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Infections continue to be a significant cause of morbidity and mortality after solid organ transplantation. Early identification of the pathogenic organism is extremely important as the disease process might progress rapidly resulting in fatality. In this case series, we describe varying presentations of pulmonary nocardiosis, an uncommon opportunistic bacterial infection that often complicates the diagnosis of pneumonia, especially in immunocompromised patients. Although cough, fever, expectoration and breathlessness are the most common symptoms of pulmonary nocardiosis, they can also manifest as night sweats, weight loss and malaise. Some are incidentally diagnosed while being evaluated for other causes. Radiological features are also non-specific, usual findings being irregular nodules, cavitation, reticulo nodular diffuse pneumonia and pleural effusions. Bronchoalveolar lavage has the best diagnostic yield, but may have to be repeated several times to confirm a diagnosis, if the index of suspicion is high. Initial therapy with high dose trimethoprim- sulfamethoxazole is found to be effective in most of the cases. Duration of treatment should be a minimum of 6 months, and at least 12 months if central nervous system is affected. Other agents used for treatment include imipenem, minocycline, third generation cephalosporins, linezolid and amikacin. A high index of suspicion, with aggressive evaluation in an immunosuppressed individual will enable an early diagnosis, leading to prompt treatment and limit dissemination of disease thus preventing fatality.

Background: Studies on posttransplantation anemia (PTA) are scarce. There is a large variability in its prevalence (20%–70%). Research focuses on anemia in early (3–6 months) or late (>6 months) posttransplant period. Little is known about PTA within first 3 months. Aim: The aim of the study was to determine the prevalence and possible associated factors of immediate PTA in patients undergoing renal transplant. Materials and Methods: This was a prospective, observational, single-center study of 30 consecutive patients who underwent live renal allograft transplant. Follow-up period was 3-month posttransplant. Hemoglobin (Hb) was done at 1-week and 1, 2, and 3-month posttransplant. Erythropoietin (EPO) levels were recorded pre and posttransplant. Peripheral smear, lactate dehydrogenase, iron and ferritin levels, serum creatinine, days of hospital stay, rejections, infections, and immunosuppressive regime were recorded. Results: All patients were anemic within 1 week of transplantation and 40% had severe anemia. The prevalence of PTA at 3 months was 76.7%. PTA correlated with higher donor age, lower ferritin, Hb, and EPO levels in pretransplant period. However, even though EPO levels posttransplant were lower in patients with anemia, this correlation was not statistically significant. The lowest Hb correlated with Hb levels and dose of EPO-stimulating agents pretransplant. Conclusions: The prevalence of anemia is high in the immediate posttransplant period. High donor age, graft dysfunction, and iron stores before transplantation correlate with Hb levels at 3 months. It is prudent to maintain a better Hb in the pretransplant period to avoid PTA. Lower EPO levels before transplant may indicate immediate PTA. Correlation of EPO levels posttransplant with Hb needs further study.

Left ventricular hypertrophy (LVH), the most common structural cardiac complication, is the single most important cause for sudden cardiac death. There are no published data from India looking at the changes in left ventricular mass and cardiac dysfunction after kidney transplantation. We aimed to determine the changes in the left ventricular mass and other cardiovascular risk factors in kidney transplant recipients. This was a prospective observational study. All patients who underwent kidney transplantation at Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, during the study period were included in the study. Measurement of clinical and biochemical parameters and echocardiography were done before, six months, and one year after transplantation. There was significant reduction in LV mass index (124.8 ± 39 vs. 102.2 ± 24.4 g/m2, P

Reconstruction of long tracheal defects still proves to be a challenge. Free fasciocutaneous flaps with cartilaginous struts or an allotransplant trachea have been reported but not been widely performed. This article reports with the experience of using a tracheal allotransplant in such a defect.A 43-year-old lady presented with adenoid cystic carcinoma involving the entire trachea from subglottic area up to the carina, leading to a life-threatening airway occlusion. After preliminary stenting, allotransplant trachea obtained from a brain-dead individual was revascularized in the forearm of the patient after mechanical decellularization to reduce the immune load and fulfil the need for immunosuppression in the background of active cancer. Subsequently, the trachea and larynx were resected. The vascularized neotrachea was transferred successfully into the neck. The patient did well initially but succumbed to a fatal hemorrhage due to innominate vein aneurysmal rupture on the 22nd day after the transplant.The technical details of resection, fabrication of the neotrachea, its transfer, and the lessons learnt in this tracheal allotransplant are described.

Background and Aims Cancer is now increasingly recognized as a major cause of death among patients especially after kidney transplantation. Malignancy represent a major burden in transplantation medicine. The Incidence is about 12 fold higher for PTLD and 3.5 fold higher for non-cutaneous malignancy compare to age-matched population. The increased risk is multifactorial and attributed to oncogenic viruses, immunosuppression and altered T cell immunity. In the era of longer graft survival and with the introduction of more potent immunosuppressive medication, malignancy represents a major burden. The incidence of malignancy after renal transplantation is 3 to 5 times higher. Incidence is higher in transplant patients even when compared to patients on hemodialysis. Aim: We attempted to assess the incidence of post-transplant malignancies in patients who underwent renal transplantation at our centre, along with studying the presentation, type and other factors affecting their development. Method We analysed data retrospectively from 626patients who underwent renal transplantation atour centre from January 2003 to September 2018.Pre transplant history, post transplant course including duration on hemodialysis, immunosuppression details and duration till diagnosis of malignancies were collected. Details regarding type of malignancy, histopathology, staging and treatment given and outcome were collected. Results Number of transplant recipient-626. The total number of patients with malignancy is 12. Incidence of malignancy posttransplant is 1.9%.Male-7 and female-6.One patient was detected with 2 malignanciesduring her post transplant period. The types of malignancies encountered were Conclusion The incidence of malignancy – 1.9%.Probable reason for decreased incidence of malignancy is the decreased immunosuppression needed by South Asian people. The most common malignancy was solid organ tumour; tongue being the most common organ. Most common histological variant is squamous cell carcinoma.Non-Hodgkin is more common than Hodgkin. Incidence of malignancy is low. Decision regarding cancer screening should be made on individual basis.

[This corrects the article DOI: 10.1016/j.ekir.2017.10.017.].

Introduction: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the ‘self’ from the ‘non-self’. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as ‘non-self’. Materials and Methods: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Results: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately. Discussion: Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well. Conclusion: A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

Introduction: Patients undergoing haemodialysis are vulnerable to Blood Borne Viral (BBV) infections. Longer duration of dialysis and blood transfusion increases the risk of blood borne infections in this susceptible population. Aim: To detect Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infections using Nucleic Acid Testing (NAT) in dialysis patients who were seronegative by conventional serological assay. Materials and Methods: This was a prospective crosssectional study in patients on maintenance dialysis. Patients who were known serology reactive for BBV were excluded. Risk factors for BBV infection in dialysis patients were collected. NAT was performed using Individual Donor Procleix Ultrio Plus Assay. Categorical variables were expressed in frequency and continuous variable as median with Interquartile Range (IQR). Correlation was performed to determine association of duration of dialysis with the volume of RBC transfusions. Results: Eighty eight patients non-reactive for Anti HIV, Anti HCV and HBsAg by serology were screened by NAT assay. Median Red Blood Cell (RBC) units transfused per patient was 5. There were 12.5% (n=11) patients included in the study who had undergone dialysis at more than one centre. Median duration of dialysis was 30 months. NAT assay was non-reactive in all 88 patients. Conclusion: Screening results for chemiluminescence and NAT assays were similar. Proper sterilisation protocols, isolation for BBV positive patients, use of NAT screened blood components for transfusion, less patients undergoing dialysis outside the centre and low prevalence of infection are responsible for NAT negative test results. Chemiluminescence assay was found adequate for routine screening to prevent BBV disease transmission in patients undergoing dialysis.

Renal manifestation is one of the most severe complications of SLE and the clinical presentation of lupus nephritis (LN) is variable, ranging from mild asymptomatic proteinuria, renal failure to rapidly progressive glomerulonephritis. Performing renal biopsies is needed to determine the prognosis and to guide treatment in LN. Purpose and methods To correlate the clinical, biochemical and histopathological findings in patients with biopsy proven LN and to study the renal outcome. Retrospective analysis of 100 cases of kidney biopsy proven Lupus Nephritis was done, analysed by WHO and ISN RPS Classification of Lupus Nephritis 2003. Results 82 were female and 18 males. Extra renal manifestations in 72 cases while rest 28 had purely renal involvement. Biopsy finding showed the following class : 8 cases of class II, 29 cases of class III, 32 cases of class IV and 3 cases of class V. The remaining 28 showed combined class with predominant being class III+IV. Significant microscopic hematuria, impaired GFR, proteinuria, anaemia, hypoalbuminemia, hypertension, and positive anti- dsDNA, low C3 were associated with the worst class, that is, class IV. Most of the patients with class IV or V had nephrotic range proteinuria and low serum albumin levels. These parameters were also correlated with high renal pathological activity and chronicity index. 24 had renal failure at the time of biopsy (mean S.creatinine 2.12 mg/dl) followed up period of 3 years. With treatment, for 12 patients renal functions improved with creatinine improving to mean value of 1.26 mg/dl. 4 patients went into severe renal failure requiring hemodialysis while 6 patients were lost to follow up. 76 patients had normal renal functions at the time of presentation with an average S.creatinine of 0.86 mg/dl. 3 patients went into ESRD. 15 patients lost follow up. Conclusions Clinical, laboratory findings and renal biopsy are clinically valuable in identifying different renal classifications of lupus pathology, and to plan therapeutic strategies accordingly. LN class IV G was the most common and had a reduced renal survival with significant high activity and chronicity scores.

Background: Venous and arterial thromboembolism are frequently seen in nephrotic syndrome. They generally occur during periods of sustained proteinuria in patients who are not responding to treatment and more commonly seen in minimal change disease and membranous nephropathy. Case Presentation: A 28-year-old male presented to cardiology department of our hospital with worsening breathlessness for 1 week. We found pulmonary embolism and an infarct in the lower pole of the right kidney by CT pulmonary angiogram. He had no previous history or features of nephrotic syndrome. Urine analysis showed numerous red blood cells, 3+ proteinuria and granular casts. Urine protein creatinine ratio was 5.2 g/g of creatinine. Serum creatinine was 2.61 mg/dL. Renal biopsy was suggestive of IgA nephropathy and patient was started on steroids and warfarin and responded to treatment. Conclusions: Patients with nephrotic syndrome can rarely present initially with venous and arterial thromboembolism. Rarely even IgA nephropathy can present with such thromboembolic episodes.

Suspicion and subsequent detection of renal disease is by an assessment of the urinalysis and renal function in the clinical context. Our attempt in this study is to correlate initial presenting features of urinalysis and renal function to the final histopathological diagnosis. A retrospective analysis of 1059 native kidney biopsies performed from January 2002 to June 2015 at Amrita Institute of Medical Sciences was conducted. Correlative patterns between urinalysis, renal function, and final histopathological diagnosis were studied. Five hundred and eleven (48%) patients had nephrotic syndrome. Out of these, 193 (38%) had pure: nephrotic syndrome, 181 (35.8%) had associated microhematuria, 110 (21.7%) had microhematuria and renal failure, and 27 (5.3%) had only associated renal failure. Minimal change disease (MCD) (30%), membranous nephropathy (30%), and IgA nephropathy (29%) were the major diseases in the respective groups. Five hundred and five (47.6%) patients had subnephrotic proteinuria. Out of these, 29 (5.6%) had only subnephrotic proteinuria, 134 (27%) had additional microhematuria, 300 (59%) had subnephrotic proteinuria, microhematuria, and renal failure, and 42 (8%) had subnephrotic proteinuria with renal failure. Lupus Nephritis (45% and 40%) and IgA Nephropathy (32% and 21%) were the major disorders in the subgroups respectively. Forty-two patients (3.7%) were biopsied for isolated renal failure with bland urinary sediment. Cast nephropathy and acute interstitial nephritis were the major diseases. Out of 89 patients with diabetes who were biopsied, 15 (16.8%) had diabetic nephropathy, 45 (50.5%) had no diabetic nephropathy, and 29 (32.5%) had diabetic nephropathy along with a non-diabetic renal disease. Postinfectious glomerulonephritis was the major glomerular disease. IgA nephropathy (22.2%) and membranous nephropathy (15.5%) were the major diseases in patients with diabetes with no diabetic nephropathy. In our population, MCD and membranous nephropathy formed the majority of diseases in biopsied nephrotic syndrome. Added microhematuria did not seem to decrease the incidence of either disease on the whole. We found a significant number of patients with membranous nephropathy with nephrotic syndrome, microhematuria, and additional renal failure. IgA nephropathy formed a majority of cases with nephrotic syndrome, microhematuria, and renal failure. The presence of renal failure regardless of other abnormalities in urinalysis showed a trend toward IgA nephropathy. Membranous nephropathy may have a more varied presentation than was originally thought and IgA nephropathy presenting as nephrotic syndrome may not be uncommon. MCD is the major subgroup of diseases in the pediatric population and presents both as nephrotic syndrome as well as nephrotic syndrome with microhematuria. Thus, urinalysis and renal failure may be a valuable tool in assessing renal disease.

Objectives: We aimed at creating a clinical profile of end-stage renal disease patients' gonadal function and assessing the impact of renal transplant on gonadal dysfunction. We studied the influence of age, vascular anastomosis, dialysis vintage, and immunosuppression on sexual dysfunction. Materials and Methods: Twenty adults were included. Hormones (luteinizing hormone [LH], follicle-stimulating hormone [FSH], testosterone, prolactin (PRL), and estrogen), menstrual history and International Index of Erectile Function (IIEF)-5 questionnaires were assessed before and after renal transplantation. Hormone evaluation was done by chemiluminescent microparticle immunoassay technology. Results: Seventeen patients were male and three patients were female. Native kidney diseases were chronic glomerulonephritis (10%), IgA nephropathy (20%), autosomal dominant polycyctic kidney disease (5%), diabetic nephropathy (5%), focal segmental glomerulosclerosis (5%), renal calculus disease (5%), membranous nephropathy (5%), and pauci-immune vasculitis (5%). Fifteen males had erectile dysfunction (ED) before transplant. Eleven patients showed an increase and six patients showed a decrease in IIEF scores posttransplantation. Statistically significant changes were observed in the mean levels of testosterone, LH, PRL, and FSH. Age at transplant showed a negative correlation with IIEF score. In five patients with an end to side anastomosis to the external iliac artery, all had an increase in IIEF score posttransplant. In 12 patients with an end to end anastomosis to the internal iliac artery, 5 patients (42%) had a decrease in IIEF score posttransplant. Conclusions: Incidence of ED was 88% in our study. About 65% patients showed an increase in IIEF score posttransplantation. Increasing age at the time of transplant was a significant risk factor for the presence of ED. Renal transplantation corrected hormonal abnormalities in men. About 100% of patients with an end to side arterial anastomosis showed improvement in IIEF scores. There was no effect of dialysis vintage and immunosuppression regimes on sexual dysfunction.