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   Table of Contents - Current issue
July-September 2022
Volume 16 | Issue 3
Page Nos. 243-353

Online since Friday, September 30, 2022

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Adjuvant use of ribavirin with treatment of hepatitis C virus in kidney transplant recipients: A systematic review and meta-analysis of real-world data Highly accessed article p. 243
Aamir Bashir, Ashish Verma, Ajay Duseja, Arka De, Pramil Tiwari
Hepatitis C virus infection among kidney transplant recipients (KTRs) is an important public health concern worldwide. Evidence on available treatments given shows a greater variability for safety and efficacy, thus we performed this large analysis to present the pooled findings. PubMed/Medline, ScienceDirect, and Google Scholar were searched to identify observational studies of both interferon-based conventional treatment (CT) and recently approved direct-acting antivirals (DAAs), published before November 2020. Meta-analysis of effectiveness outcome (sustained virological response [SVR12]) and safety data (adverse events and discontinuation rate) was performed using a random-effect model. Subgroup analysis based on ± ribavirin with both treatments was performed to assess its relevance in clinical practice. Chi-square and I2 tests were used to assess heterogeneity between the studies. Twenty-five and 9 observational records reporting on treatment with DAAs (n = 943) and CT (n = 125), respectively, are analyzed. The overall pooled estimate of SVR12 rate was found as 95.3%, (range: 92.6%–97%) with DAAs in comparison to 46.4% (range: 33.7%–59.6%) with CT. The pooled prevalence of adverse drug reactions (ADRs) in CT was higher as 47.8% than in DAAs as 23.8%, consequently showing a high discontinuation rate of 31.7% in CT as compared to 6.5% with DAAs. Subgroup analyses of both DAAs and interferon-based treatment ± ribavirin showed decreased effectiveness and increased ADR rates on adding ribavirin. The effectiveness of DDAs was found significantly higher than CT with a better safety profile in KTRs. Ribavirin did not provide any additional benefits while given in combination with either of the treatments available.
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A comparative study of recipients' outcomes receiving a kidney from the same deceased donor: An observational study p. 267
A Ayyappa, Manisha Sahay, Kiran Mai Ismal, P Sharmas Vali, Samuel Raju Palli, Swarnalata G
Introduction: Kidney transplantation is the renal replacement therapy (RRT) of choice for patients with end-stage renal disease. Although outcomes of deceased-donor kidney transplantation are inferior when compared to live donor kidney transplantation, they are still significantly better than being on chronic dialysis. There are very few studies comparing transplant outcomes between two kidneys obtained from the same donor. Aims: The aim of this study is to compare the graft and patient outcome of the kidneys of the same deceased donor transplanted into two different recipients. Materials and Methods: This is a prospective observational study done at the tertiary care center in South India over 2 years. A total of 29 pairs of deceased-donor transplants were followed up with one-half performed at donor institute (Group 1) and the same number performed at another network hospital (Group 2). Outcomes between the recipients of the two kidneys were compared. Data were statistically analyzed. Results: The majority of donors were relatively young (with a mean age of 37 years) and did not have multiple comorbidities. 1st kidney went to the donor hospital, whereas 2nd kidney was sent to other hospitals in the network. Cold ischemia times were higher (10.3 h vs. 6.5 h) for the 2nd kidneys. The majority of Group 1 patients did not receive induction, whereas 100% of Group 2 patients received basiliximab induction. The incidence of acute rejection (antibody plus cellular rejection) was numerically less in Group 2 compared to Group 1 but was not found to be statistically significant (P = 0.227). The incidence of acute cellular rejection in Group 1 was more compared to Group 2, and was found to be statistically significant (P = −0.038). Graft survival was similar in both groups (95.7 in Group 1 vs. 95.8 in Group 2). Patient survival was similar in both groups (P = −0.555) with a mean follow-up 25.9 months in Group 1 versus 24.6 months in Group 2. The choice of induction agent did not affect the graft or patient survival. In addition, there was no significant difference in the incidence of infections or mortality rate. Conclusion: Overall, the outcomes in the paired kidneys from the same donor transplanted to different recipients at different institutes had similar outcomes. The choice of induction agent did not have any influence on the overall graft and patient survival.
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The empathy factor: The role of empathy in knowledge, attitude, and practice of organ donation in India - A crossectional, observational study p. 274
Prathyasha George, Mahati Chittem, Rinshu Dwivedi, Chandana Pal, Yasaswini Guntupalli, Sanghamitra Pati, Rajasekara Chakravarthi
Background: Due to the scarcity of organs available for transplantation, several patients lose their lives each year. Increased awareness and positive attitudes alone may be insufficient to increase an individual's willingness to donate (i.e., the basic tenets of the knowledge-attitude-practice/KAP model). Therefore, it is pertinent to examine other psychological determinants that are associated with engaging in the altruistic/prosocial act of organ donation. Objective: To understand the association between empathy and KAP of organ donation in an Indian population. This pilot is the precursor to a larger project which aims to develop and test an empathy intervention to promote organ donation. Methods: Using a cross-sectional design, Indians (N = 419; female = 261; mean age = 28.48 years) aged 18 years and above were recruited using convenience sampling through an online survey. Questionnaires included the Awareness, Attitudes, and Practice of Organ Donation (Chakradhar et al., 2016) and Empathy Quotient-8 (Loewen et al., 2010). Multiple regression analyses were carried out to analyze the data. Results: Results showed that empathy was related to: (i) Total KAP (β = 0.123, P = 0.014), and (ii) attitudes (β = 0.195, P < 0.001) towards organ donation. Conclusion: These pilot study findings indicate that public health messages focused on evoking empathy can use the technique of patient/donor narratives, and training clinicians on empathic communication skills can help increase individuals' KAP of organ donation. Further, this pilot elucidated the need to conduct mixed-method studies with a donor and nondonor population and clinicians prior to developing and testing a larger empathy-centered intervention aimed at promoting the KAP of organ donation.
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Deceased donor renal transplant outcome in a south Indian tertiary care hospital with zonal allocation model - An observational study p. 282
Kandasamy Sadayandi, Devdas Madhavan, Prabu Murugesan, Balamurugan Mathavan, Kuppurajan Narayanasamy, Pollachi Balasundaraj Baranikumar, Anandan Murugesan, Sengoda G Balasundaram, Vengetesh Kilvani Sengottayan, R Vasanthan, S Jeevithan
Background: With the rising incidence of diabetes and hypertension, the prevalence of end-stage renal disease has increased greatly so as the need for renal replacement therapy. Availability of suitable living-related donors is a major problem which increases the demand for deceased donor renal transplantation (DDRT), making it a lifeline for the patients on dialysis without any living donors. Methodology: This is a retrospective analysis of 118 DDRT done between 2012 and 2020, in a private quaternary care hospital in a south Indian state. All patients received basiliximab induction, with maintenance immunosuppression using steroids, mycophenolate mofetil (MMF) or mycophenolate sodium, and tacrolimus. Results: In our study, we report unadjusted graft survival of 93.2% and 81.3%, patient survival of 94.9% and 83.1% at the end of 1 and 5 years, respectively. The recipients with age < 60 years had 5 years graft survival of 87%. The study group consisted of 15.25% of the patients with panel reactive antibody (PRA) positive and 10.16% of them with donor-specific antibody (DSA) during renal transplantation, and there was only one allograft loss in this subset of the patients. Conclusion: This study confirms that human leukocyte antigen matching is not very important with the current immunosuppressive protocol using tacrolimus and MMF. Early initiations of tacrolimus do not increase the incidence of delayed graft function. We report 91.6% graft survival in the DSA-positive group, with basiliximab induction and desensitization protocol.
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Organ donation-related psychosocial interventions: Towards a research-based guideline - A prospective observational study p. 288
Masoomeh Maarefvand, Maryam Zabihi Poursaadati, Mahbubeh Ziarati Niyasar, Jagdish Khubchandani
Introduction: Lack of consent from brain dead individuals' families is a major impediment for organ donation (OD) which is caused by several factors. Families need to receive information and support before, during, and after OD. Involving social workers in the transplantation team could be helpful. Methods: To develop a guideline for OD-related social work interventions, we conducted an inductive content analysis on experiences of experts providing services for families of brain dead individuals and searched scientific documents to identify eligible social work guidelines and studies. The participants were invited through purposeful and convenience sampling. Sampling was terminated when no additional information was acquired, and data saturation occurred. Results: Eleven experts who had experience in interviewing families of brain dead individuals participated voluntarily. In-depth and semi-structured interviews were conducted individually for each participant. We shared the draft for the social work guidelines with experts and finalized the guidelines according to their comments. Recommendations for social work interventions for brain dead individuals' families in three main phases were categorized; before donation (process initiation and family consent), during donation, and after donation (short-term and long-term interventions). Conclusion: Social workers can get involved in transplantation teams to improve family protection during the consent seeking process and after the family's consent about donation.
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Endovascular management of vascular complications in renal allograft - An observational study p. 296
Surya Nandan Prasad, Vivek Singh, Monika Yachha, Rajendra Vishnu Phadke, Dharmendra S Bhadauria
Context: Role of endovascular management of vascular complications in renal transplant recipients. Aims: To present our experience in endovascular management of vascular complications in renal transplant recipients with a literature review. Settings and Design: A retrospective observational study. Materials and Methods: This is a retrospective analysis of postrenal transplant recipients referred to our department for the evaluation and endovascular management of vascular complications from January 2010 to December 2014. Cases of transplant renal artery stenosis (TRAS) and common iliac artery (CIA) stenosis were treated with percutaneous transluminal balloon angioplasty with or without stenting. Intraparenchymal pseudoaneurysms, arteriovenous fistula (AVF), and active contrast extravasation cases were managed with coil and/or glue embolization. Treated patients were followed up with serial blood pressure measurements, serum creatinine estimation, and Doppler evaluation in the postprocedure period and at 3-month and 6-month intervals. Results: Among a total of ten patients, there were five TRAS, two intraparenchymal pseudoaneurysms with active contrast extravasation, one AVF, one active renal bleed with peri-graft hematoma, and one right CIA stenosis. Intraparenchymal pseudoaneurysms, AVF, and active extravasations were postbiopsy. All treated patients showed improved renal function, increased hematocrit, improved blood pressure control in the postprocedure period, and follow-up. Conclusions: Vascular complications in renal transplant patients may lead to graft dysfunction, increased morbidity, and even graft loss if left untreated. Endovascular interventions are first-line treatments with excellent short- and long-term outcomes.
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Comparison of efficacy and safety between rabbit anti-thymocyte globulin and anti-T lymphocyte globulin in kidney only transplantation: A retrospective observational study p. 303
S Sakthi Selva Kumar, Ilangovan Veerappan, Ramaswami Sethuraman, T Chakravarthy, Vijay Aanand Siddharth, A Rajagopal
Introduction: The two formulations of antihuman thymocyte immunoglobulin that are used as T-cell depleting induction agents in renal transplantation are anti-thymocyte globulins (ATG) thymoglobulin and (antiT-lymphocyte globulin [ATLG]-Grafalon-formerly ATG-Fresenius). Very few trials have compared these two formulations. In this retrospective study, we compared the incidence of infections, rejections, graft survival, mortality, and lymphocyte profile of ATG and ATLG. Materials and Methods: This was a single-center retrospective study of 127 consecutive kidney-alone transplant recipients from January 2014 to June 2019. Patients received 3 mg/kg of ATG or 4 mg/kg single dose of ATLG. CD 3 counts were done on day 3 of the transplant. Most of the recipients received standard triple immunosuppression of tacrolimus, mycophenolate mofetil, and prednisolone. Results: Fifty-eight patients received ATG and 69 patients received ATLG. Baseline demographics were similar between the two groups. Death-censored graft survival (99%) (P = 0.258) and biopsy-proven acute rejection (BPAR) (32% vs. 29%, P = 0.128) were similar in both groups. Graft survival was better in ATLG group (92.7% vs. 87.5% P = 0.020). Bacterial infections (41.1% vs. 27.6%, P = 0.03) and sepsis-related mortality (11.54% vs. 4.34% P = 0.02) were significantly higher in the ATG group. Conclusion: ATLG, when used as an induction agent, was associated with a lesser rate of bacterial infections and sepsis-related mortality, but better graft survival as compared to ATG but has comparable BPAR, death-censored graft survival, and viral/fungal infections.
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Effectiveness of awareness program on the knowledge, awareness, and perception of undergraduate paramedical and non-paramedical students toward eye donation - A cross sectional study p. 309
Anjali Rani, Pinaki Adak, Rakesh Kumar Yadav, Ashish Chander
Introduction: Corneal transplantation is the only option to treat corneal blindness. However, the corneal procurement rate is much less than the requirement. Barriers to eye donation need to be studied. Aim: The aim of this study is to understand the knowledge, awareness, and perception toward eye donation and the determination of barriers to eye donation among university students and to conduct an awareness campaign and determination of its effectiveness. Methods: A cross-sectional study was conducted among 300 graduation students of paramedical and nonparamedical department with the help of questionnaire. An awareness program was carried out through PowerPoint presentation. Responses were elicited pre- and post-awareness program. Data were analyzed using the SPSS software version 16. Results: The findings suggest that knowledge and awareness were slightly higher among paramedical students but the willingness for eye donation was higher among nonparamedical students as compared to paramedical students. The prime source of information was doctors/optometrists and media. In both the groups, female and Hindu participants showed more willingness toward eye donation. Barriers to eye donation was the lack of awareness and inappropriate knowledge including various myths and superstitions. Knowledge, awareness, and willingness for eye donation pre- and post-awareness program was comparable between both the groups. Awareness program resulted in statistically significant increase in positive attitude and willingness toward eye donation in both the groups. Conclusion: Effective measures including awareness campaign need to be taken such as education on eye donation through which procurement of cornea can be increased and burden of corneal blindness can be minimized.
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Tuberculosis in kidney transplant recipients: A retrospective study from a tertiary care center - An observational study p. 316
Sujit Surendran, K Thirumalvalavan, S Murugesh Anand, N D Srinivasa Prasad, M Edwin Fernando
Background: The incidence of tuberculosis (TB) among transplant recipients varies from 5% to 15% across the globe. We conducted a retrospective study to identify the incidence of TB among kidney transplant recipients in our transplant unit. Materials and Methods: We assessed the patients who underwent kidney transplantation in our transplant unit during the study period from January 2014 to June 2018 and included those recipients who had bacteriologically confirmed TB. We excluded the patients who had TB before transplant and those recipients who were initiated on antituberculosis treatment (ATT) empirically. The details collected were: 1. Clinical data, the presenting symptoms, and clinical findings. 2. Diagnostic investigation: Microbiological/histopathological/radiological/bronchoalveolar lavage/fluid (pleural/peritoneal/cerebrospinal fluid) analysis. 3. Antituberculous regimen, dose, and duration of the therapy. 4. Relapse/patient and graft outcome after treatment.Results: The total number of patients who underwent kidney transplantation during the study period was 177. TB occurred in 21 patients after transplantation. The incidence of TB in our transplant unit was 11.86%. In these 21 recipients, 8 had pulmonary TB and the remaining 13 had extrapulmonary/disseminated TB, which included two patients with disseminated TB and one patient with allograft dysfunction with thrombotic microangiopathy which was attributed to TB as it responded to first-line antituberculous drugs. The mortality rate was 23.8%, as five patients expired. After excluding patients who expired, the graft survival at 1 year after ATT completion was 90.5%. Conclusion: For most developing nations, the World Health Organization's “End TB Strategy” remains far from their dream. An ideal investigation to detect TB in its early stage is essential in posttransplant recipients to reduce the morbidity and mortality associated with it.
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A rare case of graft lower polar artery aneurysm: Delayed presentation after 10 years - A case report p. 322
Abhijit Patil, Arvind Ganpule, Ravindra Sabnis, Mahesh Desai
Graft artery aneurysms though rare, may have devastating consequences. We present a case of an aneurysm involving the lower polar artery anastomosed to external iliac artery using a gonadal vein graft. The patient presented with sudden onset graft fossa swelling, pain, and decreased urine output. Color Doppler and computed tomography angiography helped in diagnosis and management. Since the majority of the graft was well-perfused by the upper polar artery, the patient underwent excision of the lower polar artery aneurysm. The prompt diagnosis and management salvaged the graft. This aneurysm presented after 10 years of the underlying importance of long-term surveillance.
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Persistent headache in a young kidney transplant recipient caused by tacrolimus associated pseudotumor cerebri - A case report p. 325
Prit Pal Singh, Amresh Krishna, Prajit Mazumdar, Abhay Ranjan
Pseudotumor cerebri (PC) is characterized by chronic elevation of intracranial pressure with normal cerebrospinal fluid (CSF) examination and normal neuro-imaging. We report a case of a 22-year-old female with renal allograft and for the past 4 years on immunosuppressant including prednisolone, tacrolimus, and mycophenolate mofetil. The patient presented with persistent headache for 2 months along with nausea and vomiting. Fundoscopic examination revealed bilateral papilledema. Magnetic resonance imaging-brain with venogram was normal and cytochemical examination of CSF was also normal. Ocular coherence tomography revealed increased retinal nerve fiber layer thickness. A diagnosis of PC was made based on an elevated CSF pressure (35 cm H20). We reduced the dose of tacrolimus and added acetazolamide but the dose of prednisolone and mycophenolate mofetil was not modified. There was the gradual improvement of symptoms. On follow-up visits, papilledema disappeared and the patient is now asymptomatic with normal allograft function.
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Simultaneous live-related kidney transplant and mesenteric cyst excision - A case report p. 328
Sanjay P Kolte, Sameer Chaubey, Surojit Hazra, Meenal Kolte
Mesenteric cysts of the abdomen affecting patients of end-stage renal disease (ESRD) are not common. In the absence of symptoms, they may remain undetected unless large in size. When present, the cysts have to be treated by surgical excision. In patients awaiting kidney transplantation, surgery for the cyst can be a potential hindrance in the planning of transplantation as morbidity and mortality of surgery in patients of ESRD is very high. We report a 27-year-old male awaiting kidney transplantation, who presented to us with a large mesenteric cyst. We conducted a simultaneous surgery of mesenteric cyst and kidney transplantation successfully.
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Combined open-heart surgery and living donor liver transplantation in a 4-year-old child with Alagille syndrome - A case report p. 331
Sai Rithin Punjala, L Sasidhar Reddy, Manjunath Balasubramanyam, Manish Chandra Varma
Alagille syndrome (ALGS) is a complex multisystem genetic disorder. Patients with ALGS usually require liver transplantation (LT). Congenital heart diseases are also common in ALGS patients. ALGS patients may become ineligible for LT procedure due to cardiac abnormalities whereas any corrective cardiac surgeries are precluded due to the Child C cirrhosis of the liver in these patients. We report a unique case of a 4-year- and 10-month-old girl who underwent open-heart surgery and living donor liver transplantation (LDLT). She had significant hepatic and cardiopulmonary involvement, and Child C cirrhosis with portal hypertension and complex cardiac defects, and was ineligible for up-front LT. An open-cardiac surgery was performed and after 12 h she received LDLT using a left lateral hepatic graft. This is the first report of a case of successful combined open-heart surgery and LDLT in a child with ALGS with cardiac defects and Child C liver cirrhosis.
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Odynophagia in a renal-transplant recipient - A case report p. 334
PS Shahanas, K Vinod Kumar, Lilly Joseph, V Narayanan Unni
Opportunistic infections occur in immunosuppressed patients. The latent infections may be reactivated after transplantation with the use of immunosuppressive agents. Some infections are the result of community exposures, whereas some are transferred with allograft. Co-infections can occur, and diagnosis might be missed at initial presentation. We report a renal allograft recipient presenting with odynophagia and dysphagia who was found to have herpes simplex virus and Candida esophagitis. With appropriate therapy, there was complete resolution of symptoms. Early diagnosis and initiation of treatment would result in a better outcome.
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Successful surgical repair of inguinal hernia causing positional obstructive uropathy: A rare cause of renal graft dysfunction - Case report p. 337
K S. N S. Udhbhav, RM Meyyappan, J Saravanan, V Jayaprakash
Bladder herniation with obstructive uropathy is a relatively rare occurrence, however, urinary bladder herniation along with ureteroneocystostomy and leading to positional obstructive uropathy of the graft is an unusual presentation. This is a unique case of a 38-year-old male who presented with inguinal hernia with raised serum creatinine who had undergone renal transplant 10 years back in 2011. Magnetic resonance urogram revealed herniation of urinary bladder and hydroureteronephrosis of transplant kidney. Patient is managed by surgical exploration through inguinal incision and reduction of ureteroneocystostomy herniation after ureterolysis and hernioplasty was performed. The cause of obstructive uropathy was herniation of the bladder along with ureteroneocystostomy, and the patient has an insidious onset of symptoms, immediate exploration, and repair of hernia done without any need for percutaneous nephrostomy. Importance of this case report is that sliding herniation of the bladder with ureteroneocystostomy should be considered a diagnosis and investigated if the patient presents with positional obstructive uropathy with inguinal hernia, leading to early identification and salvaging the graft function.
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Tacrolimus-induced nonischemic dilated cardiomyopathy in a postrenal transplant recipient - A case report p. 340
Prawash Kumar Chowdhary, Sanjeev Anant Kale, Sanjay Kumar, Meena Patel
We describe a case of nonischemic reversible dilated cardiomyopathy (DCM) due to tacrolimus in patient of live-related renal transplantation. Very few cases due to tacrolimus associated DCM has been reported in the literature, especially in the renal transplant recipient. With the growing use of tacrolimus in transplant medicine, this case report expands the literature of tacrolimus cardiotoxicity and can be useful for clinicians to evaluate and manage the case of DCM in the postrenal transplant recipient.
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Postrenal transplant disseminated cryptococcosis presenting as a syndrome of inappropriate antidiuretic hormone secretion - A case report p. 343
Sandhya Suresh, Abhijit Konnur, Sishir Gang
Cryptococcosis is the most common invasive fungal infection to involve the central nervous system in the posttransplant period. Cryptococcal meningitis, which constitutes disseminated cryptococcosis, can present with nonspecific signs and symptoms leading to a diagnostic challenge. There are case reports of cryptococcal meningitis presenting as a syndrome of inappropriate antidiuretic hormone secretion (SIADH). A 54-year-old male with autosomal dominant polycystic kidney disease was a live-related renal allograft recipient 1 year back and presented with complaints of generalized weakness and imbalance while walking. His serum sodium on admission was 117 mEq/L and investigations were suggestive of SIADH. He was given hypertonic saline and fluid restriction. However, he had a recurrence of symptomatic hyponatremia. He was evaluated for the cause of SIADH. Chest X-ray and computed tomography of the thorax revealed patchy consolidation. In view of persistent giddiness and imbalance, lumbar puncture was done and cerebrospinal fluid (CSF) analysis showed hypoglycorrhachia with elevated protein and cell counts. CSF cryptococcal antigen test was positive. He was thus diagnosed with disseminated cryptococcosis with meningitis and pulmonary involvement. He received amphotericin B deoxycholate for 4 weeks, followed by fluconazole. He improved symptomatically and serum sodium normalized thereafter. This is the first case of disseminated cryptococcosis presenting with SIADH in the postrenal transplant period with one prior case being reported after a liver transplant. This highlights the variable presentations of cryptococcosis and the need to evaluate the primary cause in posttransplant patients presenting with hyponatremia.
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Partial pelviureteric junction obstruction secondary to BK virus infection early posttransplantation - A case report p. 346
Urmila Anandh, Swarnalata Gowrishankar, Hrushikesh Aurangabadkar
A 63-year-old female presented to our hospital with progressive allograft dysfunction, declining urine output and fluid overload. She had undergone a second transplant 4 months before. Her evaluation revealed partial pelviureteric obstruction in her ultrasound. She underwent a renal biopsy which revealed BK virus infection. The pelviureteric obstruction improved with oral diuretics and her mycophenolate sodium was discontinued. The case illustrates a rare urological manifestation of BK virus infection which can present with symptomatic allograft dysfunction early posttransplantation.
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Coronavirus disease 2019 could be a novel risk factor for avascular necrosis after kidney transplantation p. 350
Praveen Kumar Etta, Thatipamula Madhavi, Ramiz Samir Panjwani
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National voluntary stem cell donor data pool in India: A need of this hour p. 352
Vikash Chandra Mishra, Vimarsh Raina
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