Cadaveric Renal Transplantation Research Articles

Risk factor analysis of irreversible renal dysfunction based on fetal ultrasonographic findings in patients with persistent cloaca: Results from a nationwide survey in Japan

Aim of the studyWe conducted a nationwide survey of persistent cloaca (PC) to determine its current status in Japan. We focused on the relationship between fetal ultrasonographic findings and irreversible renal dysfunction in PC. MethodPatient information was obtained via questionnaire, and 466 PC patients were ultimately enrolled in this study. Fifteen patients (3.2%) who required dialysis or kidney transplantation were compared to those who were able to survive with their native kidney. Univariable and multivariable analyses were performed using a logistic regression analysis to clarify the relationship between irreversible renal dysfunction and fetal ultrasonographic findings. ResultsA multivariable logistic analysis showed that fetal ultrasonic findings of oligohydramnios independently increased the risk of irreversible renal dysfunction (adjusted odds ratio [OR] 5.8, 95% confidence interval [CI] 1.7–20, p = 0.005). A regression analysis showed that fetal ultrasonographic findings of hydroureteronephrosis (crude OR 5.6, 95% CI 0.9–24, p = 0.03) tended to be associated with irreversible renal dysfunction. In the PC patients with oligohydramnios, however, the ultrasonographic findings and associated anomalies did not affect the renal prognosis. The 15 renal dysfunction patients were treated as follows: hemodialysis (n = 4), peritoneal dialysis (n = 3), living donor renal transplantation (n = 8), and cadaveric renal transplantation (n = 1). ConclusionFetal ultrasonographic findings of oligohydramnios increase the risk of irreversible renal dysfunction. Such findings suggest we consider the need for earlier therapeutic intervention, such as fetal and postnatal treatment, to prevent the progression of renal dysfunction. Level of evidenceIII (Study of diagnostic test, study of nonconsecutive patients and/or without a universally applied “gold” standard).

A Successful Approach for A2 to B Cadaveric Renal Transplantation

A Successful Approach for A2 to B Cadaveric Renal Transplantation

IT'S NOT THE HEART

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: HOHF is suspected when patients present with clinical symptoms of CHF but have an elevated CI typically above 4L/min/m2 [1]. These patients can exhibit signs and symptoms of CHF and have PH as a result of elevated blood flows through the pulmonary vasculature. CASE PRESENTATION: A 56 year-old male kidney transplant recipient (KTR) presented with shortness of breath, lower extremity edema 3-months after cadaveric renal transplantation. He had a history of chronic mild systolic cardiac dysfunction (EF 50%), pulmonary hypertension (WSPH group II), and diabetes mellitus type 2 prior to kidney transplantation. Physical exam was significant for +3 pitting edema of bilateral lower extremities, crackles at lung bases and a right brachiocephalic AVF with palpable thrill. Serum creatinine was 3.5mg/dL (baseline 2.0mg/dL) and Chest X ray showed pulmonary edema. Diuresis improved the edema and shortness of breath, but worsened renal function. Renal biopsy was negative for rejection. Echocardiography (TTE) revealed an elevated right ventricular systolic pressure (RVSP) and severely dilated right atrium (RA) and ventricle (RV). Right heart catheterization demonstrated elevated right and left sided filling pressures with moderate pulmonary hypertension (PH) and an elevated cardiac output/index (CO/CI). An AVF occlusion in the cath lab resulted in a significant reduction in CO 7.75 L/min and CI 3.10 L/min/m2 by thermodilution. Findings were consistent with PH secondary to high output heart failure (HOHF), likely related to AV fistula. He underwent an AVF revision with improvement of symptoms and renal function. DISCUSSION: PH is common in patients with ESRD undergoing HD via an AVF [2] and HOHF could be an easily addressable cause of PH in ESRD. HOHF can be difficult to diagnose based on echocardiography alone. RHC typically shows an elevated CO (> 8L/min, CI>4L/min/m2), AVF/G flow > 1.5L/min, and a cardiopulmonary recirculation ratio (CPR) > 0.3 [3]. Furthermore, PH prior to transplantation appears to have an adverse impact on allograft function in kidney transplant recipients (KTR) [4]. In a retrospective analysis of KTRs in a single institution, 29/113 (26%) of patients required closure of their AVF due to symptomatic CHF. The mean AVF flow rate was significantly elevated in patients requiring AVF closure compared to those managed conservatively (2197 ml/min vs. 851 ml/min) [5]. High flow rates due to increased arterial blood shunted from left to right circulation increased the preload and stroke volume and resulted in ventricular hypertrophy leading to subsequent heart failure [6]. CONCLUSIONS: In our patient, HOHF and PH secondary to an aneurysmal AVF resulted in acute cardio-renal syndrome type 1(CRS - 1) in the transplanted kidney. The improvement in both cardiac and renal function following the revision of AVF confirmed the diagnosis of cardiorenal injury due to an aneurysmal AVF. REFERENCE #1: Reddy YN, Obokata M, Dean PG, Melenovsky V, Nath KA, Borlaug BA. Long-term cardiovascular changes following creation of arteriovenous fistula in patients with end stage renal disease. Eur Heart J. 2017 Mar 6. REFERENCE #2: Schoenberg NC, Argula RG, Klings ES, Wilson KC, Farber HW. Prevalence and Mortality of Pulmonary Hypertension in ESRD: A Systematic Review and Meta-analysis. Lung. 2020 Jun;198(3):535-45. REFERENCE #3: Wijnen E, Keuter XH, Planken NR, van der Sande FM, Tordoir JH, Leunissen KM, et al. The relation between vascular access flow and different types of vascular access with systemic hemodynamics in hemodialysis patients. Artif Organs. 2005 Dec;29(12):960-4. DISCLOSURES: Advisory Committee Member relationship with Janssen pharmaceutical Please note: 4/2020 - 4/2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee Advisory Committee Member relationship with United Therapeutics Please note: 2019-2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Breathe Technologies Please note: 2019 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting feeeducational grant relationship with Reata pharmaceuticals Please note: 2018-2019 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Grant/Research Consultant relationship with Accordant health / CVS Please note: 2020 - 2021 Added 04/27/2021 by Rahul Argula, source=Web Response, value=Consulting fee no disclosure on file for mona haj; No relevant relationships by Elena Vlachos, source=Web Response

Between a Rock and a Hard Place—Colonic Obstruction Between Two Kidneys: A Case Report

We report a case of a 70-year-old woman with a history of end-stage renal disease secondary to polycystic kidney disease with a previous failed transplant who presented for a cadaveric extraperitoneal renal transplant. The patient developed a progressively worsening bowel obstruction postoperatively and evidence of an obstruction was observed on computed tomography imaging with a transition point at the level of the sigmoid colon. Consequent to this, she underwent an exploratory laparotomy, which revealed kinking of the colon secondary to the compression between the transplanted and the left native polycystic kidneys. There were adhesive bands between the native kidney and the descending colon in the retroperitoneal space maintaining it in a fixed position mechanically. The addition of a retroperitoneal transplant exacerbated this kink and was responsible for the bowel obstruction. Her left colon was completely mobilized to relieve her obstruction, and owing to her bowel distension, her abdomen was left open for 2 days before returning to the operating room to remove her left native polycystic kidney to allow space for safe closure. This report highlights an extremely unusual cause of large bowel obstruction post-kidney transplantation.

Monomorphic Cutaneous T-Cell Lymphoma in a Patient with Cadaveric Renal Transplant on Immunosuppressive Drugs and Renal Impairment Treated Successfully with Single Agent Brentuximab Vedotin

BACKGROUND:Patients with renal transplants on immunosuppressive drugs are more likely to develop skin malignancies secondary to T-cell dysfunction and are at increased risk of viral reactivation. Cutaneous lymphomas are the second most common form of malignancy after skin cancer. B-cell lymphoma accounts for majority of the cases, with T-cell lymphoma accounting for 30% of the cases. T cell post-transplant lymphoproliferative disorder is usually an aggressive lymphoma. Skin lesions may be either erythematous, infiltrative plaque, nodular or ulcerative tumor. Cutaneous T-cell lymphoma expressing CD 30 generally have a good prognosis and can be treated with targeted antibody against CD30 avoiding systemic toxicity of chemotherapy. Brentuximab vedotin CD30 antibody is an antibody-drug conjugate (ADC) consisting of CD30-directed antibody, cAC10, conjugated by a protease-cleavable linker to a microtubule-disrupting agent, monomethyl auristatin E (MMAE). ADC binds to CD30-expressing cells, followed by internalization of the ADC-CD30 complex and the release of MMAE via proteolytic cleavage. MMAE then binds to tubulin to disrupt the microtubule network within the cell causing cell cycle arrest and apoptotic cell deathOBSERVATION:A 46 year old male received a Cadaveric Renal transplant in 1999 for presumed renal failure after Streptococcal Nephritis. Patient experienced couple of rejections and has Chronic Kidney Disease, stage III. He is maintained on immunosuppressive medication which included prednisone, Mycophenolate Mofetil and cyclosporine. Patient noticed progressive lumps in his neck, back and arms which gradually increased in size and number to occupy his front and back of neck, chest and abdomen as well as axilla. The patient did not have any constitutional symptoms. PET/CT prior to treatment revealed widespread hypermetabolic soft tissue nodules involving skin, subcutaneous fat and muscle throughout the neck, chest, abdomen and pelvis as well as anterior mediastinal lymph node consistent with malignancy. Excisional biopsy from right axillary mass showed High Grade Lymphoma in setting of post -transplant. The immunopheno type of tumor cells were positive for CD2, CD4, MUM1 and CD138 (focal, especially the larger cells). CD3 was positive mostly in apparent background lymphocytes. CD30 was strongly and diffusely positive. The malignant cells were negative for EBV, CD79A, ALK-1 and CD20. The complex immunophenotype was consistent with the diagnosis of monomorphic post-transplant lymphoproliferative disorder of T lymphocytes. The dose of immunosuppressive drug was reduced and the patient was treated with Brentuximab vedotin CD30 antibody - drug conjugate 1.2 mg/kg every 3 week (Dose adjusted for renal impairment). The patient tolerated the treatment very well with mild grade 1 peripheral sensory neuropathy localized to bilateral finger tips treated with Pregabalin. Repeat PET/CT after six cycles of treatment with Brentuximab vedotin showed interval resolution of previously described hypermetabolic soft tissue nodules and anterior mediastinal lymph node. No evidence of residual/recurrent hyper-metabolic foci. The patient continues to be on Brentuximab vedotin every three week now after 6 months of treatment.CONCLUSION:CD30+ Monomorphic cutaneous T-cell lymphoma occurring in post renal transplant patients with renal impairment and on immunosuppressive medication can be successively treated with targeted drug Brentuximab vedotin with dose adjustment with excellent response as in this case. Brentuximab Vedotin should be avoided in severe renal failure (Creatinine Clearance< 30 mlL/min) due to higher risk of Grade 3 adverse reactions. Brentuximab vedotincan be safely use with dose modification and close observation for toxicity in patients with moderate renal impairment and post renal transplant setting. [Display omitted] DisclosuresD'Cunha:Seattle Genetics Inc.: Honoraria.

A case report: anaphylaxis to cefazolin\u202fduring\u202frenal\u202ftransplant\u202fsurgery

BackgroundWhile there exist case reports of anaphylaxis occurring during renal transplant surgery, descriptions of continuing transplant surgery post-anaphylaxis have been scarce. Anaphylactic reactions that present solely with hypotension without pulmonary or mucocutaneous signs have yet to be described during renal transplant surgery.Case presentationHere we report a case of a 33-year-old female with end-stage renal disease who underwent cadaveric renal transplant. She developed anaphylaxis following the administration of cefazolin. Despite this reaction, the surgery was ultimately completed after patient stabilization, and the patient had excellent graft function postoperatively. The patient had an elevated tryptase at the time of the reaction and postoperative allergy testing revealed a positive intradermal test to cefazolin. Written informed consent was obtained from the patient for all procedures, studies, and publication of this case report.ConclusionsThis is the first case of a successful zero-mismatch cadaveric renal transplant following an anaphylactic reaction to cefazolin. Although anaphylaxis during transplant surgery typically warrants cancellation due to the hemodynamic effects that may lead to graft dysfunction, here we describe a case where surgery was continued following patient stabilization. The decision to proceed with surgery despite an intraoperative emergency along with the management and workup of intraoperative anaphylaxis are described, which can be beneficial for others who are presented with similar scenarios in the future.

POS-695 INTESTINAL OBSTRUCTION COMPLICATING CAMPYLOBATER COLI ENTERITIS IN RENAL TRASNPLANTATION PATIENT

A 30 year old male, with cadaveric renal transplantation 2 years ago , his primary disease was anti-GBM disease diagnosed one year prior to transplantation and treated with 14 sessions of plasma exchange, steroids and cyclophosphamide shortly after that he was initiated on hemodialysis followed by renal transplantation. Two months post renal transplantation his course was complicated by biopsy proven mixed rejection (T-Cell mediated rejection type IA) and active Antibody medicated rejection , however ,C4d negative. The patient received pulsed steroids, 3 sessions Plasma-exchange and IVIG 2g/kg. He completed 2 doses of Rituximab and his serum creatinine was stable at 200-220 micromole/L. The patient was admitted after 3 weeks with persistent vomiting and abdominal pain and abdominal distention, his serum creatinine 304 micromole/L, abdominal x-ray showed multiple air fluid levels with dilatation of small bowel loops. CT scan with oral contrast showed multiple dilated small bowel loops down to the terminal ileum with caliber of 3.5 mm with multiple air-fluid levels and fecal loading in distal ileum loop with collapsed colon. The contrast media reached into the small bowel in left mid abdomen at mid jejunal loop. Stool culture grew campylobacter coli, BK PCR was positive of 371,000 copies. Other infectious causes of diarrhea were excluded. The patient completed 7 days of ciprofloxacin and treated with intravenous immunoglobulins (IVIG) . His mycophenolic acid was stopped, and he was maintained on dual immunosuppression therapy in form of tacrolimus and steroids. The patient was booked for upper endoscopy and colonoscopy in outpatient setting. View Large Image Figure ViewerDownload Hi-res image Download (PPT) Diarrhea is a common symptom in renal transplant patient population. The main causes of diarrhea after transplantation include infections, immunosuppressive drugs, antibiotics, and other drugs. Viral causes of diarrhea are the most frequently reported and usually last up to 3 days. Patients have tendency to develop Clostridium difficile after antibiotics. Other enteric bacteria responsible for diarrhea are Shigella, Salmonella typhi, Salmonella typhimurium and Campylobacter. CMV can cause enterocolitis, with or without fever, gastrointestinal bleeding, perforation, and toxic megacolon are possible complications. Incidence of diarrhea with mycophenolate mofetil dose of 2 g/day was higher than in other immunosuppressants like azathioprine. Campylobacter infection has prominent features like terminal ileitis, cecitis and mesenteric adenitis. Proton pump inhibitors are main risk factor for campylobacter enteritis as it lowers the gastric juice acidity allowing for pathogen survival. Campylobacter was detected in stool culture of a 31-year-old male patient diagnosed with immunoproliferative small intestinal disease (IPSID) and it was positive in tissue biopsy samples. Antibiotics treatment is enough to eradicate campylobacter and reduce the risk of IPSID. Diarrhea is a common symptom post renal transplantation, Campylobacter coli can be one of the main causes of ileocecal enteritis and may cause small bowel obstruction, treatment is usually conservative with antibiotics.

POS-755 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) IN A 26 YEAR OLD FEMALE RENAL RECIPIENT - WHAT YOU CAN LEARN FROM OUR EXPERIENCE

PTLD accounts for almost 20% of all cancers occurring in solid organ transplantation. It represents infiltration of B cells driven by EBV/CMV infection in the background of severe immunosuppression and impaired T-cell immune surveillance. Current case presents PTLD 7 months post 2nd renal transplantation and reflects on early detection/prevention and management. Case Presentation A 26-year old female presented with 2/52 fatigue, fever, night sweats and abdominal pain, 7 months post 2nd cadaveric renal transplant EBV/CMV mismatched. Medical history included cyclophosphamide-treated proliferative lupus nephritis, tacrolimus-based immunotherapy and antirejection treatment. On examination, there was tenderness of the right iliac fossa with femoral lymph nodes. Patient had anaemia, leukopenia, deterioration in renal function, elevated LDH, EBV PCR 18,752 copies/mL and CMV PCR 300 copies/ml. CT abdomen showed an 8cm soft tissue mass obstructing the graft. Biopsy confirmed polymorphic PTLD (pictures 1, 2). View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Outcome: The patient was treated with reduction of immunosuppression and withdrawal of both Tacrolimus and Mycophenolate Mofetil. Prednisolone 5 mg daily remained and EBV load monitored weekly. Immunotherapy with CD 20 monoclonal antibody, rituximab, commenced weekly for 4 weeks. Complete remission was achieved in 3 months, Kidney function returned to baseline and 18F Fluorodeoxyglucose PET-CT revealed no sign of lymphoma. Four-year post diagnosis, patient remained disease-free as demonstrated on repeat 18 FDG PET- CT, with stable graft function and negative EBV/CMV viral load. Immunosuppression remained minimal. Seronegative EBV/CMV recipients accepting seropositive grafts have 24 times higher incidence rate of PTLD, likely within the 1st year post transplantation. Significant increase in the viral load can predict/diagnose early PTLD. Lower immunosuppression with reduction/withdrawal of Tacrolimus and rituximab use can be effective for prevention and treatment. Ganciclovir has proved to be of equal value. FDG PET-CT is highly sensitive to detect disease extent and response to treatment.

Wiskott-Aldrich syndrome

Two cases of successful cadaveric renal transplantation in patients with the Wiskott-Aldrich syndrome have previously been reported in the literature [1,2]. The first patient [1] had an almost uneventful outcome, while the second one [2] had to be treated with highdose methylprednisolone for biopsy-proven cellular rejection. The optimal immunosuppressive regimen in patients with Wiskott-Aldrich syndrome remains unknown. We report here the case of a Wiskott-Aldrich patient who underwent living-related renal transplantation. This patient however developed a number of infectious and non-infectious complications which led to his death 3 months after transplantation.

Comparison of histidine-tryptophan-ketoglutarate solution versus ringer lactate as perfusion fluid in live donor renal transplant - A randomised controlled trial

Objective: Ringer's lactate (RL) was one of the perfusion fluid used in renal transplants, which were replaced by perfusion fluid with an intracellular composition like histidine-tryptophan-ketoglutarate (HTK) solution. These are preferred in cadaveric renal transplants. However, there are no guidelines for live-related donor renal transplant. We study whether HTK solution is better than RL solution, an extracellular composition fluid in preserving allograft in live-related donor renal transplantation. Materials and Methods: A single-blinded randomized trial comparing HTK solution and RL solution in 80 patients undergoing live-related donor renal transplantation from July 2017 to June 2018. The outcome was measured in serum cystatin C and plasma malondialdehyde (MDA) and serum creatinine for 30 days. Results: In 19 cases, surgeons preferred HTK solution as perfusion fluid due to the presence of multiple arteries; hence, these cases are removed from analysis due to deviation from the study protocol. Four patients in the HTK group and five patients in the RL group were excluded due to loss to follow-up. Recipient age, sex, and donor age, sex, and basic disease were comparable in both groups. The higher warm ischemia in the HTK group (5.58 min [standard deviation (SD) 1.44 min]) as compared to the RL group (5.00 min [SD 1.12 min]) with P 0.096. Similarly, the longer cold ischemia in the HTK group (82.00 min [SD 21.31 min]) as compared to the RL group (70.32 min [SD 24.56 min]) with P 0.783. 8.3% rejection in the HTK group and 17.9% rejection in the RL group. Serum cystatin C, marker of glomerular filtration was comparable, HTK group ((3.75 ± 1.98 mg/l) and RL (3.94 ± 1.68 mg/l) with P 0.714. The plasma MDA marker of ischemia-reperfusion injury was also comparable HTK group (80.16 ± 80.08 ng/ml) and RL group (61.50 ± 92.23 ng/ml) with a P 0.446. Fall in serum creatinine was significantly more in the HTK group than RL. At the end of 30 days, both groups had similar levels of serum creatinine level. Conclusion: Graft perfused by HTK solution and RL solution at our center had comparable 30-day outcomes. Although none of the differences was statistically significant, the HTK group had consistently better metrics in terms of fall in creatinine and serum cystatin C despite a trend to longer ischemia times and higher plasma MDA levels.

THE INCIDENCE OF GLUCOSE IMPAIRMENT AND NEW ONSET DIABETES (NODAT) AFTER RENAL TRANSPLANT: A RETROSPECTIVE 12-MONTH REVIEW AT A SINGLE UK-CENTRE.

Aims: Following Renal transplant, recipients receive a combination of immunosuppressive prophylaxis depending on centre protocol. Whilst these drugs are vital for graft survival, a well-recognised side effect is serum glucose impairment and subsequent new onset diabetes after renal transplantation (NODAT). Methods: Retrospective data was collected and analysed from 110 patients, who underwent a cadaveric or live renal transplant between January 2018 – December 2018. Electronic records were accessed to decipher recipient blood glucose sugars and HbA1C levels at 1 month, 6 months and 12 months post renal transplant. This data was then utilised to establish the rate of glucose impairment and NODAT incidence at these time intervals. Results: Salient study findings are summarised in the table below. Mean (+/- standard deviations) are used unless otherwise specified.Discussion: Total number of renal transplants was 110. The unit has a standard immunosuppressive protocol of simulect 20 mg (day 0,4), Methylprednisolone 500 mg at induction. Maintenance includes Mycophenolate mofetil (500mg BD), and Tacrolimus (Trough levels 6-8) and prednisolone 5mg. The highest average glucose impairment was observed at 1 month following transplant.17 (15.45%) recipients remained diabetic, 67 (60.91%) recipients remained non-diabetic, whilst 7 (6.36%) recipients developed NODAT. Conclusion: Glucose impairment is seen more commonly within the first 6 months of renal transplant, with a NODAT rate of 6.3% per annum. Interestingly, 19 of 110 recipients (17.2%) who were diabetic pre-transplant showed improved glucose metabolism, and consequently required a reduced diabetic treatment regimen. The maintenance dose of steroids seems to have no impact on NODAT rate. Additionally, post-operative care may be enhanced with diabetologist specialist input for managing glucose impairment and NODAT.

Anaplastic large cell lymphoma as a posttransplant lymphoproliferative disorder in a renal transplant patient: A case report.

We report a case of a 45‐year‐old female who developed an ALK‐positive anaplastic large cell lymphoma (ALCL) 9 years after renal transplant. The patient underwent a cadaveric renal transplant for diabetic nephropathy, and presented 9 years later with fever and multiorgan dysfunction. The initial CT scans showed multiple enlarged supra‐ and infradiaphrgamatic lymph nodes. A CT‐guided core needle biopsy of a retroperitoneal lymph node revealed ALK positive ALCL. She received six cycles of cyclophosphamide, adriamycin, vincristine, etoposide, and prednisone, and has been in remission for over 3 years. Monomorphic T‐cell posttransplant lymphoproliferative disorder (PTLD) is an established but rare entity of PTLD and generally carries poor prognosis. This is a case report of a late PTLD with pathology reporting an aggressive T‐cell lymphoma that has been successfully treated with multiagent chemotherapy.

Volatile agents and renal transplantation

Living donor and cadaveric donor renal transplantation have received a significant interest. During the procedure, both volatile agents and total intravenous anesthesia are used.

Transversus abdominis plane block versus quadratus lumborum block type 2 for analgesia in renal transplantation: A randomised trial.

Several studies have shown an analgesic efficacy of a transversus abdominis plane block (TAPB) in reducing opioid requirements during and after cadaveric renal transplantation surgery, but the effect of a quadratus lumborum block (QLB) in this type of surgery is unclear. The main objective of this prospective, randomised, double-centre clinical study was to compare the analgesic efficacy of a one-sided lateral approach TAPB with a unilateral QLB type 2 in cadaveric renal transplantation surgery. Randomised, single-blinded trial. Two University-affiliated tertiary care hospitals between April 2016 and May 2017. A total of 101 patients aged more than 18 years, scheduled for cadaveric renal transplantation. On receiving ethical board approval and individual informed consent, consecutive patients were allocated randomly to receive either an ultrasound-guided single-shot lateral TAPB or an ultrasound-guided single-shot QLB type 2 on the surgical side using 20 ml of bupivacaine 0.25% with adrenaline after a standardised induction of general anaesthesia. All patients on surgical completion and recovery from general anaesthesia were admitted to the postanaesthesia care unit for 24 h. They received standardised intravenous patient-controlled analgesia with fentanyl, and their pain scores were noted at regular intervals. The primary endpoint was total cumulative fentanyl dose used per kg body mass in the first 24 h after surgery. Secondary outcomes were the need to start a continuous infusion of fentanyl in addition to patient-controlled analgesia boluses during the stay in post-anaesthesia care unit, postoperative pain severity measured using a numerical rating scale, patient satisfaction with analgesic treatment, evidence of postoperative nausea and vomiting, pruritus and sedation level. The 49 patients allocated to the QLB type 2 group used significantly less fentanyl per kg in the first 24 h after surgery than the 52 patients who received a TAPB (median [IQR] 4.2 [2.3 to 8.0] μg kg versus 6.7 [3.5 to 10.7] μg kg, P = 0.042). No statistically significant differences were noted in the secondary endpoints within the study, including the frequency of adverse effects of opioids. The reduction of fentanyl consumption in the first 24 h after renal transplantation with no difference in pain intensity and patient satisfaction shows a beneficial effect of one-sided QLB type 2 over a one-sided TAPB in regards to postoperative analgesia. However, the reduction in opioid consumption did not affect the frequency of opioid-related adverse effects. ClinicalTrials.gov ID: NCT02783586.

Pulmonary complications within the first year after renal transplantation

Background The lungs are commonly involved after renal transplantation, with many complications, either infectious or noninfectious. The infectious complications significantly increased morbidity and mortality. Several risk factors were involved, such as old age, smoking status, comorbid diseases, pretransplant peritoneal dialysis, cadaveric renal transplantation, heavy immunosuppression, and treatment of graft rejection. Aim To study the predisposing risk factors, etiologic factors, and the timeline of pulmonary complications within the first year after renal transplantation (either infectious or noninfectious complications). Patients and methods We conducted this prospective observational study in the Organ Transplant Center in Kuwait from March 2016 to October 2019. The kidney recipients were followed up for 1 year after transplantation. For suspected infectious pulmonary complications, the patients were subjected to blood, sputum, and or bronchoalveolar lavage within the first 24 h after admission; all samples were subjected to microbiological and serological examinations. Results We had 60 patients who developed postrenal transplant pulmonary complications. A total of 42 patients developed infectious pulmonary complications and 54 patients developed noninfectious complications. The most common infectious pulmonary complications were bacterial pneumonia (42 patients), opportunistic fungal infection (47 patients), and viral pneumonia (37 patients). The most common noninfectious pulmonary complications were pulmonary congestion (51 patients), pleural effusion (29 patients), and pulmonary embolism (16 patients). In the first 6 months, surgery-related complications and opportunistic fungal infection predominated owing to heavy immunosuppression. After 6 months, infections were due to community-acquired pathogens. The mortality rate was 38%. Bacterial pneumonia was the main cause of death (39%) followed by viral pneumonia (26%) and Pneumocystis jiroveci pneumonia (13%). Septic shock and respiratory failure were the leading causes of death. Conclusion Renal transplant was associated with infectious and noninfectious pulmonary complications. Infections were highly prevalent in the first year after transplantation. Old age, smoking status, comorbid diseases, pretransplant peritoneal dialysis, cadaveric renal transplantation, heavy immunosuppression, and treatment of graft rejection were the main risk factors for posttransplant pulmonary complications. Sepsis and respiratory failure represented the commonest causes of death.

Ventricular arrythmias in a end-stage renal disease patient during cadaveric renal transplantation

Ventricular arrythmias in a end-stage renal disease patient during cadaveric renal transplantation

Renal Transplant Guidelines with Reference to COVID-19 Infection.

Development of COVID-19 pandemic has affected organ transplant activity significantly. To start with, government of India had adviced stoppage of “elective” surgeries so as to cope with resources and manpower for COVID-19 patients. As majority of hospitals are having both COVID and Non-COVID patients, there is obvious fear of cross-infection. Also, transplant patients being immunocompromised, there is higher risk of acquiring COVID-19 infection along with atypical presentation and unpredicted course of the disease. Result was that across India, elective living related kidney transplant came to a halt. Cadaver renal transplant, being emergency in nature still done, though very few. With passing time, once it became clear that pandemic is not going to be controlled sooner, need has been felt to restart renal transplant activity. Keeping various issues in mind in relation to elective living related renal transplant and emergency deceased donor renal transplant, these guidelines have been framed to help transplant professionals for restarting renal transplant program again in the country, while keeping both health care workers and patient safe.

Anesthesia Management for Kidney Transplant Recipient in Patient with Kyphoscoliosis

Kyphoscoliosis is one of the manifestations of renal bone disease due to End stage renal disease (ESRD). Chronic renal failure patients usually present with comorbidities like hypertension, Diabetes, Dyslipedidemias, however, the risk of renal transplant increases multifold when the patient also suffers with respiratory problems. Herein we provide a patient of ESRD with severe kyphoscoliosis having severe pulmonary and systemic hypertension posted for emergency cadaveric donor renal transplantation which was successfully performed under general anesthesia with invasive Monitoring.

Can Direct-Acting Antiviral Treatment Change the Immunologic Risk Profile in Patients Infected with Hepatitis C Virus Who Are on the Cadaveric Waiting List?

BackgroundIn patients with hepatitis C virus (HCV) infection, the activation of the immune system by the virus or viral proteins leads to the production of numerous autoantibodies and clinical manifestations. The objectives of this study were to investigate the relationship between HCV and anti-HLA antibodies, as well as the effect of viremia on the antibody response and of direct-acting antivirals (DAAs) on anti-HLA antibody persistence in patients on the waiting list for a cadaveric kidney transplant. MethodsA total of 395 patients from the cadaveric renal transplant waiting list were included in the study. The patients were grouped according to the presence of HCV infection, and patients with HCV positivity were further divided into a spontaneous clearance group and a persistent group. Anti-HLA antibodies were examined before and after treatment of the patients in the persistent group. The One Lambda Luminex method (Thermo Fisher Scientific, Waltham, MA, United States) was used to assess both HLA class I and II alleles and the anti-HLA antibody profile. ResultsAnti-HLA class I and II antibodies were detected in 48.2% and 55.1%, respectively, of the patients infected with HCV and in 21.8% and 20.4%, respectively, of the patients who were not infected. The level of anti-HLA A3, A11, B72, B52, Cw6, Cw16, DR3, and DQ4 antibodies was significantly higher in the patients infected with HCV. There was no statistically significant difference in class I and II antibody titration between the HCV-infected spontaneous clearance group and the persistent group (class I mean fluorescence intensity [MFI] ± SD: 13,583 ± 6224, 13,450 ± 9540, P = .808; Class II MFI ± SD: 13,000 ± 8673, 8440 ± 8302, P = .317, respectively). There was no significant difference in the class I and class II anti-HLA antibody profile and titration in the persistent group after treatment with DAAs (P > .05). ConclusionsThe results of this study demonstrated that hepatitis C DAA treatment did not change the anti-HLA antibody profile and titration.

Calciphylaxis: A successful outcome whilst on peritoneal dialysis

Calciphylaxis is a life threatening disease for which patients with chronic kidney disease, particular those on dialysis, are at increased risk. As it is a rare condition, treatment options are limited and duration of treatment is not clear, especially when it comes to patients on renal replacement treatment with peritoneal dialysis.&#x0D; We report a case of a 55 year-old woman with end stage renal disease on renal replacement treatment with peritoneal dialysis for five months that presented with severe calciphylaxis of both legs. She had started haemodialysis at the age of 31 and 3 later she received a cadaveric renal transplant that lasted for 20 years. She was treated with warfarin due to atrial fibrillation diagnosis. The treatment approach was multimodal and multidisciplinary and included treatment with sodium thiosulfate and hyperbaric oxygen, warfarin suspension and maintenance of optimized peritoneal dialysis prescription. Additionally, wound dressings were done every other day and antibiotics started whenever there were signs of infection and pain was managed with high doses of opiates and pain adjuvants. There was significant improvement and the patient kept peritoneal dialysis treatment with preserved residual renal function. This raises the question, if there is a need to transition calciphylaxis patients on peritoneal dialysis to haemodialysis, as it is possible to ensure a high efficiency dialysis program with automated peritoneal dialysis.