Successful Kidney Transplantation From A Donor With Inherited Thrombophilia: A Case Report

Inherited thrombophilia is a blood clotting disorder caused by genetic mutations of specific coagulation plasma factors. It is a well-established predisposing factor for venous as well as arterial thromboembolism. Thromboembolic events with renal involvement in patients with inherited thrombophilia are possible but relatively rare. On the other hand, vascular complications, including renal artery and vein thrombosis, are the main causes of early graft loss after kidney transplantation. Furthermore, there is evidence that inherited thrombophilia has a role in chronic kidney disease development.Although there are data on kidney transplantation of recipients with inherited thrombophilia, to the best of our knowledge there are no reports on kidney donation from patients with thrombophilia in the English literature. We present 2 cases of successful kidney transplantation from the same donor with inherited thrombophilia.     

Successful Renal Transplantation From a Brain-Dead Deceased Donor Who Died From Snakebite: A Case Report

Even though India is the country with the highest annual number of deaths (50,000) from snakebite, there is contradictory evidence regarding acceptance of deceased donors (DD) who died from this cause. We present 2 successful renal transplantations (RTx) from a brain-dead DD who died from a neurotoxic snakebite without manifestations of a viper bite. We accepted the donor as he exhibited no evidence of hematoxic snakebite. Rather the findings were consistent with a neurotoxic bite (probably krait), which can cause hypoxic brain injury. Both recipients established good diuresis intraoperatively and did not require hemodialysis. The patients were discharged with good diuresis and normal serum creatinines. After 3-month follow-up, both recipients show normal graft function. According to our experience of favorable RTx outcomes from a brain-dead DD who died from neurotoxic snakebite may expand the donor pool.     

Successful Renal Transplantation From a Deceased Donor With Pesticide Intoxication: A Case Report

The number of individuals awaiting organ transplantation exceeds the number of organs. Patients who die from intoxication are rarely accepted as potential organ donors. Herein we have presented the results of kidney transplantations performed from a deceased 20-year-old female donor with suicidal ingestion of a pesticide (carbamate). The procured kidneys were successfully transplanted. Patients and grafts are doing well at 4 months following transplantation. There are few reports of successful transplantation of organs obtained from patients who die from various intoxications. Poisoned patients represent another pool of organ donors for transplantation services.     

Can Donor-Derived Cell-Free DNA Detect Graft-Versus-Host Disease in Solid Organ Transplantation: A Case Report

Graft-versus-host disease (GVHD) is a rare complication after solid organ transplant. We present a case of GVHD after simultaneous pancreas kidney transplant. The patient was diagnosed with a cutaneous biopsy after developing the classic symptoms of maculopapular rash, diarrhea, and pancytopenia. However, this patient had unexplained elevations in donor-derived cell-free DNA (dd-cfDNA) for months before the onset of GVHD symptoms. We hypothesize that GVHD may be associated with elevated dd-cfDNA as a result of massive donor lymphocyte proliferation and turnover. Further investigation is warranted because earlier diagnosis and treatment could improve outcomes in an otherwise lethal disease.     

Transmission of Syphilis by Solid Organ Transplantation

Two organ recipients developed serologic evidence of syphilis infection after renal transplantation from a common deceased donor with a history of treated syphilis. Testing of donor serum for syphilis, which occurred after transplantation, gave results interpreted as consistent with past infection. However, subsequent serologic results in the recipients suggested transmission of infection at transplantation due to active infection of the donor. This may be explained by recent donor re-infection in view of the current syphilis epidemic in the United Kingdom. An initial error in the treatment of recipients further served to highlight unfamiliarity in managing this resurgent infection in the context of organ transplantation.     

Reducing Infection Transmission in Solid Organ Transplantation Through Donor Nucleic Acid Testing: A Cost‐Effectiveness Analysis

For solid organ transplant (SOT) donors, nucleic acid‐amplification testing (NAT) may reduce human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission over antibody (Ab) testing given its shorter detection window period. We compared SOT donor NAT + Ab versus Ab alone using decision models to estimate incremental cost‐effectiveness ratios (ICERs; cost per quality‐adjusted life year [QALY] gained) from the societal perspective across a range of HIV/HCV prevalence values and NAT costs. The cost per QALY gained was calculated for two scenarios: (1) favorable: low cost ($150/donor)/high prevalence (HIV: 1.5%; HCV: 18.2%) and (2) unfavorable: high cost ($500/donor)/low prevalence (HIV: 0.1%; HCV: 1.5%). In the favorable scenario, adding NAT screening cost $161 013 per QALY gained for HIV was less costly) for HCV, and cost $86 653 per QALY gained for HIV/HCV combined. For the unfavorable scenario, the costs were $15 568 484, $221 006 and $10 077 599 per QALY gained, respectively. Universal HCV NAT + Ab for donors appears cost‐effective to reduce infection transmission from SOT donors, while HIV NAT + Ab is not, except where HIV NAT is ≤$150/donor and prevalence is ≥1.5%. Our analyses provide important data to facilitate the decision to implement HIV and HCV NAT for deceased SOT donors and shape national policy regarding how to reduce infection transmission in SOT.     

Lymphomas After Solid Organ Transplantation: A Collaborative Transplant Study Report

We used the Collaborative Transplant Study database to analyze the incidence, risk, and impact of malignant lymphomas in approximately 200,000 organ transplant recipients. Over a 10-year period, the risk in renal transplant recipients was 11.8-fold higher than that in a matched nontransplanted population (p<0.0001). The majority of lymphomas were diagnosed after the first post-transplant year. Heart-lung transplants showed the highest relative risk (RR 239.5) among different types of organ transplants. In kidney recipients, immunosuppression with cyclosporine did not confer added risk compared with azathioprine/steroid treatment, whereas treatment with FK506 increased the risk approximately twofold. Induction therapy with OKT3 or ATG, but not with anti-IL2 receptor antibodies, increased the risk of lymphoma during the first year. Antirejection therapy with OKT3 or ATG also increased the risk. First-year mortality in renal and heart transplant patients with lymphoma was approximately 40% and 50%, respectively, and showed no improvement in recent years. A pattern of preferential localization to the vicinity of the transplant was noted, and the prognosis of the patient was related to localization. This study highlights the continuing risk for lymphoma with time post-transplantation, the contribution of immunosuppression to increased risk, and continuing poor outcomes in patients with post-transplant lymphoma.     

Living-Donor Kidney Transplantation With Laparoscopic Nephrectomy From a Donor With Horseshoe Kidney: A Case Report

BackgroundIn living-donor kidney transplantation, laparoscopic nephrectomy from a donor has become widespread. However, more careful treatment is required for nephrectomy from a donor with horseshoe kidney. This report presents an interesting surgical case of laparoscopic nephrectomy from a donor with horseshoe kidney.Case presentationA woman aged 53 years was a donor candidate for living-donor kidney transplantation for her husband. She had no medical history and had no problems on preoperative examination, but contrast-enhanced computed tomography revealed that she had horseshoe kidney. As the isthmus was thin and the contrast effect was poor, the isthmus was considered to have poor kidney parenchyma and consisted almost exclusively of fibrous tissue. Therefore, laparoscopic nephrectomy was performed for the donor. On the basis of the 99m Tc-dimercaptosuccinic acid renal scintigraphy results, the right kidney was collected. A laparoscopic nephrectomy with a retroperitoneal approach was performed using GelPort access platforms in a right abdominal incision with an accessory port. We firmly expanded the isthmus and then dissected it just above the aorta using a linear stapling device. Subsequently, we sutured a renal artery and vein with linear stapling devices. The recipient's surgery was also performed without any problems, and the postoperative course of both donor and recipient was good.ConclusionsWe suggest that even if the donor has horseshoe kidney, laparoscopic donor nephrectomy should be actively considered depending on the thickness of the isthmus of the horseshoe kidney.     

Arterial Complication After Simultaneous Pancreas-Kidney Transplantation From an Abdominal Aortic Aneurysm Donor: A Case Report

Background

With the current disparity between the donor organ availability and recipient needs, various marginal organs with anatomical variations or concomitant diseases have begun to be used. We present a case of simultaneous pancreas-kidney transplantation (SPKTx) from a marginal donor with a giant abdominal aortic aneurysm who was incidentally found to be an organ donor after brain death.

Deceased Donor Organ Transplantation With Expanded Criteria Donors: A Single-Center Experience From India

Introduction

Deceased donor organ transplantation (DDOT) accounts for <4% of renal transplants in India. Many volunteers come forth for organ donation with increasing awareness; unfortunately, the majority are marginal donors, but their rejection would hamper the DDOT program. Judicious use of marginal organs is a challenge for developing countries.

Patients and Methods

We performed 29 renal transplants from 21 expanded criteria donors (ECD) out of 115 DDOT between January 2006 to April 2009—10 dual (DKT) and 19 single (SKT). Fourteen donors had hypertension, a cerebrovascular accident as the cause of death, 9 had both, and 4 had diabetes. Mean donor age was 70.3 ± 8.9 years. Decisions on the procedure were based upon frozen section biopsy in 13 of 21 donors. Mean DKT donor age was 76 ± 9.7 years versu 64 ± 5.7 years of SKT donors. The native kidney diseases were chronic glomerulonephritis (n = 14), diabetic nephropathy (n = 7), tubulointerstitial nephritis (n = 4) and polycystic kidney disease, focal segmental glomerulosclerosis, lupus nephritis and patchy cortical necrosis, (n = 1 each). Mean recipient age of DKT versus SKT was 43.5 versus 42.3 years. All recipients received rabbit anti-thymocyte globulin, followed by steroid, mycophenolate mofetil/calcinueurin inhibitor.

Results

Over a mean follow-up of 341 days, the mean serum creatinine (SCr) of 25/29 patients was 1.60 mg/dL (range, 1.0-2.6). The mean SCr of SKT patients was 1.59 ± 0.63 mg/dL and of DKT, 1.62 ± 0.48 mg/dL. Ten patients had delayed graft function and 11 had biopsy proven acute tubular necrosis. Seven (24%) patients had rejection (grade 3 Banff update '05, type IA; 4, type 2A); 6 responded to antirejection; 1 graft was lost at 7 months due to chronic rejection. Three (10.3%) patients were lost, 1 each due to AMI, sepsis, and CMV disease.

Conclusion

In the circumstances of organ shortage, DDOT with expanded criteria donor is a feasible option.     

Primary Cutaneous Fungal Infections in Solid Organ Transplantation: A Case Series

Cutaneous fungal infections in solid-organ transplant patients present in a variety of nonspecific ways, requiring a high index of suspicion to diagnose correctly. In the present series of four transplant recipients, subsequent primary cutaneous fungal infections presented as papules, plaques, ulcers and subcutaneous nodules. Transplantations included one cardiac, two renal and one renal-pancreatic transplant. Fungal infections were limited to the skin; there was no evidence of disseminated disease in any case. The pathogens isolated were Scedosporium apiospermum (Pseudallescheria boydii), Alternaria species, Aspergillus fumigatus, and a coelomycete in the Coniothyrium-Microsphaeropsis complex of dark molds. Individuals were successfully treated with surgical debridement, antifungal agents, and reduction of immunosuppressive therapy. All patients and allografts survived. Accurate diagnosis, aggressive surgery and appropriate antifungal therapy, combined with close outpatient follow-up, optimize the likelihood of a cure in a transplant population.     

Impact of Ethylene Glycol Toxicity on Donor Organ Viability: A Case Report

Using kidneys from deceased donors whose demise was secondary to ethylene glycol (EG) toxicity requires considerable thought and planning. The exact impact that kidneys from these donors could have is unclear. The shortage of viable organs and growing wait list mortality should lead us to consider these allografts as potential life-saving transplants. Because it is crucial for the transplant community to use every available allograft, we need to develop processes that optimize each possible scenario. This article is a discussion of the viability of kidneys from a donor with EG-induced brain death and a proposed algorithm for encouraging the use of renal allografts after EG toxicity.     

Split Liver Transplant From Deceased Marginal Donor: A Case Report

The relative paucity of deceased donor organs and the progressive increase in patients with cirrhosis have led transplant centers to consider organs from marginal donors (elderly donors, prolonged stay in the intensive care unit (ICU), liver steatosis—steatotic grafts, severe hypernatremia, and use of inotropes). Recently, the use of those marginal grafts has increased, but splitting liver is still debatable.Herein, we present a 28-year-old deceased donor who had a history of traumatic brain injury. The patient stayed in ICU for 3 days with high sodium level (188 mEq/L) and was hemodynamically supported with single inotrope. At the time of procurement, core biopsies were taken from the right lobe and left lateral segment of the liver, with results demonstrating 5% necrosis. A decision was made for split liver transplant as left lateral sector and extended right lobe.Liver graft was divided into a left lateral segment to be transplanted to a 4-year-old child with secondary biliary cirrhosis due to previous liver transplant and a right extended liver lobe for an adult patient with hepatocellular carcinoma waiting 10 months on the waiting list. Both liver transplants were performed uneventfully. Patients were discharged on the 11^th and 56^th days after transplant. The liver function tests remained normal during the follow up period of 2 years.A marginal graft with more than one risk factor should not be discarded liberally. Splitting such grafts could be considered in a highly selective recipients.     

Pulmonary Aspergillosis in Solid Organ Transplant Patients: A Report From Iran

Background

Aspergillosis is one of the most important opportunistic infections after organ transplantation. Early diagnosis and initiation of appropriate antifungal therapy are key factors for better prognosis.

Methods

We reviewed the medical records of patients with solid organ transplantation with evidence of Aspergillus infections from December 2001 to January 2008, evaluating patient demographics, time of onset after transplantation, risk factors, radiologic appearance, diagnostic criteria, antifungal therapy, and outcome.

Results

We observed aspergillosis in 8 lung, 3 kidney, and 1 heart recipient, with overall mean age of 40.6 years. Seven cases of Aspergillus tracheobronchitis were diagnosed in lung transplant recipients, all of them in the first 6 months after transplantation. All patients responded to antifungal therapy and bronchoscopic debridement. We observed 5 cases of invasive pulmonary aspergillosis. Three patients survived in response to antifungal treatment. The two patients who died were treated with a combination of itraconazole and amphotericin B, whereas all cured patients had been treated with voriconazole alone or in combination with caspofungin.

Conclusion

It seems that the prognosis of aspergillosis in solid organ recipients is improving with new treatment regimens, particularly if they are used in early stages of infection.     

Testicular Microlithiasis with Mediastinal Choriocarcinoma: A Case Report

A 19-year-old Japanese male developed a cough, chest pain, and high fever. CT of the chest revealed a bulky mediastinal tumor (13 times 1O × 8 cm) and bilateral multiple pulmonary nodules. CT of the abdomen and pelvis was normal. Laboratory evaluation showed a beta human chorionic gonadotropin (βHCG) level of 985 ng/mL. Testicular ultrasonography demonstrated multiple, bilateral punctate echoes characteristic of testicular microlithiasis (TM). No primary testicular tumor was detected. Needle biopsies of the testes did not reveal cancer and calcification. Transthoracic needle biopsy of the mediastinal tumor showed choriocarcinoma. No correlation is known between TM and choriocarcinoma without testicular cancer, but the incidence of TM in this patient may reflect his high human chorionic gonadotropin level.     

Coccidioidomycosis Transmission Through Organ Transplantation: A Report of the OPTN Ad Hoc Disease Transmission Advisory Committee

Donor‐derived coccidioidomycosis has caused unexpected morbidity and mortality in transplant recipients. All proven or probable reports of donor‐derived coccidioidomycosis to the Disease Transmission Advisory Committee between 2005 and August 2012 were reviewed. Six reports of proven or probable coccidioidomycosis were discovered. In four of six, the infection was first detected at autopsy in the recipient. In two cases it was first identified in the donor. Twenty‐one recipients received organs from these six donors. Transmission occurred in 43% at a median of 30 days posttransplant with a mortality rate of 28.5%. Eleven recipients received preemptive antifungals, seven did not receive treatment, and treatment information was not reported for three recipients. Five of seven who did not receive prophylaxis/treatment died and all 11 who received early therapy survived. Six deaths occurred 14 to 55 days after transplant, with a median of 21 days. For exposed recipients, donor‐derived coccidioidomycosis is a significant cause of morbidity and mortality. Evidence of infection in one recipient should prompt immediate evaluation for treatment of all other recipients from the same donor as preemptive treatment was effective. Further studies are needed to decide whether all donors from endemic areas should have routine serologic screening.     

Cytomegalovirus Prophylaxis and Graft Outcome in Solid Organ Transplantation: A Collaborative Transplant Study Report

We investigated relationships between cytomegalovirus (CMV) seropairing and CMV prophylaxis on graft outcome in recipients of solid organ transplants. Transplants carried out from 1985 to 2002 and reported to the Collaborative Transplant Study were analyzed. In cadaver kidney recipients, CMV prophylaxis was significantly associated with improved graft survival only in the seronegative-recipient/seropositive-donor combination (at 3 years: 79.4% with prophylaxis vs. 73.5% without prophylaxis; RR 0.80, p < 0.0001). Among patients who had a functioning graft at 1 year, significantly fewer patients who received CMV prophylaxis received rejection treatment in the preceding year (26.3%), compared with patients who did not receive prophylaxis (32.4%) (p = 0.0001), suggesting an inhibitory effect of CMV prophylaxis on acute rejection. Significant improvements in graft survival after CMV prophylaxis were found also in CMV-negative recipients of CMV-positive heart, and lung or heart-lung transplants, but not liver transplants. The age of the recipient had a differential effect on graft and patient survival after CMV prophylaxis. Use of antilymphocyte antibodies or mycophenolate mofetil was not associated with an enhanced CMV effect on graft outcome. These results may contribute to a better understanding of the influence of pretransplant CMV serology on the effect of CMV prophylaxis.