Living-related Donor Research Articles

Efficacy of single, extended and goal directed immunoadsorption in ABO incompatible living related donor liver transplantation

BackgroundLiver transplantation is one of the solid organs most commonly being transplanted across the world. The indications, affordability and accessibility have grown manifold. To increase the donor pool, inclusion of ABO incompatible liver donors is being considered. To enhance the graft functioning and survival, immunoadsorption apheresis to reduce the ABO hemagglutination titres are on the rise. Case ReportWe report three cases ABO incompatible liver transplantation with immunoadsorption protocol. The patients were in poor general condition with Child-Turcotte-Pugh (CTP) class ‘C’ and there were no suitable ABO compatible grafts at the time. For all three cases, immunosuppressive protocol consisted of induction with Rituximab, followed by tacrolimus, mycophenolate mofetil and corticosteroids. The third patient received basiliximab for induction, in addition to the above protocol. First 2 patients received 1 immunoadsorption (IA) session with Glycosorb ABO® system (Glycorex AB, Sweden), pre-operatively. The third patient received 2 IA sessions pre-operatively. Baseline IgM plus IgG titres were 1024; 64 and 1024 for anti-B, anti-A and anti-B for patient 1, 2 and 3 respectively. Target pre-operative antibody titre was ≤16. Average post-operative length of stay was 17.3 days. There were no acute rejection. None of them, required any post-operative plasma exchange. ConclusionImmunoadsorption is effective in reducing hemagglutination titres in recipients of ABO incompatible donor liver.

The Long-Term Follow-up and Support for Living Organ Donors: A Center-Based Initiative Founded on Developing a Community of Living Donors.

Transplant professionals recognize that the long-term follow-up of living organ donors is a priority, yet there has been no implemented solution to this problem. This critical gap is essential, because the transplant field is now emphasizing living donation as a means to address the organ shortage. We detail our living donor initiative, which sets several priorities we recognize as fundamental to persons who have donated organs at our transplant center. This intervention attempts to mitigate the donor and center factors that are known to contribute to the lack of long-term follow-up. Beyond that, our goals are aimed at providing ongoing engagement, wellness, clinical data accrual, laboratory follow-up, and social support for our living donors, in continuity. Our ultimate goal is to nurture the development of local living donor community networks by providing social engagement for current and past donors, which also serves as a platform for greater population education on the societal importance of living donation. This initiative is based on joint recognition by our transplant team and our hospital leadership that supporting the long-term welfare of living donors is essential to accomplishing the goal of expanding living donor transplantation. The transplant team and hospital missions are aligned, and both contribute resources to the initiative.

A novel technique for the endoscopic treatment of complete biliary anastomosis obstructions after liver transplantation: through-the-scope magnetic compression anastomosis

Magnetic compression anastomosis is a rescue technique for recanalization of complete biliary strictures. Here, we present magnetic compression anastomosis with novel through-the-scope magnets in patients with complete duct-to-duct anastomosis obstruction after liver transplantation. The magnets were 2 and 2.4mm in diameter, with a hole at the center for inserting a guidewire. One of the magnets was advanced through the scope up to the distal site of the stricture by using a 7F pusher. The other magnet was pushed percutaneously through the 10F sheath. The procedure was terminated when the magnets were approximated or properly aligned. Recanalization was followed by percutaneous cholangiography. Patients underwent multiple plastic stenting after recanalization was achieved. Nine patients with a stricture length of less than 1 cm, a stump in the donor bile ducts close to the stricture, and proper positioning of the bile duct stumps, underwent magnetic compression anastomosis. Seven patients had a live donor-related liver transplantation. The mean stricture time was 24.1 ± 17.1 months. The mean stricture length was 4.0 ± 1.2mm. Recanalization was achieved in 7 patients (77%) after a mean recanalization time of 8.1 ± 4.7 days. There was no recurrence after 4.8 ± 3.8 months of stent-free follow-up. No adverse events were observed. The through-the-scope magnet procedure was effective in the recanalization of complete anastomotic biliary obstructions after liver transplantation in a selected group of patients with a short stricture length and an appropriate anatomy.

Cytomegalovirus pneumonia after living-related donor kidney transplantation : the experiences of one single center within 10 years

Objective To report one-center experience on diagnosis and treatment of cytomegalovirus (CMV) pneumonia in recipients after living-related donor kidney transplantation (LDKT). Methods The clinical and follow-up data of 168 recipients after LDKT from April 2005 to September 2014 were analyzed retrospectively. We analyzed the general information, clinical manifestation, treatment and outcomes of 34 recipients who were diagnosed as CMV pneumonia. Of the 34 patients, 26 were male and 8 were female. The average age were 32.0 years old. Thirty-four patients developed CMV pneumonia between 12 to 402 days with an average of (91.7±60.8) days post-transplant. It was (6.4±3.7) d(range 1-14 d) from the onset of illness to seeking medical intervention. All cases presented with fever, 18 cases with dyspnea, 11 cases with cough and 6 cases with myalgia or fatigue. The highest temperature was (38.8±0.5)℃ (range 38.0-40.0℃). Leukocyte count was (10.5±4.4)×109/L, elevated in 18 cases, normal in 14 cases, reduced in 2 cases. Quantitative polymerase chain reaction(PCR) assay for CMV DNA was (9.3-15.8)×103 copies/ml for active CMV infection. Chest X ray or CT of all cases demonstrated patchy shadow or interstitial pneumonia. The etiological examination showed that 12 cases were complicated with other microorganism, including 8 cases with Pneumocystis carinii, 3 cases with Streptococcus A, 3 cases with Neisseria, 3 cases with candida albicans, 2 cases with klebsiella pneumoniae, Staphylococcus aureus, enterococcus faecium, Pseudomonas aeruginosa varied 1 case. Results In antiviral therapy, patients were treated by introvenous ganciclovir 5 mg/kg every 12 h for 14-21d and then 5 mg/kg every day. Glucocorticoid treatment included intravenous methylprednisolone 200 mg/kg for 3-5 d, then gradually reduced to 160 mg/kg for 3-5 d, 120 mg/kg for 3 d, 80 mg/kg for 3 d, 40 mg/kg for 3-5 d, until to the original oral dose. Early application of broad-spectrum antibiotics was to prevent bacterial infection, and routine application of compound sulfamethoxazole to prevent Pneumocystis carinii pneumonia. Treatment options were adjusted according to periodic bacteria and fungal culture in blood, urine or sputum, and effective anti bacterial, viral or fungal treatment was selected. After administration of antiviral therapy, methylprednisolone, treatment for other microorganism, as well as adjusted immunosuppressive drugs, 30 cases were cured. The total course of the pneumonia lasted for (28.5±9.4) days on average. However, 4 patients complicated with other microorganism died of severe pneumonia and acute respiratory distress syndrome(ARDS). Conclusion CMV infection was a common complication of living-related donor kidney transplantation. CMV infection often complicated with other microbial infections, and became one of the causes of death after renal transplantation. Early diagnosis, early antiviral therapy combined with effective anti bacterial, fungal treatment would improve the survival of kidney transplant recipients. Key words: Cytomegalovirus; Kidney transplantation; Living donors; Pneumonia

Macrovesicular steatosis in living related liver donors: correlation of biopsy findings with CT liver attenuation index and body mass index.

Hepatic steatosis threatens post-transplant graft survival; therefore, pre-operative quantification of steatosis is crucial. Gold standard for evaluation is donor liver biopsy but it is invasive. An alternative non-invasive method is a calculation of CT liver attenuation index. BMI can be an independent factor predicting grade of steatosis but it is necessary to re-define appropriate BMI cut-off points that are specific for Asians. To retrospectively analyze CT LAI and BMI for quantitative assessment of macrovesicular steatosis in living related liver donors, using histological analysis as gold standard. A radiologist blinded to histological grading calculated mean CT hepatic attenuation in 48 potential living related liver donors. CT-derived LAI correctly predicted steatosis in all except 1 patient. Parametric analysis for CT LAI and BMI showed overall weak positive correlation. No significant association was found between BMI and biopsy findings. Liver biopsy remains a gold standard for evaluation of steatosis. CT LAI of ≤0 correlates well with significant hepatic steatosis and biopsy may be avoided in such cases. Biopsy may be reserved for patients with CT LAI between 1 and 5. BMI alone is not a good predictor of hepatic steatosis in our study population.

Liver transplantation in Ireland.

The Irish National Liver Transplant program commenced in 1993 in St. Vincent's University Hospital in Dublin. It is an adult-only program and is the only liver transplant program in Ireland. Pediatric recipients are referred to King's College Hospital in the United Kingdom. To date, almost 1000 adult liver transplants have been performed. Current 1-year patient survival is 93%, and 5-year survival is 79%. The program is fully funded by the government health service. There is a close collaboration with the United Kingdom Organ Donation and Transplant Directorate, and there is an arrangement for organ sharing for super-urgent transplants. Traditionally, organ donation rates have been high in Ireland. However, demand for liver transplant has increased over the past 20 years, and waiting lists are now lengthening. Deceased cardiac death donation is now being considered, but there are no plans for living related donor liver transplant. Donor coordinators have recently been appointed to the major hospitals in Ireland, and it is hoped that this initiative will lead to an increase in organ donation rates. Liver Transplantation 22 1014-1018 2016 AASLD.

First-Degree Living-Related Donor Liver Transplantation in Autoimmune Liver Diseases.

Liver transplantation (LT) is the treatment of choice for end-stage autoimmune liver diseases. However, the underlying disease may recur in the graft in some 20% of cases. The aim of this study is to determine whether LT using living donor grafts from first-degree relatives results in higher rates of recurrence than grafts from more distant/unrelated donors. Two hundred sixty-three patients, who underwent a first LT in the Toronto liver transplant program between January 2000 and March 2015 for autoimmune liver diseases, and had at least 6 months of post-LT follow-up, were included in this study. Of these, 72 (27%) received a graft from a first-degree living-related donor, 56 (21%) from a distant/unrelated living donor, and 135 (51%) from a deceased donor for primary sclerosing cholangitis (PSC) (n = 138, 52%), primary biliary cholangitis (PBC) (n = 69, 26%), autoimmune hepatitis (AIH) (n = 44, 17%), and overlap syndromes (n = 12, 5%). Recurrence occurred in 52 (20%) patients. Recurrence rates for each autoimmune liver disease were not significantly different after first-degree living-related, living-unrelated, or deceased-donor LT. Similarly, time to recurrence, recurrence-related graft failure, graft survival, and patient survival were not significantly different between groups. In conclusion, first-degree living-related donor LT for PSC, PBC, or AIH is not associated with an increased risk of disease recurrence.

Establishing a deceased donor program in north Indian region: lessons learnt.

Living-related donors are the source of almost all organ transplants in India. However, these donations fall far short of current needs, and there remains a huge disparity between demand and supply of organs. In the last five yr, a consistent increase in deceased donor transplant activity has been observed in some southern Indian states. This report describes our experience of establishing a new deceased donor program in the state of Uttar Pradesh in north India. We describe our experience on counseling families of all brain-dead patients admitted to our center from October 2013 to September 2014 and data on retrieving and transplanting organs. A total of 99 brain-dead patients were identified, of which 67 were medically eligible as donors. Fourteen patients developed cardiac arrest before the counseling could begin. Only eight families agreed for multi-organ donation. Lack of consensus among the family members, mistrust of the medical system, fear of mutilation of the body, and delay in the funeral were identified as the main reasons behind negative consent. Conversely, mass media campaign, proper ICU care of brain-dead patients, rapport with the family and streamlining all medico legal processes were associated with positive consent.

Impact of Donor Source on the Outcome of Live Donor Kidney Transplantation: A Single Center Experience.

BackgroundRenal transplantation is the ideal method for management of end-stage renal disease. The use of living donors for renal transplantation was critical for early development in the field and preceded the use of cadaveric donors. Most donors are related genetically to the recipients, like a parent, a child, or a sibling of the recipient, but there are an increasing percentage of cases where donors are genetically unrelated like spouses, friends, or altruistic individuals. Donor shortages constitute the major barrier for kidney transplantation, and much effort has been made to increase the supply of living donors. The impact of donor source on the outcome of renal transplantation is not adequately studied in our country.ObjectivesThe aim of the study was to evaluate the impact of donor source on the outcome of live donor kidney transplantation.Patients and MethodsFrom March 1976 to December 2013, the number of patients that underwent living renal transplantation sharing at least one HLA haplotype with their donors was 2,485. We divided these patients into two groups: (1) 2,075 kidney transplant recipients (1,554 or 74.9% male and 521 or 25.1% female) for whom the donors were living related, (2) 410 kidney transplant recipients (297 or 72.4% male and 113 or 27.6% female) for whom the donors were living unrelated. All patients received immunosuppressive therapy, consisting of a calcineurin inhibitor, mycophenolate mofetil, or azathioprine and prednisolone. We compared acute rejection and complication rates, as well as long-term graft and patient survival of both groups. Demographic characteristics were compared using the chi-square test. Graft survival and patient survival were calculated using the Kaplan-Meier method.ResultsThe percentages of patients with acute vascular rejection were significantly higher in the unrelated group, while percentages of patients with no rejection were significantly higher in the related group, but there were no significant differences regarding patient and graft survivals between both groups.ConclusionsKidney transplant recipients who received their grafts either from live related donors or live unrelated donors had comparable patient and graft survival outcomes.

Association of interleukin 18-607A/C and -137C/G polymorphisms with oxidative stress in renal transplant recipients

Objectives IL-18 mediates various inflammatory and oxidative responses including renal injury, fibrosis, and graft rejection. It has been reported that the promoter -607 and -137 polymorphisms of IL-18 influence the level of IL-18. This prospective observational study investigated the association between oxidative stress with IL-18-607 and -137 polymorphisms in renal transplant recipients. Patients and methods This study included 75 renal transplant recipients (28 female, 47 male) from living-related donors. Blood samples were collected immediately before and after transplantation at day 7 and month 1. Serum IL-18, creatinine, cystatin C, CRP, and oxidative stress markers (TOS, TAC) were measured. The Oxidative Stress Index (OSI) was calculated. Polymorphisms of the promoter region of the IL-18 gene, IL18-607A/C, and -137C/G were determined by analysis of a “real-time PCR/Melting curve”. Results Serum creatinine, cystatin C, CRP, IL-18, TOS, and OSI levels significantly decreased after transplantation. Post-transplant levels of serum TAC and estimated GFR demonstrated consistent significant increases. Serum IL-18 levels were significantly higher in patients with IL-18-137 GG and IL-18-607 CC genotypes before transplantation. Conclusion Our results indicate that the IL-18-137 GG and -607 CC genotypes contribute to higher IL-18 levels; however, the influence of these polymorphisms on oxidative stress has not been observed.

Living Unrelated Versus Related Kidney Transplantation: A 25-Year Experience with 3716 Cases.

To evaluate the results of transplantation from living unrelated donors (LURD) versus living related donors (LRD) with a long term follow-up of 25-30 years. From 1984 to 2015, a total of3716 kidney transplantations (411 LRDs and 3305 LURDs) were enrolled to the study. Long-term survival of grafts and patients as well as the association between relation state and patients or grafts surveillance were the outcomes. A total of 3716 live donor kidney transplants (LRD, n = 411; LURD, n = 3305) were carried out over this period. The mean age of donors was 28 ± 54 years in the LURD group and 34.4 ± 11.7 years in LRD (P < . 001), while the mean age of the recipients was 35.6 ± 15.6 years and 27.6 ± 10.1 years for the two groups, respectively. Donor age was the only statistically significant predictor of graft survival rate (hazard ratio = 1.021, 95% confidence interval: 1.012-1.031). Between 1984 and 2015, patient survival and graft survival improved significantly also patient survival and graft survival was similar in LURDs compared with LRDs. It seems that the outcome of LURD and LRD is comparable in terms of patient and graft survival. Therefore, transplants from LURDs may be proposed as an acceptable management for patients with end stage renal disease.

Genetic diversity through human leukocyte antigen typing in end-stage renal disease patients and prospective donors of North India.

As the incidence of end-stage renal disease (ESRD) is rapidly increasing, the demand for dialysis and transplantation has dramatically increased, which has led to concerns about the availability and equitable allocation of kidneys for transplantation. The distribution of HLA-A, B and DR alleles in 148 renal transplant recipients and 191 live related prospective donors from 2009 to 2010 were analyzed. Allele frequencies and haplotype frequencies were calculated in recipients and donors. The prospective donors were further analyzed on the basis of their relationship to the patients and according to the sex ratio. A significant female preponderance was noted in the prospective donor population, most of whom were either siblings or parents of the recipients. On the contrary, the recipient population predominantly comprised of males. The most frequent HLA-A, HLA-B, HLA-DRB1 alleles in renal transplant patients were HLA-AFNx0111, AFNx0102, AFNx0101, AFNx0124; HLA-BFNx0135, BFNx0140, BFNx0144, BFNx0115, BFNx0152, and HLA-DRB1FNx0115, DRB1FNx0107, DRB1FNx0113, DRB1FNx0111 respectively. The most frequent HLA-A, HLA-B, HLA-DRB1 alleles in prospective donors were HLA-AFNx0102, AFNx0111, AFNx0133, AFNx0124; HLA-BFNx0135, BFNx0144, BFNx0140, BFNx0115 and HLA-DRB1FNx0115, DRB1FNx0107, DRB1FNx0111, DRB1FNx0113 respectively. AFNx0111-BFNx0135, AFNx0102-DRB1FNx0115, BFNx0140-DRB1FNx0115 were the most common HLA A-B , HLA A-DR, HLA B-DR haplotypes respectively in renal transplant patients, whereas, AFNx0111-BFNx0135, AFNx0111-DRB1FNx0115, BFNx0144-DRB1FNx0107 were the most common haplotypes in renal donors. In three locus haplotype, HLA-AFNx0102-BFNx0140-DRB1FNx0115 was the most frequent haplotype in patients, whereas, in prospective renal donors HLA-AFNx0133-BFNx0144-DRB1FNx0107 was the most frequent haplotype.

Update on the intraoperative management of adult cadaveric renal transplantation

### Key points Renal transplantation is increasing with 1930 transplants undertaken in the UK in 2013 compared with 1308 in 2005. This increase follows the NHS Blood and Transplant (NHSBT) ‘Organs for Transplant’ initiative, and should continue rising as part of their ‘Taking Organ Transplant to 2020’ programme. Renal transplantation confers almost immediate improvements in quality of life and improves morbidity and mortality compared with dialysis. There are also fiscal gains to the healthcare provider: renal transplantation being cheaper than ongoing dialysis. However, graft implantation is a complex surgical procedure with both short- and long-term outcomes directly attributable to intraoperative physiological status.1,2 In future there will be a need to anaesthetize more elderly recipients, with more extensive comorbidities. This article will discuss anaesthesia for implantation of cadaveric kidneys; alternative sources within this journal have discussed live related donor surgery in detail.3 ### Comorbid illness The commonest aetiology of renal dysfunction in the UK is diabetes mellitus, with an increasing prevalence since 2006 and projected to be 14 000 patients in 2014–15. This and other causes of end-stage renal failure (ESRF), such as IgA nephropathy and hypertension, each pose their own anaesthetic challenges. Chronic kidney disease (CKD) is classified using glomerular filtration rate (GFR) to quantify the …

3.0 Tesla magnetic resonance angiography (MRA) for comprehensive renal evaluation of living renal donors: pilot study with computerized tomography angiography (CTA) comparison

PurposeMost living related donor (LRD) kidneys are harvested laparoscopically. Renal vascular anatomy helps determine donor suitability for laparoscopic nephrectomy. Computed tomography angiography (CTA) is the current gold standard for preoperative imaging; magnetic resonance angiography (MRA) offers advantages including lack of ionizing radiation and lower incidence of contrast reactions. We evaluated 3.0T MRA for assessing renal anatomy of LRDs. Materials and methodsThirty consecutive LRDs underwent CTA followed by 3.0T MRA. Data points included number and branching of vessels, incidental findings, and urothelial opacification. Studies were individually evaluated by three readers blinded to patient data. Studies were reevaluated in consensus with discrepancies revealed, and final consensus results were labeled “truth”. ResultsCompared with consensus “truth”, both computed tomography (CT) and magnetic resonance imaging were highly accurate for assessment of arterial and venous anatomy, although CT was superior for detection of late venous confluence as well as detection of renal stones. Both modalities were comparable in opacification of lower ureters and bladder; MRA underperformed CTA for opacification of upper urinary tracts. Conclusions3.0T MRA enabled excellent detection of comprehensive renal anatomy compared to CTA in LRDs.

Deficiency of antidiuretic hormone: a rare cause of massive polyuria after kidney transplantation.

A 15-year-old boy, who was diagnosed with Alport syndrome and end-stage renal disease, received a renal transplant from a living-related donor. On postoperative day 1, his daily urine output was 10,000 mL despite normal graft function. His laboratory findings including urine, serum osmolality, and antidiuretic hormone levels showed signs similar to central diabetes insipidus, so he was administered desmopressin acetate nasal spray. After administering the desmopressin, urine specific gravity and osmolality increased abruptly, and daily urine output declined to the normal range. The desmopressin acetate was tapered gradually and discontinued 3 months later. Graft function was good, and urine output was maintained within the normal range without desmopressin 20 months after the transplantation. We present a case of a massive polyuria due to transient deficiency of antidiuretic hormone with the necessity of desmopressin therapy immediately after kidney transplantation in a pediatric patient.

Five years renal transplantation data: Single-center experience from Iraq.

Renal transplantation is the treatment of choice for patients with end-stage renal disease. In Iraq, renal transplantation started in 1973 and has continued until now with live donor transplantation, since deceased donor transplant program is not approved as yet. Long-term transplant data are still scarce. The aim of our study is to present data on transplantation and medical follow-up at one year and, survival analysis at one, three and five years. A total of 250 renal transplantations were performed at the Nephrology and Renal Transplantation Center, Baghdad between January 2009 and January 2014. It is a living donor, blood group compatible donor program. All patients received triple immunosuppression (calcineurine inhibitor, mycophenolate mofetil or mycophenolic acid, and steroid). The Kaplan-Meier method was used to determine the survival rate. There were 92 live related donors, 143 unrelated donors, and 15 spouse donors. The mean age was 34.07 ± 12.2 years. The one-year graft survival for related and unrelated donor transplants was 98.9% and 91.8%, respectively. Graft survival was lower (82.9%) in recipients with acute rejection episodes. The patient survival at one-year was 94%. The three-year graft and patient survival was 91% and 90%, respectively, and five-year survival for grafts and patients was 87.1% and 88%, respectively. The outcome of the renal transplantation in Iraq is improving. Long-term patient follow-up needs more meticulous attention. The development of renal transplant registry is critical for future planning. Moreover, renal transplantation practice in Iraq needs more social, religious, and governmental support.

Comparative accuracy of CT, dual-echo MRI and MR spectroscopy for preoperative liver fat quantification in living related liver donors.

Background:It is of significant importance to assess the extent of hepatic steatosis in living donor liver transplant (LDLT) surgery to ensure optimum graft regeneration as well as donor safety.Aim:To establish the accuracy of non-invasive imaging methods including computed tomography (CT), dual-echo in- and opposed-phase magnetic resonance imaging (MRI), and MR spectroscopy (MRS) for quantification of liver fat content (FC) in prospective LDLT donors with histopathology as reference standard.Settings and Design:This retrospective study was conducted at our institution on LDLT donors being assessed for biliary and vascular anatomy depiction by Magnetic Resonance Cholangiopancreatography (MRCP) and CT scan, respectively, between July 2013 and October 2014.Materials and Methods:Liver FC was measured in 73 donors by dual-echoT1 MRI and MRS. Of these, CT liver attenuation index (LAI) values were available in 62 patients.Statistical Analysis:CT and MRI FC were correlated with histopathological reference standard using Spearman correlation coefficient. Sensitivity, specificity, positive predictive value, negative predicative value, and positive and negative likelihood ratios with 95% confidence intervals were obtained.Results:CT LAI, dual-echo MRI, and MRS correlated well with the histopathology results (r = 0.713, 0.871, and 0.882, respectively). An accuracy of 95% and 96% was obtained for dual-echo MRI and MRS in FC estimation with their sensitivity being 97% and 94%, respectively. False-positive rate, positive predictive value (PPV), and negative predicative value (NPV) were 0.08, 0.92, and 0.97, respectively, for dual-echo MRI and 0.03, 0.97, and 0.95, respectively, for MRS. CT LAI method of fat estimation has a sensitivity, specificity, PPV, and NPV of 73%, 77.7%, 70.4%, and 80%, respectively.Conclusion:Dual-echo MRI, MRS, and CT LAI are accurate measures to quantify the degree of hepatic steatosis in LDLT donors, thus reducing the need for invasive liver biopsy and its associated complications. Dual-echo MRI and MRS results correlate better with histological results in the study, as compared to CT LAI method for fat quantification.

The importance of donor-specific anti-HLA antibodies (DSA) identification in renal transplant patients with C4d-negative biopsies

Two index cases of living-related donor renal allografts patients developed C4d-negative rejection. Both cases had negative cytotoxic crossmatch and negative flow crossmatch before transplantation. The serum creatinine levels were tabulated. Both cases experienced augmented anti-T cell therapy (intravenous methyl prednisolone) at the time of rejection, which failed to improve renal function. Meantime, our HLA lab identified circulating anti-class I and/or II HLA antibodies towards donor mismatched antigens by Luminex multiplex bead array. Additional therapy included high-dose IVIg and plasma exchange. The renal function improved significantly. Furthermore, the donor-specific antibody strength decreased after combined plasmapheresis and IVIG therapy. These cases highlight the importance of donor-specific antibody detection by sensitive solid phase assays in the context of C4d-negative ABMR.

Non-invasive quantification of hepatic steatosis in living, related liver donors using dual-echo Dixon imaging and single-voxel proton spectroscopy

To evaluate the diagnostic implications of hepatic fat fraction calculated using dual-echo Dixon imaging and (1)H magnetic resonance spectroscopy (MRS) to detect hepatic steatosis in potential liver donors using histopathology as the reference standard. One hundred and forty-five potential liver donors were included in the study. Magnetic resonance imaging (MRI) was performed using a 1.5 T system using a three-dimensional dual-echo MRI sequence with automated reconstruction of in-phase (IP), out-of-phase (OP), fat-signal-only, and water-signal-only images. Hepatic fat fraction was calculated by drawing 15 regions of interest on the IP, OP, fat-only, and water-only images. Single-voxel MRS was performed at echo times (TEs) of 30ms in the right and left lobes of liver. Liver fat fraction was calculated from water and fat peaks. One hundred and forty-five biopsies were prospectively evaluated for steatosis by a pathologist using traditional determination of the cell-count fraction. MRI and pathology values of steatosis were correlated using Pearson's correlation coefficient. The sensitivity and specificity of each of these methods was calculated using histopathology as the reference standard. Reproducibility was assessed in 40 patients who had repeat scanning within 4-40 days. Measurement error was calculated from the coefficient of variation (CoV) with histopathologically proven <5% fat (n=112). The Bland-Altman limits of agreement with 95% confidence intervals (CI) was -2.9 to 5.3%. The intraclass correlation coefficient (ICC) for interobserver variability and reproducibility was 0.94 (95% CI: 0.91-0.97), 0.92 (95% CI: 0.91-0.97). The CoV was 7.6% (95% CI: 3.4-11.85). The area under the receiver operating characteristic (ROC) curve (AUC) for Dixon imaging 0.89 (95% CI: 0.87-0.91), for MRS 0.88 (95% CI: 0.86-0.90). The sensitivity for detecting <5% fat was 84% and specificity was 90%. Combination of dual-echo Dixon imaging and proton MRS is a useful tool for the preoperative diagnosis of hepatic steatosis in potential living liver donors. This can help avoid unnecessary biopsies in these patients.

Attitudes Toward Living Donation in the Bolivian Population Residing in Spain

IntroductionLiving donation is increasingly necessary to address the shortage of organs for transplantation. Analyzing attitudes and influences toward living donation is essential. This study sought to analyze the attitude toward living donation in the population of Bolivians residing in Spain, and the variables that influence their attitude. Material and MethodsWe selected a sample of Bolivians living in Spain. Respondents were selected using a stratified sampling by age and sex. We used a validated questionnaire of psychosocial aspects (the questionnaire of Proyecto Colaborativo Internacional Donante about Living Kidney Donation [Donación de Vivo Renal in Spanish]), which is self-administered and anonymous. The Student t test, χ2, and Fisher tests, as well as logistic regression analysis, were used to analyze the gathered data. ResultsOf all respondents (n = 206), 83% (n = 170) were in favor of living-related donation, and 32% (n = 66) were in favor of living-unrelated donation. The rest, 8.5% (n = 18) were not in favor of living donation and 8.5% (n = 18) were undecided. Acceptance of the living donation was associated with the religious beliefs of the respondent (P = .014), with no worry about the scars that may remain after the donation (P = .016), and with the risk evaluation of living donation (P = .029). On multivariate analysis, the most important variable was the risk associated with living donation (odds ratio, 6.329; 95% CI, 30.303–1.328; P = .021). ConclusionsAttitudes toward living donation among the Bolivian population residing in Spain is favorable, and represents a group that may be encouraged to become donors.