Transplantation proceedings最新文献

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.

Hepatic artery reconstruction is technically challenging and a critical step in liver transplantation, particularly in patients with anatomical variations or compromised arterial flow. The present technical note describes an emergency liver transplantation for hepatitis B virus-induced acute liver failure, where standard vascular reconstruction options, including autologous grafts, were exhausted. Given the recipient's small-caliber hepatic arteries, vasospasm, and hemodynamic instability, a 6 × 40 mm polytetrafluoroethylene (PTFE) vascular graft was utilized to restore arterial flow. The reconstruction involved anastomosis between the infrarenal aorta and the donor's celiac trunk at splenic artery bifurcation, ensuring adequate graft perfusion with adjusted arterial and portal flow rates. To prevent passage between the small bowel which could increase the risk of intestinal obstruction, the PTFE graft was positioned retroperitoneally. This technical note highlights the feasibility of PTFE grafts as a salvage solution for arterial reconstruction in emergent liver transplantation when standard options are unavailable.

Background: Chronic antibody-mediated rejection (AMR) after heart transplantation is associated with progressive graft dysfunction and increased mortality, and effective treatment options remain limited. Interleukin-6 (IL-6) inhibition with tocilizumab has emerged as a potential therapeutic strategy, although evidence in cardiac transplantation is scarce and limited to small case series.

Objective: To describe the safety and clinical course of heart transplant recipients with chronic, treatment-refractory AMR treated with tocilizumab.

Methods: This retrospective case series included 2 adult heart transplant recipients with biopsy-proven chronic AMR refractory to plasmapheresis, intravenous immunoglobulin, and rituximab. Tocilizumab was administered intravenously at a dose of 8 mg/kg monthly for 6 months. Clinical outcomes, laboratory parameters, immunologic data, and echocardiographic findings were assessed before and after treatment (March-September 2024).

Results: Both patients completed 6 doses of tocilizumab. No serious adverse events occurred; 1 patient developed a single episode of transient febrile neutropenia. No infections, bleeding events, or clinically significant hepatic enzyme elevations were observed. Unplanned hospitalizations for heart failure decreased during treatment, and both patients reported subjective improvement in functional status (NYHA class III-II). No consistent reduction in donor-specific HLA antibody mean fluorescence intensity was observed. Left ventricular ejection fraction remained stable, while global longitudinal strain improved in 1 patient.

Conclusion: In this small case series, tocilizumab was safe and well tolerated in heart transplant recipients with chronic refractory AMR. Although clinical improvement was observed, the extremely limited sample size precludes conclusions regarding efficacy. Larger, prospective studies are required to clarify the role of IL-6 inhibition in chronic cardiac AMR.

Cell-free DNA (cfDNA) is an emerging noninvasive biomarker for detecting graft injury and rejection in kidney transplantation. Although elevated cfDNA levels often indicate underlying pathology, their interpretation can be challenging in patients with stable graft function and no clinical signs of rejection. We present a case of a kidney transplant recipient with persistently elevated cfDNA levels despite stable renal function, negative donor-specific antibodies (DSA), and unremarkable clinical findings. A biopsy revealed chronic arteriolar hyalinosis but no evidence of rejection. This case underscores the complexities of cfDNA interpretation in transplant monitoring and highlights the need for further research to refine its clinical application.

Kidney transplantation is most often performed under general anesthesia, with or without regional anesthesia for adjunctive pain control. Select patients may benefit from neuraxial anesthesia as their primary anesthetic, especially when their comorbidities preclude the safe provision of general anesthesia. In this report, we describe the case of a 75-year-old man with malignant hyperthermia and ischemic cardiomyopathy who underwent a living-related kidney transplant under epidural anesthesia. Intraoperative hemodynamics were stable, and pain control was excellent; the surgeon reported no difficulties during the procedure. Allograft function was immediate and robust, and postoperative pain was well-controlled. The patient denied any side effects from the epidural block. We then summarize relevant literature from the 1960s through the present time regarding neuraxial blocks as the primary anesthetic for kidney transplantation and address considerations around the performance of neuraxial anesthesia in patients with end-stage renal disease. We also discuss common hesitations with neuraxial anesthesia and summarize the available data on patient-centered outcomes. Neuraxial anesthesia affords benefits of similar hemodynamics, similar allograft function, and improved postoperative pain control for patients undergoing kidney transplantation, compared to general anesthesia. Spinal, epidural, or combined spinal-epidural techniques should be given consideration when designing an anesthetic for patients with certain comorbidities that heighten the risk of a general anesthetic.

Introduction: Liver retransplantation (LRT) is the only therapeutic option in cases of irreversible graft failure. It is a technically complex procedure associated with high morbidity and mortality and worse survival outcomes compared to primary liver transplantation.

Objective: To analyze the indications, outcomes, and survival rates of LRT in a referral hospital in southern Spain over a 27-year period.

Methods: A retrospective descriptive study of all LRTs performed between 1997 and 2024 at the Regional University Hospital of Málaga. Solid organ transplants other than liver were excluded. Qualitative variables were expressed as percentages and quantitative variables as medians and interquartile ranges. A P-value < .05 was considered statistically significant.

Results: A total of 1.362 liver transplants (LTs) were performed during the study period, of which 76 were LRTs (5.6%). The median age of recipients was 53 years; 63.2% were male. The main indications for LRT were hepatic artery thrombosis (HAT) (28.9%), primary nonfunction (PNF) (23.7%), and chronic rejection (18.4%). Overall mortality was 55.3%, with the main cause being perioperative complications (28.6%). One-year and five-year survival rates were 59.2% and 46.1%, respectively. Urgent LRT (≤7 days) was associated with worse five-year survival compared to nonurgent LRT (33.3% vs 62.8%; P = .02).

Conclusion: LRT, though infrequent, carries high morbidity and mortality. Long-term survival was significantly better in nonurgent cases, emphasizing the importance of proper timing and clinical stabilization before surgery.

Anti-glomerular basement membrane (anti-GBM) disease is a rare entity. The classic presentation includes circulating autoantibodies and rapidly progressive glomerulonephritis. However, there are atypical variants, which constitute 5% to 10% of cases. These variants are characterized by the absence of circulating antibodies, a more indolent clinical course, and the potential to recur in a kidney transplant. We present the case of a woman with chronic kidney disease initially diagnosed as unclassified glomerulonephritis. After the first transplant, a biopsy revealed linear IgG deposits with lambda chain restriction, leading to a diagnosis of atypical anti-GBM disease. The patient developed progressive chronic allograft dysfunction, which required a return to dialysis and, subsequently, a second transplant. The disease recurred again. This case highlights the diagnostic difficulty of atypical anti-GBM disease and the possibility of its recurrence after kidney transplantation. The recurrence of the monotypic variant may be associated with a plasma cell clone that is undetectable by conventional methods, suggesting a lower sensitivity to immunosuppression. The case also demonstrates the slow evolution of this disease, which underscores the need for long-term histological follow-up.

Disseminated coccidioicomycosis can have devastating consequences following immunosuppression. Herein, we describe a kidney transplant recipient with subsequent allograft rejection and graft loss, who developed disseminated hepatic cocccidioidomycosis that led to progressive hepatic fibrosis and cirrhosis. He then underwent simultaneous liver and kidney transplantation while maintaining antifungal therapy. No other etiology for cirrhosis was determined following extensive testing that included his explanted liver.

Introduction: Liver transplantation (LT) is increasingly performed in recipients ≥65 years. However, indications in this age group remain variably defined and long-term survival data are limited.

Objective: To evaluate survival in patients ≥65 years undergoing LT at a tertiary care center.

Materials and methods: We conducted a retrospective observational study of 114 recipients aged ≥65 years who underwent LT. The primary outcome was median overall survival (months). Secondary variables included underlying liver disease, ABO blood group, hospital length of stay, and cause of death. For context, outcomes were compared with the 2023 "Memoria General de Resultados" of the Spanish Liver Transplant Registry (RETH).

Results: Median overall survival was 112.0 ± 22.6 months, with a median follow-up of 42.5 months. Survival did not differ significantly by underlying disease or ABO group. Compared with age-matched data from RETH, our cohort showed a similar survival trajectory without statistically significant differences. When contrasted with the nationwide overall LT population, survival in recipients ≥65 years was lower at 3 years (70.0% vs 81.0%; p < .05), 5 years (64.9% vs 76.1%; p < .05), and 10 years (48.2% vs 64.7%; p < .05).

Conclusions: Survival outcomes in recipients ≥65 years at our center are consistent with the national registry data for this age group. LT, in carefully selected older adults, appears to be an appropriate therapeutic option, offering substantial life-expectancy gains for patients with advanced liver disease, despite lower survival compared with the overall national LT population.

Background: Nocardia species are gram-positive, filamentous bacteria causing opportunistic infections in immunocompromised patients. Nocardiosis in kidney transplant recipients is rare, with Nocardia cyriacigeorgica being an emerging pathogen first identified in 2001.

Case presentation: A 55-year-old male with end-stage renal disease underwent deceased-donor kidney transplantation with standard immunosuppression including tacrolimus, corticosteroids, and mycophenolate mofetil. Five months post-transplantation, he presented with cough, fever, and dyspnea. Initial chest computed tomography showed pleural effusion without consolidation. Despite percutaneous drainage and empirical antibiotics, symptoms persisted for 3 weeks. Repeat imaging revealed multiloculated pleural masses mimicking post-transplant lymphoproliferative disease. Surgical excision of the mass revealed inflamed granulation tissue, and cultures identified Nocardia cyriacigeorgica. Treatment was changed to intravenous imipenem/cilastatin and oral trimethoprim-sulfamethoxazole, with concurrent reduction of immunosuppression. The patient showed significant clinical improvement, with follow-up imaging demonstrating marked reduction in pleural masses. He was discharged after 10 weeks without graft dysfunction.

Conclusion: This rare case of pleural nocardiosis caused by Nocardia cyriacigeorgica in a kidney transplant recipient highlights diagnostic challenges, as the presentation mimicked malignancy. High clinical suspicion is crucial when standard antimicrobial therapy fails in immunosuppressed patients. Early diagnosis through tissue culture and aggressive treatment with appropriate antibiotics, combined with immunosuppression adjustment, led to successful outcomes. This report adds valuable insights to the limited literature on this emerging pathogen in transplant recipients and emphasizes the importance of considering rare opportunistic infections in the differential diagnosis.