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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 6  |  Page : 1285-1289
Ocular changes in renal allograft recipients and patients of chronic kidney disease

Department of Nephrology and Ophthalmology, Dayanand Medical College and Hospital, Ludhiana, India

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Date of Web Publication10-Nov-2014

How to cite this article:
Sandhu JS, Kansal S, Bajwa G S, Sandhu J. Ocular changes in renal allograft recipients and patients of chronic kidney disease. Saudi J Kidney Dis Transpl 2014;25:1285-9

How to cite this URL:
Sandhu JS, Kansal S, Bajwa G S, Sandhu J. Ocular changes in renal allograft recipients and patients of chronic kidney disease. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 May 31];25:1285-9. Available from: http://www.sjkdt.org/text.asp?2014/25/6/1285/144269
To the Editor,

Chronic kidney disease (CKD) affects almost every organ system of the body, including the eyes. Large-scale population-based studies have shown a significantly higher prevalence of eye disorders in patients with CKD. [1] Ocular complications are also frequent in CKD pa­tients treated with maintenance hemodialysis and in renal allograft recipients. Ocular com­plications following renal transplantation are mainly secondary to the etiology of the under­lying renal disease, opportunistic ocular infec­tions and immunosuppressive therapy. [2],[3]

We conducted a prospective cross-sectional observational study in the nephrology and oph­thalmology departments of our tertiary care medical college hospital in North India, with the aim to evaluate renal allograft recipients and patients with CKD for ocular changes. The Institutional Ethical Committee on Human Research and the State Medical University approved the study.

Twenty-five renal allograft recipients with a post-transplant duration of more than six months and a stable graft function (group A), 50 patients of stage 5 CKD on chronic inter­mittent hemodialysis (group B) and 50 patients of CKD stage 3 and 4 were included. The glomerular filtration rate (GFR) was estimated from serum creatinine using the MDRD equa­tion and the staging of CKD was based on estimated GFR. Diabetic retinopathy was clas­sified on the basis of the early treatment dia­betic retinopathy study (ETDRS). Hypertensive retinopathy was graded on the basis of Keith and Wagener classification. [4]

After taking written informed consent, detailed history into the etiology, duration and treatment was taken and the relevant physical examination and detailed eye examination were performed in each case. This included visual acuity using Snellen's chart and gross external eye examination paying attention to the globe and surrounding adnexal structures, anterior segment examination with slit-lamp in ambu­latory and diffuse torch light examination in non-ambulatory patients, intraocular pressure measurement with applanation tonometry in ambulatory and Schiotz tonometry in non-ambulatory patients and retinal examination with direct and indirect ophthalmoscope after dilating pupils with tropicamide. Fundus fluorescein angiography, B-scan and visual field testing using a Humpfery field analyzer were performed in selected cases.

Standard statistical methods like mean, stan­dard deviation (SD) and percentage were used and the results were compared using ANOVA for quantitative and Chi Square test and Z test for quantitative and Chi square test and Z test for qualitative analysis. P-value <0.05 was taken as significant.

The mean values of serum creatinine and e-GFR were 1.34 ± 0.31, 9.62 ± 4.51, 3.46 ± 1.0 mg/dL and 77.7 ± 20.6, 7.8 ± 3.8, 18.9 ± 5.0 ml/min in groups A, B and C, respectively. All patients in group C were in stage 4 CKD except three cases who were in stage 3b. The mean duration post-renal transplantation was 3.3 ± 2.6 years. Renal allograft recipients were relatively younger compared with patients with CKD. Ocular examination was unremarkable in four (16%), four (8%) and one (2%) case in groups A, B and C, respectively. Sixteen per­cent of the renal allograft recipients had visual impairment compared with approximately ΍ of the CKD patients. Seventy patients (seven in group A, 29 in group B and 34 in group C) had type 2 diabetes mellitus. Diabetic retinopathy was present in 48 (68.5%) of the diabetic patients, and diabetic maculopathy (79%) was the most common finding. Hypertension was present in 3/4 th of the patients, and only half of these had hypertensive retinopathy. One-third (30%) of renal allograft recipients had pos­terior subcapsular cataract. Nuclear and cor­tical cataract (age related) were seen in 52% and 40% of group B and C CKD patients [Table 1]. The intraocular pressure (IOP) was within normal limits in all except three patients with mean IOP of 14.49 mm Hg. The most common vision-threatening findings were dia­betic retinopathy and cataract [Table 2]. The prevalence as as well as the severity of diabetic retinopathy in diabetic renal allograft reci­pients was significantly low as compared with non-recipient diabetic CKD patients [Table 3]. The prevalence and severity of hypertensive retinopathy was insignificant in renal allograft recipients and non-recipient hypertensive pa­tients [Table 4]. In our study, normal vision defined as best corrected visual acuity (BC VA) >6/18 in the better eye was present in most (84%) of the renal allograft recipients as compared with approximately half of the pa­tients of stages 4 and 5 CKD. The likely reason for a lower incidence of visual impairment in our renal allograft recipients may be due to the lower dosage of steroids and also the lower mean age compared with the CKD patients.
Table 1: Ocular changes in renal allograft recipients and patients of chronic kidney disease.

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Table 2: Major causes of visual impairment.

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Table 3: Prevalence of diabetic retinopathy in diabetic renal allograft recipients and non-recipient diabetic patients.

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Table 4: Prevalence of hypertensive retinopathy in renal allograft recipient and non-recipient hypertensive patients.

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The major cause of visual impairment in solid organ transplant is cataract. Classically, this is subcapsular (30% in our study) and is related to steroids. [5],[6] In comparison, patients of CKD develop nuclear and cortical cataract due to age-related degenerative process, and some authors have suggested an association bet­ween cataract formation and hypocalcemia. [7]

Ocular complications in renal allograft reci­pients also occur due to opportunistic ocular infections and raised IOP. [8] After excluding acute glaucoma, the presence of impaired vision and a painful red eye strongly suggests infection in these cases. Cryptococcus choroiditis, nocardial endophthalmitis and cyto-megalovirus retinitis have been reported. [9],[10],[11] Two of our renal allograft recipients had herpetic keratitis and one each had cytomegalovirus retinitis and fungal endo-phthalmitis. None of our renal transplant patients had raised IOP.

The most important and vision-threatening complications in patients of CKD and renal transplant are in the posterior ocular segment, the most common being diabetic and hyper­tensive retinopathy. [2],[12] The incidence and seve­rity of diabetic retinopathy was significantly less in our diabetic renal allograft recipients as compared with non-recipient diabetic CKD. Although our number was very small to make a solid conclusion, the reasons for a lower incidence could be the relatively younger age of renal transplant recipients and the reported stabilization and improvements in diabetic retinopathy after renal transplantation by other workers. [13],[14] There was an insignificant diffe­rence in the incidence and severity of hyper­tensive retinopathy in renal allograft recipients versus non-recipients. The prevalence of hyper­tension is at least 60-80% in renal transplant recipients, the major causes being the use of steroids and calcineurin inhibitors, weight gain, allograft dysfunction, native kidney disease and transplant renal artery stenosis. [15] Age-related macular degeneration (only 2% in our study) is the leading cause of irreversible blindness in the United States and often co­exists with CKD. [16] Other less-commonly en­countered causes include optic atrophy, exuda­tive retinal detachment and macular coloboma.

Less-serious eye findings in CKD are in the anterior segment, including red eye, pinguecula and pterygium. The most common long-term ocular change in hemodialysis patients is conjunctival and corneal calcification. [17]

In conclusion, the results of our study show that a significant number of patients of CKD on conservative therapy and chronic intermit­tent hemodialysis and the renal allograft reci­pients have ocular changes ranging from mild visual loss to total blindness. An early detec­tion of ocular changes can help prevent and treat visual loss.

Conflict of interest: None

   References Top

Wang TJ, Wu CK, Hu CC, Keller JJ, Lin HC. Increased risk of co-morbid eye disease in patients with chronic kidney disease: A population-based study. Ophthalmic Epidemiol 2012;19:137-43.  Back to cited text no. 1
Jayamanne DG, Porter R. Ocular morbidity following renal transplantation. Nephrol Dial Transplant 1998;13:2070-3.  Back to cited text no. 2
Hilton AF, Harrison JD, Lamb AM, Petrie JJ, Hardie I. Ocular complications in hemodialysis and renal transplant patients. Aust J Ophthalmol 1982;10:247-53.  Back to cited text no. 3
Keith NM, Wagener HP, Barker NW. Some different types of essential hypertension: Their course and prognosis. Am J Med Sci 1939;197: 332-43.  Back to cited text no. 4
Matsunami C, Hilton AF, Dyer JA, Rumbach OW, Hardie IR. Ocular complications in renal transplant patients. Aust N Z J Ophthalmol 1994;22:53-7.  Back to cited text no. 5
Kian-Ersi F, Taheri S, Akhlaghi MR. Ocular Disorders in Renal Transplant Patients. Saudi J Kidney Dis Transpl 2008;19:751-5.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
Chugh SK, Goel A. Bilateral cataract as the presenting manifestation of chronic renal failure. J Assoc Physicians India 1992;40:273-4.  Back to cited text no. 7
Das T, Gupta A, Sakhuja V, Gupta KL, Minz M, Chugh KS. Ocular complications in renal allograft recipients. Nephrol Dial Transplant 1991;6:649-55.  Back to cited text no. 8
Suppiah R, Abraham G, Sekhar U, Mathew M, Shroff S, Soundararajan P. Nocardial endoph­thalmitis leading to blindness in a renal transplant recipient. Nephrol Dial Transplant 1999;14:1576-7.  Back to cited text no. 9
Biswas J, Gopal L, Sharma T, Parikh S, Madhavan HN, Badrinath SS. Recurrent cryptococcal choroiditis in a renal transplant patient: clinicopathologic study. Retina 1998; 18:273-6.  Back to cited text no. 10
Baºçil N, Erdem Y, Yalçin AU, et al. Evisceration of the eye in a renal transplant recipient with cytomegalovirus chorioretinitis. Am J Nephrol 1996;16:367-8.  Back to cited text no. 11
Grunwald JE, Alexander J, Maguire M, et al. Prevalence of ocular fundus pathology in patients with chronic kidney disease. Clin J Am Soc Nephrol 2010;5:867-73.  Back to cited text no. 12
Laatikainen L, Summanen P, Ekstrand A, Groop L. Ophthalmological follow-up of diabetic patients after kidney transplantation. Ger J Ophthalmol 1993;2:24-7.  Back to cited text no. 13
Mittal NS, Bajwa GS, Sandhu JS. Diabetic retinopathy before and after renal transplantation: A longitudinal study. Transplant Proc 2005;37:2077-9.  Back to cited text no. 14
Kasiske BL, Zeier MG, Chapman JR, et al. KDIGO clinical practice guideline for the care of kidney transplant recipients: A summary. Kidney Int 2010;77:299-311.  Back to cited text no. 15
Liew G, Mitchell P, Wong TY, Iyengar SK, Wang JJ. CKD increases the risk of age-related macular degeneration. J Am Soc Nephrol 2008;19:806-11.  Back to cited text no. 16
Diaz-Couchoud P, Bordas FD, Garcia JR, Camps EM, Carceller A. Corneal disease in patients with chronic renal insufficiency undergoing hemodialysis. Cornea 2000;20: 695-702.  Back to cited text no. 17

Correspondence Address:
Dr. Jasvinder S Sandhu
Department of Nephrology and Ophthalmology, Dayanand Medical College and Hospital, Ludhiana
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DOI: 10.4103/1319-2442.144269

PMID: 25394452

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


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