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Kriplani A, Sureka SK, Mani A, Rustagi S, Singh UP, Ansari MS, Prasad N, Sharma H, Srivastava A. Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients. EXP CLIN TRANSPLANT 2023; 21:645-651. [PMID: 37698398 DOI: 10.6002/ect.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival. MATERIALS AND METHODS We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design. RESULTS Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls. CONCLUSIONS Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.
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Affiliation(s)
- Akshay Kriplani
- >From the Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Krawczyk B, Wysocka M, Michalik M, Gołębiewska J. Urinary Tract Infections Caused by K. pneumoniae in Kidney Transplant Recipients – Epidemiology, Virulence and Antibiotic Resistance. Front Cell Infect Microbiol 2022; 12:861374. [PMID: 35531341 PMCID: PMC9068989 DOI: 10.3389/fcimb.2022.861374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/23/2022] [Indexed: 12/11/2022] Open
Abstract
Urinary tract infections are the most common complication in kidney transplant recipients, possibly resulting in the deterioration of a long-term kidney allograft function and an increased risk of recipient’s death. K. pneumoniae has emerged as one of the most prevalent etiologic agents in the context of recurrent urinary tract infections, especially with multidrug resistant strains. This paper discusses the epidemiology and risk factors associated with urinary tract infections in kidney transplant recipients, multi-drug resistance of K. pneumoniae (ESBL, KPC, NDM), treatment and pathogenesis of K. pneumoniae infections, and possible causes of recurrent UTIs. It also addresses the issue of colonization/becoming a carrier of K. pneumoniae in the gastrointestinal tract and asymptomatic bacteriuria in relation to a symptomatic UTI development and epidemiology.
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Affiliation(s)
- Beata Krawczyk
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
- *Correspondence: Beata Krawczyk,
| | - Magdalena Wysocka
- Department of Molecular Biotechnology and Microbiology, Faculty of Chemistry, Gdańsk University of Technology, Gdańsk, Poland
| | | | - Justyna Gołębiewska
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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Allograft Vesicoureteral Reflux after Kidney Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010081. [PMID: 35056389 PMCID: PMC8780114 DOI: 10.3390/medicina58010081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/04/2022] [Indexed: 01/06/2023]
Abstract
Allograft vesicoureteral reflux (VUR) is a leading urological complication of kidney transplantation. Despite the relatively high incidence, there is a lack of consensus regarding VUR risk factors, impact on renal function, and management. Dialysis vintage and atrophic bladder have been recognized as the most relevant recipient-related determinants of post-transplant VUR, whilst possible relationships with sex, age, and ureteral implantation technique remain debated. Clinical manifestations vary from an asymptomatic condition to persistent or recurrent urinary tract infections (UTIs). Voiding cystourethrography is widely accepted as the gold standard diagnostic modality, and the reflux is generally graded following the International Reflux Study Committee Scale. Long-term transplant outcomes of recipients with asymptomatic grade I-III VUR are yet to be clarified. On the contrary, available data suggest that symptomatic grade IV-V VUR may lead to progressive allograft dysfunction and premature transplant loss. Therapeutic options include watchful waiting, prolonged antibiotic suppression, sub-mucosal endoscopic injection of dextranomer/hyaluronic acid copolymer at the site of the ureteral anastomosis, and surgery. Indication for specific treatments depends on recipient’s characteristics (age, frailty, compliance with antibiotics), renal function (serum creatinine concentration < 2.5 vs. ≥ 2.5 mg/dL), severity of UTIs, and VUR grading (grade I-III vs. IV-V). Current evidence supporting surgical referral over more conservative strategies is weak. Therefore, a tailored approach should be preferred. Properly designed studies, with adequate sample size and follow-up, are warranted to clarify those unresolved issues.
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Ho CJ, Huang YH, Hsieh TY, Yang MH, Wang SC, Chen WJ, Lee TH, Sung WW, Chen SL. Native Kidney Hydronephrosis Is Associated with Upper Urinary Tract Urothelial Carcinoma in Post-Kidney Transplantation Patients. J Clin Med 2021; 10:jcm10194474. [PMID: 34640492 PMCID: PMC8509333 DOI: 10.3390/jcm10194474] [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: 07/08/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Upper urinary tract urothelial carcinoma (UTUC) is the most common malignancy occurring after kidney transplantation (KT) in Taiwan. The aim of this study was to investigate the association between native kidney hydronephrosis and UTUC in post-KT patients. Methods: From 2003 to 2018, we conducted a retrospective cohort study that enrolled 1005 post-KT patients, 67 of whom were subsequently diagnosed with UTUC. We divided patients into two groups based on whether or not they had UTUC. Multivariate analysis and Kaplan-Meier plot were used to evaluate if native kidney hydronephrosis was associated with post-KT UTUC. Results: The total cohort consisted of 612 men (60.9%) and 393 women (39.1%) with a mean age of 48.2 ± 12.0 at KT. The mean follow-up time was 118.6 ± 70.2 months, and mean time from KT to UTUC was 7.53 years. There was a significant gender difference with a female predominance among the UTUC patients (73.1% versus 26.9%, p < 0.001). Native kidney hydronephrosis occurred more frequently in the UTUC group (68.7% versus 4.8%, p < 0.001). Multivariate analysis showed that native kidney hydronephrosis and female gender were significantly associated with UTUC with odds ratios of 35.32 (95% CI, 17.99–69.36; p < 0.001) and 3.37 (95% CI, 1.55–7.29; p = 0.002), respectively. UTUC in the post-KT patients also showed aggressive pathological characteristics and a tendency toward bilateral lesions (41.8%). Conclusions: Native kidney hydronephrosis is significantly associated with post-KT UTUC patients in Taiwan. Native kidney hydronephrosis may be a deciding factor for standard nephroureterectomy and bladder cuff excision in selected patients. Nevertheless, almost half of the patients with kidney hydronephrosis do not present with UTUC at the end of our study.
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Affiliation(s)
- Cheng-Ju Ho
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
| | - Yu-Hui Huang
- Department of Physical Medicine and Rehabilitation, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Tzuo-Yi Hsieh
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
| | - Min-Hsin Yang
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
| | - Shao-Chuan Wang
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Wen-Jung Chen
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
| | - Tsung-Hsien Lee
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Wen-Wei Sung
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Sung-Lang Chen
- Department of Urology, Chung Shan Medical University Hospital, Taichung 402, Taiwan; (C.-J.H.); (T.-Y.H.); (M.-H.Y.); (S.-C.W.); (W.-J.C.); (W.-W.S.)
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Correspondence: ; Tel.: +886-4-2473-9595 (ext. 34808); Fax: +886-4-2472-8098
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Kutlutürk K, Şahin TT, Çimen S, Dalda Y, Gönültaş F, Doğan SM, Altunışık Toplu S, Ünal B, Pişkin T. Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation. Turk J Surg 2020; 36:33-38. [PMID: 32637873 DOI: 10.5578/turkjsurg.4605] [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: 08/24/2019] [Accepted: 09/26/2019] [Indexed: 02/05/2023]
Abstract
Objectives Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents). Material and Methods This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients. Results Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively). Conclusion In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.
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Affiliation(s)
- Koray Kutlutürk
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Tevfik Tolga Şahin
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Serhan Çimen
- Clinic of Urology, Malatya Education and Research Hospital, Malatya, Turkey
| | - Yasin Dalda
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Fatih Gönültaş
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Sait Murat Doğan
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
| | - Sibel Altunışık Toplu
- Department of Infectious Diseases and Clinical Microbiology, Inonu University School of Medicine, Malatya, Turkey
| | - Bülent Ünal
- Department of General Surgery, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey
| | - Turgut Pişkin
- Department of General Surgery, Inonu University School of Medicine, Malatya, Turkey
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Abstract
In patients with end-stage renal disease, the treatment of choice for most patients is renal transplantation. Complications that occur after kidney transplant can be broadly divided into vascular and non-vascular categories. Non-vascular complications can further be divided into surgical and medical categories. When evaluating renal transplant imaging, it is helpful to consider the occurrence of complications in a timeline from time of surgery. Ultrasound is often the first modality used for evaluation of renal transplants particularly in the early postoperative period. Contrast-enhanced ultrasound can be a helpful adjunct in evaluating certain complications such as hematoma, rejection, and infection. Computed tomography (CT) is also helpful in accurately diagnosing complications. Surgical complications include perinephric fluid collections (hematoma, urinoma from urine leak, abscess, and lymphocele), urinary obstruction, and incisional fluid collections and hernias. One major category of medical complications that affect the renal parenchyma includes rejection (hyperacute, acute, and chronic), delayed graft function, acute tubular necrosis (ATN), and nephrotoxicity. Infection, renal calculi, and neoplasms such as post-transplant lymphoproliferative disease are medical complications that occur after renal transplantation. It is important for radiologists to be aware of the ultrasound and CT findings of the surgical and medical complications after renal transplant for prompt identification and treatment.
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Affiliation(s)
- Nancy Kim
- Department of Radiology, MedStar Georgetown University Hospital, CCC Building, Ground Floor, 3800 Reservoir Road NW, Washington, DC, 20007, USA.
| | - Roxanna Juarez
- Department of Radiology, MedStar Georgetown University Hospital, CCC Building, Ground Floor, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Angela D Levy
- Department of Radiology, MedStar Georgetown University Hospital, CCC Building, Ground Floor, 3800 Reservoir Road NW, Washington, DC, 20007, USA
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Buttigieg J, Agius-Anastasi A, Sharma A, Halawa A. Early urological complications after kidney transplantation: An overview. World J Transplant 2018; 8:142-149. [PMID: 30211022 PMCID: PMC6134271 DOI: 10.5500/wjt.v8.i5.142] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/21/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023] Open
Abstract
Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.
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Affiliation(s)
- Jesmar Buttigieg
- Renal Division, Mater Dei Hospital, Msida MSD2090, Malta
- Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool L69 3BX, United Kingdom
| | | | - Ajay Sharma
- Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool L69 3BX, United Kingdom
- Department of Transplantation, Royal Liverpool University Hospital, Liverpool L7 8XP, United Kingdom
| | - Ahmed Halawa
- Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool L69 3BX, United Kingdom
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
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Salamanca-Bustos JJ, Gomez-Gomez E, Campos-Hernández JP, Carrasco-Valiente J, Ruiz-García J, Márquez-López FJ, Zurera-Tendero L, Requena-Tapia MJ. Initial Experience in the Use of Novel Auto-expandable Metal Ureteral Stent in the Treatment of Ureter Stenosis in Kidney Transplanted Patients. Transplant Proc 2018; 50:587-590. [PMID: 29579860 DOI: 10.1016/j.transproceed.2017.09.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 09/22/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Ureter stenosis in renal transplantation patients is a relatively frequent complication that negatively conditions graft evolution. The use of ureteral stents is a valid treatment alternative to the use of double-J catheters in patients for whom surgery is not contemplated or after surgical recurrence. We present our initial experience with five patients treated using this technique. MATERIALS AND METHODS We describe a total of five patients with ureteral stenosis after renal transplantation who were treated using ureteral stent model UVENTA (Taewoong Medical, Seoul, Korea) in our center. The median follow-up was 18 months (range, 4 to 38 months). We describe the clinical history of patients and previous treatments on ureteral stenosis. The technical procedure of placement is described. The clinical course is analyzed by measurement of renal function and imaging tests, as well as post-stent complications. Survival of the renal graft is evaluated. RESULTS The procedure could be completed in all patients without complications. The technique was effective in all patients, with correction of creatinine value and hydronephrosis during the renal ultrasound test. One patient suffered a urinary tract infection episode associated with the use of the ureteral stent. One patient suffered the loss of the renal graft secondary to the development of cryoglobulins. One hundred percent of the ureteral stents are functioning as of the writing of this article. CONCLUSIONS In renal transplantation patients with ureter stenosis, metallic stents are a useful technique with low morbidity and associated complications.
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Affiliation(s)
| | - E Gomez-Gomez
- Department of Urology, University Hospital Reina Sofia, Córdoba, Spain
| | | | | | - J Ruiz-García
- Department of Urology, University Hospital Reina Sofia, Córdoba, Spain
| | - F J Márquez-López
- Department of Urology, University Hospital Reina Sofia, Córdoba, Spain
| | - L Zurera-Tendero
- Department of Vascular Radiology, University Hospital Reina Sofia, Córdoba, Spain
| | - M J Requena-Tapia
- Department of Urology, University Hospital Reina Sofia, Córdoba, Spain
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Hollyer I, Ison MG. The challenge of urinary tract infections in renal transplant recipients. Transpl Infect Dis 2018; 20:e12828. [PMID: 29272071 DOI: 10.1111/tid.12828] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/13/2017] [Accepted: 12/15/2017] [Indexed: 12/11/2022]
Abstract
Urinary tract infections (UTI) are an important cause of morbidity and mortality in renal transplant patients. These infections are quite common, and the goal of care is to identify and reduce risk factors while providing effective prophylaxis and treatment. Better understanding of long-term outcomes from these infections has led to the distinctions among UTI, recurrent UTI, and asymptomatic bacteriuria (ASB), and that each requires a different therapeutic approach. Specifically, new research has supported the perspective that asymptomatic bacteriuria should not be treated. Symptomatic UTI, on the other hand, requires intervention and remains an ongoing challenge for infectious disease clinicians. Many bacteria species are responsible for UTI in renal transplant patients, and in recent years there has been a global rise in infection caused by bacteria with newly acquired antibacterial resistance genes. Many renal transplant patients who experience UTI will also have multiple recurring episodes, which likely has a distinct pathophysiological mechanism leading to chronic colonization of the urinary tract. In these cases, long-term management includes bacterial suppression, which aims to reduce rather than eliminate bacteria to levels below the threshold for symptomatic infection. This review will address the current understanding of UTI epidemiology, pathogenesis, and risk factors in the renal transplant community, and also focus on current prevention and treatment strategies for patients who face an environment of increasingly antibiotic-resistant bacteria.
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Affiliation(s)
- Ian Hollyer
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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