Status Of Renal Transplantation Research Articles

Prevalence and characteristics of people with a high body mass index across the kidney disease spectrum: a population-based cohort study

The prevalence of obesity is growing globally and has major health implications, particularly for those with chronic kidney disease (CKD). People with obesity have a higher risk of CKD progression and face barriers to transplantation. Studies on the epidemiology and outcomes of obesity in the Canadian CKD population are lacking. This population-based cohort study included adults aged 18 and over with a hospital encounter in London, Ontario, Canada from 2010 to 2019 where height and weight were recorded. They were stratified into CKD stages 1-5 (by estimated glomerular filtration rate (eGFR)), dialysis or renal transplant status and by body mass index (BMI) using Canada Obesity Guidelines. Outcomes included prevalence of BMIs by CKD stage, and CKD progression and transplant outcomes across BMI classes. Our cohort included 198,151 patients. The prevalence of BMI ≥30 kg/m2 grew as eGFR declined (i.e., 37% in stage 1, 41.5% in stage 3b, 40.9% in stage 4) but fell in end-stages (i.e., 37.4% in Stage 5, 38.8% in dialysis, 38.5% in transplant recipients). CKD progression and kidney failure appeared more frequent in those with a BMI ≥30 kg/m2. In a smaller sample, we noted that end-stage patients with a BMI ≥30 kg/m2 were less frequently transplanted, but experienced post-transplant complications less often. This study revealed that high BMI is a prevalent issue in the Canadian CKD population and may influence kidney outcomes and transplant candidacy. This data will help inform clinical trials to create and study weight loss interventions for those with CKD and obesity.

The EKFC equation outperforms the CKD-EPI and CKiD equations for GFR estimation in adolescent and young adult kidney transplant patients.

This study evaluated the bias and accuracy of the CKD-EPI/CKiD and EKFC equations compared with the reference exogenous tracer-based assessment of glomerular filtration rate (GFR) in adult and pediatric patients according to their renal transplant status. We assessed the bias and P30 accuracy of the CKD-EPI/CKiD and EKFC equations compared with iohexol-based GFR measurement. In the overall population (n = 59), the median age was 29 years (IQR, 16.0-46.0) and the median measured GFR was 73.9 mL/min/1.73m2 (IQR, 57.3-84.6). Among non-kidney transplant patients, the median was 77.7 mL/min/1.73m2 (IQR, 59.3-86.5), while among kidney transplant patients, it was 60.5 mL/min/1.73m2 (IQR, 54.2-66.8). The bias associated with the EKFC and CKD-EPI/CKiD equations was significantly higher among kidney transplant patients than among non-kidney transplant patients, with a difference between medians (Hodges-Lehmann) of +10.4 mL/min/1.73m2 (95% CI, 2.2-18.9; p = .02) for the EKFC and +12.1 mL/min/1.73m2 (95% CI, 4.2-21.4; p = .006) for the CKD-EPI/CKiD equations. In multivariable analysis, kidney transplant status emerged as an independent factor associated with a bias of >3.4 mL/min/1.73m2 (odds ratio, 7.7; 95% CI, 1.4-43.3; p = .02) for the EKFC equation and a bias of >13.4 mL/min/1.73m2 (odds ratio, 15.0; 95% CI, 2.6-85.7; p = .002) for the CKD-EPI/CKiD equations. In our study, which included adolescent and young adult kidney transplant patients, both the CKD-EPI/CKiD and EKFC equations tended to overestimate the measured glomerular filtration rate, with the EKFC equation exhibiting less bias. Renal transplant status significantly influenced the degree of estimation bias.

Safety and utility of panniculectomy in renal transplant candidates and end stage renal disease patients.

As the obesity crisis in the United States continues, some renal transplantation centers have liberalized their BMI criteria necessary for transplant eligibility. More individuals with larger body-habitus related comorbidities with End-Stage Renal Disease (ESRD) now qualify for renal transplantation (RT). Surgical modalities from other fields also interact with this patient population. In order to assess surgical outcomes of panniculectomy in the context of renal transplantation and ESRD, the authors performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines. Due to a paucity of existing primary studies, we retrospectively collected data on patients with ESRD undergoing panniculectomy from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) to evaluate outcomes of body contouring in this patient population. From the systematic review, a total of 783 ESRD patients underwent panniculectomy among the studies identified. Of these, 91 patients underwent panniculectomy simultaneously to RT while 692 had their pannus resected prior to kidney transplant. The most common complication was hematoma followed by wound dehiscence. From the NSQIP database, 24868 patients met the inclusion criteria for analysis. In the setting of renal transplant status, patients with diabetes, hypertension requiring medication, and requiring dialysis were more likely to suffer postoperative complications (OR 1.31, 1.15, and 2.2, respectively). However, upon sub-analysis of specific types of complications, the only retained association was between diabetes and wound complication. Preliminary data show that panniculectomy in ESRD patients appears to be safe, though with a nominal increased risk for complications. Pannus resection does not appear to impact post-transplantation outcomes, including long-term allograft survival. Larger, higher powered, randomized studies are needed to confirm the safety, utility, and medical benefit of panniculectomy in the context of renal transplantation.

Clinical outcomes of renal transplant recipients undergoing percutaneous coronary intervention

Abstract Background Cardiovascular disease is the leading cause of mortality among renal transplant (RT) recipients. Despite this, the clinical outcomes of patients with RT undergoing percutaneous coronary intervention (PCI) remain poorly elucidated. Purpose This study compared characteristics and outcomes among three groups of patients undergoing PCI: (1) RT recipients, (2) patients receiving dialysis and (3) patients with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate 30–59 ml/min/1.73m²) without previous RT. Methods Data were analyzed for consecutive patients undergoing PCI enrolled in a large, multicenter Australian registry between 2014 and 2021 stratified into RT (n=226), dialysis (n=992) and CKD (n=15,534) groups. The primary outcome was 30-day major adverse cardiac and cerebrovascular events (MACCE) (composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularization and stroke). Long-term mortality was derived from linkage with the Australian National Death Index. Multivariable logistic and Cox regression were performed to assess the risk of 30-day MACCE and long-term mortality, respectively. Results RT recipients were younger compared to dialysis and CKD patients (61±10 vs 68±12 vs 78±8.2 years, p<0.001). The majority of patients were male: 72%, 76% and 61% in RT, dialysis, and CKD groups, respectively (p<0.001). RT patients had fewer comorbidities (diabetes mellitus, peripheral vascular disease and previous cerebrovascular events) than dialysis patients, however more than the CKD group (all p<0.001). Compared to dialysis and CKD groups, RT patients less frequently had severe left ventricular dysfunction (14% and 8.5% vs 6.7%), however more often presented with acute coronary syndrome (52% and 48% vs 58%), especially ST-elevation myocardial infarction (12% and 17% vs 20%) (all p<0.001). RT and CKD patients had lower rates of in-hospital mortality (2.7% and 3.8% vs 6.4%), target vessel revascularization (0.4% and 0.7% vs 1.7%) and 30-day MACCE (4.4% and 6.8% vs 11.6%) compared to the dialysis group (all p<0.001). Three-year survival was similar between RT and CKD groups, however lower in the dialysis group (80% and 83% vs 60%) (p<0.001) (Figure 1). After adjustment, dialysis at baseline was an independent predictor of 30-day MACCE (OR 1.90, 95% CI 1.44–2.50, p<0.001), however RT status was not (0.91, 0.42–1.96, p=0.802). In contrast, both RT status (HR 2.07, 95% CI 1.46–2.95, p<0.001) and dialysis at baseline (1.35, 1.02–1.80, p=0.036) conferred a heightened long-term hazard for mortality (Figure 2). Conclusions RT recipients have more favorable clinical outcomes following PCI compared to patients receiving dialysis. Nevertheless, despite having similar short-term outcomes to those with CKD, the hazard of long-term mortality is significantly greater for RT recipients. Close follow-up is warranted in this high-risk population.Figure 1Figure 2

Differences by transplant type in stool multiplex PCR testing for acute diarrhea in post-solid organ transplantation

BackgroundDiarrhea in solid organ transplant (SOT) recipients is common, morbid, and increasingly evaluated using multiplex gastrointestinal PCR panel (GI panel) testing. We aimed to characterize differences between transplant organ types in GI panel evaluation of acute diarrhea in SOT recipients.MethodsWe performed a dual-center retrospective cross-sectional study of adult SOT recipients with acute diarrhea who underwent GI panel testing. Demographic, transplant, testing context, and GI panel data were collected. Patients were stratified by transplant type. The primary outcome was a positive GI panel.ResultsOf 300 transplant recipients (58 heart, 65 liver, 68 lung, and 109 renal), 118 had a positive GI panel. Renal transplant status correlated with more frequently positive GI panel and less frequent hospitalization. In a multivariate analysis adjusting for demographic factors, hospitalization, immunosuppression, and transplant age, renal transplantation was independently associated with a positive GI panel compared to lung transplantation (aOR 2.98, 95% CI 1.27-7.16). Older transplant age and outpatient testing were also independently associated with a positive GI panel. The GI panel result was associated with changes to antibiotic management.ConclusionsIn the evaluation of SOT recipients with acute diarrhea, GI panel result varies by transplant type, transplant age, and testing location and may affect subsequent antimicrobial therapy.

COVID-19 impact on kidneys

Introduction and purposeThe COVID-19 pandemic, which has been ongoing since early 2020, has significantly affected the health care system worldwide. SARS-CoV-2 virus being the etiological factor of the disease has a high affinity for the renal organ. The purpose of this study was to provide an overview of the current knowledge of the problem of frequent AKI in the course of coronavirus infection, the impact of COVID-19 disease in patients with chronic kidney disease and on renal replacement therapy or dialysis.Review methodIn the process of writing, we used available articles and scientific papers in Pubmed and Google Scholar databases based on keywords: COVID-19, SARS-CoV-2, AcuteKidneyInjury, ChronicKidneyDisease.State of knowledgeSARS-CoV-2 virus enters target cells through the ACE2 receptor. In the pathophysiology of AKI in the course of COVID-19, a key role is attributed to secondary damage mechanisms such as cytokine storm, hypoperfusion with hypoxia, endothelial dysfunction. The incidence of acute kidney injury ranges from 5.1% to 36.6%. The development of AKI, renal transplant status, the presence of chronic kidney disease or renal replacement therapy is associated with an increased risk of severe course and higher mortality on COVID-19. SummaryThe COVID-19 pandemic has posed new logistical and therapeutic challenges to the health care system. Due to the high tropism of SARS-CoV-2 to the kidneys and the frequent occurrence of AKI during the course of the infection, nephrology patients, those on renal replacement therapy and those awaiting transplantation should be placed under special surveillance. Patients in these groups are at particular risk for a severe course of COVID-19.

A rare case of dystrophic calcification in anterior aspect of C4-C5 vertebrae due to infection in hemodialysis catheter

A 42 year old female, known case of Lupus nephritis with post renal transplant status since 2 years was admitted with complaints of chronic neck, back and right shoulder pain, which was stabbing in nature. She had on and off pain for which she was being managed on OPD basis since 1 year. However, her pain has aggravated in past 1 week. Radiological imaging of cervical spine showed area of calcification in anterior aspect of C4 C5 vertebrae in lateral view.

Urine and vaginal microbiota compositions of postmenopausal and premenopausal women differ regardless of recurrent urinary tract infection and renal transplant status

Postmenopausal women and renal transplant recipients are at increased risk of recurrent urinary tract infections (RUTI). Urine and vaginal microbiota of premenopausal controls (N = 18) and RUTI cases (18), and of postmenopausal controls (30) and RUTI cases (20) with and without a renal transplant, were characterized using 16S rRNA sequencing. Participants did not have UTI symptoms at the time of sampling. Gram-negative uropathobionts (predominantly Escherichia/Shigella, Pseudomonas, Klebsiella, and Acinetobacter) had a much higher mean relative abundance in urine than vaginal samples, especially in premenopausal women. No statistically significant differences in mean relative abundances of bacterial groups were found within the premenopausal group or within the postmenopausal group by RUTI or renal transplant status without chronic antibiotic use. Comparing postmenopausal to premenopausal women, mean relative abundances of lactobacilli (especially L. crispatus) in urine and vaginal samples and of Gram-negative uropathobionts in urine were lower, and of BV-anaerobes and Gram-positive uropathobionts in urine and vaginal samples were higher. While RUTI in premenopausal women is predominantly caused by Escherichia, the causative organisms in postmenopausal women are likely more diverse. The relative importance of individual organisms is currently unknown. We recommend that future studies, including intervention studies, include longitudinal microbiota assessments.

A DEEP LEARNING-BASED CAD SYSTEM FOR RENAL ALLOGRAFT ASSESSMENT: DIFFUSION, BOLD, AND CLINICAL BIOMARKERS.

Recently, studies for non-invasive renal transplant evaluation have been explored to control allograft rejection. In this paper, a computer-aided diagnostic system has been developed to accommodate with an early-stage renal transplant status assessment, called RT-CAD. Our model of this system integrated multiple sources for a more accurate diagnosis: two image-based sources and two clinical-based sources. The image-based sources included apparent diffusion coefficients (ADCs) and the amount of deoxygenated hemoglobin (R2*). More specifically, these ADCs were extracted from 47 diffusion weighted magnetic resonance imaging (DW-MRI) scans at 11 different b-values (b0, b50, b100, …, b1000 s/mm2), while the R2* values were extracted from 30 blood oxygen level-dependent MRI (BOLD-MRI) scans at 5 different echo times (2ms, 7ms, 12ms, 17ms, and 22ms). The clinical sources included serum creatinine (SCr) and creatinine clearance (CrCl). First, the kidney was segmented through the RT-CAD system using a geometric deformable model called a level-set method. Second, both ADCs and R2* were estimated for common patients (N = 30) and then were integrated with the corresponding SCr and CrCl. Last, these integrated biomarkers were considered the discriminatory features to be used as trainers and testers for future deep learning-based classifiers such as stacked auto-encoders (SAEs). We used a k-fold cross-validation criteria to evaluate the RT-CAD system diagnostic performance, which achieved the following scores: 93.3%, 90.0%, and 95.0% in terms of accuracy, sensitivity, and specificity in differentiating between acute renal rejection (AR) and non-rejection (NR). The reliability and completeness of the RT-CAD system was further accepted by the area under the curve score of 0.92. The conclusions ensured that the presented RT-CAD system has a high reliability to diagnose the status of the renal transplant in a non-invasive way.

Quality of life in chronic kidney disease: a community perspective using world health organization quality of life: BREF questionnaire

Background: The quality of life is an important assessment tool in improving the quality of care among chronic kidney diseases (CKD) especially in a palliative care setup. This study attempted to assess the quality of life of chronic kidney disease patients.Methods: This community based cross sectional study was conducted among 140 patients who were registered at palliative clinics in Malappuram District, Kerala using a standard tool for quality of life (QOL) in Malayalam version. Domain scores were analysed across clinic epidemiological factors.Results: Mean age of the study population was 53.99 (14.36%). Majority 73 (52.1%) were educated up to upper primary. The median duration of CKD was 4 years and ranged from 3 months to 22 years. 55.3% were undergoing dialysis 16.3% had renal transplantation. Hypertension was reported by 65% and diabetes by 50.7%. The highest score was obtained in the environmental and lowest in the psychological domain. Age below 40 years, male gender and provision of an income was associated with better QOL scores and perception scores. QOL was significantly higher in all domains among those who had undergone renal transplantation compared to those on hemodialysis. Conclusions: The status of renal transplantation and younger age group positively affected the good quality of life. Considering the cost of renal transplantation and post-transplant survival peritoneal dialysis could be promoted in low resource settings. Secondary prevention of hypertension and diabetes should be addressed at programme level to delay nephropathy.

National Analyses on Survival in Maltese Adult Patients on Renal Replacement Therapy Started During 2009–2012

Chronic kidney disease patients on maintenance dialysis (CKD 5D) experience major morbidity and mortality. No data on survival in Maltese dialysis patients exist; therefore, the aim of this study was to rigorously examine survival statistics in a complete cohort of Maltese CKD 5D patients. The study population was comprised of all incident chronic patients (N=328) starting dialysis at the renal unit, Mater Dei hospital, Msida, Malta, for 4 consecutive years (2009–2012). Each yearly cohort was analysed in detail up to 31st December 2017, providing up to 8 years follow-up. Demographics (male 65%; female 35%), aetiology of renal failure (diabetic kidney disease: n=191; 58.2%), comorbidities, transplant status, and death were documented. Data collection and follow up were completed and statistical analysis was performed on the aggregated cohorts with SPSS version 23 with censoring up to 31st December 2017. The cumulative adjusted 5-year overall survival in Maltese CKD 5D patients was 0.36 and 0.25 at 8 years. No statistical difference was observed according to the year of starting dialysis. Cox regression analysis showed that age and transplant status influenced survival. The unadjusted hazard of death increased by 3% for every 1-year increase in age and was increased by 7% if the patient did not receive a transplant, and overall 22% (n=72) of the entire cohort eventually received transplants. This study reports an approximate 65% mortality at 5 years in Maltese haemodialysis patients, a poor prognosis that, despite optimal medical management, is consistent with worldwide reports.

A Novel CNN-Based CAD System for Early Assessment of Transplanted Kidney Dysfunction

This paper introduces a deep-learning based computer-aided diagnostic (CAD) system for the early detection of acute renal transplant rejection. For noninvasive detection of kidney rejection at an early stage, the proposed CAD system is based on the fusion of both imaging markers and clinical biomarkers. The former are derived from diffusion-weighted magnetic resonance imaging (DW-MRI) by estimating the apparent diffusion coefficients (ADC) representing the perfusion of the blood and the diffusion of the water inside the transplanted kidney. The clinical biomarkers, namely: creatinine clearance (CrCl) and serum plasma creatinine (SPCr), are integrated into the proposed CAD system as kidney functionality indexes to enhance its diagnostic performance. The ADC maps are estimated for a user-defined region of interest (ROI) that encompasses the whole kidney. The estimated ADCs are fused with the clinical biomarkers and the fused data is then used as an input to train and test a convolutional neural network (CNN) based classifier. The CAD system is tested on DW-MRI scans collected from 56 subjects from geographically diverse populations and different scanner types/image collection protocols. The overall accuracy of the proposed system is 92.9% with 93.3% sensitivity and 92.3% specificity in distinguishing non-rejected kidney transplants from rejected ones. These results demonstrate the potential of the proposed system for a reliable non-invasive diagnosis of renal transplant status for any DW-MRI scans, regardless of the geographical differences and/or imaging protocol.

Adverse effects of chronic nicotine exposure on the kidney: Potential human health implications of experimental findings .

With the increasing popularity of E-cigarettes, chronic exposure to nicotine (NIC) is emerging as a novel risk factor for the kidney. NIC increases oxidative stress in the kidneys, which impairs the viability and function of renal tubular and endothelial cells, alters renal hemodynamics, and compromises overall kidney function. Moreover, long-term NIC exposure increases the risk of development and progression of chronic kidney diseases and may escalate the impact of coexisting morbidities such as obesity-associated renal disease, hypertension, renal transplant status, or the toxicity of various anticancer agents. In this review, we summarize experimental findings describing increased renal risk of chronic NIC exposure and explore therapeutic interventions to alleviate adverse effects of NIC. .

Comparison of the Frequency of Acute Kidney Injury in Patients With Renal Transplant Who Underwent Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) are established modalities of coronary revascularization. Choosing between the two requires taking into consideration not only disease severity, patient characteristics, and expected outcomes but also adverse effects. One such adverse effect is acute kidney injury (AKI), especially when considering coronary revascularization in patients with renal transplant (RT). We searched the National Inpatient Sample from 2008 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for patients with RT (V42.0) who underwent PCI (00.66, 36.06, and 36.07) and CABG (36.1×, 36.2, and 36.3×). We further identified patients with AKI (584.5, 584.6, 584.7, 584.8, and 584.9) and those on dialysis (39.95). The propensity score model/method was used to form matched cohorts for PCI and CABG. We compared the incidence of AKI and AKI requiring dialysis in CABG and PCI groups. We identified 1,871 patients who underwent PCI and 1,878 patients who underwent CABG after propensity score matching. We found the incidence of both AKI (22% vs 38%, odds ratio 2.20, 95% confidence interval 1.91 to 2.54, p <0.0001) and AKI requiring dialysis (1% vs 3%, odds ratio 2.50, 95% confidence interval 1.49 to 4.19, p = 0.001) to be significantly higher in the CABG compared with the PCI cohort. In conclusion, the results of the study reflect the importance of accounting for the RT status before choosing between PCI and CABG for coronary revascularization.

Pulmonary infections in immunocompromised patients: the role of image-guided fine needle aspiration cytology.

To evaluate the role of fine needle aspiration cytology (FNAC) in the diagnosis of pulmonary infections in immunocompromised patients and to identify the imaging pattern of infections on computed tomography (CT). This was a retrospective study of 42 immunocompromised patients who underwent FNAC under image guidance owing to a clinical pulmonary infection. Each patient was evaluated for an underlying immunocompromised condition, cytological diagnosis, CT findings and complications. The most common predisposing condition was diabetes mellitus (n = 11), renal transplant status (n = 11) followed by connective tissue disorders (n = 6) and malignancy (n = 5). There were four patients with renal disease and three had a human immunodeficiency virus (HIV) infection. The most common cytological diagnosis was mucormycosis (n = 13) followed by nocardiosis (n = 8) and necrotising inflammation (n = 7), tuberculosis (n = 6), cryptococcosis (n = 2), aspergillosis(n = 2), histoplasmosis(n = 1) and atypical mycobacterial infection (n = 1). Mucormycosis presented as a pulmonary nodule (n = 7), mass lesion (n = 5) or consolidation (n = 4). The patients with nocardiosis had lung nodules with associated consolidation and cavitation. None of the patients had any major complication. FNA is a relatively reliable, safe and quick method of diagnosing pulmonary infection in immunocompromised patients. Cytomorphological features, when aided by special stains, can accurately detect the specific infection which is potentially treatable. Specific infections may be suggested based on specific imaging patterns.

Renal Transplant Status Correlates With Expression of BAFF and Localises Within Intra-Graft Lymphoid Aggregates During Acute Antibody-Mediated Rejection.

Purpose of Study: To measure serum and intra-renal expression of B cell-activating factor (BAFF) as a marker of B cell-mediated pathology. Methods: CD19+ cells from patients with deteriorating (n=33), stably-impaired (n=29) and stable (n=31) grafts were examined for CD19, CD27, IgD & BAFF-receptor (BAFF-R) expression by flow cytometry. Serum BAFF (sBAFF) levels were measured by ELISA and HLA antibodies using Luminex technology. Renal biopsy sections from cohorts with (n=16) and without (n=11) acute antibody-mediated rejection (AAMR) were studied by immunohistochemistry. Results: The stable group had significantly lower sBAFF and more CD19+BAFF-R+cells. Those with above average sBAFF (sBAFFhigh) had a higher rate of allograft deterioration and greater prevalence of donor-specific HLA antibody compared to those with below average sBAFF levels. Moreover, naïve B cells (CD19+CD27-IgD+) were reduced and memory B cells (CD19+CD27+IgD-) increased in sBAFFhigh patients. Examination of biopsy sections demonstrated a higher frequency of CD19+ cells associated with small populations of sub-capsular interstitial lymphoid aggregates in patients with AAMR. BAFF-R expression showed a similar distribution to CD19, but BAFF more often had a diffuse distribution across the core. The presence or absence of AAMR made no difference to sBAFF levels. Conclusion: BAFF is a central component of the B cell compartment regulating cell maturation and survival. Here elevated expression of sBAFF and low frequency of BAFF-R on CD19 cells correlate with deteriorating graft function and intra-renal expression of CD19, BAFF-R and BAFF is increased during AAMR. These data provide direct evidence of BAFF expression on infiltrating B cells during humoral rejection, and a rationale for measuring expression levels of BAFF as a biomarker of allograft function.

English

BACKGROUND AND OBJECTIVES: Fungal urinary tract infections have become frequent, as a result of increased use of broad spectrum antibiotics, corticosteroids, immunosuppressive drugs and bladder catheters in acute care settings. The associated risk factors which are seen in cases of candiduria are: antibiotic therapy, female gender, urinary catheterization, surgical procedure and extended hospitalization. Candiduria has become a potential source of morbidity and mortality if untreated. We undertook a prospective study to note the incidence of non-Candida albicans in patients with urinary tract infection with special reference to speciation, antifungal susceptibility and the associated risk factors. METHODS: Candida species isolated from urine samples of patients with urinary tract infection were subjected to speciation using standard yeast identification protocol and CHROM agar. Antifungal Susceptibility testing was done by the disc diffusion method to amphotericin B and fluconazole. Clinical details and risk factors of the patients were noted down. RESULTS: Among the 60 culture positive cases, six Candida species which were isolated are : C.tropicalis (66.66%), C.albicans (13.33%), C.parapsilosis (8.33%), C.glabrata (6.66%), C.kefyr (3.33%) and C.guilliermondii (1.66%) The susceptibility pattern showed, that of the 60 isolates, 40% were resistant to fluconazole. No resistance was seen to amphotericin B. CONCLUSION: Isolation of non-Candida albicans species was more than Candida albicans. Candida tropicalis was the predominant isolate. The following risk factors were noted: 43.33 % of the patients had diabetes mellitus, 30%had history of prolonged antibiotics (cephalosporin and aminoglycosides), 16.66% had underlying renal pathology, 3.33% had post -renal transplant status, 1.66% were on steroids, 1.66%had pregnancy and 3.33% had no identifiable risk factors.20% patients had an indwelling catheter in them. The antifungal resistance was more in the non-Candida albicans species than in Candida albicans. Hence there is a need for speciation, susceptibility testing of Candida species.

Renal transplant status in patients undergoing colorectal surgery: Is immunosuppression safer than kidney disease?

It is unknown how colorectal surgical outcomes in recipients of renal transplants (TXP) compare to the outcomes in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Data from the Nationwide Inpatient Sample for 2004 to 2008 were reviewed. International Classification of Diseases (ICD-9) codes identified patients undergoing colorectal surgery who were stratified as having no kidney disease, CKD, ESRD, or TXP. The effects of renal status on mortality, length of hospital stay, and hospital costs were determined. A total of 171,133 patients were identified; 162,986 had no kidney disease, 3,686 had CKD, 1,296 had ESRD, and 3,765 had had TXP. The odds of death after surgery were 43% more likely for patients with CKD, 82% more likely for TXP, and 240% more likely for those with ESRD. TXP resulted in an additional length of hospital stay of 3.4 days, compared to 3.2 days for those with ESRD, and 1.1 days for those with CKD (P < .0001). CKD added $4,223 in additional costs, TXP added $8,213, and ESRD added $12,821 (P < .0001). TXP demonstrated odds of mortality between those of CKD and ESRD for cardiovascular complications (OR 2.47). Pulmonary complications resulted in the highest odds of mortality for TXP (OR 6.3). After TXP, patients undergoing colorectal surgery have mortality and costs between those of patients with CKD and ESRD, with pulmonary complications remaining high mortality events.

Outcomes and Timing of Aortic Surgery in Renal Transplant Patients

Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.

Five Decades of Indian Nephrology: A Personal Journey

Impressive accomplishments have been made in Indian nephrology during the last 5 decades. The first renal biopsy performed in 1956 ushered in a new era of modern nephrology practice in India and led to the recognition of nephrology as a distinct specialty. The first hemodialysis facility was established in 1961; presently, there are 950 nephrologists, 850 hospitals equipped with dialysis facilities, and 170 institutions recognized for kidney transplantation, with approximately 3,500 transplantations performed every year. The majority of dialysis units are small minimal-care facilities with fewer than 5 dialysis stations, and more than 85% are in the private sector. Government hospitals provide free treatment to poor patients with chronic kidney disease; however, inadequate funding and lack of health insurance schemes pose serious hurdles in providing renal replacement therapy. In contrast, private/corporate hospitals located in big cities have large units with state-of-the-art dialysis and transplantation facilities, similar to advanced centers of the world, but are accessible to only upper-income groups. Of the estimated 175,000 new patients who develop end-stage renal disease annually, less than 10% are able to gain access to renal replacement therapy. Research in the field of renal diseases has evolved slowly and is focused primarily on tropical conditions. The availability of structured nephrology training programs coupled with excellent diagnostic and therapeutic facilities in some academic institutions and tertiary-care private/corporate hospitals have diminished the need for foreign travel by students, patients, and consultants to a considerable extent. The expansion of therapeutic facilities in India is hampered by only economic constraints, not lack of expertise.