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Shah P.R.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2013

Acute kidney injury (AKI) is an independent risk factor for mortality in sepsis syndrome. Few Indian studies have focused on describing the epidemiology of sepsis with AKI. Adult patients with sepsis-induced AKI were evaluated for the clinical characteristics and outcome and to correlate various parameters associated with sepsis to the outcome of patients. This prospective study included 136 patients with sepsis-induced AKI between 2007 and 2009. All patients required renal replacement therapy. Males comprised 44% of the patients while 56% were females; their mean age was 38.6 years. When we compared the survivor and non-survivor groups, it was found that mortality was associated with delayed presentation (6.8 vs 9.4 days), presence of hypotension (132/80 vs 112/70 mmHg), oliguria (300 vs 130 mL), anemia (8 vs 9.3 gm/dL), prolonged prothrombin time (15 vs 29 s) and activated partial thrombin time (38 vs 46 s), creatinine (7.8 vs 6.4 mg/dL), blood urea (161 vs 135 mg/dL), higher D-dimer (1603 vs 2185), short hospital stay (27.9 vs 8.3 days), number of hemodialysis sessions (11.9 vs 6 times), need for vasopressors (14% vs 52%) and ventilator (7.2% vs 75%) and higher Sequential Organ Failure Assessment (SOFA) score (6.7 vs 11.4) (P <0.05). The most com-mon source of infection in this study was urogenital tract (34%). About 51.4% showed complete recovery of renal function. The overall hospital mortality rate was 38.9%. Less than 10% of the patients developed impaired renal function following septic AKI. In conclusion, the most common renal manifestation of sepsis was AKI, which is a risk factor for mortality in sepsis syndrome. SOFA score >11 and multi-organ dysfunction are the risk factors for mortality.


Kute V.B.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2012

Methanol is a cheap and potent adulterant of illicit liquors. Hemodialysis (HD) is the best method to rapidly remove both toxic acid metabolites and parent alcohols, and it plays a fundamental role in treating severely poisoned patients. This retrospective study was carried out on 91 patients with detectable serum methanol levels who underwent HD. Because toxic alcohol levels were not immediately available, the initial diagnosis and treatment was based on clinical history with evidence of toxic alcohol intake, presence of high anion metabolic acidosis and/or end organ damage. Patients received bicarbonate, ethanol, according to clinical features and blood gases. Patients underwent HD in the setting of known methanol ingestion with high anion gap metabolic acidosis, or evidence of end-organ damage, regardless of methanol level. HD prescription included large surface area dialyzer (≥ 1.5 m 2), blood flow rate of 250-350 mL/min and dialysate flow rate of 500 mL/min for 4-6 h. Between 9 and 11 July 2009, 91 males with mean age 40 ± 8.5 years underwent HD, and 13 patients required a second HD session. Patients consumed 100-500 mL illicit liquors, and symptoms appeared six and 60 h later. Clinical features were gastro-intestinal symptoms (83.5%), visual disturbances (60.4%), central nervous system symptoms (59.3%) and dyspnea (43.9%). Before HD, mean pH was 7.11 ± 0.04 (range 6.70- 7.33) and mean bicarbonate levels were 8.5 ± 4.9 mmol/L (range 2-18). Three patients died due to methanol intoxication. Mortality was associated with severe metabolic acidosis (pH ≤ 6.90), ventilator requirement and coma/seizure on admission (P < 0.001). Timely HD, bicarbonate, ethanol and supportive therapy can be life-saving in methanol intoxication.


Devra A.K.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2010

Although laparoscopic donor nephrectomy is now a well-accepted alternative to traditional open donor nephrectomy at many transplantation centers, there are always concerns regarding quality of graft and vessels after laparoscopic harvest, especially with right donor nephrectomy. Several methods of graft retrieval have been explored to achieve acceptable graft outcome. We share our initial experience at the Institute of Kidney Diseases and Research Center, Amedabad, India of laparoscopic right donor nephrectomy performed by subcostal open, and pure laparoscopic approach with the use of Endo TA stapler. Nine laparoscopic right donor nephrectomies were performed by the trans-peritoneal approach at our centre from January 2006 to March 2007. In the first five cases, the grafts were retrieved through subcostal incision (Group A) and the last four cases were performed purely laparoscopically by using Endo TA stapler device (Group B). None of the patients needed open conversion. The mean operative time and hospital stay were comparable in each group. The warm ischemia time was longer in pure laparoscopic group (415 seconds) than the subcostal open approach group (176 seconds). The serum creatinine of the recipients on day seven was comparable in both the groups. The recipient surgery was effectively performed with graft retrieved using Endo TA stapler device (Group B) without any compromise to the renal vein length. Our study suggests that the Endo TA stapler device is safe and provides all the benefits of minimally invasive surgery to the donor.


Everly M.J.,Olympic Research, Inc. | Terasaki P.I.,Terasaki Foundation | Trivedi H.L.,Institute of Kidney Diseases and Research Center
Transplantation | Year: 2012

Background: Evidence of the short-term effect of bortezomib on donor-specific human leukocyte antigen (HLA) antibody (DSA) removal capacity has emerged. However, no published data characterize the durability of DSA response. Here, we report the long-term DSA response results on renal transplant patients treated with bortezomib. Methods: In this single-center study, 26 living-donor renal transplant patients with a positive level of de novo DSA were preemptively treated with bortezomib (1.3 mg/m 2×4 doses). A total of 15 patients received bortezomib as part of a combination regimen; 11 received bortezomib alone. Weekly serial measurements of HLA antibody were noted before, during, and after treatment using single-antigen beads. Results: At a median follow-up of 25.8 months posttreatment, allograft function remained good in each of the patients. Following treatment, 96% of the patients achieved at least a partial response. Eighteen patients (69%) experienced a complete response followed by a period of DSA remission. Ten patients had DSA relapse after remission, at a median of 3.8 months. The remaining eight patients are still in remission at 14 months posttreatment (median). Patients with remission enjoyed better allograft functional stability than those who relapsed (P=0.023). After bortezomib therapy, the addition of a calcineurin inhibitor or mycophenolate mofetil was predictive for maintaining a DSA remission (hazard ratio 0.09, 95% confidence interval 0.01-0.76). Conclusions: Bortezomib therapy consistently provides reduction in DSA and in many a DSA remission may occur. However, sustaining remission is likely necessary to improve allograft stability. © 2012 by Lippincott Williams & Wilkins.


Sharma V.,Institute of Kidney Diseases and Research Center | Margreiter M.,Medical University of Vienna
Current Urology Reports | Year: 2013

Long-term outcome data indicate that open partial nephrectomy has cancer-free survival rates comparable to those of radical surgery, with better preservation of renal function, decreased overall mortality and reduced frequency of cardiovascular events. Open partial nephrectomy is increasingly being challenged by laparoscopic and/or robot assisted partial nephrectomy, which in the hands of experts appears to achieve comparable oncological results, albeit at a higher complication rate. We report a review based on literature published over the past years, which may provide insight into the role of open partial nephrectomy in the present urological practice and in years to come. © 2012 Springer Science+Business Media New York.


Kute V.B.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2014

Acute kidney injury (AKI) is one of the most challenging and serious complications of pregnancy. We present our experience on the clinical profile and outcome of 57 patients with pregnancy-related AKI, of a total of 580 patients with AKI seen during the study period. This is a prospective single-center study in a civil hospital conducted from January to December 2010. The most common age group of the study patients was 20-25 years; 43.8% of the patients had received antenatal care. AKI was observed in the puerperium (n = 34), early pregnancy (n = 10) and late pregnancy (n = 13). The cause of AKI included puerperal sepsis (63.1%), pregnancy-induced hypertension (PIH) (33.33%), post-abortion (22.80%), ante-partum hemorrhage (APH) (14%) and post-partum hemorrhage (PPH) (8%). Complete, partial and no renal recovery was observed in 52.64%, 21.05% and 26.31% of the patients, respectively. Low platelet count and plasma fibrinogen and high bilirubin, D-dimer and activated partial thromboplast in time were observed more commonly in patients with partial recovery. Of the 57 patients, 50 received hemodialysis, three received peritoneal dialysis and seven patients were managed conservatively. A total of 13 patients developed cortical necrosis that was associated with sepsis in six, PPH and pre-eclampsia/eclampsia in three patients each and APH in one. Nine patients died, and the cause of death was septicemia in four, pre-eclampsia in three and APH and PPH in one patient each. In our study, puerperal sepsis was the most common etiological factor for pregnancy-related AKI. Prolonged oliguria or anuria were bad prognostic factors for renal recovery. Sepsis, thrombocytopenia, disseminated intra-vascular coagulation and liver involvement were associated with increased mortality.


Gumber M.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2014

Acute renal failure (ARF) is a serious medical complication during pregnancy, and, in the post-partum period, is associated with significant maternal morbidity and mortality as well as fetal loss. The objective of our study is to find the etiology and maternal outcome of ARF during pregnancy. The study was conducted at the Obstetrics and Gynecology Department of the Institute of Kidney Disease and Research Center, Ahmedabad, India from January 2009 to January 2011. Fifty previously healthy patients who developed ARF, diagnosed on oliguria and serum creatinine >2 mg%, were included in the study. Patients with a known history of renal disease, diabetes and hypertension were excluded from the study. All patients were followed-up for a period of six months. Patient re-cords, demographic data, urine output on admission and preceding history of antepartum hemorrhage (APH), post-partum hemorrhage (PPH), septicemia, operative interventions and retained product of conception were noted and need for dialysis was considered. Patients were thoroughly examined and baseline biochemical investigations and renal and obstetrical ultrasound were performed on each patient and bacterial culture sensitivity on blood, urine or vaginal swabs were performed in selected patients. The age range was 19-38 years (mean 26 ± 3.8). The first trimester, second trimester and puerperal groups comprised of four (8%), 25 (50%) and 21 patients (42%), respectively. Hemorrhage was the etiology for ARF in 15 (30%), APH in ten (20%) and PPH in five (10%) patients. Eleven (22%) patients had lower segment cesarian section (LSCS) while 36 (78%) patients had normal vaginal delivery. In 20 (40%) patients, puerperal sepsis was the etiological factor, while pre-eclampsia, eclampsia and HELLP syndrome accounted for 18 (36%) patients. Two (4%) patients had disseminated intravascular coagulation on presentation while one (2%) patient was diagnosed with hemolytic uremic syndrome. Maternal mortality was 12% (n = 6). Of the 38 (88%) surviving patients, 21 (42%) had complete recovery of renal function, eight (16%) patients had partial and 15 (30%) patients required dialysis on a long-term basis. ARF in pregnancy is associated with poor maternal and renal outcome if not detected and treated in time.


Gumber M.R.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2013

Nowadays, a repeat transplantation is considered to confer a better survival advantage to patients over dialysis. The cost-effectiveness of transplantation for end-stage renal disease patients shows benefits over dialysis even for re-transplanted patients. This retrospective single center ten-year study was undertaken to evaluate patient/graft survival, function vis-à-vis serum creatinine (SCr) and rejection episodes in 62 re-transplanted patients. Sixty-two patients underwent a second renal transplant (24 living related, 38 deceased donors) at our center between 2000 to 2009. The mean recipient age was 41.9 ± 12.27 years. Fifty-three recipients were male and nine recipients were female. Recipients had negative acceptable lymphocyte cross-matching using anti-human globulin complement-dependent cytotoxicity tests and flow cytometric cross-match before transplant. All recipients except those who were hepatitis C virus or hepatitis B surface antigen positive received single-dose rabbit-anti-thymocyte globulin induction and steroids, calcineurin inhibitor ± mycophenolate mofetil/azathioprine for maintenance immunosuppression. Of the 62 patients, 38 patients received kidneys from deceased donors and 24 patients received kidneys from live donors. Over the mean follow-up of 4.03 ± 2.93 years, the 1-year, 5-year and 10-year patient survival rates were 85.33%, 66.7% and 66.7%, respectively, and the graft survival rates were 96.7%, 79.7% and 79.7%, respectively. The acute rejection rates were 17.6%, with a mean SCr of 1.92 ± 0.5 mg/dL. There was unexplained interstitial fibrosis with tubular atrophy in 11.2% patients (n = 7), all leading to graft loss eventually. Overall, 25% (n = 16) of the patients were lost, mainly to infectious complications. Re-transplantation has acceptable graft and patient survival over a ten-year follow-up period and should be encouraged for better quality of life as compared with dialysis.


Everly M.J.,Olympic Research, Inc. | Terasaki P.I.,Terasaki Foundation | Hopfield J.,Olympic Research, Inc. | Trivedi H.L.,Institute of Kidney Diseases and Research Center | Kaneku H.,Terasaki Foundation
Transplantation | Year: 2010

Background. Proteasome inhibition abrogates donor-specific anti-human leukocyte antigen (HLA) antibody (DSA) in patients posttransplant. However, its effects on protective humoral immunity to vaccine antigens remain unknown. Herein, we report on bortezomib's safety regarding protective immunity in patients who have experienced HLA antibody reduction/removal. Methods. Thirteen living donor renal transplant patients were treated with bortezomib one to two cycles (1.3 mg/m2×4 doses) and plasmapheresis in 2008 to remove HLA antibodies posttransplant. Serial measurements of HLA antibody were conducted weekly before, during, and after treatment by means of single antigen bead on Luminex (One Lambda Inc., Canoga Park, CA). Measles and tetanus toxoid IgGs were measured quantitatively by using ELISA (American Research Products Inc., Belmont, MA). Results. All patients treated with bortezomib/plasmapheresis resulted in a primary DSA reduction of more than 50%. In 10 of 13 patients, complete DSA removal (to below 1000 mean fluorescent intensity) occurred. At 1 year posttreatment, antibody intensity remains significantly depressed in the group as a whole. Despite the significant effect on antibody production, tetanus toxoid and measles IgG levels remained unchanged and above the level of protection at 1 year posttreatment. Conclusion. These data indicate that proteasome inhibitors plus plasmapheresis results in prolonged reduction of HLA antibodies while leaving protective immunity intact. © 2010 by Lippincott Williams & Wilkins.


Patel H.V.,Institute of Kidney Diseases and Research Center
Saudi journal of kidney diseases and transplantation : an official publication of the Saudi Center for Organ Transplantation, Saudi Arabia | Year: 2014

We conducted a single-center prospective double-arm open-labeled study on kidney transplant patients from 2010 to 2011 to evaluate the efficacy of induction therapy using low, single-dose rabbit-antithymocyte globulin (r-ATG), 1.5 mg/kg on Day 0 (n = 80, 60 males, mean age 35.9 years), versus basiliximab (Interleukin-2 blocker) 20 mg on Days 0 and 4 (n = 20, 12 males, mean age 45.1 years) on renal allograft function in terms of serum creatinine (SCr), rejection and infection episodes and patient/graft survival and cost. Demographic and post-transplant follow-up including immunosuppression was similar in both groups. In the r-ATG group, donors were unrelated (spouse, n = 25), deceased (n = 31) and parents/siblings (others), with a mean HLA match of 1.58. Donors in the basiliximab group were living unrelated (spouse, n = 15) and deceased (n = 5), with a mean HLA match of 1.56. No patient/graft was lost in the r-ATG group over a mean of one year follow-up, and the mean SCr was 1.28 mg/dL with 7.5% acute rejection (AR) episodes; infections were also not observed. In the basiliximab group, over the same period of follow-up, there was 95% death-censored graft survival, and the mean SCr was 1.23 mg/dL with 10% AR episodes. One patient died due to bacterial pneumonia and one succumbed to coronary artery disease; one graft was lost due to uncontrolled acute humoral and cellular rejection. The cost of r-ATG and basiliximab were $600 and $2500, respectively. We conclude that induction immunosuppressive therapy with a low-dose r-ATG may be a better option as compared with basiliximab in terms of graft function, survival and cost benefit in kidney transplant patients.

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