A prospective analysis of testicular androgenic function in recipients of a renal allograft

Eighteen adult males with end stage renal disease (ESRD) were studied to determine the serum levels of gonadotropins (LH and FSH), prolactin (PRL) and testosterone. All of the patients were studied longitudinally while undergoing maintenance hemodialysis (HD) and six months after renal transplantation. Prior to transplantation, significantly high levels of gonadotropins and PRL were observed. During HD the serum testosterone levels tended to be subnormal in most of the uremic patients and low normal in some of the subjects. Renal transplantation led to a significant improvement (P < 0.05) in serum testosterone. Elevated gonadotropin and PRL levels observed in patients on HD returned to the normal range in most of the patients after successful renal transplantation.

Fungal panniculitis in renal transplant recipients

Panniculitis may result due to various etiologies. In post-transplant immunosuppressed patients infection is the foremost cause of panniculitis. We present 2 cases of fungal panniculitis in renal transplant recipients. The first patient presented with non-tender firm erythematous plaques on the left thigh. Biopsy showed panniculitis with cryptococci. Subsequent investigations revealed the presence of cryptococcal antigens in the blood, urine, and bronchoalveolar lavage fluid. There was no evidence of cryptococcal meningitis. The second patient complained of subcutaneous nodules on the trunk and right thigh. Biopsy of one of the nodules showed panniculitis with histoplasma. This patient had been treated earlier (inadequately) for disseminated histoplasmosis. Both the cases responded well to conventional amphotericin B therapy. Their renal functions remained stable.

Effect of bisphosphonates on bone mineral density after renal transplantation as assessed by bone mineral densitometry

INTRODUCTION

Steroid-induced osteoporosis is a major problem after organ transplantation. There is considerable evidence that bisphosphonates are effective in decreasing osteoporosis.

AIM

This prospective study was carried out to see the effects of bisphosphonates on bone mineral density (BMD) after successful renal transplantation.

MATERIAL AND METHODS

Fifty consecutive patients of successful renal transplantation were randomized into two groups. Group A (n = 27) received 35 mg/wk of Alendronate for 6 months after transplantation. Group B (n = 23) did not receive Alendronate and served as a control. Both groups underwent a pretransplant baseline dual-energy X-ray absorptiometry (DEXA) scan of their hips and lumber spines. Both groups received oral calcium and vitamin D supplement. Both groups were matched for the regimen and dose of immunosuppressive drugs. BMD was measured at 3 months and 6 months after transplantation.

RESULTS

Both groups showed a decline in BMD in early months posttransplantation. However, the 6-month DEXA scans showed a significant rise in BMD in group A as compared to group B.

CONCLUSION

Bisphosphonates appear to have a beneficial effect on steroid-induced bone loss.

Monitoring of anti-HLA and anti-Major histocompatibility complex class I related chain A antibodies in living related renal donor transplantation

This study was undertaken with the aim to analyze the clinical relevance of posttransplant anti-HLA and anti-major histocompatibility complex class I related chain A (MICA) antibodies in response to living related donor renal transplantation. A total of 185 consecutive post-renal transplant recipient serum samples were analyzed for the detection of anti-HLA and MICA antibodies using enzyme-linked immunosolvent assay techniques. Patients carrying both anti-HLA as well as anti-MICA antibodies (MICA(+)/HLA(+)) were the worst affected, showing significantly poorer graft survival compared with the MICA-/HLA-negative group (17% vs 89%, chi(2) = 19.63, P = .000). Similarly, patients with only MICA antibodies or those with only HLA antibodies also had significantly lower graft survival (P = .035 and P = .001, respectively) as compared to the nonsensitized group. The study illustrated that posttransplant monitoring antibodies to both MICA as well as HLA could be good predictors of renal allograft failure.

Tacrolimus (Pan Graf) in Live Related Renal Transplantation: An Initial Experience of 101 Recipients in India

BACKGROUND

Success of modern transplantation is in large part due to the successful development of effective immunosuppressive agents. The safety and efficacy of tacrolimus in transplantation is well established. However, tacrolimus (Pan Graf, Panacea Biotec Ltd, India) has only been available in India for the last 2 years. This study was conducted to assess the safety and efficacy of tacrolimus in live related kidney transplantation. We report an initial experience of tacrolimus as de novo therapy in a live related renal transplantation program.

MATERIALS AND METHODS

One hundred one consecutive recipients of a live renal allograft were commenced on triple immunosuppression consisting of tacrolimus, mycophenolate mofetil or azathioprine, and steroids. The dose of tacrolimus was adjusted to keep trough levels at 10-12 ng/mL in the first 3 months, 8-10 ng/mL in the next 3 months, and 5-8 ng/mL thereafter. All patients were followed up for a period ranging from 4 weeks to 24 months. The effect of this regimen on the incidence of graft rejection, graft survival, patient survival, and new-onset diabetes mellitus was evaluated. Any evidence of graft dysfunction was evaluated using a graft biopsy.

RESULTS

There were 89 male and 12 female patients with mean age of 32.08 years. The incidence of acute rejection was 3.96%; 21.05% developed new-onset diabetes mellitus. Six patients were diabetic prior to transplantation and 9 patients were hepatitis C virus (HCV)-positive; 77.7% of HCV-positive patients and 15.1% of HCV-negative patients developed posttransplantation diabetes mellitus. The patient survival rate at the current follow-up was 92.07%. No graft was lost due to rejection.

CONCLUSION

Tacrolimus is a safe and effective immunosuppressant in live related renal transplantation.

Allosensitization to HLA and MICA is an important measure of renal graft outcome

The objective of this study was to evaluate the donor-specific antibody repertoire against T and B cells and monocytes, as well as the non-donor anti-HLA, and MICA (MHC class I-related chain A) antibodies in recipients of the live related donor renal transplantation. Sera collected before and after transplantation were tested by ELISA for the presence of HLA class I- and class II-specific antibodies and by Luminex MICA single-antigen bead assay for the detection of MICA antibodies. Patients having a combination of both anti-HLA and MICA antibodies had worse graft survival and more rejection episodes as compared to the group without antibodies. Further, presence of IgG antibodies against the donor cells (T, B & monocytes) led to a compromised graft survival along with higher incidence of acute rejection as compared to the negative groups. These results suggest that a comprehensive assessment of anti-donor antibody repertoire and monitoring of anti-HLA, MICA antibodies following transplantation is a useful exercise to detect the sensitization status of the recipient and this can prove to be of immense prognostic value in renal transplantation.

Tacrolimus (Pan Graf) as de Novo Therapy in Renal Transplant Recpients in India

The safety and efficacy of tacrolimus in transplantation is well established. However, tacrolimus has only recently been available in India. We report an initial experience using tacrolimus as de novo therapy in a living related renal transplant program. Fifty-two consecutive recipients of living renal allografts were treated with tacrolimus, mycophenolate mofetil, or azathioprine and steroids. The dose of tacrolimus was adjusted to keep trough levels at 10 to 12 ng/mL in the first 3 months, 8 to 10 ng/mL in the next 3 months, and 5 to 8 ng/mL thereafter. Any evidence of graft dysfunction was evaluated by graft biopsy. The effect of this regimen on the lipid profile as well as the incidence of posttransplant diabetes mellitus was evaluated in an Indian population. All patients were followed for periods ranging from 6 to 72 weeks (mean = 29 weeks). The incidence of acute rejection was 3.84%; 17.3% developed posttransplant diabetes mellitus. Graft and patient survivals at the current follow-up were 100% and 96.26%. In conclusion, tacrolimus is a safe and effective immunosuppressant in a living related renal transplant program.

Significance of Protocol Biopsies in Living Related Renal Transplant Recipients

INTRODUCTION

Subclinical rejection (SCR) in a normally functioning renal allograft may have an impact on long-term graft outcome. SCR detection is best done by protocol biopsies in clinically normal grafts.

METHODS

We evaluated 20 stable living related renal allografts with protocol biopsies on days 7 and 90 posttransplant. SCR when detected was treated with a 3-day pulse of methylprednisolone therapy. The outcomes of these grafts were compared with 63 other clinically stable renal allografts that did not undergo protocol biopsies.

RESULTS

SCR was observed in 60% of cases. The patients who received antirejection therapy for SCR based on protocol biopsies showed better graft survival and mean serum creatinine values at the end of the follow-up period.

Functional assessment of immune markers of graft rejection: a comprehensive study in live-related donor renal transplantation

A better understanding of the immunobiological processes and predictors of graft rejection holds promise for the development of potential therapeutic strategies and also individualization of immunosuppression. The objective of this study is to analyze the clinical relevance of immune parameters such as antidonor antihuman leukocyte antigen (anti-HLA) antibodies, monitoring of cytokines and their receptors on the graft outcome following live-related donor renal transplantation. Flow cytometry-based methods were used to detect antidonor antibodies (flow cytometry crossmatch, FCXM) and intracellular cytokines. Enzyme-linked immunosorbent assay (ELISA) methods were employed to detect anti-HLA class I and class II antibodies and quantitative serum-soluble interleukin-2 receptor (sIL-2R) levels. The data revealed that patients with HLA class I-specific IgG antibody experienced higher acute rejection (AR) episodes at 1 yr in comparison to the antibody negative group (82% vs. 56%, p = 0.01). On the contrary, donor-specific class II antibodies (B+) did not have any influence on the graft survival. However, 15 recipients having both T- and B-cell antidonor antibodies (T+B+) had significantly poor graft survival (60%) as compared to the antibody-negative group (T-B-, 82%, p = 0.05). Additionally, patients having non-donor but HLA-specific antibodies (FCXM-/ELISA+) had poor graft survival as compared to the antibody-negative group (64% vs. 88%, p < 0.05). Further, patients undergoing AR episodes had significantly higher expression of IFN-gamma-producing T cells (19.16 +/- 7.4% median 17.50) as compared to their pre-transplant levels (5.68 +/- 1.63%, Median 5.20) and the non-rejecter group (5.97 +/- 4.39%, median 4.3, p = 0.0004). Similarly sIL-2 was significantly increased in AR episodes during the first month of transplantation (292 +/- 131.5 pmol/L) as compared to those with well-functioning grafts (p = 0.01) and healthy controls (p = 0.001). Evaluation of antidonor antibodies by flow cytometry is found to be relatively more sensitive and a better predictor of graft outcome. Further monitoring of cytokine expression profile of primed peripheral T-helper cells and quantitative analysis of sIL-2R offer additional valuable diagnostic and prognostic tools for follow-up of transplant subjects and a better alternative for functional assessment of immunosuppression.

Prospective randomized control trial of isoniazid chemoprophylaxis during renal replacement therapy

BACKGROUND

Infectious diseases remain among the major morbid events in patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT). In developing countries, tuberculosis (TB) has been found to occur more frequently in these patients than in the general population. Efficacy of isoniazid (INH) chemoprophylaxis has been seen in other situations, such as human immunodeficiency virus infection. However, studies on INH prophylaxis in ESRD patients on RRT are limited.

METHODS

In this prospective randomized controlled trial, from April 2000 to June 2001, a total of 109 ESRD patients registered for renal transplant and accepted for maintenance hemodialysis in our hospital were included and followed up until June 2004 to assess the role of INH prophylaxis in preventing development of TB. At the time of acceptance for hemodialysis, 54 patients were assigned to receive daily INH for 1 year and 55 patients were assigned to the control group. Primary outcome was development of TB. Secondary outcome was INH hepatotoxicity. To evaluate the effect of INH prophylaxis on the development of TB, a Kaplan-Meier survival estimate was used to plot TB-free survival curve and log-rank test was used for comparison.

RESULTS

Overall, TB was diagnosed in 27 patients during RRT, with an incidence of 24.8%. TB developed in 9 (16.7%) patients in the INH group and in 18 (32.7%) patients in the control group. There was a significantly lower incidence of TB in the INH group as compared with the control group. The risk ratio of INH vs. control group for development of TB was 0.40 (95% confidence index [CI], 0.17-0.92; P=0.032). In the INH group 27 (50%) patients and in the control group 17 (30.9%) patients developed some hepatic dysfunction. However, significant hepatitis that required discontinuation of INH developed in only 9 (16.7%) patients in the INH group. Furthermore, significant hepatitis also developed in 6 (10.9%) patients in the control group. The majority of patients with significant hepatitis in both groups (INH as well as control) were subsequently found to be positive for hepatitis B and/or hepatitis C viral infection. Mild hepatitis (which did not require discontinuation of INH) was seen in 18 (33.3%) patients in the INH group and 11 (20%) patients in the control group. Viral hepatitis infection was not found in any of the milder cases of hepatitis in either group.

CONCLUSION

This study shows significant efficacy of INH chemoprophylaxis during RRT in preventing development of TB, when the INH was started during dialysis itself. INH chemoprophylaxis was safe and well tolerated in the majority of patients. However, mild hepatic dysfunction was common, both in the treatment as well as in the control group. As the incidence of viral hepatitis overall was high in our patients on RRT, it is difficult to identify INH-induced hepatitis in this clinical setting.

The Effect of Renal Transplantation on Pulmonary Function and Respiratory Muscle Strength in Patients With End-Stage Renal Disease

Pulmonary function and respiratory muscle strength was assessed in 29 hemodialysis patients who underwent successful renal transplantation. These tests were performed 7 days prior to transplantation, 30 days following transplantation, and 90 days posttransplantation. Patients with end-stage renal disease showed dyspnea, a restrictive defect in pulmonary function, respiratory muscle weakness, and hypoxia. Following transplantation the dyspnea improved and mechanical indices of respiratory muscle function and lung volume improved. In conclusion transplantation resulted in a significant improvement in lung and respiratory muscle function.

Ureteric Complications of Renal Transplantation: The Impact of the Double J Stent and the Anterior Extravesical Ureteroneocystostomy

The urological complications of renal transplantation are well documented. In 1990, our experience of 507 consecutive renal transplants using the Leadbetter-Politano technique, which was unsplinted in the vast majority of patients, had a ureteric complication rate of 7.7%. Here, we report the long-term incidence and management of our ureteric complications in 1186 consecutive renal transplants done over the following 11 years using an extravesical onlay stented ureteroneocystostomy. We report a considerable reduction in the urological complications of renal transplantation to 3.8%. Furthermore, we were able to use percutaneous radiological techniques to salvage the majority (84.7%) of ureteric complications. Recourse to surgery was required rarely but enabled salvage of all treatment failures.

The first successful simultaneous pancreas-kidney transplant in India

Insulin-dependent diabetes mellitus is associated with renal failure, diabetic retinopathy, neuropathy and vasculopathy. We report the first successful simultaneous pancreas-kidney transplant in India in a young diabetic with renal failure. The dual transplant has cured his diabetes and renal failure and has had a beneficial effect on his neuropathy, retinopathy and quality of life. Obstacles to dual transplant in India include a lack of suitable recipients and a cadaver donor programme that is still in its infancy.

Scintigraphic patterns of lymphocele in post-renal transplant

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.