Diagnostic efficacy of C4d immunostaining in the detection of the humoral component of renal allograft rejection and therapeutic implications.

Context: In the current scenario of renal transplantation, the role of immunological methods in the detection of C4d has emerged as a useful adjunct in the recognition of acute humoral rejection (AHR). Few reports of this nature are available from the Indian context although there are several from the Western literature. Aims: To study the humoral component of renal allograft rejection in patients presenting clinically with graft dysfunction by histopathological detection of polymorphs in the peritubular capillaries and the expression of C4d using immunological techniques, as well as the response of patients to appropriate antirejection therapy. Settings and Design: This study from a tertiary care center reemphasizes the importance of recognition of AHR as a cause of renal allograft dysfunction. Materials and Methods: Percutaneous renal biopsies were obtained from 40 postrenal transplant patients and evaluated for C4d using immunofluorescence and immunohistochemical methods. Statistical a0 nalysis used: SPSS software. Results: Positive expression of C4d was seen in a total of 19/40 cases (44.4%) indicating immunological evidence of AHR. Diffusely positive cases were treated with IV immunoglobulin therapy, plasmapheresis and Rituximab following which graft function was restored. Patients with minimal to focal positive expression of C4d responded well to pulse steroids and change in immunosuppressive therapy. Conclusions: C4d staining is a useful adjunct to routine histopathological methods in evaluating the humoral component of acute renal allograft dysfunction and helps in planning appropriate antirejection therapy with the goal of achieving long-term graft survival.

Chronic kidney disease: a silent epidemic in Indian subcontinent--strategies for management.

The incidence and prevalence of non-communicable diseases such as diabetes mellitus, hypertension, cardiovascular disease and cancer are on the rise. The awareness about chronic kidney disease and its burden on the society is highlighted in the last decade in developed countries. However, this is not the case in India, where studies have shown the prevalence of terminal kidney disease is 785 people per million population. Chronic kidney disease is insidious in onset, slowly progressive, often asymptomatic, irreversible and resulting from fibrosis and scaring in the kidneys. Intervention at an early stage has shown to slow the progression and hence reduces cardiovascular morbidity and mortality. Hence, early detection programmes in susceptible individuals including those with diabetes mellitus, hypertension and family history of kidney disease will have major impact on the health of the population.

Interleukin 2 receptor expression in renal biopsies and the diagnosis of acute allograft rejection.

The aim of the study is to test the diagnostic usefulness of assessing interleukin 2 receptor (IL2R) expression in infiltrating lymphocytes in renal biopsies from patients with suspected acute renal allograft rejection and to compare the NIH-CCTT and the Banff 97 systems of classifying the histopathologic changes in acute renal allograft rejection. The expression of interleukin 2 (IL2) and IL2R, as shown immuno-histochemically, is the final step in T cell mediated acute renal allograft rejection. Renal biopsies obtained from 40 patients clinically suspected to have early acute allograft rejection were examined histologically to diagnose acute allograft rejection and classified by the two systems. Frozen sections of the biopsies were stained with specific antibody for the presence of IL2R. 31 of the 40 patients were histologically and clinically confirmed to have acute allograft rejection. There was significant correlation with this diagnosis and the demonstration of IL2R on infiltrating lymphocytes. The CCTT system of grading correlated better with the presence of IL2R and the confirmed diagnosis of acute allograft rejection. The immunohistochemical demonstration of IL2R is a useful adjunct in the evaluation of biopsies suspected to show changes of acute cellular rejection. Since IL2 expression reflects the relative proportion of activated lymphocytes in the cellular infiltrate, it is proposed that the degree of IL2 expression may reflect the response of the use of monoclonal antibodies (Humanised/Chimaerised) as anti rejection therapy.

Bilateral renal papillary necrosis due to Candida infection in a diabetic patient presenting as anuria.

A 38 years insulin-dependent diabetic male, with nephropathy on antituberculous treatment presented with painless frank hematuria followed by anuria for a day which was associated with fever. Ultrasonogram of the abdomen showed bilateral hydroureteronephrosis. Necrotic papillae were retrieved after ureteroscopy which on histopathological examination and culture showed Candida albicans. This was successfully treated with fluconazole and ureteroscopic removal of necrotic papillae.

Continuous ambulatory peritoneal dialysis: Indian scenario.

Chronic peritoneal dialysis (CPD) has been initiated as a treatment modality for chronic renal failure patients in the Indian subcontinent since 1990. Over a period of 9 years both continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD) have emerged as accepted forms of renal replacement therapy in our country. Although there were government restrictions on import of dialysis fluid until 1993, the availability of locally manufactured fluid in collapsible bags had facilitated the expansion of the programme to the far corners of the country and in neighbouring countries. Initially majority (78%) of the patients who were started on this programme were diabetics with other comorbid conditions who were drop-outs from haemodialysis and unfit for transplantation. Both CAPD and CCPD have been used for all age groups and for men and women. Majority of the patients do 3 x 2 l exchanges a day on CAPD; 8-10 l using a cycler at night those who are onCCPD. Peritonitis rate was 1 episode every 18 patient months. With the introduction of new connection and disposable sets the incidence of peritonitis is dropping down. The major cause of drop-out is cardiovascular death followed by peritonitis. Malnutrition is a major problem in both CAPD and haemodialysis patients. The programme has been expanded and there are over one thousand patients on this treatment in the country. The introduction of CPD had a major impact on the treatment of renal failure in India.