Living with chronic kidney disease (CKD) is associated with hardships for patients and their care-partners. Empowering patients and their care-partners, including family members or friends involved in their care, may help minimize the burden and consequences of CKD-related symptoms to enable life participation. There is a need to broaden the focus on living well with kidney disease and re-engagement in life, including an emphasis on patients being in control. The World Kidney Day (WKD) Joint Steering Committee has declared 2021 the year of “Living Well with Kidney Disease” in an effort to increase education and awareness on the important goal of patient empowerment and life participation. This calls for the development and implementation of validated patient-reported outcome measures to assess and address areas of life participation in routine care. It could be supported by regulatory agencies as a metric for quality care or to support labelling claims for medicines and devices. Funding agencies could establish targeted calls for research that address the priorities of patients. Patients with kidney disease and their care-partners should feel supported to live well through concerted efforts by kidney care communities including during pandemics. In the overall wellness program for kidney disease patients, the need for prevention should be reiterated. Early detection with a prolonged course of wellness despite kidney disease, after effective secondary and tertiary prevention programs, should be promoted. WKD 2021 continues to call for increased awareness of the importance of preventive measures throughout populations, professionals, and policy-makers, applicable to both developed and developing countries.

Immune response directed towards the allograft is a major barrier to the longterm graft survival in kidney transplantation. The importance of various tools for histocompatibility testing including the significance of panel reactive antibodies in transplant immunology is discussed here.

Background: ABO incompatible (ABOi) transplantation is a relatively newer option for renal transplant. Despite the encouraging results and the presence of organ shortage, it is still not routine in many developing countries. This can be attributed to the lack of experience, lack of technical infrastructure, and financial limitations. Objectives: Our study aimed to compare the outcomes of living-donor ABOi renal transplantation with matched recipients of ABO-compatible (ABOc) transplantation. We also assessed the impact of Vitamin D deficiency on posttransplant outcomes in terms of graft function and rejections in these groups. Methods: We retrospectively analyzed the results of 33 ABOi living-donor kidney transplants performed between January 2013 and June 2016 at our center. We compared patient and graft survival, acute rejection episodes, Vitamin D status, and graft function of the ABOi group with an equal number of matched live-related ABOc KTs done during the same time period. Results: The patient survival in both the groups was 97%; however, death-censored graft survival was 94% in the ABOi recipients versus 100% in ABOc group over a mean follow-up of 14–15 months, respectively. Graft function was overall better in the ABOc recipients, with statistical significance seen at 6 and 12 months posttransplant. We also observed a significantly higher incidence of acute antibody-mediated rejections (ABMRs) in the ABOi cohort, with 11 episodes of ABMR versus just 2 in the ABOc recipients (P = 0.005). Vitamin D deficiency was associated with higher levels of anti-ABO antibody and increased development of ABMR due to anti-ABO antibodies (P = 0.01). Conclusions: ABO incompatible transplantation is an option with excellent patient and graft survival; results almost comparable to the ABO compatible grafts. However, in our study, ABOi transplants were associated with higher risk of acute ABMR. These episodes were amenable to treatment, and thus, the overall graft survival had similar outcomes. Vitamin D deficiency was associated with increased ABMR in ABOi cohort of renal transplantation.

Introduction: Erectile dysfunction (ED), defined as an inability to obtain or maintain an erection adequate for satisfactory sexual function, is present in up to 50–80% of patients with chronic kidney disease (CKD) (1). The rate of erectile dysfunction (ED) in patients with chronic kidney disease (CKD) was shown to be 75%, whereas it decreased to 59% in kidney transplantation recipients (KTRs). Materials and Methods: A 264 Renal Transplant Patient is included in this study. Both male and female patient included in this study. The International Index of Erectile Function questionnaire – 5 (IIEF-5) (SHIM) Scoring systems is used. Results: Total 264 patients are included in the study.34 patients not responded. According to SHIM score 4 patients have sever erectile dysfunction, 21 patient have moderate erectile dysfunction, 78 patients have mild to moderate erectile dysfunction, 104 patients have mild erectile dysfunction and 23 patients have no erectile dysfunction. After 1 year of renal transplant, according to SHIM score 3 patients have sever erectile dysfunction,14 patient have moderate erectile dysfunction, 47 patients have mild to moderate erectile dysfunction, 67 patients have mild erectile dysfunction and 99 patients have no erectile dysfunction. Conclusion: IIEF-5 is an effective means to establish and diagnose the erectile dysfunction. Advance age, prolonged dialysis, diabetes mellitus and smoking were important risk factors for erectile dysfunction. The incidence of ED in patients with ERSD and KTRs is quite high, and its management is particularly difficult due to many interfering factors.

Context: There are concerns regarding the use of induction immunosuppression during deceased donor renal transplantation in the coronavirus disease 2019 (COVID-19) pandemic and whether lower doses may suffice. Aims: We aimed to compare different induction immunosuppression regimens in deceased donor renal transplantation during the COVID-19 pandemic. Settings and Design: A multicenter, prospective observational study of patients undergoing deceased donor renal transplantation during the COVID-19 pandemic in Southern Kerala from April to June 2020 with differing induction immunosuppression and follow-up for at least 6 months. Subjects and Methods: Patients were from Government (Group A) and Private hospitals (Group B). Induction immunosuppression included low dose rituximab and/or low dose anti-thymocyte globulin in group A and higher dose induction with anti-thymocyte globulin or basiliximab in Group B. Graft function at 1 and 6 months, infectious complications, and cost of induction immunosuppression were compared. Statistical Analysis Used: Mood's median, Chi-square, Fisher Exact, and Mann–Whitney U test. Results: Of eleven deceased donor kidney transplantations, six were from Group A and 5 from Group B. Three in Group A and two in Group B had reversible antibody-mediated rejections. Median serum creatinine (interquartile range) in both groups at 1 month was 1.35 (1.1, 3) and 1.5 (1.1, 3.5) mg/dl, respectively, and by 6 months 1.5 (1.05, 2.33) mg/dl and 1.7 (1.15, 2.6) mg/dl, respectively. Two patients in Group A died, one due to Gram-negative septicemia at the 2^nd month and the second by the 3^rd month following a cardiovascular event. Mean cost of induction immunosuppression in both groups was INR 40,500 ± 22,827 and 107,200 ± 57,595 (P = 0.01). There was no difference in infection episodes in both groups. Rituximab in a dose of 100 mg was used as induction in 4 patients with comparable graft functions and cost-benefit with a mean cost of INR 33,750 ± 26,196 and Rs. 92,000 ± 53,715 in the rituximab and nonrituximab groups, respectively (P = 0.056). Conclusions: Low-dose induction immunosuppression in the COVID pandemic was cheaper with comparable graft functions at 1 and 6 months.

Context: Diarrhea is one of the important causes of morbidity and graft dysfunction in renal transplant recipients. Aims: We aimed to study the risk factors and causes of diarrhea in renal transplant recipients and to assess the impact of diarrhea on graft function. Settings and Design: This was a retrospective observational study. Materials and Methods: A retrospective analysis of 912 renal allograft recipient records who underwent renal transplantation between January 2006 and June 2019 was performed. Patients with severe diarrhea requiring hospitalization were included. Investigations like stool microscopy including modified acid-fast stain and stool culture were performed. Statistical Analysis Used: Mean was calculated for normally distributed variables and median for not-normally distributed parameters. P < 0.05 was considered statistically significant. Univariate analysis was done to assess risk factors for diarrhea. Results: There were a total of 618 diarrheal episodes in 149 (16.3%) patients. Significant risk factors were deceased donor renal transplantation (58 [39%]) (P = 0.00024), the use of induction immunosuppression (44 [29.5%]) (P = 0.0002), and antirejection therapy (ART) (60 [40.3%]) (P = 0.0034). Infectious cause was identified in 85 (57%) patients, and cytomegalovirus was the predominant agent. Entamoeba histolytica (16 [10.7%]) was the predominant protozoal etiology. Temporary graft dysfunction during diarrheal episode occurred in 67 (45%) patients. Conclusions: Diarrhea occurred in 16.3% of renal transplant recipients. Deceased donor source, the use of induction immunosuppression, and ART were significant risk factors. Infectious cause was identified in 57% of diarrheal episodes. Following diarrhea, permanent graft dysfunction occurred in 10.7% of patients.

Background: India performed 7936 kidney transplantation operations in 2018 with living donor as the source in 85%. Identifying a living kidney donor (LKD) is difficult due to medical, social, and regulatory barriers. In addition, only a proportion of patients who volunteer may be able to donate eventually. Despite living donors being the predominant source, there are very few studies addressing the factors influencing living donor kidney donation in India. Methods: We analyzed data from our prospective LKD registry between July 1, 2011 and June 31, 2018. Demographic details, medical history, serum creatinine, and measured glomerular filtration rate (mGFR), blood pressure and the eventual outcome of LKD evaluation, including reason for noneligibility were collected. In a prospective cohort of 12 LKDs, renal functional reserve was studied using protein loading and dietary protein intake was measured from urine urea nitrogen excretion. Results: Over a period of 81 months, 316 LKDs were enrolled in our program. On 101 instances factors related to recipients prevented transplantation and on 92 occasions donor related factors precluded donation. Among 182 medically eligible LKDs with no evidence of CKD, only 33% had mGFR >90 ml/min/1.73 m². Based on our institutional criteria, 22% of LKDs with mGFR <70 ml/min/1.73 m² were ineligible solely based this criterion. Eventually, only 32% of enrolled LKDs were accepted for donation. Dietary protein intake was low in all 12 LKDs studied, only one had mGFR >90 ml/min/1.73 m². Eight LKDs with mGFR <90 ml/min/1.73 m² showed renal functional reserve of more than 20% with protein loading. Conclusion: Only one-third of voluntary kidney donors enrolled for evaluation were eventually able to donate their kidney. Low mGFR in otherwise apparently healthy LKDs was an important reason precluding kidney donation. Only 33% of individual found medically fit for donation had a mGFR ≥90 ml/min/m² at our center. Low dietary protein intake may be a factor contributing to low mGFR in healthy LKDs.

Objective: The objective of the study is to assess the graft and patient outcome after desensitization in human leukocyte antigen incompatible kidney transplantation (KT) with positive baseline complement-dependent cytotoxic (CDC) crossmatch and high mean fluorescein intensity (MFI) of donor-specific antibodies (DSA). Methods: This was a retrospective study conducted at Jaypee Hospital, Noida. This study included highly sensitized patients who were transplanted with positive CDC and DSA >10,000 MFI for single antigen or >5000 MFI for multiple donor antigens. The patient's renal outcomes were documented. The desensitization protocol consisted of rituximab, therapeutic plasma exchanges (TPE), and thymoglobulin. Results: A total of five patients who had positive CDC crossmatch with very high level of preformed DSA underwent KT. Three patients had end-stage renal disease due to diabetic kidney disease while other two due to autosomal dominant polycystic kidney disease and chronic glomerulonephritis. All the patients were on dialysis. The MFI by Luminex single antigen bead assay for Class I varied from 1657 to 23440 and for Class II varied from undetectable to 11120. The mean number of pretransplant TPE sessions given per patient was 7.8 ± 2.68 and posttransplant TPE sessions per patient was 0.8 ± 0.45. The mean follow-up period was 308.2 days. Mean creatinine on the day of discharge was 0.58 ± 0.17 mg/dL. None of the patients had any postoperative infections or rejections. Conclusion: The current report showed favorable short-term patient and graft outcomes post-KT without any postoperative infections or rejections with desensitization therapy comprising of rituximab, TPE, and thymoglobulin induction.

Objective: The logistical issues, limited resources, and surgical capacity are the challenges to simultaneous kidney exchange transplant surgeries in India. We report the first single-center 5-way nonsimultaneous kidney exchange cycle from India without donor renege. The challenges and solutions for the same are discussed. Methods: Five donor–recipient pairs (DRPs) participated in 5-way kidney exchange cycle after permission of Institutional and Gujarat State Level Authorization Committee for organ transplantation. Four DRP were ABO-incompatible and the fifth was compatible. Results: Two DRP were operated on November 22 and three on November 23, 2018. One bridge donor wait time was 1 day. All five recipients were discharged on November 30, 2018, without any medical or surgical complication; normal kidney allograft function and donor renege. We have increased chain length gradually from 2-way (June 2000), 3-way (February 2013), 4-way (April 2016), 5-way (November 2018), 6-way (February 2019), and 10-way (January 2020) in 440 kidney exchange transplants at our institute. We have used compatible pairs in gradually increasing chain length from 2-way (May 2012), 3-way (August 2013), 4-way (July 2018), 5-way (November 2018), and 6-way (February 2019) to increase transplant for difficult to match pairs. Conclusions: To the best of our knowledge, this is the first single-center 5-way kidney exchange cycle from India. Increasing chain length has the potential to offer better quality of matching and transplants rates for difficult-to-match pairs in kidney exchange.

Patients with liver disease can have varied cardiac manifestations including pulmonary arteriovenous dilatation. The stress of surgery associated with catecholamine surges can also potentiate stress-related changes. We report management of hypoxemia in a patient who underwent liver transplantation. Although her preoperative oxygenation (SpO₂ 97%) measured 2 weeks earlier was normal, she manifested hypoxemia on the day of surgery and cardiovascular failure perioperatively. Postoperative investigations revealed a stress cardiomyopathy. The cause of persistent and refractory hypoxemia was uncertain in the context of normal preoperative tests. However, she responded immediately to inhaled nitric oxide, suggesting a correction of ventilation perfusion dynamics. We wish to highlight a possible role of nitric oxide in postoperative liver transplant patients with refractory hypoxemia of uncertain etiology.

Dreaded complication of kidney transplantation in a sensitized patient is hyper-acute rejection immediately after vascular anastomosis. Although pretransplant complement-dependent cytotoxic cross match (CDC) has been the gold standard for many years, this assay is not perfect. The Luminex-based anti-HLA antibody detection assay is more sensitive and specific. While performing live-related kidney transplantation, luminex cross match is routinely performed but in a situation like deceased donor transplantation, in view of time constraints, we do CDC cross match and go ahead with transplantation if the result is negative (Cell lysis <10%). Here, we present two cases of deceased donor transplantation where CDC cross match was negative, based on this report, we went ahead with kidney transplantation but report of Luminex cross match turned out to be positive after the transplantation was already over. Both the recipients had the features of hyper acute rejection. One patient could be salvaged but the other lost the graft.

In this report, we present our experience with combined en bloc combined heart and liver transplantation performed in 2015 on a 29-year-old male with Ebstein's anomaly with cardiac cirrhosis and decompensation. Entire procedure was done under cardiopulmonary bypass. Portocaval shunting was done during the procedure to reduce bowel congestion. He remains well on regular follow-up at 4 years. This is the first procedure to be reported from India.

Hemophilia A is caused by a genetic mutation affecting the levels of factor VIII in serum. With improvement in management and widespread availability of factor VIII, the life expectancy of hemophiliac patients has increased. The change in the history of hemophiliacs has led to the increased surge of chronic diseases in such patients. End-stage renal disease is rarely seen among hemophiliacs and institution of renal replacement therapy is controversial not only for the lack of literature but also differing opinions on protocols for factor VIII replacement. We describe here a case of a moderate hemophiliac A patient with end-stage renal disease undergoing renal replacement therapy initially hemodialysis and later on undergoing kidney transplantation. The patient successfully underwent live unrelated kidney transplant without any major complications and is currently healthy with good graft function. Patients with hemophilia A can successfully undergo renal replacement therapy under factor VIII cover.

Renal insufficiency is a distinct possibility in patients with congenital lower urinary tract abnormalities even though they are managed right from early childhood. Previously, such patients were not considered candidates for renal transplantation due to the fear of abnormal bladder affecting the graft kidney too. In the current era, it has been shown that the graft and patient survival rates are similar in such patients to those with normal lower urinary tract, if the urological abnormalities are managed well, before the transplantation. We present a case of successful renal transplantation in a pediatric patient with renal insufficiency due to pure urogenital sinus.

Inflammatory bowel disease (IBD) is rarity after renal transplantation. Immunosuppressive therapy forms the cornerstone for the treatment of IBD. Ideally, IBD should not occur in this immunosuppressive state. However, local activation and dysregulation in the mucosal immune system has been proposed after tacrolimus and mycophenolate after renal transplantation. Our case report describes a very early-onset IBD after renal transplant which is hardly reported in literature.

Transplant in COVID era is a challenging task given a paucity of data and limited experience worldwide. A 35-year-old male patient with chronic kidney disease on dialysis for the past 9 months underwent successful living-related donor transplant with his father (aged 64 years) as donor at our center. In this case, donor was diagnosed with reverse-transcription polymerase chain reaction (RT-PCR)-confirmed COVID-19 during evaluation, and he was managed with supportive care and comprehensive social distancing at home. Donor was asymptomatic throughout this period. Interval from positive to negative RT-PCR for nasopharyngeal swab test was 37 days. Interval from negative RT-PCR to kidney transplant was 33 days. Later, recipient and donor were discharged with negative RT-PCR posttransplant. At 71 days of follow-up, both recipient and donor have stable kidney function with normal urinalysis. Hence, prospective donor with a history of COVID-19 infection can be taken for transplant after thorough pretransplant evaluation and having two negative RT-PCR reports after infection, normal imaging, and additional preprocedural negative RT-PCR testing.

Fungal infections have devastating consequences in a renal transplant recipient. The risk of mortality is high despite early diagnosis and appropriate therapy. Here, we report the case of a 62-year-old male with multiple comorbidities who developed a deep-seated cerebellar abscess due to disseminated aspergillosis. Neuroimaging features and galactomannan features were critical in aiding the diagnosis as the abscess was difficult to access surgically. Early institution of appropriate antifungal therapy along with reduction in immunosuppressive medications helped in the successful treatment of a surgically difficult to access cerebellar abscess.

Amyloidosis is an infiltrative disease where amyloid fibrils get deposited in the extracellular space. Inflammatory arthritis, chronic infections, and malignancies are some known etiologies. Liver is commonly involved in amyloidosis, more common in primary (AL) than secondary (AA) amyloidosis. It is a perplexing diagnosis as it usually presents with nonspecific symptoms and minimal laboratory derangements. In this study, the patient had ankylosing spondylitis as an existing risk factor, but renal cell carcinoma detected in the native kidneys after transplantation accelerated the liver decompensation. This case highlights the importance of excluding liver amyloidosis in patients of systemic amyloidosis as liver amyloidosis can be clinically silent pretransplantation.

Coronavirus disease (COVID-19) caused by novel coronavirus (SARS-CoV-2) infection is still incompletely understood in transplantation, and there have been a few reports of multisystem inflammatory syndrome in adults (MIS-A) like illness in transplant patients. Herein, we report a case of MIS-A in a renal transplant that ultimately was successfully managed. The case was a 32-year-old man, transplanted 3 years ago, with chronic graft dysfunction and no other comorbidities. He presented with a 3-day history of fever and abdominal pain with no respiratory complaints. The patient had multi-organ involvement in the form of acute pancreatitis, severe diarrhea, acute kidney injury, and shock. Inflammatory markers including D-dimer and C-reactive protein were elevated. Chest radiology showed bilateral haziness on admission. The patient had two consecutive SARS CoV 2 reverse transcription–polymerase chain reaction (RT PCR) tests negative initially but eventually SARS CoV 2 antibody test came positive. The patient was managed initially with broad-spectrum antibiotics, and after confirmation of MIS-A, steroids, intravenous immunoglobulin, and anticoagulation were administered. The patient survived and was discharged on the 29^th day of admission. Our reports highlight that MIS-A should be suspected in atypical cases irrespective of COVID-19 tests and should be confirmed with repeated RT-PCR and SARS-CoV-2 antibody tests.

Acute kidney injury (AKI) remains a major complication after transplantation; its common causes include acute rejection and urinary tract obstruction. Here, we report an unusual case of a 16-year-old renal transplant patient with congenital anomalies of the kidney and urinary tract (CAKUT) and anorectal malformation. She developed AKI owing to obstructive nephropathy caused by impacted stool in the colon. Our patient presented with complaints of hypertension and facial edema. She had a neurogenic bladder and a history of surgery for anal atresia. Abdominal computed tomography revealed renal hydronephrosis in the transplanted kidney and a mass of impacted stool in the sigmoid colon and rectum that compressed the neck of the bladder. Despite maintenance of daily defecation, the impacted stool had accumulated over several years; however, softening and removing the stool improved kidney function. Defecation management is therefore important in patients with CAKUT and anorectal malformation.

Subcutaneous opportunistic fungal infections are rarely encountered in renal transplant recipients. Phaeohyphomycosis is one such fungal infection caused by the members of dematiaceous fungi affecting predominantly the skin and subcutaneous tissue. Herein, we report the case of histopathological and culture-proven subcutaneous phaeohyphomycosis presenting as a recurrent abscess. The patient was treated with wide surgical excision of the lesion along with antifungal therapy. We also attempted successfully autologous skin grafting for the raw area of skin.