Renal Transplant Program Research Articles

P.236: Short-term outcomes of a living renal transplant program at a private hospital in Nairobi, Kenya.

P.236: Short-term outcomes of a living renal transplant program at a private hospital in Nairobi, Kenya.

Anesthesia in Renal Transplant

Background: Transplantation provides near-normal life and excellent rehabilitation compared to dialysis and is the preferred method of treating end-stage renal disease (ESRD) patients. Methods: We conducted a retrospective analysis of anesthesia management from 20 cases of live renal transplants carried out between August 2017 and April 2019 at Dr. Sardjito Central General Hospital, Yogyakarta. The subjects ' preoperative patient status, anesthesia management, and postoperative care were assessed. Results: Most patients had preoperative anemia, normal serum potassium, serum creatinine, and average ejection fraction. Anesthesia management began 24 hours before surgery, in which the patients were hospitalized, had peripheral IV access and fluid maintenance, and hemodialysis, followed by premedication 1 hour before surgery. Before surgery, anesthesia induction and intubation were done, followed by maintenance of anesthesia and intraoperative monitoring. Postoperative care consisted of the administration of analgesia and management of complications. Conclusion: Optimization of preoperative status, proper anesthesia management, and good postoperative care are keys to a successful renal transplant program.

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

424.3: Trends of Antibiotic Resistance in E. Coli, Klebsiella Spp., Pseudomonas Aeruginosa and Enterococcus Spp. Urinary Tract Infection in Renal Transplant Recipients From Pakistan Over a Decade

Introduction: Antimicrobial resistance is a major public threat worldwide. There has been an emergence of multi-drug resistant (MDR) bacterial infections over the last decade. MDR Klebsiella species have become one of the most common nosocomial pathogens in hospitals. In Pakistan, many studies reported a rising trend of resistance to antimicrobials in clinical isolates of Klebsiella species (spp.), E-coli, Pseudomonas aeruginosa and Enterococcus spp. Solid-organ transplant (SOT) recipients are more prone to infections, particularly with MDR organisms due to immunocompromised status, multiple hospital visits, and increased exposure to antibiotics. There is a paucity of data on antibiotic susceptibility patterns among renal transplant recipients from Pakistan. This study is conducted to find the trends in antimicrobial resistance patterns among common organisms isolated in the urinary tract over a 10-year period in renal transplant recipients. The aim is to guide the physicians regarding decisions over empirical antimicrobial choices. Methods: Sindh Institute of Urology and Transplantation (SIUT) is a 700-bedded tertiary care hospital in Karachi, Pakistan. It has had a comprehensive renal transplantation program with more than 6500 transplantations now. A retrospective computerized data review of urine cultures from renal transplant recipients in 2010 and 2020 was conducted. The trend of E.coli, Klebsiella species (spp.) Pseudomonas aeruginosa and Enterococcus spp. were collected. The resistance pattern of amoxicillin-clavulanic acid, ceftriaxone (ceftazidime for Pseudomonas aeurginosa), piperacillin-tazobactam, ciprofloxacin, amikacin, co-trimoxazole, and imipenem were compared over the 10 years period. Results: A total of 2,088 out of 6,249 (33%) and 2902 out of 8,115 (36%) urine cultures were positive in 2010 and 2020 respectively. The most common organisms isolated and their trend in the last decade is shown in figure 1.Over the decade, E-coli strains become 100% resistant to ciprofloxacin, ceftriaxone resistance has increased to 80%, and imipenem to 11%. In Klebsiella spp. imipenem resistance has increased to 19%. There is no significant change in the resistance pattern among Pseudomonas aeurginosa. Regarding Enterococcus spp. there is a rise in vancomycin resistance over the decade from 13% to 17% (Figure 2).Conclusion: Resistance to broad-spectrum antimicrobials has been increased with a>10% increase in carbapenems resistance over the last 10 years. E-coli has particularly become more resistant over the decade. We are also seeing more vancomycin-resistant enterococcus. The alarming increase in resistance may lead to increased morbidity in renal transplant recipients because we are left with only injectable options. We need a robust stewardship program for judicious use of antimicrobials and better infection control measures to contain increasing resistance.

243.9: Equality and Equity in Transplant for Children

Introduction: Thomas E. Starzl, conducted the first paediatric liver transplant in 1963, a routine successful clinical procedure today due to his pioneering efforts. India the second most populous country, 41% under 18 yrs of age, has followed on the heels of developed nations with 1522 pediatric transplants from 2013-2020 for all organs but majority done in private sector. To enable equality and equity, Govt of India has proposed establishing department of transplant medicine in major government hospitals, at least one in each state in the latest National Organ Transplant Program Guidelines. Our aim is to develop an SOP for the establishment of paediatric transplant units in line with the Transplantation of Human Organs and Tissues Rules 2014, starting with VMMC & SJH. Materials & Methods: In 2019, India reported 4,49,002 Road traffic accidents(RTA) with resultant 1,51,113 deaths. Delhi accounted for 5610 RTA with 1463 deaths.DD transplants prove to be exceptionally useful in diseases with high risk of recurrence particularly in children. VMMC & SJH is one of the largest govt tertiary care centres in Delhi catering to a large paediatric population and a large proportion of the RTA victims, the greatest source of deceased donor (DD) organs, if tapped. Living Donor Renal transplant is conducted in adult patients on a regular basis by urologists. A paediatric nephrologist being available, the paediatric renal transplant program can be started by a combined team of paediatric surgeons & urologists. Training in paediatric liver transplants can be done either locally in ILBS, Delhi or internationally through TTS-ILTS paired centers program similar to JIPMER, Pondicherry with St.James University hospital Leeds, UK. TTS in collaboration with NOTTO conducted an online survey of intensivists with regard to brain death declaration. The intensivists need to be trained for brain death declaration and donor maintenance to enable DD transplants. Augmentation of pediatric transplant intensive care beds and personnel is required along with round the clock lab facilities. Results: The Govts of Delhi, Tamilnadu, Kerala, Maharashtra, etc have issued have issued GOs for mandatory declaration of brain death in all patients who fulfill the criteria. DGHS has sought monthly submission of brain death data. Intensivist training for brain death declaration and donor maintenance was first started by NOTTO during the CAST 2019 congress and two more have followed. However, progress can only be achieved with implementation of training and establishment of dedicated centers.

MO574: Use of The Highly Hypoproteic Supplemented DIET in the Therapy of Patients With Advanced Chronic Renal Failure

Abstract BACKGROUND AND AIMS A low-protein diet has shown to be effective in slowing the progression of chronic kidney disease (CKD) and allows a later start to dialysis treatment [1]. However, the very low protein diet (0.3 g/kg/day) supplemented with aminoacids and ketoanalogues (sVLPD), but it is difficult to implement for the high number of tablets to take [2]. In order to increase compliance, we decided to prescribe balanced sVLPD to all patients with eGFR < 15 mL/min or with specific indications (e.g. renal transplantation program and conservative therapy) supplemented with amino acids without ketoanalogues. The aim of this approach was to evaluate the efficacy, compliance and safety of the personalized sVLPD, developed by a trainer dietitian mainly focused on nitrogen, acid–base, hydroelectrolytic balances and malnutrition [3]. METHOD During last 2 years, 91 patients were initiated into diet therapy. They were 58.2% males, all hypertensive, 33% diabetic, 65.9% on EPO therapy. At the beginning and quarterly were detected characterizing blood chemistry tests, anthropometrich measures and body composition (with impedance analysis) in all the patients. RESULTS The average observation time was 9.1 ± 5.1 months. Laboratory tests have shown improvement in mean azotemia (Fig. 1) values (144.2 ± 44.2 versus 94.6 ± 19.7 mg/dL; T0 versus T18; P < 0.005), phosphorus (4.4 ± 0.9 versus 4 ± 0.7 mg/dL; T0 versus T15; P < 0.05), bicarbonate (24.6 ± 5.7 versus 27 ± 4.7 mmol/L; T0 versus T6, P < 0.005); eGFR (Fig. 2) remained stable during follow-up (12.1 ± 3.6 versus 12.4 ± 4 mL/min; T0 versus T18; NS). Hemoglobin, uricemia, serum albumin, glycemia (downward trend NS), potassium, sodium, chlorum, calcium, magnesium, pH and lipids remained within normal values; average TSAT always >20% and average ferritin >100 mg/dL. The body mass index (BMI) was always on average within the normal range with an increase in patients with adequate hydration and lean mass (Fig. 3); improvement trend (NS) of the PAS, PAD within limits. Reduction of effective protein intake (0.85 ± 0.29 versus 0.61 ± 0.20 g/kg/die; T0 versus T9 P < 0.05). During the observation, 8 deaths occurred (7 patients over 85 years old), 10 admissions on dialysis peritoneal, 4 in hemodialysis and 3 pre-emptive transplants from living donors. To date, we estimated that the initiation of dialysis was delayed on average by 8.7 months/patient. CONCLUSION The approach we have adopted allowed to achieve good adherence to the diet, a slowdown in the progression of the CKD, improve and maintain good metabolic control, electrolytic and acid–base and body composition. A personalized sVLPD resulted in delayed starting of dialysis treatment, allowing patients to continue pre-dialysis education-program, increasing the choice for home peritoneal dialysis.

Factors Influencing Survival Outcome in Deceased Renal Transplant Recipients

Background: Renal replacement therapy is the gold standard treatment of end-stage renal disease. Since the number of cases of chronic kidney diseases are increasing exponentially in our country, only live-related transplant is not enough to bridge the gap between disease and their treatment which increased the demand for deceased renal transplant program in our country. Objective: The objective is to study donors and recipients' characteristics for association with survival of patients in deceased renal allograft transplant. Materials and Methods: It is an ambispective observational analysis of 42 deceased donor renal transplants performed in our institute from January 2012 to December 2019. The difference among donors and recipients' characteristics was analyzed for association with the outcome for survival or death of the patient. Statistical analysis was done using SSPS 21.0 software and P value < 0.05 was taken as statistically significant. Results: In association with survival and expired outcomes, donors and recipients age, donors sex, cause of brain death (traumatic/nontraumatic), standard or extended criteria of donor, serum creatinine at the time of death, dialysis vintage period, warm and cold ischemia time, duration of hospital stay had shown no significant association with survival. While donors' urine output at the time of death, recipients sex, previous sensitization of recipients either by previous episodes of blood transfusion or pregnancy, achievement of normal renal function at day 14 of transplant, and tacrolimus level at 1 month of transplant shown significant association with the outcome. Conclusion: Deceased donors' characteristics, mainly urine output at death, recipients characteristic, namely any previous sensitization, achievement of normal renal function at day 14, serum tacrolimus level at 1-month posttransplant have a significant association with survival of deceased renal allograft transplant recipients. Sepsis and severe acidosis were the main complications contributing to mortality.

Pediatric renal transplantation; 10 years experience.

Although renal transplantation (RT) is the first treatment option for children with end-stage renal failure, the number of transplanted chil- dren remains low compared to adults. Experience of the individual pediatric transplant center is very important in the prognosis of pediatric transplant recipients. In this study, our pediatric RT experience was presented. We retrospectively analyzed the data of 27 patients who had RT in our clinic between April 2009 and April 2019. Fifteen of the patients were males, and mean age of all patients was 12.36 ± 4.18 years (range 4-17 years). The most frequent etiology for end- stage renal disease (ESRD) was vesicourethral reflux. Eighteen (66.7%) of the transplanted kidneys came from cadaveric donors and 9 (33.3%) from live donors. One patient had preemptive RT and one patient had a re-RT. Twenty-two patients were on peritoneal dialysis program and four patients were on hemodialysis program. Mean dialysis time before transplantation was 29 (3-104) months. Bleeding was the most common surgical complication. Delayed graft function developed in four patients, and all of their grafts were from cadaveric donors. Rejection developed in 12 of our patients, graft loss was observed in only four of them. Considering all patients, graft survival rates were 100% in the 1st and 3rd years, and 92% in the 5th year. Pediatric RT program is difficult to establish, maintain and develop. Complications after transplantation are not uncommon; therefore, early detection and appropriate management are needed. Strategies are still needed to increase post-transplant success.

Short-term Outcomes of Pediatric Renal Transplantation in Nigeria; A Single-Center Experience :

Introduction This case-series describes a short term follow-up of Renal Transplantation (RT) in three children at the Zenith Medical and Kidney Centre (ZMKC), Abuja, Nigeria. Methods The immediate allograft function (IAF) and recipients’ survival at 6-24 months of follow-up from January 2018 to January 2020 were described. RT involved the use of basiliximab and thymoglobulin for induction therapy and oral prednisolone, tacrolimus and mycophenolate mofetil for maintenance immunosuppressive therapy. Results Recipients were 9 years to 17 years (average age of 12 years) of age. Primary steroid-resistant focal segmental glomerulosclerosis nephrotic syndrome, congenital posterior urethral stricture and lupus nephritis were the causes of the end-stage kidney diseases. The IAF was excellent in all the cases. All the 3 children are alive with good allograft functions at 6-24 months of the follow-up period. Conclusion This case series shows that a successful paediatric RT programme is feasible in a resource-constrained setting like Nigeria

The Impact of COVID-19 on Deceased Donor Renal Transplant Program in a Federal State of South India

The Impact of COVID-19 on Deceased Donor Renal Transplant Program in a Federal State of South India

Kidney Transplantation in Low- to Middle-Income Countries: Outcomes and Lessons Learned from Armenia.

BackgroundTreatment of end-stage renal disease constitutes a heavy financial burden, especially in developing countries. Maintaining a kidney transplantation program is an extremely complex task in countries with limited resources. It often requires expertise and support from developed countries. Living donor kidney transplantations (LDKT) have been performed regularly in the Republic of Armenia since 2002. The purpose of this article is to review the history and outcomes of kidney transplantation in Armenia.Material/MethodsA chart review was performed retrospectively on all patients who had undergone LDKT in Armenia. The key personnel involved in the development and operation of the unique kidney transplant program in the country were interviewed for a comprehensive review of the history and challenges of transplantation.ResultsThere were 172 LDKT (4 re-transplantations) performed between 2002 and 2019. The mean age of recipients was 35.9±13.4 years (range 7.1–65.7): 116 (67.4%) were male and 12 (6.9%) were children (<18 years). Seventy-four patients (43%) had peri- (n=5) and postoperative (n=69), mostly mild, surgical complications. Delayed graft function occurred in 17 (9.9%) patients, requiring hemodialysis in 16, and 6 patients stayed hemodialysis dependant. Sixty-nine patients (40.1%) had at least 1 episode of acute rejection, with 26 (15.1%) having more than 1. Late complications were mostly infectious (n=49) or malignant processes (n=13).Follow-up studies showed that out of 172 patients, 126 had functioning grafts, 17 died with functioning grafts, 3 were lost to follow-up, and 26 lost grafts. Graft survival at 1, 3, 5, and 10 years, non-censored for death, after LDKT was 96.4% (CI 93.6–99.2), 93.7% (CI 89.9–97.5), 90.5% (CI 85.7–95.3), and 75.3% (CI 66.9–83.7), respectively.ConclusionsFindings from this study suggest that a renal transplant program with acceptable outcomes can be successfully introduced in countries with limited resources.

Renal transplant evaluation: multimodality imaging of post-transplant complications.

With advancements in surgical techniques and immuno-suppression, renal transplantation is established as the most effective treatment option in patients with end-stage renal disease. Early detection of renal allograft complications is important for long-term graft survival. Late clinical presentation often causes diagnostic delays till the time allograft failure is advanced and irreversible. Imaging plays a key role in routine surveillance and in management of acute or chronic transplant dysfunction. Multimodality imaging approach is important with ultrasound-Doppler as the first-line imaging study in immediate, early and late post-transplant periods. Additional imaging studies are often required depending on clinical settings and initial ultrasound. Renal functional MRI is a rapidly growing field that has huge potential for early diagnosis of transplant dysfunction. Multiparametric MRI may be integrated in clinical practice as a noninvasive and comprehensive "one-stop" modality for early diagnosis and longitudinal monitoring of renal allograft dysfunctions, which is essential for guiding appropriate interventions to delay or prevent irreversible renal damage. With rapidly increasing numbers of renal transplantation along with improved patient survival, it is necessary for radiologists in all practice settings to be familiar with the normal appearances and imaging spectrum of anatomical and functional complications in a transplant kidney. Radiologist"s role as an integral part of multidisciplinary transplantation team continues to grow with increasing numbers of successful renal transplantation programs across the globe.

A renal transplantation programme in Bangladesh during the COVID-19 pandemic

A renal transplantation programme in Bangladesh during the COVID-19 pandemic

Evaluation of anesthetic management in renal transplant patients in a tertiary care centre

&lt;b&gt;Aim:&lt;/b&gt; To evaluate anesthetic management in renal transplant patients. &lt;b&gt;Methodology:&lt;/b&gt; Ninety- two renal transplant patients were part of the study. Parameters such as type of transplant, reason for chronic kidney disease, preoperative data, history of dialysis, preoperative anesthesia management, monitoring details and the outcome were recorded. &lt;b&gt;Results:&lt;/b&gt; Chronic glomerulonephritis (CGN) in 28 (30.4%), chronic interstitial nephritis (CIN) in 20 (21.7%), polycystic kidney disease (PCKD) in 11 (11.9%), obstructive nephropathy (Ob. N) in 4 (4.3%), diabetic nephropathy (DN) in 8 (8.7%), hereditary nephropathy in 3 (3.2%), reflux nephropathy in 12 (13%) and membranoproliferative glomerulonephritis (MPGN) in 6 (6.5%). In 32 (35.6%) patients, isoflurane was inhalational agent and recovery time was 25.1 minute, in 40 (43.4%), desflurane was inhalational agent and recovery time was 22.7 minutes and in 20 (21.7%), sevoflurane was inhalational agent and recovery time was 32.1 minutes. A significant difference was observed (P&lt; 0.05). &lt;b&gt;Conclusion:&lt;/b&gt; Anesthesia management has made renal transplantation safe and predictable. Postoperative maintenance of renal transplant patients have contributed to the success of renal transplant programme.

Anesthesia management of renal transplantation: A retrospective analysis

Transplantation provides a near normal life and excellent rehabilitation compared to dialysis and is preferred method of treatment for end stage renal disease patients. After ethics committee approval, a retrospective analysis of recipients of renal transplantation was done at our hospital from January 2010 to December 2014. Preoperative patient status, fluid management, hemodynamic parameters, anesthesia management, and perioperative complications were recorded and analyzed.Total 100 patients were recorded, 92% living and 8% were cadaveric related transplant. 92% were done electively. Most common co-morbidity recorded was hypertension in 49% patients. Predominant cause of end stage renal disease was chronic glomerulonephritis (41%). General anesthesia was technique of choice in all patients, 27 also received epidural. Invasive blood pressure monitoring was done in 3 patients with cardiac co-morbidities. 15% patients required blood transfusion. CVP maintained &amp;#62; 12 mmHg and maximum at de-clamping. Mean arterial pressure maintained above 95 mmHg. Ionotropic support required in 2 patients. 76% patients were transfused with only crystalloid (NS and/or RL) while 24 patients received a combination of both crystalloid and colloid. 97% patients were extubated postoperatively while 3% required ventilator support. Recovery time with desflurane was significantly less as compared to other inhalational agents. One patient died postoperatively. Recent advances in surgical techniques, anesthesia management and immunosuppressive drugs have made renal transplantation safe and predictable. Preoperative patient optimization, intraoperative physiological stability and postoperative care of renal transplant patients have contributed to the success of renal transplant program in our hospital.

Early Detection Strategy of BK Polyomavirus Nephropathy in Patients undergoing Renal Transplant: A Single-Center Retrospective Study

Introduction: BK polyoma virus nephropathy represents one of the non-immunological causes of renal graft loss with a cumulative incidence between 5 and 10 percent, and a graft loss rate on BK virus nephropathy patients that ranges from 30 to 90 percent depending on the nephropathy status at the time of diagnosis (1). Objective: To determine the outcomes regarding the kidney graft survival and kidney function of an early detection strategy for BK Polyomavirus nephropathy which is drawn upon urinary cytology in order to look for Decoy cells. Methodology: Descriptive, retrospective study type. Adult renal transplant recipients/patients from the Interdisciplinary Renal Transplant program of the Colombia University Clinic were included in a time period from 2012 to 2018, in whom monthly post-transplant monitoring with positive urinary cytology was performed. Results: 303 patients were transplanted in the program, 107 patients with positive urinary cytology were included, wherein, men predominated with 72% and 45 years old being the average age (IQR: 18–72). The cumulative incidence of polyomavirus nephropathy, under this early detection strategy, was 9.2%, thus preserving the graft survival at 24 months in a 100% of the patients with the management strategies employed. Conclusions: This early detection and monitoring study utilizing post-transplant urinary cytology proved to be useful for the early diagnosis of BK Polyomavirus nephropathy with a favorable impact on the graft livelihood.

High-throughput sequencing defines donor and recipient HLA B-cell epitope frequencies for prospective matching in transplantation

Compatibility for human leukocyte antigen (HLA) genes between transplant donors and recipients improves graft survival but prospective matching is rarely performed due to the vast heterogeneity of this gene complex. To reduce complexity, we have combined next-generation sequencing and in silico mapping to determine transplant population frequencies and matching probabilities of 150 antibody-binding eplets across all 11 classical HLA genes in 2000 ethnically heterogeneous renal patients and donors. We show that eplets are more common and uniformly distributed between donors and recipients than the respective HLA isoforms. Simulations of targeted eplet matching shows that a high degree of overall compatibility, and perfect identity at the clinically important HLA class II loci, can be obtained within a patient waiting list of approximately 250 subjects. Internal epitope-based allocation is thus feasible for most major renal transplant programs, while regional or national sharing may be required for other solid organs.

The Living-Related Kidney Transplant Program in Brunei Darussalam: Lessons Learnt from a Nascent National Program in a Small, Muslim, and Asian Country.

Brunei Darussalam commenced its living-related renal transplant program in 2013, with subsequent attainment of independent local capacity and proficiency in 2019. The preliminary outcome from the program has already begun to shape the national nephrology landscape with a 36% increment in transplant rate and mitigation of commercialized transplantations. The blueprint for the program was first laid out in 2010 and thereupon executed in four phases. The first phase involved the gathering of evidence to support the establishment of the national program, through researches investigating feasibility, public opinion, quality of life, graft survival, and cost-effectiveness. The second phase focused on laying the foundation of the program through grooming of local expertise, implementation of legal-ethical frameworks, religious legitimization, and propagation of awareness. The third phase worked on facilitating experiential exposure and strengthening local infrastructure through the upgrading of facilities and the introduction of subsidiary services. The fourth phase was implemented in Brunei in 2013 when foreign personnel worked together with the local team to perform the transplants. Between 2013 and 2019, ten kidney transplants were performed, with two being done in 2018 and three in 2019. We hope to inspire other similar countries to develop their own self-sustainable and independent local program.

Assessing the Potential and Necessity for Kidney Transplantation in the Democratic Republic of the Congo.

Assessing the Potential and Necessity for Kidney Transplantation in the Democratic Republic of the Congo.

Activity and short-term outcomes of kidney transplantation during the COVID-19 pandemic

IntroductionDuring the COVID-19 pandemic, the national transplant activity has been reduced due to the overload of the health system and concern for patient safety in this situation. The aim of our work is to expose the activity of kidney transplantation in Cantabria during the state of alarm, as well as to assess the safety of the transplantation program. Material and methodsRetrospective study of kidney transplants performed in our Center from the beginning of the state of alarm until the beginning of the lockdown easing in Cantabria. Descriptive analysis of the demographic data of recipients and their donors, intraoperative data and postoperative outcomes. Comparative analysis with the data of the same period in 2017–2019, by means of the X2 for categorical variables, Student’s T and Mann-Whitney U tests in case of quantitative variables of normal and non-normal distribution, respectively. ResultsFifteen kidney transplants were performed in the period described. Delayed renal function (DRF) was seen in 7.5% of patients, and 26.6% showed data of acute rejection; no patient presented COVID-19 disease.Comparative analysis showed a remarkable increase in the number of transplants in comparison with previous periods (15 vs 5.6), at the expense of donors from outside Cantabria (93.3%). We found no statistically significant differences in terms of cold ischemia time (p 0.77), DRF (p 0.73), need for dialysis (p 0.54), or appearance of post-surgical complications (p 0.61). ConclusionsThe evolution of the pandemic in our region, and the adoption of strict protective measures has allowed the early and safe resumption of the renal transplantation program, increasing the number of transplants performed compared to previous years and maintaining comparable early post-operative results.