Three years of cadaveric renal transplantation.

AIM: To study patient and graft outcome and donor characteristics in cadaveric renal transplantation. MATERIAL AND METHODS: Fifty nine patients (35 males and 24 females) who underwent cadaveric renal transplantation between Oct'95 and Nov'98 were analysed. The recovery of renal function was correlated with the type and duration of dialysis. The number of rejections, donor characteristics and patient and graft survival was studied. RESULTS: Fifty nine patients were followed for a mean period of 14.58 months (SD 10.73), their age ranged from 17 to 64 years. Ten patients had primary graft failure, out of which four died and six are on maintenance dialysis. Seven died of other causes. Twelve patients had been on CAPD and 47 were on haemodialysis. Recovery of renal function was earlier in the haemodialysis group (mean 19.29 days SD 16.97) than in the CAPD group (31.6 days SD 32.3 days). But the difference was not statistically significant (p=0.36). The age of the donors ranged from 2 to 72 years (mean 42.8, SD 17.3). Seventeen died of CVA, 16 died of head injury, and one died of sedative overdose. Dual kidney transplant was done in nine patients of whom five have adequate graft function. CONCLUSION: Follow up for a mean period of 14.58 months shows patient survival of 81.3% and graft survival 72.8% with no significant difference in recovery of renal function between CAPD and HD groups. Poor results are due to HLA mismatch leading to rejection. The majority of the deaths were related to septicaemia.

'O' set connector system in CAPD.

51 CAPD patients (age 55.5 +/- 14.5 yrs, 35 male, 16 female) on CAPD using 'O' set were studied retrospectively during the period January 1993 to April 1995. Etiology of ESRD was Diabetic nephropathy-25(49%) and the other causes-26(51%). The total duration of observation on 'O' set was 553 patient months, the mean duration was 10.8 +/- 6.1 months. 24 patients (47%) developed total of 30 episodes of peritonitis. The incidence of peritonitis was 18.4 patient months per episode of peritonitis. The organisms responsible for peritonitis were Gram positive-6(20%), Gram negative-3(10%), Fungal-1(3.3%), Mycobacterial-1(3.3%), Eosinophilic-1(3.3%), Sterile-12(40%) and unknown-6(20%) 2 patients of bacterial peritonitis and a patient with tuberculous peritonitis died while rest of the patients responded favourably to antibiotics. 13(52%) diabetic patients and 11(42%) non-diabetic patients had peritonitis (p-NS) and the peritonitis rates in diabetics and non diabetics were 18.3 and 18.6 patient months per episode respectively (p-NS). Exit site infection was seen in 5 patients (10%) (Staph aureus-4, Enterococci-1) and all responded to antibiotic therapy. 7 patients had total of 10 episodes of symptomatic accidental intraperitoneal sodium hypochlorite instillation, none had any long term adverse effects. The 'O' set procedure was done by self in 10(20%) and by others in 41(80%) cases. The peritonitis rates when performed by self and others were 18.5 and 18.4 patient months per episode respectively (p-NS). The cost of being on CAPD using 'O' set, Y-bag and twin bag were Rs. 1,50,000, 2,10,000 and 3,72,000 per annum respectively and cost of maintenance haemodialysis was 1,36,800 per annum. The cost of CAPD using 'O' set was comparable to that of maintenance haemodialysis. The 'O' set connector system in CAPD is found to be safe, cost effective and efficient.

A study of hepatitis B surface antigen positive patients on haemodialysis and following transplantation.

Of 1339 patients who entered the dialysis and transplantation program, 104 (7.77%) patients were HBsAg positive. On dialysis, 15 of 104 patients (14.42%) developed icteric hepatitis (serum bilirubin > 2 mg/d1) and 7 patients (6.73%) developed anicteric hepatitis (SGOT > twice the upper limit of normal--normal 5-40 IU); one patient died of hepatic failure. Sixty five patients underwent live related transplantation. Actuarial graft survival at the end of 1 year, 2 years and 6 years were 81.67%, 73.98% and 69.36% respectively, and there was no significant difference compared to the negative group. 8 grafts (12.31%) were lost due to patient death due to infection in the HBsAg positive group compared to 27 out of 390 (6.923%) HBsAg negative patients (x2 = 1.88 P > 0.1). Post transplantation hepatic dysfunction was seen in 7 out of 65 (10.77%) patients and two patients died of hepatic failure.

Natural history and response to treatment of minimal change nephrotic syndrome.

This study is a retrospective analysis of 177 patients of minimal change nephrotic syndrome seen between 1985 and 1989. Fifty nine of these had renal biopsy done and the others were diagnosed on clinical grounds. Short courses of prednisolone were used for three episodes in one year. If a fourth episode occurred in any 12 month period, cyclophosphamide was started. This was needed in 26 patients and was also used in 9 patients who did not respond to 8 weeks of prednisolone. Follow up ranged from 4 months to 5 years (mean 1.4 years). Thirty nine percent of patients sustained remission after the first course of steroids. Histological variations (presence or absence of diffuse mesangial proliferation or IgM deposits) and age made no difference to the response to treatment and subsequent relapses.

Subclavian vein catheters for haemodialysis with and without a subcutaneous tunnel.

We have retrospectively analysed the usefulness of a subcutaneous tunnel in patients undergoing haemodialysis through a double lumen subclavian catheter; 194 catheters were used in 145 patients. In 105 patients a subcutaneous tunnel was created. Entry site infection was significantly higher in the no tunnel group (30%; P < 0.02). There was no statistically significant difference in the incidence of septicaemia in the two groups. Eighty five percent of episodes of septicaemia and 67% of entry site infections were due to Staphylococcus aureus. All responded to removal of the catheter and to antibiotics. The average duration the catheter was in place was 20.39 and 21.94 days in the groups with and without tunnel respectively. The average number of dialyses was 9.13 and 9.33 per catheter in the tunnel and no tunnel groups respectively. Three patients had pneumothorax. Subclavian vein thrombosis was suspected clinically in 3 cases. There was no catheter related mortality. We concluded that while entry site infection occurred more frequently in the no tunnel group, the overall incidence of septicaemia was not different in the two groups. Creation of a subcutaneous tunnel has no added advantage.

Short term study on relative merits of acetate and bicarbonate dialysis.

We did a double blind, crossover, prospective study comparing bicarbonate and acetate containing solutions in haemodialysis. Thirty stable patients with end stage renal disease on maintenance haemodialysis while awaiting a renal transplant were each studied on three dialysis with acetate and three with bicarbonate. Nine patients developed symptoms like headache, nausea, vomiting, giddiness, and malaise and developed hypotension during acetate dialysis and three patients during bicarbonate dialysis. There were symptoms during 16.66% of acetate dialysis sessions and 5.55% of bicarbonate dialysis sessions. (P less than 0.05). There was a statistically significant decrease in PaO2 and PaCO2 on acetate dialysis at 30 minutes after initiation of dialysis. There was no significant difference in weight loss on dialysis, or in blood pressure and correction of acidosis. We conclude that bicarbonate dialysis is better tolerated, but acetate intolerance is not a major problem since we use small surface area dialysers (0.8 M2).