Proceedings of Singapore Healthcare

Renal transplantation is the treatment of choice for kidney failure. This study analyses the outcomes of kidney transplant recipients whose transplant was performed at the Singapore General Hospital from January 2000 to 31 December 2010, and who have had at least a year of follow-up in the hospital. Patient demographics, recipient and donor characteristics, graft and patient outcomes were extracted from patients' electronic and hard copy medical records. Graft and patient survival were calculated by Kaplan-Meier analysis until return to dialysis or patient death.

There are 332 deceased donor (DD) and 118 live donor (LD) kidney transplants included in this study. Majority of our transplant recipients were Chinese males, and the most common etiology of renal failure was chronic glomerulonephritis. DD recipients were significantly older than LD recipients (45.3+8.2 years vs. 36.9+11.7 years, respectively, P <0.001), and also had a significantly longer duration of dialysis (8.6+2.6 years vs. 2.3+3.5 years, respectively, P <0.001). Majority were on haemodialysis prior to transplantation. DD were significantly older than LD (45.7+8.2 years vs. 37.1+11.8 years, respectively, P <0.001); 73.2% of our DD were standard criteria donors. Graft survival at 5 years was 80.8% and 96.5%, and 65.9% and 79.4% at 10 years for DD and LD transplants, respectively. Patient survival at 5 years was 91.5% and 82.7%, and 99.1% and 84.7% at 10 years for DD and LD transplants, respectively. LD recipients had improved graft and patient survival compared to DD recipients, reinforcing LD kidney transplantation as the treatment of choice for patients with end-stage renal failure.

Critical care nephrology is an emerging sub-specialty with rapid technological advancement and a growing body of dedicated literature in blood purification techniques. Their applications have been extended to improve morbidity and survival in multiple organ dysfunctions. Novel techniques have also allowed us to push the frontiers in transplant medicine, giving high-immunological risk patients a chance at a kidney transplant where this was previously precluded by hyperacute antibody-mediated rejection. We aim to review the myriad extracorporeal blood purification techniques now available for treating various critical illnesses in our clinical practice. Some of these techniques will still require further clinical research to determine the optimal timing and dose in order to achieve significant improvement in clinical outcomes.

Management of urinary calculi has changed from open pyelolithotomy and ureterolithotomy to predominantly non-invasive procedures such as extracorporeal shockwave lithotripsy (ESWL) as well as endourological such as ureterorenoscopy (URS) and percutaneous nephrolithotripsy (PCNL). Technology has advanced rapidly allowing stone disease to be treated with minimally invasive techniques that have lower morbidity than the open operations of the past. Newer semi-rigid ureteroscopes of size 7 to 9 F allow visualisation of the ureter without traumatic dilatation. There is the flexible ureteroscope developed with smaller fibre optics, the addition of the working channel that allows the use of laser fibres for stone fragmentation and a greater deflection of the tip that enables all parts of the pelvicalyceal system to be inspected for stones. New generation lithotripters for ESWL deliver shockwave to a smaller focal zone so as to minimise damage to surrounding soft tissue but as a result, there are higher failure rates. PCNL, though more invasive than ESWL and URS, is the procedure of choice for large renal stones. It is highly efficient in such situations as newer equipment to disintegrate stone and newer techniques for percutaneous access has been developed. In addition to all these minimally invasive surgical techniques, there is medical therapy available to allow the expulsion of distal ureteric stones as well as alkalinising agents to dissolve uric acid stones. Metabolic evaluation is necessary for patients with recurrent stones. Dietary adjustments may help prevent recurrent stone formation in selected patients depending on the results. With all these techniques currently available, management of urinary calculi has to be tailored according to the size, location of stone as well as patient preference.

Singapore is facing an ageing population. This is reflected in the growing number of patients needing to consider starting dialysis in their golden years. In our review, we have found that there is a survival benefit for starting dialysis in our geriatric end-stage renal disease (ESRD) patient with low comorbidity. However, this comes at an expense of reduced quality of life, increased hospitalisation and reduced functional status. The decision to start or withhold dialysis in an elderly patient is a complex one and has to be considered on an individual basis with continuous discussions with the patient and loved ones. Advance Care Planning is a useful tool that can assist in this process.

Emphysematous cystitis is a rare serious complication of urinary tract infection characterised by gas formation in the wall or lumen of the urinary bladder due to bacterial fermentation. We report a case of an 86-year-old female with emphysematous cystitis complicated by anterior bladder wall perforation. Her urine grew Escherichia coli and imaging showed gas collection inside the urinary bladder and outside the ruptured anterior bladder wall. She was treated with antibiotics and bladder irrigation and responded well without surgery. Early diagnosis and treatment improve the outcome, hence the importance of a high index of suspicion.

Posterior mediastinal mass is not an uncommon condition seen in clinical practice. It often generates anxiety among healthcare providers, as the most common cause of a posterior mediastinal mass is a neurogenic tumour which potentially can be malignant and carries serious consequences. A very rare but generally benign cause of such a mass is an intrathoracic ectopic kidney. Due to its rarity, literature on the intrathoracic kidney, its management, prognosis and complications is sparse and confined to case reports. We report a rare case of a two-month old baby who had a chest x-ray done for a prolonged cough and was found to have a posterior mediastinal mass, which was later diagnosed to be an intrathoracic ectopic kidney. The approach to mediastinal mass and literature review of an intrathoracic ectopic kidney and its complications are also discussed.

Case report on dermatitis secondary to hypersensitivity to icodextrin, which is a rare complication of icodextrin therapy in peritoneal dialysis.

Cardiac troponins are cardio-specific and are widely used for the early diagnosis and triage of patients with acute coronary syndromes in conjunction with clinical history, electrocardiographic changes and imaging. Troponin is also useful for the prediction of outcomes in acute coronary syndromes, renal failure, sepsis, and critically ill patients. New developments in assay technology, designated as high sensitivity troponins, permit detection of lower levels of troponin in most healthy individuals, earlier diagnosis of myocardial infarction, and prognosis of stable coronary disease in the community.