Effect of Repeated Structured Diabetes Education on Lifestyle Knowledge and Self-Care Diabetes Management in Kidney Transplant Patients With Posttransplant Diabetes.

OBJECTIVES: Diabetes knowledge among kidney transplant recipients with posttransplant diabetes has not been clearly assessed. We evaluated whether diabetes education in kidney transplant recipients with posttransplant diabetes affected self-care, metabolic control variables, and reversibility of early diabetic microangiopathies. MATERIALS AND METHODS: In this prospective randomized controlled study, we enrolled 210 renal transplant recipients with posttransplant diabetes. Group 1 patients (n = 140) received structured diabetes education, and group 2 patients (n = 70) received conventional education. Patient data were collected through patient identification and metabolic control parameter forms and a diabetes self-care scale questionnaire (scores between 0 and 7). RESULTS: Diet knowledge improved and waist circumference was reduced with mild to moderate exercise in group 1 (P < .001), despite no differences between the 2 groups in mean body weight or body mass index. Patients in group 1 (structured diabetes education with repeated reinforcement) showed significant improvement in healthy lifestyle parameter scores versus group 2 (P < .05) and versus values before education (P < .05). At end of study, these achievements were translated into proper blood sugar monitoring, management of both hypoand hyperglycemia, improvements in logbook use and healthy sharp disposal, Ramadan fasting, sick day management, and knowledge on the importance of HbA1c (P < .05), which translated to decrease of HbA1c in group 1 by 1.35%. In group 1, proteinuria decreased significantly compared with before education and compared with group 2 values (P = .016). Diabetic retinopathy and neuropathy remained comparable between groups (P > .05). CONCLUSIONS: Structured diabetes education improved lifestyle knowledge, self-care diabetes management, and metabolic control variables among kidney transplant recipients with posttransplant diabetes. Structured diabetes education also resulted in partial reversibility of the present early diabetic nephropathy. We recommended such education to be delivered to all kidney transplant recipients with diabetes.

Sleep Quality Among Healthcare Workers During the COVID-19 Pandemic and Its Impact on Medical Errors: Kuwait Experience.

OBJECTIVE: Millions of people suffer from sleep disturbances. In addition, the coronavirus disease 2019 (COVID-19) pandemic created several new challenges-particularly for frontline healthcare workers (HCWs). This study assessed the sleep quality (SQ) among HCWs. MATERIAL AND METHODS: A cross-sectional study was conducted using an English-language online survey. The participants were invited via a web link sent using social network platforms. It included sociodemographic- and profession-related characteristics. COVID-19-associated risks were assessed (e.g., being on the front line, doing swabs, satisfaction about protective equipment, and management protocols). Assessment of SQ was done using the Pittsburgh Sleep Quality Index (PSQI) and various medical errors were recorded. RESULTS: A total of 217 HCWs completed the survey with mean (±standard deviation) age of 35.8 (±7.3) years; 56.2% were male, 18.43% had comorbidities, and 61.75% experienced sleep difficulties before the COVID-19 crisis. This work reports a 78.8% prevalence of poor SQ, with the mean (standard deviation) global PSQI score of 9.36 (±4.4). HCWs with poor sleep experienced more positive comorbid profile (23.64% versus 6.52%, p=0.01). Working on the front lines of COVID-19 was associated with poor sleep (69.59% versus 47.83%, p=0.006). Among the participants, 77.42% performed medical errors, particularly not checking for drug allergies (17.97%), dispensing medication with incomplete instructions (20.74%), providing incorrect doses or overdosing (14.75%), incorrectly explaining the use of medication (9.22%), and prescribing a drug to the wrong patient (10.14%). CONCLUSION: This nationwide survey reported high prevalence of poor SQ among HCWs during the COVID-19 pandemic. Being an HCW on the front lines of COVID-19 and doing swabs with a positive comorbidity was associated with poor sleep.

Pretransplant donor-specific anti-human leukocyte antigen antibodies despite a negative complement-dependent lymphocytotoxicity crossmatch: Is it wise to desensitize before kidney transplant?

The significance of pretransplant donor-specific antibodies (DSAs) despite negative complement-dependent lymphocytotoxicity crossmatch (CDC-XM) would be useful for clinical decision-making. Hence, we aimed to determine the impact of pretransplant DSA despite negative crossmatch on the outcome of kidney transplantation. One hundred and eleven kidney recipients were prospectively enrolled in this study after being transplanted at Hamed Al-Essa Organ Transplant Center of Kuwait between January 2011 and December 2013. Of them, 50 recipients with positive DSA at the time of transplant were subjected to desensitization (Group 1). Three local protocols were utilized; first included plasma exchange, high-dose intravenous immunoglobulin (IVIG), and rituximab; second included immunoadsorption plus RTX, and the third included high-dose IVIG and rituximab. The second group included 61 recipients with negative DSA. All recipients had negative CDC-XM and flow cytometry crossmatch at the time of transplant. Panel-reactive antibody (±DSA) levels with mean fluorescence intensity and graft function were monitored along the first 24 months for all patients. There were no statistically significant differences between the two groups regarding early posttransplant graft function, patient and graft survivals. Pretransplant DSA with negative CXM carries a minimal clinical risk with optimized immunosuppression.

Diabetic Nephropathy Following Posttransplant Diabetes Mellitus.

Diabetic nephropathy is one of the main long-term diabetic microangiopathies that can complicate type 1 and 2 and other secondary forms of diabetes mellitus, including posttransplant diabetes mellitus. Posttransplant diabetes mellitus was initially reported in the 1960s, with case reports of recurrent and de novo diabetic nephropathy after kidney transplant reported in the early 2000s, mostly as a result of same-risk and precipitating factors of diabetic nephropathy as in native kidneys. The disease may appear early in view of the hyperfiltration risk of being a single grafted kidney. Here, we discuss risk factors, early serologic and genetic biomarkers for early detection, and strategies to avoid and delay the progression of diabetic nephropathy after posttransplant diabetes mellitus. In this overview of published literatures, we searched PubMed and MEDLINE for all articles published in English language between January 1994 and July 2018. Included studies reported on the prevalence, incidence, or determinants of post-transplant diabetes among renal transplant recipients and studies reporting diabetic nephropathy in their cohorts. Our review showed that avoidance or good control of posttransplant diabetes is the cornerstone in management of posttransplant diabetes mellitus and hence diabetic nephropathy. Control and avoidance can be commenced in the preparatory stage before transplant using validated genetic markers that can predict posttransplant diabetes mellitus. The use of well-matched donors with tailored immunosuppression (using less diabetogenic agents and possibly steroid-free regimens) and lifestyle modifications are the best preventative strategies. Tight glycemic control, early introduction of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and possibly conversion to less diabetogenic regimens can help to delay progression of diabetic nephropathy.

Optimizing Immunosuppressive Regimens Among Living-Donor Renal Transplant Recipients.

OBJECTIVES: We review different immunosuppressant protocols used for living-donor kidney transplant recipients at our center. MATERIALS AND METHODS: Many prospective randomized studies from our center have been reported between March 1976 and 2016, with more than 2700 renal transplant procedures conducted. The first study was a prospective randomized trial of azathioprine versus cyclosporine. The second study compared triple therapy (prednisolone + azathioprine + cyclosporine) versus conventional therapy (prednisolone + azathioprine). The third study was a cost-saving study, in which 100 patients received ketoconazole along with the triple regimen. Another trial demonstrated the advantages of a microemulsion form of cyclosporine. A subsequent trial compared calcineurin inhibitor minimization versus avoidance protocols. Rescue therapies were carried out to intensify immunosuppressive regimens after repeated rejection. In addition, steroid-free regimens were evaluated during both short- and long-term treatment. A recent trial reported a step-forward avoidance protocol with a calcineurin inhibitor and a steroid-free regimen, whereas another current study is the TRANSFORM one. The rationale behind antibody therapy was tho roughly evaluated among living-donor renal trans plant recipients with different agents, including basiliximab, daclizumab, antithymocyte globulin, and alemtuzumab. RESULTS: Earlier studies have demonstrated the efficacy of conventional regimens without induction therapy, especially in longer follow-up. The standard triple therapy has emerged with intensified immunosuppressive and lowered dose of each drug, especially cyclosporine. In minimization studies, no significant differences were encountered regarding patient and graft survival, even in the long-term. Steroid avoidance was safe and effective. Calcineurin inhibitors and steroid-free regimens have shown comparable patient and graft survival. Induction therapy has lowered the incidence and severity of acute rejection. CONCLUSIONS: A better 5-year graft survival and less posttransplant complications have been achieved with steroid avoidance after induction with basiliximab. Induction therapy did not affect graft and patient survival rates despite lowered incidence and severity of acute rejections.

Relation of fibroblast growth factor-23 and cardiovascular calcification in end-stage kidney disease patients on regular hemodialysis.

More than half of deaths in end-stage kidney disease (ESKD) patients are due to cardiovascular disease. Elevated fibroblast growth factor 23 (FGF-23) was found to be associated with mortality in hemodialysis (HD) patients and correlates with peripheral calcification. Aortic calcification is associated with coronary artery calcification. Both aortic and peripheral vascular calcifications were associated with mortality in chronic kidney disease. We aimed to investigate the relation between intact FGF-23 and cardiovascular calcification in patients with ESKD who were maintained on regular HD. Sixty clinically stable ESKD patients on regular HD were enrolled into this cross-sectional study. They were evaluated by basal abdominal X-ray. They were divided into two groups: (Group A, n = 30), patients with abdominal aortic calcification who underwent multislice computerized tomography scan to measure coronary artery calcification score; and (Group B, n = 30), patients without abdominal aortic calcification. All of them were evaluated by lipid profile and dialysis adequacy parameters. Fifty percent of patients had vascular calcification. We found a significant positive correlation between age and intact FGF-23; significant positive correlations between age, body mass index, duration of HD, and abdominal aortic calcification score. FGF-23 of all patients was elevated and had significant positive correlation with aortic and coronary calcifications in addition to lipid profile, left ventricular mass index (LVMI), and inflammatory markers. Plasma intact FGF-23 was elevated in nondiabetic ESKD patients, and vascular calcification was prevalent in such group of patients with many traditional and nontraditional risk factors. Possibly through its disturbing effects on minerals and parathyroid hormone, FGF-23 might indirectly affect vascular calcification. LVMI was higher in patients with vascular calcification and correlated positively with it.

Gene expression profiling in organ transplantation.

Aim of Review. Huge effort is being made among the transplant community investigating novel biomarkers that enable transplant clinicians to identify patients at risk for allograft rejection or those who will develop tolerance so that immunosuppression could be safely minimized or even ideally withdrawn. Despite the important advances achieved in the identification of several potential biomarkers of tolerance, rejection, or both, validation and demonstration of their clinical utility still needs to be tested, which will need international cooperative networks. It is important to note that the reproducibility of differently expressed genes might be affected by many factors such as gene ranking and selection methods, inherent differences between types, and the choice of thresholds. However, because microarray analyses are expensive and time consuming and their statistical evaluation is often very difficult, gene expression analysis using the RTPCR method is nowadays recommended. Conclusions. In the field of organ transplantation, gene-expression-based decision might help in improving patient and graft outcome and there are a multitude of studies showing that gene-expression profiling is feasible.

Value of donor-specific antibody detection in first-graft renal transplant recipients with a negative complement-dependent cytotoxic crossmatch.

OBJECTIVES: The clinical significance of pretransplant donor specific antihuman leukocyte antigen antibodies that occur despite negative cytotoxicity crossmatches is still unclear. In this study, we assessed the impact of those antibodies on the outcome of renal transplants. MATERIALS AND METHODS: Our study subjects consisted of 153 living-donor kidney transplant recipients whose pretransplant sera were available. All subjects had a negative complement-dependent cytotoxic crossmatch and were retrospectively evaluated for antihuman leukocyte antigen antibodies and their donor specificities by means of LABScan 100 Flow analyzer (Luminex Corporation, Texas, USA). The follow-up data of all subjects were reviewed. RESULTS: Antihuman leukocyte antigen antibodies were detected in 49 patients, donor nonspecific antihuman leukocyte antigen antibodies were found in 33, and donor specific antihuman leukocyte antigen antibodies were identified in 16. There was a trend toward more acute rejection in the patients with antihuman leukocyte antigen antibodies (22%) than in those without antihuman leukocyte antigen antibodies (17%), but that difference had no statistical significance (P = .378). Patients with donor specific antihuman leukocyte antigen antibodies had a significantly higher incidence of acute cellular rejection (19% vs 6%, respectively) and vascular rejection (25% vs 6%, respectively) than did patients with donor nonspecific antihuman leukocyte antigen antibodies (P = .04). CONCLUSIONS: Our results suggest that there is a higher incidence of acute rejection in patients with donor specific antihuman leukocyte antigen antibodies and a negative complement-dependent cytotoxic crossmatch; however, those factors had no statistically significant impact on patient or graft survival.

Compliance of kidney transplant patients to the recommended lifestyle behaviours: single centre experience.

Successful management of kidney transplant patients requires lifelong therapeutic regimen. Lifestyle changes of the patients after transplantation is the key link between the process of transplantation and its outcome, which is why those patients are in great need for complying with their recommended lifestyle behaviours. The aim of the study was to identify compliance of kidney transplant patients to the recommended lifestyle behaviours. One hundred adult kidney transplant patients of 6 months duration and more participated in this study regardless of age or sex. A structured questionnaire was developed which included socio-demographic characteristics, the recommended lifestyle behaviours of the kidney transplant patients and the kidney transplant patient's health condition and his results from the laboratory tests. The time spent with each patient ranged between 45 and 60 min. About three or four patients were interviewed on each visit. The results found that patients have good compliance with immunosuppressive agents with partial degree to other lifestyle behaviours. The conclusion is that intensive assessment of patients before and after transplantation should be done to identify their needs which help to improve their compliance. The nurse must provide the kidney transplant patients with the necessary knowledge of the recommended lifestyle behaviours.

Rescue immunosuppressive therapies in living-related renal allotransplant: a long-term prospective randomized evaluation.

OBJECTIVES: The majority of our patients are maintained on prednisolone, cyclosporine, and azathioprine as primary immunosuppression. In the presence of repeated episodes of acute rejection, this maintenance immunosuppressive regimen is increased by replacing cyclosporine with tacrolimus or azathioprine with mycophenolate mofetil. To the best of our knowledge, there are no available data among living-related renal allotransplants that evaluate the long-term efficacy and safety of these rescue immunosuppressive therapies. Therefore, we sought to evaluate the long-term efficacy and safety of rescue immunosuppressive therapies among living-related renal allotransplant recipients. MATERIALS AND METHODS: We reviewed the long-term follow-up data of 212 renal transplant recipients at the Urology and Nephrology Center Mansoura University in Mansoura, Egypt, who had been maintained on a primary immunosuppressive protocol that included prednisolone, cyclosporine, and azathioprine. Patients were randomized at a ratio of 1:2 to receive more-intensive maintenance immunosuppression by replacing cyclosporine with tacrolimus in 65 patients (group TAC) and replacing azathioprine with mycophenolate mofetil in 147 patients (group MMF). RESULTS: We found no statistically significant difference between the 2 groups regarding rejection-free patients or those who experienced 1 or more episodes of acute rejection (P > .5). In group TAC and group MMF, graft survival rates were 87.3% and 96.3% at 2 years and 78.7% and 80% at 5 years, respectively (P = .07). The corresponding patient survival rates were 98.4% and 98.5% at 1 year, 98.4% and 97.7% at 2 years, and 94.4% and 94.4% at 5 years, respectively (P = .65%). There were more patients with diabetes and serious bacterial infections in group TAC than there were in group MMF (P = .001 and .04, respectively). CONCLUSIONS: Conversion from cyclosporine to tacrolimus or from azathioprine to mycophenolate mofetil is a safe, equipotent rescue especially with repeated acute rejections. However, mycophenolate mofetil rescue therapy was more beneficial regarding graft survival.

Risk factors of vascular access failure in patients on hemodialysis.

INTRODUCTION: The aim of this study was primarily to determine if there was any relationship between hemoglobin levels and vascular access (VA) survival. In addition, other risk factors were evaluated with special stress on sex, age, diabetes mellitus, smoking, and medications. MATERIALS AND METHODS: This study comprised 200 patients who had been on renal replacement therapy for more than 1 month through a permanent VA. The patients were categorized based on their mean blood hemoglobin levels. The possible risk factors for VA failure were also evaluated which included age at the beginning of hemodialysis, sex, diabetes mellitus, baseline levels of intact parathyroid hormone, and antihypertensive therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. RESULTS: The younger the age the longer the duration of survival of left radial, left brachial, and right radial fistulas; however, sex had no significant impact on the duration of fistulas. Diabetic patients were more likely to have failed VA compared to nondiabetics. In addition, optimization of hemoglobin levels between 10 g/dL and 12 g/dL was associated with longer fistula survival. A higher risk of right radial arteriovenous fistula failure among hypertensive patients who received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers compared to those without these drugs. CONCLUSIONS: Severe anemia, age, diabetes mellitus, and smoking are the main risk factors of VA failure. Our study showed that patients on hemodialysis should benefit from anemia correction, with a target hemoglobin level between 10 g/dL and 12 g/dL, without incurring any increased risk of VA failure.

Compliance with recommended life style behaviors in kidney transplant recipients: does it matter in living donor kidney transplant?

INTRODUCTION: Lifestyle after transplantation is the key link between transplantation and its outcome, and it is crucial to comply with the recommended life style behaviors. Our aim was to assess the compliance of kidney transplant recipients to the recommended life style behaviors in Mansoura, Egypt. MATERIALS AND METHODS: One hundred kidney transplant patients were surveyed on their compliance with the recommended lifestyle behaviors including transplant medications, preventing from infections, diet, exercise, regular medical visits, personal hygiene, sexual activity, and cancer prevention. RESULTS: Most of the kidney recipients were compliant with the immunosuppressants. One-third of the participants were compliant with low-salt diet. Noncompliance with annual dental and eye checkup was reported in the majority of the subjects 94.0%. Compliance with infection prevention was partial. Half of the patient had a poor compliance with exercise or were not complying the recommendations at all. Only 9.0% of the patients were avoiding sun exposure. The majority of women were not compliant with breast self-examination. One-third of the patients consulted with their nephrologists about their sexual problems, and only half of the women were compliant with family planning program. The women were less compliant than men with medications (P = .02), and poor compliance with medications was more frequent among those with living unrelated donors (P = .04). CONCLUSIONS: Our kidney transplant patients had good compliance with immunosuppressive medications, but not with most of the recommended behaviors. Intensive assessment of patients before and after transplantation should be done to identify their needs which help planning to improve their compliance.

Impact of treatment of dyslipidemia on renal function, fat deposits and scarring in patients with persistent nephrotic syndrome.

In this study 43 patients with idiopathic nephrotic syndrome were randomly distributed into 2 age- and sex-matched groups. The first group was given fluvastatin while the second was used as control. The cases in the 2 groups were evaluated clinically, biochemically (creatinine clearance, albumin, 24-hour proteinuria, and lipogram), neurologically, and histopathologically (examination of renal biopsies obtained basally and after 1 year of treatment with fluvastatin). In the fluvastatin-treated group but not in the control group, we observed a significant reduction in cholesterol, low-density lipoprotein, and triglyceride. Clinical and laboratory assessment showed satisfactory tolerance of the drug by the patients. Proteinuria, serum albumin and creatinine clearance values were significantly better in the statin-treated patients. There was no difference in glomerular sclerosis between the 2 groups while interstitial fibrosis and renal fat deposits were less in the statin-treated group. The reduction in renal fat deposits in the statin-treated group was highly significant, while that of interstitial fibrosis was not. We conclude that: (1) statin can be safely and effectively used in the treatment of dyslipidemia in patients with persistent idiopathic nephrotic syndrome; (2) control of dyslipidemia in nephrotic patients is associated with better control of proteinuria and creatinine clearance; (3) statin treatment may cause regression of renal fat deposits in patients with nephrotic syndrome, and (4) longer term studies are still required to study further possible beneficial effects on renal histology and disease progression.