Publications by authors named "Zia Moinuddin"

15 Publications

  • Page 1 of 1

Surgical management of Encapsulating Peritoneal Sclerosis (EPS) in children: international case series and literature review.

Pediatr Nephrol 2021 Aug 26. Epub 2021 Aug 26.

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK.

Background: Encapsulating Peritoneal Sclerosis (EPS) is a rare phenomenon in paediatric patients with kidney failure treated with peritoneal dialysis (PD). This study highlights clinical challenges in the management of EPS, with particular emphasis on peri-operative considerations and surgical technique.

Methods: Retrospective analysis of all paediatric patients with EPS treated at the Manchester Centre for Transplantation.

Results: Four patients were included with a median duration of 78 months on PD. All patients had recurrent peritonitis (> 3 episodes), and all had symptoms within three months of a change of dialysis modality from PD to haemodialysis or transplant. In Manchester, care was delivered by a multi-disciplinary team, including surgeons delivering the adult EPS surgical service with a particular focus on nutritional optimisation, sepsis control, and wound management. The surgery involved laparotomy, lavage, and enterolysis of the small bowel + / - stoma formation, depending on intra-abdominal contamination. Two patients had a formal stoma, which were reversed at three and six months, respectively. Two patients underwent primary closure of the abdomen, whereas two patients had re-look procedures at 48 h with secondary closure. One patient had a post-operative wound infection, which was managed medically. One patient's stoma became detached, leading to an intra-abdominal collection requiring re-laparotomy. The median length of stay was 25 days, and patients were discharged once enteral feeding was established. All patients remained free of recurrence with normal gut function and currently two out of four have functioning transplants.

Conclusions: This series demonstrates 100% survival and parenteral feed independence following EPS surgery. Post-operative morbidity was common; however, with individualised experience-based decision-making and relevant additional interventions, patients made full recoveries. Health and development post-surgery continued, allowing the potential for transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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http://dx.doi.org/10.1007/s00467-021-05243-0DOI Listing
August 2021

Isiris™ for Ureteric Stent Removal in Renal Transplantation: An Initial Single-Centre Experience of 150 Cases.

Surg Innov 2021 Jun 29;28(3):366-370. Epub 2021 Mar 29.

Department of Renal & Pancreatic Transplantation, 5293Manchester University NHS Foundation Trust, Manchester, UK.

. Ureteric stent insertion is performed at the time of renal transplant to minimise the risk of post-operative urological complications, including anastomotic leak and ureteric stenosis or obstruction. Transplant ureteric stent removal (TUSR) has historically been performed via flexible cystoscopy, predominantly in a theatre setting. Isiris™ is a single-use cystoscope with integrated grasper designed for removal of ureteric stents. We report our initial experience. . A retrospective analysis of a contemporaneously maintained database was performed with review of case notes from October 2017 to September 2018. TUSR was performed by surgical middle grades with a single nurse assistant. . One hundred and fifty ureteric stents were removed in transplant recipients (mean age 50.2 years, SD ± 15.2; 61.3% male). 91.3% ( = 137) of cases were performed in the outpatient clinic. Median time to TUSR was 42 days (IQR 30-42). 147 attempts at removal were successful. One urinary tract infection (UTI) was reported following TUSR. Use of the Isiris™ for TUSR corresponds to a £63,480 saving in this cohort compared to conventional practice. This value is conservative and does not include income that has been gained from the reallocation of operating theatre capacity. . Isiris™ can safely be employed for the timely performance of non-complicated TUSR. Isiris™ releases this procedure from the confines of the operating theatre to the outpatient clinic. This reduces the resource burden for healthcare providers and may result in improved patient satisfaction. The environmental implications of disposable healthcare equipment require consideration. Evaluation of Isiris™ TUSR for encrustation is required.
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http://dx.doi.org/10.1177/15533506211007268DOI Listing
June 2021

A Successful Treatment of Encapsulating Peritoneal Sclerosis in an Adolescent Boy on Long-term Peritoneal Dialysis: A Case Report.

Prague Med Rep 2020 ;121(4):254-261

Department of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust; An United Kingdom National Specialized Centre for Surgery for Encapsulating Peritoneal Sclerosis, Manchester, United Kingdom.

Encapsulating peritoneal sclerosis (EPS) is a rare life-threatening complication associated with peritoneal dialysis (PD). EPS is characterized by progressive fibrosis and sclerosis of the peritoneum, with the formation of a membrane and tethering of loops of the small intestine resulting in intestinal obstruction. It is very rare in children. We present a case of a 16-year-old adolescent boy who developed EPS seven years after being placed on continuous ambulatory peritoneal dialysis (CAPD) complicated by several episodes of bacterial peritonitis. The diagnosis was based on clinical, radiological, intraoperative and histopathological findings. The patient was successfully treated with surgical enterolysis. During a 7-year follow-up, there have been no further episodes of small bowel obstruction documented. He still continues to be on regular hemodialysis and is awaiting a deceased donor kidney transplant. EPS is a long-term complication of peritoneal dialysis and is typically seen in adults. Rare cases may be seen in the pediatric population and require an appropriate surgical approach that is effective and lifesaving for these patients.
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http://dx.doi.org/10.14712/23362936.2020.22DOI Listing
January 2021

Kidney Transplantation From a 5-Day-Old Donor With a Single Functioning Kidney.

Exp Clin Transplant 2020 11;18(6):732-736

From the Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Unitek Kingdom.

Kidney transplant restores renal function in eligible patients with end-stage renal failure who require renal replacement therapy. There remains a significant disparity between the demand and supply of suitable kidneys for transplant. In recent years, pediatric donors have formed an important area for expansion of the donor pool. However, neonatal donation (< 28 days) remains an underutilized resource. We describe a case of en bloc kidney transplant from a 5-day-old donor after circulatory death into an adult recipient. One kidney thrombosed almost immediately, leaving a single 4.5-cm, poorly functioning kidney. Eighteen months after transplant, the recipient has shown good function with the estimated glomerular filtration rate continuing to improve. This case demonstrates that a single neonatal kidney can grow and adapt to provide adequate renal function in an adult. This experience suggests that a single kidney from a neonate can sustain renal function in adults, and every effort should be made to maximize their use in transplant.
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http://dx.doi.org/10.6002/ect.2020.0254DOI Listing
November 2020

Encapsulating Peritoneal Sclerosis: A Case Report and Literature Review.

Am J Case Rep 2020 Oct 4;21:e925341. Epub 2020 Oct 4.

Department of General Surgery, Sultan Qaboos University Hospital, Muscat, Oman.

BACKGROUND Encapsulating peritoneal sclerosis (EPS) is a rare, life-threatening, and serious complication of long-term peritoneal dialysis (PD). No evidence-based management strategy has been established until now. Surgical management, including enterolysis and excision of the sclerotic and obstructing adhesions, should be considered as soon as conservative management fails to work. We report a case of EPS soon after transplantation in a patient with end-stage kidney disease who had been on long-term PD. CASE REPORT A 26-year-old man had been found to have advanced chronic kidney disease secondary to glomerulonephritis on pre-employment investigation. He was on continuous ambulatory PD for 5 years, after which he underwent a living donor renal transplant from his full HLA-matched sibling. He did well postoperatively, with excellent graft function. One month after transplantation, he repeatedly presented to our Emergency Department with signs and symptoms of complete small-bowel obstruction. Computed tomography of the abdomen showed features of small-bowel obstruction secondary to interloop adhesions. The patient was initially managed conservatively; however, as his condition continued to deteriorate, an exploratory laparotomy was carried out. Operative findings were suggestive of early EPS localized to the terminal ileum. Total enterolysis along with peritonectomy was performed along with resection of the diseased and obstructing terminal ileum. The patient did well, and he was discharged home day 10 postoperatively. CONCLUSIONS EPS remains a serious and fatal complication of long-term PD. Early definitive diagnosis, treatment, and ultimately surgical intervention may be required to prevent the morbidity and mortality associated with this condition.
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http://dx.doi.org/10.12659/AJCR.925341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545366PMC
October 2020

Surveillance arterioveNous fistulAs using ultRasound (SONAR) trial in haemodialysis patients: a study protocol for a multicentre observational study.

BMJ Open 2019 07 23;9(7):e031210. Epub 2019 Jul 23.

Department of Nephrology and Renal Transplantation, Royal Free London NHS Foundation Trust, London, UK.

Introduction: Arteriovenous fistulas (AVFs) are considered the best and safest modality for providing haemodialysis in patients with end-stage renal disease. Only 20% of UK centres achieve the recommended 80% target for achieving dialysis of the prevalent dialysis population via permanent access (as opposed to a central venous catheter). This is partly due to the relatively poor maturation rate of newly created fistulas, with as many as 50% of fistulas failing to mature.The Surveillance Of arterioveNous fistulAe using ultRasound study will examine whether a protocolised programme of Doppler ultrasound (US) surveillance can identify, early after creation, potentially correctable problems in those AVFs that subsequently fail to mature.

Methods And Analysis: This is a multicentre observational study that will assess newly created AVFs by Doppler US performed at 2, 4, 6 and 10 weeks after creation. The primary outcome measure will be primary fistula patency at week 10. Secondary outcome measures include: successful use of the fistula; clinical suitability for dialysis; creation of new fistula or radiological salvage; fistula thrombosis; secondary fistula patency rate and patient acceptability.

Ethics And Dissemination: The study has been approved by the Cambridgeshire and Hertfordshire Research Ethics Committee and by the Health Research Authority (REC 18/EE/0234). The results generated from this work will be published as open access, within 3 years of trial commencement. We will also present our findings at key national/international renal meetings, as well as support volunteers at renal patient groups to disseminate the trial outcome.

Trial Registration Number: ISRCTN36033877.
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http://dx.doi.org/10.1136/bmjopen-2019-031210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661628PMC
July 2019

Letter to Editor: Small and Laterally Placed Incisional Hernias Can Be Safely Managed with an Onlay Repair.

World J Surg 2019 11;43(11):2945-2946

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.

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http://dx.doi.org/10.1007/s00268-019-05088-7DOI Listing
November 2019

Major Adverse Cardiovascular Events Following Simultaneous Pancreas and Kidney Transplantation in the United Kingdom.

Diabetes Care 2019 04 14;42(4):665-673. Epub 2019 Feb 14.

Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, U.K.

Objective: People with type 1 diabetes and kidney failure have an increased risk for major adverse cardiovascular events (MACE). Simultaneous pancreas and kidney transplantation (SPKT) improves survival, but the long-term risk for MACE is uncertain.

Research Design And Methods: We assessed the frequency and risk factors for MACE (defined as fatal cardiovascular disease and nonfatal myocardial infarction or stroke) and related nonfatal MACE to allograft failure in SPKT recipients with type 1 diabetes who underwent transplantation between 2001 and 2015 in the U.K. In a subgroup, we related a pretransplant cardiovascular risk score to MACE.

Results: During 5 years of follow-up, 133 of 1,699 SPKT recipients (7.8%) experienced a MACE. In covariate-adjusted models, age (hazard ratio 1.04 per year [95% CI 1.01-1.07]), prior myocardial infarction (2.6 [1.3-5.0]), stroke (2.3 [1.2-4.7]), amputation (2.0 [1.02-3.7]), donor history of hypertension (1.8 [1.05-3.2]), and waiting time (1.02 per month [1.0-1.04]) were significant predictors. Nonfatal MACE predicted subsequent allograft failure (renal 1.6 [1.06-2.6]; pancreas 1.7 [1.09-2.6]). In the subgroup, the pretransplant cardiovascular risk score predicted MACE (1.04 per 1% increment [1.02-1.06]).

Conclusions: We report a high rate of MACE in SPKT recipients. There are a number of variables that predict MACE, while nonfatal MACE increase the risk of subsequent allograft failure. It may be beneficial that organs from hypertensive donors are matched to recipients with lower cardiovascular risk. Pretransplant cardiovascular risk scoring may help to identify patients who would benefit from risk factor optimization or alternative transplant therapies and warrants validation nationally.
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http://dx.doi.org/10.2337/dc18-2111DOI Listing
April 2019

Should End-of-Life Preferences Be Discussed Routinely before High-Risk Surgery?

J Palliat Med 2018 12 4;21(12):1818-1821. Epub 2018 Oct 4.

Department of Renal and Pancreas Transplantation, NHS England Funded UK referral center for Encapsulating Peritoneal Sclerosis Surgery, Manchester Royal Infirmary, Manchester, United Kingdom.

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis. It is characterized by peritoneal neovascularization, fibrosis, and calcification ultimately leading to intestinal obstruction and eventual failure. Surgery for EPS has a mortality approaching 50% and most patients require some form of postoperative life-sustaining therapy (LST) during their admission. A 43-year-old gentleman with progressive EPS and significant comorbidities was assessed for enterolysis after a failed first attempt at another center. Because of his comorbidities, postoperative mortality was quoted above 50%. The patient favored surgery to improve his survival and quality of life, but was reluctant to receive prolonged LST in the event of failure of surgical therapy. The surgical team, in conjunction with a palliative care physician, therefore held extensive discussions with the patient and his partner regarding LST and its limitations. Clinical parameters to trigger a transition to palliative care were identified and agreed. Limitations on LST that are directly expressed by patients can represent a contraindication to surgery for many surgeons. is a concept described as a perceived contract, or covenant, between the patient and clinician regarding implied consent for postoperative LST. Currently, preoperative discussions regarding limitations of LST are infrequent, and there can be reticence among patients and surgeons to have these conversations, leading to dissatisfaction on behalf of the patient and their family. After the Montgomery legal ruling, the provision and perception of informed consent are particularly pertinent. The palliative care physician is uniquely placed to contribute to such discussions as part of the surgical multidisciplinary team.
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http://dx.doi.org/10.1089/jpm.2018.0048DOI Listing
December 2018

Encapsulating peritoneal sclerosis following hyperthermic intraperitoneal chemotherapy.

ANZ J Surg 2019 10 2;89(10):E468-E469. Epub 2018 Sep 2.

Division of Transplant and Endocrine Surgery, Manchester Royal Infirmary, Manchester University Foundation Trust, Manchester, UK.

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http://dx.doi.org/10.1111/ans.14770DOI Listing
October 2019

Simultaneous en-bloc pancreas and kidney transplantation from a small pediatric donor after circulatory death.

Am J Transplant 2019 03 27;19(3):929-932. Epub 2018 Aug 27.

Department of Renal and Pancreatic Transplantation, Manchester University NHS Foundation Trust, Manchester, UK.

Simultaneous pancreas and kidney transplantation (SPKT) is an effective treatment option for patients with type 1 diabetes and end stage renal disease. Increasing demands for organs for transplantation coupled with a rise in age and size of adult donors has led to greater utilization of pediatric donors, and with good outcomes. Nonetheless, there remains reticence among transplant surgeons to transplant pancreases from small pediatric donors despite the optimal characteristics and macroscopic features of the younger pancreas. We report a successful case of SPKT from a small pediatric donor and explore the aspects of potential concern that might have led some clinicians to decline these organs. We also discuss the measures taken to overcome potential obstacles to successful transplantation from this donor source, and the rationale behind them.
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http://dx.doi.org/10.1111/ajt.15044DOI Listing
March 2019

Links between a biomarker profile, cold ischaemic time and clinical outcome following simultaneous pancreas and kidney transplantation.

Cytokine 2018 05 8;105:8-16. Epub 2018 Feb 8.

Department of Transplantation, Manchester Foundations Hospitals NHS Foundation Trust, Manchester Royal Infirmary, Manchester, United Kingdom.

In sepsis, trauma and major surgery, where an explicit physiological insult leads to a significant systemic inflammatory response, the acute evolution of biomarkers have been delineated. In these settings, Interleukin (IL) -6 and TNF-α are often the first pro-inflammatory markers to rise, stimulating production of acute phase proteins followed by peaks in anti-inflammatory markers. Patients undergoing SPKT as a result of diabetic complications already have an inflammatory phenotype as a result of uraemia and glycaemia. How this inflammatory response is affected further by the trauma of major transplant surgery and how this may impact on graft survival is unknown, despite the recognised pro-inflammatory cytokines' detrimental effects on islet cell function. The aim of the study was to determine the evolution of biomarkers in omentum and serum in the peri-operative period following SPKT. The biochemical findings were correlated to clinical outcomes. Two omental biopsies were taken (at the beginning and end of surgery) and measured for CD68+ and CD206+ antibodies (M1 and M2 macrophages respectively). Serum was measured within the first 72 h post-SPKT for pro- and anti-inflammatory cytokines (IL -6, -10 and TNF-α), inflammatory markers (WCC and CRP) and endocrine markers (insulin, C-peptide, glucagon and resistin). 46 patients were recruited to the study. Levels of M1 (CD68+) and M2 (CD206+) macrophages were significantly raised at the end of surgery compared to the beginning (p = 0.003 and p < 0.001 respectively). Levels of C-peptide, insulin and glucagon were significantly raised 30 min post pancreas perfusion compared to baseline and were also significantly negatively related to prolonged cold ischaemic time (CIT) (p < 0.05). CRP levels correlated significantly with the Post-Operative Morbidity Survey (p < 0.05). The temporal inflammatory marker signature after SPKT is comparable to the pattern observed following other physiological insults. Unique to this study, we find that CIT is significantly related to early pancreatic endocrine function. In addition, this study suggests a predictive value of CRP in peri-operative morbidity following SPKT.
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http://dx.doi.org/10.1016/j.cyto.2018.01.006DOI Listing
May 2018

Encapsulating peritoneal sclerosis-a rare but devastating peritoneal disease.

Front Physiol 2014 5;5:470. Epub 2015 Jan 5.

Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre Manchester, UK.

Encapsulating peritoneal sclerosis (EPS) is a devastating but, fortunately, rare complication of long-term peritoneal dialysis. The disease is associated with extensive thickening and fibrosis of the peritoneum resulting in the formation of a fibrous cocoon encapsulating the bowel leading to intestinal obstruction. The incidence of EPS ranges between 0.7 and 3.3% and increases with duration of peritoneal dialysis therapy. Dialysis fluid is hyperosmotic, hyperglycemic, and acidic causing chronic injury and inflammation in the peritoneum with loss of mesothelium and extensive tissue fibrosis. The pathogenesis of EPS, however, still remains uncertain, although a widely accepted hypothesis is the "two-hit theory," where, the first hit is chronic peritoneal membrane injury from long standing peritoneal dialysis followed by a second hit such as an episode of peritonitis, genetic predisposition and/or acute cessation of peritoneal dialysis, leading to EPS. Recently, EPS has been reported in patients shortly after transplantation suggesting that this procedure may also act as a possible second insult. The process of epithelial-mesenchymal transition of mesothelial cells is proposed to play a central role in the development of peritoneal sclerosis, a common characteristic of patients on dialysis, however, its importance in EPS is less clear. There is no established treatment for EPS although evidence from small case studies suggests that corticosteroids and tamoxifen may be beneficial. Nutritional support is essential and surgical intervention (peritonectomy and enterolysis) is recommended in later stages to relieve bowel obstruction.
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http://dx.doi.org/10.3389/fphys.2014.00470DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4283512PMC
January 2015

Emergency vascular access via the external iliac vein for haemodialysis and subsequent renal transplantation.

J Vasc Access 2014 Sep-Oct;15(5):434. Epub 2014 Apr 8.

Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester - UK.

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http://dx.doi.org/10.5301/jva.5000219DOI Listing
October 2015
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