INTRODUCTION: Cardiovascular morbidity and mortality in end-stage renal failure (ESRF) patients are high. We examined the incidence and predictors of death and acute myocardial infarction (AMI) in ESRF patients on different modalities of dialysis. METHOD: Data were obtained from a population-based database (National Registry Disease Offices) in Singapore. The study cohort comprised all adult patients initiated on dialysis between 2007 and 2012 who were closely followed for the development of death and AMI until September 2014. Cox regression methods were used to identify predictors of death and AMI. RESULTS: Of 5,309 patients, 4,449 were on haemodialysis and 860 on peritoneal dialysis (PD). Mean age of the cohort was 61 (±13) years (44% women), of Chinese (67%), Malay (25%) and Indian (7%) ethnicities. By September 2014, the incidence of all-cause death was 34%; close to a third of the patients died from a cardiovascular cause. Age >60 years and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and PD were identified as independent predictors of all-cause death. PD patients had lower odds of survival compared to patients on haemodialysis (hazard ratio 1.51, 95% confidence interval 1.35-1.70, P<0.0001). Predictors of AMI in this cohort were older age (>60 years) and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and current/ex-smokers. There were no significant differences in the incidence of AMI between patients on PD and haemodialysis. CONCLUSION The short-term incidence of death and AMI remains high in Singapore. Future studies should investigate the benefits of a tighter control of cardiovascular risk factors among ESRF patients on dialysis.
Adult ; Aged ; Female ; Humans ; Incidence ; Kidney Failure, Chronic/therapy* ; Male ; Middle Aged ; Myocardial Infarction/epidemiology* ; Peritoneal Dialysis ; Renal Dialysis

INTRODUCTION: There is limited literature on clinical outcomes following percutaneous coronary intervention (PCI) in Asian dialysis patients. We evaluated the angiographic characteristics and clinical outcomes of dialysis patients treated with PCI in an Asian society. METHODS: A retrospective analysis was performed of 274 dialysis patients who underwent PCI in a tertiary care institution from January 2007 to December 2012. Data on clinical and angiographic characteristics was collected. The primary endpoint was major adverse cardiac events (MACE), defined as a composite of cardiac death, acute myocardial infarction (AMI) and stroke at two years. RESULTS: 274 patients (65.0% male, median age 62.0 years) with 336 lesions (81.8% Type B2) were treated. 431 stents (35.0% drug-eluting stents) with a mean diameter of 2.96 mm and mean length of 21.30 mm were implanted. The MACE rate was 55.8% (n = 153) at two years, from death (36.5%) and AMI (35.0%). In multivariable analysis, age and diabetes mellitus were significant predictors of both mortality (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.05-1.12, p < 0.001; OR 2.65, 95% CI 1.46-4.82, p = 0.001, respectively) and MACE (OR 1.06, 95% CI 1.03-1.08, p < 0.001; OR 1.84, 95% CI 1.07-3.15, p = 0.027, respectively). Left ventricular ejection fraction (LVEF) (OR 0.97, 95% CI 0.95-0.99, p = 0.006) was a significant predictor of mortality but not MACE. CONCLUSION Asian dialysis patients who underwent PCI had a two-year MACE rate of 55.8% due to death and AMI. Age, LVEF and diabetes mellitus were significant predictors of mortality at two years.

INTRODUCTION: To evaluate the mid-term outcomes of regular surveillance venography with or without percutaneous transluminal angioplasty (PTA) in haemodialysis patients presenting with central venous occlusive disease. MATERIALS AND METHODS: A single-centre retrospective analysis of haemodialysis patients who presented with central vein occlusion (CVO) and central vein stenosis (CVS) between January 2008 and December 2011 was performed. CVO and significant CVS were defined as 100% and >50% luminal narrowing, respectively. Upon successful angioplasty on first presentation, patients were followed up with regular surveillance venography within 3-6 months of the intervention and were re-treated when a significant stenosis or occlusion was demonstrated. Data on patient's demographics, comorbidities, presenting symptoms, type of upper limb dialysis access, lesion characteristics and complications were collected. Technical success, primary patency and primary assisted patency were analysed. RESULTS: Thirty-five patients with CVO and 77 patients with CVS were enrolled. The technical success of initial PTA was 77% and 73% for the CVO and CVS groups, respectively. The primary patency at 3 months was 65% and 55% for the CVO group and CVS group, respectively ( = 0.32). The primary assisted patency at 1 year was 88% and 99% for the CVO group and CVS group, respectively ( = 0.009). At 2 years, the primary assisted patency were 77% and 90%, respectively ( = 0.07). There was significant difference in the overall primary assisted patency ( = 0.048) between the CVO and CVS groups. CONCLUSION CVOs are more difficult to treat than CVS. High primary assisted patency rates can be achieved with surveillance venography, albeit at the expense of increased number of interventions. Further cost effectiveness studies need to be performed to study the true benefit of our surveillance programme.

INTRODUCTION: To study the prevalence of hepatitis C virus (HCV) infection in blood donor (BD), haemodialysis (HD) and intravenous drug user (IVDU) populations in Singapore and assess the IL28B polymorphism if HCV positive. METHODS: The BD population were healthy volunteers, the HD population were patients who were on haemodialysis for at least six months of follow-up between January 2009 and December 2014. IVDU population was from inmates at halfway houses who consented. RESULTS: Between 2011 and 2014, of 161,658 individuals who underwent screening prior to blood donation, 95 (0.059%) were positive for HCV. Of the 42 sera available, common genotypes (GTs) were GT-3 (47.6%) and GT-1 (31.0%). Of 1,575 HD patients, 2.2% were anti-HCV positive. The HCV GT distribution was HCV GT-1 (32.4%), HCV GT-3 (20.5%) and GT-6 (8.8%). 83 halfway house inmates were screened. Of the 47 IVDUs, 36.2% were anti-HCV positive with predominant GT-3 (%). IL28B polymorphism was noted to be CC predominantly 85.3%. CONCLUSION Prevalence of HCV infection has decreased in both the BD and HD populations. However, it remains high in the IVDU population. GT-1 remains the most common in the HD population; however, GT-3 infection is now more common among the BD population in Singapore. IL28B - CC is the predominant variant among the HCV-infected individuals in Singapore.
Acute Kidney Injury ; blood ; complications ; Adult ; Alleles ; Blood Donors ; Female ; Genotype ; Hepatitis C ; epidemiology ; Humans ; Interleukins ; genetics ; Male ; Middle Aged ; Polymorphism, Single Nucleotide ; Prevalence ; Renal Dialysis ; Singapore ; epidemiology ; Substance Abuse, Intravenous ; blood ; epidemiology ; Young Adult

Blood Donors ; Genotype ; Hepacivirus ; Humans ; Interferons ; Prevalence

Background: Improving awareness, knowledge and attittude (AKA) of teachers and students about epilepsy is an important step to reduce the stigma experienced by children with epilepsy. To date there are no studies evaluating effectiveness of an information technology based epilepsy education programme in improving AKA among teachers and students. Method: Cross-sectional study was to assess the baseline AKA of epilepsy among Malaysian teachers and secondary school students, and to examine effectiveness improving their AKA using the Interactive Animated Epilepsy Education Programme (IAEEP). AKA of teachers and students were assessed pre- and post-implementation of IAEEP. Results: Total of 54 teachers and 67 secondary students participated in this study. The baseline AKA on epilepsy among Malaysian teachers was low in the awareness domain, moderate in the knowledge domain, and positive in the attitude domain. The baseline AKA on epilepsy among students was very low in the awareness domain, low in the knowledge domain, and indifferent in the attitude domain. The AKA scores in all domains of teachers and students improved significantly after introduction of IAEEP (P<0.001). Post-IAEEP the AKA of teachers was moderate in the awareness domain, high in the knowledge domain, and very positive in the attitude domain; the AKA of students was low in the awareness domain, very high in the knowledge domain, and very positive in the attitude domain Conclusion: Our findings highlight a need for epilepsy educational programmes to be implemented in Malaysian schools. The IAEEP is an effective educational programme to improve the AKA particularly in the knowledge domain among teachers and students

INTRODUCTIONAn arteriovenous fistula (AVF) is the preferred method for haemodialysis in patients with end-stage renal failure. Previous studies have shown value in attempting percutaneous transluminal angioplasty (PTA) to salvage AVFs that fail to mature, but they are relatively small in size and mainly reported in Western populations. We reviewed our data of PTA in non-maturing AVFs to establish whether this technique is translatable to our local multiethnic population.

MATERIALS AND METHODSWe retrospectively reviewed the medical records and procedural images of 105 patients who had PTA for non-maturing AVFs performed at our department from January 2008 to January 2011. Technical success was defined as ≤30% residual stenosis after angioplasty. Clinical success was defined as at least 1 successful haemodialysis session within 4 weeks after PTA.

RESULTSAll 105 patients underwent angioplasty for at least 1 haemodynamically significant stenosis. Six (5.7%) had additional embolisation of accessory veins. Technical success was achieved in 95.2% of cases. The clinical success rate was 76.2%. Primary patency rates at 3, 6 and 12 months were 83%, 45% and 28%, respectively. Secondary patency rates at 3, 6 and 12 months were 90%, 79% and 70%, respectively. The minor complication rate was 18.1%. No major complications were encountered. An average of 1.7 interventions per access-year was required to maintain AVF patency. Patients with a preoperative vein size >2.0 mm and age <55 years were more likely to achieve clinical success, although not statistically significant.

CONCLUSIONPTA is a viable option to help salvage non-maturing AVFs in a multiethnic Asian population.

Angioplasty ; methods ; Arteriovenous Shunt, Surgical ; Constriction, Pathologic ; therapy ; Embolization, Therapeutic ; Female ; Humans ; Kidney Failure, Chronic ; therapy ; Male ; Middle Aged ; Renal Dialysis ; Reoperation ; Retrospective Studies ; Singapore ; Veins

INTRODUCTIONThis study aimed to assess the outcome of percutaneous transluminal angioplasty (PTA) as the primary treatment for transplant renal artery stenosis (TxRAS).

MATERIALS AND METHODSA retrospective review of PTA of TxRAS from April 1999 to December 2008 was performed. Twenty-seven patients (17 males (M):10 females (F)) with the mean age of 49.5 years underwent PTA of TxRAS in the review period. Indications for PTA were suboptimal control of hypertension (n=12), impaired renal function (n=6) and both suboptimal control of hypertension and impaired renal function (n=9). All patients had doppler ultrasound scans prior to their PTA. In addition, 5 of these patients had computed tomography angiography (CTA) and another 7 had magnetic resonance angiography (MRA) evaluation. Mean follow-up period was 57.0 months (range, 7 to 108 months).

RESULTSThe stenotic lesions were located proximal to the anastomosis (n=2), at the anastomosis (n=15), and distal to the anastomosis (n=14). Technical success rate was 96.3%. One case was complicated by extensive dissection during PTA, resulting in subsequent graft failure. The overall clinical success rate was 76.9%. Seven out of 26 patients had restenoses (26.9% of cases). These were detected at a mean of 14.3 months post angioplasty (range, 5 to 38 months). All 7 patients underwent a second PTA successfully. Three of these patients required more than 1 repeat PTA.

CONCLUSIONPTA is safe and effective in the management of symptomatic TxRAS and should be the primary treatment of choice. Close surveillance for restenosis is required and when diagnosed, re-angioplasty can be performed.

Adult ; Angioplasty ; Female ; Humans ; Kidney Transplantation ; Male ; Middle Aged ; Postoperative Complications ; surgery ; Renal Artery Obstruction ; surgery ; Retrospective Studies ; Time Factors

Apart from clinical, histological and biochemical indices, genomics are now being employed to unravel the pathogenetic mechanisms in the disease progression of IgA nephritis (IgAN). The results of angiotensin converting enzyme (ACE) gene polymorphism have been controversial. Those patients with the DD genotype seem to have a poorer prognosis. However, with high dose angiotensin receptor blocker (ARB) therapy, the ACE gene polymorphism status of a patient may no longer be a matter for concern as those with the DD genotype would also respond favourably to high dose ARB therapy. Association studies with gene sequencing and haplotypes have suggested that multiple genes are involved in the pathogenesis of IgAN. Some workers have reported a synergistic effect in the combined analysis of AGT-M235T and ACE I/D polymorphism. With the use of deoxyribo nucleic acid (DNA) microarray, tens of thousands of gene expressions genome-wide can be examined together simultaneously. A locus of familial IgAN has been described with strong evidence of linkage to IgAN1 on chromosome 6q22-23. Two other loci were reported at 4q26-31 and 17q12-22. DNA microarray techniques could also help in the identification of specific pathogenic genes that are up- or down-regulated and this may allow genome wide analyses of these genes and their role in the pathogenesis and progression of IgAN. Recently, using genome-wide association studies (GWAS) more loci for disease susceptibility for IgAN have been identified at 17p13, 8p23, 22q12, 1q32 and 6p21.
Angiotensin Receptor Antagonists ; administration & dosage ; Disease Progression ; Dose-Response Relationship, Drug ; Genomics ; methods ; Glomerulonephritis, IGA ; drug therapy ; genetics ; pathology ; Haplotypes ; Humans ; Molecular Sequence Data ; Polymorphism, Single Nucleotide

INTRODUCTIONThe aim of this study is to investigate the risk of cancer among end-stage renal disease (ESRD) patients on dialysis in Singapore.

MATERIALS AND METHODSThe study looks at a retrospective cohort of 5505 ESRD patients who had received dialysis between 1998 and 2007. The cancer risk of these patients would be compared against the risk of the general population.

RESULTSDuring a median follow-up time of 3.9 years, 267 (4.9%) dialysis patients developed cancer. The risk of cancer (excluding non-melanoma skin cancer) is 1.66 times higher in dialysis patients than the general population, and is highest at age less than 35 years old and at first year after dialysis. Cancer risk was found to be significantly higher among Chinese dialysis patients, followed by Malays, compared to the general population. The 3 sites with highest elevated cancer risks among dialysis patients compared to the general population are kidney, tongue and multiple myeloma.

CONCLUSIONThe finding of elevated cancer risk among younger dialysis patients is similar to other international studies. High cancer risks among specific cancer sites were also consistent with other studies. In view of the lack of screening procedures for these cancers and shortened expected survival of ESRD patients, cancer screening of ESRD patients should be individualised and based on a reasonable life expectancy and transplant candidacy, keeping in mind the competing risk of cardiovascular mortality.

Comorbidity ; Humans ; Kidney Failure, Chronic ; epidemiology ; therapy ; Neoplasms ; epidemiology ; Renal Dialysis ; Retrospective Studies ; Risk Assessment ; Singapore ; epidemiology