Background: TB is encountered worldwide more frequently among renal transplant recipients than in the general population. It is reported to be nearly 50 times higher in the renal transplant population because of immunosuppression. TB may arise from unrecognized infection in the allograft or acquisition of new infection after transplantation. Objective: The aim of the current work was to determine prevalence and risk factors for development post-transplant TB, and the impact of post-transplant TB in live donor renal transplantation on both patient and graft survival. Patients and methods: This retrospective cohort study carried out in the Nephrology Unit, Mansoura Urology and Nephrology Centre in Association with Nephrology Unit, Zagazig University Hospitals in the period between January 2020 to December 2020. Included 210 patients out of 3200 kidney transplant recipients (KTRs) who underwent renal transplantation in the period between March 1976 and December 2019, divided into 2 main groups according to development of post-transplant tuberculosis, a group of 70 (KTRs) who developed tuberculosis after transplantation served as a study group and a matched group of 140 (KTRs) who did not develop tuberculosis after transplantation served as control group and evaluation of two groups through risk factor to develop TB, demographical data, clinical, laboratory and radiological evaluation. After that TB group was subdivided into 2 groups according to the site of infection: pulmonary and urinary TB. Results: Body mass index was higher among control group with statistically significant difference. Associated medical disorders as post-transplant diabetes, post-transplant bacterial and CMV infection had higher incidence among TB group. Liver enzymes and calcineurin (CNI) levels showed statistically significant difference among TB group before and during anti tuberculous treatment, in which liver enzymes were elevated while CNI levels were significantly reduced during antituberculous treatment. Post-transplant CMV infection was higher in patients who developed pulmonary TB. Graft and patient survival were comparable among both groups with no significant difference. Conclusions: It could be concluded that post-transplant diabetes, bacterial and CMV infections increase risk of development of post-transplant TB. There was no effect of post-transplant tuberculosis on both patient and graft survival.

Background and Aims TB is encountered worldwide more frequently among renal transplant recipients due to of the state of immunosuppression. Antituberculosis drugs cause CYP-450 enzyme induction that increase the metabolism of CNI and mTORi So, decreasing the plasma trough level which in turn expose the transplant recipient to the risk of rejection. Our study concerned with the impact of post-transplant TB on live donor kidney transplant recipients outcome. Method This is retrospective cohort study held in Urology and Nephrology Center, Mansoura University, Egypt. The study included 210 patients out of 3200 kidney transplant recipients (KTRs) who underwent renal transplantation at Mansoura urology and Nephrology Centre between March 1976 and December 2019. The patients were divided into 2 main groups according to history of post-transplant tuberculosis, a group of 70 kidney transplant recipients who developed tuberculosis after transplantation served as a study group and a matched group of 140 kidney transplant recipients who did not develop tuberculosis after transplantation served as control group. Study group was then subdivided into pulmonary and urinary TB groups. Results We found that patients with Low BMI are associated with higher incidence of post-transplant TB (p value: 0.023). While, post-transplant TB was associated with increased incidence of post-transplant DM, bacterial infection, CMV infection and surgical wound infection. Exposure to rejection episodes (either acute or chronic) is comparable among both groups. Post-transplant diabetes incidence was higher among TB group with statistical significant difference (p value: 0.01). Bacterial infection incidence including pneumonia, urinary tract infection and gastroenteritis were associated with higher incidence of TB with statistically significant difference (p value: 0.012). CMV infection incidence was significantly higher among TB group (p value: 0.02). Incidence of wound infection post-transplantation was higher among TB group with statistically significant difference (p value: 0.014). Both groups were comparable regarding creatinine and creatinine clearance at last follow-up (p value: 0.61, 0.51 respectively). Overall, there was no statistically significant difference among both groups regarding 5, 10 and 15 years graft and patient survival (p value: 0.54, 0.15 respectively). During treatment of TB in the study group, there was statistical significant difference regarding liver enzymes and CNI doses either before or during anti-tuberculous treatment as liver enzymes were elevated (p value: 0.023) and higher doses of CNI were required to achieve satisfactory trough level during antituberculus treatment (p value: 0.037). Liver enzymes dropped significantly and lower doses of CNI were used after cessation of anti-tuberculous treatment (p value: 0.041, 0.03 respectively). Study group was then subdivided into 2 main groups: pulmonary TB (42 KTRs) and Urinary TB (28 KTRs). There was no statistical significant difference among both groups regarding baseline data, transplantation data, post-transplant medical complication except that CMV infection incidence was higher among pulmonary TB group (p value: 0.012). Patient and graft survival were comparable. Conclusion Among renal transplant recipients, tuberculosis is a serious problem for both the disease itself and its treatment with anti-tuberculous medications. In our series the rejection was comparable in both groups (with or without tuberculosis) this may be explained by frequent monitoring of the immunosuppressive drug level.

Background and Aims Vascular access remains a significant challenge for patients on chronic hemodialysis (HD) and often requires creative thinking to preserve and construct durable long-term access. While AVFs continue to remain the gold standard for vascular access, HD access remains an ongoing challenge for surgeons and patients. The cases This report is about 4 ESRD patients on chronic hemodialysis with multiple closed A-V fistulas (left and right radiocephalic then left and right brachiocephalic). Also, they suffered from catheter related blood stream infection (CRBSI) when central lines were inserted so the vascular sureon had to find solutions for them. First patient was 36-year old hemodialysis patient since 1995 2ry to posterior urethral valve. In 1994, he sought renal transplantation from his motivated brother who was the only available living related donor but unfortunately the surgeon discovered a congenital anomaly in the donor side during surgery. So the patient was maintained on hemodialysis. After multiple thrombosed AVF and recurrent episodes of CRBSI with central lines, the vascular surgeons inserted a synthetic graft on left chest wall between axillary artery and axillary vein 3 years ago and it is well functioning with efficient dialysis. The 2nd case (figure 1) is a 42-year old graft failure patient since 2005 and In view of high PRA, 2nd renal transplantation was not an option. After multiple thrombosed AVF and recurrent episodes of CRBSI with central lines, the vascular surgeons created a new fistula in lower extremities between right great saphenous vein and common femoral artery 2 years ago and it is still functioning. The 3rd case (figure 2) is about 14-year old child who received renal allo-transplantation from his father 8 years ago. Now, he is on chronic hemodialysis. First, he underwent peritoneal dialysis. But he suffered from recurrent peritonitis, so he was shifted to hemodialysis. Unfortunately, he suffered from CRBSI with catheters and multiple AVF were thrombosed. So, vascular surgeons performed arterio-arterial synthetic graft using right subclavian artery which is well functioning over 2 years. The 4th case (figure 3) is about 43-year old graft failure case on chronic hemodialysis with widespread thrombosis and difficult central line fixation. Also,AV fistulas had short survival. So, vascular surgeons decided to create AVF in lower extremities between right greater saphenous vein and superficial femoral artery 2 years ago. The patient after that received warfarin and the graft is functioning well till now. Conclusion Hemodialysis access remains an ongoing challenge for surgeons and patients lives.

Background and Aims In 1960, Clyde shields (1st chronic hemodialysis patient) developed severe hypertension under treatment.His physician “Dr.scribner” decided to treat this complication using ultrafiltration to deplete the extracellular volume which was thought to be responsible for the increased blood pressure.It was successful, blood pressure decreased to normal and Clyde remained alive for 11 years.from these coming the rationale of dry body weight and its value in improving dialysis patient and improving his survival and decreasing his suffering. Several different techniques have been used to derive more standard methods of assessment dry weight, however optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. AIM To assess value of using IVC diameter and collapsibility index in modification of dry body weight in hemodialysis patient. Method A single center study included 98 patients hemodialysis patient unit in our center. all patients were subjected to assessment of IVC diameter before and after one hour of the first hemodialysis session of the week using ultrasound. We choose muscle cramps as an indicator for hypovolemia . Patients were allocated in two groups. Group 1 : patients with muscle cramps (hypotension) at last hour of session& Group 2 :without muscle cramps (normotensive or hypotensive) at last hour of session. Patients with other causes of muscle cramps rather than hypovolumia were excluded (e.g. hypocalcaemia, l-carnitine deficiency ,etc) . Results Patients with muscle cramps in last hour of session were 8 patients with average ivc diameter 0.7 cm & collapsibility more than 80%.Patients without muscle cramps in last hour of session were 84 patient with average ivc diameter 1.3 cm & collapsibility more than 50%. On interpretation of the eight patient :one patient had bilateral lower limb edema 2ry to local cause (varicose vein) not as a part of overload, three patient had uncontrolled blood pressure cannot tolerate more UF and was hypovolemic but on need to increase antihypertensive medication, two Patients had improved nutritional status with increased lean body mass, one patient had prepare for transplantation and during coarse of preparation NCCT chest showed bilateral diffuse ground glass opacities (overload versus interstitial lung disease). There was marked improvement, however NCCT still revealed ground glass opacities, in spite of patient become hypovolemic (clinically and confirmed by IVC diameter ), so patient investigated for the cause of interstitial lung disease and unfortunately diagnosed by further investigation as latent TB. Conclusions Using of ultrasound in assessment of IVC diameter is a promising method for estimating dry body weight in hemodialysis patient because it is simple, quick ,non-invasive and helpful especially in debatable cases. Conclusion Using of ultrasound in assessment of IVC diameter is a promising method for estimating dry body weight in hemodialysis patient because it is simple, quick ,non-invasive and helpful especially in debatable cases.