Nahla Allam¹, Asma Babiker²

¹Noura Center for Pediatric Kidney Disease and Renal Transplantation, Faculty of Medicine, Al Neelain University, Sudan

²Soba University Hospital, Khartoum, Sudan.

Introduction: The goal of treatment with cyclosporine in idiopathic steroid-resistant nephrotic syndrome in children is either to achieve complete remission or partial remission, as it is the most important predictor of disease outcome.

Aim and Objectives: The purpose is to assess remission pattern and renal function status from the use of cyclosporine in children with idiopathic steroid-resistant nephrotic syndrome.

Methods: A descriptive cross-sectional hospital-based study, conducted at the pediatric nephrology unit in Soba University Hospital, during the period from October 2021 to February 2022, covered 80 children with idiopathic nephrotic syndrome, who failed to achieve remission despite receiving oral prednisolone 60mg/SA/day for 4 weeks, and started cyclosporine therapy for 12 months

Results: The mean age of the studied children was 8.5 ± 4.6 years. The male-to-female ratio was 2.1:1. The pattern of remission of use of cyclosporine in children with SRNS was complete remission in 42 (52.5%), partial remission in 17 (21.2%), and resistance in 21 (26.3%). Regarding the safety and efficacy of cyclosporine in the treatment of patients with SRNS, the study showed that severe hypertension was reported in 6.3%, and 5% showed impaired renal function. In the majority of the children, 71 (88.7%), there were no side effects.

Conclusion: In Sudanese children diagnosed with idiopathic steroid-resistant nephrotic syndrome, cyclosporin is the drug of choice for induction of remission.

Keywords: Children, Cyclosporin, Sudanese, Steroid resistance, Nephrotic syndrome

Zalikha Al-Marzouqi¹, Fatma Homood Al-Muqbali², Hamed Al-Reesi³, Aida Al-Dhoani⁴

¹Department of Maternal Health, Oman College of Health Sciences, Oman.

²Oman College of Health Sciences, Oman.

³Directorate General of Health Service, North Al Batinah, Oman.

⁴Suhar Extended Health Center, Oman.

Introduction: Organ donation plays a vital role in healthcare by improving the quality of life and survival for individuals with end-stage organ failure. Despite its importance, there is an international shortage of donated organs, often linked to limited public awareness and sociocultural barriers. In Oman, particularly in the North Batinah Governorate (NBG), no prior study has comprehensively examined awareness, attitudes, and perceived barriers to organ donation.

Aims and Objectives: The objective is to assess the knowledge, attitudes, and barriers regarding organ donation among residents of the NBG, and to provide evidence to support targeted health policy and awareness initiatives.

Methods: A non-experimental, quantitative, analytical, cross-sectional design was employed. Data was collected at a single point in time from a convenience sample of 622 residents of the NBG.

Results: Among participants, 93% were Omani and 7% were non-Omani; 36% were male and 64% female. Most respondents (91%) were classified as “not knowledgeable” about organ donation, while only 9% were “knowledgeable.” Seventeen per cent reported a family history of organ failure. More than half (58%) expressed a positive attitude toward organ donation. The main barriers identified were fear of developing health complications from living donation (69%) and family objection to donation after death (38%).

Conclusions: Most participants lacked sufficient knowledge about organ donation, yet over half expressed a favorable attitude. Decisions were influenced not only by awareness but also by cultural and social norms, including family consensus, beliefs about bodily integrity, and religious interpretations. Culturally tailored education and engagement with community and religious leaders are essential to address these barriers and increase donation rates in Oman.

Keywords: Attitudes, Barriers, Oman, Organ Donation, People awareness

Ammar Al Ali¹, Khalfan Al Alshaaili¹

¹Nizwa Hospital, Ministry of Health, Oman.

High-anion-gap metabolic acidosis (HAGMA) is a common clinical finding. While lactate, ketoacids, and toxins are frequent causes, pyroglutamic acidosis (5-oxoproline accumulation) is a rare but under-recognized etiology associated with chronic therapeutic acetaminophen (paracetamol) use, particularly in susceptible individuals. We are presenting a 35-year-old Omani female who was admitted to the hospital with severe diabetic foot infection, which didn’t respond to medical management, so she underwent multiple surgical debridements and amputations. Her analgesia included regular paracetamol (1gram, 3 times daily). She has a complex past medical history of uncontrolled insulin-dependent diabetes mellitus, chronic kidney disease (CKD Stage IIIb, with baseline eGFR MDRD ~31.7 mL/min/1.73m²), a history of ischemic stroke 2 years back, and recurrent diabetic foot infection. Approximately two weeks post-admission, with her sepsis resolving, she developed persistent HAGMA (pH 7.31, PCO2 24 mmHg, HCO₃^- 10 mmol/L) with a normal lactate (0.7 mmol/L), absent ketonuria/ ketonemia, and no history of toxin ingestion, her renal function had acutely worsened during early days of admission (creatinine reached 246 µmol/L, eGFR MRDR ~ 20mL/min/1.73m²) but stabilized thereafter. Given the unexplained HAGMA and the presence of multiple risk factors (female gender, CKD, critical illness, malnutrition, and chronic paracetamol use), a diagnosis of suspected acquired pyroglutamic acidosis was made. Paracetamol was immediately discontinued, and analgesia was switched to an opioid. Following this intervention, the patient’s acid-base status improved dramatically over the subsequent few days, with normalization of bicarbonate levels. This case underscores the importance of considering pyroglutamic acidosis in the differential diagnosis of unexplained HAGMA, especially in patients with predisposing factors. The diagnosis can be strongly suspected based on clinical context and a dramatic response to withdrawal of the precipitant, even in the absence of confirmatory testing. Increased awareness among physicians is crucial to avoid diagnostic delay and guide appropriate management.

Keywords: Chronic Kidney Disease, Paracetamol, Pyroglutamic Acidosis, High anion gap metabolic acidosis, 5-Oxoproline

Michael Napoleon¹, Khalfan Al Shaaili¹

¹Nizwa Hospital, Ministry of Health, Oman.

A 61-year-old male patient with a history of ischemic heart disease (IHD), dilated cardiomyopathy with reduced ejection fraction (HFrEF), of 30%, atrial fibrillation (AF) on pacemaker (CRT), and had atrio-ventricular (AV) nodal ablation, presented multiple times to the emergency department with persistent epigastric and left loin pain radiating to the chest and iliac fossa, along with shortness of breath. His symptoms were initially misattributed to gastritis. On clinical examination, the patient looked unwell and in pain with tenderness on the left side and anuria and required an oxygen mask to maintain normal oxygen saturation. Laboratory investigations were also accepted except for evidence of AKI, presence of proteinuria and hematuria in the urine, and hemoglobin of 17.7g/dL. The International Normalized Ratio (INR) was 1,35. An abdominal computerized tomography (CT) scan with intravenous (IV) contrast was done, which revealed acute left renal artery thrombosis at the level of the hilum. Transesophageal echocardiography (TEE) showed a semi-organized thrombus in the LAA, and tiny thread-like masses, mostly thrombi, attached to the CRT-D leads in the RA. The patient was planned for Catheter-Directed Therapy (CDT). However, the procedure was deferred as the left kidney had already infarcted. The patient achieved complete recovery on anticoagulation and IV hydration. The frequency of this condition is higher than reported, as it is mostly misdiagnosed, as symptoms and signs can mimic pyelonephritis, nephrolithiasis, mesenteric ischemia, cholecystitis, pancreatitis, or, as in our case, gastritis. The primary cause of this condition is cardiac thrombo-embolic disease, but it may also result from local blood clots due to hypercoagulable conditions or from dissection of the renal arteries. Several factors may affect the treatment outcome, such as ischemia time, collateral flow, and pre-existing kidney disease. Given the rarity of this disease, there is insufficient evidence of therapeutic options. Thrombolytic therapy is reserved for patients diagnosed early, with the optimal port-to-treatment time being 90-180 minutes. In our case, due to late diagnosis, endovascular treatment was deferred, and only anticoagulation was started. The renal artery embolism here was likely due to a thromboembolism from atrial fibrillation. Anticoagulation therapy alone led to the complete restoration of kidney function.

Keywords: Anticoagulation, Atrial fibrillation, CRT-D, Ischemic heart disease, Renal artery thrombosis

Hanaa Mohammed Eid El Sayed¹, Khalfan AL Shaaili²

¹Department of Internal Medicine, Faculty of Medicine for Girls, Al Azhar University, Cairo, Egypt,

²Department of Nephrology, Nizwa Hospital. Ministry of Health, Oman.

Alport syndrome is one of the rare genetic disorders affecting approximately 1 in 50,000 individuals. Manifested by progressive microscopic hematuria, proteinuria, which progresses to chronic kidney disease (CKD), associated with sensorineural hearing loss (SNHL) and ocular abnormalities. It results from mutations in collagen type IV (COL4A3, COL4A4, and COL4A5) genes, which will affect the formation of the α3-α4-α5 chain in the collagen IV network. Charcot-Marie-Tooth disease (CMT) is the most prevalent inherited peripheral neuropathy, with an incidence of 1 in 2500 individuals. It is characterized by chronic motor and sensory polyneuropathy. CMT has significant genetic and clinical heterogeneity. A 21-year-old male patient. The condition started at the age of 6 years old when the patient developed persistent hematuria, investigations revealed hematuria, proteinuria, no skin rash, no arthritis and no history of upper respiratory tract infection, Immune profile (ANA, Anti DsDNA were negative, C3 and C4 were normal, virology (hepatitis scan and HIV Ab were all negative) Antistreptolysin o titer (ASOT) was negative. The renal function test was normal. There was severe bilateral SNHL associated with visual disturbance, with no family history of renal disease. Renal biopsy was done - results are suggestive of hereditary nephropathy of Alport type. Genetic testing: confirmed autosomal recessive Alport syndrome. (homozygous mutation in COL4A4 exon 17). There were associated microcephaly, learning difficulties, and poor school performance. At the age of 19 years old, the patient suffered from progressive weakness with continuous muscular pain. He sought medical advice; laboratory investigations revealed a high creatine phosphokinase (CPK) level of > 800 units/liter. A nerve conduction test showed chronic polyneuropathy, with sensory involvement greater than motor involvement, potentially part of hereditary sensory motor polyneuropathy. A homozygous likely pathogenic variant was identified in the SBF1gene; the result is consistent with a genetic diagnosis of autosomal recessive Charcot–Marie–Tooth disease type 4B3. This case highlights the rare coexistence of Alport Syndrome and Charcot-Marie-Tooth disease in the same patient. Recognizing overlapping genetic disorders is essential for accurate diagnosis, multidisciplinary management, and appropriate genetic counselling.

Keywords: Alport syndrome, Charcot-Marie-Tooth, Genetic counseling, Learning difficulties, SBF1gene

Asma Al Balushi¹, Issa Al Salmi², Hamid Reza², Bassim Al Bahrani²

¹Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman.

Introduction: Prostate cancer is a significant health dilemma globally, with varying incidence across regions. In Oman, a noticeable rise in prostate cancer cases has been observed, potentially due to lifestyle changes and increased diagnostic efforts. This study investigates the clinical features, laboratory findings, radiological assessments, and mortality outcomes associated with prostate cancer (PCa) among patients at the Royal Hospital in Oman.

Methods: Retrospective single-institution observational study conducted at the Royal Hospital, Oman, between January 2006 and December 2021. All patients diagnosed with PCa during this period were included. Clinical characteristics, biochemical markers—including prostate-specific antigen (PSA)—and treatment modalities were analyzed to assess their impact on mortality outcomes.

Results: A total of 505 patients were included. The most significant prognostic factors associated with mortality were a higher Gleason score and older age (p < 0.05). Although chronic kidney disease (CKD) was prevalent among PCa patients, it did not significantly affect mortality compared to those without CKD (p > 0.05). Treatment outcomes varied depending on disease stage and therapeutic approach.

Conclusion: Gleason score and patient age were the main predictors of mortality among PCa patients. Despite its prevalence, CKD did not show a significant effect on survival. These findings underscore the need for early detection and tailored treatment strategies to improve outcomes for prostate cancer patients in Oman.

Keywords: Prostate Cancer, Mortality, Prognostic Factors, Oman, Gleason Score

Aliya AlShamsi¹, Issa Al Salmi², Huda AlKhalili³

¹Department of Internal Medicine, Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman.

³Department of Intensive Care Unit, The Royal Hospital, Ministry of Health, Muscat, Oman.

Introduction: Acute kidney injury (AKI) is a common and serious complication among patients admitted to intensive care units. The present study was performed to determine the incidence of AKI using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, to define the risk factors, requirement for renal dialysis, and hospital mortality.

Methods: A prospective observational cohort study was performed at the Royal Hospital from January to December 2022. A total of 153 adult patients admitted to the intensive care unit were included in the study. The required data was extracted from the hospital database and statistically analyzed.

Results: The Average age of patients admitted to the ICU was 52.7 ± 21.1 years, with a mean body mass index (BMI) of 27.3 ± 7.4 kg/m². The majority of admitted patients were male, accounting for 57.5% of the total. Among 153 ICU patients, 84 either presented with or acquired acute kidney injury (AKI) during their ICU admission, yielding an incidence rate of 54.9%. Of these patients, 50% were diagnosed with diabetes mellitus, 61.9% with hypertension (P value 0.049; OR 10.234; 95%CI 1.007-104.046), 39.3% with chronic kidney disease, and 26.2% with cardiovascular disease. During their ICU stay, 92.7% of AKI patients required hemodialysis. Upon discharge from the ICU, 55.4% of AKI patients showed improvement in their AKI, while 35.7% of them died during their ICU stay, with septic shock being the major leading cause of death in 71.8% of these cases.

Conclusion: AKI affects more than half of ICU patients in our cohort and is strongly associated with increased mortality. Identifying key clinical and biochemical predictors may guide early intervention and improve patient outcomes in critical care settings.

Keywords: Acute kidney injury, Intensive care unit, KDIGO, Mortality, Risk factors

Khadija Al Habsi¹, Issa Al Salmi², Ehab Mohammed²

¹Department of Internal Medicine, Ibra Hospital, Ibra, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman.

Introduction: It is well-known that patients with chronic kidney disease and end-stage renal disease are at an increased risk of pulmonary embolism compared to patients with normal kidney function. However, in Oman, there is a lack of research on the trends, outcomes, and predictors of mortality in pulmonary embolism patients with chronic kidney disease and end-stage renal disease.

Methods: This retrospective observational cohort study was conducted from 2010 to 2019 at the Al Shifaa System, Royal Hospital. The identification of hospitalizations with a primary discharge diagnosis of PE was based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 415.11 and 415.19. Baseline patient-level characteristics, including demographics and relevant comorbidities, were considered. ICD-9-CM codes, Clinical Classification Software (CCS) codes, and procedural codes were used to identify the disease cohorts and comorbidities.

Results: The study involved 384 patients, comprising 193 males and 191 females. The average age (±SD) was 60 ± 15, and the mean BMI (±SD) was 26.6 ± 5.9. Among the 384 patients, 189 had hypertension, diabetes, and dyslipidemia, accounting for 49% of the total. Transesophageal echo was performed in 59 (15%) patients, revealing normal results in 26 (7%), vegetation in 23 (6%), and thrombus in 11 (2%). The diagnosis of pulmonary embolism was established clinically and confirmed by CT in 18 patients, of whom 10 were females and 8 were males, with a P-value of 0.06. A majority of these patients received NOACs (novel oral anticoagulants) as compared to warfarin, with 15 patients versus 3 patients, respectively. The mean treatment duration (in months ± SD) was 4 ± 2.6.

Conclusion: The incidence of pulmonary embolism in our study group was found to be 4.6%. In comparison, a study in Saudi Arabia in 2002 reported an incidence of pulmonary embolism in ESRD patients on dialysis through a fistula as 3.5%.

Keywords: Anticoagulants, Central venous catheter, End-stage kidney disease, Pulmonary embolism, Transesophageal echo

Zamzam Al Farsi¹, Issa Al Salmi², Bassim Al Bahrani³, Naima Al Alawi⁴, Hind Al Sukaili⁵, Heba Al Sinani⁵, Sara Al Abri⁵

¹Department of Internal Medicine, Khasab Hospital, Oman.

²Department of Nephrology, Oman.

³National Oncology Center, Oman.

⁴Department of Laboratory Medicine and Pathology, Oman.

⁵Department of Medicine, The Royal Hospital, Ministry of Health, Oman.

Background: Renal cell carcinoma (RCC) incidence is rising globally, yet local data in Oman remain scarce. This study aims to characterize the epidemiological profile, clinical features, histopathological types, and prognostic outcomes of RCC patients in Oman.

Methods: A retrospective analysis was conducted on 286 Omani RCC patients managed at The Royal Hospital between January 2006 and December 2022. Data on demographics, clinical presentation, histopathology, treatment, and outcomes were extracted from electronic medical records.

Results: The mean age at diagnosis was 53.3 ± 15 years, with a male predominance (60.1%). A high proportion of patients were overweight/obese (mean BMI 28.8 ± 6.5 kg/m²), and comorbidities like hypertension (44.7%) and diabetes (30%) were common. Incidental diagnosis accounted for 38% of cases, while abdominal pain was the most frequent presenting symptom (51.2%). Clear cell carcinoma was the predominant histological subtype (45.80%). Metastatic disease was present in 42.5% of patients at diagnosis, with the lung being the most common site (27.05%). Nephrectomy was performed in 83.7% of patients. Recurrence occurred in 12.5%, and 20% of patients died during the study period, with an average lifespan of 4.12 years. Notably, 7.6% developed a second primary malignancy, most commonly colon cancer.

Conclusion: This study provides valuable insights into RCC in Oman, highlighting its increasing incidental diagnosis, male predominance, association with obesity, and significant rates of metastasis and second primary cancers. The findings underscore the need for enhanced local epidemiological data, individualized screening, and comprehensive surveillance strategies to improve patient outcomes.

Keywords: Epidemiology, Histopathology, Metastatic disease, Oman, Renal cell carcinoma

Sara Al Ismaili¹, Fahad Al Zadjali², Marwa AL Riyami³, Maha AL Asmakh⁴, Faisal AL Ismaili⁵, Amira AlKharusi⁶, Razan Zadjali⁷, Zaina AL Harthi⁷, Ali Al Lawati⁸, Amal Kassab⁹, Nafila AL Riyami⁷

¹Department of Clinical Biochemistry, Oman Medical Specialty Board, Sohar Hospital, Oman.

²Center of Studies and Research, Ministry of Health, Oman.

³Department of Pathology, College of Medicine and Health Sciences, Sultan Qaboos University, Oman.

⁴Biomedical Research Center, Qatar University, Qatar

⁵Department of Medicine, The Royal Hospital, Ministry of Health, Oman.

⁶Department of Clinical Physiology, Oman.

⁷Department of Clinical Biochemistry, College of Medicine and Health Sciences, Oman.

⁸Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Oman,

⁹Biomedical Technology and Cell Therapy Research Laboratory, Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.

Background: Focal segmental glomerulosclerosis (FSGS) is a progressive disease that leads to end-stage chronic kidney disease. The therapeutic approach requires administration of steroids to prevent further damage; however, some patients develop steroid resistance. This study aims to determine the biochemical predictors and to assess the prognostic power of novel protein markers for steroid resistance in FSGS patients.

Methods: This is a cohort study. Data collected from hospital information systems of two tertiary care hospitals in Oman, Royal Hospital and SQUH, from 2006 to 2020. Ethical approval was obtained from both hospitals. Patients presented with proteinuria and had biopsy-proven primary FSGS were included. Predictors’ data were collected retrospectively from the first visit. Patients were identified as steroid resistant based on persistent proteinuria or double plasma creatinine for >8 weeks post-therapy. The biopsy tissue slides were collected. The inclusion criteria for novel protein marker selection were previous proteomic evidence, evidence of expression in renal tissue, and availability of commercial providers. Slides were quantified for staining intensity using the Fiji tool. A statistical comparison of staining intensity between steroid-resistant and sensitive patients was performed.

Results: Out of 135 FSGS patients, 32 cases with primary FSGS treated with steroids were found and analyzed. A total of 19 (59.4%) patients were found to be resistant to steroids. Baseline parameters showed that total and nonHDL cholesterol levels were significantly higher in patients who developed steroid resistance (p < 0.050). ROC curve applied, and the optimal cut point for total cholesterol was 6.7 mmol/L with 94% sensitivity and 58% specificity (95% CI: 56.5–94.5). The likelihood ratio was 2.3. For novel protein markers, we identified seven potential markers for our study: NTRK1, VDBP, Podocin, SYNPO, Human fetuin-A, Mα-Dystroglycan (DAG1), and WT1. Patients with lower expression of NTRK1 and Fetuin-A at the time of diagnosis were 92% (OR = 0.08, 95% CI: 0.01–0.89), 97 % (OR 0.03, 95% C.I 0.002-0.3), respectively, more likely to develop steroid resistance.

Conclusions: Lipid profile may serve as a biochemical predictor of steroid resistance in patients with FSGS. Fetuin-A and NTRK1 may work as potential immunohistochemical markers to predict steroid resistance in those patients.

Keywords: Focal Segmental Glomerulosclerosis, Kidney, Steroid resistance, LDL-cholesterol, Novel markers

Muzna AlHinai¹, Issa Al Salmi², Ehab Mohammed²

¹Internal Medicine Residency Training Program, Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman.

Introduction: Adrenal disorders – including primary adrenal insufficiency, congenital adrenal hyperplasia (CAH), primary hyperaldosteronism, adrenal adenoma/carcinoma, and pheochromocytoma – are individually uncommon but clinically significant. The incidence and prevalence of adrenal disorders in the active component of the Omani population have not been previously described.

Aims and Objectives: The objective of this study is to characterize the clinical, biochemical, and imaging profiles of all patients with confirmed primary adrenal disorders managed at the Royal Hospital, Oman.

Methods: Retrospective cross-sectional analysis. Data retrieved from the Alshifa system (2006–2022). Inclusion criteria were confirmed diagnoses of primary adrenal disorders. Patients with unconfirmed diagnoses or secondary adrenal disorders were excluded. Incidental adrenal findings not investigated were not included.

Results: A total of 129 patients met the inclusion criteria; the cohort showed male predominance (63.8%). Statistical disparities included the prevalence of chronic hypokalemia – serum potassium < 3.5mmol/L (14.5% of males vs 2.2% of females, p = 0.026). Biochemical profiling revealed one sex disparity in17-hydroxyprogesterone (17-OHP), levels were higher in females (p=0.021). Imaging patterns showed no sex effect: computed tomography and Magnetic resonance imaging showed similar rates of adrenal mass detection. No gender disparity appeared in diagnostic imaging or tumor size. Most adrenal diagnoses were distributed similarly in males and females. Adrenal lipomas tended to be more frequent in women, but this didn’t reach significance (p = 0.102). Aside from CAH and adrenal adenoma, the cohort’s adrenal disorders showed a near-equal male-to-female ratio. The mortality was higher in adrenocortical carcinoma compared to other included adrenal disorders, regardless of gender.

Conclusion: This 16-year analysis highlights gender differences in adrenal disorders in Oman, with CAH and adrenal adenomas being predominant. While overall disease distribution was similar between both genders, significant sex-specific differences emerged: chronic hypokalemia was more common in men, and women had higher 17-OHP. These results support sex-sensitive diagnostic approaches and provide baseline data to guide future research.

Keywords: Adrenal Adenoma, Adrenal disorders, Congenital adrenal hyperplasia, Gender differences, Hypokalemia

Samira Mohammad Hussain¹, Issa Al Salmi¹, Ehab Mohammad¹

¹Department of Nephrology, The Royal Hospital, Ministry of Health, Oman.

Introduction: Chronic kidney disease (CKD) is a major global health problem affecting millions of patients worldwide and leading to decreased survival. CKD is an independent risk factor for the development of gout; however, several mechanisms may also explain why gout predisposes to renal disease. Gout is the most prevalent inflammatory arthritis, affecting approximately 2.4 % of adults, and is associated with considerable comorbidity, including hypertension, diabetes, obesity, metabolic syndrome, and vascular disease. The association between gout, renal disease, and nephrolithiasis has long been recognized; however, early studies conducted in specialist secondary-care populations are likely to be unrepresentative of the majority of patients with gout.

Aims and Objectives: The purpose of this study was to determine the prevalence of CKD and its association with gout, as a major contribution to the CKD population at the Royal Hospital, Sultanate of Oman.

Methods: A cross-sectional study was conducted to investigate the association between gout and renal disease through data analysis of patients admitted to the hospital or followed up in outpatient clinics with a diagnosis of gout. A total of 900 patients aged 25 years or older were identified over 10 years, from 1 January 2012 to 31 January 2021. Of these, 290 patients were selected using systematic random sampling for analysis. Data were collected on presenting symptoms and signs, comorbidities documented in previous medical records, and biochemical and radiological parameters. Statistical analysis was performed using the chi-square test and Student’s t-test, followed by stepwise logistic regression for multivariate analysis.

Results: The study sample had a mean age of 54.03, with a mean age of 56.05 in males and 62.3 years in females (p value of 0.0001. The majority of male patients were aged 41-59 years, whereas most female patients were aged 60 years or older. More than 50 % of the sample had a body mass index (BMI) in the obese category. The mean systolic blood pressure was 142.7 mm Hg ± 23.7, and the diastolic blood pressure was 81.9 ± 16.4. Multiple comorbidities were common: 26.2 % had diabetes mellitus, 50.5 % had hypertension, 23 % had dyslipidemia, and 24.2 % had coronary artery disease. Regarding lifestyle factors, 2.9 % were smokers and 2.5 % were alcohol consumers, all of whom were male. Estimated glomerular filtration rate (eGFR) was above 90 ml/min/1.73m in 32 % of patients, 60-90 ml/min/1.73m in 30.3%, 30-60 ml/min/1.73m in 24%, 15-30 ml/min/1.73m in 7.5%, and <15 ml/min/1.73m in 6.1%, with a mean serum creatinine of 149.4 (SD 185.7). The mean total serum cholesterol was 4.78 ± 1.37 mg/di; mean serum glucose was 6.7 ± 3.1 mmol, and mean HbA1c was 6.33 ±1.53 mmol/mol. Serum uric acid levels were elevated overall, with a mean of 498.4 ± 141mg/mmol, and were higher in males (513.7± 129.2 mg/mmol) compared to females (450 ± 164.6 mg/mmol). The mean protein to creatinine ratio was 178.4 mg/mmol. Most patients had elevated inflammatory markers, with a mean white blood cell count of 7.98 ± 3.52 per microliter and a mean erythrocyte sedimentation rate of 47.3 ± 35.8 mm/hour. Ultrasound of the abdomen was performed in 147 patients; renal stones were detected in 7.3% of right kidneys and 5.4 % of left kidneys. Regarding medications: 66.5% received allopurinol, 26.8% received urinary alkalinizers, 60.5% were on colchicine, 8% were on thiazides, and 34.1% received aspirin.

Conclusion: One of the first studies conducted to evaluate hyperuricemia among patients with chronic kidney disease (CKD). This study highlights the burden of hyperuricemia among patients with chronic kidney disease, with the majority being relatively young males and a high prevalence of obesity. The frequent coexistence of hypertension, diabetes, dyslipidemia, and coronary artery disease reflects the close association between hyperuricemia, metabolic disorders, and chronic kidney disease. Most patients presented with inflammatory joint manifestations, including pain, tenderness, and swelling, accompanied by elevated inflammatory markers. Despite this, the management of hyperuricemia was suboptimal, as only about two-thirds of patients received urate-lowering therapy. At the same time, a considerable proportion were treated with anti-inflammatory medications that may adversely affect renal function. These findings emphasize the need for improved management strategies for hyperuricemia in patients with chronic kidney disease. A collaborative, multidisciplinary approach involving both rheumatology and nephrology services is essential to optimize urate lowering therapy, minimize treatment-related renal injury, and slow the progression of kidney dysfunction in this high-risk population.

Keywords: Chronic kidney disease, Hyperuricemia, Gout, Obesity, Renal dysfunction

Hajar Al Ghailani¹, Issa Al Salmi², Hamid Al Shahri³, Shaima Al Shidi⁴, Amer Al Amri³

¹Department of Internal Medicine, Sur Hospital, Sur, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Muscat, Oman.

³Department of Renal Medicine, Sultan Qaboos Hospital, Salalah, Oman.

⁴Department of Renal Medicine, Sohar Hospital, Sohar, Oman.

Introduction: An autoimmune dysfunction means the immune system attacks body tissues, which can quickly progress to inflammation of various organs, including the kidneys, with ensuing kidney dysfunction. Chronic kidney disease (CKD) incidence and prevalence are rising worldwide, as well as in the Sultanate of Oman. The tsunami of non-communicable diseases, including obesity, diabetes, and hypertension, fuels the rise of CKD. In addition, various autoimmune disorders are increasingly associated with the development of CKD.

Aims and Objectives: The aim of this study is to evaluate various risk factors, including autoimmune factors, that contribute to the development of CKD among patients attending the Renal Medicine Department at the Royal Hospital.

Method: This observational cross-sectional study was conducted at the Royal Hospital (RH), Muscat, Sultanate of Oman. all CKD patients who attended the adult Nephrology outpatient clinic from July 2016 to July 2020. All clinical and laboratory data were collected at the first encounter, and then the last serum urea, serum creatinine, estimated glomerular filtration rate, and death were assessed at the last visit of each patient. Those aged < 18 years and patients with inherited, congenital anomalies and drug-related causes of CKD were excluded. All the statistical analyses were performed by STATA 13/SE statistical software (Stata Corp, College Station, Texas, USA).

Results: During the study period, 800 patients were followed up for an average of 5.5 years. Females accounted for 53% of the study population, while males accounted for 46%. The mean age (SD) for females and males was 45.3 (15.7) and 45.2 (14.6) years, respectively. The prevalence of autoimmune antibodies was 26.7% among Omani CKD patients and was more common in young females. The most common autoimmune antibodies were ANA, ANCA, anti-dsDNA, anti-SSA-RO, and anti-Ro52. The simple, univariate regression analysis showed a positive linear relationship of GFR with the Hb and albumin (p < 0.05) and a negative linear relationship with age, ESR, CRP, WCC, anti-nuclear titers, urinary proteinuria, and complements (p < 0.001, for all). Multivariate regression showed a persistent relationship with age, ESR, CRP, Hb, complement, and ANA, with R2 = 38%.

Conclusion: CKD progression is a multifactorial process. Inflammation with autoimmune antibodies is quite common in Omani CKD patients and plays a significant role in its progression and ultimately death.

Keywords: Autoantibodies, Autoimmune, Chronic kidney disease, Immune dysfunction, Kidney dysfunction

Shaimaa Daoud¹, Ahmed Atris¹

¹Al-Seeb Dialysis Center, Muscat, Oman.

Pregnancy in women with end-stage kidney disease (ESKD) on maintenance hemodialysis remains uncommon and is associated with significant maternal and fetal risks. Reduced fertility, hormonal disturbances, and the uremic milieu contribute to low conception rates. At the same time, pregnancies that do occur are frequently complicated by hypertension, preeclampsia, anemia, preterm delivery, and fetal growth restriction. However, advances in dialysis technology, anemia management, and multidisciplinary obstetric–nephrology care have led to a gradual improvement in pregnancy incidence and outcomes over recent decades. We report a case highlighting the role of intensive hemodialysis and coordinated care in achieving successful pregnancy outcomes in a woman with long-standing ESKD. The patient is a 39-year-old woman with ESKD secondary to recurrent urinary tract infections since childhood, on hemodialysis since 2012. She had no history of diabetes, autoimmune disease, or chronic hypertension. Her obstetric history included five pregnancies, with the last two occurring during her hemodialysis course. These two pregnancies, detected in 2018 and 2022, resulted in live births at 34 weeks and 35–36 weeks of gestation, respectively, both delivered by caesarean section. Complications included hypertensive disorders of pregnancy and preeclampsia, but no maternal mortality occurred. Following confirmation of pregnancy, a structured multidisciplinary management plan was implemented. This included close obstetric surveillance with frequent antenatal visits, regular blood pressure monitoring, serial fetal growth assessments, and planned early delivery if maternal or fetal indications arose. Dialysis prescriptions were intensified progressively from three sessions per week in early pregnancy to five sessions per week during the second and third trimesters, achieving a total of approximately 20 hours per week and maintaining pre-dialysis serum urea levels below 15 mmol/L. Dry weight was carefully adjusted according to gestational age. Anemia management was optimized with increased doses of erythropoiesis-stimulating agents, intravenous iron supplementation, and folic acid, targeting hemoglobin levels of 10–12 g/dL. Potentially teratogenic medications were discontinued, safe antihypertensive therapy was instituted, and measures for preeclampsia prophylaxis and nutritional optimization were applied. This case illustrates that successful pregnancy outcomes are achievable in women on long-term hemodialysis when intensive dialysis regimens and meticulous multidisciplinary care are employed. Increased dialysis frequency, strict biochemical and volume control, and close collaboration between nephrology, obstetrics, and neonatology teams appear central to improving maternal and fetal outcomes. Preconception counseling and individualized care pathways are essential to further enhance safety and success in this high-risk population.

Keywords: Hemodialysis, Intensive dialysis, Pregnancy in ESKD, Maternal– fetal outcomes, Multidisciplinary care

Fatma Salim Al Gharbi¹, Issa Al Salmi², Yaseen Al Lawati³, Yaqoob Al Rawahi³, Maisa Al Siyabi³

¹Internal Medicine Residency Program, Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Oman.

³Internship Program, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.

Background: Iron deficiency anemia is a common complication of chronic kidney disease (CKD), contributing to functional decline and increased morbidity. Intravenous (IV) iron is frequently used when oral therapy is inadequate, yet real-world outcomes in Omani CKD populations remain underreported.

Aim and Objectives: The study aims to evaluate the effect of IV iron sucrose on iron indices, hematological parameters, estimated glomerular filtration rate (eGFR), and left ventricular ejection fraction (LVEF) among adults with CKD.

Methods: This retrospective longitudinal cohort included all adult patients with CKD who received IV iron sucrose at the Royal Hospital (Muscat, Oman) between January 2016 and December 2022. A total of 555 patients with complete pre- and post-treatment data were included in the analysis. Demographic, clinical, and laboratory variables were collected at baseline and at the first available follow-up assessment after treatment. Continuous variables were reported as mean ± SD, and paired statistical methods were used for comparisons.

Results: Of the 555 included patients, 54% were male, with a mean age of 56 ± 17 years. Diabetes mellitus was the leading cause of CKD (61%). At baseline, 68% were on dialysis, 30% were receiving oral iron, and 63% were on erythropoiesis-stimulating agents. The mean cumulative dose of IV iron sucrose was 533.6 ± 267.1 mg. IV iron therapy was associated with significant improvements in iron indices: serum iron increased from 6.6 ± 2.9 to 9.6 ± 5.6 µmol/L (p < 0.001), transferrin saturation from 14.4 ± 5.3% to 23.6 ± 11.8% (p < 0.001), and ferritin from 307.6 ± 220.3 to 458.8 ± 302.6 µg/L (p < 0.001). Hemoglobin increased from 9.1 ± 1.7 to 10.6 ± 2.0 g/dL (p < 0.001), with parallel rises in hematocrit and MCV. Renal function showed a small but statistically significant increase in eGFR (13.7 ± 12.9 to 16.1 ± 16.6 mL/min/1.73m², p < 0.001). LVEF also demonstrated a modest improvement (50.2 ± 11.6% to 52.4 ± 11.2%, p = 0.002). These changes likely represent physiological enhancement following anemia correction rather than a direct effect of IV iron.

Conclusions: In this large CKD cohort, IV iron sucrose significantly improved iron status and hematological parameters. Small but consistent improvements in eGFR and LVEF were observed, likely reflecting the better oxygen delivery after anemia correction. Given the single-center design and high dialysis proportion, broader generalizability is limited. Prospective multicenter studies are needed to further evaluate long-term clinical outcomes and patient-reported measures.

Keywords: Chronic kidney disease, Hematological outcomes, Iron deficiency anemia, Intravenous iron sucrose, Renal and cardiac function

Basama Hamdan AlShibli¹, Issa Salim Al-Salmi²

¹Internal Medicine Residency Program, Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Oman.

Introduction: Hyperuricemia is a frequent metabolic complication following renal transplantation and is associated with adverse outcomes, including cardiovascular disease and graft dysfunction. Its development is multifactorial and may be influenced by demographic characteristics, nutritional status, renal function, and immunosuppressive therapy. Despite the increasing number of renal transplant recipients in Oman, local data describing the burden of hyperuricemia and its associated risk factors remain limited. This study aimed to determine the prevalence of hyperuricemia among post-renal transplant patients attending Royal Hospital, Oman, and to identify demographic, clinical, and pharmacological factors associated with its occurrence.

Methods: A retrospective cross-sectional study was conducted at the renal transplant outpatient clinic of Royal Hospital, Muscat, Oman. Adult renal transplant recipients who attended follow-up between 2016 and 2020 were included. Demographic data, comorbidities, pre-transplant biochemical parameters, post-transplant renal function, and immunosuppressive regimens were collected from electronic medical records. Hyperuricemia was defined as serum uric acid levels >400 µmol/L in males and >350 µmol/L in females. Statistical analysis was performed using SPSS. Group comparisons were conducted using chi-square or Fisher’s exact tests for categorical variables and independent-samples t-tests for continuous variables. Multivariate binary logistic regression analysis was used to identify independent predictors of hyperuricemia.

Results: A total of 180 renal transplant recipients were included. The prevalence of hyperuricemia was 38.3%. Male gender was significantly associated with hyperuricemia and remained an independent predictor on multivariate analysis, with males having a markedly higher risk compared to females (OR = 16.96, 95% CI: 1.30–221.64, p = 0.031). Lower pre-transplant serum albumin levels were also independently associated with an increased risk of hyperuricemia (OR = 0.79 per unit increase, 95% CI: 0.63–0.97, p = 0.028). No significant associations were identified between hyperuricemia and diabetes mellitus, hypertension, or the use of immunosuppressive agents, including tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine, or everolimus.

Conclusion: Hyperuricemia is common among renal transplant recipients in Oman, affecting more than one-third of patients. Male gender and lower pre-transplant serum albumin were identified as independent risk factors. Routine monitoring of serum uric acid and early identification of high-risk patients may facilitate timely interventions. Prospective studies are needed to further evaluate modifiable risk factors and assess the impact of targeted management strategies on post-transplant outcomes.

Keywords: Hyperuricemia, Immunosuppressant, Kidney transplantation, Oman, Risk factors

Jawahar Al Shueili¹, Issa Al Salmi², Ehab Mohammed²

¹Oman Medical Specialty Board, Oman.

²Department of Renal Medicine, The Royal Hospital, Ministry of Health, Oman.

Introduction: Pulmonary embolism (PE) is among the most common causes of morbidity and mortality in chronic kidney disease patients worldwide. The aim of this study is to evaluate the risk of developing PE among the chronic kidney disease population on dialysis therapy.

Methods: This is a cross-sectional study of chronic kidney disease patients on renal replacement therapy (hemodialysis) who underwent computed tomography pulmonary angiogram for suspected PE at Royal Hospital from 2016 to 2020.

Results: The study includes 108 patients, with a mean age of 52.0 ± 17.5 years. Males were in a slight majority (55 males Vs 53 females) and were older (mean ± SD: 53.6 ± 16.7 years for males Vs 50.4 ± 18.4 for females). Out of the 108 patients with suspected PE, 35 patients had a confirmed diagnosis of PE. Of these, 14 were males, and 21 were females, who had PE during the study period, with a P value of 0.286. The majority of the PE group were obese. More than half of both PE and non-PE patients had hypertension, and one-third had diabetes mellitus. Most patients presented with dyspnea and chest pain. Renal parameters were worse in the PE patient group compared to the non-PE group - the most common echocardiography (ECHO) abnormalities involved right ventricular (RV) hypertrophy and dysfunction. Most patients had abnormal chest radiography (CXR). The most common RRT access among all patients was arteriovenous fistula (AVF), and the most common access among PE patients was a tunneled hemodialysis catheter (permcath). Out of 35 patients with PE, 10 were on a single blood-thinning agent at the time of diagnosis.

Conclusions: This is the first study in Oman that focuses on the development of PE among dialysis patients. It showed that the worse kidney function parameters in terms of serum creatinine, urea, and GFR, the higher the incidence of PE. Similarly, patients who have catheters for dialysis are at a higher risk of developing PE compared to those with AVF.

Keywords: Dialysis vascular access, End-stage chronic kidney disease, Hemodialysis, Pulmonary embolism, Renal replacement therapy

Wael Hamdy Abdelaty

¹Al-Seeb Dialysis Center, Muscat, Oman.

Chronic kidney disease (CKD) is a common long-term complication after liver transplantation, affecting up to half of recipients. Its development is driven by baseline renal vulnerability, perioperative hemodynamic instability, and chronic calcineurin inhibitor (CNI) nephrotoxicity. Balancing adequate immunosuppression with renal protection remains a major challenge. Renal-sparing approaches and metabolic risk control improve outcomes but require individualized planning. Liver transplantation provides excellent survival for end-stage liver disease with modern immunosuppression. However, CKD has become a leading cause of long-term morbidity and mortality among recipients. Its prevalence reaches 30–50% within five years after transplantation. Major risk factors include pre-transplant renal dysfunction, hepatorenal syndrome, diabetes, and perioperative renal injury. Tacrolimus and cyclosporine remain essential immunosuppressants but cause progressive nephrotoxicity through vasoconstriction and interstitial fibrosis. Management requires balancing rejection prevention with minimizing renal injury. CNI minimization and mTOR-based strategies show promise in selected patients. A 64-year-old male teacher with long-standing diabetes and hypertension developed progressive liver disease after a 1980 motor-vehicle accident requiring surgery and blood transfusion. In 1993, he was found to be HCV-positive, later developing cirrhosis and esophageal varices with recurrent hematemesis. He underwent cadaveric liver transplantation in China in 2006. Post-operatively, he developed AKI requiring temporary hemodialysis. He received tacrolimus and mycophenolate therapy. CKD developed by 2009, confirmed by biopsy, and progressed to ESRD in 2018, requiring left brachiocephalic AVF and regular hemodialysis. His course was complicated by recurrent GI bleeding, mineral-bone disease, and cardiovascular disease, for which PCI was performed in 2025. He continues HD 3 times/week with low-dose tacrolimus and MMF. This narrative review synthesizes evidence from major transplant and nephrology guidelines, clinical trials, and high-quality observational studies. Topics included epidemiology, risk factors, mechanisms of nephrotoxicity, and outcomes of renal-sparing immunosuppression. CKD develops in 20–50% of liver transplant recipients, while ESRD occurs in 5–10%. Risk factors include pre-transplant renal impairment, diabetes, hemodynamic instability, and CNI exposure. CNIs cause vasoconstriction, interstitial fibrosis, and metabolic complications. CNI minimization, mTOR inhibitors, mycophenolate-based strategies, and optimized perioperative care can improve renal outcomes in selected patients. CKD arises from the combined effects of baseline renal status, perioperative insults, and chronic immunosuppressive toxicity. CNI nephrotoxicity remains the major modifiable factor. Excessive reduction risks rejection. Metabolic complications also accelerate CKD progression. Early detection is difficult; emerging biomarkers may improve diagnosis. Multidisciplinary care enhances long-term outcomes. CKD substantially affects survival after liver transplantation. Management requires individualized immunosuppression, early renal monitoring, and aggressive metabolic control.

Keywords: Calcineurin inhibitors, Chronic kidney disease, Immunosuppression, Liver transplantation, Renal-sparing strategies

Aya Al Balushi¹, Issa Al Salmi², Ehab Mohammed², Fatma Al Balushi¹, Abeer Al Lawati¹

¹Oman Medical Specialty Board, Oman.

²Department of Nephrology, The Royal Hospital, Ministry of Health, Oman.

Introduction: Rituximab is a monoclonal antibody directed against the CD20 surface marker expressed on B cells. It was first approved for clinical use by the FDA in 1997 for the treatment of non-Hodgkin’s lymphoma. Since then, it has been approved for use in rheumatoid arthritis, chronic lymphocytic leukemia, Microscopic polyangiitis, granulomatosis with polyangiitis, and pemphigus vulgaris. However, over the past two decades, rituximab application has extended far beyond its approved indications, driven by the growing body of evidence demonstrating the crucial role of B-cells and autoantibodies in the pathophysiology of various autoimmune conditions. The objective of this study is to assess rituximab utilization; its various indications, clinical course, and laboratory findings at baseline and 6-12 months post-treatment.

Methods: This is a descriptive study, a cross-sectional situational analysis, that evaluates all cases who received rituximab throughout the period from January 2006 to December 2019, at the Royal Hospital, Muscat, Oman. Various demographics, clinical information, and laboratory data were collected at the time rituximab was first administered and post management at a 6-12 month period.

Results: During the study period, 496 patients received rituximab for various indications. The mean (SD) age was 40.3 ± 17.7 years, and 70% (n = 347) were females. The majority of patients (75.9%) received rituximab off-label, with refractory non-renal SLE and lupus nephritis being the most common off-label indications. Almost one quarter (24.1%) received rituximab for its approved indications, predominantly rheumatoid arthritis. Most patients had received other immunosuppressive treatments prior to or concomitant with rituximab administration. Laboratory tests indicated some complete and partial responses being achieved after rituximab treatment. There was a statistically significant improvement in anti-dsDNA antibody, complement (C3 and C4) levels, and proteinuria, compared with baseline levels.

Conclusions: Rituximab is commonly used off-label in refractory cases, often in combination with other immunosuppressants. While some patients achieve complete or partial responses, the evidence on the efficacy and tolerability of these off-label uses varies, highlighting the need for more clinical trials to improve clinical practice and off-label prescribing decisions.

Keywords: Autoimmune diseases, B-cell depletion, Off-label, Rituximab, Systemic lupus erythematosus

Ahmed Atris¹, Fatma Al Shekili¹, Naima Alblushi¹, Tahra Alblushi¹, Samia Alnabi¹ and Said Al Mazrui¹

¹Department of Renal Medicine, Directorate General of Health Services, Muscat, Oman.

Introduction: Erythropoiesis-stimulating agents (ESAs) such as erythropoietin (EPO) are widely used to treat anemia in patients on maintenance hemodialysis (HD). However, a subset of patients demonstrates poor hemoglobin response despite high ESA doses — a phenomenon termed ESA resistance or EPO resistance. The erythropoietin resistance index (ERI) — commonly defined as weekly EPO dose (IU) per kg body weight divided by hemoglobin (g/dL) — provides a quantitative measure of ESA responsiveness. Anemia management in dialysis is challenging. Keeping hemoglobin levels within a tight range is difficult. A new program, the Central Anemic Manager Team- CAMT (Nephrologist-Nurse-Pharmacist) proved to be a successful, cost-effective model with favorable outcomes. These outcomes were reproducible with every expansion phase. The CAMT reviewed the laboratory results, and the prescriptions for ESAs and iron were written simultaneously. Al Seeb Renal Dialysis Unit currently has 37 beds and serves approximately 275 maintenance HD patients across 24-hour operations in Muscat. This setting offers an ideal real-world population to apply ERI and is managed by CAMT, which determines local prevalence, identifies modifiable predictors (inflammation, iron status, dialysis adequacy, hyperparathyroidism, infection, nutritional status), and proposes unit-level interventions.

Aims and Objectives: The objective of this study was to evaluate patients who receive frequent hemodialysis for EPO resistance and optimize high doses of erythropoietin stepwise by ERI (erythropoietin resistance index) through the Central Anemic Manager Team (CAMT)

Methods: This retrospective observational study in phase I, where we selected anemic patients on HD with high ERI (>15) and collected data related to ERI, such as iron level, parathyroid hormone level, inflammatory markers, and albumin, and took the average for each. As advantages, the CAMT are available, can respond swiftly, and provide complete care, including reviewing the patients’ anemia-related medications, updating the patients’ file appropriately, monitoring patients’ compliance to medications, providing education, as well as involving family members and caregivers in the care plan, and coordinating patient care with other members of the multidisciplinary team (such as other physicians, dietitians and hematology experts) as Protocol: If Hb is in target (10–12 g/dL), but ERI ≥ 15, reduce EPO gradually. The recommended approach involves a cautious, stepwise reduction of Erythropoietin (EPO) therapy. The total weekly EPO dose should initially be reduced by 25%, followed by close monitoring of hemoglobin levels every 1–2 weeks. If hemoglobin remains stable, a further dose reduction of 10–20% can be considered. However, if hemoglobin decreases by more than 1 g/dL, the dose should be returned to the previously effective level. Throughout this process, iron stores should be optimized by maintaining serum ferritin between 200 and 500 µg/L and transferrin saturation (TSAT) between 30% and 40%. Adequacy of dialysis must be ensured, with a target Kt/V of at least 1.4, while contributory factors such as inflammation and elevated parathyroid hormone levels should be actively managed. The erythropoietin resistance index (ERI) should be monitored monthly, with a target of less than 15. Once hemoglobin has remained stable for at least eight weeks, further spacing of EPO doses or a switch to a long-acting erythropoiesis-stimulating agent may be considered.

Results: In this study, 93 out of 275 patients (33%) were identified as having erythropoietin (EPO) resistance. Analysis of treatment and laboratory parameters revealed several important associations. Higher prescribed EPO doses tended to be accompanied by higher erythropoietin resistance index (ERI) values, suggesting reduced responsiveness to therapy, although notable exceptions were observed, indicating inter-individual variability. Iron status showed no clear linear relationship with ERI, as both low and high iron levels were associated with increased resistance. Parathyroid hormone (PTH) levels demonstrated a more consistent pattern, with markedly elevated PTH correlating with very high ERI values, implying that severe secondary hyperparathyroidism may significantly worsen EPO resistance. Inflammatory markers also appeared influential; elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were associated with higher ERI, reinforcing the role of systemic inflammation in impaired EPO response. Additionally, nutritional status appeared relevant, as lower serum albumin levels were associated with higher ERI, whereas patients with normal albumin levels generally showed lower resistance to EPO therapy.

Conclusions: The CAMT model achieved and maintained hemoglobin levels within the target range through the erythropoietin resistance index (ERI) and reduced extreme hemoglobin levels. These outcomes improved patient care by avoiding high hemoglobin (increased thrombosis, cancer recurrence, stroke, and death) and low hemoglobin (weakness, poor quality of life, and need for transfusion) levels. The CAMT model was cost-effective. This model can be considered in other aspects of patient care in dialysis.

Keywords: Anemia, End-stage renal disease, Erythropoietin resistant index, Hemodialysis, Iron deficiency

Ahmed Atris¹, Shaimaa Dawoud¹

¹Al-Seeb Dialysis Center, Muscat, Oman.

Introduction: Erythrocytosis, or polycythemia, is defined as an increase in red blood cell concentration above age- and sex-specific normal levels. Unlike anemia, which is very common in patients with end-stage renal disease (ESRD), erythrocytosis is less frequent. Still, it requires specific understanding by health care professionals to provide the best care. Erythrocytosis, especially when undiagnosed and untreated, can lead to serious thrombotic events and higher mortality. Classic causes of erythrocytosis associated with CKD include cystic kidney diseases, kidney or other erythropoietin-secreting neoplasms, high-altitude renal syndrome, overdosage of erythropoietin-stimulating agents, androgen therapy, heavy smoking, chronic lung disease, obstructive sleep apnea, IgA nephropathy, post–kidney transplant erythrocytosis, renal artery stenosis, and congenital etiologies. The newest entity inducing erythrocytosis is linked to the use of sodium/glucose cotransporter 2 (SGLT2) inhibitors that hypothetically activate hypoxia-inducible factor 2α (HIF-2α). We reported four cases of ESRD on regular hemodialysis who had erythrocytosis without the use of erythropoietin, diagnosed by pocus as acquired cystic disease of the end-stage kidney.

Methods: A case series of four patients, 3 males and 1 female, were selected, who have been on hemodialysis treatment for more than 5 years; all of them had persistent high hemoglobin without use of erythropoietin (one of them, a 6-year erythropoietin-free). There was no patient selected with autosomal dominant polycystic kidney disease. The renal evaluation was performed using point-of-care ultrasound (POCUS) by two nephrologists. Acquired cystic disease of the end-stage kidney was characterized by the finding of four or more cysts in both kidneys. The largest cysts were measured for the correlation effect. The diagnosis of anemia was established based on the hemoglobin level. It has also been analyzed serum urea pre and post, albumin, percent saturation of serum transferrin, iron, and PTH.

Results: The patients were properly dialyzed (urea reduction rate >65%). They were in good nutritional state (serum albumin > 35 g/L), and three of them had normal saturation of serum transferrin iron (T sat>20%), and all had mild to moderate secondary hyperparathyroidism. The prevalence of acquired renal cystic disease was 100%. No finding of malignancy has been detected in these cysts. There was a significant correlation between ESRD duration on dialysis treatment and acquired renal cystic disease (>5 years on HD). Cyst sizes had a direct and significant correlation with hemoglobin levels (the largest cyst>4cm associated with high hgb~14gm/dl). Classic causes of erythrocytosis associated with CKD include cystic kidney diseases, kidney or other erythropoietin-secreting neoplasms, high-altitude renal syndrome, overdosage of erythropoietin-stimulating agents, androgen therapy, heavy smoking, chronic lung disease, obstructive sleep apnea, IgA nephropathy, post–kidney transplant erythrocytosis, renal artery stenosis, and congenital etiologies. The newest entity inducing erythrocytosis is linked to the use of sodium/glucose cotransporter 2 (SGLT2) inhibitors that hypothetically activate hypoxia-inducible factor 2α (HIF-2α). Patients with erythrocytosis may experience headache, dizziness, blurred vision, fatigue, tinnitus, paresthesia, shortness of breath, palpitations, and confusion. Patients who present with symptoms attributable to high hematocrit can be offered phlebotomy. Patients who manifest thrombotic events will need antiplatelet or anticoagulant therapy and preventive phlebotomy.

Conclusion: These results show that spontaneous improvement in anemia seen in patients on chronic dialysis has a significant correlation with the acquired cystic disease of the end-stage kidney diagnosed by a nephrologist through POCUS. Our data suggest a functional role of acquired kidney cysts in endogenous erythropoietin production. The importance of managing persistent erythrocytosis with ACEIs and Aspirin to prevent complications.

Keywords: Acquired cystic kidney diseases, Erythrocytosis, Erythropoiesis-stimulating agents, Hematocrit, Point of care ultrasound

Tahra Alblushi¹, Salama Alkalbani¹, Ahmed Atris¹

¹Al Seeb Renal Dialysis Center, Muscat, Oman.

Introduction: Hypertension is a common complication in patients undergoing dialysis and may be influenced by disturbances in mineral metabolism, particularly in cases of severe secondary hyperparathyroidism. Elevated serum calcium and phosphate levels, often seen in these patients, can contribute to vascular calcification and increased blood pressure. This study aims to explore the relationship between severe hyperparathyroidism, calcium-phosphate imbalance, and hypertension.

Methods: The objectives of this study are to assess the correlation between severe hyperparathyroidism and blood pressure levels in dialysis patients, to explore the association between serum calcium and phosphate levels and hypertension, and to evaluate whether abnormalities in mineral metabolism contribute to elevated blood pressure in this population. The study hypothesis is that patients with severe hyperparathyroidism and elevated phosphate and/or calcium levels have a higher prevalence or greater severity of hypertension. This is a retrospective observational study conducted on a population of 15 dialysis patients selected from the available dataset. Blood pressure readings recorded between January and July 2025 were reviewed. Additional data points included serum calcium and phosphate levels, the presence of severe hyperparathyroidism—defined by factors such as high phosphate, abnormal calcium levels, and long duration on dialysis—and the use of medications that may affect blood pressure or mineral balance, including cinacalcet and amlodipine. The analysis involved descriptive statistics of blood pressure, calcium, and phosphate levels. Blood pressure was compared between patients with normal versus high phosphate or calcium levels. Correlations between blood pressure and calcium and phosphate were assessed, and results were further stratified according to the use of hyperparathyroidism-related medications, particularly cinacalcet.

Results: This study revealed: 15 ESRD patients on regular HD thrice session/week. 4 are female, and 11 are male, age from 27:74 y, duration on HD from 3:10 y. all had severe hyperparathyroidism (PTH>200 pmol/L), average calcium1.9:2.4 mmol/l, and average phosphorus 0.8:2.5 mmol/l. Preliminary findings suggest that patients with elevated phosphate levels (above 1.5 mmol/L) and prolonged dialysis duration tend to have higher blood pressure readings. Several patients on cinacalcet and other mineral management therapies showed slightly better control of calcium and phosphate levels and good control of PTH, which may correlate with improved blood pressure profiles.

Conclusion: There appears to be a positive relationship between severe hyperparathyroidism (as indicated by elevated calcium and phosphate) and hypertension in dialysis patients. Effective control of mineral metabolism through medications like cinacalcet may contribute to better blood pressure management. Further studies with larger sample sizes are needed to confirm these findings.

Keywords: Cinacalcet, Hypertension, Hyperparathyroidism, Hemodialysis, Vascular calcification

Mohamed Ali Mohamed Elhassan¹,

Mojahid Abdallah Hassan¹, Ali Al Lawati¹

¹Sultan Qaboos University Hospital, University Medical City, Oman.

Introduction: Belatacept is the only approved co-stimulation blocker in kidney transplantation; however, supply shortages have limited its availability. Abatacept, a structurally related CTLA-4–Ig fusion protein, may serve as a rescue alternative for patients with calcineurin inhibitor intolerance.

Methods: We retrospectively reviewed kidney transplant recipients converted to abatacept due to CNI intolerance between 2023 and 2025. Two patients with ≥ 12 months of follow-up were evaluated for clinical outcomes, viral surveillance, and graft function.

Results: Both patients underwent pre-emptive living-related transplantation and developed CNI-related complications. Monthly intravenous Abatacept (10 mg/kg) was well tolerated, with no infusion reactions, rejection episodes, or viral reactivation. Renal graft function improved and remained stable at 12 months.

Conclusions: Abatacept appears to be a feasible rescue immunosuppressive option for CNI-intolerant kidney transplant recipients during Belatacept unavailability. Further studies are warranted to confirm its safety and efficacy.

Keywords: Abatacept, Belatacept, Calcineurin inhibitor intolerance, Co-stimulation blockade, Kidney transplantation