Anupma Kaul

Dengue virus infection in renal allograft recipients: a case series during 2010 outbreak

Dengue virus infection is an emerging global threat caused by Arbovirus, a virus from Flaviridiae family, which is transmitted by mosquitoes, Aedes aegypti and Aedes albopictus. Renal transplant recipients who live in the endemic zones of dengue infection or who travel to an endemic zone could be at risk of this infection. Despite multiple epidemics and a high case fatality rate in the Southeast Asian region, only a few cases of dengue infection in renal transplant recipients have been reported. Here, we report a case series of 8 dengue viral infection in renal transplant recipients. Of the 8 patients, 3 developed dengue hemorrhagic shock syndrome and died.

Cryptosporidium infection after renal transplantation in an endemic area

Cryptosporidium is one of the common causes of infective diarrhea in post‐transplant patients in endemic areas. However, data are limited on Cryptosporidium infection in recipients of solid organ transplantation. The aim of this study was to determine the incidence, disease manifestation, management, and outcome of Cryptosporidium infection in living‐donor renal transplant recipients (RTR).

Assessment of allograft function using diffusion-weighted magnetic resonance imaging in kidney transplant patients

Developing a non-invasive method such as diffusion-weighted magnetic resonance imaging (DWMRI) could be used as a feasible and reproducible modality in the differential diagnosis of allograft dysfunction. We assessed the functional status of the renal allograft by DWMRI and its applicability in assessment of graft dysfunction on all end-stage renal transplant patients who attained normal renal function on the 7th day post-transplantation. Follow-up imaging of the recipient allograft was performed at the end of 90 and 180 days and in case of graft dysfunction. Kidney biopsies were performed to correlate with the corresponding MRI. The apparent diffusion coefficient (ADC) maps of the cortex and medulla were obtained by studying the DWMRI. The ADC values were significantly lower in the medulla compared with the cortex in normal donor kidneys and normally functioning transplanted kidneys, while they decreased significantly when rejection occurred. The reduction in ADC values occurred both in the cortex and in the medulla, and correlated with the degree of rejection on the kidney biopsies. The ADC values increased significantly during the recovery from rejection. We conclude that DWMRI can be beneficial in the diagnosis and follow-up of transplant patients during acute rejection.

Safety and effectiveness of response‐guided therapy using pegylated interferon and ribavirin for chronic hepatitis C virus infection in patients on maintenance dialysis

Treatment of hepatitis C virus (HCV) infection in patients with end‐stage renal disease (ESRD) is difficult. Addition of ribavirin to pegylated‐interferon (Peg‐IFN) may help to improve the treatment response. Further, treatment duration could be shortened using a response‐guided treatment (RGT) approach.

Chickenpox infection after renal transplantation

Background. Chicken pox, although a common infection among children, is rare in immunocompromised patients, particularly renal transplant recipients, and carries a very high incidence of morbidity and mortality There is little data on chickenpox in adult renal transplant recipients, although reports have suggested that it may follow a virulent course requiring frequent hospitalization, and in severe cases can cause death. Aims. To evaluate the incidence, severity and complications of a varicella/chickenpox infection in renal transplant recipients over 10 years follow-up. Results. An incidence of 1.48% of our patients were diagnosed with varicella infection during this 10-year period from June 2000 to June 2010 in our live-related renal transplant program, with a median patient age of 39 years (range 21–54 years). Graft dysfunction was observed among five patients following the infection, two of whom became dialysis-dependent. The other three had mild graft dysfunction from which they subsequently recovered, suggesting that infection was responsible for graft dysfunction. None of them developed rejection following exposure or with modification of immunosuppression. All of our patients required admission with 47.8% presenting with various presentations, with orchitis, pancreatitis, encephalitis and gastritis each affecting 8.6% of the patients. All patients were managed with intravenous acyclovir for 2 weeks followed by oral acyclovir for 3 months. The infection was associated with an increased mortality of 13.4% due to superadded infections and central nervous system involvement in one patient with fatal bilateral pneumonia. Conclusions. This infection, which is a benign disease with a largely stable course among the general population, can have severe outcomes for immunocompromised patients, accounting for almost 90% with significant morbidity and mortality in the 8.6% of infected patients, thus highlighting the importance of pre-transplant vaccination in this subgroup of the population.

Rapidly progressive renal failure—a rare presentation of granulomatous interstitial nephritis due to tuberculosis—case report and review of literature

Granulomatous interstitial nephritis (GIN) is a rare manifestation of renal tuberculosis (TB). We report a case of rapidly progressive renal failure (RPRF), granulomatous inflammation of cervical lymph node and GIN as presenting manifestations of TB. Aspiration cytology of cervical lymph node showed granulomatous necrotizing inflammation with acid-fast bacilli (AFB). The renal biopsy and urine specimen did not show AFB. Urine polymerase chain reaction (PCR) for Mycobacterium tuberculosis was positive. We observe that GIN due to TB can present as RPRF and emphasize the value of PCR-based techniques in making a correct diagnosis.

Daclatasvir and reduced-dose sofosbuvir: an effective and pangenotypic treatment for hepatitis C in patients with eGFR <30 ml/min: HCV treatment in ESRD patients on dialysis

Sofosbuvir is a key agent for HCV treatment. It is not recommended for patients with chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) <30 mL/min. We report real‐life experience of treating a cohort of CKD patients with eGFR <30 mL/min using daclatasvir and half‐daily dose of sofosbuvir.

Efficacy and safety of sofosbuvir-based antiviral therapy to treat hepatitis C virus infection after kidney transplantation

ABSTRACT Background The objectives of this pilot study were to assess the efficacy and safety of an interferon-free sofosbuvir and ribavirin combination regimen to treat chronic hepatitis C virus (HCV) infection in kidney transplant recipients and to study the impact of sofosbuvir on calcineurin inhibitor (CNI) drug levels. Methods A total of 10 kidney transplant recipients with chronic HCV infection were included in the study. All received sofosbuvir and ribavirin combination therapy. The virological response to therapy and the adverse effects of the drugs were studied. The area under the curve (AUC) and pharmacokinetic data of levels of CNI were compared while the patients were receiving sofosbuvir and ribavirin drugs and when they were no longer on these drugs. Results In all, 9 of 10 patients (90%) achieved rapid virological response (RVR) with undetectable HCV RNA at 4 weeks and the remaining patient achieved undetectable HCV RNA at 8 weeks. A sustained virological response was seen at 3, 6 and 12 months and was maintained in all 10 patients (100%). The important aspect of the study is the effect of treatment with the sofosbuvir–ribavirin combination regimen on the CNI AUC levels, which resulted in a reduction in the CNI AUC. While used as part of triple-drug immunosuppression, no change in the dose of CNI (tacrolimus and cyclosporine) was required based on measurement of C0 levels. Conclusions The sofosbuvir and ribavirin combination therapy is effective and safe to treat HCV infection in the post-renal transplant setting. There is a need for close CNI level monitoring while these patients are on sofosbuvir therapy. With therapy and viral clearance, there could be reduction in CNI levels due to increased clearance of CNI drugs, which is shown by the AUC measurements. This could be important for patients at high risk for rejection.

The “dilemma of double lifelines”: central venous catheter co-existence with transvenous cardiac pacemaker

Nephrologists may require CVC in order to provide acute hemodialysis to patients with chronic kidney disease (CKD) who have progressed to end-stage renal disease (ESRD) without establishment of a fistula or graft, as well as those with intoxications, overdoses, and acute kidney injury. A wellfunctioning AV fistula is the most preferred access for initiating dialysis (1). According to the NKF-KDOQI guidelines, primary AV fistula should be created in at least 50% of the new patients with kidney failure electing to receive hemodialysis. However, data from the USA indicate that nearly 80% of the incident hemodialysis patients initiated treatment with a venous catheter as their vascular access. In a country like India where the majority of the population lives in small villages, the percentage of CKD patients receiving pre-ESRD nephrology care is miniscule. Hence a large majority of the incident hemodialysis patients initiate treatment with temporary catheters. Temporary uncuffed catheters are more common as the initial vascular access. Cardiovascular diseases are the most common causes of death in patients with ESRD. The ESRD patients frequently have indications for the use of transvenous pacemakers (2). Over the past 15 years, the use of cardiac implantable electronic devices in hemodialysis population has increased from a prevalence of 0.8% to approximately 7% (3). The coexistence of the two lifelines the central venous catheter and the transvenous pacemaker, may significantly increase the chance of infection. The incidence of catheter-related bacteremia has been estimated at 1.6 to 5.5 episodes per thousand catheter days; any coexisting transvenous device leads would be vulnerable to both direct and hematogenous bacterial contamination. CKD is an independent risk for lead infection, so coexistence of CKD, CVC and CIED is a potentially deadly triad (3). The presence of transvenous pacemaker wire will also increase the risk of central venous stenosis (4). Drew et al, in a retrospective study, found a high rate of central vein stenosis and catheter dependence in hemodialysis patients (5). However, in our observation of the five patients with coexisting venous catheter and pacemaker, there were DOI: 10.5301/jva.5000622

Crescentic glomerulonephritis in non-asthmatic Churg-Strauss syndrome

A 58-year-old male presented with sensory motor polyneuropathy and rapidly progressive renal failure. Investigations revealed marked peripheral eosinophilia and elevated perinuclear antineutrophil cytoplasmic antibody titers. Renal biopsy showed pauci-immune cre-scentic glomerulonephritis with interstitial eosinophil infiltrates. He had no history of asthma. Computed tomography of the chest and X-ray of the paranasal sinuses were normal. On Day 1, the patient developed ileal perforation. Resected ileal segments showed small vessel vasculitis with extravascular eosinophils. A diagnosis of non-asthmatic variant of Churg-Strauss syndrome was made. Renal recovery was achieved in 12 weeks with a combination therapy of corticosteroid and cyclophosphamide. The patient has been relapse-free for 12 months on oral prednisolone therapy.