A Multicenter Retrospective Cohort Study on Management Protocols and Clinical Outcomes After ABO-incompatible Kidney Transplantation in India

BACKGROUND

There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries.

METHODS

Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR).

RESULTS

Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P  < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P  = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P  = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P  = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P  < 0.0001) and IA use (HR: 2 [1.37-2.92]; P  < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P  = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable.

CONCLUSIONS

Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.

A196 CROHN’S DISEASE PATIENT DERIVED MACROPHAGES ARE MORE SUSCEPTIBLE TO HYDROGEN PEROXIDE INDUCED CELL DEATH

Background

Crohn’s disease (CD) is characterized by intestinal inflammation due to the interplay between immunity, genetics, and environmental factors such as diet. Selenium (Se) deficiency is common in patients with CD due to malabsorption or high enteric losses. Selenium is used in the synthesis of selenoproteins that have antioxidant properties (e.g. glutathione peroxidases (GPx)) and are highly expressed in macrophages. However, how Se deficiency affects immune system function in patients with CD is unknown. We hypothesize that characterizing Se status, selenoprotein expression and subsequently macrophage function will advance knowledge of mucosal immunity and provide novel insight into CD.

Purpose

To determine if patients with active CD and healthy controls differ in Se dietary intake and status, oxidative stress, and macrophage cytotoxicity in response to oxidative stress.

Method

Blood was collected from healthy volunteers and patients diagnosed with ileal, ileocolonic or colonic CD (age ≥18 years, with mild or moderate endoscopic disease activity or fecal calprotectin ≥250 µg/g, and Harvey Bradshaw index <16, stable medications including biologics for at least 8-weeks prior to recruitment). Serum was analyzed for GPx activity, malondialdehyde (MDA) and C-reactive protein (CRP) concentrations. Monocytes were isolated by plastic adherence and treated with M-CSF (10 ng/ml, 7d) to derive macrophages. mRNA expression of GPx1, GPx4 and SelenoP was determined by qPCR. Lactate dehydrogenase release was measured in macrophages treated with 500 µM H₂O₂ for 2h.

Result(s)

Samples and/or dietary intake data were collected from 9 patients with CD (3 female, 6 male, mean age=36.8 years) and 13 controls (7 female, 6 male, mean age=27.7 years). Dietary Se intake did not differ between patients with CD and controls (126.1 ± 23.2 vs. 123.3 ± 19.8 µg/day). GPx activity was greater in the serum of patients with CD compared to controls (369 ± 49 vs. 169 ± 27 mU/mL, n=6-8, p<0.005). Patients with CD and controls did not differ in serum MDA concentration (7.80 ± 0.57 vs. 6.53 ± 1.1 µM). CRP levels correlated with serum MDA concentration in patients with CD (r=0.95, n=5, p<0.05) but not GPx activity. Macrophages from patients with CD (n=6) and controls (n=7) did not differ in expression of GPx1 and GPx4 mRNA, whereas SelenoP mRNA was ~200-fold lower in macrophages from patients with CD. Macrophages derived from patients with CD were more susceptible to H₂O₂-evoked cell death (10.3 ± 1.1 vs. 4.7 ± 0.7 % n=2-3 p<0.05).

Conclusion(s)

Despite adequate dietary Se intake our findings suggest altered Se metabolism in patients with active CD, with increases in serum GPx potentially indicative of the need for antioxidant activity to counter oxidative stress. The increased sensitivity of macrophages from patients with CD to H₂O₂ emphasizes the role of oxidative stress and redox balance in IBD. Defining how micronutrients, in this instance Se, impacts innate immunity may provide new approaches to the management of CD.

Disclosure of Interest

None Declared

Impact of COVID-19-associated Mucormycosis in Kidney Transplant Recipients: A Multicenter Cohort Study

BACKGROUND

COVID-19-associated mucormycosis (CAM) is a recently emerging entity. There is a lack of reports of CAM in organ transplant recipients.

METHODS

We conducted a multicenter (n = 18) retrospective research in India during November 2020 to July 2021. The purpose of this study was to explore the clinical spectrum, outcome and risk factors for mortality of CAM in kidney transplant recipients (KTRs).

RESULTS

The incidence of CAM was 4.4% (61/1382 COVID-19-positive KTRs) with 26.2% mortality. The median age of the cohort was 45 (38-54) y. Twenty (32%) were not hospitalized and 14 (22.9%) were on room air during COVID-19. The proportion of postdischarge CAM was 59.1%, while concurrent CAM was reported in 40.9%. The presentation of CAM was 91.8% rhino-orbital-cerebral mucormycosis and 8.2% pulmonary with 19.6% and 100% mortality, respectively. In the univariable analysis, older age, obesity, difficulty of breathing, high-flow oxygen requirement, and delay in starting therapy were significantly associated with mortality. In the multivariable logistic regression analysis, patients requiring high-flow oxygen therapy [odds ratio (95% confidence interval) = 9.3 (1.6-51); P = 0.01] and obesity [odds ratio (95% confidence interval) = 5.2 (1-28); P = 0.05] was associated with mortality. The median follow-up of the study was 60 (35-60) d.

CONCLUSIONS

We describe the largest case series of CAM in KTRs. Morality in pulmonary CAM is extremely high. Severe COVID-19 pose extra risk for the development of CAM and associated mortality. Our report will help in better understanding the conundrum and management of CAM.

A Multicenter Cohort Study From India of 75 Kidney Transplants in Recipients Recovered After COVID-19

BACKGROUND

There is limited current knowledge on feasibility and safety of kidney transplantation in coronavirus disease-19 (COVID-19) survivors.

METHODS

We present a retrospective cohort study of 75 kidney transplants in patients who recovered from polymerase chain reaction (PCR)-confirmed COVID-19 performed across 22 transplant centers in India from July 3, 2020, to January 31, 2021. We detail demographics, clinical manifestations, immunosuppression regimen, laboratory findings, treatment, and outcomes. Patients with a previous diagnosis of COVID-19 were accepted after documenting 2 negative severe acute respiratory syndrome coronavirus 2 PCR tests, normal chest imaging with complete resolution of symptom for at least 28 d and significant social distancing for 14 d before surgery.

RESULTS

Clinical severity in patients ranged from asymptomatic (n = 17, 22.7%), mild (n = 36.48%), moderate (n = 15.20%), and severe (n = 7.9.3%) disease. Median duration between PCR positive to transplant was 60 d (overall) and increased significantly from asymptomatic, mild, moderate, and severe disease (49, 57, 83, 94 d, P 0.019), respectively. All recipients and donors were asymptomatic with normal creatinine after surgery at a median (interquartile range) follow-up of 81 (56-117) d without any complications relating to surgery or COVID-19. Patient and graft survival was 100%, and acute rejection was reported in 6.6%.

CONCLUSIONS

Prospective kidney transplant recipients post-COVID-19 can be considered for transplantation after comprehensive donor and recipient screening before surgery using a combination of clinical, radiologic, and laboratory criteria, careful pretransplant evaluation, and individualized risk-benefit analysis. Further large-scale prospective studies with longer follow-up will better clarify our initial findings. To date, this remains the first and the largest study of kidney transplantation in COVID-19 survivors.

An unusual cause of encephalopathy with renal failure in a patient with treated HCV cirrhosis

A 63-year-old teetotaller male, previously treated for hepatitis C-related compensated cirrhosis, presented with acute-onset encephalopathy with no focal neurological deficit and stable vitals. Investigations revealed elevated serum creatinine (2.94 mg/dL), hypercalcemia, hypophosphatemia, and high serum PTH levels. He was diagnosed with right parathyroid adenoma (1.3×1.2×0.7 cm) with the help of a neck ultrasound. His encephalopathy and renal failure persisted despite adequate IV fluids, calcitonin, and bisphosphonates. Urgent hemi-parathyroidectomy was performed on day four, following which he recovered completely.

Study of COVID-19 Pandemic in Representative Dialysis Population Across Mumbai, India: An Observational Multicentric Analysis

COVID-19 has emerged as a pandemic of significance with potential to cause significant morbidity and mortality worldwide. Elderly with or without following comorbidities i.e Diabetes, hypertension, cardiac disease, chronic respiratory illnesses, chronic liver disease, CKD, malignancy and immunocompromised hosts are at increased risk of developing complicated course. Hemodialysis population hence are at increased risk for contracting the infection due to patient characteristics, environmental characteristics and procedural lapses. The current study was aimed at describing prevalence and characteristics of COVID19 in hemodialysis population across different HD centers across Mumbai. We found a prevalence rate of COVID19 in 6.4%, with 9 patients (12%) died during the study period. A fair proportion of Non covid HD patients (1.5%) also died due to lack of access to dialysis. At baseline, mean age of presentation was 54.5 years. On routine test 80% were asymptomatic at presentation. Patients with COPD, requiring ICU care and those on ventilation faired poorly. Contrary to assumption patients with underlying cardiovascular disease didn't show poor outcome. Total of 4.1% health care workers turned positive during the study period with mean age of 31 years and median of 28years. Out of them 5 (45.4%) were symptomatic. All recovered from the illness without any sequelae. Seventy two percent of healthcare workers were on Hydroxy-chloroquine chemoprophylaxis didn't reach statistical significance in preventing the infection. In our study elderly age with comorbidities had poor prognosis. We proposed extra healthcare measures to be taken in the dialysis unit presuming all as COVID suspect in the resource limited settings.

Efficacy of C.E.R.A. in Routine Clinical Practice for Correction of Anaemia and Maintenance of the Haemoglobin Levels in CKD Patients not on Dialysis

INTRODUCTION

C.E.R.A. reported effective correction of anaemia and was well tolerated in International studies on CKD patients not on dialysis.

OBJECTIVE

The study aimed to describe the management of renal anaemia in CKD patients not on dialysis with C.E.R.A. in routine clinical practice in India.

METHODS

This was a prospective, single-arm, open-label, multi-centre, non-interventional, Phase IV study which followed 108 CKD Stage III-IV patients, not on dialysis with Hb < 10 g/dL for correction of anaemia with C.E.R.A.

RESULTS

Of the 108 patients with Hb < 10 g/dL at baseline, 83 (90.2%) patients achieved target Hb of 10-12 g/dL and the time taken to achieve correction of anaemia was 9.6 weeks ± 6.13 weeks in the Intent-to-treat population. Haemoglobin concentration increased from 8.59 ± 0.808 g/dL pre-therapy to 10.91 ± 0.634 g/dL post-therapy. The change in mean ± SD Hb value was 2.32 ± 0.174 g/dL. Maintenance of Hb levels within the target range of Hb 10 - 12 g/dL was observed in 78.2% of ITT and 80.8% of the PP population for mean duration of 16.69 weeks. Four patients (3.7%) experienced 5 AEs and 2 patients (1.9%) experienced 3 SAEs in the safety population. As per the treating physician none of the AEs or SAEs was considered related to study drug. There were no deaths reported.

CONCLUSIONS

This study demonstrated successful correction of anaemia in Indian patients with C.E.R.A. treatment as well as maintenance of Hb levels within the target range. C.E.R.A. was well tolerated with no new safety concerns specific to the Indian population. The less frequent up to monthly dosing schedule of C.E.R.A. may offer clinicians and patients a simplified regimen of anaemia management as compared to traditional frequently administered (thrice weekly to once weekly) ESAs.

A comparison of diagnostic imaging modalities for colorectal liver metastases

AIMS

The aims of this study were to compare the diagnostic performance of CT scan, MR liver, PET-CT and intra-operative ultrasound (IOUS) for the detection of liver metastases against the histopathological findings, and to compare PET-CT with CT for the detection of distant disease in metastatic colorectal cancer patients eligible for surgical treatment.

METHODS

A prospective study was performed that measured concordance between the number and stage of metastatic lesions identified with various preoperative imaging modalities and histology of patients undergoing surgical treatment for CRLM.

RESULTS

Compared with histopathology, concordance for the number of metastatic liver lesions was moderate for CT scan (K = 0.477, 95% CI: 0.28-0.66), moderate for MR scan (K = 0.574, 95% CI: 0.39-0.75), good for FDG PET-CT (K = 0.703, 95% CI: 0.52-0.87) and very good for IOUS (K = 0.904, 95% CI: 0.81-0.99). Additional CRLM were identified intraoperatively in six patients (9.1%) with IOUS and in 7.5% of the cases surgical strategy was changed according to the new intraoperative findings. The diagnosis of intra abdominal lymph node metastatic disease was made with PET-CT only in nine patients (13.6%)

DISCUSSION

Our study supports the recent recommendations of the Oncosurg Multidisciplinary International Consensus regarding the importance of high quality CT and MR in the staging of CRLM but provides further evidence for the added value of PET-CT, especially in detecting extrahepatic intra-abdominal metastatic disease that may be amenable to potentially curative resection. Despite these advances in preoperative staging, there still remains a role for IOUS in detecting additional metastases at the time of surgery.

Measurement of fetal fat in utero in normal and diabetic pregnancies using magnetic resonance imaging

OBJECTIVES

To assess the reliability of magnetic resonance imaging (MRI) to measure fetal fat volume in utero, and to study fetal growth in women with and without diabetes in view of the increased prevalence of macrosomia in the former.

METHODS

We studied 26 pregnant women, 14 with pre-gestational diabetes and 12 non-diabetic controls. Fetal assessment took place at 24 weeks' gestation and again at 34 weeks by standard ultrasound biometry followed by MRI at 1.5 T. Fetal fat volume was determined from T1-weighted water-suppressed images using a semi-automated approach based on pixel intensity and taking into account partial volume effects. Fetal volume was also determined from the MRI images. Fetal weight was calculated using published fat and lean tissue densities.

RESULTS

There was little fetal fat at 24 weeks' gestation, but at 34 weeks the fetal fat content was considerably higher in the women with diabetes, with a mean fat content of 1090 ± 417 cm(3) compared with 541 ± 348 cm(3) in the controls (P = 0.006). Measurements of fetal fat volume showed low intra- and interobserver variability at 34 weeks, with intraclass correlation coefficients consistently above 0.99. Birth-weight centile correlated with fetal fat volume (R(2)  = 0.496, P < 0.001), percentage of fetal fat (R(2)  = 0.362, P = 0.008) and calculated fetal weight (R(2)  = 0.492, P < 0.001) at 34 weeks.

CONCLUSIONS

MRI appears to be a promising tool for the determination of fetal fat, body composition and weight in utero during the third trimester of pregnancy.

Rarer in a rare

Though moya moya disease is a disease of Asian origin, it is one of the very rare causes of stroke in India. It is a rare disease mainly characterized by progressive cerebrovascular episode due to the slowly progressive stenosis of supraclinoid segment of bilateral internal carotid arteries, the anterior and the middle cerebral arteries, and very rarely, posterior cerebral arteries. We hereby report a case of a young female who presented to us with the psychiatric complaints and refractory headache since her childhood. Therefore, we are reporting rarer (headache and neuropsychiatric) manifestations in the rare (moya moya) disease.

Influence of γ-radiation on the structure and function of soybean trypsin inhibitor

Soybean trypsin inhibitor (STI) is a known antinutrient and food allergen present in soybean. γ-Radiation has the potential to inactivate the TI protein. However, a systematic study on the influence of different moisture levels during γ radiation on structure and function of the molecule has not been reported. Pure STI was irradiated up to 200 kGy, in dry state, with 50% moisture and in aqueous solution. The radiation damage in molecular structure was assessed using, SDS-PAGE, size exclusion chromatography, fluorescence measurement, and circular dichroism, while functional damage was assessed by the TI assay. In aqueous solution, both the structure and function of TI were almost destroyed at the 10 kGy dose. While with 50% moisture and in dry state, the loss in functional and structural attributes was discernible only at 30 and 100 kGy, respectively. The TI activity was found to be unaffected in dry and soaked seeds of soybean as well as other legumes up to irradiation doses of 100 and 50 kGy, respectively.

P2-08-11: Correlation of Mammography, Ultrasound and MRI in Patients with Nipple Discharge

BACKGROUND: Breast cancer mainly originates in the epithelial lining of milk ducts or lobules. Once early pre-malignant or malignant changes occur in the ductal lining there is a long latent period before they manifest symptoms or are detected on imaging. Symptomatic nipple discharge (SND) is a common symptom noted in approximately 5% of patients. Although, usually benign it may be the earliest sign of cancer. The current standard evaluation of patients with nipple discharge includes clinical examination (CE), mammography (MMG) and ultrasound (US). Contrast enhanced MRI is considered the most sensitive imaging modality for the breast and reports suggest it may be of benefit in the evaluation of nipple discharge. We have combined MRI with standard evaluation in an ongoing prospective study to determine its utility in patients with SND.

PATIENTS AND METHODS: Between July 2004 and 31st May 2011, 75 women underwent surgery for SND. All were initially evaluated by CE, MMG and US following which a contrast enhanced breast MRI was requested. MRI was performed on a 1.5T MR unit using a dedicated breast coil. A STIR sequence in the coronal and sagittal planes along with an unenhanced fat-suppressed T1 W sequence was used to evaluate the ducts. The imaging findings were used to direct surgical excision. All specimens were oriented and evaluated by the pathologist by sectioning at 1 cm interval, from the ductal end to the periphery. The results of preoperative MMG, US and MRI findings were compared with pathology.

RESULTS: The incidence of cancer in this series was 29% and high risk lesions were noted in 43%. MMG and US were performed in 75 patients. MRI was requested in all 75 patients but could be performed in 64. MRI proved to be the most sensitive technique for detection of an abnormality in the breast (92%) compared to MMG 25%, and US 63%. MMG, US and MRI were suggestive of benign change in 64 (85%), 65 (87%) and 43 (67%) patients respectively, of which 14 (22%), 15 (23%) and 7 (16%) were malignant on pathology. MMG, US and MRI reported suspicious change in 11(15%), 10 (13%) and 21(33%) patients respectively of which 8 (73%), 7 (70%) and 9 (43%) patients had cancer on pathology. MRI had the highest sensitivity for malignancy (54%) compared to MMG (36%) and US (32%) but MRI had a low specificity (74%) (MMG 94%; US 94%). However, MRI had a high negative predictive value (86%) (MMG 78%; US 73%). Of the 22 patients with cancers, 12 were deemed to be normal on CE, MMG and US examination. Thus standard evaluation would have missed 54% of the cancers detected in this series.

CONCLUSIONS: Nipple discharge is associated with significant incidence of cancer and high risk changes. The majority of these are missed on standard evaluation (CE, MMG, US). MRI is the most sensitive method for the detection of an abnormality in these patients. It defines the location and extent of the abnormality and can guide surgical excision. However, MRI is unable to accurately differentiate malignant from benign lesions. Hence, excision of an identified abnormality and pathological evaluation remains essential.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-11.

Cricket ball trauma causing temporal space abscess: report of a case

A 9-year-old boy reported with swelling on right side of the face after injury by a cricket ball while fielding. There was a history of hot fermentation after which the swelling increased in size leading to a temporal space abscess. The patient underwent incision and drainage with uneventful healing and was followed-up for a period of 7 years.

Splenic torsion: a case report

INTRODUCTION

Torsion of the spleen is a rare cause of abdominal pain. Predisposition occurs following abnormal development of splenic suspensory ligaments. We report a case of splenic torsion in a spleen sited in a normal anatomical position and discuss the latest treatment options. To the best of our knowledge, this has not been reported in the literature to date.

CASE PRESENTATION

A 73-year-old Caucasian woman presented to our department with sudden onset, severe, left-upper abdominal pain. An enhanced computed tomography revealed an unenhancing spleen. She underwent an urgent laparotomy and splenectomy for 360 degrees torsion of her spleen.

CONCLUSIONS

Splenic torsion in a wandering spleen has been described with an incidence of < 0.2%. Symptoms vary from asymptomatic to an acute surgical abdomen. Diagnosis is commonly made using colour Doppler sonography or enhanced computed tomography. Surgery is guided by clinical setting, with preservation of the spleen as the goal.

Pulmonary hyalinizing granuloma with ureteric fibrosis: A case report and review of relevant literature

A 52-year-old, asymptomatic patient presented with bilateral lung nodules on chest radiograph. She was diagnosed to have "pulmonary hyalinizing granuloma" on an open lung biopsy. We review the clinical features of this rare disease.

Evaluation of a pyroelectric detector with a carbon multiwalled nanotube black coating in the infrared

The performance of a pyroelectric detector with a carbon multiwalled nanotube coating was evaluated in the 0.9-14 microm wavelength range. The relative spectral responsivity of this detector was shown to be flat over most of the wavelength range examined, and the spectral flatness was shown to be comparable to the best infrared black coatings currently available. This finding is promising because black coatings with spectrally flat absorbance profiles are usually associated with the highest absorbance values. The performance of the detector (in terms of noise equivalent power and specific detectivity) was limited by the very thick (250 microm thick) LiNbO3 pyroelectric crystal onto which the coating was deposited. The responsivity of this detector was shown to be linear in the 0.06-2.8 mW radiant power range, and its spatial uniformity was comparable to that of other pyroelectric detectors that use different types of black coating. The carbon nanotube coatings were reported to be much more durable than other infrared black coatings, such as metal blacks, that are commonly used to coat thermal detectors in the infrared. This, in combination with their excellent spectral flatness, suggests that carbon nanotube coatings appear extremely promising for thermal detection applications in the infrared.

Survival to discharge among patients treated with continuous renal replacement therapy

Continuous renal replacement therapy (CRRT) is widely used in critically ill patients with acute renal failure (ARF). The survival of patients who require CRRT and the factors predicting their outcomes are not well defined. We sought to identify clinical features to predict survival in patients treated with CRRT. We reviewed the charts of all patients who received CRRT at the Toronto General Hospital during the year 2002. Our cohort (n=85) represented 97% of patients treated with this modality in 3 critical care units. We identified demographic variables, underlying diagnoses, transplantation status, location (medical-surgical, coronary, or cardiovascular surgery intensive care units), CRRT duration, baseline estimated glomerular filtration rate (eGFR), and presence of oliguria (<400 mL/day) on the day of CRRT initiation. The principal outcome was survival to hospital discharge. Among those alive at discharge, we assessed whether there was an ongoing need for renal replacement therapy. Greater than one-third (38%, 32/85) of patients survived to hospital discharge. Three (9%) survivors remained dialysis-dependent at the time of discharge. Survivors were younger than nonsurvivors (mean age 56 vs. 60 years), were on CRRT for a shorter duration (7 vs. 13 days), and had a higher baseline eGFR (74 vs. 62 mL/min/m(2)). Patient survival varied among different critical care units (medical surgical 33%, coronary 38%, and cardiovascular surgery 45%). Multivariable logistic regression revealed that shorter duration of CRRT, nonoliguria, and baseline eGFR >60 mL/min/m(2) were independently associated with survival to hospital discharge (p<0.05). Critically ill patients with ARF who require CRRT continue to have high in-hospital mortality. A shorter period of CRRT dependence, nonoliguria and higher baseline renal function may predict a more favorable prognosis. The majority of CRRT patients who survive their critical illness are independent of dialysis at the time of hospital discharge.