Refractive Changes Associated With Pediatric Kidney Transplantation.

Refractive Changes after Pharmacologic Resolution of Diabetic Macular Edema

IntroductionSubthreshold micropulse laser treatment with a 532 nm (532-SML) wavelength has been suggested as a treatment option for the treatment of chronic central serous retinopathy (cCSR). The objective is to present its effects and complications.MethodsWe present a retrospective cohort study of cCSR patients submitted to 532-SML. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) parameters – central macular thickness, subfoveal outer nuclear layer, external limiting membrane, ellipsoid band, interdigitation band, subretinal fluid and choroidal thickness – were evaluated before and 12 weeks after treatment. A power of 50%, a duty cycle of 5%, exposure time of 200 ms and a spot size of 160 µm were the applied laser parameters.ResultsWe included 26 eyes. Overall there were no significant changes in visual acuity (median 0.20 (IQR 0) logMAR before and after treatment) or SD-OCT parameters. However, visual benefits occurred in 42.3% (n=11) of the patients and in half of the cases, subretinal fluid was completely reabsorbed. There were no complications.ConclusionIn this study, 532-SML was overall ineffective on cCSR as it did not lead to significant changes in the overall median visual acuity and SD-OCT parameters. However, some patients may have benefited functionally and anatomically from the treatment; further investigation is necessary to understand the potential of 532-SML.

Anterior and Posterior Subcapsular and Polar Cataracts

Simultaneous en-bloc pancreas and kidney transplantation from a small pediatric donor after circulatory death.

To determine the incidence of steroid induced glaucoma and treatment characteristics in kidney transplant patients in a tertiary level multispecialty institution. In this prospective cross-sectional study, the patients who underwent kidney transplant were enrolled and underwent comprehensive ophthalmological evaluation including intraocular pressure (IOP) measurement with Goldmann Applanation tonometry, visual field examination with Humphrey Field Analyzer, and gonioscopy. Cases with IOP > 21 mm Hg, visual field defect, and optic disc cupping > 0.7 or asymmetry of 0.2 or more were labeled as glaucoma, whereas IOP > 21 mm Hg with a normal visual field was designated as ocular hypertension (OHT). The mean age of patients was 39 ± 9 (range: 25-60) years. Out of 72 patients with kidney transplants, 7 (9.72%) patients were diagnosed with steroid-induced glaucoma, and 9 (12.5%) patients had ocular hypertension (OHT). Four (5.55%) patients underwent trabeculectomy to control IOP whereas 3 (4.16%) patients were controlled on anti-glaucoma medications. Best-corrected visual acuity < 6/9 was noted in 23 (31.94%) patients in at least one eye. The average follow-up was 30 months with interquartile range of 18-84 months. There was a significant association of cumulative dosage of steroid and development of cataract and OHT and glaucoma (P < 0.01). Kidney transplant patients must be screened for glaucoma and other ocular abnormality and should be on routine ophthalmological follow-up due to the possibility of steroid induced glaucoma.

IntroductionTransient hyperphosphatasemia (TH) is a rare benign condition of elevated serum alkaline phosphatase (AP) levels seen in healthy children. TH has been reported to occur in pediatric solid organ transplants, including kidney transplant patients. Little is known about TH in pediatric kidney transplant patients.ObjectiveTo evaluate the incidence and natural history of TH in pediatric kidney transplant patients.MethodsA retrospective chart review of patients < 18 years of age who underwent kidney transplantation at the University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh between 2008 and 2019 was performed to identify patients with TH, defined as an AP level greater than 1,000 IU/L. Exclusion criteria included repeat kidney transplants or kidney transplant as part of a multiorgan transplant.ResultsOne hundred seventy-six patients underwent a solitary kidney transplant, of which 87 were less than 12 years of age. Eleven patients (6.5%) were found to have TH, all of whom were < 12 years of age (12.8%) (median age: 5 years; range: 1 - 11 years). The median AP level prior to transplant was 183 IU/L (range: 104 - 309 IU/L) and the median peak AP was > 2,300 IU/L (range: 1,227 - 4,912 IU/L). The median time from a kidney transplant to the diagnosis of TH was 0.6 years (range: 0.3 to 7.7 years). The median length of time that TH persisted was 0.5 years (range: 0.2 to 0.9 years). The median estimated glomerular filtration rate (GFR) at the time of diagnosis of TH was 84 mL/min/1.73m2 per the bedside Schwartz equation (range: 45 to 152 mL/min/1.73m2). One patient had variable AP levels over nine months prior to resolution; the other 10 patients had a solitary peak of AP prior to resolution. No patient required treatment of elevated AP levels and the TH resolved spontaneously without intervention. No patients had significant abnormalities of markers of metabolic bone disease or were on active vitamin D, calcium, or phosphorus supplements. Two patients reported bone pain, and one patient was found to have avascular necrosis of the hip.ConclusionsTH is a relatively common finding following a pediatric kidney transplant in pre-pubertal children less than 12 years of age. It primarily occurs in the first year following a kidney transplant and usually resolves without recurrence within one year of onset.

Long-term Follow-up of Tacrolimus Ointment for Treatment of Atopic Keratoconjunctivitis

Background: The waitlist period for kidney transplantation (KT) has been increasing due to intractable shortage of brain-dead donors in Korea. To solve this organ shortage issue, KT cases with expanded criteria brain-dead donor (ECD) organs have been increasing. This study intended to analyze the willingness of waitlist patients to undergo KT with ECD in a single institution in or der to use as the basic data for selecting and managing patients waiting for deceased donor KT (DDKT). Methods: We carried out a survey with 1,069 patients who were enrolled at the waitlist for DDKT from 2015 to 2019 at a single in stitution. They were asked whether they were willing to undergo KT with ECD of type 1 and 2. The answers were analyzed through descriptive statistics. ECD type 1: age over 60 years, but serum creatinine is normal (<1.5 mg/dL) without hypertension or diabe tes and type 2: serum creatinine is higher than 3.0 mg/dL due to acute kidney injury, under continuous renal replacement therapy to improve acute renal failure, or serum creatinine is normal (<1.5 mg/dL) but over 60 years of age with hypertension or diabetes. Results: Of them, 390 patients (36.0%) refused ECD type 1. In contrast, other 345 patients (32.0%) answered to undergo KT with deceased donors over 60 years, but they did not want KT with donors over 70 years; 231 (22.0%) patients did not have a limit in the donor age; and 103(10%) patients hesitated or avoided answers. As a result, 576 (52.6%) of 1,096 patients were willing to undergo KT with ECD type 1. The proportions of such affirmative-answer group according to the patient age were 196 (34.1%) in their 50s, 171 (29.7%) in their 60s, 115 (19.9%) in their 40s, 57 (9.9%) in their 30s, 21 (3.7%) in their 70s, 14 (2.4%) in their 20s and three (0.30%) in their teens. Meanwhile, 538 patients (50.3%) refused to undergo KT with ECD type 2. Other 419 patients (39.2%) were willing to undergo KT with ECD type 2; and 112 patients (10.5%) avoided answer or did not responded. In the 419 patients who expressed their willingness to undergo KT with ECD type 2, the waitlist periods were ≥1 year in 135 patients, ≥2 years in 110, ≥3 years in 83, ≥4 years in 58, and ≥5 years in 33. Their distributions by age were 148 patients over 50s, 116 patients over 60s and 70s, 93 patients over 40s, 52 patients over 30s, and 10 patients over 20s. Among the 576 patients who expressed their willing ness to undergo KT with ECD type 1, 322 (55.9%) answered to undergo any type of ECD DDKT. Conclusions: We believe that the results of this study are helpful to select and manage the DDKT candidates quickly and effi ciently when occurrence of ECD is notified. It is necessary to establish practical protocols and to improve awareness toward KT with ECD.

A paper published by the author in 1988 in this journal provided some important findings about the lack of precision of visual acuity (VA) measures made with commonly used Snellen charts and the advantages of using letter charts designed using the principles proposed by Bailey and Lovie in 1976. That 1988 paper has been cited a number of times since, mostly supporting the findings. The purpose of this review is to examine the changes that have occurred in VA measurement in research and clinical practice since that earlier study. While precise measures of VA using Bailey-Lovie or ETDRS charts are now commonly used in major, multi-centre research studies, it is disappointing to see that many research papers still report VA measured with Snellen charts and even use Snellen fractions, invalidly converted to logMAR notation, in parametric analyses of VA. Many studies have examined the test-retest variability (TRV) of VA measures in groups and individuals, but it is difficult to determine if clinicians or researchers determine patients' individual TRVs to more accurately detect real changes in VA for each individual. This paper summarises the findings of the 1988 study: (1) Snellen charts and VA notations are not appropriate for accurate clinical and research measures of VA; (2) Charts employing the Bailey-Lovie design principles should be used to provide precise measures of VA. (3) Test-retest variability should be used to determine the limit for detecting significant change in VA. This author suggests that it is time for Snellen charts, Snellen fractions and decimal notation to be confined to the teaching of the history of VA measurement. A request is also made to stop the use of the redundant term 'best corrected' VA (BCVA). Recommended procedures are given for precise measures of VA and accurately monitoring changes in VA in clinical practice and research.

BackgroundTo assess the effect of switching patients previously incompletely treated with ranibizumab (RBZ) to aflibercept (AFL) using a pro re nata (PRN) treatment strategy in neovascular age-related macular degeneration (nvAMD).MethodsA retrospective case series was conducted on patients who had persistent or recurrent intra- and/or sub-retinal fluid treated initially with RBZ and subsequently switched to AFL. The main outcome measures were best corrected visual acuity (BCVA) and central retinal thickness (CRT) measured at different stages of the study. Friedman analysis of variance and Wilcoxon test were used to examine differences in BCVA and CRT.ResultsTwo hundred and seven eyes from 182 patients were included. BCVA and CRT improved significantly initially following 3 RBZ injections with a mean gain of 3.7 letters (p < 0.001) and a mean loss of 69 μm (p < 0.001) respectively. Following PRN RBZ therapy and immediately prior to switching to AFL (mean 129 weeks), there was a mean loss of 6.7 letters (p < 0.001) BCVA and a mean gain of 24 μm (p < 0.001) CRT.AFL loading resulted in a mean improvement of 0.7 letters (p = 0.28) BCVA and 55 μm (p < 0.001) CRT. At final follow-up following AFL PRN therapy (mean 85 weeks), there was a mean loss of 8.9 letters (p < 0.001) BCVA and a mean gain of 12 μm (p < 0.05) CRT.ConclusionAFL loading resulted in a significant anatomical improvement but no significant change in visual acuity. However, the benefits of switching were gradually lost over time with AFL PRN dosing despite an increased injection rate when compared with RBZ PRN treatment.Trial registrationNot applicable

Kidney transplantation in small children is technically challenging. Consideration of whether to use intraperitoneal versus extraperitoneal placement of the graft depends on patient size, clinical history, anatomy, and surgical preference. We report a large single-center experience of intraperitoneal kidney transplantation and their outcomes. We conducted a retrospective review of pediatric patients who underwent kidney transplantation from April 2011 to March 2018 at a single large volume center. We identified those with intraperitoneal placement and assessed their outcomes, including graft and patient survival, rejection episodes, and surgical or non-surgical complications. Forty-six of 168 pediatric kidney transplants (27%) were placed intraperitoneally in children mean age 5.5±2.3years (range 1.6-10years) with median body weight 18.2±5kg (range 11.4-28.6kg) during the study period. Two patients (4%) had vascular complications; 10 (22%) had urologic complications requiring intervention; all retained graft function. Thirteen patients (28%) had prolonged post-operative ileus. Eight (17%) patients had rejection episodes ≤6months post-transplant. Only one case resulted in graft loss and was associated with recurrent focal segmental glomerular sclerosis (FSGS). Two patients (4%) had chronic rejection and subsequent graft loss by 5-year follow-up. At 7-year follow-up, graft survival was 93% and patient survival was 98%. The intraperitoneal approach offers access to the great vessels, which allows greater inflow and outflow and more abdominal capacity for an adult donor kidney, which is beneficial in very small patients. Risk of graft failure and surgical complications were not increased when compared to other published data on pediatric kidney transplants.

Soluble Human Leukocyte Antigen-G in Pediatric Renal Transplantation

Kidney transplantation (KT) is the preferred treatment for paediatric patients with kidney failure, but information on trends in paediatric KT in Europe is lacking. We aimed to report on time trends in paediatric (0-17years) KT rates and recipient characteristics in Europe between 2010 and 2021. Thirty-one countries contributing data from 2010 to 2021 on paediatric KT to the European Society for Paediatric Nephrology/European Renal Association Registry were included. We reported trends in KT rates [per million age-related population (pmarp)], overall and by patient subgroup for Europe, and at macro-economic and country-specific levels. We also reported clinical variables in the first year post-KT. The 2020-21 period was analysed separately to account for the COVID-19 pandemic. The paediatric KT rate was stable at ≈5pmarp between 2010 and 2019, and about one-fourth were pre-emptive KTs. In 2020-21 the KT rate was 5.6pmarp. In low-, middle- and high-gross domestic product (GDP) countries, KT rates (pmarp) were 2.1, 6.1 and 7.6, respectively, and increased in low-GDP countries by 4.1% per year from 2010 to 2019, mainly in the youngest recipients. The proportion of pre-emptive KT increased only in middle-GDP countries. Low-GDP countries showed a higher prevalence of short stature while high-GDP countries showed more overweight/obese, hypertensive and anaemic patients. The rate of paediatric KT in Europe has remained stable, with differences between GDP groups. Low-GDP countries had the lowest KT rates, but with an increasing trend over time. Opportunities to further increase access to paediatric KT should be explored.

Refractive changes in nuclear, cortical and posterior subcapsular cataracts. Effect of the type and grade

Preliminary visual outcomes following three-dimensional conformal radiation therapy for optic nerve sheath meningioma