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   Table of Contents - Current issue
October-December 2019
Volume 13 | Issue 4
Page Nos. 237-310

Online since Tuesday, December 31, 2019

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Men are from mars, women are from venus: Gender disparity in transplantation p. 237
Manisha Sahay
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Comprehensive management of the renal-transplant recipient p. 240
Praveen Kumar Etta
Renal transplantation (RT) is the current treatment of choice for patients with end-stage renal disease (ESRD). Innovations in RT and immunosuppressive regimens have greatly improved both the patient and graft survival. A successful RT offers enhanced quality and duration of life and is more effective (medically and economically) than long-term dialysis therapy for patients with ESRD. Close follow-up and monitoring treatment are the important part of the management of RT recipients (RTRs). Cardiovascular disease, infections, and drug toxicity play a key role in the long-term morbidity and mortality of this patient population. As RTRs survive for longer periods of time with functioning allografts, physicians will likely become more involved in their management, mandating at least a basic understanding of management of an adult RTR.
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ABO-incompatible kidney transplantation: Indian working group recommendations Highly accessed article p. 252
AK Bhalla, BT Anil Kumar, Munish Chauhan, Pratik Das, Bhupendra Gandhi, Umapati Hegde, Tarun Jeloka, Manish Mali, Pranaw Kumar Jha, Ajay Kher, Kamal Kiran Mukkavilli, Raja Ramachandran, Vivekanand Jha
Expanding use of ABO-incompatible kidney transplant (ABOiKT) globally and in India demands harmonized protocols. With an aim to provide unified and standardized consensus for ABOiKT in Indian setting, a 14-member working group formulated this document on key critical areas to guide ABOiKT. The recommendations include the following: (i) Gel column agglutination test is a method of choice for antibody (Ab) titer assessment with tube method as acceptable alternative. Immunoglobulin G measurement is advised for clinical decision making. (ii) Assessment of one Ab titer before subjecting patient to Ab removal is recommended. Postplasmapheresis (PP) titers to be monitored anywhere between 2 and 12 h. (iii) Target Ab titer recommended is ≤1:16 irrespective of the method used for titer assessment. (iv) If cost and availability are not a concern, immunoadsorption (IA) should be preferred. (vi) Choice of replacement fluid depends on the method employed for Ab removal. (vii) Donor or AB-positive plasma transfusion can be considered to avoid coagulopathy and bleeding in posttransplant period. It also decreases the risk of coagulopathy associated with greater number of PP cycles performed during and after transplant. (viii) IA column can be reused if cleaned, sterilized and stored properly. (ix) Intravenous immunoglobulin (IVIG) is optional for use in ABOiKT. Choose IVIG batch with lowest ABO- Ab titers and use in low dose (~ 100 mg/kg). (x) Rituximab in a low dose of 100–200 mg is effective and its use (at-least 2 weeks prior to transplant) is at the discretion of treating renal transplant physician. (xi) Avoid, if possible, the combined used of antithymocyte globulin and rituximab as it increases risk of infections significantly. (xii) Posttransplant PP is needed if there is Ab mediated rejection with increasing titers. (xiii) Standard immunosuppression should be followed. These recommendations are first of a kind that aims to standardize the practice of ABOiKT, serve as a guiding tool to the transplant physicians in India.
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Comparison of automatic depth correction versus manual depth correction in the calculation of glomerular filtration rate in gates renal processing of diethylenetriaminepentaacetic acid renogram in prospective renal donors p. 259
Ranadheer Mantri, Priyanka Kosana, Ramya Priya Rallapeta, Ravi Parthasaradhi, Sailaja Aka, Tekchand Kalawat, Siva Kumar Vishnubotla
Aim: The aim of the study was to compare the glomerular filtration rate (GFR) obtained by gates method of renal processing using automated system generated method (ASGM) of depth correction with manual depth correction method (MDCM), in prospective renal donors using 99m-Tc diethylenetriaminepentaacetic acid (DTPA) scintigraphy. Materials and Methods: Prospective interventional study involving 20 voluntary renal donors of age 26–65 years were included. 99m-Tc DTPA renograms were acquired by dynamic acquisition for 30 min. Presyringe and postsyringe counts, prevoid and postvoid images, and both sides of lateral images (for manual depth correction) were acquired. GFR was calculated by Gates renal processing with the depth correction both by ASGM and MDCM methods. Results: The mean depth of right and left kidneys calculated by MDCM and ASGM were 7.2 ± 1.1 and 6.4 ± 1.1 and 7.0 ± 1.2 and 6 ± 1.2, respectively. The mean total GFR calculated by Gate's Method using MDCM and ASGM was 96.2 ± 15.4 and 82.0 ± 11.5. There was a statistically significant difference in the depth correction of both kidneys and improvement in total GFR values by MDCM methods compared to the ASGM method. Conclusion: There was a significant difference in depth and GFR values, calculated from MDCM compared to ASGM. Hence, the MDCM is better in calculating GFR for renal donors, especially when using low-energy high-resolution collimators, as full-width half-maximum varies considerably for every centimeter of the distance of the source from the collimator.
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Upside-down kidney transplantation using single-suture single-knot technique p. 264
Prem Gyawali, Sujeet Poudyal, Suman Chapagain, Bhojraj Luitel, Pawan Chalise, Uttam Sharma
Aim: The aim of the study was to evaluate the outcomes of upside-down transplanted kidney with single-suture single-knot technique.Methods: From August 2013 till date, a total of 299 living-related kidney transplantations were done in the Department of Urology and Kidney Transplantation Surgery TU Teaching Hospital and Grande International Hospital, Kathmandu, Nepal. Out of them, 71 upside-down kidney transplantations were performed using single-suture single-knot technique. In this study, their overall outcome is evaluated. Results: Our study showed no difference in the overall outcome between upside-down and standard kidney transplantation and even less blood transfusion rate in upside-down group. Conclusion: There should be no hesitation to perform the upside-down kidney transplantation.
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Impact of single classroom-based peer-led organ donation education exposure on high-school students and their families p. 267
Lakshya Aggarwal, Smita Mishra, Manish Agrawal, Dheeraj Shah
Aims: The aim of the study is to assess the impact of single classroom-based, organ donation education session by high-school students on improvement in knowledge and intent to donate organs in their peers and their families. Settings and Design: Quantitative interventional study with before-after design done in high-school sections of two private schools of Delhi in July and August 2018. Subjects and Methods: Participants were all 1583 high-school students present on the day of activity. Organ donation education was provided by 30-min presentation in individual classrooms, along with distribution of frequently asked questions booklet on organ donation by 44 self-motivated high-school students to the peers. We collected pre- and post-intervention questionnaire and family interaction feedback responses from participants, within 1 week before, on intervention day and 3 weeks after it. Main outcome measures were improvement in students' knowledge, intent to donate, family discussion, and actual organ donor pledge registrations. Results: There was a significant improvement in students' knowledge (mean scores increased from 9.16 to 13.91 [P = 0.000]). Significantly increased (P = 0.000) proportion of students had positive intent to donate (66.9% vs 80.9%) and wanted to encourage their family members for organ donation (72.6% vs 87.2%) after the intervention. 1144 (84.2%) students reported discussion in their families, 250 (18.4%) students' families planned to take, and 67 (4.9%) families (one or more persons) actually took organ donor pledge after the intervention. Conclusions: The educational intervention by peers, instead of health-care personnel, led to significant improvement in high-school students' knowledge, intent to donate, family discussion, and actual organ donor pledge registrations.
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Lymphocele complications following renal transplantation p. 273
Rajendra B Nerli, Deole Sushant, Shridhar C Ghagane, Sreeharsha Nutalpati, Shyam Mohan, Neeraj S Dixit, Shivayogeeswar Neelagund, Murigendra B Hiremath
Introduction: Lymphocele formation following renal transplantation is a well-known complication. Mostly these are small and inconsequential, but large lymphocele may cause symptoms like pain, infection , renal dysfunction, surgical drainage of lymphatics Surgical damage of the lymphatics of the graft during the procurement and of the lymphatics around the iliac vessels of the recipients has been responsible with development of lymphocele. Several factors such as diabetes, obesity, blood coagulation abnormalities, anticoagulation prophylaxis, high dose of diuretics, delay in graft function and immunosuppressive drugs are known to be related to these complications. We report three cases of symptomatic lymphoceles managed at our centre during the past one year. Patients and Methods: We retrospectively reviewed patients undergoing renal transplant at our centre. Out of 18 transplant recipients 3 cases developed large symptomatic lymphoceles. These were evaluated by Computed Tomography (CT) scan/ Ultrasound (USG) and serum creatinine levels. These patients were managed by ultrasound guided aspiration and instillation of doxycyline. Results: All three patients underwent USG guided aspiration and doxycyline instillation had significant reduction in serum creatinine levels with no recurrence of lymphoceles on follow-up. Conclusions: lymphocele remains important surgical complications following renal transplantation. Prompt diagnosis and early intervention is crucial to prevent permanent renal damage..
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Deceased organ donation of foreign nationals in India p. 277
Pallavi Kumar, Sunil Shroff, Sumana Navin, Muneet Kaur Sahi, Jaya Jairam, Surendra Kumar Mathur, Anant Kumar, Darius Mirza, Subba B Rao, Gunadhar Padhi
Inward foreign tourism in India is on the rise and the tourists are equally at risk of fatal road accidents and stroke leading to brain death. This provides an opportunity for organ donation; however, no guidelines are available on how to proceed in such cases. The Transplantation of Human Organs Act 1994 is also silent on this aspect. This paper seeks to lay down recommendations and guidelines for hospitals, healthcare professionals, Transplant Coordinators and the state machinery allocating such organs on how to proceed with such cases. Three such donations by foreign nationals in India were examined and based on the experience of coordinating them, guidelines have been drawn up. It was seen that families agreed readily where the individual had expressed the desire to be an organ donor (by opting the same on the driving licence or coming from a country that follows presumed consent). Effective counselling also encouraged consent in case of no prior wish. However, absence of guidelines and standard protocols creates confusion. In order to increase the donor pool, donations from foreign nationals in India should be streamlined. Also, from a human rights perspective, India needs to enable the choice of organ donation for every person who is declared dead within its territory.
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Isolated gastrointestinal posttransplant lymphoproliferative disorder in a child p. 282
K Vinod Kumar, V Narayanan Unni, Nanda Kachare, Ismail Siyad, Jojo Pullockara, Bipi Prasannan
We report a 12-year-old male renal allograft recipient, 10 months following the transplant surgery, who presented with diffuse abdominal pain, constipation, vomiting, and weight loss of 5 kg in 2 months. He was on standard maintenance immunosuppression (tacrolimus/mycophenolate mofetil/prednisolone) and had not received induction agents. Upper gastrointestinal (GI) endoscopy showed nodularity in the body of the stomach, and colonoscopy showed deep ulcers in the sigmoid colon and descending colon. Biopsy from the lesions showed dense infiltration of atypical lymphoid cells (B-cell markers, CD20, CD30, and BCL2 being positive), with immunohistochemistry showing strong positivity for Epstein–Barr virus (EBV). EBV DNA polymerase chain reaction in the blood was strongly positive (2200 copies/mL), confirming EBV-positive posttransplant lymphoproliferative disorder (PTLD). Positron emission tomography–computed tomography and bone marrow biopsy confirmed that the disease was confined to the GI tract. It is a rare complication seen after solid organ transplantation occurring usually in the 1st year after transplant. The most important risk factor is a higher degree of immunosuppression; tacrolimus levels remained high in spite of repeated revisions of the drug dose in our case. The patient was treated with injection rituximab (dose: 375 mg/m2), weekly injections of four doses, and his immunosuppressive medications were reduced by 50%. He had a good symptomatic relief. PTLD confined to GI tract is rare; constipation as a presenting manifestation is very rare. A high index of suspicion is essential to make an early diagnosis.
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Guillain–Barre syndrome in an ABO-incompatible renal allograft recipient during pregnancy treated with plasma exchange p. 286
Praveen Kumar Etta, Sreepada Subhramanyam, Vivek Narain Mathur, Karopadi Shivanand Nayak
Guillain–Barre syndrome (GBS) is an extremely rare complication after solid organ transplantation (SOT) and its clinical course can be more severe in them. Most of the cases of GBS in SOT have been associated with Cytomegalovirus infection. GBS presenting after an ABO-incompatible (ABOi) transplant and during pregnancy has never been reported in the past among SOT recipients. We report a case of a 27-year-old female ABOi renal transplant recipient who presented with acute flaccid paralysis all four limbs during the second trimester of pregnancy, diagnosed to have GBS. Pregnancy and vaccination might have played a role in precipitating GBS in our patient. She was treated with plasma exchange and experienced GBS treatment-related fluctuations but finally recovered completely without any adverse pregnancy outcome.
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Successful salvage of ruptured renal allograft resulting from renal vein thrombosis p. 289
Subrahmanian Sathiavageesan, Vel Arvind Subramaniam, Alagappan Chockalingam, Naveen Sangamareddy
Allograft renal vein thrombosis is a rare vascular catastrophe which occurs usually in the first few weeks following renal transplantation. The occurrence of allograft rupture due to venous thrombosis compounds the situation and often it leads to allograft nephrectomy. We present a case of renal allograft rupture resulting from allograft renal vein thrombosis which was successfully salvaged. We describe the clinical presentation and Doppler imaging findings of allograft vein thrombosis and surgical therapy undertaken in the patient.
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Successful kidney transplantation from a deceased donor with chronic hepatitis B infection and review of literature p. 292
Dhanin Puthiyottil, AS Ramesh, Rahul Dhodapkar, Manikandan Ramanitharan, Sandeep Kumar Mishra, Nabadwip Pathak, Satyaprakash Ray Choudhury, Arjun Pradeep Vazhayil, Dorairajan Narayanan Lalgudi, Sreerag Sreenivasan Kodakkattil, Puthenpurackal S Priyamvada, Sreejith Parameswaran
There is huge gap between patients requiring organ transplantation and the available organ donor pool. Various strategies are being pursued to expand the organ donor pool. Infection with hepatitis B virus (HBV) in the donor is considered a contraindication for organ donation. However, HBV infection is endemic in some regions, and a significant number of donors may harbor chronic HBV infection. Safe transplantation from donors with chronic HBV infection may allow significant expansion of the donor pool in such areas. We report the first instance in India of successful organ harvesting and kidney transplantation from a deceased donor with chronic HBV infection with no evidence of transmission of infection for 1 year after transplantation, and we briefly review the relevant literature.
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En-bloc kidney transplant from an 11-month-old pediatric donor to an adult recipient: Case report and review of literature p. 297
Gaurav Shankar Pandey, Ashish Sharma, Deepesh Benjamin Kenwar, Abhinav Seth, Sarbpreet Singh
The huge disparity between the number of end-stage renal disease patients awaiting renal transplant and the available donor organs can be overcome by increasing the utilization of donor organs from deceased donors. The use of kidneys from a deceased pediatric donor is technically challenging because of the smaller size of the donor organ, leading to a higher incidence of graft thrombosis apart from concerns of low nephron load resulting in early graft failure. We present a case of en-bloc kidney transplant from an 11-month-old to a 38-year-old female recipient. The cold ischemia was 250 min and operative time was 300 min. The 1st day urine output was 6.7 l with serum creatinine dropped to 0.9% mg on postoperative day 3.
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Mediastinal tuberculous abscess: A rare presentation after renal transplant p. 300
Sukanto K Das, Subodh K Das, Manas Jena, Prasant Kundu, Sarat Behera
Despite successful renal transplantation, the risk of opportunistic infections posttransplant is a major concern. Cases of mediastinal tuberculous abscess are rare with nonspecific presentation. Here, we describe the case of a 55-year-old renal transplant recipient with complaints of fever, recurrent hiccups, and generalized weakness. Moreover, only after high-resolution computed tomography and microbiological examination of the aspirate of the abscess fluid, the diagnosis was confirmed as mediastinal tuberculosis (TB) with abscess formation. The use of immunosuppressants was the probable risk factor. Thus, a keen observation along with a high degree of suspicion should be kept to diagnose and thereby reduce the morbidity and mortality due to mediastinal TB in posttransplant recipients.
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Successful transcatheter aortic valve replacement in a kidney allograft patient on rapamycin p. 303
Aashish Chopra, Vijayakumar Subban, Ravinder Singh Rao, Mullasari Ajit, Georgi Abraham
Aortic valvular stenosis producing hemodynamic compromise is a major determinant of allograft function in kidney transplant recipients. Here, we describe successful transcatheter aortic valve replacement in a 59-year-old patient who had a kidney transplantation 14 years ago on 3 drug maintenance immunosuppression, including rapamycin.
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Hyperacute rejection in a blood group incompatible renal transplant recipient – enigma of unfathomable thrombotic microangiopathy! p. 307
Vivek Sood, Ahmed W Kashif, Ritambhra Nada, Ashish Sharma, Raja Ramachandran
Transplantation-associated thrombotic microangiopathy (TMA) is one of the most disastrous complications of renal transplantation. It may be either de novo (more common with a poor prognosis) or recurrent (with genetic background due to underlying mutations). Varied presentation mandates a high index of clinical suspicion, and the diagnosis usually requires allograft biopsy demonstrating TMA with or without underlying etiology. It has never been reported to mimic hyperacute rejection. In this context, we describe an end-stage renal disease patient with underlying IgA nephropathy, who underwent blood group incompatible renal transplant following successful desensitization and after that had systemic TMA in the 1st-h posttransplant itself, with allograft biopsy revealing florid TMA with no evidence of rejection, tacrolimus toxicity, or infection. Etiology remained elusive despite exhaustive workup and all possible attempts to salvage the allograft went in vain, with subsequent graft nephrectomy at 3 months. The patient after that has undergone a blood group compatible deceased-donor renal transplant and fortunately has normal graft function at 2 years follow-up, enthralling us to hypothesize possible interaction between the endothelial cells of renal allograft and anti-donor hemagglutinin antibodies; a mechanism already avowed for graft loss in blood group incompatible liver transplantation. We, therefore, suggest that patients willing for blood group incompatible renal transplantation need to be counseled beforehand about this, although a rare but devastating entity.
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