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 two­month 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 E­modified 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.

The number of patients with end-stage renal disease maintained on chronic hemodialysis is increasing progressively. Arteriovenous fistula (AVF) is a common vascular access for hemodialysis, however, its effect on limb distal circulation has not been studied well. Palpation of pulse at the wrist is a crude method of clinical assessment. Over one year period, 26 AVFs were created; 16 at the wrist (61.5%) and ten fistulas at the elbow (38.5%). Six of the latter were through the brachio-basilic approach while the other four were performed by basilic vein transposition. Doppler measurement of both wrist-brachial index (WBI) and finger pressure was carried out for all patients pre-operatively and on the first post-operative day. Of the patients with AVF created at the elbow, there was a decrease of WBI in seven patients (70%) and a decrease of finger pressure in three (30%); one patient (14%) had steal syndrome. Creation of AVF at the wrist resulted in a decrease of WBI in one patient (6.25%) and a decrease of finger pressure in another patient (6.25%). WBI changes as a result of creation of AVF at the elbow were significantly greater than the changes of those fistulas performed at the wrist (P < 0.001). On the other hand, the difference between the effect of both procedures on finger pressure was statistically not significant. These results may help to explain the higher incidence of steal syndrome in patients with elbow fistulas compared to patients with wrist fistulas. Further studies on a larger scale are required to determine the value of non-invasive indices at which AVF creation would have future risk of compromised distal limb circulation.

Living unrelated transplantation (LURT) is emerging as a practical option in renal transplantation due to shortage of living related and cadaver donors. We report a six-years (December 1991 to December 1996) follow-up of 60 LURT patients. The majority of these patients (95%) were transplanted outside the Kingdom of Saudi Arabia; 37 in India, 14 in Egypt, five in the USA and one in Pakistan. Only three patients (emotionally related) were transplanted in Saudi Arabia. Before transplantation, 50 (83.4%) patients were on chronic hemodialysis, three (5%) on peritoneal dialysis and three (5%) were transplanted pre-emptively. Post-operatively, the majority of the study patients were on three drug immunosuppressive therapy. One and five year graft survival was 93.0% and 59.6%, while patient survival at one and three years was 93.7% and 81%, respectively. Surgical complications included lymphocele in 10% of the study patients, urinary leak in 8.3%, and bleeding from the vascular anastomosis in 6.6%. There were eight episodes of acute rejection in eight (13.3%) patients and all episodes were successfully treated; two patients required monoclonal anti-lymphocyte antibodies (OKT3). Eleven (18.3%) patients developed chronic rejection, which resulted in the loss of ten (90%) allografts. Infection was the commonest cause for hospital admission; urinary tract infection (UTI) being responsible for 40% of admissions. Three patients had Cytomegalovirus pneumonia, one had Pneumocystis Carinii pneumonia and one had candida pneumonia. Two (3%) patients developed Kaposi's sarcoma. We conclude that LURT can help in overcoming the shortage of organs for transplant, however, commercial transplantion in developing countries is associated with high morbidity and mortality.

One hundred fifty three kidney transplant recipients whose grafts functioned for longer than one year were evaluated for evidence of post-transplant diabetes mellitus (PTDM). Twenty-six patients (17%) developed PTDM. Patients with PTDM were older than controls (mean age 49.4 vs 37.9 years). There was no demonstrable association between sex of patients and PTDM. The body mass index (BMI) was persistently higher in patients with PTDM compared to controls, although the difference did not amount to statistical significance. The association of PTDM with HLA-A28, A30 and B8 observed in other studies was not seen in our patients. Similarly, neither the positive association of HLA-DR3 and DR4, nor the negative association of HLA-B7 and DR2 seen in population­based studies of insulin dependent diabetes mellitus, were seen in our patients with PTDM. To our knowledge, this is the first report that has looked into the association of HLA antigens and PTDM in Saudi Arabia.

Glomerulonephritis (GN) is one of the leading causes of end-stage renal disease. A good understanding of its pattern and prevalence as well as exploration of effective therapeutic strategies for protecting the glomerulus, would have tremendous impact on public health. In the Kingdom of Saudi Arabia (KSA), focal and segmental glomerulo sclerosis (FSGS) is the commonest type of primary glomerular diseases (PGD) encountered in clinical practice. Its prevalence varies from less than 4% in Gizan, in the southern part of KSA, to approximately 35% in Riyadh, central Saudi Arabia. In our experience, the nephrotic syndrome was the commonest mode of presentation of FSGS. Response to corticosteroid therapy is generally poor and the mortality rate is high. Mesangioproliferative GN is the second most common GN constituting up to 25% of PGD in our experience. Other researchers from different parts of the Kingdom, however, have given prevalence rates ranging from 8 to 57.1%. The reported prevalence of Immunoglobulin-A nephropathy (IgAN) in KSA ranges from 5.8% to 13.6%. It is more common in the elderly, and men are affected more often than women. In contrast to KSA, IgAN is the commonest PGD in Japan, China, Hong Kong, Singapore and Taiwan. Membranous GN (MGN) is less common in KSA than encountered elsewhere, the prevalence ranging from 3.9 to 21.8%. Nephropathy secondary to systemic diseases are also common in KSA. Lupus nephritis (LN) accounted for 48.5% of secondary glomerular diseases (SGD) with the combination of WHO classes III and IV (aggressive types of LN) accounting for 56% of all patients. LN is another disease where differences in racial susceptibility may account for the uneven distribution. Post-streptococcal GN seems to be declining in frequency in KSA, the reported prevalence ranging from 2.7% to 2.9%.

Tuberculous peritonitis (TBP) remains a major medical problem in many developing countries, wherein the incidence of tuberculosis (TB) is still high. Since the clinical presentation may be insidious and variable, diagnosis of TBP may be delayed or missed, resulting in undue patient morbidity and mortality. Tests frequently associated with TB such as chest radiograph and Mantoux test are not usually sensitive enough for the diagnosis of TBP. The diagnosis becomes all the more difficult in the presence of chronic liver disease and/or renal failure, since the ascitic fluid may not be of the exudative type and lymphocytosis may not be the predominant cell picture. We present here three cases of TBP in diabetic Saudi patients on maintenance hemodialysis who also had associated chronic liver disease. All three patients responded satisfactorily to standard anti­tuberculous therapy. We stress that high index of suspicion is required to establish early diagnosis of TBP particularly in patients with chronic renal and/or liver disease. Laparoscopy with tissue biopsy for histology and, microbiological examination including culture are the most sensitive and specific diagnostic procedures.

A 53-year-old renal allograft recipient developed nocardial cerebral abscess. It manifested clinically with encephalitis, polycythemia, convulsions, syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and a space-occupying lesion presenting as multiple ring shadows in the left fronto-parietal lobe on computerized tomography (CT scan) of the brain. The initial clinical presentation included an afebrile patient with headache, convulsions and altered sensorium with no lateralising neurological deficit. He deteriorated later and developed coma with right hemiplegia. Purulent material was drained through left frontal craniotomy, and the culture confirmed the presence of nocardial infection. Despite aggressive therapy, the patient died a few days later. We conclude that high degree of early suspicion, diagnosis and prompt treatment should be stressed.

A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.

Fifty consecutive patients of acute renal failure (ARF) seen over a period of two years at the Dammam Central Hospital, Dammam were studied. The mean age of the patients was 39.3 years ranging from 14 to 90 years. The main etiological factors for ARF were acute tubular necrosis (67.5%) and obstructive uropathy (30%). The mortality rate was 26% and the poor prognostic factors included sepsis, acidosis, shock and the need for emergency hemodialysis.