Transplantation proceedings最新文献

Background: The shortage of ideal liver donors (ID) has led to increased use of marginal donors (MD), characterized by factors such as advanced age, macrosteatosis, anti-HBc positivity, or controlled donation after circulatory death. In hepatocellular carcinoma (HCC), this raises concerns regarding tumor recurrence and post-transplant survival.

Methods: A retrospective, single-center observational study was conducted, including all patients transplanted for HCC between 2010 and 2023. Patients were classified into two groups: ID and MD, with MD defined by at least 1 marginality criterion. Survival analyses were performed using Kaplan-Meier curves, and statistical significance was set at P < .05.

Results: Of 99 patients, 76% received grafts from MD. Among MD, 31.3% derived from circulatory death donors and 53.5% were over 60 years old. No significant differences were found in biliary or vascular complication rates between groups. Tumor recurrence occurred in 7 patients-6 in the MD group-but without statistical significance in disease-free survival (P = .79). Overall survival at 12, 24, and 36 months was 72%, 63%, and 58% for ID vs 92%, 80%, and 74% for MD, respectively (P = .06).

Conclusions: In this series, liver grafts from marginal donors were not associated with higher recurrence rates or reduced survival in HCC patients compared to ideal donors. Although larger, multicenter studies are needed to confirm these findings, the use of MD may safely increase organ availability without compromising clinical outcomes.

Anemia is a common complication after kidney transplantation (KT), often multifactorial and worsened by cytomegalovirus (CMV) infection, which promotes inflammation and erythropoiesis resistance through hepcidin elevation and HIF-2α inhibition. Roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), has shown promise in treating ESA-resistant anemia, though evidence in transplant recipients remains limited. We report 2 cases of ESA-refractory anemia post-KT with concurrent CMV infection successfully treated with roxadustat. Case 1: A 72-year-old woman developed anemia (Hb 8 g/dL) during asymptomatic CMV viremia despite valganciclovir, everolimus switch, and escalating ESA doses (up to 18,000 IU/wk). Roxadustat was started, and Hb recovered (11 g/dL) in 1 month. After a second anemia episode, dose adjustment restored Hb to 11.3 g/dL. The patient later died of unrelated causes. Case 2: A 78-year-old woman with recurrent CMV and inflammatory anemia (Hb 8.9 g/dL; ferritin 673 ng/mL) showed no ESA response. Roxadustat was stated and Hb raised to 14.2 g/dL in 1 month, allowing dose reduction and temporary withdrawal. Anemia recurred with new CMV viremia and responded again to roxadustat (Hb 11.6 g/dL). In both patients, we did not observe any side effects related to the use of the drug, and renal function remained stable during the follow-up. These cases support roxadustat as a valuable option in managing post-KT anemia with CMV-associated ESA resistance, by stimulating endogenous EPO, reducing hepcidin, and improving iron utilization. Further prospective studies are needed to establish its safety and efficacy in this population.

Objective: Persistent chronic hypotension (PCH) is a debilitating condition in patients undergoing long-term hemodialysis that is often deemed a relative contraindication to kidney transplantation. We present a high-risk case demonstrating the feasibility and curative potential of transplantation under a stringent, multidisciplinary protocol.

Case presentation: A 26-year-old woman with end-stage renal disease after 16 years of hemodialysis presented with severe, refractory PCH (70/50 mm Hg at rest, dropping to 50/30 mm Hg during dialysis), superior vena cava obstruction, anuria, and a microscopic bladder capacity of 15 cc. Following multidisciplinary evaluation and preoperative bladder training, the patient underwent living-related kidney transplantation. A dual renal artery graft, necessitating back-table side-to-side reconstruction, complicated the procedure. Intraoperative management included invasive hemodynamic monitoring, transesophageal echocardiography (TEE), and preemptive norepinephrine infusion.

Results: The allograft achieved immediate function upon reperfusion. Vasopressor support was weaned and discontinued early postoperatively, with concurrent cessation of all pretransplant antihypotensive medications. The patient's blood pressure rapidly normalized to the reference ranges without pharmacological support. The patient was discharged on postoperative day 7 with excellent and sustained graft function.

Conclusion: Kidney transplantation is the only curative treatment for refractory dialysis-induced hypotension. The successful outcome, even in the presence of major comorbidities, was contingent on a proactive, protocol-driven, and multidisciplinary perioperative strategy. Consequently, PCH should not be a barrier to transplantation but rather an indication for referral to a specialized center capable of providing this level of care.

Background: Symptomatic lymphoceles are a frequent complication following kidney transplantation and are commonly managed with percutaneous drainage and sclerotherapy using agents such as povidone-iodine or ethanol. Refractory cases often require laparoscopic peritoneal fenestration. Although these interventions are generally effective, their cytotoxic properties and cumulative effects may predispose to rare but severe delayed complications.

Case presentation: A 71-year-old man underwent living-donor kidney transplantation, followed by postoperative wound dehiscence requiring mesh repair and the subsequent development of a symptomatic peri-graft lymphocele. Management progressed from percutaneous drainage with povidone-iodine sclerotherapy to ethanol sclerotherapy and, ultimately, laparoscopic peritoneal fenestration on postoperative day 46. The patient was readmitted 4 days after discharge with sepsis. Imaging demonstrated a retroperitoneal collection communicating with the ascending colon. Surgical exploration confirmed a contained colonic perforation, necessitating right hemicolectomy with end ileostomy to preserve allograft function.

Conclusion: This case describes a rare, life-threatening delayed colonic perforation following sequential lymphocele interventions. Histopathological findings were most consistent with delayed chemical ischemic necrosis, strongly implicating ethanol diffusion as a major contributing factor, likely exacerbated by altered anatomy from prior surgery and repeated interventions. The delayed presentation underscores the cumulative risk associated with sequential minimally invasive therapies. It highlights the need for meticulous technique, individualized risk assessment, prolonged post-procedural surveillance, and early surgical readiness in high-risk transplant recipients.

Sleep is a critical component of health, yet its role is underexplored in patients awaiting organ transplantation. This study examined sex-based differences in circadian sleep indicators among liver transplant candidates. Fifty patients (40 men (M) and 10 women (W)) on the waiting list at Hospital Clínico Universitario Virgen de la Arrixaca (Murcia, Spain) wore the Kronowise K6 wrist device on their nondominant wrist for 1 week pre-transplantation. Data were analysed using Kronowise 100 software (Kronohealth, Spain). Forty-two variables related to sleep quality and circadian rhythms were assessed via Student's t-test. Significant differences between sexes emerged in actual sleep time (p = .03), sleep efficiency (p = .022), total movement time (p = .011), and blue light exposure before sleep (p = .04). Men exhibited longer sleep duration, greater movement, and higher pre-sleep light exposure, whereas women demonstrated superior sleep efficiency. The midpoint of sleep-related peak values occurred later in women. Despite shorter sleep duration, women achieved better sleep quality, potentially due to reduced exposure to blue light before sleep, which was up to 2.5 times less than that of men. This disparity likely reflects differing pre-sleep behaviors, such as screen use. Additionally, women's core sleep phase was delayed by approximately 30 minutes. These findings suggest sex-specific differences in circadian sleep profiles among liver transplant candidates. Given men's less favorable sleep hygiene, targeted interventions may be warranted to improve pre-transplant sleep health.

Post-transplant mucormycosis is a rare but life-threatening complication with high mortality. We report a severe case of upper limb mucormycosis in a 58-year-old diabetic kidney transplant recipient. Despite standard immunosuppression, progressive skin lesions developed on the left forearm. Initial debridement failed to arrest progression, revealing extensive muscle necrosis and vascular thrombosis. Rhizopus oryzae was confirmed by histopathology and culture. Surgical management required mid-humeral amputation followed by shoulder disarticulation due to persistent fungal invasion. Antifungal therapy included liposomal amphotericin B and isavuconazole alongside immunosuppression reduction. This case underscores the aggressive nature of mucormycosis in immunocompromised hosts, highlighting the critical need for‌ early diagnosis, radical surgical intervention, combined antifungal therapy, and most importantly sustained vigilance by transplant teams for this fungal infection, as delayed intervention could lead to catastrophic consequences.

Mucormycosis is an aggressive fungal infection associated with high mortality, particularly among recipients of solid organ transplants. Gastrointestinal involvement is rare but can be fatal due to delayed diagnosis and limited therapeutic options. We report on a 59-year-old female who developed intra-abdominal mucormycosis that was diagnosed during orthotopic liver transplantation. She initially presented with a perforated duodenal ulcer requiring emergent surgical repair and subsequently developed acute liver failure due to an iatrogenic transection of the portal triad. She underwent urgent orthotopic liver transplantation and was found to have multiple gastric ulcers. Tissue biopsies from the stomach and abdomen revealed broad, nonseptate hyphae consistent with Mucorales, which was later identified as Mucor circinelloides. Postoperatively, she required eight reexplorations with extensive debridement and amphotericin B irrigation of the abdominal cavity. She received systemic antifungal therapy with liposomal amphotericin B and azoles guided by susceptibility testing. Immunosuppression was minimized, with tacrolimus maintained at low trough levels and a rapid corticosteroid taper. Fungal cultures cleared up 25 days posttransplant. She completed 6 months of antifungal therapy and remains free from infection with excellent graft function at 1 year. This case underscores the importance of early diagnosis of intra-abdominal mucormycosis and highlights that aggressive surgical debridement, tailored antifungal therapy, and careful immunosuppression management are essential to achieving a successful outcome.

We present a rare case of multicentric Castleman disease (MCD) complicated by severe respiratory failure, which was successfully managed through bilateral lung transplantation. A 31-year-old male patient exhibited progressive dyspnea attributed to MCD associated with bronchiolitis obliterans. Pretransplant evaluations indicated severe hypercapnia and markedly impaired pulmonary function. Despite the administration of steroid therapy, the patient's respiratory status continued to decline. Consequently, he underwent bilateral lung transplantation, which resulted in significant alleviation of hypercapnia and considerable improvement in pulmonary function. Four years posttransplant, the patient remains alive and does not require supplemental oxygen. This case highlights the potential efficacy of bilateral lung transplantation in addressing severe respiratory complications associated with MCD.

A 67-year-old female underwent an en-bloc double lung transplantation for idiopathic pulmonary fibrosis. The post-transplant course was complicated by refractory septic shock. Despite empiric antimicrobial coverage with vancomycin, meropenem, micafungin, and posaconazole, she continued to require high-dose vasopressors and remained unable to wean from veno-venous extracorporeal membrane oxygenation (ECMO). Blood cultures were positive for Candida Kefyr (teleomorph: Kluyveromyces marxianus), the same organism that had been isolated from donor bronchoalveolar lavage cultures 5 days prior to transplant. Micafungin and posaconazole doses were increased, and intravenous (IV) liposomal amphotericin B was added. Within 2 days, her hemodynamics improved, allowing successful weaning from ECMO. However, repeat blood cultures demonstrated persistent candidemia. Chest computed tomography revealed pericardial and bilateral pleural effusions, suspicious for mediastinitis and empyema. Transesophageal echocardiography confirmed pericardial effusion but showed no vegetations. Chorioretinal lesions were noted bilaterally without vitritis. Micafungin and posaconazole were discontinued and IV voriconazole was started for eye penetration. Amphotericin B was continued for 4 weeks and voriconazole for 3 months. Repeat blood cultures showed clearance of fungemia, and ophthalmology eye exam showed no further signs of chorioretinitis. Donor-derived infections are a rare complication of solid organ transplantation, with fungal infections posing a unique challenge due to their high morbidity and mortality. To our knowledge, there are no documented cases in the literature of possible donor-derived C. kefyr leading to blood stream infection in the recipient. This case highlights the need for heightened clinical vigilance and prompt multidisciplinary management to mitigate the impact of post-transplant complications.

Background: An active Coronavirus disease 2019 (COVID-19) infection is considered a contraindication for lung transplantation. However, missing a lung transplant opportunity for patients with end-stage pulmonary disease can lead to increased morbidity and mortality. This case report focuses on a successful lung transplantation performed on a patient with an active COVID-19 infection and aims to contribute valuable insights to the limited existing literature on this topic.

Methods: After obtaining institutional ethics approval and patient consent, medical records were reviewed to prepare the case report.

Results: A 45-year-old patient with chronic rejection after her first lung transplant was on mechanical ventilation while waiting for a donor. When a suitable donor became available, she tested positive for COVID-19 right before surgery. Despite the risks, the decision was made to proceed with the transplant. She received remdesivir and intravenous immunoglobulin therapy. Her recovery was uneventful, and 3 months posttransplant, she showed excellent graft function with no signs of rejection.

Conclusion: In carefully selected patients with limited donor availability, lung transplantation may be considered in active COVID-19 infected patient, accompanied by a tailored regimen of antiviral therapy and immunosuppression.