Rigid ring vs. flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation: A systematic review and meta-analysis.

Background & objectives: Rigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. Methods: We conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). Results: Twelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43-1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45-1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). Conclusion: Our study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.

Tracking the epidemiological trends of female breast cancer in Saudi Arabia since 1990 and forecasting future statistics using global burden of disease data, time-series analysis.

BACKGROUND: Female breast cancer stands as the prime type of cancer in the Kingdom of Saudi Arabia (KSA), with a high incidence and mortality rates. This study assessed the burden of female breast cancer in KSA by analyzing and forecasting its incidence, mortality, and disability-adjusted life years (DALYs). METHODS: We retrieved data from the Global Burden of Disease (GBD) about female breast cancer from 1990 to 2021. Time-series analysis used the autoregressive integrated moving average (ARIMA) model to forecast female breast cancer statistics from 2022 to 2026. RESULTS: From 1990 to 2021, KSA reported 77,513 cases of female breast cancer. The age groups with the highest number of cases are 45-49 years, followed by 40-44 years, 50-54 years, and 35-39 years. The analysis also showed fewer cases in the younger age groups, with the lowest number in the less than 20-year-old age group. From 1990 to 2021, KSA reported 19,440 deaths due to breast cancer, increasing from 201 cases in 1990 to 1,190 cases in 2021. The age-standardized incidence rate/100,000 of breast cancer increased from 15.4 (95% confidence interval (CI) 11.2-21.0) in 1990 to 46.0 (95%CI 34.5-61.5) in 2021. The forecasted incidence rate of female breast cancer will be 46.5 (95%CI 45.8-46.5) in 2022 and 49.6 (95%CI 46.8-52.3) in 2026. The age-standardized death rate per 100,000 Saudi women with breast cancer increased from 6.73 (95%CI 6.73-9.03) in 1990 to 9.77 (95%CI 7.63-13.00) in 2021. The forecasted female breast cancer death rate will slightly decrease to 9.67 (95%CI 9.49-9.84) in 2022 and to 9.26 (95%CI 8.37-10.15) in 2026. DALYs increased from 229.2 (95%CI 165.7-313.6) in 1990 to 346.1 (95%CI 253.9-467.2) in 2021. The forecasted DALYs of female breast cancer will slightly decrease to 343.3 (95%CI 337.2-349.5) in 2022 reaching 332.1 (95%CI 301.2-363.1) in 2026. CONCLUSIONS: Female breast cancer is still a significant public health burden that challenges the health system in KSA, current policies and interventions should be fashioned to alleviate the disease morbidity and mortality and mitigate its future burden.

Augmented anastomotic ureteral reconstruction using buccal mucosal graft, initial experience.

OBJECTIVE: To assess the augmented anastomotic ureteral reconstruction using buccal mucosal graft based on omental flap for managing ureteral stricture. SUBJECTS AND METHODS: This prospective cohort study was conducted on 13 patients with ureteric strictures of different lengths secondary to Bilhalziasis, iatrogenic (post endoscopy) and post inflammatory etiology in upper and mid ureteral segments were treated with buccal mucosal patch grafts and The graft is fixed to the undersurface or the posterior surface of the omentum before doing graft anastomosis to the ureteral walls as to ensure the process of graft take sticky to the principles of tissue transfer. All patients were subjected to full history taking, clinical examination for assessment of pain, lower or upper urinary track symptoms and laboratory investigation (complete blood count, CRP, liver function test and kidney function test (serum urea and creatinine). RESULTS: The mean operative time was 148.85 min and mean hospital stay was 3 days. Mean blood loss was ranged from 20 to 210 ml and Stent was removed after 8-12 weeks. The mean follow up was 13 months, all patients had a non-obstructive RI value <0.7 with a non-obstructed drainage pattern on the diuretic renogram except one patient who had severe postoperative UTI necessitating nephrostomy tube insertion his drainage curve was plateau. CONCLUSION: BMG ureteroplasty is a valuable option for a carefully selected patient. The fixation of the graft on the back surface of the omentum allows for better anatomical reconstruction without any twisting to the omental pedicle.

Predictors of surgical intervention for antenatally detected ureteropelvic junction obstruction (UPJO): A prospective multivariate analysis.

OBJECTIVE: We aimed to identify clinical and radiological predictors of the need for surgical intervention in infants with antenatally detected UPJO. MATERIAL AND METHODS: We prospectively followed infants born with antenatally diagnosed ureteropelvic junction obstruction (UPJO) presented at our outpatient clinics for evidence of obstructive injury with a standard protocol with ultrasonography and renal scintigraphy. Indications for surgery included progression of hydronephrosis on serial examinations, initial differential renal function (DFR) ⩽35% or >5% loss in sequential studies, and febrile urinary tract infection (UTI). Univariate and multivariate analyses were utilized to define the predictors for surgical intervention, while the appropriate cut-off value of the initial Anteroposterior diameter (APD) was determined using the receiver operator curve analysis. RESULTS: Univariate analysis revealed a significant association between surgery, the initial APD, cortical thickness, Society for Fetal Urology grade, UTD risk group, initial DRF, and febrile UTI (p-value < 0.05). No significant association between surgery and sex or side of the affected kidney (p-value 0.91 and 0.38, respectively). On multivariate analysis, the initial APD, initial DRF, obstructed renographic curve, and febrile UTI (p-value < 0.05) were the only independent predictors for surgical intervention. An initial APD of 23 mm can predict surgical requirement, with a specificity of 95% and sensitivity of 70%. CONCLUSION: For antenatally diagnosed UPJO, the APD value (at the age of 1 week), DFR value (at the age of 6-8 weeks), and febrile UTI during follow-up are significant and independent predictors of the need for surgical intervention. APD, when used with a cut-off value of 23 mm, is associated with high specificity and sensitivity for predicting surgical need.

Association of serum leptin and ghrelin levels with smoking status on body weight: a systematic review and meta-analysis.

Background and aims: Smoking cigarettes is a major global health problem that affects appetite and weight. The aim of this systematic review was to determine how smoking affected plasma leptin and ghrelin levels. Methods: A comprehensive search of PubMed, Scopus, Web of Science, and Ovid was conducted using a well-established methodology to gather all related publications. Results: A total of 40 studies were included in the analysis of 11,336 patients. The overall effect showed a with a mean difference (MD) of -1.92[95%CI; -2.63: -1.20] and p = 0.00001. Subgroup analysis by study design revealed significant differences as well, but with high heterogeneity within the subgroups (I2 of 82.3%). Subgroup by sex showed that there was a significant difference in mean difference between the smoking and non-smoking groups for males (MD = -5.75[95% CI; -8.73: -2.77], p = 0.0002) but not for females (MD = -3.04[95% CI; -6.6:0.54], p = 0.10). Healthy, pregnant, diabetic and CVD subgroups found significant differences in the healthy (MD = -1.74[95% CI; -03.13: -0.35], p = 0.01) and diabetic (MD = -7.69[95% CI, -1.64: -0.73], p = 0.03). subgroups, but not in the pregnant or cardiovascular disease subgroups. On the other hand, the meta-analysis found no statistically significant difference in Ghrelin serum concentration between smokers and non-smokers (MD = 0.52[95% CI, -0.60:1.63], p = 0.36) and observed heterogeneity in the studies (I2 = 68%). Conclusion: This study demonstrates a correlation between smoking and serum leptin/ghrelin levels, which explains smoking's effect on body weight. Systematic review registration: https://www.crd.york.ac.uk/ prospero/display_record.php, identifier (Record ID=326680).

Sodium-glucose co-transporter 2 inhibitors & glucagon-like peptide-1 receptor agonists, efficacy & safety in diabetic kidney transplant recipients.

INTRODUCTION: Cardiovascular and renal complications define the outcomes of diabetic kidney transplant recipients (KTRs). The new diabetes medications have changed the management of diabetes. However, transplant physicians are still reluctant to use sodium-glucose cotransporter 2 inhibitors (SGLT2i) and Glucagon-like peptide-1 receptor agonists (GLP-1RA) post kidney transplantation due to fear of drug related complications and lack of established guidelines. PATIENTS AND METHODS: We collected 1-year follow-up data from records of 98 diabetic KTRs on SGLT2I, 41 on GLP- 1RA and 70 on standard-of-care medicines. Patients were more than 3 months post-transplant with a minimum estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73 m2 . Demographic data were similar except for a slightly lower HbA1c in the control group and higher albuminuria in SGLT2i group. RESULTS: HbA1c dropped significantly by .4% in both SGLT2i and GLP-1RA compared to .05% in the control group. A significant decrease in BMI by .32 in SGLT2i and .34 in GLP-1RA was observed compared to an increase by .015 in control group. A tendency for better eGFR in study groups was observed but was non-significant except for the SGLT2i group with an eGFR above 90 (p = .0135). The usual dip in eGFR was observed in the SGLT2i group at 1-3 months. Albuminuria was significantly reduced in both study groups. Adverse events were minimal with comparable safety in all groups. CONCLUSION: The use of SGLT2i and GLP-1RA appears to be effective and safe in diabetic KTRs with good outcomes. Randomized control trials are required to confirm these findings and establish guidelines.

Mini-laparotomy in-situ pyeloplasty for repair of the ureteropelvic junction obstruction: Outcome of 150 cases.

OBJECTIVE: To evaluate the functional and cosmetic outcomes of using the mini-laparotomy technique In Situ pyeloplasty to repair UPJ obstruction in young infants less than 6 months. MATERIALS AND METHODS: Between January 2014 and March 2020, 150 young infants (less than 6 months) diagnosed with unilateral ureteropelvic junction obstruction (UPJO) and treated by mini-laparotomy In Situ pyeloplasty were included in this analysis. Once the UPJ has been identified, it was grasped by an Allis forceps for gentle traction. Two facing transverse incisions were made in the dilated pelvis facing the upper ureter. The transverse ureteric incision was then opened longitudinally. An anastomosis was done between the most dependent part of the lower lip of the pelvis and the apex of ureteric spatulation using 6/0 polyglactin (Vicryl®) sutures in the direction of "out-in-in-out." Follow-up was scheduled for 1 month and then every 3 months for a year with abdominal ultrasonography. DTPA was done for all patients 1 year after repair. RESULTS: The mean age was 3 ± 0.5 months, and the mean follow-up was 1.5 ± 0.3 years. Our technique was done in all included patients with a functional success of 96% (all patients restored normal function, and no obstruction was reported). Parents were satisfied with the cosmetic appearance of the wound in 91% of cases. Major complications occurred in 4% of cases. CONCLUSION: Successful repair of ureteropelvic junction obstruction in young infants can be achieved by using mini-laparotomy In Situ pyeloplasty technique with satisfactory functional and cosmetic outcomes.

Comparative effects of minimally invasive approaches vs. conventional for obese patients undergoing aortic valve replacement: a systematic review and network meta-analysis.

BACKGROUND: Minimally invasive approaches like mini-thoracotomy and mini-sternotomy for Aortic Valve Replacement (AVR) showed impressive outcomes. However, their advantages for obese patients are questionable. We aimed in this network meta-analysis to compare three surgical approaches: Full sternotomy (FS), Mini-sternotomy (MS), and Mini-thoracotomy (MT) for obese patients undergoing AVR. METHODS: We followed the PRISMA extension for this network meta-analysis. PubMed/Medline, Scopus, Web of Science, and Cochrane searched through March 2023 for relevant articles. The analysis was performed using R version 4.2.3. RESULTS: Out of 344, 8 articles met the criteria with 1392 patients. The main outcomes assessed were perioperative mortality, re-exploration, atrial fibrillation, renal failure, ICU stay, hospital stay, cross-clamp time, and bypass time. In favor of MS, the length of ICU stay and hospital stay was significantly lower than for FS [MD -0.84, 95%CI (-1.26; -0.43)], and [MD -2.56, 95%CI (-3.90; -1.22)], respectively. Regarding peri-operative mortality, FS showed a significantly higher risk compared to MS [RR 2.28, 95%CI (1.01;5.16)]. Also, patients who underwent minimally invasive approaches; MT and MS, required less need of re-exploration compared to FS [RR 0.10, 95%CI (0.02;0.45)], and [RR 0.33, 95%CI (0.14;0.79)], respectively. However, Intraoperative timings; including aortic cross-clamp, and cardiopulmonary bypass time, were significantly lower with FS than for MS [MD -9.16, 95%CI (-1.88; -16.45)], [MD -9.61, 95%CI (-18.64; -0.59)], respectively. CONCLUSION: Our network meta-analysis shows that minimally invasive approaches offer some advantages for obese patients undergoing AVR over full sternotomy. Suggesting that these approaches might be considered more beneficial alternatives for obese patients undergoing AVR.

Contrast-induced Nephropathy in Kidney Transplant Recipients: A Single-center Experience.

INTRODUCTION: Data regarding contrast-induced nephropathy (CIN) in kidney transplant (KT) recipients are scarce despite the distinct risk factors such as the use of immunosuppressive agents, sympathetic denervation, glomerular hyperfiltration, and high prevalence of the cardiovascular disease. This study aimed to determine the prevalence of CIN in KT recipients who received low-osmolality iodine-based contrast material (CM) for radiological assessment. METHODS: Between 2010 and 2020, 79 of the 3180 KT recipients followed at Hamed Al-Essa organ transplant center received low-osmolality iodine-based contrast for radiological assessment for various indications. Preventive measures including holding metformin, intravenous hydration, sodium bicarbonate and N-acetylcysteine were given before contrast administration. CIN was defined as an increase in serum creatinine of 25% from the baseline within 72 hours. RESULTS: The enrolled patients were divided into two groups: those who developed CIN (n = 7) and those with no increase in serum creatinine level (n = 72). The mean age of the patients was 52.1 ± 12.3 years; 44 of them were males, and the cause of end-stage kidney disease was mostly diabetic nephropathy. The pre-transplant demographics were comparable between the two groups. Fortyseven cases received contrast for coronary angiography, and 32 received it for a CT scan. The graft function deteriorated in group 1, but no significant difference was found between the two groups at the end of the study. CONCLUSION: CIN is not uncommon in KT recipients receiving CM, especially with ischemic heart disease. Risk stratification, optimizing hemodynamics, and avoiding potential nephrotoxins are essential before performing CM-enhanced studies in KT recipients.  DOI: 10.52547/ijkd.7165.

Utility of YouTube online learning for junior gastrointestinal endoscopists: A rewarding or deterring practice?

Endoscopy is a competitive field in clinical practice, in which skilled endoscopists are in high demand. The learning process for Junior Gastrointestinal Endoscopists (JGEs) is difficult, quite long, and technically demanding. This directs JGEs to seek additive learning sources, including online sources. The purpose of this study was to determine the frequency, context, attitudes, perceived benefits, drawbacks, and recommendations for using YouTube videos as an educational platform among JGEs from the uses'prespective. We disseminated a cross-sectional online questionnaire from January 15th to March 17th, 2022, and recruited 166 JGE from 39 different countries. The majority of surveyed JGEs (138, 85.2%) were already using YouTube as a learning tool. The majority of JGEs (97, 59.8%) reported gaining knowledge and applying it in their clinical practice, but 56 (34.6 %) reported gaining knowledge without application in real practice. Most participants (124, 76.5 %) reported missing procedure details in YouTube endoscopy videos. The majority of JGEs (110, 80.9%) reported that YouTube videos are provided by endoscopy specialists. Only one participant, 0.6% out of the 166 JGEs surveyed, disliked video records, including YouTube as a source of learning. Based on their experience, 106 (65.4%) of participants recommended YouTube as an educational tool for the coming generation of JGEs. We consider that YouTube represents a potentially useful tool for JGEs, supplying them with both knowledge and clinical practice tricks. However, many drawbacks could make the experience misleading and time-consuming. Consequently, we encourage educational providers on YouTube and other platforms to upload well-constructed, peer-reviewed, interactive educational endoscopy videos.

Antecedentes : La endoscopia es un campo competitivo en la práctica clínica en el que los endoscopistas calificados tienen una gran demanda. El proceso de aprendizaje para los endoscopistas gastrointestinales junior (JE) es difícil, bastante largo y técnicamente exigente. Esto dirige a los JE a buscar fuentes de aprendizaje adicionales, incluidas las fuentes en línea. El propósito de este estudio fue determinar la frecuencia, el contexto, las actitudes, los beneficios percibidos, los inconvenientes y las recomendaciones para el uso de videos de YouTube como una plataforma educativa entre los JE desde la perspectiva de los usuarios. Métodos: Se aplicó un cuestionario transversal en línea difundido del 15 de enero al 17 de marzo de 2022 reclutó a 166 endoscopistas gastrointestinales junior de 39 países diferentes. Resultados : La mayoría de los JE encuestados (138, 85,2%) ya utilizaban YouTube como herramienta de aprendizaje. La mayoría de los JE (97, 59,8 %) refirieron adquirir conocimientos y aplicarlos en su práctica clínica, pero 56 (34,6 %) informaron adquirir conocimientos sin aplicación en la práctica real. La mayoría de los participantes (124, 76,5 %) informó que faltaban detalles del procedimiento en los videos de endoscopia de YouTube. La mayoría de los JE (110, 80,9%) informaron que los videos de YouTube son proporcionados por especialistas en endoscopia. Solo a un participante, el 0,6% de los 166 JE encuestados, le disgustaron los registros de video, incluyendo a YouTube como fuente de aprendizaje. Según su experiencia, 106 (65,4 %) de los participantes recomendaron YouTube como una herramienta educativa para la próxima generación de JE. Conclusión: YouTube representa una herramienta potencialmente útil para los EJ, brindándoles tanto conocimientos como trucos para la práctica clínica. Sin embargo, muchos inconvenientes podrían hacer que la experiencia sea engañosa y consuma mucho tiempo. En consecuencia, alentamos a los proveedores de educación en YouTube y otras plataformas a subir videos de endoscopia educativos interactivos, bien construidos y revisados por pares.

Cystinosis in Pediatric Renal Transplant Recipients: A Case-Control Study From Kuwait.

OBJECTIVES: Cystinosis is the most frequent cause of the inherited renal Fanconi syndrome and is also potentially treatable. In this study, we have reported our single-center experience of the longterm outcomes of kidney transplant in patients with cystinosis. MATERIALS AND METHODS: Pediatric patients with cystinosis (n = 17) were compared with a matched control group without cystinosis (n = 126). The 2 groups were compared with regard to demographic data, posttransplant complications, and graft and patient outcomes. RESULTS: Most patients with cystinosis were male teenagers (52.9%) with comparable mean age (12.4 ± 4.1 vs 14 ± 3.1 years) versus the group without cystinosis. The 2 study groups were comparable with regard to type of dialysis, type of donor, blood group, and pretransplant comorbidities (P > .05). Patients with cystinosis received significantly more potent induction therapy (P < 0.05), but both groups were maintained on comparable immunosuppressive regimens (mostly tacrolimus based) (P > .05). Most grafts in both groups displayed immediate graft function. The percentage of patients with cystinosis with primary graft function was significantly higher than the percentage of those patients without cystinosis who had primary graft function (P = .024); this was associated with a relatively lower baseline creatinine level, although this was not significant (P > .05). Posttransplant complications, especially posttransplant diabetes, cytomegalovirus viremia, or BK nephropathy, were comparable (P > .05). Moreover, patient and graft survival rates were similar in the 2 groups (P > .05). CONCLUSIONS: Under standard immunosuppression, renal transplant and cysteamine therapy were safe with good long-term outcomes in patients with cystinosis. Studies that can include more patients and that have longer follow-up are needed to better understand the nature of this genetic disease and to discover the best treatment options.

Management of Chronic Active Antibody-Mediated Rejection in Renal Transplant Recipients: Single-Center Experience.

OBJECTIVES: Data on the management of chronic antibody-mediated rejection after kidney transplantation are limited. We aimed to assess the impact of treatment of biopsy-proven chronic active antibodymediated rejection with combined plasma exchange, intravenous immunoglobulin, and rituximab treatment versus intravenous immunoglobulin alone or conservative management on the evolution of renal function in renal transplant recipients. MATERIALS AND METHODS: In this retrospective study, we compared patients diagnosed with chronic active antibody-mediated rejection who were treated with standard of care steroids, intravenous immunoglobulin, plasma exchange, and rituximab (n = 40) at our center versus those who received intravenous immunoglobulin only or just intensified maintenance immunosuppression (n = 28). All patients were followed for 12 months clinically and by laboratory tests for graft and patient outcomes. RESULTS: The two groups were matched regarding mean recipient age (41.9 ± 15.4 vs 37.8 ± 15.5 y in patients with conservative versus combined treatment), recipient sex, mean body weight, and the cause of end-stage kidney disease. Most patients and their donors were males. Glomerulonephritis represented the most common cause of end-stage kidney disease in both groups followed by diabetic nephropathy. The type of induction and pretransplant comorbidities were not different between groups (P > .05) except for the significantly higher number of chronic hepatitis C infections in patients who received conservative treatment (P = .007). Mean serum creatinine values before and after treatment of chronic active antibodymediated rejection were comparable between groups (P > .05). Active treatment with heavier immunosuppression (rituximab and plasma exchange) was associated with posttreatment viral (cytomegalovirus and BK virus) and bacterial infections that necessitated more hospitalization (P > .05). However, graft and patient outcomes were significantly better in the active treatment group than in patients with conservative treatment (P = .002 and .028, respectively). CONCLUSIONS: Combined treatment of chronic active antibody-mediated rejection with plasma exchange, intravenous immunoglobulin, and rituximab can significantly improve outcomes after renal transplant.

Elderly Kidney Transplant Recipients: Single-Center Experience in the Middle East.

OBJECTIVES: The number of renal transplants in elderly patients is increasing as age per se does not constitute a contraindication to transplant. We compared renal transplant outcomes in elderly recipients versus a group of middle-aged patients. MATERIALS AND METHODS: Our retrospective casecontrolled study compared elderly transplant recipients (n = 252; > 60 y old) with a matched cohort of younger adult recipients (n = 710; between 40 and 60 years old) who underwent renal transplant at the Hamed Al-Essa Organ Transplant Center of Kuwait between 2000 and 2014. Demographic characteristics, comorbidities, complications after transplant, and graft and patient outcomes were compared between groups. RESULTS: There were 252 elderly kidney transplant recipients (mean age of 65.5 ± 4.8 y; 59.52% males) and 710 younger adult patients (mean age of 49.3 ± 5.5 years; 61.4% males). Most donors were males in their thirties. Deceased donors predominated in the younger adult group, whereas living unrelated donors predominated in the elderly group (P < .05). Diabetes represented the most common cause of endstage kidney disease. Younger patients tended to receive heavier induction therapy but comparable maint enance immunosuppression. Posttransplant diabetes was higher in younger patients; however, there were more elderly patients with micro- and macroangiopathies (P < .05). No significant differences were shown between groups with regard to patient or graft survival (P > .05). This could be attributed to a significantly higher number of patients with cardiovascular risks, less rejection episodes, and higher number of malignancies in the elderly group (P < .05). CONCLUSIONS: Due to relatively less potent immunosuppression, elderly patients experienced lower rejection rates and better graft survival; however, patient survival was lower due to higher cardiovascular risk factors. Older patients should not be discouraged from living-donor renal transplant. Targeted research studies on protocols for the elderly are needed.

Role of Diabetes Education Program in Controlling Posttransplant Diabetes in a Recent Renal Transplant Bodybuilder: Case Report and Review of the Literature.

Posttransplant diabetes is a common complication of solid-organ transplantation. We present the possible role of diabetes education in improvement of posttransplant diabetes in a 36-year-old bodybuilder who was a kidney transplant recipient. The patient had been abusing some medications to help in bodybuilding. He underwent living unrelated-donor renal transplant with thymoglobulin induction and was maintained on steroids, tacrolimus, and mycophenolate mofetil. Posttransplant diabetes was confirmed by blood tests. His blood sugar was partially controlled by 3 oral agents. The patient participated in our structured diabetes education program. This program was created to cover different items related to diabetes control, including diet, proper exercise, blood sugar monitoring, sick day management, and pathophysiologic roles of diabetes medications. Within 4 months of participation in this program, the patient's blood sugar became well controlled and his diabetes medications started to be minimized. He presently has stable graft function with hemoglobin A1c level around 5.6% on only diet management. Bodybuilders are at risk of deterioration of their kidney function. A proper diabetes education program is recommended to help renal transplant recipients with early posttransplant diabetes mellitus to control their disease. Success requires close evaluation and a multidisciplinary approach.

Successful Management of Late-Onset Cytomegalovirus-Induced Hemophagocytic Lymphohistiocytosis in Kidney Transplant Recipient After Coronary Artery Bypass Graft Surgery.

Hemophagocytic syndrome combines febrile hepatosplenomegaly, pancytopenia, hypofibrinemia, and hepatic dysfunction. It is characterized by bone marrow and organ infiltration of activated, nonmalignant macrophages that phagocytize blood cells. It is rare among renal transplant recipients. Here, we present the successful management of late-onset cytomegalovirusinduced hemophagocytic lymphohistiocytosis in a kidney transplant recipient after coronary artery bypass graft surgery. In 2012, our patient had end-stage kidney disease due to diabetic nephropathy and underwent related living-donor renal transplant. He was also hypertensive and hyperuricemic and had heart ischemia for which percutaneous coronary intervention for triple vessel disease was performed before transplant. In March 2017, he underwent successful aortic valve replacement and coronary artery bypass graft surgery; however, the patient had persistent thrombocytopenia. Heparin-induced thrombocytopenia was negative. His bone marrow showed hemophagocytosis possibly due to cytomegalovirus. Moreover, antiglycoprotein IIb/IIIA autoantibodies were positive. A positron emission tomography scan was negative for malignancy. He started treatment for cytomegalovirus with modifi cation of his immunosuppressive regimen (pulse steroid). Antiplatelet therapy was held and only resu med if platelet count exceeded 30000/L. Moreover, he received intravenous immunoglobulin and romiplostim treatment with partial response. Throughout treatment, he had stable kidney graft function with improving platelet count. A multi disciplinary approach is needed to treat patients with hemophagocytic syndrome, especially renal transplant recipients. Late-onset cytomegalovirus is an important cause for this syndrome.

Mutations in the Spike Protein of Middle East Respiratory Syndrome Coronavirus Transmitted in Korea Increase Resistance to Antibody-Mediated Neutralization.

Middle East respiratory syndrome coronavirus (MERS-CoV) poses a threat to public health. The virus is endemic in the Middle East but can be transmitted to other countries by travel activity. The introduction of MERS-CoV into the Republic of Korea by an infected traveler resulted in a hospital outbreak of MERS that entailed 186 cases and 38 deaths. The MERS-CoV spike (S) protein binds to the cellular protein DPP4 via its receptor binding domain (RBD) and mediates viral entry into target cells. During the MERS outbreak in Korea, emergence and spread of viral variants that harbored mutations in the RBD, D510G and I529T, was observed. Counterintuitively, these mutations were found to reduce DPP4 binding and viral entry into target cells. In this study, we investigated whether they also exerted proviral effects. We confirm that changes D510G and I529T reduce S protein binding to DPP4 but show that this reduction only translates into diminished viral entry when expression of DPP4 on target cells is low. Neither mutation modulated S protein binding to sialic acids, S protein activation by host cell proteases, or inhibition of S protein-driven entry by interferon-induced transmembrane proteins. In contrast, changes D510G and I529T increased resistance of S protein-driven entry to neutralization by monoclonal antibodies and sera from MERS patients. These findings indicate that MERS-CoV variants with reduced neutralization sensitivity were transmitted during the Korean outbreak and that the responsible mutations were compatible with robust infection of cells expressing high levels of DPP4.IMPORTANCE MERS-CoV has pandemic potential, and it is important to identify mutations in viral proteins that might augment viral spread. In the course of a large hospital outbreak of MERS in the Republic of Korea in 2015, the spread of a viral variant that contained mutations in the viral spike protein was observed. These mutations were found to reduce receptor binding and viral infectivity. However, it remained unclear whether they also exerted proviral effects. We demonstrate that these mutations reduce sensitivity to antibody-mediated neutralization and are compatible with robust infection of target cells expressing large amounts of the viral receptor DPP4.

Expression of thioredoxin and glutaredoxin in experimental hepatocellular carcinoma-Relevance for prognostic and diagnostic evaluation.

Hepatocellular carcinoma (HCC), represents more than 85% of liver cancers. The diagnosis of HCC may be delayed due to the absence of early, sensitive and specific biomarkers. This study was conducted to investigate whether the expression of thioredoxin (Trx) and glutaredoxin (Grx) is helpful for HCC diagnosis in an experimental model. Twenty male albino rats were equally divided into two groups (HCC and control). Hepatocarcinogenesis was performed by single intraperitoneal (i.p) injection of 200 mg/kg of diethylnitrosamine (DENA). Two weeks later, 0.05% of phenobarbital (PB) was supplied in the drinking water for other 14 weeks. HCC was diagnosed by measuring serum alpha-fetoprotein (AFP) level and histopathological examination. Our results found that hepatic indices alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin were elevated but decreased total protein level. Lipid peroxidation was elevated through increasing hepatic content of MDA with decreased antioxidant parameters like hepatic SOD, CAT activities and GSH. The current study also found that Trx and Grx tissue genes were overexpressed in HCC group significantly, compared to control group. This study substantiated that increased expression of these enzymes may be predictive of outcomes in HCC.

Early Versus Late Acute Antibody-Mediated Rejection Among Renal Transplant Recipients in Terms of Response to Rituximab Therapy: A Single Center Experience.

OBJECTIVES: There are no comparable trials concerning the use of rituximab among renal transplant recipients with acute antibody-mediated rejection. Here, we compared early and late acute antibody-mediated rejection in renal transplant recipients in terms of response to rituximab therapy. MATERIALS AND METHODS: Of 1230 kidney transplants performed at Hamed Al-Essa Organ Transplant Center (Kuwait) over the past 10 years, 103 recipients developed acute antibody-mediated rejections and were subcategorized into 4 groups according to the onset of rejection and rituximab treatment. All patients received the standard treatment for acute antibody-mediated rejection according to our protocol (plasma exchange and intravenous immunoglobulin). We added rituximab to the treatment regimen in 2 groups of patients: 27 patients with early rejection (group 1) and 38 patients with late rejection (group 2). Groups 3 and 4 represented nonrituximab groups, with 20 patients with early (group 3) and 18 patients with late rejection (group 4). We compared the 4 groups regarding graft and patient outcomes. RESULTS: All patients were comparable regarding patient age, sex, pretransplant type of dialysis, viral profile, type of induction, donor criteria, and pretransplant comorbidities. We observed that delayed and slow graft function were significantly higher in groups 1 and 3 (P = .016); however, we found no significant differences in the 4 groups regarding new-onset diabetes after transplant, BK viral infection, and malignancy. Graft outcomes were significantly better in groups 1 and 2 than in groups 3 and 4 (P = .028). However, patient outcomes were comparable in the 4 groups (P > .05). CONCLUSIONS: Early acute antibody-mediated rejection in renal transplant recipients had significantly better outcomes when rituximab was added to the standard treatment regimen.

Bariatric Surgery in Renal Transplant Patients.

OBJECTIVES: The idea of transplanting organs is not new, nor is the disease of obesity. Obese transplant recipients have greater risk of early death than their cohorts, which is not due to increased rejection but due to obesity-related complications, including arterial hypertension, diabetes, and delayed graft function. Here, our aim was to evaluate the effects of bariatric surgery versus lifestyle changes on outcomes of moderate to severely obese renal transplant recipients. MATERIALS AND METHODS: Twenty-two morbidly obese patients with stable graft function who underwent bariatric surgery were compared with 44 obese patients on lifestyle management (control group). Both groups were evaluated regarding graft and patient outcomes. RESULTS: The studied groups were comparable demographically. In the bariatric study group versus control group, we observed that the mean body mass index was 38.49 ± 9.1 versus 44.24 ± 6 (P = .024) at transplant and 34.34 ± 7.6 versus 44.38 ± 6.7 (P = .002) at 6 months of bariatric surgery. Both groups received a more potent induction immunosuppression, but this was significantly higher in the obese nonbariatric control group (P < .05). There were more patients with slow and delayed graft functions in the same nonbariatric group. The 2 groups were comparable regarding new-onset diabetes after transplant, total patients with diabetes, and graft outcomes (P > .05). CONCLUSIONS: Bariatric surgeries are feasible, safe pro cedures for selected obese renal transplant recipients.