The peritoneal dialysis prescription was, for a long time, based on clinical experience and very empirical, especially for patients on continuous ambulatory peritoneal dialysis (CAPD). Better comprehension of the peritoneal membrane as a dynamic dialysis surface allows an individualized prescription, especially for children on automated peritoneal dialysis (APD). Fill volume prescription should be scaled for body surface area (mL/m²) and not in a too low amount to avoid a hyperpermeable exchange. Fill volume enhancement should be done under clinical control and is best secured by intraperitoneal pressure measurement (IPP; cm H2O). A peak fill volume of 1400-1500 mL/m² could be prescribed both in terms of tolerance and of efficiency. The dwell times should be determined individually with respect to two opposite parameters namely: short dwell times which provide adequate small solute clearance and maintain ultrafiltration capacity and long dwell times which enhance phosphate clearance but can contribute to dialysate reabsorption. The new peritoneal dialysis fluids which are free of GPD's, have neutral pH and are not exclusively lactate buffered, appear as the best choice in the context of peritoneal exchange membrane recruitment and of peritoneal vascular hyperperfusion preservation.

L-Carnitine supplementation has shown beneficial effects in patients on hemodialysis. We studied 36 ESRD adult patients with a mean age of 47.5 ± 15 years to evaluate the effect of L­Carnitine supplementation on hemoglobin, lipid levels and physical performance in patients on hemodialysis. The study group consisted of 18 randomly selected patients who received L-Carnitine 15 mg/kg and the control group consisted of 18 randomly selected patients who received equal volume of normal saline as a placebo three times a week for six months. Laboratory tests were performed at baseline, then monthly until the end of the study. A significant increase in the hemoglobin (Hb) and hematocrit (HCT) in the presence of unchanged doses of erythropoietin hormonal supplementation was observed (pre 79 ± 7.5 gm/l, post 103 ± 10.6 gm/l) P<0.001 (pre 24± 2 %, post 33 ± 4%) P<0.001 respectively) in the L-Carnitine treated group. Similarly total serum cholesterol (TCL) and serum triglyceride (TG) levels showed a statistically significant decrease in the study group, TCL (pre 4.6 ± 1.2, post 3.7 ± 1.1 mmol/L), P <0.03 and TG (pre 3.1 ± 1.7, post 1.8 ± 0.6 mmol/L) P < 0.004. The physical performance as assessed by mild and moderate exercise showed a trend towards improvement. There was a significant increase in free carnitine and total carnitine levels in the L­Carnitine treated group. In conclusion, these results demostrate positive effect of L-Carnitine supplementation in the hemodialysis patients marked by an increase in Hb, HCT, a decrease in TCL and TG and improved physical performance in comparison to the control group.

Mycophenolate Mofetil MMF has been widely used in post-transplant immunosuppression. Its role is emerging in GN. MMF demonstrated promising results compared with cyclosphosphamide in stage IV lupus nephritis, in a recently published trial. It has been found to have a wide safety profile, with mostly gastroinetestinal side effects, which can be avoided through titration. Its action is through inhibition of the enzyme IMDPH (ionosine monophosphate dehydrogenase), leading to purine antagonism and inhibition of lymphocytes. We were aiming to demonstrate the efficacy of MMF in our GN population. In this study, we reviewed 17 patients who received MMF (dose - 1 gm po bid) for the past year. They were only included if it was given for the management of resistant primary glomerulonephritis. Complete remission has been defined as proteinuria of less than 0.5 g/day and partial remission as a reduction of proteinuria < 50% of starting MMF therapy; all 17 MMF therapy patients uniformly achieved good BP (< 140/80) control. MMF was used for a minimum of 1 year and a maximum of 2 years. The results indicate that 7 patients (41%) had a partial remission to MMF. This group was composed of 2 membranous GN, 2 lupus GN (stage IV and stage V) and two with FSGS (1 with single kidney not biopsied) and one with MPGN. Five of 17 (29%) achieved complete remission and this group consisted of 1 membranous GN, 2 lupus GN (type IV and membranous), one FSGS and one with MPGN. Four of 17 (23%) were non-responders to therapy. This group articles.aspx? id=41 to side effects. We conclude that the MMF appears to be an effective alternate treatment modality in resistant membranous GN, lupus nephritis (type IV and V) and possibly MPGN, and to a lesser extent in resistant FSGS. Further prospective data may demonstrate the efficacy of MMF in GN.

To evaluate the complications of CAPD and their contributing factors in order to improve the patients' survival and reduce morbidity and mortality, we studied records of 65 CAPD patients treated at our hospital from October 1996 to January 2002. There were 32 (49%) males and the mean age of the patients was 48 ± 16 years. All the patients were on the twin bag CAPD system. The mean duration of follow-up on CAPD was 29 ± 20 months. There were 75 episodes of complications occurring in the patients with a rate of 0.41 episodes/patient years. Peritonitis was the most frequent and serious complication accounting for 55 episodes with a rate of 0.35 episodes/patient years. Only 51% of the episodes showed positive culture; the organisms included Staphylococcus epidermidis (18.2%), Staphylococcus aureus (3.6%), Pseudomonas (16.4%), E. coli (1.8%), Azadobacter (5.45%) and Serratia (3.6%). All the episodes of infection, except one, responded to treatment but 10 patients had recurrent infection; one patient was cured only after removal of the catheter. There were 12 exit site infection episodes and five catheters were removed due to mechanical and infectious reasons. Three patients were switched to hemodialysis (HD), nine patients were transplanted and 11 patients expired; none died due to peritonitis. We conclude that the mortality rate of the complications on CAPD has declined in the present study compared to our previous report early in the 1990s due mostly to the adoption of the twin bag CAPD system.

Sexual dysfunction impairs the quality of life of patients undergoing hemodialysis (HD). The aim of this study was to evaluate the prevalence and the nature of sexual dysfunction in a Moroccan cohort of patients with chronic renal failure (CRF) on HD. This cross-sectional study was carried out with a questionnaire in 86 patients undergoing hemodialysis. Clinical and biological investigations were done. The mean age of our patients was 46.27 ± 15.68 years old. 81.4% of the cases suffered from a decrease in sexual activity after the onset of HD. The decrease or the loss of libido was noted in 59.3% of the cases. Total impotence was present in 22.1% of the cases and 36% reported partial impotence. Ejaculation was present in 86% of the cases. The comparison between the group of patients who had no sexual dysfunction (group I) and the group of those who had this problem (group II) showed significant differences of age, social status and sexual life before HD. Other significant differences were found regarding frequency of intercourses and sexual satisfaction. Group II was divided into 2 subgroups: IIA included patients who had sexual dysfunction before HD and IIB: those who developed it after. The comparison of this subgroups showed that differences were significant regarding age, weight and vascular risk factors (diabetes mellitus, atherosclerosis). Sildenafil was more efficient in the patients of the subgroup IIB. This study suggested that HD was one of many factors causing sexual dysfunction in hemodialysed patients. After this clinical evaluation of sexual dysfunction, we emphasize the value of a global approach of this problem. The use of sildenafil seems to be more valuable in young patients with erectile dysfunction which appeared after long dialysis duration.

Renal transplantation is considered the optimal form of renal replacement therapy for patients with end stage renal disease. Kidney transplantation was started in Iraq in 1973 at Al-Rasheed military hospital after Jordan in 1972 and Lebanon in 1973. In this study we analyze retrospectively the data of (182) kidney recipient patients selected randomly from 1979 to 1999, including (165) male and (17) female patients. Their age ranging from 18 to 54 years and the follow up period was 0 to 240 months postoperatively. The average duration of dialysis before transplantation was 4 to 5 months. The donors in most instances were live related (89.6%). The immunosuppressive imereg include both double and triple therapy and all episodes of rejection were treated with pulse methyl prednisolon. The patient survival rates at 1, 5 and 10 years were 82.9%, 79.7%, and 71.2% respectively while the graft survival rate at 1, 5 and 10 years were 83.5%, 64.5% and 61.6% respectively. These results were found to be comparable to the average values of Arab countries reported in the survey of Arab Society of Nephrology & Renal Transplantation (ASNRT) in 1999. All the medical and surgical complications encountered in our series are described and discussed and the effect of sanction imposed on Iraq is clarified.

Hemodialysis (HD) patients are at considerably high risk for vascular access­related blood stream infections (VRBSI) that result in serious complications. Such severe infections are a great deal more frequent with central venous catheters (CVCs) and polytetrafluoroethylene (PTFE) grafts than with arteriovenous fistula (AVF). Nonetheless, the CVCs, though having "undesirable" side effects, remain "unavoidable" for the patients requiring instant dialysis access, as a consequence of the unpredictable course of chronic renal disease. Although early antibiotic treatment should include the coverage for Staphylococcus aureus, the treatment of catheter-related blood stream infections (CRBSI) remains controversial. Antimicrobial- anticoagulant 'locks' have shown promising results in several recent randomized controlled trials in the treatment and prevention of CRBSI. Policy of increasing AVF prevalence beyond 50% is bound to have an enduring positive effect on HD outcomes. Standard infection control measures for hygiene and aseptic handling of CVCs cannot be overemphasized. The catheters with 'bioactive' surface with thrombo-resistant and infection-resistant properties will be available in the near future.

Chronic renal failure develops in 4-18% of patients with sickle cell anemia. Hemodialysis and kidney transplant are viable options in the management of end-stage renal disease in patients with sickle cell disease (SCD). Information on kidney disease among Saudi patients with SCD is non-existing. In this report, the clinical course of two adult males with end-stage sickle cell nephropathy from Eastern Saudi Arabia is described. Literature on renal replacement therapy in sickle cell anemia (SCA) is discussed.

Retroperitoneal fibrosis is an uncommon disease that can be defined as the presence of a fibrous mass, which surrounds vascular structures and ureters. The start of the disease is insidious but can be diagnosed by radiological means such as computerized tomography and magnetic resonance imaging. Steroids and immunosuppressive agents may prevent progression toward advanced renal failure. We report a case of 41-year-old man who presented with bilateral renal colic as the only clinical manifestation of this disease and its favorable response to treatment.

Occurrence of chronic renal disease in more than one member of a family is not uncommon. Here, we studied 29 families with such status. Genetic and heredofamilial causes were evaluated. These families have to be recognized for family counseling and the study of the pathogenesis of chronic renal failure.

Chronic kidney disease (CKD) is a world-wide public health problem, the causes of which differ in children from that reported in adult patients. There is an increased incidence of congenital and hereditary diseases causing chronic renal failure in the pediatric age-group and virtually no diabetic nephropathy. To determine the major causes, clinical expression, course, and outcomes of CKD in Syrian children we conducted a prospective study from February 2002 to February 2003 in the pediatric nephrology department at the Kidney Hospital in Damascus, Syria. Fifty-five patients with varying degrees of renal impairment were involved in the analysis. A total of 31 children (56%) had obstructive nephropathy (ON) as the cause of chronic renal insufficiency and 24 children (44%) had non-obstructive nephropathy (Non-ON). Neurogenic bladder was the commonest cause of ON, seen in 15 patients (27%), nephrolithiasis was seen in 10 patients (18%), urethral stenosis in three (5%), Uretro-Pelvie Junction (UPJ) stenosis in two (3%), and posterior urethral valves in one case (2%). Chronic glomerulonephritis and renal hypoplasia were the commonest causes of non­ON seen in six patients each (11%). Reflux nephropathy was seen in four patients (7%), hereditary nephritis in three (5%), polycystic kidney, nephrocalcinosis and Prune Belly syndrome in one case each (2%), and the cause was unknown in two patients (3%). The study is still ongoing and will be reviewed after two years with a bigger sample and possibly more reliable results.

Diabetes is the main cause of end-stage renal disease (ESRD) in the developed countries and its prevalence and incidence have been constantly increasing over the years. To determine the prevalence and profile of diabetic nephropathy in our ESRD population, we retrospectively studied 564 hemodialysis patients in ten dialysis units in Casablanca. The mean age was 49 ±16.2 years. The diabetic nephropathy came at the third rank with a prevalence of 13.5% behind chronic glomerulonephritis (21.8%) and hypertensive nephropathy (14.7%). Almost 74% of our diabetics were type 2. From the time of diagnosis the type 2 diabetics reached the ESRD earlier than the type 1 diabetics with a mean period of 15.1 ± 7 years and 18.8 ± 5 years, respectively; however, the difference was not statistically significant. There was at least another microangiopathic complication in 95.4% of the patients and macroangiopathic complication in 82%. The median hemoglobin A1C in all patients was higher than normal value. We conclude that ESRD is a serious complication of diabetes, which is constantly increasing. The appropriate management of diabetes and a multidisciplinary approach are necessary to avoid it or at least delay its occurrence.