Intensive Immunosuppression Research Articles

Increasing access to renal transplantation in India through our single-center kidney paired donation program: a model for the developing world to prevent commercial transplantation.

Because access to transplantation with HLA-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end-stage renal disease (ESRD) patient in India. We present a government and institutional ethical review board approved study of 56 ESRD patients [25 two-way and 2 three-way pairs] who consented to participate in KPD transplantation at our center in 2013, performed to avoid blood group incompatibility (n=52) or positive cross-match (n=4). All patients had anatomic, functional, and immunologically comparable donors. The waiting time in KPD was short as compared to deceased donor transplantation. Laparoscopic donor nephrectomy was performed in 54 donors. Donor relationships were spousal (n=40), parental (n=13), others (n=3), with median HLA match of 1. Graft survival was 97.5%. Three patients died with functioning graft. 16% had biopsy-proven acute rejection. Mean serum creatinine was 1.2mg/dl at 0.73±0.32months follow-up. KPD is a viable, legal, and rapidly growing modality for facilitating LDRT for patients who are incompatible with their healthy, willing living donor. To our knowledge, this is the largest single-center report from India.

A Lower Cylex Score May Be a Useful Tool to Prevent the Development of Circulating Antibodies After Heart Transplantation?

Purpose: The Cylex score is a new test to detect immune responsiveness for heart transplant (HTx) patients (pts). A low Cylex score represents more intense immunosuppression and therefore a less responsive immune systemin general. Circulating antibodies (Ab) are seen in more than 50% of post-HTx pts. It is believed that more intense immunosuppression may decrease the risk of Ab production post-HTx. Although the Cylex score represents T cell immunoresponsiveness, it may also reflect a general immunosuppressive state and thereby may reflect the ability of the recipient to make Abs. Methods: Between 2007 and 2012 we evaluated 103 HTx pts who did not have circulating Abs pre-HTx. Post-HTx Ab levels were assayed at 1,3,6,12 months post-op and correlated to the Cylex score. Cylex scores were obtained routinely at the time of endomyocardial biopsy. Pts were divided into 3 Cylex score groups: <200, 200-500, >500. All pts were under tacrolimus and mycophenolate mofitel immunosuppression. Endpoints included: development of de novo Abs, 1-year freedom from cellular (CMR) and antibody-mediated rejection (AMR), 1-year survival, 1-year freedom from cardiac allograft vasculopathy (CAV) and 1-year freedom from Non-Fatal Major Adverse Cardiac Events (NF-MACE: Myocardial Infarction, Heart Failure, angioplasty, pacemaker/ICD, stroke). Results: There were 5.4 ± 2.9 first-year Cylex scores per pt. Pts with Cylex scores <200 had numerically more suppressed Ab responses compared to Cylex score 200-500 and >500 groups (4.8% vs 13.7% vs 22.2%), but numbers are small. However, there was no difference in 1-year freedom from CMR or AMR. There was also no significant difference in 1-year survival, 1-year freedom from CAV and 1-year freedom from NF-MACE among groups (see table).Table: No Caption available.Conclusion: Low Cylex score reflecting more intense immunosuppression may be a useful tool to suppress Ab response after HTx, but a larger number of pts are needed to confirm this observation. DISCLOSURES:Patel, J.: Grant/Research Support, Alexion Pharmaceuticals. Chang, D.: Stockholder, Abbot Pharmaceuticals, ABBV. Esmailian, F.: Grant/Research Support, Transmedics. Kobashigawa, J.: Grant/Research Support, XDx Inc, Novartis.

Paired Donation Improves Kidney Transplantation Rate- A Single Centre One Year Experience of 56 Kidney Paired Donations.

Background:Because access to transplantation with HLA-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD)promises hope to a growing number of end stage renal disease (ESRD) patients. KPD is feasible for any center performing living donor renal transplantation (LDRT). Materials and methods: We present a government and Institutional Ethical Review Board approved study of 56 end stage renal disease (ESRD) patients [25 two-way and 2 three-way pairs] who consented to participate in KPD transplantation at our center in 2013. They were performed to avoid blood group incompatibility (n=52) or positive cross-match (n=4). All patients had anatomic, functional and immunologically comparable donors. Patient ABO type was A (n=24), B (n=22), AB (n=2) and O (n=8). Donor ABO blood group type was A (n=23), B (n=20), AB (n=2) and O (n=11). Results: Commonest original disease leading to ESRD was hypertension (n=23), chronic glomerulonephritis (n=12) and diabetic nephropathy (n=4). Laparoscopic donor nephrectomy was performed in 54 donors. The waiting time in KPD is short(less than 3 months) as compared to deceased donor transplantation (30 months). Median warm ischemia time, cold ischemia time and anastomosis time were 165 seconds, 66 minutes and 33 minutes respectively. Donor relationships were spousal (n= 40), parental (n=13) or others (n=3), with median HLA match of 1. Graft survival was 100 %. Three patients died with functioning graft due to sepsis and cardiac disease, and 16% had biopsy proven acute rejection. Mean serum creatinine at last follow-up was 1.2 mg/dl. Conclusion KPD is viable, legal and rapidly growing modality for facilitating LDRT for patients who are incompatible with their healthy, willing living donor. To our knowledge, it is largest single-center report from developing country.

Post-Transplant Malignancy in Incompatible Kidney Transplantation: A National Study.

Introduction: Desensitization for HLA-incompatible kidney transplantation (IKT) requires additional immunosuppression compared to compatible patients, potentially leading to an increased rate of malignancy. No national studies have compared post-transplant malignancy rates in HLA-IKTs to compatible patients. Methods: Data on IKT status was collected on 3,683 patients with Medicare from 20 centers nationally. Patients were linked to Medicare claims data those with diagnoses of malignancy within 3 years post-transplant were identified. Rates of malignancy were compared between IKT patients and an age and gender matched cohort of compatibles, using Fisher's exact test as appropriate for small sample sizes. Results: IKTs were significantly less likely to develop multiple myeloma compared to non-IKTs (0 IKTs versus 18, 0.87% of non-IKTs, p =0.036, Table 1). Rates of Hodgkin's disease and non-Hodgkin's lymphoma were 1.69 and 2.06 times higher among IKTs; however, these differences were not statistically significant. IKTs had 2.75 times the rate of head and neck cancer and 2.06 times the rate of stomach cancer (not statistically significant). Discussion: Rates of most malignancies were similar 3 years post-transplant. Multiple myeloma may be less common in IKTs due to use of B-cell ablative therapies for induction and treatment of antibody mediated rejection. Rates of cancers with an infectious component (e.g non-hodgkins lymphoma, head and neck cancer) may be elevated in IKTs due to intense immunosuppression; however, longer follow-up is needed to determine if differences are significant.Table: No Caption available.

Mooren’s Ulcer in a Cornea Referral Practice in Korea

Purpose: To investigate the clinical characteristics of patients with Mooren’s ulcer in the Korean population, and to identify the risk factors that affect the therapeutic outcome.Methods: We reviewed the medical records of 33 eyes of 24 Korean patients who were referred to a cornea clinic and clinically diagnosed with Mooren’s ulcer.Results: Despite intensive immunosuppression, corneal perforation occurred in 16 of 24 (66.7%) patients, which required tectonic graft. Age was significantly correlated with corneal perforation development: the age was 52.5 ± 21.8 years in patients with perforation and 70.2 ± 6.1 years in those without perforation (p = 0.036). Also, all 8 patients who were 55 years and younger had corneal perforation, while 8 of 16 patients older than 55 years developed perforation (p = 0.022). Other factors had no significant correlation with the occurrence of perforation.Conclusions: Young patients with Mooren’s ulcer should be treated and carefully followed for high possibility of corneal perforation.

AB0591 Acute Respiratory Failure – the Reason for Urgent Rheumatologic Examination?

BackgroundAcute respiratory failure is a reason for urgent admission to ICU. Statistical data show, that about 10 percent of deaths of respiratory failure patients on ICU is caused by diffuse...

Rheumatoid vasculitis—down but not out

Rheumatoid vasculitis is one of the most severe complications of rheumatoid arthritis. New data suggests that hydroxychloroquine and low-dose aspirin might be protective, but that there remains notable mortality despite intensive immunosuppression with cyclophosphamide or biologic agents.

Induction immunosuppressive therapy in kidney transplantation.

Induction therapy after kidney transplantation is intensive immunosuppression in the initial days after transplant when the immune system of the recipient has the first contact with donor antigens. Initial intensive immunosuppression may be required to prevent acute rejection and graft loss, and subsequent immunosuppression may be decreased to minimize adverse events associated with immunosuppressive drugs. Induction agents include lymphocyte-depleting antibodies such as rabbit antithymocyte globulin, alemtuzumab, muromonab-CD3, rituximab, and bortezomib; lymphocyte-nondepleting antibodies such as interleukin 2 receptor antibodies; and other discontinued or investigational agents such as efalizumab and alefacept. Induction therapy may be adjusted for special situations such as living-donor kidney transplant, pediatric transplant, hepatitis C virus-seropositive recipients, recipients who require desensitization, patients who are at risk for developing delayed graft function, and old donors. The optimal immunosuppressive regimen may vary, and clinical practice guidelines are available.

Monoclonal antibody therapy and renal transplantation: focus on adverse effects.

A series of monoclonal antibodies (mAbs) are commonly utilized in renal transplantation as induction therapy (a period of intense immunosuppression immediately before and following the implant of the allograft), to treat steroid-resistant acute rejections, to decrease the incidence and mitigate effects of delayed graft function, and to allow immunosuppressive minimization. Additionally, in the last few years, their use has been proposed for the treatment of chronic antibody-mediated rejection, a major cause of late renal allograft loss. Although the exact mechanism of immunosuppression and allograft tolerance with any of the currently used induction agents is not completely defined, the majority of these medications are targeted against specific CD proteins on the T or B cells surface (e.g., CD3, CD25, CD52). Moreover, some of them have different mechanisms of action. In particular, eculizumab, interrupting the complement pathway, is a new promising treatment tool for acute graft complications and for post-transplant hemolytic uremic syndrome. While it is clear their utility in renal transplantation, it is also unquestionable that by using these highly potent immunosuppressive agents, the body loses much of its innate ability to mount an adequate immune response, thereby increasing the risk of severe adverse effects (e.g., infections, malignancies, haematological complications). Therefore, it is extremely important for clinicians involved in renal transplantation to know the potential side effects of monoclonal antibodies in order to plan a correct therapeutic strategy minimizing/avoiding the onset and development of severe clinical complications.

Rituximab treatment combined with methylprednisolone pulse therapy and immunosuppressants for childhood steroid-resistant nephrotic syndrome

Calcineurin inhibitors (CIs) with/without intravenous methylprednisolone pulse therapy (MPT) constitute the standard treatment for childhood-onset, steroid-resistant nephrotic syndrome (SRNS). However, some patients fail to achieve remission. We treated SRNS patients resistant to CIs and MPT with additional rituximab combined with MPT and immunosuppressive agents. Ten patients (aged 2-14years) with CI- and MPT-resistant SRNS were enrolled. Patients were administered rituximab (1-4 doses; 375mg/m(2)) followed by MPT (30mg/kg/day of methylprednisolone for 3 consecutive days) once every 2-4weeks until complete remission (CR). We analyzed clinical outcome and safety. Six patients received a single dose of rituximab, 2 received two doses, and 2 received four doses. Seven patients achieved CR, 1 achieved partial remission, and 2 showed no response. Although 2 patients with no response progressed to end-stage renal failure, 7 patients with CR preserved normal renal function without proteinuria at the last observation. There were two serious adverse events. Additional rituximab combined with conventional MPT and immunosuppressive agents is a promising option for overcoming refractory SRNS. Aggressive B cell suppression by rituximab may ameliorate resistance to conventional treatments and a cocktail of other immunosuppressive agents, such as CIs, MMF, mizoribine, may be beneficial. However, as intense immunosuppression may cause serious adverse events, further evaluation is necessary.

Rheumatoid arthritis complicated with myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-associated vasculitis: a case report.

This article describes a patient with rheumatoid arthritis (RA) with crescentic glomerulonephritis (CrGN) associated with myeloperoxidase-antineutrophil cytoplasmic antibodies (MPO-ANCA), who responded well to methotrexate (MTX). A 48-year-old woman with a 4-year history of RA was admitted with fever and elevated C-reactive protein. On laboratory evaluation, her level of MPO-ANCA was 422 EU, and urinalysis revealed proteinuria and hematuria. Because she was also suffering from episcleritis, vasculitis was considered. A renal biopsy was performed, which revealed necrotizing CrGN. We diagnosed RA complicated with MPO-ANCA-associated vasculitis. We considered treatment with high-dose oral prednisolone for vasculitis, but the patient refused this treatment. We started MTX at a dose of 8 mg/week for RA from the time of admission, and the patient responded immediately. Biochemical parameters, including C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, and MPO-ANCA, improved. Seven months later, MPO-ANCA had decreased to 46 EU. In clinical studies, few patients have been reported with RA complicated with ANCA-associated CrGN. This case differs from previous cases in the treatment given. No high-dose steroid with intensive immunosuppression or plasma exchange was required.

Chapter 34 - Nervous system viral infections in immunocompromised hosts

The advent of effective immunosuppressive regimens has improved the prognosis for many patients with neoplasms and autoimmune diseases. However, the resulting extended duration of impaired B- and T-lymphocyte function predisposes these patients to viral infections whose course may be unusually virulent. This chapter discusses the presentation, differential diagnosis, clinical consequences, and therapy of common central nervous system viral infections, including human herpesviruses-6 and 7, herpes simplex virus, varicella-zoster virus, Epstein–Barr virus, cytomegalovirus, and JC virus (JCV). Particular patient groups covered in detail include hematopoietic stem cell and solid-organ transplant recipients, patients receiving intensive chemotherapy for malignancies without transplantation, and patients with primary brain tumors, multiple sclerosis, and a diverse group of rheumatologic and autoimmune conditions for which intensive immunosuppression is a consequence of effective therapies.

PReS-FINAL-2122: Autologous stem cell transplantation in a patient with severe systemic sclerosis in Portugal

Systemic sclerosis (SSc) is a progressive disease, whose pathogenesis includes early immunological events and vascular alterations. There is a subgroup of patients with a rapidly progressive disease or refractory to conventional treatment which can benefit from intensive immunosuppression and rescue with transplant of haematopoietic progenitors (TPH).

More Intensity Immuno-Suppression In Conditioning Regimen may Favor Donor Stem Cell Sustained Engraftment In Allogeneic Stem Cell Transplantation For Acquired Severe Aplastic Anemia Patients

BackgroundHematopoietic stem cell transplantation (HSCT) is the first-line therapy for patients younger less than 40 years old with severe aplastic anemia (SAA). And the long-term survival for patients with SAA who received HSCT reaches to 70%-90%. Cyclophosphamide-based conditioning regimen with or without antithymocyte globulin (ATG) has been adopted in majority of HSCT for SAA patients with HLA matched related donor. However the graft rejection and graft failure in HSCT for SAA with cyclophosphamide-based conditioning regimen is still as high as 5%-16%. The aim of this study is to explore whether more immue suppression in conditioning regimen could favor the donor stem cells sustained engraftment for severe aplastic anemia patients receiving allogeneic hematopoietic stem cell transplantation. Fludarabine and busulfan were added in cyclophosphamide-based conditioning regimen to intensity immune suppression in conditioning. MethodsTo analyze the outcomes and chimeras of 40 patients with SAA who received HLA matched allo-HSCT from 2000 to 2012 with either fludarabine-based conditioning regimen or cyclophosphamide-based conditioning regimen retrospectively and to explore the relationship between the chimeras and conditioning regimen. ResultsForty patients with SAA who received HLA matched allo-HSCT From May, 2000 to Dec. 2012. Twelve patients ( median age 25 year old range 13-52, male 7, femal 5) received fludarabine-based conditioning regimen which composed of fludarabine (30 mg/m2/d ×5d), busulfan ( 3 mg/kg ×2d ), cyclophosphamide ( 60mg/kg/d×2d) and ATG (2.5mg/kg/d ×5d). Twenty patients( median age 23 year old range 12-42, male 19, femal 9) received cyclophosphamide-based conditioning regimen which composed of cyclophosphamide (50mg/kg/d ×4d )and ATG (2.5mg/kg/d ×2d ). The median dose of MNC were 4.5×108/kg (range 3.8-7.0×108/kg )and 3.58×108/kg (range 3.2-6.8×108/kg ) and CD34+ cells were 4.5×108/kg and 3.58×108/kg respectively. GVHD prophylaxis were cyclosporine and short-term course methotrexate. Donor chimera was detected on day+30, +90, +180, and 360 after HSCT by short tandem repeat polymerase chain reaction, or fluorescein in situ hybridization for X and Y chromosomes in cases when patients and donors were sex mismatched. ResultsAll patients with fludarabine-based conditioning regimen were successful Hematopoietic reconstitution and no graft failure occurred in this group patients. But two patients could not get recovery in cyclophosphamid-based conditioning regimen group. And complete donor chimeras always present when chimeras were detected by STR-PCR or FISH at day 30,day 60, day 90 and d 180 post transplantation in fludarabine-based conditioning regimen group, while seven patients with cyclophosphamide-based conditioning regimen were mixed chimeras at day 30 post transplant. The graft was rejected in six of the seven patients at day 90 post transplant in cyclophosphamide-based conditioning regimen group. The complete donor chimera in fludarabine-based conditioning regimen group was obvious higher than that in cyclophosphamide-based conditioning regimen group ( p=0.037). The incidence of aGVHD in the fludarabine group was 16.7% and 10.7% in the cyclophosphamide-based group. There is no significant difference of aGVHD between two group (P = 0.627). The incidence of cGVHD was 8.3% and 10.7% respectively. The bacterial infections developed in 16.7% and 28.6% of patients respectively (P=0.693), The overall survival were 83.33% and 82.14% in fludarabine-based conditioning regimen group and cyclophosphamide-based group respectively (p=0.870). ConclusionsMore intensity immuno-suppression in conditioning regimen may favor donor stem cell sustained engraftment in allogeneic stem cell transplantation for acquired severe aplastic anemia patients. Disclosures:No relevant conflicts of interest to declare.

Long-Term Exposure to Belatacept in Recipients of Extended Criteria Donor Kidneys

Patients in the BENEFIT-EXT study received extended criteria donor kidneys and a more intensive (MI) or less intensive (LI) belatacept immunosuppression regimen, or cyclosporine A (CsA). Patients who remained on assigned therapy through year 3 were eligible to enter a long-term extension (LTE) study. Three hundred four patients entered the LTE (n = 104 MI; n = 113 LI; n = 87 CsA), and 260 continued treatment through year 5 (n = 91 MI; n = 100 LI; n = 69 CsA). Twenty patients died during the LTE (n = 5 MI; n = 9 LI; n = 6 CsA), and eight experienced graft loss (n = 2 MI; n = 1 LI; n = 5 CsA). Three patients experienced an acute rejection episode (n = 2 MI; n = 1 LI). The incidence rate of serious adverse events, viral infections and fungal infections was similar across groups during the LTE. There were four cases of posttransplant lymphoproliferative disorder (PTLD) from the beginning of the LTE to year 5 (n = 3 LI; n = 1 CsA); two of three PTLD cases in the LI group were in patients who were seronegative for Epstein–Barr virus (EBV(−)) at transplantation. Mean ± SD calculated GFR at year 5 was 55.9 ± 17.5 (MI), 59.0 ± 29.1 (LI) and 44.6 ± 16.4 (CsA) mL/min/1.73 m2. Continued treatment with belatacept was associated with a consistent safety profile and sustained improvement in renal function versus CsA over time.

De novo malignant disease after liver transplantation? Risk and surveillance strategies

De novo malignant disease after liver transplantation? Risk and surveillance strategies

Cancer risk after ABO-incompatible living-donor kidney transplantation.

Recipients of ABO-incompatible (ABOi) living-donor kidney transplants often undergo more intense immunosuppression than their ABO-compatible counterparts. It is unknown if this difference leads to higher cancer risk after transplantation. Single-center studies are too small and lack adequate duration of follow-up to answer this question. We identified 318 ABOi recipients in the Transplant Cancer Match Study, a national linkage between the Scientific Registry of Transplant Recipients and population-based U.S. cancer registries. Seven cancers (non-Hodgkin lymphoma, Merkel cell carcinoma, gastric adenocarcinoma, hepatocellular carcinoma, thyroid cancer, pancreatic cancer, and testicular cancer) were identified among ABOi recipients. We then matched ABOi recipients to ABO-compatible controls by age, gender, race, human leukocyte antigen mismatch, retransplantation, and transplant year. There was no demonstrable association between ABOi and cancer in unadjusted (incidence rate ratio, 0.83; 95% confidence interval, 0.33-1.71; P=0.3) or matched control (incidence rate ratio, 0.99; 95% confidence interval, 0.38-2.23; P=0.5) analyses. To the extent that could be determined in this registry study, current desensitization protocols are not associated with increased risk of cancer after transplantation.

Successful Tolerance to Fully MHC Disparate Renal Allografts via Donor Hematopoietic Mixed Chimerism in Non-Human Primates

To the Editor: Rodent studies clearly show that sharing of MHC genes between donors and recipients is regularly associated with improved allograft survival. This is essentially attributed to: (1) reduction of early inflammatory direct T cell responses involved in acute allograft rejection and (2) self-MHC molecules expression on donor cells promoting regulatory immunity. The precise contribution of donor/recipient MHC gene matching to transplant rejection or acceptance in clinical transplantation has been somewhat more difficult to define due to the use of intensive immunosuppression in all human allograft recipients. Nevertheless, most authors agree that improved long-term graft survival is generally expected in patients receiving MHC-matched renal allotransplants. Rodent studies also demonstrate that transplant tolerance is easier to accomplish when allogeneic tissues express some or all of the recipient's MHC proteins. Nevertheless, tolerance of fully allogeneic transplants is regularly achieved in laboratory-bred mice using a variety of procedures including donor specific transfusion, donor hematopoietic chimerism and lymphocyte costimulation blockade. In contrast, such tolerance in primates has proven to be much more arduous due presumably to the presence in these recipients of preexisting alloreactive memory T cells (TMEM). These TMEM undergo differentiation and clonal expansion following previous exposure to alloantigens through blood transfusion, pregnancy, a previous transplantation or via cross-reactivity with microbial antigens. A recent article in AJT by Ramakrishnan et al. 1, referring to a recent report from our group 2, suggested that we had achieved tolerance of renal allografts in non-human primates via mixed chimerism only in highly MHC-matched transplant pairs. This interpretation of our experience is not fully accurate. Indeed, we have reported an inverse correlation between the level of IL-2 and γIFN memory alloreactivity and the degree of MHC class II and I gene sharing among monkey pairs 3. However, this is not an absolutely consistent observation with a substantial number of fully MHC disparate donor–recipient pairs displaying low pro-inflammatory memory responses 3. This suggests that tolerance susceptibility vs. resistance in primates depends primarily upon the frequencies of pre-existing donor-specific TMEM rather than upon donor–recipient MHC matching. In support of this view, we have observed that over one third of the monkeys that became tolerant of renal allografts had actually received a highly MHC-mismatched (>4/6 CyLA mismatches) transplant 4, 5. In summary, the beneficial effects of MHC matching with regards to transplantation tolerance are undeniable. In addition, it is likely that harnessing anamnestic T cell alloreactivity in primates will be essential to successful tolerance of allogeneic transplants across MHC barriers in non-human primates and patients. G. Benichou*, O. Nadazdin, A. B. Cosimi, and T. Kawai Transplantation Research Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA *Corresponding author: Gilles Benichou, gbenichou@partners.org The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Use of a multiplex polymerase chain reaction system for enhanced bloodstream pathogen detection in thoracic transplantation

Bloodstream infections (BSIs) constitute a frequent post-transplant complication in thoracic allograft recipients, especially during the early post-surgical period when patients are under intense immunosuppression. Thus, early and accurate identification of the responsible pathogens is of critical importance for patient survival. In this study we investigated the potential clinical utility of a multiplex real-time polymerase chain reaction (PCR) technology (SeptiFast; Roche Diagnostics) for the detection of BSIs in a cohort of thoracic allograft recipients. Our observational study included analysis of 130 blood samples from 30 thoracic allograft recipients (23 heart and 7 lung) using SeptiFast in parallel with blood culture. Samples were drawn when there were clinical and laboratory signs of BSI. The applied molecular assay has been designed to allow direct detection of a wide panel of Gram-positive and Gram-negative bacteria and fungi in blood samples. Real-time PCR yielded concurrent negative and positive results with blood culture methodology in 113 (86.9%) and 5 (3.9%) samples, respectively, with 100% concordance in species identification. SeptiFast identified microorganisms in 9 (6.9%) additional samples that were negative by blood culture. The combined use of SeptiFast and blood culture during the early post-transplant period (<2 months) significantly increased the number of positive samples detected to 17.9% (14 of 78) from 7.7% (6 of 78) detected by blood culture alone (p < 0.05). SeptiFast results were available, on average, within 6 hours from sample collection. The PCR-based SeptiFast test is a valuable addition to the traditional blood culture method for rapid etiologic diagnosis of BSIs in thoracic transplant recipients, especially during the early post-transplant period.

A diagnostic dilemma in AL(L)PS

Dear Editor, An 18-month-old female infant presented to the paediatric haematology service in 1985 with lymphadenopathy, hepatosplenomegaly, anaemia (Hb 6.3 g/dL, range 11.7– 14 g/dL) and thrombocytopenia (17×10, range 150– 400×10). Bone marrow and lymph node examinations were reported as ‘reactive’. Karyotyping was normal. Viral, autoimmune and metabolic screens were negative. Following a period of observation and external review, during which time her marrow blast count rose to 9 %, the decision was made to proceed with Medical Research Council protocol for acute lymphoblastic leukaemia, with complete normalisation of peripheral blood counts and regression of spleen size for the duration of treatment (1986–1988). Her subsequent disease course included recurrent sinus and respiratory tract infections, fluctuating cytopenias, chronic lymphadenopathy and an elective splenectomy in the setting of massive splenomegaly. She developed severe autoimmune haemolytic anaemia, requiring intense immunosuppression and ultimately plasma exchange followed by recurrent invasive pneumococcal septicaemia on ages 14, 16 and 18 years. She was referred for immunological assessment in 2009 when a biopsy of an epitrochlear lymph node revealed paracortical T cell zone expansion with evidence of clonal T cell rearrangements, subsequently confirmed on bone marrow biopsy. CT images of thorax, abdomen and pelvis showed no evidence of lymphoma. On review, it emerged that her father, paternal aunt and first cousin all had a previous diagnosis of lymphoma. Screening for autoimmune lymphoproliferative syndrome (ALPS) confirmed the presence of double negative (DN) αβT cells (18 %, normal<1.5%) andFasL 1.5 ng/mL (normal range<0.2 ng/mL). Genetic testing demonstrated heterozygous nonsense mutation in exon 9 of the Fas gene confirming the diagnosis. Her father was found to have the same mutation. She failed to respond to the meningococcal vaccine and to both conjugated and unconjugated pneumococcal vaccines. She had a low IgG (IgG 4.6, range 6–15 g/L) and absent IgG2 with an elevated IgA (IgA 5.65, range 0.7–4.0 g/L) and normal IgM (IgM 1.0, range 0.5–2.3 g/L). Hypogammaglobulinaemia, recurring infection and failure to respond to vaccination is consistent with common variable immune deficiency which has been reported in association with ALPS [1]. At age 28, she presented with left hand and forearm swelling following minor trauma. C4 was undetectable (<0.0167 g/L, range 0.14–0.54 g/L). Both C3 and C1 inhibitor levels were reduced at 0.55 g/L (range 0.75–1.65 g/L) and 0.38 mg/L (range 150–350 mg/L), respectively. C1q levels were 44 mg/L (normal range 50– 250 mg/L). Based on the history, reduced C4, C1 inhibitor and C1q levels, a diagnosis of acquired C1 inhibitor deficiency was made. The diagnostic criteria for ALPS are elevated CD3 TCRαβ CD4 CD8 DNT cells ≥1.5 % of the total lymphocytes along with chronic non-malignant, non-infectious C. Lee-Brennan :M. Keogan Department of Immunology, Beaumont Hospital, Beaumont, Dublin 9, Ireland