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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 5  |  Page : 751-755
Ocular Disorders in Renal Transplant Patients


Esfahan Medical University, Esfahan Eye Research Center, Iran

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   Abstract 

This cross-sectional study was performed to determine ocular findings in renal transplant recipients and to correlate them with certain clinical characteristics related to transplantation. The study was performed on 150 patients who had received a renal transplant at least three months earlier and had serum creatinine levels < 3 mg/dL. All patients underwent a complete ophthalmologic examination. Clinical variables studied related to the transplant included cause of renal failure, duration of hemodialysis prior to transplantation and immunosuppressive regimen. Overall, 91 male and 59 female subjects with a mean age of 39.9 ± 17.7 years were included. At least one ocular abnormality could be detected in 89.3% including impaired visual acuity 0 20/25 (48.6%), conjunctival degeneration in the palpebral fissure (36.6%), posterior sub­capsular cataracts (24%), pinguecula (17.3%), retinal pigment epitheliopathy (14%), arteriovenous crossing changes (8.6%), proliferative diabetic retinopathy (6%), central serous chorioretinopathy and retinal vein occlusions (each in 3.3%), and non-proliferative diabetic retinopathy, optic nerve atrophy and diabetic macular edema (each in 2.7%). Abnormal ocular findings were not correlated with the underlying renal disorder or use of cyclosporine and prednisolone; however, they were positively correlated with transplant duration, pre-transplant dialysis duration and usage of azathioprine or mycophenolate mofetil. Our study suggests that ocular disorders are frequent among renal transplant patients especially with older transplants and those with a longer period of pre-transplant hemodialysis.

How to cite this article:
Kian-Ersi F, Taheri S, Akhlaghi MR. Ocular Disorders in Renal Transplant Patients. Saudi J Kidney Dis Transpl 2008;19:751-5

How to cite this URL:
Kian-Ersi F, Taheri S, Akhlaghi MR. Ocular Disorders in Renal Transplant Patients. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Oct 17];19:751-5. Available from: http://www.sjkdt.org/text.asp?2008/19/5/751/42448

   Introduction Top


Advances in surgical technique and develop­ment of more effective immunosuppressive agents have rendered kidney transplantation an effective renal replacement therapy. Nowadays, patients with end-stage renal disease (ESRD) have better survival rates and enjoy improved quality of life after renal transplantation. [1] Ocular complications following renal trans­plantation are mainly secondary to the cause of the underlying renal disease, accumulation of noxious materials, cytomegalovirus infection and immunosuppressive therapy. These factors can result in significant ocular morbidity secon­dary to conditions such as cataracts, glaucoma, hypertensive retinopathy, conjunctival deposits, and drug-induced retinitis. [2] Management of ocular complications in renal transplant patients can decrease morbidity and improve their quality of life. The aim of this study was to determine the prevalence of ocular abnorma­lities in renal transplant patients and to correlate them with the underlying cause of renal insufficiency, transplant duration, dura­tion of pre-transplantation dialysis and immuno­suppressive regimen.


   Methods Top


Between February and November 2004, renal transplant patients being followed-up at the Nephrology Clinic of Feiz Hospital, Isfahan, Iran were referred for a comprehensive ophthalmologic examination. Only patients who had completed at least three months post­transplantation and had serum creatinine levels less than 3 mg/dL were included in the study. After obtaining informed consent, all patients underwent a complete ocular examination including autorefraction, best corrected Snellen visual acuity (BCVA), ocular motility and external examination, slit-lamp biomicroscopy, applanation tonometry and fundoscopy using a non-contact 78 D lens following pupil dilation with tropicamide 1% in hypertensive patients or tropicamide 1% and phenylephrine 5% in normo­tensive subjects. A vitreoretinal subspecialist performed all ocular examinations. Ocular findings were classified as diabetes related complications including clinically significant macular edema, non-proliferative diabetic retino­pathy and proliferative diabetic retinopathy; and non-diabetes related complications. Previous nephrologic history including underlying disease causing ESRD, post-transplant duration, dura­tion of pretransplant dialysis and immuno­suppressive regimen were recorded. Data were analyzed using Mann-Whitney U and Chi square tests for comparing differences in mean values and frequencies, respectively. Statistical signi­ficance was set at p < 0.05.


   Results Top


During the study period, 150 renal transplant patients including 91 male (60.7%) and 59 female (39.3%) subjects with mean age of 39.9 ± 17.7 years (range 20–72) were evaluated. There was at least one abnormal ocular finding in 134 subjects (89.3%); in the remaining 16 patients (10.7%) the eye examination was un­remarkable. [Table 1] summarizes the ocular fin­dings in these patients. The most prevalent abnor­mality was subnormal visual acuity (BCVA < 20/25) in 73 cases (48.7%). Cataracts were present in 45 patients (30.0%) which were pre­dominantly posterior subcapsular (37 cases). Cataract surgery was performed in seven cases after renal transplantation. Ocular findings of less clinical importance or less frequency included lid swelling, blepharoptosis, phthisis bulbi, and pseudotumor cerebri, all seen in two patients each (1.3%), and fourth nerve palsy, herpes zoster ophthalmicus, retinal drusen, and corneal leukoma, seen in one patient each (0.7%). None of the patients had intra-ocular pressure (IOP) more than 21 mm or glauco­matous optic nerve head changes. Hyper­tension (HTN) was the most frequent cause of ESRD and was present in 38 patients (25.3%), of whom 35 (92.1%) had abnormal ocular findings [Table 2]. Ocular complications unre­lated to diabetes were found in 90% of diabetic and 86% of non-diabetic patients (p= 0.48). Diabetes related ocular complications were seen in 40% of diabetic subjects. The post­transplant immunosuppressive regimen consisted of single therapy in nine patients (6.0%), dual therapy in 34 (22.7%) and triple therapy in 107 (71.3%). The frequency of occurrence of ocular abnormalities in patients with single, dual and triple immunosuppressive therapy were 100%, 94.1%, and 86.9%, respectively. The mean number of immunosuppressive agents was 2.93 and 2.67 respectively in patients with and without ocular complications (p= 0.006). Ocular findings are cross-tabulated with immunosuppressive agents in [Table 3]. The ocular complications were not signi­ficantly different in patients under treatment with regimens containing cyclosporine or pred­nisolone; however, they were more prevalent in patients who received azathioprine or myco­phenolate mofetil. The mean duration post­transplant was 4.1 ± 3.6 years in patients with ocular findings versus 2.9 ± 3.6 years in pa­tients without ocular findings (p< 0.05). [Table 4] summarizes the frequency of ocular com­plications based on post-transplant duration and shows that only the incidence of central serous ocular disorders such as chorioretino­pathy (CSCR) was significantly positively correlated with the duration of renal transplant. The mean duration of pre-transplantation dia­lysis was 18.3 ± 22.9 and 6.6 ± 7.2 months in patients with and without ocular complications, respectively (p< 0.001). The corresponding figures were 2.1 ± 2.5 and 1.03 ± 1.1 months in patients with and without conjunctival degene­ration, respectively (p< 0.001).


   Discussion Top


In the current study, only patients with good renal allograft function (serum creatinine <3 mg/dL) were selected to avoid interference by ocular complications associated with renal failure per se. HTN was the most prevalent underlying etiology of chronic renal failure; however it could have been the result of the renal disease. Based on previous reports, the most common cause of renal failure is diabetes mellitus followed by HTN. [3] Subnormal visual acuity (BCVA < 20/25) was the most pre­valent functional ocular disorder (47%) in our series which can also be a sign of various conditions. This is in contrast to the results reported by Shimmyo et al [4] in which most cases had BCVA of 20/20. The most frequent anatomical disorders in the present study were conjunctival degenerations and depositions (36.7%). This complication has not been addressed much in other studies. Conjunctival degenerative lesions often result from ultra­violet radiation, [5] but in renal transplant patients they seem to be mainly correlated with hemo­dialysis. These conjunctival lesions may result from accumulation of toxic materials in the body. We found a significant relationship between this complication and pretransplant duration of dialysis.

Posterior subcapsular cataracts were the next most prevalent complication (30%) in the pre­sent study group. The incidence of this com­plication varies from 5 to 62.5% in different studies. [2],[4],[6] Early studies have reported a dose­ dependent relationship between corticosteroid treatment and cataracts; however, with the in­creased use of cyclosporine, evidence suppor­ting this relationship is weak. [7] Some studies have also reported a direct dose-dependent relationship between steroid treatment and seve­rity of cataract. [8] We did not find any signi­ficant relationship between the use of oral prednisolone and cataracts. This observation may be due to the early tapering of dose of prednisolone as a result of co-administration of immunosuppressive agents.

Our study showed a decrease in ocular com­plications by increasing the number of immuno­suppressive agents; thus, all patients who received single drug therapy versus 86.9% of patients who received triple drug therapy, had ocular abnormalities. Although IOP rise is a common side effect of topical steroids, sys­temic corticosteroid treatment rarely causes glaucoma. [9],[10] Based on the current series and similar studies [2],[4] the rate of IOP rise secondary to systemic corticosteroids in renal transplant patients does not seem to be higher than the general population. However keeping in mind other reports on the relatively high incidence of IOP rise, [6],[11] special attention is necessary in these particular cases. We found non-glauco­matous optic disc changes in 2.7% of our patients which is consistent with other studies. [2]

Our study as well as others [2] showed that certain ocular complications are directly rela­ted to post-transplant survival. The strongest association was seen between CSCR and post­transplant survival which may indicate a direct relation between renal transplantation and CSCR. In a study on 60 CSCR patients, three cases (5%) had previously undergone renal transplantation [12] which also suggests a rela­tionship between these two entities. In conclusion, the incidence of ocular com­plication in renal transplant patients is rela­tively high. Although most complications are not sight-threatening, regular ophthalmic exa­ mination can result in early detection, better management and improved quality of life.

 
   References Top

1.Danovitch GM. Hand book of kidney trans­plantation. 4th ed. Philadelphia: Lippincot, Williams and Wilkins; 2001: 2-3.  Back to cited text no. 1    
2.Jayamanne DG, Porter R. Ocular morbidity following renal transplantation. Nephrol Dial Transplant 1998;13(8):2070-3.  Back to cited text no. 2    
3.Katznelson S, McClelland J, Cecka JM. Primary disease effects and associations. Clin Transpl 1994;403-17.  Back to cited text no. 3    
4.Shimmyo A, Miyazaki S, Nojima M, Ihara H, Ikoma F. Ocular complications after renal transplantation. Nippon Ganka Gakkai Zasshi 1997;101(3):220-6.  Back to cited text no. 4    
5.Hilton AF, Harrison JD, Lamb AM, Petrie JJ, Hardie I. Ocular complication in hemodialysis and renal transplantation. Aust J Ophthalmol 1982;10;247-53.  Back to cited text no. 5    
6.Jahadi Hosseini HR, Rahmani B, Karbassi A, Mehrian M, Medghalchi AR. Ocular compli­cation in renal allograft recipients. Transplant Proc 2003;35(1):309-10.  Back to cited text no. 6    
7.Satio S, Matsuno N, Shimozaki S, Tanaka K, Fujiwara T. Impact of cyclosporine on deve­lopment of immunosuppressive therapy. Trans­plant Proc 1996;28:64-74.  Back to cited text no. 7    
8.Matsunani C, Hilton AF, Dyer JA, Rumbach OW, Hardie IR. Ocular complication in renal transplant patient. Aust NZJ Ophthalmol 1994; 22(1):53-7.  Back to cited text no. 8    
9.Stewart WC; ISV-205 Study Group. Prevention of corticosteroid-induced interaocular pressure elevation using ISV-205. Arc Ophthalmol 2003;121(11):1543-7.  Back to cited text no. 9    
10.Jones R 3rd, Rhee DS. Corticosteroid-induced ocular hypertention and glaucoma: a brief review and update of the literature. Curr Opin Ophthalmol 2006;17(2):163-7.  Back to cited text no. 10    
11.Ansano T, Tsuji A, Nakajima F, Hayakawa M. Ocular hypertension in renal transplant recipients. Transplant Proc 1998;30(7):3094-5.  Back to cited text no. 11    
12.Kian Ersi F, Fesharaki F. Therapeutic effect of propranolol in central serous retinopathy. Bina J Ophthalmol 2004;9:144-8.  Back to cited text no. 12    

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Correspondence Address:
Mohammad Reza Akhlaghi
Feiz Hospital, Ghods Square, Modarres Street, Esfahan
Iran
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PMID: 18711290

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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