Indian Renal Transplant Recipients Research Articles

Cytomegalovirus disease among renal transplant recipients in India

SUMMARY: There is a paucity of data on cytomegalovirus (CMV) disease in renal transplant recipients from India. We have encountered this problem with increasing frequency at our centre, and document our experience in this paper. Case records of 514 recipients of renal transplants performed between 1980 and 1997, including 96 autopsies, were reviewed. Diagnosis was made by demonstration of classic cytomegaly and intranuclear inclusions on histology, and/or detection of CMV pp‐65 antigen in the peripheral blood leucocytes. Cytomegalovirus disease was documented in 21 cases (11 at autopsy, six by antigen detection, and four by a combination of histological demonstration and antigenemia detection). the incidence of this infection rose from 0.6% in 1980–1991 (pre‐cyclosporin era) to 5.5% (4.4% lethal) during 1992–1997 (postcyclosporin era). At autopsy, the lung was the most frequently involved organ followed by the gastrointestinal tract. Ninety‐five per cent of patients had co‐infection with other organisms, and fungi were isolated in 80% of all patients with co‐infection. Graft dysfunction was present in 17 cases (81%). We conclude that there has been a four fold increase in the incidence of lethal CMV disease in renal transplant recipients after the introduction of cyclosporin immunosuppression. There is a high incidence of co‐infection with other organisms, with fungi being the commonest offenders in tropical environment. This, along with allograft dysfunction, could account for the high mortality seen with CMV disease.

Increasing incidence of cytomegalovirus disease in indian renal transplant recipients on cyclosporine immunosuppression

Increasing incidence of cytomegalovirus disease in indian renal transplant recipients on cyclosporine immunosuppression

Impact of cyclosporine withdrawal on living related renal transplants: A single-center experience

High treatment costs force the discontinuation of cyclosporine (CSA) in a vast majority of renal transplant recipients in India. The impact of CSA withdrawal among 108 living related renal transplant recipients 12.54 +/- 4.2 months after transplantation was studied retrospectively. In 83 patients, CSA was withdrawn over a 12-week period (group I). Azathioprine dosage was increased to 2 to 2.5 mg/kg/d, and prednisolone, to 30 mg/d 2 weeks and 1 week before starting CSA withdrawal, respectively. In the other 25 patients, CSA had to be withdrawn faster (mean, 28.52 +/- 14.18 days; group II). Twenty-nine rejection episodes (26.9%) were noted in 22 patients (20.4%; 19% in group I and 52% in group II; P: = 0.008). Fifteen group-I patients (18%) and 11 group-II patients (44%) died or lost their grafts (P: = 0.017). There was no difference in age, donor source, HLA matches, pretransplantation cross-match positivity, delayed graft function, immunosuppressive drug doses, rejection episodes, or prewithdrawal serum creatinine levels between the patients who did or did not develop acute rejection after CSA withdrawal. On follow-up, 10 patients (50%) died or returned to dialysis among the rejection group compared with 16 patients (18%) in the nonrejection group (P: = 0.007). The mean creatinine level at last follow-up was greater in the rejection group (3.97 +/- 2.54 versus 1.65 +/- 1.1 mg/dL; P: < 0.001). CSA withdrawal because of economic constraints carries a significant risk for acute rejection and death and/or graft loss in Indian living donor renal transplant recipients, even after 12 months.

The high incidence of tuberculosis among renal transplant recipients in India.

Tuberculosis is an important infection encountered after renal transplantation in third-world countries. Over an 8-year period, 36 cases of tuberculosis were encountered in 305 renal transplant recipients (11.8%) with grafts functioning for more than 3 months followed up at our center. The infection was limited to the thoracic cavity in 41.7% and a single extrapulmonary site in 11.1%, and it was disseminated in 27.8% cases. In 19.4% of cases, the disease appeared as pyrexia of unknown etiology and the diagnosis was confirmed by a good therapeutic response to antitubercular therapy. Tuberculosis was diagnosed within 1 year of transplantation in 58.3% of cases. There was no significant difference in the incidence of tuberculosis in patients on different immunosuppressive regimens. The Mantoux test was positive in 33.3% patients. A total of 23 patients were treated with isoniazid and rifampicin, with the addition of a third drug for the first 2 months. Treatment was continued for 9 months in 11 cases with isolated pleuropulmonary disease and for 12-15 months in the other 12 patients. The other 13 were on cyclosporine and were given isoniazid, pyrazinamide, and ethambutol for 18 months. Two patients died of fulminant disease and five more died from unrelated causes. No recurrence of disease has been noted in any of the patients after a mean follow-up of 14.6 months. We conclude that the incidence of tuberculosis in renal allograft recipients in third world countries is much higher than that seen in the western world. Most of the cases are encountered in the first posttransplant year. Tuberculosis must be considered seriously in all patients who have prolonged fever of undetermined etiology. Treatment with isoniazid and rifampicin for 9 months is adequate for patients with localized pleuropulmonary disease. In patients on cyclosporine to whom rifampicin cannot be given because of economic considerations, treatment with isoniazid, pyrazinamide, and ethambutol should be given for 18 months.