Multiple infections after commercial renal transplantation in India.

Sir, The increased demand for transplantable kidneys has not met with a corresponding increase in the supply of these organs. Many patients travel to other, mostly developing countries, in search of commercial transplantation. In order to perform the procedure rapidly, standards of transplanta-tion are compromised [1]. Besides the clinical issues, ethical problems are also of equal concern. We report the case of a 56-year-old Slovenian male who underwent renal transplantation for undiagnosed chronic renal failure. He refused a suggested haemodialysis and await for transplantation. With no consultation with a nephrologist, he privately arranged the transplantation in India. Live-donor renal transplantation was performed in September 2004, in a New Delhi private clinic. The donor was a 28-year-old male from Bangladesh. The post-operative course was uneventful, and the patient was discharged from the hospital on the day 10. Tacrolimus and methylpredniso-lone were used for immunosuppression. The patient immediately returned to Slovenia and consulted his nephrologist. His initial renal function and laboratory parameters were within normal ranges. Three weeks after the transplantation he became febrile; ESBL-producing Escherichia coli was isolated from blood and urine cultures. Despite treatment with imipenem he remained febrile. Aspergillus terreus was isolated from a partially dehiscent post-operative wound, followed by positive serum galactomannan assay. Treatment with voriconasol was initiated. On the day 40, deep venous thrombosis of the right ileofemoral vein developed (the allograft vein was anastomosed to the right external iliac vein). A few days later, Plasmodium falciparum and Plasmodium vivax were found in the peripheral blood smear (Figure 1A). He was treated with intravenous quinine; parasitaemia (initially 4.8%) cleared in 6 days and his condition temporally improved. On the day 53, symptoms and signs of infection reappeared and renal function began to deteriorate. On the basis of a computed tomography scan and sequential renal scintigraphy, a urine leak from the lower renal pole was suspected; the allograft was removed and immunosuppres-sion stopped, the patient was placed in the intensive care unit. The clinical suspicion was confirmed, as the lower pole of the kidney was found to be necrotic (Figure 1B). From the necrotic kidney tissue, ESBL-producing E. coli, Mucor spp. (Figure 1C) and Mycobacterium fortuitum were isolated. Furthermore, strongly birefringent crystalline vascular Fig. 1. (A) Plasmodium falciparum and Plasmodium vivax in the patient's peripheral blood smear. (B) Necrosis of the lower pole of the transplanted kidney. (C) The surface of severely inflammed and necrotic pelvic mucosa covered …