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23 Paired exchange (swap) kidney donation in India: A five year single center experience
Abstracts of the XXII Annual Conference of ISOT, New Delhi, 2011
Abstracts
155
Results: Over a mean follow-up of 2.28 ± 2.59 years, patient and graft survival rates were 68.5% and 88.5%, respectively, with mean SCr of 1.9 ± 0.62 mg/dL. Delayed graft function was observed in 34.3% patients, and 25.7% had biopsy-proven acute rejection; 31.5% patients died, mainly because of infections (22.8%), coronary artery disease (2.86%), and cerebrovascular events (5.7%).
Introduction: Mycophenolate mofetil (MMF) has replaced azathioprine in immunosuppression regimens worldwide to prevent graft rejection. However, evidence that its anti-rejection activity is better than that of azathioprine has been provided only by registration trials with an old formulation of cyclosporine and steroid.
Conclusion: DDRTx in patients with DN has an acceptable graft function and patient/graft survival over 10-year follow-up in our center and, therefore, we believe it should be encouraged.
Aim and objectives: Previous studies like MYSS have already raised doubt about the superiority of Mycophenolate mofetil in deceased donor situation but not evaluated in live donor transplants. Therefore, we aimed to compare the outcome of these two drugs with a micro emulsion of cyclosporine and tacrolimus in live donor scenario.
21 doi: 10.1016/S2212-0017(11)60025-7 Impact of pre-transplant through tacrolimus level on early acute rejection in live donor kidney transplantation K Gohel, U Hegde, S Gang, M Rajapurkar Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India
Introduction: The risk of acute rejection is greater in the first week post-transplant and progressively decreases after the first month. Thus, the concentration of immunosuppressive drugs must be maximal at this initial phase and tapered during the subsequent months, according to the evolution of patient and graft function. Aim: There is paucity of literature on the impact of pre-transplant immunosuppression on acute rejection. So, we aim to assess the correlation of pre-transplant trough tacrolimus level with early rejection. Materials and methods: We prospectively analyzed the trough tacrolimus level on the day prior to transplantation of 179 patients, transplanted from September 2007 to September 2009. We divided them into three groups, according to the trough levels: Group I < 5 ng/mL, Group II 5–15 ng/mL and Group III > 15 ng/mL. Their demography including immunosuppression, native kidney disease, HLA match, donor characteristic, incidence of BPAR, NOD, posttransplant infection and biopsy-proven CNI toxicity were studied. Results: The demography including age, gender, immunosuppression, donor age was comparable in all the three groups. Incidence of biopsy-proven acute rejections were highest in Group I and lowest in Group III. None of the patients in Group III had rejection with Banff grade > 2. Incidences of post-transplant infection, new onset diabetes were comparable. Trend of higher biopsy-proven CNI toxicity was noted from group I to group III. Conclusion: Incidence and severity of early acute rejection reduces significantly as the pre-transplant trough tacrolimus level increases. Trend towards higher nephrotoxicity with higher trough level, was noted.
22 doi: 10.1016/S2212-0017(11)60026-9 Is mycophenolate mofetil (MMF) superior to azathioprine in live donor renal transplantation scenario? K Gohel, U Hegde, S Gang, M Rajapurkar Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India
Materials and methods: We, retrospectively, analyzed a total of 368 patients transplanted from January 2001 to August 2007. We divided them into two groups according to their antiproliferative regimen: Group I—who received Azathioprine, Group II—who received MMF. Their demography, immunosuppression, donor characteristics, surgical complications, infection, rejection episodes as well as graft and patient survival were studied. Results: Group I had 198 patients while Group II had 170 patients. Both groups were comparable for age and gender. Primary calcineurine inhibitors were not different between the two groups. Group I had more grafts from related donors than Group II. More number of patients in Group II received induction therapy. Incidence of rejection, post-transplant infection, NOD, graft and patient survival were comparable between both the groups. Conclusion: In recipients of live donor kidney transplants who were given cyclosporine microemulsion or tacrolimus, MMF probably does not offer a significant advantage over azathioprine in preventing acute rejections as well as graft and patient survival in the current series.
23 doi: 10.1016/S2212-0017(11)60027-0 Paired exchange (swap) kidney donation in India: A five year single center experience Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
Introduction: Swap kidney donation is an evolving strategy for overcoming the barriers that confront patients with end-stage renal disease, when the only living potential donors who are willing to donate to them are deemed to be unsuitable as donors for them owing to an incompatibility of blood type, HLA cross-match, or both. In the swap donation, the incompatibility problems with two donor-recipient pairs can be solved by exchanging donors. Materials and methods: Between March 2006 and June 2011, we performed 44 Swap living donor kidney transplantations. All donor and recipient procedures were performed successfully. ABO-incompatibility or positive lymphocyte cross-match were found in 20 pairs and 2 pairs respectively. Results: The mean recipient age was 42.5 years (range 33–59 years). The mean donor age was 38 years (range 31–56 years).
156 Indian Journal of Transplantation 2011 July–September (Supplement); Vol. 5, No. 3 Abstr
acts
At a median follow-up of 24 months (range: 1–59 months), graft survival rate was 100%. All patients have functioning grafts with a median serum creatinine level of 1.13 mg/dL, 1.5, 1.35 mg/dL at 3-months, 1-year, and 3-years, respectively. One patient died after 4 months of transplant, due to pneumonitis with sepsis. Allograft dysfunction was not seen in any of the recipients.
Introduction: Intimal dissection of external iliac artery is a rare but devastating event during or after renal artery anastomosis in renal transplant. This not only results in compromised blood flow to graft kidney but also jeopardizes lower limb perfusion. We share our experience of this event which was managed by PTFE graft interposition.
Conclusion: The Swap kidney transplantation is a medically and economically viable procedure, which can be promoted in centers with a low deceased donor transplantation rate and a high number of incompatible related donors.
Aim and objectives: Our aim is to highlight the use of external iliac artery PTFE interposition graft as an important salvage procedure in case of an irreparable intimal injury.
24 doi: 10.1016/S2212-0017(11)60028-2 A study to evaluate the effect of ratio of donor kidney weight to the recipient body weight on renal graft function Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
Introduction: The effect of kidney weight and the recipient body weight on renal functions has been studied with variable results. Aim and objectives: To study the effect of donor kidney weight to the recipient weight on short- and long-term graft function of live donor kidney transplant. Methods: It was a prospective study of 81 live donor kidney transplant recipients from May 2008 to June 2011, conducted at Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi. Patients were divided in 3 groups, depending on the ratio of donor kidney weight in grams to the recipient body weight in kilograms (dkw/rbw < 2, 2 to 3, and > 3 in group 1, 2, and 3 respectively). Serum creatinine in milligrams percent on the day of surgery, the 7th day, 1 month, 6 months, 1 year, and 3 years after the surgery, was recorded and their means were compared. Patients with acute tubular necrosis, sepsis, drug toxicity and graft rejection were excluded. Results: The comparison showed that the decrease in the mean creatinine level was statistically significant in group 3 patients at 7 days and 30 days (P value 0.023 and 0.029 respectively) and did not show a significant difference at 6 months, 1 year, and 3 years. Conclusion: The ratio of donor kidney weight to the recipient body weight does not have a significant effect on the long-term graft function, inspite of an early improvement.
25 doi: 10.1016/S2212-0017(11)60029-4 External iliac artery polytetrafluroethylene (PTFE) graft interposition; an effective rescue procedure for kidney transplant in progressive intimal dissection Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Abdul Rouf Department Of Urology, Sir Ganga Ram Hospital, New Delhi, India
Materials and methods: Since 1987, we have performed approximately 3000 transplants. On five occasions, we encountered intimal dissection of external iliac artery just after opening the clamp following anastomosis. The dissection was too bad to be repaired. Thus, in order to salvage the lower limb and the graft kidney, we used PTFE interposition graft in the external iliac artery after detaching the kidney. The graft renal artery, then, was anastomosed to the PTFE graft in end-to-side manner. Results: The use of the interposition graft has resulted in an increase in the warm ischemia time twice. All the five cases had normal postoperative course with normally perfused graft kidney and lower limb. Two patients had mild ATN in the immediate postoperative period which settled within one month. Conclusion: It is a safe salvage procedure to save the lower limb and the graft kidney.
26 doi: 10.1016/S2212-0017(11)60030-0 Extrapulmonary nocardiosis and perigraft abscess, managed with percutaneous drainage and antibiotics therapy Ravi Angral, A Marwaha, SPS Subhramanian, A Khullar, T Kataria, RS Chahal Kidney Hospital and Lifeline, Jalandhar, Punjab, India
Introduction: Pulmonary nocardiosis is a rare bacterial infection and may present as a localized or disseminated suppurative or granulomatous disease, leading to sever complications in renal transplant recipients. Reported cases in literature are few and rare from India. We report a case of extrapulmonary nocardiosis due to Nocardia sp. in a 28-year-old man, managed successfully with percutaneous drainage and antibiotics therapy. Materials and methods: 28-year-old male, kidney transplant recipient on triple immunosuppression therapy, presented 4 months posttransplant at our hospital. Patient had a history of fever (off and on), pain in right iliac region, with inability to extend right leg. Lab investigation revealed all the parameters (Hb-11.4 g%, Tlc-8200, Platelet count-2.6 lac, s.cr-1.2 mg%, Chest x-ray), within normal limits. Ultrasound revealed 10*3*3 size collection in right iliac region, behind transplanted kidney, MRI showed thick-walled collection in the right Iliacus muscle 10.3*3.8*3.1 extending inferiorly into its insertion with adjoin soft tissue edema. Ultrasound guided percutaneous drainage of perigraft fluid was done and 180 mL of thick pus was drained. Pus examination showed stippled branching bacteria suggestive of Nocardia species, no AFB, fungal hyphae
Abstracts
155
Results: Over a mean follow-up of 2.28 ± 2.59 years, patient and graft survival rates were 68.5% and 88.5%, respectively, with mean SCr of 1.9 ± 0.62 mg/dL. Delayed graft function was observed in 34.3% patients, and 25.7% had biopsy-proven acute rejection; 31.5% patients died, mainly because of infections (22.8%), coronary artery disease (2.86%), and cerebrovascular events (5.7%).
Introduction: Mycophenolate mofetil (MMF) has replaced azathioprine in immunosuppression regimens worldwide to prevent graft rejection. However, evidence that its anti-rejection activity is better than that of azathioprine has been provided only by registration trials with an old formulation of cyclosporine and steroid.
Conclusion: DDRTx in patients with DN has an acceptable graft function and patient/graft survival over 10-year follow-up in our center and, therefore, we believe it should be encouraged.
Aim and objectives: Previous studies like MYSS have already raised doubt about the superiority of Mycophenolate mofetil in deceased donor situation but not evaluated in live donor transplants. Therefore, we aimed to compare the outcome of these two drugs with a micro emulsion of cyclosporine and tacrolimus in live donor scenario.
21 doi: 10.1016/S2212-0017(11)60025-7 Impact of pre-transplant through tacrolimus level on early acute rejection in live donor kidney transplantation K Gohel, U Hegde, S Gang, M Rajapurkar Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India
Introduction: The risk of acute rejection is greater in the first week post-transplant and progressively decreases after the first month. Thus, the concentration of immunosuppressive drugs must be maximal at this initial phase and tapered during the subsequent months, according to the evolution of patient and graft function. Aim: There is paucity of literature on the impact of pre-transplant immunosuppression on acute rejection. So, we aim to assess the correlation of pre-transplant trough tacrolimus level with early rejection. Materials and methods: We prospectively analyzed the trough tacrolimus level on the day prior to transplantation of 179 patients, transplanted from September 2007 to September 2009. We divided them into three groups, according to the trough levels: Group I < 5 ng/mL, Group II 5–15 ng/mL and Group III > 15 ng/mL. Their demography including immunosuppression, native kidney disease, HLA match, donor characteristic, incidence of BPAR, NOD, posttransplant infection and biopsy-proven CNI toxicity were studied. Results: The demography including age, gender, immunosuppression, donor age was comparable in all the three groups. Incidence of biopsy-proven acute rejections were highest in Group I and lowest in Group III. None of the patients in Group III had rejection with Banff grade > 2. Incidences of post-transplant infection, new onset diabetes were comparable. Trend of higher biopsy-proven CNI toxicity was noted from group I to group III. Conclusion: Incidence and severity of early acute rejection reduces significantly as the pre-transplant trough tacrolimus level increases. Trend towards higher nephrotoxicity with higher trough level, was noted.
22 doi: 10.1016/S2212-0017(11)60026-9 Is mycophenolate mofetil (MMF) superior to azathioprine in live donor renal transplantation scenario? K Gohel, U Hegde, S Gang, M Rajapurkar Muljibhai Patel Urological Hospital and Society for Research in Nephro-Urology, Nadiad, Gujarat, India
Materials and methods: We, retrospectively, analyzed a total of 368 patients transplanted from January 2001 to August 2007. We divided them into two groups according to their antiproliferative regimen: Group I—who received Azathioprine, Group II—who received MMF. Their demography, immunosuppression, donor characteristics, surgical complications, infection, rejection episodes as well as graft and patient survival were studied. Results: Group I had 198 patients while Group II had 170 patients. Both groups were comparable for age and gender. Primary calcineurine inhibitors were not different between the two groups. Group I had more grafts from related donors than Group II. More number of patients in Group II received induction therapy. Incidence of rejection, post-transplant infection, NOD, graft and patient survival were comparable between both the groups. Conclusion: In recipients of live donor kidney transplants who were given cyclosporine microemulsion or tacrolimus, MMF probably does not offer a significant advantage over azathioprine in preventing acute rejections as well as graft and patient survival in the current series.
23 doi: 10.1016/S2212-0017(11)60027-0 Paired exchange (swap) kidney donation in India: A five year single center experience Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
Introduction: Swap kidney donation is an evolving strategy for overcoming the barriers that confront patients with end-stage renal disease, when the only living potential donors who are willing to donate to them are deemed to be unsuitable as donors for them owing to an incompatibility of blood type, HLA cross-match, or both. In the swap donation, the incompatibility problems with two donor-recipient pairs can be solved by exchanging donors. Materials and methods: Between March 2006 and June 2011, we performed 44 Swap living donor kidney transplantations. All donor and recipient procedures were performed successfully. ABO-incompatibility or positive lymphocyte cross-match were found in 20 pairs and 2 pairs respectively. Results: The mean recipient age was 42.5 years (range 33–59 years). The mean donor age was 38 years (range 31–56 years).
156 Indian Journal of Transplantation 2011 July–September (Supplement); Vol. 5, No. 3 Abstr
acts
At a median follow-up of 24 months (range: 1–59 months), graft survival rate was 100%. All patients have functioning grafts with a median serum creatinine level of 1.13 mg/dL, 1.5, 1.35 mg/dL at 3-months, 1-year, and 3-years, respectively. One patient died after 4 months of transplant, due to pneumonitis with sepsis. Allograft dysfunction was not seen in any of the recipients.
Introduction: Intimal dissection of external iliac artery is a rare but devastating event during or after renal artery anastomosis in renal transplant. This not only results in compromised blood flow to graft kidney but also jeopardizes lower limb perfusion. We share our experience of this event which was managed by PTFE graft interposition.
Conclusion: The Swap kidney transplantation is a medically and economically viable procedure, which can be promoted in centers with a low deceased donor transplantation rate and a high number of incompatible related donors.
Aim and objectives: Our aim is to highlight the use of external iliac artery PTFE interposition graft as an important salvage procedure in case of an irreparable intimal injury.
24 doi: 10.1016/S2212-0017(11)60028-2 A study to evaluate the effect of ratio of donor kidney weight to the recipient body weight on renal graft function Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Yousuf Saifee Department of Urology, Sir Ganga Ram Hospital, New Delhi, India
Introduction: The effect of kidney weight and the recipient body weight on renal functions has been studied with variable results. Aim and objectives: To study the effect of donor kidney weight to the recipient weight on short- and long-term graft function of live donor kidney transplant. Methods: It was a prospective study of 81 live donor kidney transplant recipients from May 2008 to June 2011, conducted at Institute of Renal Sciences, Sir Ganga Ram Hospital, New Delhi. Patients were divided in 3 groups, depending on the ratio of donor kidney weight in grams to the recipient body weight in kilograms (dkw/rbw < 2, 2 to 3, and > 3 in group 1, 2, and 3 respectively). Serum creatinine in milligrams percent on the day of surgery, the 7th day, 1 month, 6 months, 1 year, and 3 years after the surgery, was recorded and their means were compared. Patients with acute tubular necrosis, sepsis, drug toxicity and graft rejection were excluded. Results: The comparison showed that the decrease in the mean creatinine level was statistically significant in group 3 patients at 7 days and 30 days (P value 0.023 and 0.029 respectively) and did not show a significant difference at 6 months, 1 year, and 3 years. Conclusion: The ratio of donor kidney weight to the recipient body weight does not have a significant effect on the long-term graft function, inspite of an early improvement.
25 doi: 10.1016/S2212-0017(11)60029-4 External iliac artery polytetrafluroethylene (PTFE) graft interposition; an effective rescue procedure for kidney transplant in progressive intimal dissection Harsha Jauhari, Sudhir Chadha, Vipin Tyagi, Tanveer Iqbal, Abdul Rouf Department Of Urology, Sir Ganga Ram Hospital, New Delhi, India
Materials and methods: Since 1987, we have performed approximately 3000 transplants. On five occasions, we encountered intimal dissection of external iliac artery just after opening the clamp following anastomosis. The dissection was too bad to be repaired. Thus, in order to salvage the lower limb and the graft kidney, we used PTFE interposition graft in the external iliac artery after detaching the kidney. The graft renal artery, then, was anastomosed to the PTFE graft in end-to-side manner. Results: The use of the interposition graft has resulted in an increase in the warm ischemia time twice. All the five cases had normal postoperative course with normally perfused graft kidney and lower limb. Two patients had mild ATN in the immediate postoperative period which settled within one month. Conclusion: It is a safe salvage procedure to save the lower limb and the graft kidney.
26 doi: 10.1016/S2212-0017(11)60030-0 Extrapulmonary nocardiosis and perigraft abscess, managed with percutaneous drainage and antibiotics therapy Ravi Angral, A Marwaha, SPS Subhramanian, A Khullar, T Kataria, RS Chahal Kidney Hospital and Lifeline, Jalandhar, Punjab, India
Introduction: Pulmonary nocardiosis is a rare bacterial infection and may present as a localized or disseminated suppurative or granulomatous disease, leading to sever complications in renal transplant recipients. Reported cases in literature are few and rare from India. We report a case of extrapulmonary nocardiosis due to Nocardia sp. in a 28-year-old man, managed successfully with percutaneous drainage and antibiotics therapy. Materials and methods: 28-year-old male, kidney transplant recipient on triple immunosuppression therapy, presented 4 months posttransplant at our hospital. Patient had a history of fever (off and on), pain in right iliac region, with inability to extend right leg. Lab investigation revealed all the parameters (Hb-11.4 g%, Tlc-8200, Platelet count-2.6 lac, s.cr-1.2 mg%, Chest x-ray), within normal limits. Ultrasound revealed 10*3*3 size collection in right iliac region, behind transplanted kidney, MRI showed thick-walled collection in the right Iliacus muscle 10.3*3.8*3.1 extending inferiorly into its insertion with adjoin soft tissue edema. Ultrasound guided percutaneous drainage of perigraft fluid was done and 180 mL of thick pus was drained. Pus examination showed stippled branching bacteria suggestive of Nocardia species, no AFB, fungal hyphae