As the powerful tools of molecular biology continue to delineate new concepts of pathogenesis of diseases, new molecular-level therapeutic modalities are certain to emerge. In order to design and execute clinical trials to evaluate outcomes of these new treatment modalities, we will soon need a new supply of investigators with training and experience in clinical research. The slowly-progressive nature of chronic pediatric kidney disease often results in diagnosis being made at a time remote from initial insult, and the inherently slow rate of progression makes changes difficult to measure. Thus, development of molecular markers for both diagnosis and rate of progression will be critical to studies of new therapeutic modalities. We will review general aspects of clinical trials and will use current and past studies as examples to illustrate specific points, especially as these apply to chronic kidney disease associated with obstructive uropathy in children.

To consider the correlation of serum parathormone on severity of hypertension in end­stage renal disesase (ESRD) patients on hemodialysis (HD). A cross-sectional study was done on patients with ESRD on treatment with maintenance HD. Levels of serum calcium, phosphorus, alkaline phosphatase, albumin and intact parathormone (iPTH) were measured. Stratification of hypertensive patients was done from stages one to three. The total number of patients studied was 73 (Females=28, Males=45), consisting of 58 non-diabetic (F=22 M=36) and 15 diabetic patients (F=6 M=9). The mean age of the study patients was 46.5 ± 16 years.The mean duration on HD of the study patients was 21.5 ± 23.5 months. The mean serum PTH of the study patients was 309 ± 349 pg/ml and the mean serum alkaline phosphatase was 413 ± 348 IU/L. There was a significant positive correlation between the stage of hypertension and serum PTH levels (r =0.200 p=0.045). Also, there was a significant positive correlation between stage of hypertension and calcium-phosphorus product (r = 0. 231 p=0.027).There was no significant correlation between stage of hypertension and serum ALP (r =0.135 p=0.128). Relationship between serum PTH and severity of hypertension in patients on HD needs to be studied in more detail. Hypertention and secondary hyperparathyroidism interact in the process of accelerated atherosclerosis in HD patients thus warranting appropriate measures to control hyperparathyroidism vigorously.

To evaluate the response to alpha-interferon (INF) in patients who develop acute hepatitis C virus (HCV) infection during hemodialysis, we studied 17 patients who had infection while on dialysis. We administered three million units of alpha interferon subcutaneously to nine adult patients three times per week for 12 weeks; the rest of the patients served as controls. The patients in both groups were followed for 24 months after the diagnosis of seroconversion to anti-HCV antibody. Serum alanine aminotransferase (ALT) levels, anti-HCV antibody levels and HCV- poly chain reaction (HCV-PCR) were performed at regular intervals during the follow-up. Two patients in the treatment group dropped out; one because of colitis and another because of non-compliance. Of the seven patients who completed the course of therapy, all the patients had normal serum ALT levels in 2-8 weeks of therapy, three (42%) patients converted back to anti-HCV antibodies negative and six (86%) had HCV-PCR negative at 12 weeks of therapy (primary virological response) and remained so till the end of follow-up (sustained virological response). The liver biopsy performed in all the responders to therapy at 4-24 months after completion of treatment showed mild hepatitis. In the control group, all the patients continued to have raised serum ALT levels throughout the study; 12% converted anti-HCV antibodies to negative and HCV-PCR (performed on five patients) remained positive during the whole study period. In conclusion our study suggests the efficacy and safety of alpha interferon in the therapy of acute HCV infection in hemodialysis patients.

We attempted in this study to evaluate the attitude of the physicians in The Kingdom of Saudi Arabia (KSA) towards the use of recombinant human erythropoietin (r-HuEPO) in patients on hemodialysis (HD). We sent a questionnaire to 181 physicians in the 147 active dialysis centers in KSA; 110 (74.9 %) of them were under the Ministry of Health (MOH), 14 (9.5%) in Governmental non-MOH hospitals and 23 (15.6 %) were in private hospitals. This covered a population of more than 7300 chronic HD patients. The study was conducted from October to December 2004. Response was obtained from 144 physicians (79.5%), working in 135 dialysis centers (92.5%) that totally treated 7107 (97%) HD patients in the KSA. Of the 144 respondents, 99 (72.8%) responded that they would use r-HuEPO therapy for all new HD patients not guided by hemoglobin (Hb) level. Almost all the respondents would start the patients on a weekly dose of < 200 units/kg, while they would maintain the patients on a weekly dose of < 150 units/kg. Written protocols to guide the administration of r­HuEPO were available in only half of the dialysis centers. A total of 83 respondents (58%) would aim at a target Hb of 110-120 g/l while 29 (20.3%) would go higher to 121-130 g/l. There were 51 (37.5%) respondents who considered multi-dose vials of the drug better for expense saving. There were 35 (24.8%) respondents who believed the type of r-HuEPO (alfa, beta) determines the development of the antibodies to r-HuEPO, while 84 (59.6%) had no idea. After regrouping of the respondents according to their affiliation, there was a significantly less percentage of the MOH centers which treated > 70% of the dialysis patients with the drug in comparison with the non-MOH and private sector centers (81% vs 100%, respectively P<0.04). There was a significantly less percentage of MOH than the non­MOH centers to have a written protocol for administration of r-HuEPO (49.1% vs 95% respectively, P<0.0002). In conclusion, a protocol to guide the r-HuEPO therapy in HD patients is lacking in many centers of the KSA and there is a need for increased awareness of the physicians working in those centers in the practical aspects of the use of this drug in the treatment of anemia in this population

We have introduced an annual timetable format for addressing the "primary care" needs of the hemodialysis population. For 102 patients enrolled, fourteen interventions adapted for the dialysis population from the US Preventive Services Task Force recommendations were implemented successfully in 65% areas in our pilot year, which include important features like annual history and physical examination, breast examination, mammography, pap smear, lipid profile, adult specific immunization and stool occult blood. Flexible sigmoidoscopy program was unsuccessful in our pilot year.

The health related quality of life (HRQOL) has not been compared between live related and un-related donations. We set out to assess the HRQOL in 52 recipients and compare them to 68 HD patients using the Karnofsky performance status scale. Statistical package for social sciences (SPSS) was used for data analysis. The duration of end-stage renal disease was 7.14 + 3.8 years and 5.30 + 4.15 years for transplant and HD patients respectively. The HRQOL was similar in both living and emotionally related recipients but both were significantly better than that of HD patients (P < 0.0001). There was significant negative correlation between HRQOL and age (r = -0.363, P < 0.0001), serum creatinine (r = -0.502, P = 0.0001), serum urea (r = -0.493, P < 0.0001), serum phosphate (r = -0.363, P = 0.003) and calcium-phosphate product (r = -0.305, P < 0.0001). There was significant positive correlation between HRQOL and haemoglobin (r = +0.495, P < 0.0001) and serum calcium (r = +0.247, P = 0.017). Age of the patients appears to be the most important determinant of HRQOL in the studied population. HRQOL was similar in the related and unrelated donors and was better than in hemodialysis patients.

Acute tubulo-interstitial nephritis (ATIN) is an important cause of acute renal failure, where renal impairment tends to be variable but recovery is the rule. End-stage renal failure (ESRF) has been rarely reported as a complication of ATIN. We report here a case of idiopathic ATIN that resulted in severe acute renal failure. The patient developed ESRF, which required permanent renal replacement therapy.

Glue sniffing refers to the deliberate inhalation of volatile solvents, commonly found in adhesives, for the purpose of intoxication. The globally increasing prevalence of glue sniffing suggests that physicians will encounter many such patients some time during their practice. We present a 19-year-old male who presented with acute abdomen and renal failure. He was treated conservatively and had complete recovery of renal functions in a week. The etiology of renal failure remained elusive on admission. While recovering from his illness, the patient revealed history of glue sniffing. The aim of presenting this case is to spread awareness among clinicians that glue sniffing should be considered in the differential diagnosis of unexplained acute reversible renal failure, particularly in young patients.

We report a case of a 32-year-old man who presented with invasive pulmonary aspergillosis and bronchial ulcerations that resulted in massive hemoptysis and concomitant thrombotic microangiopathy shortly after cadaveric renal transplantation. Despite vigorous antifungal therapy the patient succumbed due to apoplexy of brain fungal mass lesion.

This is a prospective study of the outcome of patients with end-stage renal disease (ESRD) on regular hemodialysis admitted to a referral hospital in Madinah Al Munawarah, Saudi Arabia during a six-month period from January-June 2003. Ninety four patients out of 395 (23.7%) patients on regular hemodialysis were admitted 125 times of whom 27 (28.7%) patients were admitted twice; males accounted for 58.5% of the patients. The mean hospital stay period was 9.1 days per patient. The major cause of ESRD was diabetes mellitus (40%) followed by hypertension (13.6%). The main cause for admission was the vascular access related problems (33.6%) followed by infection (31.2%) and cardiovascular causes (18.4%). Most of the admissions were in the general ward but 17 % of the total stay in hospital was in the intensive care unit. Twelve out of the 94 (12.7%) study patients died during the study period; five patients died of cardiac failure, three of septicemia, one of severe gastrointestinal bleeding and one of Wegner's syndrome complicated by severe intra-pulmonary bleeding. Two patients had sudden death (most likely due to cardiac disease). In conclusion, our experience with morbidity and mortality of the hemodialysis patients admitted to hospital is comparable to other places in the world.

Renal transplantation (RTx) is widely accepted as the preferred method of treatment for children with end-stage renal disease (ESRD). This is a retrospective analysis of the results of RTx in children performed at the Surgical Kidney Hospital, Damascus, Syria. Between November 2002 and November 2004, a total of 176 RTx procedures have been performed in our center. Of them, 11 recipients (6%) were younger than 14 years of age. The mean age was 11 years with range of 5 to 14 years. There were six males (55%) and five females (45%). All patients received kidneys from living donors. Seven donors were related (64 %) while four (36%) were unrelated .The cause of ESRD in these patients were reflux nephropathy in three, nephronophthisis and hypoplastic kidneys in two cases each and polycystic kidney disease, rapidly progressive crescentic glomerulonephritis, Alport's syndrome and chronic pyelonephritis in one patient each. All grafts were placed extra-peritoneally. Immunosuppression was based on triple therapy with cyclosporine (CsA) mycophenolate mofetil (MMF), and prednisolone. Tacrolimus (TAC), MMF, and prednisolone, and sirolimus (SRL), MMF, and prednisolone were used in one patient each. Induction immunosuppression in immunologically high-risk patients was, with anti-thymocyte globulin (ATG) in one patient and basiliximab in two patients. The mean duration of follow-up was 12 months {3 to 24 months}. All 11 (100 %) patients were alive at last follow-up with functioning graft. Ten patients (88%) had normal graft function and one (12%) had mild graft dysfunction. Complications encountered were infections in four patients, early steroid-responsive acute rejection in one patient, and mild biopsy-proven chronic rejection in another patient; the latter probably due to poor compliance. No urological complications were encountered. Our study, despite involving a small number of patients with a relatively short duration of follow-up, suggests that the results of pediatric renal transplant at our center are encouraging.

This is a retrospective study of the course of children who received peritoneal dialysis (PD) at King Abdul Aziz Hospital, Jeddah, Saudi Arabia, from June 2000 to June 2004. A total of 15 children (9 boys and 6 girls) with end-stage renal failure (ESRF) received PD for a mean duration of 9 ± 8.6 months; 11 children received continuous ambulatory dialysis (CAPD) and four received automated PD. The mean age of the children at the start of PD was 7.3 ± 4.3 years. All the children had low socio-economic status. The most common complication was peritonitis (53%) followed by exit site infection (26.6%). The over all rate of peritonitis was one episode per 5.9 patients treatment months. Five children had recurrent peritonitis. Gram negative bacteria were the cause of peritonitis in 43.5% of the cases, gram positive in 30.4%, fungi in 8.9% and unknown in 17.4%. PD catheters were removed in five children; four because of infection and one because of obstruction. Three children were shifted to hemodialysis permanently, two children received renal transplantation from living donors and five children died. There was no difference in the age, duration of therapy or number of siblings, between the eight children who had peritonitis and the seven children who did not have peritonitis. However, illiteracy was higher and a separate room was less available in the peritonitis group compared to the peritonitis free group (37.5% vs 14.3% and 50% vs 100%, respectively). In conclusion; PD may still be a suitable modality of renal replacement therapy for children living in low socioeconomic conditions despite the challenging problems in them.