Past, present and future of kidney paired donation transplantation in India

One third of healthy willing living kidney donors are rejected due to ABO blood group incompatibility and donor specific antibody. This increases pre-transplant dialysis duration leading to increased morbidity and mortality on the kidney transplantation waiting list. Over the last decade kidney paired donation is most rapidly increased source of living kidney donors. In a kidney transplantation program dominated by living donor kidney transplantation, kidney paired donation is a legal and valid alternative strategy to increase living donor kidney transplantation. This is more useful in countries with limited resources where ABO incompatible kidney transplantation or desensitization protocol is not feasible because of costs/infectious complications and deceased donor kidney transplantation is in initial stages. The matching allocation, ABO blood type imbalance, reciprocity, simultaneity, geography were the limitation for the expansion of kidney paired donation. Here we describe different successful ways to increase living donor kidney transplantation through kidney paired donation. Compatible pairs, domino chain, combination of kidney paired donation with desensitization or ABO incompatible transplantation, international kidney paired donation, nonsimultaneous, extended, altruistic donor chain and list exchange are different ways to expand the donor pool.In absence of national kidney paired donation program,a dedicated kidney paired donation team will increase access to living donor kidney transplantation in individual centres with team work. Use of social networking sites to expand donor pool, HLA based national kidney paired donation program will increase quality and quantity of kidney paired donation transplantation. Transplant centres should remove the barriers to a broader implementation of multicentre, national kidney paired donation program to further optimize potential of kidney paired donation to increase transplantation of O group and sensitized patients. This review assists in the development of similar programs in other developing countries.

International kidney paired donation transplantations to increase kidney transplant of O group and highly sensitized patient: First report from India

AIM To report the first international living related two way kidney paired donation(KPD) transplantation from India which occurred on 17 th February 2015 after legal per-mission from authorization committee. METHODS Donor recipient pairs were from Portugal and India who were highly sensitized and ABO incompatible with their spouse respectively. The two donor recipient pairs had negative lymphocyte cross-matching, flow cross-matchand donor specific antibody in two way kidney exchange with the intended KPD donor. Local KPD options were fully explored for Indian patient prior to embarking on international KPD. RESULTS Both pairs underwent simultaneous uneventful kidney transplant surgeries and creatinine was 1 mg/d L on tacrolimus based immunosuppression at 11 mo follow up. The uniqueness of these transplantations was that they are first international KPD transplantations in our center.CONCLUSION International KPD will increases quality and quantity of living donor kidney transplantation. This could be an important step to solving the kidney shortage with additional benefit of reduced costs, improved quality and increased access for difficult to match incompatible pairs like O blood group patient with non-O donor and sensitized patient. To the best of our knowledge this is first international KPD transplantation from India.

A chemical odyssey:Exploring renal stone diversity by age and sex in Punjab,Pakistan

Dear Editor,Renal calculosis is one of the most common urological disorders worldwide,with a prevalence ranging from 1%to 13%across different regions[1].Renal stones are crystal concretions that form on the inner surface of the kidney,resulting from disruptions in the metabolism,the excretion of stone constituents,or the formation of Randall's plaques and plugs.These stones are a result of various endogenous factors.

Endothelial injury and inflammation in patients with hyperuricemic nephropathy at chronic kidney disease stages 1-2 and 3-4

BACKGROUND Endothelial injury and inflammation are the main pathological changes in hyperuricemic nephropathy(HN);however,they have not been assessed in patients in the early,middle,and late phases of HN.AIM To investigate endothelial injury and inflammatory conditions between patients with HN at chronic kidney disease(CKD)stages 3-4 and CKD 1-2.METHODS This study enrolled 80 patients(49 and 31 with HN at CKD stage 1-2 and 3-4,respectively)from the Department of Nephrology,Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine between July 2021 and January 2022.Plasma levels of heparan sulfate,endocan,oxidized low-density lipoprotein(Ox-LDL),E-selectin,soluble intercellular adhesion molecule-1(slCAM1),interleukin(IL)-1β,and IL-6 and urine levels of lipocalin-type prostaglandin D synthase(L-PGDS),IL-1β,and IL-6 were measured using enzyme-linked immunosorbnent assay.RESULTS Comparison between patients with HN at CKD 1-2 and those with HN at CKD 3-4 showed that age and disease course were significant factors(P<0.001 and P<0.010,respectively).There were no statistical differences in sex,heart rate,body mass index,and systolic and diastolic blood pressures.The incidence of hypertension was also significant(P=0.03).Plasma levels of heparin sulfate(P<0.001),endocan(P=0.034),E-selectin(P<0.001),slCAM1(P<0.001),IL-1β(P=0.006),and IL-6(P=0.004)and the urine levels of L-PGDS(P<0.001),IL-1β(P=0.003),and IL-6(P<0.001)were high in patients with HN at CKD 3-4 than in those with HN at CKD 1-2.The difference in plasma Ox-LDL levels was not significant(P=0.078).CONCLUSION Vascular endothelial injury and inflammation were higher in patients with HN at CKD3-4 than at CKD 1-2.Plasma heparin sulfate and slCAM1 levels are synergistic factors for CKD staging in HN.

Long-term Effect of TCM Decoctions in Treatment of Nephrotic Syndrome

Fifty-seven cases of nephrotic syndrome were treated with TCM decoctions as accessory treatment for prednisone and cyclophosphamide, and the effects were observed in a follow-up period of 5-15 years. The long-term complete remission rate of 68.4% and recurrence rate of 26.3% in the treatment group were respectively higher and lower than those in the control group (P

Kidney exchange transplantation current status, an update and future perspectives

Kidney exchange transplantation is well established modality to increase living donor kidney transplantation. Reasons for joining kidney exchange programs are ABO blood group incompatibility, immunological inco-mpatibility(positive cross match or donor specific antibody), human leukocyte antigen(HLA) incompa-tibility(poor HLA matching), chronological incompa-tibility and financial incompatibility. Kidney exchange transplantation has evolved from the traditional si-multaneous anonymous 2-way kidney exchange to more complex ways such as 3-way exchange, 4-way exchange, n -way exchange,compatible pair, non-simult-aneous kidney exchange,non-simultaneous extended altruistic donor, never ending altruistic donor, kidney exchange combined with desensitization, kidney ex-change combined with ABO incompatible kidney tr-ansplantation, acceptable mismatch transplant, use of A2 donor to O patients, living donor-deceased donor list exchange, domino chain, non-anonymous kidney exchange, single center, multicenter, regional, National, International and Global kidney exchange. Here we discuss recent advances in kidney exchanges such as International kidney exchange transplantation in a gl-obal environment, three categories of advanced dona-tion program, deceased donors as a source of chain initiating kidneys, donor renege myth or reality, pros and cons of anonymity in developed world and(non-) anonymity in developing world, pros and cons of donor travel vs kidney transport, algorithm for management of incompatible donor-recipient pairs and pros and cons of Global kidney exchange. The participating transplant teams and donor-recipient pairs should make the decision by consensus about kidney donor travel vskidney transport and anonymity vs non-anonymity in allocation as per local resources and logistics. Future of organ transplantation in resource-limited setting will be liver vs kidney exchange, a legitimate hope or utopia?

Increasing access to kidney transplantation for sensitized recipient through three-way kidney paired donation with desensitization: The first Indian report

The combination of kidney paired donation(KPD) with desensitization represents a promising method of increasing the rate of living donor kidney transplantation(LDKT) in immunologically challenging patients. Patients who are difficult to match and desensitize due to strong donor specific antibody are may be transplanted by a combination of desensitization and KPD protocol with more immunologically favorable donor. We present our experience of combination of desensitization protocol with three-way KPD which contributed to successful LDKT in highly sensitized end stage renal disease patient. All recipients were discharged with normal and stable allograft function at 24 mo follow up. We believe that this is first report from India where three-way KPD exchange was performed with the combination of KPD and desensitization. The combination of desensitization protocol with KPD improves access and outcomes of LDKT.

Six end-stage renal disease patients benefited from first non-simultaneous single center 6-way kidney exchange transplantation in India

AIM To avoid desensitization protocols and ABO incompatible kidney transplantation(KT) due to high costs and increased risk of infections from intense immunosuppression.METHODS We present institutional ethical review board- approved study of single center 6-way kidney exchange transplantation. The participants comprised ABO incompatibility(n = 1); positive cross-match and/or presence of donor specific antibody(n = 5). The average time required from registration in kidney paired donation(KPD) registry to find suitable donors was 45 d and time required to perform transplants after legal permission was 2 mo. RESULTS Graft and patient survival were 100%, and 100%, respectively. One patient had biopsy-proven acute borderline T cell rejection(Banff update 2013, type 3). Mean serum creatinine was 0.8 mg/dL at 9 mo followup. The waiting time in KPD was short as compared to deceased donor KT. CONCLUSION We report first non-simultaneous, single center, 6-way kidney exchange transplantation from India. Our experience will encourage other centers in India to undertake this practice.

Outcomes of Layered versus Mass Closure in Transverse Incision during Emergency Laparotomy in Children

Background: The value of laparotomy closure technique may be measured by the incidence of early and late wound complications. The best laparotomy closure technique should be less time consuming, easy and cost-effective, while preventing both early and late complications. Objective: To compare the outcomes of layered versus mass closure in transverse incision during emergency laparotomy in children. Methods: This prospective comparative study was conducted at Department of Pediatric Surgery, Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh from July 2016 to June 2018. A total of 60 pediatric age cases that underwent laparotomy were included in this study. Cases were randomly allocated into two groups;30 patients were in Group A (Layered closure) and 30 patients were in Group B (Mass closure). The outcome variables were time required for wound closure, wound infection, wound dehiscence and incisional hernia. Data were analyzed and compared by statistical tests. Results: The mean age of Group A and Group B patients were 31.08 ± 30.25 months and 34.70 ± 42.73 months respectively (p = 0.706). The ratio between male and female subject was 1.1:1 in Group A and 3.3:1 in Group B. The common diseases of the study patients who underwent laparotomy were intussusceptions, intestinal obstruction due to bands and adhesion, perforated appendix and perforation of small intestine due to blunt trauma respectively. Mean wound closure time was significantly less in mass closure group [28.20 ± 2.17 minutes in layered closure group and 18.80 ± 1.67 minutes in mass closure group, (p ≤ 0.001)]. Wound infection rate, incidence of superficial wound dehiscence, and incisional hernia were relatively less in mass closure group, however, the differences were not statistically significant (p = 0.053, p = 0.095 and p = 0.301 respectively). There was no complete wound dehiscence in Group A, but that was in 1 (3.3%) patient in Group B (p = 0.313). Conclusion: Mass closure technique is comparatively better than layered closure technique.

Uremic clearance granule combined with Alprostadil in the treatment of chronic renal failure: A systematic review and meta-analysis

Objective: To evaluate whether the combination of Uremic clearance granule with Alprostadil is superior to Alprostadil alone for CRF. Methods: Relevant RCTs were searched through March 2019. Data were analyzed by Stata 15.0. Results: Nine articles involving 726 patients were enrolled in this study. Meta-analysis showed that the total effective rate [OR = 3.68 (2.44, 5.55), P < 0.001], Scr [SMD =-2.34 (-3.49,-1.19), P < 0.001], BUN [SMD =-1.80 (-2.73,-0.87), P < 0.001], Ccr [SMD = 0.71 (0.44, 0.97), P < 0.001] were better in the experimental group. But there were no significant difference in UA, CysC, 24h-Upro and incidence of adverse reactions (all P > 0.05) between two groups. No serious adverse reactions were found. Conclusions: The effect of the integrated medicine on CRF was better than Alprostadil alone. Uremic clearance granule is safe and has no obvious adverse reactions.

Meta-analysis of Laparoscopic cyst decortication versus traditional open cyst decortication for ADPKD in China: evidence based on 362 cases and 399 controls

Objectives:To assess the safety,feasibility and clinical benefits of LCD and OCD for the treatment of ADPKD.Methods:Databases articles comparing LCD and OCD in treating PKD were collected through March 2019.After screening for inclusion and data extraction,meta-analysis was performed by the RevMan 5.3 software.Results:A total of 9 studies involving 761 patients were finally included,with 362 cases in LCD group and 399 cases in OCD group.LCD was associated with a shorter operative time(MD=-36.24,95%CI:-44.20^-28.28,P<0.00001)and postoperative hospital stay(MD=-4.04,95%CI:-5.13^-2.95,P<0.00001).Besides,LCD had an earlier time to postoperative ambulation(MD=-14.90,95%CI:-16.33^-13.48,P<0.00001)and earlier time to first flatus(MD=-1.52 days,95%CI:-1.65^-1.40,P<0.00001;MD=-10.76 hours,95%CI:-12.71^-8.81,P<0.00001).In addition,LCD had a lower intraoperative blood loss(MD=-159.81,95%CI:-243.32^-76.31,P=0.0002)and lower analgesic dosage(MD=-56.62,95%CI:-84.16^-29.08,P<0.0001).There showed no statistically significant difference between the two groups in Scr,Bun,systolic and diastolic blood pressure(all P>0.05).Conclusions:Current evidence demonstrated a shorter postoperative hospital stay,lower blood loss,less postoperative pain,and other advantages.LCD may therefore be a feasible and safe surgical approach of ADPKD.

Persistent mullerian duct syndrome presenting as retractile testis with hypospadias: A rare entity

A rare entity of persistent mullerian duct syndrome usually presents with a common symptom of undescended testis(UDT) or hernia. Male pseudo-hermaphroditism with persistent internal mullerian duct structures can present with a 46, XY karyotype with normal external genitalia and. It arises due to deficiency of antimullerian substance, resulting from reduced production/responsiveness to mullerian duct, leading to persistence of mullerian duct along with normal development of Wolffian duct structures. Presence of mullerian structure prevents testicular descent increasing the risk of testicular vanishing syndrome. The authors here report a case of 16 years old phenotypical male who came with retractile right sided testis and left side UDT in the urology outpatient department. Explorative laparotomy was performed and an ill-defined mass was excised and sent for histopathological examination. Histopathology revealed presence of mullerian structures. The serum testosterone level was normal, buccal smear cytology and karyotyping revealed a 46, XY genotype of the patient.

Minimal change disease caused by polycythemia vera: A case report

BACKGROUND Polycythemia vera(PV),often attributed to the JAK2 V617F mutation,is characterized by enhanced red blood cell counts in the peripheral blood.PV-associated renal disease is clinically rare;to date,there have been reports of other chronic kidney diseases related to PV,but no reports on PV-associated minimal change disease.CASE SUMMARY A 37-year-old man presented with proteinuria and high red blood cell count on January 4,2021.The patient underwent bone marrow and renal biopsies,then was subsequently diagnosed with PV and minimal change in disease.Hydroxyurea was administered and proteinuria remission was achieved.The patient’s last visit was on April 14,2022.CONCLUSION We inferred that there may be a causal relationship between PV and minimal change disease.

Primary Adrenal Tumors-Five Years Single Centre Experience

Primary adrenal tumors are less commonly encountered in clinic. They may be functional/non-functional and noted incidentally when investigating for other problems. However there is no study available in Asian countries, and especially India regarding the incidence and natural history of these tumors. We carried out a study on adrenal tumors noted in our set-up for last five years to document the prevalence of adrenal tumors, their presentation along with the most common tumor followed by incidence of other tumors and their clinical and pathological presentation. This was a retrospective study in our hospital from June 2006 to 2011. 29 adrenalectomies performed over 5 years. Their clinical presentation and investigations were recorded and analyzed. Adrenal tumors accounted for 0.6% of total surgical specimens, 18 out of 29 belonged to males. Majority (85.2%) of the patients were adults with mean age, 39.8 years. Majority (79.3%) had presented with symptoms, incidentalomas were found in 20.7% patients out of which 2 belonged to potential kidney donors. Nonfunctioning tumors were noted in 58.6% patients. Pheochromocytoma was the commonest tumor noted in 68.9% followed by adrenal cortical adenoma in 13.7%, carcinoma in 6.9% and lipoma, myelolipoma and ganglioneuroma, 3.45% each. All the patients are doing well over a mean follow-up of 2.5 years. To our knowledge this is the first study on incidence and natural history of primary adrenal tumors which are less commonly encountered and usually have good prognosis.