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ABSTRACT: There are conflicting data regarding the comparative efficacy of mycophenolate mofetil (MMF) versus azathioprine (AZA) as maintenance immunosuppressive agent in kidney transplantation. The data are even less in combination with tacrolimus (TAC) in living donor kidney transplantation. A total of 205 living donor kidney transplants, on TAC-based triple drug immunosuppression were included in the study. A total of 113 patients received AZA and rest 92 were on MMF based protocol. TAC levels were monitored and graft biopsy was done whenever rejection was suspected. The outcomes were evaluated in terms acute rejection (AR) episodes at 1 year, infections, renal function, graft loss, and death between two groups. The study group comprised 163 males (79.5%) and 42 (20.5%) females. The mean age of patients was 42.4±11.8 years in the AZA group and 39.4 ±13.4 in the MMF group (P=0.09). The mean duration of follow-up was 491.7±240.7 and 478.8±334.4 days respectively in the AZA and MMF groups (P=0.75). Thirty-seven of 92 (40.2%) patients in the MMF group and 70/113 (61.9%) patients in the AZA group received IL-2 RAb induction (P=0.002). 32 patients (15.6 %) developed AR within a year. The incidence of AR was similar in patients who received MMF (12/92, 13%) and those who received AZA (20/113, 17.5%), (P=0.36). There was no difference in the incidence of AR in the subgroup of patients who received IL-2 RAb compared to those who did not receive induction in the two groups (5/37 vs. 7/55 in the MMF group and 10/70 vs. 10/43 in the AZA group, P=0.72). The incidence of infections was similar in the two groups (19/92, 20.6% vs. 25/113, 22.1%, P=0.79). Three patients developed CMV disease, of which two were in the MMF group. Graft loss occurred in 7/205 (3.4%) and death in 8/205 (3.9%) patients. Six of eight patients who died had functioning grafts. The rate of graft loss (3/92 vs. 4/113, P=0.97) and death (5/92 vs. 3/113, P=0.27) was similar in two groups. The overall patient survival was 94.5% and death censored graft survival was 97.4%. Cost comparison suggests AZA to be 6-10 times cheaper than MMF. This study suggests that, in tacrolimus-based immunosuppression, azathioprine may be as good as MMF as maintenance immunosuppressive drug in living donor kidney transplantation. It is also a more cost-effective immunosuppression.
Indian Journal of Nephrology 10/2011; 21(4):258-63.
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ABSTRACT: Human immunodeficiency virus (HIV) disease was considered an absolute contraindication to kidney transplantation until recently. The main reason was the concern regarding the side effects of immunosuppressive drugs in already immunocompromised patients. Kidney transplantation is considered to be the best form of renal replacement therapy in most patients with kidney failure. Nowadays, many world medical centers are successfully doing kidney transplantation in HIV patients with kidney failure. However, HIV disease is still considered a contraindication to kidney transplantation in most Indian centers. Here, we report a case of a patient with HIV infection and ESRD, who underwent successful kidney transplantation in our center.
Indian Journal of Nephrology. 01/2009;
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ABSTRACT: Endopyelotomy is a well-accepted modality of treatment for pelviureteral junction (PUJ) obstruction, but the time period of stenting is debatable. The present study was aimed at evaluating the optimum duration and effectiveness of splinting after endopyelotomy.
Twenty-nine consecutive patients with primary PUJ obstruction were randomized to have an external splint (for economic reasons) for 2 weeks or 4 weeks. Thirteen patients in each group were available for evaluation. The groups were comparable in age, sex, symptoms, and preoperative glomerular filtration rate (GFR). All patients underwent antegrade endopyelotomy with placement of an 8F-12F polyethylene splint across the PUJ. A nephrostogram was performed after removal of splint at 2 or 4 weeks. Nondraining units were managed by putting in a 6F double-J stent for 6 weeks and considered failures. Patients were evaluated at 3, 6, and 12 months for symptomatic improvement, change in GFR, and drainage pattern on a diuretic renogram.
At 1 year, a nonobstructed curve pattern was seen in 70% and improvement in GFR in 54% of the patients in the 2-weeks group, whereas in the 4-weeks group, these values were 54% and 39%, respectively. All patients in the 4-weeks group and 90% of those in the 2-weeks group were symptom free at 1 year of follow-up. Morbidity in terms of tube-related complications was comparable.
Two weeks of splinting is as effective as 4 weeks in the successful outcome of endopyelotomy.
Journal of Endourology 04/1999; 13(2):89-92. · 1.85 Impact Factor
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ABSTRACT: To assess the role of primary open surgery versus the recommended combination approach (percutaneous and lithotripsy) to treat staghorn calculi in a developing country.
Available records (n = 91) of patients with staghorn managed during the last 4 years were retrieved. Patients were placed in two groups, open surgery and combination group, according to the primary procedure chosen by the patient. Demographic data in two groups was comparable in most of the respects except that renal failure patients were more in the combination group. Stone clearance, major residue, auxiliary procedures, morbidity, hospital stay and the cost were studied in the two groups for comparison.
Complete clearance could be obtained in 66 and 59% with open and combination method respectively. Major residue (> 16 mm2) was present in 21% of open and 38% of the combination group. In patients with primary stone burden < 900 mm2, the total clearance rates were 66 and 60% in open and combination group, respectively. Total clearance was not affected by caliceal dilatation, total stone burden, pelvic and caliceal bulk separately or their ratio, as arrived by logistic regression analysis. The incidence of haematuria in the combination group was marginally higher, probably due to more renal failure patients in this group. Hospital stay in the two groups was comparable (13.0 days in combination vs. 12.1 days for open). The cost of treatment with combination group was significantly higher.
Open surgery for staghorn is still an economically viable option for difficult stone disease, specially in a developing country, with comparable efficacy, favourable morbidity and hospital stay.
Urologia Internationalis 01/1999; 63(4):228-33. · 0.99 Impact Factor
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ABSTRACT: We determined the role of intervention and its outcome in patients with a solitary kidney, nephrolithiasis and chronic renal insufficiency, as well as the role of clearance in these patients compared to those with a solitary kidney, nephrolithiasis and normal renal function.
A total of 36 records was evaluable, including 16 from patients with normal (group 1) and 20 from those with abnormal (group 2) renal function. Group 2 was further subdivided into those with mild to moderate (group 2A) and advanced (group 2B) renal failure. Patients with acute renal failure were excluded from the study. Glomerular filtration rate was calculated by the Cockcroft and Gault formula. The reciprocal of serum creatinine was used to determine outcome.
Groups 1 and 2 were comparable demographically except for serum creatinine, stone bulk and hospital stay. Of 36 patients 8 with normal renal function and 15 with chronic renal failure underwent percutaneous nephrolitholapaxy, 6 underwent extracorporeal shock wave lithotripsy and 7 underwent open surgery. Total clearance was achieved in 25 of 36 patients (72%). Glomerular filtration rate improved in 24 patients, remained stable in 8 and deteriorated in 4. However, 3 patients had less than 20% deterioration and 1 had significant deterioration in function after intervention. Improvement in glomerular filtration rate after intervention was significantly greater in cases of advanced renal failure. Patients with residual stones did worse than those without residual calculi. Mean hospital stay, deterioration in glomerular filtration rate and major morbidity rate were significantly greater in patients with residual calculi than in those with total clearance.
Intervention should be contemplated in patients with a solitary kidney, stone disease and renal failure as in any other patient with stone disease, with the aim being total clearance. Stone eradication delays deterioration, and decreases the requirement for dialysis and renal replacement.
The Journal of Urology 06/1997; 157(5):1574-7. · 3.75 Impact Factor
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ABSTRACT: Twenty-nine patients with significant haematuria after a renal invasive procedure (27 of whom had undergone a percutaneous renal procedure and 2 surgical pyelolithotomy) were investigated with angiography. Out of the 21 patients with evidence of arterial injury, 19 were treated by transarterial embolization with gelfoam with or with hydrogel particles; (n = 11), steel coils with gelfoam (n = 4), hydrogel particles (n = 1), surgicel (n = 2), silk with gelfoam (n = 1). The efficacy and technique of the therapeutic embolization procedure is emphasized.
Clinical Radiology 03/1997; 52(2):119-23. · 1.95 Impact Factor
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Australian and New Zealand Journal of Surgery 02/1997; 67(1):69-70.
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ABSTRACT: Spontaneous perforation of the ureter proximal to an obstruction has not been well described in the literature. We present a rare case of spontaneous perforation of the ureter, proximal to a radiolucent upper ureteric stone, in a 58-year-old diabetic female, causing a large infected urinoma and septicaemia in a solitary functioning kidney. The diagnosis was confirmed by computer tomography scan. We managed the case successfully by endourology only. The case emphasizes the importance of the differential diagnosis in a diabetic patient with obstructive uropathy.
Urologia Internationalis 02/1996; 57(2):122-5. · 0.99 Impact Factor
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ABSTRACT: To assess the role of Whitaker's test (WT) and 99mTc-diethylene triamine penta-acetic acid diuretic renography (DRG) in determining objectively the outcome of endopyelotomy, and to rationalize the frequency and timing of such evaluation after endopyelotomy.
Thirty-one patients (age > 15 years) were prospectively evaluated after percutaneous endopyelotomy. WT was performed at 4-6 weeks via the nephrostomy maintained for external drainage, 24 h after removing the splint. DRG was performed at 3, 6 and 12 months, and then annually.
WT performed 24 h after removing the splint diagnosed pelvic pressures in the unobstructed range (< 15 cmH2O) in 21 of the 24 patients were also evaluated with DRG at 3 months. An intra-pelvic pressure of > 15 cmH2O was correlated with a pattern of obstruction on DRG in all three units. Despite an unobstructed WT in 18 patients, categorization of DRG drainage showed disparity in six cases. All six renal units had a large pelvic area (> 15.0 cm2 in two and > 20.0 cm2 in four) and/or a poor renal function (separate glomerular filtration rate [GFR] of < or = 25 ml/min in four of the six units). The drainage pattern on DRG was unevaluable in two renal units as the function was poor (separate GFR < 15 ml/min). During the first year, the drainage pattern on DRG improved in four cases. When followed beyond one year, the drainage pattern deteriorated at 2 years in only one of 14 evaluated renal units with an initial unobstructed WT.
Using objective methods of evaluation, endopyelotomy was successful in relieving obstruction in 87% of cases. If inaccuracies in the interpretation of DRG, i.e. a large pelvic capacity and poor renal function, are accounted for, the results of WT as early as 24 h after removal of the splint correlated with DRG. Drainage patterns on DRG did not deteriorate during the first year. An early post-operative evaluation with WT or DRG, as appropriate, is thus sufficient evidence of the success of the procedure. Evaluations repeated during the first year after endopyelotomy may be unnecessary.
British Journal of Urology 12/1995; 76(6):686-91.
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ABSTRACT: Allograft lithiasis is usually secondary. Donor-graft lithiasis is a rare cause and only 5 cases have been reported. We report 2 such cases which are the first in the live-related transplantation programme. The pressing need to increase the donor pool in developing countries, safety of therapy in graft lithiasis coupled with minimal estimated risk of lithiasis recurrence in the donor are the main justifications for accepting calculi bearing kidney for transplantation. The 2 cases underwent extracorporeal shockwave lithotripsy using the overhead table module of the Lithostar Plus. The technical ease of lithotripsy using an on-line ultrasound module in these 'ectopically' placed kidneys is discussed. The effect of shockwaves on allograft function was studied by a pre- and post-renal scan (99Tc-DTPA) and serum creatinine. No adverse effect of shockwave on allograft function was noted both on short- and long-term follow-up.
Urologia Internationalis 02/1995; 55(1):51-5. · 0.99 Impact Factor
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ABSTRACT: A prospective study was undertaken to assess the feasibility and safety of bilateral simultaneous percutaneous nephrolithotomy (BPNL) under single anesthesia. BPNL was attempted in 16 consecutive patients with upper tract urolithiasis suitable for percutaneous treatment bilaterally. Bilateral simultaneous PNL could be accomplished in 14 of 16 cases; the opposite side was abandoned in 2 due to technical reasons. The operating sides could be switched within a short period (15 min) by rotating the patient table by 180 degrees. The average total operating time and irrigation time was 83 and 43 min, respectively. A total of 29 tracts and 18 sessions were required for endourologic treatment of 28 units in 14 patients. There was no significant morbidity. Complete clearance was achieved in 11 of 14 patients; there was insignificant residue in 1, while 2 with major residue required adjunct JJ stenting and extra-corporeal shockwave lithotripsy. The average hospital stay was 5.4 days. After initial proficiency with endourology, preparedness for BPNL is advisable in all such cases.
European Urology 02/1995; 28(2):116-8. · 8.49 Impact Factor
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ABSTRACT: Whether all upper ureteral stones must be manipulated before extracorporeal shock wave lithotripsy (ESWL*) is an ongoing controversy. In a prospective trial, symptomatic patients with solitary upper ureteral calculi less than 1 year in duration were alternated between ESWL in situ and pre-ESWL stone manipulation. Pretreatment excretory urograms were assessed for stone size and degree of proximal hydroureteronephrosis, which was graded from zero (no dilatation) to 3 (severe dilatation). Stone manipulation was done with the patient under intravenous sedation and local anesthesia. A total of 4,000 shock waves was given in a single session using Siemens Lithostar Plus, and treatment was repeated on days 4, 15 and 30 if required. The patients were evaluated 3 months after onset of therapy with excretory urogram and urine culture. Seventy patients qualified for the study (group 1-35 in situ and group 2-35 stone manipulation) and were comparable in relation to age and sex, stone size and degree of hydronephrosis. There was no significant difference between the 2 groups regarding the number of sessions (group 1-1.86 +/- 1.2 and group 2-2.03 +/- 1.2) or shock wave requirement (group 1-5,705.8 +/- 3,536.9 and group 2-5,549.1 +/- 3,837.2) for stone fragmentation. The degree of proximal dilatation did not contribute significantly towards the outcome (F ratio 0.675, p = 0.57). A total of 30 patients (85.5%) in group 1 had a satisfactory outcome at 3 months, while 3 (8.5%) had significant residual calculi and 2 stones could not be fragmented. Of the manipulated stones 33 (94%) were successfully cleared, while 2 patients required auxiliary procedures. Ureteroscopy was required in 1 patient for upward migration of the stent. Morbidity in both groups was comparable. We conclude that upper ureteral stones should be treated in situ to avoid the morbidity of manipulation.
The Journal of Urology 09/1994; 152(2 Pt 1):320-3. · 3.75 Impact Factor
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Archivos españoles de urología 07/1994; 47(5):547.
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ABSTRACT: 46 symptomatic adult patients with documented ureteropelvic junction obstruction were treated with pyeloplasty (n = 23) or endopyelotomy (n = 23). Basic characteristics in both the groups were comparable. The technical aspects, complications and outcome, in the form of improvement in function and drainage patterns, were compared in both the groups. Endopyelotomy enjoyed the significant advantages of a shorter operating time and hospital stay, and obviously better cosmetic acceptance. The major complications in the endopyelotomy groups were related to external drainage and secondary infection in the form of fever, secondary hemorrhage and slippage of tubes in 44, 9 and 13% of cases, respectively. Complications associated with pyeloplasty were prolonged urinary leak, wound infection and urinary tract infection in 12, 17 and 22% of cases, respectively. Using 99Tc-DTPA diuretic scan, an improvement of more than 10% in split renal function could not be documented for any case from either group. In none of the patients did the function deteriorate either. Of all evaluable cases, only 1 in the pyeloplasty group showed a persistent obstructive pattern. The rest all demonstrated adequate drainage across the ureteropelvic junction. Overall in 12 cases (8 pyeloplasty, 4 endopyelotomy) drainage could not be determined postoperatively due to poor radionuclide uptake. A nephrostogram and/or pressure flow study, however, demonstrated a nonobstructive pattern in all these patients. It is concluded that endopyelotomy scores over pyeloplasty with a shorter operating time and hospital stay. The complication rate and outcome following surgery, however, are comparable in both the groups. Using external drainage following endopyelotomy, early resumption of work, however, could not be obtained.
European Urology 02/1994; 26(4):281-5. · 8.49 Impact Factor
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British Journal of Urology 01/1994; 72(6):990.
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British Journal of Urology 11/1992; 70(4):456-7.
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ABSTRACT: Despite the availability of lithotripsy and endourology, clear guidelines on the management of impacted upper ureteric calculi are lacking. In this study, 51 upper ureteric calculi treated with in situ extracorporeal shock wave lithotripsy (ESWL) were classified according to the degree of impaction as indicated by proximal back pressure changes. Patients with mild proximal hydronephrosis (or none at all) had a success rate of 93% but only 35% of those in the impacted group (moderate to severe hydronephrosis) had a successful outcome. A percutaneous antegrade approach to 29 impacted upper ureteric calculi resulted in total clearance in 23 cases; 4 other patients were rendered stone-free following additional procedures, an overall success rate of 93%. The only complication was a ureteric stricture in 1 patient. We recommend the percutaneous approach in the management of impacted upper ureteric calculi.
British Journal of Urology 10/1992; 70(3):252-7.
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British Journal of Urology 07/1992; 69(6):667-8.
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ABSTRACT: Chyluria is a common presentation of filariasis in developing countries and mostly affects economically poor classes. The judicious use of investigations is mandatory to keep the cost of treatment acceptable. A modified plan is suggested for managing such patients without using retrograde pyelography or lymphangiography. A total of 54 patients were studied at 2 separate institutions, with retrograde pyelography being carried out at one institution but not at the other. All patients were treated primarily by the instillation of 1% silver nitrate, with an initial success rate of 70%. Eight patients who failed to respond underwent pyelolymphatic disconnection, the success rate being 88%. The omission of retrograde pyelography and lymphangiography had no effect on either treatment or outcome. The value of these radio-imaging techniques is discussed.
British Journal of Urology 04/1992; 69(3):291-3.
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ABSTRACT: The spectrum of urinary stone disease has changed considerably in India from the common childhood bladder stone to the more frequent upper tract calculi. We analysed the gravel retrieved from the upper urinary tract using X-ray diffraction analysis in an attempt to evaluate the composition of the stones.
We analysed 434 upper urinary tract calculi from May 1993 to June 1994 obtained endourologically, as well as by extracorporeal shock wave lithotripsy and open surgery. The stones were analysed using a Phillips compact X-ray diffractometer (PW1840). The PC-APD software was used for data collection and peak search. The phase matching was done by the software using the JCPDS reference database.
Oxalate stones comprised 97% of the total stones with calcium oxalate monohydrate forming 90% and calcium oxalate dihydrate and mixed stones forming the remainder. Struvite stones were found in 1.4%, while uric acid and apatite stones were less than 1%. There were no cystine calculi. Seventy per cent of calcium oxalate monohydrate and 40% of calcium oxalate dihydrate stones were pure. All the struvite and apatite calculi were almost pure. Only 15% of staghorns did not consist of oxalate. Nine of the ten stones in children were of the calcium oxalate monohydrate variety. The stone composition in females was similar to that in males.
X-ray diffraction data indicate that urinary stone disease in north India is different from that in the western world. Calcium oxalate monohydrate stones predominate. These stones are hard to break and have a different metabolic origin from those consisting of calcium oxalate dihydrate. These findings might help in selecting the most appropriate method of treatment in north India and they indicate directions in which further metabolic studies might be planned.
The National medical journal of India 9(1):10-12. · 0.60 Impact Factor
