Effect of cold ischaemia time on outcome after living donor renal transplantation

BACKGROUND

The aim of the present study was to determine the effects of cold ischaemia time (CIT) on living donor kidney transplant recipients in a large national data set.

METHODS

Data from the National Health Service Blood and Transplant and UK Renal Registry databases for all patients receiving a living donor kidney transplant in the UK between January 2001 and December 2014 were analysed. Patients were divided into three groups depending on CIT (less than 2 h, 2-4 h, 4-8 h). Risk-adjusted outcomes were assessed by multivariable analysis adjusting for discordance in both donor and recipient characteristics.

RESULTS

Outcomes of 9156 transplants were analysed (CIT less than 2 h in 2662, 2-4 h in 4652, and 4-8 h in 1842). After adjusting for confounders, there was no significant difference in patient survival between CIT groups. Recipients of kidneys with a CIT of 4-8 h had excellent graft outcomes, although these were slightly inferior to outcomes in those with a CIT of less than 2 h, with risk-adjusted rates of delayed graft function of 8·6 versus 4·3 per cent, and 1-year graft survival rates of 96·2 versus 97·1 per cent, respectively.

CONCLUSION

The detrimental effect of prolonging CIT for up to 8 h in living donation kidney transplantation is marginal.

Suicidal ideation during pregnancy in British Pakistani women

Introduction

Suicide is a major public health problem and one of the common causes of maternal mortality. Rates of suicide and self-harm are higher in British South Asian women compared to the majority white population. Suicidal Ideation (SI) is a significant risk factor associated with self-harm and suicide.

Objective

To explore the prevalence and risk factors of SI in British Pakistani women.

Aim

To identify risk factors associated with SI, in order to inform future preventive strategies.

Method

This is a secondary analysis of a larger study which looked at depression during pregnancy and infant outcomes. Participants who consented (women aged 18 or over, in their third pregnancy trimester) were initially assessed for maternal depression using the Edinburgh Post-Natal Depression Scale (EPDS), with one of the questions on the EPDS being on SI. Participants who met the study criteria, were further assessed regarding socio-demographic factors, perceived social support, social adversity and isolation.

Results

The rate of SI in this group of women was 8.1%, with baseline interview results suggesting that women with SI being significantly more likely to be aged 20 or less, have experience of severe life events and being less likely to have social support.

Conclusion

This area of research is key to understanding SI in British Pakistani women, to better develop culturally sensitive interventions for use within this group.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The diagnosis of posttransplantation diabetes mellitus: meeting the challenges

Posttransplantation diabetes mellitus (PTDM) is a major complication after renal transplantation due to its negative impact on patient and graft survival, and affects up to 40% of renal transplant recipients. The generation of evidence regarding its optimal treatment is now progressing with some emphasis on early postoperative insulin treatment that targets β-cell failure. This therapy seems to benefit renal transplant patients but contrasts with previous PTDM guidelines that were following treatment of type 2 diabetes mellitus (DM): oral antidiabetics first, insulin last. Similarly, in the current PTDM consensus recommendations, diagnostic procedures are in accordance with the American Diabetes Association (ADA) recommendations for diagnosis of DM. PTDM and type 2 DM, however, are distinct disease entities with different pathophysiological backgrounds. This review will discuss the significance of the standard diagnostic criteria for DM in patients after renal transplantation without prior DM. In particular, the role of glycated hemoglobin (HbA1c) and oral glucose tolerance testing (OGTT) will be reviewed. In addition, the potential role of other glycated proteins and continuous glucose monitoring will be covered, although these parameters are not yet part of the consensus recommendations.

Formulation and evaluation on human skin of a water-in-oil emulsion containing Muscat hamburg black grape seed extract

BACKGROUND

Vitis vinifera 'muscat hamburg' (Vitaceae) is a blue-black grape variety commonly found in Pakistan. It has been consumed and used in traditional medicine for centuries. Compared to other grapes, M. hamburg records one of the greatest amount of polyphenols and displays potent antioxidant activities, which make it a great candidate for its exploitation in the development of stable cream emulsions destined to improve the skin appearance.

OBJECTIVE

Evaluate the effects of stable water-in-oil (W/O) emulsion containing 2% M. hamburg grape seed extract ('formulation') on human cheek skin in comparison with the placebo ('base').

METHODS

An occlusive patch test, containing either the formulation or the base, was topically tested for 8 weeks during a winter period in young adult and healthy Pakistani male volunteers. The subjects were instructed to use twice a day the base and the formulation on their right and left cheek skin, respectively. Non-invasive measurements on these skin areas were carried out every week to assess any effects produced on melanin, elasticity and sebum. Skin compatibility assay (Burchard test) was used to report any potential skin reactivity. ANOVA, paired sample t-test and LSD test were applied to determine the statistical data significance.

RESULTS

Significant differences (P ≤ 0.05) were found between the placebo and the formulation in terms of their respective skin effects elicited on melanin, elasticity and sebum content. Nevertheless, placebo and formulation exerted similar effects on skin erythema and moisture contents. Importantly, no skin hypersensitivity cases were reported during the whole course of the study.

CONCLUSION

The developed grape-based cream could be efficiently and safely applied to improve a number of skin conditions (e.g. hyper-pigmentation, premature ageing, acne).

Organ procurement from executed prisoners in China

Organ procurement from executed prisoners in China is internationally condemned, yet this practice continues unabated in 2014. This is despite repeated announcements from Chinese authorities that constructive measures have been undertaken to conform to accepted ethical standards. While there is unanimous agreement on the unethical nature of using organs from executed prisoners, due to its limitations on voluntary and informed consent, there is insufficient coverage of forced organ procurement from prisoners of conscience without consent. Strategies to influence positive change in China over the last few decades have failed to bring this practice to an end. While organ donation and transplantation services in China have undergone considerable structural changes in the last few years, fundamental attempts to shift practice to ethically sourced organs have floundered. In this article, we discuss the organ trade in China, reflect upon organ procurement from executed prisoners (including both capital prisoners and prisoners of conscience) and provide an overview of contradictory Chinese efforts to halt forced organ procurement from executed prisoners. Finally, we highlight current actions being taken to address this issue and offer comprehensive recommendations to bring this ethically indefensible practice to an immediate end.

Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions

A consensus meeting was held in Vienna on September 8-9, 2013, to discuss diagnostic and therapeutic challenges surrounding development of diabetes mellitus after transplantation. The International Expert Panel comprised 24 transplant nephrologists, surgeons, diabetologists and clinical scientists, which met with the aim to review previous guidelines in light of emerging clinical data and research. Recommendations from the consensus discussions are provided in this article. Although the meeting was kidney-centric, reflecting the expertise present, these recommendations are likely to be relevant to other solid organ transplant recipients. Our recommendations include: terminology revision from new-onset diabetes after transplantation to posttransplantation diabetes mellitus (PTDM), exclusion of transient posttransplant hyperglycemia from PTDM diagnosis, expansion of screening strategies (incorporating postprandial glucose and HbA1c) and opinion-based guidance regarding pharmacological therapy in light of recent clinical evidence. Future research in the field was discussed with the aim of establishing collaborative working groups to address unresolved questions. These recommendations are opinion-based and intended to serve as a template for planned guidelines update, based on systematic and graded literature review, on the diagnosis and management of PTDM.

Metformin for patients with diabetes and concomitant renal restrictions--is there an evidence base?

Despite its array of benefits that comparatively outweigh alternative oral anti-glycaemic agents, the ability of clinicians to prescribe metformin is restricted. There are numerous contra-indications and cautions concerning the putative risks of metformin-related side effects that necessitate cessation of metformin. Notably the often stated, yet completely unsubstantiated, heightened risk for development of lactic acidosis in the context of renal insufficiency or a kidney transplant is particularly contentious. In this article, I will critique current regulatory advice and argue for further research to evaluate the safety and efficacy of metformin use in populations where the benefits of metformin are likely to far outweigh any infinitesimal risk (such as advanced chronic kidney disease and those after kidney transplantation). The only way to settle this debate is for well-designed trials and registry analyses to ascertain the safety and efficacy of metformin in these 'high-risk' populations. That is what evidence-based medicine demands and unfortunately is long overdue.

Incompatible kidney transplantation: a brief overview of the past, present and future

Live kidney donor transplantation across immunological barriers, either blood group or positive crossmatch [ABO- and human leucocyte antigens (HLA)-incompatible kidney transplantation, respectively], is now practised widely across many transplant centres. This provides transplantation opportunities to patients that hitherto would have been deemed contra-indicated and would subsequently have waited indefinitely for a suitably matched kidney. Protocols have evolved with time as experience has grown and now a variety of desensitization strategies are currently practised to overcome such immunological barriers. In addition, desensitization protocols are complemented by kidney paired donation exchange schemes and therefore incompatible patients now have strategies to either confront or bypass immunological barriers, respectively. As the field expands it is clear that non-transplant clinicians will be exposed to incompatible kidney transplant recipients outside of experienced centres. It is therefore timely to review the evolution of practice that have led to current desensitization modalities, contrast protocols and outcomes of current regimens and speculate on future direction of incompatible kidney transplantation.

Ethnocentric approach to address South Asian health issues

South Asian populations have distinct healthcare requirements to other ethnic demographics. Epidemiologically they constitute a high-risk group for many public health diseases such as cardiovascular disease, chronic kidney disease and diabetes mellitus. Despite individuals of South Asian backgrounds encompassing many individual countries, cultures, religions and backgrounds they share many common health concerns that are poorly tackled in established models of healthcare delivery. To successfully address this burgeoning public health burden, it is important for healthcare professionals and providers to appreciate the need for an ethnocentric approach to South Asian health requirements. Key stakeholders need to understand the need for an integrated ethnocentric approach to challenge the poor health status of this population. Appreciation of the socio-cultural dimension to South Asian healthcare requirements should help guide targeted and focused strategies to improve the outlook for this unique population at high public health risk.

Integrated central-autonomic multifractal complexity in the heart rate variability of healthy humans

PURPOSE OF STUDY

The aim of this study was to characterize the central-autonomic interaction underlying the multifractality in heart rate variability (HRV) of healthy humans.

MATERIALS AND METHODS

Eleven young healthy subjects participated in two separate ~40 min experimental sessions, one in supine (SUP) and one in, head-up-tilt (HUT), upright (UPR) body positions. Surface scalp electroencephalography (EEG) and electrocardiogram (ECG) were collected and fractal correlation of brain and heart rate data was analyzed based on the idea of relative multifractality. The fractal correlation was further examined with the EEG, HRV spectral measures using linear regression of two variables and principal component analysis (PCA) to find clues for the physiological processing underlying the central influence in fractal HRV.

RESULTS

We report evidence of a central-autonomic fractal correlation (CAFC) where the HRV multifractal complexity varies significantly with the fractal correlation between the heart rate and brain data (P = 0.003). The linear regression shows significant correlation between CAFC measure and EEG Beta band spectral component (P = 0.01 for SUP and P = 0.002 for UPR positions). There is significant correlation between CAFC measure and HRV LF component in the SUP position (P = 0.04), whereas the correlation with the HRV HF component approaches significance (P = 0.07). The correlation between CAFC measure and HRV spectral measures in the UPR position is weak. The PCA results confirm these findings and further imply multiple physiological processes underlying CAFC, highlighting the importance of the EEG Alpha, Beta band, and the HRV LF, HF spectral measures in the supine position.

DISCUSSION AND CONCLUSION

The findings of this work can be summarized into three points: (i) Similar fractal characteristics exist in the brain and heart rate fluctuation and the change toward stronger fractal correlation implies the change toward more complex HRV multifractality. (ii) CAFC is likely contributed by multiple physiological mechanisms, with its central elements mainly derived from the EEG Alpha, Beta band dynamics. (iii) The CAFC in SUP and UPR positions is qualitatively different, with a more predominant central influence in the fractal HRV of the UPR position.

Should metformin be our antiglycemic agent of choice post-transplantation?

New onset diabetes after transplantation (NODAT) is a major complication associated with solid-organ transplantation, sharing many similarities with type 2 diabetes mellitus. While metformin is recommended as the antiglycemic agent of choice in the general population, guidelines post-transplantation do not endorse metformin with equal importance and promote meglitinides as the agents of choice. Concerns with tolerability and safety of metformin in the complex polypharmacy of transplant recipients are likely causative factors for reluctant prescription among clinicians. However, such practice denies recipients a wide array of benefits attributed to metformin use in the general population. These include attenuation of abnormal glucose metabolism (diabetes treatment and prevention), weight neutrality, improvement in pathophysiological components of the metabolic syndrome (insulin resistance, subclinical inflammation, endothelial dysfunction and nonalcoholic fatty liver disease [NAFLD]), lipid-lowering properties, cardiovascular protection and antineoplastic potential. Whether such benefits translate from the general population to our high-risk recipients requires further investigation. By discussing the evidence of the risk/benefit ratio of metformin, the aim of this article is to promote the safe use of metformin as the first-line antiglycemic agent in the context of solid-organ transplantation for a host of indications that require clinical validation with appropriately designed trials.

Formulation and characterization of modified release tablets containing isoniazid using swellable polymers

The aim of this work was to develop swellable modified release (MR) isoniazid tablets using different combinations of polyvinyl acetate (PVAc) and sodium-carboxymethylcellulose (Na-CMC). Granules were prepared by moist granulation technique and then compressed into tablets. In vitro release studies for 12 hr were carried out in dissolution media of varying pH i.e. pH 1.2, 4.5, 7.0 and 7.5. Tablets of all formulations were found to be of good physical quality with respect to appearance (width and thickness), content uniformity, hardness, weight variation and friability. In vitro release data showed that increasing total polymer content resulted in more retarding effect. Formulation with 35% polymer content exhibited zero order release profile and it released 35% of the drug in first hr, later on, controlled drug release was observed upto the 12(th) hour. Formulations with PVAc to Na-CMC ratio 20:80 exhibited zero order release pattern at levels of studied concentrations, which suggested that this combination can be used to formulate zero order release tablets of water soluble drugs like isoniazid. Korsmeyer-Peppas modeling of drug release showed that non-Fickian transport is the primary mechanism of isoniazid release from PVAc and Na-CMC based tablets. The value of mean dissolution time decreased with the increase in the release rate of drug clearly showing the retarding behavior of the swellable polymers. The application of a mixture of PVAc to Na-CMC in a specific ratio may be feasible to formulate zero order release tablets of water soluble drugs like isoniazid.

Neck swelling with renal stone

Since the advent of screening of calcium and imaging techniques (CT and MRI), hyperparathyroidism has been detected with increasing frequency. Although in the past, most patients present with severe bone and renal diseases, a large number of patients are asymptomatic. Number of parathyroid glands and their ectopic locations in individuals are the problem of its management. Parathyroid adenoma or hyperplasia may be a part of Multiple Endocrine neoplasia type II. This is the story of a boy of 18 years who had got admitted in the department of Otolaryngology, Mymensingh Medical College Hospital with the complaints of a neck swelling, abdominal discomfort, inability to walk, frequency of micturation for almost same duration of 1 year. After search, hypercalcaemia, bilateral renal stone, raised parathormone level and enlarged one parathyroid gland in lower pole of left thyroid lobe was identified. Clinically it was diagnosed as parathyroid adenoma which was proved histologically after surgical excision. Many controversies still exist regarding the treatment policy of parathyroid adenoma.