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Pandey P, Tiwari A, Shekhar Das S, Shastry S, Kute V, Chowdhry M, Marik A, Aggarwal G, Kumari S, Setya D, Mandal S, Ranjan S. I-JAMM-(I): A survey providing an insight into the practices of isoagglutinin titration in ABO incompatible kidney and liver transplantation. Transfus Apher Sci 2024; 63:103862. [PMID: 38135545 DOI: 10.1016/j.transci.2023.103862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/22/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND OBJECTIVES ABO-incompatible transplantations allow patients to receive timely transplants. Isoagglutinin titration to ascertain levels of incompatible antibodies in the recipient is important in determining patient selection and transplant survivability. To find out the prevalent trends in India, the largest, first of its kind survey was carried out among the transplant centers regarding their practices in isoagglutinin titration. METHODS The survey was drafted by a working group of Transfusion and Transplant Immunology specialists from six different centers. Data was obtained via the use of an online questionnaire. RESULTS Results were categorized into four categories, Hospital information, Titration methodology, Role of transfusion specialists and cut-off titers. Most centers had a well-established solid-organ transplant program with considerable number of ABO-incompatible transplantations. Most centers performed isoagglutinin titration in Transfusion Medicine department. Column Agglutination Technique (CAT) was the most common method, using EDTA blood samples and freshly-prepared in-house pooled cells. Most centers had a turn-around time of less than 12 h. While the policy for ascertaining baseline and threshold titers is well-defined in ABO-incompatible renal transplants, variations from center to center still exist for ABO-incompatible liver transplants. Most centers required a Transfusion Medicine consultation for the patients before such transplants. CONCLUSION With increasing ABO-incompatible kidney and liver transplants across the country, the role of Transfusion medicine specialists has become vital in pre-conditioning regimes enabling the viability and success of such transplants. This was a unique survey that provided a snapshot of current trends and practices of isoagglutinin titration for ABO-incompatible transplants in India.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine & Transplant Immunology, Jaypee Hospital, Sector, 128, Noida 201304, India
| | - Aseem Tiwari
- Department of Transfusion Medicine, Medanta, The Medicity, Gurugram, India
| | | | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India 576104
| | - Vivek Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Ahmedabad, India
| | - Mohit Chowdhry
- Department of Transfusion Medicine, Indaprastha Apollo Hospital, New Delhi, India
| | - Arghyadeep Marik
- Department of Transfusion Medicine & Transplant Immunology, Jaypee Hospital, Sector, 128, Noida 201304, India.
| | - Geet Aggarwal
- Department of Transfusion Medicine, Medanta, The Medicity, Gurugram, India
| | - Supriya Kumari
- Department of Transfusion Medicine & Transplant Immunology, Jaypee Hospital, Sector, 128, Noida 201304, India
| | - Divya Setya
- Department of Transfusion Medicine, Manipal Hospital, Jaipur, India
| | - Saikat Mandal
- Department of Transfusion Medicine & Transplant Immunology, Jaypee Hospital, Sector, 128, Noida 201304, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Patna, India
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Pawar N, Tiwari V, Gupta A, Divyaveer S, Rather I, Chadha S, Bhargava V, Malik M, Gupta A, Bhalla AK, Rana D, Gupta P. ABO-Incompatible Renal Transplant: A Single-Center Experience from India. Indian J Nephrol 2024; 34:24-30. [PMID: 38645921 PMCID: PMC11003606 DOI: 10.4103/ijn.ijn_247_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/31/2023] [Indexed: 04/23/2024] Open
Abstract
Introduction In view of ever-increasing end-stage renal disease (ESRD) population but inadequate availability of suitable donors, ABO-incompatible (ABOi) transplantation can be an important void filler. However, at present, ABOi transplantation is limited to a few centers in India and there is a lack of adequate experience and expertise to guide this program to other centers in the country. Methods Data of all the ABOi transplants performed from 2012 to 2021 in a tertiary care hospital was retrospectively analyzed. The anti-ABO antibody (IgG) titers (≤1:4) were considered safe before transplantation. Desensitization included rituximab, plasma exchange, or selective immunoadsorption column. Tacrolimus and mycophenolate mofetil were initiated at day -7. Induction agents included ATG, ATLG, basiliximab, or no induction. Postoperatively, anti-ABO titers were done daily for 2 weeks. Results A total of 202 patients underwent transplantation; of these, 195 patients whose data were for available for 12 months were included in the study. Mean duration of follow-up was 28.9 ± 21.7 months. UTI was the most common source of infection, occurring in almost half (46.1%) of the patients. Antibody-mediated rejection (ABMR; 15%) was common in the first year. Patient survival was 86.6% (169/195) at 1 year. Sepsis was the most common of death in more than two-thirds of the population, including coronavirus disease 2019 (COVID-19)-associated mortality in nine patients (4.6%). Death-censored graft survival was 89.3% (174/195). AMR was the leading cause of graft loss in almost half of the patients. Conclusion ABOi should be considered in ESRD patients for whom suitable ABO-compatible donor is not available. Higher rate of rejection and infection are still a major concern.
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Affiliation(s)
- Nikita Pawar
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Vaibhav Tiwari
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Anurag Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Smita Divyaveer
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Imran Rather
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Chadha
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Anil Kumar Bhalla
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - D.S. Rana
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
| | - Pallav Gupta
- Department of Pathology, Sir Ganga Ram Hospital, New Delhi, Delhi, India
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John GT, Jacob CK, Sundaram M, Alexander S, Kekre NS, Daniel D, Varughese S. The First ABO Incompatible Kidney Transplantation without Splenectomy in India - A Review at 12 Years. Indian J Nephrol 2023; 33:234-236. [PMID: 37448893 PMCID: PMC10337219 DOI: 10.4103/ijn.ijn_295_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/31/2021] [Accepted: 11/14/2021] [Indexed: 07/15/2023] Open
Affiliation(s)
- George T. John
- Kidney Health Service, Royal Brisbane and Women’s Hospital, Brisbane, Herston, Queensland, Australia, India
| | - Chakko K. Jacob
- Department of Nephrology, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Madhivanan Sundaram
- Department of Nephrology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nitin S. Kekre
- Department of Urology, Naruvi Hospitals, Vellore, Tamil Nadu, India
| | - Dolly Daniel
- Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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Prasad N, Chellapan A, Srivastava A, Bhadauria D, Kaul A, Patel M, Gupta A. ABO-incompatible repeat kidney transplantation: Coping with the 'twin immunological barrier'. Indian J Nephrol 2022; 32:82-86. [PMID: 35283567 PMCID: PMC8916154 DOI: 10.4103/ijn.ijn_64_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/01/2020] [Accepted: 10/13/2020] [Indexed: 11/11/2022] Open
Abstract
A repeat renal transplantation is believed to confer the best survival advantage for allograft failure. The scarcity of matching donors at one end, coupled with the expanding pool of ABO-incompatible (ABOi) donors at the other end, lead us to consider the option of ABOi kidney re-transplantation. However, ABOi kidney re-transplantation is associated with heightened immunological risk due to the presence of two substantial immunological barriers. Concern, queries, and uncertainty exist over the course and outcome of this option. We prospectively studied five patients who underwent live-related ABOi re-transplantation after a failed previous transplant. Four patients (mean age 40.8 ± 6.6 years, 4 males) underwent a second renal transplant, whereas one patient had a third renal transplant. All patients received desensitization with rituximab, plasmapheresis, and intravenous immunoglobulin as per routine protocol. One patient required immunoadsorption to achieve the desired Anti-ABO titer. All five patients had good graft survival. One of them developed combined antibody and cell-mediated rejection and another antibody-mediated rejection. Live-related ABOi kidney re-transplantation could be a viable option for patients with a previously failed graft.
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Jha P, Bansal S, Rana A, Nandwani A, Kher A, Sethi S, Jain M, Bansal D, Yadav D, Gadde A, Mahapatra A, Sodhi P, Ahlawat R, Kher V. ABO-incompatible kidney transplantation in India: A single-center experience of first hundred cases. Indian J Nephrol 2022; 32:42-46. [PMID: 35283580 PMCID: PMC8916160 DOI: 10.4103/ijn.ijn_465_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/24/2020] [Accepted: 11/30/2020] [Indexed: 11/04/2022] Open
Abstract
Aim: Material and Methods: Results: Conclusion:
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Singh K, Kaushal R, Srivastava A. A case report of ABO-Incompatible kidney transplant in human immunodeficiency virus-positive patient coinfected with both hepatitis B and hepatitis C viruses: A case report. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_20_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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7
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Gaur L, Bhalla A, Shingada A, Gupta A, Malik M, Gupta A, Bhargava V, Gupta P, Joshi A, Jauhari H, Ranjan V, Khillan K, Rana DS. Outcomes of ABO-Incompatible kidney transplantation with respect to baseline isoagglutinin immunoglobulin G titers: A retrospective observational study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_64_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Prabhakar A, Gang S, Hegde U, Konnur A, Patel H, Rajapurkar M. Kidney Transplantation with ABO-Incompatible Donors: A Comparison with Matched ABO Compatible Donor Transplants. Indian J Nephrol 2021; 31:358-364. [PMID: 34584351 PMCID: PMC8443094 DOI: 10.4103/ijn.ijn_206_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction: ABO-incompatible kidney transplantation (ABOiKTx) expands the living donor pool. There is limited long-term outcome data from India especially in comparison with ABO-compatible kidney transplantation (ABOcKTx). Here we report outcomes of the first 100 ABOiKTx compared to ABOcKTx from our center. Methods: Between August 2013 and December 2019, 100 consecutive ABOiKTx were compared with 100 ABOcKTx done during the same period.Controls were matched for age, donor characteristics, HLA mismatches, and date of transplantation. Results: Mean (SD) follow up period was 25.9 ± 20.5 and 27.2 ± 20.6 months in ABOi and ABOcKTx respectively. Patient survival at 1 and 5 years post-transplant was 93.3 and 73.5% vs. 95.4 and 93% (P = 0.03), while graft survival rates were 85 and 60% vs. 93.1 and 83% in ABOi and ABOcKTx respectively (P = 0.03). The incidence of antibody-mediated rejections was 15% vs. 4%, and that of T-cell-mediated rejections was 10 vs. 12% respectively. Infections, malignancies, and surgical complications were similar. Level of anti ABO titers, HLA mismatches, recipient age, donor age, and presence of diabetes did not impact graft survival amongst ABOiKTx. The predicted survival and incidence of acute rejections and infections in the later 50 ABOiKTx transplants were better than the first 50 ABOiKTx when compared to their respective controls. Conclusion: Outcomes of ABOiKTx were inferior to ABOcKTx but tends to improve as more experience is gained. Incidence of ABMR was higher but infections and surgical complications were comparable. This data provides evidence that ABOiKTx is viable option for those without a ABO compatible donor.
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Affiliation(s)
- Aniketh Prabhakar
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Sishir Gang
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Umapathi Hegde
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Abhijit Konnur
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Hardik Patel
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Mohan Rajapurkar
- Department of Nephrology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
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Jha PK, Yadav DK, Siddini V, Bansal SB, Sharma R, Anandh U, Jeloka T, Reddy S, Pokhariyal S, Nandwani A, Jain S, Saxena V, Sethi SK, Bansal D, Jain M, Sodhi P, Gadde A, Augustine R, Zafar FA, Ghosh P, Tiwari AK, Ahlawat R, Kher V. A retrospective multi-center experience of renal transplants from India during COVID-19 pandemic. Clin Transplant 2021; 35:e14423. [PMID: 34255903 PMCID: PMC8420412 DOI: 10.1111/ctr.14423] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) pandemic led to a sudden drop in renal transplant numbers across India in the initial months of 2020. Although the transplant numbers increased with easing of lockdown, the outcome of these transplants remains unknown. METHODS This was a retrospective, observational, multi-center study done across eight different transplant centers in India. All the transplants done from January 30, 2020 to December 31, 2020 were included. The primary outcomes studied were patient and death censored graft survival as well as incidence of COVID-19 infection and its outcomes. RESULTS During the study period a total of 297 kidney transplants were done. After a median follow up of 265 days the patient and death censored graft survival was 95.3% and 97.6%, respectively. Forty-one patients (13.8%) developed COVID-19 post-transplant. Majority (58.5%) were asymptomatic to mildly symptomatic and the case fatality ratio was 14.6%. On multivariable logistic regression analysis older age was associated with higher likelihood of COVID-19 infection (odds ratio 1.038; CI 1.002-1.077). CONCLUSIONS Patient and graft outcome of kidney transplants done during the COVID-19 pandemic in India was acceptable. The incidence of COVID-19 was 13.8% with a high case fatality ratio.
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Affiliation(s)
- Pranaw Kumar Jha
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Dinesh Kumar Yadav
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Vishwanath Siddini
- Department of Nephrology, Manipal Hospitals, Old Airport Road, Bengaluru, Karnataka, India
| | - Shyam Bihari Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Reetesh Sharma
- Nephrology and Kidney Transplant Medicine, Asian Institute of Medical Sciences, Faridabad, Haryana, India
| | - Urmila Anandh
- Department of Nephrology, Yashoda Hospitals, Secunderabad, Telangana, India
| | - Tarun Jeloka
- Department of Nephrology and Renal Transplant, Aditya Birla Memorial Hospital, Pune, Maharashtra, India
| | - Sreedhar Reddy
- Department of Nephrology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
| | | | - Ashish Nandwani
- Department of Nephrology, Manipal Hospital Delhi, Delhi, India
| | - Salil Jain
- Department of Nephrology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Vishal Saxena
- Department of Nephrology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Sidharth Kumar Sethi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Dinesh Bansal
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Manish Jain
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Puneet Sodhi
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Ashwini Gadde
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Rohan Augustine
- Department of Nephrology, Manipal Hospitals, Old Airport Road, Bengaluru, Karnataka, India
| | - Feroz Amir Zafar
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Prasun Ghosh
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Aseem Kumar Tiwari
- Department of Transfusion Medicine, Medanta - The Medicity, Gurugram, Haryana, India
| | - Rajesh Ahlawat
- Department of Urology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
| | - Vijay Kher
- Department of Nephrology, Medanta Institute of Kidney and Urology, Medanta - The Medicity, Gurugram, Haryana, India
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Kahlyar H, Roxby D, Badrick T, Vanniasinkam T. Challenges in antibody titration for ABO-incompatible renal transplantation. Vox Sang 2021; 117:109-118. [PMID: 34105779 DOI: 10.1111/vox.13160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/16/2021] [Accepted: 05/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Accurate and regular monitoring of anti-A and anti-B titres pre- and post-transplantation plays a crucial role in the clinical management of patients receiving ABO-incompatible renal transplants. There is no standardized protocol or an external quality assurance program (EQA) currently available for this testing in Australia. The aim of this study was to investigate the diversity of techniques, test platforms and reagents that were currently in use in various laboratories with the aim of developing an EQA. MATERIALS AND METHODS An online survey was sent to the participants enrolled with the Royal College of Pathologists of Australasia Quality Assurance Program (RCPAQAP) to assess their interest in participation in the pilot study. A total of 24 participants who expressed interest were sent the group O plasma, A1 , A2 and B cells to perform ABO titration using their own methods. RESULTS Participants reported a wide range of titre results, from 8 to 1024 for the anti-A titre using A1 cells, from 2 to 128 for anti-A titre using A2 cells and from neat to 32 for anti-B titre using B cells. CONCLUSION There was a wide variation in titre results between and within different technologies. These findings demonstrate the need for an ABO titration EQA. Development of a standard technique and participation in an EQA program should, over time, reduce variation and enable transferrable results across testing centres, which will assist in consistent clinical interpretation and better outcomes for patients.
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Affiliation(s)
- Htar Kahlyar
- Royal College of Pathologists of Australasia, Sydney, New South Wales, Australia
| | - David Roxby
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Tony Badrick
- Royal College of Pathologists of Australasia, Sydney, New South Wales, Australia
| | - Thiru Vanniasinkam
- School of Biomedical Sciences, Charles Sturt University, New South Wales, Australia
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Gupta P, Bhargava V, Gupta A, Bhalla AK, Gupta A, Malik M, Tiwari V, Rana DS, Sapra RL. Renal Biopsy and Clinical Outcomes in Patients With ABO-Incompatible Renal Transplant: Experience From a Tertiary Care Hospital. EXP CLIN TRANSPLANT 2021; 19:527-533. [PMID: 33952177 DOI: 10.6002/ect.2021.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Renal transplant with ABO-incompatible donors expands the donor pool. Earlier studies have focused the use of protocol biopsies in ABO-incompatible transplant patients. Our study described outcomes of indication (for cause) renal biopsies and clinical outcomes in patients with ABO-incompatible renal transplant. MATERIALS AND METHODS This retrospective study included 164 patients from January 2012 to June 2019. Biochemical parameters, serial immunoglobulin G anti-ABO titers, and class I and II donor-specific antibody findings were obtained from hospital records, and renal graft biopsies were reviewed according to the Banff 2017 update. RESULTS We analyzed the results of 65 biopsies from 54 patients. Biopsy-proven acute antibody-mediated rejection (12.8%) was found to be more prevalent than acute cellular rejection (1.8%). Patients with antibodymediated rejection all had microvascular inflammation (g+ptc score of 2 or more, where g+ptc is the sum of the glomerulitis and peritubular capillaritis scores) and were positive for C4d. Acute tubular injury per se was seen in 10.3% of patients; 65% of these patients had C4d positivity in peritubular capillaries, and only 1 patient developed chronic active antibody-mediated rejection on follow-up. Patient and death-censored graft survival rates were 92% and 98% at 1 year after transplant and 88% and 91% at 3 years, respectively. Patients with an episode of antibody-mediated rejection had lower rates of patient (76.5%) and deathcensored graft survival (84.6%) at 1 year. CONCLUSIONS The microvascular inflammation score (g+ptc score of 2 or higher) is more reliable than diffuse C4d positivity to determine antibody-mediated rejection in ABO-incompatible transplants because diffuse C4d positivity may also be seen in etiologies unrelated to antibody-mediated rejection. Acute tubular injury with C4d positivity without microvascular injury does not confirm antibody-mediated rejection. We suggest that Banff classification be updated in ABO-incompatible transplants to include diagnostic criteria for the diagnosis of antibody-mediated rejection.
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Affiliation(s)
- Pallav Gupta
- From the Department of Renal Pathology, Division of Histopathology, Sir Ganga Ram Hospital, New Delhi, India
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12
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Kute VB, Patel HV, Mishra VV, Agarwal SK. Optimum Chain Length in Kidney Exchange Program and the Way Ahead. Indian J Nephrol 2021; 31:95-96. [PMID: 34267429 PMCID: PMC8240927 DOI: 10.4103/ijn.ijn_376_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/17/2020] [Accepted: 03/08/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Vivek B. Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Himanshu V. Patel
- Department of Nephrology, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Vineet V. Mishra
- Department of Nephrology, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Sanjay K. Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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Mukherjee D, Hooda AK, Jairam A, Nair RK, Sharma S. Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India. Med J Armed Forces India 2021; 77:15-21. [PMID: 33487860 DOI: 10.1016/j.mjafi.2019.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/25/2019] [Indexed: 11/16/2022] Open
Abstract
Background We present our experience of ABO-incompatible renal transplant using immunoadsorption (IA) columns. We have compared efficacy of two commercially available columns. Methods This single-center prospective study was conducted at Army Hospital Research and Referral, Delhi. All consecutive ABO-incompatible renal transplants from January 2014 to February 2018 were analyzed. Of 30 patients who underwent transplantations, 28 underwent antibody depletion with immunoadsorption columns. Of them, 14 cases were in the "Glycosorb group," while 14 in the "Adsopak group." Results The donors in the Adsopak group were older than those in the Glycosorb group (p < 0.05). Both groups had spousal donors in majority. The cutoff for the antibody titer was 1:8. The median titer in the Adsopak group was 128 (range, 1:4 to 1:2048), while that in the Glycosorb group was 24 (range, 1:8 to 1:128). All patients in the Glycosorb group had baseline titers ≤1:128, while 13 patients in the Adsopak group had baseline titers ≤1:512. Nil titer was achievable with Glycosorb® (50%,7/14) but not with Adsopak® (P < 0.01). Around 4 sessions were required for the Glycosorb group, while around 8 sessions were required for the Adsopak group before transplantation (p < 0.001). The Glycosorb group was advantageous in terms of graft failure because no rejection was noticed in these patients in their follow-up period. Three patients in the Adsopak group developed rejection (two had mixed rejection, and one had antibody-mediated rejection). Four patients died of sepsis (three in the Glycosorb and one in the Adsopak group). Lower baseline serum creatinine level was achieved in the Glycosorb group. Conclusions Results of ABO-incompatible renal transplantation were satisfactory, and the use of immunoadsorption columns could effectively deplete antibody titers. Glycosorb columns were more efficient than Adsopak columns. Graft survival was better with Glycosorb. Posttransplant infections were a major cause of mortality.
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Affiliation(s)
- D Mukherjee
- Senior Advisor (Med & Nephrology), Army Hospital (R&R), Delhi Cantt, India
| | - A K Hooda
- Director General (Org & Pers), O/o DGAFMS, Ministry of Defence, 'M' Block, New Delhi 110001, India
| | - A Jairam
- Consultant (Med & Nephrology), Command Hospital (Eastern Command), Kolkata, India
| | - Ranjith K Nair
- Senior Advisor (Med & Nephrology), Command Hospital (Eastern Command), Kolkata, India
| | - Sourabh Sharma
- Senior Resident (Med & Nephrology), Army Hospital (R&R), Delhi Cantt, India
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Pandey P, Setya D, Sinha VK, Devra AK, Bhatt AP, Pande A, Kumar P, Singh MK, Ranjan S. Outcome of desensitization in human leukocyte antigen and ABO incompatible living donor kidney transplantation: Single center experience of first 200 incompatible transplants. J Clin Apher 2020; 36:299-312. [PMID: 33316838 DOI: 10.1002/jca.21860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Although desensitization is well established, concerns about graft outcome, patient survival and rejection still exist. The present study aims at comparing outcomes of renal transplant recipients across simultaneous ABO and human leukocyte antigen (HLA) incompatibility barriers to those with ABO or HLA incompatibility alone. MATERIALS AND METHODS This was a retrospective study conducted from October 2015 to December 2018. All patients with a clinical diagnosis of chronic kidney disease, who were prospective HLA incompatible (HLAi) and/or ABO incompatible (ABOi) renal transplant recipients were included. A total of 400 cases including 36 ABOi transplants, 154 HLAi transplants, 10 simultaneously ABO and HLA incompatible transplants, and 200 ABO (ABOc) and HLA (HLAc) compatible kidney transplants from living donors were included. RESULTS There were significantly more number of blood transfusions, previous transplants and pregnancies in HLAi transplant recipients relative to the ABOi or the control group. Mean number of therapeutic plasma exchange procedures per patient and mean plasma volume processed per procedure were slightly higher in the ABOi + HLAi category. The incidence of graft dysfunction due to suspected antibody-mediated rejection during first year was highest in the ABOi + HLAi group, followed by ABOc + HLAi and ABOi + HLAc, lowest in the ABOc + HLAc category. Mean time to first episode of graft dysfunction was significantly shorter with incompatible transplants. There were no kidney transplant recipient deaths in the study. CONCLUSION Patient outcome and graft outcomes observed with incompatible transplants were not worse than those observed with compatible transplants.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Kumar Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit K Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Prasad Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
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15
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Pandey P, Setya D, Sinha V, Bhatt A, Devra A, Chaudhary A, Ranjan S, Srivastava R, Kumar P, Singh MK. Therapeutic apheresis in
ABO
‐incompatible kidney and liver transplantation: A single‐center experience of 50 patients. Ther Apher Dial 2020; 25:103-117. [DOI: 10.1111/1744-9987.13495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/07/2020] [Accepted: 03/31/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Vijay Sinha
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Anil Bhatt
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Amit Devra
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Abhideep Chaudhary
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Roli Srivastava
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
| | - Mukesh Kumar Singh
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology Jaypee Hospital Noida India
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16
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Pandey P, Setya D, Sinha V, Bhatt A, Devra A, Pande A, Kumar P, Ranjan S. Renal transplantation in HLA sensitized patients: Traversing the immunological barrier. Ther Apher Dial 2019; 24:578-590. [PMID: 31863544 DOI: 10.1111/1744-9987.13467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/23/2019] [Accepted: 12/19/2019] [Indexed: 11/27/2022]
Abstract
Successful renal transplantation across HLA barrier in sensitized individuals has been on the rise during the past decade, primarily due to improved desensitization regimes. The aim of this study was to share outcome of desensitization in renal transplant recipients with donor-specific anti-HLA antibodies (DSA). This was a retrospective analysis of all HLA immunized individuals who were prospective renal transplant recipients. All such patients underwent preconditioning as per the institutional desensitization protocol. Complement-dependent cytoxicity-based crossmatch (CDC-XM), luminex-based crossmatch (LM-XM) and flowcytometry-based crossmatch (FC-XM) were done in all cases. If any of these tests turned out positive, single antigen bead assay (SAB) was performed. Desensitization for DSA was performed in 55 patients and all patients were followed-up for 1 year to assess graft function and patient outcome. CDC-XM being a less sensitive assay, could not detect incompatibility in 29 (52.73%) cases. After desensitization, even though SAB and LM-XM results revealed an MFI within acceptable range, FC-XM being an extremely sensitive assay, continued to give a positive result in eight (14.55%) cases. The mean ± SD number of pretransplant TPE were 3.44 ± 0.98 (2-11). Out of 55, there were 10 patients who were lost to follow up. Patient and graft survival of 45 patients at 1 year was found to be 100%. Preconditioning for renal transplants in the form of immunosuppression with TPE is an extremely useful auxiliary for transplantation in HLA sensitized renal transplant recipients.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Vijay Sinha
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Anil Bhatt
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Devra
- Department of Nephrology and Renal Transplantation, Jaypee Hospital, Noida, India
| | - Amit Pande
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Praveen Kumar
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
| | - Shweta Ranjan
- Department of Transfusion Medicine, Histocompatibility and Molecular Biology, Jaypee Hospital, Noida, India
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17
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Chauhan K, Mehta AA. Rituximab in kidney disease and transplant. Animal Model Exp Med 2019; 2:76-82. [PMID: 31392300 PMCID: PMC6600632 DOI: 10.1002/ame2.12064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
Rituximab is a chimeric monoclonal antibody that binds to CD20 antigen of B-cells. It depletes the level of mature B-cells by various mechanisms such as mediation of antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity, and B-cell apoptosis. Rituximab is a USFDA approved drug for clinical use in non-Hodgkin's B-cell lymphoma (NHL), rheumatoid arthritis, chronic lymphocytic leukemia (CLL), granulomatosis with polyangiitis and pemphigus vulgaris. It is also known for its "off label" use in renal disease and renal transplant worldwide. However, the exact mechanisms by which it exerts its effect in the aforementioned condition remain unclear but may be related to its long-term effects on plasma cell development and the impact on B-cell modulation of T cell responses. This review discusses the current use of rituximab in renal disease and renal transplantation, and its potential role in novel therapeutic protocols.
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Affiliation(s)
- Kajal Chauhan
- Medical ServicesTorrent PharmaceuticalsAhmedabadIndia
| | - Anita A. Mehta
- Department of PharmacologyL. M. College of PharmacyAhmedabadGujaratIndia
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18
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Jha V, Bhalla AK, Anil Kumar BT, Chauhan M, Das P, Gandhi B, Hegde U, Jeloka T, Mali M, Jha P, Kher A, Mukkavilli K, Ramachandran R. ABO-incompatible kidney transplantation: Indian working group recommendations. INDIAN JOURNAL OF TRANSPLANTATION 2019. [DOI: 10.4103/ijot.ijot_39_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Kher A, Agarwal A, Jha P, Bansal D, Madken M, Narula AS, Khurana R, Kher V. Anti A/B Antibody Titer Rebound: Are we Making it Worse? Be Aware of Your Intravenous Immunoglobulin. Indian J Nephrol 2018; 28:407-409. [PMID: 30271009 PMCID: PMC6146724 DOI: 10.4103/ijn.ijn_230_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- A Kher
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - A Agarwal
- Division of Blood Bank, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - P Jha
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - D Bansal
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - M Madken
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - A S Narula
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - R Khurana
- Division of Blood Bank, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
| | - V Kher
- Fortis Escorts Kidney and Urology Institute, Escorts Heart Institute and Research Centre Limited, Okhla, New Delhi, India
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20
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de Weerd AE, Betjes MGH. ABO-Incompatible Kidney Transplant Outcomes: A Meta-Analysis. Clin J Am Soc Nephrol 2018; 13:1234-1243. [PMID: 30012630 PMCID: PMC6086717 DOI: 10.2215/cjn.00540118] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES ABO blood group-incompatible kidney transplantation is considered a safe procedure, with noninferior outcomes in large cohort studies. Its contribution to living kidney transplantation programs is substantial and growing. Outcomes compared with center-matched ABO blood group-compatible control patients have not been ascertained. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Comprehensive searches were conducted in Embase, Medline, Cochrane, Web-of-Science, and Google Scholar. Meta-analyses Of Observational Studies in Epidemiology study guidelines for observational studies and Newcastle Ottawa bias scale were implemented to assess studies. Meta-analysis was performed using Review Manager 5.3. A subgroup analysis on antibody removal technique was performed. RESULTS After identifying 2728 studies addressing ABO-incompatible kidney transplantation, 26 studies were included, describing 1346 unique patients who were ABO-incompatible and 4943 ABO-compatible controls. Risk of bias was low (all studies ≥7 of 9 stars). Baseline patient characteristics revealed no significant differences in immunologic risk parameters. Statistical heterogeneity of studies was low (I2 0% for graft and patient survival). One-year uncensored graft survival of patients who were ABO-incompatible was 96% versus 98% in ABO-compatible controls (relative risk, 0.97; 95% confidence interval, 0.96 to 0.98; P<0.001). Forty-nine percent of reported causes of death in patients who were ABO-incompatible were of infectious origin, versus only 13% in patients who were ABO-compatible (P=0.02). Antibody-mediated rejection (3.86; 95% confidence interval, 2.05 to 7.29; P<0.001), severe nonviral infection (1.44; 95% confidence interval, 1.13 to 1.82; P=0.003), and bleeding (1.92; 95% confidence interval, 1.36 to 2.72; P<0.001) were also more common after ABO-incompatible transplantation. CONCLUSIONS ABO-incompatible kidney transplant recipients have good outcomes, albeit inferior to center-matched ABO-compatible control patients.
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Affiliation(s)
- Annelies E de Weerd
- Department of Nephrology and Kidney Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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21
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Cozzi E, Colpo A, De Silvestro G. The mechanisms of rejection in solid organ transplantation. Transfus Apher Sci 2017; 56:498-505. [PMID: 28916402 DOI: 10.1016/j.transci.2017.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Organ transplantation represents the preferred treatment option for many patients in terminal organ failure. The half-life of transplanted organs, however, is still far from being satisfactory with the vast majority of the organs failing within the first two decades following transplantation. At this stage, it has become apparent that rejection (prevalently mediated by humoral events) remains the primary cause of graft loss after the first year. In this light, studies are underway to better comprehend the immune events underlying graft rejection and novel immunosuppressive strategies are being explored. In this context, therapeutic apheresis techniques, that include therapeutic plasma exchange (TPE), immunoadsorption (IA) and extracorporeal photochemotherapy (ECP), represent an important adjunct in the current immunosuppressive armamentarium. This article briefly reviews our current understanding of the immune process underlying rejection of a solid organ transplant and describes the principal areas of application of therapeutic apheresis techniques in transplantation.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences, Transplant Immunology Unit, Padua University Hospital, Padova, Italy; CORIT (Consortium for Research in Organ Transplantation), Padova, Italy.
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Padova, Italy
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22
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Aggarwal G, Tiwari AK, Dorwal P, Chauhan R, Arora D, Dara RC, Kher V. Successful Renal Transplantation Across HLA Barrier: Report from India. Indian J Nephrol 2017; 27:210-214. [PMID: 28553042 PMCID: PMC5434688 DOI: 10.4103/0971-4065.200518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Organ donors are sometimes found “unsuitable” due to the presence of donor-specific anti-HLA antibodies in the recipient. In recent years, improved desensitization protocols have successfully helped to overcome HLA incompatibility hurdle. We present three cases where optimum desensitization was achieved in patients with the donor-specific anti-HLA antibody (DSA) leading to successful renal transplantation. All patient–donor pair underwent HLA typing, complement dependent cytotoxicity crossmatch (CDC-XM), flow cytometry XM (FC-XM), and panel reactive antibody. If any of the three tests was positive, single antigen bead assay was performed to determine the specificity of the anti-HLA antibody (s). Patients with DSA were offered organ-swap or anti-HLA antibody desensitization followed by transplantation. Desensitization protocol consisted of single dose rituximab and cascade plasmapheresis (CP) along with standard triple immunosuppression. The target DSA mean fluorescence index (MFI) was <500, along with negative CDC-XM and FC-XM for both T- and B-cells. Three patients with anti-HLA DSA, who did not find a suitable match in organ swap program, consented to anti-HLA antibody desensitization, followed by transplantation. Mean pre-desensitization antibody MFI was 1740 (1422–2280). Mean number of CP required to achieve the target MFI was 2.3 (2–3). All the three patients are on regular follow-up and have normal renal function test at a mean follow-up of 8 months. This report underlines successful application of desensitization protocol leading to successful HLA-antibody incompatible renal transplants and their continued normal renal functions.
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Affiliation(s)
- G Aggarwal
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - A K Tiwari
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - P Dorwal
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - R Chauhan
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - D Arora
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - R C Dara
- Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
| | - V Kher
- Kidney and Urology Institute, Medanta-The Medicity, Gurgaon, Haryana, India
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