The Learning Curve of Pure Retroperitoneoscopic Donor Nephrectomy.

BACKGROUND: Retroperitoneoscopic donor nephrectomy (RDN) is a well-established modality for the procurement of kidneys for renal transplantation. However the learning curve of pure RDN is not yet defined. Defining the learning curve will help in proper mentorship of the new donor surgeons besides providing safety to the donors. OBJECTIVE: To define the learning curve of pure RDN. METHODS: We analyzed the prospectively collected data of 102 voluntary kidney donors who underwent RDN by a single surgeon between August 2012 and April 2015 at our center. The donors were classified into group A (1-34), group B (35-68), and group C (69-102) according to the chronological order of their surgery. Left RDN was performed in 28 (82%), 25 (74%), and 28 (82%) donors of group A, B, and C, respectively. Right RDN was performed in 6 (18%), 9 (26%), and 6 (18%) donors of group A, B, and C, respectively. The clinical data were analyzed for each group. RESULTS: Statistically significant difference was observed for the mean operative time (p<0.01) and warm ischemia time (p<0.04). The operative time remained around 200 minutes after the initial 35 cases. CONCLUSION: The learning curve of pure RDN was 35 cases, although the mastery requires more number of cases to be performed.

Buccal Mucosal Graft Urethroplasty in Patients Awaiting Renal Transplantation.

OBJECTIVE: To assess the perioperative morbidity and early outcome of buccal mucosal graft (BMG) urethroplasty in patients with urethral stricture awaiting renal transplantation. METHODS: Thirteen patients awaiting renal transplantation underwent BMG urethroplasty for long anterior urethral stricture between June 2011 and March 2013. The management issues, complications, and outcome of the BMG urethroplasty in this cohort of patients were studied. RESULTS: Mean age of the patient was 38.7 ± 12.7 years. History of urethral manipulation was present in 8 patients. Mean stricture length was 6.92 ± 2.90 cm. Mean serum creatinine of the patient was 8.1 ± 3.6 mg%. Three patients required oral exploration for bleeding. Two patients had urinary extravasation, 3 patients had infected hematoma, and 1 patient developed dry gangrene of the glans. One patient had sepsis due to pyonephrosis in the postoperative period and succumbed to it. Mean follow-up of the patients was 34.54 ± 6.46 months. Three patients underwent VIU for recurrence of the stricture in the follow-up. At 3-month follow-up mean Qmax was 23.8 mL/sec, whereas at 6-month and 1-year follow-up, Qmax was 23.6 and 23.4 mL/sec, respectively. CONCLUSION: This study shows a relatively higher complication rate of urethroplasty in prerenal transplant patients. Although the number of cases is too small to arrive at any definite conclusion, this study does gives an insight into the management issues, complications, and success of urethroplasty in this group of patients.

Histological and Clinicopathological Evaluation of Liver Allograft Biopsy: An Initial Experience of Fifty Six Biopsies.

INTRODUCTION: Liver biopsy is gold standard for diagnosis of allograft dysfunction. AIM: The aim of study was to evaluate liver allograft biopsies performed for graft dysfunction, study the pattern of injury and intensity, and timeline of occurrence of graft dysfunction. MATERIALS AND METHODS: Retrospective study was carried out of 56 liver allograft biopsies and their histological findings with clinical presentation were correlated. Totally 56 needle liver allograft biopsies from January 1210 to July 2014, obtained from 35 patients were studied for histological and clinicopathological evaluation. RESULTS: The mean age was 53.2±5.48 years. The most common original disease was alcoholic cirrhosis. The most common histological lesion was acute cellular rejection (ACR) in 31 (55.36%) biopsies followed by preservation-reperfusion injury (PRI) in 10 (17.86%) biopsies and drug toxicity in 8 (14.29%) biopsies. Chronic rejection was reported in 2 (3.57%) and recurrence of HCV in 3 (5.36%). Ischemic coagulative necrosis and acute cholangitis were seen in 1 (1.79 %) case each. CONCLUSION: Alcoholic cirrhosis was the most common etiology for end stage liver disease. ACR and PRI were the major complications in liver allograft biopsies at our centre.

De Novo Esophageal Carcinoma in Post-liver Transplant Patient.

De novo esophageal malignancy following liver transplantation is very rare. Esophageal squamous cell carcinoma following liver transplant is closely associated with history of alcohol intake and tobacco chewing. We report on a 45-year-old man, chronic tobacco chewer and alcoholic who underwent liver transplantation for alcoholic cirrhosis and developed esophageal squamous cell carcinoma 23 months following the procedure. He was treated surgically and has had a tumor-free survival after 34 months of regular follow-up.

Outcome of live and deceased donor renal transplantation in patients aged ≥55 years: A single-center experience.

Renal transplantation (RTx) has now become an accepted therapeutic modality of choice for elderly ESRD patients. This single-center study was undertaken to evaluate the outcome of RTx in ESRD patients ≥55 years. A total of 103 patients underwent RTx 79 living related living donors [LD], 24 deceased donors [DD]) at our center. Post-transplant immunosuppression consisted of calcineurin inhibitor-based regimen. The mean donor age was 58.3 years in the LD group and 59.5 years in the DD group. Male recipients constituted 92% in LD and 75% in DD group. In living donor renal transplantation, 1- and 5-year patient survival was 93% and 83.3% respectively and death-censored graft survival was 97.3% and 92.5% respectively. There were 12.6% biopsy proven acute rejection (BPAR) episodes and 12.6% patients were lost, mainly due to infections. In deceased donor renal transplantation, 1- and 5-year patient survival was 79.1% and 74.5% respectively and death-censored graft survival was 95.8% and 85.1% respectively. There were 12.5% BPAR episodes and 25% of patients were lost, mainly due to infections. RTx in ESRD (≥55 years) patients has acceptable patient and graft survival if found to have cardiac fitness and therefore should be encouraged.

Successful three-way kidney paired donation transplantation: The first Indian report.

Providing transplantation opportunities for patients with incompatible live donors through kidney paired donation (KPD) is an important strategy for easing the crisis in organ availability. KPD is can overcome the barriers when the only living potential donors are deemed unsuitable owing to an incompatibility of blood type, of human leukocyte antigen cross-match, or both. In KPD, the incompatibility problems with two donor recipient pairs can be solved by exchanging donors. In the absence of well-organized deceased donor program, or transplantation with desensitization protocol and ABO incompatible transplantation, living donor KPD promises hope to the growing number of patients suffering from end-stage renal disease in India. We report our first successful three-way KPD transplantation from India. In an era of organ shortage, this approach is relevant to encourage wider participation from KPD donors and transplant centers to prevent commercial transplantation.

Successful renal transplantation from a brain-dead deceased donor with head injury, disseminated intravascular coagulation and deranged renal functions.

Deceased donors (DDs) with the brain death due to head injury are the major source of organs for transplantation. The incidence of post-head injury disseminated intravascular coagulation (DIC) ranges from 24% to 50%. Many centers do not accept organs from donors with DIC due to increased risk of primary graft non-function and/or high chances of morbidity/mortality. We performed two successful renal transplants from a DD with head injury with DIC and deranged renal function. One of the recipients developed transient thrombocytopenia, but there was no evidence of DIC or delayed graft functions in either of the recipients. Over a follow-up of 1 month, both are doing well with stable graft function and hematological profile. Thus, a carefully selected DD with severe DIC even with deranged renal function is not a contraindication for organ donation if other risk factors for primary non-function are excluded. This approach will also help in overcoming organ shortage.

Intercity deceased donor renal transplantation: a single-center experience from a developing country.

In a developing country such as India, deceased donor renal transplantation (DDRTx) accounts for only about 1% of all renal transplants (RTx). Our institute initiated an intercity DDRTx in the year 2006, which significantly increased the number of RTx. We retrieved 74 kidneys from 37 deceased donors from various cities of Gujarat from January 2006 to December 2009. We transplanted the allografts in 66 recipients and a retrospective analysis of the donor profile and management and recipient outcome was performed. The mean age of the donors was 43.3 ± 18.8 years. The causes of death included road traffic accident in 51.35% of the donors and cerebrovascular stroke in 48.65% of the donors; 83.78% of the donors required ionotropes for hemodynamic stability in addition to vigorous intravenous fluid replacement. The average urine output of the donors was 350 ± 150 mL. The organs were perfused and stored in HTK solution. The mean cold ischemia time (CIT) was 9.12 ± 5.25 h. The mean anastomosis time in the recipient was 30.8 ± 8.7 min. 57.6% of the recipients established urine output on the operating table and 42.4% developed delayed graft function. At the end of 1 month after transplantation, the mean serum creatinine was comparable to the Ahmadabad city DDRTx, although the CIT was significantly longer in the intercity patients. Intercity organ harvesting is a viable option to increase the donor pool. Distance may not be an impediment, and good recipient outcome is possible in spite of prolonged CIT in case of proper harvesting and preservation.

Primary renal carcinoid tumor.

Primary renal carcinoid tumor is extremely rare and, therefore, its pathogenesis and prognosis is not well known. We report a primary renal carcinoid in a 26-year-old man treated by radical nephrectomy.

Successful renal transplantation from a brain-dead deceased donor who died from snakebite: a case report.

Even though India is the country with the highest annual number of deaths (50,000) from snakebite, there is contradictory evidence regarding acceptance of deceased donors (DD) who died from this cause. We present 2 successful renal transplantations (RTx) from a brain-dead DD who died from a neurotoxic snakebite without manifestations of a viper bite. We accepted the donor as he exhibited no evidence of hematoxic snakebite. Rather the findings were consistent with a neurotoxic bite (probably krait), which can cause hypoxic brain injury. Both recipients established good diuresis intraoperatively and did not require hemodialysis. The patients were discharged with good diuresis and normal serum creatinines. After 3-month follow-up, both recipients show normal graft function. According to our experience of favorable RTx outcomes from a brain-dead DD who died from neurotoxic snakebite may expand the donor pool.

Outcome of renal transplantation from deceased donors after cardiac death: a single-center experience from a developing country.

BACKGROUND: Limited information is available in the literature about the use of organs from donation after cardiac death (DCD) renal transplantation (RTx) from a developing country. MATERIAL AND METHODS: We report RTx outcome between DCD donors ≥70 years (Group 1; n = 14; mean age, 75.7 ± 5.81) and DCD donors <70 years (Group 2; n = l9; mean age, 51.7 ± 10.1) between January 1999 and January 2012. The mean age of recipients was 39.5 ± 14.7 years, 24 of whom were males. The mean donor age was 61.9 ± 14.6 years, 21 of whom were males. All recipients received single-dose thymoglobulin induction followed by immunosuppression with a steroid, a calcineurin inhibitor, and mycophenolate mofetil or azathioprine. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis. RESULTS: Over a mean follow-up of 3.21 ± 3.46 years, one-, five-, and ten-year, patient survival rates were 77%, 67.4%, and 67.4%, respectively, and death-censored graft survival rates were 85.7% for one, five, and ten years. Delayed graft function (DGF) was observed in 36.4% (n = 12) with 12.1% (n = 4) biopsy-proven acute rejection (BPAR). Patient survival (P = .27), graft survival (P = .20), DGF (P = .51), and BPAR (P = .74) were similar in 2 groups. A total of 27.2% (n = 9) of patients died, mainly due to infections (n = 5). CONCLUSION: Given the widespread organ shortage, outcomes of controlled DCD renal transplantation has a potential to expand the donor pool and shorten the waiting list for RTx, encouraging the use of this approach even in low-income countries.

Outcome of second kidney transplant: a single center experience.

Nowadays, a repeat transplantation is considered to confer a better survival advantage to patients over dialysis. The cost-effectiveness of transplantation for end-stage renal disease patients shows benefits over dialysis even for re-transplanted patients. This retrospective single center ten-year study was undertaken to evaluate patient/graft survival, function vis-à-vis serum creatinine (SCr) and rejection episodes in 62 re-transplanted patients. Sixty-two patients underwent a second renal transplant (24 living related, 38 deceased donors) at our center between 2000 to 2009. The mean recipient age was 41.9 ± 12.27 years. Fifty-three recipients were male and nine recipients were female. Recipients had negative acceptable lymphocyte cross-matching using anti-human globulin complement-dependent cytotoxicity tests and flow cytometric cross-match before transplant. All recipients except those who were hepatitis C virus or hepatitis B surface antigen positive received single-dose rabbit-anti-thymocyte globulin induction and steroids, calcineurin inhibitor ± mycophenolate mofetil/azathioprine for maintenance immunosuppression. Of the 62 patients, 38 patients received kidneys from deceased donors and 24 patients received kidneys from live donors. Over the mean follow-up of 4.03 ± 2.93 years, the 1-year, 5-year and 10-year patient survival rates were 85.33%, 66.7% and 66.7%, respectively, and the graft survival rates were 96.7%, 79.7% and 79.7%, respectively. The acute rejection rates were 17.6%, with a mean SCr of 1.92 ± 0.5 mg/dL. There was unexplained interstitial fibrosis with tubular atrophy in 11.2% patients (n = 7), all leading to graft loss eventually. Overall, 25% (n = 16) of the patients were lost, mainly to infectious complications. Re-transplantation has acceptable graft and patient survival over a ten-year follow-up period and should be encouraged for better quality of life as compared with dialysis.

Post-renal transplant cytomegalovirus infection: study of risk factors.

OBJECTIVES: Cytomegalovirus (CMV) is a common opportunistic infection following renal transplantation (RTx). It responds promptly to antiviral treatment. The mortality rate reaches 90% if untreated. Identification of risk factors helps in the early diagnosis of CMV. We studied demographic features, risk factors, and outcomes associated with CMV infection in RTx recipients despite ganciclovir prophylaxis. MATERIALS AND METHODS: We reviewed 720 RTx recipients between 2007 and 2009. We examined the serostatus of the donor and recipient before transplantation using an enzyme-linked immunosorbent assay, and diagnosed CMV infections in recipients by CMV DNA detection with a polymerase chain reaction. RESULTS: A total of 42 of 750 (5.6%) patients were identified to display CMV infection (69.1%) or disease (30.9%). Their mean age was 34 ± 13.5 years, with 80.9% men. CMV serologic status was D+/R- in 21.4% and D+/R+ in 59.5% patients. Fever, malaise (76.2%), and leukopenia (52.3%) were the commonest presenting symptoms; diabetes (30.9%) and hepatitis C virus (28.6%) the commonest comorbid conditions. Risk factors were triple drug immunosuppression (47.6%), antithymocyte globulin ATG induction (54.8%), and a rejection episode (26.1%) and methylprednisolone (76.2%) which were more common in CMV disease than infection. Mean CMV DNA at diagnosis was 78,803; 71.2% patients developed CMV within 6 months posttransplantation, the majority occurring after 3 months. With a mean follow-up of 4 ± 1.9 years, patient and graft survival rates were 85.7% and 81% with a mean serum creatinine value of 1.83 ± 12 mg/dL. CONCLUSIONS: Universal CMV prophylaxis was associated with a low incidence (5.6%) and mild form of CMV disease among our patients.

World kidney day 2010: medical aspects of 10 live-donor renal transplantations in a single center from a developing country.

BACKGROUND: World Kidney Day (WKD) has become the most widely celebrated event associated with kidney disease in the world and the most successful effort to raise awareness among both the general public and government health officials about the dangers of kidney disease. We celebrated WKD 2010 in a unique way by performing 10 live-donor renal transplantations (RTx) on March 11, 2010. PATIENTS AND METHODS: We report a single-center experience on RTx vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr) level, and rejection episodes in 10 live-donor RTx performed on WKD. Recipient diseases leading to end-stage renal disease (ESRD) were chronic glomerulonephritis (60%), benign nephrosclerosis (20%), and chronic interstitial nephritis (20%). Mean recipient age was 35 ± 8.7 years. Nine recipients were males. Mean donor age was 37 ± 8.7 years, Nine donors were females. Donors were spouse (n = 6), mother (n = 2), sister (n = 1), and extended family member (n = 1), with mean HLA match 1.8 ± 1.48. All patients received steroids, calcinueurin inhibitors, and mycophenolate mofetil/azathioprime for maintenance immunosuppression. RESULTS: During a mean follow-up time of 18 months, patient and graft survival rates were 90% and 90%, respectively, with a mean SCr level of 1.21 mg/dL; 20% had biopsy-proven acute rejection. One patient died due to infection after antirejection therapy. CONCLUSION: RTx has acceptable graft and patient survival. RTx is the best cost-effective therapeutic modality for patients suffering from ESRD and should be encouraged in view of organ shortage on events such as WKD. To our knowledge, this is the first report from a developing country on 10 successful RTx on WKD.

Retroperitoneoscopic left donor nephrectomy with duplicated IVC.

Vascular anomalies increase the difficulty during live donor nephrectomy. We herein report a left-sided retroperitoneoscopic living donor nephrectomy performed in a donor with a duplicated inferior vena cava (IVC). Computed tomography angiography provided accurate delineation of the venous anatomy and allowed preoperative planning. The duplicated IVC was clipped and divided just below its confluence with the left renal vein. The length of the left renal vein was sufficient for anastomosis in the recipient, and the recipient's serum creatinine was 1.21% on day 7. The donor made an uneventful recovery. Duplicated IVC is not a contraindication for left retroperitoneoscopic donor nephrectomy.

Deceased donor organ transplantation: A single center experience.

Renal transplantation (RTx) is the best therapeutic modality for patient suffering from end-stage renal disease (ESRD). Deceased donor organ transplantation (DDOT) accounts for <4% of RTx in India. We report 4 years single centre experience on DDOT vis-à-vis patient/graft survival, graft function in terms of serum creatinine (SCr), rejection episodes, and delayed graft function in 160 DDOT. Between January 2006 to December 2009, 160 RTx from 89 donors were performed, of which 25.2% were expanded criteria donors. Majority of the donors were brain dead due to road traffic/cerebrovascular accidents. The commonest recipient diseases leading to ESRD were chronic glomerulonephritis (49%), diabetes mellitus (10%), and benign nephrosclerosis (10%). Mean recipient/donor age was 35.6±14.68 and 44.03±18.19 years. Mean dialysis duration pretransplantation was 15.37±2.82 months. Mean cold ischemia time was 5.56±2.04 hours. All recipients received single dose rabbit-anti-thymocyte globulin induction and steroids, mycophenolate mofetil/calcinueurin inhibitor for maintenance of immunosuppression. Delayed graft function was observed in 30.6% patients and 14% had biopsy proven acute rejection. Over mean follow-up of 2.35±1.24 years, patient and graft survival rates were 77.5% and 89.3% with mean SCr of 1.40±0.36 mg/dl. DDOT has acceptable graft/patient survival over 4 years follow-up and should be encouraged in view of organ shortage.

Expanded criteria donor kidneys for younger recipients: acceptable outcomes.

INTRODUCTION: European senior programme (ESP) is well known for acceptable outcomes using expanded criteria donor (ECD) kidneys from donors older than 65 years for recipients older than 65 years. The incidence of end-stage renal disease (ESRD) is 229/million in India with a mean age of 45 years. We performed a retrospective analysis of transplantation of ECD versus standard criteria donor (SCD) kidneys into younger recipients. METHODS: Forty-three ECD transplantations among 158 deceased donor organ transplantation (DDOT) were performed between January 2006 and December 2009. Among 43 transplantation from 30 donors, 14 were dual kidney transplantations (DKT) performed based upon biopsy evaluation. All recipients received thymoglobulin (rATG) induction followed by immunosuppression with a steroid, mycophenolate mofetil (MMF), and a calcineurin inhibitor. Statistical analysis used chi-square test and unpaired Student t test. Kaplan-Meier curves were used for survival analysis. RESULTS: For ECD the mean donor age was 64 ± 11 years. Cerebrovascular accidents (CVA) were the cause of death among 60% of donors, 73.13% of whom were hypertensive and 23.13% diabetic. Mean DKT donor age was 75 ± 9.17 years versus 60 ± 8.0 years for single kidney transplantation (SKT). Mean recipient age of DKT versus SKT was 44 ± 12.4 years versus 43 ± 14 years. Mean serum creatinine (SCr; mg/dL) of SKT patients was 1.64 ± 0.75 versus 1.68 ± 0.46 in DKT. Mean follow-up was 455 ± 352 days. Mean SCr of 43 ECD recipients of mean age, 43.4 ± 14.2 years was 1.61 ± 0.61 mg/dL. Among 43 recipients, 23.25% were diabetic, 41.86% displayed delayed graft function (DGF), and 23.25% experienced biopsy-proven acute rejection (BPAR). Patient survival rate was 72.09% and graft survival rate was 67.44%. For SCD transplantations (n = 115), the mean donor age was 36 ± 14 years and recipient mean age was 32.8 ± 14.07 years. Mean SCr was 1.32 ± 0.46 mg/dL with 26.95% recipients displaying DGF, whereas 20.86% had BPAR. In the SCD group the patient survival rate was 79.13% and the graft survival rate was 72.17%. Thus, although the ECD group showed poor graft function (P = .042), they had acceptable patient and graft survivals (P = .34 and P = .56, respectively). CONCLUSION: Because of the organ shortage, DDOT using ECD transplants for younger recipients is a feasible option with acceptable outcomes.