Cardiovascular morbidity and mortality after kidney transplantation

Kidney transplantation is the optimal treatment for patients with end stage renal disease (ESRD) who would otherwise require dialysis. Patients with ESRD are at dramatically increased cardiovascular (CV) risk compared to the general population. As well as improving quality of life, successful transplantation accords major benefits by reducing cardiovascular risk in these patients. Worldwide, cardiovascular disease remains the leading cause of death with a functioning graft and therefore is a leading cause of graft failure. This review focuses on the mechanisms underpinning excess cardiovascular morbidity and mortality and current evidence for improving cardiovascular risk in kidney transplant recipients. Conventional cardiovascular risk factors such as hypertension, diabetes mellitus, dyslipidaemia, and pre-existing ischaemic heart disease are all highly prevalent in this group. In addition, kidney transplant recipients exhibit a number of risk factors associated with pre-existing renal disease. Furthermore, complications specific to transplantation may ensue includingreduced graft function, side effects of immunosuppression and post transplantation diabetes mellitus. Strategies to improve cardiovascular outcomes post transplantation may include pharmacological intervention including lipid lowering or antihypertensive therapy, optimisation of graft function, lifestyle intervention and personalising immunosuppression to the individual patients risk profile

A novel framework for enhancing marine dual fuel engines environmental and safety performance via digital twins

The Internet of Things (IoT) advent and digitalisation has enabled the effective application of the digital twins (DT) in various industries, including shipping, with expected benefits on the systems safety, efficiency and environmental footprint. The present research study establishes a novel framework that aims to optimise the marine DF engines performance-emissions trade-offs and enhance their safety, whilst delineating the involved interactions and their effect on the performance and safety. The framework employs a DT, which integrates a thermodynamic engine model along with control function and safety systems modelling. The DT was developed in GT-ISE© environment. Both the gas and diesel operating modes are investigated under steady state and transient conditions. The engine layout is modified to include Exhaust Gas Recirculation (EGR) and Air Bypass (ABP) systems for ensuring compliance with ‘Tier III’ emissions requirements. The optimal DF engine settings as well as the EGR/ABP systems settings for optimal engine efficiency and reduced emissions are identified in both gas and diesel modes, by employing a combination of optimisation techniques including multi-objective genetic algorithms (MOGA) and Design of Experiments (DoE) parametric runs. This study addresses safety by developing an intelligent engine monitoring and advanced faults/failure diagnostics systems, which evaluates the sensors measurements uncertainty. A Failure Mode Effects and Analysis (FMEA) is employed to identify the engine safety critical components, which are used to specify operating scenarios for detailed investigation with the developed DT. The integrated DT is further expanded, by establishing a Faulty Operation Simulator (FOS) to simulate the FMEA scenarios and assess the engine safety implications. Furthermore, an Engine Diagnostics System (EDS) is developed, which offers intelligent engine monitoring, advanced diagnostics and profound corrective actions. This is accomplished by developing and employing a Data-Driven (DD) model based on Neural Networks (NN), along with logic controls, all incorporated in the EDS. Lastly, the manufacturer’s and proposed engine control systems are combined to form an innovative Unified Digital System (UDS), which is also included in the DT. The analysis of marine (DF) engines with the use of an innovative DT, as presented herein, is paving the way towards smart shipping.The Internet of Things (IoT) advent and digitalisation has enabled the effective application of the digital twins (DT) in various industries, including shipping, with expected benefits on the systems safety, efficiency and environmental footprint. The present research study establishes a novel framework that aims to optimise the marine DF engines performance-emissions trade-offs and enhance their safety, whilst delineating the involved interactions and their effect on the performance and safety. The framework employs a DT, which integrates a thermodynamic engine model along with control function and safety systems modelling. The DT was developed in GT-ISE© environment. Both the gas and diesel operating modes are investigated under steady state and transient conditions. The engine layout is modified to include Exhaust Gas Recirculation (EGR) and Air Bypass (ABP) systems for ensuring compliance with ‘Tier III’ emissions requirements. The optimal DF engine settings as well as the EGR/ABP systems settings for optimal engine efficiency and reduced emissions are identified in both gas and diesel modes, by employing a combination of optimisation techniques including multi-objective genetic algorithms (MOGA) and Design of Experiments (DoE) parametric runs. This study addresses safety by developing an intelligent engine monitoring and advanced faults/failure diagnostics systems, which evaluates the sensors measurements uncertainty. A Failure Mode Effects and Analysis (FMEA) is employed to identify the engine safety critical components, which are used to specify operating scenarios for detailed investigation with the developed DT. The integrated DT is further expanded, by establishing a Faulty Operation Simulator (FOS) to simulate the FMEA scenarios and assess the engine safety implications. Furthermore, an Engine Diagnostics System (EDS) is developed, which offers intelligent engine monitoring, advanced diagnostics and profound corrective actions. This is accomplished by developing and employing a Data-Driven (DD) model based on Neural Networks (NN), along with logic controls, all incorporated in the EDS. Lastly, the manufacturer’s and proposed engine control systems are combined to form an innovative Unified Digital System (UDS), which is also included in the DT. The analysis of marine (DF) engines with the use of an innovative DT, as presented herein, is paving the way towards smart shipping

Should we ligate arteriovenous fistulas in asymptomatic patients after kidney transplantation?

No abstract available

Continued monitoring of acute kidney injury survivors might not be necessary in those regaining an estimated glomerular filtration rate > 60 mL/min at 1 year

Background. Severe acute kidney injury (AKI) among hospitalized patients often necessitates initiation of short-term dialysis. Little is known about the long-term outcome of those who recover to normal renal function. The aim of this study was to determine the long-term renal outcome of patients experiencing AKI requiring dialysis secondary to hypoperfusion injury and/or sepsis who recovered to apparently normal renal function. Methods. All adult patients with AKI requiring dialysis in our centre between 1 January 1980 and 31 December 2010 were identified. We included patients who had estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2 12 months or later after the episode of AKI. Patients were followed up until 3 March 2015. The primary outcome was time to chronic kidney disease (CKD) (defined as eGFR persistently <60 mL/min/1.73 m2) from first dialysis for AKI. Results. Among 2922 patients with a single episode of dialysis-requiring AKI, 396 patients met the study inclusion criteria. The mean age was 49.8 (standard deviation 16.5) years and median follow-up was 7.9 [interquartile range (IQR) 4.8–12.7] years. Thirty-five (8.8%) of the patients ultimately developed CKD after a median of 5.3 (IQR 2.8–8.0) years from first dialysis for AKI giving an incidence rate of 1 per 100 person-years. Increasing age, diabetes and vascular disease were associated with higher risk of progression to CKD [adjusted hazard ratios (95% confidence interval): 1.06 (1.03, 1.09), 3.05 (1.41, 6.57) and 3.56 (1.80, 7.03), respectively]. Conclusions. Recovery from AKI necessitating in-hospital dialysis was associated with a very low risk of progression to CKD. Most of the patients who progressed to CKD had concurrent medical conditions meriting monitoring of renal function. Therefore, it seems unlikely that regular follow-up of renal function is beneficial in patients who recover to eGFR >60 mL/min/1.73 m2 by 12 months after an episode of AKI

Stability upgrade of a typical Philippine ferry

The waterborne transport in the Philippines has been a sensitive subject amplified by the lack of rules and regulations to restrict ship-owners profit-driven decisions, leading to overloading, with significant impact on ship stability. Most of the Tier-II vessels are using solid ballast to balance trim and increase static stability at the expense of freeboard. To improve matters whilst facilitating the currently adopted process, solutions are required that offer additional buoyancy with increased stability. To this end, a solution is proposed here through the addition of sponsons, providing the required level of intact stability and residual floatability/stability, using a typical Ro-Pax. In this paper, a case study is presented to demonstrate the validity of the proposed solution

Obstetric and long-term kidney outcomes in renal transplant recipients: a 40 year single-centre study

Female renal transplant recipients of childbearing age may ask what the outcomes are for pregnancy and whether pregnancy will affect graft function. We analyzed obstetric and transplant outcomes among renal transplant recipients in our center who have been pregnant between 1973 and 2013. A case−cohort study was performed identifying 83 pairs of pregnant and non-pregnant controls matched for sex, age, transplant vintage, and creatinine. There were 138 pregnancies reported from 89 renal transplant recipients. There were live births in 74% of pregnancies with high prevalence of prematurity (61%), low birth weight (52%), and pre-eclampsia (14%). Lower eGFR (OR 0.98; p = 0.05) and higher uPCR (OR 1.86; p = 0.02) at conception were independent predictors for poor composite obstetric outcome. Lower eGFR (OR 0.98; p = 0.04), higher uPCR (OR 1.50; p = 0.04), and live organ donation (OR 0.35; p = 0.02) were predictors of ≥20% loss of eGFR between immediately pre-pregnancy and one yr after delivery. There was no difference in eGFR at one, five, and 10 yr in pregnant women compared with non-pregnant controls and a pregnancy was not associated with poorer 10-yr transplant or 20-yr patient survival. Despite high rates of obstetric complications, most women had successful pregnancies with good long-term transplant function

Ferumoxytol-enhanced magnetic resonance angiography for the assessment of potential kidney transplant recipients

Objectives: Traditional contrast-enhanced methods for scanning blood vessels using magnetic resonance imaging (MRI) or CT carry potential risks for patients with advanced kidney disease. Ferumoxytol is a superparamagnetic iron oxide nanoparticle preparation that has potential as an MRI contrast agent in assessing the vasculature. Methods: Twenty patients with advanced kidney disease requiring aorto-iliac vascular imaging as part of pre-operative kidney transplant candidacy assessment underwent ferumoxytol-enhanced magnetic resonance angiography (FeMRA) between December 2015 and August 2016. All scans were performed for clinical indications where standard imaging techniques were deemed potentially harmful or inconclusive. Image quality was evaluated for both arterial and venous compartments. Results: First-pass and steady-state FeMRA using incremental doses of up to 4 mg/kg body weight of ferumoxytol as intravenous contrast agent for vascular enhancement was performed. Good arterial and venous enhancements were achieved, and FeMRA was not limited by calcification in assessing the arterial lumen. The scans were diagnostic and all patients completed their studies without adverse events. Conclusions: Our preliminary experience supports the feasibility and utility of FeMRA for vascular imaging in patients with advanced kidney disease due for transplant listing, which has the advantages of obtaining both arteriography and venography using a single test without nephrotoxicity

Numerical study of a marine dual-fuel four-stroke engine

Continuously increasing environmental demands in conjunction with the planned strong penetration of the LNG, render the use of LNG as an attractive alternative marine fuel. In this framework, the traditional ship propulsion plants based on Diesel engines running with HFO, should be revisited and compared to the more efficient and environmentally friendly propulsion systems that use dual fuel engines. The present study deals with the computational investigation of a marine four-stroke dual fuel (DF) engine, in both diesel and DF mode operation. The engine model was set up in a commercial software and used to compare the performance and emissions of the investigated engine operation at steady state conditions. The engine diesel mode was initially set up and the model was calibrated to adequately represent the engine operation. Subsequently, the engine dual fuel model was set up by considering the injection of two different fuels; methane and pilot diesel fuel. The derived results were analysed for revealing the differences of the engine performance and emissions at each engine mode. In addition, the turbocharger matching at each mode is investigated revealing the challenges due to the completely different air-fuel ratio strategies used in diesel and dual fuel modes, re-spectively

Towards marine dual fuel engines digital twins - integrated modelling of thermodynamic processes and control system functions

This study aims at developing an integrated model that combines detailed engine thermodynamic modelling and the control system functional modelling paving the way towards the development of fidel digital twins. To sufficiently represent the combustion process, a multi-Wiebe function approach was employed along with a database for storing the Wiebe functions parameters and the use of quadratic interpolation. The developed model was employed for the systematic investigation of a marine four-stroke dual fuel engine response during demanding transient operation with modes switching and load changes. The derived results are analysed for identifying the engine critical components and their effect on the engine operational limitations. The results demonstrate that the developed model can sufficiently represent the engine and its subsystems/components behaviour and effectively capture the engine control systems functionality. The appropriate turbocharger matching along with the sufficient design of the exhaust gas waste gate valve and fuels control systems are crucial for ensuring the smooth engine operation of dual fuel engines