Organ donation (OD) is one of the most profound acts of compassion, where a single decision can save multiple lives. However, when OD involves foreign nationals, the process often presents unique challenges. This study presents the case of a 2-year-old brain-dead foreign national who turned out to be India’s youngest foreign national organ donor, highlighting the legal, cultural, and procedural complexities encountered and the gaps in existing frameworks for cross-border OD. Persistent counseling, compliance with procedural and legal provisions requirements, and embassy coordination ultimately led to the kidneys, pancreas, and cornea transplantation, showcasing the success of pediatric-to-adult organ use. This case report emphasizes the need for national protocols to minimize procedural hurdles, prevent delays, and spare donor families’ prolonged grief.
Background: Organ transplantation systems generally follow centralized or decentralized architectures. Centralized systems lack transparency, resulting in ethical issues such as unauthorized waiting-list modifications, unfair organ allocation, and susceptibility to data breaches. While blockchain-based decentralized systems enhance security and trust, they often involve high deployment costs. Additionally, both approaches fail to support real-time monitoring of crucial organ transportation conditions, such as temperature, humidity, vibration, container orientation, and lid open/close status, thereby increasing the risk of organ contamination and degradation. Aims and Objectives: This study aims to develop a transparent, secure, and cost-efficient decentralized framework for organ transplantation logistics by integrating blockchain technology, smart contracts, and Internet of Medical Things (IoMT) devices, with a focus on real-time monitoring and data integrity. Materials and Methods: The proposed system adopts a decentralized blockchain architecture supported by smart contracts to manage transplantation workflows. IoMT sensors embedded within organ containers continuously capture environmental and physical parameters during transportation. Sensor data are securely recorded on the blockchain to ensure immutability, traceability, and authorized access. A comparative analysis is performed to assess deployment cost and system efficiency. Results: The results demonstrate that the proposed system effectively enables real-time monitoring of organ transportation conditions while maintaining transparency and security. The framework achieves high cost efficiency, with a deployment cost of only 0.00111595 Ether, equivalent to approximately 2.74 USD. Conclusion: The proposed blockchain–IoMT–based system enhances trust, reduces the risk of organ degradation, and improves the overall safety and sustainability of the organ transplantation process, making it suitable for scalable healthcare applications.
Background: BK virus nephropathy (BKVN) poses significant challenges in kidney transplantation, often leading to graft dysfunction and loss. This study retrospectively evaluated incidence, risk factors, immunosuppression adjustments, and graft survival among kidney transplant (KT) recipients with BKVN from 2000 to 2024 at Manipal Hospital, Bangalore. Materials and Methods: All adult KT recipients with biopsy-confirmed BKVN as defined by histological viral cytopathy with SV40 positivity and/or plasma BK viral load >104 copies/mL were included; those with incomplete data or <6 months follow-up were excluded. Clinical data were extracted from the institutional records. The continuous and categorical variables were summarized using standard descriptive statistics, with comparisons performed using Wilcoxon, Chi-square, or Fisher’s exact tests. Graft survival was assessed via Kaplan-Meier analysis, with P < 0.05 considered significant. Analyses were performed using the SPSS softwareversion 29. Results: BKVN incidence was 1.29% (20/1541). Mean diagnosis occurred at 14.65 months posttransplant. Median estimated glomerular filtration rate declined significantly from 60.05 to 40.85 mL/min/1.73 m2 at diagnosis (Wilcoxon signed–rank test, P = 0.0001). Graft loss occurred in 30% of cases. Interventions included immunosuppressant dose adjustments and adjunctive therapies. Conclusion: Timely detection and standardized surveillance protocols are critical for the optimal outcomes. Prospective implementation of the proposed screening algorithm, coupled with BKV specific T-cell immunity assays, could clarify optimal viral load thresholds for intervention and prevent allograft dysfunction.
Background: Parasitic infections, though less common than bacterial or viral infections, are a significant yet under-recognized cause of morbidity in renal transplant recipients. Indian literature is largely limited to case reports or small series. Methods: We conducted a single-center retrospective observational study of all renal transplant recipients diagnosed with parasitic infections between January 2010 and January 2025. Demographic, transplant, and clinical data were retrieved. Outcomes assessed included graft dysfunction, hospitalization, and recovery of graft function. Statistical analysis compared single parasitic infection versus co-infection groups. Results: Among 895 renal transplants, 20 patients (2.2%) had experienced 24 parasitic infections. Gastrointestinal involvement was predominant (90%). Three patients (15%) had parasitic co-infection and one had recurrence. The mean age at transplant was 31 years, with male predominance (65%). During infection, the mean serum creatinine rose from 0.9 mg/dl to 1.7 mg/dl, with incomplete recovery in 30%. Graft dysfunction occurred in 55% and hospitalization in 65% including intensive care unit care in 10%. Two patients (10%) died, yielding a patient survival of 90% at follow-up. On comparative analysis, no statistically significant associations were found between co-infection and donor type, induction or maintenance immunosuppression, rejection history, calcineurin inhibitor toxicity, hypertension, or posttransplant diabetes mellitus. Conclusion: This study represents one of the largest Indian series on parasitic infections in renal transplant recipients. It highlights gastrointestinal predominance, frequent graft dysfunction, and high hospitalization despite favorable survival. No specific risk factors were significantly associated with co-infection suggesting multifactorial causation. Early diagnosis and timely therapy remain crucial to optimize graft and patient outcomes.
Postrenal transplant lymphocele is usually a peri-graft collection of fluid in a nonepithelized extra-peritoneal cavity between the allograft renal capsule and surrounding structures (superomedially by peritoneum and anterolaterally by the abdominal wall and pelvic wall). Most often, lymphoceles are found either superolateral or inferior to the allograft. Herein, we report the presentation and management of lymphocele in two cases with atypical anatomical localization. We have analyzed the details of two patients who had postrenal transplant lymphocele collection in atypical anatomical locations. Case 1: A 40-year-old male underwent ABO compatible live-related renal transplantation in 2019. He presented with rising serum creatinine in 2024 for which renal biopsy was done. Histopathology findings showed no evidence of rejection. After 4 weeks of biopsy, he presented with a complaint of early postprandial fullness. On evaluation, a large subcapsular collection was seen anterolateral to the allograft. Case 2: A 39-year-old male presented with swelling in the abdomen in the allograft region after 4 weeks of live-related renal transplantation. On evaluation, a hypoechoic collection was seen in the anterior abdominal wall in the intermuscular and subcutaneous planes. The analysis of fluid collection in both cases was consistent with lymphocele like composition. Both patients were initially managed by drainage and sclerotherapy but finally responded well to laparoscopic deroofing as definitive management. The lymphoceles in an atypical anatomical location such as in the intermuscular or subcutaneous planes or subcapsular region can be successfully managed with laparoscopic deroofing.
Human adenovirus infection is a rare life-threatening event in immunocompromised patients, postsolid organ transplantation, leading to significant morbidity and mortality. We present a unique case of a 52-year-old male, live-related renal transplant recipient, who developed early-onset acute graft dysfunction in the absence of any other clinical features. Graft biopsy revealed interstitial inflammation with lymphocytes, epithelioid histiocytes, and a few tubulocentric ill-defined granulomas. There were no intranuclear viral inclusions. We opined the biopsy as acute pyelonephritis with presumptive adenovirus interstitial nephritis. Subsequently, serum polymerase chain reaction (PCR) for adenovirus was positive, and the patient was managed with intravenous immunoglobulin, along with lowering of immunosuppression. His posttherapy repeat PCR for adenovirus was negative, and his graft function is improving. We highlight a rare infection with its even rarer clinical presentation.
Background: Simultaneous liver–kidney transplantation (SLKT) is a complex but life-saving procedure for patients with combined liver and kidney failure. The present study evaluates the outcomes of SLKT in a single-center setting. Methodology: This was a retrospective analysis of six patients who underwent SLKT at Zydus Hospital, Ahmedabad, between May 2023 and December 2024. Primary outcomes included patient survival, graft function, and postoperative complications. Results: Out of the total six recipients, five patients had normal renal function at the time of discharge, and one patient underwent graft nephrectomy for cortical necrosis. All patients completed a 3-month posttransplant duration with a normal functioning graft. Patients who completed a 12-month duration had no episodes of rejection, and one patient had renal allograft dysfunction related to lack of treatment adherence. Overall, there was no mortality among these patients. One patient developed cytomegalovirus infection, and one patient developed transplant renal artery stenosis. Conclusion: SLKT is a viable option for patients with concurrent end-stage liver and kidney disease, with favorable outcomes.
Duplication of the inferior vena cava (IVC) is a rare congenital vascular anomaly with a reported incidence of 0.1%–3.5%. It is usually asymptomatic and often detected incidentally on imaging or during surgery. We report the case of a 48-year-old female donor undergoing laparoscopic left donor nephrectomy in whom a duplicated IVC was unexpectedly encountered intraoperatively. Preoperative computed tomography angiography failed to identify the anomaly, resulting in significant intraoperative technical challenges due to an extremely short left renal vein. Prompt recognition and careful surgical modification allowed successful donor nephrectomy and transplantation without vascular complications. This case highlights the importance of meticulous preoperative vascular assessment and intraoperative vigilance for rare venous anomalies during donor nephrectomy.
Background: Renal transplantation is the definitive treatment for end-stage renal disease. However, both vascular and nonvascular complications can significantly affect graft and patient outcomes. This study retrospectively evaluates such challenges in our institution. Materials and Methods: We retrospectively reviewed 100 renal transplantations performed at our institution. Data were collected on intraoperative anatomical variations, postoperative complications, and their management. All donor nephrectomies are being done laparoscopically while vascular anastomoses follows no ligation protocol. Results: Multiple renal arteries were found in 11% of cases of renal donor, eight with double arteries and three with triple arteries. Equal-caliber double arteries were managed using pantaloon technique; while arteries with unequal calibers required separate anastomoses. Triple arteries were managed using a no-ligation strategy. One donor exhibited dolichoectasia of the aorta and renal artery with atheromatous plaques, requiring atherectomy. Two patients developed mycotic aneurysms, requiring graft nephrectomy. Urological complications included ureteric stricture and complete duplication, managed via uretero-ureterostomy. One patient with low bladder capacity (120 ml) demonstrated posttransplant adaptive remodeling to 300 ml. Dialysis-dependent female with refractory pseudoporphyria underwent transplant, with complete lesion resolution by the postoperative day-22. Among five ABO-incompatible and four deceased donor transplants, one ABO-incompatible recipient developed fulminant necrotizing pancreatitis and succumbed on day 2, while another developed nonhealing wound by Mycobacterium chelonae which was managed successfully. Conclusion: Vascular anomalies, infectious complications, and ureteric challenges and some unusual entity can substantially impact the transplant outcomes. Tailored surgical approaches and multidisciplinary care ensured successful management, emphasizing institutional preparedness and technical innovation in renal transplantation.
Machine perfusion (MP) in renal transplantation has revolutionized organ preservation, offering advantages over static cold storage methods. This approach involves the continuous circulation of a preservation solution through the renal vascular system, maintaining metabolism and reducing ischemia-reperfusion injury. MP systems include both hypothermic and normothermic variants. Hypothermic MP operates at low temperatures (1°C–10°C), reducing metabolic demands while providing nutrients and oxygen. Normothermic MP maintains organs at physiological temperatures (35°C–37°C), allowing for functional assessment and therapeutic interventions. Kidney viability assessment during MP incorporates several parameters and biomarkers. Perfusion dynamics, including renal blood flow, vascular resistance, and pressure gradient, provides insights into organ function. Biochemical markers such as lactate dehydrogenase, aspartate aminotransferase, and neutrophil gelatinase-associated lipocalin indicate cellular damage and graft function. Real-time imaging and metabolomic profiling enhance organ quality evaluation and outcome predictions. This review highlights advances in graft viability assessment and MP technologies, which improve marginal donor organ utilization and expand the donor kidney pool for transplantation.
Introduction and Objective: Venous anastomosis with a short right renal vein (SRRV) remains a technical challenge in living donor kidney transplantation. Although various manoeuvres are routinely employed to address this, they may occasionally fail to provide adequate venous length. The present study evaluates the role of posterior right renal vein disposition (PRVD), with or without external iliac vein transposition (EIVT), as a rescue technique in such critical situations. Materials and Methods: All living donor renal transplant recipients receiving right renal grafts between January 2023 and July 2025 were included in prospective series. Standard manoeuvres to achieve tension-free venous anastomosis included IVC cuff inclusion, intra-sinus vascular dissection, external iliac vein (EIV) mobilization, and/or internal iliac vein ligation. Failing these manoeuvres PRVD with or without EIVT was used to achieve venous anastomosis. Renal vein length from venous confluence to IVC on CT angiography, available vein length beyond the renal sinus on bench, and apparent vein prolongation after PRVD on bench were measured. Results: Total 61 recipients received right renal grafts. Donor nephrectomy was performed via an open approach in 22 cases (36.1%), laparoscopic with open extraction in 19 cases (31.1%), and total laparoscopic technique in 20 cases (32.8%). A tension-free venous anastomosis was achieved in all transplants. Rescue techniques were employed in selected cases to optimize venous length. PRVD was performed in 20 cases (32.8%)—including 4 open, 5 laparoscopic with open extraction, and 11 total laparoscopic donor grafts. PRVD with EIVT was used in 4 cases (6.6%), while gonadal vein interposition grafting was performed in 1 case (1.6%). Mean renal vein length on CT angiography, mean available vein length beyond the renal sinus on bench were 20.1 ± 3.6 mm and 15.4 ± 1.7 mm respectively. In cases where PRVD or PRVD with EIVT was performed, the mean apparent vein prolongation was 14.8 ± 2.3 mm. Early graft function was satisfactory in all recipients. Conclusion: Posterior renal vein disposition with or without lateral EIV transposition is an effective rescue manoeuvre to tackle SRRV in critical situations in living donor transplantation. This technique also facilitates total laparoscopic approach to right donor nephrectomy.
A 9-year-old male who has been evaluated for recurrent urinary tract infection was found to have right renal agenesis with grade IV Vesicoureteric reflux in the left kidney. He became a case of chronic kidney disease. He underwent Cohen’s left ureteric reimplantation despite the patient’s creatinine level slowly starting to rise, so the patient was put on the transplant list for renal transplantation. His mother came as a voluntary donor. The preoperative assessment was within normal limits; hence, it was planned for right iliac fossa implantation. During the procedure, the patient was found to have a small-sized common iliac artery and an absent internal iliac artery. Hence, anastomosis was done with the renal vessels with the contralateral common iliac vessels, having implanting the kidney in the retroperitoneum through the right iliac fossa incision.
Posttransplant malignancy is a major contributor to both morbidity and mortality among organ transplant recipients, resulting from long-term immunosuppression, oncogenic viral infections, and existing risk factors. While virus-associated malignancies are disproportionately increased, nonviral cancers such as skin cancers and solid organ tumors constitute the majority of cases. The rate of occurrence differs based on the type of transplant, the immunosuppressive regimen utilized, and geographic considerations. Timely detection through regular monitoring, biomarkers, and imaging techniques is vital. As transplant survival rates rise, posttransplant malignancy is becoming an increasingly significant challenge. Customized immunosuppressive approaches, proactive screening, and progress in oncology therapies are crucial for enhancing patient outcomes. This review offers a contemporary overview of the epidemiology, pathogenesis, risk factors, preventive and treatment approaches for posttransplant malignancy. It will also explore the role of adoptive immune therapy and factors affecting the waiting period for retransplantation after treatment.
Background: Everolimus (EVL), a mammalian target of rapamycin inhibitor, offers a potential strategy for calcineurin inhibitor (CNI) minimization in renal transplant recipients, aiming to reduce nephrotoxicity and metabolic complications while maintaining graft outcomes. Real-world evidence from Indian centers remains limited. Methodology: This retrospective, single-center study analyzed adult kidney transplant recipients (2010–2023) converted to EVL for protocol-based pre-emptive switching, biopsy-proven CNI toxicity, or mycophenolate mofetil (MMF) intolerance. Patients with stable graft function, low immunological risk, and minimal proteinuria were included. Clinical data, graft function, infection and rejection rates, and drug toxicities were compared pre- and post-conversion. Subgroup analyses were performed for early (≤6 months) versus late (>6 months) conversion and protocol versus non-protocol indications. Results: Ninety-six recipients (mean age 30.6 ± 10.0 years; 81.3% males) were included, predominantly living-related transplants (87.5%). CNI toxicity (41.7%) was the leading reason for conversion. Overall infections decreased postconversion (44.8% to 33.4%, P = 0.104), with notable reductions in urinary tract infections (15.6%–6.3%) and cytomegalovirus disease (11.5%–7.3%). Rejection rates were stable (15.6% vs. 14.6%), though acute T cell-mediated rejection declined and chronic acute antibody-mediated rejection emerged in some cases. Early conversion was associated with higher drug toxicities (35% vs. 8.3%, P = 0.003), while graft function remained comparable across groups. At a mean follow-up of 58.7 months, graft and patient survival were 87.5% and 86.5%, respectively. Conclusion: Conversion to EVL is a safe and effective CNI-sparing strategy in selected Indian renal transplant recipients, with stable graft function, reduced specific infections, and acceptable rejection rates. Early conversion may increase drug-related toxicities, underscoring the importance of timing and patient selection.
Globally, the demand for heart transplantation exceeds the available donor hearts, resulting in a persistent supply-demand gap. The objectives of this article are to identify potential challenges in facilitating heart donation, ascertain the rationale for community-based strategies, and propose effective public health interventions to bridge existing gaps. The practice of heart donation, specifically, and organ donation in general, has been plagued by the presence of different concerns in India. Acknowledging the wide gap in supply and demand for donated hearts and the presence of multiple factors that cumulatively determine rates of heart donation, there is an immense need to adopt community-based interventions, as they can play a crucial role in building trust within the community through their engagement. In conclusion, community participation has been recognized as a critical strategy for enhancing heart donation practices. The implementation of sustainable and culturally rooted strategies, well-supported by the involvement of different stakeholders, is crucial to discourage myths, improve consent, and expand the pool of heart donors.
