SARS-CoV-2-specific humoral and cell-mediated immune responses after immunization with inactivated COVID-19 vaccine in kidney transplant recipients (CVIM 1 study).

Immunogenicity following inactivated SARS-CoV-2 vaccination among solid organ transplant recipients has not been assessed. Seventy-five patients (37 kidney transplant [KT] recipients and 38 healthy controls) received two doses, at 4-week intervals, of an inactivated whole-virus SARS-CoV-2 vaccine. SARS-CoV-2-specific humoral (HMI) and cell-mediated immunity (CMI) were measured before, 4 weeks post-first dose, and 2 weeks post-second dose. The median (IQR) age of KT recipients was 50 (42-54) years and 89% were receiving calcineurin inhibitors/mycophenolate/corticosteroid regimens. The median (IQR) time since transplant was 4.5 (2-9.5) years. Among 35 KT patients, the median (IQR) of anti-RBD IgG level measured by CLIA after vaccination was not different from baseline, but was significantly lower than in controls (2.4 [1.1-3.7] vs. 1742.0 [747.7-3783.0] AU/ml, p < .01) as well as percentages of neutralizing antibody inhibition measured by surrogate viral neutralization test (0 [0-0] vs. 71.2 [56.8-92.2]%, p < .01). However, the median (IQR) of SARS-CoV-2 mixed peptides-specific T cell responses measured by ELISpot was significantly increased compared with baseline (30 [4-120] vs. 12 [0-56] T cells/106  PBMCs, p = .02) and not different from the controls. Our findings revealed weak HMI but comparable CMI responses in fully vaccinated KT recipients receiving inactivated SARS-CoV-2 vaccination compared to immunocompetent individuals (Thai Clinical Trials Registry, TCTR20210226002).

Risk Factors for Anastomosis Leakage After Kidney Transplantation.

PURPOSE: Kidney transplantation is one of the best treatment options for end-stage renal disease with an incidence of urologic complications of 2.5 to 30%. One of the most serious and frequent urological complications is urinary leakage from ureteroneocystostomy anastomosis. The purpose of this study was to evaluate risk factors of urinary leakage from ureteroneocystostomy anastomosis after kidney transplantation. PATIENTS AND METHODS: A retrospective study was performed on patients who received kidney transplantation and were diagnosed with urinary leakage thereafter based on renal scan or drain creatinine per serum creatinine compared with patients in control group. Risk factor assessment was based on inpatient and outpatient information from hospital database. RESULTS: From 459 patients who received kidney transplantation in 2016-2018, there were 20 patients who were diagnosed with urinary leakage after they underwent ureteroneocystostomy anastomosis. The significant risk factors for anastomosis leakage were size of suture materials and duration of ureteral stent insertion. No statistically significant difference in other factors such as underlying disease, surgical technique or duration of urinary catheter was found. About overall urological complication, gender and body mass index significantly affected the outcome. CONCLUSION: The rate of urinary leakage complications was found to be about 4.36%. The risk factors of overall complication comprised gender and body mass index. Although a lot of previous studies revealed many risk factors that could affect urinary leakage, size of suture materials and duration of ureteral stent insertion were the significant risk factors in our study. Proper consideration should be given to the size of suture materials and optimal duration of ureteral stent.

Perioperative hemoglobin decrement as an independent risk of poor early graft function in kidney transplantation.

OBJECTIVE: Perioperative change of hemoglobin concentration (Hb) was associated with acute kidney injury in patients who underwent non-cardiac surgery, but has never been investigated in kidney transplant patients. This study aimed to observe the effects of perioperative Hb change on early graft function in kidney transplant recipients. RESULTS: A total of 269 kidney transplant patients were enrolled, of whom 98 (36.4%) developed poor early graft function (PEGF), and 171 (63.6%) had immediate graft function. Comparing two groups, patients with PEGF had a greater decremental change of Hb (-1.60 [-2.38,-0.83] vs. -0.70 [-1.35,0.20] g/dL, respectively; p < 0.001). A Hb cut-point of -1.35 g/dL was obtained from ROC analysis. Multivariate analysis showed that perioperative Hb decrement greater than 1.35 g/dL was an independent risk of PEGF (adjusted OR of 2.52, 95% CI 1.11-5.72; p = 0.026). Subgroup analysis revealed deceased donor kidney transplant (DDKT; n = 126) (adjusted OR of 2.89, 95% CI 1.11-7.55; p = 0.029), but not living donor kidney transplantation (LDKT; n = 143) (adjusted OR of 1.68, 95% CI 0.23-12.15; p = 0.606), was influenced by the perioperative Hb decrement. In conclusion, this study suggests that decremental change in perioperative Hb greater than 1.35 g/dL may serve as a modifiable factor of PEGF in DDKT.

Treatment of a brain abscess caused by Scedosporium apiospermum and Phaeoacremonium parasiticum in a renal transplant recipient.

Cerebral mycosis is a significant cause of morbidity among immunocompromised populations. We present here a case of cerebral infection with Scedosporium apiospermum and Phaeoacremonium parasiticum in a 49-year-old renal transplant recipient. Fourteen years after renal transplantation, the patient presented with invasive pulmonary aspergillosis treated with intravenous liposomal amphotericin B. The patient had clinical and radiographic improvement. However, 6 weeks later, the patient presented with cerebral infection. Magnetic resonance imaging revealed multiple rim enhancing brain abscesses. Brain and cerebrospinal fluid cultures ultimately grew Scedosporium apiospermum and Phaeoacremonium parasiticum. The patient was treated with voriconazole for 6 months and had clinical and radiologic improvement. We believe this is the first reported case of co-infection of the brain with scedosporiosis and phaeohyphomycosis in a renal transplant recipient, who had received intravenous liposomal amphotericin B. Voriconazole may represent a new therapeutic option for these simultaneous infections in the brain.

Vascular education and training in Asia.

Cardiovascular diseases have become more prevalent and threatening to the health of the population of Asia due to the rapidly growing number of aging people. The Asian Society for Vascular Surgery unites 13 member organizations: Japan, Korea, China, India, Hong Kong, Singapore, Malaysia, Taiwan, Bangladesh, Philippines, Saudi Arabia, Indonesia, and Thailand. The essential mission of the Asian Society for Vascular Surgery is to improve training in vascular surgery to increase the number of competent vascular surgeons in Asia. Almost every member country has its own vascular training program. Most curricula for vascular surgery training are composed of basic vascular research, clinical vascular medicine, vascular investigation, and open and endovascular surgery, with the period of training ranging from 2 to 4 years.

Propofol-based fast-track for ambulatory surgery.

The purpose of this study was to provide data of propofol-based total intravenous anesthesia (TIVA) for ambulatory surgery in developing a fast-track technique. One hundred and forty-two patients scheduled for elective surgery were studied: mean (SD) age 42.21 (16.23) years, male to female 72:70, mean (SD) body weight 60.75 (11.67) kg and American Society of Anesthesiologists (ASA) physical status I/II/III 66/38/38. Mean (SD) thiopental induction 225 (55.69) mg was maintained with mean (SD) propofol 199.64 (86.26) mg for mean (SD) anesthetic time 29.02 (11.21) minutes. Various narcotics were used: fentanyl 73.48 +/- 24.38 microg for 123 cases, morphine 3.27 +/- 1.10 mg for 10 cases, remifentanil 492 +/- 105.26 microg for 7 cases and pethidine 23.33 +/- 2.88 mg for 2 cases. Midazolam was given 2.70 +/- 1.05 mg. Patients were positioned in supine, lithotomy or lateral decubitus. One-fourth were PS III with a diagnosis of chronic renal failure and renal transplants coming for incision and drainage of perianal abscess. The mean (SD) wake-up time was 36.02 (17.69) seconds. Only one case (chronic renal failure) had severe hypotension after induction. Anesthetic agents and ideas of fast-track anesthesia were discussed.

Perianal blockage with 0.5% bupivacaine for postoperative pain relief in hemorrhoidectomy.

UNLABELLED: Hemorrhoidectomy can be done in many positions under many anesthetic techniques as an ambulatory surgery. Post-procedural pain is frequently severe enough to delay home discharge. A combination between preincisional local anesthetics and general anesthesia looks attractive in terms of preemptive analgesia and starting time of surgery. The study aimed to compare anesthetic time, pain-free period and pain relief in patients with and without 0.5% plain bupivacaine infiltration after mask inhalation, total intravenous anesthesia or endotracheal tube general anesthesia. MATERIAL AND METHOD: 142 patients were randomized into control (C) and study (S) groups with n = 70 and 72 respectively. Patient characteristics in both groups were: age 40.45 +/- 13.03 VS 37.48 +/- 13.63 years old, BW 59.77 +/- 11.19 VS 58.80 +/- 9.76 kg, male:female 31/39 VS 43/29, PS 1/2/3/E = 48/19/1/2 VS 53/15/3/1 for C and S respectively. All underwent surgery in lithotomy under ET/TIVA/mask: 53/13/4 VS 22/27/23 and anesthetic time was 49.02 +/- 18.04 VS 33.33 +/- 10.31 min (p < 0.05). RESULTS: Pain-free periods in C and S were 204.44 +/- 878.07 and 540 +/- 298.03 min with median times of 57.5 (n = 67) VS 560 (n = 58) min. Pain severity in S was mainly none or mild degree while in C it was moderate or severe, apparently when analysed in subgroups of ET and TIVA. Analgesic requirements were statistically more in group C. CONCLUSION: Better postoperative pain relief could be accomplished by preincisional 0.5% plain bupivacaine infiltration after general anesthesia. The technique helped relax anal muscles for surgical ease and avoided patient discomfort in case of a prolonged procedure. Preemptive analgesia and key pain management were discussed.

Transplant renal artery stenosis in Thailand.

Transplant renal artery stenosis (TRAS) is one of the common vascular complications post kidney transplantation. A retrospective study of TRAS among transplant recipients at a single transplant center in Thailand was performed from February 1986 to December 2002. Among 750 cases, 16 cases (2.1%) of TRAS were identified. Twelve cases (3.3%) were from cadaveric donors and four cases (1%) were from living-related donors (p-value = 0.034). Most cases presented with progressive deterioration of kidney graft with or without refractory hypertension. Doppler ultrasonography was used for initial screening followed by renal angiography. Fifteen cases were treated by Percutaneous Transluminal Angioplasty (PTA) with a 73 per cent success rate. Five cases underwent surgical revascularization with an 80 per cent success rate. Two cases (13%) of successful PTA showed recurrent stenosis with 46 months follow-up which were successfully treated by repeated PTA with stents.

A comparison of the efficacy of cisatracurium and atracurium in kidney transplantation operation.

UNLABELLED: Cisatracurium is a new intermediate-acting benzylisoquinolinium neuromuscular blocking agent that is one of the ten stereoisomers contained in atracurium besylate. Atracurium is known to be the muscle relaxant of choice in end stage renal disease patients. This study aimed to compare the efficacy of cisatracurium and atracurium in the aspect of intubation and maintenance dosages, hemodynamic response after intubation and cost effectiveness between the two agents in kidney transplant patients. MATERIAL AND METHOD: From August 2001 to July 2002, 46 end stage renal disease patients obtained kidney transplantation operation under general anesthesia with 50:50 N2O:O2, fentanyl, isoflurane anesthesia. Tracheal intubation and maintenance of muscle relaxant with each drug were administered in 23 of each group-atracurium as control (C) while cisatracurium was the study (S) group. RESULTS: There was no difference in the demographic data of the 2 groups--13 males/10 females in the S group and 11 males/12 females in the C group. Eighty-seven per cent in the S group underwent living-related kidney transplantation operation, with 55.56 per cent in the C group. Most of the donors were siblings, i.e. 42.11 per cent in the S group and 46.67 per cent in the C group. The mean dosage for intubation in the S group was 0.17 +/- 0.02 mg/kg and 1.25 +/- 0.49 microg/kg/min for maintenance. The mean dosage for intubation in the C group was 0.64 +/- 0.07 mg/kg and the mean maintenance dose was 5.38 +/- 0.83 microg/kg/min. In both groups there was no statistical difference in hemodynamic changes. One patient in the S group received calcium channel blocker to reduce blood pressure before induction of anesthesia, while 2 patients in the C group were given nifedipine 5 mg before induction. Although the cisatracurium cost was higher than atracurium, from the cost-minimization analysis, it turned out to be lower per case. CONCLUSION: This study demonstrated the efficacy of cisatracurium in hemodynamic stability and safety in kidney transplantation operations. In spite of the more costly price, cisatracurium is beneficial in some end stage renal disease (ESRD) patients with coronary artery disease who need very stable hemodynamics.