Risk factors and outcomes of new-onset diabetes after transplant: single-centre experience.

OBJECTIVES: We sought to study the prevalence, risk factors, and long-term prognosis of posttransplant diabetes mellitus. MATERIALS AND METHODS: We studied all patients with end-stage renal disease without diabetic nephropathy who received a kidney transplant and were followed-up at our center since 1983 (n=218; age, 44.3 ± 13.1 y). Patients with new-onset diabetes after transplant were compared to kidney transplant recipients without risk factors for diabetes mellitus. Patients with new-onset diabetes after transplant were divided into subgroups according to time of onset (early; < 90 d vs late, ≥ 90 d). RESULTS: In total, 73/218 patients (33%) developed new-onset diabetes after transplant. Patients with new-onset diabetes after transplant were significantly older (51.2 ± 11.4 vs 40.7 ± 12.5 y; P < .001) and had a tendency to have a higher body mass index (29.6 ± 8.7 vs 21.6 ± 7.8 kg/m2; P =.05) than those that did not have new-onset diabetes after transplant. In multivariate analysis, age (P < .001), hepatitis C virus infection (P < .05), family history of diabetes mellitus (P < .03), and tacrolimus use (P < .001) were independent risk factors. Five- and 10-year death censored patient survival rates were worse in those that had new-onset diabetes after transplant compared with controls (log rank, 0.04), whereas there was no difference in outcomes between the early and late subgroups. CONCLUSIONS: The prevalence of new-onset diabetes after transplant was 33%. Age, body weight at time of transplant, tacrolimus use, family history of diabetes mellitus, and hepatitis C virus infection are independent risk factors for new-onset diabetes after transplant. New-onset diabetes after transplant has a negative effect on patient survival, irrespective of the time of onset and duration of diabetes.

Why does kidney allograft fail? A long-term single-center experience.

We studied the characteristics and the predictors of survival in Bahraini renal transplant recipients with an allograft that functioned for more than 10 years. Seventy-eight patients underwent renal transplantation between 1982 and 1999. Among them, 56 patients maintained functioning allografts for more than 10 years (range 10-30 years). Characteristics of the surviving patients, data on graft survival, and determinants of outcome were obtained by reviewing all medical records. The mean age at time of renal transplantation was 33.6 ± 15.3 years. The source of the graft in 42 (75%) recipients was from living related donors with a mean age of 31.4 ± 7.7 years, and it was the first graft in 48 recipients. The primary immunosuppression regimen consisted of cyclosporine (CsA) and prednisolone. Azathioprine (AZA) was given to 52 (92.9%) recipients, while four patients received steroids and AZA only. Induction therapy was administered to 30 patients in the CsA group. Acute rejection episodes occurred in eight (14.3%) patients, of whom two experienced two episodes. During the last follow-up in January 2010, the mean serum creatinine was 118.3 ± 46.5 µmol/L. A history of cancer was noted in one patient, whereas hypertension was encountered in 54% and diabetes mellitus in 20.5%. We compared the graft functioning group with the graft failure group and found that the independent determinants of long-term graft survival included time of late acute rejection episodes and histopathologic findings of chronic allograft damage, post-transplant hypertension and serum creatinine at one year. We conclude that renal transplantation even in its earliest years and despite the associated numerous complications has provided a ten-year or more of near-normal life to patients with end-stage renal disease.

A single-center experience of renal transplantation in elderly patients.

BACKGROUND: We retrospectively reviewed the results of renal transplantation in patients over 60 years of age at our center. MATERIAL/METHODS: A retrospective study was conducted of 212 Bahraini patients receiving renal transplants from January 1979 to December 2007. All medical records were reviewed for demographic data, graft function and survival. Patient and graft survival was compared for patients above and below the age of 60. RESULTS: Seventeen patients >60 years with a mean age of 64.1+/-3.6 years at the time of transplantation. Diabetic nephropathy (52%) was the most common causes of end-stage renal disease. Mean donor age was 26+/-6 years and most of them were unrelated (82%). Of the elderly patients, 4 died: 3 with a functioning graft, 1 within one year of transplantation. Cardiovascular causes (3 patients, 75%) were the most common cause of death. Causes of graft loss were death with a functioning graft (4) and chronic rejection (1). Cox's proportional-hazards regression analysis showed on univariate analysis that pre-transplant hypertension, diabetes mellitus and vascular surgery (CABG) before transplant significantly affected the dependent variable of graft loss. Multivariate analysis did not show these variables to be significant. Kaplan Meier patient survival curves showed statistically significant differences between study (>60 years) and control (18-59 years) patients (p=0.04) at 10 year. CONCLUSIONS: We conclude that Patients older than 60 yr of age can be transplanted safely and successfully, especially when they are properly screened for the presence of significant risk factors such as severe cardiovascular disease and diabetes.

Kidney disease in Bahrain: a biopsy based epidemiologic study.

The aim of this study was to establish the incidence of renal diseases in Bahrain based on biopsy proven results during the period from January 2003 to October 2006. We studied a total of 145 biopsies obtained from 130 patients; glomerular diseases constituted 64.8%, renal allograft biopsies 23.4%, chronic glomerulosclerosis 8.9%, and others 4.1% of the total. Primary and secondary glomerular diseases were presented equally. The incidence of renal biopsies 5.4/100,000 per year. Minimal change disease-focal segmental glomerulosclerosis (MCD-FSGS) complex was the commonest of all primary glomerular diseases, and lupus nephritis was the commonest secondary glomerulopathy in the biopsied patients. We conclude that there was no significant change in the pattern of glomerulonephritis in Bahrain in comparison with our previous report.

Renal biopsy findings in the kingdom of bahrain: a 13-year retrospective study.

Glomerular diseases continue to be the leading cause of end-stage renal disease globally. Hence, it is important to recognize the pattern of these diseases in any given geographical area. A total of 498 renal biopsies performed on patients with proteinuria, hematuria and mild to moderate renal impairment during a period of 13 years (between January 1990 and December 2002) at the Salmaniya Medical Complex (a tertiary care hospital of the Kingdom of Bahrain), were reviewed and categorized. Primary glomerular disease accounted for two-third of the glomerular diseases, which in turn constituted 44.8% of all renal biopsies. The most common histological lesion was minimal change disease (30%). Focal and segmental glomerulosclerosis was the second most common lesion (23.8%) followed by membranoproliferative glomerulonephritis (14.3%). Secondary glomerular disease comprised 33.6% of glomerular diseases (22.7% of all the renal biopsies) with lupus nephritis forming the commonest lesion (38.9%) followed by diabetic nephropathy (31.9%) and hypertension (20.4%). Tubulointerstitial diseases accounted for 13.1% of all renal biopsies whereas transplant diseases were noted in 12.2%. The miscellaneous group including inadequate biopsies constituted 7.2% of all the biopsies. The results of this analysis were compared with surveys from other parts of the World.

Hemolytic uremic syndrome in association with typhoid fever.

BACKGROUND: Hemolytic uremic syndrome (HUS) has been associated with typhoid fever caused by Salmonella typhi. The pathogenesis of HUS in the context of S typhi infection is not known. The authors report on a patient with typhoid fever in whom HUS and myocarditis developed during the course of his illness and in whom there was no evidence of a Shiga-toxin (Stx)-producing organism. METHODS: Antibodies directed against the Escherichia coli O157:H7 and S typhi lipopolysaccharide (LPS) were sought in the serum sample taken during the acute phase using line-blot immunoassays. Polymerase chain reaction was performed to detect the presence of stx1 and stx2 genes in the patient's S typhi isolate. RESULTS: There was no evidence for immunoglobulin (Ig) M and IgA against the LPS of E coli O157:H7, whereas anti-S typhi LPS IgM and IgA were strongly positive. In the polymerase chain reaction, DNA from the Stx-producing E coli controls yielded stx1 and stx2 fragments of the expected sizes on agarose gel electrophoresis, whereas no stx1 and stx2 fragments were obtained from the S typhi isolate. The S typhi did, however, yield a band when amplified with primers specific for viaB, an S typhi gene. CONCLUSION: S typhi may be responsible for some cases of HUS, and the inciting toxin may not be Stx.

Role of sequential biopsy study in the evaluation of renal transplant.

Renal biopsy is indicated in all cases of renal transplants showing renal dysfunction. This not only helps in the diagnosis but also in the institution of proper management. Study of sequential biopsies is essential for establishing the cause of renal dysfunction, evaluation of the effect of treatment and the progress of the disease. This report is based on the study of 14 samples (including three nephrectomy specimens) belonging to six patients who underwent two or more sequential renal transplant biopsies at the Salmaniya Medical Centre, Bahrain, between 1995-2000 because of deteriorating renal functions. Based on the sequential biopsies, the graft dysfunction was attributed to rejection in four cases and recurrence of primary glomerular disease in two. An important finding in this series is one case of type I membranoproliferative glomerulonephritis due to hepatitis C noticed five years after transplant and two cases of acute vascular rejection superimposed upon chronic rejection.

Membranoproliferative glomerulonephritis due to Hepatitis C in renal allograft.

Membranoproliferative glomerulonephritis type 1 is an etiologically divergent disorder. Hepatitis C with or without cryoglobulinemia is considered one of the principal causes of de novo and post transplant membranoproliferative glomerulonephritis type 1. A 49-year-old male who underwent renal allograft for end stage renal disease developed proteinuria and positive hepatitis C serology during the post-transplant period. This was associated with moderate hepatic dysfunction, which necessitated both liver and renal biopsies. Features of both chronic active hepatitis and membranoproliferative glomerulonephritis type 1 were seen as a result of histological examination of both liver and renal biopsies. Ultra structural studies showing mesangial and membranous deposits which are characteristic of membranoproliferative glomerulonephritis have been observed. The case is reported with a review of pertinent medical literature.

Renal transplant pathology: bahrain experience.

A ten-year retrospective study on renal transplant biopsies performed at the Salmaniya Medical Complex, Bahrain was performed. The histological changes were classified according to Banff 1997 working classification of renal allograft pathology. A semi quantitative scoring was also given as per the guidelines. Out of a total of 26 cases, 10 belonged to hyperacute and acute forms, while 11 could be categorized to chronic sclerosing allograft nephropathy. In the remaining five, the graft pathology was unrelated to the rejection process. Despite effective management, four cases underwent nephrectomy due to severe vascular rejection. An interesting feature was recorded in two cases in whom transmural arteritis followed chronic histological changes. Presence of tubular atrophy and interstitial matrix increase were considered useful parameters for assessing the severity in cases with chronic allograft nephropathy.