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   Table of Contents - Current issue
January-March 2021
Volume 15 | Issue 1
Page Nos. 1-90

Online since Wednesday, March 31, 2021

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NOTTO COVID-19 vaccine guidelines for transplant recipients Highly accessed article p. 1
Vivek Kute, Sanjay K Agarwal, Jai Prakash, Sandeep Guleria, Sunil Shroff, Ashish Sharma, Prem Varma, Narayan Prasad, Manisha Sahay, Subhash Gupta, S Sudhindran, Kewal Krishan, Vasanthi Ramesh, Sunil Kumar
In December 2019 Novel corona virus (SARS-CoV-2) infection started in Wuhan and resulted in a pandemic within few weeks' time. Organ transplant recipients being at a risk for more severe COVID-19 if they get SARS CoV-2 viral infection, COVID 19 Vaccine has a significant role in these patients. The vaccine is a safer way to help build protection and would either prevent COVID -19 infection or atleast diminish the severity of the disease. It would also reduce the risk of the continuing transmission and enhance herd immunity. Immuno compromised patients should not receive live vaccines as they can cause vaccine related disease and hence the guidelines suggest that all transplant recipients should receive age appropriate 'inactivated vaccine' as recommended for general population. Though trials have not been undertaken on transplant recipients, efficacy and safety of COVID-19 vaccine have been scientifically documented for few vaccines among the general population.
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Pretransplant histocompatibility testing algorithm: Laboratory and clinical approach in the Indian context Highly accessed article p. 4
Feroz Aziz, Aseem K Tiwari, Himanshu V Patel, Rajni Chauhan
Remarkable advances in histocompatibility testing have immensely improved the safety of transplantation and have decreased the incidence of rejections. Human leukocyte antigen (HLA) typing and crossmatches by complement-dependent cytotoxicity or flow cytometer-based methods are the vital tests involved in pretransplant histocompatibility testing. Continuous development in these testing technologies since the 1960s has refined these methodologies that can be used to predict graft rejection. Advancements from polymerase chain reaction-based methods to sequence based in HLA typing, and from cell-based cross-matches to virtual cross-matches using advanced solid-phase platforms, have enhanced our understanding about the donor-specific antibodies (DSAs) and have challenged the concept that the presence of DSA is an absolute contraindication to transplantation. Despite various developments, it is very difficult to perform a plethora of tests for pretransplant workup due to cost constraints in a developing country like India. In this review, we would discuss the advantages, limitations, and cost involved in the pretransplant immunologic workup along with an algorithmic approach for physicians that may help in decision-making amidst multiple information from different platforms.
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Comparison of histidine-tryptophan-ketoglutarate solution versus ringer lactate as perfusion fluid in live donor renal transplant - A randomised controlled trial p. 14
Ambuj Agarwal, Deepesh Benjamin Kenwar, Ashish Sharma, Sarbpreet Singh, W Sujata
Objective: Ringer's lactate (RL) was one of the perfusion fluid used in renal transplants, which were replaced by perfusion fluid with an intracellular composition like histidine-tryptophan-ketoglutarate (HTK) solution. These are preferred in cadaveric renal transplants. However, there are no guidelines for live-related donor renal transplant. We study whether HTK solution is better than RL solution, an extracellular composition fluid in preserving allograft in live-related donor renal transplantation. Materials and Methods: A single-blinded randomized trial comparing HTK solution and RL solution in 80 patients undergoing live-related donor renal transplantation from July 2017 to June 2018. The outcome was measured in serum cystatin C and plasma malondialdehyde (MDA) and serum creatinine for 30 days. Results: In 19 cases, surgeons preferred HTK solution as perfusion fluid due to the presence of multiple arteries; hence, these cases are removed from analysis due to deviation from the study protocol. Four patients in the HTK group and five patients in the RL group were excluded due to loss to follow-up. Recipient age, sex, and donor age, sex, and basic disease were comparable in both groups. The higher warm ischemia in the HTK group (5.58 min [standard deviation (SD) 1.44 min]) as compared to the RL group (5.00 min [SD 1.12 min]) with P 0.096. Similarly, the longer cold ischemia in the HTK group (82.00 min [SD 21.31 min]) as compared to the RL group (70.32 min [SD 24.56 min]) with P 0.783. 8.3% rejection in the HTK group and 17.9% rejection in the RL group. Serum cystatin C, marker of glomerular filtration was comparable, HTK group ((3.75 ± 1.98 mg/l) and RL (3.94 ± 1.68 mg/l) with P 0.714. The plasma MDA marker of ischemia-reperfusion injury was also comparable HTK group (80.16 ± 80.08 ng/ml) and RL group (61.50 ± 92.23 ng/ml) with a P 0.446. Fall in serum creatinine was significantly more in the HTK group than RL. At the end of 30 days, both groups had similar levels of serum creatinine level. Conclusion: Graft perfused by HTK solution and RL solution at our center had comparable 30-day outcomes. Although none of the differences was statistically significant, the HTK group had consistently better metrics in terms of fall in creatinine and serum cystatin C despite a trend to longer ischemia times and higher plasma MDA levels.
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A qualitative approach to understand the knowledge, beliefs, and barriers toward organ donation in a rural community of Haryana - A community based cross-sectional study p. 19
Puneet Misra, Sumit Malhotra, Nitika Sharma, MC Misra, Arti Vij, CS Pandav
Introduction: Organ transplantation is the therapeutic modality available for people with end-organ failure. However, only 10% of the need for transplantation is met globally. There are different factors that influence organ donation by people. Objective: This study was planned with an aim to understand the beliefs and knowledge of a rural community toward organ donation and the identification of barriers for organ donation. Materials and Methods: A qualitative community-based cross-sectional study was carried out among the adults of a rural area of Ballabgarh block of district Faridabad, Haryana. There were four groups of participants based on age and gender. Data collection was done through focused group discussion. Results: Several themes emerged and various reasons that were facilitators/barriers for donation of organ by people were listed: unawareness on what organs can be donated, misuse of donated organs by black marketing, organ donation by people having any comorbidity, no religious prohibition on organ donation, and disfigurement of body after organ donation. Conclusion: People consider organ donation a noble act. However, there are various myths and misconceptions as well as unawareness of procedure regarding organ donation that leads to lower rate of organ donation. Awareness campaigns should be organized to take care of such issues.
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Renal angiographic evaluation of prospective renal donors: Single-center data and outcome analysis from South India - A retrospective observational study p. 24
Nisha Jose, Varadharajan Jayaprakash, Deiva A, Venkata Sai, M Jayakumar
Introduction: In countries without a well-developed deceased donor program, living donors form the backbone of the renal replacement strategy. Computed tomography (CT) angiography forms an integral part of the predonation evaluation. The course, number, and morphometric evaluation of the renal vasculature provided by CT angiography help to identify which kidney to harvest and which kidney to exclude from the donation. The characteristics of the Indian renal donor are a rarely studied topic with only a few studies on the same to date. Methodology: This is an observational study done over a period of 3 years noting the clinical and morphometric characteristics of the renal donors from a database. Results: In this study, 57 prospective living renal donors were included. Most donors were women. The length of the renal artery and renal vein was shorter in this cohort than in previously known statistics. The diameter of the renal vessels was also smaller than previous data. The left side kidney was more commonly harvested compared to the right. Conclusion: Renal angiographic morphometric data among the Indian population were different from previously known statistics. Angiographic data correlated well with intraoperative findings in the majority of patients.
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Cytomegalovirus disease in post-renal transplant patients: An Indian experience - A prospective observational study p. 29
Poonam Yadav, Kamlesh Yadava, Neeraj Tandon, Narayan Prasad, TN Dhole
Background: Cytomegalovirus is an important viral pathogen causing infection in immunodeficient patient especially in solid organ transplant like renal transplant. This study aims to evaluate the prevalence and clinical impact of CMV infection in renal transplant patients in a tertiary care hospital in Northern India. Materials and Methods: 145 renal transplant patients were tested for cytomegalovirus DNA by polymerase chain reaction (PCR) and for presence of IgM and IgG antibody against cytomegalovirus by ELISA. PCR amplified product were detected by Agarose gel electrophoresis. Results: Out of 145 transplant patients CMV Viremia was detected by PCR in 16(11.0%) patients. Two patients died in the study period in which one patient had HBV and other had HCV infection. IgM antibody against CMV was detected in one out of 145 donors while IgG anti-CMV antibody was detected in all 145 donors and recipients by ELISA. Two out of 145 transplant recipients had positive CMV PCR in pre-transplant period, and both had positive CMV PCR in post-transplant period. Out of sixteen positive patients histopathology changes of CMV disease was found in 2 patients (12.5%). Conclusion: Cytomegalovirus disease is major cause of morbidity and mortality in renal transplant patients. PCR to detect specific CMV genome sequences is important tool for early diagnosis and specific anti viral therapy. In our study out of 145 transplant patients, CMV Viremia was detected by PCR in 16 patients (11.0%). Two patients in the study period died, in which one patient had HBV and other had HCV infection, remaining patients survived with varying range of serum creatinine levels. Diagnostic histological changes of CMV is seen only in minority of cases(12.5%) who are positive by PCR for CMV.
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Prevalence and risk factors for postrenal transplant hyperparathyroidism: A cross-sectional study p. 34
Krishnaswamy Sampathkumar, Andrew Rajiv, Shakthi Kumar, Kadhir Selvan
Introduction: Chronic kidney disease (CKD) commonly results in secondary hyperparathyroidism. Even after a successful renal transplant, residual parathyroid overactivity persists. We studied its prevalence and risk factors in Indian patients. Patients and Methods: Patients who underwent renal transplantation in our unit from 2013 to 2019 and completed 3 months of the posttransplant period were included. We excluded patients with advanced allograft dysfunction and those on medications with the potential impact of divalent cations. A detailed history, physical examination, and laboratory parameters were obtained. Results: There were 110 subjects, of whom 78% were male. The mean age group was 38 ± 12 years. Chronic glomerulonephritis was the most common etiology of CKD (54%). Posttransplant vintage was 48 ± 44 months. The mean serum parathyroid hormone (PTH) level was 135 ± 176 pg/ml. Sixty-seven percent of them had raised serum PTH levels above 70 pg/ml. The patients were asymptomatic. Hypercalcemia and hypophosphatemia were rare. The mean 25 OH Vitamin D levels were low (23 ± 8 ng/ml) with 41% of the subjects showing either deficiency or insufficiency. Higher serum PTH levels were significantly associated with female sex, lower estimated glomerular filtration rate, and lower serum 25 OH Vitamin D levels. Serum parathormone levels were significantly negatively correlated with serum calcium (r2 = −0.39. P = 0.0003) and Vitamin D levels (r2 = −0.50. P = 0.002). Conclusions: Posttransplant hyperparathyroidism (PTHP) persists even after many years of normal allograft function. Hypercalcemia and hypophosphatemia are insensitive tests to identify the condition. Vitamin D deficiency has a strong correlation with PTHP.
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Use of panel reactive antibodies for immunological risk stratification and its correlation with antecedent events in live donor kidney transplant: A prospective single-center study p. 39
Ashwini B Gadde, Amit Mahapatra, Assem Tiwari, Sidharth Kumar Sethi, Pranaw Kumar Jha, Manish Jain, Dinesh Yadav, Dinesh Bansal, Shyam Bihari Bansal
Background: Panel reactive antibody (PRA) is a screening test to identify the immunological sensitization of the transplant recipients. The current study focuses on the role of PRA in immunological risk stratification in live donor kidney transplant and its correlation with antecedent events and posttransplant outcomes. Methods: This was a prospective, single-center, observational study. All patients with end-stage renal disease between January 1, 2016, and October 1, 2016, were included. The patient's sensitization history and other immunological workup were recorded. Patients were followed up for 6 months. Results: PRA positivity was seen in 29/185 (15.7%) patients. Female sex (P = 0.004), longer duration renal replacement therapy (P = 0.037), and hepatitis C virus infection positivity (P = 0.047) were significantly associated with PRA positivity. Only 3/87 (3.4%) patients who had no history of sensitizing events had high PRA. Less number of patients in PRA-positive group received transplant as compared to PRA-negative group (12/29; [41.4%] vs. 143/156 [91.7%, P < 0.0001]). In transplanted patients, there was no significant difference between PRA-positive and PRA-negative group in terms of serum creatinine (1.22 ± 0.26 mg/dl vs. 1.30 ± 0.38 mg/dl, P = 0.63) and number of acute rejection (1 vs. 6, P = 0.507). Conclusions: PRA positivity is not uncommon in live donor kidney-transplant patients. Previous transplants, pregnancies, and multiple blood transfusions are important sensitizing events. PRA testing was useful in identifying high-risk patients and evaluating them further. There was no difference in short term outcomes between PRA-positive and PRA-negative groups after exclusion of high-risk patients from transplantation.
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Continuous wound infusion as an alternative to continuous epidural infusion for postoperative analgesia in renal transplant surgery: A prospective randomized controlled trial p. 45
Vinitha Narayan, Sameer Sethi, Kamal Kajal, Sarbpreet Singh
Background: Pain management is often challenging in patients undergoing renal transplant owing to the various comorbidities. Epidural analgesia is currently the standard technique but is not without complications. Continuous wound infusion (CWI) is emerging as a simple and effective technique of postoperative analgesia. Therefore, the purpose of our study was to compare the efficacy of CWI with continuous epidural infusion (CEI). Methods: Forty-two patients undergoing renal transplant surgery were randomized to receive either CEI or CWI. The visual analogue score at rest and on movement was assessed. Opioid consumption, patient satisfaction, and complications were also assessed. Results: The pain scores measured at rest 4, and 8 h postoperatively were significantly lower in the CWI group.(2.45 ± 1.317) in CWI versus (3.45 ± 1.050) in CEI, P = 0.012 at 4 h, and (1.95 ± 1.146) in CWI versus (2.75 ± 0.786) in CEI, P = 0.014 at 8 h. The pain scores at other time points were lower in the CWI group but not statistically significant. The morphine used in the first 8 h was significantly higher in the CEI group. There was a higher incidence of hypotension in the CEI group (P = 0.028). The patient satisfaction and other side effects were comparable between the groups. Conclusion: Continuous wound infiltration is an effective technique for postoperative analgesia in renal transplant surgery and can be used as an alternative to epidural analgesia.
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Graft and survival outcome in renal transplant patients receiving cyclosporine and azathioprine versus tacrolimus and mycophenolate mofetil: A single-center retrospective observational study p. 50
Renuka Sathish, Limesh Marisiddappa, Prashant Kedlaya, Vinod Nagaraj, DM Kruthika
There is paucity of data on long-term outcome of renal transplantation across different immunosuppression groups. Rationale and Objective: The study looks at long-term outcomes in renal transplant patients receiving azathioprine, cyclosporine combination (Group 1) with mycophenolate mofetil and tacrolimus (Group 2) with terms of patients and graft survival. We also analyzed the spectrum of infections across the two groups. Study Design: A retrospective observational study was conducted from 1995 to 2014 at St. John's Medical College and Hospital, Bengaluru. Patients received treatment as per standard protocol. Setting and Participants: Renal transplant recipients who regularly visited outpatient department. Analytical Approach: Statistical analysis was done by using SPSS 19 software. Continuous variables were analyzed using Student's t-test. Pearson's correlation test used for correlating variables. Kaplan–Mere curve used for calculating survival. Primary Outcomes: Rejection rates were similar across both the groups. The patient survival was 65% and 70% in Group 1 and 2 at 5 years, respectively. Graft survival was 65% and 75% in Group 1 and 2 at 5 years. Secondary Outcome: Bacterial and fungal infections were more common in Group 1, whereas viral infections were more in Group 2. In addition, infections tend to occur early in Group 2. Limitations: Single center, retrospective study. Conclusion: Patient and graft survival were similar across both the groups.
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Perceptions and attitude toward cadaveric organ donation among health-care professionals at a tertiary health-care setting: A cross-sectional study p. 56
Kenneth Xavier Da Silva, Delia Basil Dsouza, Von Richard Mascarenhas, Prajoth Narayan Kankonkar, Frederick Satiro Vaz, Manojkumar S Kulkarni
Introduction: Organ donation provides a life-saving opportunity for those individuals with organ failure who have no other options. The knowledge, attitude, and practices of medical professionals play a vital role in promoting the positive impact of organ donation. Therefore, it is necessary to understand and assess the knowledge and attitude about cadaveric organ donation among the medical health professionals. Objectives: To assess the knowledge, attitude, and practices of health-care professionals toward cadaveric organ donation and to know their awareness regarding legislations pertaining to cadaveric organ donation. Materials and Methods: A self-administered questionnaire was filled out by consenting consultants, resident doctors, and nurses working at a tertiary health-care setting, to evaluate their knowledge, attitude, and practices regarding cadaveric organ donation. Data were analyzed and summarized as frequencies and proportions. Results: Majority (74%) of the participants were females and most (67.8%) of them below 40 years of age. Hindus comprised 55.2% and Christians 41% of the study population. All consultants, 99.1% of resident doctors and 83.1% of nurses were familiar with the concept of cadaveric organ donation. Although willingness to donate organs was expressed by a majority of the health-care professionals, only a few have actually taken the initiative and pledged to donate their organs. Conclusion: The knowledge of the health-care professionals pertaining to cadaveric organ donation was found to be relatively good, whereas their attitude was found to be favorable. As far as practices were concerned, they were found to be unsatisfactory. Awareness level regarding legislations pertaining to organ donation was relatively high.
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Deceased donor transplantation – Success story from a state p. 62
Noble Gracious, Anjana Gopal, Raman Muraleedharan, Anil Sathyadas
In India, live donor transplantation is more common than deceased donor transplantations which are quite contrary to developed nations. The enactment of The Transplantation of Human Organ and Tissue Act in India in the year 1994 legalized organ donation after brainstem death. However, it was only in the last few years that the deceased donor transplantation (DDT) program increased in popularity, possibly due to increasing public awareness and direct involvement of Government in the donation and transplant process through national and regional organizations. The Government of Kerala in association with Donation and Transplantation Institute Foundation of Spain implemented transplant procurement management (TPM model) in the state in the year 2019. In Kerala, Kerala Network for Organ Sharing, a local networking organization under Government acts as a public, private provider interface, ensuring a transparent and equitable organ allocation. The purpose of this article is to highlight the importance of hospital-based organ procurement units headed by transplant procurement managers (TPM) and the role of government-run networking organizations in improving the DDT. When the COVID 19 pandemic resulted in the suspension of the transplant programs across the country, the deceased donation and transplantation activity in Kerala were going unabated.
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Live-related renal transplant with bench repair of saccular aneurysm of graft renal artery - A case report p. 66
Amit Hosamani, KG Bhaskara, Roy P John, Mohamed Iqubal
Renal artery aneurysm is a rare entity with an incidence of about 1%. The preoperative evaluation of a voluntary kidney donor incidentally revealed a saccular aneurysm of the right renal artery on a computed tomography angiogram. Laparoscopic right donor nephrectomy was performed with Bench repair of the aneurysm and transplantation of this kidney to the recipient in the right iliac fossa. Transplant kidney had good perfusion on revascularization with normal postoperative graft function. Transplanting kidneys with renal artery aneurysm can be safely performed with a win-win situation for both donor and recipient.
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Renal transplantation in a patient with polyarteritis nodosa - A case report p. 69
K Vinod Kumar, V Narayanan Unni, Nanda Kachare, R Anil Kumar, Bipi Prasannan, Vishnu Dev Urs
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis, predominantly affecting medium-sized arteries, and usually involving the kidneys, heart, gastrointestinal tract, and nervous system. The common clinical presentation is renovascular hypertension due to renal artery stenosis. We report a 38-year-old man, who presented with secondary hypertension and progressive renal failure leading on to end-stage renal disease (ESRD). He had renal artery stenosis on evaluation which caused ischemic damage to the kidneys resulting in ESRD. He also had multivessel coronary artery disease requiring percutaneous transluminal angioplasty. Coronary angiogram and renal angiogram showed areas of ectatic segments and aneurysms along with stenotic segments, which was consistent with medium-vessel vasculitis. We had challenges in considering him for kidney transplantation due to significant coronary artery disease, and he required coronary angioplasty on two occasions 6 months apart. He underwent bilateral nephrectomy prior to the transplantation as he had refractory hypertension requiring five antihypertensive medications. Histology of the nephrectomy specimen confirmed the diagnosis of PAN. Our patient did not show evidence of hepatitis B infection which is commonly associated with PAN. Renal failure and progression to ESRD are rare in PAN and are due to ischemic damage to the kidneys. He underwent kidney transplantation and had a smooth perioperative period and normal graft functions 6 months after the transplant surgery. To the best of our knowledge, this is the second reported case of PAN, who underwent successful kidney transplantation. Significant coronary artery disease is a rare manifestation in PAN.
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Immunomodulation in sepsis - A case report p. 73
Rajasekara Chakravarthi Madarasu, Girish Vasudeo Kumthekar
Sepsis and septic shock affect anywhere between 100 and 1000/100,000 person-years and 19 per 100,000 person-years depending on the cohort studied, with mortality rates ranging between 20% and 50%. The recently updated Sepsis 3.0 consensus definitions state that sepsis is an infection accompanied by life-threatening organ dysfunction caused by a dysregulated host response. Given the pivotal role of cytokine production in sepsis and post major surgery, it follows that removal of these substances may attenuate the response particularly in the early phase of sepsis.
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Acute pancreatitis in a kidney transplant recipient and proposal of a step-wise diagnostic algorithm - A case report Highly accessed article p. 76
Praveen Kumar Etta, Thatipamula Madhavi, Namrata Parikh
Acute pancreatitis (AP) is a rarely encountered complication in patients following kidney transplantation and is associated with significant morbidity and mortality. The diagnosis is often difficult due to the lack of classic symptoms and laboratory findings. Herein, we report the case of azathioprine-induced AP leading to acute kidney injury in a kidney transplant recipient, in whom we have encountered diagnostic difficulty. Patient spontaneously recovered after drug withdrawal. We propose a step-wise diagnostic algorithm for the evaluation of AP in kidney transplant recipients.
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Immunosuppression after the diagnosis of renal allograft renal cell carcinoma in two transplant recipients: Case reports and review of the literature p. 81
Joyita Bharati, Parikshaa Gupta, Ujjwal Gorsi, Ravimohan S Mavuduru, Vivek Kumar, Manish Rathi, Harbir Singh Kohli, Raja Ramachandran
Renal cell carcinoma (RCC) is a common solid malignancy among renal transplant recipients. While it commonly involves the native kidneys, renal allograft RCC is increasingly being reported in renal transplant recipients. Most often, renal allograft RCCs are locally confined and nephron-sparing interventions are successful treatments. Immunosuppression is typically reduced in transplant recipients who develop malignancies; however, there is no consensus on the same for transplant recipients with a diagnosis of RCC. We report two cases of renal allograft RCC who were successfully managed with ablative therapy and reduction of immunosuppression. However, both the patients developed irreversible graft dysfunction and are wait-listed in the deceased donor program for the second transplant. We highlight the deficiency of evidence and the need for further studies on the aspect of immunosuppression modification after the diagnosis of RCC in transplant recipients.
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Gender disparity in liver transplantation in Indian setting p. 89
Mayank Jain, Uday Sanglodkar, Jayanthi Venkataraman
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