Case Report Cochlear Implant Surgery after Renal Transplant

Sensorineural hearing loss is common in patients with chronic kidney disease (CKD), occurring in 29% of children with end-stage renal disease and in 47% after renal transplantation1. CKD leads to immunosuppression, which has been reported to be associated with poor wound healing and/or infection. These issues are leading causes of morbidity in patients receiving solid organ transplantation2. For cochlear implantation, the common cause of morbidity is wound complication and meningitis. Due to these risks, cochlear implantation is rarely undertaken in a patient who underwent a renal transplant. Case


Introduction
Sensorineural hearing loss is common in patients with chronic kidney disease (CKD), occurring in 29% of children with end-stage renal disease and in 47% after renal transplantation 1 .CKD leads to immunosuppression, which has been reported to be associated with poor wound healing and/or infection.These issues are leading causes of morbidity in patients receiving solid organ transplantation 2 .For cochlear implantation, the common cause of morbidity is wound complication and meningitis.Due to these risks, cochlear implantation is rarely undertaken in a patient who underwent a renal transplant.

Case
A 12 year old male was diagnosed at age 2.5 years to have a posterior urethral valve leading to reflux nephropathy.This progressed to chronic renal failure, and subsequently endstage renal disease (ESRD).He underwent fulguration of the posterior urethral valve , and seven years later he developed renal infection for which he received intravenous antibiotics.Within a week, he developed bilateral tinnitus and a sensorineural hearing loss, which gradually worsened.He was fitted with bilateral behind-the-ear hearing aids at that time.The child underwent a renal transplant in 2008 at the age of 10 years and is currently on immunosuppressive drugs (Cyclosporin, Prednisolone, Mycophenolic acid and Lercanidipine Hydrochloride) since then.

Abstract
We share our experience of the child with chronic kidney disease who developed profound bilateral sensorineural hearing loss, and later underwent renal transplant surgery, and subsequently cochlear implant surgery.The aim of the study is to look at the co morbidity and the complications associated with implanting an immunosuppressed kidney transplant recipient child.A 12 year old child who develops bilateral sensorineural hearing loss at the age of 7 years and underwent kidney transplant at the age of 10 years, was implanted with nucleus implant.The Child's progress in intra operative and post operative period was monitored.The child developed appropriate improvement in hearing as per expectation.This was a challenging case and only few such cases of organ transplant with a cochlear implant have been reported so far.Our implantee has done extremely well and cochlear implant surgery should be offered when indicated in renal transplant patients too.The high prevalence of Pseudomonas Aeruginosa is consistent with nosocomial infection and occurs mainly in first month after surgery.Between 1 and 6 months, there is an increased risk of opportunistic infections and after 6 months, most infections are commonly acquired.Additionally, there is an elevated risk of infection related to invasive devices 5 .Commonly used drugs after kidney transplant are Cyclosporin, Prednisolone, Myfortic (Mycophenolic acid), and Lotensyl (Lercanidipine hydrochloride).Liver transplants carry higher infection risks due to more common use of cyclosporine, which inhibits cytotoxic T cells 6 .The introduction of Mycophenolate Mofetil and Sacrolimus did not result in a significant increase in transplant wound-healing complications 7 .The anti inflammatory effect of immunosuppressive drugs peaks between 1 and 6 months, this should be considered before undertaking a cochlear implant surgery 2 .Severe intracranial infections can occur due to the insertion of such a device, so cochlear implants have not been generally described in children following kidney transplantation.In our case we showed that with antibiotic prophylaxis and an unchanged immunosuppressive drug regime, a cochlear implant can be inserted without complications.Care should be taken not to miss any immunosuppressive medication, and immunization prior to transplantation against pneumococci and meningococci should be done.The standard preoperative work up and close communication with the renal transplant team is advisable for safe and effective cochlear implantation after renal transplant.

:
End stage renal disease, immunosuppression, cochlear implant, nosocomial, sensorineural International Journal of Case Reports in Medicine __________________________________________________________________________________________ Magnetic Resonance Imagi ear and brain did not reveal any abnormalities.After consultation with the child's parents, audiologist, nephrologist, and ENT specialist, the child received a cochlear implant at the age of 12 years in his left ear (i.e. 2 years after his re ______________Satinder Singh, Shalabh Sharma, A.K.Lahiri Reports in Medicine, DOI: 10.5171/2014.

Figure 1. Cochlear implant aided audiogram showing hearing thresholds above speech banana curve in left ear Discussion
A.K.Lahiri, Asha Aggarwal and A.K.Bhalla (2014), International Journal of Case in Medicine, DOI: 10.5171/2014.160084

Cochlear implant aided audiogram showing hearing thresholds
Shalabh Sharma, A.K.Lahiri, Asha Aggarwal and A.K.Bhalla (2014), International Journal of Case Reports in Medicine, DOI: 10.5171/2014.160084Bacterial infections are the most common and are mainly related to gram-negative bacteria.