Is Age a Limitation for Organ Donation? A Comparison of Elderly and Non-elderly Donors in a Deceased Donor Organ Transplantation Program from South India.

To bridge the gap between demand and supply of organs, deceased donors with extreme ages can be utilized. The object of this study was to compare elderly with non-elderly donors and to assess the predictors of organ utilization or wastage. This was a retrospective chart analysis. Univariate and multivariate logistic regression analysis of cohorts was carried out to predict organ utilization or wastage. Of the 716 deceased donors, 16.2% were elderly (≥60 years) and 83.8% were not elderly (≤59 years). Donors in the elderly cohort were more likely to be diabetic, hypertensive, overweight, and smokers compared with non-elderly donors. They had deranged terminal creatinine and succumbed to cerebrovascular accident or intracerebral hemorrhage. They had a high kidney donor risk index (KDRI) of 1.83 ± 0.46. Those in the younger donor cohort, were more likely to have succumbed to road traffic accident-associated traumatic brain injury, were subjected to more efforts to revive them in the intensive care unit via cardiopulmonary resuscitation, had deranged liver function tests, and had a KDRI of 0.93 ± 0.28. The kidney discard rate (KDR) and liver discard rate (LDR) in the elderly donors was 50% and 8.6%, respectively (vis-a-vis the non-elderly at 13.3 % and 7.5%). The KDR was significantly higher than the LDR in elderly donors. The main reason for this was the high number of "marginal kidneys". We revealed that elderly donors formed a significant proportion of deceased donors. The utilization of the liver from deceased donors was more frequent compared with the kidney.

Focal and segmental glomerulosclerosis: does prognosis vary with the variants?

Focal and segmental glomerulosclerosis (FSGS) is a clinicopathological entity. The following five FSGS variants: Collapsing, cellular, glomerular tip, peri-hilar and not otherwise specified (NOS) are recognized, which may have prognostic value. The aim of this study was to highlight the clinical course and outcome in the different pathological variants of FSGS and to evaluate the predictive risk factors of end-stage renal disease (ESRD). It was a retrospective analysis of biopsy-proven primary FSGS patients who presented over a period of three years. The data were collected from the clinical and biopsy records of the Nephrology Unit. There were 116 patients with biopsy-proven FSGS. The frequency of occurrence of FSGS among all cases of the nephrotic syndrome seen in our unit was 35.47%. NOS was the most common pathological variant (62.2%), followed by peri-hilar (11.2%), cellular (9.4%) and glomerular tip (7.7%), and the least common variant was collapsing (4.3%). Majority of patients with collapsing, NOS and glomerular tip variants had nephrotic range proteinuria. However, the amount of proteinuria was highest in the glomerular tip and collapsing variants. A higher percentage of patients with the collapsing and cellular variants had renal failure at the time of presentation. A higher rate of tubular and interstitial changes was seen in the collapsing and cellular variants. The collapsing and cellular variants showed lower response rate and higher rates of ESRD, while the glomerular tip lesion had the highest remission rate and the lowest rate of ESRD. Poor prognostic factors for ESRD in FSGS were initial renal insufficiency, severe tubulo-interstitial change, initial nonresponsiveness to steroids and collapsing histopathological variant. Our study suggests that histopathological classification of FSGS is of paramount importance in the management and in predicting the prognosis.

Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature.

BACKGROUND: The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal. METHODS: A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients. RESULTS: There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter. CONCLUSION: Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic 'sterile' peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.

Pseudoaneurysm of left colic artery after Tenckhoff catheter removal, with unrecognized fungal peritonitis.

A 42-year-old continuous ambulatory peritoneal dialysis patient had presented to us with symptoms and signs of peritonitis, complicated by intestinal obstruction. On fourth day after admission, the Tenckhoff catheter was removed, as there was no response to intraperitoneal antibiotic. He developed hypotension during one of the hemodialysis sessions and was found to have low hemoglobin of 4 g/dL. Computed tomography revealed high-density fluid suggestive of fresh blood and clots in the peritoneal cavity. Conventional visceral angiogram with selective inferior mesenteric arterial cannulation revealed pseudoaneurysm arising from the descending branch of the left colic artery. An effort to embolize the pseudoaneurysm failed on 2 occasions. At laparotomy the pseudoaneurysm of the left colic artery was identified after evacuation of blood clots. The pseudoaneurysm was then excised and a lateral rent in the descending branch of left colic artery was repaired. The pus showed septate hyphae on potassium hydroxide mount. He was treated with injections of amphotericin B and oral voriconazole as the culture showed growth of Aspergillus flavus. The early fibrinous, ''easy'' flimsy adhesions formed during the initial intestinal obstruction phase might have resulted in formation of the pseudoaneurysm when the Tenckhoff catheter was removed with traction. The removal of the Tenckhoff catheter, drop in hemoglobin and distension of the abdomen were temporally so closely related that the pseudoaneurysm as a result of the traction removal of the catheter was undeniable. A controlled trial would provide firm evidence either in favor or against formal dissection for the removal of Tenckhoff catheters.

Isolated skin ulcers due to Mycobacterium tuberculosis in a renal allograft recipient.

BACKGROUND: A 27-year-old male renal allograft recipient presented to hospital with isolated skin ulcers on both lower limbs. At presentation, he also had a low-grade continuous fever, malaise and anorexia. INVESTIGATIONS: Physical examination, laboratory studies, histopathological examination of tissue biopsy samples from the ulcer edges and ulcer floor, culture of the biopsy tissue, chest radiograph, bone marrow biopsy, abdominal ultrasound, tuberculin skin test and examination of three early morning samples of gastric juice and urine for acid-fast bacilli. DIAGNOSIS: Isolated cutaneous ulcers caused by Mycobacterium tuberculosis. MANAGEMENT: Four-drug antituberculosis therapy with pyrazinamide, of loxacin, ethambutol and isoniazid.