Posttransplant infections in the tropical countries

Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota

BACKGROUND

Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR).

METHODS

We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared.

RESULTS

Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020).

CONCLUSION

Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.

Epidemiology, Clinical Characteristics, Diagnostic Work Up, and Treatment Options of Leishmania Infection in Kidney Transplant Recipients: A Systematic Review

Current knowledge on Leishmania infection after kidney transplantation (KT) is limited. In order to offer a comprehensive guide for the management of post-transplant Leishmaniasis, we performed a systematic review following the latest PRISMA Checklist and using PubMed, Scopus, and Embase as databases. No time restrictions were applied, including all English-edited articles on Leishmaniasis in KT recipients. Selected items were assessed for methodological quality using a modified Newcastle–Ottawa Scale. Given the nature and quality of the studies (case reports and retrospective uncontrolled case series), data could not be meta-analyzed. A descriptive summary was therefore provided. Eventually, we selected 70 studies, describing a total of 159 cases of Leishmaniasis. Most of the patients were adult, male, and Caucasian. Furthermore, they were frequently living or travelling to endemic regions. The onset of the disease was variable, but more often in the late transplant course. The clinical features were basically similar to those reported in the general population. However, a generalized delay in diagnosis and treatment could be detected. Bone marrow aspiration was the preferred diagnostic modality. The main treatment options included pentavalent antimonial and liposomal amphotericin B, both showing mixed results. Overall, the outcomes appeared as concerning, with several patients dying or losing their transplant.

Inhibition of NETosis for treatment purposes: friend or foe?

Active neutrophils participate in innate and adaptive immune responses through various mechanisms, one of the most important of which is the formation and release of neutrophil extracellular traps (NETs). The NETs are composed of network-like structures made of histone proteins, DNA and other released antibacterial proteins by activated neutrophils, and evidence suggests that in addition to the innate defense against infections, NETosis plays an important role in the pathogenesis of several other non-infectious pathological states, such as autoimmune diseases and even cancer. Therefore, targeting NET has become one of the important therapeutic approaches and has been considered by researchers. NET inhibitors or other molecules involved in the NET formation, such as the protein arginine deiminase 4 (PAD4) enzyme, an arginine-to-citrulline converter, participate in chromatin condensation and NET formation, is the basis of this therapeutic approach. The important point is whether complete inhibition of NETosis can be helpful because by inhibiting this mechanism, the activity of neutrophils is suppressed. In this review, the biology of NETosis and its role in the pathogenesis of some important diseases have been summarized, and the consequences of treatment based on inhibition of NET formation have been discussed.

"Smart" Polylactic Acid Films with Ceftriaxone Loaded Microchamber Arrays for Personalized Antibiotic Therapy

Bacterial infections are a severe medical problem, especially in traumatology, orthopedics, and surgery. The local use of antibiotics-elution materials has made it possible to increase the effectiveness of acute infections treatment. However, the infection prevention problem remains unresolved. Here, we demonstrate the fabrication of polylactic acid (PLA) “smart” films with microchamber arrays. These microchambers contain ceftriaxone as a payload in concentrations ranging from 12 ± 1 μg/cm² to 38 ± 8 μg/cm², depending on the patterned film thickness formed by the different PLA concentrations in chloroform. In addition, the release profile of the antibiotic can be prolonged up to 72 h in saline. At the same time, on the surface of agar plates, the antibiotic release time increases up to 96 h, which has been confirmed by the growth suppression of the Staphylococcus aureus bacteria. The efficient loading and optimal release rate are obtained for patterned films formed by the 1.5 wt % PLA in chloroform. The films produced from 1.5 and 2 wt % PLA solutions (thickness—0.42 ± 0.12 and 0.68 ± 0.16 µm, respectively) show an accelerated ceftriaxone release upon the trigger of the therapeutic ultrasound, which impacted as an expansion of the bacterial growth inhibition zone around the samples. Combining prolonged drug elution with the on-demand release ability of large cargo amount opens up new approaches for personalized and custom-tunable antibacterial therapy.

A Review of Neutrophil Extracellular Traps (NETs) in Disease: Potential Anti-NETs Therapeutics

Activated neutrophils release neutrophil extracellular traps (NETs) in response to a variety of stimuli. NETosis is driven by protein-arginine deiminase type 4, with the release of intracellular granule components that function by capturing and destroying microbes, including viral, fungal, bacterial, and protozoal pathogens. The positive effects of pathogen control are countered by pro-inflammatory effects as demonstrated in a variety of diseases. Components of NETS are non-specific, and other than controlling microbes, they cause injury to surrounding tissue by themselves or by increasing the pro-inflammatory response. NETs can play a role in enhancement of the inflammation seen in autoimmune diseases including psoriasis, rheumatoid arthritis, and systemic lupus erythematosis. In addition, autoinflammatory diseases such as gout have been associated with NETosis. Inhibition of NETs may decrease the severity of many diseases improving survival. Herein, we describe NETosis in different diseases focusing on the detrimental effect of NETs and outline possible therapeutics that can be used to mitigate netosis. There is a need for more studies and clinical trials on these and other compounds that could prevent or destroy NETs, thereby decreasing damage to patients.

Outcomes of Kidney Transplantation in the Elderly Recipients

Introduction:

In a developing country with a predominantly young population, the valid assumption is directed toward medical care toward the young. However, as medical technology has advanced, quality care has ensured better survival for the elderly population also. The aim of this study was to determine the clinical outcomes in elderly patients undergoing kidney transplantation.

Materials and Methods:

A retrospective analysis of 1150 patients who had undergone live related renal transplantation was done from January 2006 to December 2014. These patients were divided into two groups; Group 1: age >60 years (N = 150), Group 2: age 18–60 years (N = 1000). The clinical outcomes were compared.

Results:

The mean age in Group 1 was 69 ± 7.5 years (SD ± 7.5), and group 2 was 41 ± 8 years. In groups 1 and 2, males were 80% and 82%; death censored graft survival at 5 years was 82% and 87%; patient survival at 5 years was 86% and 94%, respectively. The incidence of biopsy-proven acute rejection was similar in both groups (11.3 vs. 10.2%, P = 0.12). Urinary tract infection was the most common infectious complication. Sepsis was the primary cause of death in both groups.

Conclusion:

In the elderly patients who underwent kidney transplantation, satisfactory graft function, and patient survival were maintained over a period of 60 months. Urinary tract infections were common, and sepsis was the most common cause of death with a surviving allograft. The acute rejection and mortality rates were comparable to the literature published from India so far.

Cadaveric renal transplantation: Our experience at a tertiary care centre in India

Background

Renal transplantation in developing countries like India is largely live donor transplantation. Cadaveric transplantation comprises <2% of all transplants in India.

Methods

Ninety-two cadaveric renal transplantations were included. Various donor and recipient characteristics were analysed along with graft and patient survival, using Kaplan-Meier method.

Results

The mean age of the recipients was 35.5 ± 10.9 years while that of cadaver was 43.9 ± 17.0 years. Proportion of females among recipients was 47.8% while that of donors was 34.8%. The most common underlying pathology was chronic glomerulonephritis (44.6%). Antithymocyte globulin was used as induction in 84.8% of cases. Tacrolimus-based triple-drug regimen was most commonly used as maintenance (80.4%). The mean follow-up time was 39.02 ± 28.24 months. The most common cause of death was sepsis (47%). More than 50% deaths (9/17) occurred within first 3 years, while 61.5% of graft loss occurred 5 years after transplantation. The mean graft survival time was 81.6 months (95% confidence interval [CI]: 72.8-90.4). Cumulative proportion of graft survival was 91.6% at 3 years and 77.1% at 5 years. Although females have better mean graft survival time (91.6 vs 73.5 months), it was not a significant difference as shown by log-rank test (p value = 0.062). Pretransplant haemodialysis has no significant effect on graft loss, but patients on peritoneal dialysis have significantly higher odds of graft loss (odds: 4.86, p value < 0.05 [0.018]). The mean patient survival time was 99.5 months (95% CI: 84.0-114.9). Cumulative proportion of patient survival was 83.3% at 3 years and 70.8% at 5 years.

Conclusion

Graft and patient survival rate of cadaveric transplant at our centre was satisfactory. There is need to sensitise and augment the rate of cadaveric transplantation to increase the donor pool.

Impact of single centre kidney paired donation transplantation to increase donor pool in India: a cohort study

In a living donor kidney transplantation (LDKT) dominated transplant programme, kidney paired donation (KPD) may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. Here, we report our experience of 300 single-centre KPD transplantations to increase LDKT in India. Between January 2000 and July 2016, 3616 LDKT and 561 DDKT were performed at our transplantation centre, 300 (8.3%) using KPD. The reasons for joining KPD among transplanted patients were ABO incompatibility (n = 222), positive cross-match (n = 59) and better matching (n = 19). A total of 124 two-way (n = 248), 14 three-way (n = 42), one four-way (n = 4) and one six-way exchange (n = 6) yielded 300 KPD transplants. Death-censored graft and patient survival were 96% (n = 288) and 83.3% (n = 250), respectively. The mean serum creatinine was 1.3 mg/dl at a follow-up of 3 ± 3 years. We credit the success of our KPD programme to maintaining a registry of incompatible pairs, counselling on KPD, a high-volume LDKT programme and teamwork. KPD is legal, cost effective and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national programmes do not exist.

Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient

We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host.

CKD and Infectious Diseases in Asia Pacific: Challenges and Opportunities

The exact number of patients with chronic kidney disease (CKD) in Asia Pacific is uncertain. In numeric terms, the region is home to the largest population of patients with untreated chronic kidney failure. The climatic, geographic, social, cultural, economic, and environmental diversity within this region is higher than in any other part of the world. Large parts of the region face a climate-related burden of infectious diseases. Infections contribute to the development and progression of CKD and complicate the course of patients with pre-existing CKD (especially those on dialysis therapy or who are immunosuppressed), increase the cost of CKD care, and contribute to mortality and morbidity. Kidney involvement is a feature of several infectious diseases prevalent in Asia Pacific. Examples include malaria, leptospirosis, scrub typhus, tuberculosis, hepatitis B and C virus, dengue hemorrhagic fever, and Hantaan virus infections. The contribution of infection-associated acute kidney injury to the overall burden of CKD has not been evaluated systematically. Research is needed to quantify the impact of infections on kidney health by undertaking prospective studies. Nephrologists need to work with infectious disease research groups and government infection surveillance and control programs.

Two cases of transplant renal artery thrombosis and spontaneous rupture caused by mucormycosis

Mucormycosis is an uncommon infectious complication after renal transplantation and is associated with fatal outcomes. We report 2 cases of transplant renal artery thrombosis and spontaneous rupture caused by mucormycosis. As stenosis, thrombosis, and spontaneous rupture of the transplant renal artery began to occur in both cases after renal transplantation, nephrectomy of the transplanted kidney was performed. Postoperative pathological findings in the transplanted kidney revealed an invasive mucormycosis infection in the renal artery. One patient survived, but the other patient died. This report also presents the diagnosis and treatment processes used for this transplant complication.

Antibiotic prophylaxis for preventing post solid organ transplant tuberculosis

BACKGROUND

Organ transplant recipients are at increased risk of infection as a result of immunosuppression caused inadvertently by medical treatment. Tuberculosis (TB) is a challenging infection to manage among organ transplant recipients that can be transmitted from infected people or triggered from latent infection. Organ transplant recipients have been reported to be up to 300 times more likely to develop TB than the general population. Consensus about the use of antibiotic prophylaxis to prevent post solid organ transplant TB has not been achieved.

OBJECTIVES

This review assessed the benefits and harms of antibiotic prophylaxis to prevent post solid organ transplant TB.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register up to 30 April 2013 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE and handsearching conference proceedings.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs that compared antibiotic prophylaxis with a placebo or no intervention for recipients of solid organ transplants were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. We derived risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI). Methodological risk of bias was assessed using the Cochrane risk of bias tool.

MAIN RESULTS

We identified three studies (10 reports) that involved 558 kidney transplant recipients which met our inclusion criteria. All studies were conducted in countries that have high prevalence of TB (India and Pakistan), and investigated isoniazid, an oral antibacterial drug. Control in all studies was no antibiotic prophylaxis. Prophylactic administration of isoniazid reduced the risk of developing TB post-transplant (3 studies, RR 0.35 95% CI 0.14 to 0.89), and there was no significant effect on all-cause mortality (2 studies, RR 1.39, 95% CI 0.70 to 2.78). There was however substantial risk of liver damage (3 studies, RR 2.74, 95% CI 1.22 to 6.17).Reporting of methodological quality parameters was incomplete in all three studies. Overall, risk of bias was assessed as suboptimal.

AUTHORS' CONCLUSIONS

Isoniazid prophylaxis for kidney transplant recipients reduced the risk of developing TB post-transplant. Kidney transplant recipients in settings that have high prevalence of TB should receive isoniazid during the first year following transplant. There is however, significant risk of liver damage, particularly among those who are hepatitis B or C positive. Further studies are needed among recipients of other solid organ transplants and in settings with low prevalence of TB to determine the benefits and harms of anti-TB prophylaxis in those populations.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Deceased donor renal transplantation at army hospital research and referral: Our experience

CONTEXT

In India, there are a large number of end-stage renal disease (ESRD) patients waiting for renal transplant. Deceased donor organ transplantation (DDOT) is the possible solution to bridge the disparity between organ supply and demand. The concept of expanded criteria donors (ECDs) was developed to combat the huge discrepancy between demand and organ availability. However, ECD kidneys have a higher propensity for delayed graft function (DGF), and therefore worse long-term survival. We present our experience of deceased donor renal transplantation.

AIMS

We report single centre experience on DDOT including ECDs vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 44 DDOT.

MATERIALS AND METHODS

Between August 1998 and April 2011, 44 renal transplants from 35 deceased donors were performed, of which 37.2% were expanded criteria donors. Results were analyzed in terms of age of donor, terminal SCr, graft ischemia time, graft function, post-transplant complications, and graft and patient survival. All recipients received sequential triple drug immunosuppression and induction with rabbit antithymocyte globulin (rATG). The induction is commenced by giving first dose of rATG intraoperatively (dose 1.5 mg/kg) and subsequent rATG infusions were administered daily for a minimum of 5 and maximum of 7 doses depending on initial graft function.

RESULTS

We have been able to achieve a mean cold ischemia time of 6.25 ± 2.55 h due to the coordinated team efforts. Delayed graft function occurred in 34% patients and 31.8% had prolonged drainage. There were no urinary leaks. Seven (16%) patients had biopsy-proven rejection episodes, all of which were reversed with treatment. Two patients underwent graft nephrectomy. One of these was due to hyperacute rejection and another due to anastomotic hemorrhage. One-year graft survival was 92.4% and the patient survival was 83.8%.

CONCLUSION

Deceased donor renal transplants have satisfactory graft function and patient survival despite the high incidence of delayed graft function. Retrieving kidneys from marginal donors can add to the donor pool.

Stem cell transplantation in living donor renal transplantation for minimization of immunosuppression

BACKGROUND

We present our experience of living-donor renal transplantation (LDRT) using pretransplant stem cell transplantation (SCT) where we have successfully achieved minimization of immunosuppression.

METHODS

Nine hundred sixteen patients underwent LDRT between 2007 and 2011: 606 under tolerance induction protocol (TIP) and 310 with our usual triple immunosuppression of calcineurin inhibitors (CNI), mycofenolate sodium (MMF), and prednisone (controls). The test group (TIP) was stratified into group 1, 1 haplomatch or greater (n=392), group 3, less than 1 haplomatch (n=214); controls were similarly stratified to group 2, 1 haplomatch or greater (n=179) and group 4, less than 1 haplomatch (n=131). The TIP consisted of donor-specific transfusion, adipose tissue-derived mesenchymal and hematopoietic stem cell transplantation, and nonmyeloablative conditioning with total lymphoid irradiation, cyclophosphamide, and rabbit-antithymocyte globulin. Posttransplant IS consisted of prednisone, CNI, or MMF, all in low doses.

RESULTS

Four-year patient survival was 93.5%, 90.7%, 88.7%, and 82.7% in groups 1 through 4, respectively, and death-censored 4-year allograft survival was 94.8%, 95.4%, 94.5%, and 74.6%, respectively. Mean serum creatinine (mg/dL) for groups 1 through 4, respectively, at 4 years was 1.26, 1.57, 1.29, and 2.1. The number of rejection episodes was highest in group 4 and lowest in group 1. Minimization of IS was successfully achieved in 82.9% patients in group 1 and in 61.7% patients in group 3, whereas no minimization in groups 2 and 4. Stem cell transplantations were safe.

CONCLUSION

Stem cell transplantation is effective in IS minimization in LDRT resulting in good graft function and patient and graft survival at 4 years.

Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: a single-center experience from a developing country

BACKGROUND

Economic constraints in operating an effective maintenance dialysis program leaves renal transplantation as the only viable option for end-stage renal disease patients in India. Kidney paired donation (KPD) is a rapidly growing modality for facilitating living donor (LD) transplantation for patients who are incompatible with their healthy, willing LD.

MATERIALS AND METHODS

The aim of our study was to report a single-center feasibilities and outcomes of KPD transplantation between 2000 and 2012. We performed KPD transplants in 70 recipients to avoid blood group incompatibility (n = 56) or to avoid a positive crossmatch (n = 14).

RESULTS

Over a mean follow-up of 2.72 ± 2.96 years, one-, five- and ten-year patient survival were 94.6, 81, 81 %, and death-censored graft survival was 96.4, 90.2, 90.2 %, respectively. Ten percent of patients were lost, mainly due to infections (n = 4). There was 14.2 % biopsy-proven acute rejection, and 5.7 % interstitial fibrosis with tubular atrophy eventually leading to graft loss.

CONCLUSION

The incidences of acute rejection, patient/graft survival rates were acceptable in our KPD program and, therefore, we believe it should be encouraged. These findings are valuable for encouraging participation of KPD pairs and transplant centers in national KPD program. It should be promoted in centers with low-deceased donor transplantation. Our study findings are relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage national KPD program. To our knowledge, it is largest single-center report from India.

Long-term outcome of deceased donor renal transplantation in pediatric recipients: a single-center experience from a developing country

RTx is best treatment for children with ESRD. Data scarcity on DDRTx outcome in children prompted us to review our experience. This study was undertaken to evaluate patient/graft survival, function vis-a-vis SCr, rejection episodes, and mortality in DDRTx performed in 37 children between 1998 and 2011. The most common recipient diseases leading to ESRD were congenital anomalies of kidney and urinary tract (48.6%) and chronic glomerulonephritis (18.9%). Mean recipient age was 13.8 ± 3.1 yr; 67.5% (n = 25) were men. Mean donor age was 38.8 ± 18.6 yr; 48.5% (n = 18) were men. Mean dialysis duration pre-transplantation was 15.5 ± 3.5 months. All recipients received r-ATG, and triple immunosuppression. Over a mean follow-up of 3.93 ± 3.5 yr, patient and graft survival rates were 72.9% (n = 27) and 83.7% (n = 31), respectively, with a mean SCr of 1.1 mg/dL; 21.6% (n = 8) of patients had acute rejection episodes; 24.3% (n = 9) of patients had DGF. A total of 27% (n = 10) patients died, mainly owing to infections (n = 6) and cardiovascular disease (n = 3). DDRTx is a viable option for children and achieves acceptable graft function with patient/graft survival over long-term follow-up, encouraging use of this approach.

Perioperative bacterial infections in deceased donor and living donor liver transplant recipients

BACKGROUND

Deceased donor (DDLT) and living donor (LDLT) liver transplant (LT) is in vogue in several centers in India. Most centers are resorting to LDLT as a preferred surgery due to shortage of deceased donor liver. The risk of infection and its effect on survival in both groups of recipients from the Indian subcontinent are not known. The study was conducted to compare the bacterial infection rates among LDLT and DDLT recipients and their impact on survival at a tertiary referral center.

METHODS

Retrospective data on 67 LT recipients were reviewed. Data on pre-, per-, and postoperative bacterial infection rates and the common isolates were obtained.

RESULTS

Thirty-five patients had LDLT and 32 had DDLT. The prevalence of pre-operative bacterial infection and the isolates was similar in both groups. The perioperative bacterial infection rates were significantly higher in DDLT recipients (P < 0.01) (relative risk: 1.44 95% confidence interval 1.04-1.9). In both LDLT and DDLT, the common source was urinary tract followed by bloodstream infection. The common bacterial isolates in either transplant were Klebsiella followed by Escherichia coli, Pseudomonas spp. and nonfermenting gram-negative bacteria. Six patients (four LDLT; two DDLT) were treated for tuberculosis. Among the risk factors, cold ischemic time, and duration of stay in the intensive care unit was significantly higher for DDLT (p < 0.01). The death rates were not significantly different in the two groups. However, the odds for death were significantly high at 26.8 (p < 0.05) for postoperative bacterial infection and 1.8 (p < 0.001) for past alcohol.

CONCLUSION

Liver transplant recipients are at high-risk for bacterial infection irrespective of type of transplant, more so in DDLT.

Deceased donor organ transplantation: A single center experience

Renal transplantation (RTx) is the best therapeutic modality for patient suffering from end-stage renal disease (ESRD). Deceased donor organ transplantation (DDOT) accounts for <4% of RTx in India. We report 4 years single centre experience on DDOT vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 160 DDOT. Between January 2006 to December 2009, 160 RTx from 89 donors were performed, of which 25.2% were expanded criteria donors. Majority of the donors were brain dead due to road traffic/cerebrovascular accidents. The commonest recipient diseases leading to ESRD were chronic glomerulonephritis (49%), diabetes mellitus (10%), and benign nephrosclerosis (10%). Mean recipient/donor age was 35.6±14.68 and 44.03±18.19 years. Mean dialysis duration pretransplantation was 15.37±2.82 months. Mean cold ischemia time was 5.56±2.04 hours. All recipients received single dose rabbit-anti-thymocyte globulin induction and steroids, mycophenolate mofetil/calcinueurin inhibitor for maintenance of immunosuppression. Delayed graft function was observed in 30.6% patients and 14% had biopsy proven acute rejection. Over mean follow-up of 2.35±1.24 years, patient and graft survival rates were 77.5% and 89.3% with mean SCr of 1.40±0.36 mg/dl. DDOT has acceptable graft/patient survival over 4 years follow-up and should be encouraged in view of organ shortage.

Outcome of renal transplantation in patients with diabetic nephropathy -- a single-center experience

BACKGROUND

Type 2 diabetes mellitus (DM) is the commonest cause of end-stage renal disease (ESRD) worldwide. Data scarcity on renal transplantation (RTx) outcome in diabetic nephropathy (DN) prompted us to review our experience. This retrospective single-center, 5-year study was undertaken to evaluate patient and graft survival and function, evaluated by serum creatinine (SCr), rejection episodes, and mortality in patients.

PATIENTS AND METHODS

One hundred type 2 DM-ESRD patients underwent RTx [80 living-related (LRD), 20 deceased donor (DD)] at our center following cardiac fitness of recipient. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age in the LRD group was 40.6 years and 52 years in the DD group. Male recipients constituted 95% in the LRD and 65% in the DD group.

RESULTS

Over a mean follow-up of 2.47 years, 1- and 5-year patient/graft survival in LRDRTx was 85.1%/95.9% and 82.6%/95.9%, respectively, and mean SCr (in mg/dl) at 1 and 5 years was 1.38 and 1.58 mg/dl, respectively, with 20% of cases developing acute rejection (AR) episodes. Fifteen percent of patients died, mainly due to infections, and 1.3% died of coronary artery disease (CAD). In DDRTx, over a mean follow-up of 3.17 years, 1- and 4-year patient/graft survival was 72%/89.7% and 54%/89.7%, respectively; mean SCr at 1 and 4 years was 1.40 and 1.75 mg/dl, respectively, with 20% of cases developing AR episodes. Totally, 30% of patients were lost, mainly due to infections, and 10% of patients died from cerebrovascular events.

CONCLUSION

In our center, in patients with RTx for type 2 DM diabetic nephropathy, the 4- and 5-year patient and graft survival rates and graft function can be considered acceptable. The results are better in LRDRTx than in DDRTx patients.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Transplantation and tropical infectious diseases

The number of transplant recipients with tropical infectious diseases is growing due to increasing international travel and the rising number of transplants taking place in the tropics and subtropics. With increases in population migration, the prevalence of individuals infected with geographically restricted organisms also rises. There are three potential categories of tropical infections in transplant patients: (1) donor-related infections transmitted by the graft or through transfusion of blood products; (2) reactivation or recrudescence of latent infections in the donor recipient; and (3) de novo acquisition of infection in the post-transplant period through the traditional route of infection. We present an overall discussion of the association of parasitic (protozoa and helminths) and non-parasitic (viral, bacterial, and fungal) tropical infectious diseases and solid-organ and hematopoietic transplantation. We also suggest potential screening guidelines for some of these tropical infections.

[Recommendations before travelling for renal transplant patients]

Travel is now a reasonable objective of CKD patients after renal transplantation. However, immunosuppressive treatment makes them particularly susceptible to infections and may interfere with vaccinations and other drugs. Travel in countries with low health level should be strongly discouraged in the first six months after transplantation or following an acute event. Otherwise, specific consultations should be arranged to prepare the patient as soon as possible. Vaccinations should be started early before departure. Specific immunisations include vaccines against hepatitis A, typhoid, meningococcus and rabies in some cases. Living vaccines are formally contra-indicated. Particular attention should be paid for protection against insects because this is the only effective measure against diseases. In the case of malaria, it should be complemented by adapted chemoprophylaxis that should be started 15 days before the departure date. Advice on hygiene measures should be clarified because this can prevent numerous infections, especially of the digestive tract. Advice on the management of diarrhoea is essential, especially in terms of preventing dehydration. Finally, advice about transport and physical risks, especially those related to sun exposure, should also be addressed.

Ophthalmoscopy in the early diagnosis of opportunistic tuberculosis following renal transplant

Chronic renal failure is a common sequel of renal inflammatory disease or diabetes mellitus. As a result of the immunosuppression that is induced by uremia, hemodialysis or posttransplant immunosuppressive medication, these patients are at a higher risk of opportunistic infections. Various viral, bacterial and mycobacterial infections have been reported. Tuberculosis is a common systemic opportunistic infection but reports of ocular involvement with pulmonary or disseminated tuberculosis are rare. We report the systemic and ocular findings in two postrenal-transplant patients with pulmonary or disseminated tuberculosis in whom detection of choroidal tubercles led to confirmation of the diagnosis in both patients and was the only specific premortem finding in one. Fundoscopy in this group of patients may help in the diagnosis of opportunistic tuberculosis, its earlier treatment and the consequent reduction of morbidity and mortality.

To Bite the Bullet of Early Graft Nephrectomy: A Case Report

Isolated renal allograft mucormycosis is rare. Only 8 cases have been reported to date, with patient survival in only 3. We recently encountered a case. The presentation was fever and graft dysfunction, which were unresponsive to extended antibiotic treatment and supportive care. It was only after three graft biopsies that mucormycosis was diagnosed and amphotericin B started. Urgent graft nephrectomy was performed, but the patient died of septicemia. In retrospect, we believe that early institution of amphotericin B and graft nephrectomy are needed for patient salvage in this difficult clinical situation.

Efficacy of High-Dose Trimethoprim-Sulfamethoxazol Prophylaxis on Early Urinary Tract Infection After Renal Transplantation

Urinary tract infection (UTI), a major cause of morbidity in renal transplant recipients, has also been found to increase mortality. The first month post-kidney transplantation is considered the critical time, with most UTI episodes during this period. The aim of this study was to compare the efficacy of various doses of trimethoprim-sulfamethoxazole (TMP/SXT) for the prophylaxis of the posttransplant UTI within the first month after kidney transplantation. In a prospective, double-blind, randomized, clinical trial, 95 kidney allograft recipients were divided into two groups: group 1 (n = 63) received low to moderate doses of TMP/SXT (either 80/400 mg or 160/800 mg, daily) and group 2 (n = 32), high doses of TMP/SXT (320/1600 mg, daily in two divided doses). These groups were comparable regarding age, gender, type of donor, and ureteral anastomosis and immunosuppressive therapy. UTI was defined as a urine culture containing more than 10(5) colonies. The mean age of the patients was 37 +/- 12.2 years with a male/female ratio of 0.98/1. The urine culture was positive in 39 patients (41.1%). UTI was more common among female than male patients (P = .003). Escherichia coli was the most common isolated organism in both groups (53.8%). UTI was observed in about 25% of patients on the high-dose versus 49.2% of those on low- to moderate-dose prophylaxis (P < .05). In conclusion, prophylaxis with high-dose TMP/SXT (320/1600 mg, daily) is preferred for renal transplant recipients during the first month posttransplantation.

Results of clinical renal transplantation in 15 dogs using triple drug immunosuppressive therapy

OBJECTIVE

To evaluate outcome of renal transplantation in dogs administered cyclosporine, azathioprine, and prednisolone immunosuppression.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Fifteen dogs with chronic renal failure.

RESULTS

Nine dogs died within 1 month of surgery; 5 died from complications associated with generalized thromboembolism. Three dogs survived for 6-25 months. Three dogs alive at the time of this report have survived 22-48 months; however, all 3 dogs have had bacterial infections that responded to antibiotic therapy. There was no biochemical evidence of acute allograft rejection in any dog. Perioperative use of enoxaparin may have prevented thromboembolism in 5 dogs.

CONCLUSIONS

Triple drug immunosuppressive therapy used in this study prevented acute renal allograft rejection in 6 dogs that survived >4 weeks; however, immunosuppression was excessive, resulting in an unacceptable frequency of infection and other drug-related complications. Perioperative anticoagulation therapy seem to be warranted.

CLINICAL RELEVANCE

Survival time and quality of life for this group of dogs was poor; however, there was no evidence of acute rejection in the dogs surviving >4 weeks. This protocol should only be used if the degree of immunosuppression is reduced, and early evidence of allograft rejection is monitored by renal biopsy or markers of lymphocyte activation.

Evaluation of the prevalence of infections in cats after renal transplantation: 169 cases (1987-2003)

OBJECTIVE

To determine the prevalence of infections developing postoperatively, document the contribution of infection to increased risk of death, and identify risk factors associated with the development of infectious complications in cats after renal transplantation.

DESIGN

Retrospective study.

ANIMALS

169 cats that received renal allograft transplants.

PROCEDURES

Medical records of cats receiving renal transplants at the University of California from January 1987 through December 2003 were reviewed.

RESULTS

47 infections developed in 43 of 169 cats. Bacterial infections were most common (25/47 cats), followed by viral (13/47), fungal (6/47), and protozoal (3/47) infections. The median duration from transplant surgery to development of infection was 2.5 months. Infection was the second most common cause of death after acute rejection of the transplant, accounting for 14% of deaths overall. Cats with concurrent diabetes mellitus had a significantly increased risk of developing an infection after renal transplantation. Sex, increasing age, concurrent neoplasia, and previous treatment for transplant rejection were not associated with development of infection.

CONCLUSIONS AND CLINICAL RELEVANCE

Infection was a common complication and an important cause of death or euthanasia in cats after renal transplantation. Development of diabetes mellitus after transplantation significantly increased the risk of infection.