Combined Kidney-pancreas Transplantation Research Articles

Draining Lymph Nodes in Human Kidney Pancreas Transplant: Potential Implications in Alloimmunity and Tolerance

Draining lymph nodes (DLNs) are implicated in alloimmunity and tolerance regulation. The role of DLNs in human organ transplant is unknown due to the lack of relevant clinical tissues. During a combined kidney and pancreas transplant, the distal vena cava and both right and left common and external iliac vessels were mobilized and exposed. Draining lymph nodes along these vessels were removed sequentially and archived before the pancreas transplant. Similarly, the DLNs along the left iliac vessels were removed and archived before implantation of the kidney allograft. Among 13 patients undergoing kidney and pancreas transplants, 6 had pre- and postreperfusion DLNs clinically archived. The remaining 7 either had only prereperfusion DLNs archived or none. Clinical archiving of DLNs did not alter operative times or parameters. This study describes an approach for clinical archiving of DLNs obtained within the operative field during combined kidney-pancreas transplant in humans. The availability of relevant DLNs is essential for investigating fundamental initial primary immune responses potentially important in allograft alloimmunity and tolerance.

Absence of association between persistent skin lesion and virological replication in severe disseminated monkeypox infection in solid organ transplant recipient

The Monkeypox (mpox) virus outbreak has been controlled worldwide. We report the case of a combined pancreas-kidney transplant recipient who presented a severe and prolonged cutaneous infection with onset of 3 successive rashes while receiving tecovirimat therapy. During follow-up, skin lesions, blood and throat samples were collected. Viral culture and mpox PCR were performed. No positive viral culture was obtained from blood and throat. The lowest mpox CT-values were obtained early after onset of skin lesions and were more likely to be associated with positive viral cultures. Furthermore, we observed persistent skin lesions up to 3 months. On these persistent lesions, mpox PCR positives were obtained but were not associated with positive viral culture after 23 days. In this immunocompromised host, who was receiving tecovirimat, in accordance with existing recommendations a 21-day isolation period appeared to be adapted. That said, isolation should not be systematically extended if complete healing of skin lesions has not been achieved.

#4960 TIXAGEVIMAB AND CILGAVIMAB (EVUSHELD) FOR PRE-EXPOSURE PROPHYLAXIS OF COVID-19: A MONOCENTRIC STUDY IN KIDNEY TRANSPLANT RECIPIENTS

Abstract Background and Aims Patients, who underwent kidney transplantation, may be at particularly high risk of mortality due to immunosuppressive therapy and underlying comorbidity such as hypertension, cardiovascular disease and diabetes mellitus finally increasing the risk of a severe form of SARS-CoV-2 infection. According to the ERA-EDTA DESCARTES expert opinion, management of immunosuppression in SARS-CoV-2 infection suggests withdrawal of antimetabolite (mycophenolate or azathioprine) in patients with mild upper respiratory and/or gastrointestinal symptoms and discontinuation of all immunosuppressive drugs with maintenance of steroid for severe bilateral pneumonia. Despite SARS-CoV-2 vaccination, kidney transplant patients remain at increased risk for severe COVID-19 infection and mortality and at high priority for additional strategies for preexposure prophylaxis.Tixagevimab and cilgavimab are long-acting monoclonal antibodies against the spike protein of SARS-CoV-2, which block the virus’ attachment and entry into human cells. This combined monoclonal antibody (Evusheld®) has been granted emergency use authorization (EUA) by the U. S food and drug administration (FDA) for individuals 12 years and older who have a moderate to severe immunocompromising condition and may not mount an adequate vaccination response.This single cohort observational study reports the incidence and outcomes of COVID-19 among kidney transplant recipients receiving Evusheld® as preexposure prophylaxis. Method Observational monocentric cohort study of 119 kidney transplant patients receiving Evusheld® 150/150 mg intramuscularly as preexposure prophylaxis between July 1, 2022 and December 31, 2022. Inclusion criteria: kidney or combined kidney-pancreas transplantation within 1 year; recent acute allograft rejection; time since COVID-19 infection of 120 days and time since last vaccine dose of 2 weeks. Results After a median (range) follow-up of 150 days, COVID-19 was confirmed in 48/119 patients (40.3%), who had only a light form of COVID-19 infection. No one complained side. Conclusion Our study reported a low rate of infections with only light symptoms among kidney transplant patients treated with Evusheld®. A long-term study with a larger cohort might better evaluate the efficacy, outcomes and safety of this preexposure prophylaxis.

Pregnancy after Kidney Transplantation—Impact of Functional Renal Reserve, Slope of eGFR before Pregnancy, and Intensity of Immunosuppression on Kidney Function and Maternal Health

Women of childbearing age show increased fertility after kidney transplantation. Of concern, preeclampsia, preterm delivery, and allograft dysfunction contribute to maternal and perinatal morbidity and mortality. We performed a retrospective single-center study, including 40 women with post-transplant pregnancies after single or combined pancreas-kidney transplantation between 2003 and 2019. Outcomes of kidney function up to 24 months after the end of pregnancy were compared with a matched-pair cohort of 40 transplanted patients without pregnancies. With a maternal survival rate of 100%, 39 out of 46 pregnancies ended up with a live-born baby. The eGFR slopes to the end of 24 months follow-up showed mean eGFR declines in both groups (-5.4 ± 14.3 mL/min in pregnant versus -7.6 ± 14.1 mL/min in controls). We identified 18 women with adverse pregnancy events, defined as preeclampsia with severe end-organ dysfunction. An impaired hyperfiltration during pregnancy was a significant risk contributor for both adverse pregnancy events (p < 0.05) and deterioration of kidney function (p < 0.01). In addition, a declining renal allograft function in the year before pregnancy was a negative predictor of worsening allograft function after 24 months of follow-up. No increased frequency of de novo donor-specific antibodies after delivery could be detected. Overall, pregnancies in women after kidney transplantation showed good allograft and maternal outcomes.

Short- and Long-Term Intestinal Complications After Combined Pancreas-Kidney Transplantation

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice in patients with type 1 diabetes and end-stage renal disease, because it improves survival and quality of life. Currently, enteric exocrine drainage is the most commonly used method. Intestinal complications continue to be a major cause of posttransplant morbidity despite improvements in surgical technique. This study analyzed early and late intestinal complications related to SPK transplantation. We performed a retrospective analysis of 100 adult patients undergoing SPK transplantation between January 2009 and December 2019. We performed systemic venous drainage and exocrine enteric drainage with duodenojejunostomy. Statistical analysis was performed using SPSS v2. This study was performed in accordance with the Declaration of Istanbul and the 1964 Declaration of Helsinki. Informed consent was obtained from all participants involved in the study. Ten patients had the following early intestinal complications (10%): ileus (n=4), intestinal obstruction (n=2), graft volvulus (n=1), duodenal graft fistula (n=1), and jejunal fistula after pancreas transplantation (n=1). Two cases required relaparotomy: graft repositioning with Roux-en-Y conversion (n=1) and Y-roux conversion (n=1). Eight patients had repeated episodes of intestinal obstruction (8%), of whom 2 required surgery for resolution with 100% postoperative mortality. SPK transplantation with enteric drainage via duodenojejunostomy has a low rate of short- and long-term postoperative intestinal complications. Surgery in patients with recurrent intestinal obstruction has a high mortality risk and should be performed in reference transplant centers.

Humoral Response After SARS-CoV-2 Vaccination in Kidney Transplant Recipients: Role of Immunosuppression Therapy

BackgroundMessenger RNA vaccination against COVID-19 has been shown to produce an immune response with sufficient efficacy to prevent natural infection in immunocompetent recipients. However, the response in kidney transplant recipients is low. We aimed to evaluate the specific humoral response to SARS-CoV-2 after vaccination in a population of kidney transplant recipients and assess the main factors associated with a lack of response.MethodsWe undertook a prospective study of 105 kidney transplant recipients and 11 recipients of a combined kidney-pancreas transplant. We analyzed immunoglobulin G and immunoglobulin M antibodies after the patients received their second and third doses of the messenger RNA 1273 (Moderna) or BNT162b1 (BionTECH-Pfizer) vaccinations between February and November 2021.ResultsMean (SD) age of the 116 patients was 50 (16) years, and 65% were men. They had their transplants for 40 months (IQR, 15-123 months), with 14% undergoing retransplant and 11% sensitized. The maintenance immunosuppression regimen was steroids + tacrolimus + mycophenolate (MMF) in 68% of the patients and any combination with mammalian target of rapamycin inhibitor (mTORi) in 28%. A humoral response developed in 40% of the patients 6 weeks (IQR, 4-10 weeks) after receiving the second dose of the vaccine. Of the 67 patients with no response to the second dose, 51 had an analysis of the humoral response after the third dose, which was positive in 16 (31%). A total of 80% received the Moderna vaccine and 20% the BionTECH-Pfizer. No patient experienced major adverse effects after the vaccination.Factors associated with a lack of humoral response to the vaccine were recipient age (odds ratio [OR], 1.02; 95% CI, 1.001-1.05; P = .04), diabetes (OR, 2.8; 95% CI, 1.2-6.9; P = .02), and treatment with MMF (OR, 2.6; 95% CI, 1.08-6.8; P = .03). Treatment with mTORi was associated with a better response to vaccination (OR, 0.3; 95% CI, 0.1-0.9; P = .04).ConclusionsThe humoral response to the COVID-19 vaccine in kidney transplant recipients is poor. Factors related with this lack of immunity are recipient age and diabetes, plus MMF therapy, whereas mTORi therapy was associated with a better response to vaccination.

Kidney and combined kidney and pancreas transplantation may be under-utilized in cystic fibrosis.

Cystic fibrosis (CF) is a multisystem disorder and represents the most common inherited condition leading to death in Western countries. Previous reports of chronic kidney disease (CKD) in CF focus on cases post lung, or other solid organ, transplantation but CKD in CF patients pre transplantation is increasingly recognized as a challenging complication of CF. CKD can evolve as a sequel to acute kidney injury for example after prolonged treatment with aminoglycoside antibiotics during episodes of infection. Nephrolithiasis, diabetic nephropathy and a variety of glomerular lesions, such as amyloidosis and Immunoglobulin A nephropathy are also seen. Muscle depletion is common in CF, hence creatinine-based estimates of kidney function may underestimate the degree of renal impairment and lead to delayed diagnosis and management. Improved treatment options for CF patients have resulted in a sustained increase in life expectancy with increasing numbers of CF patients with CKD approaching end-stage renal failure prior to consideration of lung transplantation. We believe that kidney or combined kidney-pancreas transplantation are under-utilized in this population. We provide a brief primer on the landscape of CF and CKD and discuss transplant options. Suitable patients with CF and advanced CKD should be formally assessed for kidney or kidney-pancreas transplantation.

MO1006: Cni-Induced Hypomagnesemia in Kidney Transplantation: A Comparative Monocentric Study Between Sucrosomial Magnesium and Magnesium Pidolate

Abstract BACKGROUND AND AIMS Magnesium (Mg) is the second cation in the intracellular space and the fourth prevalent cation in the body. It contributes to DNA and protein synthesis, infiammatory processes and cardiac excitability, while Mg deficiency leads to increased cardiovascular risk, atherosclerosis and diabetes [1]. In addition to gastrointestinal losses, loop or thiazide diuretics induce renal wasting, volume expansion and nephrotoxins including antibiotics Hypomagnesemia (HypoMg) is observed early after kidney transplantation and is associated with a faster decline of allograft function. Main determinants are calcineurin inhibitors (CNIs), protonic pump inhibitors (PPI), low Mg intake and diuretics. CNIs, in particular, induce HypoMg with mechanisms not fully understood, likely via downregulation of the Mg channel TRPM6 in the distal collecting tubule [2]. HypoMg should be corrected with oral supplements. Recently, in order to increase magnesium bioavailability and tolerance not shown by convetional oral magnesium supplements, a new sucrosomial magnesium formulation has been developed. Its innovative preparation encapsulates magnesium oxide in a phospholipid membrane covered by a sucrester matrix, which enhances Mg passage through the gastric and intestinal environment without any interaction with the intestinal mucosa [3]. This study evaluates magnesium bioavailability, tolerance and effectiveness after administration of sucrosomial magnesium compared with magnesium pidolate. METHOD We recruited 32 adult single, double or combined kidney-pancreas transplant recipients within 1 year from transplantation, who developed CNI-induced hypomagnesemia. Exclusion criteria include: HypoMg due to PPI or gastrointestinal losses. A total of 13 patients received magnesium pidolate, and 19 patients received sucrosomial magnesium. Venous blood samples were taken at baseline (T0) and after 10 days of magnesium supplement (T1). RESULTS Sucrosomial magnesium increased Mg bioavailability and tolerance: 0.60 ± 0.02 T0 mmoL/L versus 0.69 ± 0.05 T1; P &amp;lt; .0001 versus magnesium pidolate: 0.61 ± 0.05 T0 versus 0.64 ± 0.05 T1; P = .72 N.S. (Fig. 1A). Sucrosomial magnesium provided an increase of Mg over magnesium pidolate in terms of $\Delta \% $ increase: 12.4% for sucrosomial Mg versus 5.4%, P = .04 (Fig. 1B). CONCLUSION Our data, although obtained by a small cohort of transplant patients, shows that sucrosomial Mg is more efficient and better tolerated compared with magnesium pidolate. On the one hand, the fact that our study is the first in transplant patients to evaluate the impact of sucrosomial Mg for the correction of HypoMg might justify the limited number of patients enrolled and the short observation time; on the other hand, our results could serve as a working hypothesis for further studies with a larger number of transplant patients and for extended study duration to confirm the benefit of sucrosomial Mg.

OPTN/SRTR 2020 Annual Data Report: Introduction

OPTN/SRTR 2020 Annual Data Report: Introduction

Good Long-term Results Following Simultaneous Pancreas-kidney Transplantation in a 69-y-old Recipient: A Case Report.

In contrast to well-published data with acceptable long-term results in large cohorts of single renal transplant recipients aged >65 y (lit.), combined pancreas-kidney transplantation in recipients >50 y is discussed controversially. Some groups have identified older recipients as a high-risk group, demonstrating decreased patient and graft survival in this population.1-4 Nevertheless, several centers have reported results for pancreatic transplantation in older patients as being comparable to those for younger recipients with the age cutoff ranging from 50 to 60 y.5-10 At our center, we have long-term experience with a total of 655 pancreas transplants performed between 1979 and August 2020, whereby 21 recipients were over 60 y of age; the oldest was age 69 and in remarkably good general condition with good mental adherence and a strong wish to undergo simultaneous kidney-pancreas transplantation (SPK). We retrospectively analyzed patient, pancreas, and kidney graft survival, graft function, and complications at month 38 posttransplant.

Clinical Impact, Reactogenicity, and Immunogenicity After the First CoronaVac Dose in Kidney Transplant Recipients.

Clinical Impact, Reactogenicity, and Immunogenicity After the First CoronaVac Dose in Kidney Transplant Recipients.

Association between Use of Hydrochlorothiazide and Risk of Keratinocyte Cancers in Kidney Transplant Recipients.

Keratinocyte cancers, which primarily comprise squamous cell carcinomas and basal cell carcinomas, represent a major concern and potential risk for kidney transplant recipients. Hydrochlorothiazide, a diuretic widely used to treat hypertension, has been implicated in skin photosensitivity reaction. Recent studies conducted in the general population have found that hydrochlorothiazide use is associated with a higher risk of keratinocyte cancer, especially squamous cell carcinomas. High-risk groups, however, including transplant recipients were excluded from these. Our aim was to investigate whether hydrochlorothiazide use was associated with keratinocyte cancer in kidney transplant recipients on immunosuppressive therapy. In a single-center cohort of kidney (n=2155), combined kidney-pancreas (n=282), and pancreas (n=59) transplant recipients from the Données Informatisées VAlidées Transplantation (DIVAT) database transplanted between 2000 and 2017 in Nantes, France, we evaluated the association between hydrochlorothiazide exposure and keratinocyte cancers. Multivariable cause-specific, time-varying Cox models were used to estimate the relationship between hydrochlorothiazide exposure and the hazard of squamous cell carcinoma and basal cell carcinoma, with hydrochlorothiazide designated as the time-dependent variable. Among the participants, 279 of 2496 (11%) were exposed to hydrochlorothiazide after the transplantation. Cumulative incidence rates of keratinocyte cancer by 10 and 15 years were 7% and 9% for squamous cell carcinomas, respectively, and 8% and 11% for basal cell carcinomas, respectively. We found a relationship between exposure to hydrochlorothiazide and the risk of squamous cell carcinomas (hazard ratio, 2.04; 95% confidence interval, 1.27 to 3.28). In contrast, we found no association between hydrochlorothiazide exposure and basal cell carcinomas (hazard ratio, 0.63; 95% confidence interval, 0.35 to 1.15). In a single-center cohort of kidney, combined kidney-pancreas, and pancreas transplant recipients, exposure to hydrochlorothiazide was associated with a two-fold higher risk of squamous cell carcinoma and no higher risk of basal cell carcinoma.

A novel simple technique to enlarge the aortic annulus by two valve sizes.

A novel simple technique to enlarge the aortic annulus by two valve sizes.

1753-P: Foot Ulceration in the Immunosuppressed Population: Surgeon Beware!

Background: Over the past 3 decades, advances in transplant surgery have allowed life-saving renewal of solid organ function. Many of these patients are predisposed to the development of lower extremity wounds. There is a paucity of data describing treatment and outcomes of this complex patient population. The purpose of this study is to examine the surgical outcomes of these patients and overall limb salvage rates in a tertiary care center with a multi-disciplinary team focused on limb salvage. Methods: Medical records were reviewed for all patients with a foot wound and functioning solid organ transplant who received surgery (including debridement or toe/foot/limb amputation) at our institution from 2010-2017. Results: We identified 59 patients with lower extremity wounds and a prior transplant, 40 with a kidney transplant, 13 with combined kidney-pancreas transplant, and 6 with a liver transplant. The average solid organ transplant patient received 6.5 (±4.8) procedures during the follow-up period (46mos, 6.8-149.4). There were 32 patients (54.2%) who required toe amputations, 15/32 (46.9%) of these healed, 14 (43.8%) required a midfoot amputation, and 8 (25%) progressed to a below-knee amputation (BKA). Of patients with hind foot wounds 11/15 (73.3%) required calcanectomy, of these 7/11 (63.6%) progressed to a BKA. Overall, there were 19/59 (32.2%) patients who required below knee amputations, including the 15 which progressed from lesser procedures; two of the patients requiring BKA progressed to an above knee amputation. Conclusions: This retrospective study highlights the morbidity associated with foot ulceration in the immunosuppressed patient with an overall BKA rate of 32.2%. Solid organ transplant patients who develop lower extremity wounds require a high level of surgical care. A large proportion of these patients will eventually require a major lower extremity amputation. Further investigation is needed to develop better strategies for lower extremity salvage in the immunosuppressed patient. Disclosure E. Walters: None. K.M. Termanini: None. B.T. Jackson: None. T.M. Chadab: None. J. Wang: None. P.J. Kim: Consultant; Self; Acelity, Integra LifeSciences. K. Evans: None.

Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) for Peritoneal Metastases in Solid Organ Graft Recipients: First Experience.

BackgroundTherapy of peritoneal metastases (PM) in solid organ transplant recipients is challenging. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) might constitute a new therapeutic opportunity for these patients.Material/MethodsThis was a single-center, retrospective analysis of prospective registry data (NCT03210298) in a tertiary care center between 1.7.2016 and 31.12.2017. Intraperitoneal administration of oxaliplatin 92 mg/m2 body surface or a combination of cisplatin 7.5 mg/m2 and doxorubicin 1.5 mg/m2, repeated every 6 weeks. Objective tumor response was documented via histology (Peritoneal Regression Grading Score, PRGS), adverse events according to Common Terminology Criteria for Adverse Events (CTCAE) 4.0.ResultsOut of 71 consecutive patients treated with PIPAC, 2 patients (2.8%) were solid organ transplant recipients. The first patient had metachronous PM of colonic cancer origin after liver transplantation. The second patient had synchronous PM of pancreatic cancer origin after combined kidney-pancreas transplantation. After repeated combined systemic and PIPAC chemotherapy, objective histological response was documented in both patients. No adverse events >CTCAE 2 were recorded. There was no measurable liver or renal toxicity. PIPAC procedures could be repeated (2, resp. 3 cycles) without any interruption of immunosuppressive medication or impairment of respective plasmatic drug levels. The first patient passed away 7 months after the first PIPAC, the second patient was still alive after 8 months.ConclusionsPIPAC can induce objective regression of PM in solid organ transplant recipients without inducing organ toxicity or interfering with immunosuppressive therapy.

How a Vision Was Made to Come True.

A kidney transplant program was started at Innsbruck University Hospital in 1974. This was followed by the first liver transplant in 1977 and the first combined pancreas-kidney transplant in 1979. Because these 3 programs were quite successful, the idea was born to try to establish a unit that could provide temporary and permanent replacement for the loss of all kinds of organ function. In 1993, a special unit for transplant was opened. Dialysis was incorporated as part of available treatment right from the beginning. The new ward made it possible to routinely treat patients in need of bioartificial livers, to provide ventricular assist devices and later total artificial hearts, and to provide extracorporeal membrane oxygenation. The first heart transplant was performed in 1983, the first heart-lung in 1985, the first double-lung in 1987, followed by the first multivisceral transplant in 1989, the first isolated bowel in 1994, and finally the first double-hand transplant was performed in 2000. Thus, our vision of such a unit has become true.

1138. Retrospective Cohort Analysis of Amphotericin B Nephrotoxicity in Kidney Transplant Recipients

BackgroundTreatment of invasive fungal infections with amphotericin B is a concern in kidney transplant patients due to fear of allograft loss. Reluctance to use amphotericin B may lead to suboptimal therapy and poor treatment outcomes. The risk of amphotericin B-related nephrotoxicity and allograft dysfunction has not been studied in kidney transplant patients. Our aim was to study the association between amphotericin B and acute kidney injury (AKI) as defined by the Acute Kidney Injury Network classification, allograft loss and patient mortality in kidney transplant recipients.MethodsWe used SPSS to conduct a descriptive analysis of a retrospective cohort of 30 adult kidney transplant recipients who were admitted to Virginia Commonwealth University Medical Center and received treatment with amphotericin B from 2005 to 2015.ResultsThe median age in our cohort was 57. 40% were female, 60% were male. 60% had received a kidney transplant from a deceased donor; 13.3% from a living related donor; 13.3% from a living unrelated donor; and 13.3% had received a combined kidney–pancreas transplant. 63.3% of patients had received liposomal amphotericin B; 33.3% had received lipid-complex amphotericin B; 3.3% had received conventional amphotericin B. We found an association between cumulative amphotericin B doses above 5,000 mg and AKI, whereby 64.7% of patients exposed to less than 5,000 mg of amphotericin B developed AKI and 100% of patients exposed to more than 5,000 mg of amphotericin B developed AKI (P = 0.017). We did not find an association between cumulative amphotericin B doses above 5,000 mg and return to dialysis at 3 months and 12 months post-exposure (P = 0.436 and 0.288, respectively). We also did not find an association between such doses of amphotericin B and mortality at 30 and 90 days (P = 0.869 and 0.193, respectively).ConclusionIn the first descriptive analysis of a retrospective cohort of kidney transplant patients exposed to amphotericin B, our results suggest that the risk of nephrotoxicity may be significantly increased when a cumulative dose of 5,000 milligrams is exceeded. Our results also suggest that amphotericin B doses associated with nephrotoxicity in kidney transplant patients may not have an effect on allograft survival and patient mortality.Disclosures All authors: No reported disclosures.

A Fatal Course After Combined Pancreas Kidney Transplantation From a Donor with HELLP-syndrome

A Fatal Course After Combined Pancreas Kidney Transplantation From a Donor with HELLP-syndrome

Influence of Immunosuppression on Metabolic Outcomes One Year after Kidney Transplantation

Introduction It is widely known that immunosuppressive drugs alter lipids and carbohydrate metabolism in kidney transplant patients. The most common side effects are diabetes mellitus induced by calcineurin inhibitors and hypertriglyceridemia caused by mTOR inhibitors. However, little is known about the combination of these agents in real clinical practice and if a difference exists between patients who were already diabetics or not before transplantation. Methods longitudinal retrospective 1-year long study in which we compared two different regimens based on tacrolimus and prednisone, one with mycophenolate (MP group) and one with an mTOR inhibitor (mTORi group). The studied population included all kidney transplanted patients in the Hospital Clínic, Barcelona, performed in a 3-year period from June 2013 to May 2016. Patients who died, lost the transplant or changed the immunosuppression before completion of follow-up were excluded, as well as patients who underwent combined kidney-pancreas transplantation (34.3% of the original population, final n=272). One-year outcomes were changes in total and LDL cholesterol, triglycerides, glycated hemoglobin (HbA1c) and incidence of de-novo diabetes. Results considering the global population, patients doing mTORi experienced a more significant increase in HbA1C compared to patients doing MP (mTORi group +0.98 ± 1.13% versus MP group +0.66 ± 1.38%, p= 0.017, for the difference between baseline and 1-year values). There was a substantial increase as well in triglycerides in the mTORi group (MP +1.42 ± 85.83mg/dl versus mTORi +23.21 ± 95.87mg/dl, p= 0.003). When considering only diabetic patients at baseline (n=73), the increase in HbA1c at 1 year was much more pronounced in patients doing mTORi (MP +0.7 ± 1.97% versus mTORi +1.6 ± 1.31, p=0.020), while there was not substantially any change in triglycerides between the two groups (p=0.879).On the contrary, in patients without diabetes at baseline (n=199), the mTORi group experienced a significant increase in triglycerides (MP +1.42 ± 85.83 mg/dl versus mTORi +23.21 ± 95.87 mg/dl, p-value 0.003), while no difference was observed in HbA1c (p-value 0.298). There was no difference in the incidence of de-novo diabetes between groups (p=0.272).Conclusions mTOR inhibitors are associated with higher levels of HbA1c and triglycerides 1 year after transplantation compared to mycophenolate, in a tacrolimus- and prednisone-based protocol. However, the change in HbA1c was mainly observed only in mTORi patients who were already diabetics before transplantation and there is not an increase in the incidence of de-novo diabetes. Curiously, the increase in triglycerides was confirmed only in patients who were not diabetics before transplantation. This may suggest that mTOR inhibitors can cause different metabolic abnormalities depending on the original metabolic status of the transplanted patient.

Visceral Leishmaniasis in Renal Transplant Recipients: Report of 2 Cases

Visceral leishmaniasis is a disease caused by the protozoan Leishmania and is transmitted by Lutzomyia longipalpis (sand fly). It is an endemic parasitic infection in numerous areas around the Mediterranean basin. Though immunocompetent patients may not develop the disease, in transplant recipients the use of corticoids and intensified immunosuppressants to prevent graft rejection may accelerate the disease, causing severe damage to the liver, spleen, and hematopoietic system. We report 2 cases of visceral leishmaniasis with an atypical presentation in transplant recipients. The first patient, who had a kidney transplant, was treated successfully with liposomal amphotericin B, and the second patient, a combined kidney-pancreas transplant recipient, suffered a relapse 3 years after treatment. Visceral leishmaniasis should be considered in the differential diagnosis of pancytopenia or unexplained fever occurring after organ transplantation in patients living in endemic areas or returning from endemic countries.