South Asian Transplant Infectious Disease Guidelines for Solid Organ Transplant Candidates, Recipients, and Donors.

These guidelines discuss the epidemiology, screening, diagnosis, posttransplant prophylaxis, monitoring, and management of endemic infections in solid organ transplant (SOT) candidates, recipients, and donors in South Asia. The guidelines also provide recommendations for SOT recipients traveling to this region. These guidelines are based on literature review and expert opinion by transplant physicians, surgeons, and infectious diseases specialists, mostly from South Asian countries (India, Pakistan, Bangladesh, Nepal, and Sri Lanka) as well as transplant experts from other countries. These guidelines cover relevant endemic bacterial infections (tuberculosis, leptospirosis, melioidosis, typhoid, scrub typhus), viral infections (hepatitis A, B, C, D, and E; rabies; and the arboviruses including dengue, chikungunya, Zika, Japanese encephalitis), endemic fungal infections (mucormycosis, histoplasmosis, talaromycosis, sporotrichosis), and endemic parasitic infections (malaria, leishmaniasis, toxoplasmosis, cryptosporidiosis, strongyloidiasis, and filariasis) as well as travelers' diarrhea and vaccination for SOT candidates and recipients including travelers visiting this region. These guidelines are intended to be an overview of each topic; more detailed reviews are being published as a special supplement in the Indian Journal of Transplantation .

Anxiety and depression among living kidney donors in tertiary care hospital of low resource country setting Nepal.

Introduction: Kidneys accounted for the majority of transplanted organs worldwide in 2018, according to the Global Observatory on Donation and Transplantation. Living kidney donors continue to have negative psychosocial effects after donation. We aimed to assess anxiety and depression among Nepalese living kidney donors. Methods: This was an observational, cross-sectional study conducted from May 2020 to January 2021. All patients who had undergone donor nephrectomy and had completed 6 months of post-donation period were included in the study. Anxiety and depression was assessed using the Hospital Anxiety and Depression Scale (HADS). Fischer exact and chi-square test was used to determine the association between variables and the level of significance was maintained at 5% with p < 0.05 considered statistically significant. Results: A total of 147 kidney donors undergoing nephrectomies were included in the study. Among them 69.4% of participants were female and 55.8% of participants were aged 50 years or more. The prevalence of anxiety and depression among kidney donors was 27.9% and 6.2% respectively. Gender, earner, parental relations, occupation, and educational status were related to symptoms of anxiety among the living kidney donors. Similarly, earner was associated with symptoms of depression. Conclusion: In addition to physical health measures, routine evaluations of kidney donors should include assessments of depression and other emotional disorders. The actual issue is to come up with effective treatments for depressive symptoms and to improve health outcomes following kidney donation.

An ISN-DOPPS Survey of the Global Impact of the COVID-19 Pandemic on Peritoneal Dialysis Services.

Introduction: Home dialysis may minimize SARS-CoV2 exposure risks compared to center-based dialysis. We explored how the pandemic may have introduced challenges related to peritoneal dialysis (PD) supply availability, routine patient care, and how facility practices changed during this time. Methods: The PD/Dialysis Outcomes and Practice Patterns Study (PDOPPS/DOPPS) and International Society of Nephrology (ISN) administered a web-based survey from November 2020 to March 2021. Medical director responses were compared across 10 ISN regions. Results: One hundered sixy-five PD facilities in 51 countries returned surveys. During the initial COVID-19 wave, the reported frequency of in-person patient visits decreased in 9 of 10 ISN regions. Before the pandemic, most facilities required a mask during PD exchanges which continued over the course of the pandemic. Although most facilities in different regions did not report PD supply disruptions, sites in Africa and South Asia reported major disruptions. Reductions in laparoscopic surgical procedures for PD catheters were reported by facilities in 9 of 10 regions whereas nonsurgical percutaneous procedures increased in facilities in 6 regions. Training of new PD patients declined in facilities in each region. Increased use of remote technology by patients to communicate with clinics was observed in all regions compared to prepandemic levels. Conclusion: Marked within-region and across-region variability was noted in PD facility burden, clinical practice, and adaptation to the COVID-19 pandemic. This study highlights opportunities to improve routine PD care, adapt to the ongoing pandemic, and increase preparedness for potential future interruptions in PD care.

The COVID-19 Pandemic Identifies Significant Global Inequities in Hemodialysis Care in Low and Lower-Middle Income Countries-An ISN/DOPPS Survey.

Introduction: It is unknown how the COVID-19 pandemic has affected the care of vulnerable chronic hemodialysis (HD) patients across regions, particularly in low and lower-middle income countries (LLMICs). We aimed to identify global inequities in HD care delivery during the COVID-19 pandemic. Methods: The ISN and the Dialysis Outcomes and Practice Patterns Study (DOPPS) conducted a global online survey of HD units between March and November, 2020, to ascertain practice patterns and access to resources relevant to HD care during the COVID-19 pandemic. Responses were categorized according to World Bank income classification for comparisons. Results: Surveys were returned from 412 facilities in 78 countries: 15 (4%) in low-income countries (LICs), 111 (27%) in lower-middle income countries (LMICs), 145 (35%) in upper-middle income countries (UMICs), and 141 (34%) in high-income countries (HICs). Respondents reported that diagnostic tests for SARS-CoV-2 were unavailable or of limited availability in LICs (72%) and LMICs (68%) as compared with UMICs (33%) and HICs (20%). The number of patients who missed HD treatments was reported to have increased during the COVID-19 pandemic in LICs (64%) and LMICs (67%) as compared with UMICs (31%) and HICs (6%). Limited access to HD, intensive care unit (ICU) care, and mechanical ventilation among hospitalized patients on chronic dialysis with COVID-19 were also reportedly higher in LICs and LMICs as compared with UMICs and HICs. Staff in LLMICs reported less routine testing for SARS-CoV-2 when asymptomatic as compared with UMICs and HICs-14% in LICs and 11% in LMICs, compared with 26% and 28% in UMICs and HICs, respectively. Severe shortages of personal protective equipment (PPE) were reported by the respondents from LICs and LMICs compared with UMICs and HICs, especially with respect to the use of the N95 particulate-air respirator masks. Conclusion: Striking global inequities were identified in the care of chronic HD patients during the pandemic. Urgent action is required to address these inequities which disproportionately affect LLMIC settings thereby exacerbating pre-existing vulnerabilities that may contribute to poorer outcomes.

The Global Impact of the COVID-19 Pandemic on In-Center Hemodialysis Services: An ISN-Dialysis Outcomes Practice Patterns Study Survey.

INTRODUCTION: To assess the impact of the COVID-19 pandemic impact on hemodialysis (HD) centers, The Dialysis Outcomes and Practice Patterns Study and ISN collaborated on a web-survey of centers. METHODS: A combined approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centers in 78 countries and all 10 ISN regions. RESULTS: In 8 regions, rates of SARS-CoV-2 infection were <20% in most centers, but in North East Asia (NE Asia) and Newly Independent States and Russia (NIS & Russia), rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centers in 8 regions, although lower in North America and Caribbean (N America & Caribbean) and NE Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centers in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centers in NE Asia to ≥50% in 63% of centers in the Middle East and 68% of centers in NIS & Russia. In most centers, <10% of staff died, but in Africa and South Asia (S Asia), 2% and 6% of centers reported ≥50% mortality, respectively. CONCLUSION: There has been wide global variation in SARS-CoV-2 infection rates among HD patients and staff, personal protective equipment (PPE) availability, and testing, and the ways in which services have been redesigned in response to the pandemic.

Disseminated infection with Nocardia otitidiscaviarum in a patient under steroid therapy.

Corticosteroid recipients with lung infections should be suspected of having nocardiosis; however, nocardiosis can easily mimic malignancy, tuberculosis, or fungal infection. Though cultural identification is possible, it might be missed due to its slow growth pattern.. Therefore, if filamentous bacteria are seen during staining, plate incubation time should be extended.

Transplantation in Asia during the coronavirus disease-19 (COVID-19) pandemic: briefs from member countries of the Asian Society of Transplantation.

The coronavirus disease-19 (COVID-19) pandemic has affected 1,029,968 people in Asia as of May 16, 2020. Although Asia was the first continent to be affected, many countries in the region continue to battle COVID-19, which challenges the way transplant programs provide their services. Given the diversity of healthcare systems in Asia, the countermeasures in response to COVID-19 are as potentially diverse. This review reports the experiences of transplant services in member countries of the Asian Society of Transplantation (AST) as well as provides a platform for sharing of best practices during the COVID-19 pandemic. AST invited member countries to provide a short description of their transplant experiences during the COVID-19 pandemic. Whenever information is available, countries were asked to provide information on COVID-19 related statistics, status of transplant programs, mitigation measures taken to prevent COVID-19, and other areas of transplant programs impacted by COVID-19. Ten countries responded to the invitation of which seven still have active transplant programs at varying levels of activity. All countries have protocols for donor/recipient screening and countermeasures to prevent COVID-19 infections in recipients and healthcare providers. Interestingly, these countries report only 16 transplant recipients with COVID-19 infection but no cases of donor-transmitted COVID-19 infection. Despite the diversity of healthcare systems in Asia, transplant centers in Asia have taken appropriate precautions to avoid COVID-19 infections, though the long-term impact of COVID-19 remains unclear.

Pediatric kidney transplantation in Nepal.

BACKGROUND: Success in pediatric kidney transplantation is great achievement for the emerging countries. This report is the first of its kind from Nepal. It demonstrates the status of pediatric kidney transplantation in Nepal. METHODS: This is a retrospective review of transplants done in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Living donor kidney transplant recipients ≤17 years transplanted till September 2018 were included. Demographic data, renal function, rejections, and other complications recorded in the charts were noted. Descriptive analysis was done in September 2018. RESULTS: A total of 517 living donor kidney transplants were done till September 2018 since August 2008. Twenty-three were ≤17 years. Eighteen (78.26%) were male. Mean ± SD age was 15.35 ± 1.7 years, and weight was 41.8 ± 9.8 kg. One received ABO-incompatible transplantation. Fifteen (65.22%) donors were female, 14 (60.87%) were mothers, and seven were fathers (30.43%). Mean donor age was 40.21 ± 8 years. Patient and graft survival at 1 year were 100% and 89.2%, respectively. One patient died on dialysis in second year after graft failure due to FSGS. One is on dialysis after losing graft to oxalate nephropathy. Three (13.3%) had biopsy-proven acute rejections. Two had acute cellular rejection, and 1 had antibody-mediated rejection. CONCLUSIONS: Children from poor countries are also entitled to the benefits of medical advancements.

Primary cutaneous nocardiosis: a diagnosis of consideration in a renal transplant recipient.

BACKGROUND: The cutaneous nocardiosis remains a diagnostic challenge: similar clinical presentations as of cutaneous diseases with different etiology-and the inherent difficulty in cultivating the pathogen. CASE PRESENTATION: Herein, we describe a case of primary cutaneous nocardiosis in a renal transplant recipient; treated with anti-tubercular drugs due to misdiagnosis of cutaneous tuberculosis. On clinical examinations, a few red erythematous papules with erosions and crusting seen, over prior surgery scar of renal transplant. Multiple basophilic colonies surrounded by neutrophilic abscesses and granulation tissue were seen on histopathological examinations. The presumptive identification was done by Ziehl-neelson staining, bacterial culture, biochemical interpretations, and susceptibility pattern of the isolates to antibiotics. Radiographic imaging of brain and lungs were normal; no feature of disseminated nocardiosis seen. After 3 months of an anti-microbial therapy i.e. TMP-SMX(sulfamethoxazole and trimethoprim); the patient underwent progressive changes no relapse noted; transplant function observed in a good state, found asymptomatic with limited side effects on a regular follow up till now. CONCLUSION: Cutaneous nocardiosis can occur in the renal-transplant patient. Therefore, a high degree of clinical suspicions, extensive clinical differentiation, early detection of the pathogen, apt selection of the antimicrobial therapy, correct dosing, and treatment duration is crucial for successful outcomes.

Incidence and Outcome of Ventilator Associated Pneumonia in ICU of a Tertiary Care Hospital in Nepal.

INTRODUCTION: Ventilator associated pneumonia is an important intensive care unit acquired infection in mechanically ventilated patients. Early and correct diagnosis of Ventilator associated pneumonia is difficult but is an urgent challenge for an optimal antibiotic treatment. METHODS: A prospective observational study was conducted in Intensive Care Unit of a tertiary care hospital in Nepal. Consecutive patients were considered during the study period, who met the criteria were included for the study. Clinical Pulmonary Infection Score was used to diagnose Ventilator associated pneumonia. RESULTS: Among 60 patients ventilated for more than 48 hours, 25 (41.6%) developed ventilator associated pneumonia. The incidence was 25 VAPs per 100 ventilated patients or 26 VAPs per 1000 ventilator days during the period of study. Days on ventilator and duration in ICU were higher in the VAP group. There was a trend towards increasing mortality in the VAP group (P value=0.06). CONCLUSIONS: There exists a high rate of VAP in our Intensive Care Unit. Targeted strategies aimed at reducing Ventilator associated pneumonia should be implemented to improve patient outcome and reduce length of Intensive Care Unit stay and costs.

Disseminated Nocardiosis in renal transplant recipient under therapy for pulmonary tuberculosis: a case report.

BACKGROUND: Nocardiosis is an opportunistic infection in a patient with underlying immune suppression and organ transplant. Clinical syndromes are varied and ranges from pulmonary, disseminated, cutaneous along with central nervous system involvement. CASE PRESENTATION: Herein, we report a rare case of disseminated pulmonary nocardiosis with cerebral manifestation in a 66 year-old-Nepali farmer; with a history of renal transplantation and undergoing therapy for pulmonary tuberculosis. Radiographic imaging revealed multiple opacities of varying sizes in bilateral lung field mediastinal, retroperitoneal lymphadenopathy, and ill-defined lesion with surrounding edema seen in left occipitoparietal region of brain. Bacteriological assessments of bronchoalveolar lavage and purulent fluid extracted intra-operatively from the lesion confirmed the case as Nocardiosis. CONCLUSION: Disseminated Pulmonary nocardiosis with central nervous system involvement carries a poor prognosis. However, early diagnosis of the case, the administration of appropriate antibiotic, stereotactic aspiration alone or craniotomy has a successful outcomes even in a post renal transplant patient treated with anti tuberculosis treatment.

Outcome of low dose cyclophosphamide for induction phase treatment of lupus nephritis, a single center study.

BACKGROUND: The current standard for induction phase treatment of lupus nephritis is steroid combined with mycophenolate mofetil or pulse intravenous cyclophosphamide (IVC). The lowest dose of IVC recommended for induction therapy is that used in the Euro-Lupus Trial. It is not known whether same cumulative dose of IVC would be effective when given over six months. METHODS: We carried out a prospective, observational study on 41 patients of biopsy-proven lupus nephritis (class III, IV, V or mixed). For induction, patients received six pulses of monthly IVC (500 mg each), along with steroid. Patients were followed up monthly until one month beyond completion of the sixth pulse. The outcomes assessed were complete remission (proteinuria < 200 mg/day or urine albumin nil with serum albumin >35 gm/L, stable estimated glomerular filtration rate (eGFR) if normal at baseline or increase in eGFR by 25 % if abnormal at baseline and normal urinary sediment), response (complete or partial remissions), complications of therapy and death. RESULTS: Twenty two patients (53.7 %) had class IV nephritis. Eighteen patients (43.9 %) achieved complete remission, 16 (39.0 %) achieved partial remission, yielding an overall response rate of 82.9 %. Nephrotic range proteinuria (UTP ≥ 3 g/day) and severe hypoalbuminemia (serum albumin < 20 g/L) at baseline influenced remission (p <0.05). Infection, seen in 12 patients (29.3 %), was the most common complication. Four deaths (9.6 %) were observed, all due to infection. CONCLUSIONS: For induction phase treatment, Nepalese patients with lupus nephritis responded favorably to steroid and low dose IVC of 3 grams given as six monthly pulses.

Product of serum calcium and phosphorus (Ca × PO4) as predictor of cardiovascular disease risk in predialysis patients.

OBJECTIVES: The mortality rate of chronic kidney disease (CKD) patients is very high due to cardiovascular diseases (CVD) which cannot be fully justified by traditional CVD markers. Since, mineral bone disorder is common in CKD, product of serum calcium and phosphorus (Ca × PO4) can be a predictor of future CVD. So, our study aims to assess the utility of higher Ca × PO4 in prediction of CVD risk in predialysis CKD patients. DESIGN AND METHODS: 150 CKD patients defined by NKF-KDOQI guideline not undergoing dialysis were recruited. Anthropometric and electrocardiographic parameters were recorded. We evaluated CVD risk by: i) Biochemical CVD markers, ii) NCEP ATP III guideline postulated risk factors and iii) Framingham risk scores. RESULTS: Higher Ca × PO4 is associated with presence of Left Ventricular Hypertrophy, oxidative stress, microinflammation, hyperhomocysteinemia, hypercholesterolemia, hypertriglyceridemia and increased LDLc. Compared to cases with Ca × PO4 <55 mg2/dL2, cases with ≥55 mg2/dL2 had relative risk (RR) of 1.82 (95% CI 1.25-2.64) for CVD, 3.24 (95% CI 2.37-4.41) for stroke and 2.43 (95% CI 1.37-4.31) for coronary heart disease (CHD). Moreover, compared to lowest quartile of Ca x PO4, the highest quartile group had RR of 2.13 (95% CI 1.06-4.28) for CVD, 2.61(95% CI 1.80-3.75) for stroke and 2.84 (95% CI 1.15-7.0) for CHD. CONCLUSION: In predialysis patients, higher Ca × PO4 is independent predictor of CVD risk.