across the six GCC countries: (1) mean serum albumin concentrations ranged from 3.3 g/dL in Bahrain to 4.1 g/dL in Qatar. However, in five of the six GCC countries, mean serum albumin levels were within a narrower range of 3.33-3.59 g/dL. Relevant to understanding the serum albumin differences by country, study sites also reported their normal range values for reported laboratory measures including serum albumin. In this regard, the normal range values for serum albumin were quite similar across countries with the mean of the upper end of the normal range being 4.95-5.0 g/dL in all countries, whereas the mean of the lower end of the normal range was 3.4-3.5 g/dL in all countries except Bahrain where the lower end of the normal range of serum albumin was 3.8 g/dL. Mean nPCR varied from 0.67 in Qatar to 1.12 in Oman. However, missingness, reflecting the nonreporting of particular study variables, was particularly high in some of the GCC countries for nPCR ranging from 24% in Qatar to 100% in Bahrain, thereby limiting the generalizability of study findings [Table 2]. Mean serum creatinine levels ranged from 8.5 mg/dL in Kuwait to 9.9 mg/dL in Saudi Arabia, whereas mean total cholesterol levels displayed less variability across GCC countries ranging from 145-155 mg/dL in Kuwait and Bahrain, respectively. However, missingness for reporting of cholesterol levels varied widely from 88% in Bahrain to 0% in Qatar and Kuwait. More patients reported being very much to extremely bothered by the lack of appetite in Bahrain (32%) compared to 26% in Oman, 15-19% in the UAE and Qatar, and 11% in Kuwait and Saudi Arabia. It is interesting to note that the use of oral nutritional supplements varied considerably for HD patients across the GCC, ranging from 0-3% use in Bahrain, Kuwait, and Oman to 8-9% of patients in Saudi Arabia, the UAE, and Qatar.
Table 2: Missingness in reporting of selected study variables by country in GCC-DOPPS (2012–2015).

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Levels of nutritional measures for HD patients in the GCC are shown for younger (ages 19-59 years) versus older (ages ≥60 years) HD patients and for diabetic versus nondiabetic HD patients [Table 3]. We had 361 older patients (39%, with a mean age of 69.6 ± 15 years) versus 566 younger patients (61%, mean age of 43.8 ± 25.6 years). No differences were noted between the two age groups with regard to male to female ratio. However, older patients were more likely than the younger patients to have cardiovascular disease and DM. As can be expected, older patients displayed lower mean serum creatinine levels (<7.5 mg/dL). Which can be partially indicative of lower muscle mass levels, in addition, older patients displayed lower nPCR levels, lower mean serum albumin levels, lower mean BMI, lower postdialysis weight and were more likely to be prescribed an oral nutritional supplement.
Table 3: Patient characteristics by age and diabetes in the GCC-DOPPS (2012–2015).

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Diabetic patients represented 49 % of our population. Compared to nondiabetic HD patients, diabetic patients were older, had a larger fraction of female patients, lower mean dialysis vintage, greater mean BMI and postdialysis weight, and had a higher prevalence of cardiovascular disease. Nutritional status generally appeared to be poorer for diabetic patients, who displayed lower mean serum albumin and serum creatinine levels.

Logistic regression analyses, adjusted as indicated in [Table 4], showed that male (vs. female) patients and those of age <60 years (vs. ≥60 years) had a tendency toward a lower likelihood of having a serum albumin <3.2 mg/dL [odds ratio (OR) 0.84 and 0.72, respectively] and a significantly lower likelihood (P <0.05) of having a serum creatinine <7.5 mg/dL (OR 0.53 and 0.37, respectively) which reflects better nutrition in these groups. In contrast, compared to nondiabetic patients, diabetic patients displayed higher odds of having a serum albumin <3.2 mg/dL [adjusted odds ratio (AOR)] = 1.41 [0.98, 2.01, 95% confidence interval (CI)] and serum creatinine <7.5 mg/ dL (AOR 2.57, P <0.05) which reflect poorer nutritional status. Indeed, 41% of diabetic patients had low serum creatinine levels (<7.5 mg/dL) compared with 15% of nondiabetic patients.
Table 4: Adjusted odds of (a) serum albumin <3.2 g/dL and (b) serum creatinine <7.5 mg/dL in the GCCDOPPS (2012–2015).

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There was a significant association between some of the nutritional measures and mortality when adjusted for GCC countries [Table 5]. A low albumin level (<3.2 g/dL) was associated with a high risk of mortality [hazard ratio (HR) = 2.47 (1.66-2.46 95% CI, P <0.0001)]. Although not significant, a tendency toward higher mortality risk also was seen for HD patients having a low serum creatinine (<7.5 mg/ dL) [HR = 1.27, 95% CI (0.86-1.27) P <0.22]. Furthermore, patients who reported being moderately to extremely bothered by a lack of appetite displayed elevated mortality (HR = 2.11, 95% CI = 1.37-3.25 after stratifying analyses by country and adjusting for age, sex, time on dialysis, diabetes, coronary artery disease, and other cardiovascular disease).
Table 5: Nutritional measures and mortality in the GCC DOPPS (2012–2015).

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Lower mean QOL summary score measures, PCS and MCS, were observed in analyses adjusted for patient age, sex, diabetes, country and accounting for facility clustering effects. Thus, lower mean QOL summary scores were observed for HD patients having a low serum albumin level <3.2 g/dL (−2.18 for PCS, P = 0.03; −5.5 for MCS, P <0.001) compared with patients having a serum albumin level ≥3.2 g/dL [Table 6]. Similarly, lower mean QOL summary scores were seen for patients having a low serum creatinine level <7.5 mg/dL (−2.29 for PCS, P = 0.01; −2.15 for MCS, P = 0.04) compared with patients having a serum creatinine level ≥7.5 mg/dL.
Table 6: Nutritional measures and quality of life (MCS and PCS) in the GCC-DOPPS (2012–2015).

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   Discussion Top


Many studies have shown the characteristics of HD patients including comparisons among countries and continents. [5] DOPPS is an international study that has provided great insight into HD patient practices and outcomes. Nutrition is one of the major study areas within DOPPS. The present study is the first to address nutrition in GCC countries participating in DOPPS. Prior international DOPPS investigations have shown strong associations of mortality with patient body weight, levels of albumin and creatinine, and weight loss. [3],[13] Our study aims at evaluating these correlations in GCC countries. Although the patient sample varied by GCC country, the fact that HD patients in each GCC country have a similar ethnic background, geographic area, and living conditions, we analyzed the GCC-DOPPS patients as one group. We also evaluated each country individually to validate this point and evaluate any difference. Considerable variation was seen in HD patients across the six GCC countries in: (1) mean age, varying from 51-61years of age, (2) the percentage of patients who were male ranging from 52%-61%, (3) median dialysis vintage which varied 2-fold from 1.82 years in Kuwait to 3.52 years on Oman), and (4) mean BMI (range: 23.9-28.9) and mean body weight (59.9-75.9 kg). The mean values seen for many of these measures also differed when compared to levels previously reported for HD patients in the USA, Europe, and Japan. [17]

Qatar had higher serum albumin levels than those reported in the other GCC countries which might be related to patients using more nutrition supplements, meals provided routinely during dialysis, or having fewer patients with symptoms of depression. We did not evaluate, in this study, the variations between different albumin measurement assays among the six GCC countries. However, normal range values were quite similar across countries based on data reported by each study site. Bahrain had lower albumin levels and more patients who reported being bothered by the lack of appetite, but the number of study patients in Bahrain was low, so the significance of these findings was unclear. The inability to have a clearer picture of the differences between GCC countries could be due to the low number of patients in some countries so no definite conclusions can be made, but it opens the door for further studies to evaluate these observations. GCC data also showed the correlation of mortality as expected with low albumin.

The definition of elderly patients in our study was above 60 years which is a little lower than other studies including USRDS data (above 65 years old) but the mean age for the elderly group of HD patients was 69. Elderly patients were more likely than younger patients (<60 years old) to have cardiovascular disease and DM. Regarding nutritional measures, older patients displayed lower mean serum creatinine levels and were much more likely to have a low serum creatinine level (<7.5 mg/dL) than younger patients, which is consistent with less muscle mass among the elderly patients. In addition, older patients had lower nPCR levels, mean serum albumin levels, mean BMI and were nearly twice as likely to be prescribed an oral nutritional supplement.

Compared to nondiabetic HD patients, GCC HD patients with diabetes had higher BMIs and body weight, lower serum albumin levels (especially below 3.2 g/dL), lower serum creatinine levels and were much more likely to have a serum creatinine concentration below 7.5 mg/dL. These differences were expected as many patients with type 2 diabetes have a history of albuminuria. nPCR was lower in diabetics versus nondiabetics with diabetic HD patients being less likely to have an nPCR ≥1. Furthermore, more patients with diabetes complained of being extremely bothered by the lack of appetite than nondiabetics. These differences might reflect diabetes-related complications such as nausea and vomiting, secondary diabetic gastroparesis, hypo and hyperglycemia, and generalized weakness.


   Study Limitations Top


  1. DOPPS is an observational study with no interventions. Due to its observational design, conclusions are limited to the observations and causality cannot be concluded regarding the association of treatments with outcomes due to the possible existence of residual confounding and due to the crosssectional nature of the reported associations
  2. GCC countries include a mixture of native citizens and resident workers (expatriates) in different ratios by country which can have an impact on the results observed due to different ethnicities, socioeconomic status, and different access to health care. Some data had a high missingness rate and varied between countries [Table 2] thereby limiting generalizability and the ability to draw firmer conclusions.



   Conclusion Top


We report the first nutrition data in the GCC area as a part of the DOPPS Phase 5 study. Although the data are observational, our study provides good insight into aspects of nutrition in GCC countries and can be compared to the rest of the world to better understand trends and practice differences. Our findings are mostly comparable with results of previous studies in other countries. With extended study follow-up in the future regarding nutritional measures and patient outcomes, we hope to provide additional insights regarding nutritional practices associated with the best clinical outcomes and QOL of HD patients in the GCC.


   Acknowledgments Top


The authors wish to thank the devoted efforts of GCC-DOPPS Phase 5 Study Group members for their numerous contributions to this study including country investigators (Dr. Sameer AlArrayed, Dr. Sumaya Al Ghareeb, Dr. Bassam Al Helal, Dr. Naser Alkandari, Dr. Ali Alsahow, Dr. Anas AlYousef, Dr. Mohammad AlAzmi, Dr. Yaqob Ahmed Almaimani, Dr. Issa Al Salmi, Dr. Nabil Salmeen Mohsin, Dr. Fadwa Al Ali, Dr. Mohamed El-Sayed Abdel Fatah, Dr. Ashraf Fawzy, Dr. Abdulla Hamad, Dr. Saeed M. G. Al-Ghamdi, Dr. Mohammed Al Ghonaim, Dr. Jamal Al Wakeel, Dr. Fayez Hejaili, Dr. Ayman Karkar, Dr. Faissal Shaheen, Dr. Samra Abouchacra, Dr. Ali Abdulkarim Al Obaidli, Dr. Mohamed Hassan, Dr. Mona Nasir Al Rukhaimi, and Dr. Abdul Kareem Saleh, Dr. Sylvia Ramirez, Dr. Bruce Robinson, Dr. Ronald Pisoni), Clinical Research Associates and Project Coordinators/Managers (Dr. Amgad El-Baz El-Agroudy, Dr. Balaji Dandi, Ms. Cherry Flores, Mrs. Ph. Fatma Al Raisi, Ms. Ibtisam Al-Hasni, Dr. Ashraf Fawzy, Dr. Haroun Zakaria Ahmed and Mr. Dan Santiago from the Saudi Center for Organ Transplantation, Mr. Muhammad Awwad, Ms. Roberta Al HousaniBlakely, Christina Pustulka, Anne Vandermade, Melissa Fava, Anna Hogan, Michelle Maxim, Justin Albert), Biostatisticians (Brian A. Bieber), and Study Site Medical Directors, and Study Coordinators: Dr. Hamid Ali Alyousif, Ms. Sohair Abdulroof Albably, Dr. Ahmed Eid Alkady, Dr. Samir Al Muielo, MD, Dr. Fakreldein Elamien Ali, Dr. Ayman El Monger, Dr. Sameh Mohammed Al-sammad, Dr. Baraa Rajab, Dr. Atif Hanan, Tarek Abdelfattah Ahmed Ali, Dr. Ayman Karkar, Dr. Mohammed Abdelrahman, Dr. Mohammed Hussein, Dr. Wael Abdlah, Dr. Faisal Mushtaq, Dr. Salah Eldin El Sheik Beshir, Dr Medhat Abdelmonem Shalaby, Dr. Mustafa Khaleel Al Obeid, Dr. Mohamad El Hadary, Dr. Alaa Al Shamy; Dr. Aboud Mamari, Dr. Mohammed Raily, Dr. Mustafa Ahmed; Ramzi Abou-Ayache, Dr. Hormoz Dastoor, Dr. Mohamed Hassan, Dr. Bassam Bernieh, Dr. Hareth Muthanna Mohammed Saaed, Dr. Mustafa Kamel, Prof. Abdel Basset Hassan, MD, PhD, FASN, Dr. Hassan Khammas, Dr. Balaji Dandi, Dr. Sumaya Al-Ghareeb, Dr. Fadwa Al Ali, Dr. Anas Alyousef, Dr. Nasser AlKandari, Dr. Ali Alsahow, Dr. Bassam AlHelal, Dr. Ahmed Mandour, Dr. Yaqob Ahmed Almaimani, Dr. Amer Ahmed Alaamri, Dr. Ibrahim Sayed Ibrahim, Dr. El Badri Abdelgadir, Dr. Mohammed Al-Sayed Seleem, Dr. Ali Hassan Hakami; Dr. Samir Beshay, Dr. Nayer Morsy, Mr. Menwer Al-ofi, Ms. Sohair Abdulroof Albably, Dr. Huda Mohammed Saeed Ahmed, Ola Al-Marhoon; Dr. Samir Al Muielo, Ms. Joynalyn Barrios, Ms. Fatima Cruza; Ligaya Battad, Mr. Abdullah A. K. Al Harbi, Dr. Sameh Mohammed Al-sammad, Ms. Manal Ahmed Hamdan, Jennifer Samson, Mr. Ahmed Mousa Khawaji, Ms. Eman Al-Hejji, Ms. Rosalinda Lamis, Ms. Lagrimas Codotco, Dr. Wael Abdlah, Mrs. Priyanka Prasad, RN, Mr. Bander Faisal Justinia, Mr. Faisal Al Enazy, Sarah Brazil, Dr. Naemah Abdullah, Dr. Alaa Al Shamy, Dr. Aboud Mamari, Mely Gari Piling, Dr. Fakhriya Al Alwai, Rusmina Binti Sudin, Dr. Chandra Mauli Jha, MD; Katheryn Jamilano, Basima Khaddah, Hilal Al Rasbi, Muhy Eddin Hashem Hasan, Sr. Ekram Awadh Salem, Walid Gouiaa, Mini Issac, Jiby Mammen, Mary Ellen Monday, Mrs. Afrah Al Jamri, Mr. Yasser Khalil Abbas, Mrs. Rania Abd El-Aziz, Rania Abd El-Aziz, Cherry Flores, Mini Kumari Ramakrishnan, Shanty Mannaraprayil, Maria Charisse Bernardo, Bassam AlHelal, Evangeline Valdez, Rosily Joseph, Mrs. Ghaniya AlShukaili, Adel Mohamed Bayoumy, Hamid Alshahri, Amira Balkhair, Amina Said Al Shezawi, Sultan Saif Ali Alroshdi, Dr. Shaninaz Faisal Bashir, Dr. Ahmed Mousa Dawood, Keirin Porras, Dr. Anthonimuthu Victor, Mr. Sultan Al-Toqi.


   Source of Support Top


The DOPPS Phase 5 Study in the GCC has been supported by Amgen without restrictions on publications. The DOPPS Program is supported by Amgen, Kyowa Hakko Kirin, AbbVie Inc, Sanofi Renal, Baxter Healthcare, and Vifor Fresenius Medical Care Renal Pharma, Ltd. Additional support for specific projects and countries is also provided by Amgen, BHC Medical, Janssen, Takeda, and Kidney Foundation of Canada (for logistics support) in Canada; Hexal, Deutsche Gesellschaft fur Nephrologie (DGfN), Shire, and WiNe Institute in Germany; and the Japanese Society for Peritoneal Dialysis for Peritoneal Dialysis Outcomes and Practice Patterns Study in Japan. Funding for the DOPPS Program is provided without restrictions on publications.

Conflict of interest: None declared.

 
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Correspondence Address:
Fadwa S Al-Ali
Department of Nephrology, Hamad General Hospital, Doha
Qatar
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DOI: 10.4103/1319-2442.194888

PMID: 27991477

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    Abstract
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   Methods
   Results
   Discussion
   Study Limitations
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