Etiology of Early Renal Allograft Dysfunction and Comparison between Dysfunction and Function Group: A Single Center Study.

Over a period of two years thirty five renal allograft recipients & donors were evaluated to find out the aetiology of early renal allograft dysfunction, in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from March 2010 to February 2012. A comparison was made between dysfunction & functioning graft group. Mean age of recipients were (36.4±9.4) years, mean age of donors were (41.7±8.3) years, with a male and female ratio of 3:1. Fifty percent recipients showed one heliotype match, ninety percent recipients were anti CMV antibody IgG positive, few were anti CMV antibody IgM positive. All kidney transplant recipients received same immunosuppressive drugs. Primary disease of the renal allograft recipients demonstrates that majority 88.58% had glomerulonephritis, 5.72% had polycystic kidney disease, 2.85% had chronic pyelonephritis and another 2.85% had diabetic nephropathy. Among 35 renal allograft recipients 23(66%) showed early graft dysfunction, 12(34%) showed normal graft function. The etiology of early graft dysfunction showed, 50% developed acute rejection, 17% acute cyclosporine toxicity, 17% acute tubular necrosis, 8% had graft thrombosis and 8% developed recurrent glomerulonephritis. Sub-clinical rejection was detected in 20% cases. Comparison of donor characteristics between dysfunctioning and functioning graft groups revealed that age and sex were identically distributed between the groups (p=0.183 and p=0.087 respectively). The mean serum creatinine of donor was significantly higher in the graft dysfunction group than that in the functioning graft group (113.5±12.6 vs. 99.6±17.3; p=0.025), as well as the mean creatinine clearance rate was significantly less in the former group than that in the later group (82.1±13.5 vs. 93.9±18.6, p=0.040). The mean cyclosporine (C2) level on 7th POD were 1593.2±320.4ng/ml in graft dysfunction group and 1439.1±199.5ng/ml in the functioning graft group which decreased to 1364.8±263.7ng/ml and 1114.2±145.1ng/ml after three months in the dysfunction and the functioning graft groups respectively. There was no significant difference in the cyclosporine level between groups on 7th POD and 14th POD, 1st and 2nd month. However, at 3rd month the level of cyclosporine was higher in the dysfunction group than that in the function group. Proteinuria on 14th POD was almost similar between dysfunction and function graft groups (p=0.704). However, higher incidence of proteinuria was observed in subsequent months in the graft dysfunction group compared to the function graft group. All the postoperative variables like systolic blood pressure, diastolic blood pressure, fever and tremor were higher in dysfunction group in comparison to functioning graft group. Per operative biopsy of donor kidney, some showed increased number of sclerotic glomeruli which is more common in dysfunction group. Among 35 recipients 2(16.7%) died due to infection in dysfunction group compared to 1(4.3%) in functioning graft group.

Presentation and Treatment Outcomes of 100 Lupus Nephritis Patients: Single Center Study.

Over a period of 3 years (January 2011 to December 2013) 100 cases of Lupus nephritis patients admitted in nephrology department of Bangabandhu Sheikh Mujib Medical University (BSMMU) were evaluated. Their clinical characteristics, biochemical parameters, renal histology according to WHO classification were categorized and their treatment modalities and outcome was observed. Among 100 patients, 84 were female and 16 were male, with F:M ratio 5:1. Mean age of female were 23±4 years and male were 29±4 years, mean BP in male was systolic 135±8 mmHg, diastolic 80±9mmHg and in female systolic was 130±7mmHg, diastolic 75±6 mmHg, mean Serum Creatinine for male was 180±12µmol/L and mean serum creatinine in female was 170±20µmol/L. Sixty five percent (65%) patient showed extra renal manifestation. All patients presented with proteinuria, among them 45% were nephrotic presentation, 25% patients presented with acute nephritic illness, 15% were nephritic nephrotic, 10% patients had rapidly progressing glomerulonephritis (RPGN), and 5% were with asymptomatic proteinuria. Renal biopsy of 100 patient according to WHO classification showed class I - 5%, class II - 20%, class III - 26%, class IV - 35%, class V - 8%, class VI - 6%. Immunosuppressive protocol used was prednisolone and cyclophorphamide in the majority of patients in class III to class VI LN patients. Few patients received prednisolone and mycophenolate mofetil. Twenty four percent (24%) patients were in complete remission during this study period and 12% developed end stage renal disease (ESRD). Seventy six percent (76%) patients passed through various stages of CKD, majority of them were in CKD stage IV and stage III, and few were in CKD stage I and stage II. About 70% of the participants had suffered from one or more complications, where majority were infections. Infections and renal failure were the leading cause of death in our study.

Role of protocol biopsy in early graft dysfunction in renal transplant recipient.

This study was designed to evaluate the role of protocol biopsy in renal allograft recipients. A total of thirty five kidney transplant recipients with a mean age of 35±5 years included in this study. Mean age of donor was 41±8 years. The study was performed from April 2008 to November 2009 in the Department of Nephrology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. Immunosuppressive protocol used for transplant patient was, Cyclosporine 8mg/kg/day, Mycophenolate mofetil (MMF) 500mg twice daily, Prednisolone 0.5mg/kg/day. Protocol biopsy done on day 0 (Peroperative), day 14 and day 90. Stains used H&E and PAS. Cyclosporine blood level was done on 7th and 14th postoperative day and monthly for 3 months. Serum creatinine was done daily for 14 days & then weekly upto 3 months. Among 35 patients 23(66%) showed normal graft function and 12(34%) early graft dysfunction. Aetiology of early graft dysfunction includes 50% clinical rejection, 17% acute tubular necrosis (ATN), 17% cyclosporine toxicity, 8% graft thrombosis and 8% recurrence of GN. Per operative protocol biopsy showed normal histology in 28(80%) cases, in 4 cases 11% glomeruli showed sclerosis and in 3 cases 9% glomeruli showed sclerosis. At 14th post operative day 60% patients showed normal histology, 14% had clinical rejection (elevated serum creatinine along with histological features of rejection), another 14% had sub clinical rejections (normal serum creatinine with histological changes), cyclosporine toxicity 5.6%, ATN 5.6%, and recurrent glomerulonephritis in 3% cases. Among clinical rejection, according to Banff numerical classification, Grade-1 (20%), Grade-2 (60%), Grade-3 (20%) and among sub clinical rejections Banff Grade-1 (80%), Grade-2 (20%). Biopsy after 3 months showed normal histology 54.28%, clinical rejection 11.42%, sub clinical rejection 5.7%, borderline change 5.7%, cyclosporine toxicity 5.7% & 2.8% recurrent glomerulonephritis. According to Banff numerical classification in clinical rejection Banff Grade-1 (25%), Grade-2 (50%) and Grade-3 (25%). Among subclinical rejection Banff Grade-1 (70%), Grade-2 (30%).

Lupus nephritis in an anti-nuclear antibody-negative young male. The simultaneous presence of class III and class V renal lesions.

We report about a 27-year-old white male, a known case of class III lupus nephritis with a very high anti-nuclear antibody (ANA) titer, who after 10 years of complete clinical and serological remission presented with sudden development of malar rash, proteinuria and an increase in the serum creatinine. Repeated serologic studies were all negative for ANA. A repeat kidney biopsy disclosed the presence of focal segmental glomerulosclerosis lupus nephritis (class IIIc) superimposed with a new membranous lupus nephritis (class V).