Severe life-threatening Ehrlichia chaffeensis infections transmitted through solid organ transplantation.

BACKGROUND: Donor-derived infections from organ transplantation are rare occurrences with preoperative screening practices. Ehrlichia chaffeensis, a tick-borne illness, transmitted through solid organ transplantation has not been reported previously to our knowledge. We present cases of 2 renal allograft recipients who developed severe E. chaffeensis infection after receipt of organs from a common deceased donor. METHODS: The 2 renal transplant patients who developed E. chaffeensis infection are reported in case study format with review of the literature. RESULTS: Approximately 3 weeks after renal transplantation, both patients developed an acute febrile illness and rapid clinical decline. Recipient A underwent an extensive infectious workup that revealed positive E. chaffeensis DNA from polymerase chain reaction on peripheral blood. Recipient B's clinical team obtained acute and convalescent antibody titers for E. chaffeensis, which demonstrated acute infection. Recipients A and B were treated with doxycycline and tigecycline, respectively, with clinical cure. CONCLUSIONS: These cases demonstrate that tick-borne pathogens, such as E. chaffeensis, can be transmitted through renal transplantation. E. chaffeensis can be associated with excessive morbidity and mortality, commonly owing to delay in diagnosis and poor response to non-tetracycline antibiotics. In populations with endemic tick-borne illness, donors should be questioned about tick exposure, and appropriate antibiotics can be administered if indicated.

Urologic complications in more than 2500 kidney transplantations performed at the Saint Barnabas healthcare system.

We report our urologic complications based on one urologist's experience during a 17-year period on more than 2500 ureteral reimplantation operations performed at the time of kidney transplant. Among 2548 ureteroneocystostomies performed by the transplant urologist, a 5.5% urologic complication rate was observed. This included vesicoureteral reflux (3%), ureteral strictures (1.3%), urine leak (0.9%), and uteropelvic junction obstruction (0.3%). The factors for low urologic complication rates include the use of a shorter segment of ureter using the Lich-Gregoir technique (compared to the Politano-Leadbetter technique) and the routine use of indwelling stents. In addition, having one transplant urologist performing all ureteral reimplantations and managing all urologic complications provided consistency in results.

Clonal T-large granular lymphocyte proliferation in solid organ transplant recipients.

Large granular lymphocytic (LGL) leukemia is a rare disorder, usually caused by clonal proliferation of CD3+ CD57+ T-LGL cells. T-cell clonality is confirmed by rearrangements of the T-cell receptor (TCR) gene. Characteristic features of T-LGL leukemia include neutropenia, anemia, and constitutional symptoms such as fatigue. Many solid organ transplant recipients experience similar symptoms and have neutropenia and anemia often attributed to immunosuppressive therapy. The purpose of this study was to determine the prevalence of T-LGL proliferation in solid organ transplant recipients and demonstrate its association with leukopenia and anemia. Twenty-three cardiac and renal transplant patients were evaluated by peripheral smear examination, flow cytometry, and TCR gene rearrangement study by polymerase chain reaction. Ten of 14 (71%) cardiac transplant patients and 4 of 9 (44%) renal transplant patients, without evidence of either allograft rejection or a viral syndrome, were found to have clonal expansion of T-LGL cells. Constitutional symptoms were present in 30% of these patients. Anemia of <10 g/dL was seen in 75% of renal transplant and 10% of cardiac transplant patients. None of these patients had significant neutropenia defined as absolute neutrophil count of 1500 mu/L. Most of the patients did not require any specific therapeutic intervention. Although TCR gene rearrangement is considered a hallmark of T-LGL leukemia, we believe that this monoclonality is not a true form of posttransplant lymphoproliferative disorder. Constant antigenic stimulus from the allograft may be the underlying etiology of clonal expansion and may contribute to cytopenias and fatigue seen in transplant patients.

The effect of Daclizumab in a high-risk renal transplant population.

INTRODUCTION: African-American (AA) renal transplant recipients have a higher incidence of acute rejection when compared to Caucasian renal transplant recipients. This higher rejection rate holds true even with the addition of several of the newer immunosuppressive agents (e.g. mycophenolate mofetil (MMF) and Rapamycin). Acute rejection rates among Hispanic (H) renal transplant recipients are higher in some settings, while lower or the same as in Caucasians in other settings. IL-2 receptor antibodies have been shown to decrease rejection rates when added to a regimen of cyclosporine (CsA), azathioprine and prednisone. Limited data are available on these agents in conjunction with triple CsA, MMF and prednisone therapy, particularly in higher risk group patients. We studied the effect of the addition of the IL-2 receptor antibody Daclizumab to a CsA, MMF, prednisone regimen in a group of African American and high-risk Hispanic renal transplant recipients. METHODS: This was a non-randomized, prospective study. A total of 49 renal transplant recipients (29 African American and 20 Hispanic) were studied and followed. A simultaneous cohort of 56 (31 African-American and 25 Hispanic) renal transplant recipients receiving CsA, MMF and prednisone with no standard induction agent served as the control group. The study cohort received the same regimen with the addition of Daclizumab at 1 mg/kg for five doses over 10 wk. Multivariate analysis was performed to isolate independent factors influencing the study's results. RESULTS: A total of 56 patients in the control group and 49 patients in the Daclizumab group received an average follow-up of 17.1 +/- 6.9 and 12.7 +/- 5.1 months, respectively. Acute rejection rates were lower in the Daclizumab group as compared to the control group 26.4% versus 49.3% per patient years, respectively. A total of eight recurrent rejections in 6 patients occurred in the control group and none in the Daclizumab arm. Graft loss at this follow-up was no different between the groups. CONCLUSION: The addition of Daclizumab to a regimen of CsA, MMF and prednisone decreases acute rejection episodes in a high-risk group of African American and Hispanic renal transplant recipients.

The effects of recombinant human erythropoietin on the cell mediated immune response of renal failure patients.

Recombinant human erythropoietin (rHuEpo) is now widely employed in correction of the anemia of end stage renal disease (ESRD). Recent reports suggest that rHUEpo, in addition to its effect on CFU-E and burst-forming-unit-erythroid (BFU-E), may stimulate granulocyte/macro-phage production and pluripotential progenitors of the myeloid and monocyte lineage. Furthermore, there is now data which demonstrate that ESRD patients who received rHuEpo have enhanced cytokine production. Taken together, these observations suggest that the administration of rHuEpo may augment the diminished immune response of renal failure patients. To evaluate the effects of rHuEpo therapy on cell-mediated immunity in hemodialysis patients, a prospective controlled study was conducted. Two parameters of immune function were tested. One was natural killer cell (NK) activity, and the other proliferation in response to the T cell mitogen concanavalin A (Con-A). NK activity of the ESRD patients was comparable with that of normal controls at the start of the study and was unaffected by rHuEpo therapy. In contrast to this, anemic ESRD patients initially demonstrated impaired mitogen driven proliferation (initial stimulation index (S.I.) = 42.5 +/- 11.9) which significantly improved following rHuEpo therapy (final S.I. = 73.3 +/- 14.7, p < 0.05). The later value exceeded the mitogen response in less anemic ESRD patients who did not receive rHuEpo (initial S.I. = 60.7 +/- 16.5, final S.I. = 61.0 +/- 16.7), but did not reach values seen in normal controls. The data suggest that rHuEpo therapy may be associated with enhanced immune responses in patients with ESRD.

Boerhaaves' syndrome.

A 47 year old male with Boerhaaves' syndrome is described. A brief review of the literature is also presented.