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   Table of Contents - Current issue
October-December 2020
Volume 14 | Issue 4
Page Nos. 275-379

Online since Wednesday, December 30, 2020

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The impact of comorbidities on clinical course and outcome, in kidney transplant recipients with COVID-19: A systematic review and analysis Highly accessed article p. 275
Amit Bansal, Anant Kumar, Richa Mittal Bansal, Ruchir Maheshwari, Samit Chaturvedi
Background: The literature on the impact of comorbidities on the severity and outcome of COVID-19 in kidney transplant patients is limited. We aimed to review the same. Methods: We conducted this review as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. PUBMED, Embase, Scopus, and Science Direct were searched for studies, available online till May 31, 2020. Studies reporting comorbidities, clinical course, and outcome of each kidney transplant patient with COVID-19 were included. Studies on any other organ transplant, recommendations, or review articles were excluded. The impact of comorbidities on severity and outcome was assessed. The study appraisal was done using Joanna Briggs Institute Critical Appraisal Checklist. Continuous variables were compared using Mann–Whitney U-test. Categorical variables were compared using Fisher's exact test. A univariate and multivariate logistic regression for predictors of severity and outcome, was done. P < 0.05 was considered statistically significant. The study protocol was registered with PROSPERO (CRD42020190114). Results: We analyzed 19 studies (56 patients) out of the 355 identified. The most common comorbidity was hypertension (83.92%). Nearly 30.35% of the patients had severe clinical course. The mortality rate was 19.64%. Advanced age was statistically significantly associated with severe course (P = 0.0173) and death (P = 0.0005). Men were more likely to have nonsevere course (P < 0.0001). No comorbidity had any impact on the severity or outcome. Patients with severe disease had higher odds of dying (P = 0.002). Conclusions: Comorbidities were not found to have any significant impact, hence the contribution of immunosuppression toward the severity of COVID-19 needs to be studied. Ours is the first review to assess the impact of comorbidities in kidney transplant patients with COVID-19 but limited by the number of patients.
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Urinary tract infections in kidney transplantation: An emerging crisis of drug resistance Highly accessed article p. 283
Praveen Kumar Etta
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Clinical profile of SARS-CoV-2 infection in kidney transplant patients - A single centre observational study Highly accessed article p. 288
Maithrayie Kumaresan, Madushri Babu, Rajeevalochana Parthasarathy, Milly Matthew, Chandramouleeswari Kathir, Anusha Rohit, Georgi Abraham
Background: In India, 8.27 million documented cases of COVID 19 and a total of 123K deaths have been reported till October 2020. We were able to estimate the clinical consequences of SARS CoV 2 in 16 patients over a period of 5 months. The disease prevalence and mortality rate observed in transplant recipients were found to be higher than in the general population. Aims and Objectives: A retrospective analysis of COVID 19 infections in kidney transplant recipients and the outcome. Materials and Methods: A single centre observational study of all patients who have undergone kidney transplant between March 2001 and December 2019 and documented evidence of SARS CoV 2 infection between March 2020 and October 2020. From a large cohort of 720 kidney transplant recipients, 16 recipients who developed COVID 19 infection were studied. They were all on maintenance immunosuppression in varying doses. None of the patients in this cohort had any recent episodes of cellular rejection requiring heightened immunosuppression. The vintage of the transplant varied from 9 to 192 months. Results: Acute kidney injury was identified in two patients. Eight patients were home quarantined and eight patients were hospitalized. All patients had a reduction in immunosuppression during the covid 19 infection dosage based on the severity of the disease. Out of the hospitalized patients, three died, two of whom had stable functioning grafts and the cause of death was identified as acute lung injury 1 patient had post covid ACR which was treated with Injection. Methyl Prednisolone. Conclusions: In our study, 2.22% developed COVID-19 disease and the mortality rate was 18.75% among those who developed COVID-19. The disease prevalence and mortality rate observed in transplant recipients were found to be higher than in the general population. Obesity, diabetes mellitus, and systemic hypertension were identified as independent risk factors.
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Comparison of the CMV antigenemia and CMV-DNA QPCR results in haematopoetic stem cells transplanted recipients - A retrospective observational study p. 293
Habib Ksouri, Yosra Chebbi, Anis Raddaoui, Wafa Achour
Objectives: Diagnosis of active cytomegalovirus (CMV) infection in hematopoietic stem cell (HSC)-transplanted patients is essential because of the serious complications it causes, especially CMV disease. Such diagnosis allows the initiation of a preemptive antiviral therapy, which avoids the development of such disease. In this retrospective study made as a part of routine work for transplanted patients, we compared two diagnosis testing for CMV-active infection such as pp65 CMV antigenemia and a quantitative real-time polymerase chain reaction (QPCR). Our purpose was to assess the contribution of these tools to the diagnosis and monitoring of active CMV infections. Materials and Methods: Five hundred and fifty-eight and 156 samples belonging to 24 HSC transplanted patients were, respectively, tested by antigenemia and QPCR. Results: For the 156 samples analyzed by both testing, a number of positive samples by a QPCR were higher than that by antigenemia (44.8% vs. 13%), with a statistically significant difference (P < 0.0001). A statistically significant correlation between viral loads of these two testing was also found (rs = 0.765). In median, QPCR becomes positive 14 days before antigenemia (P < 0.0001) and its positivity lasts for 91 days, whereas antigenemia positivity lasts only for 56 days (P < 0.001). No statistically significant difference was found between the results of these two testing in CMV disease cases. Conclusions: QPCR is a rapid, standardized assay, which permits a precocious detection of CMV DNA. Kinetic of DNA evolution is a reliable diagnostic tool and more effective than antigenemia-based assays in monitoring CMV infection.
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A prospective study of correlation of blood levels of tacrolimus to graft function and adverse effect of tacrolimus in postrenal transplant patients p. 298
Krishna Asuri, Virinder Kumar Bansal, Sujoy Chatterjee, Omprakash Prajapati, Mahesh Chandra Misra
Introduction: There are limited data on the symptoms of immune-suppressive therapy after transplant on Indian patients and how tacrolimus blood level correlates with graft function and its adverse effects. This study was planned to study these factors. Materials and Methods: The study was conducted as a prospective longitudinal study. Adult patients who underwent the live renal transplant and matched the inclusion criteria from March 2018 to April 2019 were enrolled for the study. Trends of all the parameters were analyzed and their correlation was done with corresponding tacrolimus blood levels. Blood for tacrolimus level was collected at d1, 5, 15, 30, 90, and 180, and values of serum creatinine, diabetes status, hypertensive status, lipid profile, infection occurrence, and liver function tests were recorded at the same time. The subjective symptom occurrence was also recorded by Modified Transplant Symptom Occurrence and Symptom Distress Scale questionnaire at 3 months. Results: The mean age of the study population was 33.7 ± 10.1 years. The incidence of infection was highest at 48% in the 1–3 month period. The incidence of posttransplant diabetes mellitus (PTDM) was 13.7%. Patients requiring antihypertensive decreased from 93.1% immediate posttransplant to 51.5% after 6 months of transplant. There was an increase in posttransplant triglyceride levels, total cholesterol, and low-density lipoprotein level with only high-density lipoprotein showing a protective trend. Liver functions did not show any derangements during the study period. There was no significant correlation between any of the adverse effects and tacrolimus blood levels. Excessive appetite was the most commonly experienced symptoms whereas tremor was the most distressing one. There was a statistically significant increase in symptoms experienced in patients whose tacrolimus blood level was above the normal level for that period. Conclusion: Our study showed no significant correlation between blood levels of tacrolimus and graft function and also with hypertension, dyslipidemia, PTDM, and incidence of posttransplant infections. The incidence of adverse effects was significantly higher in patients who had tacrolimus blood levels higher than recommended.
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The role of povidone-iodine in prevention of lymphorrhea after kidney transplant surgery - A prospective, pilot study p. 306
Dilip Kumar Pal, Pinaki Roy, Amvrin Chatterjee, Debarshi Jana, Debasish Mandal
Objective: Lymphatic complications (lymphorrhea or lymphocele) are one of the most common and frustrating complications of renal transplantation. It was well documented in literatures that excessive lymphatic leak in the early postoperative period leads to lymphorrhea, which may transform into lymphocele. Povidone-iodine has been used as a sclerosant in lymphocele management for the past 30 years. In this study, our aim is to establish the role of povidone-iodine to prevent lymphorrhea after kidney transplant surgery. Materials and Methods: A total of 106 (live donor transplant patient = 63 and deceased donor transplant patient 43) patients had undergone renal transplantation from May 2019 to May 2020. Those patients were randomized into three groups – Group A (n = 35): where 1% povidone-iodine was used, Group B (n = 35): where 5% povidone-iodine was used, and Group C (n = 36): control group, where povidone-iodine was not used. Fifty milliliters of 1% or 5% povidone-iodine was used to wash the bed and kept for 5 min in contact with the bed and again 1% (Group A) or 5% (Group B) povidone-iodine wash was given after completion of ureteroneocystostomy and was kept for 5 min. Results: On postoperative day 6, there is a statistically significant decrease in drain output in the 5% and 1% povidone-iodine groups in comparison with the control group, but no statistically significant difference exists between 5% versus 1% povidone-iodine group. Conclusion: Intraoperative instillation povidone-iodine is a cheap, safe, and very effective procedure to prevent lymphorrhea following renal transplant surgeries.
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Pediatric kidney transplantation: Long-term outcome of living versus deceased donor program from a single center- A retrospective observational study p. 313
Kinnari B Vala, Himanshu V Patel, Vivek B Kute, Divyesh P Engineer, Pankaj R Shah, Dinesh N Gera, Pranjal R Modi, Jamal S Rizvi, Bina Butala, Shruti Mehta, Vineet M Mishra
Background: Kidney transplantation (KT) is widely accepted as most successful treatment option for patients with end-stage kidney disease (ESKD) for better survival and quality of life for both children as well as adults. Data scarcity on long term outcome of living donor (LD) versus deceased donor (DD) pediatric KT in developing countries prompted us to review our experience. Aims and Objectives: To determine(1) long term graft, (2)patient survival outcome and (3) rejection episodes in LD versus DD pediatric KT in developing country. Patients and Methods: This was a retrospective observational analysis of 151 LD and 37 DD pediatric renal transplants (age ≤18 years) performed at a tertiary care center between 1998 and 2011. This study was under taken to evaluate long term patient and graft survival, rejection episodes and other complications. Demographic details for all patients was retrieved. Kaplan-Meier curves were used for survival analysis. Results: Over a mean follow-up of 4.2 ± 3.61 years, one-, five- and ten- year death-censored graft survival in LDKT was 87.4%, 72.1%, 72.1% and patient survival was 92.5%, 80.9%, 75.1% respectively; 19.8% (n = 30) patients had biopsy proven acute rejection (BPAR) and 17.8% (n = 27) patients died, mainly due to infections (n = 12). In DDKT, over mean follow-up of 3.93 ± 3.5 years, one-, five- and ten-year death-censored graft survival was 90.4%, 86.4% ,73.3% and patient survival was 83.4%, 67.9%, 67.9 %, respectively; 21.6% (n = 8) patients had BPAR and 27% (n =10) patients died, mainly owing to infections (n = 6). Conclusion: LDKT or DDKT in children has acceptable graft function with patient/graft survival over long-term follow-up, encouraging to develop sustained deceased donor program in developing countries. However, infections are major cause of morbidity and mortality.
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Establishing a deceased donor transplantation program and its impact in a public sector hospital in India – A single centre experience from India Highly accessed article p. 321
JIPMER Deceased Donor Transplantation Committee (JDDTC)
Introduction: Organ transplantation is growing in India but is mostly dependent on living donors. Deceased donor organ procurement has grown in certain parts of the country in the past decade. However, brain death certification and organ procurement predominantly happen in private health-care sector, with less contribution from public sector hospitals. Expanding the infrastructure for deceased donor transplantation program, especially in the public sector hospitals, is likely the most important step toward improving deceased donor organ donation rates in a country like India. Methods: Here, we describe our experience with setting up a deceased donor program in a public sector hospital and its outcomes. Results: We harvested organs and tissues from 42 deceased donors between December 2013 and March 2020. The deceased donor program has helped in establishing a multi-organ transplantation program at our center, including liver and hand transplantation, in addition to kidney and corneal transplantation. Conclusion: Gathering a committed team of direct stakeholders with domain expertise, creating an organizational system, and establishing clear standard operating procedures (SOPs) are critical for success, in addition to physical infrastructure.
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Renal transplantation in polycythemia vera:- A rare case report from India p. 333
Prashant Bharat Malviya, Sanjay Maitra
Polycythemia vera (PV) is a rare myeloproliferative neoplasm usually associated with JAK2 mutation. Manifestations include blood circulation disorder, hypertension and cerebral infarction. Renal disease is quite uncommon in PV and only few cases have been reported in the literature. In majority of these cases it was considered that PVinduced glomerular hyperperfusion and hyperfiltration as a cause of CKD. PV with ESRD and undergoing successful renal transplantation is much rarer. We here report one such patient of PV who had Budd Chiari syndrome, underwent hepatic vein stenting. He developed CKD which progressed to ESRD and underwent renal transplantation. To the best of our knowledge it is first case report from India.
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Heart transplant recipient with features of COVID-19 infection: First case report from India p. 335
Dhruva Sharma, Sunil Dixit, Anil Sharma
A 16-year-old boy has been reported 3 months postcardiac transplantation with chief complaints of nausea, vomiting, pain in abdomen, and fever. The patient had remarkably increased serum lactate dehydrogenase levels, triglycerides, serum amylase, and serum lipase. The B-type natriuretic peptide level more than 35,000 ng/mL and troponin T was increased (0.57 μg/ml). Last known concentration of tacrolimus was 9 ng/ml. Supraventricular tachycardia was remarkable on electrocardiogram. His computed tomographic findings revealed bilateral pneumothorax with bilateral pleural effusion with an opacity seen in the right upper lobe. Bedside echo revealed dilated right atrium and right ventricle with left ventricular ejection fraction of 60%. He was kept on immunosuppression of mycophenolate mofetil 360 mg (2 tablets twice a day) and tacrolimus (2.5 mg twice a day). His reverse transcriptase-polymerase chain reaction throat swabs of the patient were sent for testing 2019-nCoV and were found to be negative. The patient could not be revived in spite of all medical management.
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Case report of swap kidney transplantation in Chhattisgarh – Challenges and solution p. 338
Prawash Kumar Chowdhary, Sanjeev Anant Kale, Ajay Parashar, Vivek Kute, Ashish Sharma, Sandeep Agrawal, Sudha Trivedi, Shruti Khatkhedkar
Kidney Transplantation is the best as well as the most cost-effective mode of renal replacement therapy for end end-stage renal disease patients with better survival and quality of life compared to dialysis. In the absence of a deceased donor programme in Chhattisgarh, Kidney paired donation (KPD) may provide an important strategy for easing the crisis in organ availability. In KPD, the incompatibility problems with two donor– recipient pairs can be solved by exchanging donors. We report our first successful KPD transplantation done by our institute in Chhattisgarh. Out of two, one had acute graft dysfunction which gets recovered after stopping tacrolimus and converting to sirolimus. Both the donors had a smooth hospital course and were discharged on the 5th postoperative day. They are in follow- up with us with good graft function (serum creatinine 1.2 mg/dl and 0.8 mg/dl). In the era of organ shortage, KPD provides hope to the growing number of patients suffering from end-stage renal disease in Chhattisgarh which will promote renal transplantation in our state.
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Operative surprise! A hitherto undiscovered dialysis catheter removed successfully from the external iliac vein during renal transplant - A case report p. 343
Nitin Agarwal, Anil Kumar Singh Rana, Manoj Kumar Dokania, Himank Goyal
The incidence of chronic kidney disease (CKD) has reached epidemic proportions in India over the past few decades. One of the reasons is the abnormally high prevalence of diabetes mellitus and hypertension. After conversion to end-stage renal disease, renal replacement therapy (RRT) either as dialysis or renal transplant is critical for survival. Facilities for hemodialysis are also abysmally low; this is compounded by poorly trained personnel in peripheral hospitals. These factors contribute to the poor outcome of CKD patients, even if RRT is initiated. We present a case of a middle-aged man who underwent renal transplant for CKD; during the mobilization of the right external iliac vein, a previously undocumented sequestered dialysis catheter was found in the lumen of the vein. This is probably the first such case in literature and highlights the paucity of optimal hemodialysis facilities in the country. The dilemma of continuing the transplant on the same side versus exploring the left side is also discussed. Timely transplant, preferably preemptive transplant, can mitigate many of the problems of chronic hemodialysis. These problems can arise from access to thrombosis or foreign bodies; preoperative accurate Duplex imaging is essential.
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A case report of ABO and human leukocyte antigen incompatible renal transplant – Being immunologically smart p. 346
Pranaw Kumar Jha, Ajay Kher, Vijay Kher
Blood group and human leukocyte antigen (HLA) incompatibility are major immunological barriers in renal transplantation. Desensitization and subsequent transplantation improve the longevity and quality of life of these patients when compared to being on a waitlist. For best outcomes, a complete repertoire of immunological workup and an in-depth understanding of these tests are important for choosing the most suitable donor against whom the recipient is least sensitized. We present an interesting case of a sensitized patient who had the option of undergoing renal transplant with either a blood group incompatible mother or a compatible aunt as the prospective donor. Despite the blood group incompatibility, the mother was chosen as the donor in view of the lower strength of anti-HLA antibodies against her. The patient had a successful posttransplant outcome with good graft function at 1 year follow-up. Careful donor selection after detailed immunological workup is important while transplanting sensitized recipients. HLA incompatibility rather than blood group incompatibility should be the deciding factor in such cases.
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Yellow phosphorus poisoning and living donor liver transplant - A case report p. 349
Rakesh Babu, Kishore Kanianchalil, Anish Kumar, Rajneesh Rajan, Sajeesh Sahadevan, Rajesh Nambiar
Acute liver failure due to yellow phosphorus is common in south India. Patients usually have an early asymptomatic phase and a rapidly progressing symptomatic phase. Early intensive care management can delay the progression to fulminant hepatic failure.Liver transplant is the only definitive management once fulminant hepatic failure sets in.
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Ascariasis, the uncommon cause of bile leak, postliving donor liver transplant - A case report p. 352
Nitin Gupta, Ritu Verma, Ethel Shangne Belho, Suresh Kumar Singhvi
Ascaris lumbricoides is one of the most common parasitic infections in developing countries. History of previous biliary tract surgery risks migration of these worms to the biliary tree. Usually, 10% of patients with living donor liver transplants have biliary complications including bile leak and strictures. Here, we present an unusual case of ascariasis being a cause of biliary obstruction and bile leak in the immediate postoperative period of liver transplant.
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Are weak blood groups important to look for in kidney transplantation? A case report on interchanging blood groups p. 355
Vinayak Ukirde, Deepa Usulumarty, Harita Maru, Viswanath Billa
The principles of ABO compatibility are fundamental to clinical solid organ transplantation, and conventional blood grouping techniques may mislabel patients with rare blood groups. We present a case of a kidney donor and her recipient who were mislabeled by conventional blood grouping methodology due to the presence of weak blood groups in both individuals, which were identified on detailed analysis, thus avoiding the need to undergo unnecessary desensitization protocols. The recipient underwent a successful transplant with the same donor and continues to do well 6 months after the transplant.
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Kidney transplant in the presence of massively calcified vessels: A surgical challenge - A case report p. 358
Bipin Chandra Pal, Gaurav Patel, Urmila Anandh, Vinay Kukreja
Kidney transplant in the presence of calcified vessels becomes a challenging task. There is a possibility of intraoperative complications and occasionally graft loss. Here, we present a case where we performed a kidney transplant in such a patient and discuss the importance of proper imaging and the surgical technique adapted by us to carry out the transplant.
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A case report of central nervous system mucormycosis and aspergillus pneumopericardium in a renal transplant recipient p. 360
Arushi Nautiyal, Ashwini Gadde, Amit Kumar Mahapatra, Shyam Bihari Bansal
Renal transplant recipients are at high risk of opportunistic infections. The occurrence of infections is influenced by the intensity of immunosuppression, microbial exposures and other environmental and systemic factors. We present a case of a postrenal transplant recipient who developed polymicrobial infections, including bacterial and invasive fungal infections involving the cerebrum (Mucormycosis) and lung (Aspergillosis) complicated by extension into the pericardial cavity. Despite treatment with intravenous antibiotics and antifungals along with surgical debridement of infective focus, the patient succumbed to the illness. Fungal infections in posttransplant population can have myriad presentations and many pathogens can become locally and systemically invasive unless detected and controlled in a timely manner. Risk factors such as hyperglycemia and high immunosuppression should be appropriately addressed for the prevention of high-grade infections.
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Co-infection of COVID-19 with dengue fever and acute graft dysfunction in a kidney transplant recipient - A case report p. 363
Amresh Krishna, Prit Pal Singh, Harsh Vardhan, Om Kumar
Among coronavirus disease 2019 (COVID-19) pandemic, endemic infections also peak in India during this monsoon. Kidney transplant recipients are at higher risk of contracting infections with increased morbidity and mortality. Co-infection of COVID-19 with other infections is apprehended with more unfavorable outcome. We report a case of young renal allograft recipient with co-infection of COVID-19 and dengue fever presenting with acute graft dysfunction. Apart from supportive treatment and reduction in immunosuppressants, the patient was managed with dexamethasone, remdesivir, and heparin. The patient responded to the treatment and graft dysfunction improved on conservative management. This case emphasizes the need to consider endemic diseases also during workup of COVID-19 patients and shows that co-infections even with acute graft dysfunction can also have favorable prognosis. This case also points out the difficulties faced in managing immunosuppressants due to fear of acute graft rejection.
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Amoebic liver abscess in a renal transplant recipient - A rare entity- Case report p. 366
Vishnu Dev Urs, VN Unni, Nanda Kachare, Vinod Kumar Kunjappa, Abhinav Menon, PK Bipi
Infections are the most common cause of morbidity and mortality in renal transplant recipients; respiratory, urinary, and gastrointestinal infections are the most common. Gastrointestinal manifestations are usually associated with cytomegalovirus. Although opportunistic infections are common in solid organ transplant recipients in view of the immunosuppressed state, amoebic liver abscess is uncommon in renal transplant recipients and has not been reported in literature, to the best of our knowledge. We describe a patient with an amoebic liver abscess 3 months after renal transplantation surgery.
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Guillain–Barre syndrome-like presentation and thrombotic microangiopathy with calcineurin inhibitor - A case report p. 369
Prawash Kumar Chowdhary, Sanjeev Anant Kale, Tarun Kumar Saha, Subho Banerjee
A 35-year-old male, 3 months postrenal transplant, presented with acute-onset demyelinating polyneuropathy, diagnosed to have tacrolimus-associated Guillain–Barre syndrome. He recovered within 5–7 days after converting from tacrolimus to cyclosporine (CsA). He developed graft dysfunction after 2 months due to CsA-induced thrombotic microangiopathy. He responded after converting to sirolimus from CsA. The proper knowledge of immunosuppression side effect and its discontinuation in the early period prevents permanent damage.
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A rare complication after laparoscopic donor nephrectomy: Chyle leak - A case report p. 374
Sneha P Simon, Jose Thomas, Balagopal Nair Tidayath, Sanjay H Bhat
Live kidney donors are healthy individuals who are willingly undergoing major surgery to alleviate the misery of another individual. It is important to minimize the risks of this procedure and at the same time maximize donor safety. Chyle leak following donor nephrectomy is extremely rare. We report a case of chylous ascites combined with chylothorax following laparoscopic donor nephrectomy. Usually, it responds to conservative measures. Our patient had failed to respond to a conservative line of management and required surgical correction with good outcomes.
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Plasma cell-rich rejection – The enigma revisited: Case report p. 377
Srikanth Gundlapalli, Sujeeth Reddy Bande, Venkateswar Rao Mulpuru
Plasma cell-rich rejection (PCRR) is a morphological pattern of rejection characterized by the presence of plasma cells constituting at least 10% of the cellular infiltrate. Clinical characteristics, therapeutic options, and its position in the Banff Classification for Allograft Rejection have not been clearly defined. Although morphologically discussed in close association with cellular rejection, histopathological advances and better availability of C4d helped us to understand the close relationship with the antibody-mediated rejection. T helper cell 2 predominant cellular infiltration has been identified in recent studies. Rational choices of drugs such as bortezomib have not shown outcomes as expected in various clinical trials. Newer therapeutic options directed at TH2 cytokines which are being tested in other disorders may open up new avenues of therapy. We discuss two cases of PCRR with varied presentation, one early and the other very late in the course of transplantation. Both of our patients had poor graft outcomes despite therapy.
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