Transplantation proceedings最新文献

While renal transplantation significantly enhances both life expectancy and quality of life in patients with end-stage renal disease, the necessity for lifelong immunosuppressive therapy, aimed at prolonging graft survival and maintaining optimal function, comes with certain disadvantages, including an increased risk of developing related complications such as infections, cardiovascular disease, or various types of cancer. Given the limited availability of renal grafts, urologists often endeavor to preserve these precious resources whenever possible. This report examines a 62-year-old woman with a kidney transplant who developed recurrent renal carcinoma, first identified 13 years after the transplant and recurring 3 years later, necessitating 2 partial nephrectomies on the graft. This case report underscores the crucial importance of early diagnosis in renal allograft malignancy and highlights the favorable outcomes achievable through partial nephrectomy, even in recurrent tumors. This is the first report of recurrent RCC in a renal allograft successfully treated with 2 consecutive nephron-sparing surgeries (NSS).

Primary sclerosing cholangitis (PSC) is a chronic cholestatic disorder characterized by inflammation and subsequent fibrosis of the intrahepatic and extrahepatic bile ducts. Its clinical course is variable and may progress to advanced cirrhosis, requiring liver transplantation as the treatment of choice. At our center, we conducted a retrospective observational study of patients who underwent liver transplantation due to PSC between 1998 and 2024. The objectives were to evaluate post-transplant survival, identify the most frequent cause of mortality, determine the incidence of incidental cholangiocarcinoma (CCA) in the explanted organ, and assess the recurrence of the underlying disease. Out of a total of 1,507 liver transplant recipients, 1.53% (n = 23) underwent transplantation due to PSC. Five-year survival was 87%, decreasing to 73% at 10 years. The most frequent cause of mortality was de novo tumors (50%, n = 4). With regard to the incidence of incidental CCA in the explanted organs, no cases were identified. Disease recurrence after transplantation occurred in 17.4% (n = 4). In conclusion, our study highlights that, although no cases of incidental CCA were observed in the explanted livers of our cohort, this does not imply any change in the well-documented risk of developing CCA in PSC patients reported in the literature. The recurrence rate of PSC after transplantation was consistent with published data, and overall survival exceeded 70% at 10 years post-transplant.

Background: Heparin-induced thrombocytopenia (HIT) is a rare but potentially fatal immune-mediated complication of heparin therapy. Its incidence is higher after left ventricular assist device (LVAD) implantation compared with other cardiac procedures. While bivalirudin is the most frequently reported alternative anticoagulant in this setting, evidence on argatroban use remains limited. We describe three cases of HIT following HeartMate 3 LVAD implantation, all managed with argatroban.

Results: Two patients were successfully transitioned to acenocoumarol (international normalized ratio 2-2.5) and discharged without hemocompatibility-related adverse events, without antiplatelet therapy. The third patient, with multiple thrombophilic disorders (homozygous G20210A prothrombin mutation, low protein C, positive lupus anticoagulant, and mild hyperhomocysteinemia), developed ventilator-associated pneumonia and septic shock, experienced mild bleeding at puncture and tracheostomy sites, and died postoperatively; anticoagulation transition was not achieved. In our cohort, HIT incidence was 10% overall (30 LVADs) and 15% among HeartMate 3 implants (20 LVADs), aligning with prior reports.

Conclusions: Argatroban appears to be an effective and safe alternative anticoagulant for HIT after LVAD implantation, enabling platelet recovery without a significant increase in bleeding or thrombotic events. Differentiating complications attributable to HIT or argatroban from those inherent to LVAD support remains challenging, given the device's intrinsic risks of thrombosis, bleeding, and mortality.

Background: Liver transplantation from previously transplanted donors is an emerging yet rarely reported strategy to address global organ shortages. This case describes the clinical course and outcome of a liver transplant recipient who received an organ from a multiorgan donor recently submitted to pancreas-kidney transplantation.

Case presentation: A 40-year-old woman with Budd-Chiari syndrome underwent orthotopic liver transplantation. The donor was a 24-year-old male with type 1 diabetes mellitus and end-stage renal disease who had received a pancreas-kidney transplant 10 days before suffering a fatal hemorrhagic stroke. Due to retrohepatic inferior vena cava agenesis and thrombosis in the recipient, a classical caval replacement technique was employed. The patient initially progressed well but developed a biliary anastomotic stricture at 4 months post-transplant. Despite multiple endoscopic procedures, she developed biliary cast syndrome and underwent Roux-en-Y hepaticojejunostomy. Postoperatively, she developed septic shock and died on the 10th postoperative day. Organ donation in this case was conducted in accordance with the ethical standards of the Helsinki Congress and the Istanbul Declaration.

Conclusion: This case supports the feasibility of using livers from recently transplanted donors when stringent selection criteria are applied. It also underscores the technical complexity of liver transplantation in patients with Budd-Chiari syndrome and the significant risk of biliary complications. Organ reuse may represent a valuable approach to expand the donor pool, but it must be carefully weighed against procedural risks and ethical standards.

Background: Lung transplantation represents the most definitive treatment option for patients with advanced-stage lung diseases. In recent years, improvements in anesthetic techniques, medical technologies, and coordinated perioperative care have contributed to better survival outcomes.

Case presentation: A 37-year-old male patient with a height of 168 centimeters and a weight of 70 kilograms, diagnosed with cystic fibrosis, was scheduled for bilateral lung transplantation. Shortly after transitioning to single-lung ventilation, a rapid and severe increase in carbon dioxide levels was observed, reaching 136 mm Hg, accompanied by a decrease in blood pH to 7.0, indicating pronounced respiratory acidosis. In response, flow-controlled ventilation was applied for 6 hours during the eleven-hour surgical procedure.

Conclusions: Although the patient's respiratory profile initially suggested the need for extracorporeal membrane oxygenation, the application of flow-controlled ventilation appeared to improve carbon dioxide elimination and may have reduced the risk of complications related to extracorporeal support. This case indicates that flow-controlled ventilation could be considered a supportive ventilation strategy to avoid extracorporeal membrane oxygenation in selected patients undergoing lung transplantation who develop isolated intraoperative respiratory insufficiency.

Background: West Nile virus (WNV) is an emerging arbovirus in southern Europe, transmitted seasonally by vectors, with increased risk of severe forms in immunocompromised hosts such as kidney transplant recipients.

Methods: We report 3 cases of neuroinvasive WNV infection in kidney transplant recipients in Spain between June and September 2024. Demographic, clinical, microbiological, neuroimaging, treatment, outcome, and renal function data were collected.

Results: All 3 patients developed neuroinvasive disease: 2 meningoencephalitis and 1 acute flaccid paralysis. Serum IgM was positive in all cases; cerebrospinal fluid (CSF) IgM in 2, and WNV PCR was positive in blood and urine in 1. Management included empirical antibacterial/antiviral therapy, reduction of immunosuppression, and intravenous immunoglobulin (IVIG) in 1 case. Outcomes varied: one patient fully recovered without sequelae, one had transient mild neurological deficits, and one developed irreversible neurological impairment and died after a prolonged hospitalization. Renal graft function remained stable in 2 cases, while one showed progressive deterioration during follow-up.

Conclusions: WNV is an emerging threat for kidney transplant recipients in Spain, associated with high morbidity, mortality, and neurological sequelae. Early diagnosis and tailored reduction of immunosuppression are essential, whereas the benefit of IVIG remains uncertain. Development of specific management protocols is needed in this high-risk population.

Background: Antibody-mediated rejection (AMR) after lung transplantation is defined by allograft dysfunction, detection of donor-specific antibodies (DSAs), and exclusion of alternate etiologies. Extra-pulmonary manifestations are exceptionally uncommon.

Case presentation: We report a 47-year-old man, status post bilateral lung transplant for coal workers' pneumoconiosis, who presented with progressive hypoxemia, tremors, right-sided weakness, dysarthria, headaches, and personality changes over 2 months. Comprehensive neurologic, infectious, and oncologic evaluations-including magnetic resonance imaging (MRI) of the brain, cervical and thoracic spine; lumbar puncture; and positron emission tomography-computed tomography (PET-CT)-were unrevealing. Chest computed tomography (CT) demonstrated subtle interlobular thickening and ground-glass opacities, and spirometry revealed a 6.8% decline in forced expiratory volume in 1 second (FEV₁). DSA testing showed elevated DQA05:01 (mean fluorescence intensity [MFI] 25,239), DR17 (7582), and DRw52 (4635). After exclusion of infection and structural neurologic causes, AMR was diagnosed. Treatment with plasmapheresis, intravenous immunoglobulin, rituximab, and corticosteroids resulted in complete resolution of neurologic and psychiatric symptoms after the second cycle, concurrent with reduction in DSA levels (DQA05:01 16,322; DR17 3000; DRw52 undetectable). The patient completed 5 treatment cycles.

Conclusion: This case broadens the clinical spectrum of AMR to include reversible neuropsychiatric manifestations likely mediated by systemic alloimmune inflammation. Prompt recognition and timely antibody-directed therapy can prevent misdiagnosis, preserve graft integrity, and improve outcomes in lung transplant recipients.

Lung retransplantation after prior heart-lung transplantation is uncommon and presents significant surgical and immunologic challenges. We report the case of a 24-year-old male with a history of congenital heart disease and Eisenmenger syndrome who underwent heart-lung transplantation in January 2018. While his cardiac function remained stable postoperatively, his pulmonary function declined 2 years later due to chronic lung allograft dysfunction (CLAD), confirmed by a 17% drop in forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio, recurrent infections, and positive class II donor-specific antibodies (DSAs). Between June and September 2020, he was admitted 4 times with suspected antibody-mediated rejection and managed with oxygen therapy, bilevel positive airway pressure, and supportive care. In January 2023, he underwent bilateral lung retransplantation with no major intraoperative complications. Postoperative recovery included management of a right-sided pulmonary embolism with heparin infusion. Over the next year, he developed recurrent class II DSAs (anti-DQ8 and anti-DR5), which were treated with i.v. immunoglobulin, rituximab, plasmapheresis, and antithymocyte globulin. His most recent evaluation showed stable graft function: FEV1, 1.83 L; FVC, 2.10 L; FEV1/FVC ratio, 87%; oxygen saturation, 98%. Bronchoalveolar lavage and biopsy revealed no signs of acute rejection. This case highlights the feasibility and potential success of lung retransplantation following heart-lung transplantation in selected patients. With close monitoring, individualized immunosuppressive therapy, and multidisciplinary care, favorable long-term outcomes are achievable-even in complex post-transplantation scenarios.

Background: There has been a long-standing hypothesis that simultaneous liver-kidney (SLK) transplantation has an immune protective effect on the transplanted kidney from the hepatic allograft. This hypothesis was challenged when recent data showed increased rejection rates for both liver and kidney grafts in patients with preexisting donor-specific antibodies (DSAs), particularly against class II HLA with mean fluorescence intensity (MFI) of >10,000.

Methods: We retrospectively collected clinical, biochemical, and outcome data on patients receiving SLK from 2014 to 2019 in King's College Hospital, London.

Results: After a follow-up of 5 years, 18 patients (50%) achieved an eGFR greater than 45 mL/min/1.73 m². In total, there were 11 episodes of acute rejection (AR) in 9 patients. Antibody-mediated rejection was seen in 5 patients (13.8%), T-cell-mediated rejection was seen in 6 patients (16.7%), and 2 patients had both T-cell-mediated rejection and Antibody-mediated rejection. Renal allograft outcomes were analyzed based on the presence or absence of AR within the first year. At 1 month posttransplant, the mean eGFR was significantly higher in the non-AR group (52 mL/min/1.73 m²) compared with the AR group (33 mL/min/1.73 m²; P = .022). However, the mean eGFR at the 5-year benchmark in the non-AR group was 50 mL/min/1.73 m² compared with 40 mL/min/1.73 m² in the AR group and was not statistically significant anymore (P = .081).

Conclusion: Our findings show that SLK is a viable and effective treatment option for patients with concurrent liver and kidney diseases.