HIV-Infected Liver and Kidney Transplant Recipients: 1- and 3-Year Outcomes

Improvements in human immunodeficiency virus (HIV)-associated mortality make it difficult to deny transplantation based upon futility. Outcomes in the current management era are unknown. This is a prospective series of liver or kidney transplant recipients with stable HIV disease. Eleven liver and 18 kidney transplant recipients were followed for a median of 3.4 years (IQR [interquartile range] 2.9–4.9). One- and 3-year liver recipients' survival was 91% and 64%, respectively; kidney recipients' survival was 94%. One- and 3-year liver graft survival was 82% and 64%, respectively; kidney graft survival was 83%. Kidney patient and graft survival were similar to the general transplant population, while liver survival was similar to the older population, based on 1999–2004 transplants in the national database. CD4+ T-cell counts and HIV RNA levels were stable; and there were two opportunistic infections (OI). The 1- and 3-year cumulative incidence (95% confidence intervals [CI]) of rejection episodes for kidney recipients was 52% (28–75%) and 70% (48–92%), respectively. Two-thirds of hepatitis C virus (HCV)-infected patients, but no patient with hepatitis B virus (HBV) infection, recurred. Good transplant and HIV-related outcomes among kidney transplant recipients, and reasonable outcomes among liver recipients suggest that transplantation is an option for selected HIV-infected patients cared for at centers with adequate expertise.     

Immunosuppression and cancer: A comparison of risks in recipients of organ transplants and in HIV-positive individuals

The comparison of cancers occurring excessively among HIV-infected and transplanted individuals may help to elucidate the relationship between immune surveillance, viral infections, and cancer. A longitudinal study was conducted on 2002 HIV-infected Italian subjects, 6072 HIV-infected French individuals, and 2878 Italian recipients of solid organ transplants. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed to quantify the risk for cancer, compared with the French and Italian general populations. The SIRs for all cancers were 9.8 (95% CI: 9.0-10.6) for HIV-infected individuals versus 2.2 (95% CI: 1.9-2.5) for transplant recipients. In both groups, most of the excess risk was attributable to virus-related cancers, such as Kaposi's sarcoma (KS; SIR = 451 in HIV-positive individuals, 125 in transplant recipients), non-Hodgkin's lymphoma (NHL; SIR = 62.1 and 11.1, respectively), and liver cancer (SIR = 9.4 and 4.1, respectively). Significantly increased SIRs for anal cancer and Hodgkin's lymphoma were found only among HIV-positive individuals. Among women younger than 40 years of age, a more than 10-fold increase in cervical cancer risk was found in both groups. Among HIV-infected individuals treatment with highly active antiretroviral therapies drastically reduced SIRs for KS and NHL only. These results show that HIV-infected individuals and transplant recipients share a similar pattern of cancer risk, largely due to virus-related cancers.     

Liver transplantation in HCV/HIV positive patients

Since the introduction of highly active antiretroviral therapy (HAART) in 1996 for human immunodeficiency virus (HIV)-infected patients, the incidence of liver diseases secondary to co-infection with hepatitis C has increased. Although data on the outcome of liver transplantation in HIV-infected recipients is limited, the overall results to date seem to be comparable to that in non-HIV-infected recipients. Liver transplant centers are now accepting HIV-infected individuals as organ recipients. Post-transplantation HIV replication is controlled by HAART. Hepatitis C re-infection of the liver graft, however, remains an important problem because cirrhotic changes of the liver graft may be more rapid in HIV-infected recipients. Interactions between the HAART components and immunosuppressive drugs influence drug metabolism and therefore meticulous monitoring of drug blood level concentrations is required. The risk of opportunistic infection in HIV-positive transplant patients seems to be similar to that in HIV-negative transplant recipients.     

Atrial Fibrillation and Adverse Outcomes in Patients Undergoing Simultaneous Pancreas-Kidney Transplantation

BackgroundThere are no published data on atrial fibrillation (AF) in patients receiving simultaneous pancreas-kidney transplantation (SPKT). We explored the epidemiology and adverse outcomes of AF in SPKT recipients in this retrospective observational cohort study.Materials and MethodsAll 200 SPKT recipients in Finland to date between March 2010 and April 2021 were included in the present study. Demographics, comorbidities, medications, and transplantation data were collected from the electronic patient records. Outcome measures included new-onset AF (NOAF), ischemic stroke, and death.ResultsMedian age was 42 years (interquartile range [IQR] 35-49), 69 (35%) were female, and median dialysis vintage was 13 months (IQR 9-19). Altogether 7 patients (4%) had a previous diagnosis of AF at baseline, and heart failure was independently associated with prior AF in the age-adjusted multivariable logistic regression analysis. After a median follow-up of 3 years (IQR 1-5), 2 patients (1%) were observed with incident NOAF, 4 (2%) with ischemic stroke, and 7 patients (4%) died. Prior AF or NOAF were not associated with cardiovascular adverse outcomes, mortality or graft outcomes.ConclusionsWe demonstrate a low prevalence and incidence of AF for the first time in this large observational study comprising all SPKT recipients in Finland to date.     

Kaposi's sarcoma in transplant and HIV-infected patients: an epidemiologic study in Italy and France

BACKGROUND: A follow-up study was conducted in Italy and in France to compare the epidemiology of Kaposi's sarcoma (KS) between human immunodeficiency virus (HIV)-infected people and transplant recipients. METHODS: In all, 8,074 HIV-positive individuals (6,072 from France and 2,002 HIV-seroconverters from Italy) and 2,705 Italian transplant recipients (1,844 kidney transplants, 702 heart transplants, and 159 liver transplants) were followed-up between 1970 and 2004. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were computed to estimate the risk of KS, as compared to sex- and age-matched Italian and French populations. Incidence rate ratios (IRRs) were used to identify risk factors for KS. RESULTS: A 451-fold higher SIR for KS was recorded in HIV-infected subjects and a 128-fold higher SIR was seen in transplant recipients. Significantly increased KS risks were observed in HIV-infected homosexual men (IRR=9.7 in France and IRR=6.7 in Italy vs. intravenous drug users), and in transplant recipients born in southern Italy (IRR=5.2 vs. those born in northern Italy). HIV-infected patients with high CD4+ cell counts and those treated with antiretroviral therapies had reduced KS risks. In relation to duration of immunosuppression, KS occurred earlier in transplant patients than in HIV-seroconverters. CONCLUSIONS: This comparison highlighted that the risk of KS was higher among HIV-infected individuals than in transplant recipients, and that different co-factors are likely to influence the risk of KS. Moreover, the early KS occurrence in transplant recipients could be associated with different patterns of progressive impairment of the immune function.     

Clinical outcome after coronary artery revascularization and lung transplantation

BACKGROUND: Presence of coronary artery disease (CAD) in otherwise eligible lung transplant candidates is considered a contraindication to lung transplantation. We reviewed the clinical outcome of our experience in lung transplant recipients with operable coronary artery disease and normal left ventricular function. METHODS: Medical records of all transplant recipients with coronary artery disease were reviewed. Data analyzed include demographics, coronary angiograms, coronary artery revascularization procedure, and clinical outcome after lung transplantation. RESULTS: Between April 1992 and August 2001, 354 lung transplant procedures were performed. Eighteen patients (5%) had significant CAD (greater than 50% stenoses). Six male patients (mean age 59 years) underwent percutaneous transluminal coronary angioplasty/stent and after lung transplantation all were discharged after a median hospital stay of 8.5 days. All recipients are alive at a median follow-up time of 14.5 months after their transplant. Twelve male patients (mean age 58 years) had combined coronary artery bypass grafting and lung transplantation. All recipients were discharged after a median hospital stay of 16 days. Nine recipients are alive at a median follow-up time of 7.5 months after transplant. One-year survival by the Kaplan-Meier method is 88% for the 18 patients with coronary artery disease who underwent revascularization and lung transplantation. CONCLUSIONS: Despite the traditional criteria of excluding all eligible transplant candidates due to coronary artery disease, coronary revascularization in select candidates with favorable anatomy and normal left ventricular function can allow patients to undergo lung transplantation with acceptable outcomes.     

Pancreas transplantation: advantages of both enteric and bladder drainage combined in a two-step approach

BACKGROUND: Although there is a tendency to perform enteric drainage of pancreas transplants in simultaneous pancreas-kidney (SPK) transplantation, bladder drainage is still preferable in pancreas transplantation alone (PTA) or after a previous kidney transplantation (PAK). Our hypothesis was that enteric conversion of a bladder drained pancreas is an effective and safe procedure. We studied the complication rate and physiological effects of enteric conversion in patients with primary bladder-drained SPK transplantation. PATIENTS: We performed 51 enteric conversions in bladder-drained SPK transplant recipients. As we observed a low complication rate, with time enteric conversions were also performed for less strict and severe indications. RESULTS: The main indications for conversion were urological problems, metabolic complications and reflux-pancreatitis. The median transplantation-conversion interval was 12 months (range 2-40 months). Post-operative complications consisted of seven urinary tract infections, two low-grade superficial wound infections, one minor bleeding, one phlebitis and one paralytic ileus. In two patients, a relaparotomy was necessary. No graft rejection following enteric conversion was found. Long-term renal and pancreatic function were not affected by the enteric conversion. Three-year patient, kidney and pancreas survival rates after enteric conversion were 93, 97 and 93%, respectively (censored data). CONCLUSION: Enteric conversion after pancreas transplantation is an effective and safe procedure. Therefore, we suggest a policy of a two-step approach of primary bladder drainage followed by an enteric conversion of the pancreas in a selected group of SPK patients.     

Hypertension after pancreas-kidney transplantation: role of bladder versus enteric pancreatic drainage

BACKGROUND: Recent reports suggest that hypertension may be less common after simultaneous pancreas-kidney transplantation than after kidney transplantation alone. However, the mechanisms for this beneficial effect have not been delineated. We hypothesize that lower blood pressures may result from chronic volume depletion in patients with bladder-drained pancreatic allografts. METHODS: We compared the incidence and severity of hypertension 12 months after transplantation in 79 bladder-drained pancreas-kidney recipients and 46 diabetic kidney-only recipients. These two groups were compared with a smaller group of enterically drained pancreas-kidney recipients. Blood pressure was also compared before and after surgical conversion from bladder to enteric drainage in 10 patients. RESULTS: Hypertension was significantly less common and less severe after pancreas-kidney transplantation than after kidney transplantation alone, but the benefit of the pancreas transplant was evident only in bladder-drained patients. Logistic regression analysis of the bladder-drained pancreas-kidney patients confirmed the independent impact of the pancreatic allograft on the presence of hypertension, indicated an independent association with serum creatinine concentration and donor age, but suggested no correlation with recipient age, race, or number of rejection episodes. A comparison of blood pressures before and after pancreatic conversion from bladder to enteric drainage indicated no significant change in the prevalence or severity of hypertension. CONCLUSIONS: We conclude that the beneficial effect of a pancreas transplant on the prevalence and severity of hypertension after simultaneous pancreas-kidney transplantation is limited to bladder-drained patients. Although it is possible that the effect is mediated by chronic volume depletion, the observation that blood pressure does not increase after conversion from bladder to enteric drainage suggests that other factors may be involved.     

Renal transplantation between HIV-positive donors and recipients justified

HIV infection was previously an absolute contraindication to renal transplantation. However, with the advent of highly active antiretroviral therapy (HAART), renal transplantation using HIV-negative donor kidneys has successfully been employed for HIV-infected patients with end-stage renal failure. In resource-limited countries, places on dialysis programmes are severely restricted; HIV-infected patients, like many others with co-morbidity, are often denied treatment. Kidneys (and other organs) from HIV-infected deceased donors are discarded. The transplantation of HIV-positive donor kidneys to HIV-infected recipients is now a viable alternative to chronic dialysis or transplantation of HIV-negative donor kidneys. This significantly increases the pool of donor kidneys to the advantage of HIV-positive and -negative patients. Arguments are presented that led to our initiation of renal transplantation from HIV-positive deceased donors to HIV-positive recipients at Groote Schuur Hospital, Cape Town.     

Incisional hernia after simultaneous pancreas kidney tranplantation: a single-center experience from Budapest

Introduction

The occurrence of postoperative incisional hernia is more frequent after simultaneous pancreas-kidney transplantation compared with other transplanted parenchymal organs. These complications are especially dangerous in this patient population, because they can compromise the survival of the transplanted organ.

Methods

We performed a retrospective review of a series of adult patients with incisional herniae after 23 consecutive simultaneous pancreas-kidney transplantations between January 2004 and June 2010 seeking to identify risk factors. All 23 patients had a body mass index (BMI) of <25. All surgeons used a similar technique, including a median incision with an intraperitoneal approach, and systemic venous and enteric drainage methods and a layered fascial closure. All combined pancreas-kidney transplant recipients received induction with thymoglobulin and maintenance therapy with sirolimus, reduced-dose cyclosporine and corticosteroids.

Results

An incisional hernia repair was performed in 8/23 patients (34.8%). Four reoperations were required in this group (50%), due to hemoperitoneum (n = 2), intra-abdominal abscess (n = 1), and venous thrombosis (n = 1). The mean elapsed time between transplantation and hernioplasty was 24.5 months (range, 8-51). There was no significant difference in age, gender, BMI, dialysis modality, or operative time among affected compared with the other members of the group.

Conclusion

Despite lack of obesity we observed a relatively higher rate of postoperative herniase, possibly owing to the side effects of a thymoglobulin-sirolimus combination.     

Do wound complications or lymphoceles occur more often in solid organ transplant recipients on mTOR inhibitors? A systematic review of randomized controlled trials

mTOR inhibitors have been associated with wound complications and lymphoceles. We systematically reviewed randomized controlled trials (RCTs) to compare these outcomes for solid organ transplant recipients. Relevant medical databases were searched to identify RCTs in solid organ transplantation comparing mTOR inhibitors with an alternative therapy reporting on wound complications and/or lymphoceles. Methodological quality of RCTs was assessed. Pooled analyses were performed to calculate odds ratios (OR) and 95% confidence intervals (CI). Thirty-seven RCTs in kidney, heart, simultaneous pancreas-kidney and liver transplantation were included. Pooled analyses showed a higher incidence of wound complications (OR 1.77, CI 1.31-2.37) and lymphoceles (OR 2.07, CI 1.62-2.65) for kidney transplant recipients on mTOR inhibitors together with calcineurin inhibitors (CNIs). There was also a higher incidence of wound complications (OR 3.00, CI 1.61-5.59) and lymphoceles (OR 2.13, CI 1.57-2.90) for kidney transplant recipients on mTOR inhibitors together with antimetabolites. Heart transplant patients receiving mTOR inhibitors together with CNIs also reported more wound complications (OR 1.82, CI 1.15-2.87). We found a higher incidence of wound complications and lymphoceles after kidney transplantation and a higher incidence of wound complications after heart transplantation for immunosuppressive regimens that included mTOR inhibitors from the time of transplantation.     

Liver transplantation for incidental cholangiocarcinoma: analysis of the Canadian experience.

Cholangiocarcinoma is a biliary tumor, which not infrequently complicates primary sclerosing cholangitis. It carries a poor prognosis and, with the exception of carefully selected individuals in research protocols, contraindicates orthotopic liver transplantation. There has been some suggestion that cholangiocarcinomas incidentally discovered at the time of transplantation carry a better prognosis. The goal of this retrospective study was to perform a national review of outcomes after liver transplantation in Canadian recipients found to have incidental cholangiocarcinoma in their explanted native liver. Six of the seven liver transplant centers in Canada provided clinical and follow-up information on all liver transplant recipients found to have incidental cholangiocarcinoma in their explants. The diagnosis or suspicion of cholangiocarcinoma prior to transplantation were exclusion criteria for this study. Ten individuals with cholangiocarcinoma were transplanted between 1996 and 2003. The median duration of follow-up was 28 months. Eight of the 10 had PSC. All of the tumors were stage I or II. The 3-year survival for these patients was 30%. The median time to recurrence was 26 months (95% confidence interval 13-37), and the median time to death was 30 months (95% confidence interval 28-53). In conclusion, although early survival of patients transplanted for incidental cholangiocarcinoma appears good, intermediate- and long-term survival rates are not better than for individuals historically transplanted with known cholangiocarcinoma. Aggressive investigation for cholangiocarcinoma is mandated. Incidentally found tumours remain a difficult treatment problem, and prospective adjuvant chemo-, radio-, and immunotherapies should be investigated.     

Evaluation of Herpes Simplex Virus Infection Morbidity and Mortality in Pancreas and Kidney-Pancreas Transplant Recipients

Background

Infections remain a major cause of morbidity and mortality in solid organ transplant recipients. An increased risk of up to 50% of herpes simplex virus (HSV) reactivation in transplant recipients in the first months posttransplantation was well-documented during the pre-cytomegalovirus prophylaxis era. Previous reports suggest that these patients are likely to experience a more aggressive disease course and a higher rate of acyclovir-resistant HSV. No data currently exist regarding the course of HSV infection in pancreas or pancreas-kidney transplant (PKT) recipients. The goal of this study was to evaluate the incidence and severity of HSV infections in pancreas transplant and PKT recipients.

Study Design

We analyzed a transplant patient database of the Royal Victoria Hospital to identify 137 pancreas transplant or PKT performed between January 1999 and October 2010. A retrospective chart review was subsequently performed to evaluate the incidence and severity of herpetic infections post transplantation.

Results

Our findings show that the incidence of HSV infection in our patients was approximately 10% (10/98 cases). The majority of infections (80%) took place within the first 2 years after the transplantation. Most patients (90%) experienced a uniform, mild disease course and responded well to treatment. One patient died of an unrelated cause. Six patients were treated in hospital with a mean stay of 12.3 ± 6.35 days. The initial immunosuppressive regimen remained unchanged for half of the affected patients. None of our patients developed a drug-resistant HSV.

Conclusion

These findings are intriguing and warrant a larger, multicenter, prospective study. Most important, they suggest that the new incidence of HSV reactivation is now much lower in the “cytomegalovirus prophylaxis era” and that with timely diagnosis and proper treatment most patients recover well from their HSV infections and respond to the current treatment regimens.     

Clinical Characteristics and Outcomes of Liver Transplantation Recipients With COVID-19 Pneumonia

BackgroundWe aimed to evaluate the clinical characteristics and outcomes of mild-severe COVID-19 pneumonia cases in liver transplant (LT) recipients.MethodsTen LT recipients diagnosed as having COVID-19 pneumonia in a 6-month period in our transplantation center were included. Demographic and medical data of the recipients were retrospectively collected; clinical courses, treatment responses, and outcomes were evaluated.ResultsTen LT recipients were male, had a median age of 57 years (min-max, 36-69 years; interquartile range [IQR], 13 years), and had right lobe from living donor LT performed in a median of 11 months (min-max, 1-72 months; IQR, 12 months). Five patients had severe pneumonia, and the remaining patients had mild/moderate pneumonia. The most frequent symptoms were fever (90%) and cough (70%). Favipiravir, enoxaparin sodium, and corticosteroid were initiated at the time of the diagnosis; immunosuppressive drug doses were reduced or discontinued in 3 cases. Lymphopenia median: 510/mL (min-max, 90-1400 mL; IQR, 610 mL), increased levels of C-reactive protein median: 4.72 (min-max, 0.31-23.4; IQR, 8.5), and ferritin median: 641 (min-max, 40 to ≥ 1650; IQR, 1108) were frequent. Four patients required antibacterial treatments because of emerging bacterial pneumonia and/or sepsis. All patients were hospitalized for a median of 10 days. One patient with sepsis died on the 26th day after intensive care unit admission, and the remaining 9 survived. No further complication was recorded for 1-month follow-up.ConclusionsCommencing favipiravir, enoxaparin sodium, and corticosteroid treatments; close follow-up of the developing complications; the temporary reduction or cessation of immunosuppression; a multidisciplinary approach; early awareness of the bacterial infections; and the initiation appropriate antibiotic treatments can contribute to success.     

SARS-CoV-2 in Kidney Transplant and Waitlisted Patients During the First Peak: The Welsh Experience

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) global pandemic has led to many health care services, including transplantation, being temporarily suspended. For transplantation to safely recommence, there is a need to understand the effects of SARS-CoV-2 in transplant and waitlist patients.We identified 21 patients with proven SARS-CoV-2 infection (13 transplant; 8 waitlist) during the first peak of coronavirus disease 2019 in Wales.Median patient age was 57 years (range, 24-69), 62% were male, and all were white. Median body mass index was 29 kg/m² (range, 22-42), and 81% had 1 or more significant comorbidities. Median time from transplant to SARS-CoV-2 infection was 135 months (range, 9-356) and median time since being listed was 17.5 months (range, 5-69) for waitlisted patients. Seventeen patients were admitted to the hospital (81%), 18% (n = 3) in intensive care unit, and 5 patients died (4 transplant recipients and 1 waitlist patient; 24%). Two of the 4 transplant patients who died had recent malignancy. Although the mortality of hospitalized transplant patients was high, their infection rate of 0.87% meant that the overall mortality of transplant patients due to SARS-CoV-2 was low and comparable to that of patients on the waitlist.These data provide confidence in restarting the transplant program, provided that a series of measures aiming to avoid infections in newly transplanted patients are taken.     

In situ splitting of the cadaveric liver for two adult recipients.

BACKGROUND: Split-liver transplantation offers a unique opportunity to expand the existing donor pool. However, it has previously been stated that due to inadequate liver volume the advantages of split-liver transplantation would be lost when attempting to split the liver for two adult recipients. In this study, we sought to determine the safety, efficacy, and applicability of split-liver transplantation in select adult liver transplant recipients. METHODS: Liver allografts for eight adult recipients were procured by in situ splitting of four adult cadaveric livers. The donor ages were 17, 19, 22, and 25 years and weights were 72, 77, 78, and 87 kg, respectively. In situ splitting resulted in three right trisegmental grafts, one right lobe graft, one left lobe graft, and three left lateral segmental grafts. The median recipient age was 49 years (range 38-61 years), whereas the median recipient weight was 84 kg (range 78-98 kg) for the right-sided grafts and 52 kg (range 51-53 kg) for recipients of the left-sided grafts. The median graft-to-recipient body weight ratio for right trisegmental, right lobe, left lobe, and left lateral segmental grafts was 1.31%, 1.26%, 1.35%, and 0.70%, respectively. RESULTS: Overall patient and graft survival in this series is 100%. All prothrombin times were normalized within 4 days of transplantation. No evidence of ascites or prolonged hyperbilirubinemia was encountered in any right- or left-sided graft recipient. The incidence of hepatic artery, portal vein, and hepatic vein thrombosis is 0%, 0%, and 0%, respectively. Hepatic arterial anastomotic bleeding and a cut surface bile leak each occurred in one patient. Median United Network for Organ Sharing (UNOS) waiting time was 242 days (range 4-454 days) for the patients to which the donor liver was allocated. In contrast, the median waiting time for the four patients receiving the extra split-liver graft was reduced significantly to 37 days (range 21-101 days) (P<0.02). CONCLUSIONS: This study demonstrates that split-liver transplantation can expand the cadaveric donor liver pool available for select adult liver transplant recipients. When both the donor organ and the transplant recipient are chosen carefully, split-liver transplantation can be safely performed without a delay in allograft function, increase in technical complications, or compromise in graft or patient survival.     

Liver transplantation without isoniazid prophylaxis for recipients with a history of tuberculosis

Abstract:  Tuberculosis remains one of the most serious infections after organ transplantation. Isoniazid prophylaxis for liver transplant recipients with a history of tuberculosis is generally recommended. However, its benefit is controversial because of potential hepatotoxicity of isoniazid. It is crucial to determine appropriate post-transplant managements for the recipients with a history of tuberculosis. The purpose of this study was to investigate the necessity of isoniazid prophylaxis for liver transplant recipients who had a history of tuberculosis. The medical records of 1116 liver transplant recipients were studied, of whom seven had a history of tuberculosis (0.63%). One who underwent living-donor liver transplantation for fulminant hepatic failure was excluded from evaluation because of early death, caused by bacterial sepsis two months after transplantation, although reactivation of tuberculosis was not observed. The median observation period after transplantation was 25.5 months (range 12–82). Reactivation of tuberculosis did not occur in any of these six patients. In conclusion, we could not find rationale for isoniazid prophylaxis in liver transplant recipients with past diagnosis of tuberculosis, when the disease is considered to be inactive. Tuberculosis should be considered as cause of post-transplant infections, and careful post-transplant observations are essential for an early diagnosis.     

Percutaneous dilational tracheotomy in solid-organ transplant recipients

Pulmonary complications, such as pneumonia and respiratory failure, are important contributors to posttransplantation morbidity and mortality among solid-organ transplant recipients. Percutaneous dilational tracheotomy (PDT) is cost-effective in critically ill patients who require prolonged mechanical ventilation; however, the literature lacks reports about the effectiveness of this procedure in organ transplant recipients. Between August 2001 and February 2003, five recipients underwent PDT in our intensive care unit: two kidney, two liver, and one heart transplant recipient. The respective mean values for age, weight and APACHE II score were 41 +/- 7 yrs (range, 33-51 years), 63 +/- 14 kg (range, 40-80 kg), and 23 +/- 9 (range, 15-35). All PDTs were performed at the bedside by an experienced staff anesthesiologist under endoscopic guidance using the Griggs forceps dilational technique. The mean interval from transplantation to PDT was 58 +/- 56 months (range, 8 days to 132 months). In all cases, the indication for PDT was prolonged mechanical ventilation due to acute respiratory failure. The mean duration of endotracheal intubation before PDT was 4 +/- 3 days (range, 1-8 days). Transient hypoxemia (n = 1) and mild extratracheal bleeding (n = 1) were the only early complications. There were no late complications (including peristomal infection) or deaths associated with the procedures. Among the two patients who survived their stay in the intensive care unit, the functional and cosmetic outcomes of PDT were excellent. We recommend this technique for prolonged airway management in solid-organ transplant recipients.     

Thyroid cancer in the renal transplant population: epidemiological study

BACKGROUND: The epidemiology of thyroid neoplasms in the renal transplant population has not been widely published. The present study compares the behaviour of thyroid cancer in the transplant cohort with that of the general population. It also documents the transplantation outcomes of patients with thyroid and non-thyroid cancers. METHODS: All recipients of renal grafts are registered with the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Data were obtained from this institution and analysed using Microsoft Excel and Stata statistical software. Risk ratio, attributable risk, Mann-Whitney test, and the Kaplan-Meier survival probability were calculated. RESULTS: Between 1963 and 31 March 2002, 23 (0.22%) patients were diagnosed with thyroid cancer from a cohort of 10,689 renal transplant recipients. The median age in the renal-transplant thyroid cancer group was 48.2 years (range: 23-67 years), and there were 11 (48%) male patients, compared to 26% of thyroid cancer patients in the general population (P = 0.02). The median time to thyroid cancer diagnosis after transplantation was 68 months (range: 3-253 months) compared to 102 months (range: 3-363 months; P = 0.004) in non-thyroid cancers. Ten patients (43%) were found to have lymphatic metastasis, eight of whom presented at the time of primary diagnosis. The risk ratio (RR) was 5.2 (95% confidence interval: 2.0-16.6), with an attributable risk of 17.4 cases per 10,000. There were two cancer-related deaths resulting in a survival probability of 89% at 5, 10 and 15 years. CONCLUSIONS: There is a higher incidence of thyroid cancer and an altered sex distribution in the renal transplant population. A significant proportion presents with lymphatic metastasis requiring lymph node dissection and radioactive iodine treatment.