A Rare Case of Gas Forming Enterobacter cloacae Leading to Bleeding Mycotic Pseudoaneurysm of Transplant Renal Artery Culminating in Graft Nephrectomy.

Enterobacter cloacae belongs to Enterobacter genus. It is a common gram-negative, facultative anaerobic, rod-shaped organism. It causes a variety of nosocomial infections including urinary tract infection, pneumonia, wound infection, osteomyelitis and endocarditis. Over time Enterobacter cloacae complex (ECC) has developed to be resistant to antibiotics including carbapenem. It has been rarely reported to cause gas gangrene and never been reported to cause pseudoaneurysm (PA) of transplant renal artery. We report and share our experience with this rare case of gas forming and muti-drug resistant ECC which led to mycotic PA of transplant renal artery, complicated by bleeding and infected hematoma and which resulted in graft nephrectomy.

Pros and cons of live kidney donation in prediabetics: A critical review and way forward.

There is shortage of organs, including kidneys, worldwide. Along with deceased kidney transplantation, there is a significant rise in live kidney donation. The prevalence of prediabetes (PD), including impaired fasting glucose and impaired glucose tolerance, is on the rise across the globe. Transplant teams frequently come across prediabetic kidney donors for evaluation. Prediabetics are at risk of diabetes, chronic kidney disease, cardiovascular events, stroke, neuropathy, retinopathy, dementia, depression and nonalcoholic liver disease along with increased risk of all-cause mortality. Unfortunately, most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period. There is lack of prospective long-term studies to know about the real risk of complications after donation. Furthermore, there are variations in recommendations from various guidelines across the globe for donations in prediabetics, leading to more confusion among clinicians. This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients. This review focuses on pathophysiological changes of PD in kidneys, potential complications of PD, other risk factors for development of type 2 diabetes, a review of guidelines for kidney donation, the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

The Role of Urinary Neutrophil Gelatinase-Associated Lipocalin in Predicting Acute Kidney Dysfunction in Patients With Liver Cirrhosis.

BACKGROUND: Early detection of acute kidney dysfunction (AKD) in cirrhotic patients is crucial. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) has been identified as an early marker of AKD. The aim of the study was to evaluate serial uNGAL as a marker and predictor of AKD in liver cirrhosis patients. METHODS: Serial uNGAL and serum creatinine (sCr) levels were measured daily during the first 6 days of admission. Furthermore, sCr levels and the estimated glomerular filtration rate (eGFR) were measured after 3 - 6 weeks. The uNGAL levels in patients with and without abnormal sCr were compared. RESULTS: Fifty-seven consecutive cirrhotic patients were enrolled in the study. Eight of 14 patients (57%) who developed abnormal uNGAL level also had abnormal sCr level (odds ratio (OR) = 3.4, 95% CI: 0.99 - 12.03, P = 0.05). After 6 weeks, 41% of patients exhibited an abnormal uNGAL level and abnormal sCr (OR = 6.7, 95% CI: 1.55 - 28.85, P = 0.01). Area under the curve (AUROC) and the best cut-off point for highest NGAL in 6 days were 0.64 and 72.55 ng/mL, respectively. CONCLUSIONS: There is a modest association between highest uNGAL in the first 6 days of admission and sCr at week 6 in all participants. This may indicate that in cirrhotic patients, uNGAL level during the first 6 days of admission has a potential predictability for the development of high sCr and low eGFR 6 weeks later. The AUROC of 0.64 quantifies the overall ability of uNGAL to discriminate between those individuals who will have a raised sCr levels and those who will not.

Efficacy and safety of treatment of hepatitis C virus infection in renal transplant recipients.

AIM: To assess the efficacy and safety of combined pegylated interferon and ribavirin therapy in hepatitis C virus (HCV) infection in renal transplant recipients. METHODS: This is a retrospective chart review of post renal transplant patients who were positive for anti-HCV and HCV-RNA, and who have received treatment with combination of pegylated interferon and ribavirin between October 2003 and December 2008. Only patients with stable graft function and absence of evidence of cirrhosis and who received the therapy for continuous 48 wk were included. Nineteen patients (13 male and 6 female) were identified and included. The patient's complete blood count, liver and kidney profile, and calculated glomerular filtration rate (GFR) were monitored every 6-8 wk while on treatment. HCV-RNA was tested at 12 wk for early virological response, at 48 wk for end of treatment response (ETR), and then retested at 24, and 48 wk after completion of therapy for sustained virological response (SVR). Liver biopsies were obtained before treatment from all patients and graft kidney biopsies were performed as required. RESULTS: Of the entire cohort, 9 patients (47.4%) showed an ETR and 8 had SVR (42.1%). Of the 8 patients with abnormal alanine aminotransferase (ALT) levels at baseline, 78.9% had their ALT normalized (including the virological non responders). ALT was normal in all responders at the end of therapy and at 24 wk post therapy (100%). Only one patient (5.3%) developed an increase in creatinine and decline in GFR from baseline towards the end of treatment. This patient's kidney biopsy revealed borderline rejection. There was no impact on response by HCV-genotype, initial HCV RNA load, age or sex of the patient or duration post transplant before commencement of therapy. All patients tolerated treatment in the same way as non-transplant with no unusual or increased occurrence of side effects. CONCLUSION: The combination of pegylated interferon and ribavirin is effective in suppressing HCV-RNA, with a low risk of graft rejection or failure in HCV infected renal transplant recipients.

Cystatin C-based formula is superior to MDRD, Cockcroft-Gault and Nankivell formulae in estimating the glomerular filtration rate in renal allografts.

OBJECTIVES: There are conflicting reports on the reliability of the various glomerular filtration rate formula in renal allografts, to assess the performance of various glomerular filtration rate formula in estimating renal function of renal allografts. MATERIALS AND METHODS: Glomerular filtration rate was measured using an isotope Tc99m DTPA in 97 renal transplant patients and estimated using modification of diet in renal disease, Cockroft-Gault formula, Nankivell, and a cystatin C-based formula. The overall performance of these formula was evaluated by calculating bias, accuracy and precision. RESULTS: Mean age was 39.8 years (-/+ 12.7), body mass index was 26.9 (-/+ 6.3) and serum creatinine was 114.5 micromol/L (-/+ 39.3). The mean measured glomerular filtration rate was 58.1 mL/min (-/+ 25.6). The bias with modification of diet in renal disease was 7.7 (P = .03), with Cockroft-Gault formula it was 3.2 (P = .3), with Nankivell it was 10.3 (P = .0002), and with cystatin C it was 0.31 (P = .9) The precisions (r) for modification of diet in renal disease, Cockroft-Gault formula, Nankivell, and cystatin C were 0.26 (P = .01), 0.26 (P = .01), 0.42 (P = .0001), and 0.60 (P < .0001), respectively. We also investigated the impact of sex, age, body mass index, and glomerular filtration rate on the performance of these 4 formula. CONCLUSION: The best correlation, highest precision, accuracy, and least bias were seen when using cystatin C. The largest bias was seen when using Nankivell and modification of diet in renal disease formula.