Outcomes after lung resection in renal transplant patients with pulmonary mucormycosis.

BACKGROUND: Pulmonary mucormycosis has been associated with high mortality (reported up to 100%) in renal transplant recipients. METHODS: This was a retrospective analysis of renal transplant patients with pulmonary mucormycosis between April 2014 and March 2020, who underwent surgical resection of the affected lung along with liposomal amphotericin therapy. Patients with lower respiratory illness features underwent chest X-ray, high-resolution computed tomography of the chest, and those with suspicious findings underwent analysis of bronchioloalveolar fluid and transbronchial lung biopsy. Patients with histological or microbiological evidence of mucormycosis were started on liposomal Amphotericin B. Tacrolimus and mycophenolate mofetil were stopped at the time of diagnosis. RESULT: Ten patients underwent combined management, while five patients were managed medically. At last follow up, seven out of ten patients (70%) who underwent combined management and two of the five patients (40%) who were managed medically, had a mean survival of 28.86 months (sd = 15.71, median = 25) and 14.17 months (sd = 12.21, median = 18), respectively, post-diagnosis of pulmonary mucormycosis. CONCLUSION: Surgical resection combined with antifungals in the perioperative period and decreased immunosuppression may improve the outcomes in renal transplant patients with pulmonary mucormycosis.

Outcome of tibio-saphanous arteriovenous fistula in patients with failed upper extremity dialysis access: A report of two cases.

Arteriovenous fistulas (AVF) are the preferred access for hemodialysis in patient with end stage renal disease. Usually, distal vessels of upper limb are preferred. There are situations in which the upper limb cannot be a site for AVFs or graft as in cases of bilateral central venous stenosis or with exhausted sites in upper limb. In these cases, lower limb AVF can be considered. Tibial-saphanous (ankle) fistula should be the preferred site over femoral AVF/graft following the principle of distal to proximal. Also, femoral AVFs are associated with more ischemic and infective complications. The present report describes successful hemodialysis in two patients with tibial-saphanous fistula a site rarely used as an option for HD access. Hemodialysis for over 1 year in one patient and 6 months in the other portrays the success of this approach.

Impact of a trained vascular access coordinator on a vascular access program in India.

BACKGROUND: Native AV fistulas are the ideal access for hemodialysis but require monitoring and multiple interventions in some patients to keep them functioning. The aim of the study was to assess the impact of the appointment of a trained vascular access coordinator (VAC) for fistula monitoring, on the evolution of the vascular access program at our institute. METHOD: Data was retrieved from the departmental database for the baseline year 2014 and compared with the data from 2018. Initial review showed that appointment of the VAC in 2015 resulted in a steady increase in the number of AV fistula interventions over 2 years to a plateau in 2018 which was chosen as the comparison year. The number of AVF's created, number of salvage procedures performed, and follow-up data were compared. Other parameters like number of operation theatre hours, surgeons, and nursing staff remained constant during this period. RESULT: Total numbers of AVFs increased from 511 to 713 (39.3%). The number of follow-up visits to surgeons reduced from an average of 4-0.25 visits per patient during this period. Follow up Doppler examinations increased from 761 to 1296 (70%) indicating improved follow up. The salvage procedures increased from 44 to 161 (272%) with early detection of fistula dysfunction. Primary and secondary patency rates of 86% and 92% at 3 months could be achieved whereas limited follow-up data was available for 2014. CONCLUSION: Appointment of trained VAC increased the number of vascular access procedures, improved follow-up care, and led to early detection and intervention for access dysfunction while reducing the workload of surgeons.

Deceased Donor Renal Transplantation: A Single Center Experience.

INTRODUCTION: Deceased donor kidney transplant are still not common across India. This study was done to assess various measures taken at a single center level to increase organ donation rate and to analyse the outcomes of transplants performed from these donors. METHODS: All deceased donor renal transplants performed from November 2011 to February 2017 were analysed for patient and death censored graft survival, rate of delayed graft function, rate of rejection and mortality. Kaplan Meir analysis for Survival Curves was used. RESULTS: Organ donation rate at our center improved from one donation every alternate year in 2004 to a peak of 44 donations in 2017. Patient survival was 93.42%, 89.44%, 85.53%, and death censored graft survival was 94.07%, 88.21%, and 82.86% at 1, 2 and 3 years respectively. Mean duration of hemodialysis pre transplantation was 34.6 ± 27.43 months. CONCLUSIONS: This study has shown that steps taken at a single center level alone can also significantly improve organ donation rates. Employment of dedicated professionals including transplant surgeons and coordinators, developing a protocol-based approach for referral, and early counseling in triage along with regular audits can help to establish deceased donor program with acceptable outcomes elsewhere in the country.

Analysis of Organ Utilization From Deceased Organ Donation in India.

OBJECTIVES: This report presents an audit of utilization of various organs from deceased donors in different states of India over a 3-year period METHODS: Data released by the various regions on their official website was analyzed from 2015 to 2017.Regions with less than 25 donations per year were excluded while calculating utilization rates. RESULTS: Total organ donation in India had increased from 570 to 843 donations from 2015 to 2017 (47.8% increase) with southern states performing exceedingly well compared with northern states. Total organs retrieved during the 3-year period were 6659 with a 54.7% increase in organ retrieval in 2017 compared with 2015 (2592 vs 1675 respectively). The net utilization rate of kidneys was 87.35%. Total liver transplants done during this period were 1894. Net liver utilization rate was 86.81% over 3 years. Total Heart transplants during this period were 641 with net utilization rate of 28.98%. An increase in utilization rates was observed from 2015 to 2017 (19.33%-34.46%). A total of 217 lung transplants were done with net utilization rate of 8.86% with an increase in yearly utilization rate from 6.5% in 2015 to 11.97% in 2017. Total pancreas transplants remained low with 48 transplants over 3 year duration with net utilization rate of 2.25% but an increase in utilization rate was observed. (0.92% in 2015 to 2.1% in 2017). CONCLUSION: There is a significant regional variability in organ utilization in India. Evaluating and addressing the cause of high variability can further increase the transplant activity.

Experience With 15 Years of Laparoscopic Donor Nephrectomy: Review of 2500 Cases.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events. METHODS: The records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications. RESULTS: The mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3). CONCLUSIONS: LDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Real-life Bioequivalence of Tacrolimus in Patients With Living-Related Donor De Novo Renal Transplantation: An Observational Study.

Tacrolimus is a narrow therapeutic index drug. As a result, regulatory agencies worldwide recommend stringent bioequivalence evaluation criteria for approval of generics. Despite this, the professional transplantation societies have raised concerns over the safety and efficacy of generic substitutions. We conducted this pragmatic real-life bioequivalence study to assess the effect of generic substitutions of tacrolimus. This was an observational study including recipients of renal transplantation who were considered for generic medication substitution. Transplanted organs were from living-related donors and were performed at least 1 month before the study. Time of administration of the drug, time of dosing with respect to meals, and time of blood sample collection were controlled; however, the lot number of the generic drugs was not controlled. The participants were allowed to use their usual supplies irrespective of the lot number. Concentration (C0) was quantified by liquid chromatography with tandem mass spectrometry after the generic substitution from ABC brand to XYZ brand. The average C0 ± SD with generic ABC was 11.09 ± 4.26 ng/mL and generic ABC was 9.7 ± 4.12 ng/mL. Though there was no statistically significant difference observed between the concentrations, when the individual patient data was examined, 2 patients were found to have a very high concentration of tacrolimus and at least 7 patients fell below the therapeutic range. These derangements called for retitration with the new generic tacrolimus (40%). The results of our study suggest that generic-to-generic substitutions should be carried out very carefully in a closely observed setting in patients with renal transplants. The strength of our study is that it matched the real clinical practice setting as much as possible unlike a bioequivalence study. Therefore, we recommend repeating C0 at least 3 times over a period of 7 to 10 days with a generic substitution to prevent untoward consequences.

Risk for Delayed Graft Function in Deceased Donor Renal Transplant Patients: A Single-Center Experience From North India.

OBJECTIVES: Delayed graft function (DGF) in renal allograft transplantation refers to the need for dialysis in the first week after renal transplantation. This study analyzed the causes of DGF in deceased donor transplantation. METHODS: Data from January 2018 to July 2019 was reviewed with regard to donor and recipient characteristics such as demographics, biochemical parameters, organ dysfunction, and preterminal management. The recipients were divided into 2 groups: group I: patients without DGF and group II: patients with DGF. RESULTS: Kidneys were retrieved from 49 deceased donors (male:female = 41:8) and transplanted to 95 recipients (male:female = 60:35). Mean age of the donors and recipients was 35.34 ± 18.2 and 40.72 ± 13.30 years, respectively. The most common cause of brain death was central nervous system trauma (45 out of 49, 91%). In total, 20/95 (21%) recipients had DGF. Twelve recipients had received kidneys from donors who had circulatory arrest. Two patients were re-explored on postoperative day 1 for bleeding from renal artery anastomosis. The mean age in group I and group II was 28.65 ± 10.2 and 37.38 ± 12.28 years, respectively. The mean cold ischemia time in group I and group II was 398.73 ± 187.19 and 333.24 ± 115.49 minutes, respectively. The mean hospital stay of donor before donation in group I and group II was 4.34 ± 1.27 and 6 ± 2.95 days, respectively. The terminal donor creatinine in group I and group II was 0.88 ± 0.47 and 2.33 ± 1.73 mg/dL, respectively. CONCLUSION: DGF in deceased donor transplantation may be attributed to donation after circulatory death, prolonged donor hospital stay, high donor leukocyte count, and high terminal creatinine.

Reasons for Low Utilization of Pancreas for Transplantation From Deceased Donors: Analysis of Data From a Single Center in India.

OBJECTIVES: Although pancreas transplants were started at our center in 2014, the number of pancreases procured have remained low. This report presents an audit of donors over the past 18 months with the aim to identify factors preventing pancreas utilization. METHODS: This was a retrospective study. All deceased donors from January 2018 to July 2019 were included in this study. The medical records of deceased donors were reviewed with regard to donor characteristics such as demographics, biochemical parameters, and preterminal management. RESULTS: Organs were retrieved from 49 deceased donors over the duration of the study. Mean age of the donors was 35.34 ± 18.2 years (11 months to 72 years). Most donors were men (M:F 41:8). In total, 45/49 (92%) donors had central nervous system trauma as a cause of brain death. Out of 49, multiple abdominal organs were retrieved from 21 donors (42.8%), whereas kidneys alone were retrieved from the rest. Pancreases were retrieved from 8 donors (16.3%). Pancreases were rejected in 21 donors (42.8%) because of age limit criteria. Other reasons for refusal included donor sepsis (n = 12, 24.5%), severe hemodynamic instability (n = 5, 10.2%), donation after cardiac death (DCD) (n = 2, 4.1%), and ischemic hepatitis (n = 7, 14.3%) while 3 (6.1%) donations happened while awaiting license renewal. A suitable recipient was not available for 1 donor (2.0%). CONCLUSION: Pancreas retrieval rates remain low because of donor-related factors. Expansion of age limits and better donor management could improve pancreas transplant activity.

Successful re-transplantation in patient with recurrent parvovirus B19 pure red cell aplasia.

Impaired cell-mediated, as well as antibody-mediated immunity predisposes a renal transplant recipient to a wide variety of atypical infection. With an increasing number of re-transplant, the balance between immunosuppression and the risk of recurrent disease poses a clinical and therapeutic challenge. Here, we report a successful re-transplantation in a case of parvovirus B19 infection leading to anaemia and collapsing glomerulopathy in the allograft managed with intravenous immunoglobulin (IVIG) and reduction of immunosuppression. This case emphasizes re-consideration to renal transplant after clearance of the virus in a previous renal allograft lost to PVB19 infection.

A Novel Technique of Dual Kidney Transplantation (DKT) From Adult Donors.

OBJECTIVE: To discuss a novel technique of dual kidney transplantation that has not been described in literature. METHODS: Dual Kidney Transplantation (DKT) is done for kidneys from expanded criteria donors. The 3 described techniques in literature (bilateral placement, unilateral placement with separate or patch anastomosis) have some disadvantages. This newer technique describes the use of the donor iliac artery as an interposition Y graft for joining both kidneys of the dual kidney transplant. This method can overcome some of the disadvantages associated with the previously described techniques. The ureters were implanted in urinary bladder separately in one recipient and together in another recipient. RESULTS: This technique was used in 2 cases. The cold ischemia time was 275 minutes and 765 minutes, respectively while the operative time was 187 minutes and 192 minutes, respectively in the 2 patients. The first patient has creatinine of 0.83 mg/dl on last follow up at 6 months whereas the other patient has creatinine of 1.12 mg/dl at 3 months follow up. Computed tomography angiography of both the patients revealed good contrast uptake in both kidneys with no stenosis, torsion or lymphocele. CONCLUSION: The newer technique avoids scarring of both iliac fossa in DKT while reducing operative time and secondary warm ischemia time by doing a single arterial anastomosis in the recipient and allows easier placement of both kidneys in the right iliac fossa.

Chylous Ascites: Complication of Laparoscopic Donor Nephrectomy. Case Report and Review of Literature.

BACKGROUND: Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes the importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment. METHODS: A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using "chyle," "complications," and "laparoscopic donor nephrectomy" as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described. RESULTS: Fifty-four cases of chyle leak/ascites have been reported after LDN in literature to date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parenteral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large-volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up. CONCLUSIONS: Chylous ascites is a rare complication after donor nephrectomy in experienced centers. Although conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.

Retroperitoneal Single Port Versus Transperitoneal Multiport Donor Nephrectomy: A Prospective Randomized Control Trial.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) converted a retroperitoneal (RP) procedure into a transperitoneal (TP) operation with reports of bowel and solid organ injuries leading to mortality in occasional cases. Laparoscopic RP donor nephrectomy can reduce these risks but never became popular because of the muscle cutting approach. Lumbotomy incision can be used to approach retroperitoneum by incising fascial planes, eliminating disadvantages of the RP approach. This report compares the outcomes of the standard multiport TP LDN with translumbar laparoendoscopic single-site donor nephrectomy (LESS-DN). METHODS: Between January 2016 and June 2017, 50 voluntary kidney donors out of 267 donors were randomized to undergo LESS-DN vs LDN. Donors with body mass index ≥30 kg/m2, multiple renal arteries, and right-sided nephrectomy were excluded from the study. Postoperative pain, duration of surgery, length of graft vessels and ureter, warm ischemia time, intraoperative blood loss, incision length, convalescence period, duration of hospital stay, and recipients' creatinine at discharge were compared among both the groups. Pain assessment was done using visual analogue scale (VAS). RESULTS: The RP group experienced lesser pain (VAS score 0.3 ± 0.3 vs 1.1 ± 0.0, p = 0.000), lesser analgesic requirement (186 ± 51.07 mg vs 254 ± 62.7 mg, p = 0.000), and faster convalescence (7.0 ± 3.0 days vs 10.7 ± 3.3 days, p = 0.00) related to smaller cumulative incision (7.8 ± 0.8 cm vs12.4 ± 2.0 cm, p = 0.00), and had reduced operative time (142 ± 26.2 minutes vs 170.8 ± 34.75 minutes, p = 0.001) and blood loss. Other recorded parameters were similar in both the groups. CONCLUSIONS: The single port RP approach significantly reduced postoperative pain and hastened recovery when compared with the TP approach. Converting to a RP approach presents an opportunity for surgeons to further reduce morbidity associated with the donor nephrectomy.

Successful Implantation of a Renal Allograft With Quintuple Arteries Retrieved From a Living Donor.

In renal transplant, multiple renal arteries in a donor require meticulous vascular reconstruction for successful allograft function in the recipient. Presence of more than 4 renal arteries is usually considered to be a relative contraindication for proceeding with renal donation. We report a living-donor renal transplant procedure where preoperative radiologic imaging of the donor showed 3 left renal arteries. Two additional arteries were identified intraoperatively. All 5 arteries were reconstructed during the back-table procedure, and the allograft was implanted in the recipient. At 3-month follow-up, computed tomographic imaging demonstrated patency of all 5 renal arteries, and the patient had a serum creatinine level of 0.8 mg/dL. Unidentified arteries on preoperative imaging may occasionally require complex reconstruction. A renal allograft with 5 renal arteries is usually a contraindication for renal donation. Here, we describe the first published case of successful kidney transplant after reconstruction of 5 renal arteries in the donor graft.

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.

Primary sternal tuberculous ulcer with dissemination to the bone marrow: a clinical rarity.

Primary tubercular osteomyelitis of the sternum with dissemination to bone marrow is a rarely described entity even in countries where tuberculosis is endemic. Delayed presentations can be in the form of sinus formation, spontaneous fracture of the sternum, extrasternal spread, and sepsis. Diagnosis can be made by CT of the chest wall and Ziehl-Neelsen staining of aspirate from the lesion or by tissue biopsy. We present a case of tuberculous osteomyelitis of the sternum with sinus formation along with widespread involvement of bone marrow, which was successfully treated with antituberculous therapy. Sternal osteomyelitis is difficult to diagnose on chest radiography and ultrasonography, but we were able to make the probable diagnosis of sternal tuberculous osteomyelitis. CT showed erosion of part of the sternal bone. Diagnosis was confirmed on histopathology and by bone marrow trephine biopsy. During the follow-up period of 3 months, the patient showed a satisfactory response to treatment.

Traumatic anterior abdominal wall hernia: A report of three rare cases.

Traumatic abdominal wall hernia is a rare condition that can follow any blunt trauma. Associated intra-abdominal injuries are infrequent. In this study, we are reporting three cases, diagnosed as abdominal wall hernia associated with herniation of bowel loops due to blunt trauma. In one case, injury of the herniated bowel was seen. In western medical literature, only few cases have been reported especially with intra-abdominal injuries.

Xanthogranulomatous cholecystitis: case series in a rural area, clinicopathological study and review of literature.

Xanthogranulomatous cholecystitis is a destructive inflammatory disease of the gallbladder, rarely involving adjacent organs and mimicking an advanced gallbladder carcinoma. The diagnosis is usually possible only after pathological examination. We are reporting two of such rare cases in female patients attending our institute. In both patients xanthogranulomatous cholecystitis was diagnosed on histopathology.