Normal Graft Function Research Articles

When the plan “A” does not work, there is an “O” in the alphabet: Orthotopic kidney transplant. A case report

Introduction: The prolonged wait for an organ can lead to depletion of vascular access in patients with chronic kidney disease. The lack of suitable vessels forces surgeons to explore alternative approaches for renal graft anastomosis, such as the orthotopic transplant procedure. The aim of this article is to present a case of a patient with exhaustion of vascular access and urgent need for kidney transplantation, which was successfully performed using orthotopic technique. Case Report: A 33-year-old man with stenosis of the iliac arteries underwent an orthotopic transplant with placement of the graft to the splenic vessels and pyeloureteral anastomosis. The patient had a very successful evolution and normal graft function. Conclusion: As surgical techniques evolve, increasingly complex patients require advanced, individualized approaches. This case exemplifies the multidisciplinary planning and execution needed to meet the growing challenges in transplantation. The report underscores the importance of innovative surgical strategies and comprehensive transplant protocols to address the future demands of the transplant community.

#1844 Pregnancy outcome among kidney transplant recipients

Abstract Background and Aims Background The possibility of a term pregnancy is one of the benefits of solid organ transplantation for women. The gonadal dysfunction, caused by the failure of the kidney or another organ, is reverted within a few months after normal graft function. Unplanned pregnancies in transplant recipients, however, may compromise graft function and survival, and may also risk unnecessary fetal exposure to immunosuppressive medications. Aims To study the prevalence of pregnancy and pregnancy related complication after kidney transplantation (KT). Method Retrospective cohort study conducted on 236 patients out of 3000 kidney transplant recipient who underwent renal transplantation (RT) at Mansoura Urology and Nephrology Centre between March 1976 and December 2019. divided into group I; 118 kidney transplant female's recipient experienced pregnancy at any time after kidney transplant and group II; 118 kidney transplant female's recipients who didn`t experience pregnancy after renal transplantation, they were matched according to age and duration of renal transplantation and comparable in primary immunosuppressant drugs. all kidney recipients were reviewed for preoperative & operative and post-operative details also we record maternal and fetal complication. Results Prevalence of pregnancy in our center is 191 pregnancies in 118 women who had underwent kidney transplantation between 1976 and 2019. We have found that the mean age of pregnancy between (26.27 ± 4.37-29.89 ± 4.6), the mean gestational age between (33.69 ± 6.4 – 33 ± 7.5) weeks, the live birth rate is 126 (66%). Preterm delivery rate in our study is 85 (44.5%), neonatal death 8 (4.1%), miscarriage 59 (30.9%), intrauterine fetal death 6 (3.1%) and birth defect 4 (2%). The prevalence rates of gestational hypertension is 87 (45.5%), pre-eclampsia 48 (25.1%), gestational diabetes 19 (9.9%), urinary tract infection 36 (18.8%), and graft rejection 8 (4.1%) during pregnancy. caesarean section is the most common method of delivery in our study 133 (69.6%). Kidney transplant recipients who aged more than or equal to 30 years at time of pregnancy are at higher risk for having non live-birth outcome (OR: 3.2, p value: 0.05). Proteinuria more than or equal to 0.5 g/day before pregnancy is a significant risk factor for having non live-birth outcome (OR: 4.7, p value: 0.009). Also, proteinuria ≥0.5 g/day during pregnancy is associated with increases risk for non-live-birth (OR: 10.2, p value: 0.013). Gesatational hypertension is associated with increases risk for non-live-birth (OR: 8.3, p value: 0.010).Preeclampsia is associated with increases risk for non-live-birth (OR: 4.6, p value: 0.005). Conclusion Although the outcome of live births is favourable, the risks of maternal and fetal complications are high in kidney transplant recipients including pregnancy-induced hypertension, increased rates of preeclampsia, gestational diabetes, and caesarean section rates. The risk of miscarriage, prematurity, and low birth rate is also high.

#2252 Outcome of pregnancy after kidney transplantation

Abstract Background and Aims Background The possibility of a term pregnancy is one of the benefits of solid organ transplantation for women. The gonadal dysfunction, caused by the failure of the kidney or another organ, is reverted within a few months after normal graft function. Unplanned pregnancies in transplant recipients, however, may compromise graft function and survival, and may also risk unnecessary fetal exposure to immunosuppressive medications. Aims To study the prevalence of pregnancy and pregnancy related complication after kidney transplantation (KT). Method Retrospective cohort study conducted on 236 patients out of 3000 kidney transplant recipient who underwent renal transplantation (RT) at Mansoura Urology and Nephrology Centre between March 1976 and December 2019. divided into group I; 118 kidney transplant female's recipient experienced pregnancy at any time after kidney transplant and group II; 118 kidney transplant female's recipients who didn't experience pregnancy after renal transplantation, they were matched according to age and duration of renal transplantation and comparable in primary immunosuppressant drugs. all kidney recipients were reviewed for preoperative & operative and post-operative details also we record maternal and fetal complication. Results Prevalence of pregnancy in our center is 191 pregnancies in 118 women who had underwent kidney transplantation between 1976 and 2019. We have found that the mean age of pregnancy between (26.27 ± 4.37 - 29.89 ± 4.6), the mean gestational age between (33.69 ± 6.4 - 33 ± 7.5) weeks, the live birth rate is 126 (66%). Preterm delivery rate in our study is 85 (44.5%), neonatal death 8 (4.1%), miscarriage 59 (30.9%), intrauterine fetal death 6 (3.1%) and birth defect 4 (2%). The prevalence rates of gestational hypertension is 87 (45.5%), pre-eclampsia 48 (25.1%), gestational diabetes 19 (9.9%), urinary tract infection 36 (18.8%), and graft rejection 8 (4.1%) during pregnancy. caesarean section is the most common method of delivery in our study 133 (69.6%). Kidney transplant recipients who aged more than or equal to 30 years at time of pregnancy are at higher risk for having non live-birth outcome (OR: 3.2, p value: 0.05). Proteinuria more than or equal to 0.5 g/day before pregnancy is a significant risk factor for having non live-birth outcome (OR: 4.7, p value: 0.009). Also, proteinuria ≥0.5 g/day during pregnancy is associated with increases risk for non-live-birth (OR: 10.2, p value: 0.013). Gestational hypertension is associated with increases risk for non-live-birth (OR: 8.3, p value: 0.010).Preeclampsia is associated with increases risk for non-live-birth ( OR: 4.6, p value: 0.005). Conclusion Although the outcome of live births is favourable, the risks of maternal and fetal complications are high in kidney transplant recipients including pregnancy-induced hypertension, increased rates of preeclampsia, gestational diabetes, and caesarean section rates. The risk of miscarriage, prematurity, and low birth rate is also high.

#1492 Metabolic switch in CD8+ T cells may influence immune response in chronic antibody-mediated rejection (CAMR)

Abstract Background and Aims CAMR is the main cause of chronic graft injury and subsequent graft loss, but its pathogenesis is still largely unclear. Our group demonstrated an increase in CD8+ T cells infiltrating biopsies from CAMR patients (PMID: 20595199), but their role remains to be defined. Recently, immunometabolism has emerged as a field connecting cell energy metabolism with the immune cell differentiation and functions. Particularly, the permanent aerobic glycolysis of CD8+ lymphocytes induces their transition from naïve to activated state and effector T cells (PMID: 37315709). Thus, the aim of the study was to investigate the molecular mechanisms underlying the development of CAMR by the analysis of gene expression profiles of CD8+ T lymphocytes in conjunction with their metabolic state. Method We enrolled 14 patients with biopsy-proven CAMR and 12 stable transplant recipients with normal graft histology and function (control group). CD8+ T cells were purified by CD8 MicroBeads (Miltenyi Biotec) then counted (TC20™ Automated Cell Counter). Gene expression profiles of CD8+ T lymphocytes isolated from both groups were assessed using Agilent microarrays. Data obtained were statistically and functionally evaluated (IPA software) and validated by qPCR. Oxygen consumption rate (OCR) in CD8+ and CD8- cells was measured by a Resipher oxygen sensing lid (Lucid Scientific Inc., USA). The contribution of mitochondrial respiration to OCR was investigated in isolated CD8+ T cells from CAMR and controls treated with rotenone/antimycin A (Rot/AA), oligomycin (Olygo) or carbonyl cyanide-p-trifluoromethoxyphenylhydrazone (FCCP) to evaluate spare respiratory capacity (SRC), ATP-linked respiration, proton leak and maximal respiration. Results Gene expression profiles of CD8+ T cells showed a characteristic alteration of lipid metabolism in CAMR patients with the triglyceride biosynthesis pathway (p = 2.69E-3) as the most altered pathway and several genes de-regulated all potentially involved in the altered metabolic state of CD8+ T cells. Among others, we validated the increased expression of Nicotinamide Phosphoribosyltransferase (NAMPT) (FC = +2.39), the rate-limiting enzyme of nicotinamide adenine dinucleotide (NAD+) salvage pathway involved in the glycolysis progression, mostly activated in effector T cells. We then decided to evaluate the OCR and the metabolic state of CD8+T cells. Basal OCR was higher in CD8+ rather than CD8- cells, but with different trends among cells isolated from control and CAMR patients. Indeed, CD8+ cells from CAMR patients showed higher OCR compared to control, while OCR was lower in CD8- from CAMR rather than control patients. CD8+ OCR from both CAMR and control patients was mostly dependent on mitochondrial respiration, since it was deeply reduced by Rot/AA treatment. Interestingly, inhibitory response to Oligo treatment by CD8+ cells from CAMR patients was modest, while OCR was noticeably stimulated by FCCP in these cells, suggesting that mitochondrial oxygen uptake was not ATP linked but rather associated with increased uncoupling. These data suggest that CD8+ T cells from CAMR patients are activated effector T cells primarily utilizing aerobic glycolysis. To confirm this hypothesis, we evaluated the gene expression levels of: i) HIF1a, which involves permanent dependence on glycolysis even in the presence of oxygen (Warburg effect); ii) fatty acid transporter CD36, whose levels mimic an energy dependence on the beta oxidation of fatty acids, a process activated in memory T cells. We confirmed an increased expression of HIF1a and a reduced expression of CD36 in CD8+T cells from CAMR patients compared to controls (p<0.05), that confirm the T effector phenotype. Conclusion Our data suggest that CD8+ T cell from CAMR patients showed permanent dependency on glycolysis leading to altered immune phenotype and response, thus indicating novel opportunities to modulate the immune system for therapeutic purposes in kidney transplanted patients and reduce graft rejection.

Diplopia as the presenting symptom of a post‐transplant lymphoproliferative disorder in a bilateral inferior lim transplanted young adult

Aims/Purpose: To present a unique case of post‐transplant lymphoproliferative disorder (PTLD) after bilateral inferior limb transplantation, which is still controversial due to the absence of precedents in the literature and the unclear risk–benefit ratio.Methods: Case report.Results: A 22‐year‐old male presented to the emergency room complaining of double vision. He had a history of bilateral inferior limb amputation 8 years ago and received a bilateral lower limb transplantation 2 years later. He had normal graft function and was receiving cytomegalovirus prophylaxis. During neurological examinations left abducens nerve (CN VI) palsy was noted. Other cranial nerves affected produced facial hypoesthesia (CN V) and mild paresis (CN VII), hearing loss and tinnitus in left side (CN VIII) and soft palate asymmetry (CN X). He was otherwise neurologically intact, alert and orientated. MRI revealed a lesion located at the facial colliculus at the floor of 4th ventricle. In the context of immunosuppression, the differential diagnosis included abscess versus PTLD. Biopsy of the lesion was performed. Morphologically atypical lymphocytic cells suggestive of B lymphoma were identified. Monoclonal rearrangement for heavy chain Igen and immunoglobulins were identified with molecular biology techniques. The histology features were consistent with a diagnosis of CNS B lineage primary lymphoma. Two days later, bilateral supracondylar amputation was performed. Following the explant, immunosuppression was withdrawn. His underlying condition was finally diagnosed as PTLD, for which he started a chemotherapeutic regimen with radical intention (methotrexate and cytosine arabinoside). The patient recovered fully and up to date, 10 years later, is doing well.Conclusions: Due to its diverse aetiologias, a proper workup must be done of the patients presenting with diplopia to the emergency room. PLTD must be a condition to always be considered in patients with history of solid organ transplant; since the early diagnosis is crucial for a successful management of this often‐fatal condition.

Functional MRI evaluation of blood oxygen dependent (BOLD) in renal allograft dysfunction: a prospective study.

Blood oxygen level dependent-magnetic resonance imaging (BOLD-MRI) is a non-invasive functional imaging technique that can be used to assess renal allograft dysfunction. To evaluate the diagnostic performance of BOLD-MRI using a 3-T scanner in discriminating causes of renal allograft dysfunction in the post-transplant period. This prospective study was conducted on 112 live donor-renal allograft recipients: 53 with normal graft function, as controls; 18 with biopsy-proven acute rejection (AR); and 41 with biopsy-proven acute tubular necrosis (ATN). Multiple fast-field echo sequences were performed to obtain T2*-weighted images. Cortical R2* (CR2*) level, medullary R2* (MR2*) level, and medullary over cortical R2* ratio (MCR) were measured in all participants. The mean MR2* level was significantly lower in the AR group (20.8 ± 2.8/s) compared to the normal group (24 ± 2.4/s, P <0.001) and ATN group (27.4 ± 1.7/s, P <0.001). The MCR was higher in ATN group (1.47 ± 0.18) compared to the AR group (1.18 ± 0.17) and normal functioning group (1.34 ± 0.2). Both MR2* (area under the curve [AUC] = 0.837, P <0.001) and MCR (AUC = 0.727, P = 0.003) can accurately discriminate ATN from AR, however CR2* (AUC = 0.590, P = 0.237) showed no significant difference between both groups. In early post-transplant renal dysfunction, BOLD-MRI is a valuable non-invasive diagnostic technique that can differentiate between AR and ATN by measuring changes in intra-renal tissue oxygenation.

Liver Transplantation for Zellweger Syndrome.

Zellweger syndrome or cerebrohepatorenal syndrome is a rare, multisystem disorder occurring due to defect in metabolic pathway within the peroxisomes. Cirrhosis with portal hypertension is an important presentation of these patients. Given its progressive, multisystem nature, the role of liver transplantation (LT) in Zellweger syndrome remains undefined and controversial. An 11-y-old boy diagnosed with Zellweger syndrome presented to theauthors with decompensated cirrhosis along with bilateral proptosis. After a meticulous evaluation, he was offered an ABO incompatible liver transplantation with hismother being the donor. He had an uneventful post operative period. After a follow up of 24 mo, he has normal graft function,normal cognition along with resolution of proptosis. Therefore, in a group of carefully selected patients with Zellweger syndrome, a liver transplantation can be offered successfully with an excellent prognosis.

Diagnostic significance of TGF-β1 in kidney recipients with graft dysfunction

Development of minimally invasive diagnosis techniques for complications in recipients, based on analysis of the levels of molecular and genetic biomarkers, is an urgent task facing modern transplantology. Transforming growth factor beta 1 (TGF-β1), which has multiple effects in the body, among the potential indicators of complications.Objective: to assess the diagnostic significance of serum TGF-β1 in kidney recipients with graft dysfunction.Materials and methods. The study included 129 kidney recipients aged 17 to 68 years and 35 healthy subjects. Serum TGF-β1 levels in the recipients were determined by immunoenzyme technique.Results. Kidney recipients included 95 patients with laboratory and clinical signs of graft dysfunction, who underwent biopsy of the transplanted kidney, followed by morphological examination, and 34 recipients with normal graft function. Serum TGF-β1 levels in the kidney recipients were significantly higher than in their healthy counterparts (p = 0.00001); it did not correlate with most blood test parameters; with the glomerular filtration rate (GFR). Kidney recipients with graft dysfunction had significantly higher TGF-β1 levels than other recipients (p = 0.018). In recipients with graft dysfunction, morphological study revealed the following: acute tubular necrosis (ATN, n = 11), acute T-cell mediated rejection (ACR, n = 26), acute antibody-mediated rejection (AMR, n = 35), non-immune-mediated nephrosclerosis with signs of calcineurin inhibitor nephrotoxicity (CNI nephrotoxicity, n = 13), and recurrent glomerulonephritis (chronic graft rejection, n = 10). Recipients with immune-mediated graft injury (ACR, AMR and chronic rejection) had higher serum TGF-β1 levels than recipients with graft dysfunction resulting from other causes, p &lt; 0.0001. Kidney recipients with serum TGF-β1 levels above the threshold value of 94.3 ng/mL had a higher risk of immune-mediated graft dysfunction than other kidney recipients (RR = 2.2 ± 0.22 [95% CI 1.46–3.46]) with 77.5% test sensitivity and 60.3% specificity.Conclusion. The calculated threshold serum TGF-β1 level in kidney recipients can be considered as an auxiliary indicator of graft dysfunction resulting from acute or chronic rejection.

Non-invasive rejection surveillance in stable heart transplantation using local laboratory-run donor-derived cell-free DNA assay: two-centre European feasibility study

Abstract Background Monitoring adverse events is crucial after heart transplantation (HTx). Allograft rejection is a major etiological factor of graft dysfunction, hospitalisation, and death posttransplant. Endomyocardial biopsy (EMB) is the standard method of monitoring rejection; however, there are risks and limitations associated with it. The ISHLT guidelines for the care of HTx recipients have included non-invasive surveillance such as testing for donor-derived cell-free DNA (dd-cfDNA). While major studies have been conducted with patient cohorts and centralised testing in the USA, hereby we explored a European two-site cohort where dd-cfDNA was quantified at local centres by next-generation sequencing-based CE-marked assay. Purpose Our objective was to assess feasibility of assay and evaluate dd-cfDNA values in clinically stable HTx recipients. Methods HTx patients were enrolled at their scheduled visits in this cross-sectional study in 2 European HTx centres. Serial data after HTx, including clinical status, maintenance immunosuppression therapy and drug levels, diagnostic tests (blood tests, echocardiograms, coronary angiograms, EMBs), and adverse events were collected. Venous blood specimens were drawn in Streck cfDNA blood collection tubes for quantification of dd-cfDNA levels. We analysed dd-cfDNA fraction in plasma using AlloSeq cfDNA assay. For analysis, clinical stability was defined as asymptomatic patients &amp;gt;28 days post-HTx with normal graft function, without cytomegalovirus infection, history of rejection, or allograft vasculopathy. Results Between July 2021 and December 2022, 50 HTx recipients were enrolled at a median of 274 (112–395) days posttransplant. The median age at enrolment was 55.5 years. Of the total 82 dd-cfDNA results, 34 samples were excluded as they did not meet stability criteria. The median dd-cfDNA value of stable patients was 0.11% (95% CI 0.08%–0.13%). Median levels of dd-cfDNA did not differ between samples drawn in the first year after HTx (n=40) and at later time (n=8) [0.11% vs. 0.11%; p=0.41]. Of the 48 dd-cfDNA samples, 7 had values at risk based on the dd-cfDNA cut-off values from previous clinical validation trials: 4 at the injury cut-off of ≥0.20% and 3 at the severe injury threshold of ≥0.35%. Comparing clinical variables of samples with dd-cfDNA ≥0.20% (n=7) and &amp;lt;0.20% (n=41), we observed a 3-fold, non-significant increase in rate of de novo DSA formation (33.3% vs. 10.8%; p=0.19). Conclusions Our data show feasibility to analyse dd-cfDNA at the local level. In our two-site European reference cohort, dd-cfDNA is present at low levels (median 0.11%) which is within former reported ranges for clinically stable HTx recipients. Levels of dd-cfDNA do not vary beyond the first post-HTx year. The fact that in patients with de novo DSA higher dd-cfDNA levels are found; although, not statistically significant, suggests that dd-cfDNA may be a marker of subclinical rejection and requires further study.

Abstract 12560: Single Cell RNA Sequencing Signature of Cardiac Allograft Vasculopathy

Background: Cardiac allograft vasculopathy (CAV) is one of the major causes of death after heart transplantation (HTx). However, immunological mechanisms of CAV remain incompletely understood. This study aimed to determine distinct immune profiles of CAV compared to HTx patients with normal graft function (CONTROL). Methods: Peripheral blood mononuclear cells (PBMC) obtained from the International Society for Heart and Lung Transplant grade 2 or 3 CAV (n=6), and CONTROL (n=12) patients were analyzed using single cell RNA sequencing (498 genes) on the BD Rhapsody platform combined with 56 protein markers (CITE-seq) and VDJ-seq. Cells were clustered into major cell types using 18 protein markers. Targeted clustering was then performed to determine subclusters using proteomic and transcriptomic data. Results: Proportions of memory B cell (0.5±0.4% vs 1.4±0.8%, p=0.01) and CD16+CD56+ TEMRA CD8 T cell (0.5±0.3% vs 1.0±1.7%, p=0.007) were decreased and proportion of C1q+ nonclassical monocyte (1.0±0.5% vs 0.4±0.3%, p=0.01) was increased in CAV patients compared to CONTROL. In Th1 effector memory CD4 T cell cluster, CAV had a significantly higher proportion of clonally expanded cells (24.1±10.0% vs 11.3±9.2%, p=0.01) characterized by higher expression of NKG7, GZMH, CCL5, and CST7 compared to non-expanded cells in this cluster. Signature genes with the highest positive coefficients determined by LASSO regression to predict CAV (72.2% accuracy) included IFITM3, LAIR2, CD52, IFITM2, NKG7, NAMPT, CD74, F13A1, IL3RA, and RNASE2. IFITM3 and LAIR2 were the best positive predictors for CAV and overexpressed predominantly in CD4 T and CD8 T cells (Figure). Conclusion: CAV demonstrates distinct immune cellular and transcriptomic phenotypes compared to CONTROL. IFITM3 and LAIR2 overexpression in PBMCs may predict severe CAV in HTx patients.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

Simultaneous 3-way Paired Exchange Liver Transplantation Without Nondirected Donation: Novel Strategy to Expand the Donor Pool.

Quantification of extracellular matrix remodeling for the non-invasive identification of graft fibrosis after liver transplantation

Detecting patients with early post-transplant fibrosis after liver transplantation (LT) is very important. Non-invasive tests are needed to avoid liver biopsies. We aimed to detect fibrosis in liver transplant recipients (LTR) using extracellular matrix (ECM) remodeling biomarkers. ECM biomarkers for type III (PRO-C3), IV (PRO-C4), VI (PRO-C6) and XVIII (PRO-C18L) collagen formation and type IV collagen degradation (C4M) were measured by ELISA in prospectively collected, cryopreserved plasma samples (n = 100) of LTR with paired liver biopsies from a protocol biopsy program. Fibrosis ≥ F2 was present in 29% of patients (median 44 months post-LT). APRI and FIB-4 neither identified significant fibrosis nor were correlated with histopathological fibrosis scores, while ECM biomarkers (AUCs 0.67–0.74) did. The median levels of PRO-C3 (15.7 vs. 11.6 ng/ml; p = 0.002) and C4M (22.9 vs. 11.6 ng/ml; p = 0.006) levels were elevated in T-cell-mediated rejection compared to normal graft function. The median levels of PRO-C4 (178.9 vs. 151.8 ng/ml; p = 0.009) and C4M (18.9 vs. 16.8 ng/ml; p = 0.004) levels were increased if donor-specific antibodies were present. PRO-C6 had the highest sensitivity (100%), NPV (100%) and negative likelihood-ratio (0) for graft fibrosis. To conclude, ECM biomarkers are helpful in identifying patients at risk of relevant graft fibrosis.

Successful Deceased Donor Kidney Transplantation in a Highly Sensitized Patient after Reclassification of Unacceptable Antigens Based on HLA Epitope Analysis

For patients with end stage renal disease, kidney transplant offers significant survival and quality-of-life advantages compared with dialysis. But for patients seeking transplant who are highly sensitized, waiting times have traditionally been long and options limited. We present the case of a 34-year-old hypersensitized female who underwent renal retransplantation. Histocompatibility tests revealed a calculated panel-reactive antibody of 99.53% with multiple antibodies against class I and II human leucocyte antigens and an eplet analysis was performed. The donor’s potential unacceptable antigens were re-defined and the calculated panel-reactive antibody decreased to 88.38%. After one month the patient received a deceased-donor kidney transplant. Complement dependent cytotoxicity crossmatch was negative; virtual crossmatch and flow cytometry crossmatch with historical serum were positive. High-dose intravenous immunoglobulin and rituximab were added to the thymoglobulin-based induction immunosuppression. Three donor-specific antibodies were detected and plasmapheresis was performed. Renal allograft biopsy revealed no manifestations of rejection. Repeated testing observed a decrease in donor-specific antibodies median fluorescence intensity values. Four months post-transplant, the patient remained with normal graft function without proteinuria. She is receiving a standard maintenance immunosuppression regime with prednisolone, mycophenolate mofetil and tacrolimus. The careful discussion among the transplantation center and histocompatibility laboratory in association with intense immunosuppression and close laboratory monitoring allowed a successful human leukocyte antigen-incompatible deceased donor kidney transplantation in the most critical phase for the occurrence of humoral rejection. It is noteworthy that the new histocompatibility and immunogenetics methodologies provide a more affirmative and comprehensive assessment of mismatch acceptability.

Gender Differences in microRNA Expressions as Related to Long-Term Graft Function in Kidney Transplant Patients.

In recent studies, much has been discussed about biomarkers used in the evaluation of the transplanted graft function. However, there remains a lack of research regarding the long-term effects of microRNAs (miRNAs) on the different genders for kidney transplant (KTx) patients. In this study, we aim to assess the functions of miRNAs on long term outcomes of KTx patients by extracting differently expressed miRNAs between patients of normal graft function and graft dysfunction, while further analyzing their impact on the different genders. We analyzed the data of 40 patients who had received KTx for a period of more than ten years and included data regarding renal function, immuno-related markers and plasma miRNAs. Data were classified by gender for further studies. Twelve out of 17 females and 8 out of 23 males had undergone graft dysfunction. Renal function analysis showed significantly worse outcomes in the female patients. There were five differently expressed miRNAs between the female control group and female dysfunction group: miR-128-3p, miR-21-5p, miR-150-5p, miR-92a-3p and miR-15a-5p, and five between the male control group and male dysfunction group: miR-23a-3p, miR-126-3p, miR-142-3p, miR-223-3p and miR-26a-5p. Gender differences exist in incidences of kidney graft dysfunction, with male patients displaying better preservation in graft functions. Overall, these differently expressed miRNAs either enhance or suppress host immune responses. They can be predictive markers for graft survival and can also be important factors that lead to worse long term kidney graft function in females when compared to males.

POS-098 MILKY URINE IN RENAL ALLOGRAFT RECIPIENT - CAN NATIVE KIDNEY BE THE CULPRIT ?

Milky urine can be caused due to both infectious and non-infectious causes. We present a case of 48 years old male, 6 years post kidney transplant who presented as milky urine and was initially managed with diethylcarbamazine (DEC) and intravenous antibiotics. As he was not responding he was evaluated further to be diagnosed as candiduria arising from left native kidney. He had a quick response to left native nephrectomy and liposomal amphotericin. 48 years old male patient, who was 6 years post kidney transplant (Basic disease - diabetic nephropathy), with normal graft function on triple drug immunosupressants ( tacrolimus, mycophenolate and pednisolone) presented with complaint of milky white urine during morning hours only. He was afebrile and had no symptoms of burning or pain during micturition. His urine examination showed few pus cells and was hazy in appearance. Urine cytology for malignant cells showed no evidence of atypical cells. Urine for fat globules was negative though triglycerides were 470 mg/dl and urine was labelled as chylous. His ultrasound was suggestive of mild pelvicalyceal fullness of transplant kidney which was confirmed by CT scan. His leucocyte counts, calcium and phosphorus were within normal range. His early morning smear sample showed no evidence of wuchereria bancrofti microfilariae. He was emperically started on DEC 6mg/kg. After 5 days his urine culture yielded growth of klebsiella species and was treated with injectable ceftriaxone-sulbactum combination as per culture sensitivity report for 2 weeks. He was asymptomatic till the time he was on antibiotics and again developed episodes of milky urine. He also passed some fleshy material in urine was sent for histology. He was posted for cystoscopy which revealed whitish efflux from left native uretric orifice, which was sent for cytology and left uretric catheterization was done. Both the tissue and fluid showed colonies of budding yeast cell and pseudohyphae suggestive of candida species. Considering the non functional status of left native kidney (by imaging and history of anuria pre transplant), left laproscopic native nephrectomy was done and in view of post transplant immunosupressed state, intravenous liposomal amphotericin was given for 2 weeks. He had a quick response to the treatment. In post transplant urinary tract infections, we should also focus on native kidneys especially in diabetic population. There are many case reports of recurrent urinary tract infections post transplant due to native pyelonephritis requiring native nephrectomy.

312.3: Outcomes of Duct-To-Duct Biliary Anastomosis in Pediatric Liver Transplantation Using Left Sided Graft

Background: Roux-en-Y hepaticojejunostomy(HJ) is the standard-of-care for biliary reconstruction in pediatric liver transplantation(LT), especially in left sided grafts. This study aimed to investigate the learning curve and the risk of biliary complication of duct-to-duct biliary anastomosis(DDA) in pediatric LT using left sided grafts. Method: This was a retrospective study from a surgical unit of a university-affiliated center. From 2017-2020, DDA was performed in pediatric LT with a high hilar dissection and patch anastomosis technique under a prospective protocol.(Figure 1) The exclusion criteria were: 1) disease mandated HJ, 2) widely separated graft bile ducts that ductoplasty was infeasible, 3) native biliary anatomical factors that rendered a patch infeasible. Size discrepancy was not a contraindication. The primary endpoint was the risk of biliary complication at 1-year after LT. Results: During study period, 137 pediatric recipients fulfilled inclusion and were considered eligible for DDA, 110 (80.3%) patients had DDA. The pre-transplant characteristics were listed in table 1. The first 40 patients belonged to learning curve period and after that, more patients were eligible for DDA (7.2% vs. 15.1%, P<0.001). The overall risk of biliary complication at 1-year was 2.9% (4/137) and it was higher in the learning phase (9.1% vs 1.3%, P=0.045). Of the 4 biliary complications: 1 had bile leakage and stricture and required endoscopic stenting; 3 had biliary stricture with 2 required conversion to HJ and 1 had endoscopic stenting. All 4 patients have normal graft function at time of analysis. There was only one hospital mortality (1/137, 0.7%) and was due to post-operative bleeding and was unrelated to biliary complication. Graft survival rates at 1-and 3-year after DDA were 98.2% and 96.8% respectively. Conclusion: DDA was safe and feasible with excellent perioperative and long-term outcomes and should be considered the primary choice for biliary reconstruction in eligible pediatric transplant patients.

Effect of regulatory T cells on short-term graft outcome in kidney transplant recipients, a prospective observational, single-center study

BackgroundRegulatory T cells (Tregs) are important for maintaining immune homeostasis, limiting kidney transplant rejection, and promoting transplant tolerance. Tregs are characterized as CD4 + CD25+ T cells and the transcription factor Foxp3; they constitute 5–10% of all peripheral CD4+ T cells in healthy humans. The reduction in Treg cells after transplantation may be a predictive factor in graft rejection. Therefore, in this study, we investigated the association between Tregs and short-term graft outcomes in renal transplant recipients. MethodsThis prospective observational study included 50 patients of both sexes, aged between 18 and 60 years, with end-stage renal disease (ESRD), and who underwent kidney transplantation at the Nizams Institute of Medical Sciences. Flow cytometry was used to measure the percentage of Tregs (CD4 + CD25+) pre-transplant (baseline) and monthly post-transplant in 50 transplant recipients and 20 healthy controls (HC) over six months. The correlation between Treg percentages and graft outcomes was analyzed. ResultsThe percentage of Tregs (Treg%) was significantly lower in ESRD patients before transplantation (baseline) than in the HCs [median 8.5% vs. 14.25%; p < 0.01]. After transplantation, Treg% decreased significantly within a week after grafting compared to the baseline pre-transplant level [median 5.13% vs. 8.5%; p < 0.01]. Moreover, Treg% was lower in the older (> 40 years) than that in the younger age group at one week after transplantation (p > 0.001). Treg% (CD4 + CD25+) was significantly lower in patients with deceased donor renal transplantation (DDRT) than in live renal transplantation (LRT) within the first week of transplantation [median 2.16% vs. 4.6%; p < 0.05] and at the time of graft rejection [median 3.2% vs. 9.2%; p < 0.001]. Induction therapy with anti-IL-2 receptor monoclonal antibody (IL-2RB) lowered Tregs to a greater extent than anti-thymoglobulin (ATG) therapy and no induction therapy [median 3.22% vs. 5.47%, 8.4%, p < 0.05]. In contrast, an increased Treg% was observed in transplant recipients with normal kidney graft function within six months after transplantation compared with the pre-transplant baseline level [median 11.54% vs. 8.5; p < 0.001]. ROC analysis of graft rejection resulted in an area under the curve (AUC) of 0.8 with a p-value <0.05. ConclusionWithin the first week after transplantation, the percentage of pre-transplant Tregs was significantly decreased compared to that in age- and sex-matched HC. The percentage of Tregs was also lower in patients with advanced age, DDRT, and those who received IL-2RB induction therapy. Patients who experienced graft rejection had lower Treg% compared to their pre-transplant levels. In contrast, patients with normal graft function at six months showed increased Treg%. Together, these results suggest that Treg% measurements are correlated with clinical outcomes.

Contrast-Enhanced Ultrasonography Value for Early Prediction of Delayed Graft Function in Renal Transplantation Patients.

Delayed graft function (DGF) is a common early complication after kidney transplantation. The aim of the present study was to evaluate the value of contrast-enhanced ultrasonography (CEUS) in the early prediction of DGF after kidney transplantation. A total of 89 renal transplant recipients were retrospectively enrolled and divided into DGF group or normal graft function (NGF) group according to the allograft function. Conventional Doppler ultrasound and CEUS examination data on the first postoperative day were collected and analyzed. The resistive indices of segmental and interlobar artery in the DGF group were significantly higher than those in the NGF group (0.71 ± 0.17 versus 0.63 ± 0.08, P=.006; 0.70 ± 0.16 versus 0.62 ± 0.08, P=.004, respectively). The patients experiencing DGF had significantly lower PI-c (14.7dB ± 6.1dB versus 18.5 dB ± 3.3dB, P=.001) and smaller AUC-c (779.8 ± 375.8dB·seconds versus 991.0 ± 211.7dB·seconds, P=.003), as well as significantly lower PI-m (12.6dB ± 5.9dB versus 15.9 dB ± 3.9dB, P=.006), shorter MTT-m (30.7 ± 9.4seconds versus 36.3 ± 7.1seconds, P=.01), and smaller AUC-m (P=.007). Multivariate analysis demonstrated that PI-c, AUC-c, and MTT-m were independent risk factors for DGF. The area under the receiver operating characteristic curve values of the combined predicted value (PI-c + MTT-m, PI-c + AUC-c + MTT-m) of DGF incidence were bigger than that of PI-c, AUC-c, or MTT-m. CEUS parameters of the cortex and medulla have a good value for an early prediction of DGF after renal transplantation.

Sarcopenia and Fat Mass in Children With Chronic Liver Disease and Its Impact on Liver Transplantation.

Children with end-stage chronic liver disease undergoing assessment for LT were recruited into an observational longitudinal study. Anthropometry and body composition (BC; whole-body dual-energy x-ray absorptiometry scan) were assessed before and, on average, 1 year after LT. Eleven children (6 females:5 males) were assessed (4.7 to 17.2 years; median, 9.9) at baseline. Nine children went on to have an LT. The aspartate aminotransferase-to-platelet ratio index had a significant positive correlation with trunk lean mass and trunk lean mass index (LMI) SD score (SDS). At baseline, 4 patients were sarcopenic with appendicular LMI SDS less than -1.96. All fat mass and fat mass index (FMI) SDSs were within the normal range (above -1.96). There was a strong negative correlation between FMI SDS and height SDS. After transplant, there was a significant reduction in trunk LMI from 1.20 to -0.51 (95% CI, 1.03-2.4; P < 0.01). Body mass index SDS had a negative correlation with days to discharge after transplant. The majority of patients discharged after 16 days were sarcopenic. One year after transplantation, all patients were alive with normal graft function regardless of BC before LT. FMIs were normal regardless of LMIs and correlated negatively with height. BC was related to days to discharge after LT but not to outcomes a year after LT.

The role of the NGAL biomarker in the assessment of early and prediction of late graft function in kidney transplantation from a living related donor

The aim. To study the role of NGAL in assessing the recovery of early graft function (GF) and in predicting GF in the first year after kidney transplantation (KT) from a living-related donor (LRD). Materials and methods. For this aim, a total of 60 kidney recipients who underwent KT from LRDs were examined. To study the early GF, NGAL concentrations in urine samples were measured on days 1, 2, 3, 7 after KT. To study the late GF, the glomerular filtration rate (GFR) was calculated at 3, 6, 12 months after KT. To study the prognosis of GF during the first year after KT, the relationship between u-NGAL and GFR levels at 3, 6, 12 months after KT was analyzed. The incidence of acute kidney transplant rejection (AKTR), delay of graft function (DGF), primary non-function was recorded. Results. DGF was observed in 5 (8.33 %) recipients with statistically significantly increased mean NGAL levels (P &lt; 0.05) on days 1, 2, 3, 7 as compared to those in normal GF. AKTR was detected in 10 (16.67 %) recipients with statistically significantly increased mean NGAL levels (P &lt; 0.05) on days 1, 2, 3, 7 compared to those in normal GF. Primary allograft non-function was diagnosed in 8 (13.33 %) recipients with statistically significantly increased mean NGAL levels (P &lt; 0.05) on days 1, 2, 3, 7 compared to those in normal GF. Assessing the relationship between NGAL levels on days 1, 2, 3, 7 and GFR at 3, 6, 12 months after transplantation, it was found that GFR was higher in recipients with NGAL levels on days 1, 2, 3, 7 after transplantation within the reference values (&lt;131.7 ng/ml) than that in recipients with NGAL levels on days 1, 2, 3, 7 after transplantation above 131.7 ng/ml. Conclusions. Evaluation of NGAL after KT informs about the restoration of renal function (rapid decrease in NGAL) or the development of complications (DGF, primary allograft non-function, AKTR) with slow decrease or increase in NGAL levels. Thus, u-NGAL is an early, non-invasive and accurate predictor of the need for dialysis in the first week after KT and the restoration of GF within 12 months.