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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 14 | Issue 3
Page Nos. 189-273

Online since Wednesday, September 30, 2020

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REVIEW ARTICLE  

An approach to allograft renal biopsy interpretation for the beginner- A narrative review p. 189
Swarnalata Gowrishankar
DOI:10.4103/ijot.ijot_30_20  
Allograft renal biopsy remains the gold standard for diagnosing many conditions in the transplant recipient including rejections, infections, recurrent, and de-novo renal disease. The Banff schema of reporting is followed worldwide in arriving at the right diagnosis. The guidelines, the categories, and the Banff scores in this schema are constantly evolving and this has made the interpretation of the biopsy seem complex and difficult especially for the novice. In this review, a detailed description of the various patterns of injury specific to the graft, the Banff categories of diagnoses, the lesions, and the Banff scores are simplified and explained. Lastly, a systematic approach to these allograft biopsies, which can be followed in regular practice, and by which a tentative diagnosis can be made in most cases is laid out.
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COMMENTARIES Top

C4d staining and antibody-mediated rejection in renal transplantation: Current status Highly accessed article p. 197
Praveen Kumar Etta
DOI:10.4103/ijot.ijot_22_20  
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Voiding cystourethrogram in adult pretransplant evaluation – Will it make a difference? p. 202
Srikanth Gundlapalli, Sarika Pandya, Taif Bendigeri
DOI:10.4103/ijot.ijot_23_20  
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ORIGINAL ARTICLES Top

Bedside strategy to prevent postrenal transplant urinary tract infection-non randomised, case control pilot study p. 204
Mital Parikh, Neel Patel, Abhijit Konnur, Sishir Gang, Rajapurkar Mohan, Umapati Hegde
DOI:10.4103/ijot.ijot_62_19  
Background: Post renal transplant UTI is very common, increasing the morbidity and mortality with high chances of graft failure. Majority of centres use prophylactic antibioitcs like TMP-SMX after renal transplantation within first 6 months. Aims and Objectives: To understand the incidence of UTI and it's risk factors, to compare the effectiveness of using individual commode in decreasing incidence of post transplant UTI with historical cohort of renal transplant recipients. Materials and Methods: 25 patients were recruited from April 01, 2017, to June 01, 2017. They were encouraged to bring along a portable commode to use it during their stay as well as at home after discharge and followed for 1 month for presence of urinary tract infection. Results: 6 patients had culture proven UTI(24%) in historical cohort while no patient had UTI in study group using commode(0%). Conclusion: Individualizing personal waste disposal techniques using disposable bedside commode is an effective and economical strategy.
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Immediate donation of eyes after life: The first prospective, nurse driven, smart phone-based observational study on cornea donation in India p. 208
Avnish Kumar Seth, Twinkle Singh, Preeti Monga, Swati Kalra, Minimole John, Lalita Thambi, Girja Sharma, Doli Biswas, Ratna Rana, CA Leelamma, Mary Panoose
DOI:10.4103/ijot.ijot_24_20  
Aim: This study aims to evaluate the efficacy of the Immediate Donation of Eyes after Life (IDEAL) protocol in establishing and monitoring hospital-based cornea retrieval programs. Methods: Nursing staff was sensitized to the process of cornea donation (CD), contraindications, and counseling by holding workshops and role-plays. All deaths in each of the participating hospitals of the prospective study were reported on WhatsApp “Code Angel Group” in a specific format. Each death was evaluated to rule out any contraindication to CD, the family was approached by the nurse on duty and counseled for donation. In case of negative or equivocal response to counseling for CD, smart phone-based messages were sent by eye bank (EB), followed by a phone call. Cornea retrieval was carried out by the same EB throughout the study period. In case of negative consent to donation, follow-up phone call to the next of kin at 1–2 weeks was done and response recorded. Results: Of 2140 deaths recorded, 1540 (71.9%) were ineligible for donation, largely due to sepsis. Of the remaining 600, counseling was done in 484 (83%). Ninety-nine of 484 (20.5%) families consented to donation. Counseling was carried out by a total of 70 nurses. Of the 45 nurses who counseled 3 or more families, conversion rate for CD was above 50% in 4, 40%–49% in 2, 30%–39% in 5, 20%–29% in 11, and below 20% in 12. Conclusions: Nursing teams on duty, with brief training on CD, can effectively drive the CD program in hospital setting.
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Thrombotic microangiopathies postrenal transplantation p. 213
Kartik Ganesh, Abi M Abraham, Jithin S Kumar, Renu S Paul, Sunita Simon, Nirmal Harshan
DOI:10.4103/ijot.ijot_29_19  
Aims: The aim of the study was to describe 12 cases of thrombotic microangiopathy (TMA) postrenal transplantation and study the causes, treatment, and outcomes. Materials and Methods: A retrospective observational study was conducted among renal transplants conducted from 2005 to 2018. Results: Of a total number of 1210 transplants, 12 patients (1%) developed posttransplant thrombotic complications. The mean age of recipients was 36.75 years, and the male-to-female ratio was 9:3. Native kidney diseases included diabetic nephropathy, chronic glomerulonephritis, chronic interstitial nephritis, lupus nephritis, atypical hemolytic uremic syndrome (HUS), and immunoglobulin A nephropathy. Treatment options included plasmapheresis, intravenous immunoglobulin, and everolimus. Seven (58.3%) were associated with an acute rejection, 2 (16.6%) had associated histopathological evidence of calcineurin toxicity, 1 (8.3%) had an unknown etiology, 1 (8.3%) had recurrent HUS in the graft, and 2 (18.2%) patients developed glomerular microthrombi, both of which resolved spontaneously. Graft loss was 50% within the 1st year. Six patients (50%) had a good 1-year graft survival. Two patients succumbed (16.6%). Conclusion: TMA in the posttransplant period may be commonly associated with drug toxicities, antibody-mediated rejection, or recurrent HUS. There is no correlation between drug levels and extent or prognosis of TMA. Empirical plasma exchange may be tried even in cases with no evident cause for TMA. Graft loss is common.
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Employment and quality of life postkidney transplant: Are we justifying the choice of RRT - A cross sectional study p. 219
Shikha Khandelwal, Vinay Malhotra, Dhananjay Agarwal, Pankaj Beniwal, Sanjeev Sharma, Rajesh Jorawat, Vartul Gupta, Shiv Chada
DOI:10.4103/ijot.ijot_47_20  
Introduction: For kidney, patients' socioeconomic status (SES) and employment significantly contribute to their general well-being, mental health (MH), and quality of life (QoL). Due to the scarcity of the literature, the present study was conducted to analyze the interrelationship between QoL, employment, and sociodemographic factors postkidney transplant and to identify the possible predictors of employment. Materials and Methods: This cross-sectional study was conducted on 90 kidney transplant patients during follow-up visits from July 2018 to June 2019 in the tertiary care government institute in North India. Employment before and after transplant was evaluated using a sociodemographic schedule. Short-form health survey 36 was used for the QoL. Results: Lower SES was not found in any of the subject's prekidney transplants, whereas it was revealed in 27.8% of the subject's postkidney transplant with a statistically significant difference. Unemployed status was also increased from 23.3% to 47.8% postkidney transplant. Employment posttransplant (EPT) is not associated with a good perception of psychophysical well-being: EPT/general health, r = −01.6; EPT/MH, r=-0.08, and EPT/ Mental component summary score (MCS), r = −0.34. It emerged that job return depends on the highest education, exercise, and insurance, while it is inversely proportional to the residence in a rural area and lower SES. Conclusion: Maintaining employment pretransplant and posttransplant should be actively supported and in case employment is lost, return to work should be integrated into the transplant planning. It may be useful to organize psychological support for these patients and to cure any psychological fragility in the posttransplant condition.
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Day and night surgery: Comparing outcomes in deceased donor renal transplant with surgeons' perspectives to operate at odd hours - a prospective observational study p. 224
Ketan Mehra, Ramanitharan Manikandan, Lalgudi Narayanan Dorairajan, Kodakkattil Sreenivasan Sreerag, Rajiv Kumar
DOI:10.4103/ijot.ijot_26_20  
Introduction: Working in stress during night may be hazardous to the patients as well as professionals. The aim of the present study was to compare the outcomes of emergency renal transplants performed during the day with those during the night. Materials and Methods: The data of deceased transplants performed between March 2012 and June 2018 was reviewed retrospectively. Group 1 included patients operated between 8 am and 8 pm while Group 2 patients were operated between 8 pm and 8 am. The outcomes compared included cold ischemia time, vascular and urologic complications, creatinine over time period, graft survival, and mortality, if any. A custom-designed questionnaire was distributed to surgeons covering the practice of urgent renal transplant, including fatigue. Results: A total of 71 transplant recipients were included in this study. Forty (56.3%) belonged to Group 1 and 31 (43.7%) to Group 2. There were no significant differences with respect to complications, renal graft function, and patient survival between day and night time surgeries. Conclusion: Emergency renal transplants during night hours do 'not have inferior outcomes in comparison to patients operated during day time. The majority of surgeons feel less proficient in performing surgery during emergency hours and given a choice would prefer to operate during the subsequent elective operating hour.
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Correlation of methods of glomerular filtration rate estimation: Cockcroft–gault equation, modification of diet in renal disease, chronic kidney disease epidemiology collaboration, and DTPA renography in prospective renal donors -a retrospective analytical study p. 230
Sandeep Malik, Amrit Pal Singh Gill, TC Sadasukhi, Hoti Lal Gupta, Manish Gupta, Ketul Patel
DOI:10.4103/ijot.ijot_34_20  
Introduction: The gold standard method for estimating glomerular filtration rate (GFR) in potential donors is diethylenetriaminepentaacetic acid (DTPA) renogram. But DTPA renogram being inconvenient, expensive, and with limited access , hence we need other methods which are noninvasive and provide a comparatively accurate estimation of GFR. Various estimating equations such as Cockcroft–Gault (CG) equation, Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) are available but have not been well studied or compared to DTPA GFR measurement. Methods: A total of 100 healthy donors (females and males) were studied. All participants underwent 99mTc DTPA renogram, and the GFR obtained was compared with MDRD, CG, and CKD-EPI-estimated GFR. Correlation between variables was estimated by statistical analyses in SPSS software version 18.0, and accuracy of various methods was studied. The data were analyzed by paired t-test, and Pearson's correlation test was used to correlate between two variables. Results: Out of the 100 donors, 79% were females and out of 100 renal recipients, 88% were males. The mean age for donors was 47.27 ± 10.93 years and for recipients was 35.02 ± 11.11 years. The mean GFR (mL/min per 1.73 m2) obtained by DTPA, CG, MDRD, and CKD-EPI was 109.91 ± 20.3, 114.10 ± 21.25, 128.66 ± 22.69, and 108.86 ± 12.72, respectively. The overall mean bias was smallest for CKD-EPI (standard deviation: 18.79). The bias and mean absolute difference between calculated and measured GFR for CKD-EPI, MDRD, and CG were 8.98 and 16.05, −17.97 and 23.26, and −5.76 and 23.29, respectively. There was a positive correlation between GFR by DTPA and GFR by CKD-EPI (0.408) and MDRD (0.399). Conclusions: Despite a wide variation in absolute values of GFR obtained by these methods, CKD-EPI and MDRD showed a positive correlation with DTPA GFR. CKD-EPI had least bias and thus correlated best with DTPA. In potential donors, these equations may be inadequate to replace DTPA for estimating GFR and due to limitations of our study further studies are needed with bigger sample size and longer duration.
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Reducing opioid consumption in postoperative renal transplant patients: A retrospective analysis p. 235
Marian Sherman, Geoffrey Ho, Everett Chu, Ivy Benjenk, Sam Gumbert, Connie Lin, Richard Amdur, Jason Podolnick, Joshua Slocum, Eric Heinz
DOI:10.4103/ijot.ijot_44_20  
Background: Opioid use is high in renal transplant patients, both before and after surgery, in part due to the chronic pain associated with end-stage renal disease. Recent studies have shown patients with high opioid consumption post-transplant have higher incidences of graft loss and mortality. Despite this, opioids remain the mainstay of postoperative analgesia. Aims and Objectives: We wanted to see if known analgesic adjuncts, namely regional anesthesia via a continuous transversus abdominis plane (TAP) catheter block or systemic intravenous lidocaine, could reduce the postoperative opioid requirement in this patient group. Materials and Methods: We conducted a retrospective analysis of renal transplant patients over a 2-year period, comparing patients who had an opioid patient-controlled analgesia pump as their main treatment modality, against patients who had either a TAP block or systemic lidocaine as an adjunct. As a primary outcome measure, we calculated their oral morphine equivalents for the 72 hours post-transplant. We excluded patients who had surgical complications, or were on chronic opioid therapy for other conditions. Results: We identified 86 patients over this study period. We found that regional anesthesia was associated with a 34.4% reduction (P < 0.01) and systemic lidocaine with a 36.5% reduction (P = 0.134) in cumulative opioid consumption without adversely affecting the quality of pain control. No significant complications were noted. Conclusion: Both regional anesthesia and systemic lidocaine are viable opioid sparing adjuncts for postoperative acute pain in this patient population.
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CASE REPORTS Top

Elevated procalcitonin level in early postoperative period after liver transplantation is not an indicator for systemic infection - a case report p. 240
Hirak Pahari, Nikhil Shellagi, Barun Nath
DOI:10.4103/ijot.ijot_38_20  
Elevated procalcitonin (Pct) in the early postoperative phase after liver transplantation often may present a diagnostic dilemma. We report a 40-year-old patient after deceased donor liver transplant who had elevated Pct on postoperative day (POD) 2 which gradually declined by POD 6. This was not accompanied by any signs of clinical infection and did not coincide with mild rejection in the recipient. We conclude that raised Pct in early posttransplant phase is not an independent marker for systemic infection, whereas persistently elevated Pct level or a second peak may be more contributory to the diagnosis of infection. The level of Pct must be correlated with clinical symptoms, signs, and other infective markers for better diagnostic accuracy.
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Isolated B cell central nervous system posttransplant lymphoproliferative disorder: Role of magnetic resonance imaging in the diagnosis and management in the absence of neurological signs - a case report p. 243
Monisha Jacob, Milly Mathew, Rajeevalochana Parthasarathy, Jayanthi Arulneyam, Siddartha Ghosh, Jose Easow, Sivaranjini Narayanan, Georgi Abraham
DOI:10.4103/ijot.ijot_40_20  
A 29-year-old female who received a kidney from her mother 9 months ago, on minimal triple immunosuppression presented with short duration vertigo. There were no focal neurological deficits. Magnetic resonance imaging of the brain revealed peripherally enhancing periventricular lesions, predominantly in the bilateral frontal lobes. Positron-emission tomography showed increased uptake in the brain lesions. A stereotactic biopsy revealed CD20+ monomorphic B cell posttransplant lymphoproliferative disorder. The donor mother and daughter were Epstein–Barr virus (EBV) immunoglobulin G (IgG+)/IgG−. The cerebrospinal fluid and brain biopsy were positive for EBV. Treatment consisted of discontinuing prednisolone and MMF and reducing tacrolimus to 0.5 mg od. Rituximab, zidovudine, ganciclovir, and dexamethasone are being used. She has stable renal function.
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Abdominal wall pseudoaneurysm after percutaneous renal allograft biopsy: A preventable complication? - a case report p. 247
Zeeshan Kareem, Abhijit Patil, Ravindra Sabnis, Mahesh Desai
DOI:10.4103/ijot.ijot_53_20  
Percutaneous renal allograft biopsy (PRAB) complications have been extensively described in literature. We report an unusual case of a pseudoaneurysm in the anterior abdominal wall that developed after a PRAB in a 26-year-old male patient done for suspected posttransplant graft dysfunction. Surgical exploration and ligation of feeding vessel was done for this case. Such a distressing complication warrants extra care as it can lead to significant morbidity in the patient.
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Coronavirus disease in a renal allograft recipient: A case report p. 250
Yuvraj Gulati, Narayan Prasad, Manas R Behera, Manas R Patel, Dharmendra Bhadauria, Anupama Kaul, Monika Yachha, Ravi Kushwaha, Amit Gupta
DOI:10.4103/ijot.ijot_63_20  
Coronavirus disease-19 (COVID-19) affected everyone on the globe, including renal transplant recipients who are at increased risk of infection. The clinical manifestations, immunosuppressive modifications, and treatment protocol are not well defined. We are reporting a case of renal transplant recipient and reviewed all case reports and series (a total of 100 patients) published to date to comprehend the clinical manifestations, immunosuppression modifications, treatment given, and outcomes of the patients. A 57-year-old male kidney transplant recipient had a fever, headache, weakness, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. He became asymptomatic with the treatment of hydroxychloroquine, azithromycin, and oseltamivir. However, he remained persistently positive by reverse transcriptase-polymerase chain reaction for SARS-CoV-2 for 4 weeks and became negative only after Ivermectin therapy, a safer medicine than antivirals/antiretrovirals used for COVID therapy in renal transplant recipients. Of the 100 patients review of case series, fever was noted in 85%, cough 71%, diarrhea 10%, and radiographic abnormalities in 75% of cases. Only in 3% of cases, steroid was stopped, and in the rest of the cases, 63% either continued in the same doses or changed to methylprednisolone in 34%. Calcineurin inhibitors were temporarily stopped in 42% of cases, reduced in 9% of cases, and continued in the same doses in 49% of cases. The anti-metabolites were discontinued in 83%, reduced in 9% of cases, and not changed in 8% of cases. SARI was observed in 18% and acute kidney injury (AKI) in 26% of cases. Of all the AKI, 11% required renal replacement therapy. Mortality was observed in 21% of cases. COVID in renal transplant recipients may show an unusually longer positivity. Ivermectin may be used in the absence of any conclusive SARS-CoV-2 antivirals. Mortality is high in renal transplant recipients.
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Fosfomycin for post-renal transplant urinary tract infection: Re-emergence of an old drug - a Case report p. 255
Ajay Jaryal, Sanjay Vikrant
DOI:10.4103/ijot.ijot_39_20  
Urinary tract infection (UTI) is a common problem in renal transplant recipients (RTR). It is challenging to treat UTI in RTR, as they are immunosuppressed, prone to allograft dysfunction, and can have adverse drug interactions due to the concomitant use of other immunosuppressant drugs. The UTI in RTR may present as asymptomatic bacteriuria (ASB), cystitis, pyelonephritis, or asymptomatic allograft dysfunction. Many times, UTI is caused by drug-resistant organisms, making it difficult to treat and also limiting the choice of empirical and specific antimicrobial therapy. Besides this, the treatment of ASB is controversial in RTR. Fosfomycin is an old drug which is re-emerging as an empirical antibiotic for UTI. Herein, we report a patient with multidrug-resistant ASB, within 1st month of transplant treated successfully with a single dose of fosfomycin.
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Spontaneous closure of stage 3 full-thickness macular hole after vitreomacular traction release in a renal transplant patient -a case report p. 257
Mohammed Abdulkarem, Ahmed A Al-Muhaylib, Adel Gady AlAkeely
DOI:10.4103/ijot.ijot_27_20  
The aim of our study is to describe spontaneous closure of a macular hole (MH) after vitreomacular traction (VMT) release in a 62-year-old patient with a history of renal transplant 6 months ago who was on tacrolimus, mycophenolate mofetil, nifedipine, and atorvastatin. The patient presented to our practice complaining of poor vision in his right eye for the past 6 months. On examination, he showed a full-thickness MH, Stage III, and VMT in the right eye evident in OCT which is an indication for surgical intervention. However, we elected to observe the patient upon his request. On further follow-up, visual acuity improved and OCT showed release of the VMT and closure of the MH. We attribute the release of the VMT to vitreolytic properties of atorvastatin. Our report highlights the possibility of observation of Stage 3 MHs in patients on atorvastatin as an option for the management.
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Combined aspergillus and mucormycosis infection in a renal allograft recipient - a case report p. 260
Manjunath Jeevanna Kulkarni, Amith Dsouza, GR Pramod, Farhan Fazal, Don Gregory Mascarenhas, Archana Bhat, Lenon Jason Dsouza
DOI:10.4103/ijot.ijot_75_20  
We report a case of combined fungal infection with and aspergillus and mucormycosis in a kidney transplant recipient. Though fungal infections are common in solid organ transplant cases, combined infection with two fungi are not commonly reported. This case report describes one such infection in a kidney transplant patient, Awareness of such infections is essential in management of fungal infections in kidney transplant patients.
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A case report of late-onset gastrointestinal cytomegalovirus infection 17 years post kidney transplantation p. 263
Sneha Haridas Anupama, Priyanka Koshy, Arun Ramaswamy Saraswathy, Rajeevalochana Parthasarathy, Milly Mathew, Georgi Abraham
DOI:10.4103/ijot.ijot_15_20  
Cytomegalovirus (CMV) infection, one of the most common viral infections seen post-transplantation, is rarely known to occur after 15 years. Here, we report a 59-year-old male on minimum immunosuppressive agents who presented with abdominal pain and was found to have CMV infection of the distal ileum with concurrent high CMV viral load 17 years post kidney transplantation.
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Liver retrieval from brain-dead kidney transplant recipient – Expanding the organ pool - case report p. 266
Aniruddha V Bhosale, Bipin B Vibhute, Dinesh K Zirpe, Shailesh Sable
DOI:10.4103/ijot.ijot_65_19  
Organ shortage is the leading cause of mortality while on the waiting list for an organ. There is a huge difference between the number of organs required for transplants and the number of organs and organ donations available for transplants. In Asian countries such as India, with a high prevalence of decompensated chronic liver disease requiring organ transplantations, organ shortage is one of the most important issues. Various modifications in donor criteria have been done in the past few decades to expand the organ pool. Organ donation from a brain stem dead person, who was a living donor organ recipient, is a novel and attractive option for expanding the organ pool. Few noteworthy cases have been reported from the west. There are no reports from Asian countries, especially from India. Here, we report a case where liver retrieval was performed from a renal transplant recipient after brain stem death.
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LETTERS TO EDITOR Top

Screening for dengue virus in endemic areas prior to transplantation: Indian perspective p. 269
Praveen Kumar Etta
DOI:10.4103/ijot.ijot_25_20  
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Liver transplant in a patient with sick sinus syndrome and a permanent pacemaker: Anesthetic implications p. 272
Roopa M Nagabhushan, Andrews O Varghese, P Shyamsundar, Lakshmi Kumar
DOI:10.4103/ijot.ijot_37_20  
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