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   Table of Contents - Current issue
Coverpage
July-September 2018
Volume 12 | Issue 3
Page Nos. 161-231

Online since Friday, September 28, 2018

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EDITORIAL  

Challenges in setting up of a deceased donor transplant program in South Asia p. 161
Sunil Shroff
DOI:10.4103/ijot.ijot_34_18  
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COMMENTARY Top

ABO-incompatible transplantation: A pipe dream to practice p. 163
Srikanth Gundlapalli, Girish Kumthekar
DOI:10.4103/ijot.ijot_30_18  
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REVIEW ARTICLES Top

Comparison of patient and graft survival in tacrolimus versus cyclosporine-based immunosuppressive regimes in renal transplant recipients – Single-center experience from South India p. 165
Kiran Chandra Patro, S Ramakrishnan, Santhosh Kumar, J Roopa, R Dilip
DOI:10.4103/ijot.ijot_6_18  
Studies have shown better graft function and reduced acute rejection rates among renal transplant recipients who were on Tacrolimus (Tac)-based immunosuppression regimens as compared to cyclosporine (CsA)-based regimens in the first year. However, the long-term follow-up data did not reveal better outcomes in the Tac-based regimens. In view of the short term benefits, the trend has been to change to Tac-based regimens off late. Data from the Indian subcontinent are, however, sparse. We, therefore, looked at our data to ascertain if Tac-based regimen does have better outcomes in our population. We studied a total of 108 individuals who underwent renal transplantation between January 2007 and June 2013, with a mean follow-up of 38.22 months (comparable to both groups). In our group, males constituted 77.8%,; and among the 108 individuals, 16.7% were diabetics. New-onset diabetes after renal transplantation was more common in the Tac group (21 vs. 12 and was statistically significant [P = 0.03]). At the last follow-up, serum creatinine was higher in the CsA group (1.77 mg/dl vs. 1.35 mg/dl) and was statistically significant (P = 0.03). Individuals requiring hemodialysis were also significantly higher in the CsA group (9 vs. 2; P = 0.05). The patient survival was similar in both groups (1-year and 5-year follow-up); however, graft survival was better in Tac group as compared to CsA group (0.94 vs. 0.88 at 1 year and 0.85 vs. 0.72 at 5 years).
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Legal aspects of transplantation in India p. 169
Sunny B Shah, Bharat Vallabhdas Shah
DOI:10.4103/ijot.ijot_43_18  
The shortage of organ donors for patients with end-stage organ diseases requiring transplant is a global problem. This led to organ trafficking with exploitation of poor people who were made to sell their organs. To address the issue of organ trafficking and to ensure fair allocation of organs from cadaver donors, most countries have passed laws to regulate transplants. In India, the law (THE TRANSPLANTATION OF HUMAN ORGANS ACT, 1994) was passed in 1994 and the rules framed in 1995. The most important aspect of the Act was that it legalized brain-stem death as death allowing organs to be retrieved from brain-stem dead patients. Other important aspects of the Act include the following: (1) regulation of removal of organ/s for transplantation from cadaver donors, (2) regulation of removal of organ from living donors, (3) regulation of hospitals, (4) regulation of medical practitioners, and (5) punishment for those flouting the Act. The Act has significantly regulated living and cadaver donor transplant but made the process of obtaining approval for living donor transplant difficult even in genuine-related cases. Swap transplant or paired donation between related pairs is treated as unrelated donor transplant, making the process of obtaining approval very lengthy and tedious. For reasons that cannot be understood, although living unrelated transplant can be performed if there is no commercial dealing, swap transplant between unrelated pairs is not permitted. Punishment is harsh for anyone who contravenes any provision of the Act and unfortunately, transplant team doctors are made liable in most cases.
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Deceased organ donation in India – Current challenges and scenario p. 174
Ansy H Patel, Manish Ramesh Balwani, Himanshu Patel, Amit S Pasari, Utkarsh Rajesh Patel, Priyanka Tolani, Vivek Kute
DOI:10.4103/ijot.ijot_26_18  
Worldwide, organ transplantation has saved and enhanced the lives of thousands of recipients over the past five decades. Organ transplantation rates are still lower in developing countries including India. The cause of this low rate is attributable to many factors including unawareness about procedure and concerned laws, low education levels, inadequate trained workforce, low socioeconomic status, and costly immunosuppressive drugs. In the last few years, the government has tried positively to increase the organ transplantation by forming the National Organ and Tissue Transplant Organization. Now, the government needs to push for affordable transplantation by strengthening the public sector hospitals and by making the transplant medications more affordable. Moreover, the transplant community should strive to increase the organ donation awareness, improve the infrastructure for organ retrieval, storage, and allocation in an equitable way.
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ORIGINAL ARTICLES Top

ABO-incompatible renal transplantation: The journey so far on a road less traveled p. 177
Pranaw Kumar Jha, Ashish Nandwani, Ajay Kher, Shyam Bihari Bansal, Sidharth Sethi, Reetesh Sharma, Manish Jain, Dinesh Kumar Yadav, Dinesh Bansal, Rajan Duggal, Rajesh Ahlawat, Vijay Kher
DOI:10.4103/ijot.ijot_23_18  
Introduction: ABO-incompatible (ABOi) renal transplant is the only option for patients who have neither blood group-compatible donors nor a suitable swap available. Published Indian experience of ABOi transplants has been far and few. Materials and Methods: This study was conducted across two different centers. All the consecutive ABOi renal transplants performed from November 2011 onward and who had completed at least 6 months of follow-up were included. Data were accessed retrospectively from the medical records. Results: There were fifty ABOi recipients who had completed at least 6 months of follow-up. Most common recipient blood group was group O. Median baseline antiblood group antibody titer (immunoglobulin G) was 256. Patient and death-censored graft survival were 94% and 88%, respectively, and biopsy-proven acute rejection was 22%. Acute antibody-mediated rejection was seen in 8% of the patients. Mean serum creatinine was 1.12 mg/dl at 1-month posttransplant and infection rate was 22%. Conclusion: The outcomes of ABOi transplant were acceptable and it should be promoted to bridge the demand and supply gap for renal transplant and expand the living donor pool.
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Erythrocytosis in renal transplant recipients: A single-center experience p. 182
Dhanasekaran Rajasekar, Jayachandran Dhanapriya, Thanigachalam Dineshkumar, Ramanathan Sakthirajan, Thopalan Balasubramaniyan, Natarajan Gopalakrishnan, Srinivasan Arivazhagan
DOI:10.4103/ijot.ijot_32_18  
Background: Posttransplant erythrocytosis (PTE) is defined as persistently elevated hemoglobin (Hb) >17 g/dl and or PCV >51% in renal transplant recipients. The incidence of PTE varies from 8% to 22%, with occasional life-threating thromboembolic complications. Our aim was to study the prevalence, risk factors, course, and complications of PTE. Materials and Methods: We conducted a cross-sectional descriptive study in 327 renal transplant recipients. Patients with Hb >17 g/dl were considered as PTE group, and others were considered as non-PTE group. The pattern of Hb, serum creatinine, mean arterial pressure (MAP) change, and requirement of anti-hypertensive medications was noted. Complications and their management were noted. Results: PTE was diagnosed in 51 (15.5%) patients with the median time of onset at 8 (95% confidence interval: 6–10) months after transplantation. During PTE, the mean highest documented Hb was 18.68 ± 0.73 g/dl. Mean Hb change had significant positive (r = 0.8493; P = 0.0156) correlation with mean MAP change. The dose of antihypertensive medications was increased more within 6 months of PTE diagnosis and decreased thereafter significantly. Thrombotic complications were observed in 5 (10.6%) patients. PTE was treated with enalapril in 35 (72.5%) patients and combination with phlebotomy in 11 (21.6%). Around 30 (58.8%) patients continued enalapril therapy to maintain the Hb. Conclusion: PTE was observed in 15.5% of renal allograft recipients. Hb change was temporally related to blood pressure in PTE patients. Both erythrocytosis and hypertension responded well to angiotensin-converting enzyme inhibitor.
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A novel method to increase the kidney donor pool: A fusion model linking the deceased donor waitlist to a paired kidney exchange program p. 187
Viswanath Billa, Utkarsh Verma, Deepa Usulumarty, Narayan Rangaraj, Ganesh Sanap, Jatin Kothari, Rajesh Kumar, Shrirang Bichu
DOI:10.4103/ijot.ijot_44_18  
Aim: To merge the deceased donor (DD) and the paired kidney exchange (PKE) allocation processes, creating a fusion model. Materials and Methods: One of the DD kidneys are allocated to the first patient on the DD wait-list and the other kidney is allocated to the PKE registry to initiate a chain of swap transplants. The last donor of this PKE chain donates his kidney back to the second patient on the DD wait-list. Results: There was a 28.1% (P < 0.05) increase in the total number of transplants in the fusion model as compared to the standalone DD and PKE allocation. The mean gain ranges from 8.29 to 19.3 (P < 0.05) across various allocation groups for the O recipients, which is disadvantaged in the standalone PKE registry. Similarly, the mean gain ranges from 5.8 to 18.1 (P < 0.05) across various allocation groups for the AB recipients, which is disadvantaged in the standalone DD registry Furthermore, no blood group type is worse off in terms of the opportunity to receive a kidney by the fusion model. Conclusions: The fusion model can potentially increase the number of transplants that can be performed whenever a DD become available. Despite fairness considerations for patients and their living donors participating in the fusion model, this process increases the opportunity to receive a kidney as well as reduces transplant waiting time in both the registries. This would translate into a survival advantage for the patients.
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Recurrent focal segmental glomerulosclerosis after kidney transplant in adults: A report on various treatment regimens p. 193
Joyita Bharati, Krishan Lal Gupta, Deepesh Benjamin Kenwar, Ritambhra Nada, Manish Rathi, Harbir Singh Kohli, Raja Ramachandran
DOI:10.4103/ijot.ijot_33_18  
Aim: Recurrence of focal segmental glomerulosclerosis (FSGS) in the post-transplant setting is variable with high rates of graft loss. Risk factors of recurrence include young age and Caucasian race. Data on outcome of recurrent FSGS from South Asia is scanty. We describe our experience of managing adults with recurrent FSGS with different therapies. Settings and Design: The study was conducted at the Department of Nephrology and Renal transplant surgery, Post Graduate Institute of Medical education and Research Institute, Chandigarh, India, and this was an observational study. Methods: We analyzed outcomes of patients with biopsy-proven recurrent FSGS over the last 5 years (2012–2017). Recurrence was defined as significant proteinuria (albuminuria ≥ 3+) and a demonstrable FSGS lesion on light microscopy and/or electron microscopy suggestive of diffuse foot process effacement. Results: Thirteen patients with 14 recurrences of FSGS post-renal transplant were identified. Mean age of the patients was 33.15 (±8.32) years. Median time to recurrence of FSGS was 45 days. Plasma exchange (PLEX) alone was used in two patients with 50% in remission. Combined PLEX and rituximab were used in six recurrences with remission in 83.3% of them. Five recurrences were treated with only angiotensin-converting enzyme inhibitor/angiotensin receptor blockade (ACEi/ARB) due to financial constraints. Of them, 4 (80%) achieved remission in proteinuria. One patient did not receive any therapy and expired in the 1st month of follow-up. Conclusion: The present series is one of the largest reports of recurrent FSGS from South Asia. Furthermore, the current report strengthens the use of ACEi/ARB in patients with recurrent FSGS.
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Prevalence, clinical profiles, and outcome of hypertension in renal transplant recipients p. 199
AT Maasila, C Subash Chandrabose, T Balasubramaniyan, N Gopalakrishnanan, J Dhanapriya, T Dineshkumar, R Sakthirajan, S Ganesh Aravind
DOI:10.4103/ijot.ijot_37_18  
Background: Hypertension is more prevalent risk factor for cardiovascular morbidity and mortality among renal transplant recipients. Materials and Methods: It is a retrospective study conducted to assess the prevalence, clinical profiles, and outcome of hypertension in renal transplant recipients. Posttransplant hypertension was defined as systolic blood pressure (BP) ≥140 mmHg, diastolic BP ≥80 mmHg, or the need of antihypertensive medication. Donor and recipient demographical details were obtained from medical records. Patients who underwent second renal transplant or graft nephrectomy were excluded from the study. Results: Among 375 patients, 88% were male. The mean age of our study population was 35.82 ± 9.37 years. Almost 82.67% of patients had posttransplant hypertension, of which 80.97% had pretransplant hypertension. Nearly 19.03% patients developed hypertension posttransplant. Following transplantation, hypertension resolved in 12.85%. The prevalence of well controlled, poorly controlled, and resistant posttransplant hypertension was 49.68%, 50.32%, and 7.42%, respectively. Majority of them (90.97%) received calcium channel blockers. In univariate analyses, recipient sex, pretransplant hypertension, etiology of kidney disease, female donors, female donors of male recipient's subgroup, use of cyclosporine, left ventricular mass, weight gain, and presence of metabolic syndrome were statistically significant. In multiple logistic regression analyses, recipient sex, presence of metabolic syndrome, and use of cyclosporine were associated with posttransplant hypertension. Kaplan–Meier analyses showed low graft survival in posttransplant hypertensive patients when compared to normotensives. Conclusion: The prevalence of hypertension in our renal transplant recipients was 82.67%. Early identification of risk factors, treatment, and adequate BP control will improve the long-term patient, graft survival.
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CASE REPORTS Top

Timelines, an important tool for matched unrelated donor stem cell transplant: A case report and review of literature p. 205
Vikash Chandra Mishra, Aseem Kumar Tiwari, Vimarsh Raina, Girish Sharma
DOI:10.4103/ijot.ijot_18_18  
Stem cell transplant (SCT) is the “standard of care” for several malignant disorders such as leukemia as well as nonmalignant disorders such as thalassemia and aplastic anemia. In SCT, family (usually a sibling) is screened for human leukocyte antigen (HLA)-matched related donor (MRD), and failing this, matched unrelated donor (MUD) transplants are considered. There are seven major steps involved in the process of MUD SCT, while the patient is prepared for receiving the SCT in parallel after achieving remission. Here, we report the timelines involved in MUD SCT along with a case report and review of literature.
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Recurrent parvovirus B19 infection in postrenal transplant recipient p. 207
Kim Jacob Mammen, Jija Elizabeth Varghese, Viral Shah, Amit Tuli
DOI:10.4103/ijot.ijot_27_17  
Anemia after solid organ transplantation is common and can be infectious or noninfectious. We present a case of recurrent PV infection in a patient of renal transplant. Early diagnosis and management of such infection is very important.
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Posttransplant lymphoproliferative disorder coexisting with extrapulmonary tuberculosis: A diagnostic dilemma p. 210
Mohammed Shoeb Ahmed Khan, VN Unni, K Nanda, K Vinod, PK Bipi, P Jojo
DOI:10.4103/ijot.ijot_24_18  
Solid organ transplant recipients have a higher risk of malignancy and infections. We present a case of deceased donor renal transplant recipient diagnosed to have co-existing tuberculoma and CNS-PTLD. 61 year old male who underwent deceased donor renal transplantation and was given induction with Anti-Thymocyte globulin, continued on triple immunosuppression (Tacrolimus, Mycophenolate mofetil and Prednisolone). He developed New onset diabetes after transplantation and had multiple infections. He presented with bilateral multiple space occupying lesions on MRI brain. MRI spectroscopy from parietal region was suggestive of Tuberculoma. ATT was started and patient improved. He presented after 4 weeks with ataxia and slurring of speech, MRI brain showed regression in lesion of right parietal area, but a new lesion appeared in the left parieto-occipital region along with an enlarged left cerebellar lesion. Decompressive craniotomy and excision of lesion in left cerebellum, was done. Histology confirmed Non-Hodgkin's Lymphoma, diffuse Large B-cell type. He was treated with whole brain radiotherapy. Repeat MRI brain after 6 months demonstrated a near total clearance of lesions.
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Graft versus host disease occurring in living donor liver transplant p. 213
Nalini Bansal, Manav Wadhawan, Vivek Vij
DOI:10.4103/ijot.ijot_17_18  
Graft versus host disease (GVHD) is a serious disease occurring posttransplant. Most cases are seen after hematopoietic bone marrow/stem cell transplantation where the donor cells recognize host antigens and start reacting against them. The initial organs to be involved are skin, gut, and liver. Patients can present with maculopapular rashes, diarrhea, or jaundice. Early diagnosis and timely institution of therapy may salvage these patients. GVHD is rarely also identified in solid organ transplantation seen frequently with small bowel transplantation. Cases of GVHD after liver transplantation are very rare. We herein describe a case of GVHD following a deceased donor liver transplant with a review of pathophysiology of GVHD in liver transplant.
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Postrenal transplant dual viral infection: A double jeopardy p. 216
Avinash Rao, Abhijit Konnur, Sishir Gang
DOI:10.4103/ijot.ijot_27_18  
Despite significant advances in the field of renal transplantation, long-term graft survival has not dramatically increased. The reasons for this are varied but include the persistent impact of infectious diseases on transplant recipients. Viral infections continue to be a potential contributor to graft failure, but also a cause of severe mortality and morbidity. We hereby present a case of early posttransplant dual viral infection detected and treated during the initial 2 months and discuss the risk factors which were involved, potential preventive strategies and therapies that could be helpful in treating such patients.
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Pleomorphic presentations of IgA nephropathy - postrenal transplantation p. 219
Andrew Rajiv, Sampath Kumar Krishnaswamy, Shakti Kumar
DOI:10.4103/ijot.ijot_29_18  
IgA nephropathy (IgAN) is a common cause of glomerulonephritis and end-stage renal disease. The recurrence of IgAN postrenal transplant is well documented. IgA recurrence posttransplant manifests as recurrent IgAN, de novo IgAN, and crescentic IgAN. Three cases are described in this article, representing the above-mentioned presentations of IgAN. The first case represents the manifestation of crescentic IgAN in a renal transplant recipient. The patient presented with severe graft dysfunction requiring hemodialysis. Inspite of aggressive immunosuppression and plasmapheresis, the graft kidney could not be salvaged. The second case represents recurrent IgAN. The patient was initiated on antiproteinuric measures and has maintained a stable graft function. The third case presented with de novo IgAN and acute antibody-mediated rejection (AMR). This patient was treated with immunosuppressants and plasmapheresis as per AMR treatment guidelines, following which his graft function improved.
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Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in detecting posttransplant lympho proliferative disorder p. 224
S Muneendra Kumar, Ramya Priya, TC Kalawat, Silpa Kadiyala, Ranadheer Gupta Manthri, N Rukmangadha, Siva Kumar
DOI:10.4103/ijot.ijot_8_18  
Posttransplant lymphoproliferative disorder (PTLD) is the second most common malignancy in adults and most common malignancy in children, following transplantation. Ascertaining the cause of PTLD requires an extensive clinical and diagnostic workup. Here, we report a case of postrenal transplant recipient presenting with the features of fever, pain abdomen, and breathlessness. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography which was done showed increased FDG uptake in axillary, mediastina, abdominal lymphadenopathy, soft tissue, and muscle deposits.
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Successful outcome of transplanting a kidney from a HCV-positive deceased donor into a HCV-negative recipient p. 227
Zaheer Amin Virani, Prashant J Rajput, Hepal M Vora, Mita B Shah, Samir Shah, Bharat V Shah
DOI:10.4103/ijot.ijot_35_18  
The discovery of direct-acting antiviral therapy has revolutionized the treatment of Hepatitis C infection. The treatment of choice in a case of end stage kidney disease with Hepatitis C infection is kidney transplant and with DAA based interferon free regimens one can treat post transplant as well. There is paucity of data regarding transplantation of kidneys from HCV-infected donors into HCV-negative recipients. We report a case of sequential liver and kidney transplantation in which a HCV-negative recipient received a kidney from a HCV-infected deceased donor.
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LETTER TO EDITOR Top

Adenovirus infections in solid-organ transplant recipients: An observational study from a tertiary care center p. 230
Sujata Lall, Ekta Gupta, Suman Lata, Rajeev Khanna, Viniyendra Pamecha
DOI:10.4103/ijot.ijot_21_18  
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