Mohamed Elsayed

Amidst the rising tide of chronic kidney disease (CKD) burden, the global nephrology workforce has failed to expand in order to meet the growing healthcare needs of this vulnerable patient population. In truth, this shortage of nephrologists is seen in many parts of the world, including North America, Europe, Australia, New Zealand, Asia and the African continent. Moreover, expert groups on workforce planning as well as national and international professional organizations predict further reductions in the nephrology workforce over the next decade, with potentially serious implications. Although the full impact of this has not been clearly articulated, what is clear is that the delivery of care to patients with CKD may be threatened in many parts of the world unless effective country-specific workforce strategies are put in place and implemented. Multiple factors are responsible for this apparent shortage in the nephrology workforce and the underpinning reasons may vary across health systems and countries. Potential contributors include the increasing burden of CKD, aging workforce, declining interest in nephrology among trainees, lack of exposure to nephrology among students and residents, rising cost of medical education and specialist training, increasing cultural and ethnic disparities between patients and care providers, increasing reliance on foreign medical graduates, inflexible work schedules, erosion of nephrology practice scope by other specialists, inadequate training, reduced focus on scholarship and research funds, increased demand to meet quality of care standards and the development of new care delivery models. It is apparent from this list that the solution is not simple and that a comprehensive evaluation is required. Consequently, there is an urgent need for all countries to develop a policy framework for the provision of kidney disease services within their health systems, a framework that is based on accurate projections of disease burden, a full understanding of the internal care delivery systems and a framework that is underpinned by robust health intelligence on current and expected workforce numbers required to support the delivery of kidney disease care. Given the expected increases in global disease burden and the equally important increase in many established kidney disease risk factors such as diabetes and hypertension, the organization of delivery and sustainability of kidney disease care should be enshrined in governmental policy and legislation. Effective nephrology workforce planning should be comprehensive and detailed, taking into consideration the structure and organization of the health system, existing care delivery models, nephrology workforce practices and the size, quality and success of internal nephrology training programmes. Effective training programmes at the undergraduate and postgraduate levels, adoption of novel recruitment strategies, flexible workforce practices, greater ownership of the traditional nephrology landscape and enhanced opportunities for research should be part of the implementation process. Given that many of the factors that impact on workforce capacity are generic across countries, cooperation at an international level would be desirable to strengthen efforts in workforce planning and ensure sustainable models of healthcare delivery.

Aflatoxins (AF), a group of closely related, extremely toxic mycotoxins, produced by Aspergillus flavus and A. parasiticus can occur as natural contaminants of foods and feeds. Aflatoxins have been shown to be hepatotoxic, carcinogenic, mutagenic, and teratogenic to different animal species. Zizyphus spina-christi L. extract was investigated for its antifungal and antimicrobial activities. The aim of the present work was to evaluate the antioxidant activity of the methanol extract of Z. spina-christi L. leaves against the oxidative stress of aflatoxin in rats. Fourty male Sprague-Dawley male rats were divided into four groups including the control group, the group fed aflatoxin-contaminated diet (3 mg/kg diet) and the groups treated with Zizyphus extract (5 mg/kg b.w) alone or in combination with AF for 15 days. Biochemical analysis revealed that treatment with AF resulted in a significant increase in ALT, AST, cholesterol, triglycerides, uric acid, TNFa, LPO, NO and CEA, whereas it decrease significantly GPX and SOD. The histopathological examination of the liver, kidney and testis showed sever histological changes typical to those reported for aflatoxicosis. Animals treated with Zizyphus extract alone or plus AF showed a significant improvement in all biochemical parameters and histological picture of liver, kidney and testis. It could be concluded that Zizyphus extract have a power protective role against aflatoxicosis.

To gain better understanding of systemic lupus erythematosus (SLE) in Dubai we studied the clinical and immunological manifestations in a cohort of 151 patients attended Rheumatology Clinic in Dubai Hospital between January 2002 and January 2007. We found that the female to male ratio was 20.5:1, with a mean age of 35.5 years (0.9). The mean age at disease onset was 28.9 years (0.8) and mean disease duration 6.7 years (0.4). Five-year survival rate in our cohort was 94%. The commonest clinical manifestations in this cohort were arthritis (88%), haematological abnormalities (61.6%), and malar rash (60.3%). Leucopenia, fever, hair loss and proteinuria were observed in approximately half of the patients. Anaemia was found in 44.3% but only 9.9% had haemolytic anaemia. Photosensitive rash was seen in 43% of patients. Approximately one-third of the patients had serositis and mouth ulcers, 30.5 and 27.2% respectively. Vasculitis was observed in 19.2% of patients. Neuropsychiatric manifestations (15.9%), discoid lupus lesions (12.6%), and brain infarcts (13.2%) were infrequent. Subacute cutaneous lupus (6%) was also uncommon. Anti-nuclear antibodies were detected in 98%, anti-double stranded DNA antibodies in 88.7%, anti-Sm antibodies in 19.7%, anti-RNP in 40.4%, anti-Ro antibodies in 52.3% and anti-La antibodies in 19.8%. Anti-cardiolipin IgM and IgG were detected in 25.3 and 22.4%, respectively. This study suggests that Arabs with SLE residing in Dubai have comparable clinical features to their counterparts in other Arab countries and Western countries. The high prevalence of positive anti-Ro antibodies among our Arab patients probably reflects a character, that is, commonly seen in SLE patients of Middle East origin.

BACKGROUND: Accurate comparisons of haemodialysis (HD) and peritoneal dialysis (PD) survival based on observational studies are difficult due to substantial residual confounding that arises from imbalances between treatments. Propensity score matching (PSM) comparisons confer additional advantages over conventional methods of adjustment by further reducing selection bias between treatments. We conducted a systematic review of studies that compared mortality between in-centre HD with PD using a PSM-based approach. METHODS: A sensitive search strategy identified all citations in the PubMed, Cochrane and EMBASE databases from inception through November 2018. Pooled PD versus HD mortality hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated through random-effects meta-analysis. A subsequent meta-regression explored factors to account for between-study variation. RESULTS: The systematic review yielded 214 citations with 17 cohort studies and 113 578 PSM incident dialysis patients. Cohort periods spanned the period 1993-2014. The pooled HR for PD versus HD was 1.06 (95% CI 0.99-1.14). There was considerable variation by country, however, mortality risks for PD versus HD remained virtually unchanged when stratified by geographical region with HRs of 1.04 (95% CI 0.94-1.15), 1.14 (95% CI 0.99-1.32) and 0.98 (0.87-1.10) for European, Asian and American cohorts, respectively. Subgroup meta-analyses revealed similar risks for patients with diabetes [HR 1.09 (95% CI 0.98-1.21)] and without diabetes [HR 0.99 (95% CI 0.90-1.09)]. Heterogeneity was substantial (I2 = 87%) and was largely accounted for by differences in cohort period, study type and country of origin. Together these factors explained a substantial degree of between-studies variance (R2 = 90.6%). CONCLUSIONS: This meta-analysis suggests that PD and in-centre HD carry equivalent survival benefits. Reported differences in survival between treatments largely reflect a combination of factors that are unrelated to clinical efficacy.