Malaria has protean clinical manifestations and renal complications, particularly acute renal failure that could be life threatening. To evaluate the incidence, clinical profile, out­come and predictors of mortality in patients with malarial acute renal failure, we retrospectively studied the last two years records of malaria induced acute renal failure in patients with peripheral smear positive for malarial parasites. One hundred (10.4%) (63 males, 37 females) malaria induced acute renal failure amongst 958 cases of acute renal failure were evaluated. Plasmodium (P). falciparum was reported in 85%, P. vivax in 2%, and both in 13% patients. The mean serum creatinine was 9.2 ± 4.2 mg%, and oligo/anuria was present in 82%; 78% of the patients required hemodialysis. Sixty four percent of the patients recovered completely, 10% incompletely, and 5% developed chronic kidney failure; mortality occurred in 21% of the patients. Low hemoglobin, oligo/anuria on admission, hyperbilirubinemia, cerebral malaria, disseminated intravascular coa­gulation, and high serum creatinine were the main predictors of mortality. We conclude that ma­laria is associated with acute renal failure, which occurs most commonly in plasmodium falci­parum infected patients. Early diagnosis and prompt dialysis with supportive management can reduce morality and enhance recovery of renal function.

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Varicocele is still an enigma. Its effects on semen analysis, fertility and, more re­cently, early ejaculation and spontaneous abortion in spouses are not yet fully understood. In this retrospective study, we evaluated these four parameters (semen analysis, fertility, early ejacu­lation and spontaneous abortion among spouses) in relation to varicocele and varicocelectomy during a 13-year period. A total of 1,711 patients with varicocele underwent varicocelectomy by high inguinal method (251 cases), subinguinal method (1,375 cases), scrotal method (34 cases), and subinguinal method with local anesthesia (38 cases). Our complication rate was acceptable. Sperm count, motility and morphology increased three months post operation in 55, 51, and 46%, respectively (P value 0.000, 0.000, and 0.015, respectively). Paternity was 56% after one year of post varicocelectomy follow-up. Only 7 out of 82 azoospermic men had sperm in their semen after varicocelectomy and only one of them with mild spermatogenic hypoplasia became a father. The spontaneous abortion rate in the spouses of respondents was 59%. Early ejaculation improved in 75% of the respondents. In conclusion, varicocelectomy does not improve sperm parameters in all men, but it improves pregnancy rate, early ejaculation, and scrotal pain.

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To evaluate the prevalence of anti-hepatitis C virus (HCV) among the hemodia­lysis patients and to identify the risk factors of infection in relation to age, sex, blood transfusions, duration of dialysis and primary cause of end stage-kidney disease. We studied 51 patients who were on chronic hemodialysis (HD) at the Al-Gamhourea Teaching Hospital, Aden, Yemen, du­ring Jan-Dec 2007. All the patients were tested for anti-HCV antibody, and we used 100 healthy blood donors as controls. The anti-HCV antibody prevalence rate among the HD patients was found to be significantly higher than that in the control group (62.7% and 0.8%, respectively). The prevalence rate of anti-HCV antibody was higher among men (64%) than that in women (35%). The anti-HCV antibody-positive patients were significantly older than the anti-HCV-anti­body-negative patients (66.5 ± 14.4 years versus 57.5 ± 15.4 years; P = 0.01). Diabetic nephro­pathy was a more frequent cause of end-stage renal disease among the anti-HCV antibody­positive patients (30%) than among the anti-HCV antibody-negative patients (19%). Among the anti-HCV-positive patients, 80% had received a blood transfusion, which was significantly higher than the 20% rate among the anti-HCV antibody-negative patients (P < 0.001).

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With the advent of potent immunosuppressive therapies in solid organ trans­plantation, patients are more susceptible to a variety of infections with atypical pathogens and presentations. We report a renal transplant recipient with atypical presentation of histoplasmosis.

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Long-term immunosuppressive therapy after renal transplantation increases the risk of developing malignancy. The aim of this study was to determine the demographic parameters and immunosupression protocol in kidney transplant recipients with and without malignancy. This case-control study was undertaken on 12 renal transplant recipients with malignancy and 48 with­out malignancy at The Shahid Beheshti Kidney Transplantation Center in Babol (north of Iran). Data including age, gender, number of anti-rejection therapies and immunosupression regimen were recorded and analyzed with SPSS and Mann-Whitney Fisher's exact t-test. P value < 0.05 was considered significant. The prevalence of malignancy in 380 renal allograft recipients was 3.15% during six years of follow-up. The malignancies noted after renal transplantation included: Kaposi's sarcoma (n = 5), lymphoma (n = 3), cutaneous basal cell carcinoma (n = 2), cutaneous squamous cell carcinoma (n = 1) and brain tumor (n = 1). Age of patients at the time of trans­plantation, duration of immunosupression treatment and number of anti-rejection therapies were not significantly different in patients with and without malignancy (P > 0.05). Males were signi­ficantly more affected with malignancy compared to females (P < 0.05). Our study shows that there was no significant correlation between age at transplantation, duration of immunosupression treatment and number of anti-rejection therapies and occurrence of post-renal transplantation malignancy; however, the prevalence of malignancy was significantly higher in male patients. The most common malignancy seen was Kaposi's sarcoma followed by lymphoma.

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A maximum of efficacy with a minimum of toxicity is the ultimate goal of immuno­suppressive therapy. Calcineurin inhibitors are widely used as immunosuppressive drugs, and there is still a discussion about the optimal blood levels of cyclosporine A (CsA) and tacrolimus (Tac), balancing safety and efficacy. Monitoring of calcineurin inhibitor therapy is usually per­formed by blood trough levels, pharmacokinetics such as measurement of two-hour peak levels, or by various areas under the curve assessments (AUC, 4 to 12 hours). All these mentioned phar­macokinetic measurements cannot predict the individual biological effects of the immuno­suppressive drug. Several approaches have been undertaken to measure immunosuppression by calcineurin inhibitors. In this manuscript, general and specific immune monitoring strategies of calcineurin inhibitors and their clinical benefits are discussed.

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To assess the effect of aqueous extract of Carum carvi seeds in experimentally induced diabetic nephropathy (DN) in rodents, we studied 48 adult male Wistar rats divided into 4 groups: normal controls (group A), diabetes positive control (group B), and experimental (groups C and D). They received Carum carvi extract as a renoprotective agent. Rats having fasting blood glucose levels over 280 mg/dL were included in this study. Group C rats received STZ (60 mg/kg) and aqueous extract of Carum carvi at 30 mg/kg of body weights. On the other hand group D rats received STZ (60 mg/kg) and aqueous extract of Carum carvi at 60 mg/kg of body weight. Blood samples were collected on the 60 ^th day, and kidneys were also extracted for examination. The diabetic group rats showed a variable increase in the serum levels of glucose, urea, creatinine, total urinary protein and microalbuminuric levels. Body weight decreased and urine volume increased in the diabetic groups. 30 mg/kg body weight of Carum carvi dose decreased the levels of these parameters in rats. On the other hand, 60 mg/kg body weight of Carum carvi dose significantly decreased the levels of the biochemical parameters. The morphological examination of group C rats showed no changes whereas the rats in group D showed moderate changes. Carum carvi constituents, especially flavonoids and carvone have strong anti-oxidant activity, which provides reno-protection against diabetes and its complications. In conclusion, high dose of Carum carvi aqueous seeds extract (60 mg/kg) showed reno-protection against STZ induced dia­betic nephropathy in rats.

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Hepatitis C virus (HCV) is one of the perilous problems in hemodialysis (HD) centers around the world. There are many risk factors regarding HCV infection in HD units. The aim of this study was to evaluate the incidence of HCV infection in HD units and also to assess the potential risk factors in this regard. A total of 334 patients on regular HD were evaluated. All the patients were seronegative for anti-HCV antibody in the beginning of this study. They were followed every 6 months with repetition of tests. Positive samples were tested by polymerase chain reaction (PCR) for confirmation. The prevalence of HCV infection was about 20%. No sig­nificant relationship between numbers of blood transfusion, age and sex was obtained. A positive correlation between HCV infection and duration of HD for more than 5 years was significant. In conclusion, our study found the prevalence of HCV infection to be significantly higher than its incidence in the general population.

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Cystic kidney disease is an important cause of chronic renal failure. Since the utili­zation of imaging techniques in the diagnosis of diseases has become widespread, cystic kidney disease is now being increasingly diagnosed. This study is designed to determine the prevalence and pattern of cystic kidney disease at the Nephrology Unit of University of Ilorin Teaching Hospital (UITH), Ilorin. All consecutive adult patients seen in the Nephrology Unit of UITH during a ten-year period (January 1999-December 2008) were studied for the presence of cystic kidney disease. The results were analyzed with specific reference to age, gender, annual inci­dence, type of cystic disease, location of cyst, mode of presentation, complications and prognosis. A total of 67 out of 436 renal patients (15.4%) studied had cystic kidney disease. A progressive annual increase in the number of cases was noticed. The age-range was 20-83 years with a mean of 47.4 +/- 16.2 years and the peak incidence was in the third and sixth decades with male to female ratio of 1.3:1. The types of cystic kidney disease identified in the study were: 26 simple cysts (38.8%), 35 polycystic kidney disease (53.3%) and six multicystic kidney disease (8.9%). The most common mode of presentation was abdominal pain followed by hypertension, urinary tract infection, chronic renal failure and palpable abdominal mass, in decreasing order. Our study indicates that cystic kidney disease is not an uncommon problem among our renal patients and the incidence is on the increase. Although, routine screening of family members with cystic kidney disease still remains a contentious issue because the knowledge may evoke anxiety in terms of employment and insurance, screening of symptomatic cases or those that develop hypertension, hematuria and proteinuria is strongly recommended.

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Continuous renal replacement therapy (CRRT) has proved to be beneficial for the treatment of critically ill patients with acute renal failure (ARF). The aim of this study is to determine the outcome and identify the predictors of mortality of critically ill patients treated with CRRT for ARF in the intensive care unit (ICU). This prospective cohort study of critically ill patients with ARF requiring CRRT admitted to the ICU was carried out at a tertiary care hospital in Saudi Arabia from 2002 to 2008. A total of 644 of 7173 patients with ARF required CRRT were studied. About 9% of the ARF patients required CRRT and comprised mainly those with medical causes, carrying a mortality of 64%. Multivariate analysis found high serum creatinine as an independent factor for better outcome and requirement of mechanical ventilation (MV) as an independent factor for worse outcome. In our cohort study, ARF requiring CRRT in the ICU was associated with a high mortality.

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Wegener's granulomatosis usually presents with focal necrotizing glomerulonephritis with crescents. We present here a 45-year old man who was treated for tuberculosis and later pre­sented with bilateral ankle swelling. His serum creatinine was 2.4 mg/dL and urine analysis revealed hematuria and proteinuria. His 24-hour urine protein excretion was 1.9 g. Anti neutrophil cytoplasmic antibodies (ANCA) test was positive with cytoplasmic florescence pattern. Renal biopsy revealed focal segmental sclerosis with no active vasculitis and lung biopsy revealed extensive breakdown with cavitations and scattered granulomas.

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We report a case of a 32-year-old female who presented with right flank pain. Ultrasonography done for hematuria 10 years ago indicated the presence of renal cysts in the right kidney, but she had been asymptomatic since then. This history attracted our attention to the possibility of "localized renal cystic disease" (LRCD). Diagnosis was confirmed by computerized tomogram, negative renal ultrasound of one of the parents and absence of family history of renal disease. She is still being followed up for the last 3 years and is doing well. LRCD has been given various names since it was first recognized as a distinct clinical entity but the term LRCD appears to be the most accurate. Here, we present a brief discussion of clinical significance, diagnosis and differentials of this rare condition.

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The aim of this prospective study was the assessment of left ventricular and right ventricular diastolic function in patients on hemodialysis (HD) and the correlation of this func­tion with the duration of HD. The study included 42 patients (22 females and 20 males) with chro­nic renal failure (CRF), treated with HD, and 40 healthy subjects (24 females and 16 males) with no history of cardiovascular disease and with normal renal function, who constituted the control group. The groups were matched for age and sex. All study patients and control subjects under­went detailed history taking and physical examination. They also underwent electrocardiogram, echocardiography and biochemical and hematological blood analyses. Significant differences were noted between the two groups in the two-dimensional and M-mode echocardiography findings concerning aortic root dimension, transverse diameter of the left atrium, thickness of the inter-ventricular septum, thickness of the left ventricular posterior wall, left ventricular diastolic diameter, left ventricular systolic diameter, shortening fraction, ejection fraction as well as findings from the pulse Doppler study, including E wave, A wave, E/A ratio, deceleration time of E wave (DT-E), acceleration time of E wave (AT-E), tricuspid E and A waves (E _tr and A _tr ) and E _tr /A _tr , ratio. There were significant changes in HD patients without arterial hypertension as well in the control group subjects. Our study suggests that the left ventricular and left atrial dimensions as well as the left ventricular wall thickness are augmented in patients with CRF treated with HD compared with the control group. Additionally, the left and right ventricular diastolic function is also reduced in these patients. These differences were also noted in patients with CRF without arterial hypertension. Left ventricular diastolic dysfunction had no correlation with the duration of HD.

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There are no available data about the prevalence of chronic kidney disease (CKD) and its risk factors in the general population of the kingdom of Saudi Arabia. To estimate the prevalence of CKD and its associated risk factors in the Saudi population, we conducted a pilot community-based screening program in commercial centers in Riyadh, Saudi Arabia. Candidates were interviewed and blood and urine samples were collected. Participants were categorized to their CKD stage according to their estimated Modification of Diet in Renal Disease (MDRD3)-based, the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the presence of albuminuria. The sample comprised 491 (49.9% were males) adult Saudi nationals. The mean age was 37.4 ± 11.3 years. The over­all prevalence of CKD was 5.7% and 5.3% using the MDRD-3 and CKD-EPI glomerular filtration equations, respectively. Gender, age, smoking status, body mass index, hypertension and diabetes mel­litus were not significant predictors of CKD in our cohort. However, CKD was significantly higher in the older age groups, higher serum glucose, waist/hip ratio and blood pressure. Only 7.1% of the CKD patients were aware of their CKD status, while 32.1% were told that they had protein or blood in their urine and 10.7% had known kidney stones in the past. We conclude that prevalence of CKD in the young Saudi population is around 5.7%. Our pilot study demonstrated the feasibility of screening for CKD. Screening of high-risk individuals is likely to be the most cost-effective strategy to detect CKD patients.

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To compare the accuracy of artificial neural network (ANN) analysis and multi­variate regression analysis (MVRA) for renal stone fragmentation by extracorporeal shock wave lithotripsy (ESWL). A total of 276 patients with renal calculus were treated by ESWL during December 2001 to December 2006. Of them, the data of 196 patients were used for training the ANN. The predictability of trained ANN was tested on 80 subsequent patients. The input data include age of patient, stone size, stone burden, number of sittings and urinary pH. The output values (predicted values) were number of shocks and shock power. Of these 80 patients, the input was analyzed and output was also calculated by MVRA. The output values (predicted values) from both the methods were compared and the results were drawn. The predicted and observed values of shock power and number of shocks were compared using 1:1 slope line. The results were calculated as coefficient of correlation (COC) (r2 ). For prediction of power, the MVRA COC was 0.0195 and ANN COC was 0.8343. For prediction of number of shocks, the MVRA COC was 0.5726 and ANN COC was 0.9329. In conclusion, ANN gives better COC than MVRA, hence could be a better tool to analyze the optimum renal stone fragmentation by ESWL.

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Preoperative severe renal impairment is included in the risk scores to predict out­come after open cardiac surgery. The purpose of this study was to assess the impact of pre­operative mild renal impairment on the early postoperative mortality after open heart surgery. Data of all cases of open cardiac surgery performed from January 2005 to June 2006 were collec­ted. Cases with preoperative creatinine clearance below 60 mL/min were excluded from the study. Data were retrospectively analyzed to find the impact of renal impairment on short-term outcome. Of the 500 cases studied, 47 had preoperative creatinine clearance between 89-60 mL/min. The overall mortality in the study cases was 6.8%. The mortality was 28.7% in those who developed postoperative ARF, 33.3% in those who required dialysis and 40.8% in those with preoperative mild renal impairment. Binary logistic regression analysis showed that female gender (P = 0.01), preoperative mild renal impairment (P = 0.007) as well as occurrence of multi organ failure (P < 0.001) were the only independent variables determining the early postoperative mortality after cardiac surgeries. Among them, preoperative mild renal impairment was the most significant and the best predictor for early postoperative mortality after cardiac surgery. Our study suggests that renal impairment remains a strong predictor of early mortality even after adjustment for several confounders.

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Individuals with chronic renal disease (CKD) are prone to have accelerated process of atherosclerosis. Importantly, cardiovascular disease is the main cause of morbidity and mortality in kidney transplant recipients. Recent studies suggest a potential benefit of the lipid lowering medica­tions in preventing cardiovascular events in the CKD and the transplant populations. In particular, statin was shown to be effective in reducing low density lipoprotein (LDL)-cholesterol. However, refractory dyslipidemia and difficulty in lowering LDL to target were reported with the CKD and the kidney transplant patients. The second United Kingdom Heart and Renal protection study (UK­HARP-II) showed that the addition of ezetimibe to simvastatin was safe and effective in treating dyslipidemia in CKD. Furthermore, the combination of ezetimibe and statin was also effective and safe in treating dyslipidemia in kidney transplant recipients. The Study of Heart and Renal Pro­tection (SHARP) trial will evaluate the effects of lowering LDL-C with ezetimibe 10 mg and simvastatin 20 mg daily versus placebo in 9,000 patients with chronic kidney disease. The current evidence suggests that the addition of ezetimibe to satin is effective and safe in treating dyslipidemia in the CKD and the kidney transplant patients. Future clinical trials are needed to determine whether ezetimibe will reduce cardiovascular risk in the CKD patients.

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Acute Antibody Mediated Rejection (AMR) is rarely reported as a long-term com­plication of renal transplantation, and it can present on top of another chronic pathology affecting the graft. A 45-year-old gentleman with chronic kidney disease due to unknown etiology received renal transplantation from his sister with 4 HLA mismatches. He received antithymocte globulin induction therapy and was maintained on steroids, azathioprine (AZA) and cyclosporine A (CsA). Up to eight years post-transplantation he was clinically and biochemically stable. He lost follow­up for about one year, and then presented with nephritic nephrotic syndrome and rise of serum creatinine (SCr.) to 210 μmol/L. Graft biopsy revealed picture suggestive of acute AMR on top of de novo membranoprolipherative glomerulonephritis (MPGN) with focal crescent formation, diffuse immune complex deposition and peri-tubular capillaries C4d positivity. Anti-HLA donor specific antibodies were highly positive for B and T cells class I and class II. The patient was treated with intravenous immunoglobulin, plasma exchange and anti-CD20 (rituximab). AZA was changed to mycophenolate mofetil and CsA to tacrolimus. He had partial response, but SCr. continued at 220 μmol/L.

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Increased predilection for hypokalemia-induced rhabdomyolysis has been noted in pregnant women. We managed a woman with distal renal tubular acidosis (RTA) with persistent hypokalemia who presented with recurrent rhabdomyolysis in her consecutive pregnancies despite adequate potassium citrate therapy.

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A 15-year-old girl, a known case of Bartter's syndrome (BS) for 7 years, developed severe pain in her right knee and right and left ankle. Her older sister had BS and developed end­stage renal disease (ESRD) at the age of 14 years. Her serum uric acid was 12.6 mg/dL, 6 months ago, and 15.4 mg/dL in her recent lab data. Hyperuricemia and gouty arthritis are commonly seen in adults with BS, but to our knowledge there is no report of gouty arthritis in pediatric literature.

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Cystic lymphangioma is a common benign tumor caused by lymphatic malformation. The scrotum is a very rare site for this tumor and only few cases have been reported in the literature. We herewith present a rare case of cystic lymphangioma of the scrotum in an ado­lescent who presented with an incidental scrotal swelling with no other abnormality, where the diagnosis was suspected on scrotal ultrasonography.

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Daytime urinary incontinence is an involuntary or intentional voiding of urine in an awake child who is old enough to have developed control, and has a variable prevalence throughout the world. In Yemen, data regarding this problem are almost absent. In this study from the capital city of Aden, we aimed to: (1) determine the prevalence of daytime incontinence in kindergarten children aged 4-6 years, (2) identify the relation between daytime enuresis with personal and family characte­ristics of the children studied, and (3) describe the severity and characteristics of daytime enuresis in the studied children. A cross-sectional comparative study was undertaken in all kindergarten children aged 4-6 years in Aden Governorate and 1061 responded. Data were obtained by using a precoded self-administered questionnaire completed by the parents. The questionnaire consisted of two parts: personal and family characteristics of the studied children and the presence of daytime incontinence. The second part was responded if there was history of daytime incontinence, and contained information on the severity and possible associated factors. Daytime incontinence was encountered in 34 cases (3.2%); 18 were females. Significant differences between cases and incontinence-free children were encountered in birth order and type of kindergarten (P < 0.05). Majority (85.3%) had severe form of daytime incontinence. Bed wetting and combined day and night wetting were more frequent among males, whereas urinary symptoms (urgency, squatting, dysuria, dribbling) were more frequent among females. Working mother and frightening and emotionally stressful events in the 6 months preceding the study were significantly associated with daytime incontinence, while parents' education, punish­ment for daytime incontinence, and the presence of family history of incontinence were insignificant. In conclusion, this is the first study from Yemen reporting the prevalence of enuresis, similar to pre­vious reports. Further studies are needed to explore this problem in our region to end the misery of the child and the family.

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Post-transplant diabetes mellitus (PTDM) is an adverse complication of kidney transplantation, associated with decreased graft and patient survival. We investigated the risk factors for PTDM and their relation to graft rejection in our kidney transplant recipients. We prospectively included 109 consecutive first kidney transplant recipients transplanted at the Sina Hospital in Tehran from June 2003 to May 2004. Patients were excluded if they had diabetes at the time of transplantation either as the cause of kidney failure or as a comorbidity. PTDM was defined by fasting blood sugar ≥126 mg/dL or random blood sugar ≥200 mg/dL on two occasions and the need for insulin therapy and/or oral hypoglycemic drugs for at least two weeks. Thirty non-diabetic transplant recipients were diagnosed as having PTDM during the six month follow­up period after transplantation. Sixty non-PTDM controls, matched for age, sex and immuno­suppressive regimen, and transplanted as closely as possible to the PTDM cases, were randomly selected. The risk factors for PTDM were investigated in these 90 transplant recipients. Age older than 50 years (P = 0.04), history of hypertension (P = 0.02), polycystic kidney disease (P = 0.015), duration on dialysis more than one year (P < 0.0001), family history of diabetes mellitus (P < 0.0001), mean daily dose of prednisolone ≥15 mg/day (P < 0.0001) and cyclosporine ≥240 mg/day (P < 0.0001) were all more in the PTDM group. Also, the mean serum triglycerides was higher (P = 0.019) and there was an increased risk of graft rejection (P < 0.0001) in the PTDM group.

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To assess the effect of regional anesthesia on the outcome of elbow arteriovenous fistula (AVF), prospectively studied consecutive patients with end-stage renal disease referred for permanent vascular access to the Vascular Unit of King Fahd University Hospital between September 2004 and September 2007. The patients were divided into 2 groups: Group 1: patients who underwent the construction of the AVF under regional anesthesia and Group 2: patients who were operated under general anesthesia, indicated by their preferences or failure of regional anesthesia. Data including patient characteristics and type of AVF were recorded. The internal diameter of the vein and the artery and intra-operative blood flow were measured. The complications of both types of anesthesia were recorded. The patients were followed up for three months. Eighty four cases were recruited in this study. Complete brachial plexus block was achieved in 57 (68%) patients. Seven patients were converted to general anesthesia and 20 patients had AVF under general anesthesia from the start. There were no significant differences between the 2 groups with regard to basic characteristics or operative data. There were no instances of systemic toxicity, hematomas, or nerve injury from the regional block. No major complications were reported from the general anesthesia. There was no significant difference between both groups regarding early failure of AVF (Group 1, 14% vs. Group2; 11%. P= 0.80). No significant advantage of regional over general anesthesia in terms of early outcome of AVF was seen in this study.

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End-stage renal disease (ESRD) is known to be an important risk factor for cardiac operations performed with cardiopulmonary bypass. We investigated the influence of preoperative status on perioperative mortality and morbidity. We retrospectively analyzed data from 26 patients with ESRD, who were on maintenance dialysis and underwent a cardiac surgical procedure bet­ween 2000 and 2007. Of them, 61.5% of the patients had isolated coronary artery bypass grafting (CABG) and 38.5% had replacement or reconstruction of one or two valves. The perioperative mortality rate was 26% with five deaths occurring in patients undergoing CABG procedure. We found CABG procedure, being female and left ventricular (LV) function < 30% to be associated with a higher relative risk for perioperative death. In conclusion, our data suggest that both indi­cations and referral for surgical intervention for coronary artery disease may be delayed in pa­tients who have ESRD, contributing to the relatively high perioperative mortality.

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