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146 Jul 2007 / Vol 17 / Issue 3 Indian Journal of Nephrology

 Indian
Abstracts

Journal of
Nephrology
Offical Publication of the Indian Society of Nephrology
July - September 2007 ! Volume 17 ! Number 3

Table of Contents
ABSTRACTS TO BE PRESENTED DURING THE XXXVIII ANNUAL CONGRRESS
OF THE INDIAN SOCIETY OF NEPHROLOGY 13-15 DECEMBER 2007

Clinical Nephrology
Oral 91
Poster 104

Dialysis
Oral 121
Poster 125

Transplantation
Oral 135
Poster 139

Indian Journal of Nephrology Jul 2007 / Vol 17 / Issue 3 147

 Abstracts
Transplantation
Oral
RTO-1
DO WE HAVE A ANSWER FOR PATIENTS WITH HIGH PRA OR
POSITIVE CROSS MATCH?
Varma PP, Hooda AK
Dept. of Nephrology, Army Hospital (RandR), Delhi Cantt - 110010, India
Introduction: Patient with high PRA or positive cross match
have preformed humoral antibodies to HLA class I antigens. To
remove these antibodies various approaches like plasmapheresis,
immunoadsorption or IVIG have been tried with variable success. A
logical way will be to remove the preformed antibodies and to stop
further antibody formation.
Aim: Present study was done to test our simple self designed
hypothesis of removing antibodies and preventing further antibody
formation followed by successful transplantation.
Methods: All prospective renal transplant recipients with
consistently high PRA or positive cross match (atleast on two
occasions during one month waiting period) and with no history
of blood transfusion /fever in previous month, were subjects of the
present study. Patients were started on mycophenolate mofetil 1 gm
twice a day. Twenty days after start of MMF patients underwent 5
sittings of plasmapheresis over 1 week period. During this period
and afterwards MMF was continued. On day 30 PRA and Cross match
was repeated. If cross match and PRA was negative, the patient was
taken up for transplantation and MMF was continued through the
transplantation.
Results: 11 patients with mean age 39.55 years (range 23-58 years),
with male: female ratio 8:3 were the subjects. The mean waiting
period to transplantation due to high PRA/ Cross match in these
patients was 5 months (range 1-18 m). Mean PRA before therapy
was 75.5 (range 40-100%) and mean cross match was 32% (range
10-100%). After one month of treatment, mean cross match dropped
to <10% and PRA also to <10% in 10/11 patients (90.9%). In one
patient PRA didn’t come down and remained 100%. None of these
patient was a retransplant or multigravida or had received blood
products. All these 10 patients received renal transplant with triple
drug immunosuppression (Tacrolimus, MMF and presdnisolone). In
addition six of them were given IL-2 blockers while the other four
received ATG. One patient developed graft venous thrombosis and
required graft nephrectomy. The remaining 9 patients have been
on follow up for a mean duration of 4.6 m (range 2-8 m). None of
these patients have developed any episode of rejection. Their mean
creatinine is 1.38 mg/dl (range 0.8-2.3 mg/dl
Conclusion: Our study shows that with plasmapheresis and MMF,
excellent results in antibody reduction can be obtained in patients
with high PRA or positive cross match. (This simple regimen has been
devised by us and used for the first time in the world by us).
RTO-2
THE UTILITY OF 1 AND 3 MONTH PROTOCOL BIOPSIES ON
RENAL ALLOGRAFT FUNCTION: A RANDOMIZED CONTROLLED
STUDY
Vivekanand Jha, Jagadeesh Kurtkoti, Kamal Sud, Mukut Minz*,
Ritambhra Nada, Harbir S Kohli, Krishan L Gupta, Kusum Joshi,
Vinay Sakhuja
Dept. of Nephrology, Transplant Surgery and Histopathology, PGIMER,
Indian Journal of Nephrology
Chandigarh, India
Identification of pathological events in the renal allograft using
protocol biopsies at predetermined time intervals may yield useful
information and improve outcomes. We examined the influence of
decisions taken on the basis of 1 and 3-month protocol biopsies
findings on 1-year renal allograft function in a prospective
randomized study. Out of 102 living-donor allograft recipients, 52
were randomized to undergo protocol biopsies and 50 controls
had only indicated biopsies. All acute rejection episodes (clinical
and subclinical) were treated. CNI dose adjustments were made on
clinical judgement. Baseline recipient and donor characteristics,
immunosuppressive drug usage, HLA matches, and 2-hour
cyclosporine levels were similar in both groups. At 1 and 3 months,
protocol biopsies revealed borderline changes in 11.5% and 14%
patients, acute rejection in 17.3% and 12%, and chronic allograft
nephropathy in 3.8% and 10%. The incidence of clinically evident
acute rejection episodes was similar in the two groups, but biopsy
group had lower serum creatinine at 6-months (P=0.0003) and 1-
year (P< 0.0001). The creatinine values were similar in those with
normal histology and borderline changes. Protocol biopsies are
helpful in detecting subclinical histological changes in the graft;
and management decisions based on this information improve
short-term renal allograft function.
RTO-3
R O L E O F T R E G U L A T O RY C E L L S I N K I D N E Y
TRANSPLANTATION
Sharad Kumar Mittal, RK Sharma, Mahendra Atlani, Amit Gupta,
Sita Naik
Departments of Nephrology and Immunology, Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow, India
Background: Organ recipients recognize graft as foreign and generate
anti-donor immune response which causes acute and chronic
rejections. CD4+/CD25+ T regulatory (T regs) cells have been recently
shown to play an important role in modulating immune responses.
The role of Tregs in human renal allograft has not been well studies.
The aim of the present study is to assess the role of Tregs in transplant
survival and rejection.
Materials and Methods: Twenty one transplant recipients (on
standard immunosuppressive regimen) with stable graft functions
were assessed prior to transplantation and 6-8 week (n=21), 14-
18 weeks (n=16), >24 weeks (n=14) after renal transplantation.
Proliferative responses in mixed lymphocyte reaction (MLR) using
donor/third party stimulators,T regs enumeration by flow cytometry
and IL-10 and TGF-β concentration in supernatant of MLR cultures
by ELISA were evaluated.
Results: See Table.
Conclusion: These results demonstrate an early stable decline of
donor specific and third party allo-responses in the post-transplant
period in patients with stable graft function. This is associated with
increased production of IL-10 although Tregs has decreased.
RTO-4
OUTCOME OF PERCUTANEOUS INTERVENTION IN TRANSPLANT
RENAL ARTERY STENOSIS
B Kalani
Muljibhai Patel Hospital, Nadiad, India
Background: Transplant renal artery stenosis (TRAS) is the most
common vascular complication. It presents as difficult to control
Jul 2007 / Vol 17 / Issue 3 135
 Abstracts

Table: Various parameters at different time points

MLR (Donor) MLR (Third) IL-10 (Donor) IL-10 (third) TGFB (Donor) TGFB (third) Tregs
(SI) (SI) (pg/ml) (pg/ml) (pg/ml) (pg/ml) (CD4CD25)
Pre Tx
Median 13.75 14.69 0 10.48 1028.96 1072.39 1.03
(range) (8.65-18.25) (8.35-21.39) (0-89.27) (0-96.24) (43.4-2636.15) (278.13-1647.25) (0.18-2.79)
Post Tx1
6-8 weeks
Median 9.48* 10.36* 48.53* 69.31* 672.92 1097.95 0.39*
(range) (4.29-16.58) (2.89-17.92) (9.16-245.26) (0-257.59) (113.19-2155.71) (359.24-2053.68) (0.12-2.33)
Post Tx2
14-18 weeks
Median 6.42* 7.98* 124.18* 115.38* 319.76* 1179.18 0.28*
(range) (3.17-10.49) (5.14-13.65) (14.8-324.56) (8.27-359.73) (90.62-917.3) (726.49-1737.33) (0.112-2.78)
Post Tx3
<24 weeks
Median 4.08* 4.67* 169.7* 147.13* 635.45 905.28 0.26*
(range) (1.48-7.13) (3.16-10.57) (23.59-348.01) (54.73-424.08) (291.85-1628.64) (628.39-1615.74) (0.12-1.65)

hypertension and / or allograft dysfunction. Renal arteriography
remains the gold standard for diagnosis. Percutaneous transluminal
angioplasty (PTA) with or without stent is being increasingly used
to correct TRAS.
Methods: Department of Nephrology carried out 28 renal
arteriographies in 1600 renal transplant patients from 1981 to 2006
for suspected TRAS.TRAS was suspected on basis of difficult to treat
hypertension, allograft dysfunction, renal doppler findings or any
combination of these findings.Significant TRAS was diagnosed if >
60% stenosis was detected on arteriography. The effect of intervention
on blood pressure and allograft function were analysed.
Results: Fourteen patients had TRAS. Nine patients had difficult to
control hypertension and 5 patients had allograft dysfunction. Five
patients presented within first 6 months and 2 patients presented
between 6 months to 2 years. 12 patients underwent percutaneous
intervention (PTA =6; PTA + stent = 6). Graft thrombosis leading to
graft loss following intervention mishappened in 1 patient. Median
follow up was 18 months after intervention.
There was significant reduction in systolic blood pressure from
164.5±20 to 138.44±23.7 mmHg (P=0.002) as well as significant
reduction in diastolic blood pressure from 100±13.47 to 86.44±7
(P=0.001).However, antihypertensive requirement decreased
insignificantly (P=0.09) fr0m 3 1 to 2.43 1.13 medicines. There was
no difference observed in the renal function.
Conclusion: Treatment of TRAS with PTA with or without stent is
associated with significant improvement in blood pressure.
RTO-5
EFFECT OF DONOR AND RECIPIENT AGE AND GENDER
ON LIVING DONOR KIDNEY TRANSPLANT: LONG TERM
OUTCOME.
RK Sharma, M Atlani, A Gupta, A Saxena, Alok Kumar,
Narayan Prasad, Anupama Kaul, Aneesh Srivastava, R Kapoor
Department of Nephrology and Urology, SGPGIMS, Lucknow, India
The influence of donor age and sex on long term graft survival and
acute rejection episodes in living donor (LD) kidney transplantation
has not been well described. We retrospectively studied a cohort
of 885, first (n=869) or second (n=16) time LD transplantations,
transplanted between 1989 and 2006 with mean follow up time of
45.0 months. Death censored overall graft survival and graft survival
according to recipient age, sex and donor age, sex was compared
with Kaplan-Meier plots. Cox regression was performed to estimate
the association between different risk factor and graft survival and
acute rejection episodes. Death censored over all graft survival at 1
yr, 5 yr and 10 yr is 97%, 89% and 78% respectively. Mean survival
time (MST) is 150.7±6.19 months with 95% CI 138.5 to 162.8 months.
Graft survival at 10 years was not statistically different for grafts
from donors of age more than 60 years as compared to grafts from
donors of age<60 years. At 10 years it is 82% for grafts from <60
yrs age donors, with MST of 147±7.6 months (95% CI 132.1 to 161.9
months) and 75% for grafts from donors of age >60 yrs with MST
of 144.6±9.3 (95% CI 126.4 to 162.8) (P=0.618). However grafts of
>60 years age suffered more early acute rejections as compared to
grafts of <60 years age. (26.1% v/s 18.3%; P=0.03). In presence of
early acute rejection, again the graft survival at 10 years was not
statistically different for grafts from <60 years donors and >60
years donors. (76% v/s 63% ; P=0.44 respectively). Graft survival
of recipients of age > 50 years was not statistically different as
compared to graft survival of recipients of age<50 years (76% v/s
80%; P=0.51). However recipients of <50 yrs suffered more no of
acute rejections (20.7%) as compared to 12.6% for recipients age >50
years (P=0.02). Graft survival in presence of acute rejections, was
not statistically different between these two patient groups. 63%
v/s 80% for recipients of age<50 years and >50 years respectively
(P=0.18). Overall graft survival at 10 years for grafts from male
and female donors was nearly similar. It was 80% for female grafts
and 79.9% for male grafts. The graft survival of female grafts at 10
years was not significantly different when transplanted in male
recipients as compared when transplanted in female recipients
(78% v/s 92% ; P=0.425).Female grafts suffered more early acute
rejections when transplanted into male recipients (21% v/s 11.1% ;
P=0.07). Graft survival for male grafts according to recipient gender
is 81% in male recipient and 78% in female recipients (P=0.68).
In multivariate analysis donor age ≥65 years was a risk factor for
graft loss in all time periods after transplantation. During the first
5 years after transplantation a steroid resistant rejection episode,
late acute rejections were additional risk factor. More than 5 years
after transplantation again steroid resistant rejection was the only
additional risk factor for graft loss. Grafts from donors age >60 years
and females do not have statistically different long term graft survival

136 Jul 2007 / Vol 17 / Issue 3 Indian Journal of Nephrology

 Abstracts
as compared to donors of age<60 years and males. Also recipients
of age more than 50 years do not have statistically different long
term graft survival as compared to recipients of <50 years age and
grafts from donors age >65 years are independently associated with
poor graft survival in all time periods. Hence our result supports the
continued use of older male and female living donors of age up to
64 years who meet carefully constructed medical criteria and who
are highly motivated.
RTO-6
TRANSPLANTATION IN HIGHLY SENSITIZED PATIENT:
DESENSITIZATION PROTOCOL
Falodia J, Shah PR, Dabhi M, Gumber M, Goplani K, Vanikar A,
Trivedi HL
Institute of Kidney Diseases and Research Center and Institute of
Transplantation Sciences, Ahmedabad, India
Introduction: The highly sensitized patient is destined to remain
on the waiting list for extended periods on dialysis. Therefore,
early transplantation results in considerable cost savings, reduced
morbidity and mortality, and improvement in quality of life, an elusive
goal until recently.
Aims: We did study to evaluate the efficacy and safety of
desensitization protocol in sensitized patients in Indian context
and to evaluate the influence of this protocol on patient and graft
survival.
Materials and Methods: Between January 2006 to June 2007, We did
a prospective study of 14sensitized patients awaiting transplantation
whose Lymphocyte cross-matching done by CDC-AHG method, > 25
% was considered as cross match positive. All these patients were
subjected to desensitization protocol using tacrolimus (0.1mg/kg from
-10 days) and cyclophosphamide (15 mg/kg on -10th day as a bolus),
we did plasmapheresis using polysorba 0.6 plasma filter alternating
with IVIG 100 mg/kg for 4 sessions. We gave ATG(1.5 MG/KG) 3
days prior and rituximab (375 mg/m2) 1 day prior to transplant. We
repeated the LCM prior to transplant. We had to repeat this protocol
in 4 patients. Post transplant patients were maintained on steroid
+ tacrolimus + MMF.
Results: In our study group mean age of patient was 40.6±15.2
years, 11 were male. Mean duration on dialysis was 13.9±17.6
months. 43% were retransplant. Average third party transfusion
received were 8.2±4.5, 30% had autoimmune disease and 15% were
multipara. Preprotocol LCM was 61.4±17.4. after desensitization
was 26.9±5.4. Patient survival was 100%, graft survival was 93%,
mean s.creatinine was 1.12±0.25 mg% at 6.2±4.7 months follow
up. Acute rejection was noted in 21.4% which responded to steroid
+ ATG+plasmapheresis.
Conclusion: Transplant in Sensitized patient is safe and effective in
Indian context with this protocol.
RTO-7
INCIDENCE, CLINICAL SPECTRUM AND OUTCOME OF
OPPORTUNISTIC INFECTIONS IN LIVE RELATED RENAL
TRANSPLANT RECIPIENTS
Vi n o d P B , R K S h a r m a , A m i t G u p t a , Ra ke s h K a p o o r,
Aneesh Srivastava, Anita Saxena, N Prasad, Alok Kumar,
Anupama Kaul
Department of Nephrology, SGPGIMS, Lucknow, India
Background: Opportunistic infection is a serious clinical complication
Indian Journal of Nephrology
in patients receiving immunosuppressive therapy after kidney
transplantation. The overall incidence of opportunistic infections
varies from center to center, up to 15% of renal transplant recipients
died of these infections. We present our experience of opportunistic
infections during the period of 1989 to 2006 with reference to
incidence, time frame of infections, clinical spectrum,organ
involvement and outcome in renal transplant recipients
Materials and Methods: Retrospectively 1625 patients of renal
transplant recipients data were analyzed.All of them received tipple
immunosuppressant regimen. Opportunistic infections requiring
hospitalization and those who were diagnosed on OPD basis were
noted in 828 patients were analyzed.
Results: The incidence of opportunistic infections from our center
experience was 828 (50.6%). Clinical spectrum includes Viral 587
patients (35.7%); fungal 87 patients (05%), bacterial 136 patients (8.3%)
and parasitic 18 patients (1.1%). In the viral group CMV infection was
common with 421cases (25.9%), followed by Herpes zoster 144 cases
(8.8%), BKV 11 cases (0.67%), EBV 9 cases (0.55%), Parvo- B-19 virus
02 cases (0.12%). In the fungal group, Candidiasis was the commonest
with 27 patients (1.7%), followed by Aspergillosis 24 patients (1.4%),
Cryptococcal 23 patients (1.4 %) and Mucormycosis 8 patients
(0.5%); Pneumocystis carinni in 05 cases (0.3%).In the bacterial group
mycobacterial tuberculosis was the common opportunistic infection
with 119 patients (7.3%), followed by Nocardiosis in 10 patients (0.61%),
Listeria monocytogen in 5 patients (0.3 %), and mycobaterial leprosy in
2 patients (0.12%). In the parasitic group Cryptospridiosis in 09 cases
(0.55 %); Amoebiasis in 02 cases (0.12%), toxoplasmosis in 01 cases
(0.06%); leishmaniasis in 2 cases (0.12%) and strongyloids in 4 cases
(0.24%) respectively. Majority of opportunistic infection occurred in
the initial 6 months of post transplantation.
Invasive organ involvement occurred in 461/823 patients (56%). The
various organ involvement include lung involvement 84 pts (18.2%)
[viral 10 ; bacterial 47, fungal 27]; GI tract 46 pts (9.9 %) [viral 09;
bacterial 7, fungal 16; parasitic 14]; CNS 38 (8.2%)[viral 07; bacterial
19; fungal 11; parasitic 01];’Para Nasal Sinus 5 (1 %) [fungal 5]; graft
kidney 40 (8.6%)[viral 16;bacterial 16;fungal 08];liver 7 (0.43 %); lymph
nodes -36(7.8%); skin 158 (34.2%); and disseminated infection in 47
(10.1%) cases. Total mortality was 17.4% (143 cases / 828 pts who
had opportunistic infections). Among that viral constitutes 84 / 587
(14.3%); fungal 33/82 (40.2%); bacterial 26/136 (19.1%).
Conclusion: The incidence of CMV infection in renal transplant
recipient is increasing because of increased in use of newer
immunosuppression, mycophenolate mofetyl, tacrolimus and anti
rejection therapy (ATG and IORT-3. Mortality was high with the
pulmonary invasive fungal infections.Early diagnosis and adequate
treatment and regular follow up will reduce the mortality in these
group of patients.
RTO-8
LONG TERM IMPACT OF HEPATITIS B AND C ON GRAFT
LOSS AND MORTALITY OF PATIENTS AFTER KIDNEY
TRANSPLANTATION
M Atlani, RK Sharma, A Gupta, A Saxena, Alok Kumar, N Prasad,
Anupama Kaul, R Kapoor, Aneesh Srivastava
Department of Nephrology and Urology, SGPGIMS, Lucknow, India
Background: chronic liver disease and its complication are major
problem in renal transplant patients.Our aim was to elucidate the
influence of hepatitis B(B+C-), C(C+B) virus infection on the long
term outcome of renal transplantation.
Jul 2007 / Vol 17 / Issue 3 137
 Abstracts
Methods: The data of 889 of renal transplant patients who underwent
renal transplant at our centre between 1989-2005, and had adequate
virological data were analyzed retrospectively. Qualitative differences
between groups were assessed by means of the Chi-square test.
Patient and graft survival were estimated by means of the Kaplan-
Meier product limit method and compared by means of the log-rank
test; Proportional hazard Cox’s model, was used for multivariate
analysis.
Results: Prevalence were 4.4% for B+C-, 4.9% for C+B-, 0.9% for
hepatitis B and C both positive (B+C+) and 89.8% for hepatitis B
and C both negative (B-C-) patients. Because of very low prevalence
of B+C+ patients, this group was removed from the analysis. The
10-year death censored graft survival was not significantly different
between the B+, C+ and B-C- patients, it was 81%, 81%, 85%, in
B-C-, B+C- and C+B- patients respectively. (P=0.639). The patient
survival at 10 years was inferior (85%) among the infected patients as
compared to 93% in non-infected patients (P=0.04). In patients with
C+B- group patient survival was significantly inferior as compared
to C-B- (non infected) patients. (P=0.015). Odd`s risk ratio: 5.9;95%
CI 91.7-115.2. For B+C- group patient survival was not statistically
significantly inferior as compared to B-C- patients (88% v/s 93%;
P=0.58). There were more deaths in infected groups because of liver
disease. In infected patients, the causes of death was sepsis in 66.6%
(4/6) and related to liver failure in the remaining 33.3% (2/6). Whereas
83.3% of deaths in non infected group were because of sepsis, 33.3%
because of cardiovascular disease and 4.2 % died of malignancy
(P=0.002). At multivariate analysis HCV infective status (RR, 3.4;
95% CI, 1.19-9.9; P=0.042) was independently associated with a
worse patient survival. Among the infected patients 27.8% patients
developed Chronic liver disease (CLD) [persistent deranged LFT >6
months] as compared to 0.8% in non infected group (P<0.0001).
21.6%, 33.3% of patients in groups B+ and C+ respectively developed
CLD. Significantly more no of infected patients developed post
transplant diabetes (PTDM); C+ 37.5%, B+C- 12.1%,as compared to
8.4 % in non infected group. (P<0.0001).
Conclusion: In the long term B+ and C+ patients had a higher risk
of poor patient survival and death related to liver disease, but the
graft survival is not significantly affected.
RTO-9
BASILIXIMAB INDUCTION IN RENAL TRANSPLANTION–LONG
TERM OUTCOMES
M Atlani, RK Sharma, A Gupta, A Saxena, Alok Kumar, N Prasad,
Anupama Kaul, R Kapoor, Aneesh Srivastava
Department of Nephrology and Urology, SGPGIMS, Lucknow, India
Anti-IL-2 receptor has been proved to be effective in reducing the rate
of acute rejection in kidney transplantation and also improving both
the rate of graft and patient survival. In this study, we retrospectively
reviewed the role of anti-IL-2 receptor (basiliximab) as induction
immunosuppression.
Methods: Sixty five kidney transplant recipients from living donors
who received IL-2 blocker basiliximab (group 1) as induction therapy
in combination with CsA, Steroid and MMF or Azathioprine, were
compared with similarly matched renal transplant recipients (N=555)
who did not receive induction therapy (group 2). Survival analysis
was done using Kaplan- Meir analysis. Chi –square test was used to
compare the outcome difference of various parameters between the
two groups.
Result: Both the groups were similar in terms of male to female ratio,
basic disease, mean age of recipient as well as of donors. Group 1 has
138 Jul 2007 / Vol 17 / Issue 3
more no of immunologically high risk patients {2nd transplants 4.6%
v/s 1.5%, P>.05}, More spousal donors {35.4% v/s 20.8 % P<0.009).
Significantly more no of patients in group1 (47.7%) received MMF
based immunosuppression as compared to group2 (22.6%) (P=0.016).
Total no of rejections were significantly less in Group1 (15.4%)
v/s 29.4% in group 2 (P=0.023, Odds ratio=0.44). More number of
patients in Group 2 suffered steroid resistant rejections however the
difference was not statistically significant. (11.1% in group 2 v/s 4.6%
in group 1). Three percent patients suffered late acute rejections in
group 1 v/s 3.9% in group 2. (P=NS). Death censored graft survival
was significantly better in group 1 at 5 yr as compared to group 2.
(86% v/s 77% P<0.02).It was 100% at 1yr (group1) v/s 96%, in group 2.
Actuarial patient survival at one and 5 yr was 100% and 92% in group
1 v/s 99% and 95% in group2 (P=>.05). On multivariate analysis
for association with graft survival only the late acute rejections and
steroid resistant rejection were independently associated with poor
graft survival, whereas type of maintenance immunosuppression
(MMF v/s non MMF),use of induction therapy and total no of acute
rejection episodes had no association.
Conclusions: The use of anti-IL-2 receptor antibodies (basiliximab) as
induction immunosuppression in immunologically high-risk patients
results in the significantly better prevention of acute rejection,
and 5yr graft survival.It also results in reduced severity of acute
rejection.
RTO-10
BODY COMPOSITION AND VOLUME OVERLOAD IN RENAL
TRANSPLANT PATIENTS
Anita Saxena, RK Sharma, A Gupta, N Prasad, A Kumar, A Kaul
Department of Nephrology, SGPGIMS, Lucknow, India
To evaluate graft function and its effect on body composition and
nutritional status of renal transplant patients using Bioelectrical
Impedance Analysis. 100 patients (male 82; female 18) who
underwent renal transplant between year 1997 and 2006. Their
mean age was 39±10.3 years, mean height 164.2±7.6 cm and
weight 58.9±9.0 kg, mean serum creatinine 1.48±.0.59 mg%
and mean GFR 43.8±15.3 ml/min. GFR and body composition was
assessed using multi frequency bioelectrical impedance analyzer
BIOSCAN. All the patients were on 2 or 3 immunosuppressive drugs.
All the patients had normal SGA scores. Data were analyzed in two
steps. First analysis included comparison of patients with well
matched 61 healthy controls (male 45 female16) for age (41.7±11.3
years), sex and height (163.5±9.7 cm), with weight 63.7±12.0 kg)
and serum creatinine 0.97±0.19 mg%. Patients were then divided
into two groups based on GFR as calculated by Bioscan (group 1:
borderline graft function GFR <40 ml/min: n= 33, X 27.8±10.2
ml/min and group 2: good graft function GFR ³40 ml/minute, n
=67, X 51.7±10.4 ml/min). Both groups were compared with each
other. The results show that there was significant difference (p
0.000 for all variables unless specifically mentioned otherwise)
between controls and PTP in weight (P.0 08), creatinine, body mass
index (BMI, phase angle (PA) fat free mass (FFM, FFM% fat mass (FM)
FM%, total body water (TBW %, extracellular water (ECW), ECW%,
Intracellular water (ICW), ICW%, ECW/ICW, body cell mass (BCM
P=0.002), GFR, extracellular solids (ECS 0.32) ECfluid (ECF) plasma,
interstitial fluid (ITSF), target fat min (TFM P=0.021), target water
min (TWM) systolic BP and diastolic BP. When groups 1 and 2 were
compared, significant differences (P=0.000) were observed. Group
1 patients had low weight, PA (P=0.017), BMI (P=0.003), resting
metabolic rate (RMR), FFM, TBW, ICW, ICW% (0.001), BCM, ECM
(P=0.026), GFR, Protein (P=0.020), Mineral (P=0.050), Calcium,
Indian Journal of Nephrology
 Abstracts
glycogen, dry weight, ECS, TFmax (P=0.046). Group 1 patients had
higher ECW%, ECW/ICW compared to group 2. Though clinically
all patients had normal SGA scores and were non-edematous, their
intravascular compartments were expanded as depicted by high
absolute values of ECW, ECW/ICW, ECF, plasma INSTFL compared
to controls. Significant differences between Group 1 and Group 2
patients indicate that transplant patients with borderline graft
function were more nutritionally depleted as compared to those
with better GFR. Transplant patients as a group had higher systolic
and diastolic blood pressure which may be related to their volume
expanded status. Both nutritional deficit and volume expansion
were detected objectively by BIA which is a non-invasive tool for
out patient monitoring.
RTO-11
PRE-TRANSPLANT TREATMENT WITH INTERFERON IN HCV
POSITIVE PATIENTS - WHERE DO WE STAND?
PP Varma*, AK Hooda*, AK Seth**, P Puri**
Departments of *Nephrology and **Gastroenterology, Army Hospital (R
and R), Delhi Cantt 110010, India
Introduction: Hepatitis C virus (HCV) infection is a major threat in
dialysis units today and is associated with increased morbidity and
mortality in post-transplant period. Treatment with Interferon (IFN)
in the pre-transplant period is the only treatment option for such
patients, however there is paucity of data on duration and response to
therapy in dialysis population. Patients who remain HCVRNA negative
for atleast 6 months after therapy are called sustained responders.
Aim: To study the sustenance of response in post-transplant period
in HCV positive patients treated with IFN while on dialysis.
Methods: All prospective transplant recipients on dialysis, who
were HCVRNA positive were included in the study. Liver function
tests (LFT), virological status (HCVRNA and viral load), genotyping
and liver histology were done in all these patients. Patients
with positive HCVRNA were treated with IFN. Depending on the
availability, patients were given either IFN 3 MU thrice a week or
pegylated IFN once a week. LFT and HCVRNA levels were monitored
every month during treatment. IFN was continued till HCVRNA
became negative or for a minimum of three months even if viral
load became 0 earlier.
Results: 10 dialysis patients with mean age of years were the subjects.
Mean ALT and viral load prior to treatment were 206.16 (range 48-644)
and 354053.2 (range 208722-7,00,000) respectively. Genotyping was
done in 7 cases and 5 of these were of genotype 1, one of genotype 3b
and in another none of the genotypes from 1 to 6 could be detected.
Liver histology showed mean HAI score of 4.4 (range 0 to 8/22). Seven
patients received IFN for 3 months while one each received for 4,
6 and 7 months. All 10 patients had virological response prior to
transplantation i.e. HCVRNA became negative in all and viral load was
0 copies. Following transplantation, all patients were given triple drug
immunosuppression with Cyclosporine, MMF and prednisolone. During
follow up period, one patient died 4 months after transplantation
due to sepsis while another was lost to follow up. Review of other 8
patients after six months of transplantation revealed that in 5 patients
HCVRNA had become positive again, with mean quantitative HCVRNA
of 1126413 copies /ml (107-5483703), while three patients were
sustained responders. All three patients with sustained response had
received over 3 m of IFN (4, 6 and 7 months respectively).
Conclusions: Though study has small number of patients, it shows
that a sustained response to treatment with IFN is seen only if
treatment duration is longer than 3 months.
Indian Journal of Nephrology
Poster
OUR EXPERIENCE WITH RABBIT ANTITHYMOCYTE GLOBULIN
AS INDUCTION IN RENAL TRANSPLANTATION AND COMPARISON
WITH IL2 RECEPTOR BLOCKER”
K. Sengupta, H. Nagar, A. Mitra, S. Nandi, S. Ganguly, S. S. Saha,
A.R. Dutta
Wockhardt Hospital and Kidney Institute, Kolkata, India
Introduction: Antithymocyte Globulin (ATG) induction in renal
transplantation, although currently most common in western world,
is used sparingly in India primarily due to concerns regarding infective
risks. A recent trial (Brennan D C et al, NEJM 2006), which showed no
major difference in the risk profile, prompted us to do this study.
Aims and Objectives: To study the efficacy and safety of rATG
induction in renal transplant recipients with particular reference to
CMV and non CMV viral infections.
2. To compare the results with that of IL-2 receptor blockers.
Materials and Methods: We studied 15 renal allograft recipients who
received induction therapy with rabbit ATG (Dose: 1.25-1.5 mg/kg)
between September 2006 and August 2007 and compared with other
2 groups (15 patients each) who had received either Basiliximab or
Daclizumab in the past or concurrently at our center. All the recipients
in the ATG group received Tacrolimus, MMF, Methyl prednisolone
followed by Prednisolone as maintenance immunosuppression.
Results: In the rATG group, the median age of the recipients was
37 yrs, and that of the donors was 43 yrs. All the recipients had
undergone first kidney transplantation except 1 patient who had
received second transplantation. 60% of patients (9/15) had HLA
mismatch of 5 or more and 26.67% (4/15) had mismatch of 3 - 4.
CMV seropositivity: 60% (9/15) were D+/R+; 26.67% (4/15) were
D+/R-. The HLA matching and CMV seropositivity were comparable
in the three groups. Prophylactic Acyclovir and Trimethoprim
– Sulphamethoxazole were given in all the patients. Renal function
was stable at the end of 1 month, 6 months and 12 months. No
incidence of acute rejection or delayed graft function was noted.
There was no incidence of thrombocytopenia or leucopenia. 66.67%
(10/15) of the patients has completed 3 months post transplant and
46.67% (7/15) - 6 months: no incidence of CMV or non CMV viral
infection noted. Among the adverse events, UTI was most common.
There were 3 episodes of UTI, 1 incidence of PTDM and 1 incidence of
worsening of pre existing diabetes mellitus. The observations were
similar in the other 2 groups who had received either Basiliximab or
Daclizumab as induction therapy. The overall cost of ATG is 20% less
compared to IL2 receptor blockers.
Conclusion: In our study, use of rATG as induction therapy was
found to be safe and effective. No CMV infection was noted despite
seropositivity and absence of gancyclovir prophylaxis. Acyclovir
might have contributed, however the exact role is uncertain.
rATG is cost effective induction therapy without any increased
incidence of CMV and non CMV infection in comparison to IL2
receptor blocker.
BK VIRUS NEPHROPATHY CAUSING POST TRANSPLANT KIDNEY
DYSFUNCTION: A CASE REPORT
Ram Prasad, Venkatraman, Ramesh, Sidharthan, Chirancheevi
Abstract: BK virus is a polyama virus, which is found as asymptomatic
latent infection in 70 to 80 percent of general population and
Jul 2007 / Vol 17 / Issue 3 139
 Abstracts
causing nephropathy in immunosuppressed state esp. in post renal
transplant patients under potent immunosuppressive drug therapy.
This viral infection causes post Tx kidney dysfnction which has to
be differentiated from the graft rejection. Appropriate management
ensures the recovery of the Tx kidney function. Here we discuss
such a case which was treated successfully with modification of
immunosuppressive drug therapy and institution of Leflunomide.
Case Report: A 32 year lady with end stage (CKD V) renal disease
underwent living donor renal Tx on 22nd September 2005 with
uneventful post Tx period. She was on tacrolimus 8mg per day (0.15
mg/kg) mycophenolate mofetil 750 mg twice daily and prednisolone
10 mg once a day.
Her renal function was stable untill August 2006, almost for one year
duration. By September 2006 her renal parameters started raising.
USG abdomen study was normal. Urine analysis was also normal.
Further rise in renal parameters occurred in following months (values
reached 61 mg% and 2.6 mg%, urea and creatinine respectively). Her
CMV status was negative. TC-5, 600 cells Hb-8.8gm% urine analysis
normal. Patient was afebrile with normal blood pressure and no graft
tenderness, pedal edema or facial puffiness. Her hydration was good.
Normal Tacrolimus serum level (7.5 ng/ml).
At this stage BK virus nephropathy was suspected. Renal biopsy
was done, which showed interstitial nephritis with intranuclear
inclutions suggestive of polyoma virus infection. Urine cytology
revealed few uroepithelial cells showing intracellular inclusions
(decoy cells) suggesting polyoma infection. So diagnosis of polyoma
virus (BKV) was confirmedand patient was treated by reducing the
immunosuppressive drug dosage. Tac. 4 mg per day, MMF 250 mg
BD, prednisolone 5 mg were the reduced dosage administered. Also
Tab. Leflunomide (ARAVA) 100 mg once a day for 6 days followed
by 20 mg OD for 3 months was given. Patient showed remarkable
improvement. Renal function improved.
LARYNGEAL STRIDOR- AN UNUSUAL PRESENTATION OF
DISSEMINATED MUCORMYCOSIS
Arun Kumar, PP Varma, S Badwal, AK Hooda
Dept of Nephrology, Army Hospital (R and R), Delhi Cantt - 110010,
India
Introduction: Fungal infections are common opportunistic infections
in renal transplant recipients. Mucormycosis affects 2% of renal
transplant recipients and generally carries a poor prognosis.
Case: We present here a 39 years old patient who received unrelated
renal transplant from his mother-in-law for basic disease ADPKD.
After an uneventful year his immunosuppression was reduced
and he was receiving only cyclosporine and prednisolone. He
was bye and large doing well and maintaining a creatinine of 1.8
mg/dl. After one and a half year post transplantation he presented
with 3- day history of fever, irritation in throat and hoarseness of
voice. He was being managed as upper respiratory infection with
antibiotics. Within 24 h of hospitalization he developed laryngeal
stridor and required tracheostomy. ENT exam was normal except
for sluggish movement of vocal cords. On 3rd day of hospitalization
he developed anterior wall acute mycocardial infarction. Despite
thrombolytic therapy patient succumbed. Post mortem revealed
disseminated mucormycosis.
Case highlights a rare and unreported presentation of mucormycosis
with laryngeal stridor.
140 Jul 2007 / Vol 17 / Issue 3
STUDY OF RISK FACTORS FOR URINARY TRACT INFECTION IN
RENAL TRANSPLANT RECIPIENTS
Dilip M Babu, NK Hase, AR Halankar
Dept. of Nephrology, Seth G S Medical College, Mumbai, India
Background: Urinary tract infection is the most common bacterial
infection occurring in the renal transplant recipients, particulaly in
the first few months post transplant. The major risk factors for UTI
in renal transplant include indwelling bladder catheter, anatomic
abnormalities of the native or transplanted kidneys, neurogenic
bladder and possibly rejection and immunosuppression.
Aims: The purpose of this study is to determine the risk factors of UTI
among early renal transplant recipients (<3 months) and its effect
on graft function at 1 year
Methods: We conducted retrospective analysis of 200 renal
transplant recipients from Jan 1,1995 to Jan 31,2006.50 patients
had post transplant UTI. Variables assessed included donor and
recipient age, sex, pretransplant UTI, induction and maintainance
immunosuppression, allogrft rejection, specific causes of end stage
renal disease, post op duration of per urethral catheterization and
D-J stent.
Results: The incidence of UTI during the first 3 months after renal
transplantation was 20% (equivalent for both men and women) and
at 1 year was 60% for women and 47% of men. Significant risk factors
for post renal transplant UTI were advanced age, female gender, use of
cyclosporine MMF and azathioprine, post op duration of per urethral
catheterization and D-J stent. UTI did not increase risk for renal graft
loss but caused significant allograft dysfunction at 1 year.
Conclusion: Urinary tract infection is the most common bacterial
infection occurring in the renal transplant recipients, particularly
in the first 3 months post transplant. Significant risk factors were
advanced age, female gender, immunosuppression, post op duration
of per urethral catheterization and D-J stent. UTI caused significant
allograft dysfunction at 1 year.
EARLY POST TRANSPLANTATION ANAEMIA: ANALYSIS OF
RISK FACTORS
Amit P Nagarik, Sachin S Soni, Shriganesh Barnela, Shailesh
Gondane, A Gopal Kishan, Anuradha
Department of Nephrology, Mediciti Hospitals, Hyderabad, India
Introduction: Anaemia is not uncommon after renal transplantation
and is associated with significant morbidity.
Aim: To analyse the risk factors associated with early post transplant
anaemia.
Materials and Methods: Patients who underwent renal transplantation
from August 1997 to March 2007 were included.Patient data
included basic disease, age, sex, donor source, HLA matching,
Immunosuppression, acute rejections, infection. They were followed
at monthly intervals for 6 months. Laboratory parameters eg
Haemogram, Renal functions and urine examination were done. Early
Post transplant anaemia was defined as Haemoglobin <13 gm% for
male and <12 gm% for females at 6 months. Comparison was done
between patients with and without anaemia. Statistical analysis was
done using Strata 6 software for windows and P<0.05 was taken as
statistically significant.
Results: Of 65 patients, 47 were males. Donors included related in
45, Unrelated in 18 and cadavers in 2. Induction with IL 2 receptor
Indian Journal of Nephrology
 Abstracts
antibody was given in 6 patients. All patients were on triple immuno
suppression. Cyclosporine was used in 56, Tacrolimus in 9, Azoran
in 53, MMF in 12 and sirolimus in 1 patient. Rejection was seen in
15 patients of which cellular rejection was seen in 14and Humoral
rejection in 1 patient. Infections were seen in 14 patients, most
common infection being urinary tract infection (09). No patients
had malignancy. None were treated with Erythropoietin. 16(24%)
patients had anaemia (9 females:7 males). Mean age of patients with
and without anaemia was 39.30±10.24 and 34.47±8.24 respectively.
Mean haemoglobin levels were 9.6±3.6 and 14.2±2.4 and the mean
creatinine was 1±0.3 and 1.3±0.4 respectively.
Female sex, Unrelated donor (P<0.05), Azathioprine (P<0.05), Acute
rejection episode (P<0.05) and infections (P<0.05) were significant
risk factors for early post transplant anaemia.
Conclusions: 1) 25% of post transplant patients have anaemia. 2)
Female sex, Unrelated donor, Azathioprine, Acute rejection episodes
and infections are significant risk factors for anaemia.
POST TRANSPLANT DIABETES MELLITUS: A SINGLE CENTRE
EXPERIENCE
Amit P Nagarik, Sachin Soni, Shriganesh Barnela, Shailesh Gondane,
A Gopal Kishan, Anuradha
Department of Nephrology, Mediciti Hospitals, Hyderabad, India
Introduction: Post transplant diabetes mellitus (PTDM) has been
variously reported between 2-53% and is associated with increased
incidence of morbidity and mortality.Advances in immunosuppression
has led to an increased incidence of PTDM with its attendent
complications.
Aim: To analyse incidence and risk factors for PTDM
Materials and Methods: Patients who underwent renal transplantation
from August 1997 to January 2007 in Department of Nephrology,
Mediciti Hospitals, were included. Patient data included detailed
history, Body mass index (BMI), donor source,age, immunosuppression,
rejections and antirejection treatment (including mean cumulative
steroid dose). Laboratory data included haemogram, renal functions,
complete urine examination and other relevant investigations. PTDM
was defined as per WHO guidelines. Risk factors for PTDM were
analysed. Statistical analysis was done using Strata 6 software for
windows and P<0.05 was considered statistically significant.
Results: Of 65 patients,males were 47. Among donors, 45 were
related,18 unrelated and 2 cadavers.All patients were on triple
immuno suppression: Cyclosporine in 56, Tacrolimus in 9, Azoran in
53, MMF in 12 and sirolimus in 1.15 patients had rejection.
PTDM developed in 15 non diabetic recepients (23%) (Males 10:
Females 5; Mean age 44.8±11.60). Mean BMI was 27.Mean duration
to PTDM was 154±30 days. Mean Fasting and post prandial blood
sugar was 134±20.14 and 254±22.4 and the mean serum creatinine
was 1.3±0.5. Mean cumulative steroid dose including the dose used
for anti rejection treatment was 7324±5428 mg. Infections were seen
in 8 patients. The most common infection was urinary tract infection
(04). Other infections included viral infections like CMV and Herpes
in 1 patient each and fungal infection in 1 patient. 2 patients were
HCV RNA PCR positive at the time of transplant. 13 patients needed
insulin while 1 was on Oral hypoglycaemic drug and 1 was controlled
with dietary management. Use of Tacrolimus and presence of acute
rejection was associated with significantly increased risk of PTDM.
Conclusions: 1) 23% of patients developed PTDM. 2) Use of Tacrolimus
and rejections are significant risk factors. 3) Patients with PTDM are
prone for infections.
Indian Journal of Nephrology
TACROLIMUS DOSE IN RENAL TRANSPLANTATION- DO WE
HAVE AN ANSWER?
AK Hooda, Arun Kumar, PP Varma
Department of Nephrology, Army Hospital (RandR), Delhi Cantt - 110010,
India
Introduction: Tacrolimus is today the pivotal immunosuppressive
agent in organ transplantation. Conventional dose of tacrolimus
(0.15-0.20 mg/KG BW) which was used in initial trials is associated
with high incidence of new onset diabetes mellitus (NODM).
Aim: To study two dosage schedules of tacrolimus (conventional and
low dose) in de novo transplant recipients and to compare rejections,
major infections and NODM in them.
Methods: Our centre is conventionally using triple drug
immunosuppression with tacrolimus, MMF and prednisolone in all
de novo renal transplant recipients. Patients receiving retransplant,
spousal transplant or with historical high PRA were additionally
given IL-2 blockers/ATG. Diagnosis of rejection was made on renal
biopsy and patient was said to have major infection if he/ she required
hospitalization. Patients were randomly divided in two groups; group
I received approx. 0.15 and group II was given 0.10 mg/kg BW of
tacrolimus. Other medications e.g. MMF and steroid dosages remained
unchanged. Tarolimus level was done on day 5 and dose was adjusted
to keep levels between 10-15 ng/ml. Repeat tacrolimus levels were
done if under or over exposure to tacrolimus was suspected. Each
patient was followed for a period of three months for development of
rejection, infections and NODM. Results: A total of 32 patients were
included in the study, 17 patients formed group I and 15 group II.
Mean age of patients in gr I and Gp II was 33.5 years (range 10-62)
and 35.5 years (range 9-52) respectively. Gp I had M:F ratio of 3.2:1and
gp II had 2:1. Median tacrolimus level achieved in GpI was 9.8 (range
3.5-14.8) and in gp II was 8.4 ng/ml (range 3.9-29.9) respectively.
Two patients in Gp I and 3 patients in Gp II developed rejection (P=
0.645). NODM developed in 9 patients of Gp I and only one patient
in gp II (P=0.007). One patient from group I developed caries spine 8
weeks after transplantation while no patient from group II required
hospitalization. Mean creatinine after 3months of follow up in Gp I
and II was 1.30 mg/dl (range 0.9 -2.1 mg/dl) and 1.31 mg/dl (range
0.9- 2.2 mg/ dl) respectively (P>0.05)
Conclusion: Our study though on small number of patients, suggests
that low dose tacrolimus significantly reduces incidence of NODM
without compromising graft functions.
SPECTRUM OF SKIN AND SUBCUTANEOUS FUNGAL INFECTION
IN RENAL TRANSPLANT RECIPIENTS
Alok Kumar1, Anupama Kaul1, Rungemi SK Marak2, RK Sharma1,
Amit Gupta1, Narayan Prasad1
Departments of 1Nephrology and 2Microbiology, SGPGIMS, Lucknow,
India
Objective: Fungal infection of skin is common problem in post
transplant period which affects quality of life adversely. Therefore
we conducted study with objective to look for spectrum of skin and
subcutaneous infection in our renal transplant recipients and effect
of treatment on these infections.
Materials and Methods: We retrospectively reviewed records of 550
patients attending transplant clinic from January 2004 to Feb 2007.
Patients with skin or subcutaneous infections (102) were included
in study. All relevant details of patients were recorded Patients
were diagnosed with fungal infection by clinical examination,
skin scrapings or by aspiration cytology (in case of subcutaneous
Jul 2007 / Vol 17 / Issue 3 141
 Abstracts
infection). Univariate and multivariate analysis was performed to see
impact of various factors on recurrence of skin infections.
Results: 102 patients (18.54%) had fungal infection of skin or
subcutaneous tissue. Mean age of patients was 32.4±13.8 years.
Gender ratio was 2.8:1. 80 patients were on calcineurine inhibitors,
mycophenolate and prednisolone, 11 patients received azathioprine
and prednisolone and 5 patients received sirolimus, calcineurine
inhibitors and prednisolone.32 patients had history of acute
rejection. 96 patients (94.22%) had evidence of skin infection
and 6 patients (5.88%) suffered from subcutaneous infection. 42
patients had infection during first year of transplant and remaining
patients had infection afterwards. Most common cause of skin
infection was dermatophytosis (79.17%) and other causes were
P.versicolour (12.5%), Candida (8.33%). 22 patients had evidence
of nail involvement.
28 patients (34.47%) with candida or Tinea infection had 2 or
more episode of skin infections. All patients were treated with oral
fluconazole and topical therapy. Duration of therapy <3 weeks
and presence of diabetes were predictor of relapse.6 patients had
subcutaneous infection. 4 patients had phaeohyphomycosis. Other
causes were aspergillus (1) and Cryptococcus(1). 3 patients needed
surgery. 2 patients needed repeated course of amphotericin B.
Conclusions: Duration of treatment <3 weeks and diabetes were
predictor of relapse. Patients with subcutaneous infection may need
surgical excision.
PANNICULITIS DUE TO DISSEMINATED FUNGAL INFECTION IN
RENAL TRANSPLANT RECIPIENTS
D Bhowmik, AK Dinda, I Xess, G Sethuraman, S Mahajan,
S Gupta, SK Agarwal, S Guleria, SC Tiwari
Departments of Nephrology, Pathology, Microbiology and Surgery, AIIMS,
New Delhi, India
Introduction: Panniculitis may result due to various etiologies. In
post-transplant immunosuppressed patients infection is the foremost
cause of panniculitis. We present two cases of fungal panniculitis in
renal transplant recipients.
Case Reports: CASE 1: A 33 year old male patient who had been
transplanted 13 years earlier presented with erythematous nontender
plaques on left thigh. He was already in CAN with sr creat. 6.0 mg%.
Deep skin biopsy revealed panniculitis with cryptococci. He also had
cryptococcal pneumonitis and UTI. He was treated with amphotericin
B (total dose 2g). The lesions resolved completely. Renal function
remained stable. One year later he was retransplanted and is doing
well.
Case 2: A 22 year old male developed pyrexia of unknown origin
six months post transplant. Bone marrow examination revealed
histoplasmosis. He was treated with amphotericin B (total dose 1
gm). Three months later he developed multiple subcutaneous nodules
on the trunk and right thigh. Incisional biopsy of one of the nodule
revealed panniculitis with histoplasma in macrophages. He was
treated with amphotericin (total dose 2.5g). Itraconazole 200 mg/day
was added with the advise to continue it for one year. He is doing
well with normal renal functions.
Conclusion: Cutaneous lesions may be the only sign of serious
systemic disease in post-transplant immunosuppressed patients, as
seen in both the patients described above. Transplant physicians need
to be aware of this presentation as appropriate timely investigations
and optimal treatment is associated with good outcome.
142 Jul 2007 / Vol 17 / Issue 3
MYCOPHENOLATE AND DIARRHOEA: A REPORT OF 3 CASES
Ashwin A, Vandana W, Prashant R, Shah B V
Dept. of Nephrology, Lilavati Hospital and Research Centre, Mumbai,
India
Background: Mycophenolate has arisen as an important addition in
the immunosuppression armamentarium. GI disturbance in the form
of diarrhea is one of its main side effects requiring dose reduction and
at times even withdrawal. The mechanism of diarrhoea is unknown,
although multiple theories have been postulated.
Aim: To understand the mechanism of diarrhoea and plan an
appropriate treatment.
Materials and Methods: A detailed evaluation was done of 3 patients
who developed chronic diarrhoea while on Mycophenolate therapy.
Two were Renal Transplant Recipients while one was a case of SLE
with Lupus Nephritis. Routine investigations including stool analysis
was done. Each was subjected to an Oesophago-Gastro-Duodenoscopy
(OGD) with duodenal biopsy.
Observations and Results: One patient developed diarrhea 2
months after initiation of Mycophenolate, one after 4 months and
one after 6 months. Each of them presented with weight loss and
signs of malabsorption. OGD revealed features of duodenitis with
biopsy showing features of duodenal villous atrophy. These features
were similar to those observed in tropical sprue. Withdrawal of
Mycophenolate and treatment with folic acid led to complete
improvement.
Conclusion: Tropical sprue like disease resulting from use of
Mycophenolate might be one of the mechanisms of chronic
diarrhoea.
STUDY OF SKIN DISEASES IN RENAL TRANSPL ANT
RECIPIENTS
R Nikalji, G Daga, H Shah, D Kirpalani, AL Kirpalani, S Bitchu,
V Billa
Dept. of Nephrology, Bombay Hospital Institute of Medical Sciences,
Mumbai, Marine Lines, India
This study has been undertaken with a view to note the incidence
of skin diseases in renal allograft recipients, to study the clinical
spectrum of skin disorders and correlation between dose, duration,
regimen of immunosuppressive protocol and incidence of skin
infections, inflammatory diseases and malignancies.
Fifty consecutive unselected kidney transplant recipients attending
transplant clinic at a tertiary health care centre between September
2005 and August 2006 were evaluated for presence of skin diseases.
Detailed dermatological history was obtained and examination of
skin lesions including their morphology, number, size, shape, surface,
distribution, pigmentation and configuration was carried out in all
fifty patients.
We concluded that skin diseases are common in renal transplant
recipients due to side effects of immunosuppressive drugs as well
as prolonged immunosuppressed state. Cushingoid features due to
steroid therapy are the most common cutaneous manifestations.
They are common in early post – transplant period, are dose related
and tend to improve when steroids are reduced to maintenance
dosages.
Gingival hyperplasia and hypertrichosis are common in patients on
cyclosporine. Hypertrichosis is cosmetically troublesome in female
patients, it is reversible with gradual dose reduction. There is high
Indian Journal of Nephrology
 Abstracts
incidence of skin infections; superficial fungal infections are the most
common and the incidence is higher in patients on maintenance
immunosuppression as compared to patients who are in first post
transplant year, and those who receive Mycophenolate mofetyl and
triple immunosuppression. Both dose as well as duration of steroid
treatment contribute to skin infections. There is no correlation between
absolute neutrophil count and skin infections. Diabetes mellitus,
MMF based or triple drug regimen and lymphopenia contribute to
dissemination and refractoriness of fungal infections. HPV induced
warts are the most common viral infections ; the frequency and
number of warts increase with duration of transplant.
INFLUENCE OF HCV INFECTION ON SURVIVAL IN RENAL
TRANSPLANT PATIENTS
Anil Kumar BT, Vikranth Reddy, G Gopalakrishna, TK Saha
Dept. of Nephrology, Kamineni Hospitals, Hyderabad, India
There is significant association of Hepatitis C infection with graft
and patient survival in renal transplant patients. Though most
studies showed poor graft and patient survival few studies show
contrasting results.
Aim of the study: To assess the influence of HCV infection on patient
and graft survival in our centre.
Methods: We retrospectively analyzed medical records of renal
allograft recipients who were transplanted between June 2000 to
Dec 2006. Patients were divided into two groups those positive and
negative for anti HCV antibody. HCV RNA was tested in all patients
positive for anti HCV. Graft and patient survival were compared
between the two groups.
Statistical tools used: Odds ratio, and Kaplan Meir analysis.
Results: Of the 196 transplant recipients 43 were anti HCV positive.
9(21%) patients in the positive group and 17 (11%) patients in the
negative group expired. The HCV infected transplant patients had
increased risk of death [Odds ratio 2.8107, 95% CI, (1.2010 to 6.5775)]
however the risk for graft failure was not significant [Odds ratio 0.93,
95%CI, (0.2047 to 4.2938)]. HCV positive patients with high SGPT
levels [OR 1.35, 95% CI (0.29 to 6.18)] and more rejection episodes [OR
1.37, 95% CI (0.27 to 6.87)] increased the risk of death. Low albumin
levels and high serum creatinine levels were observed in patients
who died in HCV positive group. Sepsis was the important cause of
death in both the groups (58.3% Vs 47.1%). Only one died of cirrhosis
of liver in the anti HCV positive group.
Conclusion: HCV infection increases the risk of mortality in transplant
recipients. Most common cause of death is sepsis rather than liver
failure. Higher transaminase levels and rejection episodes increased
the mortality risk.
ROLE OF PSI IN RENAL TRANSPLANTATION
Sanjeev Gulati, Dinesh Khullar, Sandeep Guleria, Vivekanand Jha,
PP Verma, RK Sharma, Vijay Kher
For the North Zone PSI Consensus Group
Introduction: Chronic allograft dysfunction continues to be
a significant problem in renal allograft recipients despite the
introduction of newer immunosuppression agents
Methods: A consensus meeting of nephrologists and transplant
surgeons from North Zone was organized to review the role of PSIs
in renal transplantation. A modified Delphi process was used to
evaluate the following:1) to identify patients who would benefit for
Indian Journal of Nephrology
use of PSIs 2) evaluate the status of PSI in maintenance setting 3) to
define methods used to diagnose renal function deterioration. Three
of the members were asked to review the available literature and
present it before the group. This was followed by a discussion and
inputs from the each of the participating members. The conclusions
were based on the degree of consensus achieved.
Results: The group felt that PSIs are a useful addition to the
immunosuppressive armamentarium. It was agreed that PSI would be
beneficial in special clinical situations like patients with pre-existing /
history of malignancies in post transplant period or those who are at
high risk of developing malignancies such as those who had received
long term immunosuppression for the native kidney disease. Another
special scenario where PSIs are likely to beneficial are in patients who
have developed post transplant hemolytic uremic syndrome due to
cyclosporine / tacrolimus. In maintenance immunosuppression it
was felt that PSIs could be effective if introduced at the right time.
Based on current evidence, it was felt that they should be avoided
as denovo therapy and the introduction delayed upto 4 weeks. The
optimal time of introduction is still unknown but could be between
1-3 months. In the maintenance setting, it was felt that even the low
dose CNI combination with PSI is nephrotoxic and it may be preferable
to withhold CNIs and combine PSIs with MMF. TDM is mandatory in
these patients. Further it was agreed that protocol biopsy would be
the optimal method to identify early allograft dysfunction.
Conclusion: The group concluded that PSIs are a useful addition
to the current immunosuppressive armamentarium. The cost of
immunosuppression remains an important deciding factor in our
country. Further studies with specific protocols are required in Indian
settings.
OUTCOME OF KIDNEY TRANSPLANTATION IN SECONDARY
RENAL AMYLOIDOSIS: A SINGLE CENTRE EXPERIENCE
Rokade MS, Hegde UN, Gohel K, Gang S, Rajapurkar MM
Muljibhai Patel Urological Hospital, Nadiad, India
Background: Renal transplantation is regarded as the effective renal
replacement therapy in patients with renal amyloidosis.
Aim: This retrospective study was done to investigate the results
of kidney transplantation in patients with secondary renal
amyloidosis.
Materials and Methods: We studied 9 patients with systemic
amyloidosis who received live related renal transplantation from 1987
to 2007. Graft survival, patient survival, post transplant infections
and number of rejections were noted and compared with a control
group of nine nonamyloidotic patients.
Results: 8/9 patients were male with a mean age of 30±7.59 years.
Amyloidosis was secondary to tuberculosis in seven, bronchiectasis
and rheumatoid arthritis in one each. Two patients were seropositive
for hepatitis B. The mean follow up was 30 months. One year, five year
and ten year actuarial patient survival rates of the amyloidosis versus
control groups were 77.7%, 48.61%, 32.4% versus 100%, 100%, 100%
respectively (P=0.08, P=0.02*, P=0.006* respectively). 5/9 patients
with renal amyloidosis died; while 4/9 lost their grafts. Two patients
died with functioning grafts. Both the patients who were seropositive
for hepatitis B died of hepatic failure. The other three patients died due
to fungal sepsis, acute pulmonary edema and aspiration pneumonitis.
The actuarial graft survival of the amyloidosis versus control groups
was 66.67%, 66.67%, 66.67% versus 100%, 100%, 87.50% respectively
(P=0.04*, P=0.08, P=0.21 respectively). The frequency of acute
rejection episodes was not significantly different between members
Jul 2007 / Vol 17 / Issue 3 143
 Abstracts
of the two groups. The number of post transplant infections in the
two groups was not statistically significant.
Conclusion: Though renal transplantation has been proven to be a
safe option in patients with renal amyloidosis, our study showed
a statistically significant lower graft as well as patient survival
when compared with non-amyloidotic patients. The lower patient
survival may be due to two patients with hepatitis B who died of
hepatic failure.
A COMPARATIVE STUDY BETWEEN TACROLIMUS AND
CYCLOSPORINE IN LIVE DONOR RENAL TRANSPLANT
RECIPIENTS
M Jain, S Dasgupta, A Roychowdhury, J Dutta, V Makkar, A Taraphder,
R Pandey, SK Bhattacharya
Dept. of Nephrology, IPGME and R, Kolkata, India
Tacrolimus (Tac) is a new inclusion in our immunosuppression
protocol since last 3 years in the Dept. of Nephrology, IPGMEandR,
SSKM Hospital, Kolkata. The present study was conducted to
compare age old Cyclosporine ME (CSA) with Tac in respect of graft
function (Creatinine at 3 months, 6 months, 1 year), number of
rejection episodes, graft survival, patient survival and side effects
(infective episodes, antihypertensive requirements, dysglycaemia,
dyslipidaemia and hyperuricaemia). Total 38 patients were enrolled
in our study from January 06 to January 07 in post transplant clinic.
10 patients received CSA and 28 patients received Tac.
Age, sex distribution, dose of MMF/AZA and steroid were comparable
in both groups. Creatinine at 3 months and 6 months did not reveal
much significant difference but creatinine at 1 year was significantly
better in Tac group [P<0.05]. Number of acute rejection episodes in
CSA group was 20% vs. 10% in Tac group. No patients had lost graft
in last 1 year. 3 patients died in CSA group [Sepsis-2, Intracranial
haemmorage-1] and 3 patients died in Tac group [Sepsis-2, extensive
arterial thrombosis-1]. PTDM was more in Tac group [6in Tac group
vs. 1 in CSA group]. Infective episodes were more in Tac group but
not statistically significant. [0.6/patient/year vs. 1.14/patient/year].
Lipid profile and uric acid level were comparable in both groups.
Antihypertensive requirement was significantly less in Tac group
(2+1.2 vs. 1+ 0.09].
PRE AND POST RENAL TRANSPLANT BONE DISEASE A
PROSPECTIVE STUDY
Siva Rama Krishna, Manisha Sahay, Girish Narayan, Anuradha
Department of Nephrology, Osmania General Hospital, Hyderabad,
India
Introduction: Bone disease is common cause of morbidity pre and
post transplant. Our aim was to evaluate clinical, biochemical and
skeletal abnormalities in live related renal transplant patients before
and after renal transplantation
Methods: A total of 45 patients who underwent first renal
transplantation over 2 year period (January 2005 to December 2006)
were recruited in the study. All patients were followed from 3 months
before till 6 months after renal transplantation. A detailed history was
taken. Biochemical investigations, X ray lumbo sacral spine and X ray
hands were done. Monthly serum calcium, phosphorus, ALP, serum
albumin was done in all patients pre and post transplant. Serum intact
para thyroid hormone assay, lumbo sacral DEXA SCAN were done one
month before and 6 months after renal transplantation.
Results: All patients received hemodialysis with average of 12 hours per
week. 59% were on cyclosporine based, 36% were on tacrolimus based,
144 Jul 2007 / Vol 17 / Issue 3
5% were on MMF based regimens. Mean cumulative steroid dose was
4.337±1.447 Gms. 56.4% has hypocalcemia and 5.1% has hypercalcemia
pre transplant. In the post transplant state 20% has hypocalcemia, 5%
has hypercalcemia. 64.2% has hyper phosphatemia pre transplant. In
the post transplant state 18% has hyper phosphatemia. Only 2.5% has
hypophosphatemia. Pre transplant mean PTH was 165±90 pg/ml and
post transplant mean PTH was 91±43 pg/ml. Only 50% had normal
PTH at 6 months post renal transplant. There is a trend towards
osteopenia post renal transplant. 35% of patients had high turn over
bone disease and 25% had low turn over bone disease pre transplant.
Low turn over bone disease was the predominent bone disease in the
post renal transplant state.
Conclusions: Most patients had hypocalcaemia and hyper
phosphatemia pre transplant, which tends to normalize post
transplant.Post transplant hypophosphatemia was not a significant
problem and seen only in 2.5% of patients.Calcium phosphorus
product was not significantly elevated in our patients.Half of patients
had persistent high PTH post transplant. Only 49% has normal bone
mineral density by DEXA post transplant. Predominant bone disease
post transplant was low turn over bone disease.
HIGH RATE OF ACUTE REJECTIONS IN RENAL TRANSPLANT
RECIPIENTS WITH NEORAL AND MYCOPHENOLATE IN
THE MOST STUDY: THE INDIAN EXPERIENCE A DOSING
CONSIDERATION
V Kher, V Sakhuja, RK Sharma, HS Kohli, S Sundar, GT John,
M Rajapurkar, HS Ballal, CM Thiagaraj
MOST Study Group
The multinational observational study in transplantation (MOST) was
undertaken with the objective of documenting immunosuppressive
treatment options and the clinical outcomes of their use under
conditions of normal clinical practice in large population of transplant
recipients. 1204 patients (964 denovo and 195 on maintenance therapy)
at nine renal transplant centers were enrolled throughout India; to
study the impact of different immunosuppressive regimens use in
combination with Neoral. Globally 20243 patients (14993 evaluatble
patients) (GLOBAL MOST Group) were available for comparison. All
patients received Neoral based therapy (55% Neoral + Azathioprine
+ Steroid; 33% Neoral + MMF + Steroid). Mean follow up was 19,
6, 13.9 months. The incidence of AR, BPAR and BPCR were 18,10 and
< 10% respectively. Patients receiving Neoral based MMF therapy
showed significantly higher AR (27% vs 12%) and more so at 4th and
5th year, quite in contrast to the global data. Between 1-5 years mean
dose of Neoral was 1.5 to 2.5 mg/kg and MMF 750 mg to 1.2 gms/day
amongst Indian patients in contrast to 2.5-3 mg/kg of Neoral and 1.5
to 1.8 gms/day of MMF in the global data. This is largest multicentric
data in India showing that low dose of MMF with Neoral leads to higher
rates of acute rejections especially late acute rejections
THE INFLUENCE OF MEDICAL AND NON-MEDICAL
DETERMINANTS THAT AFFECT LIVING KIDNEY DONOR
SELECTION AMONG LIVING-RELATED KIDNEY TRANSPLANT
CANDIDATES
Ilangovan V, John. GT, Basu G, Nithya N, Santhosh V, Madhivanan
S, Manish G
Departments of Nephrology, Christian Medical College, Vellore, India
Aim: To assess the medical and non-medical determinants that affect
living kidney donor selection among live-related kidney transplant
candidates.
Indian Journal of Nephrology
 Abstracts
Objectives and Methods: Patients with CKD-stage 5 were evaluated
prospectively from Dec. 2006 to Aug. 2007 in nephrology OPD.
The factors affecting different modalities of therapy chosen were
studied.
Results: Of the 749 patients with CKD-stage 5, the mean age was
43.2±13.7 yrs and 74% were male. 257 patients (34.3%) opted
for transplant, 300 (40.1%) conservative therapy, and 192 (25.6%)
opted for dialysis. 119 patients (46.3%) of 257 patients who opted
for transplant were of upper middle or upper socioeconomic class
(Kuppusamy-urban classification) while 72.4% (110 patients) were
of same class in the 152 patients who presented for transplant
evaluation. Of the 660 donors available, 335 donors (50.8%) were
never approached for donation, 180 (27.3%) were rejected and 68
donors (10.3%) declined to donate. Of the 180 donors rejected, 48
patients (26.7%) were rejected for ABO incompatibility, 26 patients
(14.4%) for diabetes mellitus or risk of DM and 12(6.7%) for various
renal disease. Of the 152 patients, 41 patients (28.9%) had no first
degree related donor, 56 patients (36.8%) had a parental donor,
56(36.8%) had a sibling donor and 21(13.8%) had a spousal donor.
At initial evaluation 60 donors (39.5%) were unsure of the peri-
operative risks and only 70 donors (46.1%) felt that kidney failure was
unlikely after donation. The mean evaluation period was 89.5±71.25
days, median (60 days), mode (30 days), range (10-340 days) with
commonest being medical illness in 42 patients (28.3%). 45 patients
(29.6%) were supported by the government and 33 (21.7%) had private
sponsorship or insurance cover.
Conclusion: Both Socio-economical and medical factors reduce the
number of living-related renal transplant significantly.
IMPACT OF CYCLOSPORINE WITHDRAWAL ON GRAFT
OUTCOMES: A SINGLE CENTRE EXPERIENCE OF 131 LIVE
RELATED RENAL TRANSPLANTS
David VG, Neelakantan N, Basu G, Varughese S, Chacko B,
John GT
Department of Nephrology and Biostatistics, Christian Medical College,
Vellore, India
Aim: Impact of Cyclosporine (CsA) withdrawal on graft survival
is variable. We analyzed the outcome of CsA withdrawal among
131 living related renal transplant recipients on Prednisolone +
CsA+ Azathioprine; 18.4+14.1 months after transplantation,
retrospectively.
Materials and Methods: Patients were divided into 2 groups based
on the duration after transplant when CsA was withdrawn; Group
A (< 12 months, n= 14), Group B (>12 months, n= 117). Predictors
of poor outcome; rate of change of GFR and proteinuria after CsA
withdrawal and 5 year graft survival data were analysed. SPSS v
11.5 was used.
Results: The mean age at transplant was 34+10 years and mean
follow-up was 60 months after transplantation (range 10,184
months). After CsA withdrawal there was an improvement in the
rate of change of GFR. (P=<0.00). HLA, blood transfusion, induction,
crossmatch positivity, rejection episodes, Sr. Creatinine and GFR while
on CsA were not predictors of poor outcome. However proteinuria
at the 6th month (P=<0.00) and 12th month (P=<0.02) while on
CsA were predictors of poor outcome. The graft function measured
as the mean GFR at 6th month after CsA, significantly improved in
both the group A (38.2 ml/min to 46.5 ml/min) and B (57.9 ml/min to
61ml/min) respectively. Rejection episodes following CsA withdrawal
were similar in group A (8.3%) and B (6.4%) (P=0.6). The 5-year graft
survival was 92% in group A and 94% in group B.
Indian Journal of Nephrology
Conclusions: Cyclosporine withdrawal had a beneficial effect on graft
outcomes. Proteinuria while on CsA was an important predictor of
poor outcome. Following CsA withdrawal patients with lower GFR
had a significant improvement. Early CsA withdrawal after live related
renal transplantation is safe although associated with a minimal risk
of acute rejection. Late CsA withdrawal had a marginal improvement
of GFR. Therefore in live related renal transplants early withdrawal
of CsA is safe.
IMPACT OF NEW ONSET DIABETES AFTER TRANSPLANTATION
ON OUTCOME OF PRIMARY ADULT LIVING RELATED RENAL
TRANSPLANT: SINGLE CENTER STUDY
Soumita Bagchi, SK Agarwal, SC Tiwari, S Gupta, D Bhowmik,
S Mahajan, S Guleria
Department of Nephrology and Transplantation, AIIMS, New Delhi,
India
Aim: New onset diabetes mellitus after transplantation (NODAT) is an
important complication of immunosuppression (IS). It also may affect
selection of an IS. This study was done to assess the impact of NODAT
on patient and graft survival in living renal transplantation (LRT).
Method: Data of 1206 patients who underwent renal transplantation
(RT) between March 1983 to May 2007 at our hospital were reviewed
retrospectively. 436 patients were excluded (118 RT after May 2006-
less than 1 year follow up, 67 RT with basic disease diabetes mellitus,
31 second RT, 28 pediatric RT and 35 cadaver RT). Of the 870 patients
included, 104 (11.9%) had been diagnosed NODAT by ADA criteria.
These 104 patients with NODAT were compared to 104 controls without
NODAT,matched for time of transplantation, IS and HLA mismatch.
Results: The mean age was significantly higher in the NODAT group
than the control group (36±10.6 years vs 32±9 years, P=0.001).
There was no significant difference in the time of transplantation,
etiology of CKD, HLA mismatch, pre transplant PRA, pre transplant
hepatitis and the type of IS in the two groups. Donor GFR was higher
in the NODAT group (88±18 ml/min vs 82±14.7 ml/min, P=0.0650).
Number of acute rejection (AR) and AR in the first 3 months were
similar in the two groups. The median follow up was 44 months in
the NODAT group and 46 months in the control group.
More patients got anti-tubercular drug prophylaxis in the NODAT group
than in the controls (69 vs 52, P=0.0240). Inspite of this, there were
more cases of TB in the NODAT group compared to the control group,
though statistically insignificant (31 vs 19, P=0.0730). Patients with
NODAT had significantly more fungal infections (9 in NODAT and 1 in
non NODAT group P=0.0186) but there was no significant difference in
systemic fungal infections (2 in NODAT cases and 1 in controls). There
were 5 cases of PCP in the NODAT group and none in the control group
(P=0.0590). Skin infections were also significantly more in the NODAT
group than in controls (38 vs 16, P<0.0008). There was no difference in
bacterial and viral infections including CMV in the two groups. However
serious infections requiring hospitalization were significantly more
common in NODAT group (39 vs 13, P<0.0001). There were no cases
of cardiovascular disease recorded in both the groups. Mean serum
creatinine on last follow up was lower in the NODAT group than in
controls (2.4±2.3 mg/dl vs 3±2.8 mg/dl, P=0.0345). There was no
significant difference in patients survival between two groups (25 vs 27
deaths, P=0.8729), graft loss (30 vs 35, P=0.5490) and death censored
graft loss (5 vs 8, P=0.5685).
Conclusion: In our set-up, development of NODAT is associated with
significant morbidity, though there was no negative impact of NODAT
on graft and patient survival. Longer follow up is needed to ascertain
the long-term outcome in these patients.
Jul 2007 / Vol 17 / Issue 3 145