Vayu bubble continuous positive airway pressure is a promising solution with favorable treatment outcomes for respiratory distress syndrome in newborns: a qualitative study in Bangladesh.

Background: According to Bangladesh Demographic and Health Survey (2022), neonatal mortality, comprising 67% of under-5 deaths in Bangladesh, is significantly attributed to prematurity and low birth weight (LBW), accounting for 32% of neonatal deaths. Respiratory distress syndrome (RDS) is a prevalent concern among preterm and LBW infants, leading to substantial mortality. The World Health Organization (WHO) recommends bubble continuous positive airway pressure (bCPAP) therapy, but the affordability and accessibility of conventional bCPAP devices for a large number of patients become major hurdles in Bangladesh due to high costs and resource intensiveness. The Vayu bCPAP, a simple and portable alternative, offers a constant flow of oxygen-enriched, filtered, humidified, and pressurized air. Our study, conducted in five health facilities, explores the useability, acceptability, and perceived treatment outcome of Vayu bCPAP in the local context of Bangladesh. Methods: A qualitative approach was employed in special care newborn units (SCANUs) of selected facilities from January to March 2023. Purposive sampling identified nine key informants, 40 in-depth interviews with service providers, and 10 focus group discussions. Data collection and analysis utilized a thematic framework approach led by trained anthropologists and medical officers. Results: Service providers acknowledged Vayu bCPAP as a lightweight, easily movable, and cost-effective device requiring minimal training. Despite challenges such as consumable shortages and maintenance issues, providers perceived the device as user-friendly, operable with oxygen cylinders, and beneficial during referral transportation. Treatment outcomes indicated effective RDS management, reduced hospital stays, and decreased referrals. Though challenges existed, healthcare providers and facility managers expressed enthusiasm for Vayu bCPAP due to its potential to simplify advanced neonatal care delivery. Conclusions: The Vayu bCPAP device demonstrated useability, acceptability, and favorable treatment outcomes in the care of neonates with RDS. However, sustained quality service necessitates continuous monitoring, mentoring and retention of knowledge and skills. Despite challenges, the enthusiasm among healthcare providers underscores the potential of Vayu bCPAP to save lives and simplify neonatal care delivery. Development of Standard Operating procedure on Vayu bCPAP is required for systematic implementation. Further research is needed to determine how the utilization of Vayu bCPAP devices enhances accessibility to efficient bCPAP therapy for neonates experiencing RDS.

Transcriptional analysis of nitrogen fixation in Paenibacillus durus during growth in nitrogen-enriched medium.

Paenibacillus durus strain ATCC 35681T is a Gram-positive diazotroph that displayed capability of fixing nitrogen even in the presence of nitrate or ammonium. However, the nitrogen fixation activity was detected only at day 1 of growth when cultured in liquid nitrogen-enriched medium. The transcripts of all the nifH homologues were present throughout the 9-day study. When grown in nitrogen-depleted medium, nitrogenase activities occurred from day 1 until day 6 and the nifH transcripts were also present during the course of the study albeit at different levels. In both studies, the absence of nitrogen fixation activity regardless of the presence of the nifH transcripts raised the possibility of a post-transcriptional or post-translational regulation of the system. A putative SigA box sequence was found upstream of the transcription start site of nifB1, the first gene in the major nitrogen fixation cluster. The upstream region of nifB2 showed a promoter recognizable by SigE, a sigma factor normally involved in sporulation.

A peculiar case of Morel-Lavelle lesion of upper limb.

Morel-Lavallee lesions (MLL) are post-traumatic, closed internal degloving injuries that can result in severe complications if not diagnosed early. It is conventionally seen in cases of the high energy injuries of the pelvis and lower limb. The accumulation of extravasated blood, secondary to fracture and soft tissue damage may cause internal degloving injury, skin necrosis, soft tissue damage and acute osteomyelitis. We report here the clinical and radiological features in a 32-year-old male referred from the emergency department of a tertiary hospital who had sustained high energy motor vehicle accident. On examination, there was a fluctuant, mobile, non-tender subcutaneous mass over the distal arm with suspicion of internal degloving injury. Plain radiographs showed no fractures. Ultrasound showed a fluid collection with the presence of septations and echogenic debris within the collection. Extravasation was noted between subcutaneous tissue layer and fascia at the posterolateral aspect of the arm. Wound debridement under general anaesthesia was carried out. Intraoperative findings reported a significant amount of thick serous fluid with necrotic debris. Unhealthy skin and fat layers were debrided. Underlying muscles were found to be healthy. The results of the intraoperative fluid culture and sensitivity showed no growth. Negative pressure vacuum dressing was carried out. After five cycles of vacuum dressing, the wound showed signs of healing with an improved range of motion of the elbow. Orthopaedic surgeons need to be vigilant of the possibility of MLL in the upper limb as a differential diagnosis in the management of high energy trauma.

Lipid Profile Status in Natural and Surgical Menopausal Women: A Comparative Study.

This cross sectional, study was carried out in the department of Obstetrics and Gynaecology in Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from October 2015 to September 2016. The objective of the study was to evaluate dyslipidaemia between natural and surgical menopausal women. Patients who attended the menopausal clinic of Mymensingh Medical College Hospital, Mymensingh were included in the study. For this purpose 91 patient were divided into study (n=46) and comparison (n=45) groups. Serum total cholesterol (TC), serum triglyceride (TG), Serum high density lipoprotein cholesterol (HDL-cholesterol) were estimated by colorometric method and serum low density lipoprotein cholesterol (LDL-cholesterol) was calculated by using Friedwald's formula. Age range of menopausal women was 45 to 60 years. The mean age with SD was in study group 50.26±2.57 years and control group 49.02±3.13 years. It was observed that women with surgical menopause had higher mean plasma level of total cholesterol with standard deviation 192.84±52.43mg/dl while that of mean and standard deviation of natural menopause 192.26±27.56mg/dl i.e. Mean difference was statistically insignificant (p>0.05). Mean plasma levels of Triglyceride (TG) with standard deviation (215.87±67.73mg/dl) higher in surgical menopause as compared with natural menopause (147.33±65.17mg/dl) which was statistically significant (p<0.001). There was significant rise of mean with standard deviation of HDL cholesterol in natural menopause was (44.42±8.14mg/dl) as compared to surgical menopause (34.61±8.55mg/dl) and the mean difference was statistically highly significant (p<0.001). Mean with standard deviation of plasma LDL cholesterol (122.02±49.16mg/dl) rise in surgical menopause as compared to physiological menopause (118.06±20.56mg/dl) and was statistically insignificant (p>0.05). Serum total cholesterol, serum triglyceride (TG) and serum low density lipoprotein (LDL) was found significant higher level in surgical menopause. And only serum high density lipoprotein (HDL) was found significantly higher level in physiological menopause. So, surgical menopausal women were marked dyslipidaemia.

Exploring the perceptions, practices and challenges to maternal and newborn health care among the underprivileged teagarden community in Bangladesh: a qualitative study.

Poor health care-seeking behaviour, access to services and availability of service delivery have implications for the health of the community. This study explored the perceptions, practices and challenges related to maternal and neonatal care in the teagarden community in Bangladesh. The study also identified service gaps and problems prevalent in teagarden health facilities. A qualitative study was conducted in five teagardens in the Moulvibazar district of Bangladesh. Six focus group discussions (FGDs) were completed with individuals from the teagarden community, and twelve in-depth interviews (IDIs) were performed with health facility staff working in those teagarden facilities. Misconceptions and harmful traditional practices were found to exist among the families in the teagardens, restricting them from accessing quality health care. Pregnant women are not aware of antenatal care, and deliveries are being conducted at home by untrained birth attendants. Unhygienic and harmful postnatal practices are used. Teagarden health facilities are not well equipped or prepared to provide good care. Inequities exist within the teagarden communities, with unregistered workers having even poorer access to care. Improvement of the quality of maternal health care for this marginalised community is needed to progress maternal health.

Validation of SmartPill® wireless motility capsule for gastrointestinal transit time: Intra-subject variability, software accuracy and comparison with video capsule endoscopy.

BACKGROUND: There is interest in ultimately combining endoscopy and motility assessments. Gastric emptying (GET), small bowel (SBTT), colon (CTT) and whole gut transit (WGTT) times are conveniently obtained by SmartPill® wireless motility capsule (WMC) that records luminal pH, temperature and pressure. Reproducibility within same subjects and accuracy of software derived times (MotiliGI® ) were investigated for diagnostic application. GET and SBTT were separately measured using video capsule endoscopy (VCE). The aim of this investigation was to assess same subject reproducibility of WMC, accuracy of software derived transit times and relate to Pillcam® SB (small bowel) VCE motility data. METHODS: Seventy three healthy adults ingested a 260 kcal mixed meal followed by WMC tests. Food intake was permitted after 6 hours. Regional transit data was obtained for GET, SBTT and CTT, the sum yielding WGTT. Nineteen subjects repeated WMC tests 2 or 4 weeks later; a separate 70 underwent VCE while fasted. KEY RESULTS: Visually derived data from WMC yielded GET 3.46±0.27, SBTT 5.15±0.21, CTT 20.76±1.19 and WGTT 29.53±1.28 hours (mean±SEM). Pearson's correlation coefficients (r) against software derived results were: GET 0.78 (P<.0001), SBTT 0.28 (P<.05), CTT 0.96 (P<.0001), WGTT 0.99 (P<.0001). VCE yielded lower GET (0.71±0.08 hours) and SBTT (4.15±0.13 hours). CONCLUSIONS AND INFERENCES: GET, SBTT, CTT and WGTT obtained by WMC are commensurate with literature values, including by other methods. Visually and software derived transit times have strongest correlations for CTT and WGTT. WMC yields longer GET and SBTT than VCE, perhaps due to meal related effects on motility.

Maternal complications in a geographically challenging and hard to reach district of Bangladesh: a qualitative study.

Background: Maternal complications contribute to maternal deaths in developing countries. Bangladesh still has a high prevalence of maternal mortality, which is often preventable. There are some geographically challenging and hard to reach rural districts in Bangladesh and it is difficult to get information about maternal complications in these areas. In this study, we examined the community lay knowledge of possible pregnancy complications. We also examined the common practices associated with complications and we discuss the challenges for the community. Methods: The study was conducted in Moulvibazar of north east Bangladesh, a geographically challenged, difficult to reach district. Qualitative methods were used to collect the information. Pregnant women, mothers who had recently delivered, their guardians and traditional birth attendants participated in focus group discussions. Additionally, in-depth interviews were conducted with the family members. Thematic analyses were performed. Results: The study revealed that there is a lack of knowledge of maternal complications. In the majority of cases, the mothers did not receive proper treatment for maternal complications.   There are significant challenges that these rural societies need to address: problems of ignorance, traditional myths and family restrictions on seeking better treatment. Moreover, traditional birth attendants and village doctors also have an important role in assuring appropriate, effective and timely treatment. Conclusions:  The rural community lacks adequate knowledge on maternal complications.  Reduction of the societal barriers including barriers within the family can improve overall practices. Moreover, dissemination of adequate information to the traditional birth attendant and village doctors may improve the overall situation, which would eventually help to reduce maternal deaths.

Exploration of social factors associated to maternal deaths due to haemorrhage and convulsions: Analysis of 28 social autopsies in rural Bangladesh.

BACKGROUND: Social autopsy is an innovative approach to explore social barriers and factors associated to a death in the community. The process also sensitize the community people to avert future deaths. Social autopsy has been introduced in maternal deaths in Bangladesh first time in 2010. This study is to identify the social factors in the rural community associated to maternal deaths. It also looks at how the community responses in social autopsy intervention to prevent future maternal deaths. METHODS: The study was conducted in the Thakurgaon district of Bangladesh in 2010. We have purposively selected 28 social autopsy cases of which maternal deaths occurred due to either haemorrhage or due to convulsions. The autopsy was conducted by the Government health and family planning first line field supervisors in rural community. Family members and neighbours of the deceased participated in each autopsy and provided their comments and responses. RESULTS: A number of social factors including delivery conducted by the untrained birth attendant or family members, delays in understanding about maternal complications, delays in decision making to transfer the mother, lack of proper knowledge, education and traditional myth influences the maternal deaths. The community identified their own problems, shared within them and decide upon rectify themselves for future death prevention. CONCLUSIONS: Social autopsy is a useful tools to identify social community within the community by discussing the factors that took place during a maternal death. The process supports villagers to think and change their behavioural patterns and commit towards preventing such deaths in the future.

Environmental Heat Stress Among Young Working Women: A Pilot Study.

BACKGROUND: Heat waves are increasing significantly in frequency and severity and threaten the health and income of outdoor workers. Pregnant women workers are particularly at risk due to their delicate physiological systems and accountabilities to future generations. Animal and human studies propose that elevated body temperatures during pregnancy can induce adverse pregnancy outcomes. OBJECTIVE: To measure the change in internal body temperature (Tcore) in young working women before, after, and during work (both outdoor and indoor) on hot humid days and relate threshold temperature to the upshot adverse effects of pregnancy (teratogenicity and related miscarriage). METHODS: Tympanic temperatures were measured using infrared ear thermometers and workplace temperatures were collected using Lascar Data Logger. Brief exploratory interviews were conducted to gather qualitative data, and content analysis was also carried out. FINDINGS: Body temperatures were found elevated among outdoor women workers compared with that of indoor women workers. CONCLUSIONS: The present study found that outdoor work during pregnancy in hot, humid days might increase body temperature up to levels that could induce fetal destruction or anomaly.

Nitric oxide regulation of migrating motor complex: randomized trial of N(G)-monomethyl-L-arginine effects in relation to muscarinic and serotonergic receptor blockade.

AIM: The migrating motor complex (MMC) propels contents through the gastrointestinal tract during fasting. Nitric oxide (NO) is an inhibitory neurotransmitter in the gastrointestinal tract. Little is known about how NO regulates the MMC. In this study, the aim was to examine nitrergic inhibition of the MMC in man using N(G)-monomethyl-L-arginine (L-NMMA) in combination with muscarinic receptor antagonist atropine and 5-HT3 receptor antagonist ondansetron. METHODS: Twenty-six healthy volunteers underwent antroduodenojejunal manometry for 8 h with saline or NO synthase (NOS) inhibitor L-NMMA randomly injected I.V. at 4 h with or without atropine or ondansetron. Plasma ghrelin, motilin and somatostatin were measured by ELISA. Intestinal muscle strip contractions were investigated for NO-dependent mechanisms using L-NMMA and tetrodotoxin. NOS expression was localized by immunohistochemistry. RESULTS: L-NMMA elicited premature duodenojejunal phase III in all subjects but one, irrespective of atropine or ondansetron. L-NMMA shortened MMC cycle length, suppressed phase I and shifted motility towards phase II. Pre-treatment with atropine extended phase II, while ondansetron had no effect. L-NMMA did not change circulating ghrelin, motilin or somatostatin. Intestinal contractions were stimulated by L-NMMA, insensitive to tetrodotoxin. NOS immunoreactivity was detected in the myenteric plexus but not in smooth muscle cells. CONCLUSION: Nitric oxide suppresses phase III of MMC independent of muscarinic and 5-HT3 receptors as shown by nitrergic blockade, and acts through a neurocrine disinhibition step resulting in stimulated phase III of MMC independent of cholinergic or 5-HT3 -ergic mechanisms. Furthermore, phase II of MMC is governed by inhibitory nitrergic and excitatory cholinergic, but not 5-HT3 -ergic mechanisms.

Hydrogeochemical quality and suitability studies of groundwater in northern Bangladesh.

Agriculture, rapid urbanization and geochemical processes have direct or indirect effects on the chemical composition of groundwater and aquifer geochemistry. Hydro-chemical investigations, which are significant for assessment of water quality, were carried out to study the sources of dissolved ions in groundwater of Dinajpur district, northern Bangladesh. The groundwater samplish were analyzed for physico-chemical properties like pH, electrical conductance, hardness, alkalinity, total dissolved solids and Ca2+, Mg2+, Na+, K+, CO3(2-), HCO3(-), SO4(2-) and Cl- ions, respectively. Based on the analyses, certain parameters like sodium adsorption ratio, soluble sodium percentage, potential salinity, residual sodium carbonate, Kelly's ratio, permeability index and Gibbs ratio were also calculated. The results showed that the groundwater of study area was fresh, slightly acidic (pH 5.3-6.4) and low in TDS (35-275 mg I(-1)). Ground water of the study area was found suitable for irrigation, drinking and domestic purposes, since most of the parameters analyzed were within the WHO recommended values for drinking water. High concentration of NO3- and Cl- was reported in areas with extensive agriculture and rapid urbanization. Ion-exchange, weathering, oxidation and dissolution of minerals were major geochemical processes governing the groundwater evolution in study area. Gibb's diagram showed that all the samples fell in the rock dominance field. Based on evaluation, it is clear that groundwater quality of the study area was suitable for both domestic and irrigation purposes.

Uptake and translocation of metals in different parts of crop plants irrigated with contaminated water from DEPZ area of Bangladesh.

Metal contamination in arable soils and crops grown in and around an industrial area of Bangladesh were measured, and the transfer factor from soils to crops was calculated accordingly. The highest concentration was observed for Fe and the order of metal concentration was Fe > Zn > Cr > Pb > Cu > Ni > Cd in soils. Bioaccumulation and translocation of metals from roots to edible parts of the crop plants were varied for almost all elements studied. Absorption of metals was significantly more in the roots compared to other plant parts. Accumulation of all metals in the edible parts of the plants was compared with the recommended maximum tolerable levels proposed by the Joint FAO/WHO Expert Committee on Food Additives. Bioconcentration factors values based on dry weights were below one for all metals except Cu in the rice roots and decreased in the order of Cu > Zn > Fe > Pb > Ni > Cd > Cr.

Serial soluble CD30 measurements as a predictor of kidney graft outcome.

BACKGROUND: High levels of soluble CD30 (sCD30), a marker for T-helper 2-type cytokine-producing T cells, pre or post-renal transplantation serves as a useful predictor of acute rejection episodes. Over the course of 1-year, we evaluated the accuracy of serial sCD30 tests to predict acute rejection episodes versus other pathologies that affect graft outcomes. PATIENTS AND METHODS: Fifty renal transplant recipients were randomly selected to examine sCD30 on days 0, 3, 5, 7, 14, and 21 followed by 1, 3, 6, and 12 months. The results were analyzed for development of an acute rejection episode, acute tubular necrosis (ATN), or other pathology as well as the graft outcome at 1 year. RESULTS: Compared with pretransplantation sCD30, there was a significant reduction in the average sCD30 immediately posttransplantation from day 3 onward (P<.0001). Patients were divided into four groups: (1) uncomplicated courses (56%); (2) acute rejection episodes (18%); (3) ATN (16%); and (4) other diagnoses (10%). There was a significant reduction in sCD30 immediately posttransplantation for groups 1, 2, and 3 (P<.0001, .004, and .002 respectively) unlike group 4 (P=.387). Patients who developed an acute rejection episode after 1 month showed higher pretransplantation sCD30 values than these who displayed rejection before 1 month (P=.019). All groups experienced significant improvement in graft function over 1-year follow-up without any significant differences. CONCLUSION: Though a significant drop of sCD30 posttransplantation was recorded, serial measurements of sCD30 did not show a difference among subjects who displayed acute rejection episodes, ATN, or other diagnoses.

Posttransplantation calcineurin inhibitor-induced hemolytic uremic syndrome: single-center experience.

INTRODUCTION: Calcineurin inhibitor (CNI) induced HUS, although rare, can be a serious complication of renal transplantation. Classical syndrome of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury may not be fully manifested. METHODS: We retrospectively analyzed our data in 950 kidney recipients under follow-up in our center (1994-2008). We reviewed the kidney biopsies performed for these patients to exclude conflicting diagnoses like antibody mediated rejection. RESULTS: HUS was diagnosed in 12 patients (1.26%). None of them had HUS as the original kidney disease. Cyclosporine was the primary immunosuppression in 9 and tacrolimus in 3 patients. The median day of onset was 7 days. Manifestations were anemia (100%), thrombocytopenia (75%), elevated reticulocyte count (62.5%), fragmented red blood cells (8.3%), elevated lactate dehydrogenase (LDH) enzyme (83.3%), increased fibrin degradation product (FDP) (83.3%), reduced haptoglobin level (42.9%) and hyperbilirubinemia (25%). CNI elimination was the first step in the management. Transfusion of fresh frozen plasma (FFP) was used in 10 patients and plasma exchange with FFP in the other two. All grafts recovered function. Cyclosporine or tacrolimus were reintroduction in two patients after complete clinical and laboratory recovery. Both patients developed recurrence of HUS. While the former did not the latter did recover on further treatment of HUS. CONCLUSION: Anemia, thrombocytopenia, elevated LDH and FDP are the most frequent manifestations of HUS. Early CNI elimination and fresh plasma transfusion can revert CNI induced HUS and save the graft. Reintroduction of CNI may be deleterious to the graft and should be avoided.

Evaluation of processes controlling the geochemical constituents in deep groundwater in Bangladesh: spatial variability on arsenic and boron enrichment.

Forty-six deep groundwater samples from highly arsenic affected areas in Bangladesh were analyzed in order to evaluate the processes controlling geochemical constituents in the deep aquifer system. Spatial trends of solutes, geochemical modeling and principal component analysis indicate that carbonate dissolution, silicate weathering and ion exchange control the major-ion chemistry. The groundwater is dominantly of Na-Cl type brackish water. Approximately 17% of the examined groundwaters exhibit As concentrations higher than the maximum acceptable limit of 10 microg/L for drinking water. Strong correlation (R(2)=0.67) of Fe with dissolved organic carbon (DOC) and positive saturation index of siderite suggests that the reductive dissolution of Fe-oxyhydroxide in presence of organic matter is considered to be the dominant process to release high content of Fe (median 0.31 mg/L) in the deep aquifer. In contrast, As is not correlated with Fe and DOC. Boron concentration in the 26% samples exceeds the standard limit of 500 microg/L, for water intended for human consumption. Negative relationships of B/Cl ratio with Cl and boron with Na/Ca ratio demonstrate the boron in deep groundwater is accompanied by brackish water and cation exchange within the clayey sediments.

Erythema nodosum in renal transplant recipients: multiple cases and review of literature.

We report 4 renal transplant recipients with erythema nodosum. Erythema nodosum is a cutaneous inflammatory reaction located on the anterior aspects of the lower extremities. It may be associated with a wide variety of diseases, including infections (as in Cases 1 and 2), sarcoidosis, rheumatologic diseases, inflammatory bowel diseases (as in Case 3), medications (as in Case 4), autoimmune disorders, pregnancy, and malignancies. Histopathologically, erythema nodosum is the stereotypical example of a mostly septal panniculitis with no vasculitis, and the inflammatory infiltrate in the septa varies with age of the lesion. In early lesions edema, hemorrhage, and neutrophils are responsible for the septal thickening, whereas fibrosis, peri-septal granulation tissue, lymphocytes, and multinucleated giant cells are the main findings in late stage. Etiological management - by anti-tuberculous therapy in Cases 1 and 2, by salazopyrin in Case 3, and by discontinuation of ciprofloxacin in Case 4 - was associated with regression. Erythema nodosum can develop in renal transplant patients who did not receive induction therapy, non-rejecters, and those with steroid-free protocols. Management of erythema nodosum should be directed to the underlying associated condition, which could be tuberculosis, inflammatory bowel disease, or drug related.

Early sirolimus therapy in renal transplant recipients at high risk: is it justified?

BACKGROUND: We studied early sirolimus (SRL) therapy in renal transplant recipients at high risk after administration of antithymocyte globulin or interleukin-2 receptor blockade induction. PATIENTS AND METHODS: In 45 patients, SRL therapy was started within 1 month after transplantation. The primary indications for conversion of treatment from calcineurin inhibitors (CNIs)-mycophenolate mofetil (MMF)-steroid to SRL-MMF-steroid were biopsy-proved rejection (after treatment), CNI toxicity, CNI elimination, and acute tubular necrosis. Pediatric, geriatric, and other patients with medical comorbidities were not excluded. RESULTS: Post-SRL rejection episodes were reported in 22.2% of recipients including 15.6% who were resistant to steroid therapy. Mean (SD) follow-up after SRL therapy was 59.9 (8.1) months. Proteinuria greater than 2 g/d (P = .001), leukopenia (P < .001), hyperlipidemia (P < .001), and transaminases values (P = .02) increased significantly after SRL therapy. Graft survival was 88.8%, and patient survival was 93.3%. There was significant improvement in serum creatinine concentration and estimated creatinine clearance by the end of the study (P < .001). A high incidence of adverse effects and infections was noted post-SRL therapy, and the drug was discontinued in 31% of patients because of multiple adverse effects. At multivariate analysis, age, hypertension, nutritional status, bone marrow suppression, hyperlipidemia, and graft dysfunction were identified as risk factors for worse graft and patient outcome. CONCLUSION: Early treatment with combined SRL-MMF-steroid may be effective as a CNI-free immunosuppression regimen in patients at high risk; however, there is a high rate of adverse effects during long-term follow-up.

Active management of post-renal transplantation BK virus nephropathy: preliminary report.

OBJECTIVE: To assess the efficacy of leflunomide, intravenous immunoglobulins, and ciprofloxacin as active treatment of postrenal transplant BK virus nephropathy (BKVN) in graft outcome at 1 year. PATIENTS AND METHODS: Renal transplant recipients with positive results of 2 BK virus polymerase chain reaction tests of urine and blood underwent graft biopsy to confirm BKVN. If BKVN was diagnosed, antimetabolite therapy (mycophenolate mofetil or azathioprine) was changed to leflunomide therapy accompanied by a course of immunoglobulin and oral ciproflxacin. RESULTS: Of 18 patients evaluated, 72% were men. Nine patients received cadaveric organs, with a mean of 3.6 HLA mismatches. All patients received induction thereapy (61% thymoglobulin), and 61% received antirejection therapy before BKVN was diagnosed. Maintenance immunosuppression therapy was primarily with prednisolone (94%); mycophenolate mofetil, 2 g/d (94%); and tacrolimus (61%). At baseline, mean (SD) creatinine clearance was 35.6 (11.5) mL/min/1.73(2), which decreased to 29.3 (17.3) mL/min/1.73(2) at 1 year (P = .01). Patients were divided into 2 groups of 9 each according to creatinine clearance values. In group 1, baseline value was 44.5 (6.6) mL/min/1.73(2), compared with 25.36 (7.8) mL/min/1.73(2) in group 2, which decreased to 42.66 (12.8) mL/min/1.73(2) (P = .23) and 16.76 (9.0) mL/min/1.73(2) (P = .009), respectively, at 1 year. Three grafts (16.7%) were lost by the end of the study, all in group 2 (P = .03). CONCLUSION: Late diagnosis and intensive immunosuppression predispose to BKVN. Early active treatment of BKVN may improve graft outcome at 1 year posttransplantation.

Long-term follow-up of 100 high-risk renal transplant recipients converted from calcineurin inhibitors to sirolimus: a single center experience.

While conversion of stable renal transplant recipients (RTR) from calcineurin inhibitors (CNI) to sirolimus (SRL) is safe and effective, it is still under investigation for recent, high-risk cases. We studied the long-term effects of conversion of high-risk subjects maintained on a CNI, mycophenolate mofetil, plus steroid regimen to SRL, mycophenolate mofetil, plus steroid on graft and patient outcomes. We retrospectively reviewed the first 100 RTR converted to SRL treatment over approximately 5 years. The main indications for conversion were biopsy-proven acute rejection (BPAR), CNI toxicity, CNI elimination, and acute-tubular necrosis (ATN). Exclusion criteria were limited to bone marrow suppression. The overall mean +/- SD age was 38.5 +/- 15.6 years, including pediatric and geriatric age groups. Mean +/- SD body mass index (BMI) was 28.99 +/- 8.0 and 40% had a BMI > 30. There were 40% RTR from deceased donors and 60% showed 4 to 6 HLA mismatches. Preconversion total BPAR and steroid-resistant rejection incidences were 35% and 14%, respectively. Mean +/- SD time to start of SRL was 11.9 +/- 22.8 months posttransplantation. Proteinuria > 2 g/d, leukopenia, and hyperlipidemia increased significantly after conversion (P = .001, P = .0003, and P = .0001, respectively). Patient and graft survivals were 95% and 90%, respectively. There was significant improvement in graft function postconversion (P < .0001). There was a high incidence of side effects and cases of SRL discontinuation. Multivariate analysis demonstrated the influence of bone marrow suppression, obesity, hyperlipidemia, nutritional status, proteinuria, and graft function on graft and patient outcomes. We concluded that conversion from CNI to SRL was effective among high-risk RTR, but with a high incidence of adverse events during long-term follow-up.