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In patients undergoing renal transplantation, dose individualization for tacrolimus is routinely achieved with therapeutic drug monitoring (TDM). The patient started on 5.5 mg/day of tacrolimus had a significantly elevated tacrolimus trough concentration. The tacrolimus dose was regularly reduced following TDM at many time periods in the post transplant period but the tacrolimus concentration was consistently elevated. Genomic analysis done after four years revealed mutations in the genes encoding for CYP3A5 and MDR1 (2677G > T). Pharmacogenomics alongside TDM, will soon emerge as the backbone of dose individualization. But for genomics to be beneficial, it should be advocated in the pre-transplant or early post transplant period.

Non-O1, non-O139 Vibrio cholerae is an encapsulated bacterium, ubiquitous in the marine environment and generally considered to be non-pathogenic. However, it is known to cause diarrheal illness, wound infection, and bacteremia in immunocompromised hosts. Here we have describe non-O1, non-O139 V. cholerae sepsis in a patient with nephrotic syndrome following exposure to sea-water. Interestingly, the exposure occurred remotely 4 months prior to the onset of nephrotic syndrome. The occurrence of florid sepsis after a prolonged interval from the time of exposure is peculiar and raises the possibility of an association between occult Vibrio sepsis and nephrotic syndrome.

Hepatitis C virus (HCV) infection is an important cause of liver-related morbidity and mortality in patients with end-stage renal disease (ESRD). Though indicated, antiviral therapy adds to the existing financial burden and is poorly tolerated in these patients. We studied HCV treatment outcomes in patients with moderate and severe chronic kidney disease (CKD) between June 2010 and June 2012. Out of 46 patients with CKD, only 16 (genotype 1:6, 3:9, indeterminate 1) received interferon treatment (conventional 9, pegylated 7; with low-dose ribavirin 5). End of treatment response was achieved in 50 % and sustained viral response in 44 %. Adverse effects such as tuberculosis, anemia, and cardiac failure resulting in discontinuation of therapy were seen in three. The dropout rate was 38 %. Though interferon therapy was efficacious and safe, it was received by only 35 % of patients with CKD. We suggest that antiviral therapy be offered under close monitoring in the absence of contraindications in patients with moderate and severe CKD.

The significance of pretransplant anti-human leukocyte antigen antibody levels that are detectable by more sensitive platforms (including the Luminex platform) yet undetected by complement-dependent cytotoxicity (CDC) assay remains unclear. The aim of this study was to determine the clinical significance of the donor-specific antibody (DSA) assay Luminex crossmatch and its impact on short-term renal graft outcome such as acute rejections, graft survival, and graft function. The results of pretransplant DSA-lymphocyte crossmatching (LCXM) assay in 126 renal allograft recipients whose CDCs crossmatches were negative were retrospectively analyzed for correlation with posttransplant outcomes. Of the 126 recipients, 32 (25.4%) had pretransplant DSA positive. Statistically significant association was found between DSA-LCXM positivity with 14th day estimated glomerular filtration rate (eGFR) (P = 0.05), DSA Class I with 3rd (P = 0.014) and 6th month (P = 0.02) eGFR, DSA Class II with 14th day (P = 0.06) and 1st month (P = 0.10) eGFR, mean fluorescent intensity (MFI) DSA with 7th day (P = 0.08) and 14th day (P = 0.09) eGFR, and maximum MFI DSA with 7th day eGFR (P = 0.09). The posttransplant eGFR was higher at various time intervals in DSA-LCXM-negative patients as compared to DSA-positive patients. However, pretransplant DSA-LCXM results did not predict the rejection episodes, graft loss, and 1-year posttransplant 24 h urine protein. Pretransplant DSA detected by LCXM in patients with a negative CDC does not predict adverse short-term outcomes. However, the difference in posttransplant eGFR supports further investigation in long-term effects.

Background. Acute febrile illnesses are a common cause of tropical acute kidney injury (AKI). The incidence and severity of AKI in tropical febrile illnesses and validity of RIFLE classification are unclear. Methods. Consecutive adult inpatients of a tertiary hospital in southern India with tropical acute febrile illness between January 2007 and January 2008 were prospectively studied for the incidence and severity of AKI based on RIFLE classification and its association with mortality and dialysis requirement. Results. The 367 patients (mean age 39.7 ± 16.9 years; 60% males) with tropical acute febrile illness due to scrub typhus (51.2%), falciparum malaria (10.4%), enteric fever (8.7%), dengue (7.6%), mixed malaria (6.5%), leptospirosis (3.3%), undifferentiated acute febrile illness (8.4%) and others (3.8%) (spotted fever, vivax malaria and Hantaan virus infection) had an overall mortality rate of 12.3%. The incidence of AKI was 41.1%; of which, 17.4%, 9.3% and 14.4% were in the Risk, Injury and Failure classes, respectively. Of the patients, 7.9% required dialysis. Among the Risk, Injury and Failure groups, there was an incremental risk of mortality (OR 6.9, 20.2 and 25.6; P < 0.001) and dialysis requirement (OR 3.4, 28.8 and 178.8; P < 0.001). Conclusions. The incidence of AKI in the common tropical acute febrile illnesses in our study such as scrub typhus, falciparum malaria, enteric fever, dengue and leptospirosis is 41.1%. RIFLE classification is valid and applicable in AKI related to tropical acute febrile illnesses, with an incremental risk of mortality and dialysis requirement.

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

The aim of the study was to determine the reliability of estimating area under the curve from 0 to 6 hours (AUC0-6) of mycophenolic acid (MPA) by pooling the blood samples from different sampling time points. Eighty 6-hour concentration-time profiles were obtained from 68 patients on mycophenolate mofetil and the MPA AUC0-6 was calculated. In the pooled strategy, each of the equally spaced time point samples was pooled into two samples. Two rectangles were created instead of multiple trapezoids and the sum of their areas equal to the MPA AUC0-6. The linear correlation (r), intraclass correlation, bias, and precision were calculated between the pooled MPA AUC0-6 and the MPA AUC0-6 derived from measurements at different time points. Pharmacokinetic profiles of an additional 20 patients were obtained to study the possibility of using fewer time points to create a single pooled sample to obtain MPA AUC0-6. The linear correlation (r) and intraclass correlation between pooled and measured MPA AUC0-6 was 0.982 and 0.979, respectively. There was a highly significant correlation (r) of 0.978 between the pooled versus measured for both MPA AUC0-3 and MPA AUC3-6. The mean bias and precision (95% confidence interval) for pooled with total measured MPA AUC0-6 was -6.4% (-7.8% to -4.94%) and 7.37% (6.21%-8.54%), respectively. The pooled sample approach using only five time points to estimate MPA AUC0-6 had an unacceptable bias and precision. Pooling 10 samples to a set of two samples gave a highly accurate measure of MPA AUC0-6. The advantages for a central laboratory are the high throughput of samples and the transportation of only two specimens from other centers, all of which leads to a reduction in cost. This approach is extremely useful for studies aimed at examining the bioavailability of mycophenolate mofetil in different ethnic populations within India.

Background In developing countries such as India, extending donor-swap transplantation (DSTx) to human leukocyte antigen (HLA)-mismatched patient-donor pairs would increase well-matched living donor kidney transplantation rates, resulting in use of less immunosuppression and less expenses, lower infective morbidity, and better survival. A model for DSTx based on HLA matching is presented. Methods Consecutive HLA class 1 antigen (A, B) tests of prospective renal allograft recipients and their related donors, performed at a single center in India was analyzed retrospectively using an HLA matching program to determine the proportion of prospective recipients with poorly matched related donors who could have benefited by DSTx based on HLA matching. Results Over the past 17.5 years, 2,129 prospective renal allograft recipients and 2,890 donors were tested for HLA class I (A and B) antigens. Of the prospective recipients, 33% did not have well-matched donors (defined as blood group compatible and sharing > or =2 of 4 HLA class I antigens). Among such recipients, 19.2% could have found a well-matched donor-swap pair within a year at a single center. This number would increase to 38% if four major national centers were involved with a shared HLA registry. Conclusions Nearly 40% of prospective recipients without well-matched donors would find a donor-swap pair based on HLA matching within a year, with coordination among four national centers and a shared HLA registry, increasing the well-matched living donor renal transplant rates and improving transplant outcomes. This finding is relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage DSTx.

Cysticercosis is a common public health problem in the Tropics. However, disseminated cysticercosis is rare. We report a patient with chronic liver disease and seizures, in whom a simple plain radiographic examination helped in narrowing down the differential diagnosis to disseminated cysticercosis. The diagnosis was confirmed by serum cysticercal antibody enzyme-linked immunosorbent assay (ELISA) and computerized tomography of the brain.

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels

We report an unusual case of a enlarging anterior abdominal wall hematoma after percutaneous biopsy of a renal allograft. Angiography-directed embolization of the vessels filling the pseudoaneurysm was done and followed up with surgical exploration of the hematoma. In order to avoid this complication, Color Doppler evaluation of the overlying abdominal wall is suggested to look for significant vessels before the biopsy procedure.

Infections are the bugbear of kidney transplantation in the tropics, being responsible for majority of the deaths. Despite the several challenges posed by infections in kidney transplant recipient in the tropics, various developments have resulted in a decline in the rate of infections as well as their consequences. This review aims to be a basic overview of the common infections in KTR with an attempt to provide a unique tropical country perspective.