Human organ and tissue transplantation was started in India in 1962. Initially, the organ transplant was unregulated, and organ trafficking was rampant. The act governing the transplantation was passed in 1994. This has been subsequently amended in 2011, and new rules came into force in 2014. Many of the students as well as practicing physicians are not aware of the act as it is generally not a part of the curriculum. This article highlights the important components of the act and focuses on what all physicians involved in transplant should know about the legal aspects of transplantation.

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Background: Organ donation (OD) is the process of surgically removing an organ or tissue from one person (donor) and placing it into another person (recipient). Of the overall deaths occurring annually in India, nearly one lakh deaths occur due to organ failure. Shortage of donor organs can be resolved by raising awareness and educating the youth about various aspects of OD since they comprise of the majority of the population. The purpose of our study is to determine the level of awareness, knowledge and attitude regarding OD among pupils related to both medical and non-medical fields. Objective: To assess the awareness, knowledge, and attitude regarding OD among final year students of medical, dental, engineering, and arts and science students in Thiruvallur and Chennai. Materials and Methods: A cross-sectional study was conducted among 486 undergraduate students belonging to medical, dental, engineering, and arts and science from various colleges in Thiruvallur and Chennai. A 30 item self administered English questionnaire was given which assessed levels of awareness from Q1-Q7, knowledge from Q8- Q20 and attitude from Q21-Q30 among the study population regarding organ donation. Results: A total of 486 students participated in the study, out of which 183 (37.7%) were males and 303 (62.3%) were females. Among the study population, 455 (94%) were aware and 31 (6.4%) were not aware of the term OD. A total of 261 (54%) students were aware and 225 (46%) were not aware of the “organ transplantation act”. A total of 240 (49.4%) students had the knowledge about the risks involved in OD. A total of 329 (68%) students felt the need for laws to govern the process of OD. Knowledge about the human donor card was observed among 169 (35%) students among the study population. Three hundred and eight (63.4%) wanted to be a part of any OD group and also motivate others for OD. Conclusion: A well-organized approach is required to raise awareness among the youth about various aspects of OD which is necessary to eliminate the setbacks that affect the rate of availability of donor organs. Motivational messages and facts are some of the means of intervention to bring about changes regarding perceptions and intentions about OD among the students.

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Background: The knowledge and attitude of medical students regarding organ donation is quintessential for the success of the organ donation program in a country. Objective: This study aimed to assess the knowledge and attitude of medical students regarding organ donation at Government Medical College, Trivandrum, Kerala, India. Methodology: Data of this cross-sectional study were collected by self-administered questionnaire from 194 final-year MBBS students during 2016, who were selected by convenient sampling. The questionnaire had three sections to gather information of sociodemographic details of the students, knowledge on organ donation, and the attitude toward organ donation. Results: The findings showed that a majority of the students had adequate knowledge regarding organ donation, but it is not translated into their willingness for donation – both cadaveric and live. Conclusion: The study reiterates the need for educational interventions for medical students which cut across various disciplines to make them understand the nuances of the issue in a holistic way.

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With the onset of 21^st century, organ donation (OD) has taken a big stride, still waiting for organ transplants is higher than its availability. Donating a life after one's death to someone you even do not know is one of the noble humanity causes. In Indian scenario, with the inception of Transplantation of Human Organs Act, 1994, multiple active initiatives were undertaken time to time for promoting OD; similarly, green corridors have also come in a big way for transfer of organs for interinstitutional transplantation. The institute undertook its first green corridor for OD in 2015 when liver was sent to one of the hospitals, and till date, 25 green corridors have been established where 27 organs have been shared with other institutes nationwide besides intrainstitute transplantations. Although this noble cause has taken its initial steps, still, innovations, and opportunities for promoting OD should be explored in a continuum for foreseeable better future.

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Progression of proliferative lupus nephritis to end-stage renal disease is common. Anemia in chronic kidney disease has multifactorial etiology, but it is rarely associated with β- Thalassemia trait. Iron deficiency is common in hemodialysis patients due to increased blood loss. Microcytic hypochromic anemia may be due to iron deficiency, hemoglobinopathies and aluminum toxicity. Because chronic kidney disease is a chronic inflammatory state, it is difficult to exclude iron deficiency with classical biochemical markers. Treatment of anemia in chronic kidney disease is important as iron therapy may cause iron overload, increased susceptibility to infection, atherosclerosis and increased oxidative stress. Multiple blood transfusions may cause iron overload, risk of infection transmission and alloimmunization. Alloimmunization decreases donor pool and increases chances of rejection.

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Extension of life through organ transplantation is indeed a glorious tribute to the progress of science and the progressive mentality of the society at large. It is a sign of our changing times. Even though India has all the potential in becoming the leading nation in the transplantation process, the country lags behind due to multiple determinants. The present paper looks into those determinants that restrict deceased organ transplantation in India, through empirical evidences and literature review. The evidences suggest that the practice of deceased organ transplantation in India is still on the back foot due to various factors such as the lack of awareness among general public as well as medical professionals, sociocultural and religious factors, organizational issues, and legal and ethical aspects.

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Objective: To assess knowledge, attitude, and practices regarding organ/tissue donation. Materials and Methods: A cross-sectional descriptive study was conducted among ambulatory, consenting adult (>18 years) visitors of a mid-level government hospital using a predesigned, pretested, semistructured interview schedule. Data were analyzed by calculating proportion, Chi-square test, and odds ratio (OR). Results: Of 450 respondents, 271 (60.2%) were aged more than 31 years, 264 (58.7%) were male, 345 (76.7%) were married, 374 (83.1%) were Hindu, 304 (67.6%) had studied up to 10^th class, 278 (61.8%) were working, 217 (48.2%) had 0–2 previous visit to this hospital, and 142 (31.6%) reported history of hospitalization. Majority (337, 74.9%) of the respondents had heard the term organ donation (OD). On probing further, nearly 87.3% and 82.4% of respondents had ever heard of eye and kidney donation, respectively. Encouragingly, more than half of respondents, i.e., 261 (58.0%), showed willingness for OD. Statistically (P < 0.001) higher odds for OD willingness was found among participants who were aware of the term OD (unadjusted OR [UOR] = 2.8, 95% confidence interval [CI]: 1.82–4.39), eye donation (UOR = 3.2, 95% CI: 1.78–5.76), and kidney donation (UOR = 4.0, 9.5% CI: 2.40–6.84). Similarly, higher willingness was found among single/separated participant and with higher level of education (P < 0.05). About one-fourth (120, 26.7%) of respondents had donated blood in the past, but this practice had no statistical bearing on the willingness for OD (P = 0.61). Nearly half of the respondents, i.e., 239 (53.1%), were aware that organs could be removed from both living and dead person; 373 (82.9%) of respondents were aware that organs cannot be removed from the body without authorized permission (UOR = 2.7, 95% CI: 1.57–4.88 and adjusted OR [AOR] = 2.6, 95% CI: 1.27–5.66). However, only 119 (26.4%) respondents consented to sign a pledge card for OD. Higher odds (AOR = 12.8, 95% CI: 5.02–32.75) for OD willingness was found among those who consented to sign a pledge card. A high of 364 (80.9%) respondents had no misconception that a person will be born with missing organ following donation of organ/tissue in this life. Conclusion: A high awareness but low level of positive attitude and practices was noticed among sampled metropolitan respondents toward organ/tissue donation.

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Objectives: We aimed at creating a clinical profile of end-stage renal disease patients' gonadal function and assessing the impact of renal transplant on gonadal dysfunction. We studied the influence of age, vascular anastomosis, dialysis vintage, and immunosuppression on sexual dysfunction. Materials and Methods: Twenty adults were included. Hormones (luteinizing hormone [LH], follicle-stimulating hormone [FSH], testosterone, prolactin (PRL), and estrogen), menstrual history and International Index of Erectile Function (IIEF)-5 questionnaires were assessed before and after renal transplantation. Hormone evaluation was done by chemiluminescent microparticle immunoassay technology. Results: Seventeen patients were male and three patients were female. Native kidney diseases were chronic glomerulonephritis (10%), IgA nephropathy (20%), autosomal dominant polycyctic kidney disease (5%), diabetic nephropathy (5%), focal segmental glomerulosclerosis (5%), renal calculus disease (5%), membranous nephropathy (5%), and pauci-immune vasculitis (5%). Fifteen males had erectile dysfunction (ED) before transplant. Eleven patients showed an increase and six patients showed a decrease in IIEF scores posttransplantation. Statistically significant changes were observed in the mean levels of testosterone, LH, PRL, and FSH. Age at transplant showed a negative correlation with IIEF score. In five patients with an end to side anastomosis to the external iliac artery, all had an increase in IIEF score posttransplant. In 12 patients with an end to end anastomosis to the internal iliac artery, 5 patients (42%) had a decrease in IIEF score posttransplant. Conclusions: Incidence of ED was 88% in our study. About 65% patients showed an increase in IIEF score posttransplantation. Increasing age at the time of transplant was a significant risk factor for the presence of ED. Renal transplantation corrected hormonal abnormalities in men. About 100% of patients with an end to side arterial anastomosis showed improvement in IIEF scores. There was no effect of dialysis vintage and immunosuppression regimes on sexual dysfunction.

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Post transplant liver biopsies (PTLB) form a cornerstone in management of transplant cases. They provide critical information regarding rejection or reoccurrence of diseases. With the development in understanding of transplant pathology new updates have come in reporting guidelines of liver transplant biopsy specimens. The recent updates also include criteria for reporting of antibody mediated rejection in liver. This review aims to cover all those aspects.

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The best and most cost-effective treatment for end-stage renal disease patients is living donor (LD) renal transplantation. It has survival benefit compared to deceased donor (DD) kidney transplant (DDKT) and long-term dialysis and provides a better quality of life. Efficient and effective kidney allocation methods are increasingly necessary to address the problem of organ scarcity. The use of kidney paired donation transplant has increased access to LD kidney transplantation (LDKT) with outstanding results. ABO-incompatible kidney transplantation (KT) and desensitization protocol can expand the donor pool, but as integral to any aggressive immunosuppression protocol, they are associated with increased risk of infection and malignancy. Given the widespread organ shortage, DDKT from donors with sepsis, donors who died from snakebite or acute kidney injury, controlled donation after cardiac death, older donors, can be considered for KT with an acceptable outcome. The acceptable outcome can be achieved with dual KT using kidneys from expanded criteria donors in older population. Dual KT from pediatric donors to adult recipients or from adult marginal DDs is a promising way to expand the donor pool. Carefully selected donor with HIV, HCV, and HBV positivity is not a contraindication for living kidney donation. Careful and meticulous selection of patient and donor is essential for successful outcome. Affordable or free transplantation is other way to increase transplantation rate in developing country. The community support can make transplantation available free to the poor patients under community-government partnership. Various steps should be taken to promote LDKT and DDKT program.

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Background: Renal transplantation has become moderately accepted and successful due to advancement in overall management. However, long-term complications of renal transplantation still post new challenges. Pharmacologic treatment along with “appropriate level” of exercise helps to prevent long-term complications. This study reports the efficacy of appropriate level of aerobic exercises along with resisted training to prevent post-renal transplant complications in a single case of renal transplant recipient. Methods: This single- subject experimental study design consist of A1, B1, A2, B2 and A3 phases which include either of aerobic exercise, aerobic exercise with resisted training or home programme. Visual analysis and 2SD- band method was used to analyze serum creatinine, postprandial blood sugar, blood pressure, VO2 max and amount of medicines required to renal transplant recipient. Results: A favorable changes were noted among the specific variables even after longtime, when combined aerobic exercises with resisted training were given. Conclusion: This case study shows that Aerobic exercises with resisted training are effective to prevent post renal transplant complications among renal transplant recipient within two years of transplantation, which could not be generalized but provides impetus to further research.

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Dynamic renal scintigraphy scores above other methods for evaluating grafts as it can demonstrate perfusion, function, and drainage pattern. A difficult scenario in evaluating delayed graft function is excluding rejection. Perfusion indices help in the diagnosis of delayed graft function and ruling out rejection. We report a case of renal transplant recipient presenting with delayed graft function. Renal scintigraphy was performed 2-day posttransplantation. Time-activity curves were obtained for 1^st min images to evaluate the perfusion of graft and iliac artery. Normal perfusion index is considered as below 150. The results were suggestive of maintained perfusion, more in favor of acute tubular necrosis. Hilson's perfusion index with appropriate modifications interpretation can rule out rejection.

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Introduction: The present study compared the efficacy, safety, and immunogenicity of the biosimilar darbepoetin alfa to the reference innovator darbepoetin alfa in the treatment of anemia in chronic kidney disease (CKD) patients. Materials and Methods: Out of 140 randomized individuals, 107 individuals were administered biosimilar darbepoetin alfa (study arm) and 33 individuals received reference innovator darbepoetin alfa (reference arm). Primary objective evaluated was hemoglobin responder rate for individuals achieving >1 g/dL rise in Hb from baseline to week 8. The secondary objectives were proportion of individuals achieving rise in hemoglobin (>1 g/dL rise from baseline) at week 24 to assess the proportion of individuals maintaining mean Hb within target range and evaluation of safety. Results: The hemoglobin responder rate for individuals achieving >1 g/dL rise in Hb from baseline to week 8 was similar in both the study and reference arms (56 [62.92%] and 22 [70.97%]). Overall, 86.27% individuals treated with biosimilar darbepoetin alfa achieved hemoglobin rise >1 g/dl as compared to 86.67% individuals in the reference darbepoetin arm at 24 weeks. Individuals maintaining Hb value within the target range at the end of week 24 were also similar in both the arms (60.80% and 60.00% in study and reference arms, respectively). There were 147 treatment emergent adverse events (34.58% in the study arm and 42.42% in the reference arm). Conclusion: The biosimilar darbepoetin alfa (DarbeRel^TM) showed clinical biosimilarity to reference innovator darbepoetin alfa in anemia of CKD.

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Aim of This Study: This study aims to describe the utility of high-resolution computed tomography (HRCT) of chest in renal transplant recipients in patients with pulmonary infection. Materials and Methods: We retrospectively analyzed the findings of HRCT of chest in 48 postrenal transplant patients with documented pulmonary infection from September 2013 to August 2014. All patients underwent detailed investigations including specific pathological tests, chest X-ray, sputum analysis, bronchoalveolar lavage and pleural fluid analysis as and when required. HRCT was done in all patients on Somatom sensation 64 scan. The spectrum of causative organism and utility of HRCT was studied. Results: Out of 48 patients, the causative organism was confirmed by microbiology in 27 patients. These include 14 patients with Gram-negative bacteria, 5 patients with Gram-positive bacteria, 8 patients with fungal infection, and 3 patients with Mycobacterium tuberculosis infection confirmed on sputum analysis. The causative organism was confirmed to be cytomegalovirus-based on serological tests in 3 patients. Laboratory investigations could not identify the causative organism in 18 patients, 2 of them were treated with broad spectrum antibiotic, 13 patients with anti-tuberculous drugs, and 3 patients with antifungal therapy based on CT findings. Spectrum of HRCT findings was studied. Conclusion: We found bacterial infection is the most common in postrenal transplant patients followed by M. tuberculosis. Tree in bud appearance is common in M. tuberculosis infection. We found HRCT makes the road of early diagnosis of pulmonary infections smoother when coupled with clinical data.

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Aim: Tacrolimus has proven efficacy as an immunosuppressive therapy to prevent transplant rejection and is widely used as an immediate-release formulation in a twice-daily regimen. Once-daily prolonged-release tacrolimus aims to improve the outcomes by reducing variability in exposure and improving adherence. However, there are limited published data available on prolonged-release tacrolimus in routine clinical practice in India. Methods: This was a Phase IV, multicenter, prospective study of prolonged-release tacrolimus conducted over 12 weeks in adult patients eligible for de novo kidney or liver transplantation in India. Primary efficacy end-point was the event rate of biopsy-confirmed acute rejections (BCARs). Secondary end-points included corticosteroid-resistant rejection incidence, time to first BCAR, graft loss, and death. Safety end-points included renal function, lipid profile, incidence of new-onset diabetes mellitus after transplantation (NODAT), and infection. Results: The study enrolled 92 patients undergoing kidney (81 [88.0%]) or liver transplantation (11 [12.0%]); a total of 76 patients (82.6%) completed the study. Ten kidney transplant patients (overall 10.9%) experienced BCAR. There were seven corticosteroid-sensitive and three corticosteroid-resistant rejections. Median (range) time to kidney transplant rejection was 6.5 (1.0–76.0) days. Renal function was stable or improved. Lipid levels showed a significant increase. Eleven instances of NODAT and seven infections occurred and there were eight deaths (8.7%; six kidney and two liver transplant patients). Conclusions: In de novo kidney and liver transplant recipients in India, prolonged-release tacrolimus was well-tolerated and efficacious with a low incidence of acute rejection. Safety profile was similar to immediate-release tacrolimus from published data.

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Only a few cases of acute appendicitis (AA) have been reported in renal transplant recipients. The presentation may be delayed or non-specific due to the masking of inflammatory signs in the immunosuppressed patient. It is essential to differentiate this condition from acute rejection, which may present in the same manner. The management of AA in the setting of a transplanted patient is not clear. A case report and review of literature is presented.

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Aim: The study aim was to evaluate the prevalence, risk factors, and clinical importance of abnormal elevation in liver enzyme levels in children after renal transplantation. Materials and Methods: The files of all 62 patients (mean age 10.2 years), who underwent renal transplantation at a tertiary pediatric medical center in 2001-2013, were reviewed for clinical data, including: Postoperative liver function, tacrolimus level, and serology for cytomegalovirus (CMV) and hepatitis B and C viruses. Results: The most common indication for transplantation (53%) was dysplastic hypoplastic kidney. Liver enzyme levels were abnormal in 7 patients (11%) before transplantation and 42 (67.7%) during the first 6 months following, with a peak on day 14 (P < 0.001). Seroconversion was documented during the first post-transplantation year in 9 patients (14.5%), of whom 8 (89%) were CMV IgG negative. Post-transplant abnormal levels were highest in patients who also had abnormally high-level pre-transplant levels (100%), CMV seroconversion (89%), and dysplastic kidney or nephronophthisis (80%). An abnormally elevated liver enzyme level was significantly correlated with high blood tacrolimus level, but only on post-transplant day 3 (P < 0.001). Conclusion: High liver enzyme levels are common in pediatric kidney transplant recipients, usually starting in the first post-transplant month. The etiology is probably multifactorial; drug hepatotoxicity, previous liver injury, and acute viral infection or reactivation are all likely possibilities. About 10-20% of cases are related to CMV infection.

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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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Aim: Posttransplant hypertension (HTN) is a strong predictor of patient and graft survival. As there is a paucity of data in India, this retrospective analysis was done to look at the blood pressure (BP) in 506 renal transplant recipients, with 240 males, 266 females, mean age 42.90 ± 13.31 years, looking at their BP, at the initial and after 1 year later. Methods: This is a retrospective tertiary care study looking at serial BP measurements in 506 renal transplant recipients, correlating with their body mass index (BMI), graft function, proteinuria, antihypertensive used, erythropoietin usage, echocardiography native kidney disease, and new-onset diabetes mellitus till 1 year after transplantation. Results: According to the Joint National Committee 7 classification, initial BP was normal in 24 (4.74%), pre-HTN in 145 (28.65%), HTN Stage I in 227 (44.86%), and Stage II in 110 (21.73%) patients. One year later, BP was normal in 43 (8.55%), pre-HTN in 153 (30.26%), HTN Stage I in 236 (46.71%), and Stage II in 74 (14.47%) patients. Diabetics had a higher initial systolic BP (SBP) (P = 0.005). Patients with left ventricular hypertrophy had a higher SBP 1 year later (P = 0.001). Patients with BMI > 35 kg/m², had higher initial SBP (P = 0.01), initial diastolic BP (DBP) (P = 0.01) and also higher 1 year posttransplant SBP (P = 0.02) and DBP (P = 0.01). Conclusion: There was a high incidence of HTN in renal transplant recipients, 66.59% patients with HTN and 28.65% with pre-HTN in the initial posttransplant period, and 61.18% with HTN and 30.26% with pre-HTN in the 1-year posttransplant period.

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Objective: To assess knowledge, attitude, and practice (KAP) of organ donation (OD) among pharmacy students. Methodology: A web-based, cross-sectional study of students pursuing different pharmacy courses was conducted. A specially designed questionnaire was used to survey the students. Results: A total of 160 students responded to survey. Nearly, three-fourth students wished to donate organs to anyone, 83.1% wanted to donate by considering the health status of the recipient, and 98.1% feel that OD should be promoted. Some negative findings were as follows: less knowledge about some uncommon organs that can be donated, for example, blood vessels, bone, intestine, and heart valves; 76.3% students do not know the process of registering while 84.4% have not registered/pledged for OD. Average knowledge about law related to OD was also poor, i.e., 1.87. Conclusion: Overall KAP for OD was positive for except for a few issues. There is need to add some OD related topic/s in the pharmacy curriculum.

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Background: Living donor renal transplantation is the dominant type of renal transplantation in developing countries such as India. We looked at factors affecting allograft and patient survival in such circumstances as these could be different owing to unique socioeconomic, demographic, and patient characteristics. Methods: We retrospectively analyzed data of living donor renal transplantation done at Postgraduate Institute of Medical Education and Research, Chandigarh, over 5 years (2002–2007) to ascertain the factors that affect allograft and patient survival. The relationship of pretransplant characteristics of patient and donor, comorbid conditions, posttransplant immunosuppressive drug regimens, and infectious and noninfectious complications to allograft survival and patient survival were assessed. Results: A total of 554 living donor renal transplantation surgeries were performed during this period. Rates of death-censored renal allograft survival at 1, 3, and 5 years after transplant were 94%, 90%, and 79%, respectively. Independent predictors of death-censored graft loss were BK virus nephropathy, episodes of rejection, and use of immunosuppressive drug protocols other than triple drug regimen of tacrolimus, mycophenolate mofetil, and prednisolone. The patient survival at 1, 3, and 5 years after transplant in our study was 92%, 87%, and 83%, respectively. Presence of cytomegalovirus disease, recipient age ≥50 years, unrelated transplant (spousal donor or donor beyond first-degree relative), and presence of any opportunistic infection were found to be significant independent predictors of patient survival. Conclusions: Although retrospective, our data have shown comparable rates for allograft and patient survival for living donor renal transplantation in India.

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Anesthetic and surgical management of small children is challenging because of technical difficulties and repeated re-explorations for vascular or biliary complications. Preoperative optimization and meticulous intraoperative and postoperative management can achieve the survival rates comparable to older children. In our institution, we have successfully managed living donor liver transplant in four small children ≤8 kg, and with these case reports, we have tried to present anesthetic concerns and management of these cases along with surgical and postoperative details.

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