Baseline Anti-blood Group Antibody Titers and their Response to Desensitization and Kidney Transplantation.

In recent years, immunological barriers historically considered as absolute contraindications to transplantation are being reevaluated. One such barrier is the ABO blood group incompatibility. With better understanding of immunological mechanisms and effective various regimens for controlling it, ABO-incompatible (ABO-I) kidney transplantation is now being performed with increasing frequency. For good outcome, most important is to achieve and maintain low anti-blood group antibody titers (ABGATs). Twenty-two patients with ABO-I donors have been studied. The anti-A and anti-B antibody titers (IgG and IgM) were estimated by column agglutination technology using Automated Ortho BioVue System. For desensitization, pretransplant plasmapheresis and/or immunoadsorption and rituximab were used. ABGAT was determined before transplant and periodically after transplant. It was observed that one-third of the patients have low baseline ABGAT. In these cases with low ABGAT, transplant can be performed without any desensitization. In those with titers <1:256, rituximab (two doses of 200 mg weekly) and 3-6 sessions of plasmapheresis can bring down titers to <1:32. In those with titers >1:256, immunoadsorption may be used from the beginning to reduce ABGAT. After transplant, the titers drop to <1:8 in majority. Rise in titers to >1:64 require close observation and biopsy. If there is evidence of antibody-mediated rejection, treatment should be promptly started. Rise in titers 4-6 weeks after transplant is not associated with any graft dysfunction, and hence not of any clinical significance.

Sirolimus: a new immunosuppressant.

Though organ transplantation has evolved in many a ways over the years, it is not without the disadvantage of causing rejections. Cyclosporin, azathioprine and corticosteroids are time tested and efficacious; however each is accompanied with its own array of disadvantages. Sirolimus is a relatively new immunosuppressant isolated from a macrolide antibiotic. It may have a beneficial role in prophylaxis of rejection as well as treatment of refractory rejection. It also has antifungal, antitumor and anti-smooth muscle proliferative roles.

Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients.

To obtain estimates of the frequency of nosocomial infections nationwide, those occurring at the four major sites--urinary tract, surgical wound, lower respiratory tract and bloodstream--were diagnosed in a stratified random sample of 169,526 adult, general medical and surgical patients selected from 338 hospitals representative of the "mainstream" of U.S. hospitals. We estimate that in the mid-1970s one or more infections developed in 5.23 percent (+/- 0.16) of the patients and that 6.62 (+/- 0.24) infections occurred among every 100 admissions. Risks were significantly related to age, sex, service, duration of total and of preoperative hospitalization, presence of previous nosocomial or community-acquired infection, types of underlying illnesses and operations, duration of surgery, and treatment with urinary catheters, continuous ventilatory support or immunosuppressive medications. Seventy-one percent of the nosocomial infections occurred in the 42 percent of patients undergoing surgery and 56 percent in the 38 percent financed by Medicare, Medicaid or other public health care plans.

Innovative strategies using SUDAAN for analysis of health surveys with complex samples.

Large-scale health surveys provide a wealth of information for addressing problems in health sciences research. Designed for multiple purposes, these surveys frequently have large sample sizes and extensive measurements of demographic and socioeconomic characteristics, risk factors, disease outcomes and health care service use and costs. Complex features of the sampling design typically employed to select the survey sample, coupled with the vast amount of information available from the survey database, underlie issues that must be addressed during data processing and analysis. Numerous articles in the literature have focused on the debate of whether or not, and how, to control for features of the sample design during data analysis. Traditional statistical methods for simple random samples and the software that accompanies them have historically not had the capacity to account for the survey design. Recent advancements in statistical methodology for survey data analysis have greatly expanded the analytical tools available to the survey analyst. Commercial software packages that incorporate these methods offer the analyst convenient ways for applying such tools to large survey databases in an easy and efficient manner. We present an overview of analysis strategies for survey data and illustrate their application via the SUDAAN software system. Examples for analyses are provided through data from two large US health surveys, the National Health Interview Survey and the Longitudinal Study of Aging. Questions of both a cross-sectional and longitudinal nature are addressed. The examples involve logistic regression, time-to-event analysis, and repeated measures analysis.

The role of dietary protein restriction in Indian patients with chronic renal failure.

OBJECTIVE: To determine dietary protein intake in Indian patients with chronic renal failure and the impact of prescribing protein restricted diets to these patients. METHODS: Baseline dietary protein intake was estimated in forty five patients with chronic renal failure on an unrestricted diet. Of these 45 patients, 27 were vegetarian and 18 were non-vegetarian. Then the patients were divided into 2 comparable groups. Twenty group I patients were allowed to continue unrestricted diet while 25 group II patients were advised 0.6 g/kg/day (50% high biological value) protein. Protein intake was estimated at 1 and 2 month follow up. RESULTS: The baseline dietary protein intake in 45 patients was 0.65 +/- 0.15 (mean +/- 1 SD) g/kg/day. There was no significant difference in protein intake of group I and group II patients at 1 and 2 month follow up. Also, the protein intake in group II patients was not different at 1 and 2 month follow up compared to baseline value. CONCLUSION: Protein intake of Indian patients with CRF is usually low even on an unrestricted diet. The usual practice of advising dietary protein restriction has no significant impact on the protein intake.

Severe muscle weakness due to hyperkalemia.

Hyperkalemia is a commonly encountered electrolyte disturbance in patients with renal insufficiency. It develops very rapidly when potassium is supplemented while a patient is on a potassium-sparing diuretic. Most often it remains asymptomatic and manifests in the form of electrocardiographic changes. Muscle weakness and paralysis although described is seldom observed in clinical practice. We report one such case.

Renal transplant in hepatitis B and C positive patients--a ten years experience.

OBJECTIVE: To determine the outcome of renal transplantation in hepatitis B (HBsAg) and C (HCV antibody) positive end-stage renal disease (ESRD) patients. MATERIAL AND METHODS: In past ten years, out of 245 live renal transplants performed 33 (13.63%) (mean age 36.5 +/- 10.7 yr.) recipients tested positive for HBsAg and/or HCV Ab. Eighteen were HCV Ab positive, 10 HBsAg positive and five both. Two HBsAg positive cases transplanted elsewhere and followed up at our centre were also included. Pre-transplant, thirteen patients had elevated serum alanine aminotransferase (serum ALT). Of these 13, 10 patients were subjected to liver biopsy. Seven showed changes of chronic hepatitis (CH) while three were normal. Seven patients with CH on liver biopsy and three who refused biopsy but had elevated serum ALT were treated with interferon (IFN). In all ten cases there was normalization of serum ALT and six patients (2 HCV and 4 HBV) even became sero-negative. RESULTS: The actuarial 1, 5 and 10 year patient survival was 94.28%, 85.71% and 85.71% and the graft survival was 88.5%, 77.1% and 77.1%, respectively. Infection was the commonest causes of death and rejection was the commonest cause of graft loss. Post-transplant, one patient, (HCV antibody positive) died of fulminant hepatic failure and eleven patients developed elevated serum ALT levels which normalized in six recipients after lamivudine therapy and in four cases on their own. CONCLUSION: Our study shows that the patient and graft survival in hepatitis seropositive recipients is similar to non-hepatitis recipients. Most patients maintain stable liver function over a follow up period of six months to ten years. Lamivudine therapy is effective and safe in post-transplant period.

Comparing serology, antigenemia assay and polymerase chain reaction for the diagnosis of cytomegalovirus infection in renal transplant patients.

BACKGROUND: Cytomegalovirus (CMV) disease is responsible for significant morbidity and mortality following renal transplantation. Currently serology is the only method widely available in our country. Newer methods like early CMV pp65 antigenemia assay and CMV DNA amplification can diagnose CMV disease in its very early period. AIM: The aim of our study was to compare serologic method with antigenemia assay and CMV DNA amplification to diagnose CMV. METHODS: Seventy-three renal transplant recipients (from 7 centres) with clinical suspicion of CMV disease were studied prospectively. The diagnosis of CMV infection was suspected on the basis of fever and leucopenia. RESULT AND DISCUSSION: Three tests were done in all 73 patients and in 22 healthy subjects (control group). The sensitivity and specificity of serological test (CMV IgM) was 72.97 and 62.06%; of antigenemia assay was 89.18 and 100% and of PCR was 100 and 72.41%. CONCLUSION: Antigenemia assay is a sensitive and specific test for early and rapid diagnosis of CMV infection. Qualitative PCR is a sensitive marker but has low specificity.

Clinical trial of benidipine in mild to moderate hypertension.

Thirty four patients with mild to moderate hypertension, were put on benidipine 4 mg/day after two weeks of placebo therapy. Twenty five patients completed the trial successfully for 4 mg benidipine. The blood pressure of 20 patients was controlled with benidipine 4 mg/day (effective rate 80%). Five patients with unsatisfactory control on 4 mg/day benidipine were put on 8 mg/day. Four of them were controlled and one was considered as failure (effective rate 80%). Most of the patients tolerated the drug well. Three patients had mild side effects like headache and heaviness in the head. One of them also had puffiness of face and body (on benidipine 8 mg/day) and was withdrawn from the study. One patient had mild constipation. We conclude that benidipine is well tolerated in the dose of 4-8 mg/day and is an effective antihypertensive agent for treatment of patients with mild to moderate hypertension.

Dual kidney transplantation--a solution for less than ideal brain dead donors.

For renal transplantation, an elderly cadaver donor is often rejected because of the relatively poor long-term graft survival. Considering that a number of potential recipients are waiting for a renal transplant, dual kidney transplantation would be a more appropriate approach in this situation. We report one such case with a successful outcome.

Renal involvement in multiple myeloma.

The present study is a retrospective chart analysis of 33 patients who satisfied the diagnostic criteria of multiple myeloma. Sixteen (49.5%) of these 33 patients developed renal failure at some point in time. The mean age +/- 1SD of patients who developed renal failure was 59.2 +/- 13 years (range 34-85 years). There were 12 males and 4 females. The precipitating factors for renal failure were dehydration (12.5%), hypercalcemia (62.5%) and use of non-steroidal antiinflammatory drugs (6.2%). Hypercalcemia was observed in 10 of the 16 patients who developed renal failure while it was seen in only 4 of the 17 cases who did not develop renal failure (relative risk 5.4). In 11 (68.7%) patients, the renal function improved with hydration, treatment of hypercalcemia and chemotherapy. The 1 and 3 year actuarial survival of patients with renal failure and multiple myeloma was 87% and 74% respectively.

Cytomegalovirus nasal polyp after renal transplant.

Infection is a major problem after transplantation. Cytomegalovirus (CMV) is the most common viral infection affecting transplant patients. We describe a case of CMV infection with rare clinical manifestation in the form of nasal polyp. Patient presented 6 weeks following renal transplantation with history of fever and stuffy nose. On evaluation he was found to have nasal polyp which was excised. Histopathology revealed characteristic CMV inclusion bodies. Patient responded to ganciclovir therapy and is presently doing well eighteen months after transplantation.

Ehlers-Danlos syndrome.

A case of Ehlers-Danlos Syndrome in a 19 years old male involving cutaneous and skeletal systems is reported. A clinical scoring system to diagnose such cases is highlighted.