Ocular Surface Squamous Neoplasia in Renal Transplant Patients.

Transplantation surgery becomes more widespread with time worldwide; organ transplantation increases the risk of developing malignancies. This phenomenon is primarily due to immunosuppressive treatment which is one of the mainstay approaches to prevent transplant rejection. It is aimed to describe clinical signs and symptoms of histologically proven ocular surface squamous neoplasia (OSSN) in renal transplant patients. Three patients, who previously underwent renal transplant surgery, diagnosed with OSSN are presented. The histopathological examination results were conclusive for squamous cell neoplasia in all cases. No recurrence in any patients was observed after total surgical excision, cryotherapy, and reconstruction with amniotic membrane. Solid organ transplant patients undergo intense immunosuppressive treatment to prevent transplant rejection. That immunosuppressive treatment increases the risk of developing secondary malignancies including OSSN. It is important to inform all transplant patients about these risks. Even though OSSN is known to be a relatively benign acting tumor that rarely metastasizes to distant organs, the clinical course might change if it develops in an immunocompromised patient. For this reason, these patients should be monitored for any formation of a mass on the ocular surface. Surgical management through complete excision can result in the complete resolution of a tumor.

Febrile Immunocompromised Renal Transplant Recipient with Allograft Dysfunction: Detection of an Undiagnosed Prostate Abscess by [ 18 F]FDG-PET/CT along with Treatment Response Monitoring.

The purpose of this report is to provide a comprehensive description of a post-transplant febrile patient's clinical course, complications, surgical procedure, and long-term management including evaluation by 18 F-fluorodeoxyglucose [( 18 F)FDG] positron-emission tomography combined with computed tomography (PET/CT). A 35-year-old male, a postrenal transplant patient, developed chronic allograft dysfunction and presented with fever with chills, with suspicion of acute-on-chronic graft dysfunction, but no infective focus localization on chest X-ray, ultrasonography (USG) whole abdomen, or blood culture. Urine microscopy showed 8 to 10 pus cells/high-power field (hpf) and culture showed Klebsiella pneumoniae and Pseudomonas aeruginosa with low colony count. Culture-sensitive antibiotics were prescribed for 2 weeks, and after 3 weeks febrile episodes relapsed, symptoms progressed, and required emergency hospitalization due to acute painful urinary retention. Proteinuria and no growth were noted in urine analysis, serum creatinine was 5.36 mg/dL, and C-reactive protein was 15.7mg/dL, and remaining parameters were unremarkable. [ 18 F]FDG-PET/CT was considered in order to resolve diagnosis, which revealed abnormal heterogeneous tracer uptake in the enlarged prostate with hypodense areas within, suggesting prostatitis with abscess formation and pyelonephritis in the upper pole of the transplant kidney. USG kidney urinary bladder (KUB) correlation confirmed prostatic abscess and transurethral drainage done, and pus culture revealed Burkholderia pseudomallei . Culture-sensitive intravenous meropenem treatment was given for 3 weeks. At 5 weeks, follow-up [ 18 F]FDG-PET/CT showed low metabolic residual prostate uptake, suggesting a good response with residual infection. Thus, intravenous antibiotics was changed to oral antibiotics for another 6 weeks. His symptoms completely resolved at the end of treatment; however, his graft function worsened, with serum creatinine reaching 6 to 7 mg/dL, and eventually, after 8 months he became dialysis dependent.

Calcineurin inhibitor-induced pain syndrome (CIPS) affects the hips in a renal transplant recipient: A case report.

Calcineurin inhibitor-induced pain syndrome is a rare but debilitating complication of organ transplantation. This case report describes a man in his forties who developed bilateral hip pain, an atypical presentation of calcineurin inhibitor-induced pain syndrome, after undergoing renal transplantation. Initially, avascular necrosis was suspected as a potential cause of pain. The initial radiographs revealed no abnormalities. However, high trough levels of calcineurins and subsequent magnetic resonance imaging of the hip revealed bilateral symmetric bone marrow edema, which was consistent with calcineurin inhibitor-induced pain syndrome. Adjustments made to the immunosuppressive regimen and multidisciplinary management resulted in an improvement in the patient's symptoms. This case report emphasizes the importance of adopting a comprehensive approach to post-transplantation pain management. Moreover, this report emphasizes the importance of considering the diagnosis of calcineurin inhibitor-induced pain syndrome while investigating and managing post-transplantation patients presenting with hip pain. Clinicians need a high index of suspicion for calcineurin inhibitor-induced pain syndrome, thereby contributing to enhanced post-transplantation care and outcomes while improving the quality of life of transplant recipients experiencing musculoskeletal pain.

Prophylactic Peri-Nephric Drain Placement in Renal Transplant Surgery: A Systematic Review and Meta-Analysis.

Renal transplantation is common worldwide, with >25,000 procedures performed in 2022. Usage of prophylactic perinephric drains is variable in renal transplantation; drains are associated with risks, and there is a lack of consensus regarding benefit of routine drain placement in these patients. This meta-analysis assessed whether prophylactic drainage reduced need for reintervention postoperatively. This systematic review and meta-analysis was carried out using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis, and prospectively registered on PROSPERO. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). A systematic literature search in June 2023 revealed 1,540 unique articles across four databases. Of these, four retrospective cohort studies were selected. Meta-analysis of three studies showed no significant reduction in reintervention rate with pre-emptive drain placement, OR = 0.59 (95% CI: 0.16-2.23), p = 0.44. Meta-analysis did not show a significant reduction in perinephric collections with prophylactic drain insertion OR = 0.55 (95% CI: 0.13-2.37), p = 0.42. Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Further work is needed, including well-designed, prospective studies to assess the risks and benefits of drain placement in these patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422685, Identifier PROSPERO CRD42021255795.

A Rare Parasitic Infection from the Common Cockroach: A Case of Lophomonas Blattarum from a Tertiary Center in Kerala.

Immunocompromised patients are prone to various opportunistic infections. Most of the infections are easily detectable through staining, culture, and polymerase chain reaction techniques. Nevertheless, it is also important to have wet smear examinations of samples. We present a case of pneumonia in a post-transplant recipient who was on immunosuppressants and detected to have an infection from the parasite, lophomonas blattarum, which usually resides in the hindgut of cockroaches.

Medical and Surgical Weight Loss as a Pathway to Renal Transplant Listing.

PURPOSE: Severe obesity is a barrier to listing for kidney transplantation due to concern for poor outcomes. This study aims to compare bariatric surgery with medical weight loss as a means of achieving weight loss and subsequent listing for renal transplant. We hypothesize that bariatric surgery will induce greater frequency of listing for transplant within 18 months of study initiation. MATERIALS AND METHODS: We performed a randomized study of metabolic bariatric surgery (MBS) vs medical weight loss (MM) in patients on dialysis with a body mass index (BMI) of 40-55 kg/m2. The primary outcome was suitability for renal transplant within 18 months of initiating treatment. Secondary outcomes included weight loss, mortality, and complications. RESULTS: Twenty patients enrolled, only 9 (5 MBS, 4 MM) received treatment. Treated groups did not differ in age, gender, or race (P ≥ .44). There was no statistically significant difference in the primary endpoint: 2 MBS (40%) and 1 MM (25%) listed for transplant ≤18 months (P = 1.00). With additional time, 100% MBS and 25% MM patients achieved listing status (P = .048); 100% of MBS and 0 MM received kidney transplants to date (P = .008). Weight, weight loss, and BMI trajectories differed between the groups (P ≤ .002). One death from COVID-19 occurred in the MM group, and 1 MBS patient had a myocardial infarction 3.75 years after baseline evaluation. CONCLUSION: These results suggest MBS is superior to MM in achieving weight loss prior to listing for kidney transplantation. Larger studies are needed to ensure the safety profile is acceptable in patients with ESRD undergoing bariatric surgery.

Silent Manifestations of Disseminated Nocardia in a Renal Transplant Patient.

This case report describes a unique presentation of disseminated nocardiosis in a 45-year-old male transplant recipient who initially presented with acute left hip pain. Despite being asymptomatic for respiratory symptoms, the patient developed a fever and subsequently exhibited hypoxia. A diagnostic workup revealed a cavitary mass in the right upper lobe and multiple pulmonary nodules, confirming silent pulmonary nocardiosis. Concurrently, an MRI identified myositis and a possible abscess in the left hip musculature. Treatment involved a regimen including imipenem-cilastatin and linezolid, tailored for Nocardia species farcinica. This case underscores the importance of vigilant evaluation for metastatic infections in immunocompromised patients presenting with atypical symptoms, highlighting the necessity of imaging studies such as CT of the thorax for early detection of silent pulmonary involvement.

Clinical characteristics of renal cell carcinoma in the transplanted kidney in renal transplant recipients: a systematic scoping review.

Background: Renal transplant recipients confront a substantially elevated susceptibility to renal cell carcinoma (RCC), particularly in their native kidneys as opposed to allografts. Methods: In this systematic scoping review, exhaustive searches were conducted of the MEDLINE and EMBASE databases. Information was gathered on clinical manifestations, donor demographics, diagnostic intervals, tumor dimensions, histopathological characteristics, and therapeutic outcomes associated with RCC arising in allograft kidneys. Results: The searches yielded a corpus of 42 case reports and 11 retrospective cohorts, encompassing a cohort of 274 patients. The majority of cases (75.4%) were clinically latent, discerned primarily through imaging modalities. Symptomatic presentations encompassed manifestations such as hematuria, elevated serum creatinine levels, abdominal discomfort, and graft-related pain. The mean temporal interval between renal transplantation and RCC diagnosis was calculated at 11.6 years, albeit displaying considerable variance. Notably, papillary and clear cell RCC emerged as the prevailing histopathological subtypes. However, the paucity of longitudinal follow-up data represents a notable caveat. Conclusion: This investigation underscores the imperative of rigorous posttransplant surveillance regimes owing to the substantial prevalence of asymptomatic RCC instances. Future research should focus on clinical outcomes and cost-effectiveness of screening practices to develop preventive strategies.

A Rare Case of Urinary Bladder Leiomyoma Invading Urachal Remnant Managed With Robotic Partial Cystectomy.

Leiomyoma is a rare benign tumour of the urinary bladder. Typically, bladder leiomyomas are treated with transurethral resection, which yields favourable results. We present a clinical case of a 29-year-old man with a symptomatic bladder tumour, initially diagnosed on flexible cystoscopy and CT scan. Subsequent transurethral resection and MRI scan confirmed a transmural bladder leiomyoma invading the urachal remnant. The patient was subsequently treated with robotic partial cystectomy. The presentation and management, including imaging and histopathology results, are discussed with a brief review of the literature.

Cancer Screening in Renal Transplant Recipients: Real-World Data.

Background: Multiple international guidelines have endorsed cancer screening in renal transplant patients. This study aimed to describe a series of patients with post-transplant cancer and to report physicians' adherence to cancer screening guidelines. Methods: This is a retrospective study of cancer patients who had a history of renal transplant. Charts of patients who were treated at our institution between 2012 and 2023 were reviewed, patients' clinical data were collected. Results: Thirty-nine patients were identified. The most common types of cancer were lymphoma (n = 9, 23%), squamous cell carcinoma (SCC) of the skin (n = 8, 20.5%), and breast (n = 6, 15.4%). The median age at diagnosis was 56.5 years (range: 16.9 - 70.2), family history of malignancy was depicted in 18 (46.2%) cases. Chart review and patients' questionnaire revealed that increased risk of malignancy was discussed in seven (18%) out of 39 recipients (P < 0.001) at time of transplant, and only three (7.7%, P < 0.001) patients were on post-transplant age-matched cancer screening. Conclusions: The increased risk of malignancy is a serious post-transplant complication. Lymphoma and non-melanoma skin cancer were the most common cancers. Most patients were not offered routine cancer screening; it is important to raise awareness among nephrologists and caregivers regarding the risk of post-transplant malignancy.

When Medications Backfire: A Case Report of Rifaximin-Induced Rhabdomyolysis in a Kidney Transplant Patient.

Rhabdomyolysis involves significant skeletal muscle injury and destruction, which can be triggered by trauma, intense physical activity, heat, prolonged immobility, certain medications, and endocrine disorders. Rhabdomyolysis in renal transplants can be more complicated, and the prognosis is not well known, especially in the context of coexisting rejection. We present a case of rifampicin-induced rhabdomyolysis with superimposed acute cellular rejection in a kidney transplant patient.

Definitive chemoradiotherapy for a patient with anal cancer after renal transplantation.

Patients after renal transplantation are susceptible to secondary malignancies, including anal squamous cell carcinoma. Chemoradiotherapy is the standard treatment for anal squamous cell carcinoma; however, typical irradiation fields for anal cancer encompass a transplanted kidney located in the right iliac fossa, which causes complete renal dysfunction. Thus, typical irradiation fields are not feasible for this population. Additionally, standard concurrent chemotherapy demonstrates nephrotoxicity. Here, we report a case of modified definitive chemoradiotherapy for a 40-year-old patient with locally advanced perianal squamous cell carcinoma after renal transplantation whose abdominoperineal resection was difficult because of a history of repeated open surgeries and long-term steroids. We modified the cranial side of the elective nodal irradiation fields in this case to spare the transplanted kidney, considering the lymph chains of the perianal tumor. We then used continuous 5-fluorouracil to avoid nephrotoxicity of mitomycin C, considering his life expectancy. Modified definitive chemoradiotherapy achieved complete remission with expected toxicities. Now, approximately five years after the procedure, the patient remains disease-free, preserving anal and renal function. Definitive chemoradiotherapy using modified irradiation fields and chemotherapy may be an option for patients with anal squamous cell carcinoma after renal transplantation.

Role of Shear Wave Elastography for Assessment of Renal-Allograft Fibrosis and its Correlation With Histopathology.

OBJECTIVES: To investigate whether shear wave elastography (SWE) can accurately identify interstitial fibrosis and tubular atrophy (IFTA) in chronic renal allograft injury (CRAI) and whether it can differentiate between different grades of IFTA. MATERIALS AND METHODS: Prospective observational study on renal transplant recipients who presented with CRAI. Patient selection was done on the basis of clinical presentation, serum creatinine, and eGFR levels. Biopsy and SWE were performed and SWE values were correlated with histopathological findings according to Banff schema. Receiver operating characteristic (ROC) was also analyzed to assess the diagnostic efficacy of SWE. RESULTS: Sxity-one patients were evaluated. Ten patients had no IFTA, 33 patients had mild IFTA, 16 patients had moderate IFTA, and 2 patients had severe IFTA. Mean parenchymal stiffness values in no IFTA, mild IFTA, moderate IFTA and severe IFTA were 39.86 ± 2.17 kPa (3.64 ± 0.09 m/s), 41.59 ± 3.36 kPa (3.71 ± 0.15 m/s), 47.59 ± 3.34 kPa (3.98 ± 0.14 m/s), and 53.83 ± 1.41 kPa (4.25 ± 0.03 m/s), respectively. SWE values of parenchymal stiffness reached statistical significance to differentiate between mild, moderate, and severe IFTA. ROC analysis revealed cut-off values of 45.09 kPa (3.89 m/s) to differentiate between mild IFTA and moderate IFTA, 52.06 kPa (4.18 m/s) to differentiate between moderate IFTA and severe IFTA with acceptable sensitivity and specificity. CONCLUSION: SWE is a non-invasive and cost-effective imaging tool to evaluate the disease status of renal allografts affected by CRAI. Thus, it can be of paramount importance if added to the regular follow-up imaging protocol of renal allograft along with grayscale and Doppler imaging.

Impact of Renin-Angiotensin System Blockade on Mortality and Allograft Loss among Renal Transplant Recipients: A Systematic Review and Meta-Analysis.

INTRODUCTION: The blockade of the renin-angiotensin system (RAS) has a beneficial effect on reducing the levels of proteinuria and blood pressure in patients with chronic kidney disease (CKD) and reduces the risk of developing end-stage kidney disease in CKD patients. Nonetheless, a debate persists regarding the impact of RAS inhibitors on outcomes such as mortality and graft survival in renal transplant patients. To assess the effect of RAS inhibitors on graft recipients in the past decade, we conducted a systematic review and meta-analysis. METHODS: We searched Embase, PubMed, and the Cochrane Central Register of Clinical Trials from January 1, 2012, to August 1, 2022. We included 14 articles, comprising 5 randomized controlled trials (RCTs) and 9 cohort studies, including 45,377 patients. These studies compared patient or graft survival between an RAS inhibitor treatment arm and a control arm. RESULTS: The meta-analysis revealed that RAS blockade was significantly associated with lower mortality in cohort studies (risk ratio [RR] = 0.66, 95% confidence interval [CI]: 0.55-0.79), reduced allograft loss in cohort studies (RR = 0.62, 95% CI: 0.54-0.71), and significant changes in systolic blood pressure in RCTs. Subgroup analysis of the groups of interest (interventions involving RAS blockade, follow-up period of ≥5 years) showed consistently reduced mortality (RR = 0.67, 95% CI: 0.56-0.81) and reduced allograft loss (RR = 0.61, 95% CI: 0.54-0.70). CONCLUSIONS: Our results demonstrated that the application of RAS blockade among renal transplant recipients was associated with lower mortality and allograft loss in cohort studies but not in RCTs. More powered clinical trials are needed to evaluate the effects of RAS blockade in renal transplant recipients.

Redo Tricuspid and Pulmonary Valve Replacement with On-X in Renal Transplant Patient: A Case Report.

Surgical treatment is recommended in patients with symptomatic severe tricuspid regurgitation and pulmonary regurgitation. Although renal transplant patients are a high-risk patient group for cardiac surgery, heart valve surgeries can be performed successfully. There are a limited number of studies published on this subject in the literature. Therefore, we present a case who underwent tricuspid ring annuloplasty (TRA) before being followed up with renal transplantation and then successfully performed redo tricuspid valve replacement (TVR) and pulmonary valve replacement (PVR).

Rectus sheath patch. A novel surgical technique in the repair of isolated renal pelvis necrosis in a transplanted kidney. A case report.

INTRODUCTION: Focal necrosis of the renal pelvis in a transplanted kidney is a rare but often morbid complication that may lead to graft loss. Given the scarcity of donor organs, all attempts are made to preserve the graft. Currently there is no standard surgical technique for reconstruction or repair of isolated renal pelvic necrosis. PRESENTATION OF CASE: A 70-year-old male with end stage kidney disease underwent renal transplantation. The patient developed a day-three post-operative urine leak. During surgical exploration, a focal area of pelvic necrosis was observed without evidence of proximal or distal ureteric involvement. Given the excellent function of the renal allograft, a novel surgical technique was successfully used to repair the necrotic defect. Reconstruction of the renal pelvis was performed using an avascular rectus sheath patch. The patch was secured over the open pelvis following necrotic tissue debridement. The patient made a successful recovery with complete resolution of urine leak. A 6-week post-operative retrograde pyelogram confirmed no ongoing urine leak. DISCUSSION: To restore anatomy, the pelvic defect was patched with avascular rectus sheath fascia. Advantages of this reconstructive method were technique simplicity and low donor site morbidity. Potential complications included patch failure with ongoing urine leak, ventral wall hernia through the fascial donor site and stenosis of the ureteropelvic junction. CONCLUSION: This case highlights the successful surgical management of a renal pelvis urine leak patched with rectus sheath fascia. This technique could be considered as a graft saving procedure in similar cases where the alternative is transplant nephrectomy.

Protean Drainage Patterns of the Left Renal Vein: A Cadaveric and Retrospective Clinical Study on the Surgical Implications and Technical Feasibility.

BACKGROUND: The diverse drainage patterns of the left renal vein (LRV), often with asymptomatic congenital anomalies, present considerable challenges in renal and retroperitoneal surgical contexts. The potential for significant bleeding and subsequent renal compromise upon vascular injury highlights the need for increased surgical awareness. OBJECTIVE: This study investigates the LRV's variable anatomical drainage patterns and morphometry. It also evaluates the embryological factors contributing to these variations and discusses their surgical implications and technical considerations. METHODS: Anatomical dissections were conducted on 21 adult human cadavers within the Department of Anatomy. Concurrently, a retrospective analysis was conducted on 15 patients who underwent various retroperitoneal surgical interventions in the Urology Department. Demographic variables and intraoperative findings were recorded and analyzed. RESULTS: Dissection analysis predominantly identified preaortic LRVs in 18 cadavers. Notable anatomical variations included a circumaortic left renal vein (CLRV), a delayed preaortic confluence of extrahilar duo LRVs, and an extrahilar tetramerous confluence with a retroiliac topography. The majority of LRVs usually end in the inferior vena cava. However, an extrahilar tetramerous variant had an unusual drainage pathway. Out of 15 cases, three (20%) had a retroaortic left renal vein (RLRV). One patient with a nonfunctioning kidney had type 1 RLRV, and another patient with pelvic ureteric junction obstruction had type 4 retroiliac left renal vein (RILRV). In both of these patients, symptoms were relieved after surgery. In a young patient with left varicocele and microscopic hematuria who had type 2 RLRV, symptoms resolved spontaneously after a few months. CONCLUSION: A thorough understanding of the variable anatomical drainage patterns of the LRV is crucial for surgeons. Accurate preoperative identification can provide valuable insights, potentially leading to improved surgical outcomes in renal procedures.

A novel approach to therapeutic drug monitoring of Ciclosporin in pediatric renal transplant recipients using volumetric absorptive microsampling (VAMS) - Teaching old dog new tricks.

BACKGROUND AND AIMS: Ciclosporin (CSA) is an immunosuppressive agent that requires therapeutic drug monitoring (TDM). High partitioning in erythrocytes indicates that whole blood (WB) is a suitable matrix for CSA determination. Alternative sampling strategies, such as volumetric absorptive microsampling (VAMS), are novel possibilities for blood collection during TDM for various analytes, including immunosuppressants. This technique is attractive for vulnerable pediatric patients, including home-based self-sampling, remote therapy, and adherence control. MATERIALS AND METHODS: This study aimed to develop and validate a new method for CSA determination based on liquid chromatography-tandem mass spectrometry (LC-MS/MS) of WB and VAMS samples. Additionally, these methods were applied for CSA determination in clinical samples from pediatric transplant recipients. A strong point of this study is the assessment of an external proficiency testing scheme. RESULTS: Both methods were successfully validated within the 1-2000 ng/mL calibration range, with LOD 0.5 and 1 ng/mL for WB and VAMS methods, respectively. All the validation parameters fulfilled the international acceptance criteria for bioanalytical methods. Cross-validation confirmed the interchangeability of the LC-MS/MS method developed in this study. CONCLUSION: This study developed and validated novel methods for CSA determination in whole blood and VAMS using LC-MS/MS. Clinical validation and proficiency testing confirmed their utility in routine clinical practice.

Assessment of the herpes zoster risk among renal transplant recipients administered the influenza vaccine.

BACKGROUND: Reactivation of the latent varicella-zoster virus can cause herpes zoster (HZ) infection, and renal transplant recipients undergoing immunosuppressive therapy are particularly susceptible to this condition. This study aims to evaluate the potential increase in HZ incidence following influenza vaccination among this specific patient population. METHODS: This study was a population-based, retrospective, self-controlled case series. Data were retrieved from Taiwan's National Health Insurance Research Database spanning the years 2008 to 2017. Patients diagnosed with HZ within a 6-month period before and after receiving the influenza vaccine were eligible for inclusion. Two distinct time intervals were defined for analysis: the initial 15 days and 30 days following vaccination were categorized as risk intervals, while all other periods served as control intervals. Incidence rate ratios (IRRs) were computed to compare HZ incidence during the risk intervals with that during the control intervals. RESULTS: This study encompassed a cohort of 4,222 renal transplant recipients who had received the influenza vaccine. Among this group, 67 recipients were subsequently diagnosed with HZ. The IRR during both the initial 15 days (IRR = 0.63; 95 % CI, 0.23-1.89) and the first 30 days (IRR = 1.50; 95 % CI, 0.71-3.16) following influenza vaccination did not demonstrate a statistically significant increase when compared to the post-exposure observation times. Comparable results were also observed when comparing these IRR values to the pre-exposure observation times. The subgroup analysis, stratified by age, sex, and underlying medical conditions (including cancer and autoimmune diseases), revealed that the IRRs did not exhibit statistically significant differences. CONCLUSIONS: No significant association between the influenza vaccine and an elevated risk of HZ was detected. The administration of annual influenza vaccines appears to be a reasonable practice for renal transplant recipients.