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Rashad R, Kwan JT, Shanbhag SS, Ngowyutagon P, Saeed M, Tahboub MA, Haseeb A, Chodosh J, Saeed HN. Long-term outcomes of glued (sutureless) amniotic membrane transplantation in acute Stevens-Johnson syndrome/toxic epidermal necrolysis: a comparative study. Br J Ophthalmol 2024:bjo-2023-324076. [PMID: 38490716 DOI: 10.1136/bjo-2023-324076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 03/03/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE To compare the effectiveness and efficiency of a glued (sutureless) technique for amniotic membrane transplantation (AMT) with a traditional sutured one in the setting of acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). METHODS This retrospective cohort study evaluated all patients diagnosed with SJS/TEN between 2008 and 2020 within our hospital network who received AMT in the acute phase according to our protocol and had at least one ophthalmic follow-up in the chronic phase. Primary outcomes included best-corrected visual acuity (BCVA) at the most recent visit, presence of a severe ocular complication (SOC) via predefined criteria, time to procedure and duration of procedure. Random effects model analysis was used to evaluate the impact of potential covariates on outcome measures. RESULTS A total of 23 patients (45 eyes) were included: 14 patients (27 eyes) in the AMT suture group and 9 patients (18 eyes) in the AMT glue group. There was no difference between the two groups in BCVA at the most recent visit (p=0.5112) or development of a SOC (p=1.000). The glue method was shorter in duration than the suture method (p<0.001). Random effects model additionally indicated that there was no difference in BCVA at most recent follow-up between patients who had received glued versus sutured AMT (p=0.1460). CONCLUSIONS Our glued technique for AMT is as effective as our sutured technique in stabilising the ocular surface and mitigating chronic ocular complications in SJS/TEN. The glued technique is also shorter in duration and performed more expediently than the sutured technique.
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Affiliation(s)
- Ramy Rashad
- Department of Ophthalmology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - James T Kwan
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, New England Eye Center, Boston, Massachusetts, USA
| | - Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- The Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, Telangana, India
| | - Panotsom Ngowyutagon
- Department of Ophthalmology, Mahidol University, Salaya, Thailand
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
| | - Musa Saeed
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
| | - Mohammad A Tahboub
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Abid Haseeb
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Division of Ophthalmology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, Illinois, USA
- Department of Ophthalmology, Loyola University Medical Center, Maywood, IL, USA
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Haseeb A, Elhusseiny AM, ElSheikh RH, Tahboub MA, Kwan JT, Saeed HN. Ocular involvement in Mycoplasma induced rash and mucositis: A systematic review of the literature. Ocul Surf 2023; 28:1-10. [PMID: 36396020 DOI: 10.1016/j.jtos.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/12/2022] [Indexed: 11/16/2022]
Abstract
Mycoplasma pneumoniae induced rash and mucositis (MIRM) is a relatively newly identified clinical entity which is characterized by mucocutaneous manifestations in the setting of Mycoplasma infection. Though a clinically distinct disease, MIRM exists on a diagnostic continuum with entities including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, and the recently described reactive infectious mucocutaneous eruption (RIME). In this systematic review, we discuss published findings on the epidemiology, clinical manifestations, diagnosis, and management of MIRM, with an emphasis on ocular disease. Lastly, we discuss some of the most recent developments and challenges in characterizing MIRM with respect to the related diagnosis of RIME.
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Affiliation(s)
- Abid Haseeb
- Department of Ophthalmology, Nazareth Hospital, Philadelphia, PA, USA; Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Abdelrahman M Elhusseiny
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA; Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Reem H ElSheikh
- Department of Ophthalmology, Kasr Al-Ainy Hospitals, Cairo University, Cairo, Egypt
| | - Mohammad A Tahboub
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - James T Kwan
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA; Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; Department of Ophthalmology, Loyola University Medical Center, Maywood, IL, USA.
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Kwan JT, Ramsey DJ. Multimodal image alignment aids in the evaluation and monitoring of sector retinitis pigmentosa. Ophthalmic Genet 2023; 44:93-102. [PMID: 35769018 DOI: 10.1080/13816810.2022.2092755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE To present a semi-automated method of image alignment to aid in monitoring the progression of inherited retinal degenerations (IRDs). RESULTS A 22-year-old woman presented with nyctalopia and a family history of retinitis pigmentosa (RP), but with no prior genetic testing. Fundus examination showed a sectoral retinal degeneration involving the inferior and nasal retina with rare, pigmented deposits. Goldmann kinetic perimetry demonstrated corresponding superotemporal visual field defects. The best-corrected visual acuity was 20/20 in both eyes. Multimodal imaging delineated geographically restricted peripheral retinal degeneration extending to the inferior edge of the macula. Central visual function remained intact with normal multifocal electroretinography findings. Optical coherence tomography (OCT) through the leading edge of the retinal degeneration confirmed loss of the photoreceptor layer and associated retinal pigment epithelium. In the region of retinal degeneration, loss of vascular flow density was noted on optical coherence tomography angiography (OCTA). Genetic testing identified a pathologic sequence variant in RHO (c.68C>A, p.Pro23His), confirming autosomal dominant sector retinitis pigmentosa (SRP). Image alignment allowed for precise measurement of the progression of SRP over a period of 18 months. CONCLUSION SRP is a rare subtype of RP characterized by focal, typically inferior and nasal, retinal degeneration of the peripheral retina. Although the onset and extent of peripheral retinal degeneration varies, compared with RP, SRP typically progresses more slowly to involve the macula. In this report, we highlight the utility of image registration and alignment to aid in monitoring disease progression in IRDs by means of multimodal imaging.
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Affiliation(s)
- James T Kwan
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA.,Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
| | - David J Ramsey
- Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA.,Department of Surgery, Division of Ophthalmology, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
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Kwan JT, Lanzo E, Ramsey DJ, Kalra A, Athappilly-Rolfe GK. Papilledema and retinopathy lead to diagnosis of IgA nephropathy: a case report. Ther Adv Rare Dis 2023; 4:26330040231152957. [PMID: 37181072 PMCID: PMC10032434 DOI: 10.1177/26330040231152957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 01/04/2023] [Indexed: 05/16/2023]
Abstract
This case features a young healthy male who was diagnosed with immunoglobulin A (IgA) nephropathy after presenting with blurry vision that was caused by hypertensive retinopathy and papilledema. In this report, we examine the relationship between hypertension and increased intracranial pressure (ICP), along with the ocular signs of IgA nephropathy that may present in the setting of kidney disease.
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Affiliation(s)
- James T. Kwan
- Department of Ophthalmology, Tufts Medical Center,
Boston, MA, USA
- Department of Ophthalmology, Lahey Hospital & Medical
Center, Burlington, MA, USA
| | - Erin Lanzo
- Department of Ophthalmology, Tufts Medical Center,
Boston, MA, USA
- Department of Ophthalmology, Lahey Hospital & Medical
Center, Burlington, MA, USA
| | - David J. Ramsey
- Department of Ophthalmology, Tufts Medical Center,
Boston, MA, USA
- Department of Ophthalmology, Lahey Hospital & Medical
Center, Burlington, MA, USA
| | - Aarti Kalra
- Department of Pathology, Lahey Hospital & Medical
Center, Burlington, MA, USA
| | - Geetha K. Athappilly-Rolfe
- Department of Ophthalmology, Atrius Health, Medford MA,
USA
- Department of Ophthalmology, Lahey Hospital & Medical
Center, Burlington, MA, USA
- Harvard Vanguard Medical Associates Medford, Medford,
MA, USA
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5
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Ramsey DJ, Kwan JT, Sharma A. Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity. World J Diabetes 2022; 13:1035-1048. [PMID: 36578874 PMCID: PMC9791566 DOI: 10.4239/wjd.v13.i12.1035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/27/2022] [Accepted: 11/18/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.
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Affiliation(s)
- David J Ramsey
- Department of Ophthalmology, Lahey Hospital and Medical Center, Burlington, MA 01805, United States
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111, United States
| | - James T Kwan
- Department of Ophthalmology, Lahey Hospital and Medical Center, Burlington, MA 01805, United States
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111, United States
| | - Arjun Sharma
- Department of Ophthalmology, Lahey Hospital and Medical Center, Burlington, MA 01805, United States
- Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111, United States
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Shareef O, Kwan JT, Lau S, Tahboub MA, Saeed HN. An alternative model for assessing mortality risk in Stevens Johnson syndrome/toxic epidermal necrolysis using a random forests classifier: A pilot study. Front Med (Lausanne) 2022; 9:935408. [PMID: 36569158 PMCID: PMC9772610 DOI: 10.3389/fmed.2022.935408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Mortality risk prediction is an important part of the clinical assessment in the Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) patient. The SCORTEN and ABCD-10 scoring systems have been used as predictive clinical tools for assessing this risk. However, some of the metrics required in calculating these scores, such as the total body surface area (TBSA) involvement, are difficult to calculate. In addition, TBSA involvement is calculated in a variety of ways and is observer dependent and subjective. The goal of this study was to develop an alternative method to predict mortality in patients with SJS/TEN. Methods Data was split into training and test datasets and preprocessed. Models were trained using five-fold cross validation. Out of several possible candidates, a random forests model was evaluated as being the most robust in predictive power for this dataset. Upon feature selection, a final random forests model was developed which was used for comparison against SCORTEN. Results The differences in both accuracy (p = 0.324) and area under the receiver operating characteristic curve (AUROC) (p = 0.318) between the final random forests model and the SCORTEN and ABCD-10 models were not statistically significant. As such, this alternative method performs similarly to SCORTEN while only requiring simple laboratory tests from the day of admission. Discussion This new alternative can make the mortality prediction process more efficient, along with providing a seamless implementation of the patient laboratory tests directly into the model from existing electronic health record (EHR) systems. Once the model was developed, a web application was built to deploy the model which integrates with the Epic EHR system on the Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface (API); this only requires the patient medical record number and a date of the lab tests as parameters. This model ultimately allows clinicians to calculate patient mortality risk with only a few clicks. Further studies are needed for validation of this tool.
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Affiliation(s)
- Omar Shareef
- Harvard College, Cambridge, MA, United States,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States
| | - James T. Kwan
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States,Tufts University School of Medicine, Boston, MA, United States
| | - Sarina Lau
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States,Department of Biology, Simmons University, Boston, MA, United States
| | - Mohammad Ali Tahboub
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States
| | - Hajirah N. Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States,Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois Chicago, Chicago, IL, United States,*Correspondence: Hajirah N. Saeed,
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7
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Kwan JT, Ebert BE, Roby BB, Scott AR. Detection of Chronic Hypoventilation Among Infants With Robin Sequence Using Capillary Blood Gas Sampling. Laryngoscope 2021; 131:2789-2794. [PMID: 33914349 DOI: 10.1002/lary.29594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/03/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS To describe the use of capillary blood gas (CBG) sampling to detect and quantify hypoventilation in infants with Robin sequence (RS). METHODS Case series with chart review at two institutions. Infants with RS presenting over a 10-year period were identified using departmental databases. CBG values obtained during infancy or until airway intervention (AI) were reviewed. RESULTS From 2008 to 2018, 111 infants with RS were identified as having had been assessed and managed from birth or transfer until discharge home and having CBG data available. In most cases, CBG sampling was obtained every other day until intervention or discharge. A total of 81 (73%) infants required AI: 72 (89%) underwent mandibular distraction osteogenesis, five (6%) underwent tracheotomy, and four (5%) were discharged home with a nasopharyngeal airway. The mean PCO2 at day of life (DOL) 7-30 for the AI group was 52.7 mmHg (95% confidence interval: 51.7-53.7) and for the no AI group was 45.9 mmHg (44.8-47.0; P < .0001). The mean HCO3 at DOL 7-30 for the AI group was 29.8 mEq/L (29.4-30.1) and for the no AI group was 27.0 mEq/L (26.5-27.4; P < .0001). Receiver operating characteristic curves were created for maximum PCO2 and HCO3 values and cutoffs were established by optimizing a balance of sensitivity and specificity. Infants requiring AI surpassed the PCO2 and HCO3 cutoff at a median of DOL 9. CONCLUSIONS Among infants with RS and hypoventilation, objective measures of respiratory acidosis may be apparent by DOL 9. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- James T Kwan
- Department of Otolaryngology - Head & Neck Surgery, Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Bridget E Ebert
- Department of Otolaryngology - Head & Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A
| | - Brianne B Roby
- Department of Otolaryngology - Head & Neck Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, U.S.A.,Department of Otolaryngology and Facial Plastic Surgery, Children's of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Andrew R Scott
- Department of Otolaryngology - Head & Neck Surgery, Tufts University School of Medicine, Boston, Massachusetts, U.S.A.,Divisions of Pediatric Otolaryngology and Facial Plastic Surgery, Department of Otolaryngology-Head and Neck Surgery, Tufts Children's Hospital - Tufts Medical Center, Boston, Massachusetts, U.S.A
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8
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Noah B, Keller MS, Mosadeghi S, Stein L, Johl S, Delshad S, Tashjian VC, Lew D, Kwan JT, Jusufagic A, Spiegel BMR. Impact of remote patient monitoring on clinical outcomes: an updated meta-analysis of randomized controlled trials. NPJ Digit Med 2018; 1:20172. [PMID: 31304346 PMCID: PMC6550143 DOI: 10.1038/s41746-017-0002-4] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/28/2017] [Accepted: 08/31/2017] [Indexed: 12/31/2022] Open
Abstract
Despite growing interest in remote patient monitoring, limited evidence exists to substantiate claims of its ability to improve outcomes. Our aim was to evaluate randomized controlled trials (RCTs) that assess the effects of using wearable biosensors (e.g. activity trackers) for remote patient monitoring on clinical outcomes. We expanded upon prior reviews by assessing effectiveness across indications and presenting quantitative summary data. We searched for articles from January 2000 to October 2016 in PubMed, reviewed 4,348 titles, selected 777 for abstract review, and 64 for full text review. A total of 27 RCTs from 13 different countries focused on a range of clinical outcomes and were retained for final analysis; of these, we identified 16 high-quality studies. We estimated a difference-in-differences random effects meta-analysis on select outcomes. We weighted the studies by sample size and used 95% confidence intervals (CI) around point estimates. Difference-in-difference point estimation revealed no statistically significant impact of remote patient monitoring on any of six reported clinical outcomes, including body mass index (-0.73; 95% CI: -1.84, 0.38), weight (-1.29; -3.06, 0.48), waist circumference (-2.41; -5.16, 0.34), body fat percentage (0.11; -1.56, 1.34), systolic blood pressure (-2.62; -5.31, 0.06), and diastolic blood pressure (-0.99; -2.73, 0.74). Studies were highly heterogeneous in their design, device type, and outcomes. Interventions based on health behavior models and personalized coaching were most successful. We found substantial gaps in the evidence base that should be considered before implementation of remote patient monitoring in the clinical setting.
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Affiliation(s)
- Benjamin Noah
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Michelle S Keller
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,3Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA
| | - Sasan Mosadeghi
- 4Department of Medicine, University of Arizona, College of Medicine Tucson, Tucson, AZ USA
| | - Libby Stein
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Sunny Johl
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Sean Delshad
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Vartan C Tashjian
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,5Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Daniel Lew
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,5Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - James T Kwan
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA
| | - Alma Jusufagic
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,3Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA
| | - Brennan M R Spiegel
- 1Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA USA.,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, CA USA.,3Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA USA.,5Cedars-Sinai Medical Center, Los Angeles, CA USA.,American Journal of Gastroenterology, Bethesda, USA
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9
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Chang RW, Snowden S, Palmer A, Kwan JT, Nicholson M, Kashi SH, Fernando ON, Perner F, Neild GH. European randomised trial of dual versus triple tacrolimus-based regimens for control of acute rejection in renal allograft recipients. Transpl Int 2001; 14:384-90. [PMID: 11793035 DOI: 10.1007/s001470100003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Two large multicentre studies have shown superiority of tacrolimus-based immunosuppressive regimens compared with standard cyclosporine-based therapy in renal transplantation. In these studies, tacrolimus was used in a triple drug regimen of tacrolimus, corticosteroids, and azathioprine. The present study aimed to determine whether a tacrolimus-based dual regimen achieves a similar efficacy and safety profile compared with conventional triple therapy. In this prospective, open, multicentre trial, 249 patients were randomised to receive either dual therapy (n = 125) of oral tacrolimus (initial daily dose of 0.2 mg/kg) and oral prednisone or additionally, as a triple therapy (n = 124), oral azathioprine. The primary endpoint was the incidence of acute rejection at month 3. In addition, all patients were included into a follow-up evaluation at 1 year after transplantation. Both treatment groups had similar baseline characteristics. At month 3, patient survival was 97.6 % (dual) and 96.7 % (triple); graft survival was 92.7 % (dual) and 91.7 % (triple). The incidence of treated acute rejection confirmed by biopsy was 27.4 % (dual) and 24.8 % (triple); difference 2.6 %, 95 % CI [-9.4 %-12.9 %], P = 0.755. The incidence of corticosteroid-resistant rejection (biopsy-confirmed) was 9.7 % (dual) and 10.7 % (triple). The overall adverse events profile was similar; leukopenia (1.6 % vs 11.6 %, P = 0.002) was more frequent with triple therapy. Between months 4 and 12, six (dual) and eight (triple) patients had a rejection. At month 12, patient survival was 95.6 % (dual) and 93.6 % (triple); graft survival was 91.8 % (dual) and 90.7 % (triple). Tacrolimus proved to be efficacious and safe with both dual and triple low-dose regimens. The addition of azathioprine to a tacrolimus/corticosteroid-based therapy did not result in an increased efficacy.
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Affiliation(s)
- R W Chang
- Department of Renal Transplantation, St. George's Hospital, Black Shaw Road, London SW17 0QT, UK.
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Patel S, Kwan JT, McCloskey E, McGee G, Thomas G, Johnson D, Wills R, Ogunremi L, Barron J. Prevalence and causes of low bone density and fractures in kidney transplant patients. J Bone Miner Res 2001; 16:1863-70. [PMID: 11585351 DOI: 10.1359/jbmr.2001.16.10.1863] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Osteoporosis is known to occur in patients with kidney transplants, but limited information is available about the prevalence and causes of this complication. We asked all 330 patients with kidney transplants in our unit to participate in this study of whom 165 (50%) agreed to do so. The characteristics of the participating patients were similar to the remaining 165 nonparticipants. Seventy of 165 (42%) of the participants were women of whom 40 were postmenopausal in contrast to the men of whom only one was hypogonadal. Bone mineral density (BMD) was significantly reduced at the radius (Z score, -1.5) and femoral neck (Z score, -0.7), but the lumbar spine was normal. BMD was lower in women than men at all skeletal sites. Osteoporosis was found in 10-44% and osteopenia was found in 35-50% of women depending on the site. BMD was related inversely to time since transplantation and cumulative prednisolone dose. Twenty-seven of the 165 (16%) patients had either vertebral deformities or a history of a low trauma fracture after transplantation. This fracture group consisted of 10/27 (37%) men and 17/27 (63%) women, of whom 14 were postmenopausal. Fracture patients tended to be older and have a longer duration of renal failure, dialysis, transplantation, greater cumulative steroid dose, and higher bone resorption markers than the nonfracture group. No differences were found for cumulative doses of cyclosporin or tacrolimus. Logistic regression showed that only duration of dialysis and time since transplantation significantly increased fracture risk, with odds ratio (OR) for each year of dialysis or transplantation being 1.21 (CI, 1.00-1.48) and 1.14 (CI, 1.05-1.23), respectively. These data show that low bone density and fractures are common in patients with kidney transplant and are determined by both pre- and posttransplant variables. Fracture risk was greatest in women, particularly if they were postmenopausal and we recommend that this subgroup is targeted for assessment and treatment.
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Affiliation(s)
- S Patel
- Department of Rheumatology, St. Helier Hospital, Epsom and St. Helier NHS Trust, Carshalton, Surrey, United Kingdom
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11
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Affiliation(s)
- S Gunda
- South West Thames Renal and Transplant Unit, St Helier Hospital, Carshalton, UK
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Gallagher H, Kwan JT, Andrews PA. Post-transplantation lymphoproliferative disorder: an unusual presentation in a patient receiving tacrolimus. Nephrol Dial Transplant 2000; 15:928-30. [PMID: 10831670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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13
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Patel S, Kwan JT, McGee G, Thomas G, Johnson D. Calcaneal bone ultrasonometry in patients with renal failure treated with dialysis. Clin Nephrol 1999; 51:387-8. [PMID: 10404701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
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14
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Abstract
Optical biosensor technology has revolutionized the assessment of receptor binding, enabling the characterization of low affinity interactions in real time. We report the application of the LAsys Optical Biosensor to the investigation of the affinity and specificity of the putative proximal tubular scavenging receptor for protein reabsorption and the specificity of AGE-modified protein interactions with primary human mesangial cells. Using the LLCPK cell line, the carboxy-methyl dextran cuvette surface and five different proteins (ranging in size and charge), we have shown that there is evidence to support the existence of a single scavenging receptor for all the proteins tested. The proteins competed with each other differing only in their relative binding affinity for the common receptor. We have also shown that human mesangial cells can bind to AGE-modified human serum albumin (AGE-HSA) immobilized onto the carboxylate surfaced planar cuvette and that binding can be inhibited using increasing concentrations of soluble AGE-HSA. However, increasing concentrations of soluble Non-AGE modified HSA can also inhibit binding to a similar extent which implies that there is relatively little AGE-receptor (RAGE) expression on cultured primary human mesangial cells. These results demonstrate the exciting potential of this technology as a tool to explore cellular interactions with renal cells.
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Affiliation(s)
- D J Newman
- South West Thames Institute for Renal Research, St Helier Hospital, Carshalton, Surrey, United Kingdom.
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D'Souza RJ, Kwan JT, Chang R, Bending MR. OKT3 in renal allografts: survival and complications. Clin Nephrol 1999; 51:257-8. [PMID: 10230561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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16
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Al-Saady NM, Leatham EW, Gupta S, Kwan JT, Eastwood JB, Seymour CA. Monocyte expression of tissue factor and adhesion molecules: the link with accelerated coronary artery disease in patients with chronic renal failure. Heart 1999; 81:134-40. [PMID: 9922347 PMCID: PMC1728923 DOI: 10.1136/hrt.81.2.134] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the expression of monocyte tissue factor (MTF) and adhesion molecules in patients with chronic renal failure (CRF) and to look for any correlation with thrombin generation and Lp(a) lipoprotein. DESIGN A study of MTF expression and adhesion molecules, prothrombin fragments 1+2 (PTf1+2), an index of thrombin generation, and lipoproteins in patients with CRF and in normal control subjects. BACKGROUND Patients with end stage renal failure have an increased risk of coronary artery disease despite advances in therapy. Stimulated monocytes are potent activators of blood coagulation through the generation of MTF, which was recently implicated in the aetiology of acute coronary ischaemic syndromes. METHODS MTF expression and adhesion molecules were measured in whole blood using immunofluorescence of monocytes labelled with anti-tissue factor antibody and CD11b and c by flow cytometry. PTf1+2 and Lp(a) lipoprotein in plasma were measured by enzyme linked immunosorbent assay (ELISA). PATIENTS 70 patients with CRF without documented coronary artery disease (30 patients with CRF undialysed, 20 patients undergoing chronic ambulatory peritoneal dialysis (CAPD), and 20 undergoing haemodialysis (HD)), together with 20 normal controls, were studied. RESULTS The (mean (SD)) increased MTF of CRF (48.0 (29) v 33.3 (7.2) mesf unit/100 monocytes in controls, p = 0.04) was more pronounced in patients undergoing dialysis (HD 73.1 (32.8) (p < 0.003) and CAPD 62.8 (28.9) mesf unit/100 monocytes, p < 0.04). MTF activity showed a positive correlation with both PTf1+2 and serum creatinine (p < 0.003) but not with Lp(a) lipoprotein. Lp(a) lipoprotein was significantly increased in both dialysis groups compared with controls (p < 0.005) and non-dialysis CRF groups (p < 0.02). Monocyte adhesion molecule (CD11b) was significantly higher in all three CRF groups than in the controls (p = 0.006). CONCLUSION This study has demonstrated a hypercoagulable state in patients with CRF. This was especially pronounced in the dialysis patients. These findings provide a possible explanation for the increased cardiovascular and cerebrovascular morbidity and mortality in these patients.
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Affiliation(s)
- N M Al-Saady
- Department of Cardiological Sciences, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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Steele M, Kwan JT. Potential problem: delayed detection of peritonitis by patients receiving home automated peritoneal dialysis (APD). Perit Dial Int 1997; 17:617. [PMID: 9655167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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18
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Lam-Po-Tang MK, Bending MR, Kwan JT. Icodextrin hypersensitivity in a CAPD patient. ARCH ESP UROL 1997; 17:82-4. [PMID: 9068028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M K Lam-Po-Tang
- South West Thames Renal Unit St. Helier Hospital Carshalton, Surrey, England
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D'Souza RJ, Kwan JT, Hendry BM, Fallon M, Cunningham D. Successful outcome of treating hemolytic uremic syndrome associated with cancer chemotherapy with immunoadsorption. Clin Nephrol 1997; 47:58-9. [PMID: 9021244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- R J D'Souza
- South West Thames Renal Unit, St. Helier's Hospital, Carshalton, Surrey, UK
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20
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Affiliation(s)
- J T Kwan
- Royal London Hospital, United Kingdom
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21
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Kon SP, Fan SL, Kwan JT, Dodd SM, Raftery MJ. Membranous nephropathy complicating adenolymphoma of the parotid (Warthin's tumour). Nephron Clin Pract 1996; 73:692-4. [PMID: 8856273 DOI: 10.1159/000189162] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Membranous nephropathy has been described in association with many malignancies including various lymphomas. However, it has not been previously described as a complication of benign solid adenolymphoma of the parotid, also called Warthin's tumour. We describe a patient who presented with an adenolymphoma of the parotid, and developed a severe nephrotic syndrome due to membranous nephropathy 6 months after the parotid swelling. The nephrotic syndrome resolved following parotidectomy and a short course of immunosuppression with prednisolone and cyclophosphamide. The possible pathophysiologic mechanisms are discussed.
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Affiliation(s)
- S P Kon
- Department of Renal Medicine and Transplantation and Histopathology, London Hospital Medical College, UK
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22
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Kon SP, Kwan JT, Raftery MJ. Reversible renal failure due to the antiphospholipid antibody syndrome, pre-eclampsia and renal thrombotic microangiopathy. Clin Nephrol 1995; 44:271-3. [PMID: 8575129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 27-year-old Caucasian female, with a past history of recurrent spontaneous abortions, was admitted with pre-eclampsia at 26 weeks' gestation during her sixth pregnancy. She was previously known to have antiphospholipid antibodies since her fifth abortion, but had no clinical or serological evidence of systemic lupus erythematosus. A small-for-dates infant was delivered by emergency Caesarean section at 27 weeks for poor placental blood flow and fetal distress. She was transferred to the renal unit on the sixth post partum day with pulmonary edema, hypertension, disseminated intravascular coagulation and acute renal failure. Renal biopsy showed lesions compatible with thrombotic microangiopathy with diffuse glomerular necrosis. She was plasma exchanged and remained dialysis dependent for 7 months. Antiphospholipid antibodies were present in high titres and were the presumed cause of her acute renal failure. The patient now has stable renal function with a creatinine clearance of 30 ml/min for over two years. The late recovery of renal function is unique in the above circumstances.
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Affiliation(s)
- S P Kon
- Department of Renal Medicine and Transplantation, Royal London Hospital, UK
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23
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King GN, Healy CM, Glover MT, Kwan JT, Williams DM, Leigh IM, Worthington HV, Thornhill MH. Increased prevalence of dysplastic and malignant lip lesions in renal-transplant recipients. N Engl J Med 1995; 332:1052-7. [PMID: 7898522 DOI: 10.1056/nejm199504203321602] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Renal-transplant recipients are known to have increased rates of skin cancer associated with exposure to the sun. Little is known, however, about the prevalence and histologic features of lesions of the lips in these patients, or about risk factors for such lesions. METHODS We examined the lips of 160 renal-transplant recipients (105 men and 55 women; mean [+/- SD] age, 48 +/- 13 years) and 160 normal subjects matched with the transplant recipients for age, sex, and skin type. The mean length of time between transplantation and the examination was 69 +/- 52 months; 58 percent of the recipients had received their grafts more than 60 months earlier. RESULTS Among the 160 renal-transplant recipients, 21 (13 percent) had leukoplakia; in 2 (1.2 percent) the leukoplakia contained squamous-cell carcinoma. In contrast, only one normal subject (0.6 percent) had leukoplakia. Histologically, 13 of the 21 leukoplakias (62 percent) in the renal-transplant recipients who underwent biopsy were dysplastic, and 2 (10 percent) contained squamous-cell carcinoma. Actinic change was evident in 91 percent of the dysplastic lesions but not in the nondysplastic lesions (P < 0.001). Exposure to the sun and smoking were risk factors for dysplastic and malignant lip lesions in the renal-transplant recipients (P < 0.001 and P = 0.003, respectively). Among these recipients, only men had dysplastic or malignant lip lesions (P = 0.006); lipstick was used frequently by 73 percent of the women. The clinical appearance of lip lesions did not predict the presence of dysplasia or cancer. CONCLUSIONS Renal-transplant recipients have an increased prevalence of leukoplakia, dysplasia, and cancer of the lip.
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Affiliation(s)
- G N King
- Department of Oral Medicine and Periodontology, London Hospital Medical College, United Kingdom
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24
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King GN, Healy CM, Glover MT, Kwan JT, Williams DM, Leigh IM, Thornhill MH. Prevalence and risk factors associated with leukoplakia, hairy leukoplakia, erythematous candidiasis, and gingival hyperplasia in renal transplant recipients. Oral Surg Oral Med Oral Pathol 1994; 78:718-26. [PMID: 7898908 DOI: 10.1016/0030-4220(94)90086-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aims of this study were to determine the prevalence of intraoral lesions in renal transplant recipients and to identify possible risk factors. The oral mucosa of 159 renal transplant recipients and 160 control patients was examined. The most common lesion in renal transplant recipients was cyclosporin-induced gingival hyperplasia (prevalence 22%) and patients with gingival hyperplasia were found to be taking significantly more cyclosporin-A than those without (p < 0.001). The prevalence of hairy leukoplakia and leukoplakia in renal transplant recipients was 11.3% and 10.7%, respectively, compared with 0% and 5.6% in the controls. Oral candidiasis was observed in 9.4% of renal transplant recipients compared with 2.5% of the controls; 3.8% of renal transplant recipients exhibited erythematous candidiasis, but this was not seen in the controls. Renal transplant recipients had a significantly increased risk of developing gingival hyperplasia (p < 0.0001), oral candidiasis (p < 0.0005), and two other conditions that have a well-established association with the immune suppression accompanying HIV infection, hairy leukoplakia (p < 0.0001) and erythematous candidiasis (p < 0.01).
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Affiliation(s)
- G N King
- Department of Oral Medicine and Periodontology, London Hospital Medical College, University of London, England
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25
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Glover MT, Niranjan N, Kwan JT, Leigh IM. Non-melanoma skin cancer in renal transplant recipients: the extent of the problem and a strategy for management. Br J Plast Surg 1994; 47:86-9. [PMID: 8149064 DOI: 10.1016/0007-1226(94)90164-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Over the past 2 years, we have examined all patients with a functioning renal allograft attending a regional nephrology unit. A total of 291 patients were examined. 172 (59%) were found to have cutaneous warts, and 64 (21.9%) had non-melanoma skin cancer (NMSC). The proportion of patients with both warts and NMSC increased with time from transplantation: 40% of patients who had been transplanted for more than 9 years had NMSC. Fifteen patients had extensive dysplastic change in all sun-exposed areas, particularly the dorsal aspect of the hands. This subgroup of patients develop large numbers of tumours, particularly squamous cell carcinomas (SCC), and require close surveillance and frequent surgery. One patient has died as a result of rapidly evolving metastases from an SCC on the dorsum of the hand. Excision and grafting of the backs of the hands in four patients, and long term etretinate therapy in 6 patients have led to a marked reduction in the frequency of surgery to remove tumours. The very high rate of NMSC, frequently multiple, found in this study of UK residents is a source of concern and indicates the need for close dermatological monitoring of allograft recipients, with intensive surveillance of patients with extensive dysplasia, who may develop tumours requiring surgery every few weeks.
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Affiliation(s)
- M T Glover
- Department of Dermatology, Royal London Hospital NHS Trust
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26
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Beales P, Almond MK, Kwan JT. Acyclovir neurotoxicity following oral therapy: prevention and treatment in patients on haemodialysis. Nephron Clin Pract 1994; 66:362-3. [PMID: 8190194 DOI: 10.1159/000187841] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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27
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Almond MK, Kwan JT, Evans K, Cunningham J. Loss of regional bone mineral density in the first 12 months following renal transplantation. Nephron Clin Pract 1994; 66:52-7. [PMID: 8107953 DOI: 10.1159/000187765] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A high incidence of osteopenia is likely in renal transplant recipients in whom pre-existing uraemic osteodystrophy, persisting hyperparathyroidism and glucocorticoids constitute a formidable array of risk factors. The correction of some biochemical and hormonal abnormalities, an increase in body weight and an increase in physical activity following transplantation could favour improvements in skeletal integrity. Using dual energy X-ray absorptiometry (DEXA), we studied prospectively the regional bone mineral density (BMD) of 34 consecutive cadaveric renal allograft recipients who were already established on dialysis. BMD of these patients was measured at the time of transplantation and was repeated at 3, 6 and 12 months following the transplantation. Immunosuppression was achieved using triple therapy: azathioprine, cyclosporin-A and prednisolone. At baseline, total BMD and BMD at the lumbar spine and femoral neck did not differ from age- and sex-matched controls. Females experienced marked and progressive bone loss at the lumbar spine, with less marked changes at the femoral neck. Males, in contrast, experienced substantial reduction of BMD at the femoral neck at 6 months and a recovery at 12 months without significant change at the lumbar spine. Whole body bone mineral content fell transiently in males, with partial recovery by 6 months. No significant correlation was found with the cumulative doses of either corticosteroids or cyclosporin-A, the duration of hospitalisation, the function of the transplant, patient age or menopausal status.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M K Almond
- Department of Nephrology, Royal London Hospital, UK
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28
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Ayatse JO, Kwan JT. Serum and urinary alpha-1 microglobulin levels in renal disease. East Afr Med J 1993; 70:789-92. [PMID: 7517837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Serum and urinary levels of alpha 1-microglobulin (AM) were measured in healthy volunteers and patients with varying degrees of renal insufficiency (from mild impairment to functionally anephric patients). In all 33 healthy volunteers, 57 chronic renal disease and 22 functionally anephrics were studied. Serum creatinine (sCr) and 24-hour creatinine clearance (CCr) were used to assess renal function. Serum AM (SAM) increased with declining glomerular filtration and correlated well with CCr (r = -0.89, n = 90, P < 0.001) and sCr (r = 0.90, n = 112, P < 0.001). sAM increased faster than sCr as the filtration function diminished and may be a more sensitive indicator of impairment in renal glomerular filtration. Urinary AM (uAM) also increased as renal filtration decreased and the number of functional nephrons reduced. uAM correlated with sAM (r = 0.62, P < 0.001) and CCr (r = -0.50, P < 0.001). uAM had a higher percentage increase compared with sAM during the decline in renal function but was more poorly correlated with CCr or glomerular filtration function. It is concluded that AM is useful in assessing glomerular filtration function in addition to its well established relevance in tubular evaluation, and has potential in the longitudinal assessment of changes in renal function in renal disease and systemic diseases that affect the kidney.
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Affiliation(s)
- J O Ayatse
- Department of Biochemistry, University of Surrey, Guildford, England
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Affiliation(s)
- I Junaid
- Department of Transplantation, Royal London Hospital and Medical College, Whitechapel, England
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Abstract
It could be advantageous for the parathyroids to be able to sense not only the absolute concentration of extracellular Ca2+, but also the rate and direction of change of Ca2+, thereby allowing the parathyroids to respond earlier to threats to Ca2+ homeostasis. By using high and low Ca2+ dialysis in a single session, we examined the parathyroid response to direction of change of Ca2+ during acute Ca2+ perturbation in nine hemodialysis patients. Separate PTH/ionized calcium (PTH/iCa) response curves were generated for rising Ca2+ and falling Ca2+. Significant directional hysteresis (higher PTH level during falling than during rising Ca2+) was found. During hypercalcemia, PTH levels were between 2.2 and 1.6 times higher at iCa concentrations of between 0 and +0.1 mM above the baseline iCa, when Ca2+ was falling than when it was rising. During the phase of induced hypocalcemia, parathyroid fatigue was seen in six of the nine patients. Fatigue patients tended to have higher basal PTH (1-84) levels than those not showing fatigue. The existence of fatigue provides an explanation for directional hysteresis during hypocalcemia, and therefore parathyroid sensing of the direction of change of Ca2+ could not be assessed during hypocalcemia. These studies demonstrate a capacity of the parathyroids to sense the direction of movement of Ca2+ during hypercalcemia.
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Affiliation(s)
- J T Kwan
- Department of Nephrology, Royal London Hospital and Medical College, England, United Kingdom
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31
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Holt RI, Kwan JT, Sefton AM, Cunningham J. Successful treatment of concomitant pulmonary nocardiosis and aspergillosis in an immunocompromised renal patient. Eur J Clin Microbiol Infect Dis 1993; 12:110-2. [PMID: 8388790 DOI: 10.1007/bf01967584] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A case is reported of rapid onset concomitant pulmonary infection with Nocardia and Aspergillus fumigatus in a patient six weeks after the institution of immunosuppressive therapy for renal vasculitis. Pulmonary lesions completely resolved on treatment with a combination of imipenem, cotrimoxazole and a prolonged course of itraconazole.
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Affiliation(s)
- R I Holt
- Department of Nephrology, Royal London Hospital & Medical College, Whitechapel, UK
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Glover MT, Bodmer J, Bodmer W, Kennedy LJ, Brown J, Navarrete C, Kwan JT, Leigh IM. HLA antigen frequencies in renal transplant recipients and non-immunosuppressed patients with non-melanoma skin cancer. Eur J Cancer 1993; 29A:520-4. [PMID: 8435203 DOI: 10.1016/s0959-8049(05)80143-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An increased frequency of human leukocyte antigen (HLA)-DR1 was found in 49 non-immunosuppressed patients with non-melanoma skin cancer (NMSC), being highest in patients under the age of 60 with multiple squamous cell carcinomas (SCC). Of 266 patients receiving long-term immunosuppression following renal transplantation 46 (17%) were found to have NMSC. No increase in HLA-DR1 was found in renal transplant recipients (RTR) with non-melanoma skin cancer (RTR+C) when compared with matched renal transplant recipients without skin cancer (matched RTR-C), or when compared with healthy controls. There was an increased frequency of DQw2 in RTR+C, most pronounced in RTR with SCC (61.9% compared with 18.75% in matched RTR-C), giving a relative risk of 13.98. We found statistically significant differences in the frequency of a number of HLA antigens on comparing RTR+C with healthy controls, but none of these differences were found when we compared RTR+C against matched RTR-C.
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Affiliation(s)
- M T Glover
- Department of Dermatology, Royal London Hospital, U.K
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Kwan JT, Carr EC, Barron JL, Bending MR. Carbamylated haemoglobin--a retrospective index of time-averaged urea concentration. Nephrol Dial Transplant 1993; 8:565-7. [PMID: 8394542 DOI: 10.1093/ndt/8.6.565] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- J T Kwan
- SW Thames Regional Renal Unit, St Helier Hospital, Carshalton, Surrey, UK
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Abstract
Carbamylated haemoglobin arises from the non-enzymic modification of haemoglobin monomers by isocyanate derived from the spontaneous dissociation of urea. We measured carbamylated haemoglobin by high performance liquid chromatography in healthy subjects, non-uraemic hospital patients, diabetics, and different groups of uraemic patients. Carbamylated haemoglobin levels were found to be raised in uraemic subjects, but were independent of age, sex, glycaemic state and haemodialysis procedure. There was no significant difference in carbamylated haemoglobin levels between two groups of patients having different modes of dialysis treatment, probably indicating a similar degree of uraemic exposure in these patients.
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Affiliation(s)
- J T Kwan
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, UK
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Abstract
We present a case of Wegener's granulomatosis in a teenage boy with systemic onset juvenile chronic arthritis. We discuss the implication of these two uncommon conditions coexisting in one patient. The recent characterization of the antineutrophil cytoplasmic antibody (ANCA) as a marker of small vessel vasculitis has helped in the differential diagnosis of pulmonary renal syndromes.
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Affiliation(s)
- L R Wedderburn
- Department of Rheumatology, Royal London Hospital, Whitechapel
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Kwan JT, Cotter FE, Pollock LE, Altmann P, Lord RH, Raftery MJ, Cunningham J. EBV-genome positive monoclonal B cell cerebral lymphoma in a renal allograft recipient following OKT3 therapy. Nephrol Dial Transplant 1992; 7:360-1. [PMID: 1317529 DOI: 10.1093/oxfordjournals.ndt.a092143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- J T Kwan
- Department of Nephrology, Royal London Hospital, UK
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Kwan JT, Hart PD, Raftery MJ, Cunningham J, Marsh FP. Mycobacterial infection is an important infective complication in British Asian dialysis patients. J Hosp Infect 1991; 19:249-55. [PMID: 1686037 DOI: 10.1016/0195-6701(91)90242-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To define the extent and nature of mycobacterial infection in patients on an adult dialysis unit whose catchment population contains a large proportion of non-Caucasian subjects, a retrospective survey of all new patients accepted onto our maintenance dialysis programme between January 1987 and December 1989 was carried out. Twenty-six Asian, 13 Afro-Caribbean, two Oriental and 170 Caucasian patients were accepted onto the dialysis programme in the three-year recruitment period. Eight of the 26 Asian patients, but none of the others, had developed mycobacterial infection by the end of December 1990. One patient had a cerebral tuberculoma with miliary mottling on chest X-ray, one pulmonary tuberculosis, one tuberculous adenitis and 5 tuberculous peritonitis (four due to Mycobacterium tuberculosis and one Mycobacterium kansasii). All the patients had been living in the UK for an average of 15 (range 6-24) years, with no known recent exposure to tuberculosis. Five patients are now alive and well, one developed malabsorption following M. kansasii peritonitis, but two with tuberculous peritonitis died before treatment could be instituted. Mycobacterial infections were associated with a high level of mortality and morbidity. No Asian patient developed mycobacterial infection during post-transplant immunosuppressive therapy in the study period, probably because of the routine anti-tuberculous chemoprophylaxis employed in this group of patients. The diagnosis of mycobacterial infection should be suspected when an Asian dialysis patient develops a pyrexia of unknown origin. It is likely, though not proven, that anti-tuberculous chemoprophylaxis might reduce this high incidence of tuberculous infection in Asian dialysis patients.
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Affiliation(s)
- J T Kwan
- Department of Nephrology, Royal London Hospital, Whitechapel, London
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Ayatse JO, Kwan JT. Relative sensitivity of serum and urinary retinol binding protein and alpha-1 microglobulin in the assessment of renal function. Ann Clin Biochem 1991; 28 ( Pt 5):514-6. [PMID: 1720299 DOI: 10.1177/000456329102800517] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- J O Ayatse
- Department of Biochemistry, University of Surrey, Guildford, UK
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Abstract
A 31 year old man first developed steroid-resistant idiopathic membranous glomerulonephritis in 1981. Stable normal renal function was maintained until August 1988 when he suffered a clinical relapse with heavy proteinuria and declining renal function. Immunosuppressive therapy with prednisolone and cyclophosphamide was instituted in an attempt to arrest this relapse. Despite this, he later developed acute renal failure with histological evidence of crescentic transformation of his nephritis. This unusual transformation was not associated with features of systemic vasculitis or positive anti-glomerular basement membrane and anti-neutrophil cytoplasmic antibodies.
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Affiliation(s)
- J T Kwan
- Department of Nephrology, Royal London Hospital, Whitechapel, UK
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Kwan JT, Foxall PJ, Bending MR. Monitoring of renal transplant graft function by regular postal capillary blood sampling. Ann Clin Biochem 1991; 28 ( Pt 3):303-4. [PMID: 1872580 DOI: 10.1177/000456329102800320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- J T Kwan
- S W Thames Regional Renal Unit, St Helier Hospital, Carshalton, Surrey, UK
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Kwan JT, Cunningham J. Comment on "Use of aminohydroxypropylidene bisphosphonate (AHPrBP, "APD") for the treatment of hypercalcemia in patients with renal impairment" by Yap et al. Clin Nephrol 1991; 35:182. [PMID: 1855321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Kwan JT, Carr EC, Neal AD, Burdon J, Raftery MJ, Marsh FP, Barron JL, Bending MR. Carbamylated haemoglobin, urea kinetic modelling and adequacy of dialysis in haemodialysis patients. Nephrol Dial Transplant 1991; 6:38-43. [PMID: 2057114 DOI: 10.1093/ndt/6.1.38] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Urea kinetic modelling (UKM) has increasingly been used for assessing adequacy of dialysis and protein nutritional status of dialysis patients. Using a precise HPLC method we developed, we measured carbamylated haemoglobin (CarHb) values in 20 stable twice-weekly dialysed patients and attempted to correlate their CarHb values with their UKM-derived indices. Based on these indices, 11 patients were found to have been adequately dialysed with sufficient protein intake, three patients were adequately dialysed but malnourished and six patients were under-dialysed. Estimated dietary protein intake correlated poorly with calculated daily protein catabolic rate in our patients. CarHb values were found to correlate strongly with the time-averaged urea concentrations, suggesting that CarHb might be a time-integrated urea-derived index. Those adequately dialysed patients have a mean (SD) CarHb value of 142 (29) micrograms CV/gHb against the underdialysed patients, 197 (30) micrograms CV/gHb (t-test, P = 0.002). We suggest that a CarHb value less than 175 micrograms CV/gHb may represent satisfactory uraemic exposure, whereas CarHb value greater than 175 micrograms CV/gHb is undesirable.
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Affiliation(s)
- J T Kwan
- Department of Nephrology, London Hospital, Whitechapel, UK
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Abstract
Abstract
We have developed an HPLC method for measuring carbamylated hemoglobin (CarHb), based on the quantification of valine hydantoin formed from the released NH2-terminal carbamyl valine residue after acid hydrolysis of hemoglobin. In uremia, CarHb is produced by nonenzymatic post-translational modification of the terminal amino group of hemoglobin monomers by isocyanic acid, derived from the spontaneous dissociation of urea. We measured CarHb in 25 nonuremic control subjects, 24 nonuremic diabetic subjects, and 30 patients with stable chronic renal failure. There was no significant difference between the controls and diabetic patients, their mean (SD) CarHb values being 41 (11.5) and 38 (10.8) micrograms of carbamyl valine per gram of hemoglobin (microgram CV/gHb), respectively. Mean (SD) CarHb values in the uremic patients were much greater, 164 (87.7) microgram CV/gHb. There was significant correlation between the concentrations of CarHb and plasma urea in the uremic subjects. Thus CarHb provides a urea-derived index of chronic uremia.
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Affiliation(s)
- J T Kwan
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, U.K
| | - E C Carr
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, U.K
| | - M R Bending
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, U.K
| | - J L Barron
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, U.K
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Kwan JT, Carr EC, Bending MR, Barron JL. Determination of carbamylated hemoglobin by high-performance liquid chromatography. Clin Chem 1990; 36:607-10. [PMID: 2323040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We have developed an HPLC method for measuring carbamylated hemoglobin (CarHb), based on the quantification of valine hydantoin formed from the released NH2-terminal carbamyl valine residue after acid hydrolysis of hemoglobin. In uremia, CarHb is produced by nonenzymatic post-translational modification of the terminal amino group of hemoglobin monomers by isocyanic acid, derived from the spontaneous dissociation of urea. We measured CarHb in 25 nonuremic control subjects, 24 nonuremic diabetic subjects, and 30 patients with stable chronic renal failure. There was no significant difference between the controls and diabetic patients, their mean (SD) CarHb values being 41 (11.5) and 38 (10.8) micrograms of carbamyl valine per gram of hemoglobin (microgram CV/gHb), respectively. Mean (SD) CarHb values in the uremic patients were much greater, 164 (87.7) microgram CV/gHb. There was significant correlation between the concentrations of CarHb and plasma urea in the uremic subjects. Thus CarHb provides a urea-derived index of chronic uremia.
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Affiliation(s)
- J T Kwan
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, U.K
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Abstract
A renal transplant patient developed a fatal caecal perforation after Histoplasma capsulatum infection acquired abroad. Disseminated histoplasmosis is an uncommon fungal infection, usually seen in patients with impaired immunity. The diagnosis should be considered in immunosuppressed patients who develop prolonged fever or whose health deteriorates unexpectedly after travelling overseas. The infection is endemic in parts of the United States of America but occurs all over the world. Rapid diagnosis is often possible by histological examination of infected tissues. Treatment if started early may lead to recovery, but if it is not treated it is usually fatal.
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Affiliation(s)
- M T Brett
- Department of Histopathology, St Helier Hospital, Carshalton, Surrey
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Stokely DJ, Kwan JT, Bending MR, Chin AT, Eisinger AJ. Isolation of organisms in CAPD peritonitis: use of nutrient broth cultures and Bactec blood culture media. J Hosp Infect 1988; 11:77-81. [PMID: 2895141 DOI: 10.1016/0195-6701(88)90042-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cultures of the first cloudy dialysates from 51 consecutive episodes of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis were carried out using concentrated nutrient broth and Bactec blood culture media in addition to primary culture on solid media. Thirty-seven episodes (73%) were positive on solid media, and 42 episodes (82%) were positive by both nutrient broth and Bactec methods. The value of Gram-stained smears and WBC counts on dialysates is discussed.
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Affiliation(s)
- D J Stokely
- South West Thames Regional Renal Unit, St. Helier Hospital, Carshalton, Surrey, UK
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Kwan JT, Foxall PJ, Townend JN, Thick MG, Bending MR, Eisinger AJ. Therapeutic range of cyclosporin in renal transplant patients by specific monoclonal radioimmunoassay. Lancet 1987; 2:962-3. [PMID: 2889874 DOI: 10.1016/s0140-6736(87)91438-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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