Normal Allograft Research Articles

Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure From Heatstroke

BackgroundExertional heatstroke is an extremely rare cause of fulminant hepatic failure. Maximal supportive care has failed to provide adequate survival in earlier studies. This is particularly true in cases accompanied by multiorgan failure. Methods and MaterialsOur prospectively collected transplant database was retrospectively reviewed to identify patients undergoing liver transplantation for heatstroke between January 1, 2012, and December 31, 2016. We report 3 consecutive cases of male patients with fulminant hepatic failure from exertional heatstroke. ResultsAll patients developed multiorgan failure and required intubation, vasopressor support, and renal replacement therapy. All patients were listed urgently for liver transplantation and were supported with the molecular adsorbent recirculating system while awaiting transplantation. All patients underwent liver transplantation alone and are alive and well, with recovered renal function, normal liver allograft function, and no chronic sequelae of their multiorgan failure at more than one year. ConclusionExtreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that may benefit from therapy using the Molecular Adsorbent Recirculating System while waiting for liver transplantation as a component of a multidisciplinary, multiorgan system approach.

Assessment of acute renal allograft dysfunction by MRI diffusion techniques

AimTo assess the role of DW MRI and ADC in acute allograft renal dysfunction as a possible alternative for graft biopsy. Material & methodsThis study included 31 renal transplant recipients divided into 2 groups A: (11 patients) with normal allograft function and group B: (20 patients) with allograft dysfunction. Color Doppler Ultrasound was done for both groups, MRI with contrast for groups A, non-contrast MRI for group B, DW MRI at b 600 & 1000 for both groups. Ultrasound-guided needle biopsy and histopathological examination for group B. ResultsAt b 600; ADC values of group B are significantly lower than group A (P = 0.047). In group B, ADC values of the cortex are lower than those of medulla. No significant difference was founded between ADC values of AR and ATI (P = 0.981). At b 1000; ADC values of group B was significantly lower than that of group A (P = 0.030). ADC values of cortex correlate better than those of medulla. ADC values of ATI are slightly lower than those with AR, no significant difference (P > 0.05) regarding ADC values between AR and ATI. Sensitivity, specificity, accuracy, PPV, NPV for ADC values at b 600 & b1000 were 60%, 90.91%, 70.97%, 92.3%, 55.6 and 85%, 54.55%, 74.79%, 77.3%, 66.7 respectively. ConclusionDW MRI is a promising noninvasive tool for early detection graft dysfunction especially at higher b values.

An integrated deep sequencing analysis of microRNAs in transplanted corneas

Illumina Hiseq 2500 deep sequencing was used to screen for differentially expressed genes (DEGs) in matched pairs of isograft corneas and normal corneas, allograft corneas and isograft corneas. Our results showed that 22 miRNAs were significantly upregulated and 4 were significantly downregulated in the isograft group when compared with the control group (P < 0.01), while 17 miRNAs were significantly upregulated and 3 were significantly downregulated in the allograft group when compared with the isograft group (P < 0.01). Among the miRNAs with altered expression levels, miR-155-5p, miR-142-3p, miR-142-5p, and miR-223-3p displayed simultaneous changes in the above two comparisons. Potential target genes among the DEGs were predicted using target prediction software (TargetScan, Miranda, miRDB, and CLIP), and the overlay portion was analyzed using the Gene Ontology (GO) database and the Kyoto Encyclopedia of Genes and Genomes (KEGG). GO and KEGG analyses showed that the DEGs were mainly involved in metabolic pathways, cytokine secretion, and tumor immunity functions. An analysis of the interactions between DEG proteins (PPI analysis) and a MetaCore software analysis of 4 key DEGs revealed that the genes regulated by miR-155-5p played important roles in the miRNA-mRNA regulatory network. Furthermore, the MetaCore analysis identified C/EBP beta, p53, and sp1 as key transcription factors in that network. Our study identified transplanted corneas-specific miRNA in matched pairs of isograft corneas and normal corneas, allograft corneas and isograft corneas. Furthermore, bioinformatics analysis of the key miRNA regulatory network revealed the molecular mechanisms, which suggests miRNAs may as new molecular targets for treating corneal injuries and corneal transplant rejection.

Inflammasome Priming Mediated via Toll-Like Receptors 2 and 4, Induces Th1-Like Regulatory T Cells in De Novo Autoimmune Hepatitis.

De novo autoimmune hepatitis (DAIH) is an important cause of late allograft dysfunction following liver transplantation, but its cause and underlying pathogenesis remains unclear. We sought to identify specific innate and adaptive immune mechanisms driving the pro-inflammatory cytokine secreting regulatory T cell (Treg) phenotype in DAIH and determine if modulation of these pathways could resolve the inflammatory milieu observed in the livers of patients with DAIH. Here, we demonstrate toll-like receptors (TLRs) 2- and 4-mediated inflammasome activation in CD14++ monocytes, a finding that is key to maintaining dysfunctional Tregs in patients with DAIH. Furthermore, silencing of TLR 2 and 4 in CD14++ monocytes prevented activation of the inflammasome and significantly decreased IFN-γ production by FOXP3+ Tregs. We also observed significantly increase in expression of tumor necrosis factor α-induced protein 3 (TNFAIP3), a negative regulator of the NLRP3 Inflammasome, in monocytes/macrophages of liver transplant subjects who have normal allograft function and do not have DAIH. TNFAIP3 expression was virtually absent in monocytes/macrophages of patients with DAIH. Our findings suggest that autoimmunity in DAIH is promoted by CD14++ monocytes predominantly through activation of inflammatory signaling pathways.

Activation of insulin receptors and IGF-1 receptors in COLO-205 colon cancer xenografts by insulin and insulin analogue X10 does not enhance growth under normo- or hypoglycaemic conditions.

Recent studies with normal rats and mouse allograft models have reported that insulin and insulin analogues do not activate the IGF-1 receptor in vivo, and that this characteristic therefore cannot be responsible for the increased incidence of mammary tumours observed for the insulin analogue X10 in chronic toxicity studies with Sprague Dawley rats. This is in clear contrast to reports of insulin and insulin analogues in vitro. Clarification of this is important for understanding the mechanisms behind possible growth-promoting effects of insulin analogues, and will have implications for the development of novel insulin analogues. We established a xenograft model in BALB/c nude mice with the human colon cancer cell line COLO-205, which expresses human insulin and IGF-1 receptors, and explored the acute and chronic effects of treatment with supra-pharmacological doses of human insulin, insulin analogue X10 and human IGF-1. With a novel antibody, acute IGF-1 receptor activation was also examined in various tissues from normal rats treated with human insulin, insulin analogue X10 or human IGF-1. Finally, the effects of pharmacologically relevant doses of human insulin and insulin analogue X10 on receptor activation and growth of COLO-205 xenograft were explored in BALB/c nude mice with alloxan-induced hyperglycaemia. In normal rats and in BALB/c nude mice bearing a COLO-205 cell xenograft, treatment with supra-pharmacological doses of human insulin, insulin analogue X10 or human IGF-1 resulted in activation of insulin receptors as well as IGF-1 receptors. Treatment of diabetic nude mice with pharmacologically relevant doses of human insulin or insulin analogue X10, which decreased blood glucose from hyperglycaemic levels to the normoglycaemic range, did not increase IGF-1 receptor activation. Furthermore, repeated treatment with supra-pharmacological as well as pharmacological doses of human insulin or insulin analogue X10 did not influence the growth of COLO-205 xenografts. This study demonstrates that activation of IGF-1 receptors in cancer cells by insulin and insulin analogues cannot be considered as a purely in vitro phenomenon. It does occur in vivo in animal models, although only after treatment with supra-pharmacological doses. Furthermore, treatment with insulin or insulin analogue X10 did not influence the growth of COLO-205 xenografts under normo- or hypoglycaemic conditions. Further studies are needed before a conclusion can be reached on whether IGF-1 receptor activation by insulin analogues correlates with increased growth in vivo.

Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure from Exertional Heatstroke

Introduction Exertional heatstroke is an extremely rare cause of fulminant hepatic failure, and when complicated by multiorgan failure, is fatal without liver transplantation. The ability to support patients with heat stroke complicated by massive hepatic necrosis with mechanical replacement therapies while awaiting recovery or transplantation has not been reported. We utilized a multidisciplinary approach of critical care and liver transplant specialists to rapidly identify and treat cases of heat stroke-induced liver failure. Methods A retrospective review of three consecutive cases of male patients with fulminant hepaticfailure from exertional heatstroke was performed after IRB approval. Results All patients developed multiorgan failure, and required intubation, renal replacement therapy, and vasopressor support. All patients were listed urgently for liver transplantation, and were supported with the Molecular Adsorbent Recirculating System while awaiting transplantation. All patients underwent liver transplantation alone, and the liver explant showed massive hepatic necrosis in all cases. All patients required multiple operations including fasciotomy, serial washout, and wound closure. Renal replacement therapy was weaned within 30 days.All patients remain alive and well, with normal renal function, normal liver allograft function,and no long term sequelae of their multiorgan failure at 1, 2, and 4 years post-transplant.Conclusion Extreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that can be successfully treated with liver transplantation as a component of a multidisciplinary, multiorgan system approach.

Tomotherapy and Hematopoietic Stem Cells for Tolerance to Kidney Transplants in Rhesus Macaques

NIH NHP Transplantation Tolerance Cooperative Study Group. The goal of this project was to develop a tolerance induction protocol for kidney transplantation (tx) in a rhesus macaque model that would permit complete elimination of all immunosuppression (IS). We hypothesized that tolerance to MHC 1-haplotype mismatched kidney tx between living related donor/recipient pairs can be achieved by establishing a mixed chimeric state. The chimeric state would be achieved using a newly established post-kidney tx, non-myeloablative, helical tomotherapy-based total lymphoid irradiation (TLI)-based conditioning regimen followed by donor mobilized peripheral blood-CD34+ hematopoietic stem cell (HSC)/T cell (CD3+) infusions (Figure 1). The hypotheses was tested in a series of 5 HSC-only txs followed by 18 kidney txs with (n=11) and without (n=7) donor HSC infusions. The kidney allografts came from blood group compatible, T and B cell flow cytometric crossmatch negative donors. All recipient animals underwent IS withdrawal according to the same schedule and were followed for rejection. We determined the proportion of recipients that achieved chimerism and that could be withdrawn from all IS for greater than 3 years, while maintaining normal allograft function. Mixed chimerism in the recipient was assessed by quantifying the proportion and duration of donor/recipient DNA, using STR, in various immune cellular lineages circulating within the peripheral blood post-tx. Results are shown in There were 11 kidney+HSC txs. Two achieved transient multilineage chimerism for at least 3 months and both were long-term tolerant survivors (still alive and off IS for more than 3 years). Nine animals in the kidney+HSC group did not achieve any evidence of chimerism – all lost the kidney tx before or during the IS weaning (5 due to rejection, 4 with engraftment syndrome, 1 each from infection and PTLD). All animals in the kidney tx-alone control group lost kidney function, with one having prolonged graft survival without IS, but eventually succumbed to chronic antibody mediated rejection. Furthermore, we assessed the correlation between the presence (n=5, including 3 with HSC-only infusions) or absence (n=8, including 2 with HSC-only infusions and excluding the 4 engraftment syndrome cases) of achieving chimerism and the development of de novo donor specific antibody (DSA) (Figure 3). DSA was absent in all 5 animals that achieved chimerism. Development of early de novo DSA, primarily against Class II MHC, was associated with lack of development of mixed chimerism, and therefore, inability to successfully eliminate IS. The study demonstrated that this TLI-based tolerance induction protocol can result in chimerism and operational tolerance in the rhesus macaque model across a 1-haplo mismatch. However, challenges remain to enhance the frequency of achieving chimerism. Future studies to extend the protocol to animals that are more MHC disparate will include modifications of the conditioning regimen to minimize development of DSA and engraftment syndrome. Funding supported by NIH NIAID.

Identification of Leukocyte Subpopulations as Potential Biomarkers of Long-term Survival With Normal Allograft Function After Lung Transplantation

Identification of Leukocyte Subpopulations as Potential Biomarkers of Long-term Survival With Normal Allograft Function After Lung Transplantation

Acquired cystic disease associated renal cell carcinoma

Acquired cystic disease predisposes to renal cell carcinoma. We describe a patient who had received kidney transplant 7 years back with normal allograft function who suffered sudden cardiac death at home and was discovered to have acquired cystic disease and renal cell carcinoma in her native kidneys. This case highlights the need to assess native kidneys periodically after kidney transplant.

Influence of the Novel ATP-Competitive Dual mTORC1/2 Inhibitor AZD2014 on Immune Cell Populations and Heart Allograft Rejection.

Little is known about how new-generation adenosine triphosphate-competitive mechanistic target of rapamycin (mTOR) kinase inhibitors affect immunity and allograft rejection. mTOR complex (C) 1 and 2 signaling in dendritic cells and T cells was analyzed by Western blotting, whereas immune cell populations in normal and heart allograft recipient mice were analyzed by flow cytometry. Alloreactive T cell proliferation was quantified in mixed leukocyte reaction; intracellular cytokine production and serum antidonor IgG levels were determined by flow analysis and immunofluorescence staining used to detect IgG in allografts. The novel target of rapamycin kinase inhibitor AZD2014 impaired dendritic cell differentiation and T cell proliferation in vitro and depressed immune cells and allospecific T cell responses in vivo. A 9-day course of AZD2014 (10 mg/kg, intraperitoneally, twice daily) or rapamycin (RAPA) (1 mg/kg, intraperitoneally, daily) prolonged median heart allograft survival time significantly (25 days for AZD2014, 100 days for RAPA, 9.5 days for control). Like RAPA, AZD2014 suppressed graft mononuclear cell infiltration, increased regulatory T cell to effector memory T cell ratios and reduced T follicular helper and B cells 7 days posttransplant. By 21 days (10 days after drug withdrawal), however, T follicular helper and B cells and donor-specific IgG1 and IgG2c antibody titers were significantly lower in RAPA-treated compared with AZD2014-treated mice. Elevated regulatory T cell to effector memory T cell ratios were maintained after RAPA, but not AZD2014 withdrawal. Immunomodulatory effects of AZD2014, unlike those of RAPA, were not sustained after drug withdrawal, possibly reflecting distinct pharmacokinetics or/and inhibitory effects of AZD2014 on mTORC2.

PTLD Involving the Colon Graft in Small Bowel Transplant Recipient

Intestinal transplant is indicated in those who have intestinal failure with resultant life-threatening complications. Complications from intestinal transplant include surgical complications eg. graft thrombosis, rejection and complications due to a high immunosuppressive requirement eg. atypical viral/fungal infections and PTLD. We present a 23-year-old white female with combined small bowel and colonic transplant 11 months ago due to intestinal failure from small bowel volvulus. She was diagnosed with PTLD with diffuse large B-cell lymphoma 1 month ago after presenting with painless LAD. She was on tacrolimus 4 mg BID, 2000 mg/day MMF, and 5 mg/day prednisone. Her EBV DNA was > 2 million copies/ml at the time of diagnosis. She underwent reduction in immunosuppression followed by 1 cycle of R-CHOP and presented with new-onset GI bleeding. EGD to jejuno-jejunal anastomosis was unremarkable but colonoscopy showed a large amount of fresh blood in the colon and ileum. The visualization of colonic mucosa was limited but CTA showed positive luminal extravasation just beyond jejuno-jejunal anastomosis which was successfully treated with embolization. Follow-up colonoscopy to evaluate for small bowel and colonic graft rejection showed normal small bowel and colonic allograft and multiple non-bleeding discreet raised yellowish black-crusted sub-epithelial nodules obliterating nearby normal colonic vasculature in native colon. Pathology showed an atypical lymphoid infiltrate with necrosis in the native colon confirmed to be monomorphic PTLD (positive for CD79a, Pax5, Mum-1, CD 20, EBV-LMP, negative CD3, Ki-67 of 70%). Her abdominal CT scan showed progressive disease burden with extensive liver metastasis. Despite treatment, her hospital course was complicated by neutropenic fever, septic shock, malignant ascites, and spontaneous intracranial hemorrhage from CNS involvement of PTLD. Therefore, no escalation of treatment was discussed and she was made comfort care. The risk of PTLD is high in intestinal transplant recipients due to high immunosuppression requirement (tacrolimus and MMF) and occur in 15% of adults and 20% of children. Colonic involvement of PTLD may portend the aggressive nature of PTLD and be seen more in disseminated or multiple organs involvement. This case highlights a variety of symptoms of PTD in an intestinal transplant recipient from initial presentation with painless LAD followed by an obscure overt GI bleeding due to colonic PTLD

Effects of DNA Methylation on Progression to Interstitial Fibrosis and Tubular Atrophy in Renal Allograft Biopsies: A Multi-Omics Approach.

Progressive fibrosis of the interstitium is the dominant final pathway in renal destruction in native and transplanted kidneys. Over time, the continuum of molecular events following immunological and nonimmunological insults lead to interstitial fibrosis and tubular atrophy and culminate in kidney failure. We hypothesize that these insults trigger changes in DNA methylation (DNAm) patterns, which in turn could exacerbate injury and slow down the regeneration processes, leading to fibrosis development and graft dysfunction. Herein, we analyzed biopsy samples from kidney allografts collected 24 months posttransplantation and used an integrative multi-omics approach to understand the underlying molecular mechanisms. The role of DNAm and microRNAs on the graft gene expression was evaluated. Enrichment analyses of differentially methylated CpG sites were performed using GenomeRunner. CpGs were strongly enriched in regions that were variably methylated among tissues, implying high tissue specificity in their regulatory impact. Corresponding to this methylation pattern, gene expression data were related to immune response (activated state) and nephrogenesis (inhibited state). Preimplantation biopsies showed similar DNAm patterns to normal allograft biopsies at 2 years posttransplantation. Our findings demonstrate for the first time a relationship among epigenetic modifications and development of interstitial fibrosis, graft function, and inter-individual variation on long-term outcomes.

Intravenous immunoglobulin therapy in kidney transplant recipients with de novo DSA: Results of an observational study

BackgroundApproximately 25% of kidney transplant recipients develop de novo anti-HLA donor-specific antibodies (dnDSA) leading to acute antibody-mediated rejection (ABMR) in 30% of patients. Preemptive therapeutic strategies are not available.MethodsWe conducted a prospective observational study including 11 kidney transplant recipients. Inclusion criteria were dnDSA occurring within the first year after transplant and normal allograft biopsy. All patients were treated with high-dose IVIG (2 g/kg 0, 1 and 2 months post-dnDSA). The primary efficacy outcome was incidence of clinical and subclinical acute ABMR within 12 months after dnDSA detection as compared to a historical control group (IVIG-).ResultsAcute ABMR occurred in 2 or 11 patients in the IVIG+ group and in 1 of 9 patients in the IVIG- group. IVIG treatment did not affect either class I or class II DSA, as observed at the end of the follow-up. IVIG treatment significantly decreased FcγRIIA mRNA expression in circulating leukocytes, but did not affect the expression of any other markers of B cell activation.ConclusionsIn this first pilot study including kidney allograft recipients with early dnDSA, preemptive treatment with high-dose IVIG alone did not prevent acute ABMR and had minimal effects on DSA outcome and B cell phenotype.

Nature and Clonality of the Fluoresceinated Secondary Antibody in Luminex Multiplex Bead Assays Are Critical Factors for Reliable Monitoring of Serum HLA Antibody Levels in Patients for Donor Organ Selection, Desensitization Therapy, and Assessment of the Risk for Graft Loss.

Luminex multiplex immunoassays enable simultaneous monitoring of Abs against multiple Ags in autoimmune, inflammatory, and infectious diseases. The assays are used extensively to monitor anti-HLA Abs in transplant patients for donor organ selection, desensitization, and assessing the risk for graft rejection. To monitor IgG Abs, fluoresceinated IgG constant H chain-binding polyclonal F(ab')2 (IgHPolyFab) is used as the fluoresceinated secondary Ab (2nd-Ab), whereas IgG subclasses are monitored with Fc-specific monoclonal whole IgG (FcMonoIgG). The fluorescent signal from the 2nd-Ab is measured as mean florescence intensity (MFI). When IgHPolyFab is used, the signal is amplified as a result of the binding of multiple polyclonal Fabs to the C region of primary IgH. The reliability of such amplification for Ab measurements was not validated, nor were MFIs compared with 1:1 binding of FcMonoIgG to primary Abs. Comparing the MFIs of anti-HLA Abs obtained with IgHPolyFab and FcMonoIgG against normal human sera, IVIg, and allograft recipients' sera, it was observed that the number of HLA-Abs was notably higher with IgHPolyFab than with FcMonoIgG The MFIs of anti-HLA Abs also remained higher with IgHPolyFab in the normal sera and in IVIg, but the reverse was true when the autologous and allogeneic IgG concentrations were augmented in allograft recipients. Indeed, MFIs of the de novo allo-HLA Abs were markedly higher with FcMonoIgG than with IgHPolyFab. Serum titration established the superiority of FcMonoIgG for monitoring MFIs of de novo allo-HLA Abs in allograft recipients. Avoiding false amplifications of the number and MFIs of anti-HLA IgG with FcMonoIgG may minimize immunosuppressive therapies, maximize the number of donors for patients waiting for allografts, and enable better prediction of graft rejection.

Sustained Viral Response after Treatment with Ledipasvir/Sofosbuvir (Harvoni®) in a Patient with Hepatitis C Following Intestine and Renal Transplantation

Introduction: Sustained viral response (SVR) following treatment with Ledipasvir and Sofosbuvir (Harvoni®-Gilead Sciences, CA) for chronic hepatitis C (HCV) is well documented in liver transplantation (TX). There is no report of SVR following treatment with Harvoni® in a patient after intestine TX (ITx). We report a case of an adult with HCV genotype 1A, treated with Harvoni® for 12 weeks post intestine-kidney transplantation (IKTX) who achieved SVR 3 months after treatment. Method: Retrospective review of patient with HCV who underwent IKTX at a quaternary level ITX center. Results: Case report: We report a 40 year old male with hypertension (HTN), severe coronary artery disease (CAD), Hepatitis C (HCV) and end stage renal disease (ESRD) due to hemolytic uremic syndrome (HUS). He was diagnosed with HCV, genotype 1a in 2000. Prior to initial presentation, patient was on peritoneal dialysis and developed progressive sclerosing peritonitis with 2 failed attempts at small bowel and ileo-colonic resection for recurrent intestinal obstruction. Patient was switched to hemodialysis (HD) and with continued enteral intolerance and failure to thrive, was commenced on TPN and listed for combined IKTX. Decision was made to not treat the HCV prior to TX due to ESRD and decreased absorption due to intestinal failure from sclerosing peritonitis. Safety and efficacy of Harvoni has only been established in patients with GFR >30, and there are no guidelines on safety and efficacy in patients on HD. Liver biopsy 18 months prior to IKTX, showed portal fibrosis (gr1, stage 1). Liver biopsy at time of IKTX showed worsening fibrosis (gr 2, stage 2), suggesting progression of HCV. Patient underwent IKTX in January 2015. Post-IKTX course was uncomplicated with normal renal and intestinal allograft function. Patient did not require further dialysis after IKTX and was weaned off TPN rapidly. He was treatment naïve and started on Harvoni® 8 months after IKTX. HCV PCR had increased from 2.9 million copies pre-IKTX, to 14.1 million copies at start of treatment (Figure 1). He tolerated 12 weeks of Harvoni® with no adverse effects or impact on IKTX allograft function. Viral load was undetectable at treatment completion.FigureConclusion: This report suggests that treatment with Harvoni® is a viable treatment option for HCV following ITX. This case illustrates potential to successfully treat patients with HCV and porto-mesenteric venous thrombosis who may be candidates for multi-visceral TX.

Subclinical Antibody-Mediated Rejection

Subclinical Antibody-Mediated Rejection

Immunotolerance in Liver Transplantation.

AbstractThe burden of life-long immunosuppressive medication must be overcome if progress is to be made in long-term outcomes following transplantation. The liver exhibits intrinsic tolerogenic properties that contribute to a unique propensity toward spontaneous acceptance when transplanted. Hence, a proportion of liver transplant recipients develop a state of immunotolerance and display persistently normal allograft function despite the discontinuation of immunosuppression. However, this phenomenon remains elusive for the majority of recipients. Investigations performed in experimental models of spontaneous liver allograft tolerance and in clinical cases of immunosuppression-free liver transplant acceptance have yielded mechanistic insights at the heart of recent strategies toward tolerance prediction and promotion. Results from recent clinical trials signal a shift in how liver allograft tolerance is viewed—not an elusive rarity of academic interest, but a potentially relevant clinical opportunity, which can be safely pursued if appropriately targeted.

Simultaneous Liver Transplantation and Sleeve Gastrectomy: Prohibitive Combination or a Necessity?

Previously, many morbidly obese (MO) patients were denied liver transplantation (LT) because of the higher operative risk. However, nowadays, 5 and 10years graft survival is the rule, and patients whose lives can be prolonged with LT are dying of obesity-related comorbidities. Recent experience suggests that weight reduction in MO liver transplant recipients would improve their long-term survival. The bariatric surgery before LT is contraindicated for patients with decompensated cirrhosis, while post-transplant intervention is associated with increased technical difficulty. We present our experience with three patients who underwent simultaneous liver transplantation and sleeve gastrectomy. After a median 13months follow-up, all patients are alive, having normal allograft function and significant weight loss. Combined liver transplantation with simultaneous sleeve gastrectomy appears technically feasible and relatively safe in selected patients.

DELAYED GRAFT FUNCTION FOLLOWING LAPAROSCOPIC LIVE DONOR NEPHRECTOMY: A MULTIVARIATE ANALYSIS

Objective: This study was performed to define and investigate the incidence, risk factors, and clinical characteristics of delayed graft function (DGF) in laparoscopic live donor nephrectomy (LDN). Material &amp; methods: We retrospectively analyzed the medical records of donor and recipient from our first 100 cases of laparoscopic LDN in Cipto Mangunkusumo General Hospital Jakarta, from November 2011 to February 2014. The criteria used to define DGF were the requirement for dialysis in postoperative week 1 and/or serum creatinine greater than 2.5 mg/dl at postoperative day 7. Patients who did not match any of these criteria were define as having normal renal allograft function. Results: The overall prevalence of DGF was 14%. Recipients body mass index, cold ischemia time, vascular anastomosis time, and total ischemia time were higher among the delayed graft function group, but no risk factors for DGF were significantly associated after multivariate analysis. Conclusion: The incidence of DGF in our study was in the range of that observed in previous studies. The factors that previously reported and believed as risk factors of DGF in laparoscopic LDN were not significantly associated with the development of DGF in our study.

Biopsy transcriptome expression profiling to identify kidney transplants at risk of chronic injury: a multicentre, prospective study

Chronic injury in kidney transplants remains a major cause of allograft loss. The aim of this study was to identify a gene set capable of predicting renal allografts at risk of progressive injury due to fibrosis. This Genomics of Chronic Allograft Rejection (GoCAR) study is a prospective, multicentre study. We prospectively collected biopsies from renal allograft recipients (n=204) with stable renal function 3 months after transplantation. We used microarray analysis to investigate gene expression in 159 of these tissue samples. We aimed to identify genes that correlated with the Chronic Allograft Damage Index (CADI) score at 12 months, but not fibrosis at the time of the biopsy. We applied a penalised regression model in combination with permutation-based approach to derive an optimal gene set to predict allograft fibrosis. The GoCAR study is registered with ClinicalTrials.gov, number NCT00611702. We identified a set of 13 genes that was independently predictive for the development of fibrosis at 1 year (ie, CADI-12 ≥2). The gene set had high predictive capacity (area under the curve [AUC] 0·967), which was superior to that of baseline clinical variables (AUC 0·706) and clinical and pathological variables (AUC 0·806). Furthermore routine pathological variables were unable to identify which histologically normal allografts would progress to fibrosis (AUC 0·754), whereas the predictive gene set accurately discriminated between transplants at high and low risk of progression (AUC 0·916). The 13 genes also accurately predicted early allograft loss (AUC 0·842 at 2 years and 0·844 at 3 years). We validated the predictive value of this gene set in an independent cohort from the GoCAR study (n=45, AUC 0·866) and two independent, publically available expression datasets (n=282, AUC 0·831 and n=24, AUC 0·972). Our results suggest that this set of 13 genes could be used to identify kidney transplant recipients at risk of allograft loss before the development of irreversible damage, thus allowing therapy to be modified to prevent progression to fibrosis. National Institutes of Health.