Ophthalmic Findings in Patients After Renal Transplantation

Ocular Symptoms in Kidney, Liver, and Heart Transplant Patients

OBJECTIVES

The purpose of this study was to report the ocular manifestations in kidney, liver, and heart transplant recipients.

MATERIALS AND METHODS

We reviewed the medical records of kidney, liver, and heart transplant recipients who were examined at the ophthalmology clinic of a tertiary hospital between October 2021 and October 2022. We evaluated the ocular complaints of the patients, ophthalmological examination findings, the etiology of the underlying disease, comorbidities, posttransplant duration, and the medications used. Ocular pathologies were classified as corneal, conjunctival, lens, vitreoretinal, and optic disc pathologies for the analysis.

RESULTS

Our study included 233 patients (191 kidney, 40 liver, 2 heart transplant patients). Mean age of patients was 42.94 ± 17.45 years. Among the patient group, 80.3% had at least 1 pathological ocular finding. In subgroup analysis, 12.4% of the patients had corneal pathologies, 19.3% had conjunctival pathologies, 33.0% had lens pathologies, 33.5% had vitreoretinal pathologies, and 18.9% had optic disc-related pathologies. The most common finding was dry eye, followed by cataract and vitreoretinal pathologies. The most common vitreoretinal pathology was diabetic retinopathy, followed by hypertensive retinopathy. The ocular pathology incidence in kidney and liver transplant patients was similar (P = .05). The 2 heart transplant patients did not have any ocular pathologies except refractive errors. In addition, no significant correlation was observed between posttransplant duration and ocular pathologies (P = .28).

CONCLUSIONS

Ocular findings were seen in most of the kidney and liver transplant recipients. Therefore, it is required that these patients undergo routine ocular screenings in order to facilitate early diagnosis and prompt treatment when needed.

Choroidal and retinal thinning in chronic kidney disease independently associate with eGFR decline and are modifiable with treatment

In patients with chronic kidney disease (CKD), there is an unmet need for novel biomarkers that reliably track kidney injury, demonstrate treatment-response, and predict outcomes. Here, we investigate the potential of retinal optical coherence tomography (OCT) to achieve these ends in a series of prospective studies of patients with pre-dialysis CKD (including those with a kidney transplant), patients with kidney failure undergoing kidney transplantation, living kidney donors, and healthy volunteers. Compared to health, we observe similar retinal thinning and reduced macular volume in patients with CKD and in those with a kidney transplant. However, the choroidal thinning observed in CKD is not seen in patients with a kidney transplant whose choroids resemble those of healthy volunteers. In CKD, the degree of choroidal thinning relates to falling eGFR and extent of kidney scarring. Following kidney transplantation, choroidal thickness increases rapidly (~10%) and is maintained over 1-year, whereas gradual choroidal thinning is seen during the 12 months following kidney donation. In patients with CKD, retinal and choroidal thickness independently associate with eGFR decline over 2 years. These observations highlight the potential for retinal OCT to act as a non-invasive monitoring and prognostic biomarker of kidney injury.

Comprehensive Assessment of Eyes in Kidney Transplant Recipients after Recovering from COVID-19

INTRODUCTION

Patients after organ transplantation with COVID-19 have a higher risk of morbidity and mortality than patients in the general population. There are single studies that assess the eyes of COVID-19 patients, but there are no such studies on organ transplant recipients. The purpose of this study was to comprehensively examine the eyes of kidney transplant recipients (KTR) after recovery from mild to moderate SARS-CoV-2 infection.

METHODS

A total of 40 KTR after COVID-19 and 20 KTR without clinical and immunological symptoms of SARS-CoV-2 infection as a control group was qualified for the cross-sectional study. A total of 76 eyes from 38 KTR on an average of 7 weeks after COVID-19 and 36 eyes from 18 KTR from the control group were studied. The participants underwent an ophthalmological examination, and the retinal and choroid vessels and nerves were assessed by optical coherence tomography angiography.

RESULTS

We found a lower vessel density (VD) in the deep capillary plexus in the central part of the retina (VD deep central) of the study group. Women had significantly lower VD deep central in the study group (15.51 vs. 18.91, p < 0.001). Multivariate linear regression analysis confirmed an independent, negative impact of COVID-19 (p < 0.001) and female gender (p = 0.001) on VD deep central.

CONCLUSION

The results of our study confirmed that changes in microcirculation induced by SARS-CoV-2 infection may affect the retinal vessels in KTR. Mild to moderate COVID-19 in KTR resulted in a significant reduction in VD deep central of the retina, with these changes being more common in females.

Eye Lesions in Patients After One Year of Kidney Transplantation

Purpose

Determine the incidence of some eye lesions in kidney transplant patients after one year at Military Hospital 103 and comment on related factors.

Patients and Methods

A cross-sectional study description of 111 kidney transplant patients (222 eyes) at Military Hospital 103. We assessed several eye lesions, including dry eyes, corneal conjunctival calcification, cataracts, and retinopathy.

Results

The rate of retinopathy was 84.7%, dry eye was 59.5%, cataract was 29.7%, and corneal conjunctival calcification was 24.8%, atrophy optic nerve was 9.9%, epiretinal membrane was 1.8%. Post-transplant influence factors associated with cataracts include the dose of prednisolone (OR= 1.6, p < 0.05) and post-transplant diabetes (OR=1.4, p < 0.05). The influence factor related to the atrophy of the optic nerve is systemic infection after transplantation (OR=2.4, p < 0.05).

Conclusion

Retinopathy accounted for the highest rate, followed by dry eye disease; cataracts ranked third; and finally, calcified corneal conjunctiva. Factors that affect cataracts are diabetes mellitus and prednisolone dose. Factors affecting optic nerve atrophy are infections after kidney transplantation.

Morphologic and Functional Changes of Macula and Optic Nerve Head in Adult Kidney Transplant Recipient

AIM

To assess macular and optic nerve head characteristics in patients after kidney transplantation using noninvasive optical coherence tomography (OCT) imaging.

METHODS

The study had a prospective character and was performed during period from November 2019 to November 2020 at the University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina, and included 59 patients with renal graft who underwent OCT. The obtained OCT images, pathologic changes on the fundus, including macula and optic nerve, were analyzed by reviewing nonparametric measures such as scanning laser ophthalmoscope, B-scan, 3D display, as well as parametric measurements such as central macular thickness, optic nerve head excavation, and retinal nerve thickness fiber (RNFL).

RESULTS

There is a statistically significant difference in RNFL values (P = 0.031) and cup to disc (P = 0.002) ratio in relation to duration of graft. The highest average values of RNFL was in patients with creatinine clearance <30 mL/min, while average cup to disc ratio was lowest in patients with creatinine clearance >60 mL/min. Optic nerve head edema was bilateral in 9 and unilateral in 5 patients. Fundus examination also revealed changes on posterior segment, including retinal detachment (1 patient), bilateral macular edema (9 patients), unilateral macular edema (3 patients), central serous chorioretinopathy (2 patients), and macular pseudo hole (3 patients).

CONCLUSIONS

Different retinal pathology is present in high incidence in patients secondary to renal transplant. Immunosuppressive therapy, older age, and comorbidities are the usual causes of these changes.

Insights From the Eye for Patients With Kidney Transplant

The eye and the kidney share structural and developmental similarities on a cellular and clinical level, and they are often affected by the same disease processes. Performing an eye exam to look for signs of conditions such as hypertension and diabetes can provide a helpful window into the health of the kidney. Patients with kidney transplants (KT) are a unique population that require close monitoring. These patients are maintained on a number of immunosuppressive medications and may face complications such as medication side effects, infections, and graft rejection. Patients with KT are at higher risk of both infectious and noninfectious eye conditions related to underlying systemic disease or use of immunosuppressive medications. Screening for eye conditions is important because preserving visual function is integral to quality of life, and also because the eye exam can help with early detection and treatment of systemic conditions. Here we describe some of the common eye findings and conditions in patients with KT. We recommend that patients with KT receive annual eye exams, and we hope that the information provided here can help nephrologists become more familiar with eye findings and identify situations where a referral to ophthalmology is warranted.

Peripapillary Vascular Density Measurement in Pediatric Renal and Liver Transplant

OBJECTIVES

Noninvasive monitorization of retinal structures of the eye could be a predictor for systemic microvasculature dysfunction in transplant recipients. In this study, our purpose was to determine the optic disc and peripapillary microvascular changes in pediatric patients who had undergone liver or renal transplant surgery.

MATERIALS AND METHODS

The study was performed at Başkent University. The medical records were reviewed, and patients who had liver or renal transplant in the last 10 years and were between 4 and 18 years old were included in the study. The optic disc and peripapillary vascular density parameters were obtained by optical coherence tomography angiography (Avanti RTVue XR). The results were compared with the results from age-matched, sex-matched, and spherical equivalent-matched healthy subjects.

RESULTS

Our study included 32 eyes of 16 liver transplant patients, 20 eyes of 10 renal transplant patients, and 64 eyes of 32 healthy participants (control). Whole image peripapillary, inside disc, peripapillary, superior and inferior hemisphere, and superior, inferior, temporal, and nasal quadrant peripapillary vascular densities were evaluated. No statistically significant differences in any parameter were noted between the healthy control group and the patient groups (P > .05 for all parameters).

CONCLUSIONS

Peripapillary vascular density measurements were not affected in pediatric renal and liver transplant patients.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

ssessment of Tacrolimus Neurotoxicity Measured by Retinal OCT

BACKGROUND

Neurotoxicity secondary to anticalcineurinics is a prevalent side effect in transplant recipients. Optical coherence tomography (OCT) scans the central nervous system by direct access to the retina. OCT assesses central nervous system involvement by measuring the thickness of the retinal layers, especially the ganglion cell layer (GCL). The retinal scan divides the scanned area into affected and unaffected segments, which can be quantified for each eye. The aim of this study was to determine retinal GCL thickness by means of OCT, analyzing the proportion of affected segments in individuals exposed to tacrolimus compared with a control group.

MATERIALS AND METHODS

We evaluated 20 renal transplant recipients exposed to tacrolimus for ≥6 months. The number of affected segments in the GCL of the retina was quantified by OCT. The control group was drawn from the general population attending routine ophthalmologic checkups.

RESULTS

Patients exposed to tacrolimus had a pathologic examination in 50% of cases compared with 20% in the control group (P < .044). Furthermore, among patients with an exposure time to tacrolimus >5 years, the examination was pathologic in 80% (P < .005). Linear regression analysis showed the presence of GCL segments with decreased thickness to be associated with the duration of exposure to tacrolimus (P = .036) and the time in dialysis before kidney transplant (P = .030).

CONCLUSION

Although this is a preliminary study, OCT scanning could serve to detect the neurotoxic effect of tacrolimus on the retinal GCL and central nervous system in renal transplant recipients.

Evaluation of changes in lens optical densitometry using Pentacam HR after renal transplantation: A prospective study

BACKGROUND

To compare the optical densitometric changes in the lens of patients with renal transplantation with those of a healthy group using Pentacam HR.

METHODS

Twenty-four right eyes of 24 healthy patients (Group 1) were compared with 24 right eyes of 24 kidney transplant recipients. Kidney transplant recipients were evaluated thrice (preoperatively: Group 2a, postoperative 1st month: Group 2b, postoperative 12th month: Group 2c). Corneal endothelial cell count, intraocular pressure, and central corneal thickness of all participants were measured. Lens optical densitometry was measured with Pentacam HR using 3D scanning mode. The optical density of the lens was analyzed by taking the corneal apex as the center and analysing the 12 mm diameter area. (Zone 1: 2.0 mm, Zone 2: 4.0 mm, and Zone 3: 6.0 mm).

RESULTS

Corneal endothelial cell count was 2571.2±106.7 cells/mm² in Group 1 and 2462.8±127.6 cells/mm² in Group 2a (p=0.001). For lens optical densities, significant differences were observed between the groups in Zone 1 and Zone 3, but the difference in Zone 2 was not significant (p=0.003, p=0.164, p=0.009, respectively). There was a positive correlation between dialysis time and preoperative lens optical densitometry in Zone 1, Zone 2, and Zone 3 (r= 0.496, r= 0.131, r= 0.463, respectively).

CONCLUSIONS

Although a decrease in lens transparency was observed after kidney transplantation, steroids may cause an increase in lens transparency in the postoperative period. Patients with renal transplantation should be followed closely for possible lens changes in the post-transplant period.

Ocular manifestations in renal allograft recipients: An Indian perspective

Purpose

The aim of this study was to report the ocular findings in renal allograft recipients in India.

Methods

A cross-sectional, comprehensive ophthalmic evaluation was performed, at least three months postrenal transplant, in 152 renal allograft recipients for the ocular findings. In addition, ocular findings were assessed for an association with the clinical variables like major etiologies of end-stage renal disease, pre-transplant dialysis duration, post-transplant duration, and dosage of immunosuppressive drugs.

Results

72.36% of the recipients (mean age, 38.16 ± 10.04 years) had at least one ocular finding at 3 ± 2.6 years (range, 0.3-14 years), postrenal transplant. Hypertensive retinopathy was the commonest ocular finding followed by posterior subcapsular cataract (20.4%), nuclear sclerosis (19.7%), diabetic retinopathy (15.1%), dry eye (11.2%), allergic conjunctivitis (9.9%), pterygium (6.6%), open-angle glaucoma (3.3%), meibomitis (3.3%), pinguicula (2.6%), chalazion (1.3%), subconjunctival haemorrhage (1.7%), central serous chorioretinopathy (1.7%), healed ocular toxoplasmosis (1.7%), papilledema (1.7%), and dry ARMD (1.7%). In addition, a significant association existed between some of the ocular findings with major aetiologies of ESRD, post-transplant duration, and dosage of immunosuppressive drugs. However, no association existed between the ocular findings and pre-transplant dialysis duration.

Conclusion

Ocular findings are seen in 72.36% of the renal transplant recipients with hypertensive retinopathy being the commonest one. Hence, a mandatory regular ophthalmic screening of the recipients is recommended for an early detection and timely intervention to improve the quality of life.

The eye, the kidney, and cardiovascular disease: old concepts, better tools, and new horizons

Chronic kidney disease (CKD) is common, with hypertension and diabetes mellitus acting as major risk factors for its development. Cardiovascular disease is the leading cause of death worldwide and the most frequent end point of CKD. There is an urgent need for more precise methods to identify patients at risk of CKD and cardiovascular disease. Alterations in microvascular structure and function contribute to the development of hypertension, diabetes, CKD, and their associated cardiovascular disease. Homology between the eye and the kidney suggests that noninvasive imaging of the retinal vessels can detect these microvascular alterations to improve targeting of at-risk patients. Retinal vessel-derived metrics predict incident hypertension, diabetes, CKD, and cardiovascular disease and add to the current renal and cardiovascular risk stratification tools. The advent of optical coherence tomography (OCT) has transformed retinal imaging by capturing the chorioretinal microcirculation and its dependent tissue with near-histological resolution. In hypertension, diabetes, and CKD, OCT has revealed vessel remodeling and chorioretinal thinning. Clinical and preclinical OCT has linked retinal microvascular pathology to circulating and histological markers of injury in the kidney. The advent of OCT angiography allows contrast-free visualization of intraretinal capillary networks to potentially detect early incipient microvascular disease. Combining OCT's deep imaging with the analytical power of deep learning represents the next frontier in defining what the eye can reveal about the kidney and broader cardiovascular health.

Ophthalmologic Diseases in Kidney Transplant Recipients: A Single-Center Prospective Study

BACKGROUND

Kidney transplant (KTx) recipients usually experience many comorbidities (eg, hypertension, diabetes, cardiovascular disease, glaucoma). They usually are older and have some ophthalmologic disorders, which may deteriorate after Ktx and some others may develop.

OBJECTIVE

We aimed to review a 1-year examination of the eyesight characteristics in patients after KTx.

METHODS

The study encompassed 82 eyes in 41 patients who underwent KTx in the years 2014 to 2018. All patients had visual acuity measurement, tonometry, slit lamp examination, and spectroscopic optical coherence tomography.

RESULTS

The most frequently observed changes during the 1-year observation were cataract (46%), hypertensive angiopathy (20%), and glaucoma (20%). One year after the renal transplant visual acuity declined in 22 patients (54%). In 45% of those with eyesight deterioration the cause was cataract, while in patients with no changes in eyesight (n = 9) cataract was not diagnosed. Patients with cataracts had been more often treated with high doses of steroids (steroid boluses), mainly because of acute rejection, which was significantly associated with cataract developing after Ktx (42% vs 11%; P = .019). On univariate analysis Charlson Comorbidity Index, total ischemic time, and steroid boluses were significantly associated with cataract developing after Ktx; none of these factors were an independent predictor on multivariate analysis.

CONCLUSIONS

The most common ophthalmologic diagnoses in patients after Ktx include cataract, glaucoma, and hypertensive angiopathy. Visual acuity deterioration, seen so often in the studied group of the patients, was mainly the effect of cataract progress. The effect of steroid boluses on cataract progress was meaningful.

A 10-year monitoring of the eyesight in patients after kidney transplantation

A pilot study of a 10-year analysis of the eyesight characteristics in patients after renal transplantation with a view to a later wider study of the same population.The study encompassed 50 eyes in 25 patients who underwent renal transplantation in the years 2007 and 2008. All patients underwent: visual acuity measurement, tonometry, slit lamp examination, and spectroscopic optical coherence tomography.Changes in the eyes observed during the 10-year observation period included mostly: cataract (48%), hypertensive angiopathy (28%), diabetic macular edema (16%), and glaucoma (16%). Ten years after the renal transplant visual acuity declined in 15 patients (60%). In 67% of those with eyesight deterioration the cause was cataract, while in patients with no changes in the eyesight (n = 10) cataract was diagnosed only in one. Patients with cataracts had been more often treated with cyclosporine, and that difference was statistically significant (73% vs 21%; P < .05). Comparing patients with hypertensive angiopathy with controls has shown that in the first group creatinine levels were statistically significantly higher (1.6 vs 1.16 mg/dL; P < .05). Patients with angiopathy had been also longer on renal replacement therapy before transplant (57 vs 26 months, P > .05), and this group included also statistically more persons after retransplantation (43% vs 5%, P < .05).Most frequent ophthalmological diagnoses in patients after a kidney transplant include cataract, diabetic retinopathy, and hypertensive angiopathy. Visual acuity deterioration was seen in 60% of patients and was mainly the effect of cataract progress. The effect of cyclosporine on cataract progress was significant. The diagnosis of hypertensive angiopathy corresponded with poorer function of the transplanted kidney.