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   Table of Contents - Current issue
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January-March 2022
Volume 16 | Issue 1
Page Nos. 1-143

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EDITORIAL  

COVID-19 and transplantation – A pathway to rebuild transplantation services p. 1
Darius F Mirza, Thamara Perera
DOI:10.4103/ijot.ijot_32_22  
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SPECIAL ARTICLES Top

NOTTO guidelines for vaccine-induced thrombotic thrombocytopenia in organ donation and transplantation Highly accessed article p. 3
Vivek B Kute, Sonal Asthana, Subhash Gupta, Sanjay K Agarwal, Swarnalatha Guditi, Manisha Sahay, Sujoy Pal, S Sudhindran, Ashish Sharma, Sandeep Seth, Alla Gopala Krishna Gokhale, Milind Dhahir Hote, Arpita Ray Chaudhury, Arvinder Singh Soin, Mohamed Rela, Rajesh Malhotra, Virinder K Bansal, Devinder Singh Rana, Rajneesh Sahai, Vasanthi Ramesh
DOI:10.4103/ijot.ijot_135_21  
From the context of organ donation, COVID-19 vaccine-induced thrombotic thrombocytopenia (VITT) is important as there is an ethical dilemma in utilizing versus discarding organs from potential donors succumbing to VITT. This consensus statement is an attempt by the National Organ and Tissue Transplant Organization (NOTTO) apex technical committees, India, to formulate the guidelines for deceased organ donation and transplantation in relation to VITT to help in appropriate decision-making. VITT is a rare entity, but a meticulous approach should be taken by the organ procurement organization's (OPO) team in screening such cases. All such cases must be strictly notified to the national authorities (NOTTO) as a resource for data collection and ensuring compliance with protocols in the management of adverse events following immunization. Organs from any patient who developed thrombotic events up to 4 weeks after adenoviral vector-based vaccination should be considered to be linked to VITT and investigated appropriately. The viability of the organs must be thoroughly checked by the OPO, and the final decision in relation to organ use should be decided by the expert committee of the OPO team consisting of a virologist, a hematologist, and a treating team. Considering the organ shortage, in case of suspected/confirmed VITT, both clinicians and patients should consider the risk‒benefit equation based on limited experience. An appropriate written informed consent of potential recipients and family members should be obtained before the transplantation of organs from suspected or proven VITT donors.
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Consensus statement on organ donation from COVID-positive deceased donors-Indian Society of Organ Transplantation, Liver Transplant Society of India and Indian Society for Heart and Lung Transplantation Highly accessed article p. 8
Sonal Asthana, Vivek Kute, Unmil Shah, Ravi Mohanka, Manisha Sahay, Chinnadurai R , Swati Rajagopal, Sujata Patwardhan, Narayan Prasad, Sandeep Guleria, Shyam Bansal, Arpita Roy Choudhary, Deepak S Ray, Sanjay Kolte, Sanjeev Gulati, Sandeep Seth, Sanjay K Agarwal, Jai Prakash Ojha, PP Varma, Sunil Shroff
DOI:10.4103/ijot.ijot_29_22  
COVID has drastically impacted organ donation across the world, leading to untold misery for thousands of patients who have been waiting for organs. Early rules on the use of organs from COVID positive or affected donors were stringent due to the fear of spread of disease or thrombotic complications in patients who received these organs. However much has changed in the past two years. Most of our adult population has either been infected with COVID, or has received two doses of vaccine, or both. The current variant, despite being more infective, is associated with mild disease, especially in those who have been vaccinated Our armamentarium against severe COVID has improved dramatically in the past year- we have effective vaccines, monoclonal antibodies for treatment of mild COVID in high risk patients and post exposure and antiviral prophylaxis and treatment which can substantially reduce the risk of severe COVID requiring ICU admission. The risk of transmission of COVID infection has to be balanced against the risk of patients dying with end organ disease. We will have to learn to live with COVID- this also means investigating whether organs from donors who are, or have been COVID positive can be used with acceptable risk –benefit in selected patients with end stage organ failure. This document is a summary of evidence and information regarding donor screening for SARS-CoV-2 and considerations for organ acceptance from donors with a history of COVID-19.
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NARRATIVE REVIEWS Top

On the way to mandate booster vaccine dose of coronavirus disease 2019 for transplant recipients: A narrative review of literature p. 17
Vivek B Kute, Sudeep Nimish Desai, Hari Shankar Meshram, Kinjal Narendra Shah, Sanshriti Chauhan, Vineet V Mishra, Manisha Sahay
DOI:10.4103/ijot.ijot_7_22  
Coronavirus disease 2019 (COVID-19) vaccine efficacy, especially against severe disease is known to wane over time. We examined current knowledge of COVID-19 vaccine booster dose in solid organ transplant recipients (SOTR). We have systematically searched PubMed, EMBASE, MEDLINE, Scopus and Google Scholar with the following MeSH terms: “SARS-CoV-2 vaccine,” or “COVID-19 vaccine,” and “organ transplantation” and “booster” or “third dose.” This review article examines a number of studies including guidelines from professional societies examining the safety as well as increased immunogenicity of a booster dose among SOTR. Equitable distribution of vaccines across the globe is the need of the hour. While some countries are well into the booster dose phase, the lower-income countries are languishing behind with primary doses for their health workers. Available reports suggest less efficacy of COVID-19 vaccine in SOTR suggesting booster dose for them. Several studies highlighted the safety and efficacy of COVID-19 vaccines booster dose among SOTR. SOTR should also continue to adhere to all safety and COVID-19 appropriate behaviors. There is a growing need for alternative strategies to improve protection. As Omicron cases rise around the world, India announced that COVID-19 vaccination for children aged 15–18 years and “precautionary (booster) doses” would be administered to healthcare and frontline workers and people above 60 years of age with comorbidities from January 2022. In near future, with increased availability of vaccinations, all SOTR will have access to booster dose in a phased manner.
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Organ donation after circulatory determination of death in India: A joint position paper p. 26
Avnish Kumar Seth, Ravi Mohanka, Sumana Navin, Alla Gopala Krishna Gokhale, Ashish Sharma, Anil Kumar, Bala Ramachandran, KR Balakrishnan, Darius F Mirza, Dhvani Mehta, Kapil G Zirpe, Kumud Dhital, Manisha Sahay, Srinagesh Simha, Radha Sundaram, Rahul Anil Pandit, Raj Kumar Mani, Roop Gursahani, Subhash Gupta, Vivek Kute, Sunil Shroff
DOI:10.4103/ijot.ijot_61_21  
Organ donation following circulatory determination of death (DCDD) has contributed significantly to the donor pool in several countries, without compromising the outcomes of transplantation or the number of donations following brain death (BD). In India, majority of deceased donations happen following BD. While existing legislation allows for DCDD, there have been only a few reports of kidney transplantation following DCDD from the country. This document, prepared by a multi-disciplinary group of experts, reviews the international best practices in DCDD and outlines the path for furthering the same in India. The ethical, medical, legal, economic, procedural, and logistic challenges unique to India for all types of DCDD based on the Modified Maastricht Criteria have been addressed. India follows an opt-in system for organ donation that does not allow much scope for uncontrolled DCDD categories I and II. The practice of withdrawal of life-sustaining treatment (WLST) in India is in its infancy. The process of WLST, laid down by the Supreme Court of India, is considered time-consuming, possible only in patients in a permanent vegetative state, and considered too cumbersome for day-to-day practice. In patients where continued medical care is determined to be futile following detailed and repeated assessment, the procedure for WLST, as laid down and published by Vidhi Centre for Legal Policy in conjunction with leading medical experts is described. In controlled DCDD (category-III), the decision for WLST is independent of and delinked from the subsequent possibility of organ donation. Once families are inclined toward organ donation, they are explained the procedure including the timing and location of WLST, consent for antemortem measures, no-touch period, and the possibility of stand down and return to the intensive care unit without donation. While donation following neurologic determination of death (DNDD) is being increasingly practiced in the country, there are instances where the cardiac arrest occurs during the process of declaration of BD, before organ retrieval has been done. Protocol for DCDD category-IV deals with such situations and is described in detail. In DCDD category V, organ donation may be possible following unsuccessful cardiopulmonary resuscitation of cardiac arrest in the intensive care. An outline of organ-specific requisites for kidney, liver, heart, and lung transplantation following DCDD and the use of techniques such as normothermic regional perfusion and ex vivo machine perfusion has been provided. With increasing experience, the outcomes of transplantation following DCDD are comparable to those following DBDD or living donor transplantation. Documents and checklists necessary for the successful execution of DCDD in India are described.
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REVIEW ARTICLE Top

Issues and concerns in the management of progressive allograft dysfunction: A narrative review p. 42
Urmila Anandh, Pradeep Deshpande
DOI:10.4103/ijot.ijot_114_20  
Nephrologists taking care of dialysis patients are increasingly encountering patients returning to dialysis after a failed transplant. These patients have a different pathophysiology and their medical issues differ from transplant-naïve dialysis patients. Prolonged cumulative immunosuppression and long-term exposure to chronic kidney disease (CKD) pathology are major factors responsible for increased complications and mortality. Often, their CKD-related issues are managed suboptimally as the emphasis is mostly on endeavors related to protecting allograft function. Managing their immunosuppression and allograft-related symptomatology poses serious challenges. There is also a dilemma as to whether the failed allograft should be left in situ or not. Considerate and appropriate decisions are required when these kidney allograft failure patients are offered re-transplantation. This review aims to address the major issues faced by transplant nephrologists in managing patients with allograft failure.
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ORIGINAL ARTICLES Top

A study of visual outcome in deep anterior lamellar keratoplasty at a tertiary eye care institute p. 48
Superna Mahendra, Srinivas Prasad Killani, Swathi Pola
DOI:10.4103/ijot.ijot_58_21  
Introduction: Deep anterior lamellar keratoplasty is a surgical procedure for removing the corneal stroma down to Descemet's membrane. It is most useful for the treatment of corneal disease in the setting of a normally functioning endothelium. Materials and Methods: Patients attending Sarojini Devi Eye Hospital were screened. Twenty-eight eyes of 23 patients with anterior corneal pathologies and who had a best-corrected visual acuity of less than 6/60 and not improving beyond it were included in the study. Results: Conditions in which the pathology is limited to the anterior stroma and sparing the endothelium, lamellar keratoplasty as a procedure offers many advantages with fewer risks of complications. Conclusion: Corneal pathologies involving anterior stroma are better treated with DALK with fewer complications.
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Clinical outcome of ABO-Incompatible kidney transplant with low baseline anti-A/B antibody titer without the use of plasma exchange - A retrospective study p. 56
Tarun Kumar Jeloka, Anand Dharaskar, Ravindra Singh
DOI:10.4103/ijot.ijot_60_21  
Background: The outcome of ABO-incompatible (ABOi) transplant (Tx) may be compromised because of the need for added immunosuppression. Many centers still use plasma exchange (PEX) even when anti-A/B titers are low. We compared the outcome of ABOi kidney Tx with low baseline anti-A/B titers without PEX to those with high titers managed with PEX and to ABO-compatible (ABOc) Tx. Materials and Methods: In this retrospective study, all adult kidney Tx done at our institute were eligible. Patients <18 years of age, deceased donor transplant recipients, and those with hepatitis B, C or HIV infections at the time of transplant were excluded from this analysis. Outcomes including biopsy-proven AR, estimated glomerular filtration rate (eGFR) (Modification of Diet in Renal Disease equation), infections, and patient and graft survival were determined in ABOi kidney Tx with low baseline anti-A/B antibody titers managed without PEX (Group A). These outcomes were compared to a contemporary cohort of those with high titers and use of PEX (Group B) and ABOc Tx (Group C). Continuous variables were compared by Student's t-test and categorical variables with Chi-square test. Patient and graft survival was calculated by Kaplan–Meier curve and compared between the groups by log-rank test. Results: Baseline characteristics reveal no difference in recipients and donor factors such as age, gender, and HLA match. Initial immunoglobulin G anti-A/B titers were higher in Group B as compared to Group A (P = 0.04), but final titers pretransplant were similar (P = 0.6). Biopsy-proven rejections were not different between Groups A and B or Groups A and C. Serum creatinine and eGFR at 1 month and at last follow-up were also similar in all the groups. Infections were seen in 22.2% of the patients in Group A, 44.4% in Group B, and 27.7% in Group C. Patient survival and death-censored graft survival were similar in all three groups. Conclusion: This retrospective study shows that patients with low baseline anti-ABO antibodies managed without PEX are safe and have similar outcomes such as patient and graft survival, rejections, infections, and renal function.
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Clinicopathologic features of polyomavirus nephropathy: Our experience - A retrospective observational study p. 61
Ramya Veduruvada, Nishika Madireddy, Soundarya Samskruthi Koyya, Swarnalatha Guditi, Gangadhar Taduri, Sree Bhushan Raju, Megha Shantveer Uppin
DOI:10.4103/ijot.ijot_115_20  
Introduction: Polyomavirus nephropathy (PVN) is now being frequently encountered in renal transplant recipients receiving highly potent immunosuppressive drugs and has emerged as an important cause of allograft loss. In this study, we tried to study the clinical and morphological features while incorporating the latest Banff 2018 classification of PVN and correlating it with graft outcomes. Materials and Methods: This was a retrospective study including ten patients with biopsy-proven PVN. The risk factors, clinical, histomorphological, and immunohistochemical features of all the patients were studied. We scored the intrarenal polyomavirus load and Banff interstitial fibrosis as described by Banff 2018 working group. Results: There were 6 male and 4 female patients and the mean age at the time of biopsy was 42.5 ± 10.8 years. All patients were on triple immunosuppression and the mean transplant duration to the time of diagnosis was 6.98 ± 4 months. The mean serum creatinine at the time of biopsy was 2.73 ± 1.12 mg/dl. A prior history of antibody-mediated rejection was present in two patients. All ten biopsies showed tubular epithelial basophilic, intranuclear inclusions suggestive of BK virus which was confirmed by positivity for SV40 antigen on immunohistochemistry (IHC). As per the Banff 2018 classification, seven biopsies were categorized as Class 2 and three were class 3. On follow-up, three patients went into graft loss, five patients had persistent graft dysfunction, and two expired. Conclusion: PVN is an important cause of renal dysfunction and premature allograft loss. Light microscopy for viral cytopathic changes aided by IHC with SV40 is essential for the diagnosis of PVN. The Banff scheme of classification is helpful in predicting the prognosis. It is important to diagnose PVN and differentiate it from rejection for appropriate management.
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Determinants of physical performance in Indian kidney-transplant recipients: A prospective observational study p. 67
Harda H Shah, Nehal Shah, Vivek Kute, Himanshu V Patel, Pankaj Shah
DOI:10.4103/ijot.ijot_117_20  
Background: Physical performance refers to the functional demonstration of task. Little is known about physical performance among Indian kidney-transplant recipients (KTRs). The objective of the present study was to evaluate the physical performance among Indian KTRs and to find its determinants from transplant, demographic, or behavior components. Methodology: In this single-center, prospective observational study, 149 KTRs with estimated glomerular filtration rate (eGFR) ≥45 ml/min/1.72 m2 and posttransplant duration (PTD) >6 months were enrolled. Physical performance was evaluated by 6 minute walk distance (6MWD), dominant hand grip strength (DHGS), numbers of 1 minute sit to stand (1MSTS), and time taken to perform 5 times sit to stand (5xSTS). Multivariate analysis was performed between transplant-related components (PTD, dialysis vintage, eGFR, and comorbidity); health behavioral components (total physical activity [TPA], sedentary time, fear of activity participation, body mass index, abdominal circumference); demographic components (age and gender); and each of the physical performance measures. Results: The average 6MWD was 392 ± 96.2 meters, the DHGS was 33.1 ± 6.8 kg, the number of 1MSTS repetitions was 24.0 ± 3.7/min, and the time taken to do 5xSTS was 10.6 ± 1.9 s among participants. When adjusted for cofounders with multivariable analyses, the health behavior of habitual physical activity was statistically significantly (P < 0.001) associated with all aspects of physical performance. Conclusion: Relatively low physical performance was seen among KTRs. Behavior of participation in physical activity contributed to the positive change in all aspects of physical performance against transplant and demographic variables, and it is the major determinant of physical performance.
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Epidemiology, risk factors, and major outcomes in post kidney transplant infections at National Hospital Kandy: A cross-sectional, pilot study p. 77
M A Ayesha Nayanamali, A M Muditha Piyumali Athapaththu, B M Duminda Bandara Basnayake, T G Nadeeka Shyamali Gunarathne, Abdul W M. Wazil, R M Buddhisha S. S. Mahanama, Brammah U E W D R Thangarajah, Nishantha Nanayakkara
DOI:10.4103/ijot.ijot_132_20  
Background: Postkidney transplant (PKT) infections are associated with significant morbidity and mortality, especially in the early posttransplant period. The type of infection, associated risk factors, and predicted outcomes of the infections are essential for targeted appropriate management. Scientific published data, especially in local settings, are lacking. This study was conducted to assess the epidemiology, risk factors, and major outcomes of PKT infections requiring hospitalization. Methods: This was a prospective observational study, conducted at the Nephrology and Transplant Unit, National Hospital Kandy, Sri Lanka, for a period of 2 months from December 1, 2018, to January 30, 2019. Results: A total of 38 infectious episodes were recorded in 35 kidney recipients. The most common type of infection was urinary tract infection (UTI) noted in 36.6% (n = 14) of cases. The most frequent organisms isolated were coliform (7.9%, n = 3). Seven potential risk factors including age, gender, comorbidities, source of kidney, induction modality, enhancement therapy, and months after renal transplant were evaluated. Among those potential risk factors, age was significantly associated with gastrointestinal tract infections (P = 0.033). There was a significant association between the gender and the severity of infections (P = 0.047). Majority of patients discharged from the hospital following complete recovery. Three patients were offered intensive care, two developed acute renal failure requiring renal replacement therapy and one was expired. Conclusion: The most common type of infection in PKT patients is UTI. Patient's age is significantly associated with gastrointestinal infections. Large-scale studies warrant for adequately concluding risk factors, epidemiology, and outcomes.
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Turn around time in matched unrelated donor search workup national versus international registries: Retrospective study p. 84
Vikash Chandra Mishra, Nikki Dey, Amit Kr Bhardwaj, Dinesh Chandra, Archana Anthwal, Vimarsh Raina
DOI:10.4103/ijot.ijot_143_20  
Background: Timeline is a key factor for hematopoietic stem cell transplant (HSCT) recipient. HSCT by matched unrelated donor (MUD) is a standard definitive therapeutic approach for many hematological disorders which are not amenable to chemotherapy and other conventional treatment. Aims and Objectives: The aim of the present study was to compare the turnaround time (TAT) involved in completion of MUD HSCT workup from an Indian registry (Genebandhu) with international registries. Materials and Methods: On receipt of pre-transplant matching request through a transplant physician, patient's human leukocyte antigen (HLA) type was entered in both Genebandhu and World Marrow Donor Association search tool for initiating a “search.” The software gave the descending order of the best possible matches by performing computational analysis. The search result was considered a “match” when potential 10/10 HLA match was found. The average TAT was calculated in the middle of search request and HLA confirmatory typing (CT) and infectious disease marker (IDM). Further, TAT was also determined between the infusion of harvested stem cell product and CT and IDM. At last, the total time engaged in completion of each MUD HSCT workup was determined and compared in national versus international registries. Results: The average TAT involved in between search request and CT and IDM was 71 days in case of global registry and 67 days in case of Genebandhu. Similarly, the average TAT involved between infusion of harvested cell product and CT and IDM testing in case of donor identified in global stem cell registry was 65 days whereas 45 days in case of Genebandhu. At last, the average time associated with the finishing of a MUD workup was 136 days in case of global registry, whereas 112 days in the case of Genebandhu at P ≤ 0.05 with a 95% confidence interval. Conclusion: To conclude, the average TAT obtained through this study clearly demonstrates the advantages in terms of donor availability for MUD HSCT through the national registry.
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Role of pathogenic T-helper cells-17 in chronic antibody-mediated rejection in renal allograft recipients p. 88
Brijesh Yadav, Narayan Prasad, Vinita Agrawal, Manoj Jain, Vikas Agarwal
DOI:10.4103/ijot.ijot_149_20  
Background: Both T-cell and B-cell activities are interlinked. The role of a new subset of T-helper cells (Th17), which is thought to be more pathogenic than other effector T cells, is not much studied in cases of chronic antibody-mediated rejection (CABMR). Therefore, we aimed to determine the circulating frequency of Th17, Pgp+ Th17, Pgp+ CD4T cell, and serum interleukin (IL)-17A cytokine level in patients of CABMR and stable graft function (SGF). Materials and Methods: We had recruited 42 patients of biopsy-proven CABMR (n = 32) and SGF (n = 10). The frequency of Pgp+ CD4Tcells, Pgp+ Th17 and Th17 cell was quantified in circulating blood by flow cytometry, and IL-17A level was determined in serum by ELISA techniques. Results: We observed that the frequency of Th17 cell (2.30 ± 1.15 and 4.46 ± 2.05; P = 0.003), Pgp+ CD4T (15.73 ± 4.38 and 25.27 ± 5.15; P < 0.001), and Pgp+ Th17 (0.78 ± 0.65 and 2.19 ± 0.93; P < 0.001) was higher in CABMR as compared to that of SGF. The ratio of Th17/CD4T cell (0.077 ± 0.045 and 0.14 ± 0.06; P = 0.004), and Pgp+ CD4T/CD4T cell (0.51 ± 0.14 and 0.81 ± 0.17, P < 0.001) was also higher in CABMR as compared to SGF. Serum cytokine IL-17A level was (42.39 ± 13.25 and 66.97 ± 18.27; P < 0.001) pg/ml was also higher in CABMR than that of SGF. The frequency of Pgp+ Th17 cell was positively correlating with 24-h proteinuria (r = 0.309; P = 0.04), serum creatinine (r = 0.423; P = 0.005), and negatively correlating with eGFR (r = −0.468; P = 0.002). Similarly, the frequency of Pgp+ CD4T cell was positively correlating with 24-h proteinuria (r = 0.351; P = 0.023), serum creatinine (r = 0.310; P = 0.04), and negatively correlating with eGFR (r = −0.414; P = 0.006). Conclusions: Higher Pgp+ TH17 cell is associated with CABMR, proteinuria, and graft dysfuntion.
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Impact of pretransplant malnutrition on short-term clinical outcomes of liver transplantation - An exploratory study p. 96
Neha Bakshi, Kalyani Singh, Arvinder Singh Soin
DOI:10.4103/ijot.ijot_153_20  
Introduction: Malnutrition is highly prevalent among patients undergoing liver transplantation (LT) and can affect various clinical factors. The present study focuses on the impact of pretransplant malnutrition on various short-term outcomes of LT. Methods: Ninety LT recipients undergoing elective living donor LT were recruited in the study. Based on subjective global assessment (SGA), they were grouped as normal, moderate, and severely malnourished. Information regarding prognostic factors (Child-Turcotte-Pugh [CTP] and Model for End-Stage Liver Disease [MELD] scores), biochemical parameters (hemoglobin, TLC, platelets, bilirubin [T], serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, albumin, creatinine, and sodium), dietary intake, % weight loss, and short-term outcomes (hospital stay, intensive care unit days, blood unit usage during surgery, and dead and alive status after 1 year) were gathered. Results: The recipient evaluation showed that 54.4% of the patients were moderately malnourished and 27.8% of the patients were severely malnourished. The prognostic scores, CTP, and MELD significantly had higher scores in moderately and severely malnourished patients (P < 0.001 and P = 0.003). Among the biochemical parameters, hemoglobin, albumin, and sodium showed significantly lower levels in moderately and severely malnourished patients (P < 0.001, P = 0.02, and P = 0.01). The data also showed a significantly higher degree of ascites, % weight loss, and lower calorie intake among malnourished patients. A higher degree of malnutrition was associated with poor outcomes of LT; higher hospital stay (P = 0.014), packed red blood cell unit usage during surgery (P = 0.005), and deaths after 1 year of LT (P = 0.03). Conclusion: Pre-LT malnutrition by SGA was associated with poor short-term outcomes of LT with higher hospital stay and deaths. Hence, the present data emphasize the need for early nutrition intervention for improved surgery results.
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Efficacy and safety of bortezomib in the treatment of active antibody-mediated rejection in adult kidney-transplant recipients: A single-center retrospective study p. 101
Dharmendra Bhadauria, Sai Kumar, Monika Yachha, Anupma Kaul, Manas Ranjan Patel, Ravi Shankar Kushwaha, Manas R Behera, Narayan Prasad
DOI:10.4103/ijot.ijot_155_20  
Introduction: The management of active antibody-mediated rejection (ABMR) is evolving, and optimal treatment remains uncertain due to incomplete understanding of pathogenesis. Bortezomib is found to be useful in the treatment of active ABMR. We studied the efficacy and safety of bortezomib in renal-transplant recipients with active ABMR. Materials and Methods: We retrospectively included renal-transplant recipients with active ABMR, who received bortezomib as main management. Results: Eighteen live-related renal-transplant recipients of active ABMR were included. C4d was positive in 14 patients and negative in eight patients. Patients with active ABMR had a mean improvement in glomerular filtration rate (GFR) of 7, 10.5, and 15 ml/min/1.73 m2 at 3, 6, and 12 months, respectively, from baseline GFR. Improvement was significant at 3 (P = 0.009) and 6 months (P = 0.018) of follow-up. Conclusion: Bortezomib may be a safe and effective therapy in patients with active ABMR in patients.
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Role of telemedicine in kidney transplant recipient in COVID 19 era p. 107
Vivek B Kute, Vaibhav Gupta, Himanshu V Patel, Subho Banerjee, Divyesh P Engineer, Harishankar Meshram, Vijay Navadia, Ansy H Patel
DOI:10.4103/ijot.ijot_154_20  
Introduction: Telemedicine represents an innovative but untested approach to maintain patient care and reduce the risk of COVID-19 exposure to patients, health-care workers, and the public. In this study, we evaluated the applicability and efficacy of telemedicine in a kidney transplant recipient (KTR) cohort in COVID 19 era. Materials and Methods: An observational cohort study was conducted at a tertiary-care public-sector kidney disease institute in western India between March and September 2020. We evaluated the reasons, modes, and outcomes of patient contacts by telemedicine in the KTR cohort. We also evaluated the utility of telemedicine across three age groups. Results: Of 840 participants, whose mean age was 38.78 ± 12.39 years, male to female ratio was 4:1. The most common mode of communication was WhatsApp (653, 77.7%) followed by in-person surrogates (126, 15%). Acceptability of telemedicine was significantly better in younger and middle-age groups (P < 0.00001) compared to the elderly. Request for drug delivery (n = 756) was the most common reason for contact overall and managed through postal parcels. KTRs (n = 200) and donors (n = 75) were evaluated for medical illnesses. The most common medical reasons for contact were for febrile illness (n = 120) and graft dysfunction (n = 60). COVID-19-related disease was diagnosed and managed in 80 KTRs and 2 donors. COVID-19 updates were given to all contacts. Conclusion: Telemedicine is underutilized in the care of the KTR cohort. Telemedicine can be used across all ages although it's best suited for young and middle age groups. The impact of telemedicine on short- and long-term patient outcomes is unclear and warrants further study.
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Study of noninduction immunosuppression in intermediate-risk living donor kidney transplantation in rural population of India - A retrospective observational study p. 113
Ankit Data, Kshitija G Gadekar, Vajed R Mogal, Abhijeet S More, Sudhir Gajanan Kulkarni
DOI:10.4103/ijot.ijot_70_21  
Introduction: Kidney transplant is a costly affair, especially in a developing country like India. The current study was carried out with the aim to analyze the clinical outcome retrospectively in terms of acute rejection (AR), graft survival, and patient survival in intermediate-risk recipients undergoing first renal transplant with Tacrolimus (TAC), Mycophenolic acid (MPA), and corticosteroid based triple maintenance immunosuppression in one of the most underprivileged population of the country who has to bear the cost of the induction agent not covered by any government scheme. Materials and Methods: It is a retrospective observational study. We included 101 patients, out of which 42 were in basiliximab group and 59 patients did not receive any induction agent. Apart from the induction, agent rest of the Immunosuppression protocol was same in all patients. The primary endpoint of the study was number of biopsy-proven AR within 1st year of transplantation. The secondary endpoints were patient and graft survival by 1 year. Results: Human leukocyte antigen mismatch and mean age of the patients in basiliximab group were significantly higher than noninduction group; otherwise, both groups were similar in all other baseline parameters. There was no significant difference between AR (21.43% v/s 18.64%), graft survival (97.30% v/s 98.15%), and patient survival (88.10% v/s 91.52%) at 1 year. Conclusion: Our study suggests that Induction immunosuppression may not be necessary for patients undergoing intermediate-risk living donor kidney transplant in the current scenario of TAC and MPA-based maintenance immunosuppression.
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CASE SERIES Top

Deception and deceit in living kidney transplant program p. 119
Trilly Rachel Mathew, Muneet Kaur Sahi, Sunil Shroff, Pallavi Kumar, Saurabh Pokhariyal, Salil Jain
DOI:10.4103/ijot.ijot_113_20  
In India, the majority of kidney transplants are living donor transplants. The transplant law in India only permits donation from first degree relatives, spouses, grandparents and altruistic donation without any commercial intent. Donation that happens other than first degree relative require to go through the process of authorization by a committee that determines their intent of donation. In spite of the requirements that are clearly laid down in the Act, fake and fraudulent activities have been reported to make donations happen with a commercial intent. This paper is an attempt to inform and empower clinicians and transplant coordinators and give them the requisite skills that would help them to identify fraudulent relationships, detect discrepancies in the documents and help ensure that the hospital and the doctors follow the law of the land and not fall prey to fake documentation that has a commercial intent of donation. Sample cases have been studied based on their coordination and different ways of approaches to detect falsification of documents and tutoring of the donors by the family members or broker. It was seen that with the right approach that included thorough donor-recipient interrogation, close scrutinization of documents and keenly observing the donor-recipient relationship including their body language and attire, various discrepancies could be identified. All transplant teams should include a well-trained Transplant Coordinator who is alert to every case of a living donor recipient pair and makes a thorough assessment of the relationship by observing, interviewing and scrutinizing the documents of relationship to exclude fraud. Some recommendations have also been drawn up to minimize the risk of fraud.
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CASE REPORTS Top

COVID-associated pulmonary aspergillosis in a post renal transplant patient p. 127
Manish R Balwani, Amit S Pasari, Amol Bhawane, Prasad Gurjar, Priyanka R Tolani
DOI:10.4103/ijot.ijot_67_21  
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) is usually mild in general population, while in renal transplant patients, it can turn fatal. Some patients suffer from post COVID-19 secondary bacterial and fungal infections due to virus-induced immunosuppression. We here report a case of immediate post renal transplant patient who contracted COVID-19 illness and later developed pneumonitis which on BAL was found to be due to Aspergillus fumigatus. Through this case report, the author aims to highlight the importance of keeping check on post COVID-19 secondary opportunistic infections in post renal transplant patients. Early diagnosis with high index of suspicion is essential to start timely and effective treatment.
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Posttransplant membranous nephropathy - A case report p. 130
Shabna Sullaiman, Prabhat Chauhan, Ashwani Kumar, Ritambhra Nada, Ranjana Minz, Vinod Kumar, Ashish Sharma, Sarbpreet Singh, Vivek Kumar, Manish Rathi, Harbir Singh Kohli, Raja Ramachandran
DOI:10.4103/ijot.ijot_109_21  
Primary membranous nephropathy (PMN) is a common cause of adult-onset nephrotic syndrome. Anti-M-type phospholipase A2 receptor (PLA2R) antibodies are pathogenic and correlate with clinical outcomes. The role of anti-PLA2R in recurrent PMN is unclear. In the present manuscript, we report five cases of PMN who underwent kidney transplantation (KT) with varying titers of anti-PLA2R pre-kidney transplantation (KT). Two patients with anti-PLA2R in the second and third tertiles had a recurrence of PMN, whereas patients with a negative or anti-PLA2R in the first tertile had no recurrence. The report signals a heightened risk of PMN recurrence in patients with elevated anti-PLA2R antibody titer at KT.
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Rectal carcinoma 27 years' postkidney transplant in a chronic hepatitis B patient - A case report p. 135
Sneha Haridas Anupama, Rajeevalochana Parthasarathy, Milly Mathew, Priya Haridas Anupama, Georgi Abraham
DOI:10.4103/ijot.ijot_128_20  
Here, we report a 72-year-old male with HBsAg-positive status who had a live sibling kidney transplant 27 years ago. He was on minimal maintenance immunosuppressive therapy with prednisolone and microemulsion cyclosporine. He presented with vague abdominal symptoms and was diagnosed to have moderately differentiated adenocarcinoma of the rectum, which was treated by low anterior resection with loop ileostomy and is currently undergoing radiotherapy.
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Spontaneous renal allograft rupture due to acute rejection in early post-transplant period – A case report p. 138
Suraj Godara, Karan Saraf
DOI:10.4103/ijot.ijot_141_20  
Renal allograft rupture (RAR) is a rare but lethal complication of renal transplantation. This can be a threat to the graft and patient survival. Over the decades, allograft nephrectomy has been the standard treatment for renal allograft rupture. But now, recent evidences suggest that graft salvage treatment can be safely done in complicated cases also. We describe a case of 30-year-old male who received a living donor kidney transplant and had spontaneous graft rupture in early post transplant period due to acute rejection. Graft was successfully repaired surgically, along with medical management and now the graft is functioning well.
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LETTER TO EDITOR Top

The aeroplane takes off against the wind p. 142
Ganapathy Krishnan Subramaniam, Dhruva Sharma, Neha Sharma
DOI:10.4103/ijot.ijot_42_21  
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