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Changing spectrum of CMV disease. Is it the time for universal CMV prophylaxis? An experience at our center
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indian journal of transplantation 9 (2015) 47–60
Conclusions: Graft biopsy remains ‘‘gold standard’’ in management of transplant patients with allograft dysfunction. Major pathologies have excellent outcome if timely and adequately treated. Mixed acute rejections have worst clinical outcomes. http://dx.doi.org/10.1016/j.ijt.2015.09.003 Abstract #: ISOT2015-80 Changing spectrum of CMV disease. Is it the time for universal CMV prophylaxis? An experience at our center Sindhu Kaza, R. Dharshan, P. Ravindra, P. Shankar Kasturba Medical College, Manipal, India Background: Cytomegalovirus (CMV) is one of the most frequently encountered opportunistic viral pathogens in renal transplantation (RT). The spectrum of CMV infection ranges from latent infection to asymptomatic viral shedding to lifethreatening multisystem disease. Current KDIGO/ATS guidelines recommend that RTRs (except in D-/R-CMV serology) receive chemoprophylaxis for CMV infection with oral ganciclovir or valganciclovir for at least 3 months after transplantation and for 6 months after treatment. Aims: To study clinical profile, management and outcomes of cytomegalovirus disease (CMVD) after RT at our center before and after routine universal valganciclovir prophylaxis. Methodology: All patients who were diagnosed with post RT CMV disease from February 2014 to July 2015 were enrolled. Patients transplanted before January 2015 received valganciclovir prophylaxis for 100 days only if they received induction with anti-thymocyte globulin (ATG) or had a CMV serology D +/R . All patients transplanted after January 2015 received universal chemoprophylaxis with valganciclovir for 100 days and for 200 days if they received induction with ATG. CMVD was diagnosed if CMV infection was accompanied by clinical signs and symptoms. For analysis, patients were divided into three groups: Patients with (1) late CMV disease (>1yr posttransplant), (2) early CMV disease (<1 yr post-transplant) and (3) RTRs' after January 2015. Their clinical and immunosuppression details, treatment, response, outcomes were evaluated. Results: Out of 8 cases of CMVD diagnosed during the study period three cases belonged to group 1, five to group 2 and none in group 3. 31 patients received live RT during the study period, out of which 11 patients were transplanted after February 2015 and received universal prophylaxis with valganciclovir. All patients had D+/R+ pre-transplant CMV serology and mean CNI levels were within normal range at the time of diagnosis of CMVD. Only 2 out of 8 patients received induction (basiliximab). In group 1 all patients were on CSA/AZA/Steroids with mean duration for post-transplant CMVD being 8years. They had predominant extra renal manifestations with no leucopenia. 2 out of 3 patients had CMV diagnosed on histopathology with negative blood CMV DNA PCR. All of them responded well to anti-CMV treatment with good patient outcomes. In group 2 all patients were on TAC/MMF/Steroids with mean duration for CMVD being 72 days post-transplant. Most common presentation was leucopenia, severe CMVD and life. Conclusions: The incidence of CMV disease was 41.6% in patients with no/basiliximab induction. Early CMVD had a high incidence of life threatening opportunistic pathogens resulting in a very high mortality (80%). Late CMVD had milder nonleucopenic extra renal disease with improved patient outcomes. http://dx.doi.org/10.1016/j.ijt.2015.09.004
Abstract #: ISOT2015-89 A cross-sectional study of renal donors D. Shivakumar, P. Abeesh, C. Vasudevan, S. Ilango, V. Balaraman Government Kilpauk Medical College, Chennai, India Background: In India, for renal transplant program, the donor pool is mainly from living related donors. The evaluation of donor is done meticulously to ensure he/she is healthy and fit for donation. Also it is made sure that the donor is not at increased risk of renal disease in the future. After donating a kidney, the remaining kidney increases its function to compensate for its lost pair. We in this study evaluated donors of our institute after kidney donation. Aims: To assess for new onset proteinuria, anaemia, hypertension and diabetes during post donation period and the current renal function status of donors & to compare eGFR with GFR measured by DTPA renogram. Methodology: This cross sectional study done during August 2013 to February 2014 included renal donors of minimum of 3 months post donation. Their histories and previous medical records were reviewed and they were meticulously examined. They underwent urine analysis including spot PCR (Protein Creatinine ratio), complete blood count with peripheral smear study and their fasting blood sugar (FBS) was tested. Renal function was assessed by serum creatinine (Modified Jaffes' method) and GFR was estimated using Cockcroft–Gault (CG) formula, MDRD and CKD EPI creatinine equations. Estimated GFR derived through the above formulae were compared with GFR measured by 99mTc-DTPA renogram method so as to assess the utility of these equations in our study population. Renal imaging done by ultrasonography and renal size was noted. All the results and observations were compared and analyzed with their pre donation data. Statistical analysis was done using SPSS version 19.0. Results: Out of 30 renal donors 22 (73.3%) were females and 73.3% (22/30) of the donors were in the fourth and fifth decade. During the median period of 29 months (4–150 months) post transplant, there was neither significant raise in proteinuria, nor significant fall in haemoglobin. No significant variation in both systolic and the diastolic blood pressure. Though donors had significant raise in fasting blood sugar profile (84.50 vs. 91.90 p = 0.001), none of them developed frank diabetic status. There was significant fall in GRF estimated by all the three equations. GFR measured by 99mTc-DTPA renogram method also showed significant fall. The remnant kidney mean surface area was increased significantly (4082.8 vs. 5082 mm2, p = 0.001). There was significant increase in the GFR of the remnant kidney during post donation period (50.87 vs. 80.77 ml/mt, p = 0.001). None of the equations for estimating GFR had significant correlation with GFR measured by DTPA during both pre and post donation period. Conclusions: There was significant raise in new onset impaired fasting glucose among donors in post donation period. There was significant increase in mean surface area and GFR of remnant kidney. None of the equations for estimating GFR had significant correlation with GFR measured by DTPA in our study group. http://dx.doi.org/10.1016/j.ijt.2015.09.005
indian journal of transplantation 9 (2015) 47–60
Conclusions: Graft biopsy remains ‘‘gold standard’’ in management of transplant patients with allograft dysfunction. Major pathologies have excellent outcome if timely and adequately treated. Mixed acute rejections have worst clinical outcomes. http://dx.doi.org/10.1016/j.ijt.2015.09.003 Abstract #: ISOT2015-80 Changing spectrum of CMV disease. Is it the time for universal CMV prophylaxis? An experience at our center Sindhu Kaza, R. Dharshan, P. Ravindra, P. Shankar Kasturba Medical College, Manipal, India Background: Cytomegalovirus (CMV) is one of the most frequently encountered opportunistic viral pathogens in renal transplantation (RT). The spectrum of CMV infection ranges from latent infection to asymptomatic viral shedding to lifethreatening multisystem disease. Current KDIGO/ATS guidelines recommend that RTRs (except in D-/R-CMV serology) receive chemoprophylaxis for CMV infection with oral ganciclovir or valganciclovir for at least 3 months after transplantation and for 6 months after treatment. Aims: To study clinical profile, management and outcomes of cytomegalovirus disease (CMVD) after RT at our center before and after routine universal valganciclovir prophylaxis. Methodology: All patients who were diagnosed with post RT CMV disease from February 2014 to July 2015 were enrolled. Patients transplanted before January 2015 received valganciclovir prophylaxis for 100 days only if they received induction with anti-thymocyte globulin (ATG) or had a CMV serology D +/R . All patients transplanted after January 2015 received universal chemoprophylaxis with valganciclovir for 100 days and for 200 days if they received induction with ATG. CMVD was diagnosed if CMV infection was accompanied by clinical signs and symptoms. For analysis, patients were divided into three groups: Patients with (1) late CMV disease (>1yr posttransplant), (2) early CMV disease (<1 yr post-transplant) and (3) RTRs' after January 2015. Their clinical and immunosuppression details, treatment, response, outcomes were evaluated. Results: Out of 8 cases of CMVD diagnosed during the study period three cases belonged to group 1, five to group 2 and none in group 3. 31 patients received live RT during the study period, out of which 11 patients were transplanted after February 2015 and received universal prophylaxis with valganciclovir. All patients had D+/R+ pre-transplant CMV serology and mean CNI levels were within normal range at the time of diagnosis of CMVD. Only 2 out of 8 patients received induction (basiliximab). In group 1 all patients were on CSA/AZA/Steroids with mean duration for post-transplant CMVD being 8years. They had predominant extra renal manifestations with no leucopenia. 2 out of 3 patients had CMV diagnosed on histopathology with negative blood CMV DNA PCR. All of them responded well to anti-CMV treatment with good patient outcomes. In group 2 all patients were on TAC/MMF/Steroids with mean duration for CMVD being 72 days post-transplant. Most common presentation was leucopenia, severe CMVD and life. Conclusions: The incidence of CMV disease was 41.6% in patients with no/basiliximab induction. Early CMVD had a high incidence of life threatening opportunistic pathogens resulting in a very high mortality (80%). Late CMVD had milder nonleucopenic extra renal disease with improved patient outcomes. http://dx.doi.org/10.1016/j.ijt.2015.09.004
Abstract #: ISOT2015-89 A cross-sectional study of renal donors D. Shivakumar, P. Abeesh, C. Vasudevan, S. Ilango, V. Balaraman Government Kilpauk Medical College, Chennai, India Background: In India, for renal transplant program, the donor pool is mainly from living related donors. The evaluation of donor is done meticulously to ensure he/she is healthy and fit for donation. Also it is made sure that the donor is not at increased risk of renal disease in the future. After donating a kidney, the remaining kidney increases its function to compensate for its lost pair. We in this study evaluated donors of our institute after kidney donation. Aims: To assess for new onset proteinuria, anaemia, hypertension and diabetes during post donation period and the current renal function status of donors & to compare eGFR with GFR measured by DTPA renogram. Methodology: This cross sectional study done during August 2013 to February 2014 included renal donors of minimum of 3 months post donation. Their histories and previous medical records were reviewed and they were meticulously examined. They underwent urine analysis including spot PCR (Protein Creatinine ratio), complete blood count with peripheral smear study and their fasting blood sugar (FBS) was tested. Renal function was assessed by serum creatinine (Modified Jaffes' method) and GFR was estimated using Cockcroft–Gault (CG) formula, MDRD and CKD EPI creatinine equations. Estimated GFR derived through the above formulae were compared with GFR measured by 99mTc-DTPA renogram method so as to assess the utility of these equations in our study population. Renal imaging done by ultrasonography and renal size was noted. All the results and observations were compared and analyzed with their pre donation data. Statistical analysis was done using SPSS version 19.0. Results: Out of 30 renal donors 22 (73.3%) were females and 73.3% (22/30) of the donors were in the fourth and fifth decade. During the median period of 29 months (4–150 months) post transplant, there was neither significant raise in proteinuria, nor significant fall in haemoglobin. No significant variation in both systolic and the diastolic blood pressure. Though donors had significant raise in fasting blood sugar profile (84.50 vs. 91.90 p = 0.001), none of them developed frank diabetic status. There was significant fall in GRF estimated by all the three equations. GFR measured by 99mTc-DTPA renogram method also showed significant fall. The remnant kidney mean surface area was increased significantly (4082.8 vs. 5082 mm2, p = 0.001). There was significant increase in the GFR of the remnant kidney during post donation period (50.87 vs. 80.77 ml/mt, p = 0.001). None of the equations for estimating GFR had significant correlation with GFR measured by DTPA during both pre and post donation period. Conclusions: There was significant raise in new onset impaired fasting glucose among donors in post donation period. There was significant increase in mean surface area and GFR of remnant kidney. None of the equations for estimating GFR had significant correlation with GFR measured by DTPA in our study group. http://dx.doi.org/10.1016/j.ijt.2015.09.005