Prevalence of hypertension and its risk factors among cotton textile workers in low- and middle-income countries: a systematic review.

OBJECTIVE: The objective of this study was to evaluate the prevalence of hypertension and its risk factors among adult cotton textile workers in low- and middle-income countries (LMICs). STUDY DESIGN: Systematic review. METHODS: A review of English articles was performed between January 1, 2000, and December 31, 2021, using the following databases: PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library. Studies that measure the prevalence and risk factors of hypertension among adult cotton textile workers in LMICs were included. Extraction of articles and quality assessment of included studies were performed independently by two authors using the Mixed Methods Appraisal Tool checklist. RESULTS: Of 2476 titles screened after duplication, 50 studies were shortlisted for full-text review, and a total of 10 studies were included. Of those 10 studies, seven were carried out in India, one in Indonesia, Iraq, and Iran. Using Stata version 6, the pooled prevalence of hypertension among the cotton textile workers was 18.0% (95% confidence interval: 11.0-25.0, random effect model: I2 = 97.12%). Classic risk factors, including age, family history of hypertension, alcohol consumption, body mass index, and high waist-to-hip ratio, were recounted, whereas peculiar to the settings, noise level, improper use of earplugs, duration of noise exposure, working duration, and working in weaving section were reported. CONCLUSION: The limited available evidence indicates a significant prevalence of hypertension among cotton workers in LMICs. In the wave of double burden of non-communicable diseases in developing countries, considering context-specific risk factors is critical in controlling hypertension by prioritizing organizational plans and policies to optimize workers' health. PROSPERO REGISTRATION NUMBER: CRD42020167175.

Preparation and characterization of polyvinyl alcohol-piperic acid composite film for potential food packaging applications.

Piperic acid, a natural product-based derivative, has been used with polyvinyl alcohol for the first time to form polymer composite films for its suitable modification in physicochemical and antimicrobial properties. Initially, piperic acid was synthesized from piperine, a natural alkaloid extracted from black pepper (Piper nigrum). The solvent casting method was used for the synthesis of PVA-piperic acid composite films. The films were characterized by various spectral and microscopic techniques like UV-visible spectroscopy, FT-IR, SEM, XRD, and TGA. The antibacterial activity was shown by these polymer composites of piperic acid against Gram-positive Staphylococcus aureus (S. aureus-ATCC8738P) and Gram-negative Escherichia coli (E. coli-ATCC8739) was worthwhile. The antifungal activity of the composite films was evaluated by the food poisoning technique. Percentage mycelial growth inhibition was found maximum against Fusarium solani than Aspergillus and Penicillium. The water vapour and oxygen barrier properties are enhanced with the incorporation of increased content of piperic acid. Also, enhancement in the tensile strength of PVA/PA composite film was observed, while elongation at break shows decreased trend with the addition of piperic acid. The surface properties of polymer composite films were determined by contact angle measurements. Contact angle shows a considerable increase in these films when compared to virgin PVA film. It was increased by 56.1° in 15 mL composite film containing a higher concentration of piperic acid than virgin PVA.

Synthesis, characterization, and antimicrobial evaluation of polyvinylalcohol-osthol composite films.

Although poly-vinyl alcohol (PVA) has certain mechanical drawbacks such as a weak barrier, it has widely been used in food packaging over the last many years. To increase the suitability of PVA (C2H4O)n and render it ideal for food packaging, a diversity of studies have already been carried out. In the below-mentioned script, we, for the first time, report the use of natural product osthol in making a new composite with PVA for enhancing thermal, physicochemical, and antimicrobial properties. The significant aim of the report is the insertion of osthol (C15H16O3) into PVA polymer, which is to be subsequently used for antimicrobial applications. The synthesis of the polymer composite film is done by solvent casting method and is characterized by SEM, XRD, FT-IR, and UV-Vis spectroscopy analysis. The manifestation of antimicrobial activity against (S. aureus) (ATCC8738P), E. coli (ATCC8739), Aspergillus niger, Alternaria alternata, and Fusarium solani by the film composite is remarkable. The addition of osthol molecule increases the tensile strength of PVA films from 18.73 ± 0.56 Mpa (PVA) to 24.58 ± 0.49 Mpa (15 mL). As a result, tensile strength increases by 23.79% in a film containing a higher concentration of osthol (15 mL). The barrier properties of PVA osthol composite films improve with the incorporation of osthol. OTR and WVTR decrease by 43.03% and 30.24%, respectively, on the addition of 15 mL osthol. Reduction in OTR and WVTR of the films could increase their applicability in the food sector. An increase in contact angle from 43° (pure PVA) to 66.7° increases the hydrophobic character of the composite films which is desirable for food packaging. This noticeable enhancement of the properties of the PVA film like hydrophobicity, mechanical, barrier, and antimicrobial is supporting the potential application of achieved material in packaging of easily perishable foods like fruits and vegetables by extending their shelf life.

Change in Insulin Sensitivity and Lipid Profile After Dopamine Agonist Therapy in Patients With Prolactinoma.

Background Prolactinomas are prolactin(PRL)-secreting neoplastic lesions that can lead to metabolic disturbances and insulin resistance. We aimed to find the change in insulin sensitivity and lipid profile in prolactinoma patients after dopamine therapy.  Methodology A prospective observational study was conducted at the Hayatabad Medical Complex, Peshawar between June 2019 to July 2020. All patients with newly diagnosed prolactinoma were eligible to partake in the study. Individuals with multiple hormone-producing pituitary tumors, hyperprolactinemia secondary to other causes than tumors, and those taking medication for hypercholesterolemia were excluded. Diagnosis of prolactinoma was established on the basis of elevated PRL levels on at least two occasions three days apart in addition to an MRI detecting prolactinoma on the hypothalamic-pituitary area. The mean dose for dopamine agonist was 5.8 ± 4.1 mg per day with a range between 1.25 to 15 mg. To assess the change in insulin resistance, the homeostatic model assessment insulin resistance (HOMA-IR) was computed. All data were recorded in a predefined proforma.  Results  The difference between pre- and post-treatment values for mean PRL levels was statistically significant (p<0.0001). There was a significant association between dopamine agonist treatment and the BMI (pre- vs. post-treatment; 28.9 ± 4.28 vs. 24.53 ± 2.2, p<0.0001). Both low-density lipoprotein (LDL)-cholesterol and HOMA-IR scores were significantly lower in the post-treatment group as compared to the pre-treatment group (p<0.0001).  Conclusion The present study indicated that dopamine agonist therapy was effective not only in lowering the serum PRL levels but also improved insulin sensitivity and decreased lipid metabolism, resulting in improved BMI. Further studies should explore the long-term side effects of dopamine agonists on patients with prolactinoma.

Role of Depression in Total Knee Arthroplasty: A Retrospective Analysis of Perioperative Outcomes in Patients in the United States.

We evaluate the patient demographics, perioperative outcomes, in-hospital complications, and assess recent national trends in clinically depressed and non-depressed patients undergoing primary total knee arthroplasty (TKA). Using the National Hospital Discharge Survey from 2001 and 2010, patients undergoing primary TKA in the United States were identified based upon the diagnosis of depression. Differences in gender, patient-demographics, comorbidities, complications, length of stay, and discharge disposition were analyzed. A total of 32,761 TKA patients were identified, consisting of 1,880 patients with a diagnosis of depression and 30,881 patients without. The depression group had an average age significantly younger than the non-depression cohort (p < 0.01). The depression group contained a significantly greater percentage of females when compared to the non-depression group. The non-depression group had a significantly greater percentage of African-Americans (p < 0.01), and a significantly smaller percentage of Caucasians (p < 0.01). Our findings contribute to the literature on the role of depression on perioperative outcomes of TKA. (Journal of Surgical Orthopaedic Advances 30(1):007-009, 2021).

A novel method for predicting superior gluteal nerve safe zones in the lateral approach to the hip.

INTRODUCTION: The superior gluteal nerve (SGN) is at risk for laceration during lateral approach total hip arthroplasty (THA). The purpose of this study is to assess the accuracy of the trochanter-to-iliac crest distance (TCD) and the nerve-to-trochanter distance (NTD) ratio in determining a reproducible safe zone around the SGN independent of height. MATERIALS AND METHODS: Eighteen hemipelvises were dissected and the SGNs were exposed. The distance (NTD) from greater trochanter (GT) to the most inferior branch of the SGN encountered in each of the three approaches (Bauer et al., 1979) was measured. A reference distance (TCD) was measured from the GT to the highest point on the iliac crest. The NTD was divided by the TCD to generate standardized ratios. Coefficient of variation CV = (SD/mean) × 100 was calculated for each distance and ratio to measure relative variability. RESULTS: The standardized ratios (and CV) were determined for the nerve branches in three different surgical approaches: Hardinge 0.464 (0.9%), Bauer 0.406 (1.7%), and Frndak 0.338 (4.1%). There was a strong correlation of the individual NTDs with the TCD: NTD for Hardinge (r = 0.996, p < .001), NTD for Bauer (r = 0.984, p < .001), and NTD for Frndak (r = 0.932, p < .001). CONCLUSION: By measuring the TCD preoperatively and using the respective standardized ratios, surgeons can accurately predict the NTD and how proximal to the GT each SGN branch can be expected to be encountered during lateral approach to the hip. This will allow surgeons to work with a more precise safe zone around the SGN and minimize the possibility for a nerve injury.

The Role of Patient Education in Arthritis Management: The Utility of Technology.

Technologies continue to shape the path of medical treatment. Orthopedic surgeons benefit from becoming more aware of how twenty-first century information technology (IT) can benefit patients. The percentage of orthopedic patients utilizing IT resources is increasing, and new IT tools are becoming utilized. These include disease-specific applications. This article highlights the opportunity for developing IT tools applicable to the growing population of patients with osteoarthritis (OA), and presents a potential solution that can facilitate the way OA education and treatment are delivered, and thereby maximize efficiency for the health care system, the physician, and the patient.

The ratio of patient body mass index to age: a cost-effective implant selection guideline for total knee arthroplasty.

BACKGROUND: We sought to develop an objective implant selection guideline based on the ratio of patient body mass index (BMI) to age in order to select implants preoperatively and reduce cost while maintaining quality. The BMI-to-age ratio can be used to distinguish patient demand and select those patients who may benefit from newer technology and higher cost implants and those who would do well with standard-demand implants. METHODS: A retrospective analysis investigated the types of implants received by patients undergoing total knee arthroplasty from January 2012 to August 2014. Patients with a BMI-to-age ratio >0.60 were categorized as high demand and were eligible for either a high-demand implant or a standard-demand implant. Patients with a BMI-to-age ratio ≤0.60 were recognized as standard demand and would be eligible for only standard-demand implants. The actual implant received was identified and compared with the implant as predicted by the BMI-to-age ratio and potential cost savings were identified. RESULTS: A total of 1507 operative knees were identified. The high-demand implant carries a 31% greater cost than that of a standard-demand implant. Thirty-eight of 1084 high-demand implants were placed in standard-demand knees. An additional 1.1% cost was realized with 38 standard-demand knees receiving high-demand implants and 28.6% if high-demand knees had been used in all standard-demand patients. CONCLUSIONS: Limiting the use of high-demand implants to high-functional-demand patients based on the BMI-to-age ratio may guide the surgeon's choice in optimizing implant selection while providing value-based purchasing criteria to the selection of total knee arthroplasty implants.

Variance in predicted cup size by 2-dimensional vs 3-dimensional computerized tomography-based templating in primary total hip arthroplasty.

BACKGROUND: Preoperative total hip arthroplasty templating can be performed with radiographs using acetate prints, digital viewing software, or with computed tomography (CT) images. Our hypothesis is that 3D templating is more precise and accurate with cup size prediction as compared to 2D templating with acetate prints and digital templating software. METHODS: Data collected from 45 patients undergoing robotic-assisted total hip arthroplasty compared cup sizes templated on acetate prints and OrthoView software to MAKOplasty software that uses CT scan. Kappa analysis determined strength of agreement between each templating modality and the final size used. t tests compared mean cup-size variance from the final size for each templating technique. Interclass correlation coefficient (ICC) determined reliability of digital and acetate planning by comparing predictions of the operating surgeon and a blinded adult reconstructive fellow. RESULTS: The Kappa values for CT-guided, digital, and acetate templating with the final size was 0.974, 0.233, and 0.262, respectively. Both digital and acetate templating significantly overpredicted cup size, compared to CT-guided methods (P < .001). There was no significant difference between digital and acetate templating (P = .117). Interclass correlation coefficient value for digital and acetate templating was 0.928 and 0.931, respectively. CONCLUSIONS: CT-guided planning more accurately predicts hip implant cup size when compared to the significant overpredictions of digital and acetate templating. CT-guided templating may also lead to better outcomes due to bone stock preservation from a smaller and more accurate cup size predicted than that of digital and acetate predictions.

The utility of bicruciate-retaining total knee arthroplasty.

BACKGROUND: We describe the features of modern and historical bicruciate-retaining (BCR) total knee arthroplasty (TKA) implants compared with other TKA implant designs, reviewing kinematics, proprioception, operative technique, and clinical results. METHODS: We performed a review based on PubMed, Embase, CINAHL Plus, and Cochrane databases from January 1990 to April 2016 using combinations of the following keywords: "bicruciate-retaining arthroplasty," "bicruciate-retaining total knee arthroplasty," "bicruciate-retaining TKA," "kinematics," "knee kinematics," and "TKA kinematics." RESULTS: Four studies have supported the notion that preservation of both cruciate ligaments in TKA preserves more "normal" knee kinematics. BCR implants provide greater proprioceptive performance when compared with posterior cruciate-retaining (CR) TKA implants. However, the operative implantation is more challenging with BCR TKAs, requiring the surgeon to take additional precautions. Overall, there did not seem to be a significant difference in short-term clinical outcomes between the BCR and CR implants. CONCLUSIONS: The utility of BCR TKA is still debatable. The literature has not shown clear indications and guidelines for the value and use of this implant. Although kinematics have been shown to mirror the native knee more closely, the clinical outcomes of BCR vs CR TKAs do not differ significantly. Moreover, additional care must be taken when inserting a BCR implant. The anterior cruciate ligament exploration and preservation is more challenging and certain preparation and precautions must take place. Overall, we have not found that BCR implants are significantly superior to CR implants with regards to short term clinical outcomes despite the BCR TKA having improved kinematics and proprioception.

Strategies to Prevent Periprosthetic Joint Infection After Total Knee Arthroplasty and Lessen the Risk of Readmission for the Patient.

There is yet to be a standardized total knee arthroplasty (TKA) surgical protocol that has been studied to a sufficient degree to offer evidence-based practices regarding infection and readmission prevention. Although high-level evidence is often sought to provide guidance concerning protocol- and process-level decisions, the literature is often confusing and nondefinitive in its conclusions and recommendations regarding periprosthetic joint infection and readmission prevention. Areas of study that require further investigation include the following: the role of patient optimization and preoperative mitigation of risk; perioperative antibiotics; operating room environment; blood management; operative techniques, implants, and infection prevention measures; wound care management; and post acute care. Patient-associated modifiable risk must be optimized to decrease poly joint infection rates after TKA. Protocol measures for TKA need to be standardized, and evidence-based practice measures need to be validated.

Dimethoate Induced Behavioural Changes in Juveniles of Cyprinus carpio var. communis under Temperate Conditions of Kashmir, India.

The present study was designed to investigate acute toxicity of dimethoate on juvenile Cyprinus carpio var. communis. Fishes weighing 10 ± 2 gms were selected and mortality data was statistically evaluated by Finney's Probit Method. The 96-hour LC50 value for Cyprinus carpio was found as 1.1 ppm in static bioassay system. Mean values of physicochemical parameters of aquarium waters determined during bioassay depicted slight variation indicating that the mortality in aquarium fishes occurred due to pesticide exposure and not suffocation. Lab. temperature ranged from 12 to 13°C; water temperature ranged from 11 to 12°C; dissolved oxygen ranged from 3.90 to 4.56 mg/L; pH ranged from 6.90 to 7.05; total dissolved solids ranged from 2.66 to 3.0 × 10(3) mg/L, while CO2 remained at a constant value of 2.0 mg/L. The fishes elicited various behavioural responses such as uncoordinated movements, convulsions, excessive mucus secretion, and imbalanced swimming which ended in a collapse to the bottom of the aquarium. Prior to death, the clinical signs like scale erosion, pale body colour, and hemorrhagic patches over the body were noticed which became more vivid up to the termination of experiments. Results of the study indicate potential toxicity of dimethoate in fingerlings of common carp for which the natural waterbodies must be continuously monitored to reduce its impact across food chains.

The Pharmacochaperone Activity of Quinine on Bitter Taste Receptors.

Bitter taste is one of the five basic taste sensations which is mediated by 25 bitter taste receptors (T2Rs) in humans. The mechanism of bitter taste signal transduction is not yet elucidated. The cellular processes underlying T2R desensitization including receptor internalization, trafficking and degradation are yet to be studied. Here, using a combination of molecular and pharmacological techniques we show that T2R4 is not internalized upon agonist treatment. Pretreatment with bitter agonist quinine led to a reduction in subsequent quinine-mediated calcium responses to 35 ± 5% compared to the control untreated cells. Interestingly, treatment with different bitter agonists did not cause internalization of T2R4. Instead, quinine treatment led to a 2-fold increase in T2R4 cell surface expression which was sensitive to Brefeldin A, suggesting a novel pharmacochaperone activity of quinine. This phenomenon of chaperone activity of quinine was also observed for T2R7, T2R10, T2R39 and T2R46. Our results suggest that the observed action of quinine for these T2Rs is independent of its agonist activity. This study provides novel insights into the pharmacochaperone activity of quinine and possible mechanism of T2R desensitization, which is of fundamental importance in understanding the mechanism of bitter taste signal transduction.

Importance of Proper Utilization of International Classification of Diseases 10th Revision and Clinical Documentation in Modern Payment Models.

BACKGROUND: Health care payment models are changing rapidly, and the measurement of outcomes and costs is increasing. METHODS: With the implementation of International Classification of Diseases 10th revision (ICD-10) codes, providers now have the ability to introduce a precise array of diagnoses for their patients. RESULTS: More specific diagnostic codes do not eliminate the potential for vague application, as was seen with the utility of ICD-9. Complete, accurate, and consistent data that reflect the risk, severity, and complexity of care are becoming critically important in this new environment. Orthopedic specialty organizations must be actively involved in influencing the definition of value and risk in the patient population. CONCLUSION: Now is the time to use the ICD-10 diagnostic codes to improve the management of patient conditions in data.

C1q nephropathy with acute hemolytic uremic syndrome.

C1q nephropathy with hemolytic uremic syndrome (HUS) is an uncommon combination associated with rapidly progressive renal failure. We report a case of C1q nephropathy with HUS in an 18-year-old man associated with rapidly progressive renal failure. The patient did not respond to treatment with steroids and was started on maintenance hemodialysis. C1q nephropathy with HUS is rare and can lead to rapidly progressive renal failure.

Nocardia infection in a renal transplant recipient.

Opportunistic infection occurs in up to 20% renal transplant patients and is associated with a high mortality. We report a 47-year-old diabetic female with 1-year-old deceased donor renal allograft on triple drug immunosuppression. She developed cytomegalovirus retinitis at ten months post-transplant followed by nocardiasis manifested by hemiparesis with comatose state due to lumbar epidural and multiple brain abscesses, in spite of immediately curtailing immunosuppression. She recovered with linezolid and cotrimoxazole and was discharged two weeks later. She is maintaining stable graft function with serum creatinine 1.4 mg/dL on cyclosporin 2.5 mg/kg/day and prednisone10 mg/day with maintenance therapy for nocardiasis.

Operational tolerance in living-related renal transplantation: a single-center experience.

INTRODUCTION: Various methods have been tried to induce operational tolerance in organ transplantation. We present a single-center experience using 6 tolerance induction protocols (TIP) in living-related renal transplantation. METHODS: We evaluated 6 TIP protocols: (1) peripheral blood stem cells employed (n = 38); (2) midified the protocol by portal infusion (n = 292); (3) the second protocol plus TIP+DST+BM+intrathymic and intramarrow infusion plus low-dose, nonmyeloablative conditioning employed (n = 174), (4) the third protocol of TIP plus cultured hematopoietic stem cells (HSC) with target-specific irradiation (n = 290); (5) TIP 4 plus thymus, intramarrow infusion, and target-specific irradiation converted to total lymphoid irradiation (TLI) (n = 366); and (6) TIP 5 plus bortzomib-TLI (n = 165). Patient/donor demographics were comparable. RESULTS: We evaluated patient and graft survival, rejection episodes, recurrence, drug toxicity, and chimerism revealed; groups 4 and 5 showed better survival, graft function, chimerism, and decreased rejection episodes compared with previous protocols. Serum creatinine (mg/dL) at 1 year was 1.5, 1.39, 1.5, 1.51, 1.46, and 1.41, and at 5 years, 1.69, 1.72, 1.82 and 1.59, in groups 1-6, respectively. Chronic rejection episodes were 10.5%, 14.1%, 10.4%, 9.3%, 3.5%, 1.7%, and 1.8% respectively. Patient survival of groups 1, 2, and 3 at 1, 5, and 10 years was 86.5%, 56.8%, and 40.1%; 89.4%, 69.1%, and 56.4%; and 89.6%, 67.7%, and 64.6%, respectively; of group 4 for 1 and 5 years was 92.4% and 81.8%; for groups 5 and 6 for 1 year was 94% and 96.3%, respectively. The death-censored graft survival of groups 1, 2, and 3 at 1, 5, and 10 years was 91.9%, 70.3%, and 64.7%; 89%, 66%, and 57.6%; and 86.7%, 67%, and 42.5%, respectively. In group 4 for 1 and 5 years was 87.9% and 74.7%; and for groups 5 and 6 for 1 year was 94% and 96.5%, respectively. CONCLUSION: TIP results showed improved graft/patient survivals, minimum immunosuppression, and fewer rejection episodes and recurrence.

Ahmedabad tolerance induction protocol and chronic renal allograft dysfunction: pathologic observations and clinical implications.

BACKGROUND: Chronic Renal Allograft Dysfunction (CRAD) is responsible for a large number of graft failures. We have abrogated acute T-cell rejections using Ahmedabad Tolerance Induction Protocol (ATIP) with hematopoietic stem cell transplantation (HSCT) under non-myeloablative conditioning pre-transplant. However B-cell mediated rejections and CRAD continue to haunt us. We carried out retrospective analysis of renal allograft biopsies performed in the last 4 years to evaluate the effect of ATIP on CRAD. MATERIALS AND METHODS: Biopsies diagnosed as per modified Banff criteria belonged to 2 groups: ATIP under low dose immunosuppression of cyclosporine/Azathioprine/Mycofenolate mofetil+ Prednisolone, subjected to donor leucocyte transfusion, anti-T/B cell antibodies, low dose target specific irradiation, cyclophosphamide, cyclosporin followed by HSCT pre-transplant; controls who opted out of ATIP were transplanted under standard triple drug immunosuppression. Demographics of both groups were comparable. RESULTS: Incidence of chronic changes was higher in controls (17.5%) vs. 10.98% in ATIP over a mean follow up of 151.9 months in the former and 130.9 months in the latter. Proteinuria and hypertension were higher in controls (48.4%) vs. ATIP (32.7%) with chronic transplant glomerulopathy, focal global sclerosis in 67.7% in controls vs. 46.7% in ATIP, acute on chronic T/B cell rejection in 51.6% controls vs. 28.1% ATIP, with peritubular capillary C4d deposits in 19.4% controls vs. 1.9% ATIP biopsies. Acute on chronic calcineurin inhibitor toxicity was higher in ATIP (71.9%) vs. 48.4% in controls. CONCLUSION: Chronic immune injury was less with ATIP vs controls as compared to a higher incidence of chronic calcineurin inhibitor toxicity in the former.

Clonal deletion using total lymphoid irradiation with no maintenance immunosuppression in renal allograft recipients.

A total of 69 individuals received a kidney from a living donor after a TLI-based clonal deletion protocol with no post-transplant maintenance immunosuppression planned. If needed, immunosuppression was started on a patient-specific basis, adding one drug at a time, a strategy we AWN". call "Drugs Added When Needed," or "DAWN. Following this strategy, at last follow-up 40 of the 69 patients (58%) had to be rescued by conventional immunosuppression, 23 (33%) had to be started on daily prednisone and six (9%) remained with no maintenance immunosuppression. The overall rate of de novo donor-specific antibody produced was 36% (in 25 of the 69 patients), and mean time to detection was about four months. The incidence of acute rejection episodes that displayed humoral components was 27% (19 cases), of which 14 were pure antibody-mediated rejection, five combined antibody- and T-cell-mediated rejection, and six were episodes (9%) of pure T-cell-mediated rejection. Finally, this study shows that although complete clonal deletion was not achieved, an important proportion of patients--42%, or 29 of the original 69--could be maintained with prednisone alone or even with no immunosuppression for a total mean follow-up of 13.3 months. Moreover, 16 patients with recent follow-up are surviving with no maintenance immunosuppression or just on prednisone. The mean serum creatinine at last follow-up for these 16 patients is 1.33 +/- 0.2 mg/dL with a mean follow-up of 19.3 months. Clonal deletion can be used to transplant patients without maintenance immunosuppression, adding drugs only as needed.