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The determination of Brain Death (BD)/Death by neurological criteria (DNC) is now widely accepted among various international societies following the World Brain Death project recommendation. As per the World Brain Death project, ancillary testing should be performed when standard brain-death examination components are inconclusive or cannot be performed. BD was defined legally in 1994 under the Transplantation of Human Organs Act (THOA). However, even after 27 years of the formulated law, there are no guidelines in the THOA regarding the determination of BD using ancillary tests. The present brief report describes two instances where ancillary tests like four-vessel angiography and transcranial doppler-aided brain-death certification were done. It is the first available literature from our country where ancillary tests aided in confirmation of BD when the standard clinical components of DNC could not be performed.

Background: Native AV fistulas are the ideal access for hemodialysis but require monitoring and multiple interventions in some patients to keep them functioning. The aim of the study was to assess the impact of the appointment of a trained vascular access coordinator (VAC) for fistula monitoring, on the evolution of the vascular access program at our institute. Method: Data was retrieved from the departmental database for the baseline year 2014 and compared with the data from 2018. Initial review showed that appointment of the VAC in 2015 resulted in a steady increase in the number of AV fistula interventions over 2 years to a plateau in 2018 which was chosen as the comparison year. The number of AVF’s created, number of salvage procedures performed, and follow-up data were compared. Other parameters like number of operation theatre hours, surgeons, and nursing staff remained constant during this period. Result: Total numbers of AVFs increased from 511 to 713 (39.3%). The number of follow-up visits to surgeons reduced from an average of 4–0.25 visits per patient during this period. Follow up Doppler examinations increased from 761 to 1296 (70%) indicating improved follow up. The salvage procedures increased from 44 to 161 (272%) with early detection of fistula dysfunction. Primary and secondary patency rates of 86% and 92% at 3 months could be achieved whereas limited follow-up data was available for 2014. Conclusion: Appointment of trained VAC increased the number of vascular access procedures, improved follow-up care, and led to early detection and intervention for access dysfunction while reducing the workload of surgeons.

Arteriovenous fistulas (AVF) are the preferred access for hemodialysis in patient with end stage renal disease. Usually, distal vessels of upper limb are preferred. There are situations in which the upper limb cannot be a site for AVFs or graft as in cases of bilateral central venous stenosis or with exhausted sites in upper limb. In these cases, lower limb AVF can be considered. Tibial-saphanous (ankle) fistula should be the preferred site over femoral AVF/graft following the principle of distal to proximal. Also, femoral AVFs are associated with more ischemic and infective complications. The present report describes successful hemodialysis in two patients with tibial-saphanous fistula a site rarely used as an option for HD access. Hemodialysis for over 1 year in one patient and 6 months in the other portrays the success of this approach.

Objective: Ringer's lactate (RL) was one of the perfusion fluid used in renal transplants, which were replaced by perfusion fluid with an intracellular composition like histidine-tryptophan-ketoglutarate (HTK) solution. These are preferred in cadaveric renal transplants. However, there are no guidelines for live-related donor renal transplant. We study whether HTK solution is better than RL solution, an extracellular composition fluid in preserving allograft in live-related donor renal transplantation. Materials and Methods: A single-blinded randomized trial comparing HTK solution and RL solution in 80 patients undergoing live-related donor renal transplantation from July 2017 to June 2018. The outcome was measured in serum cystatin C and plasma malondialdehyde (MDA) and serum creatinine for 30 days. Results: In 19 cases, surgeons preferred HTK solution as perfusion fluid due to the presence of multiple arteries; hence, these cases are removed from analysis due to deviation from the study protocol. Four patients in the HTK group and five patients in the RL group were excluded due to loss to follow-up. Recipient age, sex, and donor age, sex, and basic disease were comparable in both groups. The higher warm ischemia in the HTK group (5.58 min [standard deviation (SD) 1.44 min]) as compared to the RL group (5.00 min [SD 1.12 min]) with P 0.096. Similarly, the longer cold ischemia in the HTK group (82.00 min [SD 21.31 min]) as compared to the RL group (70.32 min [SD 24.56 min]) with P 0.783. 8.3% rejection in the HTK group and 17.9% rejection in the RL group. Serum cystatin C, marker of glomerular filtration was comparable, HTK group ((3.75 ± 1.98 mg/l) and RL (3.94 ± 1.68 mg/l) with P 0.714. The plasma MDA marker of ischemia-reperfusion injury was also comparable HTK group (80.16 ± 80.08 ng/ml) and RL group (61.50 ± 92.23 ng/ml) with a P 0.446. Fall in serum creatinine was significantly more in the HTK group than RL. At the end of 30 days, both groups had similar levels of serum creatinine level. Conclusion: Graft perfused by HTK solution and RL solution at our center had comparable 30-day outcomes. Although none of the differences was statistically significant, the HTK group had consistently better metrics in terms of fall in creatinine and serum cystatin C despite a trend to longer ischemia times and higher plasma MDA levels.

Background Cytomegalovirus (CMV) reactivation or infection is one of the most important infectious complications in transplant recipient leading to significant morbidity and mortality. Its early detection and prompt treatment is imperative to improve transplant outcome. The present study estimated the frequency of CMV in renal transplant recipients (RTR). Various aspects of pp65Ag assay and quantitative real-time polymerase chain reaction (qRT-PCR) were evaluated in relation to the recent guidelines for CMV detection and treatment. Methods Retrospectively, data of clinically suspected cases of CMV (1610 out of total 2681 renal transplants) were analyzed along with a comparison of pp65Ag assay and qRT-PCR. Results The overall incidence of CMV syndrome was 14.25%; however, the incidence of CMV viremia in the clinically suspected group was 23.73%. The proportion of positive cases with pp65Ag assay and qRT-PCR were 13.6% (95% CI; 7.9-22.3) and 19.3% (95% CI; 12.4-28.8) with a substantial agreement (Cohen’s kappa = 0.632) between the 2 techniques. CMV positive recipients were treated with ganciclovir until their viral count was negative or up to 3 weeks, followed by 3 months of prophylaxis with valganciclovir. No graft failure or mortality was reported secondary to CMV infection until 3 to 5 years of follow-up. Results CMV infection is quite prevalent in RTR, and early detection and immediate treatment or prophylaxis is of utmost importance. qRT-PCR is the gold standard and preferred over other methods; however pp65Ag assay still holds its importance in low-economic countries and populations where CMV infection is more prevalent and financial constraints are a major limitation.

Pulmonary mucormycosis has been associated with high mortality (reported up to 100%) in renal transplant recipients.This was a retrospective analysis of renal transplant patients with pulmonary mucormycosis between April 2014 and March 2020, who underwent surgical resection of the affected lung along with liposomal amphotericin therapy. Patients with lower respiratory illness features underwent chest X-ray, high-resolution computed tomography of the chest, and those with suspicious findings underwent analysis of bronchioloalveolar fluid and transbronchial lung biopsy. Patients with histological or microbiological evidence of mucormycosis were started on liposomal Amphotericin B. Tacrolimus and mycophenolate mofetil were stopped at the time of diagnosis.Ten patients underwent combined management, while five patients were managed medically. At last follow up, seven out of ten patients (70%) who underwent combined management and two of the five patients (40%) who were managed medically, had a mean survival of 28.86 months (sd = 15.71, median = 25) and 14.17 months (sd = 12.21, median = 18), respectively, post-diagnosis of pulmonary mucormycosis.Surgical resection combined with antifungals in the perioperative period and decreased immunosuppression may improve the outcomes in renal transplant patients with pulmonary mucormycosis.

Background COVID-19 infection is considered to cause high mortality in kidney transplant recipients (KTR). Old age, comorbidities and acute kidney injury are known risk factors for increased mortality in KTR. Nevertheless, mortality rates have varied across different regions. Differences in age, comorbidities and varying standards of care across geographies may explain some variations. However, it is still unclear whether post-transplant duration, induction therapy, antirejection therapy and co-infections contribute to increased mortality in KTR with COVID-19. The present study assessed risk factors in a large cohort from India. Methods A matched case–control study was performed to analyze risk factors for death in KTR (N = 218) diagnosed with COVID-19 between April 2020 to July 2021 at the study centre. Cases were KTR who died (non-survivors, N = 30), whereas those who survived were taken as controls (survivors, N = 188). Results A high death-to-case ratio of 13.8% was observed amongst study group KTR infected with COVID-19. There was a high incidence (12.4%) of co-infections, with cytomegalovirus being the most common co-infection among non-survivors. Diarrhea, co-infection, high oxygen requirement, and need for mechanical ventilation were significantly associated with mortality on regression analyses. Antirejection therapy, lymphopenia and requirement for renal replacement therapy were associated with worse outcomes. Conclusions The mortality was much higher in KTR who required mechanical ventilation and had co-infections. Mortality did not vary with the type of transplant, post-transplant duration and usage of depletion induction therapy. An aggressive approach has to be taken for an early diagnosis and therapeutic intervention of associated infections.

Objective To discuss a novel technique of dual kidney transplantation that has not been described in literature. Methods Dual Kidney Transplantation (DKT) is done for kidneys from expanded criteria donors. The 3 described techniques in literature (bilateral placement, unilateral placement with separate or patch anastomosis) have some disadvantages. This newer technique describes the use of the donor iliac artery as an interposition Y graft for joining both kidneys of the dual kidney transplant. This method can overcome some of the disadvantages associated with the previously described techniques. The ureters were implanted in urinary bladder separately in one recipient and together in another recipient. Results This technique was used in 2 cases. The cold ischemia time was 275 minutes and 765 minutes, respectively while the operative time was 187 minutes and 192 minutes, respectively in the 2 patients. The first patient has creatinine of 0.83 mg/dl on last follow up at 6 months whereas the other patient has creatinine of 1.12 mg/dl at 3 months follow up. Computed tomography angiography of both the patients revealed good contrast uptake in both kidneys with no stenosis, torsion or lymphocele. Conclusion The newer technique avoids scarring of both iliac fossa in DKT while reducing operative time and secondary warm ischemia time by doing a single arterial anastomosis in the recipient and allows easier placement of both kidneys in the right iliac fossa.

Introduction: Treatment options for recurrent C3 glomerulopathy (C3G) are not explored in large trials. Only Eculizumab has been successfully used to improve the renal function in patients with recurrent C3G. In the current report, we are sharing our experience with plasma exchange (PLEX) in the management of early recurrent C3G post-renal transplantation. Materials and Methods: A total of four patients underwent PLEX. Time to recur was less than two weeks in all the patients. Serology levels, autoantibody testing and limited genetic workup was done in all the four patients. The clinical details of patients were recorded. Results: All the patients underwent 5 PLEX (40 ml/kg/session) with fresh frozen plasma as the replacement. The median time for post-transplant recurrence was 3-days. Immediate reduction in serum creatinine was seen in three (75%) patients. After a median last follow-up of 8.5 (range: 4-18) months, two (50%) patients achieved remission and the other two (50%) had resistant disease resulting in graft loss. Three patients tested positive for autoantibodies (two cases had positive C3-nephritic factor and one had anti-complement factor-H autoantibodies. Complement factor H gene analysis revealed rs1061170; p.His402Tyr (missense variant), rs1061147; p.Ala307= (synonymous variant) and rs2274700; p.Ala473= (synonymous variant) in three cases. All the three patients who had immediate response to PLEX had positive autoantibodies against complement pathway regulators. Conclusion: In the present report, we performed extensive workup for complement pathway abnormality and found that patients with recurrent C3G following transplantation having autoantibodies benefited with PLEX.

Traditionally, fluid administration during kidney transplant surgery is guided by central venous pressure (CVP) despite its limited reliability as a parameter for assessing intravascular fluid volume, particularly in patients with cardiovascular diseases. The recommended goals at graft reperfusion are a mean arterial pressure of 90 mm Hg and a CVP of 12-14 mm Hg. This approach may increase the risk of significant adverse effects due to volume overload. Perioperative fluid therapy guided by dynamic indices of fluid responsiveness has been shown to optimize intravascular volume and prevent complications associated with overzealous administration of fluids in major abdominal surgeries. We hypothesized that pulse pressure variation (PPV)-guided fluid administration would result in better optimization of intravascular fluid volume compared with a CVP-guided strategy during kidney transplant surgery.In this single-centre randomized double blinded trial, 77 end-stage renal disease patients, who underwent kidney transplant surgery under general anesthesia with epidural analgesia, were randomized to receive either CVP-guided (n = 35) or PPV-guided (n = 35) fluid therapy using predefined hemodynamic endpoints. The primary outcome was the total volume of intraoperative fluids administered. Secondary outcomes were intraoperative hemodynamic changes, serum lactate levels, serum creatinine, need for dialysis within the first week, creatinine elimination ratio, and incidence of immediate and delayed graft dysfunction.Results were analyzed for 70 patients. Eighty percent of the patients underwent living-related donor allograft kidney transplant. Operative variables related to donor characteristics, duration of surgery, graft cold ischemia time, and blood loss were comparable in both groups. The mean (standard deviation) volume of intravenous fluids administered intraoperatively was 1,346 (337) mL in the PPV-guided group vs 1,901 (379) mL in the CVP-guided group (difference in means, 556 mL; 95% confidence interval, 385 to 727; P = 0.001). There were no significant differences in secondary outcomes between the two groups.Pulse pressure variation -guided fluid administration significantly decreased the total volume of crystalloids compared with CVP-guided fluid therapy during the intraoperative period in patients who underwent kidney transplant surgery. Nevertheless, our study was underpowered to detect differences in secondary outcomes.www.ctri.nic.in (CTRI/2018/01/011638); registered 31 January 2018.RéSUMé: CONTEXTE: Traditionnellement, l’administration liquidienne pendant une chirurgie de transplantation rénale est guidée par la pression veineuse centrale (PVC) et ce, malgré sa fiabilité limitée en tant que paramètre d’évaluation du volume liquidien intravasculaire, en particulier chez les patients atteints de maladies cardiovasculaires. Les objectifs recommandés lors de la reperfusion du greffon sont une tension artérielle moyenne de 90 mmHg et une PVC de 12–14 mmHg. Cette approche pourrait augmenter le risque d’effets indésirables importants dus à une surcharge volémique. Il a été démontré que la thérapie liquidienne périopératoire guidée par des indices dynamiques de réponse au remplissage optimisait le volume intravasculaire et prévenait les complications associées à l’administration liquidienne exagérée lors de chirurgie abdominale majeure. Nous avons émis l’hypothèse qu’une administration liquidienne guidée par la variation de pression différentielle (VPD et delta PP) entraînerait une meilleure optimisation du volume liquidien intravasculaire par rapport à une stratégie guidée par la PVC pendant une chirurgie de transplantation rénale. MéTHODE: Dans cette étude randomisée monocentrique à double insu, 77 patients atteints d’insuffisance rénale terminale, qui ont bénéficié d’une greffe rénale sous anesthésie générale avec analgésie péridurale, ont été randomisés à recevoir une administration liquidienne guidée soit par la PVC (n = 35) ou par la VPD (n = 35) en utilisant des critères hémodynamiques prédéfinis. Le critère d’évaluation principal était le volume total de liquides peropératoires administrés. Les critères secondaires comprenaient les variations hémodynamiques peropératoires, les taux sériques de lactate, la créatininémie, le besoin de dialyse au cours de la première semaine, le taux d’élimination de la créatinine et l’incidence de dysfonctionnement immédiat et retardé du greffon. RéSULTATS: Les résultats ont été analysés pour 70 patients. Quatre-vingts pour cent des patients ont subi une allogreffe de rein provenant d’un donneur vivant apparenté. Les variables opératoires liées aux caractéristiques du donneur, la durée de la chirurgie, le temps d’ischémie froide du greffon et les pertes sanguines étaient comparables dans les deux groupes. Le volume moyen (écart type) de liquides intraveineux administrés en peropératoire était de 1346 (337) mL dans le groupe guidé par VPD vs 1901 (379) mL dans le groupe guidé par PVC (différence de moyennes, 556 mL; intervalle de confiance à 95 %, 385 à 727; P = 0,001). Aucune différence intergroupe significative n’a été observée dans les critères d’évaluation secondaires. CONCLUSION: L’administration liquidienne guidée par la variation de pression différentielle a significativement diminué le volume total de cristalloïdes par rapport à la thérapie liquidienne guidée par la PVC pendant la période peropératoire chez les patients ayant bénéficié d’une greffe de rein. Néanmoins, notre étude ne disposait pas de la puissance suffisante pour détecter les différences dans les critères d’évaluation secondaires. ENREGISTREMENT DE L’éTUDE: www.ctri.nic.in (CTRI/2018/01/011638); enregistré le 31 janvier 2018.

Objectives Although pancreas transplants were started at our center in 2014, the number of pancreases procured have remained low. This report presents an audit of donors over the past 18 months with the aim to identify factors preventing pancreas utilization. Methods This was a retrospective study. All deceased donors from January 2018 to July 2019 were included in this study. The medical records of deceased donors were reviewed with regard to donor characteristics such as demographics, biochemical parameters, and preterminal management. Results Organs were retrieved from 49 deceased donors over the duration of the study. Mean age of the donors was 35.34 ± 18.2 years (11 months to 72 years). Most donors were men (M:F 41:8). In total, 45/49 (92%) donors had central nervous system trauma as a cause of brain death. Out of 49, multiple abdominal organs were retrieved from 21 donors (42.8%), whereas kidneys alone were retrieved from the rest. Pancreases were retrieved from 8 donors (16.3%). Pancreases were rejected in 21 donors (42.8%) because of age limit criteria. Other reasons for refusal included donor sepsis (n = 12, 24.5%), severe hemodynamic instability (n = 5, 10.2%), donation after cardiac death (DCD) (n = 2, 4.1%), and ischemic hepatitis (n = 7, 14.3%) while 3 (6.1%) donations happened while awaiting license renewal. A suitable recipient was not available for 1 donor (2.0%). Conclusion Pancreas retrieval rates remain low because of donor-related factors. Expansion of age limits and better donor management could improve pancreas transplant activity.

Objectives This report presents an audit of utilization of various organs from deceased donors in different states of India over a 3-year period Methods Data released by the various regions on their official website was analyzed from 2015 to 2017.Regions with less than 25 donations per year were excluded while calculating utilization rates. Results Total organ donation in India had increased from 570 to 843 donations from 2015 to 2017 (47.8% increase) with southern states performing exceedingly well compared with northern states. Total organs retrieved during the 3-year period were 6659 with a 54.7% increase in organ retrieval in 2017 compared with 2015 (2592 vs 1675 respectively). The net utilization rate of kidneys was 87.35%. Total liver transplants done during this period were 1894. Net liver utilization rate was 86.81% over 3 years. Total Heart transplants during this period were 641 with net utilization rate of 28.98%. An increase in utilization rates was observed from 2015 to 2017 (19.33%-34.46%). A total of 217 lung transplants were done with net utilization rate of 8.86% with an increase in yearly utilization rate from 6.5% in 2015 to 11.97% in 2017. Total pancreas transplants remained low with 48 transplants over 3 year duration with net utilization rate of 2.25% but an increase in utilization rate was observed. (0.92% in 2015 to 2.1% in 2017). Conclusion There is a significant regional variability in organ utilization in India. Evaluating and addressing the cause of high variability can further increase the transplant activity.

Background Laparoscopic donor nephrectomy (LDN) is considered the gold standard for live donor nephrectomies owing to lesser pain, shorter hospitalization, and earlier return to normal activities, yet it remains a technically challenging surgery. Repetition of a highly skilled task such as LDN should lead to improved performance reflected in shorter surgery times and a decrease in adverse events. Methods The records of over 2524 LDNs from February 2004 to June 2019 were evaluated for duration of surgery (from incision time to clamping of the renal artery) and occurrence of complications. Results The mean duration of surgery ± SD from incision to clamp time for the first 100 cases at the inception of LDN was 166.13 ± 33.28 minutes whereas it was 124.59 ± 35.91 minutes for the best 100 consecutive cases in 2015 with a decrease of 41 minutes duration of surgery from incision to artery clamping. The adverse events were accessory renal artery injury (n = 10), splenic laceration (n = 2), bowel and mesocolon injuries (n = 12), venous or arterial clip slippage (n = 4), inferior vena cava tear (n = 2) pneumothorax (during stapler application, n = 1), missing gauze counts (n = 1), chylous ascites (n = 1), ureteric thermal injury (n = 2), and renal parenchyma injury (n = 3). Conclusions LDN is a technically demanding surgery where surgeon experience appears to affect operative metrics such as operative time. The occurrence of intraoperative complications appears to be acceptably low, although serious complications are a possibility.

Objectives Delayed graft function (DGF) in renal allograft transplantation refers to the need for dialysis in the first week after renal transplantation. This study analyzed the causes of DGF in deceased donor transplantation. Methods Data from January 2018 to July 2019 was reviewed with regard to donor and recipient characteristics such as demographics, biochemical parameters, organ dysfunction, and preterminal management. The recipients were divided into 2 groups: group I: patients without DGF and group II: patients with DGF. Results Kidneys were retrieved from 49 deceased donors (male:female = 41:8) and transplanted to 95 recipients (male:female = 60:35). Mean age of the donors and recipients was 35.34 ± 18.2 and 40.72 ± 13.30 years, respectively. The most common cause of brain death was central nervous system trauma (45 out of 49, 91%). In total, 20/95 (21%) recipients had DGF. Twelve recipients had received kidneys from donors who had circulatory arrest. Two patients were re-explored on postoperative day 1 for bleeding from renal artery anastomosis. The mean age in group I and group II was 28.65 ± 10.2 and 37.38 ± 12.28 years, respectively. The mean cold ischemia time in group I and group II was 398.73 ± 187.19 and 333.24 ± 115.49 minutes, respectively. The mean hospital stay of donor before donation in group I and group II was 4.34 ± 1.27 and 6 ± 2.95 days, respectively. The terminal donor creatinine in group I and group II was 0.88 ± 0.47 and 2.33 ± 1.73 mg/dL, respectively. Conclusion DGF in deceased donor transplantation may be attributed to donation after circulatory death, prolonged donor hospital stay, high donor leukocyte count, and high terminal creatinine.

Aim: The study evaluated whether a single dose pretransplant 2-h tacrolimus concentration (C2) could predict the post-transplantation trough concentration (C0). Materials & methods: C2 concentration of tacrolimus was measured after single-dose administration (0.1 mg/kg) in 20 patients, 4–7 days prior to renal transplantation. Tacrolimus C0 monitoring was done on post-transplant day 2, 5, 10, 15 and 30. Results: The mean C2 was 21.79 ± 16.83 ng/ml (4.25–69.46) and the mean C0 obtained 48 h after transplant was 10.2 ± 6.27 (1.63–22.07) ng/ml. The Spearman correlation between C2 and C0 was 0.71 (p 2 could explain only 50% of the total variation in the post-transplant dose requirement hence it may not be sole predictor of the post-transplant dose.

Background: Pain management is often challenging in patients undergoing renal transplant owing to the various comorbidities. Epidural analgesia is currently the standard technique but is not without complications. Continuous wound infusion (CWI) is emerging as a simple and effective technique of postoperative analgesia. Therefore, the purpose of our study was to compare the efficacy of CWI with continuous epidural infusion (CEI). Methods: Forty-two patients undergoing renal transplant surgery were randomized to receive either CEI or CWI. The visual analogue score at rest and on movement was assessed. Opioid consumption, patient satisfaction, and complications were also assessed. Results: The pain scores measured at rest 4, and 8 h postoperatively were significantly lower in the CWI group.(2.45 ± 1.317) in CWI versus (3.45 ± 1.050) in CEI, P = 0.012 at 4 h, and (1.95 ± 1.146) in CWI versus (2.75 ± 0.786) in CEI, P = 0.014 at 8 h. The pain scores at other time points were lower in the CWI group but not statistically significant. The morphine used in the first 8 h was significantly higher in the CEI group. There was a higher incidence of hypotension in the CEI group (P = 0.028). The patient satisfaction and other side effects were comparable between the groups. Conclusion: Continuous wound infiltration is an effective technique for postoperative analgesia in renal transplant surgery and can be used as an alternative to epidural analgesia.

Introduction Deceased donor kidney transplant are still not common across India. This study was done to assess various measures taken at a single center level to increase organ donation rate and to analyse the outcomes of transplants performed from these donors. Methods All deceased donor renal transplants performed from November 2011 to February 2017 were analysed for patient and death censored graft survival, rate of delayed graft function, rate of rejection and mortality. Kaplan Meir analysis for Survival Curves was used. Results Organ donation rate at our center improved from one donation every alternate year in 2004 to a peak of 44 donations in 2017. Patient survival was 93.42%, 89.44%, 85.53%, and death censored graft survival was 94.07%, 88.21%, and 82.86% at 1, 2 and 3 years respectively. Mean duration of hemodialysis pre transplantation was 34.6 ± 27.43 months. Conclusions This study has shown that steps taken at a single center level alone can also significantly improve organ donation rates. Employment of dedicated professionals including transplant surgeons and coordinators, developing a protocol-based approach for referral, and early counseling in triage along with regular audits can help to establish deceased donor program with acceptable outcomes elsewhere in the country.

PurposeIn patients with end-stage renal disease, arteriovenous fistulas (AVFs) are the access of choice for hemodialysis but are often complicated by stenosis. We present single-center experience of 78 ultrasound-guided angioplasty procedures for treating peripheral stenoses of AVFs.MethodsBetween January 2013 and November 2015, 78 angioplasties were performed under ultrasound guidance in 53 patients with end-stage renal disease who were referred from dialysis centers with low flow rate, difficult cannulation, increased cannulation site bleeding, immature or thrombosed AVF. Angioplasties were carried out in the presence of a structural lesion in the AVF resulting in at least 50% reduction in vein diameter with a blood flow of 300 cm/s. Clinical success, anatomical success and post-intervention primary and secondary patency rates at 6, 12, 18 and 24 months were studied.ResultsIn 49/53 patients (92.4%), 74 angioplasty procedures were successfully performed, whereas 4/53 patients (7.6%) had primary failure. A total of 35/49 patients (71.4%) underwent single angioplasty procedure whereas 14/49 patients (28.6%) underwent multiple angioplasty procedures. Post-intervention primary patency rates at 6, 12, 18 and 24 months were 78.6%, 60.2%, 53.8% and 48.9%, respectively. Post-intervention secondary patency rates at 6, 12, 18 and 24 months were 100%, 100%, 95.4% and 89%, respectively. Clinical success and anatomical success was 94.8% and 89.7%, respectively.ConclusionsUltrasound-guided angioplasty is an effective method with good long-term outcomes in selected dialysis patients with peripheral stenosis of AVF.

The objective of this study was to evaluate the oxidant and antioxidant status in living donor renal allograft transplant recipients. Ninety-two renal transplant recipients with mean age of 34.75 ± 11.22 years were included in the present study. Venous samples of the recipients were drawn: before the transplant (baseline), 5 min after reperfusion, and 2 weeks after transplant. Samples were processed for the measurement of markers of oxidant and antioxidant status viz. malondialdehyde, catalase, glutathione peroxidase, reduced glutathione, ascorbic acid, and total antioxidant system. The mean baseline levels of reduced glutathione, ascorbic acid, and total antioxidant system were 1.61 ± 0.84 mg/g hemoglobin, 3.64 ± 1.49 mg/dL, and 1.42 ± 0.14 mmol/L which decreased at 5 min after reperfusion to 1.32 ± 0.72 (p = 0.010), 2.96 ± 1.25 (p = 0.002), and 1.36 ± 0.12 (p = 0.042), respectively. The malondialdehyde levels increased from a baseline value of 3.11 ± 1.02 µmol/mL to 3.32 ± 1.09 at 5 min after reperfusion (p = 0.344) and 4.01 ± 1.21 (p = 0.000) at 2 weeks. Glutathione peroxidase level decreased from 68.59 ± 32.79 units/g hemoglobin (baseline) to 63.65 ± 32.92 at 5 min after reperfusion (p = 0.530) and increased significantly at 2 weeks to 86.38 ± 37.18 (p = 0.00). There was no significant change in the catalase level. In living donor renal transplantation, oxidative stress starts after reperfusion and is reflected by fall in antioxidant factors and enzymes in the early period. Over the next 2 weeks, there is increased oxidative stress and simultaneous strengthening of antioxidant system which is implied by increase in malondialdehyde and improvement in the markers of antioxidant status.