Relationship of Creatinine and Cystatin C-based Estimated Glomerular Filtration rates with Measured Glomerular Filtration Rate in Healthy Kidney Donors from South Asia

Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m². The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft–Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m², Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m², CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m², CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m², CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m². The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland–Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.

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.

Profile of incident chronic kidney disease related-mineral bone disorders in chronic kidney disease Stage 4 and 5: A hospital based cross-sectional survey

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels <30 ng/mL was 66.3%, 59%, 89.3% and 74.7% respectively. Echocardiography was carried out in 471 patients; 96% of whom had VC (calcification score ≥1). Patients with VC were older and had lower 25(OH) D levels than those without. Lateral abdominal X-rays were obtained in 558 patients, 6.8% of whom were found to have AAC, which was associated with older age. Indian patients with incident CKD-MBD have a high prevalence of hypocalcemia, 25(OH) D deficiency and VC even prior to initiating dialysis while AAC does not appear to be common. The association between 25(OH) D deficiency and VC needs further exploration.

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.

Infections with atypical mycobacteria in renal transplant recipients

Infections due to atypical mycobacteria are infrequent in renal transplant recipients but they cause serious morbidity. These pathogens are common in patients with acquired immune deficiency syndrome (AIDS). We report four proven cases of infections caused with atypical mycobacteriae from 1997 to 2003, by different organisms namely, M. chelonei, M.fortuitum, M. abcessus and M. terrae in renal transplant recipients. Infection with M. terrae documented here is the first occurrence in a renal transplant patient. Histopathological examination of aspirates or biopsy specimens from involved areas and staining and culture for mycobacteriae are essential for diagnosis. Treatment involves antimycobacterial therapy, reduction in immunosuppression and surgery, if indicated. Atypical mycobacterial infections, though currently uncommon, are significant and could prove to be an emerging pathogen in renal transplant recipients in the context of the AIDS epidemic in India.

Pre-tertiary hospital care of patients with chronic kidney disease in India

BACKGROUND & OBJECTIVES

There is paucity of data available on how chronic kidney disease (CKD) is treated before referral to a tertiary hospital. This study was conducted to assess pre-tertiary hospital care of patients with CKD 5 at their presentation to nephrology services at a tertiary care hospital.

METHODS

Over a period of 8 months, consecutive patients with CKD 5 presenting at the Nephrology services at Christian Medical College, Vellore, Tamil Nadu, and their relatives were interviewed to assess the pre-tertiary hospital care and knowledge about CKD 5 and its treatment.

RESULTS

A total of 561 patients with CKD 5 were enrolled. The mean duration (months) of known CKD was 12.4 +/- 23.1 and known CKD 5 was 3.2 +/- 3.5. Of these, 369 patients (65.8%) had been under the care of a nephrologist; 305 patients had CKD 5 as the initial presentation of renal illness. Vaccination against hepatitis B had been initiated in only 133 patients (23.7%). Only 172 patients(38%) had an adequately controlled blood pressure. Care under a nephrologist was more likely to result in appropriate investigation, treatment and patient education though blood pressure control did not differ.

INTERPRETATION & CONCLUSION

Paucity of symptoms in the initial stages of certain forms of CKD probably led to 50 per cent of patients presenting with CKD 5 as the initial presentation of renal disease. Inadequate vaccination against hepatitis B infection highlights the need for appropriate vaccination. Prevention of CKD and its progression are important targets which requires physician awareness at all levels. Early referral to a nephrologist's care is more likely to result in appropriate investigations and treatment.

Acute graft pyelonephritis following renal transplantation

BACKGROUND

Urinary tract infection is the most common form of bacterial infection encountered in a renal transplant recipient. Studies explaining the long-term consequences of acute graft pyelonephritis (AGPN) are few.

METHODS

A total of 1022 consecutive renal allograft recipients were studied retrospectively over a period of 10 years for evidence of AGPN. These patients were classified into two groups according to the presence or absence of at least one AGPN episode. Only culture-proven infections were included in the study.

RESULT

Of the 1022 renal transplant recipients, 169 patients (16.5%) developed AGPN. In the multivariate analysis with stepwise logistic regression, significant associations were observed between AGPN and placement of ureteric stent (odds ratio [OR]=4.6), urological malformations of native kidney (OR=2.1), cytomegalovirus (CMV) disease (OR=2.0), mycophenolate mofetil (MMF)-based regimen (OR=1.9), and acute rejection episodes (OR=1.5). However, age>40 years, female gender, induction therapy, anti-CD3 treatment, and hyperglycemia did not show such an association. In comparison with the non-AGPN group, these patients had a lower graft and patient survival (though it did not attain statistical significance). In the multivariate analysis using the Cox model for the entire study population, AGPN did not independently contribute to poor graft or patient survival.

CONCLUSION

AGPN in the renal transplant setting is an ominous event, as these patients are also more prone to develop bacteremia, acute rejection, and CMV disease, which could then lead to poor graft and patient survival. Its association with MMF needs further clarification.

Spectrum of severe chronic kidney disease in India: a clinicopathological study

BACKGROUND

The healthcare burden due to chronic kidney disease has increased worldwide in the past decade. Elucidating the aetiology of chronic kidney disease may help in identifying strategies for prevention, both in the population and the Individual patient. Only a clinicopathological study can define the exact spectrum of chronic kidney disease since epidemiological studies have not shown a consistent aetiological profile. The histological evidence used to support the diagnosis varies with the degree to which renal biopsy is done. Renal biopsy is the gold standard in making an aetiological diagnosis in renal failure, but as a diagnostic tool in chronic kidney disease it is underutilized.

METHODS

This prospective study done at Christian Medical College, Vellore in southern India from 1998 to 2003 aimed to determine the aetiological profile of severe chronic kidney disease by analysing renal biopsies. The value of pre-renal biopsy clinical Judgement in predicting the histological diagnosis was also assessed. Patients with diabetic nephropathy were excluded from the study.

RESULTS

Four hundred and fifty-seven patients had evidence of chronic kidney disease as evidenced on biopsy as well as on clinical parameters. Three hundred and twenty-two of these patients (70.5%) had glomerulonephritis as the histological diagnosis. Fifty-five (12%) had Interstitial nephritis, 30 (6.6%) had hypertensive arteriosclerosis and 28 (6.1%) had metabolic nephropathies. The positive predictive value of a pre-biopsy clinical diagnosis in predicting interstitial nephritis was very low (33%). A large number of patients clinically diagnosed to have chronic interstitial nephritis had other aetiologies of chronic kidney disease.

CONCLUSION

Glomerulonephritis was the most common cause of chronic kidney disease, not including diabetic nephropathy, followed by interstitial disease and benign arterionephrosclerosis. In patients with unidentified severe chronic kidney disease, renal biopsy provided an aetiological diagnosis.

A Prospective Evaluation of Leflunomide Therapy for Cytomegalovirus Disease in Renal Transplant Recipients

AIM

A preliminary observation suggests leflunomide is effective in the treatment of cytomegalovirus (CMV) disease in renal transplant recipients. A prospective evaluation was conducted in renal transplant recipients to study the efficacy of leflunomide in the treatment of CMV disease.

PATIENTS AND METHODS

With prior approval and informed consent for therapy and follow-up, 17 consecutive consenting renal transplant recipients with proven CMV disease were treated with leflunomide. CMV disease was defined as a clinical syndrome of fever and/or symptoms of organ involvement, leukopenia, and a positive nested CMV quantitative PCR test at 0.001 microg/5 microL template input, with or without histologic evidence of tissue invasion. Leflunomide metabolite concentrations (A77 1726) were monitored.

RESULTS

Of the 17 patients, 14 patients were treated for 6 months for CMV disease the first time; the remaining 3 received leflunomide treatment for relapse after ganciclovir treatment, for a year. Seven patients had fever with viremia and no organ involvement, nine had viremia with involvement of gastrointestinal tract, and one had fever with CMV inclusions in the allograft, with no demonstrable viremia. The three patients with relapse treated with leflunomide responded. Overall, 15 patients (88%) clinically responded to leflunomide therapy and with viral clearance from blood and healing of involved organs. The cost of therapy with intravenous ganciclovir (Cymevene, Roche) for 2 weeks was US 721 dollars while that of leflunomide (Cleft, Cipla Ltd) for 6 months was US 64 dollars.

CONCLUSION

Leflunomide treatment for CMV disease in renal transplant recipients is effective, simple, and economical.

Pre- and postrenal transplantation pharmacokinetics of cyclosporine microemulsion

The availability of a microemulsion formulation (ME) of cyclosporin (CyA) displays improved bioavailability and reduced inter and intra-patient variability, resulting in improved long-term outcomes. Recent developments in therapeutic drug monitoring stress the need to optimize peak drug levels during the early posttransplant period to obtain long-term benefit.

METHODS

We studied early CyA-ME pharmacokinetics, comparing pre- versus immediate posttransplant values, to assess predictability of pre-transplant profiles in 22 patients including 3 diabetics. An 8 mg/kg per day amount in two divided doses was administered, for 5 days pretransplant and 10-14 days posttransplant before performing the pharmacokinetic studies. Drugs interacting with CyA metabolism/absorption were withdrawn and patients with liver disease were excluded the CyA level monitoring used a 5-point blood sampling (at 0 hours, 1 hours, 2 hours, 3 hours, and 4 hours post-dose). The study compared actual concentrations at each individual time and the limited 0-4 hour AUC.

RESULTS

The paired values at each point pre- and posttransplant were: C0 = 171 +/- 63 and 215 +/- 112, C1 = 723.86 +/- 345 and 1239.95 +/- 415, C2 = 972 +/- 185 and 1249.95 +/- 336, C3 = 822 +/- 242 and 942.7 +/- 286, and C4 = 601.54 +/- 190 and 670.5 +/- 208 ng/mL respectively. The C1 and C2 values were significantly higher posttransplant (P =.008 and 0.0045 respectively), suggesting a steeper absorption phase, a conclusion consistent with the higher 0-4 hour AUC posttransplant (P =.0089). However, linear regression analysis of pre- versus posttransplant values showed poor correlations.

CONCLUSIONS

CyA absorption is significantly lower among patients on maintenance hemodialysis and showed no predictive correlation with posttransplant levels. The possible role of uremia in retarding absorption which may have clinical significance for primary graft dysfunction, needs further evaluation.

Problems of classification of Henoch Schonlein purpura: an Indian perspective

A 2-year prospective study was carried out in which 71 patients with primary cutaneous vasculitis were classified using the American College of Rheumatology (ACR) classification and the Chapel Hill Consensus Conference (CHCC) recommendations for Henoch Schonlein purpura (HSP). The sensitivity of the ACR criteria was 64.8% and that of the CHCC definition 31%. When the ACR criteria were combined with results of direct immunofluorescence (DIF) the sensitivity was 78.9%. The concordance between the two systems was low as only 12 patients fulfilled criteria for both classifications. Although the ACR criteria were found to be more useful in the classification of HSP our data suggest that they need to be modified to include adults with disease. The age at onset of disease was higher than that in the west. Seventy per cent of patients identified by either classification were > 20 years of age. The prevalence of gut involvement, microhaematuria and proteinuria was < 25% in both groups. The sensitivity of histopathology on the other hand was 80.4% and was not influenced by the duration of the lesion. The DIF test was a useful adjunct to histopathology if it was done within 48 h as the yield of a positive test was significantly higher in this group as compared to the patients who had the test done later.

Severe hyponatraemia: current concepts on pathogenesis and treatment

Severe hyponatraemia (serum sodium <120 mEq/L) is a serious electrolyte disorder associated with life-threatening neurological complications. It develops most often when the ability of the kidney to excrete free water is impaired. The initial adaptation of the brain to hyponatraemia includes loss of water, sodium, potassium and chloride into the cerebrospinal fluid and the late adaptation consists of the loss of organic osmolytes. Adaptation of the brain to hyponatraemia causes potential problems during therapy, as re-adaptation requires a considerably longer time. Rapid correction of hyponatraemia may lead to the development of the osmotic demyelination syndrome. Though the ideal treatment for severe hyponatraemia remains controversial, a consensus regarding therapeutic guidelines has emerged. The rate of correction and the type of infusate depend on the duration and cause of the hyponatraemia, clinical presentation, volume status, renal function and the serum potassium level. The prognosis of the osmotic demyelination syndrome is rather dismal although several therapeutic modalities have been tried.

Risk factors for post-transplant tuberculosis

BACKGROUND

Post-transplant tuberculosis (post-TxTB) occurs in 12 to 20% of patients in India and results in the death of 20 to 25% of those patients. Prospective studies on post-TxTB are few.

METHODS

Renal allograft recipients were studied prospectively for 3.1 (0 to 13.9) median (range) years for incidence, manifestations, risk factors, and prognosis for post-TxTB. Kaplan-Meier analysis was used to study the survival rates. The extended Cox proportional model for time-dependent covariates was used to measure the risk factors when the hazard was nonuniform.

RESULTS

Of the 1414 patients considered for inclusion, multiple-transplant subjects (N = 37) and patients who developed pre-transplant TB (pre-TxTB; N = 126) were excluded from the study. The prevalence of post-TxTB was 13.3% (N = 166). The risk of post-TxTB when on cyclosporine (CsA) therapy was 2.5 (P = 0.0311) and 1.9 (P = 0.0430) times at < or =6 and < or =12 months, respectively, compared with patients on prednisolone plus azathioprine (PRED + AZA). The risk of post-TxTB in the presence of diabetes mellitus, chronic liver disease, and other co-existing infections [including deep mycoses, cytomegalovirus (CMV), Pneumocystis carinii pneumonia (PCP), nocardia] was 2.2 (P = 0.0011), 1.7 (P = 0.0010) and 2.4 (P < 0.0001) times, respectively. Of the 166 patients with post-TxTB, 53 patients died, and of those deaths, 17 (32%) were due to post-TxTB; 11 (65%) of the 17 had co-existing infections. The factors associated with death were HLA mismatches, PRED + AZA immunosuppression, pre- and post-TxTB, diabetes mellitus, post-transplant diabetes (PTDM), and other co-existing infections. The extended Cox model for death as the outcome variable showed the following to be significant risk factors: post-TxTB> 2 years (P = 0.0036), chronic liver disease> 6 years (P = 0.0457), PTDM> 5 years (P = 0.0729), diabetes mellitus (P = 0.0091), human lymphocyte antigen match < or =1 antigen (P = 0.0134), two to three antigens (P = 0.0448), and the presence of other co-existing infections (P < 0.0001).

CONCLUSIONS

Cyclosporine therapy is associated with early post-TxTB. Diabetes mellitus and chronic liver disease are risk factors for post-TxTB. The occurrence of both pre-TxTB and post-TxTB (>2 years) along with hyperglycemia, liver disease, and other co-existing infections are important risk factors for death.

Plasmcapheresis--principles and practice

The concept of removal of blood "blood letting" was practised in ancient times. In the last four decades plasmapheresis, plasma exchange, or apheresis as the modality of treatment of certain specific disorders has become available. This article is a review of the principles of plasmapheresis. The equipment needed, the technique of plasmapheresis and guidelines for its use are discussed.

Characterization of antibody response to human cytomegalovirus in Indian renal transplant patients

BACKGROUND & OBJECTIVES

Cytomegalovirus (CMV) disease in seroendemic transplant populations is due to reactivation of the virus, or reinfection. In this context, the antibody response is likely to influence presentation, clinical severity and outcome of the disease, and may provide a diagnostic and prognostic marker. This study was carried out in Indian renal transplant patients and healthy adults to characterize the antibody response to cytomegalovirus.

METHODS

Thirty three transplant recipients with CMV illness (symptomatology with IgM and/or nPCR positive status), 20 recipients who were asymptomatic in the 6 months of follow up after transplantation and 62 healthy controls were investigated for markers of CMV infection. These individuals were tested for IgG avidity and neutralizing antibody by ELISA techniques.

RESULTS

All 53 transplant recipients were found to have an IgG avidity index of > 50 per cent. Antibody to a CMV envelope glycoprotein gB/AD-1 (putative neutralizing antibody) was expressed as S/N ratio and was > or = 5 in asymptomatic (65%) and symptomatic (27%) immunosuppressed renal transplant recipients. However, none of the 53 CMV IgG positive healthy controls were positive for neutralizing antibodies S/N ratio > or = 5 (S/N ratio = sample mean OD/mean OD of 3 negative controls in each run). We observed the simultaneous presence of CMV PCR signal in leukocytes and neutralizing antibody (S/N ratio > or = 5) in the plasma in 22 (41.5%) of the 53 renal transplant recipients.

INTERPRETATION & CONCLUSIONS

In this study among the immunosuppressed transplant patients we observed an association between symptomatic disease and the relative absence of neutralizing antibodies. The neutralizing antibodies are less frequently demonstrable among controls; while appearance in a higher proportion of asymptomatic recipients especially in association with high IgG avidity (> 90%) is suggestive of its role in control of CMV disease despite reactivation as evidenced by DNAemia while on immunosuppressive therapy.

Immunosuppression in live-related donor renal transplantation

BACKGROUND

Triple immunosuppression with cyclosporine, azathioprine and prednisolone is the most common regimen employed following renal transplantation. No information is available regarding its impact on the results of renal transplantation in India. The present study is an audit of a fixed-dose cyclosporine-based immunosuppressive regimen in an exclusively live-related donor transplant programme, with specific regard to graft and patient outcomes.

METHODS

Patients transplanted over a 3-year period and receiving cyclosporine-based immunosuppression were studied. The relationship between immunosuppression and graft outcomes [rejection episodes (RE), graft function, graft survival], and patient outcomes (patient survival) was analysed in those receiving triple immunosuppression. Dosage schedules were audited. Cyclosporine trough level monitoring was employed at graft dysfunction episodes, or at dose reduction points.

RESULTS

The median follow up was 14 months. Triple drug immunosuppression was used in 191 patients and double drug therapy in 26. The overall one-year patient survival rate was 91% and the corresponding graft survival rate was 90%. An audit of dosing schedules showed that over the first 6 months post-transplant, cumulatively, 20%-50% of patients received azathioprine, and 55%-60% received cyclosporine in doses below the protocol. The immunosuppressive doses (both of cyclosporine and azathioprine) in the first month were significantly related to the RE (p < 0.01) in the first month and the total number of RE in the first 6 months (p < 0.01). The other predictors were younger recipient age and older donor age. The sixth-month serum creatinine level was predicted by the donor age, the level of serum creatinine in the first month and the total number of RE in the first 6 months post-transplant. While no specific predictors of graft loss were identified in this cohort, diabetic nephropathy (p = 0.000) as the native renal disease, and the total number of RE were strongly related to patient mortality. The occurrence of > or = 2 RE in the first 6 months was an independent predictor, increasing the risk of death in the first 2 years post-transplant by 2.3 (p = 0.0001, 95% CI: 1.5-3.4).

CONCLUSIONS

Sub-therapeutic baseline immunosuppression in the early post-transplant period predisposes to acute RE. This has an impact not only on graft function but also forms an important proximate marker of mortality, as seen in this cohort. Thus, immunosuppressive drug dosage should be optimized and therapeutic drug level monitoring strategies should be preemptive rather than event related, especially in the early post-transplant period. While fixed-dose immunosuppressive drug schedules are widely followed, it is possible to fall short of the target unless a specific effort is made to meet and sustain schedules.

Pre-transplant risk factors for renal allograft dysfunction at one year in Indian patients

BACKGROUND

Only a few patients with end-stage renal disease in the Indian subcontinent receive optimal treatment. Of these only a minority can afford a second renal transplant. Awareness of modifiable pre-transplant risk factors that influence allograft function is crucial before embarking on the first transplant. There are no reports from the Asian subcontinent describing the pre-transplant risk factors.

METHODS

We studied the effect of donor age, gender, and relation with the recipient, patient age, gender, HLA matching, native kidney disease and immunosuppression on one-year allograft function using data from 1177 consecutive primary living related donor renal transplants at the Christian Medical College Hospital, Vellore. We performed a univariate followed by a multivariate analysis using a logistic regression model to calculate the odds ratio for the effect of the above factors on two levels of graft function (serum creatinine > 1.4 mg/dl and > 2 mg/dl) at one year.

RESULTS

On univariate analysis, older donors, women donors, mother being the donor, men recipients, < 1 HLA antigen match, cyclosporine-based immunosuppression and patient age between 16 and 40 years were associated with serum creatinine levels > 1.4 mg/dl at one year. Multivariate analysis showed that donor-related factors, namely mother as donor, older donors, and a < or = 1 HLA antigen match, were risk factors for graft dysfunction (serum creatinine level > 1.4 mg/dl) at one year. Recipient-related risk factors were male patients and those between the age of 16 and 40 years.

CONCLUSION

In patients undergoing living related donor renal transplants from large extended families, a younger haplomatched donor, for instance, a brother, is a better choice than an older haplomatched donor, for instance, the mother, particularly in young male recipients at a higher risk of renal dysfunction.

A randomised controlled trial of intradermal hepatitis B vaccination and augmentation of response with erythropoietin

AIM

Intradermal administration of Hepatitis B vaccine (HBV) achieves better seroconversion in patients on dialysis compared to intramuscular administration. The aim of the study was to determine whether twice weekly intradermal injections of the vaccine can further augment the vaccine response as compared to once weekly injections. Patients with end stage renal failure on haemodialysis were randomly allocated over a period of 22 months to receive 20 mu gms of recombinant HBV by intradermal injections once a week (group 1) or twice a week (group 2) for 6 weeks. The patients recruited during the first 12 months of the study did not receive recombinant human erythropoietin (Epo) as it was not available (phase 1). During the last 10 months of study all patients received Epo (phase 2) in addition to HBV.

RESULTS

A total of 85 patients were enrolled of whom 77 completed the study. There were 41 patients in group 1 and 36 patients in group 2. Seroprotection (anti HBs > 10 mIU/ml in the absence of HBs Ag and anti HBc) was achieved in 56.1% patients of group I compared to 77.8% of group 2 (p < 0.05). The seroprotection rate was 78.1% among patients receiving Epo (phase 2) compared to 60% among 45 who did not receive Epo (phase 1). Anti HBs titre in responders was 308.5 +/- 148.7 mIU/ml in patients of phase 2 compared to 198 +/- 112.8 mIU/ml in patients of phase 1 (p < 0.05). The subgroup receiving both Epo and twice weekly vaccine (group 2 of phase 2) had the highest seroprotection rate of 86.7%.

CONCLUSION

Twice weekly intradermal vaccination is more effective than once weekly regime in achieving rapid seroconversion. The vaccine response may be augmented by use of Epo probably due to reduction in transfusion requirement and concomitant immunosuppression.

Calculated nitrogen balance in hemodialysis patients: influence of protein intake

BACKGROUND

Optimal nutrient intake is important in the maintenance of a positive nitrogen balance in hemodialysis (HD) patients. The objectives of this study were (1) to assess the influence of two levels of protein intakes on nitrogen balance in stable adult HD patients, and (2) to identify a minimum level of protein intake that would result in a negative nitrogen balance, so that preliminary recommendations may be made in Indian patients on maintenance HD (MHD).

METHODS

Stable, adult, nondiabetic MHD patients were recruited after informed consent into a cross over trial with a high-protein (HP) diet [1.2 g/kg ideal body weight (IBW)/day), followed by a low-protein (LP) diet (0.6 g/kg IBW/day] after appropriate periods of equilibration; for both diets, 50% of protein was of high biological value, and calorie intake was 35 kCal/kg IBW/day. Duplicate meals and residues were weighed, homogenized, and stored at -20 degrees C for analysis of dietary N by the Kjeldahl method, used to check the consistency of the N content of the diet supplied. Pre- and post- (30-minute equilibrated) blood urea samples were drawn, and details of weights and other HD parameters were recorded. Interdialytic urine collections for urea were obtained. N input came from dietary protein calculated as 16% of the weight of biological protein; N output was calculated using blood-side urea measurements and urinary urea excretion and was the sum of urea N (UN) and nonurea N (NUN) losses (assumed to be equal to 0.031 g N/kg/day).

RESULTS

Fifteen patients were recruited. Twelve patients completed both limbs of the study. The mean age was 30.3 +/- 12.7 years. The body mass index was 18.9 +/- 2.4. Serum albumin was 3.8 +/- 0.35 g/dL, and Kt/V (equilibrated) was 1.17 +/- 0.3 g/dL. Protein consumed was 1.06 +/- 0.18 g/kg IBW/day in the HP limb versus 0.61 +/- 0.1 g/kg IBW/day in the LP limb (P = 0.000). Energy intake was 33 +/- 6.5 vs. 32.8 +/- 6. 7 kCal/kg IBW/day, respectively (P = 0.8). The normalized protein N appearance (nPNA) was 0.88 +/- 0.2 g/kg/day in the HP limb versus 0. 78 +/- 0.2 g/kg/day in the LP limb (P = 0.02). Dietary N was 73.5 +/- 15.3 g in the HP week and 42.5 +/- 7.5 g in the LP week (P = 0. 000). The difference between this and the sum of (UN + NUN) losses over the week was 29 +/- 13.2 g versus 1.2 +/- 8.1 g, respectively (P = 0.001), showing a strong, uniformly positive nitrogen balance with HP diet and neutral to negative nitrogen balance with LP diet. The ratio of dietary protein intake (DPI) to nPNA was significantly lower (anabolic) in the HP limb (0.7 +/- 0.2 vs. 1.12 +/- 0.3, P = 0. 000). On a scatter plot of nPNA to DPI, a catabolic relationship was demonstrated below a DPI of 0.75 g/kg/day (95% CI, 0.65 to 0.85 g/kg/day).

CONCLUSION

A DPI of approximately 1.1 g/kg/day produces a positive nitrogen balance and 0.6 g/kg/day a neutral to negative nitrogen balance, demonstrating protein anabolism as a function of protein intake. It is suggested that a protein intake of 0.85 g/kg/day should be considered unsafe. These conclusions apply in stable nondiabetic adult HD patients in the setting of adequate dialysis and adequate calorie intake.

Role of molecular techniques in the detection of HBV DNA & HCV RNA among renal transplant recipients in India

In this study we have investigated the occurrence of hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus (HDV) infections among 68 renal transplant recipients. Replicative HBV and replicative HCV infections were seen in 12 (17.6%) and 38 (55.9%) patients respectively, the difference was statistically significant (P < 0.001). Among the 38 HCV RNA+ individuals, anti-HCV was present only in 23. Anti-HCV in the absence of HCV RNA was detected in one patient. Anti-HDV antibody was seen in 2 (15.4%) of the 13 HBV infected individuals. Nine (13.2%) of the 68 individuals had replicative dual infection with HBV and HCV. Triple infection (HBV DNA+, HCV RNA+, anti-HDV+) was seen in 2 transplant recipients. There was significantly higher demonstration of replicative HCV (P < 0.001) in transplant recipients having elevated liver enzymes (n = 34) as compared to transplant recipients having normal liver enzyme levels (n = 34). Though not significant, a higher detection rate was also seen with replicative HBV infection and replicative dual infection among transplant recipients with elevated liver enzymes. The higher detection of HCV in renal transplant recipients by molecular techniques, emphasizes the need for HCV RNA testing. Further deliberate attempts to change practices to reduce this problem may also improve graft and patient survival in recipients.

Management and outcome of brain abscess in renal transplant recipients

Although infection is the commonest central nervous system complication following renal transplantation, brain abscess is uncommon. Over the last 11 years, five renal transplant recipients who had brain abscesses were treated by computed tomography (CT)-guided stereotactic aspiration. Three patients had a fungal abscess, one a tuberculous abscess and the other had a methicillin-resistant Staphylococcus aureus abscess. One patient required a craniotomy for the excision of a fungal abscess which was persistent after two CT-guided stereotactic aspirations. The survivors in this group are the patient with a tuberculous abscess who is alive and well 5 years after diagnosis, and another with a dematiaceous fungal abscess (phaeohyphomycosis). CT-guided stereotactic surgery is minimally invasive, and can safely be performed in these patients. It often leads to an aetiological diagnosis in renal transplant recipients with brain abscesses. Specific antibiotic management directed towards the causative organism rather than empirical treatment can be instituted following the procedure. Although the ultimate prognosis in these patients is bleak even with specific antibiotic therapy, an occasional patient might have a good outcome with prompt and appropriate therapy.

Cytomegalovirus infection in a seroendemic renal transplant population: a longitudinal study of virological markers

BACKGROUND/AIMS

The detection of viremia by polymerase chain reaction (PCR) in cytomegalovirus (CMV) infection in renal allograft recipients has been shown to have a predictive value for disease. However, its diagnostic utility in a population with high background seropositivity has not been defined. This prospective study was undertaken to assess the relationship of CMV DNAemia, and/or IgM seropositivity to CMV disease in a seroendemic transplant population.

METHODS

Consecutive patients undergoing renal transplantation between August 1997 and February 1998 were enrolled. Blood was sampled before transplantation from the donors and recipients for CMV serology and nested PCR for CMV DNA, and after transplantation from the recipients only at monthly intervals until 6 months. Patients were observed for the development of any CMV-like illness during follow-up. CMV DNA was quantitated using limiting dilution PCR on samples obtained from symptomatic patients at the time of illness and from asymptomatic patients at the end of their 6-month follow-up.

RESULTS

A total of 57 recipient-donor pairs were recruited. Immunosuppression was cyclosporine-based in 55 of 57 (95. 6%). The CMV serologic status was D+R+ in 55 of 57 and D+R- in 2 of 57 pairs. PCR positivity indicating viremia increased from 5% before transplantation to 95% at 6 months after transplantation. Similarly IgM positivity reached 80% at 3 months and thereafter; positivity for any marker was 100% by 6 months. Viremia was sustained in over half the patients. The incidence of CMV-attributable disease peaked at 3 months, and was predominantly mild and self-limiting. Tissue-invasive disease appeared later in 4 patients (7%). Asymptomatic viremia was seen in 60-70% of patients at each sampling point. The positive predictive value (PPV) of PCR positivity for disease was 35-40%, and the negative predictive value (NPV), 90-100%. However, the high NPV was of use only in the early post-transplant period, negativity for markers declining rapidly with time. Quantitative assay showed significantly higher levels of CMV DNA in symptomatic patients (p = 0.01). A cutoff of 0.001 microg had a specificity of 95% and a PPV of 92.3% for symptomatic CMV disease.

CONCLUSION

Qualitative tests to detect CMV DNAemia and IgM, although useful markers of viremia and active infection, have limited utility for the diagnosis of disease in a seroendemic transplant population. Quantitation of CMV DNAemia may play an important role in diagnosis in such a setting.

Prognostic factors in diffuse proliferative lupus nephritis

BACKGROUND

Patients with diffuse proliferative lupus nephritis (DPLN) can have variable clinical course. Identification of the predictors of outcome would help to improve the management. We have studied the prognostic significance of clinical, laboratory and histological parameters in patients with DPLN.

METHODS

Twenty nine patients diagnosed to be having DPLN seen between 1987 and 1991 were followed up for over 57 months. Parameters assessed for prognostic significance included serum creatinine, urine protein at the time of biopsy, blood pressure, type of immunosuppression, composite scores and individual components of activity index (AI) and chronicity index (CI). Kaplan-Meier survival curves were plotted and the results were compared using log rank test. Fishers' exact test was used to study the risk factors.

RESULTS

End stage renal failure developed in 7/29 (24.1%) patients; 7/19 (36.8%) who had hypertension and 7/16 (43.8%) who had nephrotic proteinuria developed renal failure, while none who had normal blood pressure or nonnephrotic proteinuria, developed renal failure (p < 0.01). Three patients had high activity index (> 12) and all three developed renal failure. Other parameters such as age, gender, serum creatinine, type of immunosuppression, CI and individual components of AI failed to predict the outcome (p > 0.05).

CONCLUSION

Hypertension, nephrotic proteinuria and high AI were predictive of progression to end stage renal failure in patients with diffuse proliferative lupus nephritis.

Transplant kidney protection during aortic aneurysm surgery

PURPOSE

Renal allografts are sensitive to ischemic insult. During aortic cross clamping prevention of ischemic damage to a kidney below an aneurysm is vital. Many maneuvers have been reported. We describe a simple technique of protecting the transplant kidney from ischemic damage during aortic surgery.

MATERIALS AND METHODS

During vascular cross clamping a sterile ice slush was placed around the kidney for surface cooling, obviating the need for some of the complicated procedures previously reported.

RESULTS

After removal of the ice slush and clamps, urine production resumed and creatinine levels remained unchanged.

CONCLUSIONS

External cooling with ice slush provides adequate renal protection during aortic cross clamping and requires no special expertise or equipment.

A dietary survey in Indian hemodialysis patients

Malnutrition is a common problem in maintenance hemodialysis (MHD) patients, and compromised intake is an important cause. There is no information available about the nutrient intakes of MHD patients in India. The nutrient intakes of 106 MHD patients were studied cross-sectionally and on follow-up. A 24-hour recall was used on 4 consecutive days. After 2 months on dialysis, the mean energy intake was 29 +/- 6.6 kcal/kg ideal body weight (IBW) and the mean protein intake was.93 +/-.39 g/kg IBW (high biological value [HBV] protein 49% +/- 8.5%). Dietary deficiency of both protein and calories was present in 64.9%. Intake was better on nondialysis days compared with dialysis days, and in women and older patients. On follow-up there was no significant increase in food intake up to 6 months. After that, the total calorie intake increased significantly with a disproportionate drop in high biological value protein consumed and appeared to be derived predominantly from carbohydrate food (mean kcal/kg, 37 +/- 6.9; mean protein g/kg, 0.96 +/- 0.19; ratio of HBV protein to total protein consumed,.42 +/-.09). In summary this study showed suboptimal energy and protein intake in an MHD population. Intakes were further compromised on dialysis days, and with increasing time spent on dialysis, the quality of nutrient intake became poorer.

The effect of cyclosporin A on plasma lipids during the first year after renal transplantation

BACKGROUND

The serum lipid profile of renal transplant recipients from the Indian subcontinent is not available. Cyclosporin A causes dyslipidaemia, a major risk factor for coronary artery disease which is a significant cause of mortality in these patients. We compared the effect of two dosage schedules of cyclosporin A on the lipid profile of transplant recipients.

METHODS

Two hundred and eight renal allograft recipients were randomized to receive either a high or a low dose of cyclosporin A for 12 months. Their cholesterol and triglyceride levels were measured at monthly intervals for the first six months and at the ninth and twelfth months. The area under the curve was measured and multiple linear regression analysis was done. ANOVA for repeated measures was carried out.

RESULT

Patients receiving a higher dose of cyclosporin A had higher cholesterol and triglyceride levels compared to those receiving the lower dose schedule. The multivariate analysis showed that a low dose of cyclosporin A was significantly associated with reduced cholesterol (p < 0.07) and triglyceride levels (p < 0.04) after controlling the effect of other covariates. ANOVA for repeated measures showed that cholesterol levels were significantly lower in the low-dose cyclosporin A group (p < 0.05).

CONCLUSION

Low dose cyclosporin A reduces the risk of dyslipidaemia in Indian renal transplant recipients.

Transplant associated Kaposis sarcoma

This case reports the first transplant associated Kaposis sarcoma reported from India.

Validation of 24-hour dietary recall: a study in hemodialysis patients

The 24-hour dietary recall method is frequently used for dietary assessment. However, it is subject to errors by both respondent and observer bias and is largely influenced by the motivation and recall ability of the respondent. The weighment method is regarded as the gold standard for estimating nutrient intake. This study was undertaken to assess the validity of dietary recall in a group of seven maintenance hemodialysis patients, who also had corresponding weighed food records. Actual food consumed and residue were weighed separately. A dietary recall was taken on the next day. Subjects were not allowed to take any food or beverage other than that served during the study period. A good agreement was obtained between dietary recall and the weighed food record (the difference was within 10% of the results of weighment), although there was a consistent underestimate by dietary recall. The results also suggested a training effect since improved recall was noted during the later weeks of the study, although this difference was not statistically significant. Therefore, dietary recall as a method of dietary assessment may be of special value in chronic hemodialysis patients in India, who are usually a motivated and informed group.

Haemodialysis for end-stage renal disease in Southern India--a perspective from a tertiary referral care centre

BACKGROUND

There is little information available regarding the practice of haemodialysis, its population characteristics or outcomes in India. These aspects were studied in a cohort of end-stage renal disease (ESRD) patients enrolling in a maintenance haemodialysis (MHD) programme in a tertiary referral centre in S. India, over a 1 year period.

RESULTS

A total of 463 ESRD patients enrolled on MHD during the 1 year period. The mean (SD) age was 38.6 (13.9) years. Definitive renal replacement therapy was instituted in 34% of these patients, including renal transplantation in 22.8%. The median duration to transplant was 93 days, and there was a 50% reduction of the original cohort by 1 month. The largest fraction left the programme (59.7%). Renal transplantation as an outcome was determined by a younger age and a planned referral from outside the state of Tamil Nadu; continuation of any form of renal replacement therapy again was more likely in the younger patient who had external financial support. Dialysis therapy was empiric but uniform for all patients, and only 50% of the dialyses delivered a single pool Kt/V > or = 1. The overall mortality was 9.5%, but 58% of the deaths took place within a week of starting dialysis, a quarter being related to severe uraemic complications.

CONCLUSIONS

Haemodialysis in India is mainly a short-term measure to support the ESRD patient to transplantation. Economic factors play an important role in outcome, the majority undergoing discharge from the programme. Early mortality is disproportionately high. Subclinical underdialysis is common. The requirement for pre-dialysis care and earlier referral from the community is apparent. Prospective studies to define standards and optimize the practice of dialytic therapy against appropriate short-term outcomes, within prevalent economic frameworks, need to be undertaken.

Vaccine-induced necrobiotic granuloma

We report two cases of necrobiotic palisaded granulomas which developed at the site of intradermal hepatitis B vaccination. To the best of our knowledge, this kind of reaction has not been reported previously.

Preemptive live-related renal transplantation

BACKGROUND

Preemptive transplantation (PTX) utilizes transplantation as the primary renal replacement therapy in the absence of any preceding dialysis. In developing countries, PTX may be a cost-effective option, offering additional benefits to conventional transplantation.

METHODS

Between 1989 and 1996, 43 patients who underwent live-related PTX were compared with 86 matched controls who underwent transplantation after hemodialysis. Pre- and posttransplant morbidity, and graft and patient survival rates were compared.

RESULTS

Median follow-up was 15 months in the preemptive group and 20.5 months in the control group. Controls received more transfusions (4.6+/-2.6 vs. 2.4+/-2.3), had higher hepatitis B surface antigen positivity [12 (14.6%) vs. 1 (2.4%)], and more commonly had hepatic dysfunction [5 (5.8%) vs. nil)] in the pretransplant period compared with the preemptive group. Similarly, at 6 months after transplant, the incidence of hepatitis B surface antigen positivity (13 vs. 2) and hepatic dysfunction (18 vs. 3) were higher in the control group compared with the preemptive group. The 1- and 2-year graft (preemptive: 82.8% and 77.3%; controls: 82% and 78%, respectively) and patient (preemptive: 92% and 89.5%; controls: 91% and 89.5%, respectively) survival rates were similar.

CONCLUSION

PTX offers comparable patient and graft survival to conventional transplantation. It eliminates the complications and inconvenience of dialysis. Transfusion requirements, and therefore associated morbidity, are lower. PTX is more cost effective, therefore, it should be a recommended practice in a developing country.

The effect on patient management of temporary non-availability of immunofluorescence for renal biopsy reporting

Delay in reporting the immunofluorescence findings on renal biopsies, owing to an interruption in supply of reagents, made possible a retrospective analysis of the effect of the lack of this information on patient management. Hospital case records of the 39 patients so affected were reviewed to determine what changes in their management took place after the immunofluorescence findings became available. The clinical, laboratory, and light microscopic findings in all except a case of pauci-immune crescentic glomerulonephritis allowed management decisions to be made that were not influenced by immunofluorescence findings. This was owing to correct prediction of the immunofluorescence findings, as in cases of IgA nephropathy presenting with recurrent haematuria; the adequacy of light microscopy in the interpretation of graft biopsies, in classifying lupus nephritis and in most cases of nephrotic syndrome; and the absence of entities identifiable only by immunofluorescence among these patients.

Leprosy and renal transplantation

Nine cases of leprosy in patients treated at a large renal transplant centre in South Asia are described. Three had leprosy diagnosed before transplantation and had either completed or were continuing chemotherapy at the time of transplantation. One showed exacerbation of undisclosed leprosy after transplantation. Five patients developed the disease for the first time 22 months to 12 years after transplantation. Immunosuppression did not adversely affect the treatment of leprosy in any of the patients though concurrent liver disease required cessation of rifampicin in one patient.

Treatment of diffuse proliferative lupus nephritis: an Indian experience

BACKGROUND

Immunosuppressive therapy has improved the prognosis in lupus nephritis. However, infectious complications may contribute to morbidity. There is also debate on the best form of therapy. We, therefore, compared the results of two different forms of therapy.

METHOD

Twenty-nine patients diagnosed to have diffuse proliferative lupus nephritis were followed up over 54 months. The treatment consisted of azathioprine (1.5 mg/kg/day) or pulse intravenous cyclophosphamide (500 mg/m2 body surface area monthly) along with prednisolone (2 mg/kg on alternate days).

RESULTS

Seventeen patients received azathioprine (group A) and 12 received cyclophosphamide (group B). The mean (SD) follow up in groups A and B were 54.35 (33.6) and 52 (35.8) months, respectively. Apart from the higher number of males in group B, both groups were comparable for age, presence of hypertension, renal function, 24-hour urinary protein excretion and composite scores for histological activity and chronicity indices (p > 0.05). The renal survival estimated by the Kaplan-Meier method was similar in both groups (p > 0.05). Four patients had renal failure requiring replacement therapy in group A and 3 in group B. Major infective episodes were more common in group B than in group A (p = 0.03).

CONCLUSION

Azathioprine was as effective as pulse intravenous cyclophosphamide in preserving renal functions up to 54 months. Major infective episodes were more common with pulse intravenous cyclophosphamide.

Aetiology of hyperkalaemia in hospital inpatients

BACKGROUND

Hyperkalaemia is a common metabolic disorder; if left untreated it can lead to life-threatening consequences. We conducted this study to determine the common aetiological factors for hyperkalaemia in hospital inpatients.

METHODS

This prospective cross-sectional study was conducted in a referral teaching hospital in south India. One hundred and forty-three patients with hyperkalaemia (> 5 mEq/L) were selected on 20 random week days over a 3-month period. All the patients were clinically and biochemically evaluated for the aetiology of hyperkalaemia.

RESULTS

Hyperkalaemia was twice as common amongst males. Potassium supplementation and drugs were the leading causes for hyperkalaemia, with renal failure being a distant second. Hyperkalaemia developed after admission to hospital in more than 75% of the patients. Severe hyperkalaemia (> 6 mEq/L) was seen in one-third of the patients.

CONCLUSION

Potassium supplementation and other iatrogenic conditions lead to hyperkalaemia in inpatients. Males are at increased risk for hyperkalaemia.

Captopril-induced changes in effective renal plasma flow in hypertensive renal transplant recipients

The role of converting enzyme inhibitor enhanced radionuclide investigations in post-transplant hypertension is not clearly defined. Presence of renal failure, chronic rejection and use of cyclosporin A complicates the results. Captopril-induced changes in effective renal plasma flow (ERPF) were studied in 10 patients with severe post-transplant hypertension and no evidence of rejection. Angiographic correlation was available in all. Six patients had a significant increase in ERPF after captopril, and all had a negative angiogram. One patient on CsA with a negative angiogram had no change in ERPF. Three patients had a fall in ERPF, and all 3 had transplant renal artery stenosis. Captopril-induced changes in ERPF can differentiate patients with native-kidney-induced hypertension from those with hypertension secondary to transplant renal artery stenosis in patients without evidence of rejection.

Gastric aspiration for diagnosis of pulmonary tubercolosis in adult renal allograft recipients

Of 213 renal allgraft recipients suspected to have had pulmonary tuberculosis, 132 had sputum examinations and 14 showed acid-fast bacilli. Of the remaining 118 patients, 25 had gastric aspirations, 18 had bronchoalveolar lavage, and 75 did not require further investigation because of spontaneous improvement or confirmation of an alternative diagnosis. While 9 of the 25 patients' gastric aspirate examination was positive, all the 18 who had bronchoalveolar lavage were negative for acid-fast bacilli. Eighty-one patients without expectoration had gastric aspiration directly and 14 showed acid-fast bacilli. Of the remaining 67 patients only 17 had bronchoalveolar lavage, of which three were positive for AFB and the rest did not require further testing for tuberculosis. A total of 106 patients had gastric aspiration. Acid-fast bacillus positivity was significantly more (P<.01) in patients with abnormal chest radiographs as compared with patients with normal chest radiographs as compared with patients with normal chest radiograph results. We suggest gastric aspiration for AFB in all renal transplant recipients who have fever, scanty expectoration, and abnormal chest radiograph with clinical suspicion of pulmonary tuberculosis.

Renal functional reserve in kidney donors assessed in different settings using scintigraphy

Glomerular filtration rate (GFR) was measured in 9 voluntary male kidney donors by scintigraphy. In the basal state, the mean GFR was 96.1 +/- 22 ml/min/1.73 m2. Four weeks after donor nephrectomy, the GFR of the remaining kidney had increased by 22.8 +/- 20.7% (p < 0.05). A protein meal given at this time failed to significantly augment the GFR. The GFR of the grafted kidney increased by 59.7 +/- 24.4% after 6 months (p < 0.01). Renal functional reserve was thus demonstrated in the remaining kidney and the allograft, though a further reserve could not be elicited in the remaining kidney.

Primary drug resistance to Mycobacterium tuberculosis in renal transplant recipients

BACKGROUND

After renal transplantation, patients have an up to 5% chance of being infected with Mycobacterium tuberculosis and there are reports from western countries of a 24% mortality if the infection is drug resistant. We investigated primary drug resistance in renal transplant recipients in Vellore, Tamil Nadu.

METHODS

Between January 1987 and December 1993 we studied 695 patients (who had received 717 renal allografts) for evidence of tuberculosis, and performed drug sensitivity tests.

RESULTS

Forty-three patients had culture-proven infection with Mycobacterium tuberculosis of whom 40 had drug sensitivity tests done. Initial drug resistance was seen from 1991. Rifampicin resistance was seen in 2, 1 and 4 patients and isoniazid resistance in 1, 2 and 2 patients in 1991, 1992 and 1993, respectively of the 23 isolates tested for drug susceptibility. Multi-drug resistance was seen in 1 and 2 patients in 1992 and 1993.

CONCLUSIONS

This is probably the first report in India of primary drug resistance of Mycobacterium tuberculosis in renal allograft recipients. It is a cause for concern as it may indicate a large reservoir of drug-resistant patients in the community.