Deceased Donor Renal Transplantation Research Articles

A Study on Early Surgical Complications in Renal Transplant Recipients

Introduction: Renal transplantation is one of the most effective treatment measures in patients with end-stage renal disease to improve their quality of life. However, postoperative surgical complications can be seen in 15% to 17% of cases, with significant morbidity in earlier periods. This study aims to study the incidence, presentation, and management of various surgical complications within 2 months of renal transplantation. Materials and Methods: This retrospective descriptive study included data from hospital records of 236 recipients who underwent renal transplantation from 2015 to 2022 at our institute. In addition, salient characteristics of the donors were also noted. Recipients whose hospital records were not available were excluded from the study. Surgery-related complications within 2 months of renal transplantation in recipients and their management were studied. Results: Of 236 cases of renal transplantation, 182 cases were live-related renal transplantation recipients, and 54 were deceased donor renal transplantation recipients. Surgical complications such as posttransplant urine leak in three patients, lymphocele in two patients, graft renal vein thrombosis in three patients, and anastomotic site pseudoaneurysm in one patient occurred. The overall incidence of early surgical complications in our study is 3.81%. The study reports the successful management of all these nine patients with necessary intervention. Conclusion: The early diagnosis of postoperative complications is essential for reducing mortality and preserving graft function.

Point-of-care-ultrasound for the assessment of post-renal transplant recipients.

Postoperative imaging for deceased donor renal transplants is often delayed, as these surgeries occur after-hours. These delays can be critical in identifying immediate complications. To our knowledge, there are no formal training programs for point-of-care ultrasound (POCUS) in this setting; therefore, we aimed to develop and evaluate a feasible and practical POCUS curriculum for the assessment of a renal transplant graft. Urology and nephrology transplant physicians completed a three-hour online course, followed by a five-hour hands-on seminar for sonographic scanning. Simulated patients with transplanted kidneys were used. Course material was developed with licensed ultrasound technologists based on Sonography Canada national competency profiles. Pre- and post-course surveys focused on user confidence, while pre- and post-course multiple-choice questionnaires assessed theoretical knowledge. Twelve participants were included, six of whom were urologists. Theoretical knowledge in POCUS improved significantly (p<0.001). Confidence in manipulation of ultrasound controls, Doppler imaging, and POCUS of the transplant kidney also improved (all p<0.001, d>2.0). Participants indicated an increased likelihood of POCUS use in clinical practice and that training should be integrated into a transplant fellowship. We introduced a novel and guideline-based POCUS curriculum that leveraged local ultrasound educators and found improved theoretical knowledge and skill confidence in our cohort of transplant physicians. This course will serve as the first step toward a validated competency-based training system for POCUS use in the immediate post-renal transplant setting, and likely will be incorporated into the training of the modern transplant physician.

Rescue Allocation Modes in Eurotransplant Kidney Transplantation: Recipient Oriented Extended Allocation Versus Competitive Rescue Allocation-A Retrospective Multicenter Outcome Analysis.

Whenever the kidney standard allocation (SA) algorithms according to the Eurotransplant (ET) Kidney Allocation System or the Eurotransplant Senior Program fail, rescue allocation (RA) is initiated. There are 2 procedurally different modes of RA: recipient oriented extended allocation (REAL) and competitive rescue allocation (CRA). The objective of this study was to evaluate the association of patient survival and graft failure with RA mode and whether or not it varied across the different ET countries. The ET database was retrospectively analyzed for donor and recipient clinical and demographic characteristics in association with graft outcomes of deceased donor renal transplantation (DDRT) across all ET countries and centers from 2014 to 2021 using Cox proportional hazards methods. Seventeen thousand six hundred seventy-nine renal transplantations were included (SA 15 658 [89%], REAL 860 [4.9%], and CRA 1161 [6.6%]). In CRA, donors were older, cold ischemia times were longer, and HLA matches were worse in comparison with REAL and especially SA. Multivariable analyses showed comparable graft and recipient survival between SA and REAL; however, CRA was associated with shorter graft survival. Germany performed 76% of all DDRTs after REAL and CRA and the latter mode reduced waiting times by up to 2.9 y. REAL and CRA are used differently in the ET countries according to national donor rates. Both RA schemes optimize graft utilization, lead to acceptable outcomes, and help to stabilize national DDRT programs, especially in Germany.

The Effect of Perfusate Temperature on Delayed Graft Function in Deceased Donor Renal Transplantation.

Introduction: Renal allograft hypothermic machine perfusion results in a decreased incidence of delayed graft function compared with static cold storage. Ensuring perfusate temperatures remain within the target range of 4-10 °C may impact delayed graft function rates. Project Aims: To identify whether this target was achieved and, if not, whether higher perfusate temperature was associated with delayed graft function. Design: In this retrospective cohort study, transplanted grafts from deceased donors placed on hypothermic machine perfusion pump from June 2019 to August 2020 were analyzed. Measurements were recovered after 5, 15, 60, and 180 min of perfusion. Univariable and multivariable analyses were performed to identify predictors of delayed graft function. Results: A total of 113 grafts from 94 donors were analyzed. Of these, 21 (19%) developed delayed graft function. On univariable logistic regression, variables associated with delayed graft function included older donor age (OR 1.08, P = .002), higher Kidney Donor Profile Index score (OR 1.03, P = .024), and higher 5-min perfusate temperature (T5 min; OR 1.49, P = .014). A higher T5 min was also associated with delayed graft function in multivariable logistic regression models (OR 1.58, P = .005; OR 1.37, P = .08). Grafts with T5 min >10 °C were more likely to experience delayed graft function than those with T5 min <10 °C (OR 4.5, P = .006). Conclusion: Higher early perfusate temperature was an independent predictor of delayed graft function and may be due to inadequate cooling of the circuit prior to placing grafts on pump. Quality improvement initiatives targeting early perfusate temperatures of ≤10 °C may reduce delayed graft function incidence.

Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes.

This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center. This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders. The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity. SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

Posttransplant Thrombotic Microangiopathy: Unraveling a Mystery

A 24 year old lady who was diagnosed with chronic kidney disease stage 5 in 2016 underwent a pre-emptive live related renal transplant in the same year. She had kidney allograft dysfunction and eventually lost the transplant kidney in 2019 requiring hemodialysis. She underwent a deceased donor renal transplant in February 2022. She developed allograft dysfunction with a creatinine of 2.5 mg/dl in October 2022, and a renal allograft biopsy subsequently showed Thrombotic microangiopathy, arteriolar form. There were no features of rejection in the biopsy and Donor specific antibody done by Luminex lysate method was negative. Her Single antigen bead done subsequently was also negative. CMV DNA PCR was not detectable. Tacrolimus was switched to Cyclosporine, however her allograft function continued to worsen. Complement mutation analysis was negative and acquired complement defects were also not detected. Subsequently, Single antigen bead for non HLA antibodies showed positivity for MICA antibodies. She underwent 7 sessions of plasmapheresis and her renal functions did not improve and her creatinine continued to increase to 4.2 mg/dl. Complement activating assay for these MICA antibodies was positive. She was treated with two doses of 300 mg Eculizumab in December 2022, her allograft functions in February 2023 have improved to 2 mg/dl. This case highlights the extensive evaluation for post transplant TMA, the use of non HLA antibody assays and complement activating assays of these antibodies to decide on appropriate use of Eculizumab for salvaging transplant allograft.

Oral 12 - Demographics and trends of deceased donor renal transplants in Ireland: A 10-year review of a National Renal Transplant Database

Oral 12 - Demographics and trends of deceased donor renal transplants in Ireland: A 10-year review of a National Renal Transplant Database

A modified perioperative regimen for deceased donor kidney transplantation in presensitized recipients without prior desensitization therapy.

Renal transplantation in HLA-presensitized recipients entails an increased risk of antibody-mediated rejection (AMR) and graft loss. There is currently no accepted standard treatment protocol that can help transplant surgeons safely perform deceased donor (DD) kidney transplantation in presensitized patients without pretransplant desensitization. Fifty-one panel-reactive antibody (PRA)-positive recipients and 62 PRA-negative retransplant recipients (control) who received DD renal transplantation were included. Patients in the presensitized group (donor-specific antibody [DSA]-positive, n=25; DSA-negative, n=26) without desensitization received a modified perioperative treatment starting on day 0 or -1 with rituximab, thymoglobulin, and low daily doses of intravenous immunoglobulin (IVIG, 10-20 g/d, for 14 days). Plasmapheresis was performed once before surgery in DSA-positive recipients. The median follow-up time was 51 months in the presensitized group and 41 months in the control group. The incidence of early acute rejection (AR) and AMR (including mixed rejection) was 35.3% and 13.7% in the presensitized group, respectively, significantly higher than in the control group (14.5% and 1.6%, respectively). Within the presensitized group, the DSA-positive subgroup had more AMR than the DSA-negative subgroup (24.0% vs. 3.8%), but the incidence of T cell-mediated rejection was comparable (20.0% vs. 23.4%). In the presensitized group, all rejections were successfully reversed, and graft function remained stable during follow-up. The 1-year and 3-year survival rates of the grafts and recipients in this group were 98.0%. With a modified IVIG-based perioperative regimen, excellent intermediate-term graft and recipient survival outcomes can be achieved in presensitized patients who received DD kidney transplantation without prior desensitization.

#3697 FAMILIAL PAPILLARY RENAL CELL CARCINOMA: A CASE REPORT

Abstract Background and Aims The incidence of Renal Cell Carcinoma (RCC) is the 9th commonest cancer worldwide. It originates from the renal tubular epithelium and to date has been subclassified into five different categories. Of which, papillary carcinoma is one subclassification and it includes two variants: sporadic and hereditary. This case report aims to outline a rare case of hereditary papillary RCC and the implications for the family involved. Method We performed a retrospective assessment of clinical and radiological characteristics of the index patient and affected relatives. Genetic diagnosis and management have been summarised. Results A 62-year-old male (II.1) was diagnosed with RCC after presenting with right-sided flank pain and multiple complex cystic lesions within both kidneys. A kidney biopsy revealed a papillary structure with foamy histocytes and clear cell-type epithelium clusters. Immunostaining of tumour cells demonstrated CK7 and P504S positivity consistent with RCC. Subsequently, he underwent bilateral nephrectomies and being rendered anephric, was commenced on haemodialysis. He underwent deceased donor renal transplantation four years later at the age of 66 (HLA 1:2:1, CMV -/-, cRF 35%) and remains dialysis independent six years on. After the diagnosis of the index patient, his son (III.1) was found to have multifocal papillary RCC, having also presented with flank pain, but this time in his 30s (Fig. 1). Patient III.1 underwent genetic testing which revealed a missense variant in the MET gene (NM_000245.4 c.3308G&amp;gt;A; p.Gly1103Glu). The variant affects a highly conserved residue in the Tyrosine Kinase domain of the MET protein. Pathogenic activating variants are associated with RCC. Identification of the same variant in the affected father with bilateral disease allowed classification of the variant as likely pathogenic according to the ACMG criteria [1]. The father has seven children, all of whom have now been tested. 5/7 of them have been found to carry the likely pathogenic MET missense variant. Of the 4 asymptomatic carriers, all are under surveillance by regular renal imaging and (one has had radiofrequency ablation). Conclusion The case outlines a rare form of hereditary RCC and the implications that detection of the genetic variant has meant in terms of early diagnosis of disease. Incidence of RCC is increasing worldwide. Hereditary papillary RCC is rare, it is typically inherited in an autosomal dominant pattern. Germline mutations in the MET proto-oncogene are located at 7q31, which encodes for the tyrosine kinase signaling pathway. Variants lead to uncontrolled activation of MET protein and aberrant cell growth [2]. Discussion Hereditary papillary RCC has an estimated incidence of &amp;lt; 1:1500000, its rarity highlighted by the fact that only ∼35 families have been reported worldwide in literature. In these cases it exhibits 100% penetrance, with patients developing renal cell carcinoma typically between their fifth and sixth decade [3]. We would like to acknowledge the family involved in this case report. As with many cancers, early diagnosis is helped by detection of a genetic variant, leading to improved long-term disease-free survival. In the case of metastatic papillary RCC 2-year survival is still estimated at 18% (3).

O038 Positive impact of an ERAS programme on living and deceased donor renal transplant recipients’ recovery during COVID pandemic

Abstract Introduction An ERAS (Enhanced Recovery After Surgery) programme was created to reduce length of stay (LoS) and improve outcomes following renal transplant surgery. This aimed to reduce post-operative hospital-acquired infection, especially COVID-19. Methods The ERAS protocol was finalised following a literature review and MDT discussion. ERAS information, with post-operative exercise advice, was distributed to patients on the renal transplant waitlist. LOS was evaluated, comparing ERAS with pre-ERAS recipients and, to remove pandemic bias, pre-pandemic (December 2019) recipients. Secondary outcomes were opiate use, mobilisation, bowel function and patient-reported outcomes. ERAS protocol compliance was monitored. Data analysis was with student t-test and Chi-2 test in GraphPad Prism. Results Some 35 consecutive recipients completed ERAS protocol (March 2021). Baseline characteristics were comparable between live-donor recipients 9/35 vs 13/35 pre-ERAS and 12/35 pre-COVID. BMI&amp;gt;30 was higher in ERAS group (19vs. 11vs. 8). Median LoS was significantly reduced: ERAS - 5 days, pre-ERAS - 7 days, pre-COVID - 8 days (p=0.01). 51% of ERAS discharges were within 5 days vs. 17% pre-ERAS vs. none pre-COVID (X2 12.59, p&amp;lt;0.001). For overstayers (&amp;gt;5 days), potential preventable reasons were identified. 79.2% of ERAS recipients mobilised on day 1 post-op. ERAS indicated no significant reduced opiate use. Two ERAS recipients were readmitted within 30 days (vs.9/70 pre-ERAS) and one returned to theatre (vs.5/70 pre-ERAS). Conclusion This ERAS programme successfully reduced the LoS by 2 days in comparative population with minimal adverse events. Patient and staff feedback was positive. It's hypothesised that assigning a specialist ERAS nurse will improve compliance.

Renal transplant anastomotic time-Every minute counts!

The impact of anastomotic time in renal transplant is under recognized and not well studied. It is one of the few controllable factors that affect the incidence of delayed graft function (DGF). Our study aimed at quantifying the impact of anastomotic time. We performed a retrospective review of 424 renal transplants between the years 2006 and 2020. A total of 247 deceased donor renal transplants formed the study cohort. Patients were divided into two groups based on the presence or absence of DGF. Variables with p < 0.3 were analyzed using the binary logistic regression test. The final analysis showed anastomotic time to be significantly associated with DGF with odds ratio of 1.04 per minute corresponding to 4% increase in DGF incidence with every minute increment in anastomotic time. Other variables that had significant impact on DGF were DCD donor (odds ratio - 8.7) and donor terminal creatinine. We concluded that anastomotic time had significant impact on the development of DGF and hence should be minimized.

Deceased-Donor Renal Transplantation: A Single-Center Experience from a Tertiary Care Hospital in North India

Deceased-Donor Renal Transplantation: A Single-Center Experience from a Tertiary Care Hospital in North India

A child with vacterl association for deceased donor renal transplantation: Perioperative anesthetic management concerns

Each letter of the mnemonic VACTERL stands for one or more types of malformation. It is defined by the presence of at least 3 of the following congenital malformations: vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities. In addition to these core component features, patients may also have other congenital anomalies. It is an association rather than a syndrome. Due to multiple congenital anomalies of different systems, anesthesia management of these patients can be challenging. Here, we present a case of a 14-year-old patient with VACTERL association posted for deceased donor renal transplantation under general anesthesia. Our article describes the uneventful perioperative course of the patient and highlights the concerns and complications in anesthesia management of a patient with VACTERL association.

Culture-Negative Endocarditis in an Immunocompromised Patient: A Case of Suspected Bartonella and Coxiella Co-Infection.

We present the case of a 23-year-old man with a previous deceased-donor renal transplant maintained on tacrolimus and prednisone who developed culture-negative endocarditis (CNE) of the mitral and aortic valves. He was suspected of being co-infected with Bartonella henselae and Coxiella burnetii, confirmed with serology testing. He was successfully managed with appropriate antibiotics and dual valve replacement.

An understanding of the evaluation of histocompatibility testing for a deceased-donor transplant

Dear Editor, Several obstacles have been overcome in the recent decades to make organ transplantation an effective lifesaving treatment for many patients. However, there is a tremendous disparity between the demand for organs and the number of organs necessary around the world, which is regarded as one of the major barriers, and India is not an exception.[1] Since 2013, the rate of deceased-donor organ donation increased from 0.27 per million people (pmp) to 0.65 pmp in 2018. Whereas the rate of deceased-donor renal transplant increased from 0.43 pmp to 0.86 pmp during the same period; this is roughly a 2.4-fold increase in just 5 years.,[2] Still, a lot of support and awareness for deceased-donor organ transplant programs is needed to help patients who do not have living kidney donors. There are numerous obstacles to overcome, with persuading family members being one of the most significant. Furthermore, transportation and allocation of the cadaver are also other issues associated with deceased-donor transplants. Once a cadaver is available, a set of histocompatibility testing of the potential patients is performed to determine the transplant’s suitability. Hence, a transplant immunology laboratory’s ability to accurately report the compatibility tests (to evaluate preformed human leukocyte antigen [HLA] donor-specific antibodies) on time is critical to the success of a deceased-donor transplant program. We want to emphasize the importance of histocompatibility testing evaluation in deceased-donor transplant programs. To support the deceased-donor transplant program, the laboratory must set up an efficient operational system to determine what kind of tests will be needed before, during, and after the transplant. In addition, a functioning 24-h on-call system should be in place. So far, a standalone transplant focused laboratory in North India, accredited for ISO15189: 2012, has aided pretransplant testing workup for 62 cadaveric cases (between February 2015 and December 2022) by optimizing the appropriate and effective test for anti-HLA antibodies between complement-dependent cytotoxicity (CDC) crossmatch, flow cytometric crossmatch (FCXM), and Luminex crossmatch.Both the CDC and the FCXM are time-consuming and labor-intensive, with the potential of false results, especially in the case of deceased donations where there is no time to redo the tests. Even technological advancements have contributed to a better understanding of transplant immunology in the recent years. In the identification of HLA antibodies, the advent of Luminex cross-matching technology provides more sensitivity than CDC and FCXM. Furthermore, unlike Luminex crossmatch, CDC and FCXM are manually created assays that require manual interpretation and whose processing method varies between laboratories. Furthermore, they (CDC and FCXM) both require a high number of viable lymphocytes to complete the experiment, whereas Luminex crossmatch requires a cell lysate to process. It is difficult to isolate a high number of viable lymphocytes from a cadaver; hence, cell count is a major concern in the cadaver transplant workup. The outcome may be harmed as a result of sample quality difficulties. Due to the aforementioned constraints, these approaches are less reliable during cadaver workup, and they also take a longer time than Luminex crossmatch. Even lysate can be saved for posttransplant monitoring.[3,4] Mishra et al. also support the findings of the use of Luminex crossmatch for pretransplant workup of renal transplants.[4] Later on, data published by Mathur et al. on 342 patients supported the usefulness of Luminex lysate crossmatch in deceased donor pretransplant workup.[3] Further, some more published literature[5,6] supports these findings; hence, Luminex crossmatch (lysate) should be used as the primary compatibility investigation for deceased-donor transplants. At present, no specific pretransplant compatibility workup for deceased-donor transplants is available. In routine practice, broadly, the pretransplant compatibility workup falls into two broad categories; cell-based tests (CDC and FCXM) and HLA bead-based (solid phase) tests (such as anti-HLA antibody screening and ant-HLA antibody identification). Laboratories typically utilize testing algorithms for compatibility, which are combinations of two or more tests, since no single test, whether cell-based or HLA bead-based, is 100% accurate and sensitive. To make donor lysate Luminex crossmatch a consensus technique, transplant physicians can be taught about the benefits. Recently, some pretransplant compatibility testing algorithm in the Indian setup is published,[7,8] which necessitates the development of one for better organ transplant outcomes, particularly in cadaver instances where there are numerous hurdles (both clinical and nonclinical). For deceased donor workup, expert analysis in a quicker turnaround time is critical, and hence, the laboratory should be equipped with cutting-edge advanced histocompatibility equipment to aid in the evaluation of histocompatibility testing for deceased-donor transplants. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Analysis of donor factors for clinical prediction of recipient after deceased donor renal transplantation in South Korea

Analysis of donor factors for clinical prediction of recipient after deceased donor renal transplantation in South Korea

Renal cell carcinoma in pretransplant native nephrectomy of hemodialysis patient with acquired cystic kidney disease for deceased donor renal transplantation

Renal cell carcinoma in pretransplant native nephrectomy of hemodialysis patient with acquired cystic kidney disease for deceased donor renal transplantation

ODP623 Life Threatening Diabetic Ketoacidosis as First Presentation of Tacrolimus-Induced Diabetes Mellitus.

Abstract Background New-onset diabetes after transplantation (NODAT) is a serious complication after a solid organ transplant. NODAT occurs in 2% to 53% of all solid organ transplant recipients.1 Tacrolimus is an immunosuppressive agent associated with diabetogenic potential which predominantly is a result of suppression of insulin secretion from pancreatic beta cells. Diabetic ketoacidosis as the first presentation of new onset tacrolimus induced diabetes is rare. We report a case of diabetic ketoacidosis (DKA) in a patient without prior history of diabetes mellitus and receiving tacrolimus as part of immunosuppressive regime post-renal transplant. Clinical Case A 62-year-old female with past medical history of autosomal polycystic kidney disease status-post deceased donor renal transplant and hypertension presented with weakness and fatigue. She had undergone transplant 8 months prior to this presentation and her immunosuppressive regime consisted of mycophenolate mofetil and tacrolimus. The patient was encephalopathic on arrival with normal vitals. Laboratory evaluation was significant for blood glucose of 673, bicarbonate of &amp;lt;10, anion gap of 24, Beta-hydroxybutyrate &amp;gt;8 and a pH of 7.19 on arterial blood gas analysis thus confirming diagnosis of diabetic ketoacidosis (DKA). Tacrolimus level was elevated at 35.7. Intravenous fluids and insulin were initiated with resolution of symptoms and DKA. She was transitioned to a basal-bolus insulin regimen. Further labs revealed Hemoglobin A1C of 11.6% (no previous value), negative insulin antibodies and glutamic acid decarboxylase antibody, and a low C-peptide level at 0.47 (when blood glucose was 150mg/dl). Her tacrolimus dose was adjusted, and she was discharged on a basal-bolus insulin regimen. On follow up, the patient had lower insulin requirements with improvement in C-peptide level to 1.8, thus, indicating beta cell dysfunction in setting of supratherapeutic tacrolimus levels. Conclusion Tacrolimus remains the preferred immunosuppressive agent after kidney transplantation given lower incidence of acute rejections and better tolerance. However, due to its toxic effects on pancreatic beta cells it is imperative blood sugar levels should be routinely monitored in patients on tacrolimus. Appropriate monitoring can lead to timely diagnosis and successful outcomes. Further studies are required to investigate risks factors associated with tacrolimus induced DKA.

S2011 Disseminated Histoplasmosis Involving the Whole Colon: It's Ulcers All the Way Down

Introduction: Histoplasma capsulatum is a dimorphic fungus endemic to river valleys of Eastern and Central U.S. that is spread via inhalation of spores from soil contaminated by bird or bat droppings. Disseminated Histoplasmosis (DH) spreads through the reticuloendothelial system via parasitized macrophages and can cause severe infection in immunocompromised patients with AIDS, hematologic malignancies, transplant recipients, and those receiving tumor necrosis factor (TNF)-alpha inhibitors or chronic corticosteroids. Gastrointestinal involvement in DH is frequently seen, but it is not uncommon for patients to be asymptomatic. We present a case of DH with pan-colonic ulcerations in a renal transplant patient. Case Description/Methods: A 83-year-old male with deceased donor renal transplantation on immunosuppression therapies presented with profound weakness. He was restarted on hemodialysis one month prior for declining renal allograft function which had been stable for the past 2 decades. Initial workup showed pneumonia on imaging, elevated procalcitonin, alkaline phosphatase, and pancytopenia. He developed hematochezia with worsening anemia which prompted colonoscopy that revealed deep and innumerable ulcers measuring greater than one cm in the whole colon. One large ulcer with a visible vessel near the hepatic flexure was treated with epinephrine, electrocautery, and endoclip for hemostasis. Ulcer biopsy revealed granulomatous inflammation with fungal yeast forms morphologically compatible with Histoplasma by Grocott's Methenamine Silver (GMS) staining. Bone marrow pathology was suggestive of fungal infiltration, but marrow and blood cultures were negative. Family revealed he lives in an old mold infested home and has history of visiting caves. Treatment was initiated with liposomal Amphotericin B then transitioned to oral Itraconazole. He has continued to make a strong recovery and remains on dialysis (Figure). Discussion: For healthy individuals, exposures to Histoplasma generally occur as asymptomatic to self-limited pulmonary infection. Disseminated Histoplasmosis is often undiagnosed and carries high mortality if untreated. These patients usually had past exposures with dormant inoculation that is reactivated after immunosuppression. GI involvement is common but can be non-symptomatic or with only vague abdominal complaints from colonic fungal invasion. Suspicion of DH should be met with a low threshold for endoscopic evaluation and requires tissue biopsy for diagnosis.Figure 1.: (A) Large ulcer in the cecum which was biopsied. (B) Numerous ulcers seen diffusely throughout the colon. (C, D) H&E and Grocott’s Methenamine Silver (GMS) stain of colonic mucosa with patchy ulceration and granulomatous inflammation including fungal yeast forms, morphologically compatible with Histoplasma.

331.6: Impact of Left Ventricular Ejection Fraction and Previous Cardiac Revascularization on Patient and Graft Survival in Kidney Transplant Receipts

Background: Single center studies have implicated baseline left ventricular ejection fraction (LVEF) and baseline coronary artery disease as strongly associated with post-kidney transplant graft and patient survival, including in limited multivariate models. However, the United States’ Scientific Registry of Transplant Recipients (SRTR) does not directly include any cardiac variables as part of its risk adjustment model, raising the question of whether the current SRTR model fairly risk adjusts potential recipients. Methods: This study used the novel prospective United States National Surgical Quality Improvement Program (NSQIP) Transplant database to assess the impact of LVEF and pre-transplant revascularization on post-transplant outcomes in deceased donor renal transplantation (DDRT). Recipients from 2017-2019 were identified and stratified by LVEF into <50 and 50+ categories. A separate analysis stratified patients into if they had received pre-transplant revascularization, defined as either coronary bypass surgery or percutaneous intervention. Post-transplant outcomes were assessed. Results: A total of 2377 DDRT recipients were included from 29 centers. Mean follow up was 200 days. Only 4.8% had LVEF<50 at transplant, while 13.3% had undergone cardiac revascularization prior to transplant. There were several baseline differences between patients who did and did not have previous revascularization. Previous revascularization was associated with increased risk of requiring cardiac CPR (1.3 vs 0.1%, p=0.002), organ space surgical site infection (3.8 vs 1.1%, p=-0.001), delayed graft function (39.2 vs 28.3%, p<0.001), requiring dialysis at last follow up (5.7 vs 3.9%, p<0.001), myocardial infarction (4.4 vs 0.8%, p<0.001), pneumonia (3.2 vs 1.1%, p=0.011), recatherization (14.2 vs 8.2%, p=0.002), sepsis (4.1 vs 1.7%, p=0.018), septic shock (1.3 vs 0.3%, p=0.036), UTI (10.1 vs 6.1%, p=0.023), and longer ICU stay (0.86 vs 0.47 days, p=0.004). In univariate analysis, previous revascularization was associated with increased hazard of death (HR 2.4, p=0.02) but not graft loss (HR 1.3, p=0.52). In a multivariate model including previous revascularization and existing SRTR variables (age, diabetes, peripheral vascular disease, albumin, KDRI) as predictors, previous revascularization was related to a higher hazard of death (HR 1.43) however this was not a statistically significant finding (p=0.42). Conclusions: We conclude that in the DDRT in patients with previous cardiac revascularization is much more common (13.3%) than in those with LVEF<50 (4.8%). We also demonstrate that previous cardiac revascularization is a powerful predictor of both patient survival and several post-transplant complications. However, we also show that existing variables (e.g. diabetes, PVD, age) in the SRTR risk stratification model largely capture the impact of previous cardiac revascularization on patient survival at least in the early follow up period.