The impact of switching to mTOR inhibitor-based immunosuppression on long-term non-melanoma skin cancer incidence and renal function in kidney and liver transplant recipients.

Background: Solid organ transplantation is associated with increased risk of non-melanoma skin cancer. Studies with short follow up times have suggested a reduced occurrence of these cancers in recipients treated with mammalian target of rapamycin inhibitors as maintenance immunosuppression. We aimed to describe the occurrence of skin cancers in renal and liver transplant recipients switched from calcineurin inhibitor to sirolimus-based regimes.Methods: We performed a retrospective study of sirolimus conversion within the Irish national kidney and liver transplant programs. These data were linked with the National Cancer Registry Ireland to determine the incidence of NMSC among these recipients. The incidence rate ratio (IRR) for post versus pre-conversion NMSC rates are referred in this study as an effect size with [95% confidence interval].Results: Of 4,536 kidney transplants and 574 liver transplants functioning on the 1 January 1994 or transplanted between 1 January 1994 and 01 January 1994 and 01 January 2015, 85 kidney and 88 liver transplant recipients were transitioned to sirolimus-based immunosuppression. In renal transplants, the rate of NMSC was 131 per 1000 patient years pre-switch to sirolimus, and 68 per 1000 patient years post switch, with adjusted effect size of 0.48 [0.31 - 0.74] (p = .001) following the switch. For liver transplant recipients, the rate of NMSC was 64 per 1,000 patient years pre-switch and 30 per 1,000 patient years post switch, with an adjusted effect size of 0.49 [0.22 - 1.09] (p .081). Kidney transplant recipients were followed up for a median 3.4 years. Liver transplants were followed for a median 6.6 years.Conclusions: In this study, the conversion of maintenance immunosuppression from calcineurin inhibitors to mTOR inhibitors for clinical indications did appear to reduce the incidence of NMSC in kidney and liver transplant recipients.

Conventional angiography findings in hemodynamically unstable patients with acute abdominal hemorrhage and a negative CT bleeding study.

BACKGROUND: CT bleeding study (CTA) is regularly requested in acute abdominal haemorrhage (AAH) with haemodynamic instability by clinical teams and interventional radiologists because CTA can; detect arterial bleeding at low rates of hemorrhage, accurately localize the bleeding point and characterize the etiology. How best to manage an unstable patient who has an AAH with a haematoma and no acute vascular findings on CTA represents a difficult clinical scenario for treating physicians and Interventional Radiologists. PURPOSE: To review the conventional angiography (CA) findings and clinical outcome of hemodynamically unstable patients with AAH who had a preceding negative CTA. MATERIALS AND METHODS: All patients who were hemodynamically unstable and underwent CTA and CA for acute arterial abdominal hemorrhage at our institution between 01/01/2010 and 31/12/2017 were identified. Patients with obstetric, penetrating trauma, abdominal aortic or venous sources of hemorrhage were excluded. Patients who had a negative CTA before CA were included. Patient medical records were reviewed for clinical outcome. RESULTS: In the study period 160 hemodynamically unstable patients underwent 178 CA procedures. 155 CA procedures were preceded by CTA. 141 CTAs demonstrated active bleeding or an abnormal artery. 14 CTAs in 13 patients demonstrated hematoma but no acute bleeding (mean age = 56-years; M:F, 12:1). Eight of the 14 CA studies demonstrated: active bleeding (n = 4), pseudoaneurysm (n = 1) or a truncated artery (n = 3). Cases of renal hemorrhage demonstrated a significantly higher proportion of false negative CTA studies (36%). Selective (n = 8) or empiric (n = 4) embolization was performed in twelve cases. All patients stopped bleeding and there were no mortalities. CONCLUSION: In a cohort of hemodynamically unstable patients, 57% (8/14) of cases with no acute vascular findings on CTA demonstrated a source of hemorrhage on CA. The false negative rate of CTA was significantly higher for renal tract hemorrhage compared to other sites of bleeding.