Aim: Tacrolimus has proven efficacy as an immunosuppressive therapy to prevent transplant rejection and is widely used as an immediate-release formulation in a twice-daily regimen. Once-daily prolonged-release tacrolimus aims to improve the outcomes by reducing variability in exposure and improving adherence. However, there are limited published data available on prolonged-release tacrolimus in routine clinical practice in India. Methods: This was a Phase IV, multicenter, prospective study of prolonged-release tacrolimus conducted over 12 weeks in adult patients eligible for de novo kidney or liver transplantation in India. Primary efficacy end-point was the event rate of biopsy-confirmed acute rejections (BCARs). Secondary end-points included corticosteroid-resistant rejection incidence, time to first BCAR, graft loss, and death. Safety end-points included renal function, lipid profile, incidence of new-onset diabetes mellitus after transplantation (NODAT), and infection. Results: The study enrolled 92 patients undergoing kidney (81 [88.0%]) or liver transplantation (11 [12.0%]); a total of 76 patients (82.6%) completed the study. Ten kidney transplant patients (overall 10.9%) experienced BCAR. There were seven corticosteroid-sensitive and three corticosteroid-resistant rejections. Median (range) time to kidney transplant rejection was 6.5 (1.0–76.0) days. Renal function was stable or improved. Lipid levels showed a significant increase. Eleven instances of NODAT and seven infections occurred and there were eight deaths (8.7%; six kidney and two liver transplant patients). Conclusions: In de novo kidney and liver transplant recipients in India, prolonged-release tacrolimus was well-tolerated and efficacious with a low incidence of acute rejection. Safety profile was similar to immediate-release tacrolimus from published data.
Renal transplantation in patients with malignancy is controversial. Renal transplantation is generally not considered for patients with multiple myeloma (MM) because of their extremely poor prognosis. There are few reports of MM recurrence among kidney transplant recipients. We present a case of disease relapse of plasmacytoma in a transplanted kidney. We present a patient with extramedullary plasmacytoma, who responded well to chemotherapy and underwent allogenic renal transplantation. He relapsed after 4 years with progression to extramedullary plasmacytoma. Despite minimal clinical symptoms, the patient had developed myeloma cast nephropathy and acute renal failure. His renal failure settled after excision of tumor. Extramedullary plasmacytoma as a mode of relapse is highly unusual. Experience of renal transplantation in MM is limited. In the literature, the recurrence of MM is mentioned as a severe complication with a poor graft prognosis. Extramedullary plasmacytoma as a mode of relapse is highly unusual. It should not be considered as a contraindication for transplantation. Renal transplantation for patients with end stage renal disease (ESRD) due to MM is possible. But large prospective studies are needed to develop a strategy for preventing multiple myeloma recurrence.
Export Introduction: Induction immunosuppression therapy plays a significant role in the prevention of acute rejection in renal transplantation. This study aimed to evaluate the effectiveness and safety of rabbit anti-thymocyte globulin (rATG) used as induction immunosuppression in Indian patients undergoing renal transplantation. Patients and Methods: RISE was a multicenter (n = 20), prospective observational cohort study of patients aged ≥ 18 years undergoing a first or repeat renal transplant and receiving rATG as part of the routine management practice. Twelve-month acute rejection was evaluated as a primary endpoint. Results: A total of 325 patients were enrolled, of which 313 patients received at least one dose of rATG with a mean (standard deviation [SD]) duration of induction therapy of 2.07 (1.33) days. The mean (SD) cumulative rATG induction dose was 2.6 (1.5) mg/kg. The mean (SD) glomerular filtration rate was 64.59 (19.57) mL/min/1.73 m2 at 6 months and 64.93 (20.26) mL/min/1.73 m2 at 1 year. The incidence of acute rejection at 1 year was 7.7% (n = 23). Graft rejection at 6 months was observed in 6.7% (n = 20) patients and an average time to first graft rejection of 5.4 and 10.3 months at 6 and 12 months, respectively. In total, 342 adverse events (AEs) were reported (n = 154, 49.2%) after 12 months, of which 11 events were related to the rATG treatment. Pyrexia was the most commonly reported serious adverse event (n = 10, 3.2%). Seven deaths were reported during the study. Conclusions: The study revealed the effectiveness and safety of rATG induction therapy in the Indian context as expected based on the data from randomized clinical trials. Trial Registration Number: CTRI/2017/09/009/009700.
Sodium nitroprusside (SNP) produces hypotension by increasing nitric oxide-mediated generation of cyclic guanosine monophosphate (cGMP), which causes vasodilatation. On the other hand, sildenafil, a phosphodiesterase type 5 inhibitor (PDE5), increases cGMP by inhibiting its degradation by PDE5. Hence, theoretically, the two should be complementary. We present a case where the two agents were used together to manage a hypertensive crisis. This, to the best of our knowledge, is the first such case report worldwide.
Invasive fungal infections are a major challenge in the management of immunocompromised patients and those with renal dysfunction. These challenges are due to the immense morbidity and mortality in such situations. Also the management strategies for invasive mycosis in patients with renal dysfunction have narrow safety profile and involve high-cost. In this review we will discuss the issues involved in the management of invasive mycosis in the patients with renal dysfunction in the form of acute renal failure, chronic kidney disease, dialysis dependency of renal transplant recipients. We also emphasize that the use of Intravenous Liposomal Amphoterecin appears to be an effective alternative to the conventional Amphoterecin B for the treatment of invasive fungal infections in patients with renal dysfunction due to its greatly improved tolerability profile. Commercially two true liposomal preparations (Fungisome and Ambisome) are available. Judgement about the preferred formulation should be made on the basis of disease morbidity, severity of renal dysfunction and the cost involved.
'%3e%3ccircle r='20' fill='%23008'/%3e%3ccircle r='17.5' fill='%23fff'/%3e%3ccircle r='3.5' fill='%23008'/%3e%3cg id='d'%3e%3cg id='c'%3e%3cg id='b'%3e%3cg id='a' fill='%23008'%3e%3ccircle r='.875' transform='rotate(7.5 -8.75 133.5)'/%3e%3cpath d='M0 17.5.6 7 0 2l-.6 5L0 17.5z'/%3e%3c/g%3e%3cuse xlink:href='%23a' transform='rotate(15)'/%3e%3c/g%3e%3cuse xlink:href='%23b' transform='rotate(30)'/%3e%3c/g%3e%3cuse xlink:href='%23c' transform='rotate(60)'/%3e%3c/g%3e%3cuse xlink:href='%23d' transform='rotate(120)'/%3e%3cuse xlink:href='%23d' transform='rotate(-120)'/%3e%3c/g%3e%3c/svg%3e)
