Clinical presentation and outcome of dengue viral infection in live-related renal transplant recipients in Karachi, Pakistan.

INTRODUCTION: In Pakistan, dengue viral infection has become hyper-endemic. Renal transplantation is also expanding. We aimed to study dengue in renal transplant recipients (RTR). METHODS: We conducted a study of RTR reported to be anti-dengue immunoglobulin-M antibody positive from January 2009 to December 2010 at our institution in Karachi and follow their clinical course and outcome. RESULTS: Median age was 28 years; 75 (73.7%) were males. Clinical presentation included fever in 82 (80.4%), gastrointestinal symptoms in 35 (34.3%), hemorrhagic complications in 9 (8.8%), and thrombocytopenia in 97 (95%), which was of >15 days duration in 24%. Fever was seen less frequently in patients on high-dose (>7.5 mg) steroids as compared with low-dose (≤7.5 mg) steroids. Forty-four patients (43%) had primary and 58 (56.8%) had secondary dengue infection. Dengue fever (DF) occurred in 90 (88%), and dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) occurred in 12 (11.7%). DHF/DSS was seen in 3 (6.8%) of those with primary and in 9 (15.5%) of those with secondary infection (P < 0.22). In secondary infection, patients on cyclosporine-containing regimen had less severe disease, with DHF/DSS in 22% as opposed to DF in 59% (P < 0.04). Of 102 RTR, 68 (66.7%) had graft dysfunction, 5 of whom died. Of the remaining 63, in 54 patients (85.7%) creatinine returned to baseline by an average of 12.6 days. Of 102 patients, 95 (93%) recovered and 7 (6.9%) died, 6 of whom had bacteremia with sepsis and 1 had respiratory failure. None died due to dengue infection alone. CONCLUSION: In conclusion, in RTR without life-threatening co-morbidities, the clinical course of dengue infection is mild, with good recovery and preserved renal function.

Pediatric kidney transplantation in the developing world: challenges and solutions.

The prevalence of pediatric RRT and transplantation are low in developing countries, 6-12 and <1 to 5 per million child population (pmcp), respectively. This is due to low GDP/capita of <$10 000, government expenditure on health of <2.6-9% of GDP and paucity of facilities. The reported incidence of pediatric CKD and ESRD is <1.0-8 and 3.4-35 pmcp, respectively. RRT and transplantation are offered mostly in private centers in cities where HD costs $20-100/session and transplants $10 000-20 000. High costs and long distance to centers results in treatment refusal in up to 35% of the cases. In this backdrop 75-85% of children with ESRD are disfranchised from RRT and transplantation. Our center initiated an integrated dialysis-transplant program funded by a community-government partnership where RRT and transplantation was provided "free of cost" with life long follow-up and medication. Access to free RRT at doorsteps and transplantation lead to societal acceptance of transplantation as the therapy of choice for ESRD. This enabled us to perform 475 pediatric transplants in 25 years with 1- and 5-year graft survival of 96% and 81%, respectively. Our model shows that pediatric transplantation is possible in developing countries when freely available and accessible to all who need it in the public sector.

Pseudomonas aeruginosa endocarditis in renal transplant recipients.

Infective endocarditis (IE) is a serious and life-threatening disease. Transplant recipients are at increased risk of acquiring serious infections. The most common organisms causing IE in solid organ transplant recipients are reported to be gram positive. IE due to Gram-negative organism has rarely been reported. We report 2 cases of renal transplant recipients who met the Duke's criteria for IE due to Pseudomonas aeruginosa.

A renal transplantation model for developing countries.

The estimated incidence of end-stage renal disease (ESRD) in Pakistan is 100 per million population. Paucity and high costs of renal replacement therapy allows only 10% to get dialysis and 4-5% transplants. Our center, a government organization, started a dialysis and transplant program in 1980s where all services were provided free of charge to all patients. It was based on the concept of community government partnership funded by both partners. The guiding principles were equity, transparency, accountability and development of all facilities under one roof. This partnership has sustained itself for 30 years with an annual budget of $25 million in 2009. Daily 600 patients are dialyzed and weekly 10-12 receive transplants. One- and 5-year graft survival of 3000 transplants is 92% and 85%, respectively. The institute became a focus of transplantation in Pakistan and played a vital role in the campaign against transplant tourism and in promulgation of transplant law of 2007, and also helped to increase altruistic transplants in the country. This model emphasizes that in developing countries specialized centers in government sector are necessary for transplantation to progress and community support can make it available to the common man.