Related Renal Transplantation Research Articles

P.278: Renal vein extension using polyester vascular graft in living donor related renal transplantation a safe and effective technique.

P.278: Renal vein extension using polyester vascular graft in living donor related renal transplantation a safe and effective technique.

241.7: Spectrum of post-transplant malignancies in live related renal transplant setting and their clinical characteristics over a period of 40 years; a single center experience.

241.7: Spectrum of post-transplant malignancies in live related renal transplant setting and their clinical characteristics over a period of 40 years; a single center experience.

Factors Responsible for Nonselection of Donors in Living Related Kidney Transplantation.

Living donor kidney transplant is the preferred method of renal transplant in Pakistan as deceased donor transplant has not yet been estab-lished. However, many patients who are dialysis-dependent, particularly younger patients, lack suitable living related donors. We aimed to determine factors contributing to nonselection of donors for living related renal transplant in Pakistan. For this cross-sectional study, we included patients seen at the Sindh Institute of Urology & Transplantation Karachi, Pakistan) from March to November 2019. Potential donors were adult family members who accompanied patients with end-stage kidney disease to the clinic. Demographic and clinical information were recorded on predesigned proforma. After workup and baseline investigations had been completed, potential living related donors were selected. Factors leading to nonselection of donors were noted for those who did not qualify for donation. We used SPSS version 20 for analysis. During the study period, 253 potential donors (151 males, 102 females) with mean age of 35.68 ± 6.14 years were found to be ineligible for kidney donation. ABO incompatibility was the most common factor leading to nonselection (n = 101; 39.92%), followed by diabetes mellitus (n = 71; 28.06%), hypertension (n= 50; 19.76%), renal disease (n = 15; 5.92%), liver disease (n = 8; 3.16%), crossmatch positive (n = 5; 1.97%), and ischemic heart disease (n = 3; 1.18%). No differences were shown between potential male and female donors regarding factors leading to nonselection; diabetes was significantly more prevalent among those <40 years of age (P = .025). ABO incompatibility, diabetes mellitus, and hypertension were the most common factors leading to nonselection of potential donors in living related kidney transplant. More efforts are needed to expand the donor pool by considering second- or third-degree relatives to tackle the scarcity of organs for transplantation.

INF2 and ROBO2 gene mutation in an Indian family with end stage renal failure and follow-up of renal transplantation.

Accurate genetic diagnosis of end-stage renal disease patients with a family history of renal dysfunction is very essential. It not only helps in proper prognosis, but becomes crucial in designating donor for live related renal transplant. We here present a case of family with deleterious mutations in INF2 and ROBO2 and its importance of genetic testing before preparing for kidney transplantation. We report the case of a 29-year-female with end-stage renal disease and rapidly progressive renal failure. Mutational analysis revealed an Autosomal Dominant inheritance pattern and mutation in exon 4 of the INF2 gene (p. Thr215Ser) and exon 26 of the ROBO2 gene (p. Arg1371Cys). Her mother was diagnosed for CKD stage 4 with creatinine level of 4.3 mg/dL. Genetic variants (INF2 and ROBO2) identified in proband were tested in her sisters and mother. Her elder sister was positive for both heterozygous variants (INF2 and ROBO2). Her mother was positive for mutation in INF2 gene, and her donor elder sister did not showed mutation in INF2 gene and had mutation in ROBO2 gene without any clinical symptoms. This case report emphasize that familial genetic screening has allowed us in allocating the donor selection in family where family member had history of genetic defect of Chronic Kidney Disease. Information of the causative renal disorder is extremely valuable for risk-assessment and planning of kidney transplantation.

Posttransplant Thrombotic Microangiopathy: Unraveling a Mystery

A 24 year old lady who was diagnosed with chronic kidney disease stage 5 in 2016 underwent a pre-emptive live related renal transplant in the same year. She had kidney allograft dysfunction and eventually lost the transplant kidney in 2019 requiring hemodialysis. She underwent a deceased donor renal transplant in February 2022. She developed allograft dysfunction with a creatinine of 2.5 mg/dl in October 2022, and a renal allograft biopsy subsequently showed Thrombotic microangiopathy, arteriolar form. There were no features of rejection in the biopsy and Donor specific antibody done by Luminex lysate method was negative. Her Single antigen bead done subsequently was also negative. CMV DNA PCR was not detectable. Tacrolimus was switched to Cyclosporine, however her allograft function continued to worsen. Complement mutation analysis was negative and acquired complement defects were also not detected. Subsequently, Single antigen bead for non HLA antibodies showed positivity for MICA antibodies. She underwent 7 sessions of plasmapheresis and her renal functions did not improve and her creatinine continued to increase to 4.2 mg/dl. Complement activating assay for these MICA antibodies was positive. She was treated with two doses of 300 mg Eculizumab in December 2022, her allograft functions in February 2023 have improved to 2 mg/dl. This case highlights the extensive evaluation for post transplant TMA, the use of non HLA antibody assays and complement activating assays of these antibodies to decide on appropriate use of Eculizumab for salvaging transplant allograft.

Ureterovesical Leak Following Renal Transplant and Effects of Acute Rejection and Antirejection Therapy: A Nested Case-Control Analysis and Outcome of 1102 Consecutive Renal Transplant Recipients.

Studies on nontechnical risk factors for ureterovesical leak after renal transplant are scarce. This study aimed to report the possible pre- and postoperative risk factors and the role of acute rejection and antirejection therapies for urine leak after transplant and its effect on graft and patient survival. We conducted a retrospective analysis of 13 patients (1.17%) with urine leak (case group) and 52 patients without leak (control group) (case-to-control ratio of 1:4) from 1102 living related (first degree) renal transplant recipients seen between January 2012 and December 2021. We analyzed demographic and clinical details and biochemical and outcome parameters using a nested case-control design. Cases were olderthan controls (P = .018), were more ABO incompatible (P = .009), and had more 6/6 HLA mismatch transplants (P = .047). Donors of cases were older than donors of controls (P = .049). The rate of postoperative hypoalbuminemia was greaterin the case group (P = .050). Rates of acute rejection (P = .012) and plasmapheresis (P = .003) were greaterin the case group than in the control group. On multivariate logistic regression analysis, recipient age, 6/6 HLA mismatch, and plasmapheresis were found to independently associated with urine leak. None ofthe patient required surgical repair, as all responded to conservative therapy. Urine leak did not affect graft outcomes (P = .324), but overall survival was less in cases than in controls. Nontechnical risk factors that cause posttransplant ureteric leak include older donor and recipient age and ABO incompatible and 6/6 HLA mismatch transplants. Acute rejection and plasmapheresis predispose leak, and an indwelling double J stent can allow adequate healing of the anastomosis. High index of suspicion and prompt management are imperative to preserve graft and patient outcome.

Live Related Kidney Transplantation: Experience of 360 Patients in a Tertiary Care Hospital of Bangladesh

Background: Live related kidney transplantation is the most preferred form of renal replacement therapy worldwide including Bangladesh. However, it is challenging and also rewarding both for patients and treating physicians. BSMMU hospital has given maximum effort for its greater success. The aim of this study was to share our ten years’ experience regarding some aspects of live related renal transplantation. Methods: This retrospective study was conducted in nephrology department of BSMMU hospital from January 2002 to December 2015. Data were collected from hospital records and some previously conducted study on these transplant recipients. Results: A total of 360 live related kidney transplant recipients were evaluated during this period. Recipients Male: Female ratio was 1.57:1. Mean age of recipients were 39.58 ± 10.46 years. The causes of ESRD were chronic glomerulonephritis 220(61.60 %), diabetic nephropathy 58(16.24%), hypertensive nephrosclerosis 22 (6.16 %), chronic interstitial nephritis 11 (3.08 %), SLE 10(2.8%), ADPKD 6(1.68 %), unknown 19(5.32 %). Most of the donors were mother (21.84% %) followed by spouse mostly wife (20.44%) and sister (18.76 %). Almost all recipients were on MHD 352(97.78%), 2 were on CAPD and 06 were pre-emptive transplantation. Triple immunosuppressive protocol Cyclosporine or Tacrolimus, MPA or Azathioprine and Prednisolone were used in each patient. Recipients with poor HLA matching received Baciliximab in standard dose. CMV prophylaxis was given in selected patients and each patient received pneumocystis jirovecii prophylaxis. Common complications during post-operative period were ATN 41(11.48%), DGF 23(6.44%), Acute rejection 50(14%) and infection mainly urinary tract infection 46(12.88%) and RTI 14(3.92) followed by wound infection and other surgical complication. Presence of BK virus infection was studied in 29 transplant recipient and it was found to be positive in 6(20.7%) cases. Protocol biopsy was done in 37 transplant recipient in the 2008-2009 on day 14, and day 90 to see subclinical rejection and early graft dysfunction. On day 14th biopsy report showed 21(56.7%) normal histology, 5(13.5%) had subclinical rejection, 5(13.5%) had clinical rejection, 4(10.8 %) developed ATN, 2(5.2 % ) cyclosporine toxicity, and report at 3 month showed normal histology 18(48.60%), subclinical rejection 7(18.90%), clinical rejection 5(10.80%). Leading cause of chronic allograft dysfunction was chronic allograft nephropathy (CAN) 60(19.80%) followed by chronic cyclosporine toxicity 37(12.21%) and de-novo or recurrent glomerulonephritis. Mean post-transplant hospital stay was 18.46 ± 5.56 days. Mean duration of normalization of serum creatinine after surgery was 7.38 ± 3.88 days. At discharge 74.40% patients had normal renal function with mean serum creatinine 1.10 ± 0.26 mg/dl and 21.34% patients showed gradual improvement of renal function with mean serum creatinine 2.12 ± 0.97 mg/dl. In our study 1 year and 5 years’ graft survival was 93.88% and 75.16% respectively and 1 year and 5 years’ patient’s survival was 346(96.08%) and 290(81.2%). Conclusion: Our report shows that short and long term graft and patient survival is encouraging and comparable to other centers of both developing and some developed countries with limited resources and facilities.

#3404 UTILITY OF RENAL BIOPSY IN THE ETIOLOGY, MANAGEMENT AND OUTCOME OF POSTPARTUM ACUTE KIDNEY INJURY

Abstract Background and Aims Acute kidney injury (AKI) is a serious complication during pregnancy and postpartum period resulting in significant maternal morbidity, mortality and fetal loss. Pregnancy related acute kidney injury is still more prevalent in developing countries. This study aims to evaluate renal biopsies in postpartum period AKI (PPAKI) with etiology and its management and outcome. Method Retrospective analysis of 83 native renal biopsies received in the department of pathology, SGPGIMS, Lucknow, a tertiary care center in India with PPAKI from January 2007 to December 2021 were analyzed. Clinical and laboratory data were retrieved and renal biopsy histology slides were reviewed. Results Eighty-three patients with mean age 27.5±4.6 years had biopsy proven PPAKI. Cesarian section, vaginal delivery, hysterectomy and abortion were performed in 51, 19, 2 and 11 patients respectively. The cause of AKI was sepsis (38.6%), postpartum hemorrhage (26.5%), thrombotic microangiopathy (TMA) (11%), pre-eclampsia (3.7%) and other (20%). Duration of onset of AKI after delivery/abortion ranged from 0 to 30 days (mean 4.5±6.3 days). Fetal loss was seen in 31.7% patients. Biopsy showed partial/complete renal cortical necrosis (56.6%), TMA (24.1%), acute tubular injury (ATI) (4.8%), Lupus nephritis flare in 3.6% and other glomerular diseases (8.4%) and Tubulointerstitial nephritis in (1.2%) patient. All received multiple sessions of haemodialysis and 10 patients also had plasmapheresis. During hospital stay one died due to sepsis and shock, remainder were discharged in a stable condition with complete recovery in (5), partially recovery in (7); and 61 (71%) patients required continued renal replacement therapy. Two patients died and two had subsequent live related renal transplantation on available follow-up. Conclusion AKI is a serious complication in postpartum period and require early and prompt attention to reduce fetal and maternal morbidity. Sepsis is the commonest cause of postpartum AKI

MP31-07 FORVEIN TRIAL: EVALUATION OF THE HEMOSTATIC ROLE OF FIBRIN SEALANT ON RENAL VEIN ANASTOMOSIS DURING RENAL TRANSPLANT SURGERY: A PROSPECTIVE RANDOMISED CONTROLLED TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP31-07 FORVEIN TRIAL: EVALUATION OF THE HEMOSTATIC ROLE OF FIBRIN SEALANT ON RENAL VEIN ANASTOMOSIS DURING RENAL TRANSPLANT SURGERY: A PROSPECTIVE RANDOMISED CONTROLLED TRIAL Tejas Mistry, Mrinal Pahwa, and Vipin Tyagi Tejas MistryTejas Mistry More articles by this author , Mrinal PahwaMrinal Pahwa More articles by this author , and Vipin TyagiVipin Tyagi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intraoperative bleeding is one of the major complications associated with vascular anastomosis in kidney transplant. One of the novel measures for its prevention is the application of fibrin sealant over renal vein anastomotic site after completing the suturing. Till date, there is no study published to evaluate its role for this purpose. Hence, the current study was undertaken to evaluate the hemostatic role of fibrin sealant on renal vein anastomosis during renal transplant surgery. METHODS: This was a prospective randomised study (FORVEIN stands for Fibrin sealant On Renal VEIN anastomosis) done in our institute from April 2017 to March 2022. Approval of the study protocol was obtained from the Institutional review board. Total 307 renal allograft recipients (with age 18 to 60 years) who had undergone live related renal transplant at our center were included in the study as per the inclusion and exclusion criteria. Patients were randomised according to computer generated random numbers into test group in whom fibrin sealant was to be used and control group in whom saline was to be applied. Time to hemostasis was measured from removal of venous clamps to complete hemostasis at the site and was compared between both the groups. Data regarding age, sex, body mass index, number of vessels was recorded for subgroup analysis. Statistical analysis was done using t-test and MedCalc software (Version 20, Ostend, Belgium). RESULTS: Out of 307 cases, fibrin sealant was applied in 129 cases, whereas 178 cases received saline application. There was significant difference between mean time to hemostasis in fibrin sealant group (7.2min) and in control group (10.2min) (p<0.0001). On subgroup analysis, it was found that hemostasis time was significantly lower in fibrin sealant group for multiple vessels, obese and complex cases with multiple factors (p=0.02, p=0.005, p=0.04 respectively). No case of venous thrombosis was observed. CONCLUSIONS: Application of fibrin sealant over renal vein anastomosis during renal transplant surgery is safe and effective for achieving early hemostasis. Larger multi-centric randomised controlled studies would be needed for its generalized extrapolation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e432 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tejas Mistry More articles by this author Mrinal Pahwa More articles by this author Vipin Tyagi More articles by this author Expand All Advertisement PDF downloadLoading ...

WCN23-0610 Single center experience of short-term outcomes of live related renal transplantation without induction – A retrospective study

WCN23-0610 Single center experience of short-term outcomes of live related renal transplantation without induction – A retrospective study

Frequency of New Onset Diabetes Mellitus in Patients with Live Related Renal Transplant

Background: Kidney transplant is only the cure of end stage renal diseases. It is because it provides the maximum replacement of renal functions. New onset diabetes after transplantation is one of the serious and chronic problem of renal transplant. NODAT is reported to occur in 4%-25% of renal transplant recipients. New onset diabetes may be identified after the renal transplant at any time. Objective: The study aimed to determine the frequency of new onset of diabetes mellitus in the patients with live related renal transplant. Study design: It is a retrospective study conducted in the department of nephrology and transplantation, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat for the duration of six months from July 2022 to December 2022. Material and Methods: There were 50 patients in PTDM group and 70 were in the non PTDM group. The anthropometric and clinical characteristics were recorded. The SPSS software was used for the analysis. The Patients were divided into two groups according to the diagnosis. Results: The average age of patients in PTDM group is 43.2 years whereas in non-PTDM group the average age is 45 years. Statistical analysis revealed that results are statistically significant with 95% CI. Most of the cases appeared during 2 weeks of transplant however, 14 patients also reported about diabetes after 2 months of transplant. Conclusion: Common metabolic disease PTDM is usually diagnosed during first 6 weeks of renal transplantation. Old age, family history of diabetes, the presence of IGF during first week of transplantation are some of the risk factors that lead to PTDM prevalence. The PTDM was observed in the 40% patients in our study. Keywords: renal functions and post-transplant diabetes mellitus.

A RARE CASE OF MASSIVE RENAL VEIN HEMORRHAGE IN TRANSPLANT FOR LUPUS NEPHRITIS END-STAGE RENAL DISEASE

A RARE CASE OF MASSIVE RENAL VEIN HEMORRHAGE IN TRANSPLANT FOR LUPUS NEPHRITIS END-STAGE RENAL DISEASE

P137 Remote inoculation mycosis: Rip Van Winkle wakes up

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectiveAfter immunosuppression, a remotely inoculated organism may be activated to produce clinical disease. We describe such a case with infection due to Medicopsis romeroi, a rare mold.Patient and MethodsA 54-year-old male, diabetic, hypertensive, status post-live related donor renal transplantation, done in February 2021. The patient was on standard triple immunosuppressant regimen. He developed a painless nodule on his thumb over 5 months which did not respond to multiple courses of antibiotics. The swelling was excised and sent for various tests. Review of USG after infectious disease referral, showed a small foreign body, like a wooden splinter in the wall of the lesion (Fig. 1). On inquiry, a 3 mm wooden splinter in the lesion was noted during surgery and there was an injury at the same site, 20 years ago when the patient used to work on a farm. Organisms derived from soil or thorn injury including bacterial and fungal organisms were considered in the differential diagnosis. Bacterial organisms were considered less likely as there was no response to antibiotics.ResultsHistopathology showed brownish septate hyphae with constrictions at the areas of septations (Fig. 2). The excised tissue grew a dematiaceous mold. In Lactophenol Cotton Blue (LPCB) mount branched, septate hyphae with sparse conidia were seen. MALDI- TOF MS was unable to identify the mold. Sequencing identified it as M. romeroi. There are no ECOFFs or break points (BP) available for M. romeroi. Minimum inhibitory concentration (MIC) of Voriconazole (VCZ) is reportedly low and hence was chosen for treatment with an appropriate dose adjustment of Tacrolimus.ConclusionThis case underscores that remote inoculation, when the patient was immunocompetent, could have introduced a mold, which remained latent and reactivated after immunosuppression. Sending excised tissue for appropriate tests is rewarding. Medicopsis romeroi is a rare mold with only 12 cases reported so far. It is difficult to identify except with sequencing. There is no standard guidance on treatment. Surgical excision along with prolonged treatment with one of the new azoles is beneficial.

P181 Mucor in the land of the liver: a case report

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Introduction and ObjectivesMucormycosis is a rare, highly lethal opportunistic fungal infection affecting immune-compromised patients. It accounts for about 2% of invasive fungal infections occurring within 1 year after solid organ transplantation. Among renal recipients, Rhinocerebral is the commonest manifestation and Rhizopus species is the most frequent pathogen.The objectives are:To report a case of Hepatic mucormycosis in a renal transplant recipient.To resolve the dilemma in identification of Mucorale species detected on microscopy but culture negative.MethodA 29-year-old male patient was admitted with severe abdominal pain on day 28 post-live related renal transplantation. Patient was hypertensive, on oral steroids for idiopathic thrombocytopenic purpura, chronic kidney disease with venous thromboembolism-presumed chronic interstitial nephritis, and maintained on hemodialysis for the last 1 year. Post-transplant he was on triple immunosuppressants.Initial ultrasound of abdomen and transplant doppler were normal. CT of abdomen in view of worsening hypotension and non-resolving abdominal pain, revealed hepatomegaly with multiple discrete, coalescing hypodense areas in both lobes of liver with minimal subcapsular extension. Initial cultures included interventional radiology-guided liver aspirate and blood culture. Patient was started on antibiotics and antifungals. Patient continued to deteriorate and a repeat abdominal CT revealed an increase in liver size and rupture of liver abscess. Sample collected on pigtail catheter insertion was also sent for culture.ResultsThe pus aspirate was received for bacterial and fungal culture. Aerobic bacterial culture yielded Klebsiella species. Examination with KOH Calcofluor revealed broad aseptate fungal hyphae. However, fungal culture did not yield any growth. Pain resistant (PDR) Klebsiella species was isolated from blood culture. Pigtail catheter sample also yielded the same. Aseptate fungal hyphae were observed in the pigtail catheter sample also. The team decided on conservative management and patient was started on intravenous amphotericin B deoxycholate(50 mg/day), tigecycline, and meropenem. Immunosuppressants were withheld. The clinical course worsened and the patient succumbed to illness after 18 days of antifungal therapy. The pus sample was then sent to the referral center PGIMER for PCR and sequencing where it was identified as Lichtheimia species.ConclusionMucormycosis is an increasingly emerging invasive fungal infection especially in immune-compromised patients, including solid organ transplant recipients. Though uncommon it is frequently a fatal mycosis in transplant patients. Hepatic mucormycosis in renal transplant recipients has been reported in three patients so far. None are due to Lichtheimia species. The diagnosis of hepatic mucormycosis was confirmed as microscopy was positive in two successive samples. Our patient also had bacteremia with PDR Klebsiella.Diagnosis is challenging and often delayed, as the clinical presentation is non-specific. Although mucormycosis in a renal transplant recipient is rare, a high index of suspicion and critical microscopic examination is warranted for early initiation of specific therapy which includes liposomal amphotericin B and surgery. Often cultures yield no growth and gene sequencing proves to be efficient and time-saving. This probably is the way ahead, especially for culture-negative samples to establish the etiological diagnosis.

348.5: Life Threatening, Cytokine Release Storm (CRS) With Antithymocyte Globulin (ATG) And Its Management

Introduction: Cytokine Release Storm (CRS) leading to fatal or near fatal hypotension has been reported in association with anti thymocyte globulin (ATG) administration. This is a very rare and unusual manifestation of ATG and early recognition and management of this unexpected manifestation will help save lives. We report a near fatal case of CRS, during renal transplantation, associated with ATG administration, its diagnosis and management. Materials and Methods: A 27-year-old, otherwise healthy male with Alport’s syndrome was undergoing live related preemptive renal transplant. Patient received morning dose of Solu-Medrol and CellCept and was getting Anti Thymocyte Globulin (ATG) slowly after the test does, as the recipient vascular bed was being prepared. Patient started to become hypotensive which was treated with IV fluids and pressors including norepinephrine, epinephrine and dopamine.There was no bleeding from recipient vascular bed.A stat chest x-ray, EKG and echocardiogram on the OR table were normal with good LV function. Despite maximum dose pressor support and IV fluids, the mean blood pressure was around 45 - 50 mm Hg and a systolic blood pressure was around 65-70 mm Hg, leading to severe metabolic acidosis and lactate buildup. The transplant was canceled and the donor was closed unharmed and the patient was moved to ICU, intubated. His response to colloids was slightly better, but transient, so he was transfused 4 units of blood as volume expander that does not leak into 3rd space.This brought his blood pressure to about 90 mm Hg. A presumptive diagnosis of ATG induced CRS was made. His inflammatory markers including IL-6, ferritin, D-dimers and CRP were very high. 400 mg of Tocilizumab (Actemra) an IL-6 inhibitor along with broad-spectrum antibiotics were given. Patient also started to developed disseminated intravascular coagulation (DIC) with deranged coagulation screen and some oozing from the wound which was treated with FFPs. In next 12 hours, the patient started to stabilize and in next 48 hours he was extubated. Discussion: Cytokine Release Storm (CRS) is a potentially fatal condition unless recognized and treated early and aggressively. In COVID pandemic, much better understanding of CRS along with its symptomatology, easy availability of its lab tests and IL- 6 inhibitors became possible. High index of suspicion is extremely important in making an early diagnosis and for early treatment. In transplant patients, use of ATG is now standard of care and very few cases of ATG induced CRS are reported. In our case, early diagnosis of CRS from ATG, use of blood as volume expander, early administration of IL-6 inhibitor and aggressive management of DIC turned out to be the life Saver. Conclusion: In patients receiving ATG, with unexplained hypotension, nonresponsive to IV fluids and pressors, high index of suspicion of ATG induced CRS with early diagnosis and aggressive management can save lives.

P16.27: A Case of Cytomegalovirus (CMV) Esophagitis Without CMV Viremia After SARS-CoV-2 Infection in a Kidney Transplant Recipient While on CMV Prophylaxis

Introduction: CMV prophylaxis significantly reduces CMV infection after solid organ transplants, but patient may still present with CMV primary disease or reactivation during the first six months post-transplant. Although high CMV viral load is usually seen in tissue invasive disease, blood CMV PCR my not be able to diagnose gastrointestinal CMV disease as sensitivity of blood CMV PCR is lower in seropositive patients. CMV and SARS-CoV-2 co-infection has been reported particularly in elderly and immunocompromised patients. We report a unique case of CMV esophagitis without viremia diagnosed after recent SARS-CoV-2 infection in a kidney transplant recipient. Case: Twenty-eight year old Caucasian female with end stage kidney disease due to unknown etiology received negative crossmatch living related renal transplant from her sister. She received Basiliximab for induction and Tacrolimus and mycophenolic acid as maintenance immunosuppression. Patient had intermediate risk for CMV (Donor CMV IgG negative and recipient IgG positive) and was on Valganciclovir for prophylaxis as per the protocol. She had a stable allograft function with serum creatinine around 1-1.2 mg/dl. She developed SARS-CoV-2 infection with mild respiratory symptoms after 2 months of kidney transplant. Mycophenolic acid was held very briefly, and Prednisone 10 mg daily was added to the regimen. She reported chest pain, nausea and vomiting after resuming mycophenolic acid. Blood CMV PCR was undetectable and other laboratory studies were significant for anemia of 9.3 g/dl (baseline 10 g/dl), with stable renal and hepatic functions, without leucopenia or thrombocytopenia. Upper Gastrointestinal endoscopy revealed a large 4-5 cm circumferential ulceration in the mid esophagus with biopsy features suggesting viral cytopathic effect and rare CMV infected cells. Stomach and duodenum were normal. HSV and fungal stains were negative. Patient was started on oral valganciclovir induction dose and showed symptomatic recovery in a few weeks. Conclusion: High index of suspicion is necessary to diagnose CMV co-infection and/or reactivation in the settings of SARS-CoV-2 infection and the tissue biopsy is the key for diagnosis of the tissue invasive gastrointestinal disease.

P8.068: Post-transplant Recurrence of Masked Monoclonal Gammopathy of Renal Significance in a Patient With C3 Glomerulonephritis: A Case Report

Introduction: Monoclonal gammopathy of renal significance (MGRS) is a recently defined group of renal diseases caused by monoclonal immunoglobulin secreted by nonmalignant proliferative B cell or plasma cell causes renal damage. Here we report a case known as primary kidney disease C3 glomerulonephritis but after kidney transplant diagnosed MGRS. Case presentation: A 32-year old man underwent live related renal transplant in December 2020 for ESRF secondary C3 glomerulonephritis. At 2 months post-transplant, his serum kreatinin levels increased from a basaline creatinine of 1.2 mg/dl to 1.7mg/dl, and he developed proteinuria (1.2 gr/day). Renal biopsy showed monoclonal membranoproliferative glomerulonephritis. His serum and urine kappa/lambda light chain ratio was normal and he had no monoclonal protein in serum and urine immunfixation electrophoresis. After the patient was treated with Rituximab (4 cycles), his serum creatinin levels and proteinuria increased and repeat biopsy showed increase of monoclonal immun complexes in glomeruler capillers. The patient was treated bortezomib-based chemotherapy (4 cycles). Repeat biopsy showed no regression renal pathology. His renal functions and proteinuria continued to deteriorate. There were a rise in urine kappa/lambda light chain ratio. He received no further chemotherapy, a decision was taken to manage her kidney condition conservatively. Conclusions: Monoclonol immunoglobulin deposits may not be detectable in standart immunofluorescence techniques and can result missing the diagnosis of MGRS. Patiens with C3glomerulonephritis should be examined in detail for monoclonal gammapathy before kidney transplantation. Case report.

Frequency of urinary tract infections in renal transplant recipients with common bacteria and its sensitivity

Objective: To determine the frequency of urinary tract infection and its common pathogens with antibiotic sensitivity among renal transplant recipients.&#x0D; Materials and methods:&#x0D; This Cross sectional descriptive study was conducted at Institute of Kidney Diseases (IKD) Hayatabad, Peshawar from January 2008 to December 2012. The cross section included 74 live related renal transplant recipients. Each renal transplant recipient was followed up for 3mpnths for developing urinary tract infection.&#x0D; Results: &#x0D; A total of 74 patients were followed after renal transplant. Among them 12 (16.22%) were females and 62 (83.78%) were males respectively. They were all live related renal transplant. UTI developed in 27/74 (36.48%) patients at first 3 months after transplantation (60 ± 15 days). Female patients were more susceptible to UTI than male patients (5 female 41.66%; 22 male 35.48%). On univariate analysis, older age (p?=?0.015), female gender (p?&lt;?0.001), hyperglycaemia (p?=?0.037) and acute rejection episodes (p?=?0.046) were all risk factors for developing urinary tract infection. Isolated bacteria were Escherichia coli (59.25%), Candida albicans (18.51%), Klebsiella (11.11%), Enterococcus spp. (7.40%), followed by Pseudomonas aeruginosa 3.70%. Antibiotic resistance was 26% for ciprofloxacin and 33% for ampicillin.&#x0D; Conclusion: Urinary tract infection is a major problem in renal transplant recipients. The female gender, increasing age and uncontrolled hyperglycemia are the risk factors for UTI in renal transplant recipients. There is high resistance to ampicillin and quinolones in renal transplant recipients.&#x0D; &#x0D;

Comparison of Outcome of Renal Transplant with and Without Double J Stenting

Background: Renal transplant is definitive treatment for chronic renal disease. Renal transplant involves three anastomosis, renal artery, vein and ureter. Some surgeons prefer urinary stenting for prevention of urinary complication like urinary leakage, while others do not. Still there is controversy whether to use or not use intraoperative stenting. The purpose of this study is to share experience of renal transplant with and without stenting. Objective: To compare the outcome of renal transplant with and without intraoperative placement of Double J Stent Study Design: Comparative study. Place and Duration of Study: Department of Urology and Kidney Transplantation, Shaikh Zaid Hospital, Lahore from 1st January 2014 to 31st December 2015. Methodology: One hundred and eight patients with chronic kidney disease had renal transplant. Randomly, 54 patients transplant was done with stenting and in 54 patients transplant was done without stenting. The patients were followed up for presence of urinary leakage. Results: Among 54 renal transplants with stenting, no urinary leakage was found (0%), while in 54 patients without stent placement, urinary leakage was observed in 2 (3.7%) patients. (p=0.153, i.e. &gt;0.05) Conclusion: Ureteric stenting is not mandatory for renal transplantation. Frequency of urinary leakage among patients with renal transplant with stent was low while no leakage was seen with stenting. Difference in rate of urinary leakage with and without stenting was not statistically significant. Keywords: Live related renal transplant; Intraoperative DJ stenting; Urinary leakage

Re-Hospitalization in First Six Months After Live Related Renal Transplantation: Risk Factors, Burden, Causes and Outcomes.

ObjectiveThe aim of our study was to evaluate the incidence, causes, risk factors, outcomes, and cost of hospital readmission after live related renal transplantation (LRRT).MethodsWe conducted a cross-sectional study and followed patients’ re-admissions for six months whose LRRT was done in our center between September 2019 and June 2020.ResultsWe recruited 53 patients, 40 (75.5%) were male. The mean age was 36.9 ± 11.9 years. Donor gender was similar, and their mean age was 31.6 ± 9.2 years. The mean length of hospital stay after LRRT was 14 ± 2.2 days. A total of 81.1% were readmitted after LRRT within the first six months, with a total of 113 readmissions. The median time of readmission after LRRT was 66 days. The median readmission hospital stay was four days. The causes of readmission were surgical in 11 (9.7%), medical in 89 (78.8%), and combined medical and surgical in 13 (11.5%). Infection was the most common medical cause, followed by rejection. Statistically significant difference between readmission and non-readmission groups was found in estimated glomerular filtration rate (eGFR) at six month 61.3 ± 25.9 vs. 84.3 ± 36.1 mL/min/1.73 m2 respectively (p = 0.02). The median cost of readmission was PKR 40629, equivalent to USD 261.ConclusionOver three-fourths of the patients were readmitted after LRRT within the first six months. The most common causes were infection and rejection. Readmissions after LRRT are associated with lower graft function at six months and a significant cost burden on the health system.