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   Table of Contents - Current issue
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January-March 2019
Volume 13 | Issue 1
Page Nos. 1-67

Online since Friday, March 29, 2019

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COMMENTARY  

Urinary tract infection in renal transplant recipients: A clinical conundrum p. 1
Praveen Kumar Etta
DOI:10.4103/ijot.ijot_62_18  
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REVIEW ARTICLE Top

World of omics in transplantation – “Transplantomics” p. 5
Manisha Sahay
DOI:10.4103/ijot.ijot_6_19  
Over recent years, the transplantation outcomes have improved dramatically. However, rejections still occur despite potent immunosuppression. Furthermore, long-term transplant complications affect outcomes, for example, new-onset diabetes after transplantation (NODAT) or cancers worsen outcomes. The science of transplantomics is a relatively novel science directed at further improving short- and long-term outcomes after transplantation. Hence, nephrologists need to be aware of potential applications of omics in transplantation.
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ORIGINAL ARTICLES Top

Chronic antibody rejection in renal allograft: An underestimated cause of renal allograft dysfunction p. 9
Nishika Madireddy, Megha S Uppin, Swarnalatha Guditi, Gangadhar Taduri, Sree Bhushan Raju
DOI:10.4103/ijot.ijot_66_18  
Introduction: Chronic antibody-mediated rejection (CAMR) has now emerged as one of the most common causes of chronic graft failure. In this study, we tried to study the clinical details, morphological features, risk factors, and outcome of biopsy-proven CAMR. Materials and Methods: This was a retrospective study including 14 patients' with biopsy-proven CAMR. The clinical details, posttransplantation duration, risk factors, histomorphological features, immunohistochemical features, treatment protocol, and graft outcome of all the patients were studied. Results: There were 11 male and 3 female patients and the mean age at biopsy was 33 ± 10 years. The mean transplant duration to the diagnosis of CAMR was 61 months. The mean serum creatinine levels and 24-h proteinuria at the time of biopsy were 5.3 ± 4.5 mg/dl and 3.4 ± 0.9 g/24 h, respectively. Four patients had a previous episode of rejection and three patients had a concurrent hepatitis C virus (HCV) infection. Transplant glomerulopathy (TG) was seen in all 14 biopsies and all were positive for C4D in the peritubular capillaries. Twelve of these progressed to graft failure. Conclusion: CAMR is an important cause of chronic graft rejection, with a majority of cases progressing to graft failure. TG is the most commonly observed histomorphological pattern and the severity of TG seems to be associated with poor graft survival. An associated HCV infection further hinders the graft survival.
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Knowledge, attitude, and practice regarding organ donation among adult Population of an Urban field practice area of a medical college in Durgapur, West Bengal, India p. 15
Sourabh Paul, Tapas K Som, Indranil Saha, Gautam Ghose, Arpan Bera, Akansha Singh
DOI:10.4103/ijot.ijot_36_18  
Background: Organ donation is either when a person allows healthy transplantable organs/tissues to be removed, after death, or when the donor is alive and transplanted into other persons. Common transplantations include eyes, kidneys, liver, heart, skin, and bone marrow. The present study was conducted to understand the knowledge, attitude, and practice pattern of organ donation among the participants and to find out the association between the knowledge of organ donation with selected variables of interest. Methods: The present study was a cross-sectional study conducted among adult participants of an urban area of Durgapur from October 18, 2016, to November 5, 2016. A predesigned and pretested pro forma was used for data collection. Results: About 73.3% of the participants had heard about organ donation. Majority of the participants were female, aged 31–40 years, illiterate, and with a monthly income less than Rs. 5000/month. Eye was the most common donatable organ identified by the participants. Majority of the participants were unaware about the existing law in India about organ donation. Not a single participant had donated any organ, but 6% of them had signed form for cadaveric donation. Participants those who have educational status above high school had better knowledge compared to those who have lesser educational qualification (P = 0.001). Similarly, participants with monthly family income ≥10,000 also had better knowledge compared to other groups (P = 0.029), and this relation was statistically significant. Conclusion: Awareness about organ donation is not satisfactory, but the community had a positive attitude toward organ donation.
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Spectrum of asymptomatic bacteriuria in renal allograft recipients and its short-term effect on graft outcome: Experience of a Tertiary Care Center from Northwest India p. 20
Gaurav Shekhar Sharma, Dhananjay Agarwal, Vinay Rathore, Alok Kumar Pandey, Rajesh Jhorawat, Sanjeev Kumar Sharma, Pankaj Beniwal, Vinay Malhotra
DOI:10.4103/ijot.ijot_52_18  
Introduction: Asymptomatic bacteriuria (AB) is not uncommon after renal transplantation with limited data from developing countries; we did this study to assess the microbiological spectrum and its short-term graft outcome in our tertiary care center. Materials and Methods: It is a prospective observational study. We included all the patients who underwent renal transplantation over a period of 18 months, from January 2016 to June 2017. Patients who had indwelling urinary catheter beyond 5 days posttransplant and those with persistent graft dysfunction within 6 months of transplant were excluded from the study. Results: A total of 67 patients were included in the study with a mean age of 33.78 ± 8.91 years and a male-to-female ratio of 7:1; live-related donors were 36 (53.73%), live unrelated were 19 (28.35%), and 12 (17.91%) were cadaveric renal allograft recipients (RARs). Twenty-eight (41.79%) patients had 42 episodes of AB over 6 months of follow-up. The maximum episodes occurred within 1 month of postrenal transplantation, and 42 out of 67 (62.68%) RARs had bacterial growth in their double-J ureteral stents (USs). The most frequently isolated pathogen from urine was Escherichia coli (n = 14, 33.33%), whereas Pseudomonas aeruginosa (n = 10, 23.80%) was in US culture (USC). The prevalence of AB was higher in cadaveric RARs compared to live RARs (83.33% vs. 32.72%, P = 0.001) and with bacterial growth in the USC compared to those who did not show any growth in USs (57.14% vs. 16.0%, P = 0.001). However, the estimated glomerular filtration rate between those with AB and those without at 6 months of follow-up (66.36 ± 14.98 vs. 66.10 ± 13.83 ml/min/1.73 m2, P = 0.943) was not different. Conclusion: AB is not uncommon in RARs and it is more common in cadaveric RARs and those with growth in US culture without compromise in allograft function at 6 months postrenal transplant.
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A leap toward brighter future – deceased-donor renal transplantation: Three years of experience in Sawai Man Singh Hospital, Jaipur, India p. 25
Harshal Joshi, Dhananjai Agarwal, Vinay Malhotra, Vinay Rathore, Pankaj Beniwal, Nishad Raveendran, Sanjeev Sharma, Rajesh Jhorawat, Nisha Gaur, Shailendra Kumar
DOI:10.4103/ijot.ijot_41_18  
Background: With an increase in the prevalence of risk factors for chronic kidney disease, the prevalence of end-stage renal disease (ESRD) is increasing in India, adding 1.75 lakh ESRD patients each year. Renal transplant is one of the best modalities of renal replacement therapy; however, it is available only in a few centers. Despite an increase in trend, deceased-donor renal transplant (DDRT) rate is only 0.34/million populations, one of the lowest rates in the world. Materials and Methods: We analyzed 25 DDRT recipients transplanted in the last 3 years. The patients were followed till death or graft loss whichever was earlier. Posttransplant outcome and complications were evaluated. Results: The patient survival was 84% (21/25), and death-censored graft survival was 84% (21/25). 16% (4/25) had the second renal transplant with a history of failed previous live renal transplant. Delayed graft function (DGF) and biopsy-proven acute rejection were seen in 16% and 12%, respectively. The mean posttransplant creatinine in recipients with functioning graft on the last follow-up was 1.14 ± 0.2 mg/dl. The most common medical complication was sepsis (40%, 10/25). Conclusion: The short-term outcome of DDRT in our center is comparable to other centers in India. DGF was the most important determinant of graft survival.
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Nutrition status and its impact on quality of life and performance status in end-stage liver disease p. 31
Neha Bakshi, Kalyani Singh
DOI:10.4103/ijot.ijot_39_18  
Aim: Malnutrition in end-stage liver disease (ESLD) patients has been associated with various prognostic factors. However, its effect on nonconventional parameters is least studied. The present exploratory study analyzes the impact of malnutrition on quality of life (QoL) and performance status (PS) in ESLD. Methods: We recruited 54 adult ESLD patients. Nutrition status assessment was performed by different validated tools such as subjective global assessment (SGA), mid-upper arm circumference, triceps skinfold measurements, mid-arm muscle circumference, and body mass index (BMI) for ascites. QoL and PS were assessed by Short Form-36 Interview and Eastern Cooperative Oncology Group-PS, respectively. Results: Malnutrition in patients ranged from 24.1% to 88.9% by various nutrition assessment techniques. ESLD patients showed lower levels of QoL and PS. SGA showed that malnourished patients had significantly lower PS grades than normal patients (P < 0.05). The Chi-square adjusted Z-scores showed that moderately malnourished patients had significantly higher PS-Grade-3 (capable of only limited self-care); further, severely malnourished patients had significantly higher PS-Grade-4 (completely disabled) (P < 0.004). Furthermore, malnutrition also showed lower QoL scores. After Bonferroni correction, SGA showed significantly lower emotional well-being scores of QoL in severely malnourished patients. BMI for ascites also showed significantly lower physical functioning and physical component summary scores of QoL among severely malnourished patients. Albumin level showed a significant positive correlation with emotional well-being of the patients.Conclusion: Hence, higher degree malnutrition among ESLD is associated with lower QoL and PS. The data addresses the need for planning nutrition interventions to ameliorate malnutrition in ESLD patients to improve QoL and PS for better prognosis.
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CASE REPORTS Top

Hepatic mucormycosis in a renal transplant recipient: A rare presentation p. 38
Sai Chandana Gali, N Rukmangadha, Aruna Prayaga, V Siva Kumar
DOI:10.4103/ijot.ijot_48_18  
Fungal infections account for 5% of all infections in renal transplant recipients. Mucormycosis has emerged as an important invasive fungal infection in transplant recipients associated with aggressive clinical course and substantial rates of death. A 28-year-old male with chronic kidney disease underwent renal transplantation from a deceased brain-dead donor. Implantation kidney biopsy showed features of acute tubular necrosis. On follow-up, the patient had progressive renal failure. The patient expired 3 months after transplantation due to sepsis with refractory shock. Postmortem needle biopsy done on the liver showed areas of necrosis with broad, aseptate filamentous fungal hyphae stained positive with Gomori methenamine silver stain favoring mucormycosis. Mucormycosis is a fatal mycosis in transplant recipient due to its angiophilic and thrombosis/hemorrhage-oriented characteristics. The overall mortality rate among solid-organ transplant recipients with mucormycosis is 38%–48%. Early detection and appropriate timely management of fungal infections play a decisive role in improving the survival and reducing the mortality.
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Deep vein thrombosis occurring early postrenal transplant p. 42
Vamsi Krishna Makkena, Manikantan Shekar, Varun Mamidi, Varun Kumar Bandi, Jayakumar Matcha
DOI:10.4103/ijot.ijot_64_18  
In kidney transplant recipients (KTRs), there can be an increased risk of thrombotic diseases. Here, we report a case of KTR, who developed ipsilateral acute iliofemoral deep vein thrombosis (DVT). A 38-year-old male with end-stage renal disease underwent deceased donor renal transplantation. He received antithymocyte globulin induction (2 mg/kg) and was maintained on tacrolimus, mycophenolate mofetil, and steroids. He had delayed graft function. One month posttransplant, the patient presented with right lower limb edema, with Doppler showing DVT of the right external iliac, common femoral, and proximal superficial femoral veins. He was treated with unfractionated heparin and underwent placement of retrieval filter in the infrarenal inferior vena cava (IVC) through the right internal jugular vein approach. Heparin was overlapped and switched to oral acenocoumarol. At 3 months postoperative, the patient is stable with no limb edema and serum creatinine of 0.8 mg/dl. A follow-up venous Doppler demonstrated the resolution of the thrombus. In conclusion, our patient developed DVT within 30-day postoperative period with no apparent risk factor and was successfully treated with anticoagulation and placement of IVC filter. Venography, thrombolysis, and thrombectomy pose challenges in the KTRs because of increased risk of adverse effects such as bleeding, contrast-induced nephropathy, and pulmonary embolism.
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Pancreatic transplant associated tuberculosis diagnosed and followed up on whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography p. 46
Aashish Gambhir
DOI:10.4103/ijot.ijot_42_18  
Infection attributable to impaired host immunity is the most commonly reported cause of morbidity and mortality among pancreatic transplant recipients. Among these, tuberculosis (TB) has been reported sporadically. Herein, we present a case illustrating the role of whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography in diagnosis and follow-up of peripancreatic abdominal TB in a pancreas-only transplant recipient who presented with unexplained fever.
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Reversible cause of renal failure in a 16-year-old allograft p. 50
Navin Pattanashetti, Ritambhra Nada, Krishan Lal Gupta, Raja Ramachandran
DOI:10.4103/ijot.ijot_59_18  
Granulomatous interstitial nephritis (GIN) is reported in 0.9% of the native renal biopsies. GIN occurrence in renal allograft is rare and a proton-pump inhibitor-induced GIN is infrequent. Our patient, a 36-year-old renal transplant recipient (2002), on triple immunosuppression with normal renal function, after 16 years of renal transplant, presented with raised serum creatinine (1.9 mg/dl), biopsy revealed GIN, workup for secondary causes were negative, on detailed inquiry, the patient was receiving pantoprazole for the last 1 month on the prescription of his primary physician for dyspeptic symptoms. On stopping pantoprazole, serum creatinine reduced to baseline (1 mg/dl) at 15 days, confirming the diagnosis of pantoprazole-induced GIN.
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Tacrolimus-induced pure red cell aplasia in a postrenal transplant patient p. 52
Prakash Khetan, Sumeet Jaiswal, Seema Khetan, Manish Ramesh Balwani
DOI:10.4103/ijot.ijot_55_18  
Acquired pure red cell aplasia (PRCA) is an uncommon cause of anemia in a postrenal transplant patient. Most of the times, it is secondary to parvovirus infection. It can also be seen with certain autoimmune diseases, pregnancy, lymphoproliferative disorders, nutritional deficiencies, or medicines. We present the case of a living-related postrenal transplant patient who developed PRCA associated with tacrolimus. The patient responded when switched over to cyclosporine in 2½ months.
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Living kidney donor with monoclonal gammopathy of undetermined significance: Is it a contraindication for kidney donation? p. 54
Vinay Rathore, Pankaj Beniwal, Dhananjai Agarwal, Vinay Malhotra, Rajesh Jhorawat, Sanjeev Sharma
DOI:10.4103/ijot.ijot_67_18  
Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. We report a case of living kidney transplantation in which the donor had monoclonal gammopathy of undetermined significance, a condition having possible implication for both donor and recipient. Both donor and recipient had an uneventful course in short-term follow-up of 1 year following kidney transplantation.
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Robot-assisted kidney transplant in a child with Bardet–Biedl Syndrome p. 56
Nishy Mathew, VN Unni, T Kishore, K Vinod, PK Bipi, P Jojo, R Vishnu
DOI:10.4103/ijot.ijot_77_18  
Bardet–Biedl syndrome (BBS) is an autosomal recessive condition characterized by retinitis pigmentosa, postaxial polydactyly, central obesity, mental retardation, hypogonadism, and renal involvement. BBS is a very rare cause of end-stage renal disease (ESRD) in children. We report a case of a 13-year-old girl with BBS who developed ESRD in early adolescence and underwent robot-assisted renal transplantation surgery. She is the first reported case of robot-assisted renal transplantation surgery in ESRD due to BBS.
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Renal anastomosing hemangioma: A diagnosis to ponder p. 59
Nivedita Chandran, Muthuvel Seral Kannan, Muthu Veeramani
DOI:10.4103/ijot.ijot_63_18  
Anastomosing hemangiomas are rare benign vascular lesions with predilections for the genitourinary tract. We present a case of bilateral renal tumors detected during pretransplant evaluation and underwent laparoscopic bilateral radical nephrectomy. Histological diagnosis was anastomosing hemangioma confirmed with immunohistochemistry. As the final diagnosis was of benign nature, the patient was maintained on the transplant waitlist. As both renal cell carcinoma and renal anastomosing hemangioma have predilection for end-stage renal disease with no radiological differentiating features, the accurate histopathological examination with immunohistochemistry is essential for the diagnosis.
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Chromoblastomycosis in a renal allograft recipient on calcineurin inhibitor-free immunosuppression Highly accessed article p. 62
PK Bipi, VN Unni, Nanda Kachare, K Vinod Kumar
DOI:10.4103/ijot.ijot_53_18  
Superficial cutaneous fungal infections are common in our country in the kidney transplant recipients. However, deep fungal infections involving the skin and subcutaneous tissue are relatively rare. Here, we report a case of chromoblastomycosis in a renal allograft recipient on a calcineurin inhibitor-free immunosuppression. The case highlights the importance of skin biopsy in differentiating various skin lesions in transplant patients and the role of the early institution of appropriate treatment in successfully treating these infections.
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Treatment of early hepatic venous outflow obstruction after living donor-related liver transplantation by the insertion of expandable metallic stent p. 65
KM Mahendra, Gaurav Gangwani, Ajit Yadav, Arun Gupta
DOI:10.4103/ijot.ijot_45_18  
Hepatic venous outflow obstruction (HVOO) is rare but serious complication after right lobe living donor liver transplantation (LDLT). Failure to identify this complication early can result in graft failure and even death. The early diagnosis and management of HVOO is very important. We report a case with this complication treated by endovascular stent placement in the early period after right lobe LDLT and review-related reports to explore the possible mechanism. A 43-year-old male with chronic liver disease underwent right lobe LDLT. On postoperative day 2, his liver function deteriorated. Hepatic venography showed an obstruction and thrombosis of mechanical heart valve with an element of torsion of the venous drainage proximal to the anastomosis of the right hepatic venous orifice and inferior vena cava. The obstruction was successfully treated by insertion of an expandable metallic stent. The result demonstrates that stent placement for obstruction is safe and effective.
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