Kok Peng Ng

Clinical Predictors of Non-diabetic Renal Disease and Role of Renal Biopsy in Diabetic Patients with Renal Involvement: A Single Centre Review

Background: Type 2 diabetes mellitus (T2DM) is reportedly the leading cause of end-stage renal disease (ESRD) worldwide. However, non-diabetic renal diseases (NDRD) are not uncommon among T2DM patients with renal involvement. Our study aimed to examine the prevalence of NDRD in T2DM and clinical markers for diabetic nephropathy (DN) and NDRD and to determine the role of renal biopsy in T2DM patients and its impact on clinical practice. Methods: We conducted a retrospective analysis of T2DM patients in whom renal biopsies were performed from January 2004 to March 2008 (n = 110). Results: Biopsy results were divided into three groups: group I/pure DN (62.7%), group II/isolated NDRD (18.2%), and group III/mixed lesions (19.1%). The causes of NDRD in decreasing order of frequency were acute interstitial nephritis, glomerulonephritides, hypertensive renal disease, and acute tubular necrosis. Significant clinical markers for DN are presence of diabetic retinopathy and longer duration of diabetes. For NDRD, useful clinical markers include the presence of acute renal failure and microscopic hematuria. In the DN subgroup, Indians had significantly shorter duration of diabetes on biopsy compared with Malays and Chinese. Conclusions: NDRD is prevalent in T2DM patients, and given its potentially treatable nature, renal biopsy should be considered in T2DM patients with nephropathy, especially in those with atypical features.

Pneumocystis jirovecii pneumonia 13 years post renal transplant following a recurrent cytomegalovirus infection

Pneumocystis jirovecii (formerly Pneumocystis carinii) pneumonia (PCP) is a rare but serious infection that usually occurs within a year after solid organ transplantation. PCP may occur after 1 year post transplantation, but the rate is reported to be very low. Studies have shown an association between cytomegalovirus (CMV) infection in solid organ transplant patients and an increased risk of opportunistic infection. This increased risk is thought to be a result of the immunomodulatory effects of the CMV infection. We present a case of PCP infection occurring 13 years after a renal transplantation. This occurred following a recurrent CMV infection while the patient was on low‐dose immunosuppressants.

Association between plasma soluble RAGE and renal function is unaffected by medication usage and enzymatic antioxidants in chronic kidney disease with type 2 diabetes

BACKGROUND This study aimed to investigate the relationship between soluble RAGE and estimated glomerular filtration rate (eGFR) in patients with chronic kidney disease (CKD) after controlling for the potential confounding factors such as medication usage and enzymatic antioxidants. METHODS A total of 222 CKD patients whose eGFR is less than 60ml/min/1.73m(2) and 111 non-CKD individuals were recruited. The study subjects were classified based on their diabetes status. The plasma glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities as well as plasma soluble RAGE level were measured. RESULTS The plasma GPx and SOD activities were significantly lower and the plasma soluble RAGE level was significantly higher in the CKD patients than in the non-CKD individuals, regardless of the diabetes status. Soluble RAGE was significantly correlated with eGFR in both diabetic CKD (D-CKD) and non-diabetic CKD (ND-CKD) patients. The association between soluble RAGE and eGFR remained largely unaffected by the confounding factors in D-CKD patients. However, the confounding effect of enzymatic antioxidants in the relationship between eGFR and soluble RAGE was observed in ND-CKD patients. CONCLUSION The increased plasma level of soluble RAGE is a better indicator of renal function decline in diabetic CKD patients instead of non-diabetic CKD patients.

Non-organ donors' attitudes toward incentives

Malaysians indicating that they did not intend to become organ donors upon their death were surveyed regarding interest in non‐fungible financial incentives to be granted to surviving family members. Among the 730 (56% of the total sample of 1311) indicating unwillingness to be donors, 29.6% (216/730) subsequently indicated that they would be willing donors if the government introduced policies that, upon their death, “rewarded your (their) family with incentives for your (their) deeds.” Among the 69% (504/730) who insisted that they would not become organ donor even with incentive, nearly 80% (404/501) of them were able to identify relevant incentives they thought should be provided by the state to those who make organ donations upon death. The majority of both groups preferred the state provide medical benefits to a surviving family member, suggesting this may be an attractive policy option for the state to raise the deceased organ donation pool.

Strategies Targeted at Motivating Unrelated Living Kidney Donation

BACKGROUND This paper aimed to assess the willingness of Malaysians with post-secondary education to be living kidney donors. MATERIAL AND METHODS From the total of 1,310 living kidney donor respondents in Kuala Lumpur and its suburbs, we focused on 688 respondents with post-secondary education. These 688 respondents were asked whether they were willing to become living kidney donors if the government provides a reasonable amount of financial incentive. Those who were not willing to be donors (490) were then asked the reasons for their unwillingness. Six options were given and respondents can choose more than 1 option. RESULTS Malaysians with post-secondary education remain unconvinced to be living donors even when provided with monetized incentives. The main reason cited was they are not convinced that individuals can live with just 1 kidney. CONCLUSIONS There is a need for the government to develop new ways to promote organ donation. These include strengthening government coordination of medical procedures and creating public awareness about the safety of living with 1 kidney. Setting up new institutions such as donor clinics, creating a living donor registry, and having independent donor advocates are also instrumental.

Rothia dentocariosa Repeat and Relapsing Peritoneal Dialysis-Related Peritonitis: A Case Report and Literature Review

Peritonitis is well recognized as the Achilles tendon of peritoneal dialysis (PD). Reoccurrence of peritonitis due to the same organism, defined as either repeat or relapsing peritonitis under the 2005 guidelines by the International Society for Peritoneal Dialysis, often results in PD technique failure. Rothia dentocariosa, a low-virulent human oropharynx commensal, is a rarely reported pathogen in human infection, particularly infective endocarditis. R. dentocariosa PD-related peritonitis is exceedingly uncommon yet potentially results in repeat or relapsing peritonitis which requires catheter removal. We report a case of R. dentocariosa repeat and relapsing peritonitis in a PD patient who was treated successfully with antimicrobial therapy.

Impact of Interventional Nephrology on Outcome and Penetration Rate of a CAPD Program

Continuous ambulatory peritoneal dialysis (CAPD) remains relatively underutilized, with the worldwide penetration rate averaging 10% – 15% (1–3). There are many reasons for this, including doctor and patient preferences, financial incentives, cost, and accessibility to Tenckhoff (TK) catheter insertion services (4–9). At the University of Malaya Medical Centre (UMMC), TK catheter insertion service was traditionally provided by junior surgeons who performed the service as part of their training requirements. Both access to and the results of TK catheter insertion were therefore dependent on the learning curve of junior surgeons who rotated every 3 months. The high complication and failure rate of TK insertion was frequently blamed for our low CAPD penetration rate of about 10% (2,10). We report here the results of TK catheter insertion by nephrologists, a practice implemented at UMMC in 2004 with the support and supervision of our senior surgical colleagues.

Estimating Renal Function in the Elderly Malaysian Patients Attending Medical Outpatient Clinic: A Comparison between Creatinine Based and Cystatin-C Based Equations

Background To assess the performance of different GFR estimating equations, test the diagnostic value of serum cystatin-C, and compare the applicability of cystatin-C based equation with serum creatinine based equation for estimating GFR (eGFR) in comparison with measured GFR in the elderly Malaysian patients. Methods A cross-sectional study recruiting volunteered patients 65 years and older attending medical outpatient clinic. 51 chromium EDTA (51Cr-EDTA) was used as measured GFR. The predictive capabilities of Cockcroft-Gault equation corrected for body surface area (CGBSA), four-variable Modification of Diet in Renal Disease (4-MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations using serum creatinine (CKD-EPIcr) as well as serum cystatin-C (CKD-EPIcys) were calculated. Results A total of 40 patients, 77.5% male, with mean measured GFR 41.2 ± 18.9 ml/min/1.73 m2 were enrolled. Mean bias was the smallest for 4-MDRD; meanwhile, CKD-EPIcr had the highest precision and accuracy with lower limit of agreement among other equations. CKD-EPIcys equation did not show any improvement in GFR estimation in comparison to CKD-EPIcr and MDRD. Conclusion The CKD-EPIcr formula appears to be more accurate and correlates better with measured GFR in this cohort of elderly patients.