ABSTRACT
Background: Recipients requiring kidney-enbloc visceral allograft often face challenges during transplantation. We report a case with a unique technique of urinary diversion in enbloc liver-intestine-kidney transplantation for irradiation enteritis and cystitis. Methods: The patient is a 65 year-old man with Crohn's disease and history of anal adenocarcinoma treated with abdominoperineal resection and adjuvant chemo- and radiotherapy. Case will be presented with pictures and/ or video. Results: The patient developed gut failure due to short gut and multiple bowel obstructions secondary to radiation enteritis. Urinary incontinence developed after irradiation caused frequent urinary tract infection leading to kidney failure. He was listed for combined liver-intestine-kidney transplantation and received en-bloc allograft from a 35 year-old male brain-dead donor. During evisceration of native organs, frozen abdomen was encountered and subtotal enterectomy leaving 30 cm of jejunum was performed. Urinary bladder was rock hard with no augmentation, unacceptable to implant the allograft ureter. Arterial inflow was established with an aortic conduit between the native and allograft infra-renal aorta. The native jejunum was transected at 10 cm and the proximal segment was connected to allograft jejunum to establish the continuity of alimentary tracts. The distal 20 cm of native jejunum was anastomosed to allograft ureter for urinary diversion Postoperative course was unremarkable with adequate urinary output and allograft functions. The patient was well rehabilitated in hospital due to lack of safe rehabilitative facilities during COVID pandemic and discharged home on post-operative day 47. Conclusion: Combined kidney and visceral transplantation in the setting of irradiated bladder requires pre-operative planning of urinary reconstruction with several options. When native intestine is available and not damaged from original disease, urinary diversion using the native jejunum is the safest option amongst others including cystoplasty and urinary diversion using allograft ileum.
ABSTRACT
Introduction: Coronavirus disease 2019 (COVID-19) outbreak posed unique challenges for immunosuppressed patients. Little is known about the clinical course and immunosuppression management of this novel infection in intestinal transplant recipients. Methods: We experienced 6 adult intestinal transplant recipients who had a positive swab test of COVID-19 and symptoms. Baseline characteristics, clinical presentation, management of immunosuppressive therapy and outcomes were collected. Results: Median age was 53 years (range 30-71). They had 3 liver-free composite allografts, 2 isolated intestine, and 1 intestine-kidney with median time from transplant of 8 years (range 4-12). Maintenance immunosuppressive therapy was tacrolimus/steroid in 4, and tacrolimus monotherapy in 2 patients. The most common symptom was cough (n=5) followed by fever (n=3) and dyspnea (n=3). All had ground glass opacities on computed tomography. Four patients were admitted to our institution but two were managed at local hospital due to difficulty of transportation. Immunosuppression therapy was never suspended and was reduced for one patient. Pharmacological therapy consisted in remdesivir and steroids for 4 recipients (67%) associated with convalescent plasma in 2 cases (33%) plus tocilizumab in 1 case (17%), and steroids for 2 patients (33%) associated with convalescent plasma in 1 case (17%). Two patients required intubation for acute respiratory distress syndrome. One patient received antibiotics for superimposed bacterial pneumonia. Mean white blood cells and lymphocyte count were 4.72±0.6 k/uL and 0.96±0.65 k/uL at presentation, respectively. Mean D-Dimer, C-reactive protein and ferritin were 740±160 ng/ml, 4.1±5 mg/dl and 249±149 ng/ml, respectively at presentation, with a peak of 1255±785 mg/ml, 10.9±8 mg/dl and 630±318 ng/ml, respectively. No significant changes were noted in liver and renal function. Before discharge, all patients underwent ileoscopy and allograft biopsies with no evidence of inflammation/rejection. Mean hospital stay was 36±21 days. Death occurred in 2 patients (33%) who were managed at local hospital. No recurrence was noted with mean follow up of 90 days. Conclusions: We treated intestinal transplant recipients symptomatic for COVID-19 without immunosuppression interruption. No increased inflammation or rejection was noted in the intestinal grafts. Aggressive treatment of COVID-19 infection should be granted under expertise of intestinal transplant and transplant infectious disease team.