V. Tamilarasi

Pediatric renal transplantation – A single center experience of 15 yr from India

Abstract:  Renal transplantation is the optimal treatment for children with ESRD. We undertook this study to establish the outcome of pediatric renal transplants in a resource‐constrained environment in a developing country. A retrospective analysis on 90 pediatric renal transplants (age at transplant ≤18 yr) done at our center over a 15 yr period was analyzed. The mean age of the recipients was 15 yr (range 6–18 yr) accounting for 6.1% of all the renal transplants done at our center (90/1472). Ninety‐six percent of patients received kidneys from live‐related donors. The major causes of ESRD were glomerulonephritis (28%) and urological abnormalities (17%), while the etiology was unknown in 50%. Immunosuppression was based on a triple drug regimen consisting of prednisolone, CsA and azathioprine in 98% of children. Amongst complications, any acute rejection episodes (46.7%), UTI (26.7%) and CMV disease (16.7%) predominated. The mean duration of follow‐up was 42 ± 33 month (range 3–159 month). Graft loss occurred in nine (10%) children at a mean duration of 25 ± 22 month (range 6–70 month). Overall 1‐, 5‐, and 10‐yr graft survival was 98%, 84% and 76%. Overall 1‐, 5‐, and 10‐yr patient survival was 95%, 87%, and 79%. The significant predictors of graft loss were CMV disease (p = 0.018) and >2 rejection episodes (p = 0.05), while sepsis (p = 0.01) was the most important contributor to patient loss. Pediatric renal transplantation in India can be accomplished successfully. The graft and patient survival in our study, the largest from India, is comparable to those published from developed countries and is encouraging given the limited resources.

Extensive emphysematous pyelonephritis in a renal allograft treated conservatively: case report and review of the literature.

Emphysematous pyelonephritis (EPN) is a rare occurrence in renal allografts. An aggressive approach resulting in transplant nephrectomy is viewed as the standard of care. Over the recent years, treatment with percutaneous drainage (PCD) of the renal and perinephric collections and appropriate antibiotics has been reported with good success in lesser grades of this infection. Only 4 cases of extensive EPN disease with Escherichia coli, treated with conservative management, are reported in the English‐language literature. We present a case of severe EPN caused by Klebsiella pneumoniae, successfully managed with early PCD, and propose a step‐up strategy aimed toward graft preservation.

A Patient with Amphotericin-Resistant Curvularia lunata Peritonitis

1. Kovacs G, Burghardt J, Pradella S, Schumann P, Stackebrandt E, Marialigeti K. Kocuria palustris sp. nov. and Kocuria rhizophila sp. nov., isolated from the rhizo plane of the narrow-leaved cattail (Typha angustifolia). Int J Syst Bacteriol 1999; 49(pt 1):167–73. 2. Altuntas F, Yildiz O, Eser B, Gündogan K, Sumerkan B, Cetin M. Catheter-related bacteremia due to Kocuria rosea in a patient undergoing peripheral blood stem cell transplantation. BMC Infect Dis 2004; 4:62. 3. Basaglia G, Carretto E, Barbarini D, Moras L, Scalone S, Marone P, et al. Catheter-related bacteremia due to Kocuria kristinae in a patient with ovarian cancer. J Clin Microbiol 2002; 40:311–13. 4. Becker K, Rutsch F, Uekotter A, Kipp F, Konig J, Marquardt T, et al. Kocuria rhizophila adds to the emerging spectrum of micrococcal species involved in human infections. J Clin Microbiol 2008; 46:3537–9. 5. Ma ES, Wong CL, Lai KT, Chan EC, Yam WC, Chan AC. Kocuria kristinae infection associated with acute cholecystitis. BMC Infect Dis 2005; 5:60. 6. Tsai CY, Su SH, Cheng YH, Chou YL, Tsai TH, Lieu AS. Kocuria varians infection associated with brain abscess: a case report. BMC Infect Dis 2010; 10:102. 7. Lee JY, Kim SH, Jeong HS, Oh SH, Kim HR, Kim YH, et al. Two cases of peritonitis caused by Kocuria marina in patients undergoing continuous ambulatory peritoneal dialysis. J Clin Microbiol 2009; 47:3376–8. doi:10.3747/pdi.2010.00125

Percutaneous continuous ambulatory peritoneal dialysis (CAPD) catheter insertion--a preferred option for developing countries.

Continuous ambulatory peritoneal dialysis (CAPD) as a modality of renal replacement therapy in patients with chronic kidney disease stage 5 (CKD 5) has the advantage of being a home-based therapy and is a preferred option in patients with inadequate access to haemodialysis and transplantation facilities and in those infected with HIV and other blood-borne viruses. While open surgical CAPD catheter placement has been the conventional mainstay of access placement, percutaneous techniques are being increasingly used with similar success rates. We report our experience over the past two years with blind insertion of the swan neck percutaneous double-cuffed Tenckhoff CAPD catheter using a trocar. There was considerable decrease in hospital stay and surgical costs. There was only one major complication of injury to the jejunal mesenteric artery requiring emergency laparotomy in one patient. In three patients, drain of peritoneal fluid was inadequate, presumably due to omental wrapping around the in-dwelling catheter, and required surgical removal of the omentum.

Posterior reversible encephalopathy syndrome in a renal allograft recipient: A complication of immunosuppression?

Posterior reversible encephalopathy syndrome (PRES) is an uncommon post-renal transplant complication. We report a 16-year-old boy who had an acute cellular rejection immediate post-transplant and was given intravenous methylprednisolone along with an increase in tacrolimus dose. He was diagnosed to have PRES based on clinical and radiological features within 6 h of intensified immunosuppression. This is an unusual case report of successfully managing PRES with continuation of the intensified immunosuppression as warranted by the clinical situation, along with aggressive blood pressure control. After 6 weeks, magnetic resonance imaging showed complete resolution of lesions. He has good graft function and no residual neurological deficits while on small doses of three antihypertensives, 12 months after transplantation.

Medical and non-medical factors that affect voluntary living-related kidney donation: A single-center study

The aim was to evaluate the patients with chronic kidney disease stage 5 (CKD 5) and their prospective renal transplant donors with regard to their renal replacement choices, and to assess the medical and non-medical factors that affect living-related renal donor selection. Over 24 months, consecutive patients with CKD 5 and their relatives were interviewed at presentation. Reasons for the choice of modality were analyzed; the prospective recipients and their donors were again interviewed separately and the medical and nonmedical factors that affected the donor selection were determined. A total of 1257 patients were enrolled. Conservative therapy, maintenance dialysis, and renal transplantation were chosen by 513 (40.8%), 320 (25.5%), and 424 (33.7%) patients, respectively. Only socioeconomic status affected the modality chosen. The age, gender, and donor availability did not emerge as significant factors. Patients or donors were likely to withdraw from transplant evaluation due to the absence of a voluntary donor, presence of a male donor, coercion not to donate, and the absence of reimbursement. The commonest cause of rejection of a donor was blood group incompatibility (45.8%), followed by diabetes mellitus (DM) or risk of DM (24%), renal disease (5.9%), hypertension (5.5%), and persistent cross-match positivity (5.1%). To improve donation rates, the donor’s spouse should be involved in the early stages of donor evaluation, financial support for the recipient has to be improved, and the apprehensions about complications of nephrectomy among the donors need to be alleyed. Male donors are at increased risk of leaving the program in the evaluation phase.

Trichosporon Surgical Wound Infection in a Renal Allograft Recipient Successfully Treated With Voriconazole

A 39-year-old chronic kidney disease patient underwent a preemptive renal transplantation in November 2009. His native kidney disease was unknown (biopsy performed in 2006 showed diffuse global sclerosis). He reached end stage in 2009 and after that he was worked up for transplantation. He was not a diabetic and did not have any other comorbidity. He did not receive any immunosuppression before renal transplantation. His wife donated the kidney. His immunosuppression included Basiliximab (two doses) for induction along with prednisolone, tacrolimus, and mycophenolate sodium for maintenance. He had a prolonged warm ischemia time because of difficulty in donor nephrectomy. After surgery, he had a slow recovery in renal function for which a graft biopsy was performed on 4th postoperative day. It showed acute tubular necrosis. Tacrolimus levels were found to be high (13 ng/mL), and hence the dose was reduced. Because renal recovery continued to be slow, a second renal biopsy was performed after a week, which showed cortical necrosis at the upper pole. Without any specific intervention, renal function slowly improved to attain a nadir creatinine of 1.4 mg/dL. Dose titration of tacrolimus and mycophenolate sodium was performed in this period with therapeutic drug monitoring. In the postoperative period, he had received ciprofloxacin as treatment for lower respiratory infection and there were no other infective episodes. After suture removal, he was found to have pus discharge from the surgical wound site. A pus swab for culture grew Trichosporon species. It was confirmed by a second culture. An ultrasonogram revealed a small subcutaneous collection. Surgeons considered exploration to be unnecessary and wanted daily dressings only. A small noncompressing lymphocele was also noted near the lower pole of the graft kidney. Imaging studies excluded involvement of other organs. He did not have neutropenia. Antifungal therapy in voriconazole was begun at standard doses (400 mg twice daily on day 1 followed by 200 mg twice daily). Tacrolimus dose was decreased based on new trough levels. Mycophenolate area under the curve was found to be high, and the dose was dropped. He showed response to the treatment with clearing of the discharge. The wound healed within 2 weeks and the subcutaneous collection resolved. Voriconazole was continued for 4 weeks and stopped. His renal function remains stable and the wound is healthy.

Renal allograft recipient with melioidosis of the urinary tract

S. Varughese, A. Mohapatra, R. Sahni, V. Balaji, V. Tamilarasi. Renal allograft recipient with melioidosis of the urinary tract.
Transpl Infect Dis 2011: 13: 95–96. All rights reserved

Jejunal Mesenteric Artery Laceration Following Blind Peritoneal Catheter Insertion Using the Trocar Method

Editor: Percutaneous peritoneal catheter insertion for peritoneal dialysis (PD) is widely used and success rates similar to those with open placement are reported. Percutaneous insertion is typically done using either a Seldinger technique or the Trocar method. We report a case where blind percutaneous catheter insertion using the Trocar method resulted in jejunal mesenteric arterial laceration and severe intra-abdominal bleeding. A 56-year-old man with diabetic nephropathy, chronic kidney disease stage 5, and ischemic heart disease presented with fluid overload. He was stabilized with ultrafiltration and hemodialysis over 2 weeks. A month later, he underwent blind percutaneous PD catheter insertion in which the trocar and cannula method was used. After a dose of preoperative intravenous vancomycin and sedation with intramuscular pentazocine, a midline incision 2.5 cm long was made about 2 cm below the umbilicus. The peritoneal cavity was filled with 1.5 L saline using an 18F intravenous cannula. The trocar and cannula were vertically maneuvered to make a point incision in the linea alba big enough to admit the lubricated permanent PD catheter, which was then secured in place by purse-string proline sutures. About 1 L PD fluid was instilled in the peritoneal cavity via the PD catheter. The drain was initially mildly blood tinged. The subcutaneous tunnel was made and the distal end of the catheter exteriorized. The incision wound was closed in layers. The effluent continued to be blood tinged and the patient’s blood pressure began to decrease. Despite two units of whole blood and fluids, the patient continued to be in hypovolemic shock. At laparotomy, the peritoneal cavity was filled with blood: a laceration of the jejunal mesenteric artery was identified and ligated. Further blood transfusions after surgery stabilized the patient. The catheter position and tunnel were left untouched. The laparotomy incision was made in the midline immediately below the incision made for catheter insertion. The patient subsequently underwent regular PD exchanges without any impediment to either inflow or drainage of PD fluid. This is the only such complication that has been experienced in over 30 percutaneous catheter insertions. Blind percutaneous PD catheter insertion is a relatively easy procedure that can be done by nephrologists without requiring a dedicated operation theater and anesthesia time. The procedure is safe when done by experienced personnel. There are two percutaneous techniques. The more common is the procedure using a peel-away sheath with the Seldinger technique (1). The other, using a trocar and cannula, is employed at our center. The laparoscopic and open surgical techniques require obtaining specialized surgical and anesthetic services, are more expensive, and increase the duration of hospital stay. The open surgical method is routinely preferred in those with prior abdominal surgeries with likelihood of adhesions. However, in the blind procedures, there always exists the unavoidable risk of misadventure and surgical backup is necessar y. The technique of catheter insertion using the peel-away sheath obviates the need of the sharp trocar and is less likely to cause injury to viscera. The fluoroscopy-guided procedure is perhaps safer and, although the two have not been directly compared, results and safety are comparable to the directly visualized surgical method (2). While the usefulness remains unproven, the surgical method has been more commonly employed in obese patients (3) and we began to adopt this practice after the occurrence of this complication. Minor hemorrhage following PD catheter placement is usually caused by abdominal wall blood vessel injury and can easily be controlled. Mital et al. (4) reported a retrospective case series of surgical placement of 292 catheters where there was major hemorrhage in 6 patients (2%). However, this was due to perioperative anticoagulation, aspirin use, or thrombocytopenia in all but 1 patient. Smith et al. reported the occurrence of bleeding associated with percutaneous placement of PD catheters in 2 of 31 (6.4%) catheter placements (5). Neither patient required exploration or blood transfusions but settled with PD fluid exchanges. One required transfusion of platelets for thrombocytopenia. When the effluent is bloody with hemodynamic compromise, as in our patient, immediate explorative

Adefovir nephrotoxicity in a renal allograft recipient

Adefovir dipivoxil, an oral prodrug of adefovir, is used in the treatment of lamivudine-resistant hepatitis B virus (HBV) infection. Nephrotoxicity manifesting as proximal renal tubular dysfunction and acute tubular necrosis (ATN) were commonly reported in the past, when higher doses were used for the treatment of human immunodeficiency virus infection. However, nephrotoxicity is rare at lower doses that are currently recommended for the treatment of HBV infection. A 31-year-old female was detected to be hepatitis B surface antigen positive months after a kidney transplant. The patient was initiated on lamivudine, but developed resistance after 1 year of treatment, at which time low-dose adefovir was added. The patient developed renal allograft dysfunction after 10 months of starting adefovir. Serum creatinine increased from 1.1 mg/dl to 1.9 mg/dl, along with progressively increasing sub-nephrotic proteinuria. Renal allograft biopsy revealed features of ATN. After discontinuation of adefovir, proteinuria resolved and renal dysfunction improved slowly over the next 2 years. Adefovir-induced nephrotoxicity, although uncommon at lower doses, needs to be considered in the differential diagnosis of renal dysfunction and sub-nephrotic proteinuria occurring in patients receiving adefovir for prolonged periods.