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Table of Contents
ABSTRACTS
Year : 2017  |  Volume : 11  |  Issue : 4  |  Page : 208-247

Abstracts


Date of Web Publication28-Dec-2017

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How to cite this article:
. Abstracts. Indian J Transplant 2017;11:208-47

How to cite this URL:
. Abstracts. Indian J Transplant [serial online] 2017 [cited 2018 Jan 16];11:208-47. Available from: http://www.ijtonline.in/text.asp?2017/11/4/208/221857


  Monoclonal Antibody Therapy Does Not Abrogate Rejection Risk in Renal Transplant Recipients Top


Sanjeev Goswami, N. K. Mehra

All India Institute of Medical Sciences, New Delhi, India. E-mail: goswamisanjeev@yahoo.com

Background: Monoclonal antibodies are being increasingly used as therapeutic agents in medicine. Rituximab (anti-CD20) and Daclizumab (anti-IL2R±) are two such monoclonal antibodies used to prevent organ rejection; but are not fail-safe. We have analyzed the pre and post-transplant antibody profile in serum of renal transplant recipients receiving Rituximab and /or Daclizumab. Aims of Study: To evaluate impact of pre-transplant monoclonal antibody therapy in kidney allograft recipients. Methods: Study Group: Kidney recipients with acute rejection and having PRA >10% pre-transplant were selected for the study (n=11). Those with well-functioning grafts served as the control group (n=15). Serum from these recipients was analyzed retrospectively by LABScreen kits for anti-HLA class-I; class-II and anti-MICA antibodies. Result: Patients undergoing graft dysfunction showed the presence of either anti-HLA or anti-MICA antibodies or both. Acute antibody-mediated rejection was preferentially associated with the presence of pre-transplant anti-HLA and/or anti-MICA antibodies (9/11 cases; p<0.05). Pre-transplant anti-MICA antibodies alone led to hyperacute rejection in two cases and pre-transplant DSA led to hyperacute rejection in one case. Two cases that had acute rejection within 10 days post-transplant revealed anti-HLA and anti-MICA antibodies in the pre-transplant serum. Conclusion: Further analysis on Luminex has shown that de-novo antibodies post-transplant; to HLA class-I/II or MICA indicate poor prognosis and may lead to accelerated graft rejection in such cases.


  Retroperitoneal Single Port versus Transperitoneal Multiport Donor Nephrectomy: A Prospective Randomised Control Trial Top


Navdeep Singh, Deepesh Benjamin Kenwar, Sarbpreet Singh, Kunal Kapoor, Sandeep Kumar, Rakesh Chauhan, Ashish Sharma

Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: nav8203@gmail.com

Background: Over the years; laparoscopic donor nephrectomy (LDN) has evolved as a preferred alternative to open donor nephrectomy (ODN). LDN can performed either by transperitoneal or retroperitoneal route. Retroperitoneoscopic live donor nephrectomy (RPLDN) results in lesser analgesic requirement; decreased stay and better cosmetic acceptance by donors. Lumbotomy incision has been thought to be an ideal approach without any muscle being cut but is limited by the amount of space in open surgery. Aims of Study: To compare duration of surgery; perioperative pain; hospital stay and graft function in patients undergoing retroperitoneal single port vs patients undergoing transperitoneal donor nephrectomy. Methods: This was a prospective randomised controlled study done on 50 healthy kidney donors who were operated in the Department of Renal Transplant Surgery; PGIMER; Chandigarh from Jan 2016 till June 2017. Donors were randomised using a computer generated sequence. 25 donors underwent retroperitoneal LESS-DN and 25 underwent transperitoneal LDN. Patients were followed up for a period of one month. In the retroperitoneal group; Alexis wound retractor with a sterile glove rolled over its inner ring was used to create an airtight retroperitoneal compartment and fingers of gloves were used to insert the ports whereas transperitoneal nephrectomy was performed using conventional multi port technique. Result: Retroperitoneal single port nephrectomy was associated with lesser post operative pain on post operative day 0 and 1 (p=0.003); shorter duration of surgery (2.4 ± 0.4 hours versus 2.8 ± 0.6 hours; p=0.003); smaller incision size (7.8 ± 0.9 cm versus 12.40 ± 2.0 cm; p=0.00); early convalescence (7.0 ± 3.0 days versus 10.7 ± 3.2 days respectively; p=0.001) and lesser complications. There was no significant difference in both methods in terms of warm ischaemia time; duration of hospital stay and graft function. Conclusion: Retroperitoneal single site donor nephrectomy is a better method compared to transperitoneal laparoscopic donor nephrectomy as it is associated with shorter duration of surgery; lesser blood loss; lesser post operative pain and early recovery.


  Robotic Kidney Transplant: Our Initial Experience and Technique Top


Anil Kumar Gulia, A. Kumar, D. Bendapudi, R. Maheshwari

Max Super Speciality Hospital, New Delhi, India. E-mail: doctorgulia@gmail.com

Background: Kidney transplant is treatment of choice for most patients with CKD stage 5. Though open surgery is the gold standard; it has its own disadvantages like pain; wound related morbidity and inferior cosmesis. Therefore; minimally invasive surgical techniques are being established. Aims of Study: Our aim is to present our initial experience and technique of robotic kidney transplant. Methods: We retrospectively studied twenty five procedures conducted from April 2016 to July 2017. Kidney was wrapped in an ice slush jacket. The kidney was inserted into the abdomen of the recipient through a midline umbilical (19 pt.) or Pfannenstiel (6). A Gel-point port was used to seal the mid-line incision. The gel point was also used to introduce a vascular punch for arteriotomy; ice-slush and the graft. Renal arterial anastomosis was done end to side to external iliac artery and renal venous anastomosis end to side to external iliac vein. Results: The average anastamotic time was 51 minutes and mean operative time was 4.46 hours. Mean operative blood loss 120 ± 20 ml and mean blood transfusion rate of 0.72%. Mean hospital stay was 11 days. There were no conversions to open; serious complications in 8% (clavein dindo 3b and 4) and one death. There was graft dysfunction in seven patients (ATN in 4 patients and rejection in 3 patients). Mean serum creatinineat discharge; at one and 3 month was 2.2 mg/dl; 1.6 mg/dl and 1.44 mg/dl respectively. Conclusion: Robotic approach confers advantages of decreased wound morbidity and better cosmesis. It looks promising; however long term follow up of large number of patients is needed.


  Ex Vivo Lung Perfusion-Acellular and Cellular Perfusate: Indian Experience Top


Rajarajan Ganesan, Kamal Kajal, Harkant Singh, Ashim Das, G. D. Puri

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: raja2n@gmail.com

Background: The utilization rate of donor lungs is only around 21% because of less than optimal condition of the lungs. Ex Vivo lung perfusion (EVLP) can evaluate the lungs; optimize the function of extended criteria lungs and increase the time between retrieval of the lungs and their implantation. Red blood cell (RBC) usage in the perfusate of EVLP provides a physiological internal milieu.The risk benefit ratio of adding RBCs to the perfusate is yet to be demonstrated. Aims of Study: To perform Ex Vivo Lung perfusion on human donor lungs and measure the physical and gas exchange properties of the lungs when perfused with red blood cell containing perfusate and acellular perfusate. Methods: Lungs from brain dead donors which were rejected for transplant in the absence of ideal condition or the absence of a recipient were used in the study. The lungs were retrieved at the time of multiorgan retrieval after flushing with PGE1 and 5 litres of cold lung preservative solution. At the site of EVLP; the outflow cannula of the perfusion circuit was placed in the Pulmonary artery (PA) and inflow cannula in the left atrial (LA) cuff. Gradual rewarming with either acellular or RBC containing perfusate was done to 37 degC over 40 minutes. Ventilation with lung protective strategy was resumed at 32 degC. Perfusate flow of 40% of predicted donor cardiac output was targeted by increasing the flow stepwise. PA pressure was maintained below 20mmHg and LA pressure between 2-3 cm of water by adjusting the reservoir level. The dynamic compliance from the ventilator was recorded; gas analyses of LA effluent and biopsies were done every hour for the next four hours. Results: We performed EVLP on five pairs of donor lungs. Acellular perfusate was used in the first three pairs of lungs. Of them; only the second lung pair had a pre EVLP partial pressure of oxygen (PaO2) of more than 300 mmHg which is considered as ideal. All three pairs of lungs had an improvement in compliance with EVLP while the pulmonary vascular resistance (PVR) was acceptable only in the third pair of lungs. This lung pair also had a post EVLP PaO2 of 380 mmHg. RBC containing perfusate was used in the fourth and fifth pair of lungs both of which were ideal donor lungs. The target flow could not be achieved in these two pairs of lungs because of high LA pressure. The fourth pair of lungs worsened in compliance and developed pulmonary edema owing to the high LA pressure. The fifth pair of lungs had a 10% reduction in compliance and 14% increase in PVR which are acceptable for transplantation. Histopathological examination did not suggest deterioration in any pair of lungs. Conclusion: Performing EVLP with locally available components is feasible and economical. Team coordination and training is required with expertise developing over time. EVLP was successful with both acellular and RBC containing perfusate as long as the LA pressures were limited to 2-3 cm H2O.


  Donor and Recipient Outcomes in Retroperitoneal Laparoscopic Donor Nephrectomy in Obese Versus Non-Obese Donors: A Prospective Study Top


S. Jamal Rizvi, N. Garg, S. Kumar, B. C. Pal, P. R. Modi

Institute of Kidney Diseases and Research Centre, Civil Hospital Campus, Ahmedabad, Gujarat, India. E-mail: hoblingoblin@yahoo.com

Background: Obese donors are increasingly accepted for living kidney donation. Obese individuals benefit the most from minimal access surgery; however laparoscopic donor nephrectomy may be technically challenging in these individuals. Retroperitoneal laparoscopic donor nephrectomy (RLDN) in particular may be hampered by excessive perinephric fat. We performed a prospective non-randomised controlled study comparing outcomes of RLDN in obese and non-obese kidney donors. Aims of Study: To compare operative parameters; donor complications and recipient outcomes in RLDN performed in obese and non-obese donors. Methods: From June 2014 to April 2016; 200 donors underwent RLDN. Of these 160 were non-obese (group I) and 40 were obese (group II). Preoperative parameters including Body Mass Index; blood pressure; blood sugar; and estimated GFR; and operative parameters including total operative time; warm ischaemia time; and estimated blood loss were recorded. Complications were compared using the Clavien-Dindo classification. Recipient s. creatinine at day 7; 15 and 30 was compared between recipients who received grafts from obese and non-obese donors. Results: There were 17.5% right sided donors in group I and 15@ in group II. Operative time; warm ischaemia time; blood loss; length of hospital stay and complications were similar in the two groups in the two groups and there were no statisctically significant differences. S. creatinine in the recipients was similar on follow-up. Conclusion: RLDN is safe and efficacious in obese donors. It gives all the benefits of minimal access surgery without compromising on recipient outcomes.


  Introduction of Laparoscopic Live Donor Nephrectomy: Challenges; Outcomes and Success Strategies Top


Yusuf Saifee, Sushil Bhatia, C. S. Chamania, Jai Kriplani, Pradeep Salgia, Achal Sepaha

Choithram Hospital and Research Centre, Indore, Madhya Pradesh, India. E-mail: yusuf.saifee@gmail.com

Background: Laparoscopic live donor nephrectomy (LLDN) is the standard of care at high-volume renal transplant centres; But the wide acceptance of LLDN is hindered by safety concerns during learning curve. At our institution; we adopted an approach that allowed us implementation of laparoscopic live donor nephrectomy without increased donor morbidity or graft failure; even during the early portion of a learning curve. Aims of Study: To present initial experience; outcome and success strategies with laparoscopic live donor nephrectomy at a smaller transplant centre. Methods: At our institute; a dedicated team of laparoscopic; urologic and transplant specialists worked together to introduce the laparoscopic live donor nephrectomy. All surgeons had some prior laparoscopic experience either in laparoscopic general surgical procedures or laparoscopic simple nephrectomy. Detailed review of literature was done and unedited videos from the pioneering institutions were viewed by all members of the team and a operative protocol was developed. Few modifications to the standard approach were introduced to maintain donor safety and graft function even in the learning curve. Also a cost saving model was adopted to avoid significant increment in procedure cost. Fifty transperitoneal Left laparoscopic live donor nephrectomy. Performed between January 2017-July 2017 were evaluated prospectively. Demographic characteristics of the patients; operative and postoperative data and complications were evaluated. Results: 37 female and 13 male patients with ages ranging from 28 to 60 years underwent left sided LDN. Eight patients had two; and one patient three renal arteries. Mean operation time was 115 (90-150) minutes; and Mean warm ischemia time 81 (70-140 sec) seconds. Mean hospital stay was found to be 2.5 ± 0.5 days. No patient required conversion to open surgery because of intraoperative complications. In all cases blood loss was low (20-100 ml) and therefore did not require transfusion. No major perioperative or postoperative complications occurred. The mean serum creatinine level of the recipients at discharge time and the last follow-up visit was 1.39 mg/dL and 1.21 mg/dL; respectively. Conclusion: We propose that with a team approach and few technical modifications; introduction of laparoscopic live donor nephrectomy becomes safe and easy especially at a smaller transplant centre or those with limited experience.


  Expanded Criteria Deceased Kidney Donor Outcome: Our Experience Top


Yajvender Rana, Aditya Pradhan, Ashish kumar, Harish Sinha

BLK Super Speciality Hospital, New Delhi, India. E-mail: ypsingh_udr@rediffmail.com

Background: As the cases of ESRD are increasing so as the need for Kidney transplant. To ameliorate the gap between waiting list and the suitable donors; the need of hour is to increase the available donor pool and optimising the outcome of the kidney transplant done from the Expanded criteria deceased kidney. Aims of Study: To study the outcome of kidney transplant from expanded criteria Donor (ECD) and to find out the possible implication of graft biopsy for optimal allocation of single vs dual kidney. Methods: Retrospective analysis of total 25 cadaveric cases done from sep 2012 to April 2017. Hospital records of 17 Expanded criteria donor were looked into and all patients were approached telephonically for the information. Results: Median followup of cases was 36 months (4-54 months). Out of 25; 17 cases were the expanded criteria donors (68%). Most common cause of Brain stem death in ECD was Intracranial haemorrhage and uncontrolled hypertension. Mean donor age was 68.3 (62-74 years). Mean recipient age was 48.17 (28-65 years).mean creatinine at time of harvest was 1.4 (0.8-1.8). Mean cold ischemia time was 7 hrs (3-18 hrs). Graft biopsy was done in all kidneys harvested at our centre and Remuzzi criteria used for allocation of single vs dual kidneys. Mean creatinine at 3 months was 1.74 (0.9-2.9 mg%). one case had primary graft dysfunction and 3 died because of infection and sepsis. Conclusion: The minimising the cold ischemia is imperative for ECD kidneys. We found graft biopsy at time of organ harvest is feasible and helpful for proper organ allocation and improves overall outcome.


  Simultaneous Pancreas-Kidney Transplantation in a Tertiary Care Centre in India: A Case Series Top


U. R. S. Vishnu Dev, George Kurian, Rajesh R. Nair, Anil Mathew, Zachariah Paul, Sandeep Sreedharan

Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: vishnudevurs@yahoo.com

Background: Type 1 Diabetes Mellitus and Diabetic Nephropathy offers a therapeutic challenge. Simultaneous Pancreas-Kidney transplantation offers a therapeutic option in the treatment of these patients; and would go a long way in improving their quality of life. Aims of Study: To analyse the outcome of six simultaneous pancreas-kidney transplants conducted at Amrita Institute of Medical Sciences and Research Centre; Kochi. Methods: Retrospective observational; cross-sectional study; involving analysis of six simultaneous pancreas-kidney transplants from August 2014 to July 2017; at Amrita Institute of Medical Sciences; Kochi. Results: Six patients underwent SPKT. Mean age was 33 years. One patient had positive cross match and was treated with 1 session of centrifugal PP; IVIg and Alemtuzumab. Triple immuno-suppression was given. Two patients had DGF in immediate post operative period and required surgical re-exploration due to bleeding complications. Three patients had episodes of rejection (two-ACR+AMR; one-AMR); 2 had acute tubular injury. Infections encountered were urinary tract infections; varicella zoster and tuberculosis. All had normal graft functions at 1 month post transplant. One patient had 2 rejections and graft loss. Steroids were tapered and stopped. None had pancreatic graft rejection. They did not require insulin or oral hypoglycemic agents. Conclusion: SPKT is the best therapeutic option in patients with ESRD due to Diabetic Nephropathy in Type 1 Diabetes Mellitus. Surgical complications is a limiting factor. However; the overall results are promising and would provide a better quality of life in these patients.


  Low Dose Alemtuzumab; Steroid Free Regimen and Early Switch to Advagraf and Azathioprine in Kidney and Simultaneous Pancreas-Kidney Transplantation: Notes from a Single Centre Top


Anil Vaidya, Dinesh Babu, Raja Mahesh, Anil Vaidya

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: Alemtuzumab induction allows for steroid free immunosuppression in the post operative period. We demonstrate the use of low dose Alemtuzumab and an early switch to once a day tacrolimus and azathioprine in kidney and simultaneous pancreas-kidney (SPK) transplantation. We explored the efficacy of two markers that may enable a safe switch after 3 months of standard therapy: a. Stable levels on the same dose of tacrolimus and b. presence of mutations in the CYP 3A4 and the TPMT gene. Aims of Study: To evaluate the safety and efficacy of low dose alemtuzumab coupled with an early switch to once a day tacrolimus and azathioprine in kidney and SPK transplant using a biochemical and genetic marker. Methods: Data from kidney and SPK transplant recipients receiving low dose alemtuzumab and having an early switch to once a day tacrolimus and azathioprine were recorded prospectively. The switch was done at 3 months post transplant in stable patients and grafts. Data collected included demographics (age/sex); type of transplant; preoperatively assessed CYP-3A4/TPMT gene mutation; mean tacrolimus level at 3 months; evidence of infection/rejection in the first 3 months before the switch; mean creatinine at 3 months; rejections/infections after the switch. Evidence of leucopenia requiring stoppage of azathioprine and/or requirement of a colony stimulating factor. Results: From June 2015 to June 2017; 32 patients underwent a kidney or a SPK transplant with low dose Alemtuzumab and early (3 month) switch to once a day dosing of tacrolimus and azathioprine. Majority were male patients (62%) with a mean age of 38 (range 22-55). Ten patients (30%) were extensive metabolisers of the CYP-3A4 gene mutation requiring 1.5-2 times the normal dose of tacrolimus at the start with stable dosing of tacrolimus in the past 6 weeks leading up to the switch. Five patients demonstrated low TPMT activity. Mean tacrolimus level at the time of the switch was 8 ng/ml (range 7-9 ng/ml) with a dose of 3 mg bd (range 2 mg-3.5 mg bd). None had demonstrated evidence of rejection in the first 3 months. Two patients had a bacterial infection (UTI and wound infection). Mean creatinine at 3 months was 1 mg/dl (range 0.6-1.2 mg/dl). One of the 5 patients with low TPMT had neutropenia requiring GCSF and stoppage of azathioprine. Conclusion: An early switch to once a day dosing of tacrolimus and azathioprine is a safe and effective protocol in selected patients undergoing kidney and SPK transplantation. The switch should be considered in selected patients that have stable dosing of tacrolimus and known CYP-3A4; and TPMT gene mutations.


  Risk Factors for New-Onset Diabetes Mellitus after Living Donor Kidney Transplantation in a Tertiary Referral Center in Eastern India: “A Prospective Single Center Study” Top


Manoj Gupta, Pratik Das, Deepak Shankar Roy, Rohit Rungta

Rabindranath Tagore International Institute of cardiac Sciences, Kolkata, West Bengal, India. E-mail: manojsrmc@gmail.com

Background: New onset diabetes after transplantation (NODAT) is a common and serious complication of renal transplantation and is associated with poor patient and graft survival rates. A number of factors affect the development of NODAT such as high body mass index (BMI); calcineurin inhibitors; corticosteroids; old age; family history of diabetes; hypomagnesemia and cytomegalovirus infection. However; data on the risk factors for NODAT in Indian transplant populations are lacking. Aims of Study: Analysis of pre-transplant risk factors of NODAT in renal allograft recipients with special consideration on unconventional and newer risk factors. Methods: We prospectively reviewed patients; who underwent living donor kidney transplantation at Rabindranath Tagore International Institute of Cardiac Sciences; Mukundapur; Kolkata between July 2014 to June 2016. Patients were excluded if they; 1) were younger than 18 years of age; 2) were diagnosed with diabetes before transplantation and 3) developed graft loss or patient loss within 1 month of transplantation. Patients were classified as having a diagnosis of diabetes within 1 year or not. This study was approved by the Ethics committee of our institution. A diagnosis of NODAT was defined according to the American Diabetes Association criteria All patients included in the study group underwent evaluation for the risk factors for NODAT during one year post transplantation follow-up. All pre-transplant risk factors were evaluated at the end of the study to assess their strength of associations. All the above variables further compared with non NODAT post-transplant recipients. Results: 100 patients were included in the study. Of these; 24% (19 male and 5 female) developed NODAT at 1 year post-transplant. 19 (79%) patients developed NODAT within 3 months of transplantation. There were no statistical differences in sex; polycystic kidney disease; between two groups. Older age; high BMI; family history of diabetes; prediabetics; dyslipidemia were more associated with NODATABO incompatible transplants were more associated with NODAT (p = 0.0282). In correlation between pretransplant Homeostasis model assessment of insulin resistance (HOMA-IR) and the development of NODAT; the point Biseriel correlation coefficient was + 0.52 and p < 0.001. Higher HOMA IR values in patient who developed NODAT. Conclusion: NODAT is a multifactorial disease. Besides conventional risk factors the new risk factors like hypomagnesaemia; prediabetes; perioperative hyperglycemia; insulin resistance (high HOMA IR) are also associated with increased risk of NODAT.


  Effect of Sofosbuvir Antiviral Therapy on Pharmacodynamics of CSA and Tacrolimus in Kidney Transplant Recipients Top


Raj Kumar Sharma, Suresh Reddy, Narayan Prasad, Amit Gupta, Anupma Kaul, Dharmendra Singh Bhadauria

Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: rksharma@sgpgi.ac.in

Background: Direct acting antiviral drugs can affect drug levels of CNIs by increasing their clearance. Pharmacokinetics of CNI drugs need to be studied while transplant patients are on Sofosbuvir to see effect on AUC as decresed exposure to immunosuppression can precipitate rejection. Aims of Study: To assess the effect of sofosbuvir used to treat chronic hepatitis C viral (HCV) infection in kidney transplant recipients on pharmacokinetics of calcineurin inhibitor (CNI) drugs. Methods: Ten patients having chronic HCV infection in kidney transplant recipients were included in the study. All received Sofosbuvir and Ribavirin combination therapy. The virological response to therapy was studied. Area under the curve and pharmacokinetic data of levels of CNI were compared while the patients were receiving sofosbuvir and ribavirin drugs to AUC while they were not on these drugs. Results: Nine (9/10) patients achieved rapid virological response (RVR) with undetectable HCV RNA at 4 weeks (90%) and the remaining 1 patient got undetectable HCV RNA at 8 weeks. The sustained virological response (SVR3) at 3 months and at 6 and 12 months (SVR6; SVR12) was seen and maintained in all the 10 patients (100%). The important aspect of the study is the effect of treatment with the sofosbuvir - ribavirin combination regimen on the CNI AUC levels with reduction in CNI AUC resulting in all patients requiring increase in the dose of CNI (tacrolimus and cyclosporine) used as a part of triple drug immunosuppression. AUC for tacrolimus was 108.83 ± 24.29 ng.h/mL before starting sofosbuvir which decreased to 85.51 ± 18.25 ng.h/mL within 7 days of staring the antiviral treatment with sofosbuvir ( p=0.001). AUC for cyclosporine was 2584.2 ± 141.7 ng.h/mL before starting sofosbuvir which decreased to 1409.6 ± 130.5 ng.h/mL within 7 days of staring the antiviral treatment with sofosbuvir (p=0.084). Conclusion: There is need of close CNI level monitoring and dose adjustment with sofosbuvir therapy. With sofosbuvir therapy and viral clearance; there could be reduction in CNI levels due to increased clearance of the CNI drugs.


  Outcome of Renal Transplant Arterial Anastomosis: Internal Iliac Artery versus External Iliac Artery with Spatulation Based on Poiseuille's Law: A Prospective Randomized Controlled Study in a Single Centre Top


N. Arjun, Sandeep Puvvada, Prasad Mylarappa

M.S. Ramaiah Medical College, Bengaluru, Karnataka, India. E-mail: arjunn8@gmail.com

Background: Results of kidney transplantation have dramatically improved during the past 3 decades due to refinements in surgical instruments; new immunosuppressive regimens; improved kidney preservation; and advances in antimicrobial therapy. However; The principles of the vascular anastomosis technique proposed by Carrel in 1902 and the accomplishment of the implantation in the iliac vessels by Kuss in 1951 are still in use. There are scarce data comparing vascular anastomosis techniques. Aims of Study: Compare outcomes of renal transplant with two types of arterial anastomosis to the internal iliac artery in end to end or external iliac artery by end to side with spatulation of donor renal artery. Methods: A prospective study of 45 patients with end-stage renal disease who received a kidney transplant from a live related donor were randomized into two groups in order to undergo either end-to-end anastomosis to the internal iliac artery (group 1) or end-to-side anastomosis to the external iliac artery with spatulation (group 2) based on Poiseulle's law. Length of arterial anastomosis; cold ischemia time; hospital stay; serum creatinine level; recovery of urinary output; and surgical and clinical complications during hospitalization were evaluated. After 3 years; in the patients with a functioning allograft; creatinine clearance measure; Colour Doppler ultrasonographic study; overall survival; graft loss; and erectile function were compared between the two groups. Results: Postoperative analyses showed better recovery of urinary output (P = .39) and creatinine (P = .95) in end-to-side anastomosis of the external iliac artery with spatulation compared to end-to-end anastomosis of internal iliac artery. Better results were seen in clinical (P = .55) and surgical (P = .80) complications or in hospital stay (P = .90) in end-to-side anastomosis of the external iliac artery with spatulation. The total study period was 5 years. The 3-year follow-up demonstrated better results in Colour Doppler ultrasonography results; creatinine clearance (P = .80); patient survival (P = .22); and graft loss (P = .72) in patients who underwent end-to-side anastomosis of the external iliac artery with spatulation. Erectile dysfunction was less in group 2; compared to group 1. Conclusion: End-to-side anastomosis to the external iliac artery with spatulation had better outcome in Colour Doppler ultrasonography results; creatinine clearance; patient survival and graft loss than end-to-end anastomosis to the internal iliac artery. Erectile dysfunction was less in group 2.


  Split Liver Transplantation: Our Initial Experience Top


Suchet Chaudhary, Mitul Shah, Vikas Patel, Vaibhav Sutariya, Pranjal Modi

IKDRC-ITS, Ahmedabad, Gujarat, India. E-mail: drsuchetchaudhary@gmail.com

Background: In view of ever increasing bulk of liver cirrhosis or failure necessitating transplantation. Deceased donor (whole liver) and living donor liver transplantation is unable to level the demand supply and divide. Split liver transplantation seems the probable answer to this dilemma. Aims of Study: Feasibility of split liver transplant as a method comparable to whole graft transplants. Methods: We have done 6 split livers transplantation at IKDRC-ITS since 2014. Demography of donors and recipients were evaluated. Outcomes were studied. Result: Mean donor age was 33 years. Mean recipient age for left lobe graft (3) 9 years and right lobe graft was 30 years. One and three months survival is 66% and 50% respectively.We have found the surgical complications are more with left lobe than right lobe graft in terms Biliary complications; non function of graft and PVT. Conclusion: Split liver transplantation seems an apt method to increase the donor pool and if used in well selected criteria donors along with short CIT and appropriate sized recipients can yield results comparable to whole graft transplants.


  Bilateral Pheochromocytoma in a Patient on Haemodialysis: Difficulties and Dilemmas in Diagnosis and Management Top


Sanand Bag, Urmila Anandh1

Departments of Urology and 1Nephrology and Renal Transplant, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India. E-mail: sanandbag@gmail.com

Background: Pheochromocytoma; a rare adrenal tumor secreting catecholamine; 0.2 to 0.6% of hypertensive patients. Pheochromocytoma is rare in ESRD; bilateral is extremely rare (few case reports). Diagnostic tests like plasma metanephrine; catecholamines may be falsely elevated due to haemodynamic instability during dialysis. Urine metanephrine can be evaluated in oligo-anuric patients. Surgical treatment is curable; but removing both adrenals poses risk to face crisis; and thus is debatable. Aims of Study: We report a case of bilateral pheochromocytoma in ESRD. Various diagnostic difficulties and dilemmas in management of bilateral pheochromocytomas in ESRD with unique considerations are discussed. Methods: 35 years lady of ESRD; with respiratory distress (oliguria; fluid overload) on haemodialysis was being evaluated for kidney transplant. She had 2 years history of uncontrolled hypertension on 4 drugs; with episodic acceleration (210/100 mmHg); palpitation; headache. Abdominal sonography revealed right adrenal lesion which on MRI shown a 4x3 cm enhancing solid mass; bright on T2 image. Left adrenal was also bright; but no lesion was noted. Plasma metanephrine; catecholamine levels were marginally elevated; cortisol level normal. MIBG scan showed increased metabolic activity in both the adrenal glands with no extra-adrenal uptake. After stabilization with intense haemodialysis; thorough evaluation; endocrinologist's consultation; preoperative preparations (alfa blockade; volume expansion with Starch and Gelofusin) surgical excision of adrenals was planned. Result: Details of pros and cons of bilateral vs only right adrenalectomy in terms of blood pressure control and risk of hypoadrenalism; Conn's Syndrome and subsequent need for physiological reaction to operative (transplant) stress; post-transplant infections etc was analysed in a debate. Following consensus; Right Laparoscopic Adrenalectomy was performed; with uneventful recovery. Per-operative surge of hypertension was managed by NTG infusion in intensive unit. Histopathology of the excised 4x3 cm encapsulated solid mass revealed typical Gel Ballon appearance of pheochromocytoma. Blood pressure is well controlled with 2 drugs; maintained on regular dialysis for last 1 year. Due to lack of suitable donor (O+ve) in family [mother 60 years; GFR 65ml right kidney 25ml; X-match positive with husband] she is waiting on deceased donor organs waiting list. Catecholamines levels on follow up has decreased. Conclusion: Pheochromocytomas in ESRD patients pose difficulty in diagnosis; biochemical work up; proper imaging. Bilateral ones pose dilemmas in therapeutic options due to subsequent challenges; pending physiological crises (hypotension during dialysis; transplant; infections) thus needs critical analysis.


  Early Post Transplant Anuria Managed by Endovascular Intervention Top


Hardik Patel, M. M. Rajapurkar, Suhas Lele, Umapati Hegde

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: hrdik_patel@yahoo.com

Background: Renal transplantation after long term hemodialysis has been associated with increased perioperative vascular complication. Aims of Study: None; this abstract is for video. Methods: None; this abstract is for video. Result: Patient with external lilac stenosis was managed well will the timely endovascular intervention. Conclusion: Experience of this patient who underwent renal transplant after 18 yrs on MHD thought us that this patient are high risk for postoperative vascular complication. Early diagnosis and timely intervention can improve the outcomes dramatically.


  Double Whammy!! Top


Srinivas Nalloor, C. B. Keshavmurthy, Sundar Sankaran

Apollo BGS Hospitals, Mysuru, Karnataka, India. E-mail: nallooris@yahoo.com

Background: To present an unusual cause of deep vein thrombosis in a patient suffering from Alport's Syndrome who had a successful kidney transplant. Aims of Study: To highlight an unusual cause of deep vein thrombosis in post-kidney transplant setting. Methods: 23y old male presented with hearing defect at the age of 15 years. He was diagnosed to have Alport's Syndrome based on presence of typical sensorineural deafness; lenticonus; and microscopic hematuria. He progressed to develop CKD and at the age of 19 years reached ESRD and was started on hemodialysis. Mother aged 40y was identified as kidney donor. She also was identified with the same mutation but with no kidney involvement in the pre-transplant workup stage. Thus chances of anti-GBM disease in the immediate post-transplant period was less. Successful kidney transplant was done in October 2014 and he maintained stable allograft function in the post-transplant period. In November 2015; he presented with vague left sided groin pain. MRI done ruled out AVN of head of femur. However doppler picked up deep vein thrombosis involving left common iliac vein. Further evaluation in consultation with Cardiologist confirmed May-Thurner Syndrome. Result: This arises as a result of hemodynamically significant compression of left common iliac vein between the vertebral body and the right common iliac artery. In this case; it was probably precipitated by the procoagulant effect of immunosuppressant medications. He underwent successful venous angioplasty and intravascular stenting followed by long term anticoagulation and anti-platelet medication use. 2 years since the procedure and 3 years since kidney transplant; he is doing well with stable allograft function. Conclusion: Patient with syndromic cause of ESRD developing syndromic cause of DVT; probably aided by procoagulant nature of immunosuppressant medications.


  Kidney Transplant in HIV Infected Patients: Our Experience Top


Sanand Bag, Bhumika Pradhan1, Munish Chauhan1, Sai Ram Reddy1

Kidney Disease and Transplantation, Sanand Max Super Speciality Hospital, Mohali, Punjab, 1Department of Nephrology, Yashoda Super Speciality Hospitals, Hyderabad, Telangana, India. E-mail: sanandbag@gmail.com

Background: Use of highly active antiretroviral therapy (HAART) has markedly reduced mortality and morbidity in patients infected with human immunodeficiency virus (HIV). Numbers of HIV-positive patients with end-stage kidney disease requiring dialysis is progressively increasing. Kidney transplantation; once contraindicated in HIV patients; has become an effective alternative. Aims of Study: We present our experience of successful kidney transplant on 4 HIV patients and discuss key issues in the management of such complex cases of kidney transplant in Indian scenario. Methods: Four HIV positive male patients on dialysis; aged 30-45 years; underwent successful kidney transplant between Dec 2013 and Nov 2016. Negative Viral RNA; CD4 Lymphocytes >200 and operative fitness were minimum requirements. Antiretrovirals was stopped 3 days before transplant and resumed after complete post-operative recovery (by 2 weeks). No induction agent used - managed with high dose methyl-prednisone; later on predniosone with gradual tapering doses. Rest of the protocols was like standard kidney transplant. One patient with prior history of tuberculosis was given INH prophylaxis for 6 months. Patients were advised to stay nearby hospital for stringent follow up for 3 months; then were followed every 3 to 6 monthly with overall health; renal function; CD4 counts; viral RNA; immunosupression dose; drug levels; any infection or event. One patient from abroad was following with referring physician who was corresponding with us over e-mail regarding patient's health and reports. Results and Discussion: All 4 patients had normal recovery, discharged by 7-10 days with average serum creatinin of 1.1. Standard tripple immunosupression was used. Tacrolimus doses was titrated according to serum level; reduced every month till maintainance desired level 4-6 ng after 3 months. Steroid also tapered by 5mg per week to maintainance prednisone dose of 5 mg. One patient developed loose stools; rhabdomyolysis and refractory hyperkalemia leading to brady-arrhythmia and circulatory arrest; despite normal renal function in 3rd week - successfully managed by immediate intubation; ventilatiory support; continued cardiac resuccitation; dialysis and intensive care. One patient had severe pancytopenia at 3 years post transplant due to? fungal infection responded to caspofungin treatment and reduction of immunosupression doses. Rest are healthy with stable graft function (average Creatinin 1.3) and well controlled HIV (negative viral RNA) till median follow up of 3.5 years. Conclusion: Kidney transplant is safe; better alternative to dialysis in selected patients; with midterm patient and graft survival similar to that of HIV-negative recipients. Complex drug Interactions; high rate of acute rejection; HCV and opportunistic infections; cardiovascular risk are important issues.


  Role of Everolimus in Liver Transplant Recipients with Calcineurin Inhibitors Toxicity Top


Mitul Shah, Suchet Chaudhary, Vikas Patel, Vaibhav Sutharia, Pranjal Modi

Institute of Kidney Diseases and Research Centre, Institute of Transplant Sciences, Ahmedabad, Gujarat, India. E-mail: shahmitul68@gmail.com

Background: Calcineurin inhibitors (CNI) are the standard of care for immunosuppression in liver transplant; but there is risk of adverse events with long-term CNI use especially nephro; neurotoxicity justifying alternate treatment regimens like combination therapy of CNI with inosine monophosphate dehydrogenase inhibitor mycophenolic acid or mammalian target of rapamycin (mTOR) inhibitors. Everolimus is an mTOR inhibitor with a favourable adverse effect profile and proven efficacy in liver transplant. Aims of Study: To explore the use of combination therapy of reduced dose Tacrolimus and Everolimus or Everolimus monotherapy in patients of liver transplant with CNI induced nephrotoxicity or neurotoxicity. Methods: The observational study was performed on a convenient sample of 16 consecutive patients with CNI induced nephrotoxicity or neurotoxicity who underwent liver transplant at IKDRC-ITS; selected retrospectively from 2007-10/08/2017 in whom Everolimus was used either alone or in combination with reduced dose Tacrolimus. The outcome variables were indication for starting everolimus; kidney function; rejection rate; side effects of everolimus. Result: Commonest indication for starting everolimus was CNI induced nephrotoxicity; followed by neurotoxicity. Patients on combination therapy had better kidney function and comparable rejection rates. Dyslipidemia due to Everolimus warranted dose reduction in two patients and withdrawal of drug in one patient. Conclusion: Everolimus is an emerging immune suppressant in patient with CNI induced nephrotoxicity and can be used in combination with tacrolimus.


  Complex Vascular Anatomy in Retroperitoneoscopic Donor Nephrectomy and Renal Transplantation Top


Bipin Chandra Pal, Pranjal R. Modi, S. J. Rizvi

Institute of Kidney Diseases and Research Centre, Institute of Transplantation Sciences, Ahmedabad, Gujarat, India. E-mail: drbipincpal@yahoo.com

Background: Donor nephrectomy is a challenging surgery as it deals with a normal person. Simple vascular anatomy is considered while performing laparoscopic donor nephrectomy. However with increasing experience and expertise kidneys with complex vascular anatomy can be considered for laparoscopic donor nephrectomy. Aims of Study: To study the surgical outcome of retroperitoneoscopic donor nephrectomy in complex renal vascular anatomy. Methods: Data of 1520 donors who underwent Retroperitoneoscopic donor nephrectomy between Sep 2004 â€"Dec. 2016 were retrospectively analyzed and parameters of O.T; WIT; blood loss and complications were studied in them. Result: Mean age of the donors was 48.5 ± 10.5 yrs. Mean BMI was 23.61 ± 4.76kg/m2. Multiple arteries were observed in 216 donors. Multiple veins were observed in 66 donors. Mean O.T (min.) was 132.62 ± 59.47 and 225.20 ± 85.28 respectively in donor having single vs. multiple arteries. Mean WIT (secs.) was 178.58 ± 67.7 and 225.20 ± 85.28 between the two groups. Mean O.T (min.) was 133.70 ± 59.99 and 141.08 ± 49.35 in single vs. multiple veins.Mean WIT (sec.) was 182.56 ± 71.14 and 250.65 ± 73.73 respectively in the two groups. Statistically significant difference was observed for O.T and WIT in single vs. multiple arteries while only for WIT in single vs. multiple veins.Two graft loss were seen in the multiple artery group. Conclusion: Retroperitoneoscopic donor nephrectomy is safe in donors with complex vasculature in experienced hands. It helps to increase the donor pool.


  Long Term Renal Outcome of Marginal Kidney Donors Top


Nidhi Aggarwal, Anupam Majumdar, Deepak Shankar Ray, Sharmila Thukral

Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India. E-mail: docnidhi21@yahoo.com

Background: Disparity between the number of available donors and number of patients in the transplant waiting list has forced many transplant centres across the world to use marginal living kidney donors to expand the donor pool. However; there is not enough scientific data to quantify the long term risks involved with such donation. Aims of Study: Evaluation of long term renal outcome of marginal kidney donors. Methods: It was a retrospective study conducted in the department of Nephrology at Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata. Records of all renal transplants between July 2007 and December 2011 were reviewed. A donor was defined as marginal if age at the time of donation was >60 years or if in donors with age <60 years; there was presence of any co-morbidity such as impaired glucose tolerance; hypertension controlled with single anti-hypertensive agent; obesity (BMI >30 kg/m2); nephrolithiasis (>1.5 cm single calculus) or cured malignancy. All marginal donors who had donated kidney at least 5 years back were contacted. Those who consented for the study underwent evaluation of their recent renal function by a single outpatient visit. The parameters assessed were BMI; blood pressure; creatinine; eGFR by Cockroft Gault formula; urine routine and microscopy; and urinary albumin creatinine ratio. They were also enquired for any cardiovascular event since donation. Result: There were total 90 marginal donors. Sixty-nine donors or their families were successfully contacted. At the time of donation; mean age was 58.9 ± 7.7 years and majority (66.7%) were females. Mean creatinine and eGFR were 0.78 ± 0.12 mg/dl and 81.2 ± 7.06 ml/min/1.73 m2 respectively. 63.8% marginal donors were >60 years of age; 50.7% were hypertensive and 7.2% had microalbuminuria at the time of donation. No donor had impaired glucose tolerance; nephrolithiasis or obesity. Four donors (age range 65-70 years) had died 5 to 10 years after donation. Present assessment of remaining 65 marginal donors revealed that the mean duration after kidney donation was 7.2 ± 1.5 years. 78.5% were hypertensive with mean BP of 140 ± 7/87.6 ± 5 mm Hg. 32.3% had developed diabetes. Mean creatinine was 1.1 ± 0.11 mg/dl and eGFR was 58.8 ± 7.9 ml/min/1.73 m2 with 60% having eGRF <60 ml/min/1.73 m2. 90.8% had microalbuminuria and none had macroalbuminuria. 19.8% had experienced a major cardiac event. Conclusion: Long term outcome of marginal donors is satisfactory and they may be considered for kidney donation to expand donor pool. A prospective follow-up and assessment of outcomes of marginal donors comparing them to standard donors is warranted.


  Donor Blood Group Plasma Sans Plasmapharesis in Abo Incompatible Transplant: An In vitro and In vivo Study Top


Prashant Rajput, Rajeev Nikte, Zaheer Virani, Hepal Vora, Pavan Deore, Hitesh Gulhane, Ashwinee Hotkar, Bharat Shah

Department of Transfusion Medicine, Institute of Renal Sciences, Global Hospital, Mumbai, Maharashtra, India. E-mail: drprashantr@yahoo.com

Background: ABO incompatible (ABOi) kidney transplant was previously considered to be an absolute contraindication to transplantation are now being performed with increasing frequency. Although ABO blood group antigens are regarded as RBC antigens they are actually secreted and are soluble in plasma. This soluble ABO antigen in the donor plasma combines with the recipient's antibody to reduce the titres. Aims of Study: To study the efficacy of donor blood group plasma infusions in-vitro and in-vivo to reduce ABGAT post PEX. Methods: In Vitro study- A set of 3 samples of 5 ml each of blood group O was taken and baseline ABGAT titers were measured. Corresponding 0.5 ml; 1 ml and 2 ml of Blood group O (Control group); saline (Control group) and donor (B) blood group (Test Group) plasma was added after removing equimolar quantity to keep volume constant at 5 ml. These were incubated at 37 degree Celsius for 2 hours and the ABGAT measured. (Column agglutination technique-semi automated Ortho-Bio Vue system) In Vivo study- This is retrospective study of 10 ABOi kidney transplant recipient transplanted at our center from March 2014-July 2017. Those with titers >1:64 were included. Group A (Historical Controls n=5) received PEX as a part of ABO desensitization (Plasmalyte A; Albumin and Fresh frozen plasma of AB Blood group). Group B (Test group n=5) included patients who received PEX (plasmalyte-A; Albumin and 500 ml of donor blood group plasma). Result: In Vitro study-The baseline titre of O blood group was 1:512; on addition of 0.5 ml; 1 ml and 2 ml plasma of blood group O and saline after removing same quantity to keep volume at 5 ml was incubated at 37 degree Celsius the Anti B titers remained 1:256 at all levels of volume replaced. On addition of donor blood group was significant as compared to the control group. In Vivo study-Both the groups were matched for age; sex and etiology of chronic kidney disease. In group A the mean baseline ABGAT (IgG) titre was 1:320 (1:64-1:512) and the mean pre transplant titers were 1:11.2 (1:4-1:16). The mean number of PEX was 5.4 (4-9 sessions). In group B the mean baseline ABGAT (IgG) titers was 1:435 (1:128-1:1024) and the mean pre transplant titers was 1:10 (1:14-1:16). The mean sessions of PEX was 4.2 (2-6). Conclusion: In our study both In-Vitro and In-vivo use of donor blood group plasma significantly reduce ABGAT titers with lesser sessions of PEX in patients even with higher baseline ABGAT.


  Clinical Impact of Pretransplant DSA Levels Measured by Luminex Method with Graft Outcome at 1 Month and 3 Months in Live Donor Renal Transplant Patients Top


Vikas Bharti, Mayuri Trivedi, J. Kothari, R. Sirsat, Alan Almeida

P.D. Hinduja Hospital and MRC, Mumbai, Maharashtra, India. E-mail: vksbharati@gmail.com

Background: Whereas CD C x-match positivity is an absolute contraindication to kidney transplantation; the clinical relevance of DSA detected by Luminex technology in patients with CDC x-match negative still remains unclear. Identification of DSAs in the pre-transplant sera can be linked with increased immunogenic graft loss; even with negative CDC. The degree of MFI that is clinically relevant is still obscure. Hence this study was planned to evaluate DSA detected by luminex in relation to graft outcome. Aims of Study: To correlate pre transplant DSA (MFI values) by Luminex method with graft outcome at 1 month and 3 months of post-transplant. Methods: Prospective and retrospective observational study; During the period of January 2015 to August 2016. Total 81 patients were enrolled in the study. All patient's pre transplant cross match was done 24 hours before the transplant surgery and baseline DSA levels (MFI values) were noted. Luminex method was used for pre transplant cross match. These patients were followed up for the next 3 months and their Sr.creatinine was noted at discharge; 1 month and 3 months post-transplant. Sr. creatinine and biopsy proven acute antibody mediated rejection were considered as graft outcomes in this study. Result: There was a preponderance of males as the recipients (males=80.35%) and females0 as the donors (75%). Parental donors were the most common category of donors followed by spousal donors. The most common blood group of the recipients was Group B followed by Group A. The history of previous sensitisation was available in 33 recipients with prior blood transfusion for anaemia being the most common cause of sensitisation. 25 patients required renal biopsy in the first three months due to renal dysfunction. 13 patients had acute cellular rejection on biopsy whereas Acute Humoral rejection or Antibody Mediated Rejection was seen 2 patients. Pre-transplant DSA detected by Luminex method (MFI) shows inconclusive correlation with graft functioning as determined by Sr. creatinine at discharge (Class1 rs = 0.032; Class 2 rs = - 0.167); at 1 month post-transplant (Class1 rs = 0.00022; Class 2 rs= - 0.176) and at 3 months post-transplant (Class1 rs = 0.0778; Class 2 rs= - 0.1110). Conclusion: The present study concludes that pre-transplant DSA detected by Luminex (measured by MFl) had no statistically significant impact on the graft function (serum creatinine).


  Renal Transplantation in HIV Positive Patients: Our Experience at Indraprastha Apollo Hospitals; New Delhi; India Top


D. K. Aggarwal, Vijaya Rajkumari, Aditya Agarwal, Afaque Manzar, Nalin Nag, Sonia Mor

Indraprastha Apollo Hospitals, New Delhi, India. E-mail: drdkagarwalindia@gmail.com

Background: HIV infection is a major health problem worldwide. These patients are at high risk for End stage Renal disease because of multiple factors including HIVAN. Previously HIV infection was considered a contraindication to renal transplantation. However with gaining experience; renal transplantation has been proved to be a safe and effective mode of treatment. Various studies have also confirmed that patient and graft survival are at par with results of renal transplantation in non HIV recipients. Aims of Study: To asses outcomes; various complications in Renal Transplantation of HIV positive Patients. Methods: We conducted a prospective observational study of Renal transplantation in HIV positive patients at our centre. HIV RNA negativity; CD4 count >200 cells/mm3 and absence of opportunistic infections were the eligibility criteria. Patients were on stable antiretroviral regimen (cART). Post transplant management was provided in accordance with protocols used for prophylaxis against opportunistic infections; indications for biopsy; Immunosuppression; management of rejection and Anti Retroviral Therapy.We also carried out a prospective observational study of HIV negative Renal transplant patients who received transplantation at our institute and compared the results with our HIV positive Renal transplant recipient group. Result: We carried out 20 Renal Transplant in HIV positive patients from 2009-2017. Most were male (18 out of 20) and African (85%). 17 of 20 patients were on MHD while the rest were on CAPD. HTN (60%) was the most common cause of ESRD followed by HIVAN and Diabetic Nephropathy. All patients had received renal allograft from live donors. All patients were started on triple drug immunosuppression including Steroids; MMF and CNI in the form of Tacrolimus or Cyclosporine along with cART. The major complications were Infections (30%); NODAT (20%); CNI toxicity (15%) and acute rejection (10%). Whereas in the HIV negative transplant patients; infections were (15%); NODAT (5%); CNI toxicity (5%) and Acute Rejection (10%). Infections; NODAT and CNI toxicity were more in HIV positive renal transplant recipients in comparison to HIV negative renal Transplant recipients but these were not statistically significant. The dose of CNI drugs was quite low in patients receiving protease inhibitors as part of cART regimen. Survival rates (1; 3; 5 years) of patient and graft in HIV positive Renal Transplant recipients were comparable with their HIV negative counterparts. There was no relapse of HIV in our cases except one (1 out of 20) with very low viral copies. Conclusion: Renal transplantation in HIV positive patients can be performed safely. NODAT and infections were more in HIV positive renal transplant recipients. Patient and graft survival (1; 3; 5 years) were comparable with those of HIV negative renal transplant recipients.


  Vitamin D Deficiency as a Risk Factor for Development of Posttransplant Diabetes Mellitus Top


Mayur Patil, V. Kute, H. Patel, P. Shah, D. Gera, H. Trivedi

Institute of Kidney Disease and Research Center, Institute of Transplantation Sciences, Ahmedabad, Gujarat, India. E-mail: mayurpatil20@gmail.com

Background: Many studies have shown a relationship between vitamin D deficiency and insulin resistance in general population but the results remains controversial especially in renal transplant patients. Post-transplant diabetes mellitus (PTDM) is a frequent metabolic complication following solid organ transplantation; affecting 10-45% of kidney transplant recipients. It leads to impaired patient and graft survival and an increased rate of cardiovascular events. Aims of Study: The study aims to provide preliminary information about the levels of 25-hydroxy Vitamin D in renal transplant patients and find any correlation between its deficiency and development of PTDM. Methods: A retrospective analysis of 468 patients transplanted between 2014 and 2016 was done. Pre and post transplant vitamin D levels; fasting blood sugar (FBS); post prandial blood sugar (PPBS); HbA1c levels were noted down. Vitamin D levels were classified into three groups <10 ng/ml; 11-30 ng/ml and >31 ng/ml. PTDM was considered as patients developing diabetes mellitus (FBS >126 mg/dl; PPBS >200 mg/dl and HbA1c >6.5) after transplant. All patients with pre transplant diabetes mellitus were excluded from study. Result: The study showed that incidence of PTDM was 12.6%. Vitamin D levels <10 ng/dl were found in 16.2%; 11-30 ng/dl in 59.8% and >31 ng/dl in 24.1% of patients. We found a positive correlation between vitamin D levels <10 ng/dl and occurrence of PTDM (p<0.001). Conclusion: To conclude; in this single centre observational study; we identified vitamin D deficiency at the time of transplantation as an independent risk factor of PTDM.


  Portal Vein Reperfusion Using Collaterals: Effective yet Under-Ultilized Solution for Extensive Porto-Mesenteric Thrombosis Top


Sasidhar Reddy, Manish C. Varma, B. Manjunath, Anand Khakkar, Anand Ramamurthy, Mahesh Gopashetty

Department of Gastroenterology and hepatobiliary surgery, Apollo Hospitals, Hyderabad, Telangana, India. E-mail: drshashi2708@gmail.com

Background: Portal Vein Thrombosis is frequently encountered during liver transplantation. Extent of thrombus decides surgical options for portal reperfusion. However; in few patients (especially those on deceased donor waitlist) the thrombus can progress in extent from time of CT scan to time of transplant; and can pose difficult challenges. Use of collaterals for portal reperfusion has been rarely considered as an option. Aims of Study: No Aim; this is a case report. Methods: Intra-operatively; Grade IV portal vein thrombus was seen and hence interposition graft was not considered. Cavo-portal hemi transposition was not done as that would not have addressed the left sided portal hypertension. End to side anastomosis between donor portal vein and spleno-portal collateral was done for reperfusion which was uneventful. Result: At one year follow up; the anastomosis was patent on Doppler ultrasound with normal waveform in the portal vein. Upper GI endoscopy demonstrated complete resolution of esophago-gastric varices. Conclusion: Thrombectomy and interposition grafts are preferred techniques for management of PVT. Portal reperfusion through collaterals is simple; effective for resolution of portal hypertension; and has long term patency. Hence; it should be preferred for extensive (Grade IV) porto-mesenteric thrombosis.


  First Case Report of Successful Combined Open Heart Surgery and Living Donor Liver Transplantation for Child with Alagille Syndrome Top


Sasidhar Reddy, Manish C. Varma, B. Manjunath, Anand Khakkar, Mahesh Gopashetty, Anand Ramamurthy, Girish Warrier, Kavitha Chintala, Meena Trehan

Apollo Health City, Hyderabad, Telangana, India. E-mail: drshashi2708@gmail.com

Background: Alagille syndrome is a complex multisystem genetic disorder. Liver and heart are commonly affected. Advanced diseaseof both these organs have always been difficult to treat. Cardiac defects may make the patient ineligible for liver transplantation and Child C cirrhosis of the liver precludes any corrective cardiac surgery. There have been no reports in the medical literature; of a combined procedure (correction of cardiac defects and liver transplantation) for children with Child C cirrhosis. Aims of Study: No aim; this is a case report. Methods: This 4 yr old girl with a diagnosis of alagille syndrome with significant hepatic and cardiopulmonary involvement was referred for evaluation to our multidisciplinary transplant centre. On evaluation; she was found to have Child C cirrhosis with portal hypertension and complex cardiac defects resulting in severe pulmonary hypertension. Additionally; she had severe growth retardation with rickets and delayed motor developmental milestones. The cardiac parameters made her ineligible for up-front LT. Balloon angioplasty for PA stenosis was attempted but failed. She underwent an open cardiac surgery with patch repair of MPA and LPA stenosis; VSD closure; pulmonary valve excision and valvuloplasty. 12 hours later; she was taken up for living donor LT using a left lateral hepatic graft. Result: Patient required prolonged ventilator support and was extubated on POD 3. Inotropic support weaned off by POD6. After extubation she had persistent inhalational oxygen requirement (10 days). She was discharged on POD14. Conclusion: Liver transplantation can be done successfully in Alagille syndrome patients with Child C cirrhosis with multidisciplinary approach.


  Early Initiation of ACE Inhibitors in Postrenal Transplant Period: A Study from a State Run Tertiary Care Centre Top


Anil Mudda, L. Umesh, S. M. Shivaprasad, V. Leelavathi, G. C. Sreedhara, Kishan, Vishwanath Patil

Department of Nephrology, Institute of Nephrourology, Bengaluru, Karnataka, India. E-mail: dranilmudda@gmail.com

Background: Renal transplantation is the best treatment for most patients with end stage renal disease and is associated with significant improvements in quality of life and survival of patients with successful kidney grafts. In patients with stable graft function; ACE Inhibitors may also retain their beneficial effects on reducing left ventricular hypertrophy and proteinuria. Aims of Study: The purpose of this study is to assess the safety of an ACE inhibitors; when started in early post transplant period. Methods: Prospective observational study we reviewed 78 kidney transplant patients during the period of January 2012 to July 2016 at our institution. 64 patients were initiated on ACEI therapy within four weeks of post transplant. Minimum duration follow up is 6 months. Result: 64 Patients were studied; 53 (83%) were male and 11 (17%) were females. For each patient haemoglobin; serum creatinine and potassium levels were analyzed at the beginning of ACE inhibitors and at the end of the first; third; sixth month. Average potassium levels; hemoglobin levels did not differ significantly between groups and were in normal clinical ranges. While incidence of graft failure did not differ; death with functioning graft was lower in the ACEI group. Conclusion: ACEI can be used successfully in post renal transplant with beneficial long term impact on renal function. There is need for further randomized controlled studies to see the effect of ACE inhibitors on Graft function and its survival.


  Gastrointestinal Tuberculosis: An Experience from a State Run Tertiary Care Hospital in South India Top


Shivan Gouda R. Patil, L. Umesh, S. M. Shivaprasad, V. Leelavathi, G. C. Sreedhara, Kishan, Vishwanath Patil

Institute of Nephrourology, Bengaluru, Karnataka, India. E-mail: drsrpatilgmed@gmail.com

Background: Kidney transplant recipients are at a high risk of opportunistic infection. Gastrointestinal tuberculosis; although rare in the general population; is about 50 times more frequent in renal transplant patients. Intestinal tuberculosis has a very difficult investigational approach; requiring a high clinical suspicion for its diagnosis. Aims of Study: To study were to describe the epidemiology; clinical features; and prognosis of abdominal tuberculosis (TB) in kidney transplant recipients. Methods: All cases of abdominal TB that occurred in kidney transplant recipients at our center between 2009 and 2016 were retrospectively reviewed. Detailed demographic data; clinical profile information; and the treatment response were recorded. Result: Among the 131 kidney transplantations performed during the study period; three patients (2.25%) developed abdominal TB. There were two men and one female in the study group. The mean age of the patients was 26 ± 3 years. The time from kidney transplantation to TB was 1.7 .4 yr. The most common symptoms were fever; weight loss; diarrhea and abdominal pain. The delay between the identification of the clinical symptoms and the diagnosis was an average of three months. The diagnosis was confirmed histopathologically for most patients. The ileo cecal junction were the most common sites involved. All patients received a 4-drug regimen of ATT; and one had hepatotoxicity. The median length of anti tuberclousis therapy was 18 months. One patient developed chronic allograft dysfunction. Conclusion: Renal transplantation increases the risk of TB; especially extra pulmonary disease. The symptoms of infection are often sub title; leading to delayed diagnosis. Therefore; a careful approach to the patient and supportive evidence are necessary to make the diagnosis.


  Let's Walk Different to Approach Live Donor Nephrectomy: Single Port Retroperitoneoscopic Approach Top


Rakesh Chauhan, Ashish Sharma

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: drrakeshchauhan66@gmail.com

Background: Donor nephrectomy is common procedure these days with the popularization of the kidney transplant surgery. Nephrectomy can be performed either by open or endoscopic technique or through NOTES. Endoscopic can be performed either transperitoneally (Most common) or retroperitoneally. Transperitoneal approach complications like viseral and vascular injuries has led to evolve an alternative like retroperitoneal approach. But traditionaly surgeons use more than one port during the procedure. Aims of Study: The authors have developed an indigenous technique to perform donor nephrectomy retroperitoneally with single port inserted through lumbar region. Methods: Out of 350 donor nephrectomies performed at our institute between November 2014 and September 2016; 82 donor nephrectomies were performed by author out of which 30 were performed by translumbar retroperitoneoscopic approach through single port after consent was obtained from the patients for the same. Result: Mean age of donors was 44.7 ± 11.4 years; M:F ratio 9:21. Average duration of surgery was 170.33 ± 52 minutes. 4 patients (13.3%) had double renal arteries and one patient had double renal vein.In one patient retrieval was completed by converting to open approach. No patient had surgical site infection. Most patients (28/30) had a VAS score of less than 4; and did not require any additional analgesics beyond POD 0. Conclusion: Single port retroperitoneoscopic approach is a feasibly safe option and a promising approach for live donor nephrectomy.


  Panel Reactive Antibody Screening Using Luminex Platform to Detect Preformed Anti Human Leukocyte Antigen Antibody and its Clinical Significance in Kidney Transplant Rejections Top


Prashant Rajput, Zaheer Virani, Hepal Vora, Ashwinee Hotkar, Sibi Mathew, Priya Dhurandhar, Bharat Shah

Institute of Renal Sciences, Global Hospital, Mumbai, Maharashtra, India. E-mail: drprashantr@yahoo.com

Background: Presence of antibodies against Human Leukocyte Antigen (HLA) molecules is a known risk factor for acute rejections and graft loss. A pre-transplant PRA estimation is done to indentify sensitized patients prior to solid organ transplant. Aims of Study: To study the prevalence of PRA in ESRD patients undergoing kidney transplantation; identify risk factors and its impact on allograft rejection. Methods: It is a single center retrospective study of 141 patients with End stage kidney disease who presented to our Institute for Kidney Transplant between July 2014 to July 2017. PRA Screening was done in all patients using a Luminex platform (LIFECODES lifescan deluxe) which detects all IgG antibodies to Class 1 and Class II molecules. Patients with a suitable donor who had a negative CDC Lymphocyte crossmatch underwent a Kidney transplantation (N=99) and others (N=42) were listed for deceased donor transplant. All transplant Patients received triple drug immunosuppression with steroids; mycophenolate sodium and calcineurin inhibitor. Induction agent was decided based on the recipients immunological risk profile. The primary end point was risk of rejection. Results: The mean age of the study population was 42 ± 12 years and 82.2% were males. The etiology of chronic kidney disease was diabetes mellitus in 32%. In patients who underwent transplantation Class 1 was positive in 0.9%; Class II in 6.06% and both (Class 1 and II) in 9% patients. In waitlisted patients there were none positive for only class 1; 14.6% were positive for class II and 12.1% had both class 1 and Class II. On multivariate analysis blood transfusions; previous transplantation and dialysis vintage was significantly associated with risk of a positive PRA. A positive class I or class II PRA was independently not associated with significant acute rejection episodes (p=0.56). Patients with both positive Class 1 and Class II PRA had more rejections (33.3%) as compared to with negative PRA (13.5%) and this was statistically significant (p=0.02). Conclusion: PRA screening is useful test to predict anti HLA antibodies pre transplantation. Patients with both positive Class 1 and Class II Panel Reactive antibodies have a significant higher risk factor for developing acute rejection episode as compared to patients with a negative PRA.


  Objective Measurement of Adequacy of Vascular Anastomosis during Renal Transplant Top


Dilip C. Dhanpal, Sanjeev Hiremath

Sagar/Apollo Hospitals, Bengaluru, Karnataka, India. E-mail: drdilipdhanpal@gmail.com

Background: A good Arterial Anastomosis is the hallmark of good outcome in a Transplant. There is a real lacuna for determining objective criteria for a satisfactory arterial anastomosis. Subjective criteria are available like colour and turgidity of kidney on release of clamps. Aims of Study: To define Objective criterion of adequacy of arterial anastomosis during Renal Transplant. Methods: Prospective study done at Sagar and Apollo Hospitals Bangalore from Jan 2014 till date. Inclusion Criteria: All adult ESRD patients undergoing Renal Transplant with End-to-end Arterial anastomosis Exclusion Criteria: Pediatric cases; End-to-side arterial anastomosis and multiple vessel anastomoses. 22G canula was used to puncture the recipient Internal Iliac Artery and preanastomotic pressure measurement taken. It was negotiated across the anastomosis and post anastomotic pressure determined. The gradient across was calculated. The limit of gradient was arbitrarily fixed at 20 mmHg. If the gradient was above the fixed limit then vascular reintervention would be indicated. The Resistive Indices were calculated at the level of Hilar; Segmental and Arcuate arteries using Ultrasound Doppler imaging on table. Result: 45 cases were done: Least gradient was 6 mmHg and highest gradient was 17 mmHg. Mean pressure gradient 11.06 mmHg. Median pressure gradient 11 mmHg. None required repeat vascular intervention. On table Resistive Indices were analysed. Conclusion: Simple method for measurement of Vascular adequacy criterion for young transplant surgeons.


  Tuberculosis in Renal Transplant Recipients: Single Centre Experience Top


Navdeep Singh, Deepesh B. Kenwar, Sarbpreet Singh, Kunal Kapoor,

Sanddep Kumar, Ashish Sharma

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: nav8203@gmail.com

Background: Tuberculosis is one of the leading infections after renal transplant. The prevalence of TB in kidney transplant patients is nearly 43 times greater than in the general population. Immunosuppressive regimens have become more potent in last few years; which increases the incidence of infections in transplant recipients. There is significant interaction of rifampicin with CNI inhibitors leading to development of modified regimen for treatment of TB. No systematic study provides outcomes of these regimen. Aims of Study: To know the prevalence and the outcome of modified ATT tuberculosis in renal transplant recipients. Methods: Between 2006 to 2016; 1900 patients underwent renal transplantation at our centre. Patient data was screened from the transplant database to identify the patients who received antitubercular therapy (ATT) during this period. 111 patients were identified to be on ATT giving a prevalence of 5.84%. The following parameters were recorded:- Donor relation and induction received, Creatinine at 1month and at 6 months post transplant, H/o rejection and anti rejection therapy, Duration of TB diagnosis post transplant, Site of tuberculosis, ATT received and duration of ATT, Complications of ATT, Re-infection of Tb, Use of second line ATT, Associated infection and Mortality. Result: In this study the prevalence of TB was found to be 5.84%. Newer immunosuppressive drugs are associated with a greater risk of tuberculosis than others. In this study 17% of patients had rejection; the odds of TB are higher with increasing episodes of allograft rejection. There were 2 deaths due to tuberculosis in our study; Pulmonary tuberculosis (63.9%); including both the miliary and the non miliary; was the leading manifestation.All patients received modified ATT for 12-18 months. Eight (9%) patients given rifampicin based ATT. Five pts had to be started on second line therapy. Majority of patients presented in first two years after transplant. INH prophylaxis remains standard of care in developed countries in patient who have previous exposed to tuberculosis. Posttransplant prophylaxis with INH is complicated by the potential for clinically significant hepatotoxicity; alterations in the metabolism of cyclosporine and tacrolimus; and the possibility of selecting out INH-resistant strains. Conclusion: Prevalence of TB in transplant recipients is high compared to general population. Modified ATT is efficaceous in curing TB. Tuberculosis is still a major infection in transplant population. There is an urgent need to define role of INH prophylaxis in these patients.


  Renal Allograft Compartment Syndrome: An Undermined Challenge Manage by Internationalization of the Graft Top


Forqan Shaikh, Tapas Kumar Saha

NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India. E-mail: forqanbs@gmail.com

Background: Renal allograft compartment syndrome (RACS) is an early complication following kidney transplantation. In the absence of prompt treatment; it can have devastating effects; including the loss of the graft. If the transplanted kidney is too big for the size of the shallow false pelvis and the limited retroperitoneal space; increased pressure will be transmitted to the graft and causing graft ischemia with reduction of renal function and kinking of the ureter. Aims of Study: To evaluate the incidence detection; treatment and possible prevention of Renal allograft compartment syndrome (RACS). Methods: April 2009 to July 2017; a total of 2500 renal transplantation's were performed from living donors by a single surgical unit. All recipient surgery was performed by standard retroperitoneal iliac approach. Real artery and vein were anastomozed with external iliac artery and vein respectively. In RACS patient presents with general discomfort; tense abdomen; tachypnea; oliguria and hypotension. Early diagnosis is a critical step to avoid the loss of the graft in the immediate post transplantation period. To date there is no standardised protocol for diagnosing RACS. Doppler ultrasound (US) of the renal vessel to identify possible impairment of blood flow; not only in the immediate postoperative period but also in the days that follow. US vascular abnormalities considered were the lack of flow in the artery or vein; high peak systolic velocity and marked reduction or absence of parenchymal renal flow. Intraperitonealization of the graft to treat and prevent the RACS can be the modality of treatment. Result: In the study of 2500 transplanted patient; 106 patients developed RACS. At least one of the vascular change like lack of flow in the artery or vein; high peak systolic velocity (with value >300 cm/s) and marked reduction or absence of parenchymal renal flow or the Doppler US indicated surgery for compartment syndrome; renal vein thrombosis (n=1); renal artery thrombosis (n=2); compartment syndrome (n= 103). 68 patients underwent Intraperitonealization of the graft before closure of the muscle suspecting of RACS. Doppler US monitoring of transplanted kidney 38 patients with abnormal flow subjected to an urgent re-intervention for RACS by intraperitonealization. One of the patient required polypropylene mesh for wound closure as the graft could not intraperitonealized. The re-operation in the immediate post transplantation period appears to be burdened by a significant risk for both patient and graft. It can be prevented by intraperitonealization in suspicion of RACS in selected cases. Conclusion: Our data suggest that it's necessary to identify all the conditions and factors already present before transplantation that could raise suspicion of developing RACS and act preventively before the onset of this syndrome by intraperitonealization of the graft before wound closure.


  Diarrheal Illnesses among Patients Undergoing Renal Transplant at a Tertiary Care Hospital in South India Top


Jeethu Joseph Eapen, Suceena Alexander, Vinoi G. David, Shibu Jacob, Shailesh K. Tulsidas, Anna Valson, Anjali Mohapatra, Santosh Varughese, V. Tamilarasi

Christian Medical College and Hospital, Vellore, Tamil Nadu, India. E-mail: jjeapen@gmail.com

Background: Diarrhoea in the post renal transplant setting contributes to significant morbidity. There is limited literature regarding etiological agents of diarrhoea occurring in the post renal transplant setting from India; particularly in the era of modern immunosuppression. This study was conducted to enumerate the causes and also provide a time line of diarrhoeal illness in patients undergoing renal transplantation. Aims of Study: To enumerate the causes of diarrhoea and provide a timeline of diarrheal illness among a cohort of patients who underwent renal transplant over a 5 year period between 2012 to 2016. Methods: A retrospective cohort of patients undergoing renal transplant between January 2012 and December 2016 were followed up for diarrheal events. A retrospective review of charts was conducted to study the following variables - the number of diarrheal episodes; etiological agents of diarrhoea (if identified - classified into bacterial; viral; parasitic; MPA related or other non infective causes) or whether no causative etiology was identified. The time point post renal transplant when each diarrheal episode occurred was also recorded. Result: A total of 442 patients underwent renal transplant between January 2012 and December 2016 at CMC Vellore. A total of 63 diarrheal episodes were recorded among this cohort; affecting 12.5% of the entire population. The most common etiological agent identified was MPA related diarrhoea - 40% of all cases of diarrhoea. Opportunistic parasitic infections accounted for about 13% of all diarrheal illnesses; CMV infections accounted for 6% of all diarrheal diseases. An etiological agent could not be identified in over 33% of all cases. MPA related diarrhoeal illnesses occurred early in the post transplant period; occurring at a median of 11.5 days post renal transplant. Bacterial diarrhoeas also occurred early - at a median of 17 days post transplant. CMV related diarrhoea occurred at a median of 183 days post transplant. Parasitic infections occurred late post transplant -at a median period of 248 days. Conclusion: Non-infectious diarrhoea (MPA related) was the most common cause for diarrhoea in this study; accounting for the majority of early post transplant diarrhoeas. Similarly bacterial diarrhoeas also occurred early post transplant. Parasitic and CMV disease occurred in the late post-transplant period.


  First Succesful Simultaneous Pancreas Kidney Transplant in IKDRC-ITS Top


Deepak Kumar, H. V. Patel, J. Rijvi, V. B. Kute, P. R. Shah, H. L. Trivedi

IKDRC-ITS, Ahmedabad, Gujarat, India. E-mail: deepak2k4sim@gmail.com

Background: A 36 year 0ld male patient diagnosed case of type 1 dm since 12 yrs of age; ckd and htn since last 6 yrs. Came to IKDRC-ITS with increasing b/l pedal edema and frequent episode of hypoglycemia since last 4 month; after admission underwent 4 cycle of hd and finally after explaning the risk and benefit of pancreas transplant with consent pt was enrolled in cadaveric simultaneous pancreas kidney transplant registry. Aims of Study: Explaning the role of simultaneous pancreas kidney transplantation in long term management of diabetes mellitus. Methods: Patient underwent spk transplant (with enteric drainage and systemic anastomosis) on 10/04/2017 from cadaver donor (age-22 yrs; male; declared brain dead due to rta with sdh). Induction agent-ratg (1.5 mg/kg) triple immunosuprresive regimen prednisolone (20 mg) tac-(0.05 mg/kg) mmf -360 mg tds later on bd 3 month post transplant follow up of patient is uneventful.patient achieved euglymia without insulin and serum creat was 0.70 mg/dl on last follow up. Result: The major benefits of combined kidney-pancreas transplantation are decreased mortality and improved quality of life. The improved quality of life is due to freedom from frequent blood sugar monitoring; insulin therapy; hypoglycemia; and dialysis. SPK Transplantation also have favourable outcome in Glucose metabolism Lipid metabolism and atherosclerosis Nephropathy and Neuropathy Retinopathy Fertility Fracture risk. Conclusion: Successful pancreas transplantation restores glucose-regulated endogenous insulin secretion; arrest the progression of the complications of diabetes; and improve quality and quantity of life.


  Factors Affecting Pancreas Organ Procurement and Usage: Single Centre Experience Top


Kirubakaran Renbanathan, Anil Vaidya, Dinesh Babu, K. Elankumaran, Johnson

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: krips1976@gmail.com

Background: Pancreas Transplantation is currently evolving in India with only few centres offering this procedure. Unlike other organs like Liver; Kidney and Heart acceptance of Pancreas organ as graft is less. Use of marginal donor organs is increasing as the result of scarcity of donors. Cadaveric organ donation is from DBD donors in India. Donor maintainance protocols are not uniform across centres. To optimize the use of Pancreas organ donors we have deviced criteria to increase safe procurement and usage. Aims of Study: To study the factors implemented for Pancreas organ procurement and to analyse the outcome of recipients after Pancreas Alone transplant and Simultaneous pancreas Kidney transplant. Methods: Data was collected from prospectively maintained donor and Recipient data base for the year 2016. Donor details were collected based on the criteria used for Pancreas organ procurement; Age < 65 years; BMI < 30; Serum Sodium < 155; High inotropic support; Past h/o Diabetes; Hypertension; HbA1c >6.5; Splenectomy; Alcohol abuse; Examination of pancreas for Calcifiaction; steatosis and; Fibrosis by the retrivel surgeon; Out station donor; Prolonged cold Ischaemia >6 hours.Data was prospectively entered in Excell sheet and Analysed. Result: Total of 47 donors were donors for the year 2016 in our centre; all of them were DBD donors; out of which 2 Pancreas Alone transplants and 7 Simultaneous Kidney Pancreas transplantation was performed. Non utilization of Pancreas was due to Diabetes in the donor in 11 cases; 5 donors were on high inotrope requirement and was hemodynamically unstable; 5 cases had high HbA1c levels and required high insulin during organ donation; 4 donors was above 65 years of age; 4 donors had fatty pancreas; 1 each had calcification and fibrosis of the pancreas; 1 donor had splenectomy following trauma; 2 donors were rejected because of outstation procurement. All Kidney Pancreas recipients were currently Insulin free. The first Pancreas Alone transplant recipient had native graft pancreatitis and requires Insulin; this recipient received pancreas from outstation with 6 hours 30 min; the other PTA recipient developed neuropathy and gangrene of the sentineal skin graft and requires insulin. Conclusion: The criteria currently followed for pancreas organ procurement had good outcome for graft and patient quality of life in Kidney Pancreas transplants. The results were not encouraging for Pancreas alone recipients the cause is this is not understood in our experience.


  Graft Versus Host Disease in Liver Transplantation Top


Kirubakaran Renbanathan, Anil Vaidya, Anand Khakar, Anand Ramamurthy, Elankumaran

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: krips1976@gmail.com

Background: Graft versus host disease is rare and life threathening complication following Liver Transplantation. Incidence of GVHD is 0.1% in the UNOS data base. Aims of Study: To study the incidence of GVHD in our centre to know the presentation pattern of the disease occurance to diagnose it early. Methods: Prospectively collected data from 2007 to 2016 was studied. Case files were retrived and analysed far the clinical signs and symptoms; time of onset from transplantation; Techinques used to confirm the diagnosis by chimerism study by STR- PCR sequencing of donor Lymphocytes in the recipient bone marrow. Treatment was instituted. Result: Out of 850 Liver Transplants from the year 2007 till 2016; 2 recipients had GVHD following deceased donor Liver transplantation. Both cases presented with in 1 month of transplantation with high fever. First patient was Erythematous Rash developed in the first patient which started in the palms and sole and gradually progressed to the trunk. The second patient was drak skinned so the rash was not much visible. WBC count and platelet count gradually dropped in both patients. Conclusion: GVHD had high mortality and low threshold for diagnosis should be considered in recipients who presents with high grade fever; Rash and low WBC counts in the first months following transplantation.


  ABO Incompatible Living Donor Kidney Transplant in a HIV Positive Woman Top


Bharat Shah, Zaheer Virani, Prashant Rajput

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: With recent advances in treatment of HIV; renal transplantation is no longer considered a contraindication in properly selected HIV positive patients. However; doing an ABO incompatible transplant could be a challenge due to higher immunosuppression that can result from the desensitization; exacerbating HIV-related immune dysfunction. Aims of Study: Present a case living related donor ABO incompatible kidney transplant in an HIV positive patient. Methods: A 27 years old HIV positive female (blood group A) underwent kidney transplant with father (blood group B) being the donor. Her Anti-B IgG and IgM titers were 1:64. Our standard desensitization protocol for ABO incompatible transplant includes rituximab 200 mg on day -7 and day 0 and plasmapheresis and/or immunoadsorption to achieve anti-blood group antibody titers (ABGAT) < 1:16 (2). This was modified in her case. She was given only single dose of rituximab 200 mg on day -7 to minimize the risk of intense immunosuppression. Further; no induction immunosuppression was used and maintenance immunosuppression comprised of tacrolimus; mycophenolate sodium and tapering doses of steroids. Antiretroviral therapy included lamivudine; abacavir and raltegravir which do not interact with tacrolimus and mycophenolate. Result: She had an uneventful post-transplant course and she was discharged with a serum creatinine of 0.78 mg%. On discharge; she was also started on valganciclovir and cotrimoxazole prophylaxis. A few days after discharge she developed diarrhea for which mycophenolate was changed to azathioprine (2 mg/kg once a day) which also does not interact with the HIV drugs she was on. A month after transplant; she developed leucopenia and her azathioprine was stoppedShe is now >12 months post-transplant with stable graft function. Conclusion: A successful ABOi kidney transplant was performed in an HIV positive woman. To our knowledge; this is only second report in the world and first in India of ABOi kidney transplant in an HIV positive patient.


  ABO-Incompatible Kidney Transplant Top


Bharat Shah, Prashant Rajput, Zaheer Virani, Pawan Deore

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: Kidney transplantation is the best form of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients. Yet; less than 5% of ESRD patients undergo kidney transplant in our country which has predominantly living related donor program. Accepting ABO incompatible (ABOi) donors can increase the living donor pool by 35%. There are only 2 reports with small number of patients from our country. Aims of Study: To determine the outcome of ABO incompatible transplant and compare with that of ABO compatible (ABOc) transplants. Methods: This is a retrospective analysis of 42 ABOi transplants performed from March 1; 2014 to July 31; 2017. All combinations of ABO-incompatibilities were accepted including a two-blood group antigen mismatch; that is; with donor AB and recipient O. The Anti-A and Anti-B antibody titres (IgG and IgM) were estimated by column agglutination technology (CAT) using automated Ortho BioVue System. For desensitization; pre-transplant plasmapheresis (PP) and or immunoadsorbtion; rituximab (200 mg; 2 doses) and bortezomib (2 mg; 2 doses) were used. Transplant was performed when anti blood group antibody titre (IgG) dropped to â< 1:16. Induction and maintenance immunosuppression used was same as that used for ABOc transplant patients. Result: Out of 208 patients; 42 (20%) were ABOi transplants and 166 (80%) were ABOc transplants. The characteristics of patients in 2 group were comparable. One and 3 years patient survival was 88% and 84% while death censored graft survival was 86% and 86% in ABOi kidney transplants. One and 3 years patient survival was 96% and 94% while death censored graft survival was 97% and 95% in ABOc kidney transplants. All patients who died after ABOi kidney transplant were elderly and diabetic. There were similar number of acute rejection episodes and infections in the 2 groups. Conclusion: Our study shows that results (1 and 3 years survival) of ABOi kidney transplants are not significantly inferior to that of ABOc kidney transplants.


  Impact of Induction Immunosuppression in Simultaneous Kidney-Pancreas Transplantation in the Current Era of Stringent HLA Cross-Matching Top


Sunil Shenvi, Vinayak Rohan, S. Shenvi, D. Taber, D. Taraskiewicz, S. Nadig, J. Mcgillicuddy, K. Chavin, P. Baliga, Charles Bratton

Medical University of South Carolina, Charleston, USA. E-mail: sunilshenvi@gmail.com

Background: Simultaneous kidney and pancreas transplantation (SPK) is a lifesaving procedure for patients with diabetes mellitus. The success of SPK is dependent upon minimization of immunologic and infectious sequelae. Little data exists quantifying the optimal induction immunosuppression (IS) for SPK. (This study was also presented in American Transplant congress). Aims of Study: The aim of this study was to determine the impact of patient; operative and IS factors on SPK outcomes. Methods: We conducted a retrospective analysis examining demographic; IS; transplant factors; complications and outcomes after SPK in recipients with IL-2 (Group A) vs. rATG (Group B) induction under our stringent HLA cross-matching protocol. Maintenance therapy consisted of a tacrolimus-based triple immunosuppressant regimen that was constant throughout the time period. Result: Of 109 total SPK transplanted during this time; 98 patients were included in this study (n=56; IL-2 induction and n= 42; rATG induction). There were no significant differences between groups with respect to age; gender; CIT; WIT; donor or maintenance IS). The rATG cohort was significantly more likely to be AA (p=0.025); have higher mean cPRA (p[lt]0.001) and cPRA[gt]20 (p[lt]0.001). For outcomes; there were no differences in post-SPK insulin resistance; technical complications; IS intolerance or rejection; graft loss or mortality. However; rATG had more CMV infections and overall infections in the first year (p=0.05; p=0.06 respectively; Table 2). In multivariate analysis; rATG showed a trend towards decreased rejection (HR=0.25; p=0.09) and was significantly associated with increased infection (HR=2.78; p=0.04). Conclusion: After controlling for immunologic risk; there was a strong trend towards lower rejection in the RATG group. However; there were more infections in this group as well. Thrombosis; leaks; other surgical complications; graft loss were similar.


  Preemptive Kidney Transplant Top


Bharat Shah, Prashant Rajput, Zaheer Virani, Bharat Shah

Global Hospital; Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: Kidney transplant is the best renal replacement therapy for ESRD. Pre-emptive kidney transplantation (PKT) refers to transplantation before the initiation of chronic maintenance dialysis. It also means substantial cost saving by avoiding cost involved in creating vascular access; regular dialysis treatment and its complications. This is significant in economically deprived country like ours. But how do patients with PKT perform? There is no data from our country. Aims of Study: To assess the outcome of PKT and compare with that of non pre-emptive kidney transplants (NPKT). Methods: We retrospectively studied 223 patients who underwent living related donor kidney transplant between August 1; 2013 and June 30; 2017. These patients were divided into two groups; PKT (defined as no or less than 1 week of dialysis) group and NPKT group. In all patients (except HLA full match patients); induction immunosuppression used was single dose thymoglobulin (1 mg/kg) or 2 doses of basiliximab (20 mg). Maintenance immunosuppression included tapering doses of steroids; tacrolimus and mycophenolate sodium salt or azathioprine. Patient survival; graft survival (death censored) and incidence of acute rejection was determined in both groups. Acute rejection was suspected when there was ≥20% rise in serum creatinine from the baseline which responded to empiric steroid pulse or was confirmed on kidney biopsy. Results: Out of 223 patients; 68 (30.5%) underwent PKT and 155 patients underwent NPKT. Patients in both groups were comparable in terms of age; sex and etiology of CKD). The 1 year and 3 year patient survival was 98% and 96% in PKT group and 94% and 88% in NPKT group. The 1 year and 3 year death censored graft survival was 100% and 100% in PKT group and 95% and 94% in NPKT group. Fourteen patients (20%) had acute rejection in PKT group and 42 patients (27%) in NPKT group. Conclusion: The patient and graft survival was better in PKT group. Also the incidence of acute rejection was lower in PKT group. Efforts should be made to perform PKT.


  Bladder Herniation; A Rare Case of Obstructive Chronic Allogaftt Nephropathy: A Case Report Top


Dilip Bhalla, Madan Sethi, S. Sahay, P. Kesarwani, Balram

Max Balaji Hospital, Patparganj, New Delhi, India. E-mail: dilipbhalla@yahoo.com

Background: Renal Transplant 6 years back and presented with Renal dysfunction .Was found to have a Inguinal Hernia on clinical examination; Imaging showed Bladder and ureteroneocystostomy Herniation in the Inguinal Region. Aims of Study: A Rare case of Obstructive Allograft Nephropathy. Methods: To study the cause of Obstructive Uropathy in Post Tx Recepient. Results: Patient underwent he underwent cystoscopy and exploratory laparotomy. On cystoscopy neoureteric orifice was patent but stenting couldnot be done. Right Gibson incision was given and bladder was seen herniating into the right inguinal canal. Ureter was also being pulled out laterally hence producing a kink that led to dilatation above this kink. Ureter and bladder was carefully dissected and dj stent was placed through a ureterotomy incision. Inguinal hernia mesh placed from inside. Conclusion: Rare cause of Graft Dysfunction surgical correction only the treatment if dtected well in time.


  A Study on the Impact of Vascular and Upper Urinary Tract Aberrations of the Donor; On the Recipient Outcomes of Live Kidney Transplantation Top


Surabhi Talwar, Rajesh Nair, George Kurian, Anil Mathew, Zachariah Paul, Sandeep Sreedharan

Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail: Surbhitalwar19@gmail.com

Background: Keeping the current scenario in mind; we know that the donor pool is ever-constricting. It has been estimated that >100; 000 new patients enter renal replacement programs annually. At the same time; there is a shortage of organs from both deceased and live donor pools. Hence; it is difficult to justify denying transplant if the donor has urological issues like- multiple renal vessels; calculi; cysts; etc. So we attempt to analyse the affect of these complexities on recipient graft function. Aims of Study: To study the impact of urological characteristics of the Donors/Grafts on recipient graft function. Methods: We retrospectively analysed data of 424 Live related renal allograft recipients and their respective donors who were operated upon at our institute from 03/01/2006 to 18/07/2017. Donors organs which were retrieved were divided into three Groups- 1) Urologically normal grafts 2) Grafts with multiple vessles 3) Grafts with other urological aberrations. Group 3 included donors with cysts; stones; etc. Recipient graft function was recorded at 1 week; 1 month and 1 year post transplant. Warm and cold ischemia times; rates of delayed graft function (DGF); bleeding and re-exploration; rejection and other complications were also compared. Results: We analysed data of 424 Donors and Recipients. The mean age of Donors was 45.89 yrs and that of recipients was 34.19 yrs. 75% of the Donors were females and 75% of the recipients were males. The Mean Serum Creatinine and GFR (DTPA) for the donors was 0.907 mg/dl and 80.87 ml/min respectively. Donors were divided into 3 Groups as mentioned above. Group II included patients with 2 renal arteries (n=102); 3 renal arteries (n=8 patients) and 4 renal arteries (n=1). Graft function was compared between group I (68.9%) and Group II (27.6%) at 1 week; 1 month and 1 year post transplant. The difference in graft function was not found to be statistically significant (p>0.05). Only 2.3% of the patients had DGF and there was no significant difference in its incidence in the two groups. Group III (3.5%) included patients with double ureter (n=1); Calculi (n=8) and cysts (n=4). Diifference in graft function when compared between group I and group III; was also not found to be statistically significant. Conclusion: In view of the organ shortage for transplantation in our country; it maybe prudent not to deny transplant for recipients with donors who have similar aberrations.


  A Single Center Experience of Deceased Donor Renal Transplant Top


Kunal Kapoor, Ashish Sharma, Deepesh B. Kenwar, Sarbpreet Singh, Navdeep Singh

PGIMER, Chandigarh, India. E-mail: dockunalkapoor@gmail.com

Background: Deceased donor transplantation is the most novel way to expand the donor pool for solid organ transplantation and bridging the gap between demand and supply of the organs. Deceased donor transplantation has been picking up pace in our country. As deceased donors do not undergo as rigorous an evaluation as the live kidney donors; it is important to know the long term outcome of transplants from these donors. Aims of Study: The aim of the study is to study the outcomes of our deceased donor transplant programme in a single tertiary care center in North India. Methods: The present study is a single center experience of our institute; PGI chandigarh from June 2001 to June 2017 during which period 212 patients underwent deceased donor kidney transplants and 9 patients underwent deceased donor SPK transplant (all type 1 diabetics). 13 of these patients had kidneys retrieved from DCD donors while the rest of all were from DBD donors. The demographics of both the deceased donors and the recipients were studied along with their outcome in terms of creatinine at 1 month and graft survival at 1 year. The effect of duration of cold ischemia time; use of induction immunosuppression (ATG vs basiliximab) on outcomes was also studied in terms of mortality; incidence of delayed graft function (defined as requirement of hemodialysis in the immediate post operative period); rejection and infective episodes. Results: The mean age of deceased donors was 38.2 years; whereas mean age of recipients was 39.7 years. Sex wise distribution of deceased donors was 1:0.6; and in case of recipents was male: female 1:0.5. Average cold ischemia time was 4 hours and 20 minutes; and 27% of the patients had delayed graft function requiring hemodialysis. Average creatinine at 1 month was 1.27 and average creatinine at 1 year was 1.16. 62% of the patients recieved ATG as induction; 29% recieved basiliximab as induction and 9% of the patients did not recieve any induction immunosuppression. 1 year patient survival was 82% and 1 year graft survival was 91%. Incidnece of post transplant infections was 32% and incidnece of rejection within 1 year was 30%. Conclusion: Deceased donor transplantation has provided good outcomes with acceptable rate of complications. The current rate of growth is likely to result in deceased donor transplants to outnumber live donor transplants at our center on an annual basis; thus setting an example for others to follow.


  Deceased Donor Renal Transplant Outcomes: A Single Centre Experience Top


Vamsi Krishan Makkena, M. Jayakumar, E. Ramprasad, Indhumati

Sri Rama Chandra Medical College and Research Institute, Chennai, Tamil Nadu, India. E-mail: vamsimakkena999@gmail.com

Background: The number of patients with end-stage renal disease (ESRD) is increasing and the gap between the demand for kidney transplantation (KT) and available donors is widening. Thus; deceased donation is very important to the donor pool for ESRD. Aims of Study: This study aims to determine the long-term graft and recipient outcome of DDRT at SRMC from 2000-2016 and to determine the donor and recipient factors that affect graft and recipient survival. Methods: This is a retrospective cohort of deceased donor KT from January 2000 to December 2016. Data were reviewed and collected from transplant medical records. Recipient and donor demographic profile were expressed as frequency counts; percentages and means with standard deviation. Kaplan Meier was used to determine graft and patient survival. Results: Among 725 KTRs; 578 (79.7%) were from living donors and 147 (20.2%) from deceased donors. All patients were recipients of first transplant; and there were no cases of second transplant or ABO incompatible transplant. The mean recipient age was 43.1 ± 10.7 years and 65.9% were males. The major causes of ESRD were presumed chronic glomerulonephritis (44.7%) and diabetic nephropathy (22.7%). All patients received induction therapy (90.1%) and 54.4% had tacrolimus-based immunosuppressive regimen. Of these; 45.5% recievd induction with daclizumab; while 27.2% each received induction with basiliximab or rabbit-antithymocyte globulin. The patient survival rate at 1; 3; and 5 years was 91; 86; and 73 percent while graft survival was 89; 79; and 68 percent respectively. Infection was the leading cause of death; followed by cardiovascular disease. Patients with in-house donors and hence lower cold Ischemia time; male donors and younger donors had significantly better graft survival. Conclusion: There was an acceptable outcome of KT from deceased donors up to 5 years post KT. Most common cause of death was infection. Male DD KT had better graft survival compared to females and CIT was significantly associated with patient survival rate.


  Diarrhoea in Renal Transplant Recipients; An Experience from a Centre in South India Top


Rajasekar Dhanasekaran, T. Dinesh Kumar, J. Dhanapriya, R. Shakthirajan, N. Malathi, V. Murugaesen, T. Balasubramaniyan, N. Gopalakrishnan

Madras Medical College, Chennai, Tamil Nadu, India. E-mail: nephroraj@gmail.com

Background: Diarrhoea in renal transplant recipient is common. It can be various etiologies including infectious and non-infectious causes. Each diarrhoeal episode can result in graft dysfunction and it is important to identify the cause for appropriate treatment and studies on diarrhea in renal transplant recipients are sparse. Aims of Study: To study the risk factors and causes of diarrhoea in renal transplant recipients. Also study the impact of diarrhoea episode on graft function. Methods: A retrospective analysis of 829 renal allograft recipient records who underwent transplant between January 2006 to July 2017 in Madras Medical College; Chennai. Patients with severe diarrhoea requiring hospitalization were included in this study. As per institution protocol all patients with diarrhoea had undergone investigations including stool microscopy; stool culture; stool for modified AFB; CMV serology and colonoscopy as indicated. Results: Post-transplant diarrhoea admissions of 127 (15.3%) patients were analysed. Among 127 patients with post transplant diarrhoea; 103 (81%) were males and 25 (19.7%) were females; 11 (8.5%) patients were under 20 years; 85 (67%) were in the 20 to 40 years age group and 31 (24.2%) patients were above 40 years. 46 (36.2%) patients were deceased donor renal transplants and 81 (63.7%) were live related renal transplant recipients. The risk factors present were NODAT {34 (27.8%)}; anti-rejection therapy {50 (39.3%)}; induction therapy {30 (23.6%} and leukopenia {43 (33.9%)}. The incidence in patients with induction therapy was 25.6% (50/195). Diarrhoea within one year post transplant was 59 (46.5%) patients and diarrhoea more than one year was 68 (53.5%) patients. Immunosuppressive regimens were TAC-MMF in 65 (51.1%); CSA-MMF in 26 (26%); CSA-AZA in 14 (11%); MMF alone in 12 (9.4%) and AZA alone in 6 (4.8%) patients. The causes for diarrhoea could be identified in 59 (46.5%) patients. Identified causes were CMV in 31 (24.4%) patients; protozoal causes in 26 (20.4%) patients and bacterial in 6 (4.7%) patients. E.Coli.2 (1.5%); Klebshiela 2 (1.5%); Citrobacter 1 (1%) and Shigella 1 (1%) were grown in faecal culture. Entamoeba histolytica 9 (7%); Strongyloides 5 (3.9%); Giardiasis 4 (3.1%); Cryptosporidium 4 (3.1%); Anchylostoma 3 (2.3%) and Cyclospora 1 (1%) were diagnosed by stool microscopy examination. Colonoscopy was done in 15 (11.8%) patients in whom 2 patients had CMV colitis. Hypotension occurred in 38 (29.9%) diarrhoeal patients. Hypokalaemia (less than 3 meq/dl) occurred in 14 (11.1%) patients. Temporary graft dysfunction during diarrhoeal occurred in 51 (40.1%) patients in whom 5 (3.9%) required dialysis therapy. After diarrhoeal episode 13 (10.2%) patients developed persistent graft dysfunction and 3 patients developed ESRD. Even in hospitalized evaluation 53.5% diarrhoeal epsiode causes were not identified. Conclusion: Diarrhoea causes significant morbity in post transplant patients. Even with hospitalized evaluation; in 68 (53.5%) cases the cause for diarrhoea remains undiagnosed. CMV colitis causes significant morbidity in our study. 10% patients had persistent graft dysfunction following diarrheal episode.


  Changing Trends of Cytomegalovirus Disease in Renal Transplant Recipients Top


Ganesh Aravind, T. Dineshkumar, J. Dhanapriya, R. Sakthirajan, N. Malathy, V. Murugesan, T. Balasubramaniyan, N. Gopalakrishnan

Madras Medical College, Chennai, Tamil Nadu, India. E-mail: sganesharavind@gmail.com

Background: CMV disease is one of the most prevalent oppurtunistist infection in renaltransplant recipient. The pattern of disease and prevelance has changed after the introduction of valganciclovir prophylaxis in high risk population. We analysed the changing trend of CMV infection in renal transplant recipients. Aims of Study: To study the clinical spectrum of CMV infection in renal transplant recipients and changing trends over eleven year period. Methods: Retrospective analysis of data of patients; who underwent renal transplantation at Madras Medical College; Chennai between January 2006 and July 2017. Pre-transplant serology for CMV was not known for any of these recipients and donors. Universal prophylaxis for 90 days was given for patients who received induction therapy. Diagnosis of CMV disease was established by DNA PCR or pp65 antigenemia assay or by tissue diagnosis. Treatment was with intravenous Ganciclovir followed by oral Valganciclovir. Factors analyzed were type of donor; use of induction agent; type of immunosuppression; presence of coexisting infection; NODAT; time line of CMV infection and treatment response. Results: 829 case records were analyzed retrospectively for CMV infection based on clinical suspicion of CMV syndrome. Eighty nine patients (10.7%) had CMV disease. Average age was 30 (2642/87); of which 11 were females. Fifty eight received live related renal transplant. The incidence in patients without induction therapy was 9.7% (62/634) and with induction therapy was 13.8% (27/195).The incidence with ATG was 9.6% (12/124) and with basiliximab was 21.1% (15/71). Diarrhea (55%) was the most common presentation followed by leukopenia (51%). Thirty four (40%) out of the eighty nine patients had acute rejection episodes. The study population was divided into two cohorts. After the introduction of valganciclovir prophylaxis in high risk group; prevalence of late onset CMV disease increased from 27% to 44.8%. Invasive disease reduced from 25% (2005 -2010) to 12% (2011 to 2017). Recurrence rate reduced from 42% to 27.7%. There was no significant change in morbidity and incidence of infection. Conclusion: The incidence of CMV disease is more prevalent in those receiving basiliximab as induction therapy. After CMV prophylaxis; there is increase in late onset CMV and decrease in incidence of invasive disease and recurrence rate. One third of the patients had NODAT.


  Correlation between 3 Generations of Immunological Tests for Renal Transplant Top


Smriti Sinha, Ashwini Gadde, Amit Mahapatra, Shyam B. Bansal

Medanta the Medicity, Gurgaon, Haryana, India. E-mail: smriti.sinha@gmail.com

Background: Detection of Anti HLA Antibodies with only CDC Crossmatch may lead to missing out of lower titres of clinically relevant antibodies. These antibodies which have ben associated with poor graft outcomes; can be detected using more sensitive methods like Flow crossmatch and luminex SAB. Aims of Study: To determine the correlation between CDC crossmatch; Flow crossmatch and Luminex SAB test. Methods: All the patients who were worked up for renal transplant at out centre from October 2016 to May 2017 were reviewed. Their CDC crossmatch (CDCXM); flow crossmatch (FLOWXM) reports; HLA typing and Luminex single antigen bead (LSA) results were collected. History of sensitization history was noted. Luminex SAB test was only done in patients with positive flow crossmatch or second transplant. The results were analysed. Results: Total 102 patients were reviewed .85 were transplanted and 17 were not. Mean recipient age was 39 ± 9 yrs and 85% were male. Sensitization history was present in 52%. The prevalence of CDC XM and FlowXM positive patients in our population is 3.92% and 22.5% respectively. All CDCXM positive patients (n=4) were flowXM positive and were not transplanted. 18 were CDCXM negative and flowXM positive. Luminex SAB testing was done in 16 patients. 2 were lost to follow up. 12/16 had anti HLA antibodies on LSA and DSA was present in 7 patients (43%). 1 patient with DSA underwent HLA Incompatible transplant after desensitization. 6/18 flowXM positive patients underwent transplant.3 were LSA negative; 3 were LSA positive of which 1 was DSA positive.10 out of 85 patients developed rejection (biopsy proven) all of whom were CDC and flowXM negative. None of the FlowXM patients have developed rejection till current follow up. Mean creatinine at discharge of flowXM positive vs negative patients is 1.02 vs 1.12 mg/dl. Conclusion: Including Flow crossmatch test into Renal transplant workup improves sensitivity of detecting Donor specific Antibodies. Doing Luminex Additionally can help confirm the accuracy of flow crossmatch and decide regarding feasibility of transplant.


  HLA Incompatible Transplantation Experience at Our Centre Top


Smriti Sinha, Ashwini Gadde, Reetesh Sharma, Manish Jain, Ashish Nandwani, Shyam B. Bansal

Medanta the Medicity, Gurgaon, Haryana, India. E-mail: smriti.sinha@gmail.com

Background: With desensitization modalities like plasmapheresis (PP); IV immunoglobulin (IVIg) and rituximab; HLA incompatible transplantation is now being offered to patients with donor specific antibodies and their survival is better than patients remaining on dialysis. However higher rates of antibody mediated rejection and infections have been reported. Aims of Study: We aimed this study to analyse the outcomes of HLA Incompatible renal transplant at our centre. Methods: All the patients who underwent kidney transplant at out centre were reviewed. Immunological workup including CDC cross-match (CXM) and Flow cytometry crossmatch (FXM) was done in all patients. Luminex single antibody bead (LSA) was done patients of high immunological risk esp. those with positive flow cross-match or High PRA levels. Patients with positive donor specific antibodies (DSA) who underwent HLA desensitization and kidney transplant were shortlisted. Clinical history including sensitization history; dialysis duration; HLA mismatch were collected. Outcomes were analysed in terms of acute rejection; infections and graft survival. Results: Total 7 HLA incompatible transplantations weredone at our centre between April 2015 to June 2107. Of these; 2 patients were female and 5 were males. Mean age was 49 yrs. Sensitization history was present in 72% patients. Mean HLA Mismatch was 4/6. Median dialysis vintage period was 3 months (0-60months). All patients were CDC XM negative and flowXM positive (3 T cell and 4 B cell FlowXM positive). LSA was done in all 7 and DSA was present in all. 3 patients had HLA class I and 4 class II antibodies. Mean MFI was 1424. They underwent desensitization with PP (n=4) or PP with IVIg (n=3). All received ATG Induction. All had smooth post OP recovery. Mean Sr creatinine at discharge was 1.05 (0.8- 1.4) mg/dl. No episodes of rejection noted till till JULY 2017. Mean follow up period 12.5 months (1- 24)) .Mean follow up creatinine 1.28 mg/dl (0.8 to 1.6mg/dl). One patient underwent kidney biopsy for increasing creatinine which showed mild ATN. One patient had CMV infection and one developed UTI. Conclusion: HLA incompatible transplant is successful if patient has low levels of antibodies with MFI <3000 with the adequate desensitization with plasmapheresis and thymoglobulin induction. Such patients should not be denied benefits of.


  Efficay of Adsopak® Columns in Reducing ABO Antibody Titers Top


Bharat Shah, Prashant Rajput, Zaheer Virani, Bharat Shah

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: Before performing ABO incompatible kidney transplant it is important to achieve low anti-blood group antibody titers (ABGAT). In those with high baseline titers; plasmapheresis may not achieve adequate drop in titers and immunoadsorption columns may be required. These columns are expensive and cost goes very high if multiple columns are used. Recently; a new; reusable column [Adsopak® columns (POCARD Ltd. Moscow; Russia)] is available in the Indian market. Are these columns effective? Aims of Study: To assess efficacy and safety of Adsopak® columns. Methods: The column was used in 4 ABO-incompatible cases (2 kidney transplants; 1 liver transplant and 1 bone marrow transplant). The patient's plasma was separated using plasma filter (PF 2000N; Baxter) and then the plasma passed through the column at the rate of 30-50 ml/minute for 6 hours. The columns were used several times after regeneration using the fluid N1 and N2 provided by the vendor. The antibody titres were monitored pre and post-procedure. Results: In 1 case; where larger column (200 ml) was used; there was a significant drop in antibody titers after first use (1:1024 to 1:128) but no further drop could be achieved with reuses. In 1 case titers dropped further when plasmapharesis could not lower to desired level. In remaining 2 cases only partial drop in titers could be achieved despite multiple reuses. The procedure was well tolerated without any adverse event. Conclusion: Adsopak® columns were effective at 1st use only when a larger column was used. The columns were not very effective when reused after regeneration.


  Intial Experience Cadaver Vessel Prosthesis for AV Fistula Grafts in Maintenance Hemodialysis Top


Deepesh Kanwar, Ashish Sharma, Sarbpreet Singh, Navdeep Singh, Kunal Kapoor

Post Graduate Institute of Medical Education and Research, Chandigarh, India. E-mail: deepesh.doc@gmail.com

Background: With increasingly better access to dialysis facilities it is imperative to create hemodialysis access even in patients with poorly suitable native venous anatomy. Conventional prosthetic AV conduits are costly and have suboptimal primary and secondary patency rates complicated by infections. With increasing deceased donor transplants it may be possible to instead use retrieved vessels after denaturation of proteinaceous antigens using glutaraldehyde. Aims of Study: To assess the feasibility of cadaver derived glutaraldehyde treated arterial conduits as hemodialysis access. Methods: Patients on maintenance HD who were not candidates for future transplantation were offered the option of either an artificial prosthetic conduit or cadaver derived conduit from organ donors. For those patients who consented segment of group matched arterial conduit harvested from deceased donors was implanted after denaturing using 2% glutaraldehyde bath. Patients received one dose of clopidogrel 300 mg and heparinization for 3 - 5 days before switching over to warfarin targeting an INR of 2. Serial ultrasound assessments were done to monitor flow and development of stenotic lesions. Hemodialysis access was initiated after inflammation settled and flow was measured consistently above 400 ml/min. Results: Six patients underwent implantation of cadaver derived glutaraldehyde treated cadaver arterial conduit AV grafts. M:F ratio was 1:1 with a mean age of 65 years. The reason for being out of active transplantation list was advanced age with poor reserve in 5 cases and lack of donor in one. All six had exhausted upper limb sites for native AV fistulas including possible brachiobasilic transposed fistulae. One patient had an infected artificial conduit that was excised 2 weeks prior and another had a tight non negotiable intimal hyperplasia of an artificial conduit. Five patients underwent brachioaxillary conduits while one underwent an artery to artificial conduit interposition grafting. Two patients required prolongation of antibiotic therapy beyond the single prophylactic dose. The mean interval up to dialysis access was 7 weeks. Complications included outflow stenosis in two patients and lymph leak on one patient. There were no infections over 3 months of follow up. Conclusion: Group specific deceased donor derived glutaraldehyde treated arterial conduits are a possible alternative to artificial conduits and should be investigated further.


  New Onset Diabetes after Renal Transplantation: A Single Centre Experience Top


Deepthi Ayanavelli, G. Swarnalatha, T. Gangadhar, Uttara Das, K. Raja Karthik, Bharathi K, Siva K. Parvathi

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: deepthi0909@gmail.com

Background: New onset diabetes after transplantation (NODAT) is one of the serious side effects of immunosuppressive medications used in renal transplantation patients. Diabetes in transplantation increases the risk of cardiovascular disease and has adverse outcome on graft and patient survival. Aims of Study: The aim of this study was to evaluate the incidence of NODAT in renal transplant recipients; the risk factors for the development of NODAT and its effect on graft and patient survival. Methods: This is a retrospective; observational study of patients who underwent renal transplantation from January 2010 to June 2016 at Nizams Institute of Medical Sciences; Hyderabad.Data of recipients who developed NODAT was collected and analyzed. The incidence of NODAT and the duration of onset of NODAT was evaluated. Data on recipient blood group; age; gender; native kidney disease; duration of dialysis; mode of dialysis; CMV status; HCV; donor details; immunosuppression protocol; change in immunosuppression prior to development of NODAT; lipid profile; graft dysfunction episodes; rejection episodes; therapy and response to rejection and infections were analyzed and compared to recipients without NODAT. patient survival and death censored graft at 6 months; 1; 2; 3 and 5 years were analyzed and compared in both the groups. Results: Mean follow-up after renal transplantation was 38.14 + 20.12. NODAT was defined as two consecutive blood glucose determinations above 126 mg/dL.Thirty five (16.66%) recipients developed NODAT; with mean follow-up period of 38.14 + 20.12.The duration of onset of NODAT was 4.22 months (range 1month to 30 months) after transplantation. All of them required insulin treatment. NODAT disappeared in 3(8.57%) recipients with reduction in tacrolimus dose and conversion to everolimus. Cox regression analysis was done to estimate the hazart ratio.There was no significant difference in 6 months; 1; 2 3 and 5 years patient survival or the death censored graft survival of recipients with NODAT compared to patients without NODAT. Conclusion: Induction therapy and graft dysfunction had 2 fold increased risk of development of NODAT and tacrolimus toxicity had 4 fold increased risk of development of NODAT. Fungal infection (17.14% Vs 2.28%; P value 0.00) was significantly higher in NODAT group compared to recipients without NODAT.


  Case Series of Post Renal Transplant Interstitial Nephritis from a Teritiary Care Centre Top


Shiv Parvati Karanam, Bharathi, Deepthi, Swarnalatha, Uttara Das, Kaarthik, Gangadhar

Nizams Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: Mrs.raviprakash@gmail.com

Background: Acute interstitial nephritis is an important cause of immune mediated acute kidney injury mediated by medication; infections and other causes.In post renal transplant recipients; the incidence of interstitial nephritis has been reported to be less than 1%; with only a fraction of these containing granulomas with a clinical response after removing the offending drug if identified. Aims of Study: We analysed the post renal transplant recipients who had biopsy proven interstitial nephritis with respect to their clinical presentation and treatment outcomes. Methods: This is a retrospective analysis of renal transplant recipients with biopsy proven acute interstitial nephritis during the period January 2010 to may 2017. Results: A total of patients with biopsy proven acute interstitial nephritis is 12; of them males constituted 75%; females 25%.of them 83% occurred in live related renal transplants and 17% in deceased donor renal transplants. Majority of the episodes occurred with in 1 month and followed by 1 to 6 months.The most common manifestation was graft dysfunction.of them 50% has granulomas on biopsy. All patients received three doses of 500 mg methyl prednisolone intravenously. The mean serum creatinine was 1.9. There is no difference in outcomes in patients with and without granulomas on biopsy. Conclusion: We studied the spectrum of intersritial nephritis in our institute; compared to other published case reports (0.5%) the incidence was high (6%) and unlike other reports (50-70%); response to therapy occurred only in one third of patients.


  Surgical Site Infections after Thoracic Organ Transplant: Where do We Stand? Top


Ramasubramanian Krishnamoorthy, Ajay Aravind, V. S. Srinath, Vidya Devarajan, K. G. Suresh Rao, K. R. Balakrishnan

Fortis Malar Hospital, Chennai, Tamil Nadu, India. E-mail: drramasubramanian.k@gmail.com

Background: Heart transplant remains the treatment of choice for end-stage heart failure. Post transplant patients are susceptible to infections including Surgical Site Infections (SSI). Current scientific literature on the incidence of SSI in thoracic organ transplant from India is sparse while the incidence of SSI available globally varies between 2-9%.Overall evidence shows that the administration of surgical antibiotic prophylaxis after the incision significantly increases SSI risk compared. Aims of Study: Analyse the SSI rates and also the adherence to prophylactic antibiotic timing in the thoracic organ transplant recipients in our centre. Methods: This is a retrospective study conducted in a tertiary care hospital and transplant centre in South India. This was done by reviewing the charts of patient who underwent thoracic organ transplant from June 2010-2017. The timing of antibiotic prophylaxis prior to surgery and the SSI rates were documented. As per the institutional policy the recommended timing for surgical antimicrobial prophylaxis is 15 minutes to 60 min prior to incision time to ensure adequate concentration of antimicrobial agent at the incision site. The latest international definition defines SSI as related to surgical procedures and classifies it according to the organic level affected: superficial incisional; deep incisional and organ/space were used (CDC/NHSN 4). Surgical site infections are tracked by both passive and active surveillance in this institution. Results: A total of 175 thoracic organ transplants were done in this centre from June 2010 to July 2017. The total cases analysed were 143 out of which 132 were heart transplant recipients; 8 were lung; 3 were heart lung transplant recipients. 99 were males and 44 were females. Prophylactic antibiotics were administered within the guideline recommendation in 129 cases (90.3%) and deviation was noted in 13 cases (9.7%) The prophylactic antibiotics were used as per the institutional policy. The total number of SSI during the study period were 4. Three SSI were noted in the heart transplant recipients (2.2%) and one in lung transplant recipient. One patient grew klebsiella; 2 pseudomonas; 1 patient had culture negative SSI. Conclusion: A multidisciplinary approach can result in good compliance to the surgical antibiotic prophylaxis policy and helps in keeping the surgical site infections at bay even in the transplant setting .The incidence of SSI in our setting is similar to the available literature globally.


  Low Dose Alemtuzumab and Steroid free Immunosuppression in Simultaneous Pancreas-Kidney Transplantation: Notes from a Single Centre Top


Anil Vaidya, Dinesh Babu, Raja Mahesh, Venkatesh Rajkumar, Anil Vaidya

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: Alemtuzumab (campath) is a humanised anti-CD 52 antibody that causes profound lymphocytic depletion when used as induction agent in the transplant population. We describe our experience with using a low dose variation of Alemtuzumab in recipients of a simultaneous Pancreas Kidney (SPK) Transplant. Aims of Study: To demonstrate the efficacy and safety of low-dose Alemtuzumab in SPK transplantation. Methods: Data from all patients undergoing a SPK transplant at a single centre with low dose Alemtuzumab and steroid free regimen were documented in a prospective manner. Data collected included demographics; lymphocytic profiles; infectious complications; rejection episodes; mean tacrolimus levels at 3 months; adherence to steroid free protocols; glycemic control; graft and patient survival. All patients received prophylaxis against CMV; PCP and mycobacterium TB (mTB) for a period of 3 months starting from the day of discharge. Results: From July 2015 to June 2016; 28 patients underwent a SPK transplant at our centre. Majority (55%) of patients were male; and mean age was 36 years (range 22-52 years). All patients received a single low dose of Alemtuzumab (15 mg); within 30 minutes of reperfusion of the last organ. Post-operatively all patients received tacrolimus at 0.1 mg/kg with mean levels of 9 ng/ml at discharge (range 8-12 ng/ml) and 7.8 at 3 months (range 7-10). At a median follow up of 12 months (range 3-24) there were 2 (6%) episodes of pancreas rejection without any evidence of kidney rejection. And one episode of kidney rejection without pancreatic involvement. Three (10%) patients had evidence of UTI; one (3%) had evidence of BKV viremia. No patients had CMV or PTLD. Mean lymphocytic percentage in the peripheral blood at day 1 was 2% (range 1-3%). Mean lymphocytic percentage of white cell count at 3 months was 12% (range 8-16%). There was no evidence of reactivation of mycobacterium TB. Conclusion: Low dose Alemtuzumab is a safe and effective means of induction immunosuppression in SPK transplants. It allows for steroid free immunosuppression in the post-operative period.


  Hallucinations after Lung Transplant Top


Ramasubramanian Krishnamoorthy, Muralikrishna, K. Ramasubramanian, D. Vidya, K. R. Balakrishnan

Fortis Malar Hospital, Chennai, Tamil Nadu, India. E-mail: drramasubramanian.k@gmail.com

Background: One of the strategies to prevent mould infections in lung transplant (LTx) recipients as per ISHLT guidelines is Universal prophylaxis with voriconazole for a period of 4-6 months.1 This drug is used in treatment and prophylaxis of invasive aspergillosis in LTx recipients. Voriconazole is a safe and often well-tolerated drug; however it is associated with adverse effects such as dermatological; neurotoxicity and visual disturbances. Hallucinations (0-9%) 2 and encephalopathy seem to be rarer. Aims of Study: This report highlights this known but less reported adverse event and the use of posaconazole prophylaxis in this lung transplant recipient. Methods: Case details 21 year old gentleman with primary pulmonary hypertension underwent a bilateral lung transplant at our centre. Basiliximab was used as the induction agent along with methyl prednisolone and he was put on Tacrolimus and Mycophenolate mofetil and oral steroids. In his immediate post-operative period he had a bacterial pneumonia which improved with carbapenam. The protocol at this centre to prevent mould infections is universal prophylaxis with oral voriconazole along with inhalational liposomal amphotericin B. This patient was started on the same protocol. On post-operative day 10 he developed hallucinations both visual and auditory. Clinical examination was non contributory. Blood pressures; total counts and other metabolic parameters were normal. Imaging of the brain was also normal. Tacrolimus levels during this period was normal although subsequently he did have an increased levels of the drug hence therapeutic drug monitoring (TDM) is recommended. Results: Since a strong correlation has been suggested between higher voriconazole trough concentrations and neurologic side effects; Voriconazole trough levels were done and were within normal limits (1.6 mg/L). It was decided to switch him to posaconazole which has been used as one of the options for prophylaxis in lung transplant recipients which he tolerated well. Patient tolerated posaconazole well. Conclusion: Hallucinations associated with voriconazole can be overlooked. Drugs as a cause of neurological symptoms have to be considered prior to exhaustive investigations. TDM play a role to maintain the trough levels within the non toxic range. Posaconazole may be an option in case of intolerance.


  Neuropsychiatric and Cognitive Profile in Postrenal Transplant Recipients in a Tertiary Care Center in South India Top


Athul Thomas, Santosh Varughese, Vinoi G. David, Suceena Alexander, Anjali Mohapatra, Anna T. Valson, Shibu Jacob, Kakde Shailesh Tulsh

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: thomasathul1@gmail.com

Background: Recent studies have shown a high prevalence of depression and cognitive changes in renal transplant recipients. There is little data available on the cognitive and emotional changes in patients undergoing renal transplantation in India. Aims of Study: To estimate the prevalence of Neuropsychiatric and cognitive alterations in renal transplant recipients. Methods: Thirty selected renal transplant recipients who underwent either live or deceased donor transplant in the last 5yrs in our center were included in the study. They were subjected to a 60 min battery of Mini International Neuropyschiatry Interview (MINI) and Montreal Cognitive Assessment (MoCA) which identifies disorders in the domains of Neuropsychiatry and Cognition respectively. . Those subjects aged <18 yrs and >60 yrs were excluded from the study. Patients with diagnosed Cerebrovascular accidents and Neurodegenerative disease were also excluded from the study. Results: Our study revealed 32% prevalence of Neuropsychiatric disorders with alterations in the various domains of Mood disorder; Anxiety disorder and Psychotic disorders in post renal transplant patients. Analysis of neurocognitive functions did not reveal any significant impairment. Conclusion: Early diagnosis is essential to enhance patient quality of life and improve the outcome of renal transplant. Therefore; having a multidisciplinary team to care for this group of patients are becoming increasingly important.


  Surrogacy in Immune Surveillance: Further Work in India Top


Anil Vaidya, Paul Ramesh, Sunder, Madhan, Ganapathy Krishnan, Leela Pravin Kumar, Dinesh Babu

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: The concept of immune surveillance has been at the forefront of transplant immunology since its inception in the middle of the last century. The ability to track the immune system is very attractive indeed with interventions placed at the right moment to prevent any rejection. We suggest the use of a vascularised skin flap from the same donor as a surrogate canvas to rejection in the target organ. Aims of Study: To evaluate the efficacy of a synchronously transplanted vascularised skin flap as a surrogate guage of the level of activation of the immune system. Methods: Data from four patients transplanted with a vascularised skin flap at the time of the visceral transplant was collected. Data included demographics; type of transplant; incidence of rejection in the flap; incidence of target organ rejection; complications with the sentinel skin flap; infections. Results: From August 2015 to May 2017; 4 patients had a sentinel vascularised skin flap synchronously placed while transplanting the visceral organ. Two had pancreas alone transplants (PTA); one had a double lung (DL) and one with a heart and double lung (HDL). Mean age was 32 year (range 22-36). There were 2 males and 2 females. The skin flaps for the PTA recipients were inset into the abdominal incision and vascularised through the inferior epigastrics. The skin flaps for DL and HDL recipients were vascularised through the ulnar artery. One graft PTA skin was lost within 24 hours. There were two episodes of rejection in the skin component (one PTA and one DL). No rejections were seen in the DL and HDL viscera. One skin flap (HDL) demonstrated a migratory pattern in her melanocytes. This patient has had no rejection in the skin or visceral graft. The PTA with skin demonstrated rejection in the skin that was not identified accurately and went on to reject the pancreas. Patient survival 100%. Conclusion: A vascularised skin flap from the same donor may be an attractive adjunct when there are no markers of rejection in the visceral organ. A skin rash heralds an activated immune system and gives a lead time of 12-15 days before the target organ experiences rejection.


  Preoperative Cyp-3a Analysis is a Good Indicator of Tacrolimus Dosing in Kidney and Simultaneous Pancreas Kidney Transplant Recipients Top


Anil Vaidya, Dinesh Babu, Raja Mahesh, Anil Vaidya

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: Tacrolimus is a substrate of cytochrome P450 (CYP) 3A; and much of the inter-individual variability in its pharmacokinetics is explained by the presence of a single nucleotide polymorphism (SNP) in intron 3 of CYP3A5 6986A>G; resulting in the absence of a functional CYP3A5 protein in homozygous carriers (CYP3A5*3/*3; poor metabolizer). Aims of Study: To evaluate the advantages of pre-operative testing of the CYP-3A gene mutations to direct tacrolimus dosing in the immediate postoperative period. Methods: Data from all patients undergoing kidney alone (KA) and simultaneous Pancreas-kidney (SPK) transplants was collected. Data included demographics; live donor or not; CYP-3A analysis; day 5 tacrolimus level; incidence of tacrolimus toxicity; DGF; rejection; infection in the first 3 months. Tacrolimus level and dose at 3 months. Results: From June 2015-June 2016; 58 patients underwent a KA and 24 an SPK transplant. Majority were male (56%). Mean age was 42 years (range 22-56). All the KA were live donor transplants. CYP-3A4 analysis was done preoperatively in all these patients. Seven patients (12%); and 5 (21%) in the SPK group were extensive metabolisers. Tacrolimus was started at 1.5-2 times the normal recommended dose of 0.1mg/kg. The mean tacrolimus dose at the time of discharge was 8.2 ng/ml (range 6.5-10 ng/ml). The mean tacrolimus level at 3 months was 9 ng/ml (range 7.8-12.1 ng/ml). There was one DGF in the SPK group and none in the KA group. There was no evidence of kidney rejection in the first 3 months. One patient presented with graft dysfunction with normal tacrolimus levels. Biopsy did not reveal rejection. He received cycles of plasma exchange and recovered. There were 2 mild pancreas rejections (raised lipase and amylase) treated with a 3 boluses of methly prednisolone. Conclusion: CYP3A analysis is cost effective and accurate in evaluating the need for exact dosing of tacrolimus in the early post operative period after kidney and SPK transplantation.


  Association of Mirna-200c and 148a with Serological Broad Specificities of Hla-B and Hla-C with Antibody Mediated Rejection Top


R. K. Sharma, Swayam Prakash1, Suraksha Agrawal1, Narayan Prasad, R. K. Sharma

Departments of Nephrology and 1Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: pradeep.jaswani3@gmail.com

Background: Micro RNA are short non coding (22 nucleotide long) regulatory element of innate and adaptive immunity; they also regulate gene function of human leukocyte antigens (HLA). Single nucleotide polymorphisms in miRNAs contribute to genetic risk by altering the expression and structural conformation of respective gene. miRNA shown an association with HLA-B (broad specificities Bw4 and Bw6) and HLA-C (Cw3) may regulate genetic element that play an important role in renal pathogenesis. Aims of Study: Present study aims to investigate the association of miR-200c with HLA-B serotypes (broad specificity Bw4 and Bw6) and miR-148a with HLA-C serotypes (Cw3) and their effect with renal graft outcome. Methods: 336 patients who underwent renal transplantation were recruited for the current study. Polymerase chain reaction-sequence specific priming (PCR-SSP) based genotyping was performed for miRNA 200c and miRNA 148a. HLA-B and HLA-C were genotyped using Invitrogen Gold SSP low resolution kits (9099 North Deebrook Trail Brown Deer; Wisconsin 53223 USA). Statistical analysis was performed using SPSS v.20 (statistical package for social science; IBM; NY) and Graphpad Instat (Graphpad Software Inc.; La Jolla; CA). Results: This is the first ever report to the best of our knowledge that reveals an association of miRNA with broad serotypes of HLA-B and HLA-C. Significant risk association was observed for individuals possessing mutant TT genotype of miR200c and homozygous HLA-Bw4 epitope with acute rejection cases (OR=6.5; p-value < 0.0001; 95% CI= 2.60-16.20). Meanwhile individuals possessing mutant GG genotype of miR148a along-with heterozygous HLA-Cw3 also revealed susceptible association (OR=5.13; p-value=0.0014; 95% CI=1.89-13.93) for acute rejection. Conclusion: High risk of graft failure was found in presence of mutant alleles of both the miRNA but we further need to find out structural conformation of HLA-B and HLA-C serotypes along with expression pattern of both miRNA with respect to their genes to finally conclude their allele based association.


  Initial Experience with Pancreas Transplantation in India: Notes from a Single Centre Top


Anil Vaidya, Dinesh Babu, Raja Mahesh, Anil Vaidya

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: Simultaneous Pancreas-Kidney (SPK) Transplantation is the gold standard for treatment of patients with diabetic nephropathy; established on dialysis. This procedure however is still in a nascent stage in India where majority of the patients are Type 2 diabetics. Aims of Study: To study the efficacy of SPK transplantation on short and intermediate glycemic control. Methods: Data from patients undergoing SPK transplant in a single centre in India was collected prospectively included demographics; Type 1 or 2; evidence of hypoglycemic unawareness; retinopathy; and neuropathy. Incidence of pancreatitis (drain amylase more than 1000 mg/dl on day 1); venous thrombosis; re-operation; graft loss; graft rejection; hypercoagulability and its management. Patient and graft survival were documented. Results: From June 2015 to date; 26 patients underwent a SPK and 2 patients a pancreas alone transplant (PTA) at our centre. Nine patients (32%) were type 2 diabetics. There were 18 males and 10 females. 7 patients had preoperative documentation of hypoglycemic unawareness (Type1 DM); all (100%) had retinopathy; whilst neuropathy was seen in 5 (18%) patients (Type 2 DM). Lose dose Alemtuzumab (15 mg; single dose) was used. Tacrolimus and cellcept as maintenance immunosuppression. A thromboelastogram (TEG) based anticoagulation was adopted with dextran 40 and/or Clexane and aspirin. Hypercoagulability was seen in all patients with a mean coagulation index (CI) of 3.5 (range 3.1-6). There was one episode of partial splenic vein thrombosis and DGF of the pancreas in this patient. Four (14%) patients had rejection of the pancreas (raised lipase). There was no kidney rejection. Both PTA patients are back on insulin in the first year (presumed rejection). Graft survival 93% and patient survival 100%. Conclusion: SPK is a valid option for Type 1 or selected Type 2 diabetic patients. Low dose Alemtuzumab may not be enough to keep PTA recipients from rejection and loss of graft. More robust methods of immune surveillance would be needed for PTA recipients.


  An Alchemy for the Conceptualisation of an Islet Cell Program in India: Lessons Learnt from the Journey in Tamil Nadu Top


Nithya Kalyani, Anil Vaidya, Anand Khakhar, Shantaram, Radhakrishnan, Vijayabaskar

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: mmnithya@gmail.com

Background: Islet cell transplantation is an established modality for the cure of diabetes. The main challenge from a regulatory framework for establishing an islet cell transplant unit in India is the interpretation of the Human Organ Donation Act and legislative authority for each state to improvise so that it allows nascent programs to initially engage in characterisation of islet activity before starting a clinical transplant program. We describe our journey to address this issue in Tamil Nadu. Aims of Study: To construct an algorithm at state government level to encourage nascent transplant units to utilise donated human pancreases for the purpose of characterisation of islets before transplantation. Methods: Our algorithm was based on the following questions that were queries raised by the regulatory authority: a. Is there a need for such a unit in the state? b. Are there provisions for a solid organ pancreas transplant unit in the state? c. Whether the criteria for solid organ transplantation has been established. d. Can the current cadaveric donation statistics support such an enterprise? e. What are the credentials of the team that is proposing such a unit? f. Is there going to be a private-public partnership to allow equity of access to this service? g. Is there a trial period of characterisation of islets before a clinical program is established? Results: Our answers helped to favourably construct this algorithm that was presented to the state authorities for approval. The health secretary with the concordance of the state organ donation authority then proposed a government order (GO) to the health minister to allow for modifications of the Human Organ Act. This GO facilitated our unit to embark on an innovative path of islet cell isolation; that keeps patient safety at its foremost principle by adhering to a two phase approach that includes a first phase of characterisation and then eventually the second phase of a sustainable clinical unit. Conclusion: Islet transplantation is an alternative method because of its low invasiveness and safety to recipient. We encourage nascent units to follow a pathway undertaken by us to help understand and interpret the Human Organ Act and bring about a two fold approach to the starting of an islet cell unit.


  Low Dose Alemtuzumab and Steroid Free Immunosuppression in Kidney Transplant Recipients: Notes from a Single Centre Top


Anil Vaidya, Dinesh Babu, Raja Mahesh, K. C. Prakash, V. Vivek, N. Nithya, Anil Vaidya

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: anil.vaidya@nds.ox.ac.uk

Background: Alemtuzumab (Campath); is a lymphocytic depleting agent used as induction immunosuppression in steroid free regimens for kidney transplantation. The traditional cumulative dose of Campath used has been 60 mg intravenously in two divided doses 24 hours apart. We have used a single dose of 15 mg tailored to their response to the Mantoux's test. Aims of Study: To demonstrate the efficacy and safety of low dose Alemtuzumab with a steroid free regimen in the post operative period in kidney transplant recipients. Methods: Data from all kidney transplant recipients receiving low dose Alemtuzumab was prospectively collected. Data included demographics; etiology of renal failure; live donor or cadavaric transplants; HLA match; Crossmatch results; adherence to steroid free regimen; mean tacrolimus levels at first week and at 3 months; primary graft function; delayed graft function (DGF); creatinine at discharge; creatinine at 3 months; bacterial infective complications; CMV status (donor-recipient); CMV reactivation; results of the mantoux test. Induction immunosuppression was with 500 mg Solumedrol at reperfusion and 15 mg Alemtuzumab; intravenously; within 30 minutes of reperfusion over two hours. Post operatively; Tacrolimus was started at 0.1 mg/kg; with mycophenolate 500 mg twice a day. Tacrolimus levels were aimed to be between 7-10 ng/ml. The mantoux test was done for the first 20 patients. These results were documented. The dose of Campath was titrated according to the Mantoux test-anergy or normal. Results: From October 2015 to July 2017; 58 patients underwent a kidney transplant using low dose Alemtuzumab (15 mg; intravenously; 30 minutes after reperfusion). 38 males and 20 female patients. Cause of renal dysfunction: diabetes (58%); FSGS (12%); IgA nephropathy (3%); Hypertension (18%); unknown (9%). 95% were live donor renal transplants; with 92% having a 3/6 HLA match; and crossmatch negative results pre transplant.There was a 98% adherence to a steroid free regimen in the postoperative period. Mean tacrolimus levels at the end of the first week were 8.2 ng/ml (range 6.5-10) and 9 ng/ml (range 7.8-12.1) at 3 months. All patients had primary graft function. Mean creatinine at discharge was 0.8 mg/dl (range 0.6-1.0) and mean creatinine at 3 months was 1 mg/dl (range 0.8-1.2). Three patients (5%) had a bacterial infection. No CMV reactivation. At a median follow-up of 14 months (range 1-21); there were no rejections. Mantoux test was normal in patients tested. Conclusion: Low dose Alemtuzumab is a safe and effective method of induction immunosuppression in kidney recipients titrated according to the mantoux test. No rejection was seen with acceptable bacterial infection rates. It allowed for steroid free immunosuppression for majority of the patients.


  Efficacy of Minus Day One Protocol for Tacrolimus in Indian Kidney Transplant Recipients Top


Abhijeet More, Nilesh Bhange, Nilrohit Paike, Kshitija Gadekar, Sudhir Kulkarni

MGM Medical College and Hospital, Aurangabad, Maharashtra, India. E-mail: doc.abhim@gmail.com

Background: Tacrolimus has a narrow therapeutic index; therefore it requires dose titration to individualize treatment. However; there are no definite guidelines about initiating Tacrolimus prior to transplantation. Various studies have mentioned initiating tacrolimus day 0; day 1 and day 14 prior to transplant. We have made an attempt to study the tacrolimus trough levels after initiating tacrolimus one dayrior to transplant. Aims of Study: To demonstrate the efficacy of 'MINUS DAY ONE Protocol' for Tacrolimus in achieving therapeutic serum tacrolimus levels on post transplant day 1 in Indian kidney transplant recipients. Methods: The objective of the study was to demonstrate attainment of therapeutic tacrolimus levels on post operative day 1; after starting tacrolimus as per 'MINUS DAY ONE Protocol' of TTS. The study comprised of 58 patients (53 male and 5 female). Tacrolimus Trough Levels were measured in laboratory with the MEIA (Micro particle Enzyme Immunoassay). Induction therapy was chosen considering the immunological risk profile of patients. 500 mg methylprednisolone was given intra-operative and 100 mg in the evening. Oral prednisolone was given on post operative day 1 (15 mg at 6 am; 5 mg at 6 pm). 1 gm mycophenolate mofetil was given twice daily from day 0. Tacrolimus was given at the dose of 0.06 mg/kg/dose orally in all kidney transplant recipients at 8pm prior to the day of transplant and twice daily thereafter. Samples for blood tacrolimus levels were taken after 4 doses (total dose received 0.24 mg/kg) at 8pm in the evening (12 hours post morning dose) on post operative day 1. Results: A total of 58 low risk renal-transplant recipients (53 male and 5 female; with mean age of 32 years) were analysed; the mean recipient age was 30.93 years (+/-8.3 standard deviation) (range; 18â€"58 years). 54 (93.10%) patients received kidneys from living donors; whereas 4 patients (6.89%) received grafts from deceased donors. Mean post operative DAY 1 Tacrolimus level was 11.925ng/dl (+/-1.28; standard deviation). Mean Serum Creatinine on post operative day 3 was 1.56 mg/dl (+/-0.86; standard deviation). 8 patients (13.79%) had culture proven infection [1 had Acute gastroenteritis; 5 had CAUTI (Catheter Associated Urinary Tract Infection); 2 had septicaemia]. Conclusion: Therapeutic TAC level can be achieved with Minus Day One protocol for Tacrolimus initiation in kidney transplant recipients.


  Histological Spectrum of Allograft Kidney Biopsies from Abo-incompatible Transplant Recipients and Their Short-term Outcome Top


Manoj Jain, D. S. Bhadauria1, Anupma Kaul1, Narayan Prasad1

Departments of Pathology and 1Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: mjain@sgpgi.ac.in

Background: ABO-incompatible (ABO-i) kidney transplantation; which was considered an absolute contraindication due to hyperacute rejection owing to blood type barrier; is now worldwide accepted practice with comparable outcomes as ABO-compatible transplants. Pre-transplant effective desensitization protocols and aggressive immunosuppression have made this possible. Aims of Study: This study analyzes the histological spectrum of transplant biopsies from ABO-incompatible recipients and their short term outcome. Methods: In this retrospective study from a tertiary care centre from north India between January 2016 till June 2017; graft kidney biopsies of fourteen patients who received ABO incompatible renal transplantation from live donors are evaluated. Pre-transplant workup including desensitization for blood group antibodies and induction protocol was performed in all. Histological spectrum of renal allograft biopsies from these patients and short term outcome is analyzed. Results: Allograft recipients mean age was 24.3 years (range 21-45 years) with 12 males. 7 (50%) were spousal donors; rest were first-degree relatives. Blood groups of recipients were A+; B+ and O+ in 8; 4 and 2; while donor blood groups were A+; B+; B-; AB+; AB- in 3; 4; 1; 3 and 3 respectively. Pre-transplant DSAs were negative in available 11 cases. Post-transplant biopsy for graft dysfunction were received after a median of 11 days (range 1 to 540 days). Histology revealed acute cortical necrosis in 1; hyperacute rejection with TMA in 1; acute antibody mediated rejection (ABMR) in 3; acute T cell mediated rejection in 2; and CNI toxicity in 1 and 6 had no evidence of rejection. C4d positivity in peritubular capillaries (PTC) was seen in 8 biopsies on immunofluorescence. Subsequent graft nephrectomy was done in 2 patients in early post-transplant period inspite of aggressive treatment. One case of ABMR became dialysis dependent; remaining 11 cases recovered at the time of discharge. Conclusion: ABO-i transplantation is successful modality with current treatment regimen. ABMR is common cause of graft dysfunction in the early post-transplant period. PTC-C4d positivity is not related to ABMR. Early graft failure; which is less common nowadays; was seen in two patients of this small cohort.


  A Modified Technique of Laparoscopic Trans-peritoneal Donor Nephrectomy Top


Samit Chaturvedi, Anant Kumar, Karamveer Sabbarwal, Pragnesh Desai, Mandeep Danda, Durgaprasad

Max Super Speciality Hospital, New Delhi, India. E-mail: samit.uro@gmail.com

Background: In living donors; Lap donor nephrectomy is the preferred method for harvesting kidneys; but sometimes complications like vascular spasms leading to ATN; post operative lymphatic leaks etc. may occur leading to donor and recipient morbidities. To reduce these complications; some modifications in the technique of lap donor nephrectomy is desirable. Aims of Study: To present a modified technique of laparoscopic trans-peritoneal donor nephrectomy which reduces total surgery time; chances of vascular spasm and post operative lymphatic leak. Methods: After mobilization of colon; ureter and gonadal vein are lifted laterally. Dissection is carried out cranially to reach renal hilum. Renal artery is dissected at its origin from the aorta without disturbing the hilar lymphatics. Renal vein is dissected after dividing adrenal and lumbar veins. The kidney is dissected from its posterior and lateral attachments remaining outside the gerota’s fascia. After cutting the ureter; renal artery and vein are clipped and cut. In the end the remaining soft tissue and lymphatics are divided between Hem-o-lock clips. The kidney is removed via a small pfannenstiel incision. Results: This technique offers several advantages. The renal artery is dissected at the origin from aorta reducing the chances of arterial spasm and subsequent ATN. The kidney is well perfused so there is brisk diuresis after cutting the ureter. Since the dissection is done outside of gerota’s fascia; the chances of renal injury is minimal. The lymphatics and hilar tissue dissection is minimal till the renal vessels are cut thus the total surgery time is reduced. After cutting the vessels; the lymphatics are clipped and divided reducing the incidence of post operative lymphatic leak.Occaisionally the kidney with all the surrounding fat may be little difficult to remove via small incision. Conclusion: This modified technique is faster with less chances of donor kidney ATN and lymphatic leakage.


  An Alchemy for the Conceptualisation of an Islet Cell Program in India: Lessons Learnt from the Journey in Tamil Nadu Top


Nithya Kalyani, Anil Vaidya, Anand Khakhar, Radhakrishnan, Vijaya Baskar

Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: mmnithya@gmail.com

Background: The main challenge from a regulatory framework for establishing an islet cell transplant unit in India is the interpretation of the Human Organ Donation Act and help the legislative authority for each state understand the need for improvisation that allows nascent programs to initially engage in characterisation of islet activity before starting a clinical transplant program. We describe our journey to address this issue in Tamil Nadu. Aims of Study: To construct an algorithm at state government level to encourage nascent transplant units to utilise donated human pancreases for the purpose of characterisation of islets before transplantation. Methods: Our algorithm was based on the following questions that were queries raised by the regulatory authority: a. Is there a need for such a unit in the state? b. Are there provisions for a solid organ pancreas transplant unit in the state? c. Can the current cadaveric donation statistics support such an enterprise? d. What are the credentials of the team that is proposing such a unit? e. Is there going to be a private-public partnership to allow equity of access to this service? f. Is there a trial period of characterisation of islets before a clinical program is established? Results: Our answers helped to favourably construct this algorithm that was presented to the state authorities for approval. The health secretary with the concordance of the state organ donation authority then proposed a government order (GO) to the health minister to allow for modifications of the Human Organ Act. This GO facilitated our unit to embark on an innovative path of islet cell isolation; that keeps patient safety at its foremost principle by adhering to a two phase approach that includes a first phase of characterisation and then eventually the second phase of a sustainable clinical unit. Conclusion: Islet transplantation is an alternative method because of its low invasiveness and safety to the recipient. We encourage nascent units to follow pathway undertaken by us to help understand and interpret the Human Organ Act and bring about a two fold approach to the starting of an islet cell unit.


  A Study on Acute Antibody Mediated Rejection in Renal Allograft Recipients: A Single Centre Experience with Bortezomib Top


Cyril Jacob Kurian, Varada Aravindan, Unnikrishnan Ramachandran, Sebastian Abraham, K. P. Jayakumar

Department of Nephrology, Government Medical College, Kottayam, Kerala, India. E-mail: cyriljkurian@gmail.com

Background: Antibody Mediated Rejection (AMR) poses a significant and continued challenge for long term graft survival in kidney transplantation. International guidelines do not define an evidence based treatment for Antibody Mediated Rejection. Recent literature concerning the treatment of AMR focus on Bortezomib; a drug that targets plasma cells. It is a selective; reversible inhibitor of proteasome; an organelle whose role is the breakdown of proteins used throughout the cell's life cycle. Aims of Study: To determine patient and graft survival at 6 months in renal transplant recipients with AMRT and compare graft outcome at 6 months in patients with and without AMR in deceased donor allograft recipients. Methods: Prospective study from date of transplantation. Patients regularly followed up and data analysed at 6 months after transplantation. All patients with AMR among patients who underwent renal transplantation from from December 2012 to June 2016 were analysed. All were treated with low dose IvIg (100 mg/kg) with plasmapheresis (5 sessions on alternate days) and Bortezomib (1.3 mg/m2/ dose on days 1; 4; 8; 11)Induction therapy with Inj. Methylprednisolone 15 mg/kg for 3 days and Inj. Basiliximab iv on day 0 and day 4. Maintenance immunosuppression with steroid; mycophenolate and tacrolimus. Immediate response to treatment; treatment related complications and outcome of these patients at 6 months were assessed. All deceased donor transplantations with similar induction therapy was studied. Patient and graft survival at 6 months were compared between those with AMR and without AMR among deceased donor allograft recipients. Results: Out of a total of 42 deceased donor renal transplantations; 6 had antibody mediated rejection. Of the 3 live allograft recipients who developed antibody mediated rejection 2 had spousal donor and one a sibling donor. Six out of the nine patients had history of prior sensitization. Recipient male: female ratio was 1.25:1 Mean peak S.Creatinine was 2.54 mg/dL (SD 0.897). Mean S.Creatinine at completion of treatment regime was 1.16 mg/dL (SD 0.298). Mean S.Creatinine at 6 months post-transplant was 1.03 (SD 0.292). Mean 6 month S. Creatinine in C4d negative patients was 1.18 ± 0.28 and in C4d positive patients it was 0.88 ± 0.22 (p value = 0.12). Mean 6 month S.Creatinine in v0 grade patients was 0.97 ± 0.23; while in other grades mean 6 month S.Creatinine was 1.2 ± 0.4 (p value = 0.28). In renal allograft recipients with AMR; all (100%) patients treated with bortezomib survived with no graft loss at 6 months. Conclusion: Bortezomib combined with low dose IvIg and plasmapheresis gives good results as compared to standard treatment modalities with 100% patient and graft survival at 6 months in the study population.


  Good Outcome of Kidney Transplant in Diabetic Patients Top


Bharat Shah, Prashant Rajput, Zaheer Virani, Pawan Deore

Global Hospital, Mumbai, Maharashtra, India. E-mail: dr_bharatvshah@yahoo.co.in

Background: Type 2 diabetes (DM); is the most common cause of end stage renal disease (ESRD). Kidney transplant is the best renal replacement therapy for ESRD. However; type 2 diabetics are older and frequently have co-morbidities. How do they do after kidney transplant compared to non-diabetics? Aims of Study: To assess the outcome of kidney transplant in type 2 diabetic and non-diabetic subjects. Methods: All renal transplants performed from August 1; 2013 to June 30; 2017 at our centre were included. These patients were divided into 2 groups: diabetic and non-diabetic. In all patients (except HLA full match patients); induction immunosuppression used was single dose thymoglobulin (1- 2 mg/kg) or 2 doses of basiliximab (20 mg). Maintenance immunosuppression included tacrolimus; mycophenolate sodium salt or azathioprine and tapering doses of steroids. Patient survival; graft survival and incidence of acute rejection and infections was determined in both groups. Acute rejection was suspected when there was >20% rise in serum creatinine from the baseline which responded to empiric steroids or was confirmed on kidney biopsy. Results: Out of 234 patients; 73 (31%) were diabetic and 161 (69%) were non-diabetic. The mean (1 SD) age of diabetic subjects was 52 (9) years while that of non-diabetic subjects was 38 (11) years. The 1 year and 3 years patient survival was 95% and 90% in diabetic subjects and 93% and 93% in non-diabetic subjects. The 1 year and 3 years death censored graft survival was 97% and 95% in diabetic subjects and 96% and 96% in non-diabetic subjects. Fourteen (19%) diabetic subjects had acute rejection episode while 42 (27%) non-diabetic subjects had acute rejection episode. Eight (11%) diabetic subjects developed TB after transplant while 6 (4%) non-diabetic subjects developed TB after transplant. Four out of 6 non-diabetic subjects developing TB had developed new onset diabetes after transplant (NODAT). Conclusion: Our study shows that short term results (1 and 3 years survival) of kidney transplant in diabetic subjects are like that in non-diabetic subjects. The rejections risk is lower while risk of developing TB is higher in diabetic subjects.


  Cryptococcosis after Renal Transplantation in a Tertiary Center in North India Top


Jasmine Sethi, Raja Ramachandran, Vivek Kumar, Manish Rathi, H. S. Kohli, K. L. Gupta

PGIMER, Chandigarh, India. E-mail: jasmine227021@gmail.com

Background: Cryptococcosis is the third most common invasive fungal infection occurring in renal transplant recipients with a high mortality rate. Our objective was to describe the pattern and risk factors of cryptococcal infection and the prognosis in our renal transplant recipients. Aims of Study: Our objective was to describe the pattern and risk factors of cryptococcal infection and the prognosis in our renal transplant recipients. Methods: We retrospectively reviewed the records of over 600 renal transplants recipients in our hospital during the period from June 2015 to June 2017. The demographic data; transplant characteristics; clinical manifestations; diagnostic criteria; treatment protocol; and long-term outcome of this cohort of patients were analyzed. Results: 7 patients developed post transplant cryptococcosis with a mean age of 46.7 ± 10.7 (range 33-61 years). The clinical manifestations were found to be diverse ranging from headache; meningeal irritation; cough; fever and skin lesions. Average time to infection after kidney transplant was 27.8 ± 22 (range 6-72 months). The forms of the disease were meningoencephalitis in 3/7 (42.8%) and disseminated in 4/7 (57.1%) patients. Among disseminated forms 3 patients had both pulmonary and CNS involvement; 1 had both pulmonary and skin lesions. Methods to diagnose were CSF cryptococcal antigen test positivity in 3 patients (42.8%); CT guided FNAC from pulmonary lesion in 2 (28.5%); skin biopsy in 1 (14.2%) and blood culture positivity in 1 patient (14.2%). Graft dysfunction was observed in 6/7 patients (85.7%) with graft loss in one patient (14.2%). A combination of amphotericin and flucytosine was used in 3/7 patients (42.8%); and rest 4/7 patients treated with amphotericin and fluconazole. 1 patient died (14.2%). Conclusion: Cryptococcosis is a serious infection among renal transplant recipients with a high mortality. Even minor symptoms like headache and fever in renal transplant recipients should alert the physicians to look for this infection with high suspicion.


  Hyphomycosis in Renal Transplant Recipient: Extreme Presentations Top


Saravanan Gobinathan, G. Venugopal, A. Murali

PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. E-mail: sarav_gobi@yahoo.co.uk

Background: Hyphomycosis is a rare fungal infection caused by filamentous fungi or moulds; which are ubiquitous in nature and are found mostly in soil and vegetation. Mostly immunocompromised individuals are affected and sites involved are cutaneous and subcutaneous tissues; the ocular region; frontal and maxillary sinuses; lungs; bones and the nervous system. We report two cases of hyphomycosis infection in post renal transplant setting. Aims of Study: The authors alert about the rarity of the case and the increasing occurrence of emerging fungi in immunocompromised patients. Methods: Descriptive study and data collection from medical records. Results: CASE 1The patient underwent surgical excision and itraconazole was introduced at a dosage of 200 mg twice daily was given for three months. No relapse until last review. CASE 2She was treated with amphotericin; voriconazole; teicoplanin and metronidazole. She was intubated and put on ventilator as GCS deteriorated. Patient died on 3/10/15 as she did not respond to treatment. Conclusion: We have reported two cases one localised to leg presenting late and the other presenting aggressively; early in the post-transplant period possibly secondary to severe immunosuppression. Common to both cases were the agricultural background possibly indicating high load of fungal exposure.


  Primary Neuroendocrine Tumor of the Liver: A Case Report Top


M. Rajgopal Acharya, Subash Gupta

Center for Liver and Biliary Surgery, New Delhi, India. E-mail: acharya.mrajgopal@gmail.com

Background: Neuroendocrine tumors develop in tissues that contain peptide and amine producing cells. These tumors; although having different embryological origin; show common phenotypic characteristics. Most common site of these tumors is the gastropancreatic system; followed by bronchopulmonary system. Neuroendocrine tumors metastasising to the liver are fairly common. However; primary hepatic neuroendocrine tumors; by comparison; are extremely rare; with only about 150 cases described so far. Aims of Study: Here; we are reporting a case of primary hepatic neuroendocrine tumor which was treated by non-anatomic resection. Methods: The patient; a 28 year old man from Afghanistan; was evaluated for occasional upper abdominal pain. CT abdomen was s/o well-defined multiseptated cystic-solid mass lesion in segments V/VI of liver. FNAC was done and was s/o cholangiocarcinoma v/s metastatic neuroendocrine tumor. Serum chromogranin was sent which was elevated (>650 ng/ml). CT guided trucut biopsy was done from the liver which was s/o primary liver neuroendocrine tumor. DOTANOC PET-CT was done which was s/o large (7X7X7 cm) Ga68 solid-cystic enhancing mass lesion in seg V/VI/VIII with mild IHBRD (l>r); there was no e/o Ga68 enhancing mass lesion anywhere else in the body. HVPG measurement was done and was 4 mm Hg. His operative and post-operative course were uneventful. Post-operative histopathology was consistent with primary NET of the liver. Post-operative chromogranin level reduced to normal value. Post-operative octrescan failed to identify any other avid lesion. Results: Liver is the organ most commonly affected by metastasis from neuroendocrine tumors. However; primary Neuroendocrine tumors of the liver are among the rarest tumors of liver. While the origin of PHNETs remains unclear; three hypotheses have been proposed: (1) they arise from neuroendocrine cells scattered in the epithelium of the intrahepatic biliary tract; (2) they originate from heterotopic pancreatic or adrenal tissue located in the liver; and (3) they arise from the neuroendocrine differentiation of a single malignant stem cell that is the precursor of other hepatic tumors. There is a stark difference between clinical presentation of PHNETs and hepatic masses due to metastasis from other NETs. While PHNETs present as endocrinologically silent hepatic mass; hepatic metastasis from extrahepatic NETs are commonly associated with carcinoid syndrome. It remains unknown why primary NETs of the liver frequently remain endocrinologically silent while their metastatic counterparts do not. PHNETs generally present with abdominal pain or symptoms secondary to mass effect of the tumor. Differentiating PHNETs from other hepatic massess preoperatively is very difficult; and it is generally misdiagnosed as other common lesions of liver; particularly hepatocellular carcinoma and cholangiocarcinoma. There are no specific radoilogical features characteristic of this tumor. However; Ultrasound; CT and MRI are all a part of work-up of this tumor. Finally; octreoscan is very useful and has a specificity of about 83%. Post-operative histopathology and immunochemistry remains the only absolute method of characterization of this tumor. NETs have been shown to be associated with immunoreactivity for chromogranin A; neuron specific enolase; and synaptophysin. Surgery remains the mainstay of treatment; and the type of surgery is largely dictated by the tumor size and location. 5 year survival rate after successful hepatectomy may increase to upto 78%; with a recurrence rate of upto 18%. Other alternative methods of treatment have been described; including chemotherapy; radiofrequency ablation and even liver transplant. Conclusion: Neuroendocrine tumors with hepatic metastasis are quite common; however primary neuroendocrine tumor of the liver is a rare tumor entity. There is no specific preoperative diagnostic method to identify PHNETs; and post-operative histopathology remains the mainstay of tumor identification.


  The Accuracy of 99mtc-DTPA Scintigraphy in the Evaluation of Acute Tubular Necrosis and Rejection Top


Sree Bhushan Raju, Krishna Prasad, Surendra

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: anvesh07@gmail.com

Background: Two most common causes of renal graft dysfunction in the immediate postoperative period are Acute Tubular Necrosis (ATN) and Acute Rejection (AR)which needs prompt and accurate diagnosis. Gold standard investigation is renal biopsy to diagnose these two complications. However it is invasive and time consuming. Hence a noninvasive method which can differentiate these two things accurately is necessary. Renal scintigraphy has been using in the evaluation of renal transplants noninvasively. Aims of Study: The purpose of the present study was to evaluate the overall accuracy of renal scintigraphy with 99mtc-DTPA in the diagnosis of ATN and AR in the immediate post-operative period. Methods: In this retrospective analysis which was conducted between 1st August 2014 and 31st May 2016; a total of 73 patients were included who underwent graft biopsy in the immediate post-operative period that were diagnosed with ATN and AR. All these patients underwent 99mTc-DTPA scintigraphy study with in 48 hours prior to perform biopsy. Dynamic images were performed in the anterior position of the abdomen and pelvis every 2 seconds for 80 seconds (flow phase) and every 15 seconds for 30 minutes (functional phase); after an intravenous injection of 370 MBq (10 mCi) of 99mTc-DTPA. Scintigraphy results were compared to biopsies performed. Results: Out of 73 biopsies 21 were AR and 52 were ATN. The sensitivities of renal scintigraphy for detection of ATN and AR 13.89% and 71.43% respectively. Specificities for detection of ATN and AR and 87.50% and 35.71% respectively. Conclusion: Renal scintigraphy with 99mTc-DTPA showed low sensitivity and high specificity for detection of ATN and it showed a high sensitivity and low specificity for detection of AR.


  Spousal Renal Transplantation: Our Experience without Induction Protocol Top


Sree Bhushan Raju, Sridhar, Anvesh

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: anvesh07@gmail.com

Background: Induction therapy is often considered to optimize outcomes; essentially in patients at high risk for poor short term outcomes. Aims of Study: We aimed to study the effect of no induction protocol in our patients undergoing spousal renal transplant vis-Ã -vis the living related renal transplantation. Methods: We retrospectively analysed the data of our transplant recipients who received living related (parents and siblings) and spousal transplant. All the recipients received standard triple immunosuppression; none of them received induction therapy. all the parents were haplomatch; all spouses were nil match with the recipient. Data analysed for Patients whose data is available till date. Primary outcome was measured as mortality or graft loss due to rejection. Mortality due to sepsis; cardiac events and other causes were noted. Rejection was noted as cellular and antibody mediated rejection.all theliving related recpients were categorised as group 1; spousal recipients were categorised as group 2. Results: There were a total of 189 living related renal transplants during the period of july-2010 to july 2016. The mean age of recipients were 29.87 ± 9.3. Mothers were the donors for 91 recipients; father in 27 recipients; sister in 14 recipients; brother in 4 recipients; wife in 48; husbands in 5. There was 19% mortality in group 1; 22.6% in group 2(p =ns). Predominant cause of mortality was sepsis in 89%. There was biopsy proven acute rejections 4 in living related; 5 in spousal transplants. 4 patients in group 1 back in MHD. Conclusion: No induction therapy irrespective of the donor; there is significant mortality among living donor transplantation. No induction protocol has less impact on biopsy proven acute rejection.


  Soluble Major Histocompatibility Complex Class I Related Chain A (Smica): A Biomarker for Assessment of Graft Outcome Following Renal Transplantation Top


Ajay Kumar Baranwal, Sanjeev Goswami1, Gurvinder Kaur2, Sanjay K. Agarwal3, Narinder Mehra4

Department of Immunology, Command Hospital, Pune, Maharashtra, Departments of 1Transplant Immunology, 2Laboratory Oncology, 3Nephrology and Transplant Immunology, AIIMS, New Delhi, India. E-mail: ajaykumarbaranwal@yahoo.com

Background: Soluble isoforms of Major Histocompatibility Complex class I related chain A (sMICA) play an important biological role in modulating immune response. Interaction of sMICA with NKG2D receptor; resulting in its internalization and subsequent suppression or impairment of NKG2D mediated immune response. The impact of sMICA on graft outcome in heart and liver transplantation has been shown in couple of studies but none in renal transplantation. Aims of Study: To evaluate a possible correlation between sMICA levels and development of acute rejection following renal transplantation. Results: Serum samples collected at pre-transplant and at different time points post-transplant from 137 live donor renal transplant recipients were evaluated retrospectively for sMICA levels by sandwich ELISA and for the presence of MICA antibodies using single antigen bead assay based on Luminex platform. Serum samples from 30 healthy volunteers were also tested for sMICA levels so as to determine the baseline value of serum sMICA in the Indian population. Conclusion: Significantly higher levels of sMICA were observed in the pretransplant sera of allograft recipients as compared to the levels in healthy volunteers (p<0.001). Patients with acute cellular rejection experienced a significant fall in their sMICA levels at the time of diagnosis as compared to their pretransplant values and all other posttransplant follow up time points (p= 0.01; 0.003; 0.005 and 0.04 respectively at pre vs Bx; POD7 vs Bx; POD 30 vs Bx; POD 90 vs Bx). However; no such difference was noted in patients with AMR. Our data did not reveal any significant correlation of MICA antibodies with either increase or decrease in levels of sMICA. Conclusion: Circulating levels of soluble MICA could well prove to be a potential biomarker of prognostic importance in assessment of patients after renal transplantation.


  Short Term Outcome with and without Induction Therapy in Low Risk Renal Transplant Recipients Top


Sabina Yusuf, Anurag Gupta, D. S. Rana

Sir Ganga Ram Hospital, New Delhi, India. E-mail: sabinayusuf@gmail.com

Background: In the era of modern immunosuppression; transplant centers now administer triple maintenance therapy with steroids; tacrolimus and MPA as the standard maintenance treatment; a shift that may partly explain the marked decrease in 1-year acute rejection rates from ~50% in 1990s to ~10-15% now. With this low basal level of acute rejection risk; the question arises of whether addition of induction therapy still offers an additional benefit in low risk kidney transplant recipients. Aims of Study: To assess the short term graft and patient outcome in low risk renal transplant recipients with and without induction therapy. Methods: This study was a retrospective and prospective observational study in which 100 low risk renal transplant recipients were included. Patients were divided into two groups- one group that received induction therapy and another that did not receive induction. 50 patients were included in each group. They were assessed daily from the day of surgery till discharge and then followed for a period of 1.5 years. Laboratory assessments were performed at baseline and at each visit. Graft and patient survival was assessed on a continuous basis. Periods of hospitalization between visits were recorded. Three main end points were analysed and compared between the two groups. These included efficacy of induction therapy; patient and graft survival and adverse effects. Efficacy was assessed by the occurrence of a rejection episode. All rejection episodes were confirmed based on the results of a percutaneous 18G needle graft biopsy. Results: Majority of the patients were male in both groups. Overall 65% participants were in the age group of 20-40 years. About 16% patients underwent a pre-emptive renal transplant. UTI was the most common inhospital complication occurring in 22% patients in the no induction group and 34% patients in the induction group (p=0.197 NS). Rejection in the early post transplant period was seen in 4% patients in no induction group and 6% patients in induction group (p=0.171 NS). Rejection as a cause of late graft dysfunction was seen in 16% patients in the induction group and 20% patients in the no induction group (p value 0.603 NS). Resistant rejections constituted 10% of total rejections in no induction group and 12.5% in induction group (p=0.652 NS). Two patients (4%) in the no induction group had more than one rejection episode compared to none in the induction group (p=0.153 NS). No difference was seen in serum creatinine between the two groups at the end of 1.5 years. Graft survival at the end of 1.5 years was also similar between the two groups with only one case of graft loss occurring in each group. Infection episodes affected 24% patients in the no induction group compared to 40% in the induction group (p=0.253 NS); with UTI being the most common infection. Relapsing and recurrent UTIs were seen in 46% patients in induction group compared to 16% in no induction group (p=0.09). Hospitalization requiring infections were seen in 76% patients in the induction group compared to 64% in no induction group (p=0.119 NS). CMV infection affected 6% patients in the induction group and none in the no induction group (p=0.07). Patient survival at the end of of 1.5 years was comparable in the two study groups with death occurring in 3 patients (6%) in the induction group and 2 patients (4%) in the no induction group (p=0.646 NS). Within the induction group; the nature of induction therapy; whether basiliximab or ATG; did not affect the graft or patient outcome. Conclusion: Study shows comparable results between induction and no induction groups in terms of graft and patient outcomes at 1.5 years; with an appreciably increased incidence of hospitalizations and infections in induction group. Use of induction may thus be avoided in low risk renal transplant recipients.


  Renal Transplantation Using Grafts with Multiple Arteries Harvested Laparoscopically Top


Anil Kumar Gulia, Karamveer Sabharwal, B. Durgaprasad, Anant Kumar

Max Super Speciality Hospital, New Delhi, India. E-mail: doctorgulia@gmail.com

Background: Kidney transplant is treatment of choice for most patients with CKD stage 5. Kidney grafts with multiple renal arteries (MRAs) make transplantation technically challenging. It is vital to maintain donor safety as well as good recipient outcome. Aims of Study: This study analyses outcomes of living donor renal transplant using grafts with MRAs harvested laparoscopically. Methods: This study reviewed 1850 living donor kidney transplantations performed from Jan 2007 to Jan 2017; with grafts harvested laparoscopically. Patients were divided into two groups according to the number of graft arteries: multiple (group 1) versus single (group 2). The serum creatinine level; warm ischemic time (WIT); rewarming time; total ischemic time (TIT); operative time; acute rejection episodes; and complications in each group were evaluated. Arterial anastomoses were primarily completed by end-to-side manner to the external iliac artery or end-to-end manner to internal iliac artery or a combination of both. In some patients; arterial anastomosis was done ex-vivo to branches of internal iliac artery graft and this later on anastomosed end-to-end to stump of internal iliac artery. This reduced WIT. Small calibre accessory arteries were anastomosed end-to-end to inferior epigastric artery. Venous anastomoses were primarily completed by end-to-side manner to the external iliac vein. Results: There were 472 patients in group 1 and 1378 patients in group 2. Donor outcomes were similar in both groups. All renal grafts had adequate vascular and ureteral length. There were no vascular complications in the recipient. No graft was lost due to injury or primary graft non-function. The serum creatinine level showed no difference among the groups. Longer TIT was observed in the group 1; but mean WIT was similar in both groups. The acute rejection rate was comparable. Furthermore; allograft survival was similar between both groups with 75% of multiple renal artery and 77% of single renal artery grafts functioning at 5 years. Conclusion: Laparoscopic procurement of renal grafts involving multiple vessels is safe. Long term graft survival rates and complications are not different for renal grafts involving multiple versus single vessels.


  Correlation of Pretransplant Glucose Metabolism and Nonalcoholic Fatty Liver Disease with the Development of New Onset Diabetes after Renal Transplantation Top


Sahil Bagai, Ajay Duseja, Ashish Sharma, Naresh Sachdeva, K. L. Gupta, Manish Rathi

PGIMER, Chandigarh, India. E-mail: Sahil.bagai@gmail.com

Background: New onset diabetes mellitus after transplantation (NODAT) is strong independent predictor of mortality. Several modifiable and non-modifiable risk factors contribute to NODAT. The aim of study was to analyze influence of pre transplant glucose metabolism and Non alcoholic fatty liver disease on NODAT and to see any change in pattern of fatty liver post transplant. Aims of Study: To correlate pretransplant glucose metabolism; insulin parameters and NAFLD with NODAT.To note changes in the frequency and pattern of NAFLD after renal transplantation. Methods: Fifty CKD-ESRD patients who underwent renal transplantation were enrolled in study. Anthropometric variables such as body mass index; waist circumference; waist-to-hip ratio; were measured according to a standard protocol. Measurements of fasting plasma glucose and 2 hours after ingestion of 75 g glucose were done. Fasting insulin and c-peptide were done using ELISA based kits. HOMA model was used to define beta cell function and insulin resistance.Insulin resistance (IR) = (FI x G) /22.5 Beta cell function (B) = (20 x FI) / (G -3.5) Insulin sensitivity (IS) = 100/ IR; FI=fasting insulin (μIU/ml); G=fasting glucose. (mmol/l) Correlation of anthropometric parameters; pre transplant glucose parameters; HbA1c; Insulin resistance and C-peptide with NODAT was analyzed. Ultrasound abdomen and fibroscan were done for these patients in pretransplant and post transplant period and any correlation with NODAT or change in pattern of fatty liver was observed. Results: NODAT developed in 17 (34%) patients. Mean age of study group was 32.26 + 9.51 years. 2 hr plasma glucose was found to be higher in group that developed NODAT (123.18 ± 8.15vs 97.30 ± 1.72; p=0.010). HbA1c; FBS; fasting insulin; c peptide measurements and insulin resistance and beta cell function were found to be non significantly higher in the group that later developed NODAT. Weight; BMI; Waist circumference; hip circumference; Wc/Hc; HbA1c; c-peptide were found to be insignificant in predicting development of NODAT. Gender; basic disease; dialysis duration had no bearing on development of NODAT.NAFLD did not show any correlation with NODAT in the study and no significant change seen in pattern of fatty liver post transplant. Conclusion: Not all pretranspalnt glucose metabolism can predict the development of NODAT. PPBS is more sensitive then FBS in predicting at risk patient. Anthropometric measures and NAFLD are not predictive of NODAT in our group of patients where malnutrition acts as a confounder.


  Asymptomatic Bacteriuria in Renal Allograft Recipients Top


Gaurav Shekhar Sharma, Dhananjai Agrawal, Alok Kumar Pandey, Pankaj Beniwal, Rajesh Johrawat, Sanjeev Sharma

Department of Nephrology, SMS Medical College and Hospital, Jaipur, Rajasthan, India. E-mail: shekhargaurav2012@gmail.com

Background: Asymptomatic bacteriuria (AB) is common among renal allograft recipients (RARs). However; characteristics and impact of AB on graft function has been found to have conflicting results in various studies. Aims of Study: To evaluate the prevalence of AB; microbiology; its risk factors in RARs and its impact on graft function in early (<6 months) post transplant period. Methods: All patients who underwent renal transplantation between July 2016 and December 2016 in the Department of Nephrology; SMS Hospital; Jaipur were enrolled in this study and systematic screening for asymptomatic bacteriuria was done by getting pyogenic urine cultures done on day 7 post transplant and then monthly up to six months. The pattern of bacterial growth obtained was assessed. S.creatinine and urine routine was done and estimated Glomerular Filtration Rate (eGFR) was calculated by Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation; on every visit up to six months. All patients were then divided into two groups- one with and the other without AB. The impact of AB on the graft function was analysed at the end of six months in each group based on S.creatinine and eGFR. Results: Twenty (43.4%) out of 46 patients who underwent renal transplantation during the study period had 30 episodes of AB. The mean age of study population was 32.5 ± 9.4 years. The Male:Female ratio was 4.7:1. Of these; 26.1% (n=12) were cadaveric renal transplantation. The most frequently isolated pathogen from urine was E.coli (n=14; 46.6%) followed by Pseudomonas (n=6; 20%) and Citrobacter (n=6; 20%) which ranked equally. Cadaveric renal transplant recipients had higher incidence of AB as compared to live related RARs (83.3 versus 23.5%; P=0.03) during the early post transplant period. There was no difference in the eGFR between those with AB and those without; at 6 months of follow up (76.0 ± 20 versus 76.2 ± 11.7 ml/min/1.73m2; P=0.97). Conclusion: AB is common in renal transplant recipients during first 6 months of transplant. Cadaveric renal transplant recipients were more likely to have AB. Further studies are required to assess its long term impact on graft function.


  CMV Detection in Postrenal Transplant Patients during Intensive Care Unit and First 6 Months Follow Up: 18 Years Experience from a Tertiary Care Centre Top


Mahendra Kumar, R. W. Minz, S. Anand, P. Singh, A. Sharma, D. Kenwar, S. Singh, S. Kumar, Y. Kumar, M. Minz

PGIMER, Chandigarh, India. E-mail: drbindmahendra@gmail.com

Background: CMV reactivation/disease can cause morbidity and death in post-transplant period. Its early detection and treatment greatly improves transplant outcome. We share our experience of 18 years in detecting CMV in post-renal transplants (PRT) patients using PP65 antigen assay (PP65AA) and viral load by Real-Time PCR (VLRTP) designed by Roche Scientific.Aims of Study: Detection of CMV virus in post renal transplant patients by PP65 antigen assay and Real-Time PCR and comparison of these two techniques. Methods: Total of 1741 PRT patients were screened for CMV during the period from Nov; 1998 to Nov; 2016. Out of these; 350 cases were screened by PP65AA and 1365 by VLRTP. Both techniques were performed in 88 cases. Most of testing was done during Intensive care Unit (ICU) stay or in 1st six months of transplant on follow-up. Results: Out of 1741; total 392 cases were positive (23%). On comparison; PP65AA showed 13% positivity while VLRTP showed 19% positivity. In 5% cases; PP65AA showed atypical signal and only 40% of which were positive by VLRTP. 2% PP65AA positive cases were negative by VLRTP. In respect of duration and ease of technique; PP65AA took five hours to perform and was cumbersome to report; however VLRTP took three hours to perform and gave easy read out reports. The latter was more costly but more sensitive and specific. Viral loads ranged from 10-100000 copies/ml. Most patients responded well to anti-viral therapy and were monitored till the viral counts turned negative. Conclusion: CMV infection remains a significant cause of morbidity and mortality in renal transplant patients. Between PP65AA and VLRTP techniques; VLRTP is more sensitive and specific and has ease of performance and interpretation. Early detection and antiviral therapy will improve outcome in PRT patients.


  Spectrum of Aetiology of Acute Kidney Injury in Renal Allograft Recipients: A Single Centre Study Top


Alok Pandey, Dhananjai Agrawal, Gaurav Shekhar Sharma, Pankaj Beniwal, Sanjeev Sharma, Rajesh Johrawat

SMS Medical College, Jaipur, Rajasthan, India. E-mail: dr.alok1981@gmail.com

Background: Renal allograft recipients (RARs) are more susceptible of developing AKI than the general population. AKI in RARs is different than that seen in the community in terms of its risk factors; aetiology and outcome. Scarce data is available on the development and impact of AKI in RARs. Aims of Study: To evaluate the spectrum of aetiology of AKI using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Methods: RARs with stable graft function for at least one month; who were admitted with AKI; in the department of Nephrology; SMS Medical College and Hospital; from September 2015 up to June 2017; were included in this prospective observational study. A total of 42 patients; both with live and deceased donor; were enrolled out of which four patients presented with a second episode of AKI. For each AKI episode; staging and evaluation was done to find out the cause. Serum Creatinine and urine output were monitored daily up to seven days; from the day of admission. Results: A total of 46 AKI episodes occurred in 42 RARs enrolled. Thus; 04 patients had a second episode. The mean age was 36.6 + 10.18 years. Male:Female ratio 3.2:1. The median period from the date of transplant to the date of AKI was 188 (IQR 95-332) days. Majority (n=32; 76.19%) of patients developed AKI within first year of transplant. Most of the AKI episodes (n=26; 56.52%) were in stage 1 at the time of admission while the remaining 16 (34.78%) and 04 (8.69%) episodes were in Stage 2 and stage 3 respectively. Infections (n=20; 43.47%) were found to be the most common cause. The next were biopsy proven rejection (n=12; 26.08%); of which Acute antibody mediated rejection was the most common type. Biopsy proven Acute tubular necrosis (n=4; 8.69%) and biopsy proven calcineurin inhibitor toxicity (n=4; 8.69%) ranked equally next followed by recurrence of native kidney disease (n=2; 4.34%) and miscellaneous causes (n=4; 8.69%). Dialysis was required only in 2 (4.34%) episodes. Conclusion: Most of the episodes of AKI in RARs occurred in the first year post transplant. Infections were the most common causes followed by rejection. Thus; meticulous efforts should be made in prevention and early detection of both of these complications in RARs.


  Sofosbuvir Based Regimens in Treatment of HCV Infected Renal Transplant Patients Top


Priyesh Damani, Hegde Umapati, Gang Sishir, Rajapurkar Mohan

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: priyesh.damani@gmail.com

Background: Hepatitis C virus Infection in Renal Transplant patients is associated with poor graft and patient survival. Newer Directly acting antiviral drugs; their efficacy; safety and interactions with immunosuppressant medicine have not been extensively studied in renal transplant patients. Aims of Study: To evaluate safety and efficacy of Sofosbuvir based regimens in Renal Transplant patients infected with Hepatitis C virus. Methods: This was a prospective observational study performed between March 2015 till May 2017. 46 patients consented and found suitable for the study; 34 patients -Post Transplant; and 12 patients were treated 4 week prior to transplant. Initially patients were given Sofosbuvir (400 mg) and various dose of ribavirin as per eGFR and weight. Later as Ledipasvir/Daclatasavir were available as per Genotype either Sofosbuvir+Ledipasvir (90 mg) or Sofosbuvir+Daclatasavir (60 mg) was used for 12/24 week.Liver function tests; Creatinine and Complete blood count; Viral Load was done every monthly and 12 and 24 week after completion of treatment. Results: Genotypes:Genotype1:35; Genotype 3:10; Genotype 4:1Antiviral Regimens; Sofosbuvir+ Ribavirin:27;Sofosbuvir+ Ledipasvir:11;Sofosbuvir+Daclatasavir: 8.Viral Response Rapid Virological Response (RVR):85%; End of Rx Response: 94%; Sustained Virological Response 12 (SVR12):95% SGOT and SGPT decreased from Baseline 81.89 ± 74.66 and 97.83 ± 90.49 IU/ml to end of treatment 22.12 ± 8.23 and 20.74 ± 11.42 IU/ml respectively. (p<0.0001) Billirubin decreased from basseline 1.04 ± 1.11 mg/dl to end of Rx 0.62 ± 0.24 mg/dl. (p<0.0001)Creatinine changed from baseline 1.31 ± 0.54 mg/dl to end of Rx 1.46 ± 1.02 mg/dl. (p-0.181). Conclusion: Newer Sofosbuvir based regimens are safe and effective in treatment of Hepatitis C infection in renal transplant patients and not associated with interactions with immunosuppressant drugs or adverse effect on graft function.


  Retrospective Comparative Study of Short-term and Long-term Outcome between Spousal and Blood Related Donor Kidney Transplant Top


Sushma Bala, Pratik Das

Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India. E-mail: sushmabala2001@yahoo.com

Background: Kidney transplant from Living Donor is the most common practice in India. Most of the living donor are either Blood related (HLA Mismatch = <3) or spousal (HLA Mismatch >3). Deceased donor organ shortage has made living donors (LD) a major source for Kidney transplantation in India. Spousal donors represent an important source of allograft especially when a patient in 4th to 6th decade of life becomes a victim of ESRD. Aims of Study: To compare the short-term and long-term outcome between spousal and blood related donor kidney transplant. Methods: It was a single centre retrospective study conducted at Rabindranath Tagore International Institute of Cardiac Sciences; Mukundapur; Kolkata. Data of all live donor kidney transplants between January 2006 and December 2011 was collected at discharge; 1 year and 5 years post transplant and the short term and long term patient and graft outcomes between spousal and blood related donor kidney transplants were analysed and compared during the study period (2015-2016). Results: 177 transplant recipients were included out of which 99 (55.9%) had blood related kidney donors and 78 (44.1%) had spousal kidney donors. 127 (71.8%) recipients were male and 50 (28.2%) were female. Mean age of the recipients in the blood related group was 33.7 ± 8.0 years and in the spousal group was 44.5 ± 9.5 years ( P < 0.05); and male:female in both the groups were 1.6:1 and 4.5:1 (P = 0.003) respectively. 8 (10.3%) recipients in the blood related group were diabetic while 44 (44.4%) were diabetic in the spousal group (P < 0.000001).Among the kidney donors; 32 (18.1%) were males and 145 (71.9%) were females. Mean age of donors in the blood related group was 50.1 ± 10.7 years and in the spousal group was 39.7 ± 10.4 years ( P < 0.05); and male:female of donor in both the groups were 1:4.2 and 1:5 ( P = 0.19). HLA mismatch (3: >3) in the blood related group was 98:1 and in the spousal group was 0:78 (P < 0.05). Rejection in the blood related group and in the spousal group was 15 (15.15%) and 9 (11.53%) respectively and is not statistically significant. Death in the blood related group and in the spousal group was 6 (6.06%) and 2 (2.56%) respectively and is not statistically significant. Number of infections in the blood related group was 25 (25.3%) and in the spousal group was 13 (16.7%). Mean serum creatinine at discharge in the blood related group was 1.15 ± 0.33 mg/dl and in the spousal group was 1.05 ± 0.31 mg/dl; ( P=0.055).Mean serum creatinine at 1 year in the blood related group was 1.27 ± 0.29 mg/dl and in the spousal group was 1.32 ± 0.30 mg/dl; (P=0.3). Mean serum creatinine at 5 year in the blood related group was 1.45 ± 0.27 mg/dl and in the spousal group was 1.54 ± 0.25 mg/dl; (P=0.029). Cumulative hospital admissions in the blood related group and in the spousal group were 30 (30.3%) and 16 (20.5%) respectively and is not statistically significant. Number of patients who had graft loss (defined by back to Dialysis) in blood related group were 10 (10.10%) at the end of 1 year and 21 (21.21%) at the end of 5 years.In the spousal group; 10 (12.82%) patients had graft loss at the end of 1 year and 15 (19.23%) had graft loss at the end of 5 years. Difference in both the group was not statistically significant. Total incidence of infection in both groups was 16.66%. There was no statistically significant difference in the two groups. Conclusion: Graft outcome was slightly superior in the blood related group at the end of 5 years but without significant difference in the rejection rates; hospital admission rates and the death rates. Graft loss was similar in both the groups.


  First Successful Experience of ECPR to Heart Transplant at a Tertiary Care Institute Top


Sarvesh Pal Singh, Ashwani Bansal, Neeraj Parakh, Manoj Kumar Sahu, Milind Padmakar Hote, Sandeep Seth, Balram Airan

All India Institute of MedicalSciences, New Delhi, India. E-mail: sarveshpal.singh@gmail.com

Background: The use of veno-arterial (VA) ECMO during cardiopulmonary resuscitation (ECPR) has been associated with improved survival and favorable neurologic outcomes. Also; ECMO has been used as a bridge to heart transplant. Veno-arterial ECMO provides survival benefit in patients awaiting transplant. Aims of Study: We describe a patient who underwent ECPR; was maintained on VA ECMO for 7 days before undergoing heart transplant surgery. Methods: A 17-year-old boy (weight 40 kg; body surface area 1.34 m2) diagnosed with dilated cardiomyopathy was admitted to our institute with class IV symptoms of heart failure. The patient sustained a cardiac arrest and was resuscitated with extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR). He was maintained on a peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) for 7 days before undergoing a heart transplant. He was discharged 1 month after his transplant. Results: He was discharged 1 month after his transplant and is doing well at 6 months followup. Conclusion: ECMO is an effective modality to providecirculatory support during resuscitation end-stage heart failure patients and can be extended to serve as a bridge to transplant in centers where heart transplant surgery is done in a regular predictable manner.


  Renal Transplant Recipients with HCV Infection: Our Early Experience with Direct Acting Antivirals Top


B. N. R. Ramesh, Sree Bhushan Raju, Sridhar, Surendra, Vamsi Krishna

Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India. E-mail: dr.bnrramesh@gmail.com

Background: Treatment options for HCV infection in renal transplant (RTx) recipients are limited. The conventional treatment with INF and Ribavirin carries the risk of allograft rejection. The availability of second generation oral anti virals has opened the new avenues for HCV treatment. Aims of Study: To study the effectiveness of 2nd generation oral anti virals for treatment of renal transplant recipients with HCV infection. Methods: 5 renal transpalnt recipients with HCV infection were treated with DAA (Direct acting antivirals) for 3 months in treatment naive patients; 6 months in prior relapsers. baseline viral load; genotype; RFT; LFT; CBP; fibroscan; US abdomen were done follow up viral load; RFT; LFTs were done at the end of 1st month; athe end of treatment; 3 months after the completion of treatment were done. Results: Among 5 patients; 4 were males. At base line 2 patients had stable graft function; 3pt had CAN. 1 patient had genotype 4; remaining 4 had genotype 1. 2 patients were treated with Sofasbuvir + Ribavirin; both were developed anaemia; 1 patient later converted to Sofa+ledipasvir; 1 patient who had CAN lossed his graft. Among 3 patients recievedSofasbuvir+ledipasvir; 1 pt had transient worsening renal function 4 patients were attained EVR; all pts were attained End of treatment response; SVR. Conclusion: Direct acting antiviral drugs were safe and effective in patients with stable graft function; without any risk of rejction.


  Laparoscopic Live Donor Nephrectomy: Right versus Left Top


Anil Kumar Gulia, Karamveer Sabharwal, B. Durgaprasad, Anant Kumar

Department of Urology and Kidney Transplant, Max Super Speciality Hospital, New Delhi, India. E-mail: doctorgulia@gmail.com

Background: Laparoscopic live donor nephrectomy (LDN) has become the standard of care. Left LDN remains the side of choice whenever possible; because the left renal vein is longer. However; there are some donors in whom right kidney is to be taken for donation due to anatomical or functional reasons. Right LDN is perceived to be difficult due to anatomical factors. Therefore; many surgeons have a bias to prefer left kidney for donation or do right side as open donor nephrectomy. Aims of Study: We routinely perform right LDN; when indicated; and herein compare the outcomes between right and left sided LDN. Methods: From January 2007 to January 2017; 1850 laparoscopic donor nephrectomies were done. Of these; 168 were right sided and 1682 were left donor nephrectomies. All the case records of donor were retrospectively reviewed. The operative time; warm ischemia time; intraoperative events; blood loss and post-operative parameters were recorded. The kidney recipient data were also recorded. Results: The demographic characteristics of donors were comparable between two groups.Among other variables; operating time was significantly less in RLDN (120 min) versus LLDN group (146 min). Intraoperative estimated blood loss (118 ml in RLDN; 126 ml in LLDN); warm ischemia time (4.8 min in RLDN; 5.2 min LLDN) and hospital stay (4.2 day in RLDN; 4.3 day in LLDN) was comparable.Vascular complications occurred in four patients in RLDN and six cases in LLDN group.Recipient outcomes were comparable. Conclusion: With adequate experience; right LDN can be accomplished in a safe manner with good outcomes.


  Difficult Donor Nephrectomy Completed Laparoscopically Top


Anil Sharma, Ghosh Prasun, Khera Rakesh, Ahmed Kamaal

Medanta the Medicity, Gurgaon, Haryana, India. E-mail: dr.anilms@yahoo.co.in

Background: Lap donor nephrectomy is now considered standard of care in most transplant centres. Donor is an other wise healthy individual. Extremel care must be taken to minimise risk to donor. Aims of Study: A case study. Methods: Pre operative; intra operative and post operative follow up of a kidney donor. Results: Left sided donor nephrectomy was challenging due to splenomegaly and fibrosis at renal hilum. The procedure was completed laparoscopically in a safe and time bound manner. Conclusion: Lap donor nephrectomy is a major advancement in procurement of living kidneys for donation. High level of accuracy and experience is required especially in difficult cases to complete the procedure laparoscopically.


  Difficult Donor Nephrectomy Completed Laparoscopically Top


Anil Sharma, Ghosh Prasun, Khera Rakesh, Ahmed Kamaal

Medanta the Medicity, Gurgaon, Haryana, India. E-mail: dr.anilms@yahoo.co.in

Background: Laparoscopic donor nephrectomy is now the standard of care in most transplant centres. Donor is an otherwise healthy individual. Extreme care should be taken to minimise risk to donor. Aims of Study: A case study. Methods: Pre operative; intra operative and post operative follow up of a kidney donor. Results: Left sided donor nephrectomy was challenging due to splenomegaly and fibrosis at Renal hilum; procedure was completed laparoscopically in a safe and time bound manner. Conclusion: Lap donor nephrectomy is a major advancement in procurement of living kidneys for donation. High level of accuracy and experience is required in difficult cases to complete the procedure laparoscopically.


  Prospective Randomised Study Evaluating the Effect of Intraperitoneal Bupivacaine after Laparoscopic Donor Nephrectomy Top


Mohan Kumar, Ankush Jairath, Abhishek Singh, Sudarshan Balaji, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai

Muljibai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: drvmohankumar@gmail.com

Background: Laparoscopic Live Donor Nephrectomy (LLDN) is now the preferred method for kidney harvestation in Renal Transplant surgery due to reduced postoperative complications with an early return to work.Pain in laparoscopy - due to visceral; somatic and shoulder pain (secondary to diaphragmatic irritation). The peritoneal origin of the pain advocates that analgesia delivered locally to the peritoneal cavity may be of benefit postoperatively in reducing pain. Aims of Study: To evaluate the analgesic efficacy of intraperitoneal bupivacaine 0.5% in postoperative period following LLND. To study the effect on heart rate; blood Pressure; respiratory rate; temperature. Methods: Prospective; randomized; double blinded; placebo-controlled study conducted in the Department of urology and transplant surgery; Muljibhai Patel Urological Hospital; NADIAD.A total of hundred live Kidney donors; of either sex belonging to ASA grade I and II from Nov13 to April15 were included.GROUP A: 50 patients received 20 mL of 0.5% Bupivacaine intraperitoneally.GROUP B: 50 patient received 20 ml of 0.9% normal saline intraperitoneally. In both groups; after completion of nephrectomy and just before removal of trocar 10 mL of the drug onto renal bed; 5 mL onto Hepatodiaphragmatic area; 5 mL onto space between diaphragm and spleen (under direct vision by the surgeon who was unaware of the nature of the study drug). Postoperatively patients were assessed based on VAS and requirement of rescue analgesic (pentozocine given when VAS >3); hemodynamic parameters and presence of any adverse effects. Results: Intraperitoneal bupivacaine reduces the incidence of post operative pain and the analgesic requirement compared to placebo. The number of patients requiring analgesics were also less in the bupivacaine group. Intraperitoneal instillation of bupivacaine led to better control of blood pressure and heart rate in immediate postoperative period. Intraperitoneal bupivacaine did not increase incidence of adverse effect or hemodynamic complications at a dose used in our study. Conclusion: Intraperitoneal bupivacaine instillation is a simple; safe; inexpensive method for control of postoperative pain in patients undergoing laparoscopic live donor nephrectomy. Use of the correct dose and concentration of the drug is essential for effective pain control.


  Diagnostic Accuracy of CT Angiography in Evaluation of Vascular Anatomy in Comparison with Intraoperative Findings an Assessment of 392 Patients Top


Mohan Kumar, Arvind Ganpule, Abhishek Singh, Ravindra Sabnis, Mahesh Desai

Muljibai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: drvmohankumar@gmail.com

Background: Transplantation of kidneys from living related donors is the treatment of choice for patients with end stage renal disease. The precise knowledge of vascular anatomy is crucial to a successful outcome. The reported accuracy of CT angiography in assessing the vascular anatomy is around 85 to 100%. We did a prospective study to assess the diagnostic accuracy of CT angiography in the evaluation of vascular anatomy in comparison with intra operative findings. Aims of Study: To assess the accuracy of CT in predicting the anatomy in patients who underwent laparoscopic donor nephrectomy. Methods: 392 patients who underwent laparoscopic donor nephrectomy in our institute between January 2010 and December 2012 were included in our study. Results: CT scan correlated well with the intra operative findings in most of our patients with good sensitivity and specificity. CT interpreted a case of double renal vein as single and a case of circumaortic vein reported on CT was notdetected intra operatively. A case of right side early branching was not detected on CT. A case of a retroaortic branch of renal vein was missed on CT scan. The incidental findings detected on CT scan such as calculi; mass and hemangioma or fibroid can be of help in managing the patient after surgery. Conclusion: Laparoscopic donor nephrectomy requires vital information regarding the vascular anatomy of the kidney. CT scan helps in accurately mapping the vascular anatomy. CT angiography helps in strategic planning of the surgery.


  Efficacy of Plasmapheresis in the Treatment of Antibody Mediated Rejection in Kidney Transplant Recipients Top


Soham Das Gupta, Sarbpreet Singh, Deepesh B. Kenwar, Mukut Minz, Ashish Sharma, Navdeep Singh, Kishan Lal Gupta, Ritambhra Nada, Ratti Ram, Rekha Hans

PGIMER, Chandigarh, India. E-mail: sohamdoc@gmail.com

Background: Antibody-mediated rejection (AMR) after renal transplantation has a reported incidence of 3-30% depending on diagnostic criteria.Therapeutic plasma exchange (TPE) with IV Immunoglobulin alone or with combination with antiCD20 antibodies or bortezomib are used as treatment for AMR although optimal treatment is unknown. These therapies are associated with significant cost and infectious complications. We have reviewed the response rates and clinical outcome of patients receiving treatment for AMR. Aims of Study: To assess the therapeutic benefit and risk of infectious complications in patients receiving TPE with IV Imunoglobulin with and without antiCD20 antibodies or bortezomib for the treatment of AMR. Methods: It is a single center retrospective study extending from 2008 to 2016; involving a total of 30 KTRs who were diagnosed with AMR based on renal allograft biopsy findings and received TPE with IVIg at our Institute. Biopsy findings were interpreted as per the modified Banff criteria. Donor Specific Antibodies could be done only in a few patients because of high cost involved and non-availability in the earlier period. Patients were given additional Bortezomib (n=4) alone or along with Rituximab (n=2) as per the clinician’s discretion. Renal function was monitored prior to starting therapy; at one month; and at one year after TPE or last follow up whichever earlier. Patients who received TPE for desensitisation to donor anti HLA antibodies; ABO incompatible donors; and other indications were excluded from the study. Results: Out of 30 patients evaluated; 18 were males and 12 females. Mean age was 36.5 (+/_21.4) years. 9 received perioperative and 21 received postoperative TPE. Patients who received TPE for desensitisation to donor anti HLA antibodies; ABO incompatible donors; and for collapsing glomerulonephritis were excluded. 13 had early (<1month) and 17 had late (>1month) AMR. The mean creatinine was 2.59 mg/dL (+/-2.82) before TPE; 1.8 mg/dL (+/-1.24) following one month and 2.22 (+/-2.2) following one year after TPE or last follow up whichever earlier. Graft function was stable in 17 patients whereas 5 had declining graft function as shown by rise in serum creatinine and/or worsening proteinuria. Infective complications were noted in 12 among which 3 had pulmonary tuberculosis; 1 bacterial; 3 fungal (2 with mucormycosis; 1 with histoplasmosis) pneumonia; 4 CMV disease; 4 with UTI 4 had graft loss and 4 died all because of infectious complications. Conclusion: Therapy of AMR has moderate therapeutic benefit and carries a high risk of infectious complications. Identification of risk factors for poor response to treatment can avoid unnecessary treatment. Further studies needed to outline the optimum management of ABMR and the role of TPE with IVIg as such.


  Difference in Short Term Outcome Following Renal Transplantation between Indian and Sub Saharan African Population Top


Sailaja Kesiraju, C. H. Uma Maheswara Rao1, Urmila2, V. S. Reddy2

Transimmun-Transplantation Immunology Research Centre, Hyderabad, Departments of 1Urology and 2Nephrology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India. E-mail: kesirajusailaja@gmail.com

Background: Differences in the outcomes following kidney transplantation has been observed in diverse ethnic groups including; African Americans (blacks). The rejection rate has been found to be significantly higher in black recipients compared to native white Americans. The question is why the demographic characters influence the outcomes of graft function/survival. Aims of Study: We attempted to compare the early outcome following kidney transplant in Sub Saharan African recipients and compared with Indian recipients. Methods: Study was conducted during March 2014 to April 2016 at KIMS hospital. 24 recipients from Sub Saharan African origin (Group-A) were compared with 24 Indian origin (Group-B) recipients and followed up for three months. Demographic characteristics; cause of end-stage renal disease; HLA mismatch; number of heamodialysis; immunosuppressive therapy; rate of acute rejection (AR) episodes and graft and patient survivals were evaluated. Results: There was no significant difference among gender; age; donor age and HLA mismatches between two groups. Black patients had significantly higher rates of diabetes as a primary renal disease than the Indian counterparts. Mean age was 41.9 yrs vs 38.2yrs in group A and B respectively. Mean S.Creatinine at the time of discharge 1.1 mg/dl in group A and 1.47 mg/dl in group B. However there was a significant difference (p=<0.05) in the eGFR at the time of discharge 99.3 vs 72.2 ml/mt/1.73 m2 as well as at three months post transplant 98.1 vs 70.4ml/mt/1.73 m2 in group A and B respectively. One patient had delayed graft function of unknown cause and one patient had been treated for biopsy proven acute rejection (4.1%) in group A. There were four episodes of AR (16.6%) observed in group B. There was one death in group B and none in group A. Rate of post operative complications and infections was similar both the groups. When we assessed the pharmacokinetics of tacrolimus it was comparable between the two groups. Conclusion: Our preliminary study results showed that graft function of black patients was marginally better as compared to Indian patients. Prospective long term follow up studies with large sample size may throw some light upon the reason behind this.


  Use of Quadruple Maintenance Immunosuppression in Renal Transplantation Top


Sailaja Kesiraju, C. H. Uma Maheswara Rao1, Urmila2, V. S. Reddy2

Transimmun-Transplantation Immunology Research Centre, Hyderabad, Departments of 1Urology and 2Nephrology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India. E-mail: kesirajusailaja@gmail.com

Background: The nephrotoxicity caused by calcineurin inhibitors (CNIs) is one of the causes of poor long term graft survival following renal transplantation. Current approach is to minimize CNI dose while maintaining the renal function. Aims of Study: To evaluate the long term outcome following renal transplantation with a combination of low dose quadruple immunosuppressive regimen. Methods: A 24 month; single centre; prospective study comprising 50 post renal transplant recipients. Group A quadruple regimen consisted of 25 recipients who received Everolimus (0.5 mgBD) + Tacrolimus (1 mg BD) + Prednesolone (Tapering dose) + Mycophenolate Sodium (360 mg BD) and Group B consisted of 25 recipients who were operated during the same period; received standard triple drug regimen. 10 patients from group A and 9 patients from group B also received induction therapy with Anti thymocyte globulin (50 mg/day for 3 days). The primary objective is to compare the graft function (Glomerular filtration rate (GFR) measured by MDRD) and other objectives are to assess graft/patient survival; rate of biopsy-proven acute rejection and incidence of post transplant diabetes mellitus (PTDM). Adverse events; infections and other laboratory investigations were compared between the groups. Results: All the patients from group A received standard triple regimen for first two months and there upon converted to quadruple regimen. Serum creatinine and GFR were comparable up to 6months; however significantly different at 12 months 1.39 mg/dl vs 1.78mg/dl and at 24 months post transplant 1.47 mg/dl vs 1.92 mg/dl between group A and B respectively. The estimated GFR at 12 months was 66.4 ml/mt/1.73 m2 and 54.5 ml/mt/m2 and at 24 months it is 65.1 ml/mt/1.73 m2 and 49.9 ml/mt/1.73 m2 in group A and group B. There was no graft loss or patient loss in group A while there was one graft loss and two patients died in group B. There was no biopsy proven acute rejection (AR) episodes in group A whereas it was 16% in group B. CNI toxicity/ATN was observed in two patients of group B. 8% of PTDM in group A and 16% of PTDM in group B was observed. Proteinuria and other biochemical parameters were comparable between the groups. Conclusion: It has been observed that long term (24month) graft and patient survival is comparatively better with quadruple regimen than standard triple regimen.


  Incidence and Risk Factors for Posttransplant Diabetes Mellitus: Data from Government Tertiary Care Centre Top


Jayanivash Jayam, B. M. Archana1, G. Chandramohan, S. Thirumavalavan, N. D. Srinivasaprasad, S. Sujit, M. Edwin Fernando

Departments of Nephrology and 1Medicine, Government Stanley Medical College, Chennai, Tamil Nadu, India. E-mail: drjayanivash@yahoo.in

Background: International consensus guidelines regarding the definition of new-onset diabetes mellitus after transplantation were originally published in 2003 and updated in 2014 which includes use of the term PTDM over NODAT. Studies prior to 2003 guidelines reported rates ranging from 7 to 46 percent. Indian literature reports rates between 16-30% with maximum cumulative incidence in 1st year post transplant. The epide miology; risk-factors and outcomes of PTDM is unknown in south indian population. Aims of Study: 1) To study the incidence and clinical profile of PTDM among the renal transplant recipients. 2) To assess the relevant risk factors contributing to the pathogenesis of PTDM. Methods: With appropriate clearance from institutional ethics committee; this single centre retrospective analytical study of adult renal transplant recipients who underwent transplant between January 2012-December 2014 was done at Government Stanley Medical college hospital; Chennai; Tamilnadu; India. PTDM was defined according to the criteria outlined in the 2003 international consensus guidelines. The study population who did not develop PTDM till the period of observation acted as controls. Recipients who had diabetes before renal transplantation and those recipients who had transient hyperglycemia while on intravenous steroids were excluded from the study. So were the recipients who died in the early post-transplant period or lost follow up before one year. Univariate and Multivariate logistic regression analysis was done to identify independent risk factors associated with PTDM. Results: Of the total 149 patients who underwent renal transplant between 2012- 2014; 115 patients were enrolled for the study. The Incidence of PTDM was observed to be 22.6% (n=26) in this study population. The mean age of the patients in the PTDM and non PTDM group was 35.23 and 28.64 years respectively. Majority of the study population was males (n= 92) and constituted 76.7% of PTDM population against 23.08% of females. Univariate analysis revealed age; smoking; history of diabetes mellitus; dialysis vintage; induction therapy; acute rejection to be significant risk factors. Dosage of tacrolimus and prednisolone at discharge; 3 and 6 months post-transplant were also significantly higher in the PTDM group. Multivariate logistic regression analysis indicated age (OR=3.77); male gender (OR = 2.35); family history of diabetes (OR = 4.54); dialysis vintage of greater than 1 year (OR = 1.75) and use of induction therapy (OR=2.0) to be independent risk factors for PTDM. Conclusion: The Incidence of PTDM was observed to be 22.6%. Age; male gender; family history of diabetes; dialysis vintage; and induction therapy were found to be independent risk factors for PTDM. Bacterial pneumonia; cytomegalovirus infection and urinary tract infection were higher in PTDM group.


  Anti Mica (Major Histocompatibility Complex Class I Related Antibody); Whether to Treat or Avoid in Renal Transplantation? Top


Umesh Godhani, Manish Balwani, Jitendra Goswami, Vivek Kute, Pankaj Shah

IKDRC, Ahmedabad, Gujarat, India. E-mail: drumesh.godhani@gmail.com

Background: Pre-transplantation anti-major histocompatibility complex class-I related chain A (MICA) sensitization is an uncommon event and its role in kidney graft evolution is not completely defined. • Even when kidney allografts are well matched for HLA as in living related transplant and antiHLA antibodies are not detected; graft rejection can still occur. Anti MICA antibody is reportedly associated with poor transplant outcomes and a high risk of acute and chronic rejection in renal transplantation. Aims of Study: To study association between isolated MICA antibody positivity and rejection in kidney transplantation. Methods: A retrospective study of patients undergone living renal transplantation between years 2000-2014 was performed. Recipients were classified in two groups; pre-transplantation Anti MICA antibody positive group (n=17) and antibody negative comparison group (n=17). Patients with anti HLA antibodies were excluded and only isolated MICA positive patients were included in the study group. • Both groups were comparable in recipient age; donor age; donor relation; HLA and immunosuppression. Results: Patients with pre transplant MICA antibody positivity were associated with increased acute rejection rate as compared to comparison group (47% vs. 11.7%; p value= 0.02). • Renal function in MICA positive group and comparison group were comparable over a mean follow up of 6.5 years (mean creatinine 1.58 vs. 1.53 mg/dl). Rate of chronic rejection was same in both groups (5.8%). • No patient loss or graft loss occurred in either group over mean follow up of 6.5 years. Conclusion: Pre transplant anti MICA antibody positivity is associated with increased acute rejection rates. However chronic rejection rates and renal function are comparable in both groups. MICA antibody positive patients may require more aggressive immunosuppression.


  Awareness and Beliefs towards Organ Donation in Chronic Kidney Disease Patients: A Single Center Experience Top


Umesh Godhani, Manish Balwani, Jitendra Goswami, Vivek Kute, Pankaj Shah

IKDRC, Ahmedabad, Gujarat, India. E-mail: drumesh.godhani@gmail.com

Background: There is a wide discrepancy between demand for and availability of donor organs for organ transplantation. There is no study on awareness about organ donation in chronic kidney disease (CKD) patients in India. Aims of Study: To study the awareness and beliefs towards organ donation in CKD patients on hemodialysis in western India. Methods: Authors conducted a cross sectional study among 85 CKD patients to evaluate knowledge about and attitude towards organ donation at a tertiary hospital. Results: Age of respondents ranged from 15 to 75 years. All were aware of term organ donation and cadaver donation. About 47% of people heard about organ donation through hospital or from doctor. Strikingly; radio was not the source of information to any of the respondents; despite radio being one of the most common medium of mass communication. Almost one third of patients were unaware about any legislation regarding organ donation. All respondents felt that organs should go to the needy irrespective of their religion. About 70% feel that medical colleges should make decisions about organ donation in case of unclaimed dead bodies. About 31.76% believe that there is a danger that donated organs could be misused; abused or misappropriated. Conclusion: There seems to be paucity of information and awareness regarding organ donation among CKD patients. Mass media; religious and political leaders may be involved to maximize awareness about organ donation.


  Bedside Strategy to Prevent Postrenal Transplant UTI Top


Abhijit Konnur, Mital Parikh, Hardik Patel, Sishir Gang, Umapati Hegde, M. M. Rajapurkar

Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India. E-mail: abhijit@mpuh.org

Background: Post transplant UTI is the commonest infection after renal transplant. Multi drug resistant UTI is common and increases hospital stay and costs. Despite optimizing primary prevention strategies like hand washing and washing toilet seats adequately there was no decrease in incidence. It was hypothesized that UTI was promoted by use of common toilet and urinary catheter touching the seat. Aims of Study: Implement a bedside strategy to prevent immediate post operative renal transplant UTI. Methods: Its a non randomized case control study where 25 patients who underwent renal transplant between 1st April 2017 to 1st June 2017 were encouraged to bring along a portable commode which was washed with 4% bleach after each use. During the in patient post operative stay of approximately 10 days they were asked to use only this for urination and defecation. This group was similarly matched to historical controls (1st February 2017 to 1st April 2017) at the same center prior to this intervention for factors implicated in post transplant UTI and outcomes were studied. Inclusion criteria was post renal transplant <2 days. Exclusion criteria was post renal transplant >2 days and not consenting for individualised commode. Primary outcomes studied were incidence of UTI. Secondary outcomes were incidence of graft dysfunction due to UTI; cost effectiveness of intervention. Results: 25 patients were studied. Incidence of Culture proven UTI was significantly less (0) in group using the portable commode than the historical controls (6); p <0.05. Graft function was not significantly different in both the groups. Duration of indwelling catheter length was significantly more in the commode using group but is influenced by outliers. 10 patients were treated for clinical UTI in the historical control out of which 6 had urine culture positive for organism. In the commode using group 4 were treated for clinical UTI out of which none had urine culture positive. Pseudomonas was the predominant causative organism in 4 patients buttressing the nosocomial nature of infection. Worryingly this was multidrug resistant with sensitivity only to colistin. 1 patients had vancomycin resistant enterococcal infection. 1 patients had multi drug resistant klebsiella infection. The average patient in hospital stay in both the groups was ~ 14 days and not significant and acute rejection episodes were not significantly different in both the groups the cumulative cost of treatment of UTI in the historical control group was twice that in the Commode using group. Limitation of study is small sample size and historical cohort. Conclusion: In the present scenario of increased incidences of post operative multidrug resistant UTI individualizing personal waste disposal techniques using disposable bedside commode is an effective and economical strategy. However it needs to be validated using a larger sample population.


  Management of Persistent Lymphorrhea in Renal Transplant Recepients: Case Series and Discussion Top


Vivek Jadhao, Umesh Oza, S. W. Thatte, Himanshu Agarwal

Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India. E-mail: vivekjadhaourocare@gmail.com

Background: Lymphocele after renal transplant is a known complication; incidence being 2% to 49% in different studies. Thus; management of patients with persistent lymphorrhea of >200 ml/day becomes crucial. However; long term indwelling drains increase possibility of introduction of infection into the collection; making the lymphocele multiloculated and thereby increasing complexity of the treatment and morbidity of the recipient. Aims of Study: To evaluate outcomes of early drain removal in cases of persistent lymphorrhea in renal transplant recepients and to discuss treatment options of subsequent lymphocele. Methods: In the last two years; we came across 6 cases of persistent lymphorrhea post renal transplant. The lymphorrhea was persistently around 200 ml per day via the abdominal drain for nearly 5 consecutive post-operative days. Our routine practice earlier was to continue with indwelling drain until the drain output decreased to <50 ml; which used to last for around 2-3 weeks. Thereafter; we had also attempted sclerotherapy with povidone-iodine for such cases with borderline results. However; in these present cases; despite of the drain output being over 200 ml/day; we decided simply to remove the drain. Results: Simple aspiration of lymphocele results in re-accumulation rates that approach 90%. Catheter drainage with sclerosant instillation improves the success rate but at the cost of long term tube drainage and increased chances of infection. Laparoscopic or open fenestration or marsupalisation are effective methods to treat uni-loculated lymphocele. Multi-loculated collections tend to occur after prolonged tube drainage and thus pose a challenge to treatment. In the cases described by us; the removal of the abdominal drain was done despite of persistent lymphorrhea. There was no significant cutaneous lymphorrhagia and follow-up of these patients at 4 weeks; 3 months and 6 months did not show any peri-nephric collection or lymphocele. Conclusion: We propose that removing the drain early in the course of lymphorrhea in renal transplant recipients is a rational option. Moreover; if at all a lymphocele occurs; the chances of it being infected or multi-loculated will be minimal; thereby simplifying it's treatment options.


  Contrasting Spectrum of De Novo Malignancy Following Renal Transplant: A Single Centre Experience over Two Decades Top


Ratan Jha, Girish Narayan1, S. Sinha2, G. Swarnalata3

Department of Neprology, Virinchi Hospital, 1Department of Nephrology, Mediciti Hospital, Departments of 2Pathology and 3Urology, Apollo Hospital, Hyderabad, Telangana, India. E-mail: jharatan08@gmail.com

Background: Renal transplant recipients are at a higher risk of malignancy. Though post transplant lymphoproliferative disorder has been universally reported as the commonest malignancy; there are limited reports from India. Aims of Study: We report our experience of a tertiary care center in India and the critical differences in the presentation of malignancy over the period between 1990-2015. Methods: Details of malignancies developed by recipients and the outcome were noted and analyzed retrospectively. A total of 338 live donor transplants were performed over the 26-year period on 332 patients. Immunosuppression varied over the years and consisted of prednisolone (332); azathioprine (201); mycophenolate (131); cyclosporine (260); tacrolimus (72); sirolimus (13). Induction immunosuppression was used in 22 cases with interleukin 2 receptor antibody (22). Overall 299 patients were on conventional triple drug immunosuppression; 33 were on CNI withdrawn treatment with 13 receiving additional sirolimus. Results: A total of 16 malignancies including PTLD (5); oral cancer (5); lung cancer (2); hepatobiliary cancer (2); colon cancer (1) and skin cancer (1) were diagnosed in 15 patients. Over the 26-year follow up 138 patients died including 13 due to cancer. Cancer occurred in 4.7% of patients but accounted for 9.4% of deaths. Oral cancer occurred after a significantly longer latency (214 versus 104.7months; p=0.007). No oral cancer occurred before 10 years of follow up. There was no sex predilection. Despite the longer latency; oral cancer patients were younger at diagnosis (44.0 versus 53.8 years; p=0.01). The outcome of oral cancer was better with 3/5 patients alive at last follow up as compared to mortality in all the other cancer patients (Fisher exact test; p=0.028). This was despite a longer overall follow-up for the oral cancer patients reflecting the better outcome for these patients (24 months versus 4 months; p=0.028). No obvious predisposing factors could be identified. Conclusion: Overall survival of non oral cancer is poor. The better outcome in oral cancers might be the result of an earlier diagnosis. Oral cancers could be related to dietary factors and viral infection with HPV.


  Ultrasound Doppler Findings in Hyperacute Vascular Rejection and Early Vascular Complications in Renal Grafts Top


Muktachand Rokade, Amit Nagarik1, Ajay Kanbur2, Supriya Dutta3

Departments of Radiology, 1Nephrology, 2Urology and 3Pathology, Jupiter Hospital, Thane, Maharashtra, India. E-mail: drmlrokade@gmail.com

Background: Hyperacute vascular rejection is a rare serious event leading to graft loss. Not many reports describing its imaging findings are available in the literature due to its rapidity of onset. This review decribes the Doppler imaging findings in hyperacute vascular rejection characterized by absent intrarenal arterial flow and graft edema. Other vasular causes of acute graft dysfunction are also described. Aims of Study: To evaluate ultrasound doppler changes in vascular rejection and other vascular causes of acute graft dysfunction. Methods: Cases with acute graft dysfunction were evalutaed with doppler ultrasound. Histopathological and clinical correlation obtained. Results: Doppler findings were helpul in diagnosing various vascular causes of acute graft dysfunction/rejection. TITLE: Ultrasound Doppler Findings in Hyperacute Vascular Rejection and Early Vascular complications In Renal Grafts. Hyperacute vascular rejection is a rare serious event leading to graft loss. Not many reports describing its imaging findings are available in the literature due to its rapidity of onset. This review decribes the Doppler imaging findings in hyperacute vascular rejection characterized by absent intrarenal arterial flow and graft edema. These finding were further corroborated with contrast enhanced ultrasound and CT angiography that demonstrated nil cortical perfusion. The condition necessitates immediate graft nephrectomy to prevent further sensitization and complications. Other vascular causes of graft dysfunction include Acute tubular necrosis commonly associated with cadaveric donors (34%) and prolonged warm ischemia time.Increased intrarenal vascular resistive indices and reduced diastolic flow are the observed findings. Similar reduction in the diastolic flow and elevation of the intrarenal resistive indices are also noted in abdominal compartment syndrome a rare cause of acute graft dysfunction. These findings rapidly revert after surgical decompression. Renal vein thrombosis characterized by early rapid diastolic flow reversal in the renal arterial Doppler. It has reported prevalence of 0.1-4.2% and leads to graft loss. Early identification and institution of thrombolysis/thrombectomy may help in graft survival. Segmental infarction is being increasingly recognized as a cause of graft dysfunction. Conclusion: Ultrasound Doppler is an important first line modality for the evaluation of the renal transplants.It can accurately predict and characterize important causes of graft dysfunction; helping in early institution of therapy and prolonging graft survival.


  HLA One Way Mismatch Donors: A Strict No in Living Donor Liver Transplantation Top


Naganathan Selvakumar, Subash Gupta

Max Super Speciality Hospital, New Delhi, India. E-mail: enselva1@gmail.com

Background: HLA one way mismatch is a strong predictor of graft vs host disease after liver transplantation. Aims of Study: To analyse the cause and effect relationship between HLA one way mismatch donors and Graft vs Host Disease post living donor liver transplantation. Methods: Retrospective analysis of HLA reports of liver donors of over 2000 LDLTs done from august 2006 to may 2017 in our institute was done. Results: 6 donors were found to have had HLA one-way mismatch. 5 were male recipients and 1 female. 5 were adults and one child. 3 had all locus mismatch; 2 had 2 locus mismatch. All the pairs were first degree relatives. All the recipients had uneventful recovery in the immediate post-operative period. The mean duration of onset of symptoms were between 8 and 16 weeks. Diarrhea was the commonest symptom. 5 patients had diarrheas and one patient had predominantly skin eruptions. All patients died of multiorgan failure. Conclusion: We recommend HLA one way mismatch donors as contraindication for living donor liver transplantation.


  An Open Label Randomized Clinical Study to Evaluate the Impact of Oral Nutritional Supplement on Malnourished Dialysis Patients (Improves Study Protocol No.: PBL/PROS/07-11) Top


Anita Saxena, Gokul Nath1, Jatin Kothari2, Amit Gupta, Juan-Jesus Carrero-Roig3, Kamyar Kalantar Zadeh4, C. M. Pandey

Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Science, Lucknow, Uttar Pradesh, 1Department of Nephrology, St. John's Medical College Hospital, Bengaluru, Karnataka, 2Apex Kidney Center, Mumbai, Maharashtra, 3Department of Renal Medicine, Karolinska Institutet, Stockholm, Sweden, 4Department of Medicine, University of California, Irvin School of Medicine, UCLA, School of Public Health, Irvin, California, USA. E-mail: anitimmy@yahoo.com

Background: Uremia induced inadequate dietary intake leads to metabolic disturbances; PEW; cachexia; and high rate of morbidity and mortality. Dialysis is a catabolic procedure which impacts nutritional status and survival. Hypoalbuminemia is most likely the strongest predictor of mortality among maintenance dialysis patients. Early identification of patients with eating behaviour disturbances can potentially reduce the burden of malnutrition through appropriate intervention. Aims of Study: Primary end point was to evaluate efficacy of Proseventy on hypoalbuminemia over a period of 6 months (increase in serum albumin). Methods: Multicentric oral nutritional intervention study on maintenance dialysis patients with established protein energy according to ISRNM criteria. The clinical trial was approved by ethics committee. A total of 180 patients (90 supplemented and 90 control) were randomly assigned 1:1 to standard nutritional prescription of 1.2 g/kg/d protein and 35 kcal/kg/d plus nutritional supplement (supplemented) for 6 months group 1 and standard nutritional prescription (control) group 2. The renal specific protein powder supplement (Proseventy) contained 70% soya protein which was administered three times a day (10 g TID). Patients attended 3 visits at months 0; 3 and 6. At each visit; nutritional status was assessed by SGA; 24 hour dietary recall and anthropometry. Three days dietary recall was maintained in food diaries. Routine biochemical parameters were assessed as well as a SF36 Quality of life questionnaire pre/post intervention. Results: At inclusion; there was no difference in age; sex; SGA and routine biochemistry in the two groups. Control group; however; had significantly higher serum albumin (3.2 ± 0.41 and 3.37 ± 0.36p 0.013) and subscapular skinfold thickness (14 ± 6.0; 12.1 ± 5.0 p 0.032) than supplemented group. At month 3; increased in serum albumin (3; 3 ± 0.48 vs 3.4 ± 0.43) and illiac SFT (15.5 ± 8.5 and 18.1 ± 8.6 0.043) was observed in supplemented group. There was significant difference between groups in; total calorie (p 0.002); potassium (p 0.009) and salt intake (p 0.041). At 6 months supplemented group had significantly low potassium (0.004); salt (0.004); fat (0.004) and urea (p 0.000). In supplemented group serum albumin increased to 3.9 ± 0.049 versus 3.3 ± 0.51 in control group at 6 months and the subscapular skinfold (0.000) also increased significantly in supplemented group. SGA score was 8.8 for supplemented and 9 for control (p 0.015) at six months. Conclusion: Addition of a protein-rich renal specific nutritional supplement to standard nutritional counseling raised serum albumin and increased skinfold thickness in PEW patients undergoing dialysis. Serum phosphate or blood lipids were not altered.


  Epidemiology and Long Term Outcome of Renal Transplantation in Patients with Abnormal Urinary Tract in a Tertiary Care Hospital over the Past 10 Years Top


Deepthi Raran Veetil, Vinoi George David, Santhosh Varughese

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: drdeepthirv@yahoo.com

Background: The patient may require bladder augmentation; reconstruction; recycling or conduit prior to renal transplantation. There is a risk of developing impaired renal function resulting from recurrent (urinary tract infection) UTI; various aspects of bladder dysfunction and suboptimal lower urinary tract that may compromise graft and patient survival. Urinary obstruction should be routinely excluded when there is allograft dysfunction. Aims of Study: Aim of the study is to describe the epidemiological profile and outcome of patients who underwent transplantation for end stage renal disease secondary to abnormalities of urinary tract. Methods: Consecutive live related and deceased donor renal allograft recipients between 2007 and 2017 were studied. The epidemiological data; immediate and long term outcome with respect to graft and patient survival data were collected retrospectively and analyzed. Immediate post transplant issues like post operative UTI; acute rejections; urine leak; bladder dysfunction; need for alpha blocker medications post transplant; need for clean intermittent self catheterization (CISC) and long term recurrence of UTI; need for antibiotic prophylaxis; development of hydroureteronephrosis; stricture urethra and vesicoureteric reflux (VUR) were analyzed. The patients who had poor graft outcome was analyzed for risk factors like recurrent UTI; immediate rejection episodes; bladder dysfunction post transplant; need for CISC and recurrence of hydronephrosis or vesicoureteric reflux. Results: Abnormalities of the urinary tract accounted for 3.16% (n=35) of renal transplants in our centre. The mean age at transplant was 26.9 years for males and 26 years for females. The gender ratio observed was observed to be M: F= 2.9:1. The various etiologies were noted to be VUR (n=14; 29.8%); PUV (n=10; 21.28%) and neurogenic bladder (n=14; 29.8%). Other etiologies were bilateral hydronephrosis; voiding dysfunction; crossed fused ectopia with hydronephrosis; voiding dysfunction; bilateral PUJ obstruction; stricture urethra and genitourinary tuberculosis. The mean duration of hemodilaysis prior to transplant was 44 months. We retrospectively studied the incidence of acute rejection episodes; post operative recurrent UTI; incidence of urine leak; recurrence of urological issues like stricture urethra; ureteral obstruction; VUR as well as patient and graft survival. 89.3% of patients received transplants from living donors. 4 patients underwent pre emptive transplant. During the cumulative follow-up period of 3744 months (mean of 41.8 months) 3 patients expired; 4 were lost to follow up and 5 had lost their allograft and 2 were initiated back on hemodialysis. Acute rejection episodes were observed in 10 of these patients (28.6%). Graft survival rates at 1; 5; and 10 years were 97.8%; 94.2%; and 76% and patient survival rates at 1; 5; and 10 years were 98%; 95.7%; 94% respectively. Conclusion: Individuals with severe obstructive uropathy had been previously considered poor candidates for renal transplantation. It is imperative to exclude urinary obstruction when there is allograft dysfunction.


  Systemic Fungal Infections in Renal Transplant Recepients Top


Varun Mamidi, E. Indhumathi, E. Ram Prasad, Manikantan, M. Jayakumar

Sri Ramachandra University, Chennai, Tamil Nadu, India. E-mail: mamidi.varun@gmail.com

Background: Invasive fungal infections (IFI) are an important cause of morbidity and mortality in renal transplant recipients. The high rates of mortality owing to fungal infections render prevention; early diagnosis and treatment imperative in immunosuppressed patients. Aims of Study: To estimate the incidence; outcome of systemic fungal infections in renal transplant recipients in a single centre from South India and to identify the main fungal agents. Methods: This was a retrospective study of invasive fungal infections in renal transplant recipient reported in our hospital from November 2013 to November 2016 on 280 renal transplant patients. Clinical data included patient-donor demographics; time to onset of infection; risk factors and graft function in terms of serum creatinine. To identify IFI; we examined bronchoalveolar lavage (BAL); blood; tissue; and wound swab samples by conventional mycological methods. Results: IFI was diagnosed in 26 (9.2%) patients on immunosuppression; with males 18 (69.2%) with mean age 36.57 ± 11.9 years. 17 (65.3%) received induction therapy. 11 (64.7%) basiliximab; 6 (35.2%) anti thymocyte globulin. All patients received triple immunosuppression. Candida was the most commen pathogen seen in 15 (57.6%) cases. Mucormycosis (4 cases; 15.3%); Aspergillosis (1 case; 3.8%); Histoplasmosis (1 case; 3.8%); Fusarium solani (1 case; 3.8%); Cladophialophora carrionii (1case; 3.8%); Cryptococcus (1 case; 3.8%); Fungal ball (2 cases; 7.6%). Sites of infection were GI tract (10 cases; 38.4%); urinary tract (4 cases; 15.3%); respiratory tract (4 cases; 15.3%); CNS (1 case; 3.8%); leg ulcer/abcesses (3 cases; 11.5%); others (3 cases; 11.5%). 6 out of 26 patients died (23% mortality). Eight patients were diabetic; 7 had superadded cytomegalovirus infection; 9 had bacterial infections. Conclusion: In our centre; IFI incidence more in patients who received induction. Candida was the most commen pathogen. GI tract being the commenst site of infection. Diabetes and infections were added risk factors. Most of the patients recovered. Hence; prevention; early diagnosis and management is necessary.


  The Challenges and Outcomes of Living Donor Kidney Transplantation in Pediatric and Adolescent Age Group in a Developing Country: A Critical Analysis from a Single Center of West India Top


Neel Patel, Mohan Rajapurkar, Sishir Gang, Umapati Hegde, Abhijit Konnur, Hardik Patel, Mital Parikh

Muljibhai Patel Urologial Hospital, Nadiad, Gujarat, India. E-mail: neelpatel2787@gmail.com

Background: Renal transplantation (Tx) is considered the treatment of choice for children with end-stage renal disease (ESRD). Although pediatric renal transplantations are being performed at quite a few centers in developing countries; there is a paucity of data on their long-term outcome. This retrospective study is an attempt to evaluate the outcome of pediatric renal transplantation at a tertiary center from a developing country and to highlight the differences in comparison with developed nations. Aim of Study: We evaluated the outcome of renal transplantation in the pediatric and adolescent age groups in our centre in the perspective of a developing country as compared with developed nations. Methods: Thirty six live related pediatric and adolescent renal transplantations were reviewed retrospectively. Variables analyzed were etiology of ESRD; donor relationship; surgical complications; rejection episodes; immuno-suppression regimens; compliance to immunosuppression; graft survival and overall survival. Result: The cohort consisted of 33 males (91.6%) and 3 (8.4%) female patients. The mean age was 14 ± 1.4 years. The etiology of ESRD was undetermined (n=15); MPGN (n=3); congenital anomalies (n=1); chronic glomerulonephritis (CGN) (n = 4); MCD (n=1); reflux nephropathy (n=10); IgA (n=1); obstructive uropathy (n=1). The overall graft survival rates were 91.9%; 90.7%; 85.7%; 85.7%; at 6 months; 1; 3 and 5 years; respectively. Conclusion: The spectrum of etiology of ESRD differs in our patients from the west; with undetermined etiology and chronic glomerulonephritis being the most common etiology. 1 year and 5 year graft survival is comparable with developed countries.


  Relationship of Creatinine and Cystatin C Based Estimated Glomerular Filtration Rates with Measured Glomerular Filtration Rate in Voluntary Kidney Donors from South Asia Top


Athul Thomas, Suceena Alexander, Vinoi George David, Anjali Mohapatra, Anna T. Valson, Shibu Jacob, Veerasamy Tamilarasi, Santosh Varughese

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: thomasathul1@gmail.com

Background: Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is currently recommended for estimation of glomerular filtration rate (GFR). Here we report the validation of cystatin C (cysC) based equations for estimating GFR in the South Asian voluntary kidney donor (VKD) population. Aim of Study: The agreement between creatinine and cystatin C based estimated GFRs and measured GFR in VKDs. Methods: Consecutive healthy adults who were accepted as VKDs at our center between January 2008 and December 2012 were included. Results: The 336 subjects who comprised the study population had a mean age of 41.6 ± 11.8 years; M:F ratio 1:1.7; mean creatinine 0.9 ± 0.1 mg/dL and mean cysC 0.8 ± 0.1 mg/dL. Mean measured GFR by Tc-99m diethylene triamine penta-acetic acid (DTPA) using Gates method was 98.4 ± 21.2 mL/min/1.73 m2. The mean±SD of estimated GFRs by various formulae were: Cockroft Gault (CG)=88.1 ± 15.9 ml/min/1.73 m2; Modification of Diet in Renal Disease (MDRD)=78Á ± 14.7 ml/min/1.73m2; CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73m2; CKD-EPI cysC =97 ± 19.9 ml/min/1.73 m2; CKD-EPI creatinine-cystatinC (CKD-EPI cr-cysC)=92.5+14.1 ml/min/1.73 m2. The CKD EPI cr-cysC equation had the highest accuracy; with 43% and 72% of values lying within ±10% and ±20% of the measured GFR respectively. Bland Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among female subjects; while among male subjects; CKD-EPI creatinine equation had the least bias. Conclusion: The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of VKDs. Among CKD-EPI equations; CKD-EPI cr-cysC had the highest accuracy; CKD-EPI cysC the least bias overall and in females; and CKD-EPI creatinine the least bias in males.


  Pediatric and Adolescent Renal Transplantation in India: Experience from a Large Tertiary Centre in South India Top


Varun Agrawal, Anna T. Valson, V. M. Annapandian, G. Venumadhav, Mercy N. Deborah, Shibu Jacob, Shailesh Kakde, Vinoi G. David, Suceena Alexander, Gopal Basu, Nitin Kekre, Antony Devasia, Veerasamy Tamilarasi, George T. John, Santosh Varughese

Christian Medical College, Vellore, Tamil Nadu, India. E-mail: varunagrawal87@gmail.com

Background: We report the patient and graft outcomes of pediatric renal transplantation (RT) at a large tertiary centre in South India spanning various immunosuppression eras. Aim of Study: To report the patient and graft outcomes of pediatric renal transplantation (RT) at our centre. Methods: All children <18 years who underwent RT at our centre between 1991 and 2016 were included in the study. Data pertaining to their baseline characteristics; post transplant events and outcome were retrieved from transplant records and the hospital information system. Result: A total of 139 children underwent RT during this period. Mean age was 15.2 ± 2.9 years (range 6-18 years); M:F ratio was 2:1; 10.8% were pre-emptive and 94.8% were live related transplants. The most common native kidney disease was glomerular disease (24.4%); followed by urological causes (17.3%). Approximately one-third (35.3%) were given induction therapy (86% Basiliximab). Biopsy proven acute rejection rate (BPAR) was 25.9%; 83% were acute cellular rejections. Infectious complications included CMV disease (12.9%); UTI (26.6%); tuberculosis (8.6%); BK virus nephropathy (BKVN; 6.5%) and invasive fungal infections (3.6%). NODAT was seen in 12.9% and recurrence of native kidney disease in 4.3%. Overall patient survival at 1 and 5 years was 97% and 92%; graft survival at 1 and 5 years was 97% and 89%. Non-compliance was the most important cause of graft loss. Graft loss was higher with Prednisolone/Cyclosporine/Azathioprin; while BK virus nephropathy was higher with Pred/Tacrolimus/Mycophenolate. Conclusion: Pediatric and adolescent RT has excellent long term graft and patient outcome; however drug compliance and infections such as BK virus nephropathy still present a challenge.


  Reterospective Analysis of Posttransplant Liver Biopsies: From Diagnosis To Therapy: Can We Guide Further?: Experience from a Tertiary Care Center in India Top


Nalini Bansal, Mukul Rastogi1, Manav Wadhawan2, Vivek Vij3, Ajay Kumar4

Department of Histopathology, SRL Limited, Fortis Escorts, Departments of 2Hepatology and 4Gastroenterology, Fortis Escorts Liver and Digestive Institute, 3Department of Liver Trnasplant Surgery, Fortis Hospitals, New Delhi, 1Department of Hepatology, Fortis Hospital, Noida, Uttar Pradesh, India. E-mail: Drnalinibansal@yahoo.com

Background: Post transplant liver biopsies form a critical part of management of complications arising post transplant. Aim of Study: To analyse the Indian experience in pathologic diagnosis of liver biopsies after orthotopic liver transplantation (OLTx) cases with emphasis on intrahepatic cholestasis. Methods: 45 post-transplant liver biopsies from 39 OLTx patients were retrospectively analyzed from May 2015 to May 2016. All biopsies were stained with H and E and MT and other stains were performed as required. Result: The number of liver biopsies performed for each patient ranged from 1 to 3 .The timing of these biopsies varied from the five days to >4 year post-transplant. Of the 39 patients who underwent post transplant liver biopsies most common aetiology of liver transplant was HCV CLD in 66.6% cases. The common complications were acute cellular rejection (ACR) (33.3%); biliary stricture (13.3%); HCV recurrence (11.1%); plasma cell hepatitis (4.4%); chronic hepatitis (4.4%); and intrahepatic cholestasis (IHC) (22.2%) and others. Cases with IHC on analysis revealed that patients with high baseline HCV RNA levels had recurrences presenting only with prominent IHC without fibrosis and ballooning of hepatocytes. These changes might represent early stages of fibrosing cholestatic hepatitis. Conclusion: This study evaluated the types; incidence and timing of major complications occurring after OLTx. ACR remains major complication following transplant. Presence of IHC on biopsy especially in HCV positive patients should prompt anti HCV therapy even if other features of FCH were not found.


  Dengue Fever and Its Impact on Renal Function in Renal Transplant Recipients; Patients with Chronic Kidney Disease and Patients with Normal Baseline Renal Function Top


K. G. Hareesh, Jacob George, E. T. Arun Thomas, Devi S. Sruthi, N. S. Vineetha, Noble Gracious

Government Medical College, Thiruvananthapuram, Kerala, India. E-mail: drhareeshkg@gmail.com

Background: Dengue fever is a mosquito-borne viral disease endemic in many tropical and sub-tropical countries. The annual average number of dengue fever cases reported has increased dramatically in recent years. There are limited data in the literature describing how the clinical course of dengue fever in renal transplant recipients and patients with chronic kidney disease are different when compared to normal population. Aim of Study: To compare the clinical course of dengue fever and its impact on renal function in renal transplant recipients; patients with chronic kidney disease and patients with normal base line renal function. Methods: An observational study was conducted from 1st May to 15th July 2017 in a tertiary care centre of South India. A major epidemic of dengue occurred during the study period. 12 renal transplant recipients; 22 patients with CKD and 58 patients with normal baseline renal function admitted with dengue fever were prospectively studied. Result: Nadir WBC count was lowest in renal transplant recipients (2575 + 1187/mm3) when compared to CKD patients (3155 + 635/mm3) and control group (3658+967); P<0.001. Renal transplant recipients took more time for normalisation of the platelet count from the nadir; 6 + 4.5 days when compared to patients with CKD (3.3 + 0.9 days) and control group (3.4 + 0.9 days); P<0.001. All the 22 patients with CKD and 11 out of the 12 renal transplant recipients had worsening of renal function where as only 17 out of 58 in the control group had worsoning; P<0.001. 16 out of 22 patients with CKD required RRT; whereas only one renal transplant recipient and none among control group required RRT; P<0.001. Out of 22 patients with acute worsening of CKD; only 8 patients had normalisation of renal function after 2 weeks; whereas 10 out of 11 renal transplantation recipients and 14 out of 17 control group had normalization (P<0.001). Patients who required dialysis support had more hemoconcentration (52.5+19.9% increase in haemoglobin concentration). Hemoconcentration showed positive correlation with blood urea/serum creatinine ratio; coefficient of correlation=0.6. Conclusion: Dengue infection in renal transplant recipients results in significant but reversible worsening of renal function.Neutopenia and thrombocytopenia occurring as a part of dengue infection are more pronounced in renal transplant recipients.


  Pediatric Renal Transplant: Our Experience Top


Rachita Dhull, Sanjeev Gulati, Manoj Singhal, Rajiv Sinha, Vishal Saxena, Deepak Kalra, Manoj Arora, Saurabh Pokhariyal

Fortis Group of Hospitals, Bengaluru, Karnataka, India. E-mail: Rsd.pedia@gmail.com

Background: Renal transplantation is the modality of the choice for the management of children with end stage renal disease. It offers better quality of life; though associated with risk of rejection and infection. Aim of Study: 1. to study the outcome of pediatric renal transplant at Fortis hospitals over the last 12 years; 2. To evaluate incidence of infection and rejection in these patients. Methods: This is a retrospective review of patients <= 18 years of age who underwent renal transplant at Fortis hospitals; India from 2006 to 2017. Data on age; sex; use of immunosuppression; incidence of infection and rejection was collected. Percentage; range and median were used to represent the data. Result: Total 75 pediatric patients underwent renal transplant between 2006-2017 at Fortis hospitals. Median age was 14 years (3-18 years) and 50 were boys and 25 were girls. The imunosuppresion protocol consisted of induction by either basiliximab or ATG; followed by tacrolimus; mycophenolate and steroids. 17 patients received no induction. Median creatinine at the time of discharge was 0.74 mg/dl (0.3-1.6 mg/dl). The median duration of follow up was 48 months (1-132 months). In our cohort; patient survival rate was 96% and graft survival rate was 90.6%. 16 patients had infections. Rate of rejection was 13.3%. 2 patients had graft loss in the early post operative period; one secondary to renal vein thrombosis and other due to BK virus infection/acute tubular necrosis. 5 patients lost the graft over the next 12 years due to non compliance with medications (4) and recurrence of FSGS (1). 2 patients died with functioning graft and one died after return to dialysis. Conclusion: With advances in immunosuppresion; rejection rate and graft survival have improved over the last decade. Compliance with medications and regular follow up are the major contributors for satisfactory long-term outcome.


  Overcoming the Under Recognition of Urinary Tract Infection Causing Rare Non-Fermenting Gram Negative Bacilli Top


Balvinder Mohan, Harsimran Kaur, Neha Gautam, Atul Raj, Parakriti Gupta, Neelam Taneja

Department of Medical Microbiology, PGIMER, Chandigarh, India. E-mail: balvindermohan2002@yahoo.com

Background: Urinary tract infection (UTI) cases caused by non-fermenting Gram negative bacilli (NF-GNB) worldwide are on the rise noted recently due to introduction of rapid automatic identification methods. These are important to clinicians due to increasing drug resistance amongst these NF. Aims of Study: To determine the isolation rate of rare NF GNB along with their clinical significance; risk factors and drug susceptibility profile. Methods: All clinical details were noted from case records. Identification was done by both conventional methods and Matrix Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF). Antimicrobial susceptibility testing was performed using Kirby Bauer disc diffusion method recommended by Clinical and Laboratory Standards Institute (CLSI). Result: Of the total 49508 samples (48370 culture positive) collected over a period of one year; 95 isolates (0.19%) of non-fermenting gram-negative bacilli (NFGNB) from 86 patients were positive. The common underlying factors were catheterization (40.6%); genitourinary surgery (29%); carcinoma bladder (20%) and renal stone disease (16.2%) and percutaneous nephrostomy tube (12.7%). The rare NFGNB identified by MALDI-TOF MS were Chryseobacterium indologenes (42.1%; n=40); C. gleum (7.3%; n=7) followed by Stenotrophomonas maltophilia (23.1%; n=22); Burkholderia species (14.7%; n=14; B. cepacia; 12.6%; n=12; B. cenocepacia and B. seminalis 1% each; n=1); Myroides odoratimimus (8.4%; n=8); Achromobacter xyloxidans (2.1%; n=2); Elizabethkingia meningoseptica (1%; n=1) and Wautersiella falsenii (1%; n=1). Conclusion: This study emphasizes the importance of MALDI-TOF in recognizing non-fermenters as a cause of UTI. It is necessary to formulate specific guidelines for the treatment in view of increasing resistance to commonly used drugs as the antibiotics required for treatment of uncommon NFGNBs are different.


  The Focus on Aneurysm: A Novel Classification Based on Site and Principles of Management of Aneurysmal Complications in Arteriovenous Fistula for Hemodialysis Access Top


Kumar Madhavan, Sanjoy K. Sureka, Rahul Jena, Ankur Bansal, Aneesh Srivastava

Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: madhavanranjit@gmail.com

Background: Aneurysmal complications occur in 4-12% of patients with an arteriovenous fistula (AVF) for hemodialysis access. The absence of a universally accepted classification system for aneurysmal complications leads to confusion regarding the nomenclature and eventual management. We have attempted to formulate a classification system; which is based on a combination of the site and also on the management strategy; to make it an easy and reproducible classification to follow. Aims of Study: Our aim is to propose a clinically relevant classification of aneurysmal complications (both true and pseudoaneurysms) based on management strategy in light of our experience. Methods: We retrospectively evaluated the records of patients who have been managed for aneurysms and pseudoaneurysms associated with arteriovenous fistulae at our centre from January 2001 to July 2010. Demographics; site of fistula; type of aneurysm (true vs pseudoaneurysm); location of aneurysm (anastomotic site vs outflow vein vs inflow artery) and the management strategy were recorded in all patients. The basic philosophy behind this classification was based on the need for observation (a) or elective (b) or emergency(c) surgical management. Most common variety of complication was classified as type I with type IV being the least common. Results: A total of 3360 arteriovenous fistulae were created during the study period at our centre; of which 176 patients (5.2%) developed aneurysms. Another 208 patients; refereed from other centers; were managed for aneurysmal complications. A total of 384 patients were managed at our centre with aneurysmal (true aneurysm n=205; 53.3%; pseudo-aneurysm n=179; 46.7%) complications of AVF. 55.2% were male (n=212) and rest were females. 302 patients had left limb aneurysms and 82 on the right. Out of 384 patients; 196 patients had radio-cephalic fistulae; 133 had brachio-cephalic fistulae and 55 had brachio-basilic fistulae. Location of pseudoaneurysm was at anastomotic site in 35.4% patients (n=136); outflow vein in 9.3% (n=36) and inflow artery in 1.8% (n=7). 39.5% patients were managed conservatively (n=152); 30.2% were managed by elective surgery (n=116) and 30.2% needed emergency surgery (n=116). The indication of emergency surgery was intractable bleeding or impending rupture. Conclusion: We propose a standardized classification system for aneurysmal complications of AVF; that is easily reproducible and will help in reporting and comparing their experiences. We observed that type 1a is most common aneurysm found in AVFs and most of the patients can be managed conservatively.


  Fulminant Hepatic Failure Secondary to Herpes Simplex Virus Type 2 Infection in a Renal Allograft Reciepient Top


Arun Kumar Ponna, Manisha Sahay, Kiran Mai Ismail, Sharmas Vali, Amaravadi Ayyappa

Osmania Medical College, Hyderabad, Telangana, India. E-mail: arunponna@gmail.com

Background: Viral hepatitis is an infrequent manifestation of herpes simplex virus. Both HSV1 and HSV2 can cause fulminant hepatitis; mainly in immunocompromised patients and Prognosis is generally poor. Aims of Study: To present an interesting case of renal allograft recipient with fulminant HSV 2 hepatitis. Methods: 30 year old male with end stage renal disease secondary to CIN. He underwent live related renal allograft transplantation in June 2010 with mother as the donor. Post transplant he was kept on triple immunosuppression - Tacrolimus; mycophenolate mofetil and prednisone. Induction therapy was not given. He had immediate good graft function post transplant and was discharged in 2 weeks time. Patient developed NODAT one year after transplantation. Patient had history of Herpes zoster; 2 years post transplant; improved after treatment with acyclovir. Patient presented to the OPD with complaints of fever with chills; abdominal pain and jaundice. 2 days after admission patient developed vesicular rash over face and right forearm; lesions progressed to involve right hand and right leg sparing the trunk and other areas of the body. Results: Investigations revealed - Haemoglobin of 10.2 g/dl; leucocyte count of 8200 cells/mm3 and platelet count of 1.2 lakhs/mm3; Blood urea -60 mg/dl; serum creatinine of 2mg/dl; LFTs: Serum bilirubin -16mg/dl; direct bilirubin: 9.0mg/dl; AST 1100 IU/ml; ALT 2200 IU/ml; ALP 500 IU /ml; PT /INR -1; serum albumin was low (2.2g/dl); PT/INR -1. Urine and Blood cultures were sterile; Fasting lipid profile Normal; Serum ferritin normal; Serological tests for Viral hepatitis including Hepatitis B (anti HBV antibody and HBsAg negative); Hepatitis C (anti HCV antibody negative); hepatitis A (anti HAV antibody test negative) and Hepatits E (anti HEV antibody negative). Malaria; Dengue serology and IgM anti leptospiral antibody tests were negative. Anti HSV 1 and HSV 2 IgM antibody Negative; HCV RNA PCR; HSV 1 DNA PCR; CMV DNA PCR and Parvovirus B 19 DNA PCR was negative HSV 2 DNA PCR POSITIVE. Ultrasound was done in view of ascites and it revealed hepatomegaly with irregular surface and ascites; Doppler spleno portal axis (SPA) axis s/o portal HTN; Fibro scan 40.4 KPa; UGI endoscopy showed grade 2 esophageal varices. Conclusion: Patient was started on I.V acyclovir; Patient continued to develop rapidly progressive liver failure despite specific treatment.


  Evolution of Bladder Dysfunction in Adult Renal Transplant Recipient with No Preexisting Bladder Abnormality: A Critical Appraisal Top


Sanjoy Sureka, Anil Mani, Kumar Madhavan, Rakesh Kapoor, Uday Pratap Singh, M. S. Ansari Aneesh Srivastava

SGPGIMS, Lucknow, Uttar Pradesh, India. E-mail: drsksureka@gmail.com

Background: Up to 20% of renal transplant recipients have anatomical or functional bladder abnormality either in pre-transplant period or during post-transplant follow up. Aims of Study: This study focused on overview; bladder management and transplant outcome in patients with evolving bladder abnormality which become evident after transplant in recipient. Methods: A retrospective review of 720 patients who underwent renal transplant with newly evolving bladder abnormality was done from January 2011 to July 2016. We have reviewed the possible etiopathogenesis; bladder assessment findings; post-transplant intervention required; bladder related complications and long term graft function. Result: 190 patients (22.2%) (Mean Age 28 ± 8.5 Years) had new onset bladder dysfunction or masked bladder abnormalities manifesting within 1 months of transplant. The study cohort was stratified in two groups on the basis of type and duration of intervention required; Group 1 (< 6 months and nonsurgical treatment; n= 142); group 2 (>6 months and or surgical treatment; n=48). Most common presenting symptom was increased frequency (n=134). Etiologic includes overactive bladder OAB (n=106); LUTS either due to transient voiding dysfunction or bladder dysfunction evident by low Qmax (< 15 ml) at uroflowmetery (n =52); established bladder neck dysfunction (n=10); dysfunctional voiding (n=4); diabetic cystopathy (n=5) and BPH or related cystopathy (n=8); unidentified aetiology (n=5) were seen. Group 1 was managed with short-term anticholinergic or alphablocker or both and improved within six months. Whereas group 2 were managed with continuous pharmacotherapy or CIC and urotherapy (n=39); bladder neck incision (n=5) or TURP/TUIP (n=4). Recurrent UTI occurred in 15 (10.5%) Vs 18 (37%); patients in group 1 Vs 2 (p=0.01) in the post-transplant period. Graft survival was satisfactory at 1 year. Conclusion: About one in four transplant recipient suffer from evolving or new onset bladder dysfunction in early post transplant period. Majority of them improve on short-term therapy nonsurgical therapy. However; those require long-term treatment; likely to develop frequent urinary tract infection.


  Renal Allograft Compartment or Compression Syndrome as Etiology of Early Graft Dysfunction: Underappreciated Because of Poor Nosography Top


Anil Mani, Sanchit Rustagi, S. K. Sureka, U. P. Singh, M. S. Ansari, Rakesh Kapoor, Aneesh Srivastava

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dranilmani@gmail.com

Background: Renal allograft compartment syndrome or renal allograft compression syndrome (RACS) is an underappreciated cause of early graft dysfunction secondary to retroperitoneal hypertension or graft compression. Due to lack of well defined diagnostic criteria; there are only few literature available related to RACS. We reviewed cases of RACS we have managed over last five years to provide insight for diagnosis and prompt management. Aims of Study: To identify all cases of renal allograft compression/ compartment syndrome and identify the clinical presentation; risk factors and preventive measures to avoid the same. Methods: All renal transplants between January 2012 and July 2017 (n= 656) at our centre in north India were reviewed. A retrospective cohort study was performed to define clinical presentation; diagnostic modality as well to identify any risk factors. Inclusion criteria included patients who were diagnosed as a possible case of RACS and confirmed on exploration with findings described below. In all patients with a clinical suspicion of RACS; USG Doppler of the graft was performed using a high resolution USG by an experienced radiologist. All suspected cases of RACS were explored in the immediate post operative period. Abdominal wall was then closed in a tension free manner by further mobilisation of muscles; partial closure of muscles layer and releasing incision of fascia of the anterior abdominal wall while strictly monitoring the urine output via the infield Foley's catheter. Results: 8 cases of RACS between January 2012 and July 2017 were identified at an incidence of 1.22%. Seven were male patients and 1 was a female patient. Doppler ultrasonographies were performed in all the suspected patients. Doppler showed normal flow in the main renal artery in all cases with diminished flow in the segmental and interlobar arteries in two cases. In six cases blood flow appeared normal. The interval after which the patients were re-explored ranged from 30 to 120 minutes; with a median time interval of 60 minutes. In all the patients; graft function could be recovered by just reopening all the layers of the wound and reclosing them with better mobilization and in a tension free manner. These patients were followed up clinically at day1; day 14 and day 30. Serum creatinine was noted on day 14 and day 30. On day 14; the serum creatinine of our patients ranged from 0.9 to 1.78 mg/dl. Mean creatinine was 1.39 mg/dl. On day 30; mean serum creatinine was 1.48 mg/dl. Conclusion: Transplant surgeons should be aware of RACS as a possible diagnosis when sudden drop in urine output become evident after good initial allograft function. A prompt surgical decompression should be performed to salvage the graft and intraoperative Foleys might be a great help in this scenario.


  Induction in Deceased Donor Renal Transplants: A Bane or a Boon? Top


Arun Kumar Ponna, Manisha Sahay, Kiran Mai Ismail, Sharmas Vali

Osmania Medical College, Hyderabad, Telangana, India. E-mail: arunponna@gmail.com

Background: Rejections are an important cause of poor graft outcomes. Acute rejection episodes are considered as a risk factor in the development of chronic rejection. Induction therapy is recommended for deceased donor transplants however the cost of induction therapy is high. Aims of Study: To study and compare the complications and outcome of 40 cases of deceased donor renal transplantation in patients with and without induction therapy. Methods: Prospective study of 40 cases of CKD patients who underwent cadaveric renal transplantation at tertiary care government hospital. 19 patients received basiliximab induction; while remaining 21 patients did not receive induction. Induction therapy was given to patients who consented for obtaining the drug. All patients recieved standard triple drug immunosupression (prednisolone; tacrolimus and MMF). All were 1st transplants. The baseline and donor characteristics were comparable among the two groups. HLA typing for donor and recipient was not done. Primary endpoint was the incidence of acute rejection at 6 months. Secondary endpoints include the safety and tolerability of basiliximab; 1-year patient and graft survival; and significant medical events upto 12 months. Results: Mean age group was 35.08 years +/-9.2 years; M:F ratio was 3.2:1. Native kidney disease was CIN in 26 pateints and CGN in 12 patients. Mean cold ischaemic time was 6.14 hours +/-3.42 hours. In induction theraphy group 3 (15.8%) had rejection; 2 AMR and one cellular rejection.While in non- induction group 7 cases (33.33%) had rejection; 4 cellular and 3 AMR (antibody mediated rejection) in the first 6 months; these rejections responded to anti rejection theraphy. Incidence of infections in induction group included 9 (47.4%) cases- bacterial in 6 cases i.e; UTI in 3 cases; pneumonia in 1 case; perineal and gluteal abscess in 1 case and leg ulcer in 1; fungal infections-mucormycosis in 1 case; fungal pneumonia in 1; CMV in 1 case. Incidence of infections in non induction group included 11 (52.4%) cases bacterial in 4 cases (2 uti; 2 pneumonia); viral - CMV colitis in 4 cases; herpes zoster in 1 case; fungal — oral candidiasis in 1 case; mucormycosis 1 case.One year graft survival and patient survival in induction group was -94.74% and 100% respectively. One year graft survival and patient survival in non induction group was 90.48% and 95.2% respectively. Conclusion: Basiliximab in combination with tacrolimus; steroids and MMF was highly effective in reducing the incidence of acute allograft rejection; without increasing the incidence of infections.


  Renal Allograft Compartment or Compression Syndrome as Etiology of Early Graft Dysfunction: Underappreciated Because of Poor Nosography Top


Anil Mani, Sanchit Rustagi, S. K. Sureka, U. P. Singh, M. S. Ansari, Rakesh Kapoor, Aneesh Srivastava

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dranilmani@gmail.com

Background: Renal allograft compartment syndrome or renal allograft compression syndrome (RACS) is an underappreciated cause of early graft dysfunction secondary to retroperitoneal hypertension or graft compression. Due to lack of well defined diagnostic criteria; there are only few literature available related to RACS. We reviewed cases of RACS we have managed over last five years to provide insight for diagnosis and prompt management. Aims of Study: To identify the cases of renal allograft compression/ compartment syndrome and identifty the clinical presentation; risk factors and preventive measures to avoid the same. Methods: All renal transplants between January 2012 and July 2017 (n= 656) at our centre in north India were reviewed. 8 cases (7 males and 1 female) of RACS were identified. Diagnosis was suspected on the basis of a clinical scenario of sudden drop in urine output in the immediate post operative period in a setting of fair diuresis after declamping when no other etiology explaining the same could be identified. Doppler showed normal flow in main renal artery in all cases with diminished flow in the segmental and interlobar arteries in six cases. Diagnosis was confirmed at exploration with an observation of pale allograft colour and soft kidney becoming turgid and pink immediately on decompression by opening the abdominal wall with restarting of diuresis. All cases were suspected and explored in the immediate post operative period with a mean time interval of 72 ± 22.5 minutes (30-180 minutes). Results: 8 cases of RACS between January 2012 and July 2017 were identified at an incidence of 1.22%. Seven were male patients and 1 was a female patient. Doppler ultrasonographies were performed in all the suspected patients. Doppler showed normal flow in the main renal artery in all cases with diminished flow in the segmental and interlobar arteries in two cases. In six cases blood flow appeared normal. The interval after which the patients were re-explored ranged from 30 to 120 minutes; with a median time interval of 60 minutes. In all the patients; graft function could be recovered by just reopening all the layers of the wound and reclosing them with better mobilization and in a tension free manner. These patients were followed up clinically at day1; day 14 and day 30. Serum creatinine was noted on day 14 and day 30. On day 14; the serum creatinine of our patients ranged from 0.9 to 1.78 mg/dl. Mean creatinine was 1.39 mg/dl. On day 30; mean serum creatinine was 1.48 mg/dl. Conclusion: Transplant surgeons should be aware of RACS as a possible diagnosis when sudden drop in urine output become evident after good initial allograft function. A prompt surgical decompression should be performed to salvage the graft and intraoperative Foleys might be a great help in this scenario.


  Surgical Approach to Postrenal Transplant Symptomatic Lymphocele: Lessons Learned Top


Anil Mani, S. K. Sureka, Rakesh Kapoor, Aneesh Shrivastava

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: dranilmani@gmail.com

Background: Lymphoceles are common and well-known complications that occur in 1% to 26% kidney transplant recipients. Due to their critical location in the pelvis lymphoceles can become symptomatic. This video will demonstrate the surgical finer details for managing the symptomatic lymphocele with focus on laparoscopic approach. Aims of Study: To assess and demonstrate the finer details of surgical management of post transplant symptomatic lymphocele. Methods: Retrospective evaluation of Patients who had symptomatic Lymphocele following live related renal transplant at a tertiary care centre from 1990 to 2015. We have managed most of the symptomatic lymphocele by surgical internal drainage in view of high recurrence rate of external drainage. External drainage and sclerotherapy (EDST) was only performed in selected cases of small lymphocele (<100 ml) or infected lymphocele. Results: 32 symptomatic lymphocele were diagnosed in 2550 renal transplant recipients. 11 patients received EDST and 8 had recurred (72%). 21 patient underwent Lap cyst deroofing and 9 patient underwent Open internal marsupilisation. Mean operative time in patients undergoing surgical deroofing was 90 minutes and 100 minutes for open and laparoscopic group. Length of Post procedural Hospital stay was 7.5 days vs 3 days for Open Vs Lap group( p=<0.01). There was no intra-operative complication. No recurrence of Lymphocele has been noted in the follow-up after surgical internal drainage. Laparascopic deroofing was found to be difficult in patients with inferomedial and posterolateral lymphocele due to their critical locations. External drainage and sclerotherapy was only performed in selected cases of small (<100 ml) or infected lymphocele. Conclusion: Symptomatic lymphocele post renal transplant should be managed preferably by laparoscopic deroofing. EDST was associated with high recurrence and should only be tried in infected and very small lymphoceles .Inferomedial and posterolateral lymphoceles should be drained by open marsupialization.


  Role of Early Povidone Iodine Instillation in Postrenal Transplant Lymphorrhoea: A Prospective Randomized Study Top


Aneesh Srivastava, Sanjoy Kumar Sureka, Priyank Yadav, Rakesh Kapoor, M. S. Ansari, Kumar Madhavan

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: madhavanranjit@gmail.com

Background: Lymphatic collections commonly develop after renal transplantationalthough most of them are asymptomatic and resolve spontaneously. Persistent drain output is one ofthe earliest signs of lymphatic leak. An encysted collection or lymphocoele if symptomatic; can lead tocomplications as grave as the graft dysfunction itself. Aims of Study: This study aimed at prospectively evaluating therole of early povidone iodine instillation in the management of post renal transplant lymphorrhoea. Methods: A prospective evaluation of live related renal transplant recipients was done from Jan 2002 to Dec 2015. Significant lymphorrhoea was defined as >50 mL lymph from drain beyond POD 5. Suchpatients were randomized into 2 groups: Group A (received 0.5% povidone iodine instillation) and GroupB (no instillation). Povidone iodine instillation was done for upto three weeks. The drain was removed ifthe output decreased to <50 ml/day or at three weeks drainage persisted. Absolute risk reduction and NNT were calculated to estimate effect of povidone iodine instillation for the treatment oflymphorrhoea. Fisher exact test or chi square test for categorical data descriptive statistics and t testwas used for continuous data SPSS version 20.0. Armonk; NY: IBM Corp. Results: 1766 patients underwent renal transplant during this period. 117 patients with lymphorrhoeathrough the drain underwent randomization into group A (n=61) and group B (n=56). In group A; 58 (95%) patients had successful resolution within two weeks while in group B; 34 (60%) patients hadsuccessful resolution within two weeks. Symptomatic lymphocoele was present in 1 patient in group Aand 7 patients in group B on follow up. Absolute risk reduction was 10.8% and for every symptomaticlymphocoele prevented; 10 patients needed povidone iodine instillation. Conclusion: Povidone iodine instillation helps in early resolution of post renal transplantation lymphorrhoea as well as reduces the incidence of lymphocoele formation.


  Posttransplant Cerebellar Abscess Top


Shivnarayan Acharya

E-mail: acharyashivnarayan@gmail.com

60 years old retired medical officer suffering from Polycystic Kidney disease had pre Transplant nephrectomy. He underwent renal transplant with his wife as donor. Induction was given with ATG 50 mg 2 dosage and he was initiated on Triple immunosuppressants with Steroid, mycophenolate and Tacrolimus. Post op period was uneventful. After 6 months had cough, fever, anemia, leucopenia and X ray chest revealed left mid zone Pneumonia. He underwent Bronchoscopy and lavage. BAL fluid analysis showed Filamentous branching gram positive bacilli. Modfied ZN stain for Nocardia showed Long filamentous acid fast bacilli suggestive of Nocardia species. He was treated with Bactrim DS, Linezolid, Meropenem for a month, then Bactrim DS was continued. He developed headache, vomiting, altered consciousness after 2 months. CT scan showed a cavity in cerebellum. Surgical evacuation done. Patient gradually recovered. Received post op Linezolid, septran and meropenem.

Summary – This highlights the successful surgical management of Post transplant Nocardia abscess of brain.




 

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Association of M...
Initial Experien...
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Awareness and Be...
Bedside Strategy...
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Contrasting Spec...
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HLA One Way Mism...
An Open Label Ra...
Epidemiology and...
Systemic Fungal ...
The Challenges a...
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Pediatric and Ad...
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Dengue Fever and...
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Overcoming the U...
The Focus on Ane...
Fulminant Hepati...
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Induction in Dec...
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Ex Vivo L...
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Expanded Criteri...
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Long Term Renal ...
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Clinical Impact ...
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Let's Walk D...
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