Deceased donor kidney transplant policies in Asia - implications on practice and recommendations for the future.

Deceased donor kidney transplantation (DDKT) is common in high income Western countries with high transplantation rates. However, the utilization of deceased organs is suboptimal in Asia, due to a multitude of factors. Coherent policies are integral to the development of DDKT programs and deterrence of commercialization, but most are still at an infancy and formative stage in Asia. This review article identifies the glass ceiling effects of social, cultural, religious, political, and technical factors hampering the progress of DDKT in Asia. Additionally, it reviews the history of policy development in different countries and describes their idiosyncratic barriers and challenges. Lastly, it discusses innovative policy measures that can be undertaken to proliferate DDKT practice and curtail commercialization. The long-term ideal is to achieve regional equity and self-sufficiency, through a shared ethos of social and ethical responsibility that transcends and resonates with the different segments of the Asian community.

Mammalian Target of Rapamycin Inhibitors and Wound Healing Complications in Kidney Transplantation: Old Myths and New Realities.

Mammalian target of rapamycin inhibitors (mTOR-I) lacks nephrotoxicity, has antineoplastic effects, and reduces viral infections in kidney transplant recipients. Earlier studies reported a significant incidence of wound healing complications and lymphocele. This resulted in the uncomfortable willingness of transplant clinicians to use these agents in the immediate posttransplant period. As evidence and experience evolved over time, much useful information became available about the optimal use of these agents. Understandably, mTOR-I effects wound healing through their antiproliferative properties. However, there are a lot of other immunological and nonimmunological factors which can also contribute to wound healing complications. These risk factors include obesity, uremia, increasing age, diabetes, smoking, alcoholism, and protein-energy malnutrition. Except for age, the rest of all these risk factors are modifiable. At the same time, mycophenolic acid derivatives, steroids, and antithymocyte globulin (ATG) have also been implicated in wound healing complications. A lot has been learnt about the optimal dose of mTOR-I and their trough levels, its combinations with other immunosuppressive medications, and patients' profile, enabling clinicians to use these agents appropriately for maximum benefits. Recent randomized control trials have further increased the confidence of clinicians to use these agents in immediate posttransplant periods.

Isolated Renal Involvement by IG4-Related Disorder Mimicking Multiple Myeloma, a Diagnosis Not to Miss.

IG4-related disorder (IgG4-RD) with isolated kidney involvement is rare. IG4-RD is a fibroinflammatory disorder leading to polyclonal activation of plasma cell and can affect kidney, orbital tissues, salivary glands, pancreas, bile duct, lymph nodes, and can cause inflammatory mass in any organ. Isolated kidney involvement is rare in this order. We share a case of isolated kidney involvement by this order presenting as enlarged kidneys with renal impairment. Kidney biopsy showed CD138 plasma cell interstitial nephritis. The biopsy also showed kappa light chain along IgG on immunofluorescence and was reported as light chain deposition disease initially. In view of hyperproteinemia and initial renal biopsy finding, workup was done for myeloma. Bone marrow biopsy showed around 20% of plasma cell infiltration. Skeletal survey did not show any lytic lesions and immunofixation did not reveal any paraprotein. Flowcytometry of the bone marrow showed nonclonal plasma cell. In view of negative workup for myeloma and nonclonal cells, re-evaluation of the kidney biopsy was done. Biopsy was reanalyzed for both IgG and IgG4. It showed 30 IgG4 cells per high-power field with a ratio of IgG4 / IgG of 40%. The staining for IgM, IgA C3, and C1q was negative. The patient was labeled as having plasma cell interstitial nephritis due toIgG4-RD. The patient responded well to oral prednisolone. It is important not to miss this potentially treatable and reversible condition by staining the biopsy sample for both IgG and IgG4 in clinically suspected cases.

The Living-Related Kidney Transplant Program in Brunei Darussalam: Lessons Learnt from a Nascent National Program in a Small, Muslim, and Asian Country.

Brunei Darussalam commenced its living-related renal transplant program in 2013, with subsequent attainment of independent local capacity and proficiency in 2019. The preliminary outcome from the program has already begun to shape the national nephrology landscape with a 36% increment in transplant rate and mitigation of commercialized transplantations. The blueprint for the program was first laid out in 2010 and thereupon executed in four phases. The first phase involved the gathering of evidence to support the establishment of the national program, through researches investigating feasibility, public opinion, quality of life, graft survival, and cost-effectiveness. The second phase focused on laying the foundation of the program through grooming of local expertise, implementation of legal-ethical frameworks, religious legitimization, and propagation of awareness. The third phase worked on facilitating experiential exposure and strengthening local infrastructure through the upgrading of facilities and the introduction of subsidiary services. The fourth phase was implemented in Brunei in 2013 when foreign personnel worked together with the local team to perform the transplants. Between 2013 and 2019, ten kidney transplants were performed, with two being done in 2018 and three in 2019. We hope to inspire other similar countries to develop their own self-sustainable and independent local program.

Chylous nephrogenic ascites in a hemodialysis patient.

Chylous nephrogenic ascites is rare in hemodialysis (HD) patients. We would like to share a rare case of chylous nephrogenic ascites in a HD patient. The patient has a history of straw-colored nephrogenic ascites which was drained through pigtail five times in the past. Later on, the ascites became turbid and milky. The chloroform test of the ascitic fluid showed fat globules with Oil Red-O stain, and the triglyceride concentration of ascitic fluid was 168.14 mg/dL (1.93 mmol/L) satisfying the criteria of chylous ascites. We believe that this may be caused by microtrauma from repeated pigtail insertions for ascites which was compounded by inadequate HD and noncompliance with fluids. Routine investigations including screening for malignancy, tuberculosis, cirrhosis, and heart failure did not reveal any other possible causes. Although there are few case reports of chylous ascites in peritoneal dialysis patients, it has never been reported in patients on HD.