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Acute pulmonary infiltrates in a renal allograft recipient
indian journal of transplantation 9 (2015) 47–60
Abstract #: ISOT2015-90 Post renal transplant opportunistic infections single tertiary care centre experience Binoy, Noble Gracious, Jacob George Medical College, Thiruvananthapuram, India Background: Life long immunosuppressant use following renal transplantation is at the risk of opportunistic infections, which have drastic consequences to the graft and recipient. Western literature enumerating various opportunistic infections and their timing and effects on graft and patient survival are numerous however there is paucity of Indian data. We in this study reviewed our post transplant opportunistic infections from August 2012 to July 2015. Aims: To analyze the post renal transplant infection in our center during the time period August 2012 to July 2015. Methodology: Retrospective analysis of infections in renal transplant recipients from August 2012 to July 2015. Inclusion criteria-recipients with post renal transplant infection and transplant surgery performed in our center were included. Recipients with post transplant infection and transplant surgery performed elsewhere were excluded. Results: 163 renal allograft recipients were done. Mean age was 36 12.23 years of which 118 of them were males. 112 were live recipients. Urinary tract infection was the commonest infection with 30% prevalence. Cytomegalovirus infection and tuberculosis had a prevalence rate of 10% and 9%, respectively. BK virus nephropathy in two recipients with evidence of virus demonstrated in the graft in one case. Systemic fungal infection was seen in one case. Post transplant hepatotropic viruses B and C seen in two recipients respectively. No Pneumocystis infection was documented. Post transplant infection had a proportional mortality rate of 7.3%. Systemic CMV infection related mortality was seen in 7 recipients. Urinary tract infection accounted for early post transplant infection. CMV infection was noted in three months to one year period and tuberculous infection at a later period. D+R+ sero-status, ATG use were significant risk factor for CMV. Conclusions: Urinary tract infection was the commonest infection. Systemic CMV infection was a major factor contributing to infection related mortality. Tuberculous reactivation occurred mostly in time period after 1 year of renal transplantation. http://dx.doi.org/10.1016/j.ijt.2015.09.006 Abstract #: ISOT2015-91 A case–control study to identify risk factors for Pneumocystis jiroveci Pneumonia (PCP) in renal allograft transplant recipients Navdeep Singh, Sunil Kumar, Deepesh B. Kenwar, Sarbpreet Singh, Ashish Sharma, Mukut Minz Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India Background: Pneumocystis jiroveci is an opportunistic pathogen that can cause severe pulmonary infection in renal transplant recipients. The infection can progress from minor illness to severe inflammatory pneumonia, resulting in respiratory failure or death. However, the risk factors for Pneumocystis infection are still not completely understood. We present a case– control study comprising 30 renal allograft transplant recipients to identify the risk factors for Pneumocystis jiroveci Pneumonia (PCP). Aims: To identify the risk factors for Pneumocystis jiroveci Pneumonia (PCP) in renal allograft transplant recipients.
49
Methodology: We retrospectively analyzed 30 renal transplant recipients who were operated between January 2000 and June 2015 at our centre. The cases (n = 10) included were either diagnosed as PCP based on the identification of Pneumocystis jiroveci in lung tissue or respiratory secretions (7/10) or were presumed as PCP (3/10) because of strong clinical and radiological suspicion and rapid response to therapy. The renal transplant recipients who were operated on the preceding and the subsequent days of the transplantation of the cases were taken as controls (n = 20). All patients received cotrimoxazole (400/80 mg) prophylaxis for six months after transplant. Various parameters studied in the cases and controls were age, sex, baseline serum creatinine, basic disease, maintenance immunosuppression, use of pulse steroids in acute rejection, use of ATG, therapy for humoral rejection and prior infections. Statistical analysis was done using Chi square test and p value <0.05 was considered significant. Results: The mean age of the cases was 36.5 9.6 years and the mean age of the controls was 34.3 12.6 years; p = 0.64. All cases were males and in controls there were 17 males (85%) and 3 females (15%). The mean baseline serum creatinine in cases and controls was 1.35 0.38 and 1.19 0.61, respectively; p = 0.46. Glomerulonephritis was the basic disease in 7/10 cases (70%) and in 12/20 controls (60%); p > 0.05. Tacrolimus based maintenance immunosuppression was observed in 8/10 cases (80%) and 15/20 controls (75%); p > 0.05. Pulse steroids were used for treating acute rejection in 4/10 cases (40%) and in 1/20 controls (5%); p = 0.015 and was found to be the only statistically significant parameter. Use of ATG, therapy for humoral rejection and prior infections were not found statistically significant when compared between cases and controls; p = 1.0, p = 0.15, p = 0.11, respectively. Conclusions: Use of pulse steroid for acute rejection in renal allograft transplant recipients is a risk factor for PCP infection. All renal transplant recipients should receive cotrimoxazole prophylaxis for 6–12 months following use of pulse steroids while treating rejection. http://dx.doi.org/10.1016/j.ijt.2015.09.007 Abstract #: ISOT2015-57 Acute pulmonary infiltrates in a renal allograft recipient Urmila Anandh, Sapna Marda, Y. Gopikrishna Departments of Nephrology, Radiology, and Pulmonology, Yashoda Hospitals, Secunderabad, India Background: Pulmonary infiltrates presenting in a renal allograft recipient early in the course of transplant is often abacterial pneumonia. It is common in heart lung transplants (22%) and rare in renal transplants (1%). However, in certain cases cardiogenic pulmonary edema, pulmonary hemorrhage and interstitial lung disease needs to be considered. We present a case of noninfective involvement of the lung in a renal allograft recipient. Aims: To present a case report of a acute lung injury in a renal allograft recipient and postulate a probable cause of the acute lung injury. Methodology: Clinical investigations performed were duly analysed and a case report was prepared. Results: A renal allograft recipient developed cough with hemoptysis on first post op day. A chest X ray was done which was suggestive of fluid overload. His fluid was restricted and diuretics were added. On post op day 3 his pulmonary infiltrates worsened and a repeat CT chest suggested the presence of right lower lobe consolidation. A bronchoscopy was done and fluid was sent for cultures. Besides routine antibiotics, treatment for CMV, fungus and Pneumocystis jiroveci was
50
indian journal of transplantation 9 (2015) 47–60
started. Noninvasive ventilation was started on Day 5. A repeat CT chest on day 8 showed further worsening of the infiltrates. As all cultures were negative a possibility of interstitial lung disease was considered. Possibility of pulmonary drug toxicity was considered and mycophenolate was withdrawn and azathioprine was added. Patient showed progressive improvement radiologically and clinically. He was discharged on post op day 14. A repeat CT chest after 4 weeks showed significant improvement. Conclusions: Pulmonary infiltrates immediate post transplantation is not always infectious. Drug toxicity should also be considered if cultures do not show the presence of infection. http://dx.doi.org/10.1016/j.ijt.2015.09.008
Abstract #: ISOT2015-65 Knowledge and attitude on organ donation among relatives of patients on hemodialysis S. Amirtha Santhi, S. Malarvizhi, K. Ravichandran Pondicherry Institute of Medical Sciences, Puducherry, India Background: Organ donation is the harvesting of an individual's organs, after he or she dies, for the purpose of transplanting them into another person. In India every year nearly 500,000 people die because of non-availability of organs. It is estimated that every three minutes, a patient requires an organ transplant. More than two lakh Indians require transplantation annually. However, not even 10% get it. 150,000 people await a kidney transplant but only 3000–5000 get one. Aims: There is a major lack of awareness about organ donation in India, and recent polls and surveys reveal that people would come forth with their wish to donate if they had received more information. Methodology: A cross sectional study conducted during August to September 2014 among the relatives of patients receiving hemodialysis. This study was approved by the Institutional Review Board consisting of Ethical Committee. The hemodialysis patient's relatives (120) such as parents, grandparents, siblings, children, grandchildren and spouse were included in this study. Convenience sampling method was used to select the study participants. The study participants were informed about the purpose of study and participant information sheet was provided to them. Oral consent was taken from each participant and also assured that confidentiality of the information will be maintained. Interview method was used to collect the data. Descriptive statistics and Chi square or Fisher's exact test were used to find association between variables. All tests were two sided and p value less than 0.05 considered statistically significant. SPSS Package and MS Excel were used in data analysis. Results: A total of 120 individuals participated in the study, comprising of 58 (48.3%) males and 62 (51.7%) females. More than one fourth (28.3%) of the respondents were aged 18–27 years and majority (64.2%) were Hindus. Most of them (74.2%) were married and 73.3% came to know about organ donation through mass media. 86.7% of the participants had inadequate knowledge and remaining had moderately adequate knowledge and no one had adequate knowledge on organ donation. Most of them (83.3%) accept that the donor can live a healthy life with one kidney and 92.5% stated that their religion accepts organ donation. 90% of the participants believe that the organs of a deceased person can be donated instead of being wasted. In the present study gender, religion, education, marital status and place of residence have no significant difference on knowledge level. Conclusions: The implications of this study are to stress the importance of educating the relatives of hemodialysis patients
about organ donation and motivate them to register as an organ donor. This can be achieved through the utilization of mass media, and conducting open discussion. http://dx.doi.org/10.1016/j.ijt.2015.09.009 Abstract #: ISOT2015-102 Single center experience in laparoscopic donor nephrectomy Deepesh B. Kenwar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sunil Kumar, Nikhil Mahajan, Shivakumar Patil, Navdeep Singh Post Graduate Institute of Medical Education and Research, Chandigarh, India Background: The transplant program at PGIMER, Chandigarh performs 200 renal transplant annually. Since 2004–2005 over 1900 laparoscopic donor nephrectomies (LDN) have been performed at the institute. Repeated performing of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and decrease in adverse events. Aims: To evaluate the improvement in surgical times with experience in LDN. To evaluate the occurrence of adverse events and the factors associated with them. Methodology: The records of over 1700 LDN from 03-05-2004 to 26-08-2015 were evaluated for duration of surgery from first incision to clamping of renal artery. The occurrence of adverse events was noted and the associated factors were noted. Also noted was whether the application of a corrective policy led to perceived decrease in the occurrence of adverse events. Results: The duration of surgery from incision to clamp time for the first 100 cases at the introduction of LDN was 166.13 33.28 min whereas it was 124.59 35.91 min for the most recent 100 cases with an increase of 41.54 min in the mean duration of surgery. The adverse events noted were chylous ascites (n = 1), venous clip slippage (n = 1), arterial clip slippage (n = 3), pneumothorax (n = 1), ureteric thermal injury (n = 1), renal parenchymal injury (n = 2), conversion for missing gauze counts (n = 1), splenectomy for splenic laceration (n = 1). Surgeon experience was not a deciding factor although the incidence appeared to decrease with the increase in the number of LDN. Slippage of arterial clips was associated with early branching with short common stump in all 3 cases. There were no adverse events in the last 350 cases of LDN after implementation of corrective measures. Conclusions: Laparoscopic donor nephrectomy is associated with a risk of adverse events that can be reduced with increasing center experience. This should be a goal given the unique nature of donor nephrectomy. http://dx.doi.org/10.1016/j.ijt.2015.09.010 Abstract #: ISOT2015-101 Severe dengue in a living related donor renal allograft recipient V. Chaitanya, B.S. Lakshmi, A.C.V. Kumar, M.H.K. Reddy, P. Sandeep, R. Ram, V. Siva Kumar Sri Venkateswara Institute of Medical Sciences, Tirupati, India Background: Dengue virus infection is an emerging global threat caused by Arbovirus, which is transmitted by mosquitoes Aedes aegypti and Aedes albopictus. Renal transplant recipients who live in endemic zones of dengue infection or who travel to an endemic zone are at risk of this infection. A high case fatality rate in Southeast Asian region is present and only few patients of dengue infection in renal transplant recipients have been reported.
Abstract #: ISOT2015-90 Post renal transplant opportunistic infections single tertiary care centre experience Binoy, Noble Gracious, Jacob George Medical College, Thiruvananthapuram, India Background: Life long immunosuppressant use following renal transplantation is at the risk of opportunistic infections, which have drastic consequences to the graft and recipient. Western literature enumerating various opportunistic infections and their timing and effects on graft and patient survival are numerous however there is paucity of Indian data. We in this study reviewed our post transplant opportunistic infections from August 2012 to July 2015. Aims: To analyze the post renal transplant infection in our center during the time period August 2012 to July 2015. Methodology: Retrospective analysis of infections in renal transplant recipients from August 2012 to July 2015. Inclusion criteria-recipients with post renal transplant infection and transplant surgery performed in our center were included. Recipients with post transplant infection and transplant surgery performed elsewhere were excluded. Results: 163 renal allograft recipients were done. Mean age was 36 12.23 years of which 118 of them were males. 112 were live recipients. Urinary tract infection was the commonest infection with 30% prevalence. Cytomegalovirus infection and tuberculosis had a prevalence rate of 10% and 9%, respectively. BK virus nephropathy in two recipients with evidence of virus demonstrated in the graft in one case. Systemic fungal infection was seen in one case. Post transplant hepatotropic viruses B and C seen in two recipients respectively. No Pneumocystis infection was documented. Post transplant infection had a proportional mortality rate of 7.3%. Systemic CMV infection related mortality was seen in 7 recipients. Urinary tract infection accounted for early post transplant infection. CMV infection was noted in three months to one year period and tuberculous infection at a later period. D+R+ sero-status, ATG use were significant risk factor for CMV. Conclusions: Urinary tract infection was the commonest infection. Systemic CMV infection was a major factor contributing to infection related mortality. Tuberculous reactivation occurred mostly in time period after 1 year of renal transplantation. http://dx.doi.org/10.1016/j.ijt.2015.09.006 Abstract #: ISOT2015-91 A case–control study to identify risk factors for Pneumocystis jiroveci Pneumonia (PCP) in renal allograft transplant recipients Navdeep Singh, Sunil Kumar, Deepesh B. Kenwar, Sarbpreet Singh, Ashish Sharma, Mukut Minz Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India Background: Pneumocystis jiroveci is an opportunistic pathogen that can cause severe pulmonary infection in renal transplant recipients. The infection can progress from minor illness to severe inflammatory pneumonia, resulting in respiratory failure or death. However, the risk factors for Pneumocystis infection are still not completely understood. We present a case– control study comprising 30 renal allograft transplant recipients to identify the risk factors for Pneumocystis jiroveci Pneumonia (PCP). Aims: To identify the risk factors for Pneumocystis jiroveci Pneumonia (PCP) in renal allograft transplant recipients.
49
Methodology: We retrospectively analyzed 30 renal transplant recipients who were operated between January 2000 and June 2015 at our centre. The cases (n = 10) included were either diagnosed as PCP based on the identification of Pneumocystis jiroveci in lung tissue or respiratory secretions (7/10) or were presumed as PCP (3/10) because of strong clinical and radiological suspicion and rapid response to therapy. The renal transplant recipients who were operated on the preceding and the subsequent days of the transplantation of the cases were taken as controls (n = 20). All patients received cotrimoxazole (400/80 mg) prophylaxis for six months after transplant. Various parameters studied in the cases and controls were age, sex, baseline serum creatinine, basic disease, maintenance immunosuppression, use of pulse steroids in acute rejection, use of ATG, therapy for humoral rejection and prior infections. Statistical analysis was done using Chi square test and p value <0.05 was considered significant. Results: The mean age of the cases was 36.5 9.6 years and the mean age of the controls was 34.3 12.6 years; p = 0.64. All cases were males and in controls there were 17 males (85%) and 3 females (15%). The mean baseline serum creatinine in cases and controls was 1.35 0.38 and 1.19 0.61, respectively; p = 0.46. Glomerulonephritis was the basic disease in 7/10 cases (70%) and in 12/20 controls (60%); p > 0.05. Tacrolimus based maintenance immunosuppression was observed in 8/10 cases (80%) and 15/20 controls (75%); p > 0.05. Pulse steroids were used for treating acute rejection in 4/10 cases (40%) and in 1/20 controls (5%); p = 0.015 and was found to be the only statistically significant parameter. Use of ATG, therapy for humoral rejection and prior infections were not found statistically significant when compared between cases and controls; p = 1.0, p = 0.15, p = 0.11, respectively. Conclusions: Use of pulse steroid for acute rejection in renal allograft transplant recipients is a risk factor for PCP infection. All renal transplant recipients should receive cotrimoxazole prophylaxis for 6–12 months following use of pulse steroids while treating rejection. http://dx.doi.org/10.1016/j.ijt.2015.09.007 Abstract #: ISOT2015-57 Acute pulmonary infiltrates in a renal allograft recipient Urmila Anandh, Sapna Marda, Y. Gopikrishna Departments of Nephrology, Radiology, and Pulmonology, Yashoda Hospitals, Secunderabad, India Background: Pulmonary infiltrates presenting in a renal allograft recipient early in the course of transplant is often abacterial pneumonia. It is common in heart lung transplants (22%) and rare in renal transplants (1%). However, in certain cases cardiogenic pulmonary edema, pulmonary hemorrhage and interstitial lung disease needs to be considered. We present a case of noninfective involvement of the lung in a renal allograft recipient. Aims: To present a case report of a acute lung injury in a renal allograft recipient and postulate a probable cause of the acute lung injury. Methodology: Clinical investigations performed were duly analysed and a case report was prepared. Results: A renal allograft recipient developed cough with hemoptysis on first post op day. A chest X ray was done which was suggestive of fluid overload. His fluid was restricted and diuretics were added. On post op day 3 his pulmonary infiltrates worsened and a repeat CT chest suggested the presence of right lower lobe consolidation. A bronchoscopy was done and fluid was sent for cultures. Besides routine antibiotics, treatment for CMV, fungus and Pneumocystis jiroveci was
50
indian journal of transplantation 9 (2015) 47–60
started. Noninvasive ventilation was started on Day 5. A repeat CT chest on day 8 showed further worsening of the infiltrates. As all cultures were negative a possibility of interstitial lung disease was considered. Possibility of pulmonary drug toxicity was considered and mycophenolate was withdrawn and azathioprine was added. Patient showed progressive improvement radiologically and clinically. He was discharged on post op day 14. A repeat CT chest after 4 weeks showed significant improvement. Conclusions: Pulmonary infiltrates immediate post transplantation is not always infectious. Drug toxicity should also be considered if cultures do not show the presence of infection. http://dx.doi.org/10.1016/j.ijt.2015.09.008
Abstract #: ISOT2015-65 Knowledge and attitude on organ donation among relatives of patients on hemodialysis S. Amirtha Santhi, S. Malarvizhi, K. Ravichandran Pondicherry Institute of Medical Sciences, Puducherry, India Background: Organ donation is the harvesting of an individual's organs, after he or she dies, for the purpose of transplanting them into another person. In India every year nearly 500,000 people die because of non-availability of organs. It is estimated that every three minutes, a patient requires an organ transplant. More than two lakh Indians require transplantation annually. However, not even 10% get it. 150,000 people await a kidney transplant but only 3000–5000 get one. Aims: There is a major lack of awareness about organ donation in India, and recent polls and surveys reveal that people would come forth with their wish to donate if they had received more information. Methodology: A cross sectional study conducted during August to September 2014 among the relatives of patients receiving hemodialysis. This study was approved by the Institutional Review Board consisting of Ethical Committee. The hemodialysis patient's relatives (120) such as parents, grandparents, siblings, children, grandchildren and spouse were included in this study. Convenience sampling method was used to select the study participants. The study participants were informed about the purpose of study and participant information sheet was provided to them. Oral consent was taken from each participant and also assured that confidentiality of the information will be maintained. Interview method was used to collect the data. Descriptive statistics and Chi square or Fisher's exact test were used to find association between variables. All tests were two sided and p value less than 0.05 considered statistically significant. SPSS Package and MS Excel were used in data analysis. Results: A total of 120 individuals participated in the study, comprising of 58 (48.3%) males and 62 (51.7%) females. More than one fourth (28.3%) of the respondents were aged 18–27 years and majority (64.2%) were Hindus. Most of them (74.2%) were married and 73.3% came to know about organ donation through mass media. 86.7% of the participants had inadequate knowledge and remaining had moderately adequate knowledge and no one had adequate knowledge on organ donation. Most of them (83.3%) accept that the donor can live a healthy life with one kidney and 92.5% stated that their religion accepts organ donation. 90% of the participants believe that the organs of a deceased person can be donated instead of being wasted. In the present study gender, religion, education, marital status and place of residence have no significant difference on knowledge level. Conclusions: The implications of this study are to stress the importance of educating the relatives of hemodialysis patients
about organ donation and motivate them to register as an organ donor. This can be achieved through the utilization of mass media, and conducting open discussion. http://dx.doi.org/10.1016/j.ijt.2015.09.009 Abstract #: ISOT2015-102 Single center experience in laparoscopic donor nephrectomy Deepesh B. Kenwar, Mukut Minz, Ashish Sharma, Sarbpreet Singh, Sunil Kumar, Nikhil Mahajan, Shivakumar Patil, Navdeep Singh Post Graduate Institute of Medical Education and Research, Chandigarh, India Background: The transplant program at PGIMER, Chandigarh performs 200 renal transplant annually. Since 2004–2005 over 1900 laparoscopic donor nephrectomies (LDN) have been performed at the institute. Repeated performing of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and decrease in adverse events. Aims: To evaluate the improvement in surgical times with experience in LDN. To evaluate the occurrence of adverse events and the factors associated with them. Methodology: The records of over 1700 LDN from 03-05-2004 to 26-08-2015 were evaluated for duration of surgery from first incision to clamping of renal artery. The occurrence of adverse events was noted and the associated factors were noted. Also noted was whether the application of a corrective policy led to perceived decrease in the occurrence of adverse events. Results: The duration of surgery from incision to clamp time for the first 100 cases at the introduction of LDN was 166.13 33.28 min whereas it was 124.59 35.91 min for the most recent 100 cases with an increase of 41.54 min in the mean duration of surgery. The adverse events noted were chylous ascites (n = 1), venous clip slippage (n = 1), arterial clip slippage (n = 3), pneumothorax (n = 1), ureteric thermal injury (n = 1), renal parenchymal injury (n = 2), conversion for missing gauze counts (n = 1), splenectomy for splenic laceration (n = 1). Surgeon experience was not a deciding factor although the incidence appeared to decrease with the increase in the number of LDN. Slippage of arterial clips was associated with early branching with short common stump in all 3 cases. There were no adverse events in the last 350 cases of LDN after implementation of corrective measures. Conclusions: Laparoscopic donor nephrectomy is associated with a risk of adverse events that can be reduced with increasing center experience. This should be a goal given the unique nature of donor nephrectomy. http://dx.doi.org/10.1016/j.ijt.2015.09.010 Abstract #: ISOT2015-101 Severe dengue in a living related donor renal allograft recipient V. Chaitanya, B.S. Lakshmi, A.C.V. Kumar, M.H.K. Reddy, P. Sandeep, R. Ram, V. Siva Kumar Sri Venkateswara Institute of Medical Sciences, Tirupati, India Background: Dengue virus infection is an emerging global threat caused by Arbovirus, which is transmitted by mosquitoes Aedes aegypti and Aedes albopictus. Renal transplant recipients who live in endemic zones of dengue infection or who travel to an endemic zone are at risk of this infection. A high case fatality rate in Southeast Asian region is present and only few patients of dengue infection in renal transplant recipients have been reported.