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  Citation statistics : Table of Contents
   2014| December  | Volume 8 | Issue 5  
    Online since December 1, 2017

 
 
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REVIEW ARTICLE
Opportunistic infection in renal transplant recipients
Anupma Kaul, Tejendra Singh Chauhan
December 2014, 8(5):57-64
DOI:10.1016/j.ijt.2014.01.012  
Despite improvements in the immunosuppressive protocols, and infection preventive method infections remains a major impediment to long-term renal graft survival especially in developing countries. Opportunistic infections after renal transplant usually follow a time table pattern with highest risk during first 6 month when intensity of immunosuppression is maximum, although this was not uniformly found in patients from this continent. In renal allograft recipient, immunosuppressive drug therapy is the major cause of immunocompromised status and occurrence of infections, which arise most commonly as a result of invasion by endogenous opportunists. Cytomegalovirus (CMV) remains one of the most important viral pathogen and studies suggest increased rejection episode associated with CMV infection. Polyomavirus-associated nephropathy (PVAN) remains an important cause of allograft dysfunction and graft loss after kidney transplantation. Tuberculosis (TB) is an important cause of morbidity in renal transplant recipients in developing world and the incidence of posttransplant tuberculosis in India has been reported to be highest in the world at 5.7–10% in various studies. The opportunistic infections with Nocardia and fungal infection like Aspergillosis, Mucormycosis, Candidiasis and others like Pneumocystis carinii in immunosuppressed patients were present with severe complications that are reviewed in this article. As a result of use of strong immunosuppressive drugs like tacrolimus, mycophenolate mofetyl (MMF) and antirejection therapy with antithymocyte globulins (ATG), these infections are now seen frequently, so they should always be included in differential diagnostic consideration.
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Post renal transplant acute kidney injury
Tarun Mittal, HS Kohli
December 2014, 8(5):33-36
DOI:10.1016/j.ijt.2014.01.011  
AKI specific to the renal transplant includes ischemia-reperfusion injury, acute rejection, acute calcineurin inhibitor (CNI) toxicity, venous or arterial thrombosis, urinary tract obstruction, graft pyelonephritis and recurrent disease. The graft is more susceptible to hemodynamic insults as it is denervated and there is at least partial loss of its autoregulatory capacity. Some factors unrelated to the transplant like sepsis may also predispose AKI in post-transplant period. The article particularly highlights the issues of AKI other than acute rejections.
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Posttransplant lymphoproliferative disorder following kidney transplant
Manoj Jain
December 2014, 8(5):21-28
DOI:10.1016/j.ijt.2014.01.004  
Posttransplant lymphoproliferative disorder (PTLD) is an important complication of kidney transplant and their presentations ranging from indolent polyclonal proliferations to aggressive lymphomas and involving various organs. There is scarce data on PTLD in live donor renal transplantation. This study highlights variable presentation of PTLD and involvement of many organ systems and higher incidence of late onset monomorphic PTLD at tertiary care center in north India over last 25 years.
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Imaging in renal transplant: Review
Hira Lal, Rajesh V Helavar, Shivanand Gamanagatti, Suruchi Jain, Rakesh Kumar
December 2014, 8(5):42-49
DOI:10.1016/j.ijt.2014.01.005  
Renal transplantation has transformed the management of end stage renal disease (ESRD), along with prolonging survival it offers good quality of life with low morbidity. Imaging plays an important role in the diagnosis of complications arising in renal transplant. Ultrasound (US) with Doppler is the first-line imaging modality for evaluation of renal graft, with US, Doppler and nuclear medicine being the main imaging modalities. Computed tomography scan (CT), Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) are used as problem solving tools in indeterminate cases. Interventional radiology plays a crucial role in the management of complications. Use of real time ultrasound guidance for percutaneous biopsy is now almost universal.
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EDITORIAL
Prof. R.K. Sharma: A Stalwart Nephrologist
Narayan Prasad
December 2014, 8(5):2-3
DOI:10.1016/j.ijt.2014.01.009  
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Message
Jawed Usmani
December 2014, 8(5):1-1
DOI:10.1016/j.ijt.2014.01.014  
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PREFACE
Preface
Sharma S Prabhakar
December 2014, 8(5):4-4
DOI:10.1016/j.ijt.2014.01.002  
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Prof. R.K. Sharma: A legend in Nephrology
UK Mishra
December 2014, 8(5):5-9
DOI:10.1016/j.ijt.2014.01.008  
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REVIEW ARTICLE
Simultaneous liver kidney transplant
Supriya Sharma, Gaurav Pande, Vivek A Saraswat, Rajan Saxena
December 2014, 8(5):50-56
DOI:10.1016/j.ijt.2014.01.010  
A significant number of patients awaiting liver transplantation have associated renal failure. Simultaneous Liver and Kidney (SLK) transplantation is increasingly offered especially since the introduction of Model for End-Stage Liver Disease (MELD). The appropriate selection of candidates for SLK is more complex and less well defined than for liver transplant alone (LTA) due to our inability to predict accurately the extent of reversibility of acute or functional renal injury, particularly in patients who also have some background renal impairment. The current allocation policy is flexible, providing a kidney to any liver transplant candidate based solely on local physician opinion. This latitude has resulted in tremendous diversity of opinion and practice. More studies are required to delineate the predictors of renal recovery, the factors which influence renal recovery and to understand the complex interplay between the background renal impairment, the functional effects on kidney of advanced liver disease, and the effect of nephrotoxic drugs including CNIs. The long-term results of SLK are comparable to those of isolated LT. The liver protects the kidney from disease recurrence and allograft loss in metabolic diseases and its immunoprotective effect has enabled renal transplant in highly sensitised patients with positive cross-match and previously failed renal transplants.
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Nephrology and kidney transplantation in India: Past, present and future
HL Trivedi
December 2014, 8(5):10-13
DOI:10.1016/j.ijt.2014.01.006  
Chronic kidney disease (CKD) has been recognized as a major global public health problem. The approximate prevalence of CKD in India is 800 per million populations (pmp). Kidney transplantation is considered as the best therapeutic modality for patients suffering from end stage renal disease (ESRD). Transplantation started in 1953 in Europe and USA and in India it started in 1965. The awareness of deceased donor organ transplants, cross-over transplants and other organs like liver and heart is also gradually increasing with Tamil nadu leading the country in deceased donor organ transplants. The alternative to post-transplant immunosuppression and associated problems is ‘transplant tolerance’ which means stable graft function with no immunosuppression while keeping immune system of the host intact. We at Ahmedabad have pioneered the technique of in vitro generation of human adipose tissue-derived mesenchymal stem cells (AD-MSC) and T-regulatory cells. Once again we have pioneered (in the world) the infusion of these cells along with hematopoietic stem cells in renal allograft recipients. Abrogation of antibodies using Bortezomib again established by our group in Ahmedabad which is now universally being adapted has improved renal transplant outcomes. This review briefly takes the reader to evolution of nephrology and kidney transplantation in India and shows that we have bright future!
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Pediatric kidney transplantation in India – The journey so far and the road ahead
Sanjeev Gulati
December 2014, 8(5):14-16
DOI:10.1016/j.ijt.2013.11.005  
In the last two decades, transplantation has advanced from an experimental procedure to become the principal goal of pediatric renal programs in the management of children with ESRD. The Pediatric transplant programme at SGPGIMS was started in late 1990s under the leadership of Prof. Sharma. Over the next decade SGPGIMS emerged as one of the leading centres in the country in the field of kidney transplant in children and so far, more than 150 kidney transplants have been performed in children. In an ideal scenario, pre-emptive kidney transplantation is the gold standard as it gives superior patient and graft survival with minimal side-effects. We were amongst the first to perform preemptive kidney transplant in children in India. This approach has a great importance for a country like ours in view of economic benefits because of the cost savings in terms of dialysis expenses. In our initial experience with 39 kidney transplants, a triple drug regimen of Csa, Aza and Prednisone was the cornerstone of immunosuppression in this public sector hospital. We also observed that discontinuation of Csa was a major reason for poorer long team graft survivals. We also found that MMF was a useful alternative in children who developed post transplant HUS secondary to Cyclosprine. In our subsequent experience at SGPGIMS, we changed over to Tacrolimus, MMF and Prednisone as the standard immunosuppressive protocol (6). In contrast quadruple immunosuppression using antibody induction with tacrolimus has been the norm at Fortis Institute. Excellent rehabilitation was observed with most children with functioning grafts, attending their school or college normally, doing well in both curricular and extracurricular activities.
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The emerging role of electron microscopy in renal allograft rejection
Vinita Agrawal
December 2014, 8(5):17-20
DOI:10.1016/j.ijt.2014.01.001  
The current criteria for renal allograft rejection are primarily based on histology, and therefore the early treatable stage of rejection is often not detected. Ultrastructural examination of renal allograft biopsy is increasingly being recognized to be essential for detecting early changes of rejection, which may not be evident on histology. These early ultrastructural lesions usually involve the glomerular and peritubular capillaries. Additionally, the routine ultrastructural examination of renal graft biopsies in patients with chronic graft dysfunction can reduce the non-specific diagnosis of interstitial fibrosis and tubular atrophy by demonstration of changes indicative of rejection-associated injury. Ultrastructural evaluation along with histology and immunofluorescence of renal graft biopsies is also vital in proteinuria to differentiate transplant glomerulopathy from recurrent or de novo glomerular pathology. The need for specific specimen collection procedures, limited graft tissue, and cost are limiting factors for routine electron microscopy in allograft biopsies. However, electron microscopy is an excellent tool for the evaluation of early changes in graft biopsies not evident on routine histology.
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HCV infection during renal replacement therapy: What we have learnt in two decade?
SK Agarwal
December 2014, 8(5):29-32
DOI:10.1016/j.ijt.2014.01.003  
HCV infection is most common hepatotropic blood borne infection in hemodialysis unit and prevalent differently in different units. It causes not only mortality but significant morbidity and difficulty in management of such cases. Prevention is better than treatment of such cases. In addition to following universal precaution, there is role of isolation of these patients to restrict spread of infection. If patient can afford, these patients should be treated with interferon (preferably pegylated) with/without ribavirin, whether patient is for renal transplant or not. Treatment prevent complication during maintenance hemodialysis and also following renal transplantation.
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Controversies and current status of pre-emptive nephrectomy for asymptomatic failed renal allograft in the late post-transplant period
Tarun Javali, Aneesh Srivastava
December 2014, 8(5):37-41
DOI:10.1016/j.ijt.2014.01.007  
This review article focuses on the controversies and pros and cons of doing a prophylactic allograph nephrectomy in asymptomatic patients with previously failed renal transplant.
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