A rare case of Schneiderian papilloma of the middle ear presenting with pulsatile tinnitus.

Schneiderian papillomas (ISP) of the middle ear are uncommon conditions, with only 45 cases published within literature. They are locally aggressive tumours, with a high rate of recurrence and associated malignancy. We present a rare case of a 53-year-old man presenting with unilateral pulsatile tinnitus, otorrhoea, aural fullness, pruritis and hearing loss. Angiography was employed to exclude a glomus tumour and the patient underwent a modified radical mastoidectomy. Tissue samples confirmed a histological diagnosis of ISP of the middle ear. Follow-up magnetic resonanc imaging one year postoperatively showed no evidence of disease recurrence.

Echocardiographic and electrocardiographic presentations of patients with endomyocardial biopsy-proven cardiac amyloidosis.

OBJECTIVE: Cardiac amyloidosis is under diagnosed and its prevalence is unknown. This is a retrospective, nonrandomised, single centre study of patients with endomyocardial biopsy-proven cardiac amyloidosis focusing on their echocardiographic and electrocardiogram (ECG) presentations. This is the first case series in Malaysia on this subject. METHODS: We identified all of our endomyocardial biopsyproven cardiac amyloidosis patients from January 2010 to January 2018 and reviewed their medical records. All patients echocardiographic and ECG findings reviewed and analysed comparing to basic mean population value. RESULTS: In total there are 13 biopsy-proven cardiac amyloidosis patients. All of the biopsies shows light chain (AL) amyloid. Majority of the patients (8, 61.5%) is male, and most of our patients (8, 61.5%) is Chinese. All seven patients on whom we performed deformation imaging have apical sparing pattern on longitudinal strain echocardiogram. Mean ejection fraction is 49.3%, (SD=7.9). All patients have concentric left ventricular hypertrophy and right ventricular hypertrophy. Diastolic dysfunction was present in all of our patients with nine out of 13 patients (69.2%) having restrictive filling patterns (E/A ≥2.0 E/e' ≥15). On electrocardiogram, 12 (92%) patients have prolonged PR interval (median 200ms, IQR 76.50ms) and 9 (69.2%) patients have pseudoinfarct pattern. CONCLUSION: Echocardiography plays an important role in diagnosing cardiac amyloidosis. The findings of concentric left ventricular hypertrophy with preserved ejection fraction without increased in loading condition should alert the clinician towards its possibility. This is further supported by right ventricular hypertrophy and particularly longitudinal strain imaging showing apical sparing pattern.

Measurement of hepatic insulin sensitivity early after the bypass of the proximal small bowel in humans.

OBJECTIVE: Unlike gastric banding or sleeve gastrectomy procedures, intestinal bypass procedures, Roux-en-Y gastric bypass in particular, lead to rapid improvements in glycaemia early after surgery. The bypass of the proximal small bowel may have weight loss and even caloric restriction-independent glucose-lowering properties on hepatic insulin sensitivity. In this first human mechanistic study, we examined this hypothesis by investigating the early effects of the duodeno-jejunal bypass liner (DJBL; GI Dynamics, USA) on the hepatic insulin sensitivity by using the gold standard euglycaemic hyperinsulinaemic clamp methodology. METHOD: Seven patients with obesity underwent measurement of hepatic insulin sensitivity at baseline, 1 week after a low-calorie liquid diet and after a further 1 week following insertion of the DJBL whilst on the same diet. RESULTS: Duodeno-jejunal bypass liner did not improve the insulin sensitivity of hepatic glucose production beyond the improvements achieved with caloric restriction. CONCLUSIONS: Caloric restriction may be the predominant driver of early increases in hepatic insulin sensitivity after the endoscopic bypass of the proximal small bowel. The same mechanism may be at play after Roux-en-Y gastric bypass and explain, at least in part, the rapid improvements in glycaemia.

Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study.

BACKGROUND: Data on spirometrically defined chronic airflow limitation (CAL) are scarce in developing countries. OBJECTIVE: To estimate the prevalence of spirometrically defined CAL in Kashmir, North India. METHODS: Using Burden of Obstructive Lung Disease survey methods, we administered questionnaires to randomly selected adults aged ⩾40 years. Post-bronchodilator spirometry was performed to estimate the prevalence of CAL and its relation to potential risk factors. RESULTS: Of 1100 participants initially recruited, 953 (86.9%) responded and 757 completed acceptable spirometry and questionnaires. The prevalence of a forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio less than the lower limit of normal was 17.3% (4.5) in males and 14.8% (2.1) in females. Risk factors for CAL included higher age, cooking with wood and lower educational status. The prevalence of current smoking was 61% in males and 22% in females; most smoked hookahs. CAL was found equally in non-smoking males and females, and was independently associated with the use of the hookah, family history of respiratory disease and poor education. A self-reported doctor's diagnosis of chronic obstructive pulmonary disease was reported in 8.4/1000 (0.9% of females and 0.8% of males). CONCLUSION: Spirometrically confirmed CAL is highly prevalent in Indian Kashmir, and seems to be related to the high prevalence of smoking, predominantly in the form of hookah smoking.

Postanastomotic transplant renal artery stenosis: association with de novo class II donor-specific antibodies.

In this study, we analyze the outcomes of transplant renal artery stenosis (TRAS), determine the different anatomical positions of TRAS, and establish cardiovascular and immunological risk factors associated with its development. One hundred thirty-seven of 999 (13.7%) patients had TRAS diagnosed by angiography; 119/137 (86.9%) were treated with angioplasty, of which 113/137 (82.5%) were stented. Allograft survival in the TRAS+ intervention, TRAS+ nonintervention and TRAS- groups was 80.4%, 71.3% and 83.1%, respectively. There was no difference in allograft survival between the TRAS+ intervention and TRAS- groups, p = 0.12; there was a difference in allograft survival between the TRAS- and TRAS+ nonintervention groups, p < 0.001, and between the TRAS+ intervention and TRAS+ nonintervention groups, p = 0.037. TRAS developed at the anastomosis, within a bend/kink or distally. Anastomotic TRAS developed in living donor recipients; postanastomotic TRAS (TRAS-P) developed in diabetic and older patients who received grafts from deceased, older donors. Compared with the TRAS- group, patients with TRAS-P were more likely to have had rejection with arteritis, odds ratio (OR): 4.83 (1.47-15.87), p = 0.0095, and capillaritis, OR: 3.03 (1.10-8.36), p = 0.033. Patients with TRAS-P were more likely to have developed de novo class II DSA compared with TRAS- patients hazard ratio: 4.41 (2.0-9.73), p < 0.001. TRAS is a heterogeneous condition with TRAS-P having both alloimmune and traditional cardiovascular risk factors.

Transplant of kidneys with small renal cell carcinoma in incompatible, heavily immunosuppressed recipients.

Renal cell carcinoma (RCC) is considered a contraindication for transplant. However, an increasing number of cases of transplant kidneys with RCC have been reported with encouraging results. We present our experience of two cases of transplanting kidneys with small RCCs. Donors and recipients were aware of the presence and possible consequences of RCC in the transplanted kidney before transplantation. Cases were discussed in the multidisciplinary team meetings. Regular, 6-12 monthly follow-up of donors and recipients was carried out with ultrasonography and/or computed tomography to detect recurrence of RCC or new tumours in the recipients' transplant kidneys or the donors' native kidneys. The outcome was recorded. There were no suspicious masses in the any of the kidneys during the follow-up period. The transplant kidneys are functioning.

Assessment of viability of the pancreas for transplantation using contrast-enhanced ultrasound.

INTRODUCTION: The main concern in pancreas transplantation is potential thrombosis of the graft due to poor perfusion. AIM: To assess the viability of the pancreas before transplantation by using contrast-enhanced ultrasound scan (CEUS). METHODS: Ten harvested pancreatas were studied using an iU22 (Philips, Bothell, USA) scanner together with an L9-3 linear probe for the CEUS. The ultrasound contrast agent SonoVue (Bracco spa, Milan), which is a commercially available second-generation microbubble-based agent, can be visualized in real time at low acoustic pressure (mechanical Index of 0.06). Prior to transplantation, the pancreas is placed in Via Span solution (Bristol-Mayer Squibb AB, Bromma, Sverige). Baseline conventional scale sonography is first performed to assess the parenchyma, which appears as homogenous soft tissue. The donor pancreas arterial supply is cannulated (16 gauge) and infused with Via Span solution. Two milliliters of SonoVue is slowly injected and the pancreas is scanned using the low MI nonlinear imaging mode to visualize the microbubbles enhancement of the pancreas to ensure uniform perfusion of the whole organ. Perfusion was scored visually (0 to 5) subjectively by two observers. RESULTS: Four grafts were not transplanted for different reasons. Lack of a recipient was the cause in one case with a high score (case 1). Cases 4 and 5 were turned down based on clinical evaluation, and arterial thrombosis was the cause in case 7. The last three cases showed a low mean perfusion score of 1.2. Of the six transplanted pancreatas, the four, that were successfully transplanted displayed a mean perfusion score of 4, compared with a mean score of 1.5 for the two cases who suffered rejection following transplantation. CONCLUSION: CEUS offers the potential to assess the perfusion of the pancreas transplant preoperatively, which may improve the selection criteria and potentially impact the outcomes of transplantation.

The use of a powdered polysaccharide hemostat (HemoStase) in live donor nephrectomies controls bleeding and reduces postoperative complications.

OBJECTIVE: This study assesses the use of microporous hemospheres (hemoStase) procedures to control bleeding and reduce associated unfavorable sequelae in live donor nephrectomy (LDN). METHODS: Forty-four consecutive patients who underwent LDN between January 2009 and August 2009 were included in this prospective study. HemoStase (CryoLife, Inc), Kennesaw, Georgia) was used topically in the kidney bed to avoid bleeding. We recorded intraoperative and postoperative bleeding control, re-exploration to control bleeding, surgical site fluid collection, infection, and postoperative wound complications. RESULTS: Hemostasis was achieved in all 44 (100%) patients, none of whom experienced postoperative bleeding, fluid collection, infection or required re-exploration of the surgical site. CONCLUSION: HemoStase is a safe, facile hemostatic agent that effectively controls bleeding and reduces associated postoperative complications in LDN cases.

A fast and safe living donor "finger-assisted" nephrectomy technique: results of 359 cases.

OBJECTIVE: To determine operative parameters and complications, using a modified approach to mini-incision living donor nephrectomy. METHODS: Three hundred fifty-nine consecutive living donor procedures were performed between October 2000 and November 2008 using the finger-assisted, mini-incision living donor nephrectomy. Patient demographics, intraoperative parameters, and postoperative complications were prospectively recorded, including operative time, blood loss, incision length, warm ischemia time, and intraoperative adverse events. RESULTS: Mean donor age was 44.2 +/- 12.3 years (range, 21-75 years), with an average body mass index of 28.2 +/- 5.3 kg/m(2) (range, 17.1-44.9 kg/m(2)). Right-sided donor nephrectomies were performed on 23 patients (6%), and 41 donors (11%) were found to have multiple renal arteries. Median incision length was 6.8 cm (range, 3.5-15 cm). Average operative time was 117 minutes (range, 50-265 minutes), with a median blood loss of 109 mL (range, 20-500 mL) and an average warm ischemia time of 4.5 minutes (range, 1.5-10 minutes). Four patients (1%) required perioperative blood transfusions. There were no other intraoperative complications, no patients required reexploration, and there were no donor deaths. Thirteen patients (4%) developed minor postoperative complications, including two incisional herniae, but no patients developed chronic wound pain, over a median follow-up period of 19 months (range, 2-97 months). CONCLUSION: This prospective series demonstrated that a modified approach to open mini-incision nephrectomy can result in a smaller incision length while maintaining patient safety, with few postoperative complications.

Mechanical complications of long-term Tesio catheters.

Vascular access catheters such as Tesio-Caths are preferentially inserted in the internal jugular vein and serve as access for hemodialysis. Complications related to the removal of these types of lines are uncommon. We report four patients in whom the tip of the Tesio-Cath broke and was left stuck in the superior vena cava. Although there is no defined limit to the maximum length of stay of vascular access catheters for dialysis, the possibility of catheter entrapment should be considered. It remains to be determined whether removing Tesio-Caths every 16- 18 months is beneficial in avoiding this complication.

Serum lipoprotein(a) levels in patients with atherosclerotic peripheral vascular disease in Hospital Kuala Lumpur.

OBJECTIVE: The objective of this study was to determine the proportion of patients with atherosclerotic peripheral vascular disease (PVD) who had elevated lipoprotein(a) [Lp(a)] levels, as well as to determine the latter's significance as a risk factor for PVD in the local population. METHODS: This case-controlled study was conducted between June and October 2004 in the Department of Surgery, Kuala Lumpur Hospital. A total of 100 patients were recruited and divided into control and PVD groups. Patients were defined as having PVD if they were symptomatic, with ankle-brachial systolic index < 0.90, or by radiological evidence. Lp(a) concentrations were determined using immunoturbidometry. Absorbance of reaction precipitate was measured by spectrophotometry to give Lp(a) concentration in grams per litre (g/L). The reference value for normal Lp(a) levels was < or = 0.36 g/L. RESULTS: Mean Lp(a) levels for control and PVD groups were 0.29 g/L and 0.56 g/L, and median values were 0.17 g/L and 0.48 g/L, respectively. Elevated Lp(a) levels in the control group was 26% compared to 58% in the PVD group. Analysis with Pearson's chi-squared test achieved a significant p value of 0.001. Multivariate analysis showed that elevated Lp(a) levels contributed significantly to the probability of having PVD with an odds ratio of 7.69. CONCLUSION: Elevated serum Lp(a) has a significant role as a risk factor for atherosclerotic PVD in the local population.

LDL-apheresis: indications and clinical experience in a tertiary cardiac centre.

OBJECTIVE: To determine the efficacy and safety of liposorber D low-density lipoprotein (LDL) apheresis system in high-risk cardiac patients. DESIGN: Retrospective analysis of 466 treatments undertaken in eight patients with coronary heart disease. Five patients had severe heterozygous familial hypercholesterolaemia (FH), one had severe hypertriglyceridaemia and two were cardiac transplant recipients with FH intolerant to statins. Acute reductions during single sessions and preprocedural long-term changes in lipoprotein subfractions, laboratory safety parameters, adverse events and clinical outcome were recorded. RESULTS: In 352 treatments performed in seven patients, acute reductions averaged 52.8% (standard deviation: 8.61%) for total cholesterol (TC), 61.8% (10.13%) for LDL-cholesterol (LDL-C), 21.1% (9.66%) for high-density lipoprotein cholesterol (HDL-C), 71.1% (median) for lipoprotein (a) [Lp(a)] and 44.5% (14.42%) for triglycerides (p < 0.05). Long-term reductions of TC, LDL-C, Lp(a) and triglycerides by 18.1%, 21.7%, 9.4% (median) and 19.8%, respectively, were achieved. HDL-C was increased by 7.5%. Results from the patient with severe hypertriglyceridaemia were analysed separately because of markedly elevated TC and triglycerides. Technical and clinical complications were mild and showed an incidence of 16.65% and 12.45% respectively. The most common clinical event was transient hypotension (5.8%), whereas vascular access difficulties (11.3%) represented a common technical problem. All patients demonstrated clinical improvement. However, two patients treated via a central line developed septicaemia, resulting in endocarditis in one of them. CONCLUSION: Liposorber D is a simple, safe and effective modality in reducing atherogenic lipoproteins in dyslipidaemic high-risk cardiac patients. The treatment via an arteriovenous fistula is the preferred vascular access in this type of patient.

Cerebral cortical dysfunction in chronic obstructive pulmonary disease: role of transcranial magnetic stimulation.

SETTING: Chest and Neurology Departments, Assiut and Al-Azhar University Hospitals, Egypt. OBJECTIVES: To study a large population with respect to previous preliminary data, using transcranial magnetic stimulation (TMS) as a prognostic method for evaluation of cerebral cortical functions during acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). DESIGN: In a case-control study, 41 patients with AE-COPD and 30 healthy controls were included. For all, TMS was used to assess corticospinal pathway function and cortical excitability. RESULTS: Patients demonstrated increased motor threshold (resting and active), central motor conduction time and increased cortical silent period. Significant correlation was identified between TMS parameters and pulmonary function tests (forced vital capacity, forced expiratory volume 1%, forced expiratory volume in one second) and arterial blood gases (pH, paO(2) and HCO(3)), serum chloride and potassium. CONCLUSION: These results indicate that the motor cortex is less excitable during AE-COPD. This is attributed to reduction of cortical excitability due to chronic hypoxaemia. Therefore, early detection of cerebral changes might be in accordance with the importance of early O(2) therapy in reducing morbidity and mechanical ventilation dependency in COPD. This opens discussion for future early therapeutic use of GABAergic and glutaminergic modulating drugs with oxygen to protect the brains of COPD patients.

Ureteral stents and their current use.

Stents in urology have been used for a long time in the management of nephro-ureterolithiasis. However, the indications for stent insertion have increased during the last few years and they are now used both diagnostically and therapeutically in a variety of cases. A brief history of the name is presented along with a review of the indications and the complications of stent usage.

Mycophenolic acid 12-h trough level monitoring in renal transplantation: association with acute rejection and toxicity.

Studies of renal transplantation utilizing trough plasma level monitoring of mycophenolic acid (MPA) have shown inconsistent associations with toxicity and rejection. In this study, 5600 12-h trough MPA samples from 121 renal transplant recipients immunosuppressed with mycophenolate mofetil (MMF) and tacrolimus in a steroid sparing protocol (steroids for 7 days only) were sequentially analyzed. Higher MPA levels were associated with lower hemoglobin concentrations and anemia (hemoglobin <10 g/dL). Similarly, higher MPA levels were associated with lower total white cell counts and an increased incidence of leucopenia (total white cell count <4.0 x 10(9)/L). Hypoalbuminemia and renal impairment were also associated with hemotoxicity. MMF-associated diarrhea and viral infection were associated with higher MPA levels. Conversely, biopsy-proven acute rejection within the first month post-transplantation was associated with lower MPA levels. Anti-CD25 antibody induction was also associated with reduced rejection rates. No association was seen between MPA levels and platelet count, thrombocytopenia or bacterial infection. An MPA level of 1.60 mg/L early post-transplantation best discriminated patients with and without rejection, and an MPA level of 2.75 mg/L best discriminated patients with and without toxicity later post-transplantation.

Surgical management of multiple donor veins in renal transplantation.

The surgical aspects of renal transplantation have been standardized for decades regarding normal anatomy of donor kidneys. In certain situations, as in multiple donor veins, there are still challenges regarding the technical management. In > 95%, there is only one renal vein, or the additional vein/veins are so small that they can be ligated without hesitation. In < 5%, there are two main draining veins, and they can be similar in diameter. The management of these cases varies. Some surgeons implant both veins separately, leave them on a common caval patch, or implant the smaller vein into the larger vein as an end-to-side anastomosis, allowing for one venous anastomosis in the recipient. We describe two cases of donor kidneys with two similar-sized veins and conclude that ligation of the smaller vein, even if its size is substantial (up to 1 cm), can be the safest option to avoid surgical complications.

Tacrolimus monitoring in renal transplantation: a comparison between high-performance liquid chromatography and immunoassay.

It is recommended that specific methods of tacrolimus monitoring rather than immunoassays, which overestimate tacrolimus levels, should be used in transplant recipients. Direct comparison of these techniques, however, has not been conducted in renal transplantation. In this study, 40 renal transplant recipients with tacrolimus monitoring by microparticle enzyme immunoassay (MEIA; target trough level 10 to 15 ng/mL) were compared with 40 patients monitored by high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS; target trough level 8 to 13 ng/mL). All patients received anti CD25 antibody induction and mycophenolate mofetil in a steroid-sparing protocol. No differences were seen between MEIA and HPLC-MS groups in patient demographics. All patients were followed for 6 months. Patient survival was 100% in both groups; graft survival was 100% in the MEIA group and 97.5% in the HPLC-MS group. The groups did not differ in the number of dose changes required in the first 6 months or in the number of patients displaying tacrolimus levels within target range at 3 and 6 months. Delayed graft function occurred in 14 patients in the MEIA group and 12 patients in the HPLC-MS group (P = NS). Biopsy-proven acute rejection occurred in four patients in the MEIA group and one patient in the HPLC-MS group (P < .2). No differences were seen for the following parameters at 3 or 6 months: biopsy-proven tacrolimus nephrotoxicity, serum creatinine or estimated creatinine clearance, systolic or diastolic blood pressure, cholesterol, cytomegalovirus disease, posttransplant diabetes, or tremor. This study suggests that renal transplantation with HPLC-MS monitoring of tacrolimus is safe and effective.

Cytokine polymorphisms do not influence acute rejection in renal transplantation under tacrolimus-based immunosuppression.

INTRODUCTION: Acute rejection remains an important cause of graft loss after renal transplantation. It has been suggested that cytokine genotyping may play a predictive role in identifying individuals who are at higher risk of acute rejection with a view to individualizing their immunosuppression. The aim of this study was to investigate any possible associations between acute rejection and certain cytokine polymorphisms. METHODS: We genotyped 91 cadaveric renal transplant recipients on tacrolimus-based immunosuppression and 84 of their donors. The cytokine polymorphisms studied were the following: tumor necrosis factor (TNF)-alpha-1032 T/C, TNF-alpha-865 C/A, TNF-alpha-859 G/A, interleukin (IL)1-R1-970 C/T, IL-10 haplotype [-1082, -819, -592], and IL-6-174 C/G. RESULTS: We found no association between any polymorphism and the incidence of acute rejection. This was true for both the recipient and donor population. CONCLUSION: Cytokine polymorphisms did not influence acute rejection in our study. We conclude that in the modern era of immunosuppression cytokine genotyping is not a significant predictor of acute rejection in renal transplantation.

Steroid sparing in renal transplantation with tacrolimus and mycophenolate mofetil: three-year results.

Although renal transplantation with a 7-day steroid-sparing regimen, tacrolimus and mycophenolate, is associated with good short-term outcomes, late allograft dysfunction and failure remain concerns. In this study 101 consecutive patients underwent renal transplantation using this immunosuppressive regimen. In addition, anti-CD25 monoclonal antibody was used in 25 high-risk patients (regrafts, two-antigen human leukocyte antigen (HLA)-DR mismatch or sensitized with anti-HLA panel reactivity >30%). After a median follow-up of 39 months (range 29 to 49), overall patient survival is 98%, with two cardiac deaths. Three other graft losses occurred, one each to early venous thrombosis, polyoma viral nephropathy, and late rejection due to noncompliance. Therefore, overall graft survival is 95%. The acute rejection rate at 6 and 12 months was 19% (no rejection occurred between months 6 and 12). Late rejection was uncommon, with only two further episodes beyond 12 months. Mean creatinine at 12 months was 144 micromol/L and mean estimated glomerular filtration rate (GFR) of 55 mL/min. Graft function was stable at 3 years with a mean creatinine of 142 micromol/L and mean estimated GFR 56 mL/min. During the study, five patients developed posttransplant diabetes mellitus (two cases beyond 12 months). Tissue-invasive cytomegalovirus disease and BK viral nephropathy each occurred in three patients, with all episodes in the first 12 months. Mean weight gain is 3.3 kg and mean blood pressure is 135/81 on an average of 1.5 antihypertensive agents. This steroid-avoidance regimen is associated with excellent medium-term patient and graft outcomes and a low incidence of side effects.

Late steroid withdrawal for renal transplant recipients on tacrolimus and MMF is safe.

INTRODUCTION: We conducted a study to assess the safety of staged, late steroid withdrawal in kidney or kidney/pancreas transplant recipients on steroids, tacrolimus, and mycophenolate mofetil (MMF). MATERIALS AND METHODS: We studied 50 patients including 33 recipients of cadaveric kidneys, eight living donor kidneys, and nine kidney-pancreas transplants. The mean time posttransplantation was 5.1 years (range 2.1 to 7.9 years). All patients were induced on prednisolone, tacrolimus, and MMF; steroids were withdrawn over 5 to 6 months. The rate of steroid reduction was altered in the face of typical steroid withdrawal symptoms (limb-girdle arthralgia/myalgia). RESULTS: No rejection episodes occurred during steroid withdrawal. No patient required transplant biopsy for graft dysfunction. Six patients failed steroid withdrawal: five due to arthralgia/myalgia and one due to recurrent pulmonary sarcoidosis. The unexplained rise in serum creatinine following steroid withdrawal described in several other steroid withdrawal studies was not observed in this patient cohort. The mean serum creatinine was 137 micromol/L with deltacreatinine -6.8 micromol/y per year prior to steroid cessation versus 132 micromol/L with deltacreatinine -5.9 micromol/y in the year post-steroid cessation. There were 14 patients with posttransplant diabetes mellitus in this cohort: eight on gliclazide and six on insulin. We observed a reduction in their daily insulin/gliclazide requirements from 52 units to 41 units, and 73 mg to 65 mg, respectively. Two patients became gliclazide-independent at the time of steroid cessation. CONCLUSIONS: Careful steroid withdrawal from a platform of tacrolimus and MMF is safe and not associated with a significant risk of rejection or graft dysfunction.