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ABSTRACT
Year : 2011  |  Volume : 5  |  Issue : 3  |  Page : 148-157

Abstracts of papers presented at xxii annual conference of indian society of organ transplantation (isot), new delhi, 2011


Date of Web Publication4-Dec-2017

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How to cite this article:
. Abstracts of papers presented at xxii annual conference of indian society of organ transplantation (isot), new delhi, 2011. Indian J Transplant 2011;5, Suppl S1:148-57

How to cite this URL:
. Abstracts of papers presented at xxii annual conference of indian society of organ transplantation (isot), new delhi, 2011. Indian J Transplant [serial online] 2011 [cited 2020 Sep 19];5, Suppl S1:148-57. Available from: http://www.ijtonline.in/text.asp?2011/5/3/148/219910



doi: 10.1016/S2212-0017(11)60005-1


  01: Assessment and comparison of the perceived quality of life (QoL) of kidney donors pre- and post-donation and in relation to the type of hospital attended Top


N Almeida, S Joshi, A Almeida

Department of Human Development, College of Home Science, Nirmala Niketan and Department of Nephrology, PD Hinduja National Hospital, Mumbai, India

Fears regarding kidney donation may contribute to the widening discrepancy between kidney demand and supply. Today, clients insist on quality services in hospitals. Dearth of Indian research prompted an examination of the QoL of donors pre- and post-kidney donation and with respect to the type of hospital attended. The sample consisted of 30 donors (31-77 years; 17 females; 13 males). While 15 attended a public hospital, the other 15 attended a private hospital in Mumbai. The four hospitals (two private, two public) studied had a Nephrology Department, providing dialysis and trans- plantation. The design was an exploratory one with a retrospective component. An interview schedule and the KDQoL SF-13 served as QoL measures in both periods (pre-donation and post-donation). Data were analyzed quantitatively (/-test and Wilcoxon test) and qualitatively. On the interview schedule, the QoL score at post- donation (M = 463.63, SD = 1.61) was significantly higher than at pre-donation (M = 437.07, SD = 8.140, P<0.01). On the KDQoL, the mental composite median score was higher in the post-donation (60.70) than pre-donation period (59.84, P < 0.01,) while the phys- ical composite median score was higher in the pre-donation (56.15) than post-donation period (55.26, P < 0.01). There was no significant difference between the median total QoL score of donors attending a public and a private hospital on the KDQoL. On the interview sched- ule, donors attending a public hospital showed greater improvement in their overall QoL score. Enhanced QoL post-donation is a reward- ing finding and should spur individuals to donate their kidney. The fact that public hospitals are providing quality services, despite their overstretched medical facilities, is noteworthy.

doi: 10.1016/S2212-0017(11)60006-3


  02: Assessment and comparison of the perceived quality of life (QoL) of successful kidney transplant recipients pre- and post-transplantation and in relation to the type of hospital attended Top


N Almeida, S Joshi, A Almeida

Department of Human Development, College of Home Science, Nirmala Niketan and Department of Nephrology, PD Hinduja National Hospital, Mumbai, India

Quality of life (QoL) assessment is vital in dialysis and transplan- tation research. The hospital attended may impact the QoL as a large amount of time is spent there. Scant Indian research prompted the study, which aimed at comparing the QoL of successful kidney

transplant recipients pre- and post-transplantation and with respect to the type of hospital attended. The sample (30 patients; 15 attend- ing a public and 15 attending a private hospital in Mumbai) had been on hemodialysis with a subsequent transplant. The patients (21 males; 9 females) ranged in age from 26-55 years (M = 39.53). The four hospitals (two private and two public) studied had a Nephrology Department providing dialysis and transplantation. An exploratory research design with a retrospective component was employed. An interview schedule, developed by the research- ers and the KDQoL SF-13 were employed to measure the QoL in both periods (pre-transplant, post-transplant). Data were analyzed quantitatively (/-test and Wilcoxon test) and qualitatively. On the interview schedule, the patient’s total post-transplant mean QoL score (1528.23, SD=48.50) was higher than the pre-transplant score (1075.80, SD = 95.34; P<0.01). On KDQoL, both physical and mental composite median scores were higher in the post- transplant (49.68, 61.43) than the pre-transplant period (29.51, P<0.01; 34.09, P<0.01). There was no significant difference between the median total QoL score of the patients, attending a pub- lic and a private hospital, on the interview schedule and KDQoL. Improvement in QoL post-transplantation should prompt chronic kidney disease (CKD) Stage 5 patients to undergo transplantation. That the high volume of patient load in public hospitals has not adversely affected the patient’s QoL, is commendable.

doi: 10.1016/S2212-0017(11)60007-5


  03: Autotransplantation as a means of revascularization after stent fracture in renal artery stenosis: A single center experience Top


M Minz, DB Kenwar, S Singh, S Kumar, J Sethi, S Arora, A Bahl, MK Rohit

Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Introduction: Where angioplasty with stenting has become the first choice for treatment of renal artery stenosis (RAS), surgical revascularization offers a means of treatment when stenting fails. When vascular anatomy is complex, autotransplantation with back- bench reconstruction allows even complicated cases to be tackled.

Aim and objectives: A review of a series of three patients with stent fracture, who subsequently underwent autotransplantation for renal revascularization.

Materials and methods: Three patients were referred following detection of stent fracture on check angiography. Stent fracture was detected at 8 months, 1-year and 6-years after first procedure. All patients presented with a history of persistent hypertension after successful stenting, and requiring 4-5 classes of antihyper- tensives. One patient had a single functioning kidney. Retrieval was done laparoscopically in two cases and as open surgery after laparoscopic dissection in one patient. Autotransplantation and postoperative course was uneventful in all the three cases.

Results: Renal function was preserved in all three cases and renal perfusion was found improved in both patients who underwent postoperative nuclear scanning. One patient became normotensive off antihypertensive medication while other two had good control allowing withdrawal of 2-3 classes of antihypertensives.

Conclusion: Renal revascularization results in better control of blood pressure and allows blockade of renin-angiotensin axis when previously contraindicated. Autotransplantation offers easier and better reconstruction of complex lesions in cases of stent fracture.

doi: 10.1016/S2212-0017(11)60008-7


  04: Safety and efficacy of basiliximab vs. anti- thymocyte globulin in living donor high risk renal transplant recipients Top


Ashish Nandwani, AK Hooda, UK Sharma, Ranjith Nair, JS Bishnoi, Arun Kumar

Army Hospital (Research and Referral), Delhi Cantt., India

Introduction: Induction therapy involves prophylactic therapy administered at the time of transplantation with the goal of pre- venting acute rejection and ultimately facilitating a tolerogenic state.

Aim and objectives: To compare the safety and efficacy of basil- iximab and anti-thymocyte globulin in high-immunological-risk renal transplant recipients.

Materials and methods: The study was conducted at Army Hospital (Research & Referral), Delhi, in patients of end-stage renal disease (ESRD) who had high immunological risk of rejection, i.e. unrelated or spousal donors, patients undergoing re- transplant and patients with historical high PRA (> 20%) or positive cross-match. Patients received either basiliximab or anti- thymocyte globulin (equine) along with triple drug maintenance immunosuppression.

Results: Sixty two patients were evaluated in the present study. 20 patients (32.3%) received ATG, whereas 42 patients (67.7%) were given basiliximab. Mean age at the time of renal transplant was 37.1 years with predominant males (72.6%). Acute rejection occurred in 5 patients (25%) in ATG group, out of which 3 (60%) were steroid-responsive. Whereas in the basiliximab group, 9 patients (21.4%) had acute rejection, out of which 5 (55.6%) were steroid-responsive (P=NS). At 1 year, 2 patients (10%) died in the ATG group and 4 patient (9.5%) in the basiliximab group (P=NS). All of these patients died due to severe infections. The overall patient and graft survival was 90.3% and 95.2% respectively. The Kaplan Meier survival curves did not reveal any survival benefit with ATG as compared to basiliximab. The incidence of infections was comparable in both the groups.

Conclusion: The overall efficacy, tolerability, ease of administra- tion and the cost-effectiveness of basiliximab makes it an attractive option for the prophylaxis of acute rejection in high immunologi- cal risk patients as compared to anti-thymocyte globulin.

doi: 10.1016/S2212-0017(11)60009-9


  05: Kidney transplant in polycystic kidney patients: Our experience Top


Vikas Agarwal, Madhuja, A Ganpule, S Mehrotra, R Sabnis, MR Desai

Muljibhai Patel Urological Hospital, NADIAD, Gujarat, India

Background: Autosomal dominant polycystic kidney disease (ADPKD) as a systemic disorder represents a special subgroup among patients with end-stage renal disease (ESRD) who need renal transplant. We, retrospectively evaluated surgical manage- ment in ADPKD transplant patient and graft outcome.

Aim: To study pre-, peri-operative management and long-term outcome of kidney transplant in an ADPKD patient.

Materials and methods: We retrospectively evaluated our trans- plant record of last 15 years. We found 28 transplant patients with native kidney disease of ADPKD. We studied pre-transplant surgi- cal management, peri-transplant and late renal function outcome in these patients.

Results: Total 28 patients of ADPKD underwent kidney transplant in the last 15 years in our institute, of which 26 were male and 2 were female. Mean age at transplant was 46.9 years, 21 patients underwent pre-transplant nephrectomy, out of which 12 had bilat- eral, 9 unilateral. Common indication for right side nephrectomy was large kidney interfering with the transplant site. Other indi- cation was hematuria, pain and infection. All patients underwent living-related transplant. 26 patients underwent transplant in the right iliac fossa and 2 in the left iliac fossa. In postoperative period, 6 patients had perigraft collection for which 3 patients needed surgical intervention. None of the patients had urine leak. 2 patients died and 5 patients were lost to the follow-up, after a mean time of 20 months. Mean follow-up period of total 28 patients is 60.25 months, ranging from 1 month to 14 years. Mean best s.creatinine is 0.98, and at the last follow-up is 1.32. 6 patients had chronic graft allopathy and one had retransplant.

Conclusion: Pre-transplant anephric state and surgical morbidity management plays a major role in the graft function outcome.

doi: 10.1016/S2212-0017(11)60010-5


  06: Extraperitoneal renal transplantation in a less than 12 kg child Top


Vikas Agarwal, Lokesh, S Mishra, S Mehrotra, R Sabnis, MR Desai

Muljibhai Patel Urological Hospital, NADIAD, Gujarat, India

Background: Extraperitoneal renal transplantation is not routine in small recipients, in whom transperitoneal engraftment is the norm. Here, we present outcome of extraperitoneal placement of renal allografts in children weighing < 12 kg.

Materials and methods: 5-year-old male child who was suffering from recurrent UTI, diagnosed as posterior urethral valve, under- went valve fulgration at the age of 7 months. At 3 years due to per- sistent UTI, underwent suprapubic cystostomy and since August

2010 started on continuous peritoneal dialysis. He presented to us for renal transplant in October 2010.

Results: During transplant evaluation, patient’s weight was 11.3 kg with a height of 89 cm, body mass index—14.26. On cystogram, no reflux and could not void. Cystoscopy revealed no residual valve with smooth bladder wall. On urodynamic monitoring, bladder capacity of 190 mL but could not void with pVes of 87 cmH2O. His father came forward as the donor; with left kidney of size 9.4 cm with a single vessel was accepted. He underwent extraperitoneal right iliac fossa renal transplant on 21/12/2010. Anastomosis was done with common iliac vessel and SPC was kept. Then best s.creatinine was 0.23. After 3 weeks, he was operated for left ureteostomy as mitro- fanoff and CAPD removal. At 9 months follow-up, serum creatinine is 0.3 and comfortable with clean intermittent catheterization.

Conclusion: Extraperitoneal renal transplantation is technically feasi- ble in children who weigh < 12 kg. This approach preserves the perito- neal cavity, and limits potential gastrointestinal complication.

doi: 10.1016/S2212-0017(11)60011-7


  07: A prospective randomized study of early versus late removal of dj stents after renal transplants and its outcome Top


B Lenin, P Ghosh, M Suryavanshi, S Gogoi, R Khera, G Gautam, R Ahlawat

Department of Nephrology, Medanta Hospital, Gurgaon, India

Introduction: DJ stents have reduced urinary complications from 9% to 1.5% in unstented patients. With over 1000 renal transplants done, no ureteric leak or anastomotic stricture were observed when stents were removed after 3 weeks but stents have been criti- cized for UTI and Pyelonephritis (incidence 8%).

Aim and objectives: To see the feasibility of early stent removal in an attempt to reduce pyelonephritis episodes but retaining advantages of DJ stenting.

Materials and methods: Patients who underwent kidney trans- plantation at a tertiary care hospital by a single team from April 2010 to January 2011 were enrolled. Patients were randomized to early (7 days) or routine (21 days) DJ stent removal after kidney transplantation. A standard Lich-Gregoir ureteroneocystostomy was performed in both the groups. The patients were evaluated for graft outcome and infective episodes.

Results: Patients fulfilled the randomized criteria (early removal n = 18; routine removal n = 18). Both groups were comparable in terms of age, sex, ischemia time, number of renal arteries and time to diuresis. No patients had UTI during the first month post-transplant. 2 out of 18 patients with stents removed at 1 week (P < 0.05) had raised creatinine next day due uretero-vesical junction edema caus- ing obstruction. Renal functions normalized when 1 patient under- went re-stenting and other required graft per cutaneous nephrostomy and re-stenting later on. Both patients required prolonged DJ stents (4 weeks). The study was abandoned due to ureteric complication with early removal.

Conclusion: No incidence of UTI noted amongst the two groups. High incidence of ureteric complications were noted when stents were removed at 1 week.

doi: 10.1016/S2212-0017(11)60012-9


  08: A case of early TRAS managed with PTRA Top


Noble Gracious, Safeer, Jose Thomas, Sajeev Kumar, Mohandas, Gomathy, Jacob George, Ramdas Pisharody, AK Gupta

Department of Nephrology, Medical College, Thiruvananthapuram, India

Transplant renal artery stenosis (TRAS) is a potentially curable cause of post-transplant arterial hypertension, allograft dysfunc- tion and graft loss. It usually occurs 3 months to 2 years after transplantation. Anastomotic site stenosis, in a recent transplant is conventionally managed with surgery and reanastomosis.

Here, we report a case of TRAS very close to anastomotic site. 21-year-old boy who underwent live-related donor transplantation, developed graft dysfunction and accelerated hypertension on the 8th postoperative day. He was managed successfully with per- cutaneous transluminal renal angioplasty (PTRA) on the 19th postoperative day after which there was excellent improvement in graft function as well as hypertension.

We report this case because this could be one of the few cases of early Anastomotic site TRAS managed successfully with PTRA rather than surgery.

doi: 10.1016/S2212-0017(11)60013-0


  09: Tacrolimus-induced neurotoxicity Top


Ajay Marwaha, Ravi Angral, SPS Subhramanian, A Khullar, T Kataria, RS Chahal

Kidney Hospital and Lifeline, Jalandhar, Punjab, India

Introduction: Tacrolimus (FK506) is an effective immunosup- pressive agent for the prevention of organ transplant rejection. Neurological complications of tacrolimus therapy that have been reported are usually mild, i.e., tremors, paraesthesia but occasion- ally severe, i.e., aphasia, ataxia, confusion, seizures. We observed an unusual case of severe encephalopathy which occurred after 24 hours of renal transplantation in the absence of metabolic abnormalities and neurological diseases.

Materials and methods: 42 years male; Basic Disease: CGN/ESRD/ HCV +ve. He underwent renal transplantation on July 2011. The donor was his wife. He was started on Triple Immunosuppressant’s: Tacrolimus, Mycophenolate mofetil and Prednisolone. 1 g sol- umedrol was given at the time of induction. Tacrolimus was started at the dose of 11 mg/day (2 mg/kg body wt.). Postoperatively, he was having good diuresis and his Sr. Creat came down from 2.5 to 0.9, and Sr. Electrolytes were within normal limits. After 24 hours of surgery, patient started c/o headache, irritability, irrelevant talks. Neurological consult was taken and he was diagnosed as having acute delirium state and he was advised CT Head and CSF study. Thinking of the possibility of steroid-induced psychosis and

tacrolimus-induced neurotoxicity, both tacrolimus and steroids were stopped. CSF study revealed WBC-20, RBC-nil, Polymorphs-4, Lymphocytes-16. Biochemistry-Microprotein-59.7 mg/dL (high), Glucose-105 (low as compared to serum). CSF-AFB-negative, CSF- ADA-0.6u/l (normal), Cryptococcus antigen-normal, culture-normal. MRI brain scan revealed Acute Demyelinating Encephalomyelitis. He was shifted on mycophenolate mofetil (MMF) and ATG. Tacrolimus level sent on the 2nd day were 13.85 ng/mL. He was given Clonazepam and Olanzapine. Low-dose of Dexona (2 mg) was started on day 4. Later on, he was shifted to Prednisolone 20 mg. He was continued on MMF and Low-dose steroid. On the 9th postoperative day, he was started on low-dose cyclosporine 100 mg/day. His sensorium improved and he was discharged on the 11th postoperative day. At the time of discharge, he was on Cyclosporine 50 mg Bid, MMF 1.5 g and Prednisolone 20 mg.

Results: Patient improved after stopping tacrolimus.

Conclusion: Tacrolimus is being used increasingly to prevent rejection after renal transplantation. Neurological complications, though rare, can occur with tacrolimus which subsides after the drug is discontinued.

doi: 10.1016/S2212-0017(11)60014-2


  10: Plasma or intravenous immunoglobulin (IVIG) for ABO compatible transplantation Top


S Mishra, M Aggarwal, G Singh

A.R.A.M. Apollo Hospital, Ranchi, Jharkhand, India

Introduction: Both IVIg and AB plasma/donor-specific plasma have been used as an adjunct to plasmapheresis in ABO- incompatible transplantation. This study was prompted by the finding that anti-A blood group titer went up in a B group patient after receiving IVIg.

Aim: To find out whether the IVIg or AB plasma/donor-specific plasma would be better for ABO-incompatible transplantation.

Materials and methods: The study was conducted on blood sam- ples collected from healthy donors at the blood bank of our hospi- tal and on three batches of IVIg samples provided by Bharat serum ltd. First, A., B and 0 plasmas (5 different samples of each group) were collected. Their anti-A and/or anti-B blood group titers were determined against 4% cell suspensions of incompatible group by serial dilution with the normal saline using gel tube technique. Then, the test process was repeated after serial dilution of the plasma samples with IVIg in place of normal saline. Similarly, the tests were performed again after serial dilution with AB plasma or plasma of the same group as the incompatiblered cell suspension used for cross-matching. The IVIg samples themselves were also tested for presence of any anti-A/B antibodies.

Results: The anti-A or/and anti-B titers reduced variably after dilution with AB plasma/red specific plasma. Whereas IVIg failed to pro- vide a negative cross-match. All the three batches of IVIg had vari- able titers of both anti-A and anti-B antibodies (titers of 1:4-1:16).

Conclusion: IVIg itself has anti-A/B antibodies that may reduce the efficacy of plasmapheresis, if given post-plasmaphcresis in a

large quantity. Whereas AB plasma/donor-specific plasma has the ability to reduce the anti-blood group antibody titer probably because of soluble blood group antigens. This makes it a better choice as an adjunct to plasmapheresis for ABO incompatible transplant.

doi: 10.1016/S2212-0017(11)60015-4


  11: Cardiovascular evaluation in renal transplant recipients: A preliminary study Top


PN Gupta, S Bansal, V Saxena, S Jain, S Pokhariyal, R Sharma, M Jain, R Goel, V Kher

Medanta The Medicity, Gurgaon, India

Introduction: Cardiovascular disease is a common cause of death with functioning graft in kidney transplant recipients.

Aim: To analyze current cardiovascular evaluation protocol in prospective kidney transplant recipients.

Materials and methods: 135 patients were included in the analysis, with a minimum follow-up of 6 months. Cardiovascular evalua- tion included clinical history, examination and cardiology consul- tation. ECG, 2D ECHO was done in all the patients. Dobutamine Stress ECHO (DSE) was done as advised. Patients who had symp- tomatic heart disease, poor LVEF (EF < 40%), Positive DSE/Stress Thallium, were taken up for Coronary Angiography (CAG).

Results: Of the135 patients, 72.5% were males, the mean age was 40.8 ± 14.0 years and 28.8% were diabetics. Mean follow-up was 340.1 ± 98.3 days. 19.2% were preemptive transplants. Of 109 patients on dialysis, mean duration of dialysis was 153.8 ± 186.2 days. All the patients had ECG and 2D ECHO. DSE was done in 64 patients and 2 patients had positive stress ECHO. CAG in these

2 patients was normal. CAG was done in 14 more patients. 4/14 had normal CAG, 4 patients had non-critical CAD, 4 had Triple Vessel Disease (TVD) and underwent CABG, 1 patients had dif- fuse TVD and non-amenable to revascularization. 1 patient had Dual Vessel Disease and underwent PTCA with Bare Metal Stent.

3 patients died, one was noncompliant and had graft failure requir- ing HD. Second patient died with multi organ failure. Third patient expired 3 months after transplantation due to cardiac arrest. He had CABG pre-transplant. Another patient had ACS and had required PTCA 2 weeks post-transplant (DSE negative pre-transplant).

Conclusion: In asymptomatic CKD patients, DSE is a poor marker of CAD.

doi: 10.1016/S2212-0017(11)60016-6


  12: Improving the yield of organ donation: Successful experience at level I center Top


Rajeev Maikhuri, Aarti Vij, Deepak Agrawal, Sandeep Seth

All India Institute of Medical Sciences, New Delhi, India

Introduction: Our country suffers from a chronic shortage of organ donors, and the list of individuals in desperate need of life- saving organ transplants is growing every year.

Objective: The purpose of this study is to assess how specific com- munication intervention programs influence family decisions about organ donation.

Setting and participants: A liaison cell for organ donation was set up at Neurosurgery ICU and Mortuary at JPNA Trauma Center, AIIMS. This cell was staffed by a team of dedicated counseling personnel who were specifically trained with interacting with relatives of potential organ and tissue donors. The team counseled and interacted with the relatives of all potential donors over a period of 3 months (May-July 2011). The organ donation rates over this period were compared with the preceding 3 months (February-April 2011).

Results: During the period of study, next of kin of potential donors were given focused counseling from the counseling team. Relatives of 10 brain stem death (BSD) patients and 63 Accidental deaths (Cardiac-Death) patients were motivated and counseled by team approach. This translated into one cadaver multi-organ donation, 13 Heart Valves and 12 corneas (pair) donation in the study period, which was significantly higher than the organ donation over the pre- ceding 3 months (which was 5 Heart Valves and 8 corneas (pair).

Conclusion: Our study shows that a dedicated counseling team which has been specifically trained to counsel relatives can markedly improve organ donation rates.

doi: 10.1016/S2212-0017(11)60017-8


  13: Anti-thymocyte globulin (ATG) vs. Basiliximab induction in renal transplant recipients: A long term outcome Top


K Sailaja, P Poorna, VS Reddy, AS Murthy, Uma Maheswar Rao, S Sahariah

Krishna Institute of Medical Science, Hyderabad, India

Introduction: Although Basiliximab and Anti-thymocyte globu- lin (ATG) are effective in delaying and reducing the incidence of acute rejection (AR), thus improving short-term graft survival, their impact on long-term graft survival has not been established.

Aim: Evaluation of long-term efficacy after the induction therapy with ATG/Basiliximab in renal transplant recipients.

Methods: A retrospective analysis of 70 renal transplant recipients of living donor renal transplantation from March 2005 to March 2008. Out of them, 35 patients received induction with ATG (3 doses of 50 mg, 25 mg, 25 mg/day on 0, 1 and 2 POD) and were compared with 35 age-matched patients who received induction with Basiliximab (20 mg/day on 0 and 4 POD). All the patients received tacrolimus, MMF and corticosteroid adjunct therapy. Episodes of AR, GFR, graft and patient survival were evaluated.

Results: Demographic characters were similar between both the groups. Patient survival at 4 years was 88.6% in ATG group and 82.9% in basiliximab group. Graft survival was 85.8% and 80% in ATG versus basiliximab, respectively. Incidence of AR is 20% and 17.1% in ATG ra. Basiliximab group. Estimated mean GFR at 4 years post-transplantation was 51.4 mL/mt and 49.8 mL/mt and mean serum creatinine levels were 1.74 ± 0.51, 1.90 ± 0.33 in

ATG ra. basiliximab groups. Incidence of tuberculosis and CMV was observed in the ATG group whereas 1 delayed graft function (DGF) was observed in the basiliximab group.

Conclusion: There were no significant differences between the two groups, however CMV and other bacterial infections were observed in the ATG group.

doi: 10.1016/S2212-0017(11)60018-X


  14: Evaluation of cardiac risk assessment in living kidney donor surgery Top


R Goel, S Pokhariyal, S Jain, S Bansal, V Saxena,

R Sharma, M Jain, PN Gupta, V Kher

Department of Nephrology, Medanta Hospital, Gurgaon,

India

Introduction: There is no data available on the evaluation of cardiac risk assessment of potential kidney donors during surgery. Hence, to evaluate the cardiac risks involved during surgery, we analyzed our data on donor evaluation.

Aim and objectives: To evaluate cardiac risk assessment protocol in living kidney donor surgery.

Materials and methods: We retrospectively collected data on car- diac risk assessment in patients undergoing living kidney donor sur- gery. A total of 210 transplants were done from February 2010 to July 2011, of which 142 donors were analyzed who had a follow-up of at least 6 months. Assessment included history and clinical exam- ination, and electrocardiogram (ECG) in all. Additionally, resting echocardiography (RECHO) and/or treadmill testing (TMT) or stress ECHO [exercise (EECHO) or dobutamine (DSE)] were conducted. Coronary angiogram [conventional (CAG) or computed tomography (CTCAG) was done in patients with a positive stress test.

Results: There were 142 donors who underwent nephrectomy. Median age was 47 years (21-70) and 67% were females. There were 21 hypertensive donors, of which 15 were diagnosed with hypertension at the time of evaluation. Three were hypertensive for > 2 years and another 3 for < 2 years. ECG was done for all candidates. RECHO was done in 49, TMT in 28, EECHO in 39 and DSE in 26 candidates. All had normal ECG except 1 who had left bundle branch block. That candidate underwent DSE which was positive for reversible ischemia. Subsequently, CTCAG was performed, which was normal. TMT was conducted in 28 and was positive in 4 candidates, of whom 3 underwent CTCAG which was normal and 1 had non-critical coronary artery disease (CAD) on CAG. EECHO was done in 39 patients. One had a positive test, whose CAG turned out normal. Dobutamine stress ECHO was done in 26 patients, of whom 1 was positive but subsequently had a normal CTCAG. CAG was done in 3 patients, 2 candidates as mentioned before and the 3rd had a normal RECHO and TMT but a non-critical CAD on CAG.

Conclusion: In potential kidney donors, who have no symptoms of cardiovascular disease, a stress test is unlikely to provide bene- fits. A longer follow-up and more number of patients are required to validate our study.

doi: 10.1016/S2212-0017(11)60019-1


  15: Post-transplant diabetes mellitus with tacrolimus-based immunosuppression Top


Prashant Rajput, BV Shah, Mita Shah

Narmada Kidney Foundation, Mumbai, India

Introduction: Post-transplant diabetes mellitus (PTDM) is a sig- nificant complication in kidney transplant patients, who receive tacrolimus-based immunosuppression. PTDM is associated with an increased cardiovascular risk, and a higher risk of death.

Aim: To determine the incidence, risk factors and natural course of PTDM in patients receiving tacrolimus-based immunosuppression.

Materials and methods: Between January 1 2005 and June 30 2011, 161 kidney transplants were performed with tacrolimus-based immunosuppression. 34 patients had diabetes mellitus (DM); 5 patients died and 3 patients lost graft in the early post-transplant period. This study is an analysis of the remaining 119 non-diabetic patients who were followed for at least 3 months. All the study patients received prednisolone and MMF in addition to tacrolimus. Tacrolimus level was monitored regularly. Body mass index (BMI), BP, urine R, CBC, FBS and creatinine was monitored during each visit. PTDM was defined as FBS > 126 mg/dL.

Results: 50 out of 119 patients (42%) developed PTDM. Forty three (86%) developed within the first 3 months post-transplant. The average tacrolimus level at the time of detection of PTDM was 10.7 + 3.1ng/mL. This was higher than the level (10.26 + 3.1) observed in those who did not develop PTDM. The difference, however, was not statistically significantly (P > 0.05). The BMI of those who developed PTDM was 22.9. It was 23.26 of those who did not develop PTDM. The difference was not statistically sig- nificant (P > 0.05). Thirty six (72%) out of 50 patients who devel- oped PTDM had resolution of diabetes, as the dose of tacrolimus and prednisolone was tapered.

Conclusion: The study shows that a high percentage (42%) of non-diabetic kidney transplants patients, receiving tacrolimus- based immunosuppression develops PTDM. In a majority of cases, it develops within the first 3 months after transplant. This resolves in a majority of cases (72%) as the dose of tacrolimus and steroids was tapered.

doi: 10.1016/S2212-0017(11)60020-8


  16: SWAP transplant (paired kidney donation): Our experience Top


Prashant Rajput, BV Shah, Mita Shah, Rajni Dhuwad

Narmada Kidney Foundation, Mumbai, India

Introduction: Only 1% of patients developing ESKD in India undergo transplant. One main reason is the extreme shortage of deceased donors. Living-related donor transplant is the main option in our country. In many cases, the related donor is immuno- logically incompatible. Desensitization therapies are costly and have inferior long-term outcomes. Swap transplant is an excellent alternative but underused, despite lower costs and better outcomes.

Aim: To study the feasibility of swap transplant in our country.

Materials and methods: Narmada Kidney Foundation maintains a registry of all the potential transplant candidates. In the registry, demographic and blood group details of recipients and their fam- ily donors is maintained. From the main registry, a special registry (swap transplant registry) of recipients with immunologically incompatible family donors is created.

Results: 58 recipient-donor pairs were registered for swap trans- plant between June 1, 2008 and May 31, 2011. These included potential recipients who had ABO incompatible or lymphocyte cross-match positive family donor. There were 22 (38%) recipi- ents with blood group A, 16 (27.5%) with blood group B and 20 (34.4%) with blood group O. Of the 58 registered recipients, 20 with blood group O, understandably, could not get suitable donor (blood group O donor would prefer to donate to his/her family member). Twenty potential recipients could not be paired. Nine A blood group recipients (with B blood group donors) could be paired with 9 B blood group recipients (with A blood group donors). Fourteen could not undergo the transplant due to complicated legal formalities (6), medical complication developing while going through legal formalities (4), and financial problems (4). Four (2 recipients with blood group A and 2 with blood group B) under- went successful transplantation. All 4 recipients are doing well.

Conclusion: In our country with the deceased donor program still in its infancy, swap transplant is a good option for potential recipients with immunologically incompatible family donor. Sim- plifying the legal formalities can go a long way in increasing such transplants.

doi: 10.1016/S2212-0017(11)60021-X


  17: Renal cortical necrosis (RCN) in a living kidney donor: First case report in literature Top


TB Singh, Jai Prakash, A Srivastav, Biplab Ghosh, S Singh

Department of Nephrology and Department of Radiology, Institute of Medical Sciences, BHU, Varanasi, India

Introduction: In a properly selected living kidney donor, the imme- diate and long-term morbidity and mortality are low. However, unexpected complications can still occur.

Aim and objectives: We are reporting a case of acute RCN in a live kidney donor, after five hours of nephrectomy.

Materials and methods: A 48-year-old female kidney donor (mother of the recipient) was subjected to left nephrectomy for renal transplant.

Results: On the transplant day, a left donor nephrectomy was done without any intra-operative and immediate postoperative compli- cations. The medications used during the operation were glycop- yrrholate, succinyl choline, isoflurane, nitrous oxide, neostigmine, inj frusemide 120 mg and mannitol 70 g. Cefoperazone 1 g was given pre-operative. She received a total of 5200 mL of fluids and the urine output was 3400 mL during the time she was in the oper- ation theater for 2 hours. She did well with a urine output of > 1.48 liters/h for 2 hours and 1.25 liters/hr in subsequent hours. In the

5th postoperative hour, her urine output decreased to 750 mL and in the next two hours she became anuric. Color Doppler study revealed no vascular occlusion. Laboratory investigations showed features of hemolytic uremic syndrome. Ultrasonography revealed an increase in the size and cortical echogenicity of the kidney. In view of absolute anuria, she was subjected to hemodialysis 3 times per week for correction of uremic features and volume overload. Subsequent contrast enhanced computed tomography (CECT) showed feature of acute renal cortical necrosis (RCN) of the right kidney. Patient remained anuric for 4 months despite of RRT. Finally, she succumbed to sepsis and CVA at five and a half months.

Conclusion: To the best of our knowledge, this is the first case of RCN in a kidney donor in the world literature.

doi: 10.1016/S2212-0017(11)60022-1


  18: Unusual presentation of tuberculosis in renal transplant recipient Top


Sharbidre Prakash Gopal, MM Bahadur

Jaslok Hospital and Research Center, Mumbai, India

Objective: Post-renal transplant status is associated with high inci- dence of opportunistic infections and malignancy. We report two cases of post-renal transplant recipients with esophageal tuberculosis.

Case summary: The first patient, a 51-year-old male presented with dysphagia and backache whose radiological and endoscopic findings were suggestive of esophageal malignancy that turned out to be esophageal tuberculosis on biopsy.

The second patient, 44-year-old presented with cough on swal- lowing of liquids and hoarseness of voice and turned to have Broncho-oesophageal fistula.

Both the patients were treated with anti-tuberculous therapy for 1 year and they showed good recovery.

Discussion and conclusion: These are the only reported cases of esophageal tuberculosis in renal transplant recipients from India. They responded to standard anti-tuberculous treatment given for a prolonged period. The differential diagnosis of tuberculosis of esophagus should be considered in patients presenting with upper gastrointestinal and upper respiratory symptoms.

doi: 10.1016/S2212-0017(11)60023-3


  19: Renal transplant in patient with augmentation cystoplast: A novel technique Top


Sudhir Chadha, Mrinal Pahwa, Vipin Tyagi, Harsh Jauhari

Sir Ganga Ram Hospital, New Delhi, India

Introduction: A congenital or acquired genitourinary anomaly is identified as the etiology in a fifth of children with end-stage renal disease and many have significant lower urinary tract dysfunction. There is some controversy about the safety of renal transplantation in a patient with an augmentation cystoplasty because of the increased possibility of urinary tract infections in immunosup- pressed patients, which can lead to pyelonephritis and graft loss.

Aim and objectives: To evaluate the feasibility and success of anastomosing graft ureter with native ureter in cases where aug- mentation has been done previously.

Materials and methods: We describe a case of renal transplant in a 16-year-old patient who had cloacal anomaly at birth. She had undergone right nephroureterectomy in childhood, followed by augmentation cystoplasty with Mitroffanof continent diversion 3 years prior to the transplant. Graft kidney was taken from a live- related donor and the patient was maintained on tacrolimus-based immunosuppresion therapy. End-to-side ureteroureterostomy was done at the time of transplant. Patient was instructed to continue with CISC at discharge.

Results: The patient has been doing well 1 year after the trans- plant, with stable graft function and no hydronephrosis of trans- planted kidney. The patient didn’t experience any morbidity due to technical complications. Patient has been continent and managing herself well with CISC.

Conclusion: Renal transplant can be performed in patients with reconstructed or augmented bladder. Graft ureter can be anasto- mosed to native ureter if there is no distal obstruction, no VUR and if low compliance normal volume reservoir is present.

doi: 10.1016/S2212-0017(11)60024-5


  20: The outcome of deceased donor renal transplant in diabetic nephropathy: A single center experience Top


SH Jain, VB Kute, DP Engineer, PR Shah, HV Patel, MR Gumber, PR Modi, HL Trivedi

Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahemadabad, Gujarat, India

Background: Type 2 diabetes mellitus (DM) is the commonest cause of end-stage renal disease (ESRD) worldwide. Renal trans- plantation (RTx) is the best therapeutic modality for such patients. First-degree relatives of patients with type 2 DM have a high risk of diabetes/pre-diabetes. Parents are often too old to be suitable donors, and siblings/children/spouse are either not suitable/accept- able or do not come forward for organ donation. This leaves deceased donation (DD) as the only suitable mode. Data scarcity on DDRTx outcome in diabetic nephropathy (DN) prompted us to review our experience.

Aim: We intend to evaluate the outcome of deceased donor renal transplant in diabetic nephropathy patients in terms of patient/ graft survival, graft function, rejection episodes and mortality.

Materials and methods: Between January 2001 and March 2011, thirty-five DN-ESRD patients underwent DDRTx in our center, following cardiac fitness assessment of the recipients. All patients received single-dose rabbit-anti-thymocyte globulin for induction and steroids, calcineurin inhibitor, and mycophenolate mofetil/ azathioprine for maintenance immunosuppression. Mean recipient age was 49.66 ± 6.76 years, and 25 were men. Mean donor age was 50 ± 16.45 years, 23 were men.

Results: Over a mean follow-up of 2.28 ± 2.59 years, patient and graft survival rates were 68.5% and 88.5%, respectively, with mean SCr of1.9 ± 0.62 mg/dL. Delayed graft function was observed in 34.3% patients, and 25.7% had biopsy-proven acute rejection; 31.5% patients died, mainly because of infections (22.8%), coro- nary artery disease (2.86%), and cerebrovascular events (5.7%).

Conclusion: DDRTx in patients with DN has an acceptable graft function and patient/graft survival over 10-year follow-up in our center and, therefore, we believe it should be encouraged.

doi: 10.1016/S2212-0017(11)60025-7


  21: Impact of pre-transplant through tacrolimus level on early acute rejection in live donor kidney transplantation Top


K Gohel, U Hegde, S Gang, M Rajapurkar

Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India

Introduction: The risk of acute rejection is greater in the first week post-transplant and progressively decreases after the first month. Thus, the concentration of immunosuppressive drugs must be maximal at this initial phase and tapered during the subsequent months, according to the evolution of patient and graft function.

Aim: There is paucity of literature on the impact of pre-transplant immunosuppression on acute rejection. So, we aim to assess the cor- relation of pre-transplant trough tacrolimus level with early rejection.

Materials and methods: We prospectively analyzed the trough tacrolimus level on the day prior to transplantation of 179 patients, transplanted from September 2007 to September 2009. We divided them into three groups, according to the trough levels: Group I < 5 ng/mL, Group II 5-15 ng/mL and Group III > 15 ng/mL. Their demography including immunosuppression, native kidney disease, HLA match, donor characteristic, incidence of BPAR, NOD, post- transplant infection and biopsy-proven CNI toxicity were studied.

Results: The demography including age, gender, immunosuppres- sion, donor age was comparable in all the three groups. Incidence of biopsy-proven acute rejections were highest in Group I and lowest in Group III. None of the patients in Group III had rejection with Banff grade > 2. Incidences of post-transplant infection, new onset diabetes were comparable. Trend of higher biopsy-proven CNI toxicity was noted from group I to group III.

Conclusion: Incidence and severity of early acute rejection reduces significantly as the pre-transplant trough tacrolimus level increases. Trend towards higher nephrotoxicity with higher trough level, was noted.

doi: 10.1016/S2212-0017(11)60026-9


  22: Is mycophenolate mofetil (MMF) superior to azathioprine in live donor renal transplantation scenario? Top


K Gohel, U Hegde, S Gang, M Rajapurkar

Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India

Introduction: Mycophenolate mofetil (MMF) has replaced aza- thioprine in immunosuppression regimens worldwide to prevent graft rejection. However, evidence that its anti-rejection activity is better than that of azathioprine has been provided only by reg- istration trials with an old formulation of cyclosporine and steroid.

Aim and objectives: Previous studies like MYSS have already raised doubt about the superiority of Mycophenolate mofetil in deceased donor situation but not evaluated in live donor transplants. Therefore, we aimed to compare the outcome of these two drugs with a micro emulsion of cyclosporine and tacrolimus in live donor scenario.

Materials and methods: We, retrospectively, analyzed a total of 368 patients transplanted from January 2001 to August 2007. We divided them into two groups according to their antiproliferative regimen: Group I—who received Azathioprine, Group II—who received MMF. Their demography, immunosuppression, donor char- acteristics, surgical complications, infection, rejection episodes as well as graft and patient survival were studied.

Results: Group I had 198 patients while Group II had 170 patients. Both groups were comparable for age and gender. Primary cal- cineurine inhibitors were not different between the two groups. Group I had more grafts from related donors than Group II. More number of patients in Group II received induction therapy. Incidence of rejection, post-transplant infection, NOD, graft and patient survival were comparable between both the groups.

Conclusion: In recipients of live donor kidney transplants who were given cyclosporine microemulsion or tacrolimus, MMF probably does not offer a significant advantage over azathioprine in preventing acute rejections as well as graft and patient survival in the current series.

doi: 10.1016/S2212-0017(11)60027-0


  23: Paired exchange (swap) kidney donation in India: A five year single center experience Top


Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee

Department of Urology, Sir Ganga Ram Hospital, New Delhi, India

Introduction: Swap kidney donation is an evolving strategy for overcoming the barriers that confront patients with end-stage renal disease, when the only living potential donors who are willing to donate to them are deemed to be unsuitable as donors for them owing to an incompatibility of blood type, HLA cross-match, or both. In the swap donation, the incompatibility problems with two donor-recipient pairs can be solved by exchanging donors.

Materials and methods: Between March 2006 and June 2011, we performed 44 Swap living donor kidney transplantations.

All donor and recipient procedures were performed success- fully. ABO-incompatibility or positive lymphocyte cross-match were found in 20 pairs and 2 pairs respectively.

Results: The mean recipient age was 42.5 years (range 33-59 years). The mean donor age was 38 years (range 31-56 years).

At a median follow-up of 24 months (range: 1-59 months), graft survival rate was 100%. All patients have functioning grafts with a median serum creatinine level of 1.13 mg/dL, 1.5, 1.35 mg/dL at 3-months, 1-year, and 3-years, respectively. One patient died after 4 months of transplant, due to pneumonitis with sepsis. Allograft dysfunction was not seen in any of the recipients.

Conclusion: The Swap kidney transplantation is a medically and economically viable procedure, which can be promoted in centers with a low deceased donor transplantation rate and a high number of incompatible related donors.

doi: 10.1016/S2212-0017(11)60028-2


  24: A study to evaluate the effect of ratio of donor kidney weight to the recipient body weight on renal graft function Top


Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee

Department of Urology, Sir Ganga Ram Hospital, New Delhi, India

Introduction: The effect of kidney weight and the recipient body weight on renal functions has been studied with variable results.

Aim and objectives: To study the effect of donor kidney weight to the recipient weight on short- and long-term graft function of live donor kidney transplant.

Methods: It was a prospective study of 81 live donor kidney transplant recipients from May 2008 to June 2011, conducted at Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi. Patients were divided in 3 groups, depending on the ratio of donor kidney weight in grams to the recipient body weight in kilograms (dkw/rbw < 2, 2 to 3, and > 3 in group 1, 2, and 3 respectively). Serum creatinine in milligrams percent on the day of surgery, the 7th day, 1 month, 6 months, 1 year, and 3 years after the surgery, was recorded and their means were compared. Patients with acute tubular necrosis, sepsis, drug toxicity and graft rejection were excluded.

Results: The comparison showed that the decrease in the mean creatinine level was statistically significant in group 3 patients at 7 days and 30 days (P value 0.023 and 0.029 respectively) and did not show a significant difference at 6 months, 1 year, and 3 years.

Conclusion: The ratio of donor kidney weight to the recipient body weight does not have a significant effect on the long-term graft function, inspite of an early improvement.

doi: 10.1016/S2212-0017(11)60029-4


  25: External iliac artery polytetrafluroethylene (PTFE) graft interposition; an effective rescue procedure for kidney transplant in progressive intimal dissection Top


Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Abdul Rouf

Department Of Urology, Sir Ganga Ram Hospital, New Delhi, India

Introduction: Intimal dissection of external iliac artery is a rare but devastating event during or after renal artery anastomosis in renal transplant. This not only results in compromised blood flow to graft kidney but also jeopardizes lower limb perfusion. We share our experience of this event which was managed by PTFE graft interposition.

Aim and objectives: Our aim is to highlight the use of external iliac artery PTFE interposition graft as an important salvage pro- cedure in case of an irreparable intimal injury.

Materials and methods: Since 1987, we have performed approx- imately 3000 transplants. On five occasions, we encountered inti- mal dissection of external iliac artery just after opening the clamp following anastomosis. The dissection was too bad to be repaired. Thus, in order to salvage the lower limb and the graft kidney, we used PTFE interposition graft in the external iliac artery after detaching the kidney. The graft renal artery, then, was anastomo- sed to the PTFE graft in end-to-side manner.

Results: The use of the interposition graft has resulted in an increase in the warm ischemia time twice. All the five cases had normal postoperative course with normally perfused graft kidney and lower limb. Two patients had mild ATN in the immediate post- operative period which settled within one month.

Conclusion: It is a safe salvage procedure to save the lower limb and the graft kidney.

doi: 10.1016/S2212-0017(11)60030-0


  26: Extrapulmonary nocardiosis and perigraft abscess, managed with percutaneous drainage and antibiotics therapy Top


Ravi Angral, A Marwaha, SPS Subhramanian, A Khullar, T Kataria, RS Chahal

Kidney Hospital and Lifeline, Jalandhar, Punjab, India

Introduction: Pulmonary nocardiosis is a rare bacterial infection and may present as a localized or disseminated suppurative or granulomatous disease, leading to sever complications in renal transplant recipients. Reported cases in literature are few and rare from India. We report a case of extrapulmonary nocardiosis due to Nocardia sp. in a 28-year-old man, managed successfully with percutaneous drainage and antibiotics therapy.

Materials and methods: 28-year-old male, kidney transplant recip- ient on triple immunosuppression therapy, presented 4 months post- transplant at our hospital. Patient had a history of fever (off and on), pain in right iliac region, with inability to extend right leg. Lab investigation revealed all the parameters (Hb-11.4 g%, Tlc-8200, Platelet count-2.6 lac, s.cr-1.2 mg%, Chest x-ray), within normal limits. Ultrasound revealed 10*3*3 size collection in right iliac region, behind transplanted kidney, MRI showed thick-walled col- lection in the right Iliacus muscle 10.3*3.8*3.1 extending inferiorly into its insertion with adjoin soft tissue edema. Ultrasound guided percutaneous drainage of perigraft fluid was done and 180 mL of thick pus was drained. Pus examination showed stippled branching bacteria suggestive of Nocardia species, no AFB, fungal hyphae

was seen. Patient was prescribed a Co-trimoxazole and linezolid combination post-procedure.

Results: Treatment with TMP-SMZ and linezolid resulted in marked clinico-radiological improvement. Patient responded well to the treatment with surgical drainage and antibiotic therapy and

the condition of the patient improved at follow-up with stable graft function.

Conclusion: The morbidity and mortality associated with rarely occurring extrapulmonary nocardiasis in perigraft region can be suc- cessfully managed with percutaneous drainage and antibiotic therapy.






 

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  In this article
01: Assessment a...
02: Assessment a...
03: Autotranspla...
04: Safety and e...
05: Kidney trans...
06: Extraperiton...
07: A prospectiv...
08: A case of ea...
09: Tacrolimus-i...
10: Plasma or in...
11: Cardiovascul...
12: Improving th...
13: Anti-thymocy...
14: Evaluation o...
15: Post-transpl...
16: SWAP transpl...
17: Renal cortic...
18: Unusual pres...
19: Renal transp...
20: The outcome ...
21: Impact of pr...
22: Is mycopheno...
23: Paired excha...
24: A study to e...
25: External ili...
26: Extrapulmona...

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