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   Table of Contents - Current issue
Coverpage
April-June 2020
Volume 14 | Issue 2
Page Nos. 85-188

Online since Monday, July 6, 2020

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SPECIAL ARTICLE  

NOTTO transplant specific guidelines with reference to COVID-19 Highly accessed article p. 85
Vivek Kute, Sandeep Guleria, Jai Prakash, Sunil Shroff, Narayan Prasad, Sanjay K Agarwal, Santosh Varughese, Subhash Gupta, A GK Gokhale, Manisha Sahay, Ashish Sharma, Prem Varma, Anil Bhalla, Harsh Vardhan, Manish Balwani, Shruti Dave, Dhamendra Bhadauria, Manish Rathi, Dhananjay Agarwal, Pankaj Shah, Vasanthi R, Rajiv Garg
DOI:10.4103/ijot.ijot_62_20  
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REVIEW ARTICLES Top

Testing for donor-specific antibodies in renal transplantation: Indian perspective Highly accessed article p. 90
Praveen Kumar Etta
DOI:10.4103/ijot.ijot_17_20  
The evaluation of donor-specific antibodies by Luminex single-antigen bead assay (in addition to other crossmatch tests) to assess pretransplant immunological risk should be performed in recipients (especially with a history of prior sensitization) even in resource-constrained settings as this approach can help in better risk stratification, to decide on transplant eligibility, selection of immunologically favorable donor, to plan desensitization protocol and induction therapy that can lead to the reduction of posttransplant rejection rates and better graft survival. Despite the cost, it is justified to use these sensitive assays in selected cases even in a cost-limited setting as this enables earlier and better-matched transplant, and avoidance of morbidity and poor graft survival.
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The relevance of complement C4d staining in renal allograft biopsies p. 94
Anju Khairwa
DOI:10.4103/ijot.ijot_60_19  
In renal transplant, the allograft is affected by many triggering agents such as innate and adaptive immune mechanisms, either mediated by macrophages and lymphocytes, or by soluble components antibodies and the complement system, which can ultimately lead to graft rejection. Antibody-mediated rejection (AMR) is a predominant cause of allograft failure. Donor-specific antibodies, mostly reactive to human leukocyte antigen antigens, are now considered by pathologists and clinicians as a significant cause of early and late graft dysfunction and failure. Complement 4d (C4d) is a fragment of the classical complement pathway (that is a part of component C4), which is activated by antigen-antibody complexes. The diagnosis of AMR improves by detection of the complement fragment C4d in renal biopsy, and it has included for diagnosis of AMR in the year 2003. There is more development about C4d after inclusion in the diagnostic criteria of AMR. This review aims to evaluate pathogenesis and current relevance of C4d in AMR.
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ORIGINAL ARTICLES Top

Spectrum and short-term outcome of acute kidney injury in renal allograft recipients: A single-center experience of Northwest India p. 99
Shyam Sundar Nowal, Gaurav Shekhar Sharma, Manish Sharma, Dhananjai Agarwal, Rajesh Jhorawat, Rakesh Kumar Gupta, Sanjeev Kumar Sharma, Pankaj Beniwal, Vinay Malhotra
DOI:10.4103/ijot.ijot_50_19  
Introduction: Acute kidney injury (AKI) episodes in postrenal transplant are important determinants of short- and long-term graft survival. Renal allograft recipients (RARs) are more vulnerable for AKI and differ in risk factor, etiology, and outcome compared to community-setting AKI. The aim of this study was to evaluate the spectrum and the impact of AKI episode on RARs. Materials and Methods: This was a single-center, prospective observational study on 72 RARs (live and cadaveric) with a total of 93 AKI episodes, who were admitted with AKI (as defined by Kidney Disease Improving Global Outcome [KDIGO] criteria) between October 2016 and September 2018 and were followed for 3 months after AKI episodes. Results: A total of 93 AKI episodes occurred in 72 RARs during the study period. The mean age was 36.32 ± 12.03 years and mean serum creatinine at AKI episode was 2.59 ± 0.85 mg/dl. The etiologies of AKI were infections (n = 67, 72.04%), biopsy-proven rejection (n = 10, 10.75%), calcineurin inhibitor toxicity (n = 9, 9.67%), biopsy-proven acute tubular necrosis (n = 3, 3.22%), recurrence of native kidney disease (n = 2, 2.15%), and miscellaneous causes (n = 2, 2.15%). The majority (n = 53, 57.98%) of AKI episodes developed in the 1st year of transplant, 14 (15.05%) between 1st and 2nd year posttransplant, while the rest 26 (27.95%) beyond 2 years. Sixty-nine (74.2%) AKI episodes were in the KDIGO Stage 1, 18 (19.4%) were in Stage 2, and 6 (6.5%) episodes were in Stage 3. At 3 months of follow-up, various factors associated with nonrecovery of renal functions, including multiple AKI episode (P = 0.006), AKI requiring dialysis (P = 0.027), AKI Stage II or III (P = 0.003), and noninfectious etiology (P = 0.027). Overall, AKI had significant impact on renal allograft function at 3 months (P = 0.045). Pulmonary infection (P = 0.016) and need for dialysis (P = 0.001) were associated with increased risk of mortality in RARs after AKI. Conclusion: AKI in RARs had significant impact on renal allograft function and recovery.
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Clinical profile and predisposing factors for the development of urinary tract infection during the first 3 months postrenal transplantation: A tertiary care hospital experience p. 104
Priti Meena, Devinder Singh Rana, Anil Kumar Bhalla, Ashwani Gupta, Manish Malik, Anurag Gupta, Vinant Bhargava, Vaibhav Tiwari, Chand Wattal
DOI:10.4103/ijot.ijot_66_19  
Background: Infections in renal allograft recipients, especially urinary tract infections (UTI), are an essential factor leading to an increase in morbidity, graft failure, and degrading the health-related quality of life. Aims and Objectives: Our objective is to assess the causes, risk factors, microbiological profile, and antibiotic sensitivity pattern of UTI in renal transplant recipients. Material and Methods: It was a prospective observational study, conducted at the Department of Nephrology, Sir Gangaram Hospital, New Delhi, India. Three hundred ten renal transplant recipients were enrolled. Results: Out of 300 transplant recipients, 107 (35.6%) had UTI. The mean age of patients with UTI was 32 ± 10.5 years. Females have a higher incidence of UTI than males. 64.5% of all diabetic patients had UTI. Escherichia coli (41%) was the most common causative agent. Gram-negative bacilli attributed the majority (88.5%) of cases. Klebsiella pneumonia was found to be multidrug-resistant in most cases. 61% of patients with reflux kidney disease before transplant suffered from UTI. Conclusion: On multivariate analysis in our study, diabetes (P=0.01), prolonged urethral catheterization (p=0.002), and double J stent kept in situ (p=0.03) and reflux kidney disease before transplant (p < 0.02) were independently associated with UTI prolonged.
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Direct-acting antivirals in the treatment of hepatitis C virus infection in renal transplant recipients: A single-center experience from South India p. 111
T Sugan Gandhi, Gopalakrishnan Natarajan, Dhanapriya Jayachandran, Dinesh Kumar Thanigachalam, Sakthirajan Ramanathan, Sheik Sulthan Alavudeen
DOI:10.4103/ijot.ijot_46_19  
Introduction: Direct-acting antivirals (DAAs) are widely used in the treatment of hepatitis C virus (HCV) infection in renal transplant recipients. Aim: The aim was to study the efficacy and safety of these drugs in our renal transplant recipients. Study Design, Subjects, and Methods: A retrospective observational study was performed among the renal transplant recipients > 18 years of age who were treated with DAA for HCV infection. The viral genotype, DAA regimen, the viral load at various time intervals, FibroScan score at the start and at the end of therapy, the changes in graft function (estimated glomerular filtration rate) and in the dosage of calcineurin inhibitors during therapy, and side effects if any during therapy were documented from history and transplant records. The viral remission rates and the safety of DAA were analyzed. Statistical analysis was done with Medcalc statistical software version 12.7.0.0. Results: Thirty-three recipients were included in the study. The DAA regimens were sofosbuvir + ledipasvir (n = 17), sofosbuvir + daclatasvir (n = 8), and sofosbuvir + ribavirin (n = 8). The most common genotype was genotype 1 (n = 30, 90.9%). End-of-therapy response and sustained viral remission (SVR) at 12 weeks of completion of therapy (SVR12) were 100% in all the three DAA regimens. About 75% (n = 6) of the patients who underwent ribavirin therapy developed anemia, unlike the ribavirin-free regimens which had no side effects. The graft function remained stable during DAA therapy. At a mean follow-up of 3 years after initiation of sofosbuvir + ribavirin therapy and 2 years after initiation of sofosbuvir + daclatasvir and sofosbuvir + ledipasvir therapy, the viral remission was sustained. Conclusion: DAAs are safe and effective in achieving and sustaining viral remission in renal transplant recipients.
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Surveillance of viral infections in renal transplant recipients – A prospective observational study p. 116
Avinash Rao, Abhijit Konnur, Sishir Gang, Umapati Hegde, Shailesh Soni, Amit Jojera
DOI:10.4103/ijot.ijot_73_19  
Background: There has been significant advancement in the field of renal transplantation in the last few decades. However, the long-term graft survival has not dramatically increased. Among all the infections, viral infections continue to be a major contributor to graft failure as well as severe mortality and morbidity in renal transplant recipients. Materials and Methods: It was a prospective, nonrandomized, observational study of the duration of 1 year that was conducted in live donor renal transplant recipients (n = 96). Blood samples were collected from all live renal allograft recipients at specified intervals and investigated for the viral infections. Glomerular filtration rate (GFR) and tacrolimus levels were measured at follow-ups. Results: Prior to renal transplant, the hepatitis C prevalence was the highest accounting for viral infection in 7.3% of the total study population. The study had pretransplant cytomegalovirus (CMV) and BK virus (BKV) infection rates of 1.04% each. CMV infection had the highest incidence rate occurring in 29.1% of the total population posttransplantation. There was significant incidence of CMV infection (CMV+) after rejection (P = 0.016). The incidence of BKV infection in our study through 1 year was 8.3%. The incidence of CMV infection correlated well with mean tacrolimus trough level of 10.58 ± 1.25 ng/mL. The mean estimated GFR (eGFR) at 12 months in infected patients was 65.12 ± 5.31 ml/min/1.73 m2 which was significantly lower compared to controls which was 75.53 ± 2.24 ml/min/1.73 m2 though they had comparable mean eGFR at baseline (P = 0.008). Conclusions: Hepatitis C was the dominant infection among all pretransplant viral infections. The highest incidence of CMV and BKV infection was after 6 months' posttransplant. Rejection was associated with CMV infection. All patients with BKV viremia had viruria. High level of tacrolimus was associated with CMV incidence. CMV infection was associated with lower eGFR at 1-year postrenal transplant.
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A prospective comparison of end-to-side and end-to-end renal transplant arterial anastomosis in living donor transplants from an Indian centre p. 125
Anil Kumar Singh Rana, Nitin Agarwal, Vinay M Hanumanthappa, Manoj Kumar Dokania
DOI:10.4103/ijot.ijot_16_20  
Background: Chronic kidney disease (CKD) is a major epidemic in India today. Renal transplant offers the best quality of life; however, only about 6000 mostly live donor transplants are performed due to socioeconomic hurdles. Live donor transplants involve tenuous (2–6 mm) graft arteries without a cuff; thus meticulous technique is importance. We have prospectively compared graft anastomosis to the external iliac artery end-to-side (EIA ES) with the internal iliac end-to-end (IIA EE) artery. Materials and Methods: This prospective randomized study was conducted in the renal transplant unit of a teaching hospital in north India for over 2 years. After ethics approval and informed consent, patients with donors were randomly divided into two groups using computer-generated tables and the sealed envelope technique; Group 1 underwent EIA ES; Group 2 underwent IIA EE. Donor nephrectomy was by a supra 11th rib flank incision, and triple immunosuppression was used. The vascular techniques were standardized; outcome parameters were the duration of anastomosis and complications, especially delayed graft function. Follow-up was for 3 months. Results: The mean age was 36.85 ± 13.56 and 29.75 ± 8.06 years while female: male ratio of recipients was 3:17 and 6:14 in Groups 1 and 2, respectively. The groups were comparable in venous anastomosis duration, warm ischemia interval, cold ischemia interval and hospital stay, and other complications, but significantly longer arterial anastomosis time was noted in the IIA EE group (P = 0.001). Conclusions: EIA ES took less time than IIA EE, but was equivalent to in most parameters. More data are needed to answer this debate.
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Effect of De novo donor-specific antibodies on graft function in renal allograft recipients p. 130
Ravi Kumar Singh, Ashwani Gupta, Vinant Bhargava, Anurag Gupta, Vaibhav Tiwari, Manish Malik, AK Bhalla, DS Rana, Monika Jain
DOI:10.4103/ijot.ijot_6_20  
Background: De novo formation of donor-specific antibodies (DSA) against donor human leukocyte antigens (HLAs) class I and II has been recognized as one of the major risk factors for reduced allograft survival. This study aimed to detect the de novo DSA in renal transplanted recipients and their association with graft function. Methods: This was a retro-prospective observational study conducted from July 2017 to March 2019. The patients with pretransplant DSA-negative renal allograft and those who fulfilled the inclusion criteria were enrolled. Posttransplant, HLA-specific antibodies were tested using a panel reactive antibody (PRA) screen and a positive PRA screen was further tested by Luminex crossmatch assay. Posttransplant biochemical data were assessed for 6-, 12-, and 18-month follow-ups. Results: A total of 72 patients were included in this study, of which 63 were diagnosed as de novo DSA negative, and nine were diagnosed as de novo DSA positive. At 18-month follow-up, in the patients with de novo DSA positive, 55.55% patients showed positive DSA levels for HLA Class II, 33.33% patients showed border-line DSA levels for HLA Class II, and 11.11% patients showed border-line DSA levels for HLA Class I (P < 0.001). Proteinuria was high in de novo DSA-positive patients than de novo DSA negative while serum creatinine, estimated glomerular filtration rate, and tacrolimus level were comparable between groups at 6-, 12-, 18-month follow-up periods. Conclusion: The incidence of de novo DSA was developed in 12.5% of patients; however, there was no significant graft dysfunction.
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The relationship between postoperative outcomes and delirium after liver transplantation in intensive care unit: A single-center experience p. 136
Ibrahim Mungan, Erbil Türksal, Sema Sari, Erdal Birol Bostanci, Sema Turan
DOI:10.4103/ijot.ijot_31_19  
Context: The incidence of delirium has been reported to be as high as 47% after liver transplantation (LT) and hepatic encephalopathy, acute kidney injury, the usage of calcineurin inhibitors, or high-dose steroids are accused as the reason for delirium. Aims: We aimed to evaluate the incidence of delirium and the relations with preoperative variables and postoperative outcomes after LT. Settings: In this single-center, retrospective, observational study, all patients who received an LT from 2015 to 2018 were enlisted. Subjects and Methods: The data were assessed by the Confusion Assessment Method for the Intensive Care Unit and Delirium Rating Scale-revised version to find the presence and the severity of delirium. Statistical Analysis Used: Spearman's rho test and Mann–Whitney U-test of contingency were used in this study. Results: During the study, 43 consecutive patients underwent LT and 10 patients (23.3%) developed delirium postoperatively. Intraoperative and postoperative features were not significantly different between the two groups, and the delirium onset day was found to be 5 ± 4.8 and the duration of delirium was 3.1 ± 2.23 days. There was no statistically significant relationship between delirium and postoperative outcomes. Conclusions: Delirium could be considered a cause or a consequence of critical illness and psychiatric disorder. Although in the present study, a statistically significant difference was not detected between delirium and outcomes after surgery, it was shown that the morbidity rate increases with delirium.
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Knowledge and practice of organ donation among police personnel in Tamil Nadu: A cross-sectional study p. 141
Ishwarya Thyagarajan, Sunil Shroff, Britzer Paul Vincent, Juhija Rajendran, Hemal Kanvinde, Siva Shankar, Kavitha Aneesh
DOI:10.4103/ijot.ijot_56_19  
Context: Police officers are one of the key stakeholders involved in the process of deceased organ donation. In India, as road traffic accidents account for the majority of brain deaths, the police play an important role to ensure legal and ethical practices of organ donation. In many instances, the undue delays in the inquest and postmortem lead to difficulties in completing the donation and also cause distress among the family members who have said yes to organ donation despite their grief. Aim: This study aims to assess the police officers' knowledge of the organ donation process and their practice toward it. Design and Subjects and Methods: This cross-sectional survey was conducted among 627 police officers in the state of Tamil Nadu in India within a period of 18 months. A structured questionnaire with multiple choice questions was used. Microsoft Excel and SPSS version 21 were used to compile and statistically analyze the data collected. The knowledge level and willingness of the officers to follow certain practices were analyzed. Results: It was found that 95.5% of the participants were aware of organ donation. Further analysis revealed that 86.6% of the police personnel were aware of brain death, but only 35.6% were aware of the transplant law, 12.1% knew about the green corridor, and 20.7% about the donor card. Very few participants (9.6%) had experience in processing brain deaths and organ donation cases. Knowledge about postmortem formalities and inquest protocols was unsatisfactory. A significant association between work experience and the knowledge and awareness about organ donation was noted. Conclusions: Including modules on organ donation awareness, transplant law, and hospital protocols in the training syllabus for the recruited personnel, followed by regular refresher courses on the subject, would be the key to enhance the knowledge and work practices of this important group to help ease pain points in the medicolegal cases where organ donation consent is provided by the relatives. A change in the attitude of police officers while handling organ donation cases would have an overall positive impact on the program.
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CASE REPORTS Top

Coexistent BK-virus-associated nephropathy and ureteric stenosis in a patient with acute cellular rejection after renal transplantation: A case report and review of literature p. 147
Praveen Kumar Etta, Thatipamula Madhavi, Swarnalata Gowrishankar
DOI:10.4103/ijot.ijot_67_19  
BK-virus-associated nephropathy (BKVN) is one of the most common causes of viral nephropathy in renal-transplant recipients. The intensity of immunosuppression is the most important risk factor for BKVN. Combined BKVN and rejection can occur rarely, which is difficult to diagnose and manage. Ureteritis, leading to ureteric stenosis, can result in secondary to both rejection and BK-virus (BKV) infection. We herein report a case of BKVN coexistent with the features of acute cellular rejection in a patient with ureteric stenosis probably induced by BKV infection, which was managed successfully with step-wise modification of immunosuppression along with double–J stenting, leading to stabilization of graft function.
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ABO-incompatible kidney transplantation in Chhattisgarh – Challenges and outcome p. 152
Prawash Kumar Chowdhary, Sanjeev Anant Kale, Ajay Parashar, Sudha Trivedi, Shruti Khatkhedkar, Pratibha Sharma
DOI:10.4103/ijot.ijot_1_20  
Patients with chronic kidney disease stage 5 are usually excluded from renal transplantation if they do not have a compatible blood group donor. Paired kidney donation and ABO-incompatible kidney transplantation are the only options for such patients. We describe the case of a 49-year-old male patient who had blood Group B positive and potential donor; his wife had blood Group nagative. The patients had an initial anti-A antibody titer of 1:32 and underwent antibody depletion with plasmapheresis (two sessions). He also received rituximab 200 mg on minus 14th days and was induced with basiliximab. At the time of transplant, his anti-A titer was 1:8. Postoperatively, the patient had delayed graft function and received one session of hemodialysis but no plasmapheresis. Postoperatively, anti-A titer was 1:8. He was discharged on the 14th postoperative day with normal renal function.
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Hanging vesical stone in post-transplant recipient – delayed and unusual complication p. 156
Mayank Agrawal, Venkat Arjun Gite, Mahesh Sane, Joseph Sengol
DOI:10.4103/ijot.ijot_48_19  
Vesical stone formation is very rare in posttransplant recipients. We describe a patient who developed hanging vesical stone more than 10 years after receiving a transplant near the ureteroneocystostomy site on polypropylene suture, treated by cystolithotripsy using the removal of suture material with cystoscopic scissors. The use of nonabsorbable suture leads to very late formation of stones over it. Hence, it should be avoided.
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A case study: Effectiveness of preoperative pulmonary rehabilitation program in liver transplantation patient p. 159
Manivel Arumugam, Srinivas Rajagopal, Pitchaimani Govindharaj
DOI:10.4103/ijot.ijot_75_19  
A 56-year-old male patient suffering from multiple conditions of decompensated chronic liver disease, alcohol-related cirrhosis of liver stage of CHILD-B, model for end-stage liver disease-11, and portal hypertension and admitted for liver transplantation in a specialty hospital was reported in this study. Previously, the patient was hospitalized for several times for hepatic encephalopathy. Preoperative evaluation was done by a pulmonologist for cardiorespiratory fitness. The patient was examined with high-resolution computed tomography chest and the functional capacity evaluation by 6-min walk test. The reports showed that the patient is not fit for surgery due to interstitial lung disorder, significant desaturation, noticeable dyspnea, and limited functional walk capacity, and hence, he was referred for cardiorespiratory fitness to the unit of pulmonary rehabilitation program for 12 weeks.
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Posttransplant thrombotic microangiopathy: A rare cause p. 162
Chaitanya Siva Marupudi, Balasubramanian Thoppalan, Venkataman Ramudu
DOI:10.4103/ijot.ijot_13_20  
Parvovirus B19 is a common cause of aplastic anemia in immunosuppressed patients. However, renal involvement in cases of B19 infection is rare. The clinical presentation and histologic pattern of renal involvement due to parvovirus B19 infection has been described only in a few case reports. We report a patient with thrombotic microangiopathy (TMA) of graft kidney presumably secondary to B19 infection. The patient presented with severe anemia and allograft dysfunction following kidney transplantation. Kidney allograft biopsy was suggestive of TMA, and acute B19 infection was confirmed by the detection of viral DNA in the patient's serum. The patient had complete recovery following high-dose intravenous immunoglobulin therapy and reduction of immunosuppression.
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Experience of using an extracorporeal cytokine hemoadsorber (CytoSorb®) in systemic inflammatory response syndrome after heart transplantation p. 166
Kewal Krishan, Rahul Dutta, Rajesh Chand, Rajneesh Malhotra
DOI:10.4103/ijot.ijot_64_19  
Heart transplantation is well-established and considered the most effective therapy for patients with end-stage heart failure. Systemic inflammatory response syndrome (SIRS) and renal dysfunction after heart transplantation are commonly experienced complications, which may significantly impact on overall survival. The extracorporeal cytokine hemoadsorber (CytoSorb®) is a novel nonpharmacologic hemocompatible adsorber, which has porous polymer beads capable of removing cytokines and other mid-molecular weight toxins from the blood. CytoSorb is a unique hemoadsorber, which has a huge surface area, a broad spectrum of adsorption, and is very easy to set up on any extracorporeal circuit. Here, we report our experience of using CytoSorb in the management of SIRS after heart transplantation in a 28-year-old male.
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Knee swelling in a renal transplant recipient p. 170
Jasmine Sethi, Smita Subhash Divyaveer, Nalini Gupta, Mahesh Prakash, Harbir Singh Kohli
DOI:10.4103/ijot.ijot_19_20  
Histoplasma knee infection in a renal transplant recipient has not been reported in the literature. The present case illustrates an interesting case of unilateral Histoplasma monoarthritis in a patient 3 years after renal transplantation who presented with pain and swelling of the right knee. The diagnosis was established by tissue aspiration from a focal lesion in lateral femur condyle. The patient was successfully managed with amphotericin followed by itraconazole with complete resolution of the symptoms. It is important to consider such rare differentials in an immunocompromised patient to avoid delays in treatment.
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Splenic peliosis and spontaneous splenic rupture: A rare complication following liver transplantation p. 172
Amey Dilip Sonavane, Ketul Shah, Vikram Raut, Ashok Thorat, C Amruth Raj, Asawari Ambekar, Tushar Parmar, Suvadeep Sen, Ambreen Sawant, Harshit Chaksota, Suresh Vasanth, Aabha Nagral, Darius Mirza
DOI:10.4103/ijot.ijot_71_19  
Peliosis is characterized by multiple blood-filled cyst-like cavities within the parenchyma of solid organs. It is a rare condition and mostly affects the liver. Splenic peliosis is even rarer, especially following solid organ transplantation with barely few cases reported in the literature. We describe a rare case of splenic peliosis complicated by spontaneous splenic rupture following deceased donor liver transplantation. Timely diagnosis and urgent re-exploration followed by splenectomy salvaged the patient.
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CASE SERIES Top

Role of donor-specific antibodies in immunological assessment for kidney transplant: A report of ten cases in a cost-limited set-up p. 175
Joyita Bharati, Deepesh Benjamin Kenwar, Sarabpreet Singh, Ritambhra Nada, Harbir Singh Kohli, Manish Rathi, Ashish Sharma, Ranjana Walker Minz, Raja Ramachandran
DOI:10.4103/ijot.ijot_45_19  
Sensitized patients, who constitute a considerable proportion of kidney-transplant recipients, often have poor allograft outcomes. Only cell-based complement-dependent cytotoxicity (CDC) assays are typically used to quantify donor-specific antibodies (DSAs) in patients in developing nations, owing to financial restraints. We report the clinical outcomes of ten sensitized patients who were stratified and managed based on Luminex single-antigen beads (SAB) method for the DSA detection in a cost-limited set-up. Sensitization events included a history of blood transfusion, multiple pregnancies, and previous allograft loss. Anti-human leukocyte antigen antibodies, measured by SAB and reported as mean fluorescence intensity (MFI), were considered positive if the value was > 1000 MFI for single antigen. Three best approaches, (1) cadaveric transplants using virtual cross-match for kidney allocation in five patients, (2) desensitization before living donor transplants for four donor–recipient pairs with immunological incompatibility (high DSAs but cross-match compatible), and (3) combined kidney paired exchange with desensitization for one donor–recipient pair with cross-match incompatibility (positive CDC cross-match), resulted in successful allograft outcomes in all the 10 patients during follow-up (range: 3–55 months). DSA by SAB to assess pretransplant immunological risk (in a sensitized recipient) is useful even in cost-limited settings, largely due to reduction of posttransplant rejection rates and avoidance of mortality while on the waitlist.
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LETTERS TO EDITOR Top

Significance of anti-phospholipase A2 receptor antibodies in membranous nephropathy after renal transplantation p. 182
Praveen Kumar Etta, Thatipamula Madhavi
DOI:10.4103/ijot.ijot_55_19  
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Automated peritoneal dialysis is a superior option for the management of postrenal transplant delayed graft function p. 185
Praveen Kumar Etta
DOI:10.4103/ijot.ijot_43_19  
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Transplantation of human organs and tissues act-simplified p. 187
Vasanthi R
DOI:10.4103/ijot.ijot_3_20  
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REPLY TO LETTER TO EDITOR Top

Transplantation of human organs and tissues act p. 188
Manisha Sahay
DOI:10.4103/ijot.ijot_59_20  
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