Pros and cons of live kidney donation in prediabetics: A critical review and way forward

There is shortage of organs,including kidneys,worldwide.Along with deceased kidney transplantation,there is a significant rise in live kidney donation.The prevalence of prediabetes(PD),including impaired fasting glucose and impaired glucose tolerance,is on the rise across the globe.Transplant teams frequently come across prediabetic kidney donors for evaluation.Prediabetics are at risk of diabetes,chronic kidney disease,cardiovascular events,stroke,neuropathy,retinopathy,dementia,depression and nonalcoholic liver disease along with increased risk of all-cause mortality.Unfortunately,most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period.There is lack of prospective long-term studies to know about the real risk of complications after donation.Furthermore,there are variations in recommendations from various guidelines across the globe for donations in prediabetics,leading to more confusion among clinicians.This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients.This review focuses on pathophysiological changes of PD in kidneys,potential complications of PD,other risk factors for development of type 2 diabetes,a review of guidelines for kidney donation,the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

Bleeding complications after percutaneous kidney biopsies–nationwide experience from Brunei Darussalam

BACKGROUND Kidney biopsy serves as a valuable method for both diagnosing and monitoring kidney conditions.Various studies have identified several risk factors associated with bleeding complications following the procedure,but these findings have shown inconsistency and variation.AIM To investigate the risk of bleeding complications following percutaneous kidney biopsy in Brunei Darussalam.We sought to explore the relevant clinical and pathological risk factors associated with these complications while also considering the findings within the broader international literature context.METHODS We conducted a retrospective study of all adult patients who underwent kidney biopsy in Brunei Darussalam from October 2013 to September 2020.The outcomes of interest were post-biopsy bleeding and the need for blood transfusions.Demographics,clinical,laboratory and procedural-related data were collected.Logistic regression analysis was used to identify predictors of outcomes.RESULTS A total of 255 kidney biopsies were included,with 11%being performed on transplanted kidneys.The majority of biopsies were done under ultrasound guidance(83.1%),with the rest under computer tomography guidance(16.9%).The most common indications for biopsy were chronic kidney disease of undefined cause(36.1%),nephrotic syndrome(24.3%)and acute kidney injury(11%).Rate of bleeding complication was 6.3%–2%frank hematuria and 4.3%perinephric hematoma.Blood transfusion was required in 2.8%of patients.No patient lost a kidney or died because of the biopsy.Multivariate logistic regression identified baseline hemoglobin[odds ratio(OR):4.11;95%confidence interval(95%CI):1.12-15.1;P=0.03 for hemoglobin≤11 g/dL vs.>11 g/dL)and the presence of microscopic hematuria(OR:5.24;95%CI:1.43-19.1;P=0.01)as independent risk factors for post-biopsy bleeding.Furthermore,low baseline platelet count was identified as the dominant risk factor for requiring postbiopsy transfusions.Specifically,each 10109/L decrease in baseline platelet count was associated with an 12%increase risk of needing transfusion(OR:0.88;95%CI:0.79-0.98;P=0.02).CONCLUSION Kidney biopsies were generally well-tolerated.The identified risk factors for bleeding and transfusion can help clinicians to better identify patients who may be at increased risk for these outcomes and to provide appropriate monitoring and management.

Clinical significance of heterotopic gastric mucosal patch of the proximal esophagus

Heterotopic gastric mucosa of the proximal esophagus (HGMPE),also referred to as"inlet patch"or"cervical inlet patch",is a salmon colored patch that is usually located just distal to the upper esophageal sphincter. HGMPE is uncommon with endoscopic studies reporting a prevalence ranging from less than one percent to 18%.Most HGMPE are asymptomatic and are detected incidentally during endoscopy for evaluations of other gastrointestinal complaints.Most consider HGMPE as clinically irrelevant entity.The clinical significance of HGMPE is mainly acid related or neoplastic transformation.The reported prevalence of laryngopharyngeal reflux symptoms varies from less than 20%to as high as 73.1%.However,most of these symptoms are mild. Clinically significant acid related complications such as bleeding,ulcerations,structure and fistulization have been reported.Although rare,dysplastic changes and malignancies in association with HGMPE have also been reported.Associations with Barrett's esophagus have also been reported but the findings so far have been conflicting.There are still many areas that are unknown or not well understood and these include the natural history of HGMPE,risk factors for complications,role of Helicobacter pylori infection and factors associated with malignant transformations.Follow-up may need to be considered for patients with complications of HGMPE and surveillance if biopsies show intestinal metaplasia or dysplastic changes.Despite the overall low incidence of clinically relevant manifestations reported in the literature,HGMPE is a clinically significant entity but further researches are required to better understand its clinical significance.

Endoscopic management of biliary disorders during pregnancy

BACKGROUND:Biliary interventions during pregnancy are associated with risks to both the pregnancy and developing fetus.In this report we summarize our experience with endoscopic interventions including endoscopic ultrasound (EUS)in the management of biliary disorders during pregnancy. METHODS:Endoscopic retrograde cholangiopancreatographies (ERCPs)performed between May 2003 through January 2010(n=607)were identified from our database,and cases of interventions during pregnancy were reviewed.All procedures were done using conscious sedation and lead shielding. RESULTS:Nine ERCPs(1.5%)were performed in 8 pregnant patients.Their median gestational period was 22 weeks (range,<2-36 weeks).Two,5 and 2 patients were in their first,second and third trimester,respectively.Indications for ERCP included obstructive jaundice(6 patients)cholangitis (2),and acute pancreatitis/obstructive jaundice(1).Two patients underwent EUS before ERCP.Fluoroscopy was used in 5 ERCPs(median 12 seconds;range 2-20 seconds),and the overall time for a ERCP ranged from 5 to 25 minutes. During ERCP endoscopic sphincterotomy was performed in 5 patients,stenting in 6,and balloon clearance in 3.One procedure caused complication in induction of labor.During pregnancy,there were 4 non-procedure related complications including acute cholecystitis(1),HELLP syndrome resulting in spontaneous abortion(1)and stent migrations(2).Five pregnancies had uncomplicated term deliveries,whereas 2 required urgent caesarian sections(one for fetal distress and 1 for cholangitis secondary to stent migration).One patient was well in her second trimester during follow-up.Seven babies were well at birth with median APGAR scores of 9,and 10 at 5 and 10 minutes,respectively.One baby died of sudden death syndrome at age of 40 days. CONCLUSIONS:ERCP is a safe procedure for pregnant women.It can be conducted for biliary stenting and subsequent clearance after deliveries.EUS has a complementary role. Different strategies can be applied according to the conditions or expertise of endoscopists.

Spontaneous gallbladder perforation,pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease

BACKGROUND:Gallstone disease is common,and complications that are frequently encountered include acute cholecystitis and acute pancreatitis,but rarely gallbladder perforation. METHOD:Data were retrospectively collected from clinical case notes and a literature review is presented. RESULTS:A 72-year-old lady presented with spontaneous gallbladder perforation,pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease.She was previously well and had no abdominal complaints.Her condition was successfully managed with initial antibiotic therapy followed by interval cholecystectomy and fistula repair. CONCLUSIONS:Our case highlighted some uncommon but severe complications which occurred simultaneously as the first manifestations of previously asymptomatic gallstone disease.Such complications need to be considered in patients suspected of intra-abdominal sepsis,even when there are no characteristic symptoms.

Profiles of autoimmune hepatitis in Brunei Darussalam

BACKGROUND:Autoimmune hepatitis(AIH)is a chronic inflammatory disease of the liver.Data on the disease remain scarce in the Southeast Asia region.This study was undertaken to assess the profiles of AIH in Brunei Darussalam.METHODS:Nineteen patients with AIH treated at the hepatology clinic,RIPAS Hospital(up until December 2008)were reviewed.Demographic,laboratory,histologic,clinical,and therapeutic data of the patients were collected.RESULTS:The median age of the 19 patients at diagnosis was 52 years(range 33-70)with a male to female ratio of 1:3.75.All patients were diagnosed with typeⅠAIH.The prevalence rate of the disease was 5.61/100 000 and was higher in the Chinese than in Malays and Indigenous people.Commonly seen presentations were abnormal liver function(52.6%),icteric hepatitis(36.8%),and decompensated liver disease(10.5%).Histologically advanced fibrosis was found in 47.4%and cirrhosis in 21.1%of the patients.Immune-mediated diseases were present in 36.8%.In a follow-up for 31 months(range 0.25-102),three patients died,2 had progressive liver failure and 1 had lymphoma.Complete biochemical response was seen in 75%of the patients,partial response in 12.5%,and no response in 12.5%.HLA DRB1*03(DR3) was detected in 18.2%of the patients and DRB1*04(DR4) in 45.5%.There were significant associations between HLA Cw7(P=0.038)and DQB1*04(P=0.007).CONCLUSIONS:The data of the 19 patients were comparable to those reported in the literature.Most of the patients were found to have abnormal biochemistry.There were significant associations between HLA Cw7 and DQB104,but not between DRB103(DR3)and DRB104(DR4).

Prevalence and risk factors of methotrexate hepatoxicity in Asian patients with psoriasis

AIM: To establish the prevalence of liver fibrosis and to evaluate the possible risk factors for fibrosis and progression in Asian with psoriasis treated with methotrexate (MTX) based on liver histology. METHODS: Patients with psoriasis treated with MTX referred to the Department of Gastroenterology, Tan Tock Seng Hospital for liver biopsy were identified and retrospectively studied. Patient case notes and electronic records were retrieved from the hospital database and relevant data collated. Histological changes of liver biopsies were staged according to Roengik score. The factors assessed were age, gender, ethnicity, cumulative dose of MTX, presence of comorbid conditions such as diabetes, hypertension, hyperlipidemia, and ethanol use. We also assessed the histological change in those with multiple liver biopsies. Statistical analysis was performed using Stata V.9.2. RESULTS: There were altogether 59 patients (median age 50 years old, range 22-81 years old, male, 88%) with 98 biopsies liver biopsies; 6 normal [median cumulative dose (MCD), 2285 mg]; 62 gradeⅠ (MCD 2885 mg), 23 grade Ⅱ (MCD 1800 mg) and 7 grade Ⅲ (MCD 1500 mg). There was no grade Ⅳ or cirrhosis. The prevalence of liver fibrosis (grade Ⅲ) was 12%. Of the factors assessed, diabetes (P=0.001) and hypertension (P=0.003) were significant for fibrosis on univariate analysis but not on multivariate analysis. Of the 26 patients who had more than one biopsy (median 2, range 2-6), 57.7% (n=15) were stable, 34.6% (n=9) had progression and 7.7% (n=2) had regression of histological grades. On univariate analysis, nonChinese ethnicity (P=0.031), diabetes (P=0.018), and hyperlipidemia (P=0.011) were predictive of progression of grades, but these were not significant on multivariate analysis. CONCLUSION: Liver fibrosis in Asian psoriatic population on MTX is comparable to the West. Cumulative dose was not associated with liver fibrosis. Metabolic syndrome is important factors.

Primary biliary cirrhosis in Brunei Darussalam

BACKGROUND:Primary biliary cirrhosis(PBC)is an uncommon autoimmune cholestatic disease that predominantly affects women.Certain human leukocyte antigens(HLAs) have been reported to be associated with susceptibility for PBC.We describe the profiles of PBC in Brunei Darussalam. METHODS:All patients with PBC(n=10)were identified from our prospective databases.The HLA profiles(n=9,PBC)were compared to controls(n=65)and patients with autoimmune hepatitis(n=13,AIH). RESULTS:All patients were women with a median age of 51 years(27-83)at diagnosis.The prevalence rate of the disease was 25.6/million-population and the estimated incidence rate varied from 0 to 10.3/million-population per year.Chinese (41.15/million)and the indigenous(42.74/million)groups had higher prevalence rates compared to Malays(22.62/ million).The prevalence among female population was 54.6/ million-population.All patients were referred for abnormal liver profiles.Five patients had symptoms at presentations: jaundice(20%),fatigue(20%),arthralgia(30%)and pruritus (20%).Serum anti-mitochondrial antibody was positive in 80%of the patients.Overlap with AIH was seen in 30%.Liver biopsies(n=8)showed stage I(n=2),II(n=4)and III(n=2) fibrosis.There were no significant differences in the HLA profiles between PBC and AIH.Compared to the controls,PBC patients had significantly more HLA class I alleles specifically B7(P=0.003),Cw7(P=0.002)and Cw12(P=0.007)but not the class II alleles.At a median follow-up of 23.5 months(2 to 108), all patients were alive without evidence of disease progression. CONCLUSIONS:PBC is also a predominant female disorder in our local setting and most had mild disease.The HLA profiles of our patients were different to what have been reported.

Pyogenic liver abscess as the first manifestation of hepatobiliary malignancy

BACKGROUND:Pyogenic liver abscess(PLA)is commonly seen in patients in the Far East.Similarly,hepatobiliary neoplasms are also common.PLA as the initial manifestation of hepatobiliary neoplasms is extremely rare. METHOD:Three patients with PLA were identified from the ward registion files and were retrospectively reviewed. RESULTS:These patients(two men aged 74 and 80 years, and one woman aged 35 years)were treated(in the right lobe in two patients and in the left lobe in one)and subsequently followed up for 11-22 months.Two patients were diagnosed with hepatocellular carcinoma and one with metastatic cholangiocarcinoma.Two patients were subjected to biopsies showing features of inflammatory pseudotumor before a diagnosis of hepatocellular carcinoma.One patient underwent hepatic resection with good results.In the other two patients who declined any further interventions,one died a few weeks after diagnosis and the other is still alive on conservative treatment. CONCLUSIONS:This series of cases highlights the importance of considering underlying hepatobiliary malignancies in patients with PLA and a close follow-up necessary for non-resolving hepatic lesions.

Prevalence of retinopathy of prematurity in Brunei Darussalam

AIM: To identify the prevalence of retinopathy of prematurity (ROP) among preterm neonates admitted to Department of Neonatology, RIPAS hospital, Brunei Darussalam. ·METHODS: We studied 67 preterm infants fulfilling the eligibility criteria for ROP screening. All infants studied were admitted to the Department of Neonatology, RIPAS Hospital, within a period of one year. Birth weight (BW), gestational age (GA), corrected age at each review, initial and final diagnoses and number of reviews required was recorded for each infant. Infants were followed up two weekly until they reach a corrected age of 40 weeks or complete vascularization was noted. Prevalence of ROP was identified. Descriptive analysis, regression analysis and independent-sample t-test were used to statistically check for differences between ROP and non -ROP groups. ·RESULTS: A total number of 201 ROP screenings were carried out for 67 preterm infants. Males outnumbered females (56.7%). The mean number of reviews per child was (3.19 ±1.1) times (range: 1 -6 times), the mean GA among the preterm babies examined was (29.5 ±2.6) weeks (range: 23 -36 weeks), and the mean BW was 1300 ±500g (range: 660 -3600g). The prevalence of ROP among the examined infants was 34.8% . Prevalence of threshold disease that required laser treatment was 25.4% . Prevalence of ROP among those with extremely low BW was 86.7% compared to 27.8% in those with very low BW. Respiratory distress and congenital heart diseases were significantly associated with higher incidence of ROP. ·CONCLUSION: Lower BW, lower GA and female gender are associated with higher risk of developing ROP among preterm infants in Brunei Darussalam.

Development of Health Literacy for Regular Hemodialysis Patients in Menoufia Governorate: A Cross-Sectional Study

Health literacy (HL) is essential to access, comprehend, assess and use health data allowing patients to make better health and quality of life decisions. To assess the health literacy level of hemodialysis Egyptian patients, a cross-sectional study from March to September 2020 was conducted at 4 hemodialysis (HD) units on 439 patients. A translated questionnaire including demographic characteristics and health literacy components was conducted. This study adapted Nutbeam’s model incorporating critical health literacy, interactive health literacy, and functional health literacy. Health literacy of hemodialysis patients was satisfactory among 35.5% of the studied patients. The average total score of health literacy questionnaire was (15.53 ± 4.32) distributed as (2.90 ± 1.26) for functional literacy, (3.10 ± 1.26) for basic health knowledge, (1.65 ± 1.21) for communicative literacy, (2.53 ± 0.70) for interactive literacy, (1.75 ± 1.30) for advanced health knowledge, (1.74 ± 0.48) for critical literacy, and (1.83 ± 0.93) for patient safety. It was found that poor health literacy was associated with low income (OR = 2.54, CI 95%: 1.66_3.89, p < 0.001), of increasing age (OR = 0.12 CI 95%: 0.07_0.19, p < 0.001), low education (OR = 1.08, CI 95%: 1.04_1.11, p < 0.001) and the patient did not undergo kidney transplant (OR = 4.19 CI 95%: 1.12_15.62, p = 0.033). There was a prevalent low health literacy among the studied regular hemodialysis patients which was affected by education, age and income and in turn it affected the adherence to treatment. Understanding the linkage between HL and self-care attitudes should enhance efforts to improve hemodialysis outcomes.

Role of biomarkers for early detection of intra-abdominal sepsis: a clinician's perspective

Infection remains an universal important cause of morbidity and mortality,with the highest mortality rate for bloodstream infections（20%-70%）.[1,2]Fortunately,most community acquired infections,

Limbal leproma in lepromatous leprosy

Dear Sir, W e are writing to you to present an unusual case of leproma growing at the limbus of a lepromatous leprosy patient. This the first report of ocular leprosy in Brunei, where leprosy is extremely rare. Leprosy, otherwise known as Hansen’s disease, is a chronic granulomatous communicable infection caused by Mycobacterium leprae and its genetic variant (Mycobacterium lepromatosis) [1]. A leproma is a superficial, ci

COVID-19 vaccine safety surveillance and emerging concerns of vaccine-induced immune thrombotic thrombocytopenia

The COVID-19 pandemic has caused signi-ficant disruption in the lives of people,af-fecting clinical services.For older people,there is a high risk of physical and psychological complications such as delirium,pressure injuries and risk of death.[1]In response to the pandemic,vaccines have been developed over compressed timelines including new platforms,such as mRNA vaccines,with international mass vaccination pro-grams currently underway to achieve herd im-munity and curb this pandemic.

The EORTC QLQ-C30 and QLQ-CR29 may play a complementary role to LARS score in evaluating the quality of life for patients following laparoscopic and robotic rectal cancer surgery

Objective:To analyze whether the European Organisation for Treatment and Research of Cancer(EORTC)Quality of Life Questionnaires(QLQ-C30 and QLQ-CR29)complement the low anterior resection of rectum syndrome(LARS)score in evaluating the quality of life of patients who underwent laparoscopic or robotic rectal cancer surgery.Methods:Initially,335 patients who underwent laparoscopic or robotic rectal cancer surgery were randomly selected at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine from June 2013 to September 2020.All the patients took the questionnaires of LARS score,QLQ-C30 and QLQ-CR29.Totally,questionnaires filled out by 224 patients were qualified after screening.Patients were divided into three groups according to LARS score:No LARS group(score 0-20),minor LARS group(score 21-29)and major LARS group(score 30-42).The scores of QLQ-C30 as well as QLQ-CR29 among the three groups were compared.Results:Major,minor and no LARS groups had 140 cases,40 cases and 44 cases respectively.In the scales of QLQ-C30,significant differences were discovered in global quality of life,physical function,role function,emotional function,cognitive function,social function,fatigue,pain,dyspnea,sleep disturbance,constipation and diarrhea between the no and major LARS groups(p<0.05).While the differences were only found in global quality of life and diarrhea between the minor and major LARS groups(p<0.05).In QLQ-CR29,scales of urinary frequency,blood and mucus in stool,body image,flatulence,fecal incontinence,sore skin,stool frequency,embarrassment,impotence,abdominal pain,buttock pain,bloating,dry mouth,hair loss,taste,anxiety and weight,had significant differences between the no and major LARS groups(p<0.05).Only six scales,ie blood and mucus in stool,flatulence,fecal incontinence,stool frequency,embarrassment and dysuria had significant differences between the minor and major LARS groups(p<0.05).Conclusion:For patients following laparoscopic or robotic low anal sphincter preserving surgery,LARS score,QLQ-C30 and QLQ-CR29 scores are consistent in overall trends.To guide disease evaluation and individualized treatment,as well as to evaluate efficacy,we suggest getting pre-and post-operative LARS scores incorporating QLQ-C30 and QLQ-CR29 scores as a comprehensive evaluation system.

Chronic kidney disease in children and adolescents in Brunei Darussalam

AIM: To determine epidemiology of Bruneian paediatric chronic kidney disease(CKD) patients and factors that affect growth and progression of disease. METHODS: A cross-sectional study conducted on all children below 18 years old who were diagnosed with CKD over a ten year period(2004 to 2013). The reference population was all children(< 18 years old) suffering from CKD and attending the tertiary paediatric nephrology clinic in Brunei Darussalam. Demographic(current age, age of diagnosis, gender, ethnicity), anthropometric(weight and height), diagnosis, laboratory data(serum creatinine and haemoglobin, urinalysis) and blood pressure were extracted from the patients' clinical case notes and recorded using a data collection form. RESULTS: The study revealed a high national prevalence [736 per million child population(pmcp)] and incidence(91 pcmp) of CKD. If CKD was defined at Stage 1, 2, 3, 4 or 5, the associated prevalence figures were 736, 132, 83, 50 and 33 pmcp. Glomerulonephritis accounted for 69% of all prevalent cases, followed by congenital abnormalities of kidney and urinary tract(20%) and tubulointerstitial diseases(8%). Minimal change disease being the most common histological diagnosis. The median age of diagnosis was 4.5 years, with congenital disease patients experiencing an earlier onset of diagnosis. A large proportion of patients were below the 5% percentile for height and weight. Non-glomerular diseases, adolescent and female patients were significantly associated with poor growth, but not glomerular filtration rate, age of diagnosis or steroid usage. CONCLUSION: Brunei has a high prevalence of chronic kidney disease in the paediatric population with glomerulonephritis being the most common disease.

Risk factors for incomplete polyp resection during colonoscopy

Colonoscopic polypectomy is extremely effective in protecting against colorectal cancers,and recognition of adenomas by colonoscopy is of paramount importance in preventing colorectal cancer(CRC)and CRC-associated mortality.Incomplete polyp resection(IPR)occurs routinely in medical practice following polypectomy.We conducted a comprehensive literature search to identify studies that reported on the potential risk factors for IPR using MEDLINE,EMBASE,and PubMed.Publication time was limited between January 2004 and July 2021.Our search revealed assessments of the position,morphology,and histologic variation of the polypsdas well as the relevant skills that may interfere with IPR.The included studies showed that colonic polyps with a diameter>20 mm and proximal in location should be dealt with cautiously.For smaller polyps,cold-snare polypectomy appeared to be the most effective method used to accomplish comprehensive polyp removal.In addition,endoscopist experience in narrow-band imaging in polyp detection were also associated with IPR.Therefore,polypectomy should be performed cautiously if the polyp growth is expected to be cancerous and situated in the proximal portion of the colon or rectum,and modalities should be standardized so as to lower the potential risk for IPR.

The Author Reply

We thank Dr.Uradomo et al for their interest in our recent publication on biliary interventions during pregnancy and value their views on one of the latest innovation for biliary interventions without radiation exposure. [1] We fully agree with their comments that such technologies should be evaluated and adopted into clinical practice.However,in any interventions including those carried out during pregnancy,several principles should be adhered to.