Transplantation Reports最新文献

Objective

We sought to assess the potential association between history of bariatric surgery and graft rejection among solid organ transplant (SOT) recipients.

Methods

We conducted a single-center retrospective study of adult (age ≥18 years) SOT recipients (2000-2015) at a large tertiary care transplant network with graft rejection and bariatric surgery history according to the international classification of diseases 9^th revision. Data were analyzed using ANOVA, Chi Square, Fisher Exact tests, and logistic regression.

Results

Of 4363 SOT recipients, 72.6% had a history of graft rejection and 55 (1.3%) had a history of bariatric surgery. On univariate analysis, patients with graft rejection were more likely to have a history of bariatric surgery than those without organ rejection (1.5% vs. 0.7%, p=0.015). In multivariable analysis adjusted for age, transplant organ type, and history of calcineurin-based immunosuppression, there was increased odds of rejection among those with a history of bariatric surgery (Odds Ratio (OR): 3.01, 95% Confidence Interval (CI):0.98-4.46, p=0.05). However, when adjusted for body mass index at transplant, the association was attenuated (OR:3.48, CI:0.81-14.9, p=0.10).

Conclusion

Our single-center data indicate that the relationship between a history of bariatric surgery and graft rejection after SOT may be explained by obesity.

Introduction

: Direct thrombin inhibitors are drugs of choice used to prevent thrombotic complications in hospitalized patients after heparin induced thrombocytopenia (HIT) diagnosis.

Material and method

: We present a case of bivalirudin resistance in patient undergoing heart transplantation due to dilated cardiomyopathy with confirmation of HIT. Bivalirudin was given intraoperatively as cardiopulmonary bypass circulation was applied. From initial infusion rate of 2.5 mg/kg/hour, up to 4 mg/kg/hour, due to low ACT results. The repeated ACT results were 422s, 452s and 468s on 5 minutes intervals.

Conclusion

: Resistance to bivalirudin, though rare, can be overbeared by high bivalirudin dosing under ACT control during surgical procedures including heart transplantation.

Introduction

Kidney transplantation (KT) demands that patients navigate a complex healthcare system and adhere to lifelong therapy and surveillance. Cultural and linguistic discordance between patients and providers has been identified as a barrier to successful KT. We studied KT outcomes and disparities among a native Somali population living in Minnesota.

Methods

Between 1995 and 2015, 2,385 patients underwent KT at our institution; 22 were self-designated Somali nationals. Patient and graft survival and time to first rejection were analyzed. Utilization of interpreter services was evaluated.

Results

Patient survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; compared to 97.2% at 1 year and 89.1% at 5 years for the Caucasian cohort (p = 0.40). Graft survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; for the Caucasian cohort 94.8% and 81.6% (p = 0.35). Rejection-free survival in the Somali cohort was 100% at 1 and 5 years, for the Caucasian cohort 86.2% and 82.1 (p = 0.41). Among 22 adult Somali KT recipients, 15 (68%) patients frequently utilized interpreter services in their KT-related clinical encounters.

Conclusion

Immigrant Somali KT recipients, appear to have comparable KT outcomes compared to a contemporaneous Caucasian cohort.

Budd Chiari syndrome (BCS) results from hepatic outflow obstruction. Endovascular management to restore venous patency, including inferior vena cava (IVC) angioplasty with stenting, and transjugular intrahepatic shunt (TIPS) placement to decompress liver congestion, have become standard of care. Herein, we describe a patient with BCS requiring liver transplantation and the surgical technique of suprahepatic IVC anastomosis including thoracic extension of an IVC stent with a review of the relevant literature. A 29-year-old female with BCS due to polycythemia vera, who had been previously managed with TIPS and IVC stent placement, was taken for liver transplantation. Preoperative imaging confirmed stent extension into the thoracic IVC and the stent was unable to be removed intraoperatively. The thoracic IVC was clamped through the diaphragm at the level of the right atrium and the stent was left in place and incorporated within the suprahepatic anastomosis with good vascular outcome at one year follow up. Diligent preoperative preparation is essential with adequate imaging and cardiac surgical consultation in patients with malpositioned stents. Review of the literature shows four cases in which performing the suprahepatic anastomosis including an embedded stent is a viable alternative that allows for avoidance of a thoracotomy.

Background

The presence of autoantibodies to angiotensin 2 type 1 receptor (anti-AT1R) have been implicated in allograft pathobiology following organ transplantation. While the significance of these antibodies has been described in renal transplantation, relatively few studies have examined their frequency and clinical implications in heart transplant patients.

Methods

We analyzed serum collected from 291 heart transplant recipients at the time of transplantation for the presence of anti-AT1R and repeated testing on serum collected from 176 of these patients following transplantation. Patients were followed for outcomes including overall survival, rejection episodes (acute cellular and antibody mediated), coronary allograft vasculopathy, and measures of allograft structure and cardiac function.

Results

Anti-AT1R was detected in the serum of 165/291 patients pre-transplant and in 86/176 patients post-transplant. The detection of anti-AT1R (either at risk or positive) compared with no detection in serum of patients pre- or post-transplantation had no influence on 10-year survival (Log rank 0.061 and 0.228, detection pre- or post-transplant, respectively). Similarly, the detection of anti-AT1R had no influence on important clinical outcomes of heart transplantation including acute cellular rejection (ACR), antibody-mediated rejection (AMR) or cardiac allograft vasculopathy (CAV), left ventricular ejection fraction (LVEF) or left ventricular mass (LV-mass).

Conclusions

The presence of anti-AT1R detected in patient serum samples by commercially available testing pre- or post- heart transplantation was not associated with clinically important outcomes including LV-mass, LVEF, ACR, AMR, CAV and overall survival. Our data brings into question the relevance of anti-AT1R testing as a risk factor or target for therapy among heart transplant recipients.

Background

The optimal management of calciphylaxis in kidney transplant recipients (KTRs) is uncertain.

Case presentation

We report 2 cases of refractory calciphylaxis in KTRs who suffered from persistent secondary hyperparathyroidism. They failed initial therapy with sodium thiosulphate but responded to treatment with bisphosphonates. No adverse events were noted with bisphosphonate therapy.

Conclusion

Bisphosphonates appear to be an effective therapy for KTRs with calciphylaxis who cannot tolerate or respond poorly to STS, particularly if they have persistent hyperparathyroidism post-transplantation.

Belatacept is a novel fusion protein that blocks signal two of T cell activation. Belatacept was approved in 2015 for the prevention of acute rejection in kidney transplant recipients. Results from a 2014 phase II clinical trial in liver transplant recipients was terminated early due to an increased risk of death and graft loss, leading to a black box warning for its use in liver transplant recipients. Here we describe the clinical course of a 55 year old male patient who underwent a liver transplant for cholestatic liver disease. His post-transplant course was complicated by multiple episodes of severe acute cellular rejection as well as multiple complications from maintenance immunosuppression including chronic kidney disease (CKD), steroid-induced diabetes, mycophenolate-associated colitis, and mammalian target of rapamycin (mTOR) inhibitor-induced lung injury. Belatacept was initiated 5 years post-transplant as a last-line option for maintenance immunosuppression. Six months post-initiation, the patient has had stabilization of his CKD, improvement in lung function, and remains without evidence of acute or chronic rejection.

Purpose

Outcome of pediatric liver transplant patients is affected by various factors, including critical care management in the early phase following surgery. This article focuses on early recognition of complications in pediatric liver transplant patients in Pediatric Intensive Care Unit (PICU). In particular, this article highlights the common problem in post-liver transplant pediatric patients in Indonesia, and the strategies to optimize recovery and minimize complications.

Summary

Almost every system organ is affected by the surgery and medications given intra- and post-operatively. Careful monitoring and appropriate management are needed to ensure long-term success of surgery and prevent both early and late complications. Early extubation is recommended, however some may need PEEP titration to obtain optimal oxygenation. Advanced hemodynamic monitoring paired with clinical signs is recommended for optimal perfusion and ventriculo-arterial coupling. Routine electrolytes examination and neurological assessment are needed. Infection control and immunosuppression have to be optimized. Early enteral nutrition, nutritional support for recovery is needed, however should be gradually administered in malnourished patients.

Conclusion

Early detection of post-transplant complications must be identified to ensure appropriate management is given as soon as possible. The ultimate goal is to retain graft acceptance as long as possible and the reduction of morbidity and mortality post-transplantation.

Today, bariatric surgery has become the main therapeutic means to fight against the escalating increase in obesity, worldwide. Besides that, non-alcoholic steatohepatitis has inflated its indication for liver transplantation. Liver transplant surgeons are prone to face more and more patients with such background. Here, we described the first case of liver transplantation for hepatocellular carcinoma in a patient with previous history of biliopancreatic diversion with duodenal switch. Biliopancreatic diversion with duodenal switch is nowadays an uncommon bariatric surgery but use to be a second stage surgery following sleeve gastrectomy. Liver transplantation can be challenging as such bariatric procedure reshape the digestive anatomy and can also be responsible for malnutrition. Without such complication and in a center specialized in bariatric surgery and liver transplantation, such cases can be successful and should not alarm liver transplant surgeons. In our case, the bariatric anatomy was conserved, and the liver transplantation was successful, without difficulty of the post-operative immunosuppressive treatment. However, long term follow-up showed an exacerbation of the sarcopenia level and establish even more the need for an association of a well-planned physical and nutritional rehabilitation in the peri-operative period in such candidate.

Immunoglobulin A (IgA) Nephropathy (IgAN) is one of the most common recurrent glomerulopathies associated with graft loss and patient survival after kidney transplantation (KT). Steroid withdrawal regimens in KT have been associated with improvements of patient outcomes. The Scripps Center for Organ Transplantation (SCOT) utilizes a rapid low-dose steroid withdrawal immunosuppression (IS) protocol for KT maintenance. We assessed the impact of our protocol on IgAN recurrence over a 10-year period to reassess our steroid withdrawal and IS protocols to see if outcomes diverged from available UNOS data. Therefore, we used IS and induction matched retrospective data from UNOS to investigate patient and graft survival for IgAN. SCOT recurrence rates for IgAN was 13.6%. Overall outcomes of graft failure and recipient death did not differ between SCOT patients and data obtained from steroid free transplants from UNOS. Our results differ from earlier studies showing IgAN was associated with a higher risk of graft loss, perhaps due to selection of a SCOT IS matched dataset. Based on our analysis, we believe that it is safe to continue the steroid avoidance protocols at SCOT and think that it may be beneficial, given the adverse effects and toxicities associated with steroid use.