Post transplant liver biopsies (PTLB) form a cornerstone in management of transplant cases. They provide critical information regarding rejection or reoccurrence of diseases. With the development in understanding of transplant pathology new updates have come in reporting guidelines of liver transplant biopsy specimens. The recent updates also include criteria for reporting of antibody mediated rejection in liver. This review aims to cover all those aspects.

Human organ and tissue transplantation was started in India in 1962. Initially, the organ transplant was unregulated, and organ trafficking was rampant. The act governing the transplantation was passed in 1994. This has been subsequently amended in 2011, and new rules came into force in 2014. Many of the students as well as practicing physicians are not aware of the act as it is generally not a part of the curriculum. This article highlights the important components of the act and focuses on what all physicians involved in transplant should know about the legal aspects of transplantation.

Aim: The study aim was to evaluate the prevalence, risk factors, and clinical importance of abnormal elevation in liver enzyme levels in children after renal transplantation. Materials and Methods: The files of all 62 patients (mean age 10.2 years), who underwent renal transplantation at a tertiary pediatric medical center in 2001-2013, were reviewed for clinical data, including: Postoperative liver function, tacrolimus level, and serology for cytomegalovirus (CMV) and hepatitis B and C viruses. Results: The most common indication for transplantation (53%) was dysplastic hypoplastic kidney. Liver enzyme levels were abnormal in 7 patients (11%) before transplantation and 42 (67.7%) during the first 6 months following, with a peak on day 14 (P < 0.001). Seroconversion was documented during the first post-transplantation year in 9 patients (14.5%), of whom 8 (89%) were CMV IgG negative. Post-transplant abnormal levels were highest in patients who also had abnormally high-level pre-transplant levels (100%), CMV seroconversion (89%), and dysplastic kidney or nephronophthisis (80%). An abnormally elevated liver enzyme level was significantly correlated with high blood tacrolimus level, but only on post-transplant day 3 (P < 0.001). Conclusion: High liver enzyme levels are common in pediatric kidney transplant recipients, usually starting in the first post-transplant month. The etiology is probably multifactorial; drug hepatotoxicity, previous liver injury, and acute viral infection or reactivation are all likely possibilities. About 10-20% of cases are related to CMV infection.

Aim: Co-occurrence of Epstein–Barr virus (EBV) with Cytomegalovirus (CMV) is associated with an increased risk of EBV-associated posttransplant lymphoproliferative disorder (PTLD). Quantitation of EBV by real-time polymerase chain reaction (PCR) can aid the clinicians in the initiation of preemptive measures to improve the survival of the graft. Methods: The study was conducted among postrenal transplant recipients (PRTRs) who were attending the nephrology department from 2011 to 2016. Real-time quantitative PCR for EBV was performed in whole blood. PRTRs were classified into asymptomatic with altered renal parameters (Group A) and symptomatic (Group B), which were further subcategorized into Group B1 (fever with anemia, leukopenia, thrombocytopenia, or altered liver enzymes (any two), Group B2 (Group B1 + end-organ disease or only end-organ disease), and Group B3 (graft dysfunction [GDF]). The posttransplant period was also defined. DNA was extracted (Qiagen, Hilden, Germany) from whole blood, and real-time PCR was performed using QuantiTect multiplex PCR kit. Unpaired t-tests and ANOVA were used to analyze the data. Results: A total of 89 PRTRs were enrolled, of which 39.3% (n = 35) had EBV DNAemia, 43.1% during very late, 41.1% in late and 28.6% in immediate post transplant periods. EBV DNAemia ranged from 324 to 32,436 copies/ml. EBV DNAemia was found in 84% (n = 75) of symptomatic (Group B) and 16% (n = 14) of asymptomatic (Group A). Among the PRTRs with GDF (Group B3), 44% (n = 11/25) had EBV DNAemia of 2893.9 ± 1869 copies/ml. EBV DNAemia was considerably higher in PRTRs without GDF (8700.2 ± 9675.6 copies/ml) than PRTRs with GDF and the difference was statistically significant (P = 0.004). EBV DNAemia with CMV DNAemia among PRTRs was found in 21.3% (n = 19). Conclusion: High EBV DNAemia may precede PTLD or GDF; therefore, regular screening of EBV DNAemia is warranted. CMV and EBV DNAemia may also co-exist in PRTRs. As CMV is an immunomodulating virus, it increases the risk of opportunistic infections, especially EBV.

Introduction: New-onset diabetes mellitus after transplantation (NODAT) is a major complication of renal transplantation, with a prevalence rate ranging from 2% to 53% across the globe. There is no information about the prevalence of NODAT in the Nepalese population. This paper describes the demographics, clinical characteristics, and risk factors associated with the development of NODAT in renal transplant patients from Bir Hospital, Nepal. Materials and Methods: Data were retrospectively collected for 110 patients that underwent renal transplantation at Bir Hospital from December 2008 to 2015. Patients who had diabetes before undergoing the transplant and those who did not have a 6-month follow-up posttransplant were dropped from the analysis, thus leaving 97 patients for analysis. Results: The incidence rate of NODAT among all patients analyzed was 22.68/100 people. Increasing age and body weight were not found to be associated with the increased incidence of NODAT. Mother-to-offspring transplants had a higher risk of NODAT presentation in the recipient. The study did not show any association between trough levels of tacrolimus and the risk of NODAT. Conclusion: New-onset Diabetes mellitus after transplantation is a major complication in patients with renal transplants and can also increase risk for cardiovascular complications. Longitudinal studies with larger sample and longer follow-up durations are required to understand the prevalence and risk factors as well as management of NODAL in the Nepalese population Discussion: Longitudinal studies with longer follow-up and rigorous data collection are required to better quantify the burden of NODAT on renal transplant patients and address these complications wisely.

With the onset of 21^st century, organ donation (OD) has taken a big stride, still waiting for organ transplants is higher than its availability. Donating a life after one's death to someone you even do not know is one of the noble humanity causes. In Indian scenario, with the inception of Transplantation of Human Organs Act, 1994, multiple active initiatives were undertaken time to time for promoting OD; similarly, green corridors have also come in a big way for transfer of organs for interinstitutional transplantation. The institute undertook its first green corridor for OD in 2015 when liver was sent to one of the hospitals, and till date, 25 green corridors have been established where 27 organs have been shared with other institutes nationwide besides intrainstitute transplantations. Although this noble cause has taken its initial steps, still, innovations, and opportunities for promoting OD should be explored in a continuum for foreseeable better future.

Objective: To assess knowledge, attitude, and practice (KAP) of organ donation (OD) among pharmacy students. Methodology: A web-based, cross-sectional study of students pursuing different pharmacy courses was conducted. A specially designed questionnaire was used to survey the students. Results: A total of 160 students responded to survey. Nearly, three-fourth students wished to donate organs to anyone, 83.1% wanted to donate by considering the health status of the recipient, and 98.1% feel that OD should be promoted. Some negative findings were as follows: less knowledge about some uncommon organs that can be donated, for example, blood vessels, bone, intestine, and heart valves; 76.3% students do not know the process of registering while 84.4% have not registered/pledged for OD. Average knowledge about law related to OD was also poor, i.e., 1.87. Conclusion: Overall KAP for OD was positive for except for a few issues. There is need to add some OD related topic/s in the pharmacy curriculum.

Background: Diabetes occurs in substantial number of patients following renal transplantation, contributing to mortality and morbidity in particular the cardiovascular disease and infection. The prevalence and risk factors in South Indian population is not precisely clear. Our study aimed at determining the prevalence, epidemiology, and risk factors in kidney transplant recipients with posttransplant diabetes mellitus (PTDM). Methodology: This is a single-center analytical, cross-sectional, and retrospective study of adult renal transplant recipients who underwent transplant between January 2014 and December 2016. Institutional ethics committee approval was obtained. Results: Of 149 patients transplanted, 115 were included for study. Twenty-six patients (22.6%) developed PTDM. The mean age of the PTDM group was 35.2 years and 76.92% were males. Univariate analysis revealed age (P < 0.001), sex (P < 0.04), smoking (P = 0.02), history of diabetes mellitus (P < 0.001), dialysis vintage (P < 0.04), and induction therapy (P < 0.01) to be significant risk factors. The dosage of tacrolimus and prednisolone at the time of discharge and at months 3 & 6 post-transplant was significantly higher in PTDM group. Multivariate logistic regression analysis indicated age (odds ratio [OR] = 3.77), male gender (OR = 2.35), family history (OR = 4.54), dialysis vintage of >1 year (OR = 1.75), and induction therapy (OR = 2.0) to be independent risk factors for PTDM. Conclusions: There is high risk of developing diabetes after transplant with one quarter of this south Indian cohort developing PTDM. Older age, male sex, family history of diabetes, dialysis vintage, and use of induction therapy were independent risk factors for PTDM.

Context: Musculoskeletal pain is a frequent manifestation in postrenal transplant recipients that caused by several diseases. Clinically used calcineurin inhibitors including cyclosporine A and tacrolimus can induce calcineurin inhibitor-induced bone pain syndrome which is characterized by severe pain, especially in both lower extremities. Aims: The aim of this study to investigate clinical studies about diagnostic and therapeutic modalities in renal transplant recipients. Settings and Design: In this retrospective study, patients with calcineurin inhibitor-induced pain syndrome after kidney transplantation were selected. Materials and Methods: This paper was searched via electronic PubMed and Google Scholar databases. Few full-text original articles in kidney transplant recipients were extracted. In this study, 18 articles were assessed for eligibility and 12 renal transplant recipients in 9 case reports were included. Statistical Analysis Used: Categorical variables as percentage, normally distributed measurements as mean ± standard deviation, and nonnormally distributed measurements as median and interquartile range were recorded. Results: Of 12 patients, 7 (58.3%) patients were male and 5 (41.6%) were female. At this study, bone magnetic resonance imaging (MRI) was diagnostic modality of choice. Radionuclide scintigraphy is also helpful. The most effective treatment of calcineurin inhibitor-induced pain syndrome consisted reduction dose of calcineurin inhibitors, calcineurin inhibitors change to another drug from the same drug class or mammalian target of rapamycin inhibitors. Conclusion: This study demonstrates that bone MRI is diagnostic modality of choice in patients with calcineurin inhibitor-induced pain syndrome. Moreover, reduction of calcineurin inhibitors and switching of immunosuppressants show the most effective treatment in these patients.

Background: Fifteen percent of adults and 20%–30% of pediatric patients develop renal failure, results from structural urological abnormalities. Successful renal transplantation depends partly on a bladder which has adequate capacity, good compliance, and efficient voluntary emptying. Urinary bladder rehabilitation with augmentation or diversion is necessary before transplant in these patients to achieve good graft outcome. We, hereby report our last 10 years' experience of such patients undergoing kidney transplant in abnormal bladder. Materials and Methods: A total of 14 patients underwent renal transplantation in rehabilitated bladder from 2006 to 2016. Demographic details, prereconstruction bladder and urodynamic findings, and type of pretransplant reconstruction were recorded. Posttransplant creatinine levels, graft survival at 7 days, 3 months, 1 year, and 3 years were recorded. Results: Mean (± standard deviation) serum creatinine posttransplant at 7 days, 3 months, 1 year, and 3 years was 0.9 (±0.20), 1.58 (±0.65), 1.92 (±1.02), and 2.47 (1.17) mg/dl, respectively. Four patients developed rejection within 6 months of transplant. Kidney biopsy was suggestive of acute cellular rejection in all cases, which was treated successfully. At three years follow-up, four patients who had rejection-have rising creatinine levels and diminishing renal functions. No patient needed dialysis support till last follow-up. All these four patients had rejection, urinary tract infection (UTI) episodes and pyelonephritis in the past. Conclusion: Native bladder is the best reservoir for urinary storage and drainage. The main cause of graft dysfunction in rehabilitated bladder is UTI as a result of poor hygiene, contamination during clean intermittent self-catheterization (CISC) and noncompliance for CISC leading to high residual urine. Controlling frequent attacks of UTI posttransplant is essential, otherwise long-term graft survival and function will deteriorate faster and might trigger rejection.

Renal biopsy is often needed to diagnose posttransplant graft dysfunction. Although it is very safe due to availability of real-time imaging, complications do occur. We report a rare case of anterior abdominal wall vessel injury during allograft biopsy resulting in a large perigraft hematoma. It mimics a subcapsular hematoma due to intrarenal vessel injury leading to diagnostic confusion. We detected a partially thrombosed pseudoaneurysm 3 weeks after the biopsy which had feeders from superior and inferior epigastric artery confirmed by injecting contrast into the pseudoaneurysm. The pseudoaneurysm is due to injury to small branch of these arteries. We used a novel and a cost-effective therapeutic intervention to treat this pseudoaneurysm. We injected thrombin percutaneously into pseudoaneurysm which enables thrombosis of the feeder vessels preventing recurrence.

Cerebrovascular accidents are a life-threatening complication in renal transplant recipients. The risk increases with old age, diabetic neuropathy, and peripheral vascular disease. Ischemic stroke contributes to two-thirds of stroke in renal transplant recipients. As they receive immunosuppressives, they are more susceptible to a spectrum of opportunistic infections. Central nervous system infections such as tuberculosis and fungal infections can present as ischemic stroke. Cerebral infarction in meningoencephalitis is due to strangulation of vessels by exudates which causes vasculitis with inflammation, spasms, constriction, and thrombosis. This case report is a rare presentation of stroke in renal transplant recipient due to an infective etiology. The patient was managed appropriately by understanding this underlying pathophysiologic mechanism.

Trimethoprim-sulfamethoxazole (TMP-SMX) is an antimicrobial agent used in a variety of infections. Adverse reactions are more common in patients with AIDS but occasionally occur in immunocompetent patients. Renal toxicity is usually a hypersensitivity reaction to the sulfa component and manifests as interstitial nephritis or sulfa crystallization in the renal tubules. Reversible hyperkalemia is a rarely reported side effect of TMP-SMX therapy attributed to TMP inhibition of potassium secretion in the distal renal tubule in a manner similar to the potassium-sparing diuretic, amiloride. We report a case of hyperkalemia associated with TMP-SMX occurring in a 32-year-old renal transplant recipient with no other risk factors for hyperkalemia. He was treated with TMP-SMX (800 mg + 160 mg) two tablets QID for suspected pneumocystis jiroveci pneumonia. He developed severe hyperkalemia on day 9 posttherapy. Hyperkalemia reverted to normal with withdrawal of trimethoprim.

Renal transplant recipients are at an increased risk for opportunistic infections especially in the first year post transplant. Ascertaining the cause of infection requires an extensive clinical and diagnostic evaluation. Here we report a case of pyrexia of unknown origin (PUO) in a renal transplant recipient, who after extensive conventional evaluation was negative. Later F18 FDG PET/CT detected the cause of fever focus as prostatic abscess. This case has been reported to highlight the utility of F18 FDG PET/CT in post renal transplant setting to evaluate the cause of fever.

The risk of malignancy in renal transplant patient is higher compared to general population. The prolonged immunosuppression received by these patients is considered to be one of the risk factors for the development of malignancies. Majority of the malignancies are epithelial in nature and predominantly are squamous cell carcinoma. The sites where squamous cell carcinoma develops in postrenal transplant patients include skin, lip, cervix, vulva, penis, scrotum, anus, and rarely lung. Very few cases of squamous cell carcinoma of the tongue after renal transplant have been documented in the literature. We present one such case where the patient developed squamous cell carcinoma of the tongue 16 years after renal transplant.