Safely navigating kidney transplantation during the COVID-19 pandemic: the Singapore General Hospital's experience.

Background: The coronavirus disease 2019 (COVID-19) pandemic curtailed transplant activities worldwide, driven by concerns about increased COVID-19-related mortality among kidney transplant recipients (KTRs), infections originating from donors, and decreased availability of surgical and intensive care resources as healthcare resources are reallocated for pandemic response. We examined the outcomes of KTRs at our center before and during the COVID-19 pandemic. Methods: We conducted a retrospective single-center cohort study examining the characteristics and outcomes of patients undergoing kidney transplantation during two periods January 1, 2017 to December 31, 2019 (pre-COVID-19 era) and January 1, 2020 to June 30, 2022 (COVID-19 era). We reviewed perioperative and COVID-19 infection-related outcomes in both groups. Results: A total of 114 transplants were performed during the pre-COVID-19 era, while 74 transplants were conducted during the COVID-19 era. No differences in baseline demographics were observed. Additionally, there were no significant differences in perioperative outcomes, except for a longer cold ischemia time during the COVID-19 era. However, this did not result in an increased incidence of delayed graft function. Among the KTRs infected with COVID-19 during the pandemic era, no severe complications such as pneumonia, acute kidney injury, or death were reported. Conclusions: With the global transition to an endemic phase of COVID-19, it is imperative to revitalize organ transplant activities. Effective containment workflow, good vaccination uptake, and prompt COVID-19 treatment are essential to ensure that transplants can proceed safely.

Hepatitis C virus antigen detection is an appropriate test for screening and early diagnosis of hepatitis C virus infection in at-risk populations and immunocompromised hosts.

Early diagnosis remains key for effective prevention and treatment. Unfortunately, current screening with anti-hepatitis C virus antibody (anti-HCV Ab) test may have limited utility in the diagnosis of HCV infection and reinfection. This is of special concern to at-risk population, such as immunocompromised hosts and end-stage renal failure patients on hemodialysis. HCV antigen (Ag) could be useful in identifying the ongoing infection in such clinical scenarios. Hence, we aimed to study the utility of HCV Ag testing for the diagnosis of acute and chronic hepatitis C. Of 89 samples studied, 19 were from acute hepatitis C patients who were immunocompromised or were on hemodialysis, 43 were from active chronic hepatitis C patients and 27 were from patients treated for chronic hepatitis C. All samples were tested for HCV Ag using the Abbott ARCHITECT HCV Ag assay. HCV Ag was reactive in 19/19 samples from acute hepatitis C patients and 42/43 samples from active chronic hepatitis C patients. It was nonreactive in all samples from treated patients. The test showed a sensitivity and specificity of 98.4% and 100.0%, respectively. The positive and negative predictive values were 100.0% and 96.4%, respectively. The HCV antigen test has high clinical sensitivity and specificity and is useful for the diagnosis of acute and chronic hepatitis C infection in at-risk and immunocompromised patients. Its short turnaround time and relatively low cost are advantageous for use in patients on hemodialysis and other at-risk patients who require monitoring of HCV infection and reinfection.

Addressing bone quality and bone density after renal transplantation: A prospective evaluation of the evolution of trabecular bone score and bone mineral density over the first 5 years following renal transplantation in Asian patients.

The evolution of trabecular bone score (TBS) and bone mineral density (BMD) over the first 5 years after renal transplantation was prospectively evaluated in 164 patients. Dual energy X-ray absorptiometry (DXA) scans were performed at 0, 6, 12, 24, and 60 months. Cumulative steroid dose, serum 25(OH)D, calcium, parathyroid hormone, and total ALP levels at these time points were checked. Incident fractures were identified from X-rays/vertebral fracture assessments. Mean (SD) age, TBS, and lumbar spine BMD at baseline were 47.11 (9.53), 1.424 (0.097), and 0.935 (0.183) gm/cm2 , respectively. Baseline TBS was lower in tertiary 1.38 (0.07) vs secondary hyperparathyroidism 1.43 (0.01) vs post-parathyroidectomy 1.46 (0.11); P = .035. Trabecular bone score and BMD significantly decreased from baseline->6 months, changes after that at consecutive time points were non-significant. 11% had incident fractures during the follow-up period, majority being metatarsal with no vertebral or hip fractures noted. This first prospective evaluation of TBS and BMD evolution at multiple time points over 5 years suggest that microarchitectural and bone density deteriorations post-renal transplantation stabilize after 6 months. Stabilization of these parameters could partially account for the absence of major fractures noted in this Asian population. Possible genetic and ethnic differences in fracture risk between Asian and Caucasian renal transplant patients have to be explored through large population-based studies.

Dermatological conditions seen in renal transplant recipients in a Singapore tertiary hospital.

INTRODUCTION: Lifelong immunosuppression after renal transplant exerts effects on the recipients' skin, including skin infections, skin cancers and drug-induced skin disorders. Our study aimed to determine the epidemiology of skin conditions among renal transplant recipients in the largest tertiary hospital in Singapore. METHODS: We reviewed the medical records of kidney transplant recipients at Singapore General Hospital, Singapore, between 1 January 2003 and 31 December 2013. Among these patients, the clinical data of patients who sought skin consultations with either dermatologists or plastic surgeons within the hospital was captured. RESULTS: A total of 178 patients were included in our study. There were 88 (45.6%) skin infections, 23 (11.9%) drug-induced skin conditions, 9 (4.7%) skin cancers and 73 (37.8%) other skin conditions. Skin infection was the predominant reason for consultation, with viral warts (15%, n = 29) being the most common. Of the nine cases in our cohort with skin cancer, there were three cases of basal cell carcinoma, three cases of Bowen's disease, two cases of extramammary Paget's disease and one case of squamous cell carcinoma. Drug-induced skin conditions, mainly attributable to long-term steroids and cyclosporin use, were represented by acne (9.3%, n = 18) and sebaceous hyperplasia (2.6%, n = 5). CONCLUSION: Our study demonstrated the spectrum of skin conditions that can be expected after renal transplantation. We wish to highlight the importance of careful dermatological screening and long-term follow-up for these patients, in order to reduce post-transplant skin complications.

Day 1 post-operative fasting hyperglycemia may affect graft survival in kidney transplantation.

BACKGROUND: Early post-operative hyperglycemia is commonly encountered in patients without pre-existing diabetes mellitus who are undergoing kidney transplantation. The aim of this study was to determine the effect of early post-operative hyperglycemia on graft and patient survival after kidney transplantation in our center. MATERIAL AND METHODS: This was a single-center retrospective review of solitary kidney recipients transplanted in our center between January 1998 and December 2007. Of a total of 432 patients, 377 were eligible for the study. Fasting plasma glucose (FPG) levels at day 1 (D1) and day 5 (D5) after transplantation were recorded. Hyperglycemia was defined as FPG ≥ 7.0 mmol/l. Outcome events recorded included deaths and graft failures. RESULTS: The mean age at transplantation was 43.2 ± 9.5 years and 50.4% were male. The mean FPG levels at D1 and D5 were 7.5 ± 1.3 mmol/L and 5.3 ± 1.3 mmol/L, respectively; 64.2% of recipients had FPG ≥ 7.0 mmol/L on D1 and this was reduced to 8.5% on D5. Recipients with D1 FPG ≥ 7.0 mmol/L had significantly poorer graft survival (39 events) compared to those without D1 hyperglycemia (6 events), with a hazard ratio of 3.708 (95% CI, 1.568-8.766, P=0.003). There was a trend towards better patients survival in recipients with D1 FPG <7.0 mmol/L (P=0.056). CONCLUSIONS: D1 post-transplantation hyperglycemia may be associated with increased risk of graft failure. It is thus important to closely monitor glucose levels during the early post-transplantation period so that high risk patients can be identified and appropriate measures can be implemented to improve the long-term outcome.

Epstein-Barr virus-associated smooth muscle tumors after kidney transplantation: treatment and outcomes in a single center.

BACKGROUND: Epstein-Barr virus-associated smooth muscle tumors (EBV SMT) in adult kidney transplant recipients (KTR) are rare. The aims of this study are to document the clinical features, types of treatment given, and outcomes of KTR with EBV SMT in our institution. METHODS: Sixteen patients were identified from our institution's databases. Patients' survival, tumor outcome, and graft survival were compared between patients who remained on cyclosporine-based immunosuppressant and those who converted to sirolimus-based therapy. RESULTS: The median time of diagnosis was 9.4 yr after kidney transplantation, and majority of the patients had multifocal disease at the time of diagnosis. Overall, the patient survival rate was 75% over a mean follow-up period of five yr. Two patients with non-functioning allograft at the time of diagnosis of EBV SMT were excluded from the treatment outcome analysis. Comparing the sirolimus (n = 7) vs. cyclosporine groups (n = 7), patient survival rate was 100% vs. 42.9% (p = 0.08), graft survival 71.4% vs. 28.7% (p = 0.53), and disease-free status 42.9% vs. 14.3% (p = 0.73), respectively. CONCLUSION: Surgical resection in combination with decreasing immunosuppression or conversion to sirolimus appears to be effective in the treatment of EBV SMT in KTR.

Limited knowledge of chronic kidney disease among primary care patients--a cross-sectional survey.

BACKGROUND: Kidney disease is the 9th leading cause of death in Singapore. While preventive effects have focused on early detection and education, little is known about the knowledge level of chronic kidney disease (CKD) locally. We seek to evaluate the knowledge of CKD among primary care patients. METHODS: We conducted a cross-sectional survey of a convenience sample of 1520 patients from 3 primary care centers. Those with existing CKD or on dialysis were excluded. Knowledge was assessed based on 7 questions on CKD in the self-administered questionnaire. One point was given for each correct answer with a maximum of 7 points. RESULTS: 1435 completed all 7 questions on CKD. Mean age was 48.9 ± 5.0 (SD) years. 50.9% were male. 62.3% had a secondary and below education and 52.4% had a monthly household income of ≤ $2000. 43.7% had chronic diseases. Mean score was 3.44 ± 1.53 (out of a maximum of 7). Median score was 4. In multivariate logistic regression, being older {>60 years [Odds Ratio (OR) 0.50, 95% Confidence Interval (CI) 0.32-0.79]; 40-60 years (OR 0.62, 95% CI 0.43,0.89)}, less educated [up to primary education (OR 0.33, 95% CI 0.22-0.49)], having a lower monthly household income [

Prevalence and patterns of bone loss in the first year after renal transplant in South East Asian patients.

BACKGROUND: Limited data are available regarding patterns of bone loss in South East Asian renal transplant patients. We aimed to determine the prevalence of low bone density and factors contributing to bone loss in Singaporean patients in the first year after renal transplant. METHODS: Seventy-nine consecutive patients who underwent renal transplant were evaluated. Bone mineral density (BMD) was evaluated at 0 (baseline), and at 6 and 12 months after transplant. Baseline parathyroid hormone and vitamin D levels were also assessed. Multivariate regression models were used to investigate the relationship between the different variables and BMD. RESULTS: Thirty-six patients (45.6%) had low BMD at baseline. Factors correlating with the low BMD were older age, postmenopausal status, and tertiary hyperparathyroidism (P<0.0005, 0.009, and 0.027, respectively). There was a linear decrease in total hip and lumbar spine BMD from baseline to 12 months, the decrease from baseline to 6 months being significant (P=0.019 for total hip and P<0.0005 for lumbar spine). Patients with tertiary hyperparathyroidism had a greater risk of decrease in BMD at 6 months compared with patients with secondary hyperparathyroidism (odds ratio=13.5, confidence interval: 1.3, 144.4) and with those who had parathyroidectomy (odds ratio=34.9; confidence interval: 2.0, 598.8). CONCLUSIONS: The prevalence of low BMD in this population of renal transplant recipients was high. Parathyroid status was the only independent factor that correlated with low BMD at baseline and subsequent bone loss highlighting the critical role of this hormone in bone metabolism after renal transplant.

Spontaneous pneumothorax outcome study (SPOT phase I): a 2-year review.

OBJECTIVE: We aim to describe the incidence of spontaneous pneumothorax presenting to the Emergency Department, the treatment given and the outcomes of treatment. METHODS: We conducted a retrospective review of patients with spontaneous pneumothorax presenting to the Emergency Department of the Singapore General Hospital from 1 January 2000 to 31 December 2001. RESULTS: Of a total of 159 patients, with a mean age of 36.1 years (standard deviation 19.3), 94.3% were men, 75 (47.2%) were treated in the Emergency Department with chest-tube insertion, 28 (17.6%) were treated with needle aspiration, and 56 (35.2%) were observed. Significantly more patients had complete re-expansion with chest-tube (65.3%) compared with needle aspiration (17.9%) (P<0.001). Patients with needle aspiration or those being observed were more likely to have a second procedure (P<0.001), whereas patients with chest tubes were more likely to have definitive treatment subsequently (pleurodesis, thoracotomy). The mean duration of hospitalization was significantly longer for chest-tube insertion (7.4 days) compared with other groups (needle aspiration 4 days). There was no significant difference in the complication rates between treatment groups at one year. CONCLUSION: We found a male predominance locally. Treatment with chest-tube insertion is still the most popular method in the Emergency Department. Needle aspiration results in a shorter hospitalization, but a high proportion require a second procedure. Complication rates do not seem to differ from chest-tube insertion.