Challenges to establishing and maintaining kidney transplantation programs in developing countries:What are the coping strategies?

Kidney transplantation(KT)is the optimal form of renal replacement therapy for patients with end-stage renal diseases.However,this health service is not available to all patients,especially in developing countries.The deceased donor KT programs are mostly absent,and the living donor KT centers are scarce.Single-center studies presenting experiences from developing countries usually report a variety of challenges.This review addresses these challenges and the opposing strategies by reviewing the single-center experiences of developing countries.The financial challenges hamper the infrastructural and material availability,coverage of transplant costs,and qualification of medical personnel.The sociocultural challenges influence organ donation,equity of beneficence,and regular follow-up work.Low interests and motives for transplantation may result from high medicolegal responsibilities in KT practice,intense potential psychosocial burdens,complex qualification protocols,and low productivity or compensation for KT practice.Low medical literacy about KT advantages is prevalent among clinicians,patients,and the public.The inefficient organizational and regulatory oversight is translated into inefficient healthcare systems,absent national KT programs and registries,uncoordinated job descriptions and qualification protocols,uncoordinated on-site investigations with regulatory constraints,and the prevalence of commercial KT practices.These challenges resulted in noticeable differences between KT services in developed and developing countries.The coping strategies can be summarized in two main mechanisms:The first mechanism is maximizing the available resources by increasing the rates of living kidney donation,promoting the expertise of medical personnel,reducing material consumption,and supporting the establishment and maintenance of KT programs.The latter warrants the expansion of the public sector and the elimination of non-ethical KT practices.The second mechanism is recruiting external resources,including financial,experience,and training agreements.

深板层角膜移植与穿透性角膜移植治疗基质性角膜营养不良

目的:比较深板层角膜移植(DALK)与穿透性角膜移植(PK)治疗基质性角膜营养不良的有效性和安全性。方法:系统回顾性Meta分析。对比较视力[最佳矫正视力(BCVA)(LogMAR)]和角膜内皮细胞计数(ECC)以及DALK和PK手术的安全性结果,包括移植物相关结果和术中术后并发症。直到2019-06,使用Embase、PubMed和Google Scholar搜索符合条件的研究。结果:最终纳入了350例黄斑点状CD患者(男性59.71%)的五项对比研究。两种手术后的平均BCVA无明显差异。然而,经过DALK手术,术后两年角膜ECC明显升高(WMD=401.62 cell/mm2,95%CI:285.39-517.85,P<0.001),与接受PK手术的患者相比,移植物和内皮细胞排斥反应率显著降低(RR=0.30,95%CI:0.14-0.64,P=0.002;RR=0.09,95%CI:0.02-0.46,P=0.004)。但是,DALK手术增加了术中后弹力膜穿孔和术后双前房的风险(P<0.001)。结论:对于间质性CDs患者,DALK治疗在随访期间相对更有效,更安全,减少排斥反应,提高视觉效果。

A Transfer Learning-Enabled Optimized Extreme Deep Learning Paradigm for Diagnosis of COVID-19

Many respiratory infections around the world have been caused by coronaviruses.COVID-19 is one of the most serious coronaviruses due to its rapid spread between people and the lowest survival rate.There is a high need for computer-assisted diagnostics(CAD)in the area of artificial intelligence to help doctors and radiologists identify COVID-19 patients in cloud systems.Machine learning(ML)has been used to examine chest X-ray frames.In this paper,a new transfer learning-based optimized extreme deep learning paradigm is proposed to identify the chest X-ray picture into three classes,a pneumonia patient,a COVID-19 patient,or a normal person.First,three different pre-trainedConvolutionalNeuralNetwork(CNN)models(resnet18,resnet25,densenet201)are employed for deep feature extraction.Second,each feature vector is passed through the binary Butterfly optimization algorithm(bBOA)to reduce the redundant features and extract the most representative ones,and enhance the performance of the CNN models.These selective features are then passed to an improved Extreme learning machine(ELM)using a BOA to classify the chest X-ray images.The proposed paradigm achieves a 99.48%accuracy in detecting covid-19 cases.

Reasons and effects of the decline of willing related potential living kidney donors

BACKGROUND Although the availability of related living donors(LDs)provides a better chance for receiving kidney transplantation(KT),the evaluation protocols for LD selection remain a safeguard for the LD’s safety.These protocols are variable from one center to another,resulting in variable rates of decline of the potential LDs(PLDs).The decline of willing PLDs may occur at any stage of evaluation,starting from the initial contact and counseling to the day of operation.AIM To identify the causes of the decline of PLDs,the predictors of PLD candidacy,and the effect on achieving LDKT.METHODS A retrospective study was performed on the willing PLDs who attended our outpatient clinic for kidney donation to their related potential recipients between October 2015 and December 2022.The variables influencing their candidacy rate and the fate of their potential recipients were studied.Two groups of PLDs were compared:Candidate PLDs after a completed evaluation vs non-candidate PLDs with a complete or incomplete evaluation.A multivariate logistic regression was performed to assess the factors contributing to the achievement of PLD candidacy.RESULTS Of 321 willing PLDs,257 PLDs(80.1%)accessed the evaluation to variable extents for 212 potential recipients,with a mean age(range)of 40.5±10.4(18-65)years,including 169 females(65.8%).The remaining 64 PLDs(19.9%)did not access the evaluation.Only 58 PLDs(18.1%)succeeded in donating,but 199 PDLs(62.0%)were declined;exclusion occurred in 144 PLDs(56.0%)for immunological causes(37.5%),medical causes(54.9%),combined causes(9.7%),and financial causes(2.1%).Regression and release occurred in 55 PLDs(17.1%).The potential recipients with candidate PLDs were not significantly different from those with non-candidate PLDs,except in age(P=0.041),rates of completed evaluation,and exclusion of PLDs(P<0.001).There were no factors that independently influenced the rate of PLD candidacy.Most patients who failed to have KT after the decline of their PLDs remained on hemodialysis for 6 mo to 6 years.CONCLUSION The rate of decline of willing related PLDs was high due to medical or immunological contraindications,release,or regression of PLDs.It reduced the chances of high percentages of potential recipients in LDKT.

Preemptive living donor kidney transplantation:Access,fate,and review of the status in

BACKGROUND Preemptive living donor kidney transplantation(PLDKT)is recommended as the optimal treatment for end-stage renal disease.AIM To assess the rate of PLDKT among patients who accessed KT in our center and review the status of PLDKT in Egypt.METHODS We performed a retrospective review of the patients who accessed KT in our center from November 2015 to November 2022.In addition,the PLDKT status in Egypt was reviewed relative to the literature.RESULTS Of the 304 patients who accessed KT,32 patients(10.5%)had preemptive access to KT(PAKT).The means of age and estimated glomerular filtration rate were 31.7±13 years and 12.8±3.5 mL/min/1.73 m2,respectively.Fifty-nine patients had KT,including 3 PLDKTs only(5.1%of total KTs and 9.4%of PAKT).Twenty-nine patients(90.6%)failed to receive PLDKT due to donor unavailability(25%),exclusion(28.6%),regression from donation(3.6%),and patient regression on starting dialysis(39.3%).In multivariate analysis,known primary kidney disease(P=0.002),patient age(P=0.031)and sex(P=0.001)were independent predictors of achievement of KT in our center.However,PAKT was not significantly(P=0.065)associated with the achievement of KT.Review of the literature revealed lower rates of PLDKT in Egypt than those in the literature.CONCLUSION Patient age,sex,and primary kidney disease are independent predictors of achieving living donor KT.Despite its non-significant effect,PAKT may enhance the low rates of PLDKT.The main causes of non-achievement of PLDKT were patient regression on starting regular dialysis and donor unavailability or exclusion.

A randomized comparative study of flexible ureterorenoscopy versus mini-percutaneous nephrolithotomy for treatment of renal stones 2 cm or less

Background Flexible ureterorenoscopy(fURS)and mini-percutaneous nephrolithotomy(mPCNL)have been increasingly used for the treatment of renal stones.However,current guidelines do not recommend one modality over the other.The aim of this study is to compare the safety and efficacy of treatment with fURS versus mPCNL for renal stones sized 2 cm or less.Materials and methods A prospective,randomized,comparative study was conducted between January 2019 and July 2021 at 3 tertiary care urology centers.Inclusion criteria were adult patients with renal stone(s)≤2 cm with inappropriateness or failure of extracorporeal shock-wave lithotripsy.Subjects were assigned to 1 of 2 treatment groups,either mPCNL or fURS.Two primary outcomes were assessed:(1)initial success rate,defined as the absence of clinically significant residual fragments(>2 mm)on kidney ureter bladder X-ray and ultrasound on the first postoperative day;and(2)complications,which were reported according to the Modified Clavien-Dindo classification system.Secondary outcomes included final success rate,defined as the absence of clinically significant residual fragments on noncontrast computed tomography on the 90th postoperative day;operative time;auxiliary procedures and blood transfusion rates;hemoglobin drop;and length of hospital stay.Results One hundred and eighteen procedures were analyzed(59 in each group).The initial success rate of the mPCNL group(93%)was significantly higher than that of the fURS group(70%).Complications occurred more frequently with mPCNL than fURS(44.1%vs.18.6%,respectively).Final success rate,operative time,and length of hospital stay were comparable between the 2 groups.Conclusions Mini-percutaneous nephrolithotomy is more effective than fURS as a single-step treatment for renal stones<2 cm because of its higher initial success rate and lower auxiliary procedure rate.However,mPCNL results in significantly higher complication rates than fURS.

Efficacy of the combination of tadalafil and tamsulosin versus tadalafil alone as a medical expulsive therapy for stone L1/3 ureter 10 mm or less: A prospective comparative placebo-controlled study

Background The lifetime occurrence of urinary stones is approximately 1%–15%,and the peak age of occurrence is 30 years.Approximately one fifths of urinary tract stones are found in the ureter,of which two thirds are in the distal ureter.Many drugs,including phosphodiesterase-5 inhibitors(PDE5Is)andα-blockers,are used to relax the smooth muscles in medical expulsive therapy(MET).We aimed to compare the combination of tadalafil and tamsulosin versus tadalafil alone as MET for stones in the L1/3 ureter of 10 mm or less.Materials and methods A total of 150 patients with L1/3 ureteric stones measuring 10 mm or less were enrolled in the study and randomly assigned to one of 3 equal groups using a computer-generated random number.Patients in group A prescribed tadalafil 10 mg/d.However,those in group B were prescribed tamsulosin 0.4 mg and tadalafil 10 mg/d,whereas those in group C received a placebo once daily.Stone expulsion rate and pain recurrence were evaluated after 14 days.Results The stone expulsion rate was significantly higher in the tadalafil and tamsulosin groups and the tamsulosin group than in the placebo group in the current study by 68%in the combination group,64%in the tadalafil alone group,and 42%in the placebo group(p=0.019).In the current study,a combination was associated with lower pain recurrence than tadalafil alone or placebo,with means of 1.06,1.9,2.98(with a p value of 0.001).Stone size was not effective in any group.Conclusions The combination of PDE5Is andα-blockers effectively increases the expulsion of lower ureteric stones(5–10 mm),but with the same effect as PDE5Is alone,with the advantage of decreasing pain recurrence.Stone size did not affect the expulsion rate in patients who received MET for stones less than 1 cm in size.