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   2017| April-June  | Volume 11 | Issue 2  
    Online since September 12, 2017

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Factors that determine deceased organ transplantation in India
GS Adithyan, M Mariappan
April-June 2017, 11(2):26-30
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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Renal transplant in a lupus nephritis patient with β-thalassemia trait
Uma Shankar Gaur, Dhananjai Agarwal, Pankaj Beniwal, Vinay Malhotra
April-June 2017, 11(2):82-83
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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Role of high resolution computed tomography of chest in posttransplant pulmonary infection
Shruti P Gandhi, Vivek Kute, Kajal N Patel, Harsh Sutariya, Vaidehi Pandya
April-June 2017, 11(2):49-54
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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Immunosuppression with prolonged-release tacrolimus in kidney or liver transplantation in India
Dinesh Khullar, Vikranth Reddy, Budithi Subbarao, Madan Bahadur, Veeraswamy Tamilarasi, Alan Almeida, Pratik Shah
April-June 2017, 11(2):70-76
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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Predictors of allograft survival and patient survival in living donor renal transplant recipients
Pinaki Mukhopadhyay, KL Gupta, Vivek Kumar, Raja Ramachandran, Manish Rathi, Ashish Sharma, Mukut Minz, Harbir S Kohli, Vivekanand Jha, Vinay Sakhuja
April-June 2017, 11(2):42-48
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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Acute appendicitis following renal transplant: A case report and review of literature
Jacob Mathew, Ramesh Rajan
April-June 2017, 11(2):89-91
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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Aerobic exercises along with resisted training to prevent postrenal transplant complications in renal transplant recipient: A single-subject design
Jani Chaitsi Kiritkumar, Harshal D Vora, Lourembam Surbala, Ritesh Vekariya
April-June 2017, 11(2):92-98
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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Postrenal transplant lymphocele causing anuria due to ureteric compression
Harsh Sutariya, Kajal Patel, Shruti Gandhi
April-June 2017, 11(2):79-81
Lymphocele is one of the most common complications following renal transplantation and can lead to an increase in morbidity. Its incidence has been reported to vary from 0.6% to 20%. The use of ultrasonography has increased the index of detection of lymphocele though the majority of them have small size and resolved spontaneously. We describe a case of a postrenal transplant patient who developed anuria due to transplanted ureteric compression by lymphocele in deceased donor dual-renal transplantation in the right renal fossa. When a transplanted patient comes with a history of sudden anuria, one should consider ureteric compression resulting from lymphocele as a possible cause.
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Transcervical resection of endometrium: A novel mode of management of patients with abnormal uterine bleeding with chronic kidney disease and renal transplant recipients
Vineet V Mishra, Shaheen Hokabaj, Priyankur Roy, Sumesh Choudhary, Ruchika Verneker, Khushali Gandhi
April-June 2017, 11(2):61-65
Objective: Abnormal uterine bleeding (AUB), especially in cases with chronic kidney diseases (CKDs) have a significant impact on physical, social, economic, and material quality of life of women. The objective of this study was to evaluate the efficacy, change in menstrual pattern, and patient satisfaction after transcervical resection of endometrium (TCRE) in women with AUB and CKD who underwent or were awaiting renal transplant and nonrespondents to medical management. Materials and Methodology: Eleven women with CKD (either underwent renal transplant or on dialysis) and AUB who did not respond to medical management underwent TCRE. The study period was 5 years. The main outcome measures were change in menstrual status, level of satisfaction with the procedure, and the need for repeat TCRE or hysterectomy. Results: The average age of the patients was 44.9 years. Out of the 22 women enrolled, 11 responded to medical management and only the remaining 11 women required TCRE. All 11 women underwent hysteroscopic-guided biopsy, and their histopathological reports revealed nonmalignant status. The average operating time for TCRE was 21.5 ± 8.02 min. Postoperatively 9 (81.81%) women had achieved amenorrhea while 2 (18.18%) developed oligomenorrhea. The duration from TCRE to amenorrhea ranges between 7 and 60 days with an average of 31.54 days. None of the women required hysterectomy. Conclusion: TCRE is clinically and cost effective alternative to medical management or hysterectomy in women with AUB and CKD. The cost-effectiveness, work performance, rapid convalescence, and improved the quality of life provide TCRE a “distinct edge” over the definitive management – hysterectomy.
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Long-term outcomes of hepatitis C virus infected renal allograft recipients
Narayan Prasad, Praveen Kumar Etta, Akhilesh Jaiswal, Raj Kumar Sharma, Dharmendra Bhadauria, Vivek Saraswat, Anupama Kaul, Gaurav Pandey, Sameer Mahindra, Amit Gupta
April-June 2017, 11(2):35-41
Background and Aim: This study aims to study the long-term outcomes of hepatitis C virus (HCV)-infected renal allograft recipients, which is still debatable. Materials and Methods: In this study (study period - January 2003 to December 2013), we studied long-term outcomes of 106 living donor renal allograft recipients - 53 HCV-infected (33 genotype 3 and 20 genotype 1) and 53 age- and gender-matched HCV-noninfected patients. Results: Thirty-nine (73.6%) patients detected HCV positive during dialysis, while 14 (26.4%) before the start of dialysis. Forty (75.5%) patients were positive for both anti-HCV and HCV RNA, while 13 (24.5%) were HCV RNA positive and anti-HCV negative. Twelve and nine patients died among HCV positive and negative groups, respectively. Major cause of death was sepsis in both groups. Hepatic failure contributed to mortality in four HCV-positive patients, two of them also had graft failure. Patient and death noncensored graft survival rates at 1, 5, and 10 years of follow-up in HCV-positive group were 100% and 100%; 79.8% and 70.8%; 58.9% and 37.8%; respectively; and in HCV-negative group were 100% and 100%; 95.9% and 91.8%; 58.9% and 27.4%; respectively. Conclusions: The long-term survival of HCV-positive renal transplant recipients was not inferior to that of HCV-negative recipients.
  559 115 -
Renal transplant in a child with Alport syndrome
Rajendra B Nerli, Shridhar C Ghagane, Mahantesh V Patil, Neeraj S Dixit
April-June 2017, 11(2):86-88
Alport syndrome is a rare inheritable renal disease characterized by renal, cochlear, and ocular involvement. Patients commonly require renal replacement therapy in the second or third decade of life. Renal transplantation in pediatric patients has become a routinely successful procedure, with 1- and 5-year patient survival rates of 98%, the range takes into account the differences between living and deceased donors. These good outcomes represent the cumulative effect of improvements in pre- and post-transplant patient care, operative techniques, immunosuppression, and infection prophylaxis, diagnosis, and treatment. We report the case of a male child with Alport syndrome who underwent preemptive live renal transplant and his mother was the donor.
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An unusual case of external iliac artery thrombosis after renal transplant surgery
Vikas Dhawan, Harshita Mehrotra, Nitish Gupta, Manisha Dassi
April-June 2017, 11(2):99-101
The rates of renal transplant for end stage renal disease are increasing worldwide. Vascular complications due to arterial thrombosis is seen only in less that 1% cases. We describe a case of 36 year old male who underwent a live-related renal transplant, whose post-operative period was complicated by juxta-anastomotic distal external iliac artery thrombosis. He was managed by thrombectomy and improved with complete recovery. Attention should be paid to anastomotic technique and prevention of formation of intimal flap. In case of arterial thrombosis, graft salvage can be attempted depending on the clinical scenario.
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Posttransplant urinary tract infections and surgical site infections among renal transplant recipients in a transplant unit in Sri Lanka
Lilani Indrika Karunanayake, Poogoda Kankanange Harischandra, UB Rambukwella, CT Hapuarachchi, Tshokey Tshokey
April-June 2017, 11(2):31-34
Aim: Kidney transplant (KT) recipients are at higher risks of infections due to the chronic disease conditions, the surgical procedure and immunosuppressive therapy following transplantation. We aimed to assess the incidence and the microbiology of urinary tract infections (UTIs) and surgical site infections (SSIs) in KT recipients at the transplant unit in Kandy Teaching Hospital, Sri Lanka. Methods: A prospective, descriptive study was carried out in patients undergoing KT for 6 months postoperatively. A urine full report and culture were carried out before transplantation and on days 1, 3, 7 and monthly for 6 months posttransplantation. Urine specimens yielding growth of ≥105 CFU/ml were considered significant. In addition, patients were screened preoperatively for Staphylococcus aureus colonization by multi-site swabbing. The surgical sites were inspected daily for SSI. Results: Thirty-nine patients were recruited in the study. Two patients (5.1%) had preoperative UTI and 4 (10.3%) developed UTI within 6 months. Majority of post-KT UTI (75.0%) occurred in the 1st month. UTI was commonly due to coliforms (50.0%) while S. aureus and Pseudomonas spp. accounted 25% each. All screened patients were colonized with S. aureus and majority (62.9%) were methicillin-resistant S. aureus. Only 3 (8.6%) KT recipients had SSIs. Conclusion: The incidence of UTI in KT recipients within the first 6 months was 10.3%, and majority occurred in the 1st month. Patients, who were treated for UTI preoperatively, did not develop post-KT UTI. Coliforms were the most common organism. Although there was high S. aureus colonization index, the incidence of SSI in post-KT recipients was low.
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Outcome of live donor kidney transplantation in a Government Hospital of Nepal
Rajani Hada, Narayan Prasad, Anil Baral, Rajendra Kumar Agrawal
April-June 2017, 11(2):55-60
Background: Live donor kidney transplantation (KT) was started in 2008 in Bir Hospital, a government hospital of Nepal. The present study aims to find out patient and graft outcome, and the factors influencing the graft survival. Methods: It is a retrospective analysis of all KT from December 2008 to May 2013. The immunosuppressive was induction with intravenous methylprednisolone and daclizumab (n = 39) or basiliximab (n = 34) or anti-thymocyte globulin (n = 22) and maintenance with steroid, calcineurin inhibitors (CNIs), and mycophenolate mofetil. All data of recipients and donors were obtained from hospital records. Kaplan–Meier method was used for survival analysis. Results: Totally, ninety-five patients with follow-up duration of 1.5–6.5 years were analyzed. Recipients and donors were disproportionate in age (74.7% vs. 16.8% below 40 years) and gender (87.4% male vs. 77.9% female), respectively. Delayed graft function was observed in 10.5%, and slow graft function in 9.5% of patients with recovery of graft function before discharge in all except two. Within 2 years, 4.2% patients died because of infection and sepsis. Graft loss was observed in 14.7% due to antibody-mediated rejection (noncompliance 50% and unaffordability to treat 21.4%) and recurrent glomerulonephritis (28.6%). Patient survival at 1, 3, and 6.5 years was 97.9%, 95.8%, and 95.8%, respectively. Death noncensored graft survival was 97.9%, 86.2%, and 77.5%, respectively and death censored graft survival was 100%, 90%, and 80.9%, respectively with no influence of induction agents and recipient and donor factors in graft survival. Conclusion: The early and intermediate-term patient and graft outcome is satisfactory and low socioeconomic status related noncompliance is the major cause of graft loss.
  446 57 -
Transplantation in India
Manisha Sahay
April-June 2017, 11(2):25-25
  369 110 -
Hepatic venous outflow reconstruction in partial liver grafts: The middle path
Selvakumar Naganathan, Subash Gupta
April-June 2017, 11(2):77-78
Background: Liver transplantation is the gold standard treatment in end-stage liver disease. Although organ donation is on the rise, living donor liver transplantation (LDLT) is still the bulk of all the transplantation procedures in our country (India). LDLT is a technically complex surgical procedure. In addition to known complications in the recipient donor morbidity and mortality are still fearsome complications, recipent complications includes multiple vasculo- biliary complications and graft dysfunctions. The surgical technique has evolved over the years to increase the recipient outcomes with negligible donor morbidities. One of them is shift from full middle hepatic vein grafts to modfied right lobe (MRL) grafts. Methods: MRL grafts were performed. In MRL grafts, drainage of the anterior sector is the critical step. Failure of this will lead to graft congestion and loss of functional graft volume. However, not all veins need to be drained. Results: In this article, we have described a simple and effective technique which we follow routinely in our institute to identify the intrahepatic veno-venous communications. Conclusion: MRL technique optimizes the drainage procedure with maximum yield.
  322 60 -
Early posttransplant granulomatous interstitial nephritis
Sriram Sriperumbuduri, Karthik Kalidindi, Swarnalatha Guditi, Gangadhar Taduri
April-June 2017, 11(2):84-85
Interstitial nephritis in graft kidney is a rare condition, and a small fraction of these contain granulomas. Most common etiology is drugs, followed by infections. Biopsy and evaluation of underlying cause are key factors determining treatment options and salvaging the graft. We present one such rare case of early posttransplant graft dysfunction due to granulomatous nephritis.
  219 36 -
Surgical technique for orthotopic small bowel transplantation in a rat
Necdet zay
April-June 2017, 11(2):66-69
Objectives: Presently, the results of small bowel transplantation (SBT) procedures are far from ideal. Problems such as rejection, sepsis and graft-versus host disease are still encountered after SBT. Here, we describe a refined rat model of SBT for researchers who wish to investigate these complications. Materials and Methods: Sixty male outbred Sprague Dawley (SD) rats were used for the study. Orthotopic small bowel transplantations were performed. An immunosuppressive regimen was not implemented and the recipients were monitored for seven days. If the recipient survived until the experimental end point, the transplantation was deemed to be successful. Recipient survival shorter than seven days was considered to be a technical failure. Results: The mean operation times for donor and recipients were 40 minutes (40 ± 5 min) and 65 minutes (61 ± 10), respectively. Cold and warm ischemia times were 32.5 ± 5 min and 25 ± 7 min, respectively. End-to side venous and arterial anastomosis times were approximately 20 minutes (20 ± 7 min). Four recipients died within the first three days after transplantation due to technical failure [bleeding (n:3), microvascular anastomosis thrombosis (n:1)]. The rest of the recipients (n: 26) reached the experimental end point in a healthy condition (success rate was 86%). Conclusion: This model is easy to perform and offers various advantages. The principle advantages of our surgical model are that it minimizes the mechanical injury of the graft and provides a high quality intestinal graft. It also allows us to make rapid and safe anastomosis in the recipient operation.
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