A rare case of aneurysm of the lateral sacral artery is reported. This 46-year-old female presented with complaints of bowel and bladder incontinence and decreased perianal sensation for the past 15 months. She underwent laminectomy and diskectomy for the diagnosis of a prolapsed disk at peripheral hospital where the surgeon was confronted with a severe and unexpected hemorrhage, and surgery was aborted without effective treatment. Prior medical history includes hypertensive kidney disease with a renal transplant eight years ago. Magnetic resonance imaging and angiographic findings were suggestive of a lateral sacral artery aneurysm. Patient with a history of renal transplant and presenting with cauda equina require a more thorough assessment, and a differential of lateral sacral artery aneurysm should always be kept in mind. Our purpose is to report the pre-operative features of the lateral sacral artery aneurysm and its treatment modalities.

Background The calcineurin inhibitor, Tacrolimus (Tac), exhibits variable absorption and undergoes first-pass metabolism when administered orally. The narrow therapeutic window and individual variability of this immunosuppressive agent make therapeutic drug monitoring essential. We hypothesized that the Tac metabolism rate - defined as the blood concentration normalized by its daily dose (the C/D ratio) - is associated with post-renal transplant (RTx) function. Methodology A retrospective observational study was conducted including 40 RTx patients. Clinical reports from four follow-up ambulatory appointments at one, three, six, and 12 months were analyzed. Tac dose and its blood levels were used to calculate the Tac concentration/dose (C/D) ratio. Patients with a Tac C/D ratio <1.05 ng/mL x 1/mg and a C/D ratio >1.05 ng/mL x 1/mg were categorized as fast and slow metabolizers. Serum creatinine levels were compared between the two groups, and their association with the Tac C/D ratio was analyzed. Student\'s unpaired t-test and the Mann-Whitney U test were used to analyze the difference in the C/D ratio between the groups. Spearman correlation analysis was conducted to analyze the association of the C/D ratio with serum creatinine in both groups. A P-value of <0.05 was considered statistically significant. Results Fast metabolizers showed increased serum creatinine (P < 0.05), and the C/D ratio correlated with creatinine levels. ROC analysis used to identify fast metabolizers for the C/D ratio at three months had an area of 0.925 (P < 0.01). Conclusions The Tac C/D ratio can be used as an earlier diagnostic tool to predict the development of nephrotoxicity in RTx patients.

Renal transplantation is undoubtedly an effective treatment for patients with end-stage renal disease, but it is certainly not a cure. Patients require lifelong immunosuppression to maintain optimal allograft function, and post-operative risk complications such as cancer in the transplant recipient cannot be ignored. Besides, infection is a silent complication that follows transplantation. Relatedly, herein, we present a report of a 40-year-old patient who underwent renal transplantation and promptly developed a diffuse large B-cell tumor in the liver and Aspergillus infection in the trachea. In addition, an inflammatory necrotizing granuloma was also observed in the muscles. Of importance, we also described the potential of 18F-FDG-PET/CT, which was instrumental in monitoring and evaluating these relevant post-operative complications in this rare case.

Background The use of kidney donors with hepatitis C virus (HCV) has been arising as a possibility to increase the donor pool. It encompasses both the use of donors with positive and negative viremia, particularly since the advent of direct antiviral agents that produce sustained virologic response. Methodology We conducted a retrospective observational study to describe the experience of our transplantation center in the use of HCV antibody-positive (HCV-Ab+) kidneys. Results We performed five transplants with HCV-Ab+ donors. The median age of kidney recipients was 63 (interquartile range (IQR) = 54-71) years, and 60% (n = 3) were males. Two recipients received a second transplant. The median dialysis vintage was 1,414 (IQR = 1,103-2,806) days. The induction immunosuppression protocol was basiliximab in most patients (60%, n = 3), and all received maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and prednisolone. One of the recipients had a personal history of cured HCV infection. Seroconversion occurred in half of the remaining patients, which was sustained during the follow-up. None of the patients developed HCV viremia. At the end of follow-up, mean creatinine and proteinuria were 1.45 ± 1.12 mg/dL and 0.099 ± 0.045 g/g, respectively. We did not observe any rejection episodes, need for dialysis, or recipient\'s death. Conclusions Our work aligns with the current literature that advocates that the use of these donors is safe and cost-effective and can be an effective strategy for expanding the donor pool and augmenting the transplantation volume. Seroconversion is a known risk whose mechanisms are not entirely understood, although it does not appear to be related to a higher transmission risk.

In solid organ transplant patients, non-melanoma skin cancer remains a leading cause of mortality. The most common skin malignancies in solid organ transplant patients are squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). In organ transplant patients, SCC is 100 times more prevalent, and BCC is 10 times more prevalent than in the general population. Many risk factors for developing such malignancies are equivalent to those in the general population. However, in the transplant population, such cancers occur at an earlier age, act more aggressively, and often appear at multiple locations. Thus, assiduousness on the patient\'s part and healthcare providers is the highest priority. The concurrence of SCC and BCC together is rarely encountered in a post-transplant individual. We report a rare case of coexistence of SCC and BCC in the same patient. A 63-year-old man had been diagnosed with SCC and BCC simultaneously by a punch biopsy performed at two different scalp lesions of different diameters. This review describes an unusual occurrence of both skin cancers concurrently in a kidney transplant recipient.

UNASSIGNED: Transplant renal artery stenosis (TRAS) is a well-recognized and potentially reversible cause of resistant hypertension post transplantation and can affect 1% to 23% of recipients. Stenosis of the iliac segment proximal to the transplant renal artery (proximal TRAS) causing dysfunction of the transplanted kidney is less common with reported incidence of 2% to 3%. Presentation typically occurs between 3 months and 2 years post transplant but may happen at any time. Noninvasive investigations such as Doppler ultrasound, computed tomography (CT) angiogram, and magnetic resonance angiogram are useful in initial evaluation, but definitive diagnosis of hemodynamically significant stenosis often requires formal angiogram. Transplant renal artery stenosis should be suspected in any kidney transplant recipient with worsening hypertension and/or deterioration in kidney function which is otherwise unexplained. We present the case of a kidney transplant recipient with resistant hypertension and impaired graft function, secondary to severe impairment of graft blood flow from proximal iliac system occlusion.
UNASSIGNED: A 74-year-old female 15 years post live donor kidney transplant presented with graft dysfunction (serum Cr 229 μmol/L) and resistant hypertension, requiring use of 8 antihypertensive medications. On physical examination, blood pressure was 160/92 mm Hg with no tenderness over the renal graft in the right lower abdominal quadrant and no audible bruit in kidney allograft area.
UNASSIGNED: Transplant Doppler ultrasound showed reversal of flow in the right external iliac artery suggestive of ipsilateral proximal iliac occlusion. Pre-procedure CT demonstrated severe atherosclerotic burden within the aorta and bilateral iliac systems. The anastomosed right renal artery appeared patent.
UNASSIGNED: Conventional angiogram showed occlusion of the right common and proximal external iliac arteries with retrograde perfusion of the transplant kidney via the contralateral left iliac system and aorta. Subintimal recanalization of the right iliac system was performed with angioplasty and kissing stent placement at the aortic bifurcation with stents extending into the proximal right external iliac artery. Post deployment angiogram demonstrated renewed patency of the right iliac system, with restoration of antegrade perfusion to the transplant kidney.
UNASSIGNED: The patient\'s blood pressure decreased significantly after the procedure, with improvement in graft function. After 6 months, the patient continued to have optimally controlled blood pressure (on 3 medications) and stable graft function (serum Cr 74 μmol/L).
UNASSIGNED: Our case describes proximal TRAS and the contribution of renal hypoperfusion to hypertension and impaired graft function, with the potential for reversibility.
UNASSIGNED: La sténose de l’artère du rein transplanté (SART) est une cause bien connue et potentiellement réversible d’hypertension résistante qui touche de 1 à 23% des receveurs après l’intervention. La sténose du segment iliaque proximal de l’artère du rein transplanté (SARTprox), laquelle cause un dysfonctionnement du greffon, est moins fréquente (incidence rapportée: 2 à 3%). Elle se produit généralement entre 3 mois et 2 ans après la transplantation, mais peut se produire à tout moment. Les examens non invasifs tels que l’échographie Doppler, l’angiographie par tomodensitométrie (TDM) et l’angiographie par résonance magnétique sont utiles pour l’évaluation initiale, mais le diagnostic définitif d’une sténose hémodynamiquement significative nécessite souvent une angiographie formelle. Les SART doivent être suspectées chez tout receveur d’une greffe rénale présentant une aggravation de l’hypertension et/ou une détérioration de la fonction rénale, autrement inexpliquées. Nous présentons le cas d’une receveuse souffrant d’hypertension résistante et d’une altération de la fonction du greffon résultant d’une grave altération du flux sanguin dans le greffon causée par l’occlusion du système iliaque proximal.
UNASSIGNED: Une femme de 74 ans, greffée 15 ans auparavant avec un rein de donneur vivant, présentait un dysfonctionnement du greffon (Cr sérique: 229 µmol/L) et une hypertension résistante nécessitant huit médicaments antihypertenseurs. À l’examen physique, la pression artérielle était de 160/92 mm Hg et la patiente ne présentait aucune sensibilité au-dessus du greffon rénal dans le quadrant inférieur droit de l’abdomen, ni bruit audible au niveau de l’artère rénale.
UNASSIGNED: L’échographie Doppler du greffon a montré une inversion du flux dans l’artère iliaque externe droite, ce qui suggérait une occlusion iliaque proximale ipsilatérale. La TDM avant l’intervention avait montré une charge athérosclérotique sévère dans l’aorte et les systèmes iliaques bilatéraux. L’artère rénale droite anastomosée semblait non obstruée.
UNASSIGNED: L’angiographie conventionnelle a montré une occlusion de l’artère iliaque commune droite et de l’artère iliaque externe proximale, avec une perfusion rétrograde du rein transplanté via le système iliaque gauche controlatéral et l’aorte. La recanalisation sous-intimale du système iliaque droit a été réalisée par angioplastie et on a procédé à la pose d’une endoprothèse au niveau de la bifurcation aortique avec des extenseurs s’étendant dans l’artère iliaque externe droite proximale. L’angiographie post-déploiement a démontré une perméabilité renouvelée du système iliaque droit, avec restauration de la perfusion antérograde vers le rein transplanté.
UNASSIGNED: Après la procédure, la pression artérielle de la patiente s’est abaissée significativement et la fonction du greffon s’est améliorée. Après 6 mois, la pression artérielle demeurait bien contrôlée (avec trois médicaments) et la fonction du greffon était stable (Cr sérique: 74 µmol/L).
UNASSIGNED: Notre cas décrit une SARTprox et la contribution de l’hypoperfusion rénale à l’hypertension et à l’altération de la fonction du greffon, avec un potentiel de réversibilité.

UNASSIGNED: Fungi are ubiquitous organisms and significantly alter the post-transplant course. They are a major cause of morbidity and mortality and more so in developing countries.
UNASSIGNED: To study the clinical profile, etiology, risk factors, treatment, and outcome of fungal infections in post-renal transplant recipients.
UNASSIGNED: This was a cross-sectional observational retrospective study from January 2014 to June 2017 wherein renal transplant recipients with invasive fungal infection were included and were followed.
UNASSIGNED: Amongst 550 renal transplant recipients, 56 (10.2%) patients developed invasive fungal infection. Mean age of patients was 40.61 ± 10.06 (13-66) years and mean duration of acquiring infection post-transplant was 25.33 ± 23.65 (1-96) months. Male to female ratio was 3:1. Fever was the commonest presentation observed in 89.3% patients. Cough (76.8%), breathlessness (64.3%), sputum (55.3%), hypoxia (50%), and hemoptysis (10.7%) were other common clinical symptoms at presentation. Mean serum creatinine at presentation was 1.70 mg/dl. Most common invasive fungal infection isolated was Mucormycosis 15 (26.7%), foolwed by Aspergillosis 13 (23.2%), Pneumocystis jiroveci 12 (21.4%), Cryptococcus 6 (10.7%), Candida 4 (7.1%), Histoplasmosis 3 (5.3%), Phaeohypomycosis 2 (3.5%), and 5 (8.9%) patients had undetermined fungal etiology. Twenty (35.7%) patients had evidence of dual infection. Use of antithymocyte globulin 27 (48.2%), post-transplant diabetes mellitus 18 (32.1%), Cytomegalovirus (CMV) infection 16 (28.5%), anti-rejection therapy 9 (16%), and Hepatitis C infection 7 (12.5%) were some identified risk factors. Ten (17.8%) patients had graft loss and 12 (21.4%) patients died in the study period.
UNASSIGNED: Invasive fungal infection is a serious threat to renal transplant recipients. Patient and graft survival is significantly affected by fungal infection in developing world.

New-onset diabetes after transplantation (NODAT) is associated with reduced patient and graft survival. This study examined the clinical and selected genetic factors associated with NODAT among renal-transplanted Malaysian patients.
This study included 168 non-diabetic patients (58% males, 69% of Chinese ethnicity) who received renal transplantation between 1st January 1994 to 31st December 2014, and were followed up in two major renal transplant centres in Malaysia. Fasting blood glucose levels were used to diagnose NODAT in patients who received renal transplantation within 1 year. Two single nucleotide polymorphisms (SNPs), namely; rs1494558 (interleukin-7 receptor, IL-7R) and rs2232365 (mannose-binding leptin-2, MBL2) were selected and genotyped using Sequenom MassArray platform. Cox proportional hazard regression analyses were used to examine the risk of developing NODAT according to the different demographics and clinical covariates, utilizing four time-points (one-month, three-months, six-months, one-year) post-transplant.
Seventeen per cent of patients (n = 29, 55% males, 69% Chinese) were found to have developed NODAT within one-year of renal transplantation based on their fasting blood glucose levels. NODAT patients had renal transplantation at an older age compared to non-NODAT (39.3 ± 13.4 vs 33.9 ± 11.8 years, p = 0.03). In multivariate analysis, renal-transplanted patients who received a higher daily dose of cyclosporine (mg) were associated with increased risk of NODAT (Hazard ratio (HR) =1.01 per mg increase in dose, 95% confidence interval (CI) 1.00-1.01, p = 0.002). Other demographic (gender, ethnicities, age at transplant) and clinical factors (primary kidney disease, type of donor, place of transplant, type of calcineurin inhibitors, duration of dialysis pre-transplant, BMI, creatinine levels, and daily doses of tacrolimus and prednisolone) were not found to be significantly associated with risk of NODAT. GA genotype of rs1494558 (HR = 3.15 95% CI 1.26, 7.86) and AG genotype of rs2232365 (HR = 2.57 95% CI 1.07, 6.18) were associated with increased risk of NODAT as compared to AA genotypes.
The daily dose of cyclosporine and SNPs of IL-7R (rs1494558) and MBL2 (rs2232365) genes are significantly associated with the development of NODAT in the Malaysian renal transplant population.

Histoplasmosis has variable clinical presentation that mimics various benign and malignant lesions. It is more often associated with pulmonary lesions and disseminated form of disease. Herein, we report a rare case of localized laryngeal histoplasmosis in a 62-year-old Indian man who presented with hoarseness of voice and dysphagia. Post-renal transplant, he was on immunosuppressive drugs for last three years. Laryngoscopy revealed an ulceroproliferative growth at base of tongue, which was extending upto the pyriform fossa. Histopathology of laryngeal biopsy revealed numerous intracellular fungal yeast forms of Histoplasma that were subsequently confirmed serologically. The patient was put on oral itraconazole therapy and he responded well to the treatment with complete resolution of the disease. Early diagnosis and management of patient helps in preventing dissemination of the disease.

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