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   Table of Contents - Current issue
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October-December 2022
Volume 16 | Issue 4
Page Nos. 355-466

Online since Friday, December 30, 2022

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ORIGINAL ARTICLES  

Pediatric renal transplantation in Southern Saudi Arabia: A single-center retrospective study Highly accessed article p. 355
Hany M El Hennawy, Ahmed Al Hashemy, Abdullah S Al Faifi, Omar Safar, Mahmoud Ali Obeid, Mohamed A Gomaa, Ayed Alkhalaqi, Mashair Babiker, Abdelaziz A Abdelaziz, Rawa M Al Humaid, Mohammad F Zaitoun, Khalid A AlAlsheikh
DOI:10.4103/ijot.ijot_118_21  
Background: The outcome of pediatric renal transplantation (RT) has improved over the last decades. Aims and Objectives: To study the outcome of pediatric transplantation at our center including patient and graft survival, acute rejection, and surgical complications. Materials and Methods: A retrospective review of pediatric RT outcomes at the only transplant center in Southern Saudi Arabia. Results: between 11/2013 till 03/2020, 63 RT were performed in pediatric recipients 2 through 18 years of age (mean 11.7 ± 3.75) including 43 patients (68.2%) aged 14 and younger. Average BMI-height-age-z were 66.05 ± 6.65 percentile. 49 patients (77.7%) received kidneys from adult living donors (LD), 8(16%) were unrelated donors.41% had preemptive KT. The commonest known etiologies of ESRD were focal segmental glomerulosclerosis, Post Urethral valve, and dysplastic kidney (9.5% each). Thymoglobulin and Basiliximab were used as induction therapy in 37 (58.7%) and 26 (41.3%) patients respectively. With a mean follow-up of 80 months, 1-year and 5-year graft survival rates for LD and deceased donors were (97.2%, 86.4%) and (96.4%, 76%) respectively. 1-year and 5-year patients survival rates were 100%. Conclusions: pediatric renal transplantation outcome at our center, despite the low volume of cases, is encouraging.
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COVID-19 infection in kidney transplant recipients during the first versus the second wave - Retrospective Observational study from a single center Highly accessed article p. 361
Namrata S Rao, Abhilash Chandra, Sai Saran, Amit Kumar Singh, Sanjeet Kumar Singh
DOI:10.4103/ijot.ijot_133_21  
Background: Kidney transplant recipients (KTRs) are deemed to be at a high risk of severe coronavirus disease (COVID-19). Herein, we describe the clinical, laboratory profiles, management, and outcomes of 26 KTRs who developed COVID-19 during the first and second waves of the pandemic from a tertiary care center in northern India. Methods: This retrospective observational study included KTRs detected with COVID-19 infection during the first wave (March–November 2020) and the second wave (March–July 2021). Their clinical and laboratory investigations, management aspects, and outcomes were compared, using data retrieved from clinical and telenephrology records, and the hospital information system. Results: Of the 23 KTRs, 20 were male (86%), 20 patients had fever (86%), and cough and breathlessness were seen in 19 (82%) and 12 (52%), respectively. Acute graft dysfunction was seen in 6 (26%) patients, and the need for renal replacement was seen in 4 (17%) patients. Supplemental oxygen by reservoir mask was utilized in 10 (43%) patients, high-flow nasal cannula in 3 (13%), noninvasive mechanical ventilation in 4 (17%), and invasive mechanical ventilation in 6 (26%) patients. All the KTRs with moderate and severe COVID illness and 6/7 nonsurvivors were infected during the second wave. Overall mortality in this group of patients was very high at 27%, and the mortality in the group on mechanical ventilation was 100%. Conclusions: The second wave of the COVID-19 pandemic was associated with greater severity of illness and high mortality in KTRs.
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Ex vivo renal bench pyelolithotomy for renal calculi in live related kidney transplant: A prospective observational study p. 366
Ashish Sharma, Nripesh Sadasukhi, Sandeep Malik, TC Sadasukhi, HL Gupta, Manish Gupta
DOI:10.4103/ijot.ijot_10_21  
Background and Objectives: Bench surgery performed just after donor nephrectomy is known as ex vivo Bench Surgery. We present a case series of Bench Pyelolithotomy in donor's kidney just before transplantation with our surgical experience and follow-up results. Patients and Methods: Fifteen ex vivo Bench Pyelolithotomy on renal graft was performed by an experienced surgeon from January 2018 to August 2020. All these patients underwent standard donor evaluation and metabolic workup. Pre- and post-operative parameters were analyzed for technical feasibility, intraoperative and postoperative complications, stone clearance, and stone recurrence rate. Results: All 15 donors were females with a mean age of 44 years. The mean stone size was 14.3 mm (range 5–30 mm). Stone extraction by pyelolithotomy on the bench was successfully performed, and a stone-free status was accomplished just before the transplantation. Complete stone clearance was achieved in all cases. Mean cold ischemia time was 32 min. Postoperatively, patients were stable with average urine output of 490 ml/h. All patients are in regular follow-up with graft functioning well measured with respect to serial serum creatinine and urine output. Conclusions: Bench surgery is safe, less time-consuming, and equally effective for a stone-bearing renal donor kidney without compromising renal allograft function.
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Allograft rejection in kidney transplantation – A retrospective study of impact on graft and patient outcome p. 371
MP Shamsudheen, Abid Kuchay, Vijay Chander Gupta, Isha Tiwari, Raja Karthik, Uttara Das, Swarnalatha Guditi, Gangadhar Taduri
DOI:10.4103/ijot.ijot_93_21  
Background: Renal allograft rejection is a major cause of graft dysfunction, and it is a predictor of long-term allograft loss. Advances in immunosuppression have decreased the influence of acute rejection on graft survival. In this study, we assessed clinicopathological profile and immediate and long-term treatment outcomes of different types of allograft rejections in our institute. Materials and Methods: We retrospectively analyzed patients who underwent renal transplantation and had biopsy-proven renal allograft rejections from January 2010 to December 2019 in our institute. Recipient–donor characteristics at the time of transplantation and graft function post transplantation were documented. Patients were followed up till graft loss or patient loss or a minimum 12-month period after rejection episode for all survived patients. Results: Allograft rejection occurred in 88/424 (20.75%) renal transplant recipients during the study period. Active antibody-mediated rejection (ABMR) was the most common type of rejection (40.9%) and was common in early posttransplant period also (54.5%). Graft dysfunction was the dominant presentation in all groups except chronic active ABMR, where heavy proteinuria was common. Chronic active ABMR was common (37.5%) in second episode of rejection. Overall graft survival, death-censored graft survival, and patient survival at the end of the study were 52.27%, 82.95%, and 69.3%, respectively. Conclusion: Renal allograft rejection decreases both graft and patient survival. Hence recommend regular surveillance for early detection and treatment.
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Quality assessment and outcomes related to deceased organ donation in a tertiary care hospital in India an observational study p. 377
Avnish Kumar Seth, Twinkle Singh
DOI:10.4103/ijot.ijot_132_21  
Background: We report quality assessment (QA) at each step of organ donation (OD), from the identification of a prospective donor with suspected brain death (BD) to organ retrieval. Methods: Case summaries and files of patients who expired or left against medical advice (LAMA) in 2019 in a 290-bed hospital were studied. Possible, potential, eligible, and actual donors were identified from among those with devastating brain injury (DBI). Potential donors (PDs) were subclassified into five types. The structure, process and outcomes related to OD were evaluated with appropriate Quality Indicators and Quality Criteria. Statistical Analysis: Data were analysed using MS Excel and we have used cross tabulation method for statistical analysis. Results: Of 352 deaths, 324 occurred in intensive care units (ICUs), of which 210 were reported from medical and surgical ICUs. ICD-10 codes relevant to process of OD were found in 27 patients, of whom 16 (7.6% of deaths) received ventilatory support and were possible donors. BD was suspected by ICU teams in 10 patients (4.7% of deaths), labeled as PDs. The presence of nonreactive pupils were recorded in 10 (100%) case files and 5 (50%) death summaries, while other brain stem reflexes were endorsed in 6 (60%) case files and none of death summaries. Rates for referral, contraindication, request, and consent were 80%, 40%, 66.6%, and 50%, respectively. From 20 patients with DBI who LAMA, 11 possible donors and five PDs were identified. Conclusion: Retrieval of data relevant to OD is possible by auditing the available mortality and LAMA records in India. Formatting of death summaries in patients with DBI to include Glasgow Coma Scale and all brain stem reflexes would help in the process of QA for OD.
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Laparoscopic versus open donor nephrectomy: Which is better for vessel length preservation – A randomized clinical study p. 384
Nripesh Sadasukhi, Ketul Patel, T Chand Sadasukhi, Manish Gupta, HL Gupta, Ashish Sharma, Sandeep Malik
DOI:10.4103/ijot.ijot_90_21  
Objectives: The objective of this study is to report the difference in loss of length of the renal artery and vein between an open and laparoscopic renal donor nephrectomy. Methodology: We take 50 open and 50 laparoscopic renal donors for comparison of loss of length of the renal artery and vein. This is a single-blinded study. All patients considered for left donor nephrectomy with a single renal artery and vein are included in the study. Patients considered for right donor nephrectomy, abnormal renal artery and vein anatomy, atherosclerotic renal artery or vein are excluded from the study. Results: In our study, we take 50 open renal donor nephrectomies and 50 laparoscopic renal donor nephrectomies from a total of 115 renal donor nephrectomies from December 2020 to April 2021. For removing bias, we take only the left side nephrectomy which has a single artery and vein. We used study randomizer software which uses cluster randomization which decides case should be operated on either open or laparoscopy. Conclusions: In our study, the difference between preoperative and intraoperative artery length for open donor nephrectomy (ODN) was 0.3 cm, and vein length was 2.3 cm and the difference between preoperative and intraoperative artery length for laparoscopic donor nephrectomy (LDN) was 0.5 cm, and vein length was 2.5 cm. The difference between renal artery length in open versus LDN is 0.2 cm, and the difference between renal vein length in ODN versus LDN is 0.2 cm, which is statistically insignificant.
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Impact of donor-specific anti-human leukocyte antigen antibodies in haploidentical hematopoietic stem-cell transplantation: A single-center retrospective study p. 390
Rajesh B Sawant, Santanu Sen, Sameer A Tulpule, Deepali Y Naker
DOI:10.4103/ijot.ijot_2_22  
Introduction: While donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) have been implicated in graft rejection in solid organ transplantation, their role in hematopoietic stem-cell transplantation (HSCT) remains unclear. Aim: The aim of this study is to study the role of DSA for proper donor selection and its effect in the setting of allogeneic HSCT. Methodology: HLA A, B, C, DRB1, and DQB1 high-resolution typing, and DSA cross match (XM) of patients (n = 73) and their prospective donors (n = 74) were assessed. A case–control study was designed retrospectively to evaluate the effect of pre- existing DSAs on engraftment. Thirty-five cases with 5/10 HLA alleles mismatches and 38 cases with full HLA matched, these two controls were selected for comparison. These were matched for disease, graft type, conditioning regimen, age, gender, blood group, and sensitizing events. DSAs were tested with solid-phase assay (Luminex 100/200 platform). Results: DSAs were detected in six of 35 patients (17%); however, donors selected for transplantation were all negative for DSA crossmatch. These six patients who underwent haploidentical (HI) transplants had antibodies against Class I and II. One patient carried antibodies against both classes. A patient who experienced primary graft failure had a second HI transplant. No other known factors that could negatively influence engraftment were associated with the development of graft failure in this patient. Conclusions: DSAs are not associated with graft rejection in patients undergoing HI stem-cell transplantation. Anti-HLA sensitization should be evaluated routinely in HSCT with HLA mismatched donors for a better outcome.
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Human leukocyte antigen association with anti-SARS-CoV-2 spike protein antibody seroconversion in renal allograft recipients - An observational study p. 397
Brijesh Yadav, Narayan Prasad, Deependra Yadav, Ankita Singh, Sonam Gautam, Ravishankar Kushwaha, Manas Ranjan Patel, Dharmendra Bhadauria, Manas Ranjan Behera, Monika Yachha, Anupama Kaul
DOI:10.4103/ijot.ijot_28_22  
Cellular and humoral responses are required for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) eradication. Antigen-presenting cells load SARS-CoV-2 peptides on human leukocyte antigen (HLA) with different avidities and present to T- and B-cells for imposing humoral and cellular responses. Due to immunosuppression, renal transplant recipient (RTR) patients are speculated to poorly form the antibody against the SARS-CoV-2. Therefore, determining the association of specific HLA alleles with anti-SARS-CoV-2 spike protein antibody formation will be helpful in managing the RTR having specific HLA alleles from SARS-CoV-2 infection and vaccination. Materials and Methods: In this study, anti-SARS-CoV-2 spike protein antibody in 161 RTRs was determined by the chemiluminescent microparticle immunoassay methods, and HLA alleles were determined by the polymerase chain reaction-single-strand oligonucleotide methods and analyzed to study the HLA allele association with anti-SARS-CoV-2 spike protein-specific humoral response and severity of COVID-19 symptoms in recently SARS-CoV-2-infected RTRs. Results: The anti-SARS-CoV-2 spike protein specific antibody seroconversion rate in RTRs was 90.06% with a median titer of 751.80 AU/ml. The HLA class I alleles, A*11 in 22.1%, A*24 in 21.37%, A*33 in 20.68%, HLA B*15 in 11%, B*07 in 8.27%, HLA-C*30 in 20.93%, C*70 in 23.25% and HLA Class II alleles, DRB1*07 in 18.62%, DRB1*04 in 13.8%, HLA-DRB1*10 in 14.48%, HLA-DQA1*50 in 32.55% of RTRs were associated with the seroconversion. The mean SARS-CoV-2 clearance time was 18.25 ± 8.14 days. Conclusions: RTRs with SARS-CoV-2 infection developed a robust seroconversion rate of 90.0% and different alleles of HLA-B, DRB1, and DQA1 were significantly associated with the seroconversion.
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Issues faced by a resource-constrained stem cell donor registry and impact of coronavirus disease 2019 on their functioning: A 9-year observational study from a single registry in India p. 405
Hina Solanki, Aseem Kumar Tiwari, Nikki Dey, Vimarsh Raina, Girish Sharma
DOI:10.4103/ijot.ijot_30_22  
Background: Allogeneic hematopoietic stem cell transplantation activity is growing globally as one of the curative treatment options for many hematological diseases. A stem cell transplant registry plays an important role in such treatment. Setting up a functional stem cell donor registry is quite challenging with several issues such as resources, donor recruitment, donor attrition, ethnicity, lack of support, and impact of coronavirus disease 2019 (COVID-19). Aim: The aim of the current study was to present the experience of a resource-constrained registry in India as well as the effect of COVID-19 on its operations. Settings and Design: The present study was a descriptive study which was designed to study the functioning of a resource-constrained registry from north India. Materials and Methods: The study data for the period of 2012–2020 pertaining to donor recruitment, number of searches, number of matched donors, number of transplants performed, and donor attrition was collected from the registry software “Prometheus.” Statistical Analysis: Descriptive statistics such as frequency and percentage was used. Results: During the past 9 years of operation, the registry has faced several issues pertaining to lack of funds, donor recruitment, donor attrition, and COVID-19 has exacerbated their pain points significantly. The registry has recruited a total of 20,093 donors, of which only 7794 have been human leukocyte antigen typed, with the remaining samples awaiting funding. Out of this small number of typed donors, registry has performed 15 matched unrelated donor transplants for Indian and international patients. As a result of COVID-19, donor attrition was on the rise and showed a peak in 2020. During the year 2020, the number of searches, donor recruitment camps, and donors all decreased considerably. Conclusion: The establishment and operation of a stem cell transplant registry necessitate extensive planning and resources. The resource-constrained registries face a number of issues pertaining to effective functioning and future developments. The external support and awareness for the cause can help minimize the pain points of these registries.
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Awareness, attitude, and willingness of organ donation among adult population in Western Rajasthan: A cross-sectional hospital-based survey p. 411
Nipin Kalal, Suresh K Sharma, Nimarta Rana, Ashok Kumar, Deepti Mathur
DOI:10.4103/ijot.ijot_38_22  
Background: Organ transplantation is a life-saving treatment for patients with end-stage organ failure all over the world, and the demand for organs has increased as a result. Organ donation involves legal, psychological, and ethical considerations. Many countries around the world have reported that people's attitudes toward organ donation are influenced by various factors such as knowledge, education, and religion. The existing study sought to explore the awareness, attitude, and willingness of organ donation among adult population in Western Rajasthan. Materials and Methods: A cross-sectional hospital-based survey was conducted with 445 adult populations who were visiting the hospital. Self-Structured Awareness Assessment Scale for Organ Donation and Attitude Assessment Scale for Organ Donation were used. Data analysis was done using the SPSS software 22.0 version. Results: 74.61% of participants were aware about organ donation. Statistically (P < 0.001) higher odds for organ donation willingness was found among participants who were aware that organ such as eye (odd ratio [OR]: 10.34, 95% confidence interval [CI]: 4.40–24.25, P < 0.001), heart (OR: 4.71.95% CI: 2.68–8.25), P ≤ 0.001), intestine (OR: 2.26, 95% CI: 1.41–3.6, P = 0.001), skin OR: 2.93, 95% CI: 1.83–4.70) P ≤ 0.001), extremities (Lower and upper) (OR: 2.46,95% CI: 1.53–3.95, P ≤ 0.001) can be donated or transplanted. 40.6% of the participants disagree that it is better to die than to receive an organ from another person. Interestingly, 35.28% of the participants agreed that organ donation is a true donation and a real service to mankind. Conclusions: This study not only echoes low awareness of organ donation among the adult population in Western Rajasthan, India but also reflects low and neutral level of positive attitude and willingness for organ donation.
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Clinicopathological correlation of transplant nephrectomies in elusive graft dysfunction - An observational study p. 419
Sneha Haridas Anupama, Immanuel Pradeep, Sharon Mathews, Georgi Abraham, Rajeevalochana Parthasarathy, Milly Mathew, Saravana Sundaraja, Abraham Kurien, Nagarajan Palaniappan
DOI:10.4103/ijot.ijot_94_20  
Aim: The objective of this study is to review the pathology and outcome of kidney allograft nephrectomies performed in a single renal transplant center in South India. In our regional center, a total of 721 renal transplants were done between January 2001 and March 2020, of which 18 underwent transplant nephrectomy (TN). Materials and Methods: Clinical data concerning patient characteristics, duration of allograft functions, indications, complications, and subsequent follow-up details were assessed. The median age of patients at the time of transplantation who underwent TN was 35 years. Among the 18 allografts, 16 were from live-related donors and a deceased donor after circulatory/brain death in two patients. Associated comorbidities found at the time of transplantation mainly consist of diabetes mellitus, hypertension, and coronary artery disease. A standard triple immunosuppressive regimen along with mTOR inhibitors was followed in all patients. The morphology of the allograft nephrectomy was studied in elusive graft dysfunction. Results: In our study, while the infection was found to be the leading cause of renal allograft failure clinically, on pathological examination of TN specimens, rejection (44.44%) contributed to failure the most. Early graft failure (55.56%) was related to hyperacute rejection or vascular complications. Late graft failure (44.44%) was associated with infection and rejection. No significant mortality was observed in our study. Conclusion: Clinicopathological correlation to arrive at a diagnosis for graft failure contributes to more effective postnephrectomy care of the patient since often the underlying pathology is masked by other incidental occurrences. It also aids in gauging the patient's chances of undergoing further transplant and graft survival.
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CASE REPORTS Top

Positive single-antigen bead assay with negative flow crossmatch in a renal transplant - A case report p. 425
Vikash Chandra Mishra, Dinesh Chandra, Archana Anthwal, Amit Kr Bhardwaj, Vimarsh Raina
DOI:10.4103/ijot.ijot_73_21  
The occasion is when there is discordance between the results of the cell-based and virtual crossmatch and requires further workup before considering a patient for renal transplant. A case of the positive single-antigen bead (SAB) with donor-specific antibodies (DSA) against HLA-A*33:01 with negative complement-dependent cytotoxicity crossmatch and flow crossmatch was identified. The acid treatments of the beads were done to denature the antigen to understand the nature of identified DSA. There was variation in the Mean fluorescence intensity (MFI) observed in between patient sera with acid-treated beads (significantly increased) in contrast to regularly untreated SAB. This indicated additional antigens become available by the denaturation process. Hence, before making a final decision about the transplant in cases of ambiguity, SAB results should be interpreted in light of other compatibility results.
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Amphotericin B-resistant disseminated cryptococcal infection with concurrent cytomegalovirus colitis in a renal transplant recipient - A case report p. 428
Mragank Gaur, Jasmine Sethi, Mahesh Prakash
DOI:10.4103/ijot.ijot_31_21  
Post renal transplant opportunistic infections always pose a challenge to the clinician due to the varied nonspecific clinical manifestations and prove fatal if not diagnosed and treated early. Here, we present a case report of a patient who was 22 years post renal transplantation with amphotericin-resistant disseminated cryptococcal infection concurrent with cytomegalovirus colitis treated successfully with oral fluconazole and ganciclovir. The clinician should always take into account the antibiotic susceptibility and culture sensitivity of cryptococcosis to diagnose this rare yet emerging phenomenon of azole resistance. Furthermore, to the best of our knowledge, this is the first reported case of amphotericin-resistant cryptococcosis in posttransplant setting.
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Brain abscess with unusual organism Staphylococcus hemolyticus in a renal transplant recipient - A case report p. 431
Neeharika Jonnalagadda, Swarnalatha Guditi, Uttara Das, Raja Karthik Kalidindi, Sarang Vijayan, Ravi Kumar Patel, Ashish Nayak, Gangadhar Taduri
DOI:10.4103/ijot.ijot_89_20  
The immunosuppressive medications in renal transplant recipients are associated with increased risk of infections, leading to significant morbidity and mortality. Here, we report a case of focal brain abscess, presented to us, 8 months after deceased donor renal transplantation with headache and altered mentation. Patient had a history of fungal pneumonia 3 months before presenting illness and received intravenous liposomal amphotericin B, for 6 weeks. On evaluation, he was found to have brain abscess, with mild graft dysfunction. Computerized tomography-guided stereotactic aspiration of the brain abscess was done which grew Staphylococcus hemolyticus. Intravenous catheter placed for 6 weeks for antifungal therapy for the management of previous fungal pneumonia was thought to be cause of staphylococcal infection. He was managed with intravenous clindamycin and levofloxacin for 6 weeks as per antibiogram and immunosuppressive medications were reduced. After 6 months of follow-up, patient was asymptomatic with normal renal function and minimal immunosuppressive medications.
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Spontaneous renal allograft rupture of unknown etiology - A case report p. 435
Umar Maqbool, Asuri Krishna, VK Bansal, Om Prakash, Subodh Kumar
DOI:10.4103/ijot.ijot_69_18  
Rupture of renal allograft is a rare but serious complication of transplantation. This is usually attributed to acute rejection, acute tubular necrosis, or renal vein thrombosis. Some other causes such as renal graft biopsy and lymphatic obstruction are also mentioned as possible causes. This usually occurs during the first 1–3 weeks following transplantation, but cases occurring as late as 72 months have been reported. A 23-year-old male with established chronic kidney disease stage 5, underwent live-related renal transplantation using a kidney from a 46-year-old donor (mother). The laparoscopic donor nephrectomy was uneventful. The patient had an uneventful intraoperative course with usual early postoperative recovery. The patient was having a good early postoperative course. On postoperative day (POD) 2, there was sudden decrease in urine output to 100 ml/h. Ultrasonography Doppler on the same day evening showed normal color flow in the renal artery and renal vein. At around 7 p.m., there was sudden increase in drain output with fresh blood as content (500 ml in 10 min) with tachycardia and hypotension. In view of increased drain output, the patient was taken to operating room and reexploration was done. At reexploration, the renal allograft was found to have two longitudinal ruptures of around 8 cm × 1 cm × 2 cm and 5 cm × 1 cm × 1 cm (length × width × depth) with active bleed. The initial attempt was made to achieve hemostasis and salvage the graft kidney, but due to uncontrolled bleed, explantation was performed. Histology showed features of acute tubular injury. However, there was no evidence of acute rejection, acute tubular necrosis, or vascular thrombosis. This case demonstrates that early diagnosis and prompt treatment of a life-threatening condition such as renal allograft rupture with explantation of the graft may be required in certain conditions as a life-saving procedure.
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Large de novo renal cell cancer in renal allograft: Rare case report and review of literature - A case report p. 438
Shashank Agrawal, Aditya Parikh, Ravindra B Sabnis, Mahesh R Desai
DOI:10.4103/ijot.ijot_37_21  
Renal cell cancer (RCC) in renal allograft is a rare entity. We report a case of RCC successfully diagnosed in a 42-year-old renal allograft recipient which developed 13 years after engraftment. The patient was initially evaluated using ultrasound for two episodes of hematuria followed by contrast-enhanced CT scan revealing 9.7 cm × 8.6 cm × 6.5 cm heterogeneously enhancing mass at mid-pole with involvement of renal sinus. Allograft nephrectomy was performed. A genetic study with DNA microsatellite analysis showed de novo RCC from donor origin. Seven months after surgery, the patient is alive with no evidence of tumor recurrence and is now planned for a second renal transplant. To the best of our knowledge, this is the largest allograft RCC reported in the Indian scenario.
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Successful management of hydronephrosis and anuric renal failure of transplant kidney, masquerading as extrarenal pelvis - A case report p. 441
Arunkumar Neelakandan, Nagarajan Palaniappan, Anil Tarigopula, Milly Mathew, Georgi Abraham
DOI:10.4103/ijot.ijot_113_21  
An unusual case of kidney allograft dysfunction following mechanical obstruction of the allograft at distal ureter, secondary to scarred vas deferens, testicular vessels, and lower abdominal muscles due to the previous right inguinal hernia mesh repair. This led to anuric renal allograft failure on the 2nd postoperative day, which was successfully managed with a multidisciplinary team.
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Transplantation in a recipient with crossed renal ectopia and donor with early branching of the left renal artery - A case report p. 444
Rajendra B Nerli, Shoubhik Chandra, Shridhar C Ghagane, Neeraj S Dixit, Ameya Muzumdar, Parveen Donkar
DOI:10.4103/ijot.ijot_43_21  
Comprehensive preoperative evaluation of potential donors is crucial for selecting the right donor. Early segmentary arterial branching is present in 10%–12% of cases. Expert surgeons require at least 1 cm of main donor renal artery to clamp and properly anastomose the artery in the recipient. We report a case of live-related renal transplantation wherein the recipient had a crossed renal ectopia and the donor had early branching of the left renal artery (<5 mm from the aorta).
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Pharmacomechanical aspiration thrombectomy of iliofemoral deep venous thrombosis to salvage the transplanted kidney - A case report p. 447
Shivakumar S Patil, Ashish Sharma, Deepesh Benjamin Kenwar, Rajesh Vijayvergiya, Sarbpreet Singh
DOI:10.4103/ijot.ijot_16_22  
Ipsilateral acute iliofemoral deep venous thrombosis (DVT) after a renal transplantation, although rare, has a high morbidity, causing complications such as allograft failure, rupture, or death. Treatment modalities are limited due to the risk of bleeding and impaired renal function. We report successful treatment of a case of iliofemoral DVT in a 58-year-old male recipient of a living donor renal transplantation. The immediate postoperative course of the patient was uneventful, and he was discharged on 6th postoperative day (POD) with serum creatinine of 0.8 mg/dl. On POD 26, the patient was admitted with diarrhea, dehydration, and decreased urine output. His serum creatinine rose from 0.8 mg/dl to 2.6 mg/dl and he developed pain and swelling of the right lower extremity. Duplex ultrasonography was suggestive of acute DVT with noncompressible right distal external iliac vein, common femoral, superficial femoral and popliteal veins, absence of color flow from the right femoral vein to the common iliac vein, dilatation of allograft renal vein and an increased renal graft resistive index of 0.97. After inferior vena cava filter insertion, initial treatment with percutaneous balloon angioplasty and catheter-directed thrombolysis could not restore blood flow. Subsequently, percutaneous transluminal pharmacomechanical aspiration was performed with complete removal of the thrombus leading to restored renal allograft vein patency and normalization of allograft function and Duplex findings.
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Disseminated nocardiosis and focal nontuberculous mycobacterial infection coexisting in a renal transplant recipient - A case report p. 451
K Vinod Kumar, V Narayanan Unni, Anup Warrier, Bipi Prasannan
DOI:10.4103/ijot.ijot_19_22  
Solid organ transplant (SOT) recipients are at increased risk of opportunistic infections, as they are on immunosuppressive drugs. The risk increases if the cumulative immunosuppression is high, especially when the patient is treated for acute rejection episodes. Multiple opportunistic infections in the same patient are reported in SOT recipients. We report a 43-year-old man, renal allograft recipient, 15 years posttransplant, on dual immunosuppression who presented with fever, generalized skin rashes, and altered sensorium. He was recently treated with pulse methylprednisolone injections for acute graft rejection episode. He had multiple pustules all over the body, predominantly over the face, eyelids, chest, and lower limbs. Pus from the facial lesion grew Nocardia, and tissue culture of skin ulcer from the leg grew nontuberculous mycobacteria. Combined infection with these organisms posed diagnostic challenge as both can present with cutaneous manifestation, both organisms are acid-fast bacilli, and both organisms were detected and grown from the sample taken from one of the large skin ulcers. It was important to identify both the organisms from the skin ulcer as the treatment options are different.
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A case report of ABO-incompatible kidney transplant in human immunodeficiency virus-positive patient coinfected with both hepatitis B and hepatitis C viruses: A case report p. 455
Raka Kaushal, Avinash Srivastava, Kulwant Singh
DOI:10.4103/ijot.ijot_20_22  
Individuals with human immunodeficiency virus (HIV) are at increased risk for end-stage kidney disease (ESKD). Kidney transplantation is the best treatment for HIV-positive ESKD patients. There are many challenges such as interactions between antiretroviral drugs and immunosuppressants, coinfection with hepatitis B (HBV) or/and C (HCV) viruses, and a higher risk of posttransplant infections and malignancies. We should not defer HIV-positive kidney transplants perceiving these medical complexities, instead employ a multidisciplinary approach to achieve successful transplantation. For HIV-positive ESKD patients, ABO-incompatible (ABOi) kidney transplantation and considering HIV-positive kidney donors are successful strategies for increasing the donor pool. We report a case of an HIV-positive ESKD patient who had coinfection with both HBV and HCV viruses and successfully underwent an ABOi live-related kidney transplant.
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Coronavirus infection in immediate postrenal transplant period - A case report p. 458
RB Nerli, Pulkit Gupta, Priyabrata Adhikari, Neeraj S Dixit, Shridhar C Ghagane, Parveen Pathan
DOI:10.4103/ijot.ijot_97_20  
The novel coronavirus (severe acute respiratory syndrome coronavirus [SARS-CoV-2]) has spread out to most of the world with the World Health Organization (WHO) classifying it as a global pandemic. There exists very little information on the infectious course of COVID-19 in immunocompromised individuals, including transplant recipients. We report a case of a young adult who tested positive for SARS-CoV-2 in the immediate postoperative period following renal transplantation.
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Unmasking of immunoglobulin a deposits posttransplant due to COVID-19 AKI-incidental or causal – A nephrologists' dilemma a case report p. 461
Luvdeep Dogra, Manisha Sahay, Kiranmai Ismal, PS Vali
DOI:10.4103/ijot.ijot_78_20  
COVID-19 is a global pandemic with the chronically immunosuppressed transplant recipients being the most vulnerable both to infection as well as complications of COVID-19. Here, we report a case of live-related renal allograft recipient who presented with complaints of loose stools and new-onset graft dysfunction 2 years posttransplant. He tested positive for COVID-19 infection. On allograft biopsy, there were significant immunoglobulin A (IgA) deposits with no evidence of rejection or ATN or crescents or significant chronicity. The initial pretransplant biopsy of the recipient had revealed chronic glomerulonephritis with nil deposits. The donor had no evidence of hematuria or hypertension and had a preserved GFR. We, therefore, considered the possibility of the unmasking of IgA deposits posttransplantation diagnosed in a recipient with COVID-19 infection.
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Curtains up – What to expect at the start of a new laparoscopic donor nephrectomy program p. 463
Devanshu Bansal, Sanjay Mittal, Piyush Mathur
DOI:10.4103/ijot.ijot_124_21  
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Acute rejection following COVID-19 vaccine (AstraZeneca) p. 465
Prem P Varma, Vivek B Kute, Prateek Kumar
DOI:10.4103/ijot.ijot_36_22  
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