Deceased Donor Renal Transplant Recipients Research Articles

O038 Positive impact of an ERAS programme on living and deceased donor renal transplant recipients’ recovery during COVID pandemic

Abstract Introduction An ERAS (Enhanced Recovery After Surgery) programme was created to reduce length of stay (LoS) and improve outcomes following renal transplant surgery. This aimed to reduce post-operative hospital-acquired infection, especially COVID-19. Methods The ERAS protocol was finalised following a literature review and MDT discussion. ERAS information, with post-operative exercise advice, was distributed to patients on the renal transplant waitlist. LOS was evaluated, comparing ERAS with pre-ERAS recipients and, to remove pandemic bias, pre-pandemic (December 2019) recipients. Secondary outcomes were opiate use, mobilisation, bowel function and patient-reported outcomes. ERAS protocol compliance was monitored. Data analysis was with student t-test and Chi-2 test in GraphPad Prism. Results Some 35 consecutive recipients completed ERAS protocol (March 2021). Baseline characteristics were comparable between live-donor recipients 9/35 vs 13/35 pre-ERAS and 12/35 pre-COVID. BMI>30 was higher in ERAS group (19vs. 11vs. 8). Median LoS was significantly reduced: ERAS - 5 days, pre-ERAS - 7 days, pre-COVID - 8 days (p=0.01). 51% of ERAS discharges were within 5 days vs. 17% pre-ERAS vs. none pre-COVID (X2 12.59, p<0.001). For overstayers (>5 days), potential preventable reasons were identified. 79.2% of ERAS recipients mobilised on day 1 post-op. ERAS indicated no significant reduced opiate use. Two ERAS recipients were readmitted within 30 days (vs.9/70 pre-ERAS) and one returned to theatre (vs.5/70 pre-ERAS). Conclusion This ERAS programme successfully reduced the LoS by 2 days in comparative population with minimal adverse events. Patient and staff feedback was positive. It's hypothesised that assigning a specialist ERAS nurse will improve compliance.

SP5.2.1 Renal Transplant Outcomes Through the COVID-19 Pandemic at a London Transplant Centre

Abstract Aims The aim of this audit was to establish the impact of COVID-19 on the outcomes of renal transplant recipients in the post-transplant period at our centre, through the 2020 calendar year. Methods Living donor and deceased donor renal transplant recipients in the period of interest were identified and any complications or adverse outcomes were reviewed and compared to outcome data from the previous year. Results A total of 88 renal transplants were performed in 2020. Fifty-five cases were performed after reopening the Unit. Five patients tested positive for COVID-19 in the post-transplant period. One patient was admitted to the Intensive Care Unit and subsequently died from related complications. Another patient suffered from internal jugular vein thrombosis shortly after testing positive and could be attributed to the hypercoagulable state post-infection. A total of 4 deaths and 1 graft loss were recorded within 2020. This compares to 1 death, 2 graft losses and 1 primary non-function in 172 transplants in 2019. Of the 4 deaths, one was directly linked to COVID-19. The other 3 deaths could be indirectly linked to the disruptions that were made in the healthcare system during this period in adapting to the pandemic. Conclusions It was anticipated that COVID-19 will directly and indirectly affect patient outcomes from surgery during this period. This was clearly seen at this Unit, with mortality rates having increased almost eight-fold in the post-transplant period compared to the same period in the previous year. However, no significant difference was seen with graft losses.

Intraoperative Near-Infrared Spectroscopy Monitoring of Renal Allograft Reperfusion in Kidney Transplant Recipients: A Feasibility and Proof-of-Concept Study.

Conventional renal function markers are unable to measure renal allograft perfusion intraoperatively, leading to delayed recognition of initial allograft function. A handheld near-infrared spectroscopy (NIRS) device that can provide real-time assessment of renal allograft perfusion by quantifying regional tissue oxygen saturation levels (rSO2) was approved by the FDA. This pilot study evaluated the feasibility of intraoperative NIRS monitoring of allograft reperfusion in renal transplant recipients (RTR). Intraoperative renal allograft rSO2 and perfusion rates were measured in living (LDRT, n = 3) and deceased donor RTR (DDRT, n = 4) during the first 50 min post-reperfusion and correlated with renal function markers 30 days post-transplantation. Intraoperative renal allograft rSO2 for the DDRT group remained significantly lower than the LDRT group throughout the 50 min. Reperfusion rates were significantly faster in the LDRT group during the first 5 min post-reperfusion but remained stable thereafter in both groups. Intraoperative rSO2 were similar among the upper pole, renal hilum, and lower pole, and strongly correlated with allograft function and hemodynamic parameters up to 14 days post-transplantation. NIRS successfully detected differences in intraoperative renal allograft rSO2, warranting future studies to evaluate it as an objective method to measure ischemic injury and perfusion for the optimization of preservation/reperfusion protocols and early prediction of allograft function.

The Impact of Atherosclerotic Cardiovascular Risk on Graft Failure in Deceased-Donor Renal Transplantation.

Pretransplant cardiovascular risk may be amplified after renal transplant, but little is known about its impact on graft outcomes. The purpose of this study was to determine if pretransplant cardiovascular risk was associated with graft outcomes. This retrospective study included deceased-donor renal transplant recipients from 2010-2015. Atherosclerotic cardiovascular disease risk for patients without prior disease was calculated and patients were categorized into high (score >20%), intermediate (7.5-20%), and low risk (<7.5%). Patients with and without prior cardiovascular disease were also compared. The main endpoint was graft failure at 3-years post-transplant. Other outcomes included major adverse cardiovascular events, biopsy-proven rejection, and mortality. In patients without prior atherosclerotic cardiovascular disease (N = 115), graft failure rates (4.5% vs 11.3% vs 12.5%; (P = 0.64) and major adverse cardiovascular events (9.1% vs 13.2% vs 5.0%; P = 0.52) were similar in the high, intermediate, and low risk groups. In those with prior disease (N = 220), rates of primary nonfunction (6.8% vs 1.7%; P = 0.04), major adverse cardiovascular events (7.3% vs 2.6%; P = 0.01), and heart failure (10.9% vs 3.5%; P = 0.02) were higher than those without cardiovascular; rates of major adverse cardiovascular events and heart failure were insignificant after adjusting for age, gender, and race. Other outcomes were not different. Outcomes did not differ based on pretransplant cardiovascular risk. Pretransplant atherosclerotic cardiovascular disease was associated with increased early graft failure but similar outcomes at 3-years, suggesting cardiac risk alone should not exclude transplantation.

The Value of Perfusion Fluid Culture Analysis in Deceased Donor Renal Transplants: A 10-Year Single-Center Experience

Microbiological analysis of kidney perfusion/transport solution is not routinely performed in all transplant centers. This paper gives a 10-year descriptive single-center experience of the routine culture of perfusion fluid in deceased donor renal transplant recipients as well as the prophylactic treatment of certain organisms if identified. Data were collected retrospectively on all deceased donor transplants performed between 2009 and 2018. Organisms detected were classified as either pathologic, of uncertain pathogenicity, or contaminants. Treatment was guided by the microbiology team. A total of 661 specimens were analyzed. Organisms were cultured in 168 of 661 (25.4%) of these samples. The most frequent organisms identified were skin and oral flora (n=95, 42%). The majority of organisms identified (131 of 226, 58%) necessitated prophylactic treatment on the advice of our microbiology department. On 7 (4.2%) occasions, the perfusion fluid cultures grew organisms not covered by the routine antimicrobial prophylaxis, and on 15 occasions Candida albicans was isolated. Candida isolates were treated preemptively with 1 month of antifungal treatment. There were no infective sequelae in this group.

The Significance and Impact of Screening Preservation Fluid Cultures in Renal Transplant Recipients.

Infectious complications can be a major cause of morbidity and mortality in solid organ transplant recipients. Preservation fluid is necessary to maintain organ viability but may serve as a vector or infection. The utility of screening preservation fluid routinely for microbial growth and the impact of culture-positive preservation fluid is controversial. Research Question: What is the clinical impact of a culture positive preservation fluid in a kidney transplant recipient? This retrospective study was performed to define the incidence of post-operative infection related to PF and examine the negative sequelae of culture-positive PF. One hundred and fifty-two deceased donor renal transplant recipients from January 2015 to December 2017 were included for analysis. Overall, 67% of patients (102/152) received an allograft from a culture-positive PF. Nearly 80% of microbial growth was consistent with skin flora, and coagulase-negative staphylococci was the most frequently isolated organism (56%). Sixty-seven percent of patients (68/102) with culture-positive PF received antimicrobial treatment for an average duration of 5 days. There was no difference in the incidence of infection between patients with culture positive PF compared to culture-negative PF. Furthermore, there were no cases of infection related to PF regardless of whether culture-positive PF was treated or untreated. The incidence of subsequent C. difficile infection and multidrug-resistant organisms was similar. This study suggests antimicrobial treatment for culture positive PF may not be necessary with pathogens that are common contaminants and of low virulence. Interventional studies are needed to validate this strategy.

Evaluating Potential Deceased Donor Renal Transplant Recipients for Asymptomatic COVID-19.

Evaluating Potential Deceased Donor Renal Transplant Recipients for Asymptomatic COVID-19.

Evaluation of Renal Anionic Secretion Following Living-donor and Deceased-donor Renal Transplantation: A Clinical Pharmacokinetic Study of Cefoxitin Microdosing.

Background.Renal transplantation is the treatment of choice for patients with end-stage renal disease. Because kidneys are the primary excretory organs for various drugs/drug metabolites, changes in renal graft function would significantly alter the clearance and exposure of renally secreted drugs. Renal allografts from living and deceased donors normally undergo numerous insults, including injuries associated with prolonged cold ischemic time, reperfusion, and nephrotoxicity due to calcineurin inhibitors. These physiologic and pharmacologic stresses can alter the expression and functional capacity of renal organic anionic transporters (OATs).Methods.The objectives of this study were to assess the longitudinal changes in renal anionic secretion in kidney transplant patients, to study the effect of prolonged cold ischemic time on OAT secretion in kidney transplant patients (living- versus deceased-donor recipients), and to compare OAT secretory capacity of renal transplant recipients with healthy volunteers. Cefoxitin was used as a probe drug to assess OAT secretion. Cefoxitin pharmacokinetics was studied in 15 de novo renal transplant recipients following intravenous administration of 200 mg cefoxitin within 14 d and beyond 90 d posttransplantation.Results.No longitudinal changes in real OAT secretion in early posttransplant period were observed, and there were no differences in renal OAT secretion between living- and deceased-donor renal transplant recipients. Overall, cefoxitin exposure was 2.6-fold higher and half-life increased by 2.2-fold in renal transplant recipients when compared with historical healthy controls.Conclusions.These results suggest that OAT system is functioning well, but renal transplant recipients would need significantly lower dosage of drugs that are primarily secreted via the OAT system compared with normal subjects.

Early Graft Function in Deceased Donor Renal Recipients: Role of N-Acetylcysteine.

Reduced graft function (RGF) in donor renal transplant recipients is caused by oxidative damage due to extensive ischemia-reperfusion (I/R) injury during transplantation. Neutrophil gelatinase-associated lipocalin (NGAL) is a promising biomarker to detect tubular injury early after renal transplantation. N-acetylcysteine (NAC) is a potent antioxidant that can reduce I/R injury by improving oxidative damage. The aim of the present study is to assess the efficacy of NAC in improving graft function and reducing renal tubular injury in deceased donor renal transplant recipients. A double-blind, randomized clinical trial was conducted on 50 deceased donor renal transplant recipients. The patients were randomized into two groups, receiving either 600 mg NAC twice daily, or placebo (days 0 to 5). Results were assessed based on the rate of RGF, levels of plasma NGAL (p-NGAL) and the estimated glomerular filtration rate (eGFR). The rate of RGF was significantly lower in the patients receiving NAC vs. placebo (21.4% vs. 50%). The measurement of p-NGAL levels showed that the patients in the NAC group had significantly greater reduction of p-NGAL by both days 1 and 5 post-transplantation than those in the placebo group. A near steady-state eGFR level was reached by week 1 in the NAC group, however, the improvement of eGFR was significantly slower in the placebo group and a near steady-state was only achieved by week 4. NAC has promising potential in reducing tubular injury and improving graft function, evidenced by significant reduction in the rate of RGF and levels of p-NGAL.

Clinical outcomes of valganciclovir prophylaxis in high-risk (D+/R-) renal transplant recipients experiencing delayed graft function.

Cytomegalovirus (CMV) outcomes with valganciclovir prophylaxis in renal transplant recipients experiencing delayed graft function (DGF) are unclear. This single center, retrospective, cohort study of CMV high-risk (D+/R- with alemtuzumab induction) deceased donor renal transplant recipients receiving valganciclovir prophylaxis assessed CMV outcomes in patients experiencing DGF (n=72) versus those with immediate graft function (IGF; n=66). Cytomegalovirus viremia by 12months occurred at similar rates in the IGF and DGF groups (30.3% vs 26.4%, respectively, P=0.71) with 89.7% (35/39) of all cases classified as CMV disease. The median time to CMV viremia post transplant was day 141 and 138 in the IGF and DGF groups, respectively (P=0.30). The incidence of biopsy-proven acute rejection (BPAR) was higher in the DGF group (18.1% vs 4.6%, P=0.02) with BPAR preceding CMV in only 1 patient. There was no significant difference in graft loss (1.5% vs 4.2%, P=0.62) or patient survival (98.5% vs 95.8%, P=0.62) at 1 year between the IGF and DGF groups, respectively. Valganciclovir prophylaxis in patients experiencing DGF yielded similar CMV outcomes up to 1-year post transplant when compared to use in patients with IGF.

Mannose binding lectin 2 gene polymorphisms in patients after renal transplantation with acute graft rejection

Mannose binding lectin 2 (MBL2) is one of the pattern-recognition soluble receptors and is responsible for complement activation via the lectin pathway, so it plays an important role in kidney transplantation.The aim of the study was to examine the association between MBL2 gene polymorphisms and acute rejection of the kidney allograft. This study enrolled 266 Caucasian deceased-donor renal transplant recipients – 69 with diagnosed acute graft rejection, 197 with stable graft function.A 969 bp DNA fragment, from chromosome 10, including promoter region and exon 1 of MBL2 gene was sequenced. The DNA fragment obtained contained 122 SNPs accordingly to the NCBI dbSNP database. Of this number only nine showed variation within our population (rs36014597, rs5030737, rs1800450, rs7095891, rs11003123, rs7096206, rs7084554, rs11003124, rs11003125), and only these were subjected to further analysis.Among the studied polymorphisms in the MBL2 gene only rs1800450 polymorphism was statistically significantly associated with kidney allograft rejection. The AA genotype was significantly associated with an increased risk of acute kidney allograft rejection. (AA vs GA+GG: OR=9.29 (95%CI: 1.83–47.17), p=0.005).The results of our study indicate that MBL2 gene rs1800450 polymorphism may be associated with the risk of acute kidney allograft rejection. The AA genotype, associated with lower MBL2 expression, may be associated with an increased risk of acute kidney allograft rejection.

Living- versus deceased-donor renal transplant recipients: A comparison on pulmonary complications

BACKGROUND: In renal transplant recipients, evaluation of pulmonary complications and investigation of reduction interventions are important due to the potentially fatal results of pulmonary complications after transplant surgery. However, data are lacking about pulmonary complications in renal transplant recipients with living- or deceased-renal donors. Therefore, we aimed to assess the pulmonary complications in living- versus deceased-donor renal transplant recipients. METHODS: We retrospectively searched the medical records of patients who underwent renal transplantation in our tertiary referral center between 2013 and 2018. Sociodemographic characteristics, pulmonary complications, and major comorbidities were compared according to the donor type (living or deceased). RESULTS: Fifty-two of 100 transplantations from living donors and 48 of 100 transplantations from deceased donors were formed the patient groups. There were no statistically significant differences in terms of sociodemographic and clinical characteristics between the groups except with regard to pneumonia complication. The pneumonia rates were 11/48 (22.9%) and 3/52 (5.8%), P = 0.020, for the deceased- and living-donor renal transplant recipients, respectively. Deceased-donor transplant recipients had a 4.8-fold risk of developing pneumonia (odds ratio, 4.8; 95% confidence interval, 1.2–18.6; P = 0.021). CONCLUSION: Deceased-donor renal transplant recipients are more vulnerable to pulmonary complications than are living-donor ones and should thus be monitored closely.

Early Versus Delayed Double J Stent Removal in Deceased Donor Renal Transplant Recipients: A Prospective Comparative Study.

Introduction: Prophylactic ureteric stents have been commonly employed to reduce the incidence of ureteric obstruction and anastomotic leaks following renal transplantation. There are very few studies on the duration of ureteric stenting in deceased donor renal transplantation (DDRT). We performed a prospective study to compare early and late double J stent removal in DDRT.Aims and methods: The aim of this study was to compare the early and delayed removal of ureteric stents after DDRT. We performed 80 DDRTs at our center from August 2012 to December 2016, which were included in the study. However, we enrolled 48 patients as the remaining had to be excluded based on the high-risk factors. The recipients were allocated on the 14th postoperative day to two groups. Group 1 underwent early stent removal on the fourteenth postoperative day and in group 2, the stent was removed in the sixth postoperative week. The two groups were followed up for six months and the incidence of urological complications and urinary tract infections (UTI) was compared.Results: The incidence of UTI during the follow-up period of six months was significantly lower in the early stent removal group (two out of 24) than in delayed stent removal group (eight out of 24) (p=0.016). Asymptomatic bacteriuria occurred in six out of 24 (25%) in group 1 and 10 out of 24 (41.6%) in group 2 (p=0.120). There was no significant difference in the incidence of urinary leak, hematuria, or ureteric obstruction between the two groups (p=0.900). However, stent-related symptoms were significantly more in the delayed stent removal group (three in group 1 versus 18 in group 2) (p=0.001).Conclusion: Prolonged stenting is associated with an increased risk of UTI and stent-related symptoms in immunosuppressed renal transplant recipients. The early removal of double J stents can be done in carefully selected patients to reduce stent-related complications in DDRT.

Clinical Outcomes of Kidney Transplant Recipients with Positive Perfusion Fluid Cultures

Introduction Transplant perfusion fluid (TPF) optimises the storage of organs for transplantation; however it can be a culture medium for pathogenic bacteria. Clinical practice in UK involves routine culture of TPF however results take several days. We did a retrospective study to assess the value of TPF in deceased donor renal transplant recipients. Materials and Methods 173 patients who received renal transplants between January 2014 and October 2016 were included in the study. Electronic data records were used to collect TPF culture result, antibiotics used, length of hospital stay and presence of septic complication in recipients. Results 106 patients received DBD and 67 had DCD organs. 54.3% (n=94) had a negative TPF culture (Cl 46.88-61.72) and 45.7% (n=79) had a positive TPF culture (CI 38.28-53.12).21% (n=36) were diabetic and 4.3% (n=6) had post transplantation diabetes mellitus. Coagulase negative staphylococci represented 55% of positive samples. E.Coli was the most common pathogenic bacteria found (11.3%, n= 9). Infection developed in 45.7% (n=43) of patients receiving a kidney with negative TPF culture compared with 32.9% (n=26) with a positive TPF culture. 7.7% (n=6) of patients with a positive TPF culture developed an infection identified to be caused as the same organism as that from the TPF. Recipients with delayed graft function (DGF) had an infection rate of 54.9% (n =51). Patients without DGF had infection rate of 32.8% (n=116). This association is not statically significant (p=0.07) but may warrant further investigation. Patients with positive TPF culture who received prophylactic antibiotics had similar length of hospital stay as patients not receiving antibiotics. Urinary tract was the commonest site of infection (50%). Patients with diabetic nephropathy or chronic pyelonephritis had higher rates of infection.Conclusion Positive TPF culture was not associated with higher rates of infection or DGF. The likelihood of infection was higher in diabetic patients. Length of hospital stay was not reduced by use of prophylactic antibiotic, even in patients with positive TPF culture. We suggest that a decision to give antibiotic should be based on patient's clinical status and virulence of pathogens found. Further studies are needed to establish role of prophylactic antibiotics in preventing septic complication in recipients with positive TPF culture results.

N-acetylcysteine decreases urinary level of neutrophil gelatinase-associated lipocalin in deceased-donor renal transplant recipients: a randomized clinical trial

Context: Acute kidney injury (AKI) is a common complication after kidney transplantation (KT), especially in recipients from deceased donors. Urinary neutrophil gelatinase-associated lipocalin (u-NGAL) is an early and sensitive marker of AKI after transplantation.Objectives: We assessed the renoprotective effect of N-acetylcysteine (NAC) on u-NGAL levels as an early prognostic marker of graft function immediately after transplantation.Materials and methods: A double-blind, randomized, placebo-controlled trial was conducted on 70 deceased-donor KT recipients (www.irct.ir, trial registration number: IRCT2014090214693N4). Patients received 600 mg oral NAC or placebo twice daily from day 0 to 5 and urine samples were taken before, and on the first and fifth days after transplantation. U-NGAL and early graft function were compared between the two groups.Results: NAC significantly reduced u-NGAL levels compared to placebo (p value = 0.02), while improvement in early graft function with NAC did not reach statistical significance.Conclusions: This study showed that NAC administration in deceased-donor KT recipients can reduce tubular kidney injury, evidenced by u-NGAL measurements. Improvement in early graft function needs a larger sample size to reach a statistical conclusion.

Cardiac output-based fluid optimization for kidney transplant recipients: a proof-of-concept trial.

Intravenous fluid management for deceased donor kidney transplantation is an important, modifiable risk factor for delayed graft function (DGF). The primary objective of this study was to determine if goal-directed fluid therapy using esophageal Doppler monitoring (EDM) to optimize stroke volume (SV) would alter the amount of fluid given. This randomized, proof-of-concept trial enrolled 50 deceased donor renal transplant recipients. Data collected included patient characteristics, fluid administration, hemodynamics, and complications. The EDM was used to optimize SV in the EDM group. In the control group, fluid management followed the current standard of practice. The groups were compared for the primary outcome of total intraoperative fluid administered. There was no difference in the mean (standard deviation) volume of intraoperative fluid administered to the 24 control and 26 EDM patients [2,307 (750) mL vs 2,675 (842) mL, respectively; mean difference, 368 mL; 95% confidence interval (CI), -87 to +823; P=0.11]. The incidence of complications in the control and EDM groups was similar (15/24 vs 17/26, respectively; P=0.99), as was the incidence of delayed graft failure (8/24 vs 11/26, respectively; P=0.36). Goal-directed fluid therapy did not alter the volume of fluid administered or the incidence of complications. This proof-of-concept trial provides needed data for conducting a larger trial to determine the influence of fluid therapy on the incidence in DGF in deceased donor kidney transplantation. www.clinicaltrials.gov (NCT02512731). Registered 31 July 2015.

Condyloma Acuminata of the Urethra in a Male Renal Transplant Recipient: A Case Report

BackgroundCondyloma acuminatum (CA) is a common sexually transmitted disease associated with human papilloma virus (HPV). CA occurring in the urethra is rare and has not been reported in male renal transplant recipients. In addition, despite immunosuppressive conditions and increased risk of HPV-related malignant neoplasms in transplant recipients, HPV testing in male transplant recipients has been uncommon. Here we report a case of urethral CA in a male deceased donor renal transplantation recipient and discuss the importance of HPV testing in male transplant recipients. Case PresentationA 33-year-old male deceased donor renal transplant recipient presented with miction pain 5 years after the transplantation. He reported repeated urinary tract infections with no sexual contact since the renal transplantation. Multiple papillary tumors in his penile urethra were detected by cystoscopy, and a biopsy sample was pathologically diagnosed with CA. Transurethral tumor resection was performed, and the tumors were completely resected. Additional HPV risk type screening with a urethral smear sample showed the prevalence of low-risk HPV. Although tacrolimus was switched to everolimus and imiquimod cream was administered, the tumors recurred 6 months after the resection, and a second resection was performed. No further recurrence has been observed for 1 year to date. ConclusionAs the urethral CA was possibly related to immunosuppressive conditions and a risk for HPV-related malignant neoplasm, the case required careful diagnosis, including HPV risk type. The methodology of sampling for HPV testing in men has not been established. This case suggests the necessity for further discussion about HPV testing in male transplant recipients.

Plasma concentration of urokinase plasminogen activator receptor is a marker of kidney allograft function.

Urokinase-type plasminogen activator receptor (uPAR) is found in a variety of cell types including monocytes, lymphocytes, macrophages, and endothelial cells and plays an important role in fibrinolysis and in the activation and chemotaxis of neutrophils and lymphocytes. In this study, we examined the correlation between uPAR plasma concentration and kidney allograft function. This study enrolled 78 Caucasian deceased-donor renal transplant recipients. Plasma concentrations of uPAR were measured using commercially available enzyme-linked immunosorbent assay (ELISA) kits. We observed elevated with borderline significance (p = 0.095) uPAR plasma concentrations in patients with tubular atrophy. Plasma concentrations of uPAR showed strong statistically significant positive correlations with serum creatinine or urea and strong negative correlation with estimated glomerular filtration rate (eGFR). There was also a borderline positive correlation between uPAR plasma concentration and protein concentration in urine as well as the duration of hemodialysis. The results of our study indicate that uPAR plasma concentrations in kidney allograft recipients are significantly negatively correlated with graft function and may be elevated in patients with tubular atrophy.

Posttransplant lymphoproliferative disorder coexisting with extrapulmonary tuberculosis: A diagnostic dilemma

Solid organ transplant recipients have a higher risk of malignancy and infections. We present a case of deceased donor renal transplant recipient diagnosed to have co-existing tuberculoma and CNS-PTLD. 61 year old male who underwent deceased donor renal transplantation and was given induction with Anti-Thymocyte globulin, continued on triple immunosuppression (Tacrolimus, Mycophenolate mofetil and Prednisolone). He developed New onset diabetes after transplantation and had multiple infections. He presented with bilateral multiple space occupying lesions on MRI brain. MRI spectroscopy from parietal region was suggestive of Tuberculoma. ATT was started and patient improved. He presented after 4 weeks with ataxia and slurring of speech, MRI brain showed regression in lesion of right parietal area, but a new lesion appeared in the left parieto-occipital region along with an enlarged left cerebellar lesion. Decompressive craniotomy and excision of lesion in left cerebellum, was done. Histology confirmed Non-Hodgkin's Lymphoma, diffuse Large B-cell type. He was treated with whole brain radiotherapy. Repeat MRI brain after 6 months demonstrated a near total clearance of lesions.

The impact of donor and recipient weight incompatibility on renal transplant outcomes.

Donor/recipient size mismatching and correlation to allograft outcome remains poorly defined. This study assessed the impact of donor body weight (DBW) to recipient body weight (RBW) ratio on allograft function and survival. A total of 898 deceased donor renal transplant recipients were included in the study. Patients were divided into quartiles depending on the ratio of DBW/RBW: Q1 (≤0.88), Q2 (0.89-1.00), Q3 (1.01-1.22) and Q4 (>1.22). Donor and recipient characteristics were obtained from the national kidney transplant service database. Serum creatinine and estimated glomerular filtration rate (eGFR) at 1 and 5 years after transplant were compared. Q4 patients had a higher eGFR 1 year post-transplant (median 59.5ml/min, IQR 46.8-76.2) compared to Q1-Q3 which had median eGFRs of 54.3, 54.8 and 55.3ml/min, respectively (p<0.001). At 5 years post-transplant, there were modest differences in the eGFR across the four quartiles, Q1-4 with median eGFRs of 56.9, 61.1, 61.2 and 58.6ml/min, respectively (p=0.02). However, there were no significant differences in 1- and 5-year allograft survival between groups. In the setting of deceased donor renal transplantation, mismatching of donor to recipient weight had no impact on 5-year allograft survival, but a low DBW/RBW ratio is modestly associated with lower eGFR.