Murine cytomegalovirus promotes renal allograft inflammation via Th1/17 cells and IL-17A.

Human cytomegalovirus (HCMV) infection is associated with renal allograft failure. Allograft damage in animal models is accelerated by CMV-induced T helper 17 (Th17) cell infiltrates. However, the mechanisms whereby CMV promotes Th17 cell-mediated pathological organ inflammation are uncharacterized. Here we demonstrate that murine CMV (MCMV)-induced intragraft Th17 cells have a Th1/17 phenotype co-expressing IFN-γ and/or TNF-α, but only a minority of these cells are MCMV specific. Instead, MCMV promotes intragraft expression of CCL20 and CXCL10, which are associated with recruitment of CCR6+ CXCR3+ Th17 cells. MCMV also enhances Th17 cell infiltrates after ischemia-reperfusion injury, independent of allogeneic responses. Pharmacologic inhibition of the Th17 cell signature cytokine, IL-17A, ameliorates MCMV-associated allograft damage without increasing intragraft viral loads or reducing MCMV-specific Th1 cell infiltrates. Clinically, HCMV DNAemia is associated with higher serum IL-17A among renal transplant patients with acute rejection, linking HCMV reactivation with Th17 cell cytokine expression. In summary, CMV promotes allograft damage via cytokine-mediated Th1/17 cell recruitment, which may be pharmacologically targeted to mitigate graft injury while preserving antiviral T cell immunity.

Allo-specific immune response profiles indicative of acute rejection in kidney allografts using an in vitro lymphocyte culture-based model.

BACKGROUND: Ability to predict the manner in which a recipient's immune system would respond to a transplanted graft by analyzing cytokine profiles of the "allograft antigen sensitized" recipient lymphocytes in vitro might provide a means to identify patients at risk to adverse clinical endpoints. METHODS: Cytokine/chemokine gene expression profiles of peripheral blood mononuclear cells co-cultured with allograft antigen-pulsed macrophages were studied in 49 renal transplant recipients-12 with acute cellular rejection (ACR) with or without antibody-mediated rejection (AMR), 7 with AMR (without ACR), and 30 with stable allografts (SA). An 86-gene inflammatory cytokines and receptors PCR array was used to measure fold changes in gene expression between pulsed and un-pulsed cultures. RESULTS: On linear discriminant analysis and multivariate analysis of variance, a gene set comprising C3, CCL3, IL1B, TOLLIP, IL10, CXCL5, ABCF1, CCR3, IL10RB, CXCL1, and IL1R1 differentiated the ACR-AMR from the SA group. Similarly, a gene set comprising IL10, C3, IL37, IL1B, CCL3, CARD18, and TOLLIP differentiated the AMR from the SA group. No significant difference was found between the ACR-AMR vs AMR groups. CONCLUSION: Distinct post in vitro stimulation cytokine profiles at the time of transplantation thus correlated with the occurrence of post-transplantation rejection episodes which indicated feasibility of this in vitro model to assess the recipient's anti-graft response at an early stage.

Effect of discontinuing morning dose of antihypertensive for renal transplant surgery on haemodynamic and early graft functioning: A prospective, double-blind, randomised study.

BACKGROUND AND AIMS: Antihypertensive drugs are continued until the day of renal transplant surgery. These are associated with increased incidence of hypotension and bradycardia. Hence, this study was designed to evaluate perioperative haemodynamic and early graft functioning in renal recipients with discontinuation of antihypertensive drugs on the morning of surgery. METHODS: This prospective, randomised, double-blind study recruited 120 patients. Group 1 patients received placebo tablet while Group 2 patients received usual antihypertensive drugs on the day of surgery. Perioperative haemodynamics and time for reinstitution of antihypertensives were the primary outcome measures. The secondary outcome measures were need for inotropic support and graft function. Perioperative haemodynamics were analysed using ANOVA and Student's t-tests with Bonferroni correction. Fischer's exact test was used for analysis. RESULTS: Systolic blood pressure (SBP) declined, which was more in Group 2. Forty-one patients developed significant hypotension; a correlation was found between the maximum observed hypotension and number of antihypertensive medications (P = 0.003). Four cases had slow graft function (one in Group 1 and three in Group 2). Twenty-eight patients in Group 2 required mephentermine boluses to maintain their SBP compared to 13 patients in Group 1 (P < 0.001). Two patients in Group 2 required dopamine to maintain SBP above 90 mmHg after the establishment of reperfusion as compared to none in Group 1. CONCLUSION: Single dose of long-acting antihypertensive drugs can be omitted on the morning of surgery without any haemodynamic fluctuations and graft function in controlled hypertensive end-stage renal disease renal transplant patients receiving a combined epidural and general anaesthesia.

Esophageal tuberculosis with coexisting opportunistic infections in a renal allograft transplant recipient.

We report a renal allograft transplant recipient with esophageal tuberculosis (TB) coinfected with herpes simplex virus (HSV) and Candida. The patient presented with oropharyngeal candidiasis and was started on fluconazole. Upper gastrointestinal endoscopy showed whitish patches with mucosal ulcers in the esophagus. Histopathological examination confirmed TB and HSV infection. The patient recovered after antiviral, antifungal, and anti-tubercular therapy with reduction in immunosuppression. In a TB-endemic zone, TB can coexist with opportunistic infections in an immunocompromised host.

Management of Graft Duodenal Leak in Simultaneous Pancreas Kidney Transplant-a Case Report from India and Review of Literature.

Pancreatic transplantation is currently the only effective cure for Type 1 diabetes mellitus. It allows long-term glycemic control without exogenous insulin and amelioration of secondary diabetic complications. In India, pancreas transplant has not yet established with only a single successful transplant reported so far in the literature. We report a 24-year-old Type 1 diabetic patient with renal failure who underwent a simultaneous pancreas kidney transplant. On postoperative day 15, he had leak from the graft duodenal stump for which a tube duodenostomy and proximal diversion enterostomy was done. He had a high output pancreatic fistula following the procedure which was managed conservatively. The tube duodenostomy was removed at three and half months and enterostomy closure with restoration of bowel continuity was done at 6 months. After a follow up of 7 months, patient is doing well with a serum creatinine of 0.8 mg/dl and normal blood sugars, not requiring any exogenous insulin or oral hypoglycemic drugs. Managing patients with graft duodenal complications after pancreas transplant is challenging. Tube duodenostomy is a safe option in management of duodenal leak, although can lead to a persistent pancreatic fistula. A proximal diversion enterostomy allows early oral feeding and avoids the cost as well as the long term complications associated with parenteral nutrition.

Early recurrence of proliferative glomerulonephritis with monoclonal immunoglobulin deposits in a renal allograft.

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMIDs) is a clinico-pathologic entity, the recurrence of which in the renal allograft has only recently been described. A 55-year-old male presented with rapid deterioration of renal function. Light microscopy showed membranoproliferative glomerulonephritis with kappa light chain restriction and only one sub-class of IgG. He subsequently underwent renal transplant. Two months later, he developed acute graft dysfunction. Renal biopsy showed a recurrence of the disease. Work up for multiple myeloma was positive. Membranoproliferative pattern of injury in the posttransplant setting has a wide range of differential diagnosis, PGNMID being one of them.

Safety and efficacy of autologous mesenchymal stromal cells transplantation in patients undergoing living donor kidney transplantation: a pilot study.

AIM: This pilot study assesses the safety and feasibility of autologous mesenchymal stromal cell (MSC) transplantation in four patients that underwent living donor renal transplantation, and the effect on the immunophenotype and functionality of peripheral T lymphocytes following transplantation. METHODS: All patients received low dose ATG induction followed by calcineurin inhibitor-based triple drug maintenance immunosuppression. Autologous MSCs were administered intravenously pre transplant and day 30 post-transplant. Patients were followed up for 6 months. The frequency of regulatory T cells and T cell proliferation was assessed at different time points. RESULTS: None of the four patients developed any immediate or delayed adverse effects following MSC infusion. All had excellent graft function, and none developed graft dysfunction. Protocol biopsies at 1 and 3 months did not reveal any abnormality. Compared to baseline, there was an increase in the CD4 + CD25+FOXP3+ regulatory T cells and reduction in CD4 T cell proliferation. CONCLUSION: We conclude that autologous MSCs can be used safely in patients undergoing living donor renal transplantation, lead to expansion of regulatory T cells and decrease in T cell proliferation. Larger randomized trials studies are needed to confirm these findings and evaluate whether this will have any impact on immunosuppressive therapy.

Prevalence and genotypes of HPV in female renal transplant recipients in North India.

Estimation of the prevalence of high-risk human papillomavirus (HPV) genotypes in female renal transplant recipients is important for formulating strategies for prevention and screening of cervical cancer in the susceptible group. Data from developing countries are very limited. The study was prospective, cross-sectional, and hospital-based. Female renal transplant recipients, who had received the graft at least 6 mo earlier, were enrolled. Women who visited the outpatient unit for varied complaints and who underwent a normal cervical examination were recruited as controls. A pap smear was obtained in all women. HPV genotyping array kit was utilized for identifying 21 HPV genotypes. Forty renal transplant recipient women and 80 controls were enrolled. The median age of cases and controls was 40 yr (range, 24-69 yr) and 38 yr (range, 23-72 yr), respectively. The mean duration since transplant was 53±42.6 mo (range, 6-168 mo). There was no evidence of cervical dysplasia in any pap smear. High-risk HPV was detected in 32.5% (13/40) and 17.5% (14/80) of cases and controls, respectively (P=0.18). Of the 21 genotypes screened, 7 subtypes were detected. HPV 16 and 31 were the most common (5/13; 38.5%) subtypes observed in the cases, followed by HPV 18 (30.7%). HPV 16 was the most common subtype in controls (10/14; 71.4%). Five (38.5%) renal transplant recipients harbored multiple HPV genotypes, as compared with 4 (28.6%) controls (P=1.0). The prevalence of high-risk HPV in female renal transplant recipients was 1.9 times that observed among controls, although there was no evidence of cervical dysplasia.

An analysis of transplant glomerulopathy and thrombotic microangiopathy in kidney transplant biopsies.

Glomerular diseases of the transplanted kidney are the most important cause of poor long- term outcome. The estimation of the magnitude of this problem and an elucidation of pathogenic mechanism is essential for improvement of graft survival. This study from the Indian subcontinent aims (i) to determine the incidence of transplant glomerulopathy (TG) and thrombotic microangiopathy (TMA) in a large cohort of indicated renal transplant biopsies, (ii) to evaluate the histological and ultrastructural features of TG and TMA, and (iii) to assess the relationship between the two glomerular lesions. Of a total of 1792 indication renal transplant biopsies received over 5 years (2006-2010), 266 biopsies (of 249 patients) had significant glomerular pathology and were further analyzed along with immunofluorescence, electron microscopy (EM), and C4d immunohistochemistry. TG is the most common glomerular lesion followed by TMA seen in 5.97% and 5.08% of allograft biopsies, respectively, which constitutes 40.23% and 34.2% of biopsies with significant glomerular lesions. Pathologic antibody-mediated rejection (AMR) is associated with both TG and TMA in 71% and 46.5%, respectively. A coexistent TG was found in 18.4% of biopsies with TMA. Endothelial swelling with subendothelial widening, a feature of TMA, is also seen in early TG by EM. Our findings support the concept that TG evolves from a smoldering TMA of various causes.

Deferred pre-emptive switch from calcineurin inhibitor to sirolimus leads to improvement in GFR and expansion of T regulatory cell population: a randomized, controlled trial.

BACKGROUND: Measures to prevent chronic calcineurin inhibitor (CNI) toxicity have included limiting exposure by switching to sirolimus (SIR). SIR may favorably influence T regulator cell (T(reg)) population. This randomized controlled trial compares the effect of switching from CNI to SIR on glomerular filtration rate (GFR) and T(reg) frequency. METHODS: In this prospective open label randomized trial, primary living donor kidney transplant recipients on CNI-based immunosuppression were randomized to continue CNI or switched to sirolimus 2 months after surgery; 29 were randomized to receive CNI and 31 to SIR. All patients received mycophenolate mofetil and steroids. The main outcome parameter was estimated GFR (eGFR) at 180 days. T(reg) population was estimated by flowcytometry. RESULTS: Baseline characteristics in the two groups were similar. Forty-eight patients completed the trial. At six months, patients in the SIR group had significantly higher eGFR as compared to those in the CNI group (88.94 ± 11.78 vs 80.59 ± 16.51 mL/min, p = 0.038). Patients on SIR had a 12 mL/min gain of eGFR of at the end of six months. Patients in the SIR group showed significant increase in T(reg) population at 30 days, which persisted till day 180. There was no difference in the adverse events in terms of number of acute rejection episodes, death, infections, proteinuria, lipid profile, blood pressure control and hematological parameters between the two groups. Four patients taking SIR developed enthesitis. No patient left the study or switched treatment because of adverse event. CONCLUSIONS: A deferred pre-emptive switch over from CNI to SIR safely improves renal function and T(reg) population at 6 months in living donor kidney transplant recipients. Registered in Clinical Trials Registry of India (CTRI/2011/091/000034).

Use of autogenous internal iliac artery for bridging the external iliac artery after excision of Aspergillus mycotic aneurysm in renal transplant recipients.

Repair of vascular defects in the presence of infection remains a challenging task in immunocompromised patients. We report two patients with postrenal transplant Aspergillus mycotic aneurysms of the allograft renal artery involving the external iliac artery which were excised along with the allograft. The defect in the external iliac artery was repaired successfully with interposition of autogenous internal iliac artery graft. Use of an internal iliac artery graft in such settings has been rarely reported in English literature. Autogenous internal iliac artery grafts provide a useful method to bridge the vascular defects created by radical debridement in the presence of fungal infections.

Cellular immune response and cytokine profile among hepatitis C positive living donor renal transplant recipients.

BACKGROUND: Hepatitis C virus (HCV) infection is prevalent among renal transplant recipients. METHODS: Twenty-five recipients of living donor renal transplantation with HCV (group I) and without HCV (group II) were serially monitored at three time points, that is, pretransplant, day 10, and 6 months posttransplant. Phenotypic characterization of T-cell subsets and natural killer cells was performed by flow cytometric immunophenotyping. Cytometric bead array immunoassay was used to simultaneously measure six cytokines (interleukin [IL]-2, IL-4, IL-5, IL-10, tumor necrosis factor-α, and interferon-γ) from phytohemagglutin-stimulated culture supernatants, and transforming growth factor (TGF)-ß1 levels were determined by ELISA. Real-time polymerase chain reaction method was used to determine the serum viral load among group I patients at three time points. RESULTS: Group I patients on day 10 posttransplant showed a significant increase in T cells subsets with reduced interferon-γ and increased TGF-ß1 levels. A significantly increased CD8 T cells and TGF-ß levels were seen at 6-month posttransplant among group I patients. Multivariate linear regression analysis showed TGF-ß and tumor necrosis factor-α as the most significant predictors affecting early (day 10) and late (6 months) posttransplant viral load, respectively. CONCLUSION: After an initial increase in the viral load immediately posttransplantation, there is a reduction in viral load. A concomitant timed dissection of the immune response shows a complex interactive environment in which, despite immunosuppression, not only the antiviral immune response persists but the virus is also able to modulate the host immune response for its survival. Per se, HCV does not adversely affect the allograft or patient outcome in this case-control study.

Single-phase 16-slice multidetector computed tomographic angiography in the evaluation of the venous system in potential laparoscopic renal donors.

OBJECTIVE: Our objective was to assess the efficacy of single-arterial-phase, 16-slice multidetector computed tomographic (16-MDCT) angiography in the evaluation of both the renal arterial and venous systems in prospective renal donors with surgical (laparoscopic) correlation. METHODS: Fifty-one consecutive renal donors (age range, 20-62 years; 12 men and 39 women) underwent 16-MDCT angiography followed by laparoscopic donor nephrectomy. Approval from institutional review board was obtained with waiver of consent. The arterial-phase image data set was reviewed independently by 2 abdominal radiologists for the number of renal arteries and veins, anomalies, and degree of opacification of the renal veins. Computed tomographic angiography results were compared with the surgical findings. Interobserver agreement was assessed using kappa statistics. RESULTS: The sensitivity, specificity, and accuracy for identifying the number of renal veins in the arterial phase on 16-MDCT angiography were 96.3%, 96.07%, and 96.2% for reviewer 1 and 94.44%, 94.11%, and 94.3% for reviewer 2, respectively. Both reviewers correctly identified all venous anomalies and had substantial interobserver agreement (kappa coefficient = 0.68). CONCLUSIONS: A single-arterial-phase image data set is sufficient for evaluation of both the renal arterial and venous anatomy in potential renal donors before laparoscopic nephrectomy. Venous-phase acquisition is not necessary, thereby substantially reducing the radiation burden on the donor.

Chylous ascites after laparoscopic donor nephrectomy.

Laparoscopic living-donor nephrectomy has decreased the disincentives to live renal donation with a risk of complications similar to that of open donor nephrectomy. We report a patient who developed chylous ascites after an otherwise-uneventful laparoscopic donor nephrectomy. On MEDLINE search, we could find only two other cases with similar complications. This condition has the potential to cause significant morbidity in the donor, which may reduce the advantages of the minimally invasive approach. We suggest that meticulous dissection of the renal hilum and clipping of lymphatic tissue around the renal vessels could prevent this untoward complication.

The pattern of mucocutaneous infections and infestations in renal transplant recipients.

Immunosuppression-related mucocutaneous lesions are a significant problem in renal transplant recipients. Infections account for the majority of these manifestations. The aim of this study was to determine the spectrum of mucocutaneous infections and infestations in renal transplant recipients. Over a period of three years, all the renal transplant recipients presenting with mucocutaneous lesions (only with infectious etiology) were included in the study. Diagnosis was based on the clinical appearance and appropriate investigations like scraping for KOH, Tzanck smear, cultures, and skin biopsies whenever necessary. In order to study the temporal effect of immunosuppression on these mucocutaneous infections, the patients were divided into six groups -with durations of graft survival ranging from 0-2, 2-6, 6-12, 12-24, 24-60, and more than 60 months in Groups A-F, respectively. A total of 104 renal transplant recipients presented with 117 infections and infestations. The mean age at presentation was 35.9 +/- 1.2 years (15-65 yrs), and the mean duration after the transplant was 23.3 +/- 3.5 months (1-175). The mean serum creatinine level at the time of clinical presentation was 1.4 +/- 0.07 mg/dl (0.7-6). Twenty-seven patients were on a two-drug regimen, prednisolone and azathioprine, and the rest were on a three-drug regimen with cyclosporine in addition. Out of the total of 117 infections in 104 patients, 57 were viral, 49 were fungal, and 8 were bacterial. Two patients had scabies and one had cysticercosis. The mean time interval for the occurrence of infections after the transplant was earlier in patients on three-drug immunosuppression (12.4 +/- 2.3 months) than in those on the two-drug regimen (51.3 +/- 1.8 months), (p<0.01). The viral infections had the shortest mean time interval for presentation following transplant, 15.8 +/- 1.2 months (p<0.05). We did not find any statistically significant difference with regard to age or sex of the patients, duration after the transplant, or the pattern of infection. Careful examination of transplant patients is essential for early detection and proper treatment, because the mucocutaneous infections can have atypical morphologies and are likely to become extensive if not treated early.