Twenty-five years of transplantation law in India – Progress and the way forward Sunil Shroff Indian Journal of Transplantation 2019 13(3):151-153

Transplantation in C3 glomerulopathy – Damned if you do, damned if you don't Srikanth Gundlapalli, Suhas Dilip Mondhe Indian Journal of Transplantation 2019 13(3):154-155

Granulomatous interstitial nephritis in native kidneys and renal allografts Praveen Kumar Etta Indian Journal of Transplantation 2019 13(3):156-159

Postrenal transplant anemia and pure red cell aplasia Praveen Kumar Etta Indian Journal of Transplantation 2019 13(3):160-163

Significance and safety of renal allograft biopsies: Experience from a tertiary care center in India Nisha Gaur, Vinay Malhotra, Dhananjai Agrawal, Shailendra K Singh, Pankaj Beniwal, Sanjeev Sharma, Rajesh Jhorawat, Parvati Joshi, Shikha Khandelwal, Vartul Gupta Indian Journal of Transplantation 2019 13(3):164-168 Introduction: Renal allograft biopsy is a useful tool in the presence of allograft dysfunction. There are many published studies regarding utility and safety of native kidney biopsies, whereas for allograft biopsies, data are scarce. Methodology: This retrospective analysis included all patients who underwent renal allograft biopsies from January 1, 2012, to December 31, 2017. Data were collected from patient records and interviews. Details regarding clinical indications, preprocedure rise in creatinine, urine analysis, periprocedure fall in hemoglobin, postprocedure hematoma in ultrasonography, and other complications were noted. Details of biopsy findings were analyzed. We noted the changes made in treatment after renal biopsies. Results: One hundred and seventeen (n = 117) patients underwent 150 renal biopsy procedures, with a mean age of 38.3 ± 11.6 years. Ninety-two (78.6%) were male. The majority (89.74%) of the patients received kidney from live donors. The most common indication for biopsy was acute allograft dysfunction (54%) with asymptomatic rise in creatinine (32.7%). In the first 15 days posttransplantation, the most common indication was delayed graft function (15.33%). Ninety percent of biopsies were adequate. For clinical diagnosis of acute allograft dysfunction, the most common pathological finding was active antibody-mediated rejection (AMR) in 14.49% patients. In the presence of chronic allograft dysfunction, the most common histopathological finding was chronic AMR in 18 (13.04%) biopsies. Major complications occurred in 4.0% of patients. Conclusion: Renal allograft biopsy is a useful tool in the evaluation of allograft dysfunction, and with current biopsy technique under real-time sonography, the major complication rate is less. It can be regarded as a safe procedure with excellent diagnostic yield.

Is the Institute Georges Lopez-1 solution an equally effective, cheaper alternative to the University of Wisconsin solution in liver transplantation? Magnus Mansard, Ravichand Siddachari, Sanjay Govil, Suresh Doraiswamy, Goutham Kumar, Navaneethan Subramanian, Olithselvan Arikichenin Indian Journal of Transplantation 2019 13(3):169-172 Aim: To compare the outcomes of deceased donor liver transplantation (DDLT) using either the University of Wisconsin solution (UW) or the Institute Georges Lopez-1 (IGL-1) solution. Materials and Methods: Adult patients who underwent DDLT between November 2015 and March 2018 were included in the study. All patients received grafts from brain-dead donors. In 30 patients, the UW solution was used to preserve the liver and in 53 patients, the IGL-1 solution was used. The data of these two groups of the patients were analyzed and compared. Results: Between the two groups of patients, donor and recipient demographics and surgery-related variables were found to be similar. No difference was observed in the incidence of postreperfusion syndrome, number of days of hospitalization, and in the 30-day mortality. Early graft dysfunction was observed in 9 (16.98%) patients in the IGL-1 group and in 7 (23.33%) patients in the UW group (P = 0.48). One patient had primary nonfunction in each group. The postoperative levels of the liver transaminases were also not found to be significantly different. Conclusions: The efficacies of liver preservation by the IGL-1 and UW solutions were found to be comparable.

Did an increase in knowledge and awareness about organ donation improve organ donation rate in India over the past two decades? Ann Alex, Sunil Shroff, V Britzer Paul, Sumana Navin, Pavithra Ramesh, John Michael, Susmitha Menon Indian Journal of Transplantation 2019 13(3):173-178 Context: The growth in the solid organ transplant has not been able to keep pace with the global requirement for organs, with great differences among countries. No previous studies about public awareness related to organ donation over two-decades have been conducted. Aim: The paper focuses on studying the difference in the knowledge and attitude among the Indian public about organ donation, over two decades. The study further probes into the impact that public knowledge has on organ donation rates. Settings and Design: This is a cross-sectional study conducted from 1998 to 2017. The first 10 years of the study (Group-I) was administered physically, whereas in the next 10 years (Group-II) online tools were used to conduct the survey. The total number of respondents in the two decades was 3914. Subjects and Methods: It contained a structured questionnaire with ten multiple choice questions and basic demographic details. The survey questions were the same for both the periods of the study. Statistical Analysis Used: The data entered was analyzed using SPSS v. 19. The knowledge on organ donation was compared between the two decades and if in any increase in awareness was reflected in the organ donation rate. Results: The increase in awareness on the organs and tissues that can be donated was high among Group-II and it was statistically significant (P < 0.001). More importantly, the proportion of respondents who were aware about the “organ donor card” more than doubled from 23.7% in Group I to 63.7% in Group II; and this was statistically significant (P < 0.001). The deceased donation rate was 0.08 per million population in 2004, whereas it had increased to 0.34 pmp in 2014 and 0.8 pmp in 2016. Conclusions: There has been an increase in awareness in the two decades, and this is also reflected in an increase in the donation rate in the country. Creating more awareness can be one of the factors to increase the organ donation rate in India.

Graft function and outcomes of deceased donor kidney transplant patients in a tertiary care center Sujit Surendran, M Edwin Fernando, S Thirumavalavan, S A. K Noor Mohamed, P Senthil Kumar Indian Journal of Transplantation 2019 13(3):179-183 Introduction: In India, deceased donor kidney transplantation accounts for less than 1% of total kidney transplants that are performed each year. Objectives: To assess the outcomes of deceased donor kidney transplantation. Methodology: We retrospectively reviewed deceased donor kidney transplantation in our centre from January 1996 to March 2016. All recipients were followed to the point of graft loss or death. Results were analysed in terms of age of donor and recipient, graft ischemia time, graft function,discharge serum creatinine, any rise in serum creatinine during follow up, post transplant complications, graft and recipient survival. Results: A total of 105 kidney transplant recipients including 81 men (77.14%) and 24 women (22.85%) were included in our analysis. The one year recipient survival rate was 75.8% and one year graft survival was 89.58%. The graft rejection rates were 18% in our centre and the mortality rate was 27.6%. Conclusions: By minimizing ischemia times, using better perfusion techniques and optimized immuno suppresion deceased donor transplant outcomes can be improved.

Posttransplant vesical calculi – A case series Dimple Kumar Chanamolu, Ravi Koti Reddy Kolatham, T Narendar, V L. N Murthy Pisapati Indian Journal of Transplantation 2019 13(3):184-187 Background: The occurrence of posttransplant vesical calculi is rare. Suture material, used during ureteroneocystostomy, both absorbable and nonabsorbable have been implicated as the nidus for stone formation. We report five cases of renal transplant recipients, who developed vesical calculi several years after renal transplantation, and the nidus was the prolene suture. Methods: Between 1997 and 2010, 344 renal transplants were performed which included both cadaver and live-related transplantations. The ureteroneocystostomy was performed by modified Lich-Gregoir technique using 6–0 prolene as the suture material. All cadaver transplants and some of the live cases were stented. The Foley catheter was removed between 3 and 5 days, and DJ stent was removed between 4 and 6 weeks postoperatively. Standard triple drug immunosuppression was given and followed up at regular intervals. Results: Five patients developed small vesical calculi between 10 and 21 years after transplantation at the site of ureteroneocystostomy, and prolene suture was the nidus. There were three ureteric leaks postoperatively, two were due to ureteric necrosis requiring reconstruction, and one was due to anastomotic leak which subsided on prolonged bladder drainage. There was one case of ureteric obstruction in the immediate postoperative period which was stented. Conclusion: Nonabsorbable suture material, however fine it is, prompts stone formation in the long run and should be avoided during ureteroneocystostomy.

Deceased donor transplantation – Our experience in the last 4 years Vilesh Valsalan Kalthoonical, Georgy K Nainan, George P Abraham, Mohan Mathew, Datson George, Renu Paul, YS Sooraj, Philip G Thomas, Vijay Radhakrishnan, Francis C Manavalan Indian Journal of Transplantation 2019 13(3):188-193 Background: Kidney transplant is the best treatment option for end stage kidney disease. Deceased donor transplantation has helped in increasing the donor pool for waitlisted dialysis patients. We received seventy deceased donor kidneys through the Kerala Network of Organ Sharing (KNOS) over the past 4 years from August 2013 to August 2017 and transplanted sixty six with good outcome. Pre-implantation biopsy performed in marginal donors helped in decision making to take the kidney and increase the donor pool. Aims and Objectives: 1)To evaluate outcome of renal transplant recipients in deceased donor transplantation. 2)To evaluate the role of pre-implantation biopsy to improve donor selection for better long term outcome. Materials and Methods: Sixty-six deceased donor kidneys were transplanted into the recipients from our pool of 253 patients registered with the KNOS. Four cadaver kidneys were rejected based on pre-implantation biopsy. Fifty-nine transplants were done at VPS Lakeshore and seven were done at PVS Memorial Hospital, Kochi. Donors of age less than 65 years were considered. Pre-tranpslant evaluation of recipients on waiting list including lab and cardiac evaluation with PRA status was done. Cross match was done prior to transplant. Triple immunosuppression including cyclosporine, mychophenolate mofetil and prednisolone with basiliximab as induction agent was used in all cases. Low dose tacrolimus was introduced after the third month in some cases. Pre-implantation biopsy was done in marginal donors for better donor selection. Results: Of the 66 recipients, 52 (78.8%) were males and 14 (21.2%) were females. PRA status was negative in all recipients. Deceased donors <65 years of age were considered. Twenty deceased donor kidneys were biopsied before implantation, of which 16 were implanted. Four kidneys were rejected as one showed glomerulocystic changes . One had extensive thrombus in all glomeruli, one had >56% IFTA changes, and other had 30%–40% IFTA changes. Results at 4 years post-transplant showed graft survival in 55/66 (83.34%) and patient survival in 60/66 (90.91%) cases. Six patients died: two with pneumocystis carinii pneumonia (PCP) (at 9 months/3.3 years post-transplant), one with mucormycosis (at 16 months post-transplant), one with acute coronary syndrome (immediate post-transplant), and two patients with sepsis. The average serum creatinine was < 1.4 mg/dl in 48 (87.2%) cases, 1.4–2.4 mg/dl in 7 (12.7%) cases, and > 2.4 mg/dl in 1 (1.8%) case. The surgical outcome was good in all (100%) patients with no intraoperative surgical complications. Delayed graft function was noted in 18% of patients. Prolonged cold ischemia time was noted in patients with acute tubular necrosis. Six patients had acute rejection, of which two were antibody mediated, and four had acute cellular rejection. One patient had tacrolimus toxicity on biopsy and was shifted to everolimus. Infections included one patient with surgical wound infection, 12 patients with urinary tract infections, one patient with invasive fungal infection, and two patients with PCP. At 4 years, deceased donor transplantation has good graft and patient outcomes. Conclusion: Deceased donor transplantation has good graft outcome which is comparable to live non related donors. It has minimal paper work and less costly than routine live transplant. Pre-implantation biopsy should be considered in marginal donors for appropriate donor selection and avoid organ wastage in doubtful cases. In our study we noted that transplant outcome was better in recipients receiving kidney from with in the city limits because of less cold ischemia time. Hence facilities for early transportation of organs with minimal procedural hurdles to minimize cold ischemia time should be carried out by the concerned authorities. Proactivity from the Government at state, zonal and national level is needed to improve deceased donor pool and cadaver transplantation in India.