|Year : 2011 | Volume
| Issue : 1 | Page : 9-45
XXI Annual conference of indian society of organ transplantation (isot), hyderabad 21st - 23rd october, 2010
|Date of Web Publication||4-Dec-2017|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. XXI Annual conference of indian society of organ transplantation (isot), hyderabad 21st - 23rd october, 2010. Indian J Transplant 2011;5:9-45
|How to cite this URL:|
. XXI Annual conference of indian society of organ transplantation (isot), hyderabad 21st - 23rd october, 2010. Indian J Transplant [serial online] 2011 [cited 2021 Apr 11];5:9-45. Available from: https://www.ijtonline.in/text.asp?2011/5/1/9/219885
| 001: STEROID FREE IMMUNOSUPPRESSION IN KIDNEY TRANSPLANTATION: A USEFUL ALTERNATIVE|| |
Author(s) - Vijay kher, Salil Jain, Manoj singhal, Reetesh Sharma, Shyam Bansal
Medanta Medicity Sector 38 gurgaon Haryana
Steroids have been the cornerstone of immunosuppressive therapy in renal transplantation ever since its early days. Availability of many potent newer immunosuppressive drugs including induction agents and to avoid the undesirable chronic adverse effects of steroids has lead to the use of steroid avoidance immunosuppressive protocols. Patient & Methods: We prospectively evaluated 59 renal transplant recipients who were initiated on steroid free protocol. Selection of patients was done following discussion with them and their desire to avoid steroids. All patients who had history of prolonged exposure to steroids in the past or were second transplants were excluded. All of the patients in the study group received two doses of IL2RA as induction. They were given IV Methylprednisolone in an initial dose 500 mg followed by oral prednisolone starting post operative day 1 at 40 mg/day which was tapered and stopped by day 5. All of them received Tacrolimus (0.1 mg/kg) and MMF as maintenance immunosuppression. Levels of Tacrolimus were targeted at 8-12ng/ml for first three months, 6-8ng/ml for next 3-6 months and 4-6ng/ml thereafter. They were followed twice weekly for first month, once weekly in second month, fortnightly in third month and then monthly. At each visit they were assessed clinically for height, weight, BP and biochemical investigations (BUN, S. Creatinine, Na, K, Blood sugar). The outcome measures that were evaluated were number of acute rejections, infections, graft loss, PTDM, requirement of antihypertensive medications and S. Cholesterol and LDL levels. We compared the outcome of the patients on steroid free protocol with 40 patients who received IL-2RA, Tacrolimus, MMF and steroids. Fisher exact test’ and ‘Chi Square’ were used for statistical analysis and a P value <0.05 was considered significant. Results: The study group comprised of 59 patients (30 males & 19 females), mean age was 39.4 + 12.5 years . The demographic characteristics were similar in the control gp (mean age 40.9 + 13. 5 yr s, 31 males and 9 females) The mean follow up was 35.8+ 21.4 months. Eight patients (13.5%) had an episode of AR and all of them were treated with IV methylprednisone followed by oral prednisone therapy as maintenance. The incidence of rejections was similar in the study group as compared to those who were on steroid based protocols 10/80 (12.5%) (p=0.9). All of them responded and regained baseline renal functions. The mean s.creatinine at last follow-up was 1.25 + 0.39 mg/dl. Two other patients had to be converted to Prednisone based protocols: 1 because of persistent low Tac levels requiring Cyclosporine based therapy and the other because of MMF related anemia requiring Azathioprine therapy. Of the 59 patients, 11 had one or more episode of infections with UTI being the commonest (9/11). The incidence of infections was similar in the study group as compared to those who were on steroid based protocols (10/80, 12.5%) (p=0.53). 3(3.3%) of these 59 pateints developed PTDM as compared to 11/ 80 in the control gp (p=0.11). There was no death or graft loss in the steroid free group. The incidence of graft loss ( 0/59 vs 4/80, p=0.23) and death ( 0/59 vs 2/80, p=1.0) were similar in the two groups. Of the 59 patients, 31.3% did not require antihypertensive medications. The mean cholesterol and LDL levels in these patients were 169 + 41.5 mg/dl and 89 + 26 mg/ dl. All the 3 children who were on steroid free protocol showed an excellent growth with mean growth velocity of 6.8 cm/yr. Conclusions: This study suggests that steroid free protocol is a safe and efficacious protocol in selected patients to avoid steroid induced adverse effects without any increased incidence of acute rejection.
| 002: ANALYSIS OF 1000 CASES OF LAPAROSCOPIC DONOR NEPHRECTOMY FROM A DEVELOPING COUNTRY|| |
Author(s) - Anant Kumar, Aneesh Srivastava, Deepak Dubey, Anil Gulia
Dett. Urology, Fortis Hospital, Aruna asaf ali marg, Vasant kunj B-1, Delhi
Analysis of 1000 cases of laparoscopic donor nephrectomy from a developing country. Place of work - SGPGIMS, Apollo Delhi, Fortis Hospital Delhi. Introduction and objective To review the results, complications and cost effectiveness of 1000 cases laparoscopic donor nephrectomy done by a single team of a developing country. Methods From September 1999 to Oct 2009, 1000 laparoscopic donor nephrectomy were done at two centers by a single team. Senior author has started it at SGPGIMS, Lucknow and subsequently trained other faculty members. In July 2006, senior author has moved to another hospital . All the case files of donor were reviewed. Donors were followed up to a month and reviewed at one year by post or telephonic conversation. Any readmission or complication was recorded. First 46 cases were laparoscopic assisted, three were hand assisted and rest was pure laparoscopic method. There were 56 right donor nephrectomy and 944 were left donor nephrectomy. On left side, 900 cases had transperitoneal lap donor nephrectomy and only 44 had retroperitoneal donor nephrectomy. On right side, all patients had retroperitoneal lap donor nephrectomy except 4 cases that had transperitoneal approach. Weck Hem O lok clips was used in 910 cases for both arterial and venous control. 720 cases kidney was retrieved by Pffananstiel incision and rest it were retrieved by 5 cm iliac fossa incision. 36 right kidneys were retrieved by 7 cm subcostal incision which was used for Satinsky clamp application. Results The mean operative time was 146 minutes . The average warm ischemic time was 5.2 minutes. the operative blood loss was 50 to 400 ml . There were 16 major complications including hemorrhage and injury to adjacent organs like bowel, spleen and pancreas. 14 of these patients required exploration to control bleeding or repair of the injury to other organs. One patient was explored for adhesive obstruction.10 patients developed paralytic ileus and treated conservatively. There were 54 minor complications which did not require any additional therapy and managed during intra-operatively or conservatively. One patient died in immediate postoperative period due to slippage of Hemolock clip. All patients have adequate vascular and ureteric length. There were 260 cases of multiple vessels.22 patients have three arteries. There were two urinary fistulae and one ureteric obstruction in recipients. Mild ATN was noticed in 36 patients who recovered within a week. None of the patient was dialyzed for the ATN. No graft was lost due to injury or primary non function. The average analgesia requirement was 330 mg of Tramadol. The average hospital stay was 3.46 days.Most of the patients resumed full activity at 4 weeks . Operative time has also come down to 110 t0 130 minutes. The average cost of the laparoscopic donor nephrectomy is US$ 1000. This low cost is due to use of metallic reusable instruments, metallic trocars, and Hem o lok Weck clips and hand retrieval. Conclusion Lap donor nephrectomy is a safe and minimally invasive procedure. It has a long learning curve and can be easily learned under the mentorship of an experienced surgeon. It is a cost effective procedures even for the developing country.
| 003: ROLE OF HEMOSTATIC AGENTS (FLOSEAL) IN THE MANAGEMENT OF POST TRANSPLANT RENAL BIOPSY BLEED REFRACTORY TO ANGIO EMBOLISATION.|| |
Author(s) -Aman Gupta, Anant Kumar, Anshuman Agarwal, Anil Gulia, Vikas Jain
Fortis Hospital, 54, Panchdeep Apts., Vikas Puri, DELHI
To report our experience with Floseal in the management of post transplant renal biopsy bleeding refractory to angioembolisation. Patients and methods: Two patients were managed using Floseal injection in the needle tract following refractory post renal biopsy bleeding over a period extending from December 2009 to June 2010. Bleeding continued even after angioembolisation and the patient continued to be hemodynamically unstable necessitating exploration. Bleeding was seen coming out of needle tract. Floseal was injected in the needle tract for 5 minutes and bleeding was successfully controlled. Result Bleeding was successfully controlled in both the cases and patients improved hemodynamically after the procedure. Graft function improved in both cases as evident by improved urine output and normalizing renal parameters. Follow up of average 5.3 months has shown stable graft function in both cases. Conclusion: Topical Floseal is an effect measure to control post transplant renal biopsy bleed refractory to conservative and less invasive measures like angioembolisation. Key points: renal transplant, renal biopsy, bleeding, Floseal.
| 004: LIVER RECIPIENTS FROM YOUNG DONORS DO NOT DEVELOP SMALL FOR SIZE SYNDROME EVEN IF THE GRAFT RECIPIENT WEIGHT RATIO IS LESS THAN 0.8|| |
Author(s) -Vasudevan K R, Sanjay Goja, Neerav Goyal, Vivek Vij, Subash Gupta
Surgical Gastroenterology and Liver Transplantation, Indraprastha Apollo Hospital Delhi
Recipients who receive small sized grafts, defined as graft recipient weight ratio (GRWR) of less than 0.8% are prone to develop small for size syndrome (SFSS). We postulated that because grafts from young donors regenerate faster, grafts with marginally smaller size would prevent SFSS. Patients ??Methods Two hundred adult to adult living related liver transplantations were performed between September 2006 and Dec 2009 at our center. We analysed outcome in recipients who received small grafts (GRWR < 0.75) from young donors (<22yrs). Results There were 4 male recipients aged between 21 to 55yrs. The average GRWR was 0.725 (0.72 to 0.74). Age of donor was from 18 to 22 yrs. The average Meld score was 23 (15, 22, 27, 27). No patient had vascular or bilary complications. INR returned to baseline value by the third post operative day in all the patients. The bilirubin value was decreased to < 10mg% in all of them by tenth post operative day. No patient had sepsis or high > 1L ascitic fluid drainage. Conclusion In our experience, recipients who received small grafts (GRWR < 0.75) from young donors did not develop small-for-size syndrome.
| 005: STEROID FREE MAINTENANCE IMMUNOSUPPRESSION IN RENAL TRANSPLANTATION - A FOLLOW-UP OF 33 PATIENTS|| |
Author(s) -Sunil Kumar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sanand Bag
Post Graduate Institute Of Medical Education And Research, Chandigarh
Steroid-free immunosuppression in kidney transplantation has been gaining popularity over the past decade, mainly after recognition of the fact that the long-term use of steroids contributes to cardiovascular morbidity and mortality in transplant recipients. Aim - To study the outcome of steroid-free immunosuppression in kidney transplantation in terms of both short term and long-term graft and patient survival. Material and methods - Between January 2007 and May 2010, 33 patients undergoing renal allograft transplant were included in the study. Seventeen patients were allocated to the study group (steroid free immunosuppression) and 16 patients to the control group (steroid based immunosuppression). Mean serum creatinine, mean GFR (calculated by MDRD equation), graft survival, patient survival and incidence of long term complications were compared between the two groups. Results - The mean serum creatinine at 1, 12, 36 months in the control and study groups were 1.35, 1.42, 1.63 and 1.35, 1.25, 1.1 mg/dl respectively. The mean GFR at 1, 12, 36 months in the control and study groups were 65.19, 59.94, 54.85 and 67.31, 71.73, 65.40 ml/min respectively. One patient in the study group (5.88%) had acute rejection as compared to 5 patients (31.2%) in the control group. Five patients (29.4%) from the study group were restarted on steroids . Conclusion - Steroid-free immunosuppression is safe and effective both in terms of short term and long term patient and graft survival, with comparable risk of acute rejections.
| 006: PROFILE OF CMV INFECTION AND DISEASE IN LIVER TRANSPLANT PROGRAM IN INDIAN SUBCONTINENT|| |
Author(s) -Kausar Makki, Manav Wadhawan, Neerav Goyal, Vivek Vij, Subash Gupta
Liver Transplant, Apollo Hospital
Western data reveal incidence of CMV disease ranging from 8% to 13.3%. Most centres treat CMV PCR positive recipients. There is no data from Indian subcontinent on post-liver transplant CMV infection. We analysed data regarding CMV infection and disease in recipient population at our centre which is primarily a living related liver transplant program. METHODOLOGY: All recipients negative for CMV IgG pretransplant are given prophylaxis if donors are positive. Rest do not receive any prophylaxis but undergo CMV-PCR and PP65-antigen testing at two weeks and then weekly post transplant if positive and monthly if negative. Increasing CMV DNA titres/ symptomatic are treated with Intravenous (IV) Gancyclovir and Valgancyclovir (oral) for 3 months. Asymptomatic patients with stable/decreasing titres are observed. RESULTS: Of 190 consecutive liver transplant patients from Indian subcontinent, between September 2007 and August 2009, 35 (18.4%) had atleast one CMV DNA positive post-transplantation. Thirty resolved without treatment over 2-6 weeks. One patient expired due to GVHD. Four (2.1%) had CMV disease (CMV DNA positive with PP65-antigenemia) including bone-marrow depression (2); progressively rising CMV titres (2). Those with progressively rising titres had been treated with steroid boluses. In all patients, CMV disease resolved after treatment for three months. CONCLUSION: Though CMV IgG positivity is almost universal in Indian subcontinent among recipients, disease incidence is low, likely due to lower levels of immunosupression, almost no use of induction agents and low use of steroid boluses. CMV DNA positivity does not correlate with disease. Nearly absent CMV disease in our group precludes the need for prophylaxis.
| 007: PRE LIVER TRANSPLANT RENAL DYSFUNCTION IS NOT NECESSARILY ASSOSCIATED WITH ADVERSE OUTCOMES|| |
Author(s) -Shishir Pareek, Neerav Goyal, Manav Wadhawan, Vivek Vij, Subash Gupta
Centre for Liver and Biliary Surgery, Indraprastha Apollo Hospital, New Delhi
Preoperative renal dysfunction is considered a major cause of morbidity and mortality in liver transplant patients. We share our experience. Material and Methods From September 2006 to December 2009, 208 adult patients, median age 52yrs underwent liver transplantation. Patients were divided into 3 groups according to Acute Kidney Injury Quality Initiative Index. Group A had serum creatinine value of < 1.5mg%, group B- 1.5 - 2.5mg%, group C had > 2.5mg%. The three groups were compared for demographic profile, pre and post operative renal dysfunction, requirement of dialysis, modification of immunosuppression, hospital stay, morbidity and mortality. The intergroup analysis was by one way Annova test and independent t tests using SPSS 16 data base. Results Patients in various groups were: A- 160, B- 31, C- 17.The demographic profile of the three groups were similar statistically for age, sex, BMI, GRWR and CPT scoring. The MELD score, creatinine clearance, urinary protiens, urinary protien creatinine ratio, terlypressin, day zero to ten creatinine, day of normalisation of creatinine, post operative day of starting immunosuppression, hospital stay, preop dialysis and infection were found to be significantly different between the three groups. Mortality was not significantly different between groups. On sub group analysis patients with creatinine clearance < 30ml/min, urinary protein creatinine ratio > 0.4 and urinary protien > 500mg% were found to have significantly higher mortality Conclusion Patients with hepatorenal syndrome have out come similar to patients without renal dysfunction following liver transplant with no higher mortality and morbidity. Even patients with type II HRS if transplanted timely will have normalisation of renal function by post operative day 10. Patient with proteinuria > 500mg%, urine protein-creatinine ratio >0.4 and creatinine clearance < 30ml/min. have significantly higher mortality.
| 008: PRE TRANSPLANT ANTI HLA ANTIBODIES AND DONOR SPECIFIC ANTIBODIES DETECTED ON THE LUMINEX PLATFORM - IMPACT ON RENAL GRAFT OUTCOME|| |
Author(s) -Dolly Daniel, Mary Purna Chacko, Basu G, Santhosh Varghese
Dept of Transfusion Medicine and Immunohaematology, CMC, Vellore
Anti HLA antibody detection is crucial for successful renal transplantation. Traditionally the complement dependant cytotoxicity (CDC) technique has been used. The advent of sensitive techniques makes it vital that the clinical significance of antibodies detected on these platforms is assessed prior to forming new pre transplant algorithms. This study was performed to develop a model of antibody screening relevant to our Indian population where the live related renal transplant programme is largely followed. Methods: All patients with a negative pretransplant CDC crossmatch, who had undergone renal transplantation during the year 2007 and 2008 and had donor lysate available were included in this retrospective study. The LMX screen for anti HLA antibodies and donor specific antibody testing using donor lysate (DSA) was performed using the bead based immunoassay (Tepnel) on the luminex platform. Graft outcome based on clinical, biochemical and biopsy proven evidence of graft failure were followed up for a period ranging from 12 - 36 months. Results & conclusions: 25 of 83 patients who had DSA performed showed the presence of donor specific anti HLA antibodies. 30 of 70 patients on whom a luminex screen was done showed the presence of anti HLA antibodies. No significant correlation between the presence of antibody and graft outcome was observed in this follow up period. However DSA had a greater correlation than the screen. The role of DSA in pre- sensitized patients appears significant. Follow up to assess impact on long term graft outcome is vital before a definite algorithm can be defined.
| 009: PRE TRANSPLANT ANTIBODIES DETECTED ON THE ELISA LAT-M PLATFORM AND ITS IMPACT ON RENAL GRAFT OUTCOME|| |
Author(s) -mary Chacko, Anila Mathan, Dolly Daniel, Basu G, Santhosh Varghese
Department of Transfusion Medicine and Immunohaematology,
Christian Medical College and Hospital, Vellore, Tamil Nadu
Detection of antibodies deleterious to graft outcome is vital in renal transplantation. Platforms with different sensitivities are available for this purpose. The ELISA LAT-M platform is a virtual solid phase assay that specifically detects antibodies to class I and class II HLA antigens of the IgG class. Its sensitivity is reportedly equivalent to the AHG -CDC platform. However, it is not donor specific. Our study aims at determining whether this platform, used pre transplant can predict graft outcome Materials and methods: Pre transplant sera of 177 patients who underwent renal transplants between January 2007 and December 2009 were retrospectively tested using the ELISA LAT-M assay. Results were analysed against post transplant outcomes using clinical, biochemical and histopathological endpoints for a period ranging from 6-36 months. Results: 31 0f 177 tested sera, were positive for anti HLA antibodies. 17 of these were positive for anti HLA class I antibodies alone, 4 for class II and 10 for both class I and II. Follow up was available for 166 patients. 41/166 had rejection episodes. 24.1% of ELISA positive patients with available follow up developed rejection compared to 24.8% of antibody negative patients.10.3% ELISA positive patients experienced vascular rejection as compared to 5.8% ELISA negative patients (p=0.41) Conclusions: The results of the pre transplant ELISA LAT-M assay are not predictive of graft outcome. While vascular rejection was found to be higher in patients whose pretransplant serum was ELISA positive, the difference was not statistically significant.
| 010: EVEROLIMUS IN RENAL TRANSPLANTATION - OUR EXPERIENCE|| |
Author(s) -Anitha Aleya, Sanjay Ram pure, Prakash G K, Ravi S hanka, Sudarshan Ballal
Department Of Nephrology, Manipal Hospital, Old Airport Road, Bangalore
Everolimus use in renal transplantation has shown comparable efficacy with CNI dose reduction protocols in denovo transplant and better long term graft function in switch therapy compared to continuation of CNI. Methods: Everolimus was used as denovo (first month) and as a late switch (6 months post transplant). The starting dose of Everolimus was 1.5mg/day (denovo) and 0.75mg to 1.0mg/day (late switch) patients. Trough levels were targeted between 3-8ng/ml (denovo) and 3-5ng/ml (late switch). Urine protein, renal functions, lipid profile were done before and after therapy. Adverse events were looked for in all the patients. Everolimus was stopped with / without switch back to CNI in patients with significant adverse events. Results: 27 received
Everolimus (4 denovo, 23 late switches). Indications for late switch were CNI toxicity in most patients and DGF for denovo use. The median creatinine was 1.5mg/dl before and 1.1mg/dl 6 months later in denovo patients; 1.7mg/dl before and 1.5mg/dl 6 months later in late switch patients. One denovo patient who had increased proteinuria was switched back to CNI. Wound healing was good, no rejections and no lymphocele were seen in denovo patients. None of the denovo or late switch patients had bone marrow suppression, or significantly elevated lipid levels. The Everolimus levels were in between 3 - 8ng/ml in denovo and 3-5ng/ml in most of late switch patients. Conclusion: Everolimus was effective and safe in our denovo / late switch transplant recipients. The long term results are awaited in these patients.
| 011: CLINICAL RELEVANCE OF ANTI HLA ANTIBODIES IN RENAL TRANSPLANTATION IN LIVING DONOR PROGRAM: A SINGLE CENTRE STUDY|| |
Author(s) -Sanjay Gupta, Mahanta Pranab, Agarwal S K, Mitra D K, Guieria Sandeep
Dept of Nephrology All India Institute of Medical Sciences New Delhi
Renal transplant recipients develop de-novo anti HLA antibodies (HLA abs) that may lead to allograft dysfunction. Because of insufficient routine monitoring the exact incidence of humoral alloimmune responses during allograft dysfunction is still uncertain. Aim was to evaluate the clinical relevance of detection of de-novo HLA Abs during the episode of renal allograft dysfunction. Methods: The study group consisted of 41 non HLA- identical living donor first renal transplant recipients (non- sensitized pre-transplant) with an episode of allograft dysfunction needing allograft biopsy. Anti-HLA class I antibodies (HLA-I Abs) and anti-HLA class II antibodies (HLA-II Abs) were tested by ELISA in study group and in the control group with stable graft function. Results: Immunosuppressive regimen was in Tac/MMF/P in 17/ 41, Tac/Aza/P in 6/41, CsA/MMF/P in 10/41 and CsA/ Aza/P in8/41. None received induction. Out of 41 allograft dysfunctions cases, acute cellular rejection (ACR) was seen in 10/41, C4d was positive in 2/10, Chronic rejection (CR) 9/41, Transplant glomerulopathy (TG) 4/41, Focal segmental glomerulosclerosis (FSGS) 7/41, Calcineurin Inhibitor toxicity (CNI) 8/41 and non specific changes 3/ 41. HLA-I Abs and HLA-II Abs were detected in 14/41 (34%) and 12/41 (29%) respectively. Ten cases had both Abs. Prevalence of HLA-I Abs was 70% in ACR, 44% in CR, 50% in TG, 14% in FSGS and nil in CNI and non specific histology. With HLA-I Abs, odd ratios (OR) for ACR was 8 [95% CI 1.4-157] and HLA-I Abs correlated negatively with CNI. Prevalence of HLA-II Abs was 50% in ACR, 44% in CR, 75% in TG and nil in FSGS, CNI and non specific histology. With HLA-II Abs, the OR for TG was 9 (95% CI 1.04-62.9). HLA-I Abs were present in 13/ 23 of immune mediated injury (ACR, CR, TG) vs 1/18 of non immune graft dysfunction (FSGS, CNI, non specific) with the OR for immune mediated graft dysfunction as 22 (95% CI 2.5-195). Conclusion: Screening for HLA Abs during the episode of allograft dysfunctions discriminate between immune mediated rejection and non immune allograft dysfunction and help in tailoring immunosuppression. HLA Abs mediated allograft injury exists as a spectrum of renal injury.
| 012: RECURRENT URINARY TRACT INFECTIONS IN RENAL ALLOGRAFT TRANSPLANT RECIPIENTS - A RETROSPECTIVE ANALYSIS IN 870 PATIENTS|| |
Author(s) -Sunil Kumar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sanand Bag
Renal Transplant Surgery, Post Graduate Institute Of Medical Education And Research, Chandigarh
Urinary Tract Infection (UTI) is the most common infection in renal transplant recipients. These infections may be recurrent in some recipients. The aim of the study was to analyze the risk factors associated with recurrent UTI in post transplant patients. Materials and Methods: Between January 2003 and June 2009, 1.83% (16/87) renal allograft recipients were identified with recurrent UTI (defined by 3 or more episodes of UTI with in period of twelve months) from the hospital records. These patients were investigated by ultrasonography, retrograde urethrogram, micturating cystogram, urodynamic studies and/or CT scan wherever indicated. Various parameters studied were age, sex, basic disease, presence of pre- transplant UTI, preoperative USG KUB, immunosuppression, causative organism, presence of any anatomical risk factors and management of recurrent UTI. Results - The most common risk factor associated with recurrent UTI was Vesicoureteric reflux (VUR) in 50% of these patients(graft ureter involved in 7 patients & native ureter in 1 patient). Other risk factors identified were urethral stricture, pyonephrosis of the native kidneys secondary to stone disease, submeatal stenosis and bladder diverticulum and exogenous infection secondary to self intermittent cathterisation. In 4 patients, no obvious risk factor could be identified as all investigations were normal. Surgical repair was done in 10 patients, in other 6 patients UTI was treated with antibiotics alone. Conclusion - Renal allograft recipients presenting with recurrent UTI frequently have underlying surgical causes. Aggressive diagnostic measures followed by appropriate surgery would lead to resolution of recurrent UTI’s in these patients.
| 013: VASCULAR RECONSTRUCTION WITH DONOR INFLOW ANAMALY IN LIVING RELATED LIVER TRANSPLANT.|| |
Author(s) -Vishal Kumar Chorasiya, Puneet Dargan, Neerav Goyal, Vivek Vij, Subash Gupta
Centre for Liver and Biliary surgery, Indraprastha Apollo Hospital
Vascular reconstruction is the most crucial step in living related liver transplant (LRLT). The challenge of adequate vascularisation becomes even more so in presence of inflow vascular anamolies like dual or short artery, or type II or III portal confluence etc. We hereby share our experiences of problems we faced during vascular reconstruction due to various donor vascular anamolies and their management in living related liver transplant, their management and outcome. Patients and methods: All patients who underwent living related liver transplant at our centre between September 2006 to July 2010 were included in the study. Result: A total of 330 liver transplants were done at our centre between September 2006 to July 2010. The various anamolies encountered included short donor arteries (2 cases), dual donor arteries (14 cases), type II portal confluence (43 cases), type III portal confluence (8 cases)and all independent sectoral portal veins for right lobe in one case. All these cases were successfully managed with unique techniques like back table arterial extension and dual arterial reconstruction for arterial anamolies and using a y-shaped portal vein extension graft for portal venous anamolies. All had excellent flow checked intraoperatively and postoperatively by routine protocol doppler and CT angiogram. No complications were reported related to the anamolous reconstruction. Conclusion: Variation in normal vascular anamolies are not a contraindication in living related liver transplant and can be dealt with successfully and excellent outcome at experienced centres.
| 014: INVASIVE FUNGAL INFECTIONS IN LIVER TRANSPLANT RECIPIENTS: AN INSTITUTIONAL PROFILE|| |
Author(s) -Anand Ramamurthy, Murali N, Bipin Vibhute, Ajitabh Shrivastava, Anand Khakhar
CLDT, Apollo Hospitals, Chennai
Invasive Fungal Infections (IFI) are uncommon following liver transplant (LT), but associated with a high mortality. Candida is the commonest reported pathogen from western countries. Reports from our country are scarce. We studied the epidemiology, risk factors and outcome of IFI in liver transplant recipients at our institution. Material and Methods Retrospective analysis of 64 LT’s (12 live donors and 52 deceased donors) performed at our institution between March 2008 and July 2010. Patients with IFI i.e. isolated from blood by culture or biopsy confirmation of tissue invasion from surgical or distant sites were included while colonization of urine or sputum was excluded. All patients received prophylactic antifungal therapy with Fluconazole till discharge. Preoperative risk factors, perioperative course, treatment and outcomes were analyzed. Results Eight IFI’s were observed in 7 patients (10.9%). Mucor was the commonest isolate (4), followed by Aspergillus (2) and Candida (2). One patient had preoperative candidemia and 2 developed delayed infection 5 months following transplant. All patients with Mucor had 1 or more comorbid conditions (diabetes, renal failure, cytomegalovirus reactivation or hemochromatosis) and had a poor outcome (75% mortality). Two patients with Aspergillus received prior treatment for rejection (1 with Anti Thymocyte globulin and 1 with steroids) and both survived. One patient with delayed presentation had Candidemia as a pre-terminal event after treatment with multiple antibiotics for septic shock. Conclusion The incidence of IFI in our setup was higher than reported in literature. The epidemiology is different with Mucor being the predominant isolate. One possibility is selection due to routine use of azoles. Further studies are needed to elucidate the contribution of preoperative comorbidities or environmental contamination.
| 015: ACUTE HUMORAL REJECTION IN LIVE RELATED KIDNEY TRANSPLANT: OUR EXPERIENCE WITH RITUXIMAB AND BORTEZOMIB|| |
Author(s) -Mohit Nagpal, D. Mukherjee, Ravi Angrai, Ajay Marwah, R.S. Chahal
Kidney Hospital&Lifeline Institutions, Jalandhar
INTRODUCTION: Humoral rejections are usually difficult to treat and have uncertain outcome using standard antirejection therapies such as ATG or Steroids. We describe our experience of treatment of five cases of acute Humoral rejection (AHR) in a single center live related transplant program using rituximab and bortezomib. METHOD: Acute humoral rejection was diagnosed by increase in Sr Creatinine >20% with histological evidence of acute rejection defined by Banff 97 criteria (update 2005).AHR was diagnosed based on histology consistent with AHR and positive C4d staining in the peritubular capillaries. Test for Donor Specific Antibodies was not carried out since the same was not available in our center. PATIENT 1: 60 yr male was transplanted on 10 May 2000. Donor: sister. No induction . Recd CSA+ Azathioprine+Prednisolone. Baseline creatinine 1.2 mg/dl. Nov 2008 Sr Creat rose to 3 mg/ dl. 3 doses of methylpredisolone 500 mg given with no response. Graft biopsy showed AHR. Treated with 04 doses Inj Rituximab (Roche) 500 mg/ wk. Sr Creat normalized to 1 mg/ dl. Switched to tacrolimus+MMF+Prednisolone. PATIENT 2: 21 yr female transplanted on 18 Dec 08. Donor: father. Induced with 2 doses Daclizumab (Roche). Recd Tac+MMF+Pred. Baseline Creat 0.9 mg/dl. On 24 Feb 09 Sr Creat rose to 2.1 mg/dl. Given total 1 gm inj methylprednisolone with no response. Sr Creat showed progressive rise. Biopsy confirmed AMR. Treated with 04 doses of inj rituximab 500 mg/wk plus 04 inj of Bortezomib 2mg each. Sr Creat normalized to 1.2 mg/dl. PATIENT 3:45 yr female transplanted on 28 May 09. Donor: Husband. Induced with 3 doses of rabbit ATG(Genzyme), 1 mg/kg. Recd Tacrolimus+azathioprine+Prednisolone. Sr Creat decreased to 1.4 mg/dl on day 5 post transplant. Subsequently Sr Creat rose to 7 mg/dl by day 10. Recd 1 gm of inj methylpred and two more doses of rATG with no response. Biopsy showed AMR. One dose Inj rituximab 500 mg and inj Bortezomib 2 mg given and switched to Tac+MMF+Pred. Sr Creat normalized to 1.2 mg/dl over next two wks. Pt refused further doses of Rituximab and bortezomib due to financial constraints. PATIENT 4: 35 yr female tx on 25 Dec 2009. Mother: donor. No induction. Recd tac+MMF+Pred. Sr Creat decreased to 1.8 mg/dl by 5th post op day.Sr Creat rose to 2.5 mg/dl on day 6. Treated with two doses of rATG 1mg/kg. Sr Creat decreased to 1.5 mg/dl,
1 wk later Sr. Creat rose to 4 mg/dl. Biopsy showed AMR. Pt has recd two doses of inj Rituximab 500 mg with two doses of inj Bortezomib 2 mg. Sr Creat came down to 1.6 mg/dl. Patient refused for further treatment because of financial constraints. PATIENT 5:51 yr Male, Tx on 20thjan2009, DONOR: Wife, Induced with 2 doses of Daclizumab(Roche), Recd Tac+MMF+pred, pt discharged with Sr.Creat 1mg% on 10th post-op day. In april’09 Sr.Creat rose to 5mg%, Given 3 doses of 500mg methylprednisolone and Biopsy showed acute humoral rejection, pt was given rATG with no response and subsequently 02 doses of Rituximab 500mg/wk and02 doses of inj bortezomib 2mg was given. Pt responded partially but developed active CMV infection which was treated but further doses of rituximab+bortezomib was not given and pt’s final Sr.Creat was 2.5mg%. RESULTS: We report five cases of biopsy proven acute humoral rejection, out of which four were successfully treated with inj Rituximab and Bortezomib. No adverse events noted. CONCLUSION: Rituximab along with bortezomib can be used safely & successfully to treat cases of AHR in renal transplant recipients. Limitations: DSA testing could not be done and that graft biopsies were not repeated on conclusion of therapy.
| 016: A STUDY COMPARING ACCURACY OF MULTISLICE COMPUTED TOMOGRAPHY AND MAGNETIC RESONANCE IMAGING FOR EVALUATING THE VASCULAR ANATOMY IN 160 LIVING RENAL DONOR|| |
Author(s) -Harsh Jauhari, Sudhir Chadha, Vipin Tyagi
Kideny Transplantation, Sir Ganga Ram Hospital, New Delhi
Multislice CT and MR angiography has replaced conventional invasive angiography for evaluation of live donors. A prospective comparison is needed to find out the better one. AIM To compare the efficacy of MRA and CTA for assessment of renal vascular anatomy. MATERIALS AND METHODS Total 160 consecutive living renal donors were evaluated; 100 had MRA done and 60 underwent CTA. The finding of angiography was compared with operative finding. RESULTS In 100 MRA, 88 had normal renal vessels out of which 14 donors found to have vascular anomalies at the time of donor nephrectomy. The remaining 12 s had abnormal vasculature on MRA but only 6 of them had same operative finding. Of the 60 donors with CTA 54 had normal vasculature and 6 had vascular anomalies. Intraoperative finding found that 6 out of 54 had abnormal vasculature and 2 out of 6 with vessels anomalies had finding from the CT finding- 1 had normal vessels and other had different anomalies.
Thus 20 out 100 (20%) MRA and 8 out of 60 (13.3%) CTA did not have same finding during donor nephrectomy. On statistical analysis CTA was found to have significant advantage over MRA for assessment of renal vascualture status for donor evaluation. CONCLUSION Multislice CTA was more accurate then MRA for comprehensive preoperative evaluation of renal vasculature of renal donors
| 017: LAPARO-ENDOSCOPIC SINGLE SITE DONOR NEPHRECTOMY: INITIAL EXPERIENCE|| |
Author(s) -Deepak Dubey, RP Shrinivas
Department Of Urology First Floor Manipal Hospital Airport Road Bangalore
Laparo-endoscopic Single Site (LESS) Donor Nephrectomy has recently been reported, using variety of access ports. These devices impose a significant cost burden on patients. We herein describe a cost-effective technique, which is carried out without the use of disposable access devices. Materials and Methods With the patient in the standard position for Laparoscopic Left donor nephrectomy, a 5cm trans-umbilical incision is made and the rectus sheath is dissected above and below the umbilicus. A 10 mm trocar (camera port) is inserted at through the umbilicus and 2 dissecting ports (5mm and 10 mm) are inserted through the same incision above and below the camera port. A 45O Storz bariatric laparoscopic lens aids in prevention of clashing of instruments. A Carter-Thompson port closure needle fitted with a needle cap is inserted through the left upper quadrant and used to provide hilar traction. The procedure is carried out as in conventional laparoscopic left donor nephrectomy. Prior to hilar clamping a ligature is taken through the lower pole fat, including the gonadal vein and exteriorized through one of the ports. After complete renal mobilization, hilar vessels are ligated using Hemolok clips and the rectus sheath is incised connecting the 3 ports. The ligature is pulled to deliver the kidney through the umbilical wound. Results The procedure has been performed on 8 donors (mean age 35.3 yrs]. All patients underwent a laparoscopic left sided donor nephrectomy. The mean operating time was 163 mts, mean blood loss 140 ml. The mean warm ischemia time was 4 mts (range 3-5 mts). All 8 recipients had brisk diuresis on completion of transplant and Sr. creatinine levels normalized by post- operative day 4. There was no donor morbidity and all donors were ready for discharge on post-operative day 3. All donors were able to resume their regular activity by 2 weeks following the procedure. Cosmetic outcomes were excellent. Conclusions Our early experience suggests that LESS donor nephrectomy is a feasible option for organ donation. The use of cost-effective innovations as described, allows this technique to be used without the addition of financial burden to patients.
| 018: OUTCOME OF RENAL TRANSPLANTATION IN ALPORT’S SYNDROME-A SINGLE CENTRE EXPERIENCE|| |
Author(s) -vivek kute, manoj gumber, pankaj shah, a runa vanikar, hargovind tri ved i
Department of Nephrology and Clinical Transplantation, IKDRC- ITS Ahmedabad
Outcome of Renal Transplantation in Alport’s Syndrome- A single centre experience Authors VB Kute, MR Gumber, PR Shah1, AV Vanikar and HL Trivedi ABSTRACT Background: There is fear of graft loss due to antiglomerular basement membrane (anti-GBM) nephritis post transplantation (PTX) in patients of end stage renal disease (ESRD) due to Alport’s syndrome (AS). Aims: to evaluated the results of kidney transplantation (KTX) in patients with AS and to evaluate the post transplantation course with regard to patient and graft survival, incidence of anti-GBM nephritis and causes of graft failure. Materials and Methods: A total of 31 patients with AS underwent KTX and result of their transplantation (TX), rejection episodes and the presence of anti-GBM nephritis were assessed in these patients. Results: We evaluated 33 renal grafts transplanted into 31 patients with a pretransplantation diagnosis of AS. Two patients underwent second KTX. Out of these 28 were males, with mean age 22 ±7.9 years. Donors were cadaveric in 6 and living in 27. Over a follow-up of 1, 3, 5, and 10 year (range: 5 months-17 year), the mean serum creatinine were 1.51 ± 0.52 mg%, 1.59±0.26, 1.61±0.30 and 1.63±0.32. Median duration of follow up was 44.1months. 1, 5 and 10 year patient survival rates were 89.71%, 81.32% and 81.32% respectively. 1, 5 and 10-year graft survival rates were 81.2%, 81.2% and 81.2% respectively. Graft failures were due to anti-GBM nephritis (n-4) chronic allograft nephropathy (n-1), acute rejection and cyclosporine toxicity (n-1) Conclusion: In KTX recipients with AS, overall long-term graft and patient survival are acceptable despite risk of anti-GBM nephritis. Anti-GBM nephritis is severe in renal allograft and nearly always results in graft loss. Other causes of graft loss are chronic allograft nephropathy and acute rejection as in any other KTX recipient.
| 019: INTRA-OPERATIVE COMPLICATIONS DURING MINIMALLY INVASIVE DONOR NEPHRECTOMY: TIPS AND TRICKS OF MANAGEMENT|| |
Author(s) -Rajan Sharma, Arvind Gan pule, V Muthu, R Sabnis, Mahesh Desai
Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
Widespread use of laparoscopy for major urological procedures has brought a whole new gamut of complications with it. Access related and vascular complications are one of the most common and fearful complications encountered during laparoscopic surgery. In this presentation we elude to the tips and tricks of managing intra-operative complications during minimally invasive donor nephrectomy. Material and Methods:- Since September 2002 we have performed 645 Laparoscopic donor nephrectomies and 49 LESS donor nephrectomies. In this presentation we elude to the complications encountered by us and how these were managed intra-operatively. The majority of these complications were managed by laparoscopic approach. During a laparoscopic donor Nephrectomy, the gonadal vein got avulsed from its junction with the IVC; the bleeding was controlled by securing the bleeder with maryland forceps and clips. We had an instance of injury to the renal artery; in this case due to the concern of patient safety, the bleeding was controlled by open approach. In another case there was a access related bowel perforation which was managed laparoscopically. Conclusion:- With experience majority of injuries can be managed with laparoscopy. The salient features for managing these injuries are, organize yourself, have good team, be prepared for open conversion, single hand suturing skilled help to tide over the situation.
| 020: DECEASED DONOR ORGAN TRANSPLANTATION WITH EXPANDED CRITERIA DONORS: A SINGLE-CENTER EXPERIENCE|| |
Author(s) -Sidhharth Jain, Kamal Goplani, Pankaj Shah, Manoj Gumber, Hargovind trivedi
Nephrology, IKDRC-ITS ahmedabad
Deceased Donor Organ Transplantation With Expanded Criteria Donors: A Single-Center Experience Introduction: Deceased donor organ transplantation (DDOT) accounts for <4% of renal transplants in India. Many volunteers come forth for organ donation with increasing awareness; unfortunately, the majority are marginal donors, but their rejection would hamper the DDOT program. Judicious use of marginal organs is a challenge for developing countries. Patients and Methods: We performed 29 renal transplants from 21 expanded criteria donors (ECD) out of 115 DDOT between January 2006 to April 2009—10 dual (DKT) and 19 single (SKT). Fourteen donors had hypertension, a cerebrovascular accident as the cause of death, 9 had both, and 4 had diabetes. Mean donor age was 70.3± 8.9 years. Decisions on the procedure were based upon frozen section biopsy in 13 of 21 donors. Mean DKT donor age was 76± 9.7 years versu 64 ± 5.7 years of SKT donors. The native kidney diseases were chronic glomerulonephritis (n = 14), diabetic nephropathy (n = 7), tubulointerstitial nephritis (n = 4) and polycystic kidney disease, focal segmental glomerulosclerosis, lupus nephritis and patchy cortical necrosis, (n= 1 each). Mean recipient age of DKT versus SKT was 43.5 versus 42.3 years. All recipients received rabbit anti-thymocyte globulin, followed by steroid, mycophenolate mofetil/ calcinueurin inhibitor. Results: Over a mean follow-up of 341 days, the mean serum creatinine (SCr) of 25/29 patients was 1.60 mg/dL (range, 1.0 -2.6). The mean SCr of SKT patients was 1.59± 0.63 mg/dL and of DKT, 1.62± 0.48 mg/dL. Ten patients had delayed graft function and 11 had biopsy proven acute tubular necrosis. Seven (24%) patients had rejection (grade 3 Banff update ‘05, type IA; 4, type 2A); 6 responded to antirejection; 1 graft was lost at 7 months due to chronic rejection. Three (10.3%) patients were lost, 1 each due to AMI, sepsis, and CMV disease. Conclusion: In the circumstances of organ shortage, DDOT with expanded criteria donor is a feasible option.
| 021: POST TRANSPLANT DIABETES MELLITUS (PTDM) - ANALYSIS OF RISK FACTORS, EFFECTS ON BIOCHEMICAL PARAMETERS AND GRAFT FUNCTION - AT THE END OF 5 YEARS AFTER RENAL TRANSPLANTATION|| |
Author(s) -Desai Madhav, R Ram, K. V Dakshinamurty
Nephrology, Nizam’s Institute of Medical Sciences
To know the risk factors for PTDM and its effects on biochemical parameters, graft function at the end of 5 years. Materials and Methods: We retrospectively analyzed the 218 records of post renal transplant patients who have minimum follow-up for 5 years. Patients were divided into Diabetes Mellitus (21), PTDM (58) and NONDM-NONPTDM (139 patients). RESULTS: Incidence was 29.4 %. The cumulative incidence was 14.01% and 19.8% at 3, 12 months respectively. The incremental incidence was 14.97% during the first post transplant year. Earliest presentation was 9 days after transplantation. 53.45% of patients were asymptomatic at presentation. The following were found as risk factor- recipient age >36 years, Hepatitis C virus infection, HLA B13, Family history of Diabetes Mellitus, BMI>30 and Calcineurin inhibitors. These were not risk factors - Donor age, Donor sex, recipient sex, Cadaver donor and anti rejection therapy. PTDM group received the same number of antihypertensive drugs and statin dose and had similar Proteinuria. PTDM had no influence on the biochemical parameters. PTDM group had less graft function than NONDM-NONPTDM group. Urinary tract infections were higher in the PTDM group. HLA B13 was first time described as risk factor for PTDM. Graft function was measured by a better method i.e; renogram and MDRD formula (creatinine did not show any difference, but GFR showed the statistically significant graft dysfunction). Though the effect on PTDM on graft survival, patient survival and cardiovascular effects were described by many studies, the PTDM effect on biochemical parameters were not analyzed by many. CONCLUSION: Regular Screening of plasma glucose is recommended from early transplant period and more frequently in the high risk patients. Regular monitoring of Graft function using MDRD formula or isotope renogram is required as PTDM influences the graft function.
| 022: CONCENTRATION CONTROLLED MYCOPHENOLATE DOSING IN RENAL TRANSPLANTATION IN INDIA|| |
Author(s) -G. Basu, V.M. Annapandian, B.S. Matthew, K. Saravanakumar, A. Mohapatra, V.G. David, M. Sundaram, S. Varughese, D.H. Fleming, V. Tamilarasi, C.K. Jacob, G.T. John
Departments of Nephrology and *Clinical Pharmacology, Christian Medical College, Vellore
Background: Weight based dose of mycophenolate has been recommended for renal transplantation.
Aim: To determine the relationship between the outcome events and weight adjusted mycophenolate (MPA) dose and drug exposure (AUC) among renal allograft recipients. Patients & methods: Renal allograft recipients, who underwent transplantation at Christian Medical College Vellore, between January 2003 and December 2009, and received mycophenolate mofetil (MMF) /sodium (MPS) along with prednisolone and tacrolimus, were studied. Extrapolated MPA-AUC0-12h were measured after transplant ( between D5-10, at third month, sixth month, one year, later than one year and ad-hoc)by HPLC and the MMF/MPS dose were adjusted to maintain it between 30-60mg.h/L. The cumulative drug exposure and MPA dose and dose controlled AUC (Dc-AUC = MPA-AUC0- 12h/Dosemg/Kg) were calculated up to the day of outcome events (rejections, infections, leucopenia or diarrhea) by applying trapezoidal rule, for the event-cases and respective controls. The difference of the mean cumulative drug exposure and dose between the cases and controls was analyzed. Results: Of the 235 renal allograft recipients (mean age 36.6±12.1 years; M:F=3:1) 90.6% received renal allografts from living related donors (with HLA AB =2 Ag match - 66.8%) and 9.4% from deceased donors. Most patients received induction therapy (74.5%)(predominantly basiliximab) and prednisolone with tacrolimus (83.0%) and MMF (51.1%) or MPS (48.9%). The recipients were followed up for a mean of 24.9±13.5 months. The mean serum creatinine (mg/dl) was 1.26±0.50 at 1 month, 1.21±0.32 at 6 months, 1.24±0.38 at 1 year, 1.27±0.41 at 2 years and 1.35±0.1 at 5 years post transplant. Patients switched from MPA to Azathioprine (9.4%) at a median of 4.9 (2.6-38.3) months after transplantation predominantly due to financial reasons (6.8%) and diarrhea (2.6%). At the first week, three months, six months, one year and later than one year respectively, the mean dose were (38.6±8.1, 39.4±13.7, 29.3±9.5, 24.9±8.7 and 24.1±10.1 mg/kg), the mean MPA-AUC0-12h were (38.1±16.5, 59.0±28.1, 56.9±23.9, 52.7±18.3 and 50.3±18.2 mg.h/L). Overall, patients taking MPS achieved significantly higher Dc- AUC than MMF (2.0±1.0 vs. 1.7±1.1 Kg.h/L: p<0.001). The cumulative exposure (MPA-AUC0-12h) till the event was significantly lower among the rejecters (16.5%) compared to the non rejecters (37.5±17.7 vs. 44.5±8.2 mg.h/L: p=0.027), but not the cumulative dose or Dc- AUC. This difference persisted even for early rejections (<3 months: 9.4%) and after controlling for the effect of induction. The cumulative MPA dose and exposure were not significantly different between patients who developed urinary tract infections (20.0%), CMV disease (8.5%), Herpes infections (5.5%), BK virus nephropathy (2.1%), systemic mycoses (.6%) or leucopenia (21.7%) and their respective controls. Conclusion: Among Indian renal allograft recipients, despite use of similar weight based dose of MPA salts, patients who achieved lower MPAAUC0-12h (even within therapeutic range of 30- 60mg.h/L) were at a higher risk of suffering rejections. Therapeutic drug monitoring of MPA during the early post transplant period is helpful in reducing rejection rates among Indian allograft recipients.
| 023: OUTCOME OF RENAL TRANSPLANTATION IN INDIAN CHILDREN WITH PRIMARY FOCAL SEGMENTAL GLOMERULOSCLEROSIS - A SINGLE CENTER EXPERIENCE|| |
Author(s) -Anil Vasudevan, Arpana Iyengar, Antony Rozario, Santosh Olakengil, Kishore Phadke
Department of Surgery, St. John’s Medical College Hospital
Recurrence of focal segmental glomerulo-sclerosis (FSGS) after renal transplantation is seen in 30-40% of pediatric patients and is associated with allograft loss in a significant proportion of this subset (50%). To our knowledge, there has been no study examining recurrent FSGS and graft outcome with renal transplantation in Indian children. Methods: A total of forty patients were transplanted over the ten years from 1999 to 2008, of which 11 children (25%) had biopsy proven non-familial FSGS. Data collected included the demographic profile of patients, time taken to reach ESRD, timing of transplantation, details of immunosuppression, complications, recurrence if any, measures taken in case of recurrence, and graft and patient survival. Results: Following transplantation, four (40%) patients developed recurrence of nephrotic syndrome (NS). We observed heterogeneity in the age at onset of NS, time to reach end-stage renal disease, and age at the time of transplant between those who had and did not have recurrences, but our small sample size precluded any definitive conclusions. All of the four patients were treated with plasmapheresis but the high cost limited the duration of therapy. In addition, they received cyclophosphamide instead of azathioprine or mycophenolate for three months. One patient lost his graft owing to recurrence while two (50%) of the four treated patients recovered completely and one remained proteinuric at the last follow- up. Conclusion: We conclude that recurrence of FSGS after renal transplantation remains an important cause of decreased graft survival and also that the cost of therapy is a limiting factor in providing optimal treatment for recurrence.
| 024: SYSTEMIC FUNGAL INFECTIONS IN RENAL TRANSPLANT RECIPIENTS - 18 YEAR RETROSPECTIVE ANALYSIS|| |
Author(s) -Anupama Kaul, R K Sharma, Jai Suresh, Vineeta Agarwal, R Marakh
To identify the etiology and outcomes of Systemic Fungal Infections (SFI) in live donor renal allograft recipients 2. To identify the risk factors for SFI in renal allograft recipients Settings: Urban tertiary care center in northern India Design: Eighteen year retrospective analysis of all patients admitted with SFI from January 1991 to December 2009. Methods: Data of 1204 renal allograft recipients were retrieved from computerized Hospital Information System (HIS). All post renal transplant patients with ‘fungal infections’ as a primary discharge diagnosis were included in the study. In patients with more than one admission for fungal infection only the first episode was included. Patients with mucocutaneous fungal infections were excluded from the study. A total of 117 episodes were included. Renal allograft recipients who did not have SFI were included in the control group. A total of 36 parameters were compared between the two groups. No antifungal prophylaxis was used. Statistical analysis used: Results were expressed as mean ± SD. Univariate analysis was performed with chi- square test or fisher’s exact test for discrete variables and student t-test for continuous variables. A p value <0.05 was considered statistically significant. Results:Incidence of SFI was 9.7%. Most common presenting manifestation was fever not responding to antibiotics (69%). The mean age of the control population was 36.9 years and the mean age of those patients with SFI was 44 years. 17% of fungal infections occurred in the first month following transplantation and 56% occured with in the first 6 months. Lung and gastrointestinal tract were the most common primary sites of isolation. Candidia sp 51.3 %, Aspergillus sp 31.6 %, Zygomycetes sp 7.69 %, Pneumocystis sp 3.4 %, Cryptococcus sp 2.6 Pheohypomycosis 2.6 % and Histoplasmosis 0.9 % were the etiological agents for SFI. Candidiasis caused majority of in-hospital mortality (58 %). The overall in-hospital mortality following hospitalization with fungal infection was 54 % (63 deaths). Age, history of tuberculosis, CMV disease, acute rejection, use of induction agents, maintenance triple immunosupression with tacrolimus, mycofenolate mofetil and steroids were identified as significant risk factors for occurrence of SFI.
| 025: DURATION OF DELAYED GRAFT FUNCTION AND CLINICAL OUTCOMES IN DECEASED DONOR KIDNEY TRANSPLANTS|| |
Author(s) -Deepa Jayaram, Fu Luan, Mallika Kommareddi, Randall Sung
Transplant Nephrology, University of Michigan Medical Center, Ann Arbor, MI, USA
MGM New Mumbai Hospital, Sector 3, Vashi, Navi Mumbai
We studied the impact of duration of delayed graft function (DGF) on clinical outcomes namely kidney graft and patient survival. Material and Methods: All deceased donor kidney transplants between 1/1/02 to 12/31/08 were included. DGF is defined as the requirement for dialysis within the first week post transplant. Duration of DGF (DDGF) is calculated as days between the last post transplant dialysis and the day of transplant. Kaplan-Meier and multivariate Cox regression analyses were performed. Results: Of 683 patients, 180 (26.4%) had DGF, median duration 5 days. Kaplan-Meier analysis showed that DGF was significantly associated with patient death (log-rank, p=0.02) but not with death-censored graft survival (log- rank, p=0.30). Multivariate Cox regression analyses showed that DDGF was associated with a nearly significant risk of patient death (HR 1.01, 95% CI 1.00, 1.02, p=0.06) but not with death censored graft survival. Multivariate analysis conditioned on patient survival to 90 days post transplant showed that each added day of DGF is associated with a 2% increased risk of patient death (p< 0.01) (Table 1). DDGF is also associated with an increased risk of Acute Rejection (AR) within 6 months post transplant (HR 1.04, 95% CI 1.02, 1.06, p < 0.01). Analysis HR 95% CI p DGF (Y/N) 1.23 0.79, 1.89 0.36 Duration of 1.02 1.01, 1.03 < 0.01 DGF Recipient Age 1.07 1.05, 1.09 < 0.01 at TxP Recipient Race 1.95 1.24, 3.06 < 0.01 African American Diabetes 1.47 0.95, 2.28 0.09 PVD 1.84 1.13, 2.98 0.01 CAD 0.92 0.53, 1.62 0.78 Donor Age 1.00 0.99, 1.01 0.80 Table 1. Time to Patient Death conditioned on 90 days post transplant survival predicted by Presence or Duration of DGF Conclusion: Our study suggests that DDGF is a significant predictor of late patient death. The results support efforts to reduce DDGF, early diagnosis and management of AR to improve post transplant clinical outcomes.
| 026: EARLY ALLOGRAFT ADAPTIVE HYPERFILTRATION INDEPENDENTLY PREDICTS ONE-YEAR GRAFT OUTCOME IN LIVING RELATED RENAL TRANSPLANTATION|| |
Author(s) -G Basu, L Jeyaseelan, Sishir Gang, Dolly Daniel, Santosh Varughese, Madhivanan Sundaram, Antony Devasia, Nitin Kekre, Mohan Rajapurkar, V Tamilarasi, Chakko K Jacob, George T John
Department of Nephrology, 2Biostatistics, 4Transfusion Medicine and Immunohematology and 5Urology Christian Medical College, Vellore, India Department of 3Nephrology, Mujibhai Patel Urological Institute, Nadiad, India
Background: In renal transplantation, one year graft function is a good predictor of long term graft outcome. We describe the association between early post transplant graft performance and one year graft function in living related renal allograft recipients of Indian subcontinent. PATIENTS AND METHODS: Consecutive living related renal allograft recipients, who underwent transplantation at Christian Medical College, Vellore from January to December 2007 were studied. Donor GFR before transplantation and recipient GFR after transplantation were calculated using the four-variable Abbreviated MDRD equation. The recipients’ baseline transferred GFR (tGFR) refers to the donor GFR transferred during transplantation after standardizing for the recipient’s body surface area. Suboptimal graft status was defined as a =33% increment of GFR from the baseline and /or presence of proteinuria of =500mg/24 hours at one year post transplant. The Normogram was then validated by bootstrapping to subgroups of the same recipients and in the next consecutive 75 living related renal allograft recipients. RESULTS: A total of 77 consecutive patients (M:F =2.7:1, age 33.1±11.5 yrs, BSA 1.54±0.19 sq.m.) received renal allografts from living related donors (M:F=1:1.96, age 39.7±11.2 yrs, BSA 1.60±0.17 sq.m.) with a mean pre-transplant eGFR of 85.9±17.7ml/min. The mean donated eGFR is 42.9±8.9ml/ min. The mean baseline transferred GFR (tGFR) is 49.1±12.8 ml/min/1.73sq.m.The mean (±SD) GFR and the mean percentage increment in GFR from baseline tGFR (%?GFR) at days 4, 8, 15, 6 month and 1 year GFR were 71.7±29.2 ml/min (67.4%), 66.6±23.7 ml/min (57.1%), 67.3±18.0 ml/min (59.0%), 67.1±15.4 ml/min (57.6%) and 65.9±15.9 ml/min (55.2%), respectively. 27 (35.1%) recipients had suboptimal one year graft status. The %?GFRs in the second week of transplantation (D8- D15) were significantly associated with the one-year graft status (O.R. 3.3-6.2). A normogram constructed using optimal cut-off %?GFR values from D8 to D15, where =5 plots falling =53% increment significantly and independently (by multiple logistic regression) predicted one-year suboptimal graft status (sensitivity SN=81.5%, specificity SP=62.0%, positive predictive value PPV=53.7%, negative predictive value NPV=86.1% (95%CI=71.3-93.9) and O.R. =11.4(2.0-64.8)). Cut-offs based on serum creatinine (D8-D15), average second week eGFR and biopsy proven acute rejections did not significantly discriminate between patients with optimal and suboptimal one-year graft states. This normogram was validated using the first six months’ recipients (SN =80.0%, SP =61.8%, PPV =48.0%, NPV =87.5%, O.R. =6.5(1.5-27.3)), the second six months’ recipients (SN =83.3%, SP =62.5%, PPV =62.5%, NPV=83.3%, O.R. =8.3 (1.3 - 51.7)), randomly selected 40 patients from the 77 recipients (SN =81.8%, SP =65.5%, PPV =47.4%, NPV=90.5%, O.R. =8.6(1.5-47.4)), the next consecutive 75 renal allograft recipients (January-December 2008)(SN =90.5%, SP =70.4%, PPV =54.3%, NPV=95.0%, O.R. =7.3 (1.7 - 31.2)) and 60 consecutive recipients from another center (MPUH, Nadiad, 2006)(SN =60.7%, SP =84.4%, PPV=77.3%, NPV=71.1%, O.R. =6.5(1.5-27.3)). CONCLUSION: In living related renal transplantation, early graft adaptive function reliably and independently predicts one year graft outcome. This prediction would help in designing patient-specific follow-up protocols and need- directed care in a resource-scarce but high-demand setting such as India.
| 027: A STUDY OF LIVER DISEASE IN RENAL TRANSPLANT RECIPIENTS IN A TERTIARY CARE CENTRE|| |
Author(s) -Prof. M.Jayakumar, Dr.Jayalakshmi Sesadri, Mohamed Haris
Nephrology, Madras medical college
BACKGROUND Infections and liver disease are still major problems in renal transplant recipients. Liver disease is reported in up to 60% of transplant recipients and carries a high mortality. Several types of liver disease can occur. The most common are acute and chronic hepatitis. Acute hepatitis is most commonly due to hepatotropic viral infections and drugs. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are the most important causes of CLD in renal transplant patients and have a deleterious effect on graft and patient survival in the long run. Also, liver disease is the leading cause of death in these infected patients. AIMS 1. To analyze the clinical profile, etiology and outcome of renal transplant recipients presenting with clinical and/or biochemical evidence of hepatic dysfunction. 2. To assess the impact of HBV and HCV infection on patient and graft survival in a group of kidney transplanted patients. 3. To compare the survival rate of infected patients with noninfected patients. MATERIALS AND METHODS This study is a prospective study conducted in the department of nephrology during the time period from august 2007 to December 2009. Renal transplant recipients with clinical or biochemical evidence of acute hepatic dysfunction were included in the study. A detailed diagnostic workup done was performed to establish the etiology of hepatic dysfunction. Patients were analyzed for pretransplant liver status (which included Liver Function Tests, viral serology, vaccination status, risk factors for liver disease). All the diagnostic work up done for liver dysfunction in the post transplant period were noted for detailed analysis (which included LFT, ultrasonogram of Abdomen, viral serology, UGI scopy, Renal biopsy, liver biopsy etc.). Outcome was assessed in terms of resolution of liver dysfunction, allograft function and mortality at defined time periods (at the time of presentation, 3 and 6 months after presentation).
| 028: FACTORS DETERMINING SHORT TERM GRAFT FUNCTION IN RENAL TRANSPLANT RECIPIENTS|| |
Author(s) - S.Jayalakshmi, Edwin Fernando, V.Baiaraman, R.Manorajan, R.Venkatraman, T.Balasubramanian, A.Vengadesan M.Jayakumar, .
Madras Medical college. Chennai.
Aim of the study: To determine the factors that influence graft functioning at 1 year in live related Donor Renal Transplant. Materials and Methods: Retrospective Study. The patients who underwent Live Donor Renal Transplantation between March 2005 and February 2007 were taken for the study. Demographic and clinical data were recorded for all the donors and recipients. Other important data such as Donor GFR(by DTPA), HLA typing and crossmatching, intraoperative details and ischaemic times were noted. The immediate post operative details including the daily urine output, other post-op events and the profile of creatinine changes were recorded in detail. The occurrence of graft dysfunction and infections with time of occurrence and relevant investigations done were recorded in detail. All these data were fed into a master chart and statistical analysis was done with Student t test, Chi square test, One way ANOVA method for analysis of variance and Cox regression model for Multivariate analysis. Results and conclusions: There were a total of 89 renal transplantations (Males: 68). 9 patients died within the first year and one underwent graft nephrectomy. Excluding these ten patients 79 were taken for analysis. Mean recipient age was 28.58±8.59 years. Mean donor age was 44.5±7.81 years. Donor age, Donor GFR and Discharge creatinine influenced 1 year graft function significantly. Events such as Acute Rejection and Graft Dysfunction influenced 1 year graft function significantly. Recepient age and First day urine output did not influence the graft function at one year.
| 029: ASYMPTOMATIC EXTRA RENAL VASCULAR PATHOLOGY IN LIVING RENAL DONORS|| |
Author(s) -Mukut Minz, Ashish Sharma, Sarbpreet Singh
Transplant Surgery, PGIMER
Preop CT angiography may often lead to detection of asymptomatic pathology in the renal donor creating dilemma for proceeding with organ donation. The present report describes asymptomatic extra renal vascular pathology in living renal donors. Materials and Methods: From July2005 to March2009, all donor CT angiographies performed at our institute were reviewed for presence of extra renal vascular anomalies. Results: Out of 714 CT angiographies, 10(1.4%) had vascular abnormalities. The anomalies were splenic artery aneurysm in 5, Coeliac and/or Superior mesenteric stenosis in 5 and internal iliac artery aneurysm in 1 patient. Mean age of donor 45.5+10.8yrs M:F3:7. All donors were otherwise healthy and asymptomatic with normal blood pressure and other preoperative investigations. Laparoscopic splenectomy was performed in 2 patients and ligation of splenic artery in one patient along with laparoscopic donor nephrectomy. Two patients with small splenic aneurysms (<1cm) were kept under surveillance. The patient with internal iliac artery aneurysm underwent open iliac aneurysm resection after nephrectomy. All patients with celiac and/or superior mesenteric artery stenosis were taken up for organ donation without any intervention for the arterial stenosis. All donors are alive at last FU with no morbidity related to the operative procedure. The mean recipient creatinine at discharge and last FU was 1.2+0.14mg% and 1.5+0.41mg% respectively. Conclusion - Presence of extrarenal vascular pathology in renal donors may not be a contraindication to organ donation. These pathologies can be given suitable therapy at the time donor surgery leading to cure of the unforeseen disease in the donor.
| 030: CONCENTRATION CONTROLLED MYCO- PHENOLATE DOSING IN PEDIATRIC TRANSPLANTATION IN INDIA|| |
Author(s) - Anajli Mohapatra, Gopal Basu, V.M. Annapandian, Binu S. Mathew, K. Saravanakumar, Vinoi G. David, Madhivanan Sundaram, Santosh Varughese, Denise H. Fleming, V. Tamilarasi, Chakko K. Jacob, George T. John
Department of Nephrology, Christian Medical College, Ida Scudder Road, Vellore
Comparative data regarding MPA dosing and AUCs in pediatric vs. adult kidney allograft recipients especially in India, are lacking. We compared the relationship between the mycophenolate (MPA) dose and drug exposure (AUC) among pediatric and adult renal allograft recipients. Patients & methods: Renal allograft recipients, who underwent transplantation at Christian Medical College Vellore, between January 2003 and December 2009, and received mycophenolate mofetil (MMF) /sodium (MPS) were studied. Extrapolated MPA-AUC0-12h were measured after transplant (between D5-10, at third month, sixth month, one year, later than one year and ad-hoc)by HPLC and the MPA dose were adjusted to maintain it between 30-60mg.h/L. Dose controlled AUC defined as AUC achieved per unit weight based dose (Dc-AUC = MPA-AUC0-12h/Dosemg/Kg) was calculated. The difference of the mean cumulative drug exposure, dose and Dc-AUC between pediatric and adult recipients was analyzed. Results: Of the 235 renal allograft recipients, there were 221 (94.0%) adult (age>18 years) and 14 (6.0%) pediatric recipients. The pediatric patients had a mean age of 15.5±3.1 years; M:F=1.3:1. There were no deaths or graft loss among pediatric patients. Among the pediatric patients 92.9% received renal allografts from living related donors. 57.1% of pediatric patients received induction therapy (predominantly basiliximab) and prednisolone with tacrolimus (71.4%) and MMF (57.1%) or MPS (42.9%). The recipients were followed up for a mean of 31.8±13.2 months. Acute rejection was observed in 7.1% only. The mean serum creatinine (mg/dl) was 1.02±0.32 at 1 month, 1.02±0.27 at 6 months, 1.04±0.27 at 1 year, and 1.15±0.24 at 3 years post transplant. For the pediatric patients, at months 1, 3, 6, 12, 24 and >24 respectively, the mean dose were (43.8±17.2, 45.6±14.9, 32.5±12.5, 24.9±11.9, 20.1±13.6 and 23.4±8.0mg/kg), the mean MPA-AUC0-12h were (35.8±15.9, 62.2±34.7, 66.8±36.1, 55.7±28.3, 51.7±49.8 and 56.7±20.2 mg.h/ L). The Dc-AUC was substantially lower during the immediate post transplant period (<1 month) among the pediatric patients compared to the adult patients (0.7±0.2 vs. 1.1±0.5, p=0.04). However subsequently the Dc-AUC was not statistically significantly different from the adult group respectively (3 months: 1.4±0.6 vs. 1.7±0.8; 6 months: 2.2±1.1 vs. 2.1±1.3; 12months: 2.4±1.3 vs. 2.2±0.9; >12 months: 2.4±1.0 vs. 2.3±1.0; all p =NS), may be because of small numbers in the pediatric group. Conclusion: During early post transplant period, Indian pediatric renal allograft recipients achieve a lower MPAAUC0-12h per unit dose compared to adults, but not later. Since adequate MPAAUC0-12h in early post transplant period reduces rejection rates, this finding is of importance.
| 031: DECEASED ORGAN DONATIONS COUNSELING - THE HYDERABAD EXPERIENCE|| |
Author(s) -Raghuram Kuppuswam, Sunil Shroff, Lalitha Raghuram
MOHAN Foundation, 6-3-634/B-1/A, II Floor, Green Channel, Khairatabad Hyderabad
MOHAN Foundation was established in Hyderabad in 2002. With limited resources, it embarked upon public and hospital education programs, so that they were sensitized on the need for deceased organ donation, with an appeal for active participation. Between 2004 and August 2010, 162 families of brain dead patients were counseled by MOHAN Foundation Hyderabad Transplant Coordinators, out of which 96 families consented to donate their loved one’s organs. While the families came from different socio-economic status, geographic locations and literacy levels, some of the important challenges have been (a) lack of awareness among public about the concept of “Brain Death” (b) lack of knowledge about organ donation (c) lack of interest among the medical fraternity to declare “brain death” (d) inadequate participation by hospitals in the organ donation movement, and (e) lack of proactive measures by government. This gives us some very interesting insights on the different approaches to be adopted to strengthen “Deceased Organ Donation” program in the country. SUMMARY: MOHAN Foundation, Hyderabad has experience with counseling the families of “Brain Dead” patients. Within five years, it has counseled 162 families, out of which consent was obtained from 96 families, translating to 174 kidneys, 8 hearts, 65 livers and 244 eyes. In addition, 38 heart valves were obtained, the most recent one being a heart valve donation from a 4 days old non-heart beating baby donor.
| 032: COMMUNICATING DECEASED ORGAN DONATION-WHAT WORKED AND WHAT DIDN’T|| |
Author(s) -Lalitha Raghuram, Raghuram Kuppuswam, Sunil Shroff,
MOHAN Foundation, 6-3-634/B-1/A, II Floor, Green Channel, Khairatabad Hyderabad
MOHAN Foundation established in Chennai, India, in 1997 initiated its operations in Hyderabad in 2002. Between 1997 and 2002, we printed brochures on organ donation in English, Tamil, Marathi and Hindi, along with booklets on “Kidney Transplantation” in English and Tamil. Over 100, 000 Donor Cards were printed and distributed. A short film on organ donation was made with help of a famous cine artiste. Several audio-visual presentations were made in high schools, colleges, hospitals and large organizations. A survey on “Public Attitudes on Organ Donation” was also conducted. When the MOHAN Foundation office was started at Hyderabad in 2002, a similar exercise was implemented. In addition to brochures and donor cards, multi-colour posters were printed and distributed in hospitals. Annually, organ donor families were honoured in the presence of a dignitary or a celebrity. When every organ donation happened, MOHAN Foundation promptly collected photographs of donors, and wrote donor centric storiesand published them. Gradually, electronic media picked up these stories and started telecasting them nationally and regionally. In addition, a dynamic website is maintained. Our communication channels and materials have helped us give a lot of visibility. Our public relations with media have paid off. MOHAN Foundation has been viewed as an organization that is serious about its business. In all, public’s attitude towards organ donation has been extremely positive. Has this alone lead to increased organ donations? Certainly not. Apart from good communications, our experience reveals that a combination of factors has lead to enhanced organ donations. The factors responsible are (a) ethical and transparent operations (b) prompt responses (c) professional approach, and (d) timely feedback. SUMMARY: MOHAN Foundation initiated a multi-pronged approach to create awareness about organ donation. Media was involved in all of these approaches. While these initiatives lead to enhancing the image of organ donation movement, and elevated the status of MOHAN Foundation, it did not lead to enhanced organ donations. Factors like ethical and transparent operations, prompt and professional response and timely feedback are noteworthy.
| 033: ROLE OF RIRS IN KIDNEY STONE DISEASE BEFORE LAPAROSCOPIC DONOR NEPHRECTOMY|| |
Author(s) -Aman Gupta, Anant Kumar, Anshuman Agarwal, Anil Gulia, Vikas Jain
Urology And Transplant, Fortis Hospital.Delhi
Sometimes only available donor has small stones in the kidney. It is desirable to makedonor kidneys free of stones. We evaluate the role of RIRS in calyceal stones of donors. Patients and Methods 5 live related donors with renal stones were accepted for renal transplantation. One patient had an asymptomatic renal stone, with 4 other being synptomatic. Maximum stone size was 1.2 cm, average being 0.8 cm. Average number of stones were 1.4. Average hospital stay was 2.2 days. All patients underwent RIRS and were rendered stone free before undergoing donor nephrectomy. DJ stenting was done in
2 cases and were removed after an average of 7 days. The laparoscopic donor nephrectomy was performed after a minimum period of one month after RIRS. Results All donors were rendered stone free. The follow up ultrasound at 3 months did not show stone in any recepient. The maximum follow up is 17 months and graft funcyion has remained normal in all. Conclusion RIRS is a minimally invasive technique for rendering donor kidneys stone free and can be accepted for transplantation in selected cases. Short term results in such transplanted kidneys show normal graft function Key words Renal transplant, donor kidney, renal calculus, RIRS.
| 034: RANDOMISED COMPARATIVE STUDY COMPARING EFFICACY OF OXYTETRACYCLINE INSTILLATION VERSUS “WAIT AND WATCH” POLICY IN MANAGING PERSISTENT ABDOMINAL DRAINS IN POST RENAL TRANSPLANT RECIPIENTS|| |
Author(s) - Sand i p Saxena, Shweta Tripathi, Amit Hartalkar.
CHRC 460 Goyal Nagar, Near Shakuntala Devi, Shiv mandir ki line, Indore
Abdominal drains persistently draining in large volume beyond 5-6 days is common problem in postrenal transplant patients. After ruling out urine leaks, large perinephric collection etc persistent drain without definitive etiology does not have much therapeutic options other than wait & watch, betadine instillation or oxytetracycline instillation. No definitive data available to guide which regimen is superior to others Study Design: Identified persistent abdominal drain in renal transplant recipient if drain volume per 24 hour is more than 200 ml on day 5 post operative. Nineteen patients were enrolled and randomized in 2 groups - Group A - treated as “wait
6 watch” & Group B - where injectible Oxytetracycline 10 ml instillation in drain tube daily for 3 days starting D5. Treatment response was considered positive if drain volume decreased to less than 50 ml / 24 Hr on or before D7. Drain time was calculated in days from D5 to the day on which response seen i.e. 24 hour drain volume less than 50 ml. Results: Group A & Group B had 10 & 9 patients respectively. Baseline characteristics in 2 groups were comparable. In Group A, 3 patients from total 10 responded positively (30%) compared from Group B where
7 patients responded positively from total 9 (77.8%) and the difference was significant (P=0.037, Pearson Chi- Square test) Drain time in Group A ranged from 2 days to 9 days (mean 8.6; Standard deviation 3.47) and in Group B ranged from 4 days to 14 days (mean 4.22; SD 2.28). This difference was significant (p=0.005, t-test for eqaulity of means) showing Oxytetracycline is an effective option in reducing days with persisitent drain. Conclusion: This study showed that using Oxytetracycline instillation in persistent abdominal drain is postop renal transplant recipients is effective in reducing drain time when compared with “wait & watch policy.
| 035: LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: TRENDS IN DONOR MORBIDITY|| |
Author(s) -Prasun Ghosh, Ahlawat Rajesh, Khera Rakesh, Mana v Suryavanshi, Vijay Kher
Urology & Kidney institute, Medanta-The Medicity, New Delhi.
To review a single-surgeon 10-year experience with laparoscopic live donor nephrectomy detailing clinical results, as well as the trends in donor morbidity. Since 2000, laparoscopic donor nephrectomy has had a significant impact on the field of renal transplantation, resulting in decreased donor morbidity, without jeopardizing procurement of a high-quality renal allograft. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging with a steep learning curve. Methods: Records from 900 consecutive laparoscopic donor nephrectomies were reviewed with evaluation of donor and outcomes. Trends in donor complications were assessed over time by comparing the outcomes between three equally divided groups. Results: All 900 kidneys were procured and transplanted successfully with only 17 (1.9%) open conversions. Mean operative time was 143(60-340) minutes, estimated blood loss 132(25-600) mL, warm ischemia time 140(60-450)sec and donor length of stay was 3.7 days. There was a significant decline in post operative complications with experience. The intraoperative events like venous bleeds Conclusion: Laparoscopic donor nephrectomy has remained a safe, less invasive, and effective technique for renal allograft procurement. Over our 6-year experience and with specific refinements in surgical technique, we have observed a decline in donor morbidity following laparoscopic live donor nephrectomy.
| 036: COMPARISON OF LONG-TERM OUTCOMES BETWEEN SPOUSAL AND PARENTAL DONOR RENAL TRANSPLANTS: SINGLE- CENTER EXPERIENCE.|| |
Author(s) - Umapati Hegde, Kalpesh Gohel, Sishir Gang, Mohan Rajapurkar
Muljibhai Patel Urological Hospital, Nadiad,
Renal transplant is limited by the availability of the donor kidneys. Better the HLA match better the long-term outcome. The spousal kidney is increasing used as an important source of Live Donors worldwide in the current era of organ shortage. This study was to compare the long-term outcomes of spousal donor grafts with other parental grafts. Methods: Out of 803 renal transplants, 285 parental donor transplants and 115 spousal donor transplants were performed between January 2000 to December 2008. Second transplants were excluded. The clinical characteristics and long-term survival rates for spousal transplants were compared with those for other parental transplants, and risk factors affecting graft survival were assessed. Results: Spousal donors were younger than parental donors (42.12±8.9 vs. 52.03±8.1years (p < 0.01).Spousal donors had a significantly higher average number of human leukocyte antigen (HLA) mismatches (3.5±0.7 vs. 1.9±0.3: p< 0.01).Wife to husband donation was predominant (88.7%). The1year, 5 years and 10years Graft survival rates were similar (p-0.18) with parental donor (97.2%, 84.2%, 58.27%) compared to spousal donor (93.9%, 81.5%, 61.5%). The 1year, 5 years and 10years patient survival rates were better (p-0.023) with parental donor (97.8%, 91.3%, 86.1%) compared to spousal donor (95.6%, 84.2%, 73.9%). More spousal recipients received induction (40.1% Vs11.2%:p<0.001 ) and Mycophenolate(48.7% Vs 36.5%: p<0.03).Biopsy-proven acute rejection rates in parental and spousal donors were (34.7% vs. 30.4%, p - NS). The degree of HLA mismatching, the spousal donor type or donor age did not significantly affect the graft survival. Conclusion: Renal transplants from spousal donors are a good alternative to overcome the organ shortage. Poorly matched spousal donors have similar survival rates compared to HLA-haplo- matched parents.
| 037: POST TRANSPLANT INFECTIVE COMPLICATIONS FOLLOWING CADAVER RENAL TRANSPLANTATION|| |
Author(s) -Sailaja K, Purna P A.S. Murthy, VS. Reddy, Sahariah S.
Transimmune, #8 First Floor, Dhruvatara Apts. Somajiguda Hyderabad
Infections remain a significant cause of morbidity and mortality following organ transplantation. This single centre study was designed to evaluate the incidence of opportunistic infections, their causative pathogens and interventional management during post transplant period in 53 patients who had underwent cadaveric renal transplantation at KIMS hospital between October 2006 and June 2010.The follow-up period is one month to 43 months. All the patients received induction therapy with IL-2 receptor antibody and maintenance immunosuppressant consisted of CNI, MMF and Prednisolone.32% patients had at least one infection episode.12% occurred in early post operative period, 20% in first 6 months and 16% after 6 months. UTI was most common, occurring in12 (22.6%), Fungal infections in 4 (7.5%), respiratory tract infections in 3 (5.6%), CMV in1 (1.8%) patient and Tuberculosis in 1 (1.8%). Overall mortality was 20.7%, of which infection related mortality was 13.2%. Mortality was associated with fungal infections in 4 patients, CMV in one patient, Varicella zoster infection (VZV) in one and cellulitis in one. Escherichia coli was the most frequently isolated organism. CMV is the most common opportunistic pathogen found in transplant recipients, however in our study group the occurrence was less may be due to the prophylaxis (Valganciclovir) and preemptive (Periodic screening) strategy employed at our centre. Infectious complications in renal transplant recipients continue to play significant role on patient outcome and preventive measures have improved the outcome.
| 038: UNMASKING THE VILLAIN- ANTIIDIOTYPI ANTIBODY IN A PROSPECTIVE RENAL TRANSPLANT RECIPIENT.|| |
Author(s) -Anila Mathan, Dolly Daniel, Mary Purna Chacko, Shanthi R, George T John
Department of Transfusion Medicine & Immunohematology, CMC, Vellore
Anti-idiotypic IgM antibodies to anti-HLA antibodies, interfering with the detection of the latter have been previously described. Such cases may not be identified on routine platforms. We report a case where pre treatment of serum with Dithiothreitol (DTT) unmasked the anti HLA antibody. Case report: A donor recipient crossmatch was performed using the complement dependent Cytotoxicity (CDC) platform on a 29 year old male with end stage renal failure. Results of the crossmatch with and without DTT showed the presence of a weak IgM antibody. Two weeks later a negative CDC crossmatch was observed. On treatment of serum with DTT a positive reaction was obtained indicating an IgG antibody possibly masked by an antiidiotypic antibody of IgM class. A fortnight later, the CDC showed positivity both prior to and following DTT treatment. However, the positivity was significantly greater while using serum treated with DTT. Donor specific antibody testing using donor lysate and the screen on the luminex platform were performed using patient’s serum with and without DTT. A similar trend was observed with the DTT treated serum showing a significantly higher median fluorescence intensity indicating an IgG anti HLA antibody being masked by an IgM antiidiotypic antibody. Conclusion: Anti idiotypic antibodies may mask clinically significant anti HLA antibodies unless the laboratory routinely uses DTT in the crossmatch. The pattern of a stronger reaction after treatment of serum with DTT should suggest the presence of anti idiotypic antibodies. The pattern manifests on different platforms, helping in validation of the finding.
| 039: C4D STAINING IN ALLOGRAFT BIOPSIES|| |
Author(s) -Ravi.E, Vara Prasa da Rao, PS. Vali, Kiranmai, Manisha Sahay
Osmania general hospital, Hyderabad
C4d deposition is considered as an immunological foot print of complement activation & antibody mediated rejection. But, in addition to antibody mediated rejection, it can also be detected in cellular rejection, ATN & even normal Kidneys.This study aims to analyze the incidence, location & intensity of c4d staining in various histological diagnoses of renal allograft biopsies. Material & Methods: It is a retrospective study (august2009-august 2010) of all the post renal Transplant cases in whom allograft biopsies were performed & in whom C4d staining (Method: polyclonal antibody and immunohistochemistry for formalin-fixed and paraffin-embedded (P-IHC) tissue samples) was performed. The various histological findings, location & intensity of C4d staining were analyzed. Results: 42 patients were analyzed in the study. Male: Female ratio was 5:2.Majority (33.34%) of the patients belonged to the third decade of life. Mean age was 32.34 years with mean duration post transplant being 25.56 months. Mean Sr. Creatinine at the time of allograft biopsies was 2.62.The various histological diagnoses were: Acute cellular Rejection (ACR) in 10, Borderline ACR in 6, Chronic humoral Rejection (CHR) in 4, Chronic
CNI toxicity in 5, Acute tubular necrosis (ATN) in 4, 1 each of combined ACR+AHR, AHR, Acute interstitial nephritis & normal histology in 6 patients.C4d was positive in 18 cases. Out of these, C4d staining was positive in 8/ 10 ACR cases, 4/4 CHR, 1/1 ACR, 1/1 combined ACR+AHR, 2/5 CNI toxicity, 1/2 mild interstitial infiltrates. None of the cases reported to have normal histology stained positive for C4d.90 % positivity was noted in 5 cases ( 3 being ACR, 1 being CHR & 1 being AHR).70 % positivity was noted in 3 cases (2 being ACR, 1 being CNI toxicity).10 % positivity was noted in the remaining 10 cases. In all the cases, C4d was detected in the peritubular capillaries. Conclusions: (i) C4d staining is not only present in the cases of humoral rejection, but also in cellular Rejection, ATN, CNI toxicity (ii) In contrast to other studies, C4d is not noted in grafts with normal histologies (iii) In Case of Humoral rejections, the intensity of the C4d staining is >90%.
| 040: HYBRID REPAIR OF LARGE ABDOMINAL AORTIC ANEURYSM IN A RENAL TRANSPLANT RECEPIENT: PREFERRED TREATMENT APPROACH|| |
Author(s) -Mukut Minz, Sanand Bag, Yash Paul Sharma, Ashish Sharma, Varinder Singh Bedi
Transplant Surgery, PGIMER, Chandigarh
To describe management of abdominal aortic aneurysm by hybrid procedure (Open + Endovascular) in a renal transplant recipient. INTRODUCTION: With increasing survival and higher cardiovascular risk, incidence and need for repair of abdominal aortic aneurysms(AAA) in renal transplant recipients is increasing. Open repair of these aneurysms has a high morbidity and mortality. In addition, renal allograft recipients often require bypass procedures to protect the allograft kidney. We report a successful hybrid procedure in a renal transplant recipient, and describe the importance of such approach. MATERIAL AND METHODS: A 40 years male renal transplant recipient (2 years back from his mother) with stable Serum Creatinine (1.2 mg %) on standard triple drug immunosuppression, presented with increasing size of AAA. CT angiography (CTA) revealed 10 x 6.5 cm partially thrombosed aortic aneurysm extending from the origin of SMA up to the aortic bifurcation. Allograft vascularity from internal iliac artery was normal. SMA was revascularised by a PTFE graft from left external iliac artery by laparotomy. Thereafter, endovascular Y stent graft was successfully deployed across the aneurysm onto the normal proximal aorta and both common iliac arteries in the same sitting. RESULT: After uneventful recovery, he was ambulatory on second post operative day. Mild elevation of serum Creatinine normalized by 5th day; patient was discharged on 8th day. Repeat CTA at 3 months showed complete exclusion of the aneurysm and patent iliac-SMA graft. CONCLUSION: Hybrid procedure significantly decreases the magnitude & associated morbidity of open aneurysm repair.
| 041: TRANSPLANT RENAL ARTERY PSEUDOANEURYSMS TREATED BY EX- VIVO REPAIR AND REIMPLANTATION|| |
Author(s) -Mukut Minz, Sanand Bag, Sarbpreet Singh, Ashish Sharma, Sunil Kumar
To describe allograft reimplantation as a therapeutic option for renal artery pseudoaneurysm following renal transplantation. INTRODUCTION: Pseudoaneurysms following renal transplant are uncommon (<1%). A defective suture technique, arterial dehiscence, local infection and chronic rejection are implicated as possible etiological factors. Graft nephrectomy remains the standard treatment. MATERIAL AND METHODS: Renal transplant database of our hospital was reviewed for presence of vascular complications from Jan 2001 to Jun 2010. Eight patients had pseudoaneurysm of transplant renal artery, out of which two were referred from other centres. The files of all these patients were reviewed to assess the factors associated with this condition and its subsequent management. RESULTS: All patients were males with mean age 35 years (range25- 53yrs), presented between 10-60 days following transplant. 7/8 patients had features of infection (Fever / leukocytosis and/or positive cultures from the pseudoaneurysm sac). Various organisms isolated were Pseudomonas in 4/8, Acinetobacter in 2/8, Enterococcus in 1/8, Aspergillus in 3/8 patients. Five patients had received steroids/ATG for rejection prior to diagnosis of pseudoaneurysm. Five patients underwent graft nephrectomy — for fungal infection in 3, arterial thrombosis in 1, hemodynamic instability in 1. One patient expired in the postop period after graft nephrectomy. Graft was explanted in 3 patients, repaired on bench and reimplanted at the same side. Adequate graft function could be obtained in all 3 cases (mean creatinine at discharge 1.36mg%). CONCLUSION: Reimplantation of renal allograft is the treatment of choice for transplant renal artery pseudoaneurysm, especially in the absence of fungal infection.
| 042: IMPACT OF HCV INFECTION ON THE OUTCOME OF RENAL TRANSPLANTATION|| |
Author(s) -Bopparaju srinivas rao, Girish Narayen, Ratan jha, Channamsetty sashidhar
Dept of nephrology, Medwin Hospitals, Hyderabad
HCV infection causes slowly progressive liver disease. . Patients who are anti-HCV positive before transplantation have increased risk of posttransplant liver disease. We have looked at outcomes of HCV positive renal transplant recipients who were diagnosed either before or after transplant . Materials & Methods: Between 1991 and 2010, 27 had HCV infection . 11 were detected to be HCV antibody positive prior to transplant. 8 (group A)out of these were treated with Interferon for 24 weeks after confirming with HCV PCR RNA Qualitative assay . Among remaining 19 patients(group B), 16 seroconverted between 2 and 10 years post transplant followup. 3 among these with positive HCV serology prior to transplant were transplanted after confirming normal liver function tests and excluding portal hypertension. Results: Allograft survival at 1 year was 100%. PTDM developed in 8 / 27 patients (29.6%) (2 in group A & 6 group B). . Group A has mean follow up of 20.1 months. 6 continued to have SVR in follow up. In a mean follow up of 22.5 months ( range:6 to 72 months), none developed Chronic Liver Disease.3 patients developed chronic allograft dysfunction over a mean follow up of 35 months( range 8 to 72 months) but none progressed to ESRD. None had acute Rejection.1 died due to sepsis with functioning graft after 18 months. Group B has a mean follow up 69.94months (range: 12 to 216 months).Graft loss occurred in 4(mean follow up 87 months).6 developed chronic liver disease and decompensated over a period of 24 to 36 months & died with functioning graft (4 Cirrhosis & 2 Fibrosing cholestatic hepatitis).Acute rejection was seen in only 2 (1 due to drug default).11(55.2%) developed chronic allograft dysfunction and 4(20.1%) progressed to ESRD over mean follow up of 87 months ( range 60 to 108 months).16 had functioning graft at 3 years (84%)and 5 at 10 years(26%). Conclusions: Treatment of HCV infection pretransplant reduced post transplant chronic liver disease. HCV infection had significant impact on incidence of PTDM. Acute allograft rejection incidence was not significant whereas Chronic graft dysfunction and progression to ESRD was significantly higher in untreated patients. Short term survival of patient and graft was similar, medium and long term survival appears to be significantly affected by treatment of HCV infection.
| 043: RENAL ALLOTRANSPLANTATION FOR IDIOPATHIC RETROPERITONEAL FIBROSIS|| |
Author(s) -Sanand Bag, Sanand, Minz, Ashish Sharma, Sarbpreet Singh, Sunil Kumar
Dept of Transplant Surgery, PGIMER, Sector 12, Chandigarh
To describe important technical points during renal allotransplantation for retroperitoneal fibrosis. INTRODUCTION ESRD patients with retroperitoneal fibrosis (RPF) present a surgical challenge because of extensive fibrosis engulfing the great vessels. Renal autotransplantation to salvage kidneys with extensive ureteral involvement has been reported. Only one case of renal allotransplant in a patient with RPF has been reported so far. MATERIAL AND METHODS A 22-years man with RPF and ESRD underwent transplant from his father with the computed tomography (CT) showing fibrosis extending from the distal IVC and aorta to the iliac vessels. Intraopertaively, patient’s right iliac artery and vein were plastered in the fibrous plaque, which were freed by sharp dissection. Frozen section biopsies of the perivascular fibrosis confirmed absence of malignancy. Omentum was wrapped around the ureter down to the extravesical neo-ureterocystostomy. RESULTS The serum Creatinine decreased to 1.6 on POD 5 which subsequently rose to 4.5. Biopsy revealed acute cellular and humoral rejection (C4d diffusely positive) which required treatment with ATG and subsequently plasmapheresis, Rituximab and Bortizomib, with partial restoration of renal function (Creatinine 3.5). Doppler and CT angiography showed stenosis of transplanted renal artery which was dilated and stented percutaneously. He was discharged with a serum Creatinine of 3.5mg%. At 8 months follow up his Creatinine is stable at 3.5 with normal renal vascular Doppler without hydroureteronephrosis. CONCLUSION Preoperative assessment of extent of fibrosis, transperitoneal approach, sharp dissection around the involved vessels and omental wrapping of the transplanted ureter are unique surgical challenges in these patients.
| 044: SINGLE INCISION LAPAROSCOPIC DONOR NEPHRECTOMY - AN INITIAL EXPERIENCE|| |
Author(s) -Ashish Sharma, Sarbpreet Singh, Sunil Kumar, Mukut Minz
There is an ever increasing interest in use of single incision laparoscopic methods for a variety of surgical procedures. Recently, two different centres have reported feasibility of single incision laparoscopic donor nephrectomy
(SILDN). We present our experience of initial six patients undergoing single port transumbilical live donor nephrectomy. Materials and Methods: SILS TM port (Covidien, USA) was inserted through an intra-umbilical incision. Angulated grasper was used in addition to the standard laparoscopic instruments. The dissection was carried out as per the standard technique. Kidney was held with the grasper at the lower pole and extracted transumbilical^ along with port. Results: Single incision donor nephrectomy was successful in 9/10 patients [Mean age 39+11.9yrs, M:F 2:7, BMI 22.6 + 3.9]. In one patient who had an accessory upper polar renal artery identified intraoperatively, the procedure was electively converted to the standard approach. Mean operating time was 224.4+ 68.6 min, warm ischemia time was 6.1 + 1.9 minutes and hospital stay was 2 days. Adequate lengths of ureter and renal vessels were obtained. No intraoperative/postoperative surgical complications occurred in either donor or recipient. Operative difficulties in SILS included the loss of triangulation, “fighting” of the laparoscopic instruments inside the abdomen and reaching the upper pole. Each allograft functioned immediately on transplantation. Conclusions: The present series reaffirms the feasibility of SILDN in living donors. Widespread application of this approach would be of immense benefit for further promoting living renal donation.
| 045: EVALUATION OF COAGULATION STATUS IN PRE AND POST-RENAL TRANSPLANT PATIENTS BY THROMBOELASTOGRAPHY|| |
Author(s) -M. Adil Asfan, Mukut Minz, Ashish Sharma, Jasmina Ahluwalia
PGIMER, H No 63, Sector 24, Chandigarh
Both hypo and hypercoagulable states have been reported in patients with end stage renal disease(ESRD). It is hypothesized that these disorders should correct after a successful renal transplant. The present study evaluated the impact of renal transplantation on coagulation parameters in ESRD patients. MATERIALS AND METHODS - Routine lab tests of coagulation i.e. PT, PTI, APTT, fibrinogen and D-dimer were measured in an automatic coagulation analyzer. Thromboelastography measures included R Time, K Time, a angle, Max Amplitude, LY30 and were done by TEG 5000, Hemoscope, USA. These tests were conducted on the day of transplantation and on post-renal transplant Days 7 and 90 RESULTS 30 patients [Mean age 40.6±9.0, M: F 28:2] were evaluated between December 2008-0ctober 2009. Mean PT, PTI, APTT, Fibrinogen levels, platelet count and mean TEG parameters both in the pre- transplant and post-transplant period were within the normal range. However, TEG could identify 6 (20.0%) of the patients who were hypocoagulable in the pretransplant period but had a normal coagulation profile in the post transplant period. Nine (33.33%) patients had a hypercoagulable state in the pretransplant period which got corrected in the postoperative period. Rest of the fifteen (50.0%) patients had a normal coagulation profile in pre-op period but had a hypercoagulable state in the immediate postoperative period which got corrected at POD90 post transplantation CONCLUSIONS Thromboelastography is a better measure of coagulation status in patients with ESRD who have both hypo and hypercoagulable state and these abnormalities get corrected after renal transplantation.
| 046: IMPACT OF RENAL TRANSPLANTATION ON CARDIAC FUNCTION IN PATIENTS WITH CHRONIC RENAL FAILURE|| |
Author(s) -Narendra Pandit, Ashish Sharma, Mukut Minz, Rohit Manoj Kumar, Krishan Lal Gupta
PGIMER, H No 63, Sector 24, Chandigarh
Cardiovascular complications are the leading cause of death in patients with end-stage renal disease. Kidney transplantation resolves many of the cardiac abnormalities associated with chronic renal failure. The present study was conducted to evaluate the impact of renal transplantation against the cardiac abnormalities. Methods: A total of 50 chronic renal failure patients on maintenance dialysis underwent kidney transplantation. The cardiac parameters were evaluated by M-mode 2- dimensional and tissue Doppler echocardiography before and 3 months after transplantation. Results: The mean age and duration of dialysis were 35 years and 7 months respectively. An improvement in anemia from haemoglobin level of 8.3 g/dl to 11.8 g/dl and decrease in mean systolic blood pressure and number of antihypertensive drugs were observed after transplantation. Echocardiographic measurement showed great improvement in left ventricular mass index and decrease in left ventricular diastolic dimension of left ventricle: 190±35 vs 134±35 g/m2 (p=.001) and 52±7 mm vs 45±5.2 mm (p=.001) respectively. Moreover, ejection fraction and peak systolic velocity (S wave) at lateral annulus rose significantly from 55±11% to 64±6.2% (p=.001) and from 8.2±1.76 cm/s to 8.6±2.08 cm/s (p=.005) respectively. Valvular abnormalities and pericardial effusion were present in 59% and 12% respectively which also improved after transplantation. Conclusions: These findings show that successful kidney transplantation can significantly improve the cardiac function of chronic renal failure patients on maintenance dialysis by 3 months posttransplant with reversal of physiological changes induced by uremic state.
| 047: MYCOPHENOLATE ASSOCIATED DIARRHEA IN RENAL ALLOGRAFT RECIPIENTS USING CONCENTRATION CONTROLLED DOSING|| |
Author(s) -Annapandian VM Co-authors: Basu G, Mathew BS, Saravanakumar K, Mohapatra M, David VG, ‘Madhivanan S, Varughese S, Jacob CK, John GT, Tamilarasi V.
Departments of Nephrologyl and Clinical Pharmacology2 Christian Medical College, Vellore-4. * Currently Department of Pharmacology & Toxicology, C.L.Baid Metha College, Chennai- 97. Abstract Introduction:
Mycophenolate is commonly used in solid organ transplantation for rejection prophylaxis. Maintaining mycophenolic acid (MPA) area under the curve (AUC0- 12h) between 30 -60 mg.h/L reduces early rejections and plasma concentration associates with side effects. Diarrhea is a common side effect of mycophenolate, and the reported incidence is 30-50%. Patients & methods: Retrospective analysis of data from 235 renal allograft recipients undergone renal transplant at Christian Medical College Vellore, between January-2003 and May-2009 and received mycophenolate mofetil/sodium as primary immunosuppressant along with prednisolone and calcineurine inhibitor. From the extrapolated MPA-AUC0- 12h measured at different time periods post-transplant and the dose, cumulative drug exposure and cumulative MPA dose was calculated up to the day of diarrhea for each patient by applying the trapezoidal rule. The difference of time average cumulative mean MPA-AUC and dose between the diarrhea and non diarrhea group was statistically analyzed using the t-test for independent samples. Results: Of 235 patients analyzed, 26 (11.06%) had diarrhea. Among the 26 patients 18 (69.23%) required MPA dose reduction. Stool parasite examination was performed for 16 diarrhea patients, 11 of which had no parasites. The cumulative average MPA-AUC in the diarrhea group was comparably higher than the non- diarrhea group but was not statistically significant (mean±SD; 51.42±22.15mg.h/L vs. 48.28±6.52 mg.h/L; p=0.444). However, the cumulative mean MPA dose in the diarrhea group was significantly lower than that in the non-diarrhea group (mean±SD; 31.77±8.28mg vs. 35.69±4.79mg; p=0.043). Conclusion: Diarrhea in renal transplant patients on MPA was not associated with higher mycophenolate dose. It’s relationship with mycophenolic acid absorption and concentration needs to be explored with larger number of patient.
| 048: DO INDUCTIONS WITH IL-2 RECEPTOR BLOCKERS INCREASE THE RISK OF NEW ONSET DIABETES ASSOCIATED WITH TRANSPLANT (NODAT)?|| |
Author(s) -Narayan Prasad, Dharmender Bhadauria, Raj K Sharma, Amit Gupta, Aneesh Srivastava
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Interleukin-2 (IL-2) receptor blocker or Anti-CD25 monoclonal antibodies (MAbs) are directed against the IL-2 (CD-25) receptor is used for induction therapy and reduces the acute rejection by 30-40% in renal transplant recipients. Animal study showed that treatment with anti- CD25 favored the onset of severe insulitis and diabetes.Until now, the role of treatment with anti-CD25 MAbs in glucose homeostasis and the development of NODAT immediately after transplantation has not been fully elucidated. NODAT affects the graft and patient survival in renal allograft recipient. There is paucity of data whether the use of Anti-CD25 monoclonal antibodies are associated with higher incidence of NODAT in renal allograft recipient. OBJECTIVE: To study the effect of induction with anti-CD25 MAbs as an independent risk factor for NODAT in kidney transplant patients. PATIENTS AND METHODS: Four Hundred and fourteen patients [male-363, mean age was 36.6±11.1 years (range 11-62 years)] who underwent renal transplant at our institute for last 4 years were included in the study. All diabetics before transplant were excluded from the study. The diagnosis of NODAT was made if patients required insulin or oral anti diabetic drugs and/or had glycemia >200 mg/ dL at 120 minutes after an oral glucose tolerance test (75 g glucose) in post transplant period. Patients were categorized in to two groups i.e. patients with anti-CD 25 antibody induction and without induction before transplant. The age, height, weight, body mass index, acute rejection, chronic hepatitis C virus (HCV) infection, and type of calcineurin inhibitor (tacrolimus versus cyclosporine ), number of patients with NODAT between two groups were compared. Logistic regression analysis was used to predict the factors associated with NODAT. RESULTS: Of the 414 patients, 32 patients have received anti-CD25 antibodies induction therapy. Of the 32 patients who received IL-2 receptor blockers induction, 16 (50%) patients had developed NODAT while only 69/382 (18%) had developed NODAT (p<0.001) amongst the patients who did not received induction therapy (p=0.001). The risk of developing NODAT was 4.4 folds high in patients [odds ratio (OR) 4.4, 95% CI 2.1-9.2, p<0.001] with induction compared to patients without anti-CD 25 induction therapy. The proportion of patients with cyclosporine and tacrolimus based regime was similar in both groups. On time dependent Cox regression analysis, Induction with anti CD-25 [ OR=2.6(95% CI1.5- 4.5)P=0.001)] and HCV [OR=6.2(95% CI 3-12.6)p<0.001] were found to be significant predictor of NODAT . On multivariate cox regression analysis, only HCV was found to be important predictor of NODAT [OR=5.9(95% CI 2.8- 12.5) p<0.0010]. Conclusion: Patients with anti CD-25 monoclonal induction therapy is associated with increased risk of NODAT.
| 049: MANAGEMENT OF UROLITHIASIS IN DONORS.|| |
Author(s) -Jitendra Jagtap, Rajan Sharma, V Muthu, Ravindra Sabnis, Mahesh Desai
Muljibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad-387001 Gujarat
We evaluated the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), ex vivo ureteroscopy (ExURS) and pyelolithotomy(ExPYL), as means of rendering a donor/ donated kidney stone-free in living related donor renal transplantation. MATERIAL AND METHODS: Five cases with calculi in donor kidneys were managed; all were from a living related donor. Two patients underwent pre transplant ESWL while one underwent pre transplant RIRS. ExURS and ExPYL were done in 1 case each. RESULTS: The male:female ratio was 3:3 and average age was 56.2 years(41-71). Average stone size was 7mm(5-10mm). In the ESWL group an average of 850 shocks (500-1200) were given. One patient underwent RIRS with a 7F flexible ureterscope. All these patients achieved complete clearance before donor nephrectomy. Immediately after cold perfusion, Ex URS was performed using iced saline with a 7F semirigid ureteroscope in one case while in the other case a 12F nephroscope was introduced via a pyelotomy and in both the cases, stones were retrieved intact with a dormia basket. Indwelling ureteral stents were kept during transplantation in both cases of ex vivo surgeries. There were no intraoperative or postoperative complications. At a mean follow up of 36 months(10-58) no new stone formed in any recipient or donor. CONCLUSIONS: ESWL/RIRS can be performed safely in the pre transplant setting while ExURS and ExPYL were equally safe and technically feasible to render a stone-bearing kidney stone- free without compromising ureteral integrity or renal allograft function.
| 050: UTILITY OF MULTIDETECTOR ROW CT ANGIOGRAPHY FOR PREOPERATIVE EVALUATION OF VASCULAR ANATOMY IN LIVING RENAL DONORS.|| |
Author(s) -Jitendra Jagtap, Rajan Sharma, V Muthu, Ravindra Sabnis, Mahesh Desai
Muljibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad-387001 Gujarat
Utility of Multidetector Row CT Angiography for preoperative evaluation of vascular anatomy in living renal donors. Abstract OBJECTIVES: Digital subtract angiography is the gold standard for anatomic assessment of renal vasculature for living renal donors. However, multidetector-row computerized tomography (MDCT) is less invasive than digital subtract angiography and provides information of kidney stones and other intra- abdominal organs. In this study, preoperative MDCT angiography results were compared with the peroperative findings to evaluate the accuracy of MDCT for the evaluation of renal anatomy. METHODS: From July 2009 to August 2010, 125 consecutive living renal donors (55 men, 70 women) underwent MDCT angiography followed by donor nephrectomy. We assessed the number and origin of renal arteries, presence of early branching arteries, and any intrinsic renal artery disease. Renal venous anatomy was evaluated for the presence of accessory, retroaortic, and circumaortic veins using venous phase axial images. The calyces and ureters were assessed with delayed topograms. The results of the MDCT angiography were compared with the peroperative findings. RESULTS: A total of 136 renal arteries were seen peroperatively in 125 renal units. Preoperative MDCT angiography detected all of them. Anatomic variations were present in nine veins, all of which were detected by CT angiography. Sensitivity of MDCT angiography for arteries and veins was 100% and 100%, respectively. Positive predictive values were 100% for both arteries and veins. CONCLUSION: MDCT angiography is highly accurate for detecting vascular anomalies and providing anatomic information for laparoscopic living donor nephrectomy.
| 051: RENAL AUTOTRANSPLANTATION IN AN EIGHT YEAR OLD CHILD WITH CONGENITAL LEFT MAIN RENAL ARTERY STENOSIS STATUS POST STENTING WITH STENT FRACTURE -CASE REPORT|| |
Author(s) -Sunil Kumar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sanand Bag
Post Graduate Institute Of Medical Education And Research, Chandigarh
Percutaneous transluminal renal angioplasty (PTRA), with or without stenting, is a valuable treatment option in paediatric Renal Artery Stenosis (RAS). However early in-stent stenosis can complicate this procedure. Rarely, the stent can fracture and cause restenosis with refractory hypertension. Renal artery stent fracture can be managed with endovascular treatment (PTRA +/- Stenting) or aortorenal bypass. Case report - An eight years old male child, referred to our department with a diagnosis of congenital left main RAS, post stenting with fracture of stent and recurrence of left RAS. His blood pressure was not controlled even on 3 antihypertensive drugs. After laparoscopic dissection and retrieval ex-vivo repair of the renal artery was done and fractured stent removed. Autotransplantation of kidney was done in right iliac fossa. The patient fared well after surgery and gradually became normotensive without any requirement of antihypertensive drugs. To our knowledge this is the first case of renal artery stent fracture in a child managed with autotransplantation of kidney. Discussion and conclusion - RAS is widely treated by PTRA and stent implantation, however the risk of stent related complications is always there. Stent fractures in the renal arteries are a rare occurrence. Once renal artery stent fracture occurred, repeat PTRA may be the first treatment option. Surgical intervention should be considered in the event of failure of endovascular treatment. Ex-vivo renal artery repair and renal autotransplantation is a suitable option in children and in cases where stent fractures are caused by anatomic factors.
| 052: USE OF AUTOGENOUS INTERNAL ILIAC ARTERY FOR BRIDGING THE EXTERNAL ILIAC ARTERY FOLLOWING EXCISION OF ASPERGILLUS MYCOTIC ANEURYSM IN RENAL TRANSPLANT RECIPIENTS|| |
Author(s) -Sunil Kumar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sanand Bag
Post Graduate Institute Of Medical Education And Research, Chandigarh
Aneurysms of the renal allograft artery are rare and occur in fewer than 1% of patients. They are commonly mycotic in origin. The repair of these aneurysms pose a great challenge to restore the continuity of recipient’s native vessels. Use of synthetic vascular grafts may result in persistent infection; therefore repair with autogenous grafts is preferable. Case report - We report 2 cases of post renal transplant Aspergillus mycotic aneurysms of allograft renal artery involving external iliac artery (EIA) which were excised along with the allograft and the defect in the EIA repaired successfully with interposition of autogenous internal iliac artery (IIA) grafts. Both the patients received Amphotericin B in post operative period. Whereas one of the patient survived, the other patient died of bacterial sepsis, however post operative CT angiography showed good flow across the EIA. The Use of IIA graft in such situations has not been reported so far in English literature. Discussion and conclusion - Fungal infection of the renal allograft artery is an uncommon but serious vascular complication in renal allograft recipients. It can lead to vascular thrombosis, anastomotic disruption or formation of pseudoaneurysm. These aneurysms may result in graft dysfunction leading to allograft loss and their diagnosis still remains a challenge. The successful treatment involves graft excision and radical debridement of the infected tissues along with prolonged antifungal therapy. Autogenous internal iliac graft provides a useful method to bridge the vascular defects created by radical debridement in presence of such fungal infections.
| 053: RIGHT LAPAROSCOPIC DONOR NEPHRECTOMY: OUR TECHNIQUE|| |
Author(s) -Rakesh Khera, Rajesh Ahlawat, Prasun Ghosh, Manav Suryavanshi, Vijay Kher
Urology & Kidney institute, Medanta the Medicity, Gurgaon
Debate surrounds laparoscopic kidney procurement for right donor nephrectomy. We detail our pure laparoscopic safe technique of right kidney retrieval. Methods: We use a five-port transperitoneal approach and extract the kidney through a low Pfannenstiel incision. Important elements include: (1) reflecting the colon; (2) identifying the vena cava early & dissecting lateral to gonadal vein; (3) minimizing ureteral dissection; (4) mobilizing the kidney within Gerota’s fascia; (5) dissecting the renal artery behind the vena cava; (6) Pfannensteil incision; (7) applying Hem-o-Lok clips on the artery; (8) applying Hem- o-Lok clips on the on the renal vein adjacent to the vena cava after sinching the vein; (9) cutting the vessels without clips/staples on the kidney side; and (10) retrieving the kidney manually under vision. Results: Right LDN was performed in 82 of 740 LDNs performed at out center by a single surgeon during the last 10 years. Average blood loss was 103 mls. All donors were discharged on 4th postoperative day. Average Warm ischemia time was 152 sec. All kidneys could be grafted without technical difficulty. There were 2 graft losses(sickle cell crisis & renal vein thrombosis). Conclusions: This is a reliable method of right pure laparoscopic donor nephrectomy that maximizes donor benefit and cost-effectiveness. Right laparoscopic nephrectomy is likely easier with this technique and should not be avoided if it is the preferred kidney for transplantation.
| 054: A CASE OF POST RENAL TRANSPLANT ANEMIA|| |
Author(s) -Jayakumar K P Usha Samuel, Sebastian Abraham, Jayameena F Joseph Vinu
Nephrology, Medical College, Kottayam
Anemia in post renal transplant period can be caused by a number of factors. Most common causes are graft dysfunction, iron deficiency, drugs, malnutrition, thrombotic microangiopathy and infections which include CMV and Parvovirus B19. We report a case of anemia in post renal transplant patient with normal graft function. Case Presentation: 38 year old female who received a live related renal allograft had excellent graft function in the immediate post transplant period (S. Creat - 1mg% on Day 4). She received triple drug immunosuppresion with steroids, cyclosporine and mycophenolate mofetil.
Her hemoglobin levels failed to rise and instead, started falling. Investigation revealed severe anemia, normal WBC and platelet counts. Reticulocyte count was 0.9%. MCV was 89, peripheral smear showed normocytic hypochromic RBC, normal WBC and platelets. There was no evidence of hemolysis. Serum ferritin, Vitamin B12 and folate levels were normal. She underwent a bone marrow study which showed normocellular marrow with normal myeloid maturation and megakaryocytes. Normoblasts were enlarged and showed pale staining inclusion bodies in their nucleus which was suggestive of chronic Parvovirus B19 infection. Parvovirus B19 DNA was detected in her peripheral blood and bone marrow by PCR. She was treated with reduction in immunosuppression and intravenous Immunoglobulin. She improved and one month later her Hb was 10.1. Conclusion: Parvovirus B19 infection even though rare; is an important and easily treatable cause for severe anemia in post renal transplant period.
| 055: A CASE OF MACROPHAGE ACTIVATION SYNDROME IN RENAL ALLOGRAFT RECIPIENT|| |
Author(s) -Jayakumar K Fl Usha Samuel, Sebastian Abraham, Jayameena P Roshin Joseph
Nephrology, Medical College, Kottayam
Hemophagocytic Syndrome is a clinicopathologic entity caused by systemic proliferation of benign haemophagocytic cells of the monocyte-macrophage- histiocyte lineage. The prognosis is severe with about half of transplant patients dying with a clinical picture of multiorgan failure. We report the case of post renal transplant hemophagocytic syndrome which was successfully treated. Case Presentation: 25 year old man who received a live related renal transplant 9 months earlier was admitted with fever, decreased appetite and acute graft dysfunction. He was on triple drug immunosuppression with steroids, cyclosporine and azathioprine and had excellent graft function in the early post transplant period. Investigation showed leucopenia, elevated serum creatinine elevated liver enzymes, prolonged prothrombin time and aPTT. Initial Blood cultures were sterile. Viral markers for hepatitis, retroviral study and stool cultures were negative. Ultrsonogram of abdomen was normal. Later he developed drop in hemoglobin, hepatosplenomegaly and elevated serum ferritin. Bone marrow analysis showed hemophagocytosis. Repeated blood cultures showed pseudomonas sensitive to meropenem. 3000copies/ml of CMV DNA was detected by PCR. He was treated with meropenem for 14 days. He became afebrile, his graft function improved, ferritin decreased, liver enzymes and coagulation profile became normal. Conclusion: Even though hemophagocytosis is a disease which carries high mortality, it can be treated successfully if the primary disease which caused the hemophagocytois can be diagnosed early.
| 056: HYPERTENSIVE RENAL DONORS - A LONGITUDINAL STUDY|| |
Author(s) -Rajiv Mukha, Nitin Kekre, Ninan Chacko, Lionel Gnanaraj, Antony Devasia
Urology, CMC Vellore
The shortage of organs for transplantation has made it necessary to use organs from marginal donors, despite some improvement in the cadaver programmes. This study looks at the impact of voluntary kidney donation on hypertensive donors. Methodology: Our institution has a policy of accepting as renal donors, first degree relatives above the age of 45 who are hypertensive, but on low dose of a single drug. This study is a longitudinal retrospective study and looks at the differences post kidney donation on the renal function and hypertension. Results: There were 28 hypertensive donors from the years 2004 to 2007 out of the total of 268 donors. The mean age of the donors was 50 years. The follow up ranged from 24 to 36 months. There was no significant change in the serum creatinine. The creatinine clearance was calculated and compared pre and post operatively and showed no significant change. None of the donors needed to have their antihypertensive medication increased or had proteinuria. Conclusions: Voluntary kidney donation is possible in donors who are hypertensive requiring a single low dose of antihypertensive medication in a short term follow up. However long term outcome needs to be assessed.
| 057: RENAL TRANSPLANTATION IN HEPATITIS C PATIENTS - IKDRC EXPERIENCE|| |
Author(s) -Surag Godara, Vivek Kute, Manoj Gumber, R R. Shah, H.L. Trivedi
Hepatitis C virus (HCV) infection is present in 20-50% of ESRD patients worldwide and contributes significantly to morbidity and mortality following renal transplantation. Aims To analyze the outcome of HCV positive patients post renal transplant. To evaluate the safety of tolerance induction protocol with reduced immunosuppressants and its effect on patient and graft survival. Materials & Methods We retrospectively analyzed medical records of renal allograft recipients who were HCV positive by ELISA and got transplanted between Jan 1999 and Dec 2009. Patients were divided into those who received tolerance induction protocol with low dose immunosuppression and routine allograft recipients with triple immunosuppression. Tolerance induction protocol for HCV positive patients included two Donor specific transfusions, Targeted lymph node irradiation; ± Thymoglobulin followed by infusion of stem cells. Results Of 250 patients studied (median age 35.5 years, range, 16-60; 207 men), 178 received tolerance induction protocol . In the protocol group 35 patients (19.66%) and in control group 19 patients (26.38 %) had lost follow up. The patient loss was 37 (20.78%) in protocol group with a mean follow up period of 64 months. In the control group patient loss was 25 (34.72%) with a mean survival period of only 14 months. The mean serum creatinine of 106 (59%) surviving protocol patients with a regular mean follow up period of 64 months is 1.47 mg%. The mean serum creatinine of 28 (38.88%) surviving control group patients with a mean follow up period of 43 months is 1.56 mg%. Causes of patient loss in 80% of both groups were either liver failure, sepsis or cardiac. 78 % of protocol patients were on 2 drug immunosuppression where as 67 % of control group were on 3 drug immunosuppression.. Conclusion The patients in the tolerance induction group with low dose immunosuppression had significantly better graft and patient survival.
| 058: IMPACT OF LEARNING CURVE ON THE SURGICAL COMPLICATIONS AND GRAFT SURVIVAL IN LIVE RENAL TRANS- PLANTATION.|| |
Author(s) -Muthu Veera ma ni, Rajan Sharma, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai
Urology, Mujibhai Patel Urological Hospital
Renal transplantation has been proved that is an effective treatment for end stage renal failure patients and gives a good quality of life. With the newer drugs and the experience from the past, the survival of graft has been increased tremendously. Objective; To study the impact of learning curve on the surgical complications and graft survival in renal transplantation. Materials and Methods ; Retrospective review of 1900 transplants, were performed between1980-2009, they were divided into three groups, group 1 first 500 transplant called phase of initiation and the group 2 (500-1000) phase of consolidation, group 3(1000-1900) phase of excellence. The surgical technique and its outcome on the graft survival, surgical like vascular and urological complications on the recipients were analyzed. Results ;Graft survival and the overall surgical complications in the phase of initiation between the period of 1980 to 1993 were 75% at one yearand 20% respectively - (vascular 24 (12%), urological 22(11%), lymphocele32(16%), wound related 20(10%).and the phase of consolidation between 1994 to 2000, were 85% at one year and vascular 12(6%), urological
10(5%), lymphocele 40(20%), wound related 14(7%), in the phase of excellence between 2001-2009, were 95% at one year, and vascular 8, urological 11, lymphocele 16, wound related 14, and the overall surgical complications were reduced to less than 0.9% in the last 500 cases . Conclusion; With improvement in learning curve and regular critical appraisal of the complications, the surgical complications were decreased and graft survival improved significantly.
| 059: THERAPEUTIC DRUG MONITORING BY LC- MS/MS|| |
Author(s) -Reema Bahri, Sreedhara Chaganty
Vimta Labs Limited
Immunosuppressant drug monitoring plays a critical role in success of organ transplantation. The pharmacokinetics of immunosuppressant drugs are complex, unpredictable and prone to numerous drug interactions with high inter- and intra-individual variability. They are extensively metabolized (> 25 metabolites of cyclosporine known) and cross-react with antibodies used in TDM immunoassays. This causes a significant and unpredictable overestimation of the drug concentrations eg. cyclosporin (35-40%). Liquid chromatography-tandem mass spectrometry (LC-MS/MS) excludes interferences attributable to hydroxylated or demethylated metabolites of these drugs, thereby providing more accurate individualized patient dosing and improving the clinical efficacy. An analytical method was developed and validated using LC-MS/MS. The calibration curve was linear over a concentration range 50 to 2000 ng/ml for cyclosporine A, 1 to 50 ng/ml for sirolimus and tacrolimus with 79.65% recovery for cyclosporine A, 81.62% for sirolimus and 89.65% for tacrolimus. The data demonstrated that the procedure is specific, accurate and reproducible. Performance was verified by participation in External Proficiency Programme by CAP (College of American Pathologists) and found satisfactory. In conclusion, testing by LC-MS/MS is the most accurate technique available and so far we have analyzed more than 3000 incurred samples, which proves that the development of the MS/MS is a grand testament to basic science and the genius involved in the conception and development of the triple quadrupole instrument and to make the dream of doctors to prolong life come true by successful organ transplantation.
| 060: ACUTE RENAL FAILURE IN A KIDNEY TRANSPLANT RECIPIENT - A CASE REPORT|| |
Author(s) -Shivnarayan Acharya, Vijay Shrikhande
Acharya Dialysis Centre & Kidney Hospital
Mr J., 56 years old male, Non diabetic, underwent Kidney Transplantation on 19.1.99 . His perioperative course was uneventful . USG & Doppler study done post op were normal . After about 4 years, On 10.11.03 patient had acute onset anuria . Renal functions deteriorated ( rise in creatinine from 1.4 to 12 mg/dl ). He had pain at graft site . He developed fever after 2 days . USG revealed slightly enlarged graft ( 11.3 x 5 cms), with Grade I echogenicity, Smooth contour and no pelvicalyceal dilatation . Doppler revealed that main Renal artery showed hypoechoic lumen with absent flow s/o thrombus, no intra-renal arterial flow observed, renal vein revealed only to and fro pulsations suggestive of complete occlusion of transplant renal artery . Nuclear scan showed absence of blood flow to the graft . Angioplasty was tried but guide wire could not be negotiated in to the graft renal artery . Patient was back on dialysis, Immuno-suppressants were stopped . But patient continued to have pain at graft site. He had rapid fall in Hemoglobin, had nausea, continuous mild grade fever, appetite loss . He felt sick in spite of adequate dialysis . Graft nephrectomy was done . patient improved . His fever disappeared, appetite improved and was well controlled on hemodialysis . Conclusion - This 56 years old renal transplant recipient had spontaneous thrombosis of graft renal artery without any predisposing factor which is very unusual .
| 061: TRENDS IN MORTALITY OF RENAL TRANSPLANT RECIPIENTS: SINGLE CENTER EXPERIENCE|| |
Author(s) - Biplab Ghosh, Ashutosh Soni, Shivendra Singh, Neelam Singh, Jai Prakash
Institute of Medical Sciences, BHU, Varanasi
The survival of transplant recipients is significantly lower than age-matched controls in the general population. The aim of this study was to analyze the trends of mortality in renal allograft recipients at our centre. Methods: We retrospectively analyzed data from all patients followed at our center who were transplanted between October 1988 and June 2010. Patients were considered to have death with graft function(DWGF) if death was not preceded by return to dialysis or re-transplantation. Result: The study included 98 renal allograft recipients (male:87, female:11). The median recipient and donor age were 34.5 (range15-69) and 42 (range22-60) years, respectively.
Basic kidney diseases were CGN(60.20%), CIN(15.31%), DN(8.16%), PKD(2.04%) and others(14.29%). They were followed up for a median 75.5 patient-months. Mortality occurred in 25 (25.51%) patients (M:F-20:5). Causes of death were Sepsis/infection (36%), coronary artery disease (28%), CVA (8%), failed graft (4%) and unknown (24%). DWGF was 88% of total death and contributed to 78.57% of total graft loss. Overall patient survival was 90.8%, 80.2%, 65.6% and 59.1% at 1, 5, 10 and 15 years, respectively(Kaplan-Meier analysis). When the group with mortality was compared to the group with those still alive, there were significant differences in recipient age (median 40 vs 31, p=0.007), pre-transplantation hypertension(HTN) (100% vs 65.75%, p<0.001), post- transplant infection(76% vs 42.47%, p=0.005), coronary artery disease(28% vs 1.37%, p<0.001), and serum creatinine at last follow up (median 2.3 vs 1.56, p=0.003). Conclusion: Along with infection, CAD is an important cause of death at all times during the first 15 years following renal transplantation even in non-diabetic recipients. Death with functioning graft is very alarming. Key words: developing country, DWGF, mortality, renal transplant
| 062: THERAPEUTIC DRUG MONITORING OF TACROLIMUS IN RENAL TRANSPLANTATION- IS C6 A BETTER MARKER THAN TROUGH LEVELS?|| |
Author(s) -Mayoor Prabhu, Sreepada Subhramanyam, G Sridhar, Pavankumar Rao, K S Nayak
Nephrology, Global Hospital, Hyderabad
Tacrolimus is a drug with a narrow therapeutic index. There have been recent reports that trough levels based monitoring of Tacrolimus may not be reflective of the Area Under the Curve (AUC) and thus may not reliably predict Acute Rejection (AR) or Tacrolimus toxicity. We aimed to determine the single best timed sample of Tacrolimus, its correlation with the AUC, and episodes of AR and toxicity. MATERIALS AND METHODS: This was an open, prospective, non randomized single centre study.21 consecutive 1st renal transplant recipients underwent whole blood Tacrolimus levels estimation by ELISA technique, at trough(C0), 2hours(C2), 4 hours(C4) and 6hours (C6), 72 hours after the initial administration of the drug, or after a change in dosage of the drug, to allow for a steady state . All patients received the same preparation of Tacrolimus and the same maintenance immunosuppression (Tacrolimus, Mycophenolate and Prednisolone). AUC(0-12) was estimated by the Trapezoidal method assuming C0 and C12 to be identical. The timed samples were correlated to the AUC by Pearsons Correlation Coefficients. Correlations of the timed samples to the AUC was also compared in patients who had AR and Tacrolimus toxicity. RESULTS: 21 patients (mean age 44 years, 81% males) underwent 31 AUC estimations over a 2 year period . All 4 timed samples showed good correlation with the AUC however the best correlation was seen with the C6 values. Correlation coefficients seen were C0-0.868, C2-0.788, C4-0.839, C6-0.904.6 patients suffered AR of which 5 had the C0 values within target range.C6 values correlated best with the AUC in patients with AR (C0-0.960, C2-0.833, C4- 0.942, C6-0.970).C6 also correlated best with AUC in the patients who developed Tacrolimus toxicity (C0-0.551, C2-0.556, C4-0.941 and C6-0.778). These results were statistically significant. We serially used regression to develop the equation with maximum predictive power for the AUC0-12.The best equation included the trough and C6 values and had a r2 value of 0.977.This equation was AUC0-12 =12.126 + 2.81xC0+2.92xC6. CONCLUSIONS: C6 levels of Tacrolimus seemed to perform better as a predictor of the AUC in our study.C6 was also a better indicator in patients who developed AR and Tacrolimus toxicity. A limited sampling strategy incorporating trough and C6 values is likely to better predict the AUC. Patients with Trough levels within the desired range still developed AR suggesting that Trough levels are not ideal markers. Prospective studies are required to validate these findings and identify C6 target values.
| 063: EARLY GRAFT OUTCOMES IN RENAL ALLOGRAFT RECIPIENTS WITH AND WITHOUT URETERAL STENTING.|| |
Author(s) -Ravi K.R., Ravi Prakash, Gokulnath
St. John’s Medical College Hospital, Bangalore.
INTRODUCTION & AIM: Stents are at times are commonly used even in live transplantation to reduce the incidence of urological complications. Though it gives comfort to surgeons at times, it carries risk of high incidence of urinary tract infection.
Aim was to study the impact of routine ureteral stenting in renal allograft recipients in live related programme.
MATERIALS AND METHODS: A retrospective analysis of 50 consecutive renal transplant surgeries performed over last 2 years were analyzed with follow up till 6 month post transplant period. Study was aimed at looking at the occurrence of urinary tract infection, urological complications, duration of hospitalization; graft functions at the time of discharge and at 6 month follow up in the post transplant period. Statistical analysis was done using Chi square test, independent T test and Manna Whitney- U test.
RESULTS: The mean recipient age was 33.2 ? 0.8 yrs. All the patients received organ from live donor. There were 17 patients with stents (34%) and 33 patients without stent (66%). The incidence of urinary tract infection was at 41.7% in patients with stents and 17.6% in recipients without stents (P - 0.16). Incidence of UTI was common within 4 weeks of transplant. Commonest organism causing UTI was E. coli (71%). Mean serum creatinine in patients with and with out ureteral stent at 14 days post transplant were 2.5 ? 0.3 mg/dl and 1.3 ? 3.1 mg/dl (P- 0.135), and at 6 months it was 1.2 ? 0.3 mg/dl and 1.2 ? 0.3 mg/dl (P-0.63) respectively. Mean duration of hospital stay was 22.4 ? 12.1 and 12.3 ? 4.4 days in patients with and without ureteral stents (P-0.001). There was no graft loss or mortality in the group at 6 months follow up.
CONCLUSION: Incidence of urinary tract infection is higher in recipients with ureteral stents as compared to without stents. Incidence of UTI was common in first 4 weeks of transplant and E.coli was the commonest organism. Duration of hospital stay in immediate post transplant is longer in recipients with ureteral stent possibly due to higher incidence of urinary tract infection. However at 6 months post transplant the graft functions were similar in both the group. It would be preferable to avoid stents if feasible in live related program.
| 064: LIVING WILLS-A TOOL TO PROMOTE?|| |
Author(s) - Vibhuti Sharma, Shiv Kumar Sarin, Teresa Pont, Nuria Masnou, Pere Salamero
Department of Medical Administration, Dr BL Kapoor Hospital, S-337 Panchsheel Park New Delhi
Assessment of trends in family decision making for organ donation. Materials and Methods: Semi-structured forms used by transplant coordinators in a Barcelona Hospital were examined between two time periods. Baseline data: Age and gender of the deceased; age range, gender, relationship of the decision-maker. Results: Mean deceased age in 2002-05 was 49 (±21.56) vs. 60(±15.65) in 2007-09 (p<0.001). Deceased gender was male while non-donors were 29-35%;p=0.4 in both periods. Decision- makers were middle class (p=0.5), females (51- 53%;p=0.64) of age range 45-55 years (p=0.3) in both periods. Spouse and child as independent decision makers showed increased trends while family joint decisions decreased (p=0.01) in 2007-09. Refusals in both periods were the deceased opting out during lifetime; family unwillingness and lack of knowledge on the deceased’s wishes (p<0.001). These reasons showed increased trends in 2007-09. Problems with body integrity and religious reasons were less relevant in 2007-09. No mandatory signed document existed to confirm refusals. Reasons for acceptance were family interviews with coordinators in both periods though percentage decreases existed in 2007-09: 63% in 2002-05 vs. 47% in 2007-09 (p=0.02). Other reasons were wishes of the deceased: 37% in 2007-
09 vs. 19% in 2002-05 (p=0.02). Conclusions: Families may be increasingly looking for evidence supporting proxy decisions on organ donation. Promotion of living wills as a tool may catalyze such decision-making. Involvement for all families in this decision making is indispensable.
| 065: TRANSPLANT CO-ORDINATORS TRAINING PROGRAM AND PROJECTS OF CANDIDATES AT MOHAN FOUNDATION|| |
Author(s) -Veena R, Sujatha S, Mukesh G, Christopher
MOHAN Foundation, Toshniwal Building, 3rd Floor, 267, Kilpauk Garden Road, Chennai
A Transplant Co-ordinator is the key person who liaisons and coordinates with the family and the transplant team. Multi-tasking is the major skill that every Transplant Co- ordinator needs to develop. The organ transplantation process will succeed only when the coordinator has a complete knowledge about the cause and gets involved in the process wholeheartedly. Material & Methods - MOHAN Foundation started a Transplant Coordinators’ Training Program in December 2009, the first such structured course in South-east Asia. The coordinators who undergo this training of one, three or six month’s training are assigned a project covering the different aspects of organ donation and transplantation. Conclusion - The project helps them enhance their skills and gain more knowledge about the concept of organ donation and transplantation. MOHAN Foundation has trained 60 transplant coordinators in Chennai and Hyderabad who are working in different parts of the country producing and most who have been working in various programmes have done some donations after the course. They all have expressed confidence in their counseling skills when speaking to the relatives for organs. Six of the sixty have been employed by the foundation itself to work in Chennai, Hyderabad, Coimbatore and Vizag after they completed their projects. Some of the material developed by them has also been showcased at the Foundation office and used for patient education.
| 066: SENSITISATION PROGRAM FOR NURSES AT GOVERNMENT GENERAL HOSPITAL, CHENNAI|| |
Author(s) - Veena R, Sujatha S, Mukesh G, Christopher
MOHAN Foundation, Toshniwal Building, 3rd Floor, 267, Kilpauk Garden Road, Chennai
Education on organ donation is vital for the medical professional especially nurses because they are the people who work at the bedside of the patient and take care of them. In organ donation process early identification of a brain dead patient is essential. The nurses are the key persons who can identify and intimate the team that handles the organ donation process. Hence awareness about organ donation is very important for nursing personnel. Material & Methods - The transplant coordinators from MOHAN foundation conducted a pre- awareness survey on organ donation for nurses in the Government General Hospital, Chennai and have, so far, sensitized around 103 nurses about the concept through these programmes. Conclusion - All the nurses who attended the program pledged for a donor card and also decided to carry this message to their family. The impact of this program was that the number of eye donations at Government General Hospital, Chennai has increased within three months and two nurses have donated their family member’s eyes at their residence.
| 067: LOGISTICS OF DECEASED ORGAN DONATION - PROBLEMS AND SOLUTIONS|| |
Author(s) -Christopher, Veena R, Sujatha S, Mukesh G,
MOHAN Foundation, Toshniwal Building, 3rd Floor, 267, Kilpauk Garden Road, Chennai
With the increasing amount of transplantation taking place in India, logistics and management of deceased organ donation play a key role in successful transplants. Logistics in organ donation refers to the problems, constraints, and issues that come up during the course of organ donation. Though transplantation is a highly planned and coordinated task performed by various teams, some problems do arise that can hamper the whole process. Material & Methods - There were various problems and issues relating to Identification and certification of brain death, consent from family, organ retrieval, post mortem etc. Conclusion - Some of the problems that were encountered by MOHAN Foundation team in the Government General Hospital are patient crashing because of the delay in giving consent for organ donation by the relatives, waiting for the lab results, and postmortem delayed because of the legal procedures that needs to be followed in medico-legal cases.
| 068: SENSITIZATION PROGRAMMES FOR STUDENTS, CORPORATES AND THE GENERAL PUBLIC ABOUT ORGAN DONATION IN TAMILNADU|| |
Author(s) -Mukesh G, Christopher, Veena R, Sujatha S
MOHAN Foundation, Toshniwal Building, 3rd Floor, 267, Kilpauk Garden Road, Chennai
The concept of organ donation has to be reached to all sections of the public for increased acceptance. Even the majority of educated people in our country are not aware of the organ donation process. Therefore, education is the key and sensitization programs play a vital role in creating awareness. Material & Methods -MOHAN Foundation has conducted several sensitization programs to create awareness among different sections of people about organ donation. Programs have been conducted all across Tamil Nadu & Pondicherry - Chennai, Vellore, Salem, Erode, Coimbatore, Dindigul, Madurai, Tirunelveli, Trichy, Thanjavur., Pondicherry and Kalpakkam. College students, corporates, NGOs, social organizations were covered through this program. In 2010 alone, more than 3, 000 people picked up the donor card to pledge their organs during the various meetings. Pre and post assessment of awareness levels about organ donation have been analyzed from the series of programs. Conclusion - The results shows that the majority of the people learnt a lot about the various aspects of organ donation and transplantation through the sensitization programs. Tremendous support for the cause of organ donation and many expressed appreciation for the kind of work being done by the Foundation staff.
| 069: CONVERSION OF DECEASED ORGAN DONATION AT GOVERNMENT GENERAL HOSPITAL, CHENNAI|| |
Author(s) -Sujatha S, Mukesh G, Christopher, Veena R
MOHAN Foundation, Toshniwal Building, 3rd Floor, 267, Kilpauk Garden Road, Chennai
Organ transplantation has been one of the greatest advances of modern science that has resulted in many patients getting a renewed lease of life. Transplantation of organs is the best line of treatment and often the only one for organ failure. The Transplantation of Human Organs Act, 1994 has legalized the concept of brain death hence it has become possible to undertake organ transplants from brain dead donors. Family members continue to play a prominent role in donation decisions at time of death.
Transplant coordinators/ Counselors play a significant role in getting consent form the donor families. Material & Methods - MOHAN Foundation has deputed three of its fully trained Transplant coordinators at Madras Medical College General Hospital for grief counseling to motivate families of brain dead patients and facilitate the organ donation and retrieval process. Conclusion - From February 2010 to July 2010 the transplant coordinators have successfully obtained yes for organ donation from the families of 22 of the 29 deceased donors. This is 76% conversion rate . Of these 15 donors went on to actual organ donation. In others the donors were unstable and because they crashed only eyes and in some heart valves were retrieved. We share our experience.
| 070: RENAL TRANSPLANTATION IN SENSITIZED PATIENTS|| |
Author(s) -Sailaja Kesiraju, Purna Parita la, Uma Maheshwar Rao Chikkam. Sahariah Sarbeswar
Transimmun/ KIMS Hospital, Hyderabad
The major complications in renal transplantation are rejection and infections. Patients with circulating antibodies to human leucocyte antigens (anti-HLA) and auto-antibodies are sensitized and are liable to hyper acute rejection. Detection of even low titer of anti-HLA antibodies in recipient serum helps in prevention of immunological rejection episodes. The aim of this analysis is to evaluate the efficacy of MMF and Prednisolone on reduction of anti-HLA antibodies and to determine whether transplantation can be successful in these circumstances. Six patients out of nine with positive donor- recipient cross match were desensitized and underwent live donor transplantation (3 awaiting transplant). Two of them had auto antibodies (no underlying alloantibody) and four had IgG HLA antibodies (PRA >50%). All of them received 250-500mg MMF and 10 mg prednisolone. A final cross match and PRA test was mandatory before transplant. After 3-6 months HLA antibodies and reaction against panel of donor lymphocytes were reduced and received transplantation after waiting for a period of 3-6 months. Patient and graft survival is 100% and the follow-up period was 3 to 26 months. Donor lymphocyte cross match was negative after three months treatment. Fall in PRA level to the normal was observed between 4-6 months after initiating the desensitization protocol. In one patient there was a biopsy proven T-cell mediated acute rejection in the 1st week post transplant and was reversed by pulse steroid therapy. The mean creatinine level is 1.66mg/dl. We report successful transplantation in highly sensitized recipients following suppression of HLA specific antibodies and non- specific antibodies.
| 071: ACUTE FEMORAL NEUROPATHY FOLLOWING RENAL TRANSPLANT|| |
Author(s) -Lokesh Sinha, Rajan Sharma, V Muthu, Ravindra Sabnis, Mahesh Desai
Muljibhai patel urological Hospital, Dr Virendra desai Road
There are many case reports in literature which describe femoral neuropathy following renal transplant possibly due to compresssion or ischaemia of nerve.we had done retrospective study to find the occurrence of acute femoral neuropathy following renal transplant Material method- We retrospectively studied 208 patients undergoing renal transplant between Jan 2008 to Aug 2010 for the occurence of acute femoral neuropathy. All patients having acute femoral neuropathy undervent neurological examination in form of reflex, motor and sensory examination.we gone through the operative notes for any predisposing factor for getting femoral nerve injury like hematoma.Prupossed mechanism of neuropathy is compression and ishaemia from prolonged use of self- retaining retractors. The inferior and medial blades of the retractors are in close proximity to the middle portion of femoral nerve Result- 5 out of 208 patient (2.4%) developed acute femoral neuropathy.All the patients were thin with low BMI( 14.6 - 20.2kg/m2).Onset-( one on 1st POD, three on 2nd POD, one on 3rd POD) Neurological examination- Motor-(three-2/5, one-3/5, one- 4/5), Sensory- (four- reduced, one- absent), Reflex- (four - reduced, one- absent). Improvement^ three in 7 days, 1 in 18 days, 1 in 21days).None had assosiated Diabetis or preexisting peripheral neuropathy. All patients underwent active & passive physiotherapy and received steroid as part of immunosupressent. Conclusion- We believe that acute femoral neuropathy is uncommon complication of renal transplant. All the patient had exellent recovery. Injury to nerve can be avoided by appropriate retractor placement. Disclosure: All authors have declared no conflicts of interest
| 072: RENAL TRANSPLANTATION WITH AORTOFEMORAL BYPASS IN PATIENT HAVING FIBROINTIMAL PROLIFERATION OF LARGE ARTERIES|| |
Author(s) -Lokesh Sinha, Rajan Sharma, V Muthu, Rabindra Sabnis, Mahesh Desai
Muljibhai Patel Urological hospital, Dr Virendradesai road Nadiad
Though uncommon aortoiliac occlusive disease can present with ESRD waiting for renal transplant. We present a case having fibrointimal proliferative disease of large arteries in which renal transplant with aortofemoral bypass was done simultaneously. Material and method - We did simultaneous aortofemoral bypass with right iliac fossa renal transplant in a 40yrs male patient having aortoiliac occlusive disease due to fibrointimal proliferative disease with ESRD .It was a multidisciplinary approach (urologist and CTVS surgeon).First aortofemoral bypass done with (Y) shape PTFE graft. Aorta anastomosed in end to end fashion and bilateral femoral artery in end to side fashion with PTFE. Once blood flow was adequate from graft donor kidney was brought .Kidney has single renal artery and single vein. Renal artery anastomosed with right arm of PTFE graft in end to side fashion .Renal vein to external iliac vein in end to side fashion. Result- Operative time-260min, Warm ischemia time -6min, Total ischemia time-57min, urine output came in 4min, s.creatinine at( 7days-1.14mg%, at 1mth-1.28mg%, at 2mth-1.4mg%).No intra or postoperative complication. Histopathology of native artery was fibrointimal proliferative disease On doppler there is good vascularity of kidney. Conclusion- Simultaneous aortofemoral bypass with renal transplant is feasible & safe but long term outcome is awaited. Though studies have shown that there is increase chance of infection & poor graft function in these cases. Disclosure: All authors have declared no conflicts of interest
| 073: ROLE OF DUPLEX ULTRASONOGRAPHY FOR THE EVALUATION OF UPPER LIMB VESSELS PRIOR TO THE CONSTRUCTION OF ARTERIO-VENOUS FISTULA FOR HEMODIALYSIS: A PROSPECTIVE, BLIND STUDY.|| |
Author(s) -Gaurav Gupta, Nilesh Khandelwal
Aware Global Hospital, Hyderabad
To assess the pre-operative value of duplex ultrasonography (DUS) for imaging artery and vein in comparison to clinical examination for arterio-venous fistula (AVF) construction. Methods: Fifty patients from May2009 to April 2010 with chronic renal failure requiring hemodialysis were included in the study. Pre and post- operatively, all the patients underwent DUS vascular mapping by the same radiologist independent of the surgeon. The single surgeon has created AVF who examined the patients in OPD. The surgery site decision was taken by the surgeon on clinical examination alone. After surgery per-operative findings were confirmed with DUS recordings. Re-exploration and re-construction of primarily failed fistula was performed according to pre and post operative DUS. The patients were followed with DUS. Results: Out of fifty patients, primary patency was seen in 42 patients (84%) on follow-up. Out of 8 primarily failed fistula patients, five (62.5%) had abnormal findings over venous or arterial DUS viz. no increase flow on proximal augmentation, thickened wall, absent wall to wall filling, small vein diameter (<2.0mm) and decreased flow in the artery. Two of the 8 patients had distal venous block. All the patients with failed AVF had long standing diabetes. Two (5%) of the 42 in whom AVF was patent, showed abnormal DUS. In eight failed AVF, 5 were well- functioning subsequent to the reattempted surgery after considering DUS findings. Conclusion: We found careful pre-operative DUS for vessel mapping is very helpful for pre-operative counseling, to reduce the number of failed fistulas and AVF exploration especially in diabetics.
| 074: ENDOVASCULAR REPAR OF LARGE ABDOMINAL AORTIC ANEURYSM IN A RENAL TRANSPLANT RECEPIENT: PREFERRED TREATMENT APPROACH|| |
Author(s) -Sanand Bag, Mukut Minz, Ashish Sharma, V S Bedi, Sarbpreet Singh
Renal Transplant Surgery, PGIMER, Chandigarh
To describe management of abdominal aortic aneurysm by hybrid procedure (Open + Endovascular) in a renal transplant recipient. INTRODUCTION: With increasing survival and higher cardiovascular risk, incidences and need for repair of abdominal aortic aneurysms in renal transplant recipients are increasing. Open repair of these aneurysms has a high morbidity and mortality. In addition, transplant recipients often require bypass procedures to protect allograft kidney. We report successful hybrid procedure in a renal transplant recipient, and describe the importance of such approach. MATERIAL AND METHODS: A 40 years male renal transplant recipient (2 years back from his mother) with stable Serum Creatinine (1.2 mg %) on standard triple drug immunosuppression, presented with back pain and abdominal discomfort for one month. CT angiography revealed 10 x 6.5 cm partially thrombosed aortic aneurysm extending from the origin of SMA up to the aortic bifurcation. Allograft vascularity from internal iliac artery was normal. SMA was revascularised by Gore-Tex graft from left external iliac artery via laparotomy. Y-Stent ENDOGRAFT was successfully deployed across the aneurysm onto the normal proximal aorta and both common iliac arteries on same sitting. RESULT: After uneventful recovery he was ambulatory on second post operative day. Mild elevation of serum Creatinine was normalized by 5 days and he was discharged on 8th day. He is doing well at 8 months follow up; CT angiography shows patent endograft and iliac-SMA bypass graft. CONCLUSION: Hybrid procedure significantly decreases the magnitude & associated morbidity of open aneurysm repair and offers similar outcomes.
| 075: RARE INFECTION IN A RENAL TRANSPLANT RECIPIENT|| |
Author(s) -Anitha Aleya, Pranaw Jha, Kishore Babu, Vishwanath Siddini, Sudarshan Ballal
Nephrology, Manipal Hospital Bangalore
A 50 year old renal transplant recipient from Nepal, who had renal transplantation 7 years ago (native kidney disease membranous nephropathy; donor - wife; on Cyclosporine, Azathioprine and steroids) presented with fever of one month duration. He was evaluated at his hometown and treated with empirical antibiotics. There were no episodes of rejection requiring intensification of immunosuppression in the past. Clinical examination revealed exudative tonsillitis, anemia, cervical lymphadenopathy and splenomegaly. He had a plaque over the vocal cord. Evaluation here revealed pancytopenia. Blood smear was negative for MP and no abnormal cells were seen on the smear. He had normal renal and liver functions. USG showed moderate splenomegaly with significant para-aortic lymphadenopathy. The differential diagnoses were tuberculosis and lymphoma. Bone marrow biopsy, vocal cord plaque biopsy and lymph node biopsy revealed leishmania in all these regions, and a diagnosis of Visceral leishmaniasis was made. He was treated with Amphotericin B (liposomal). It is a rare cause of fever in a post transplant patient and very few cases of lesihmaniasis are reported
| 076: UTILITY OF GONADAL VEIN IN LIVE RENAL TRANSPLANTATION|| |
Author(s) -Muthu Veera ma ni, Rajan Sharma, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai
Urology, Muljibhai Patel Urological Hospital
UTILITY OF GONADAL VEIN IN LIVE RENAL TRANSPLANTATION Authors: Muthu V, Rajan S, Mishra SK, Kurien A, Ganpule A, Sabnis RB, Mahesh Desai Institution:Muljibhai Patel Urological
Hospital, Nadiad, Gujarat.387001 Introduction: Gonadal vein complex has to be preserved during donor nephrectomy along with the ureter to preserve its blood supply. Renal vascular injuries are not uncommon during harvesting the graft and managing these problems is quiet challenging to the transplant surgeon. Donor gonadal vein is a readily available vascular reconstruction material for vascular reconstruction, for difficult situations, in living related renal transplantation. We applied the donor gonadal vein for an accidentally divided accessory renal artery in left donor graft and to elongate the renal vein in a right donor graft. Materials and Methods: The donor gonadal vein was used to reconstruct the lacerated accessory renal artery in one patient as an elongation. The donor gonadal vein was isolated, used as an interposition graft to bridge the gap between transected accessory renal artery and external iliac artery of the recipient. In another patient, gonadal vein was detubularised and remodelled as a tube with adequate caliber of right renal vein and used to reconstruct the short right renal vein, which got damaged during retrieval Results: This technique resulted in a tension-free anastomosis with good perfusion to the graft and able to salvage the perfusion in both the occassions. There were no procedure related complications, with successful graft outcome in the immediate and on follow up of 36 months Conclusions: The use of gonadal vein for renal vascular reconstruction seems to be an acceptable option during living related renal transplantation, lest the need arise, with no increased graft morbidity.
| 077: CAN WE FURTHER DECREASE DONOR MORBIDITY WITH LAPARO-ENDOSCOPIC SINGLE SITE (LESS) DONOR NEPHRECTOMY?|| |
Author(s) -Rajan Sharma, Abraham Kurien, V Muthu, R Sabnis, Mahesh Desai
Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
The purpose of this study was to compare in a prospective randomized fashion the clinical outcomes following Standard Laparoscopic and LESS donor nephrectomy. Materials and methods Fifty voluntary renal donors were randomized to Standard Laparoscopic (Group A) and LESS (Group B) donor nephrectomy (January 2009 till February 2010). The primary end point of the study was patients’ post-operative pain. The clinical outcomes, patient’s quality of life, body image and cosmetic scores on follow up were also compared. Results The operating time were similar in both groups. The surgeon’s difficulty as measured in VAS was significantly more in group B in 4 out of 10 defined steps. The post-operative patient pain scores were similar till 48 hours following surgery (p=0.33), but following which the patients in group B had improved pain scores (p=0.0004). Analgesic requirement was similar in both arms (p=0.47). The warm ischemia times in group B (5.11±1.01 vs 7.15±1.84 minutes, p<0.0001) were longer but the total ischemia time in both groups were similar. All grafts had on-table urine output in the recipient. Intra-operative and post-operative complications in both groups were comparable. The patients in group B had shorter hospital stay (p=0.003). The eGFR of recipients at one year were comparable on both groups (80.87±22.12 vs 81.51±29.01 milliliters/minute, p=0.46). The donor’s quality of life, body image and cosmetic scores were comparable in both groups. Conclusion LESS donor nephrectomy though challenging, reduces donor morbidity by providing early pain relief with shorter hospital stay and with comparable graft function.
| 078: RIGHT LESS DONOR NEPHRECTOMY: INITIAL EXPERIENCE|| |
Author(s) -Rajan Sharma, Shashikant Mishra, Abraham Kurien, R Sabnis, Mahesh Desai
Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
Left LDN is preferred over right LDN due to technical ease. LESS is an effort to further improve the cosmesis of donor nephrectomy while preserving efficacy. LESS left donor nephrectomy data available in recent years. However, no data on right LESS donor nephrectomy is available. Our objective was to assess whether LESS right donor nephrectomy is feasible? Material and
Methods: In this presentation, we demonstrate the technique of this procedure. In this case, Quadriport was used. Rest of the procedure was similar to multiport right donor nephrectomy. The renal vein was cut with Endo GIA stapler. Results: Out of a total of 45 LESS donor nephrectomies done at the institute, 3 were done on the right side. These included 2 females and 1 male. Triport was used in initial 2 cases while Quadriport was used in the last case. Hemolock clip was applied in 2 cases while EndoGIA stapler was applied in the last case for clipping renal vein. There was adequate stump of artery and vein segment in all cases. Mean warm Ischemia time (mean ± S.D) was 6.2 ± 2.8 minutes. There were no intra operative complications and graft complication. Recipient outcome was good in all cases. Conclusion: In our short experience, Right LESS donor nephrectomy was found to be safe and efficacious. Further multicentric data is required to label LESS donor procedures standard of care.
| 079: AN UNUSUAL PRESENTATION OF ACUTE HUMORAL REJECTION POST-RENAL TRANSPLANTATION TREATED WITH AN UNCOMMON REGIMEN|| |
Author(s) -Sanjeev Nair, Satish Reddy, Praveen Kumar
Dept of Nephrology, Narayana Medical College
Acute Humoral Rejection is a rare complication in the post-Transplant setting which was often difficult to diagnose. The introduction of the revised Banff diagnostic criteria however has lent some clarity to the situation and a diagnosis of Acute Antibody-mediated Rejection can now be reasonably suspected in the appropriate clinical setting especially in patients with prior history of sensitization. However, we present a case of a renal transplant recipient with no history to suggest sensitization and who received a kidney from his mother who was diagnosed with Acute Humoral Rejection. Case Report: The patient Mr KB is a 32 year old male with a diagnosis of CGN/CKDV/HTN who received a kidney from his mother, a 48 year old multiparous lady, with the same blood group as the recipient. Post transplantation he had Delayed Graft Function. A transplant kidney biopsy showed features suggestive of ATN and which was positive for C4D staining. To complete the picture Donor specific Antibodies which were also sent were strongly positive for IgG AntiHLA ClassII Antibodies. The patient was therefore diagnosed as Acute Humoral Rejection as per the current criteria. Given the financial constraints under which we were treating this patient, it was decided to treat this patient with a combination of plasmapharesis and rATG instead of the conventional treatment with IVIG and plasmapharesis +/- Rituximab. We would like to report subsequent response to treatment and improvement in graft function with the above treatment regimen.
Discussion: Acute Humoral Rejection has been described rarely to occur with de novo production of DSAs. Usually less than 10% of C4D positive biopsy samples show features suggestive of ATN. Conventional regimes for treatment of AMR include IVIG + Plasmapharesis +/- Rituximab. We are reporting this case for the unexpected nature of the clinical setting in which he developed Antibody mediated rejection and for the use of Plasmapharesis with rATG as an economically viable and efficacious alternative treatment regimen for Acute Antibody-mediated rejection.
| 080: URETERAL HERNIATION LEADING TO INTERMITTENT OBSTRUCTIVE UROPATHY IN A RENAL ALLOGRAFT RECIPIENT|| |
Author(s) -Rajiv Mukha, Elsa Thomas, Nitin Kekre, Ninan Chacko, Antony Devasia
Urology, CMC Vellore
A 44-year-old male underwent live related allograft renal transplantation three years ago for stage V chronic kidney disease secondary to unknown cause. The immunosuppression was with cyclosporine, azathioprine and prednisolone and the nadir creatinine of 1.5 mg/dl was reached one week postoperatively. This remained stable for 30 months when the creatinine began to fluctuate intermittently between 1.5 mg/dl and 2.2 mg/dl. He noticed a reducible swelling in the lower third of the transplant scar that was confirmed to be an incisional hernia. Ultrasonogram showed graft hydro- ureteronephrosis. Magnetic resonance urogram revealed an incisional hernia involving the lower third of the transplant scar, containing the mid-portion of the transplant ureter and compressing the distal ureter at the neck of the hernial sac, causing hydroureteronephrosis. At exploration, the ureter was found to be in the wall of the hernial sac compressed by the adjacent omentum. The ureter was released from the adherent sac and found to be draining freely. The hernia was repaired using a prolene mesh. After surgery, the serum creatinine returned to 1.5mg/dl and a follow up diuretic renogram showed free drainage . Ureteral obstruction is a known complication after renal transplantation, often resulting in obstructive uropathy. This requires re-do reimplantation, percutaneous diversion, or dilatation and stenting. Ureteroinguinal hernias are rare, with about 130 cases reported in the world literature 1. Sliding inguinal hernias containing the ureters have been reported in renal allografts with six reports in literature 2. We report a case of obstructive uropathy secondary to ureteral herniation into an incisional henia sac following renal allograft transplantation. To our knowledge this is the first such report in medical literature. 1. Michelle Elizabeth Brand, MD, Steven Brooks, CST, CFA, Karen Brooks-Searle,
MD, Robert M. Esterl, Jr., MD. Ureteroinguinal hernia: a rare cause of ureteral obstruction. Case report March 2006, surgicalroundsonline.com. 2. Leandro H. Otani, MD, Shri K. Jayanthi, PhD, Rodrigo S. Chiarantano, MD, Andre M. Amaral, MD, Marcos R. Menezes, PhD and Giovanni G. Cerri, PhD. Sonographic Diagnosis of a Ureteral Inguinal Hernia in a Renal Transplant. J Ultrasound Med. 2008 Dec; 27(12):1759-65.
| 081: LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: A SINGLE CENTRE EXPERIENCE|| |
S Sharma, S Chaturvedi, R Mahesvari, A Srivastava, R Kapoor, M S Ansari, P Ranjan
AIM -To describe our experience with transperitoneal laparoscopic live donor nephrectomy
Donors wereaccepted between ages18 and 65years after a comprehensive workup to rule out any medical risk factors, from January 2000 to December 2009, 662 cases (193 M: 469 F) were successfully completed laparoscopically. In the initial part of the series, closed Transperitoneal technique using Veress needle was used to create Pneumoperitoneum. Later on, Open Hasson technique for port placement was used. The vessels were clipped using a pair of Hem-o-lok clips and the kidney was retrieved by hand assistance. In the initial part of the series, lumber muscle cutting incision was used, and later on, Pfannensteil muscle splitting incision was used.
Results: The mean age of the donors was 40.4 ± 11.6 years, operativeduration 150-210 min, mean warm ischaemia time 3.8 min (range 2-7 min), blood loss 50- 125ml, analgesic requirement 150-330 mg of tramadol, pain score range 2-5 (on visual analogue scale) and hospital stay (3.14days). Re- exploration was required in eight patients. Trocar induced bowel injury in two, and bleeding in six cases. Conversion was required in 15 patients. Diaphragmatic injury and hydrothorax occurred in two patients which were managed conservatively. Overall complication rate was 11.78% in the entire series including single mortality. Majority of conversions and complications including mortality were seen in initial 50 cases. Pfannensteil incision was aesthetically pleasing, less painful and more acceptable to the patients. The overall costs incurred to the donor is 650-700 USD, including hospital stay.
Conclusion: Transperitoneal laparoscopic live donor nephrectomy can be safely performed, and is cost effective with use of double Hem-o-lok clips. Open Hasson technique should be preffered for the initial port placement. Pfennenteil muscle splitting incision is aesthetically superior.
| 082: A COST EFFECTIVE ALTERNATIVE TO SYNTHETIC GRAFT - VEIN TRANSPOSITION AVF|| |
Santosh Antony, Suresh HB, Hemanth, Anthony Prakash Rozario
Dept General Surgery, St Johns Medical college Hospital, Bangalore
This is a retrospective descriptive analysis of our patients who underwent venous transposition fistulae between 2003 and 2010. All patients for basilic vein transposition underwent Doppler imaging of the vein. The total number of vein transposition fistulae was 39. We had 28 basilic vein transpositions, 8 forearm vein transpositions, 3 autologus vein transfer. Out of total 39, there were 22 patent at 06 months. The complications seen were 2 haematomas, 2 aneurysm, 2 stricture, 3 thrombus and 3 lymphorrhea. There are 11 patients follow up with us at present. 5 patients died and 23 patients were lost to follow up. Our patency rate was 82.05% which was comparable to world literature. We conclude that basilica vein transposed fistulae are a good and cost effective option for dialysis access. Duplex imaging of the basilica vein a must before harvesting.
| 083: LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: A SINGLE CENTRE EXPERIENCE|| |
Sandeep Sharma, Samit Chaturvedi, Aneesh Srivastava, Rakesh Kapoor, Priyadarshi Ranjan
Sgpgi Campus, Raebareli Road, Lucknow
To describe our experience with transperitoneal laparoscopic live donor nephrectomy. Patients and methods: Donors were accepted between ages 18 and 65 years after a comprehensive workup to rule out any medical risk factors. From January 2000 to December 2009, 662 cases (193 M: 469 F) were successfully completed laparoscopically. In the initial part of the series, closed Transperitoneal technique using Veress needle was used to create pneumoperitoneum. Later on, open Hasson technique for port placement was used. The vessels were clipped using a pair of Hem-o-lok clips and the kidney was retrieved by hand assistance. In the initial part of the series, lumber muscle cutting incision was used, and later on, Pfannensteil muscle splitting incision was used. Results: The mean age of the donors was 40.4 + 11.6 years, operative duration 150 -210 min, mean warm ischaemia time 3.8 min (range 2 - 7 min), blood loss 50- 125 ml, analgesic requirement 150-330 mg of tramadol, pain score range 2-5 (on visual analogue scale) and hospital stay (3.14 days). Re-exploration was required in eight patients. Trocar induced bowel injury in two, and bleeding in six cases. Conversion was required in 15 patients. Diaphragmatic injury and hydrothorax occurred in two patients which were managed conservatively. Overall complication rate was 11.78% in the entire series including single mortality. Majority of conversions and complications including the mortality were seen in initial 50 cases. Pfannensteil incision was aesthetically pleasing, less painful and more acceptable to the patients. The overall costs incurred to the donor is 650-700 USD, including hospital stay. Conclusions: Transperitoneal laparoscopic live donor nephrectomy can be safely performed, and is cost effective with the use of double Hem-o-lok clips. Open Hasson technique should be preferred for the initial port placement. Pfannenteil muscle splitting incision is aesthetically superior.
| 084: URETERIC COMPLICATIONS IN LIVE RELATED RENAL TRANSPLANTATION|| |
Rohit Upadhya, Sandeep Sharma, Aneesh Srivastava, Rakesh Kapoor, Priyadarshi Ranjan
Sgpgi Campus, Raebareli Road, Lucknow
This study was performed with an aim of analyzing the incidence, diagnosis and treatment of urological complications in live related renal transplants done at our institute. Emphasis was also placed on any effect on long term outcome of the renal allograft in such cases. Patients and Methods- A retrospective analysis of ‘in patient’ and ‘follow up’ records of 1945 consecutive live related renal transplants performed from 1989 to 2009 was done. Cases having ureteric complications were sorted out and compared to non complication group. In initial 500 cases DJ stent was placed randomly at the time of ureterovesical anstomosis( Lich Gregoir technique). Subsequently we have been placing stent in all the cases. In non complication group sufficient data for analysis was available in 1405 patients. Statistical analysis was performed using Kaplan-Meier techniques. Results- The overall incidence of urological complications is 2%. Complications occurred at a mean interval of 32.6 days after transplantation. Mean follow up after transplantation was 86.7 months. All cases of obstruction were initially managed by PCN and antegrade placement of DJ stent. Surgical treatment was used for cases where problem recurred after removal of stent. Survival analysis showed that urological complications did not increase the risk of graft failure or patient death. Conclusion- Urological complications are not uncommon in live related transplants. If managed properly there is no impairment of graft or patient survival in such cases. Routine use of DJ stents is recommended.
| 085: VASCULAR COMPLICATIONS IN LIVE RELATED RENAL TRANSPLANTATION|| |
Sandeep Sharma, Rohit Upadhya, Aneesh Srivastava, Rakesh Kapoor, Priyadarshi Ranjan
Sgpgi Campus, Raebareli Road, Lucknow
The aim of this study was to analyze cases in which major vascular complications occurred after live related renal transplantation. The ultimate graft and patient outcomes were studied. Patients and Methods- Records of 1945 consecutive cases of live related renal transplants performed between 1989 and 2009 were reviewed. In cases with single renal artery and vein renal artery was either anastomosed to internal iliac artery using end to end technique or to external iliac artery using end to side technique and venous anastomosis was done by end to side of renal vein to external iliac vein in all cases. Cases with multiple vessels were dealt with either separate anastomoses or as a single pantaloon anastomosis depending upon individual anatomical findings. Post operatively two dimensional ultrasound and color Doppler was performed whenever there was clinical suspicion and further investigations were done accordingly. Results- The overall incidence of major vascular complications was 1.29%. Out of these, 11 cases had significant renal artery stenosis. Aneurysm formation at the site of anastomosis was seen in 2 cases. Apart from these, thromboses of renal artery and vein were seen in 9 and 3 cases respectively. 2 Cases with renal artery stenosis were managed successfully by placement of endovascular stents after balloon dilatation. Rests of the cases were managed by medical treatment alone. In cases of aneurysm formation we had to do allograft nephrectomy in all cases. Similarly cases with arterial or venous thrombosis, the allograft could not be saved. Conclusion- Major vascular complications in live related renal transplants are rather uncommon. If a timely diagnosis is made, renal arterial stenosis can be managed successfully by endovascular techniques. In cases of aneurysm formation or thrombosis of major renal vessels, it is difficult to salvage the graft.