Recycling transplanted organs: An exceptional case and literature review.

BACKGROUND: Recycling transplant kidneys, in other words using an allograft which has previously been transplanted in one recipient for transplant in a second recipient, can be a source of opportunity for expanding the pool of available grafts in the United States and beyond. SUMMARY: We describe a case of renal transplantation from a donor who had undergone a kidney transplant 3 years prior and had good graft function at the time of procurement. The recipient underwent transplantation uneventfully and to date has demonstrated excellent graft function. We also include a literature review of reported cases of recycled/retransplanted kidneys. KEY MESSAGES: -Recycling transplanted kidneys is a largely untapped resource which could help decrease the transplant waitlist. -Utilizing such kidneys does need special considerations in terms of procurement technique, backtable, crossmatch, recipient selection and follow-up.

False Positive Pregnancy Test Before Kidney Transplant: Case Report and Review of Literature.

Pregnancy tests are routinely done before any surgery under general anesthesia including kidney transplantation. Positive test usually leads to more investigations to detect a possible pregnancy or malignancy and the surgery gets canceled or postponed. Because a kidney transplant from a deceased donor is not elective, it usually gets canceled in this scenario. Some groups have reported on normally elevated human chorionic gonadotrophin (hCG) levels in perimenopausal women and in patients with chronic kidney disease. This is thought to be from the pituitary. We present a highly sensitized prospective kidney transplant recipient with a positive pregnancy test with low levels of serum human chorionic gonadotrophin. She underwent additional preoperative testing after which we proceeded with the kidney transplant. Herein, we discuss the management of patients who have an unexpected positive pregnancy test before transplant.

Optimal Timing of COVID-19 Vaccination in the Peri-Transplant Period: A Single Institution Case Series.

The outcomes of vaccination against Severe Acute Respiratory Syndrome Coronavirus 2 in organ transplant recipients are unclear. Recent studies have investigated outcomes for patients who are several years post transplant. There has not been much data in peri-transplant patients. This is important because patients are highly immunosuppressed during this period owing to induction immunosuppression and are thus susceptible to infection. We looked at 6 patients who were transplanted at our center after receiving their first dose of mRNA vaccines. We assessed their antibody response after 1, 2, and in two patients, 3 doses of the vaccine. Out of the two patients who received their third booster dose, one had a detectable antibody level after the third dose. We report that the overall antibody response to vaccination was weaker in transplant patients compared with the general population, with a rapid attrition of antibody response over time. There is a need for more studies that follow-up antibody levels in transplant patients over time, especially those in the peri-transplant period to help guide the vaccination plan for immunosuppressed transplant patients.

Pseudocyst of Pancreas Transplant Allograft: A Case Report.

BACKGROUND: Pancreatic pseudocysts are rarely reported complications of pancreas transplant. CASE: We present a case of a patient with simultaneous pancreas and kidney transplant with bladder exocrine drainage who developed reflux pancreatitis and symptomatic pancreatic pseudocyst as a result of neuropathic bladder, 15 years after the original transplant. He was initially managed with percutaneous aspiration and drainage along with Foley catheter placement to help with bladder emptying. But the pseudocyst recurred after drains and Foley were removed. Eventually, he underwent an enteric conversion of the pancreas allograft with resolution of his symptoms and the pseudocyst. CONCLUSIONS: Enteric conversion should be considered in cases of bladder-drained pancreas transplants with recurrent reflux pancreatitis and/or pseudocyst formation.

A novel, enantioselective, thermostable recombinant hydantoinase to aid the synthesis of industrially valuable non-proteinogenic amino acids.

Overexpression of a novel hydantoinase (hyuH) from P. aeruginosa (MCM B-887) in E. coli yielded optically pure carbamoyl amino acids. The use of optically pure carbamoyl amino acids as substrates facilitates the synthesis of non-proteinogenic amino acids. The enzyme hyuH shared a maximum of 92 % homology with proven hydantoinase protein sequences from the GenBank database, highlighting its novelty. Expression of hydantoinase gene was improved by >150 % by overexpressing it as a fusion protein in specialized E. coli CODON + host cells, providing adequate machinery for effective translation of the GC-rich gene. The presence of distinct residues in the substrate binding and active site of MCM B-887 hydantoinase enzyme explained its unique and broad substrate profile desirable for industrial applications. The purified enzyme, with a specific activity of 53U/mg of protein, was optimally active at 42 °C and pH 9.0 with a requirement of 2 mM Mn2+ ions. Supplementation of 500 mM of Na-glutamate enhanced the thermostability of the enzyme by more than 200 %.

Medication adherence is associated with an increased risk of cancer in kidney transplant recipients: a cohort study.

Background: Nonadherence to posttransplant immunosuppressive medication is associated with increased rates of rejection and graft loss, yet it is unknown to what degree ideal adherence is associated with the sequelae of overimmunosuppression. Specifically, we questioned whether excellent adherence increased the posttransplant cancer risk. Methods: Between August 1998 and August 2006, 195 consenting kidney transplant recipients had electronic monitoring of theirimmunosuppressive medication adherence. Results: Based on their average quantitative adherence to a single immunosuppressant drug over the first 6 months posttransplant, recipients were grouped into adherence tertiles (highest, >97.9% adherence; middle, 91-97.8%; lowest, <91%). The cumulative incidence of cancer was calculated for patients in each tertile, treating death as a competing risk. The association between adherence and cancer rate was calculated after adjusting for recipient risk factors, using a competing risk proportional hazards model. The median duration of follow-up was 10.1 years. The 10-year estimated cumulative cancer incidence was 59.4% in the most adherent, 36.1% in the middle group and 38.1% in the least adherent group (P = 0.006). Excluding nonmelanocytic skin cancers, cancer incidence remained significantly higher in the highest adherence group (P = 0.002). Conclusions: These data provide additional support for the need to individualize immunosuppression to minimize both rejection and immunosuppressive drug-related complications including cancer.

Age alone is not a contraindication to kidney donation: Outcomes of donor nephrectomy in the elderly.

With increasing organ demand, living kidney donation from older donors (>60-years-old) has become more common. Between 1975 and 2014, 3752 donor nephrectomies (DN) were performed at University of Minnesota; 167 (4.5%) were >60-years-old Short- and long-term outcomes were compared between contemporaneous >60-years-old and <60-years-old donors. On univariate analysis, >60-years-old were more likely to have had prior abdominal surgery and hypertension; and less likely to smoke. Baseline estimated glomerular filtration rate (eGFR) was lower in >60-years-old (80 ± 16 vs 101 ± 26 mL/min/1.73 m2 ; P < .001). Intraoperative and postoperative complications were similar, except a higher prevalence of <30 day ileus (3% vs 7%; P = .021) and longer postoperative length of stay (LOS) (4.2 vs 4.6 days; P = .005). On multivariate analysis, <30 day ileus and LOS continued to be significantly greater for >60-years-old After >20 years post-DN, systolic blood pressure was significantly higher among >60-years-old (142 vs 125 mm Hg; P < .001) and HTN was diagnosed earlier (9 vs 14 years). After donation, eGFR was significantly lower for >60-years-old but slope of eGFR and rates of end-stage renal disease (ESRD) were not significantly different >20 years post-DN. Thus, kidney donation among carefully selected >60-years-old poses minimal perioperative risks and no added risk of long-term ESRD.

Antibody mediated rejection due to de-novo DSA causing venous thrombosis of pancreas allograft - A case report.

This case describes a 34year old female who underwent an HLA identical living donor kidney transplant with a positive flow cytometric crossmatch (FCXM), but without any donor specific antibody (DSA). Tests to detect non-HLA antibody and autoantibody were negative. Allograft functioned well without rejection. She later received a pancreas allograft, again with a weakly positive FCXM, without DSA. After good initial graft function, she developed hyperglycemia six weeks posttransplant. Cross-sectional imaging demonstrated non-enhancing pancreas allograft with new vein thrombosis. She underwent transplant pancreatectomy, the explant pathology demonstrated changes consistent with severe acute antibody mediated rejection (AMR) causing thrombosis of the pancreas allograft. She had also developed several de-novo class-I DSAs at this time. Despite extensive testing, we could not identify a causative antibody for the initial positive FCXMs or its role in the eventual rejection of the pancreas allograft.

Outcomes of Endovascular Management of Late Vascular Hemorrhage After Pancreatic Transplant.

OBJECTIVE: The aim of this retrospective study is to evaluate the endovascular treatment of hemorrhage in the nonperioperative setting in pancreas transplant recipients. MATERIALS AND METHODS: All angiograms performed between January 1, 1999, and June 1, 2016, to treat hemorrhage after pancreatic transplant at a single large-volume transplant center were reviewed. Fourteen patients who underwent 21 angiograms were identified. The patients' charts were reviewed for clinical indications, technical aspects of the endovascular interventions, outcomes, and complications. RESULTS: The mean number of angiograms was 1.5 per patient. The primary and primary assisted clinical success rates were 64.3% (9/14 patients) and 71.4% (10/14 patients), respectively. Five patients (35.7%) experienced complications. At presentation, eight patients had functioning grafts and seven of these eight patients (87.5%) maintained graft function. CONCLUSION: It is critical to recognize transplant-related hemorrhage after pancreas transplant. Endovascular management is associated with high clinical success and rarely results in loss of graft function, suggesting that it should be a consideration for first-line therapy in this patient population.

Risk factors for early readmission after total pancreatectomy and islet auto transplantation.

BACKGROUND: Little published data exist examining causes of hospital readmission following total pancreatectomy with islet autotransplantation (TPIAT). METHODS: A retrospective analysis was performed of a prospectively collected institutional TPIAT database. Primary outcome was unplanned readmission to the hospital within 30 days from discharge. Reasons and risk factors for readmission as well as islet function were evaluated and compared by univariate and multivariate analysis. RESULTS: 83 patients underwent TPIAT from 2006 to 2014. 21 patients (25.3%) were readmitted within 30 days. Gastrointestinal problems (52.4%) and surgical site infection (42.8%) were the most common reasons for readmission. Initial LOS and reoperation were risk factors for early readmission. Patients with delayed gastric emptying (DGE) were three times more likely to get readmitted. In multivariate analysis, patients undergoing pylorus preservation surgery were nine times more likely to be readmitted than the antrectomy group. CONCLUSION: Early readmission after TPIAT is common (one in four patients), underscoring the complexity of this procedure. Early readmission is not detrimental to islet graft function. Patients undergoing pylorus preservation are more likely to get readmitted, perhaps due to increased incidence of delayed gastric emptying. Decision for antrectomy vs. pylorus preservation needs to be individualized.

The liver recipient with acute renal dysfunction: A single institution evaluation of the simultaneous liver-kidney transplant candidate.

The Organ Procurement Transplant Network (OPTN) listing criteria for simultaneous liver-kidney transplant (SLK) are not well defined. Concerns remain about rising numbers of SLKs, which divert quality kidneys from candidates awaiting kidney transplants (KT). We performed a retrospective review of liver transplants (LTs) at our center from 2004 to 2014; 127 recipients (liver transplant alone; 102 LTA, 25 SLK) were identified with short-term preoperative kidney dysfunction (creatinine >4 mg/dL or preoperative hemodialysis [HD] for <6 weeks). Both cohorts had comparable baseline demographic characteristics with the exception of higher model for end-stage liver disease (MELD) score in the LTA group (41.4 vs 32.9, P < .0001) and higher incidence of pre-LT diabetes in the SLK cohort (52% vs 26.5%, P = .0176). Duration of pre-LT HD was higher in SLK recipients, but the difference was not statistically significant (P = .39). Renal nonrecovery (RNR) rate in LTA cohort was low (<5%). No significant difference was noted in 1-year mortality, liver graft rejection/failure, or length of stay (LOS) between the cohorts. Thus, it appears that liver recipients with short-term (<6 weeks) HD or AKI without HD have comparable outcomes between LTA and SLK. With provisions for a KT safety net, as proposed by OPTN, LTA may be the most adequate option for these patients.

Significant arterial complications after pancreas transplantation-A single-center experience and review of literature.

Arterial fistulas and pseudoaneurysms are rarely described significant arterial complications associated with pancreas transplantation that sometimes present with herald or catastrophic bleeding. We herein describe our institutional case series with a focus on management and outcomes. Of 2256 pancreas transplants, 24 arterial complications were identified in 23 recipients. Chart review was performed to describe the clinical characteristics, treatments, and outcomes of the complications (pseudoaneurysm, arterial enteric/cystic/ureteric fistula, or arteriovenous fistula). Of these 23 patients, 57% had a failed allograft at the time of the complication. Nine patients underwent primary surgical repair of 10 complications, 13 were treated by endovascular methods, and one patient by medical management. In total, 3 embolized patients rebled, 2 of which had failed allografts prior to treatment. Of those with graft function that were treated by embolization alone, all retained graft function. Diagnosis of arterial complications requires a high degree of suspicion and should involve early systemic angiography to evaluate the pancreatic vasculature. Management can be endovascular or surgical and should be individualized. We report our center's evolution from a predominantly surgical to endovascular approach as a definitive vs stabilizing therapy, with selective coiling mostly reserved for well-defined peripheral lesions in patients with a functioning allograft.

High clinical suspicion of donor-derived disease leads to timely recognition and early intervention to treat solid organ transplant-transmitted lymphocytic choriomeningitis virus.

Despite careful donor screening, unexpected donor-derived infections continue to occur in organ transplant recipients (OTRs). Lymphocytic choriomeningitis virus (LCMV) is one such transplant-transmitted infection that in previous reports has resulted in a high mortality among the affected OTRs. We report a LCMV case cluster that occurred 3 weeks post-transplant in three OTRs who received allografts from a common organ donor in March 2013. Following confirmation of LCMV infection at Centers for Disease Control and Prevention, immunosuppression was promptly reduced and ribavirin and/or intravenous immunoglobulin therapy were initiated in OTRs. The liver recipient died, but right kidney recipients survived without significant sequelae and left kidney recipient survived acute LCMV infection with residual mental status deficit. Our series highlights how early recognition led to prompt therapeutic intervention, which may have contributed to more favorable outcome in the kidney transplant recipients.

Comparative study of laparoscopic and mini-incision open donor nephrectomy: have we heard the last word in the debate?

OBJECTIVE: Laparoscopic donor nephrectomy (LDN) is generally considered a better option than open donor nephrectomy (ODN) as it is associated with better cosmesis, less post-operative pain and faster recovery. Mini-incision donor nephrectomy (MDN) has proven to be an effective and less invasive modification of classic ODN. Our aim was to compare the peri-operative outcomes and quality of life of donors following laparoscopic and mini-incision ODN. METHODS: One hundred patients, underwent donor nephrectomy using laparoscopic approach (n = 50) or open mini-incision approach (n = 50) over a period of 18 months. Data were entered into a prospective database and analyzed retrospectively. RESULTS: The mean operative (skin to skin) time for MDN, 53.9 min (range, 40-75 min), was significantly shorter than the 93.7 min (range, 75-140 min) for LDN. The laparoscopic donors had a longer hospital stay, warm ischemia time and higher operative and post-operative cost. There was no significant difference in the pain scores, graft function, or quality of life between the two groups. CONCLUSIONS: MDN compares well with the laparoscopic approach in terms of post-operative pain, graft function and quality of life of donors. Significantly less operative time along with the reduced cost makes it a better option in our predominantly lower BMI patient population.

Laparoscopic bilateral transperitoneal adrenalectomy for Cushing syndrome: surgical challenges and lessons learnt.

PURPOSE: Laparoscopic adrenalectomy is well established for treatment of adrenal lesions. However, bilateral adrenalectomy for Cushing syndrome is a challenging and time-consuming operation. We report our experience of laparoscopic bilateral adrenalectomy for this disease in 19 patients. MATERIALS AND METHODS: From September 2009 to August 2012, we have operated 19 patients with Cushing syndrome and performed bilateral laparoscopic adrenalectomy using the transperitoneal approach; synchronous in 15 patients and staged in 4 patients. In 15 patients, the surgery was carried out sequentially on both the sides in lateral position with intraoperative change in position. Complete adrenalectomy including periadrenal fat was carried out on both the sides. RESULTS: Nineteen patients were referred from Department of Endocrinology for bilateral adrenalectomy for adrenocorticotropin hormone (ACTH)-dependent and ACTH-independent Cushing syndrome. The indications for surgery were Cushing disease in 15 patients, occult/ectopic source of ACTH in 2 patients, and primary adrenal hyperplasia in 2 patients. Fifteen patients underwent bilateral adrenalectomy during the same operation. Four patients underwent staged procedures. All procedures were completed laparoscopically with no conversions. The mean operating time for simultaneous bilateral adrenalectomy was 210 minutes (range, 150 to 240 min). This included the repositioning and reprepping time. There were no major intraoperative complications. The average blood loss was 100 mL (range, 50 to 200 mL). None of the patients required blood transfusions in the postoperative period. The postoperative complications included minor port-site infection in 2 patients. One severely debilitated patient died on the 14th postoperative day because of hospital-acquired pneumonia. The remaining 18 patients have done well in terms of impact on the disease. CONCLUSIONS: Laparoscopic bilateral adrenalectomy for Cushing syndrome is feasible and safe. It confers all the advantages of minimally invasive approach such as less postoperative pain, shorter hospitalization, lesser wound complications, and faster recovery. The advantages of the laparoscopic approach have led to an earlier referral for bilateral adrenalectomy by endocrinologist in patients with failed pituitary surgery.