Pancreas Transplant Patients Research Articles

Pancreas Transplantation of US and Non-US Cases from 2005 to 2014 as Reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR).

This report is an update of pancreas and kidney transplant activities in the US and non-US region in two periods, 2005-2009 and 2010-2014. The aim of the report was to analyze transplant progress and success in the US compared to non-US countries, and to compare trends between the two periods. Between 2005-2009 and 2010-2014, the number of US pancreas transplants declined by over 20%, while the overall number of pancreas transplants performed outside the US has increased. The decline in US numbers is predominantly due to the decline in primary and secondary pancreas after kidney transplants (PAK). During the time period studied, the number of PAK transplants dropped by 50%. In contrast, the number of simultaneous pancreas/kidney transplants (SPK) declined by only 10%, and the number of pancreas transplants alone (PTA) by 20%. Over 90% of pancreas transplants worldwide were performed, with a simultaneous kidney transplant and excellent results. Transplant outcomes in SPK improved significantly because of a decrease in the rates of technical and immunologic graft loss. In 2010-2014 vs. 2005-2009, US SPK transplant patient survival at 1 year post-transplant increased from 95.7% to 97.4%, pancreas graft function from 88.3% to 91.3%, and kidney function from 93.6% to 95.5%. A significant improvement was also noted in PAK transplants. One-year patient survival increased from 96.4% to 97.9% and pancreas graft function from 81.0% to 86.0%. PTA 1-year patient survival remained constant at 97%, and pancreas 1-year graft survival improved from 81.0% to 85.7%. With the decline in the number of transplants, a change towards better pancreas donor selection was observed. In solitary transplants, the donors were primarily young trauma victims, and the pancreas preservation time was relatively short. A general tendency towards transplanting older recipients was noted. In 2010-2014 vs. 2005-2009, PTA recipients 50 years of age or older accounted for 32% vs. 22%, PAK for 28% vs. 22%, and SPK for 22% vs. 20%. This may be due to a relatively lower immunologic graft loss rate, especially in solitary transplants, which historically has been high in young recipients. The number of pancreas transplants in patients with type 2 diabetes and end-stage renal disease has increased, and accounted for 9% of all SPK recipients in 2010-2014.

Bordetella Bronchiseptica in a Kidney-pancreas Transplant Recipient after Dog Vaccination

Bordetella bronchiseptica is a gram negative coccobacillus that causes infections in animals including dogs,rabbits, and guinea pigs. It’s the causative agent in kennel cough, producing a dry‚ ‘honking’ cough. We report a case of Bordetella bronchiseptica in a kidney and pancreas transplant patient. A 55-year-old gentleman with a history of a living related kidney transplant, pancreas transplant, diabetes, hypertension, hyperlipidemia, and smoking history who presented to the hospital with fever/chills. He underwent pancreas transplantation 3 weeks prior to his current hospitalization. He was immunosuppressed on Prograf, Cellcept. Patient recently had a PICC line in place due to dehydration requiring IV fluids as an outpatient. He had adopted a puppy recently after his wife went back to work for companionship. The puppy had been given live vaccines around the time of transplant. Puppy noted to have been licking the PICC line. Patient denied cough, sore throat, nausea or vomiting. Physical exam revealed blood pressure 117/84 mm/Hg, heart rate 70 beats per minute, respiratory rate 14, temperature 38.3°C, 98% on room air. Auscultation of lungs revealed clear lungs bilaterally. No leukocytosis, normal renal function. CXR revealed no infiltrate, no lymphadenopathy. Blood cultures revealed Bordetella bronchiseptica sensitive to quinolones and trimethoprim-sulfamethoxazole. Patient started on piperacillin/tazobactam. His PICC line was removed. All symptoms gradually resolved with antibiotics over a two week course of Ciprofloxacin. Household dogs and some cats are routinely vaccinated against Bordetella bronchiseptica. Transmission occurs via respiratory droplets or by direct contact. Diagnosis is based on positive cultures or polymerase chain reaction from a patient with a history of exposure to infected animals. Treatment includes aminoglycosides, antipseudomonal penicillins, quinolones, tetracyclines, thirdgeneration cephalosporins, and trimethoprim-sulfamethoxazole. Duration of therapy is based on immune status of patient, however ranges from 2-6 weeks. Immunosuppressed patients should avoid contact with unvaccinated or newly vaccinated especially those with young animals who have received live vaccines.

Pancreas and islet transplantation: psychological themes pre- and posttransplant.

To date, islet and whole pancreas transplantation have been largely researched and reported separately. Therefore, for the first time, this review seeks to examine together the recently reported psychological issues as they relate to the two different types of transplantation. In relation to pancreas transplantation, recent findings indicate potential issues relating to energy levels, including sleep problems; mood problems (anxiety, depression, traumatic stress); social interactions; and identity issues. Similarly, the research on islet allotransplantation (ITA) indicates mood disruptions associated with Type I diabetes mellitus (T1DM), which seem to improve as a result of treatment with ITA. The review indicates a need for more research to guide effective intervention to optimize psychological recovery post islet and/or pancreas transplantation for patients with T1DM. Effective psychological intervention for this group relies on researchers eliciting more detailed knowledge of pretransplant psychosocial issues, not only in relation to how these might vary by transplant group, but also in relation to patient health status vis-à-vis microvascular complications and glycaemic control, and how these issues change across the whole transplant journey.

Value of contrast-enhanced ultrasound in diagnosis of postoperative complications after pancreas transplantation

Objective To investigate the clinical value of contrast-enhanced ultrasound (CEUS) in the diagnosis of postoperative complications after pancreas transplantation. Methods Eighty-six post pancreas-transplantation patients were examined by CEUS to observe the perfusion of contrast agent, plot time-intensity curve (TIC), and compare to the results of enhanced CT, MRI and pathology. Results Eleven cases of thrombosis, 13 cases of rejection and 13 cases of pancreatitis were observed among 86 patients. Result from CEUS showed that: ①Distribution of normal pancreatic grafts vascular and parenchyma was even, TIC follows positive skewed distribution. ②Thrombosis: there was no perfusion in the embolic vessels and no enhancement or low uneven enhancement in the parenchyma. ③Rejection: perfusion of the parenchyma was slow, peak value was decreased, rising and falling slope of the TIC was reduced with blunt peak. ④Pancreatitis: perfusion of the parenchyma was uneven, the regional low enhanced area was visible, clear of the contrast agent was relatively slow, rising slope of TIC was reduced and the peak value was decreased. Conclusions CEUS can monitor the perfusion of the pancreatic grafts vascular and parenchyma, and get useful perfusion parameters. It has been proven as an effective method to definitely diagnose postoperative complications after pancreas transplantation. Key words: Ultrasonography; Microbubbles; Pancreas transplantation; Postoperative complications

Value of magnetic resonance imaging in evaluating the pancreatic allograft transplant complications.

To retrospectively investigate the value of magnetic resonance imaging (MRI) in detecting complications following pancreas transplant. Institutional review board approved this retrospective HIPAA-compliant study and waived informed patient consent. We identified all allograft pancreas transplant patients at our institution from 2001 to January 2014 who had all pertinent post-transplant imaging and clinical data available. Transplant type was documented. Patients were divided into two groups according to post-transplant period (group A; <12months, group B; ≥12months). We evaluated the parenchymal enhancement using contrast-enhanced MRI of the allograft and determined the mean percentage of parenchymal enhancement (MPPE) overall and in various abnormalities, the vessel patency, any peripancreatic fluid collection, and the ductal anatomy. We correlated these with clinical results using t test, χ (2), and Fisher's exact test; p<0.05 was considered significant. 51 patients (34 male, mean age 43.7years) were identified, 28 (55%) of whom had abnormal imaging findings; transplant rejection-related necrosis (n=7), fluid collections (n=7), vascular stenosis (n=4), isolated venous thromboses (n=3), acute pancreatitis (n=3), pancreatic and peripancreatic abscesses (n=2), pseudoaneurysm (n=1), and small-bowel obstruction (n=1). Pre vs. post-contrast pancreatic MPPE at 1min was 120% in the normal allografts and 115% in the allografts with pancreatitis and without necrosis (p>0.05). MPPE at 1min was only 9% in the allografts rejections with necrosis/infarction. More complications were found in group A than group B (p<0.05). Contrast-enhanced MRI is useful for the non-invasive assessment of pancreas transplant complications.

A randomized, open label, crossover study examining impact of Prograf and Advagraf on mycophenolic acid pharmacokinetics in kidney pancreas transplant patients

A randomized, open label, crossover study examining impact of Prograf and Advagraf on mycophenolic acid pharmacokinetics in kidney pancreas transplant patients

An analysis of pancreas transplantation outcomes based on age groupings – an update of the UNOS database

Previously, increasing age has been a part of the exclusion criteria used when determining eligibility for a pancreas transplant. However, the analysis of pancreas transplantation outcomes based on age groupings has largely been based on single-center reports. A UNOS database review of all adult pancreas and kidney-pancreas transplants between 1996 and 2012 was performed. Patients were divided into groups based on age categories: 18-29 (n=1823), 30-39 (n=7624), 40-49 (n=7967), 50-59 (n=3160), and ≥60 (n=280). We compared survival outcomes and demographic variables between each age grouping. Of the 20854 pancreas transplants, 3440 of the recipients were 50yr of age or above. Graft survival was consistently the greatest in adults 40-49yr of age. Graft survival was least in adults age 18-29 at one-, three-, and five-yr intervals. At 10- and 15-yr intervals, graft survival was the poorest in adults >60yr old. Patient survival and age were found to be inversely proportional; as the patient population's age increased, survival decreased. Pancreas transplants performed in patients of increasing age demonstrate decreased patient and graft survival when compared to pancreas transplants in patients <50yr of age.

Utility of Glucagon Stimulation Test in Type 1 Diabetes After Pancreas Transplantation

BackgroundDespite recent progress of immunosuppressive therapy with newly developed agents, long-term pancreatic graft survival after pancreas transplantation still remains low. Therefore, precise assessment of β-cell function after pancreas transplantation is necessary. MethodsPancreatic β-cell secretory activity was measured by means of the peripheral plasma fasting serum C-peptide (CPR) response to 1 mg of glucagon intravenously in 23 patients after pancreas transplantation. The utility of ΔCPR after injection was compared with other indices that reflect insulin secretion. ResultsWhen we performed the test, 6 patients still needed insulin injection after the transplantation. Mean CPR before and after glucagon intravenously were 1.9 ± 0.98 ng/mL and 4.6 ± 2.29 ng/mL, respectively. Fasting serum CPR, secretory unit of islet in transplantation (SUIT) index, and ΔCPR after glucagon injection were significantly different between insulin users and nonusers. During follow-up (501 ± 228 days), 3 patients could stop using insulin, and their increase of CPR (1.8 ± 0.5 ng/mL) was significantly higher than that in continuous insulin users (0.3 ± 0.3 ng/mL). ConclusionFasting CPR, SUIT index, and ΔCPR after glucagon injection could reflect β-cell function for post–pancreas transplant patients, and glucagon stimulation test could give us additional information to predict insulin-free treatment.

Pancreas Graft Survival in Simultaneous Pancreas-kidney Versus Pancreas-after-kidney and Pancreas Alone Transplantations: A Single Institution Experience

BackgroundPancreas transplantation offers excellent outcomes today in patients who have type-1 diabetes mellitus (DM) with difficult control in terms of increasing patient and pancreatic graft survival. Different factors in donors, recipients, and the perioperative period have been associated with long-term graft survival. The aim of this study was to compare pancreatic graft survival in simultaneous pancreas-kidney transplantation (SPK) and the other two modalities, pancreas-alone and pancreas-after-kidney transplantation (non-SPK), at our institution. MethodsThis retrospective cohort study included 63 pancreas transplantation patients from January 2007 to May 2012 at our institution. The patients were divided into two groups: SPK and non-SPK transplantations. We excluded those patients who had transplants with vascular graft loss. The primary endpoint was 1-year and overall graft survival with consideration of multiple relevant variables. Non-parametric tests were calculated with the statistical package SPSS 20 (SPSS INC, Chicago, IL). ResultsThe 1-year and overall graft survival in this period was 87.3% and 82.5%, respectively. The median follow-up was 963 days. The causes of graft loss were vascular (64%) and immunologic (34%). Finally, we included 56 pancreas transplantations, 46 (82%) were SPK and 10 (18%) non-SPK. The donor and recipient characteristics were similar in both groups, except for the duration of DM (SPK 22 years vs. non-SPK 29 years) and recipient body mass index (SPK 23 vs. non-SPK 28); P = .042 and P = .003, respectively. The cold ischemia time was 563 minutes (standard deviation, 145). Bivariate analysis showed that long-term graft loss was only influenced by matching for gender (P = .023). Using the Kaplan-Meier method, the pancreas graft survival was better in SPK than in non-SPK transplants (log rank .038). ConclusionsPatients who receive pancreas-alone or pancreas-after-kidney grafts have shorter long-term graft survival. Multiple strategies should be applied to improve immunologic surveillance and obtain an early diagnosis of graft rejection.

A Possible Role for Statin Therapy in Solitary Pancreas Transplantation?

IntroductionStatin use after renal transplantation improves long-term outcome and reduces the incidence of glomerulonephritis. With both anti-inflammatory and cardioprotective effects, statins may also improve outcomes in pancreas transplantation. MethodsA retrospective review at a single institution was undertaken. Patients who underwent solitary pancreas transplantation between 2001 and 2010 were identified. Multiple data points including recipient and donor demographics, patient and graft outcomes, and early use of statins were collected. ResultsSixty-eight patients underwent solitary pancreas transplantation within the study period. Eighteen patients (26%) were already on, or were prescribed, a statin at the time of hospital discharge; the 1-year death-censored graft survival was 81.25% for those that were on statins versus 72.9% for those without (P = NS). Excluding patients with early graft loss (<600 days) mean graft survival was 646 days longer for patients receiving statins (P = .02). ConclusionsThe use of statins in the solitary pancreas transplant patient may lead to improved outcomes. Whether this is owing to cardiovascular protection or to other factors not associated with lipid lowering remains unclear.

Pancreas transplantation, antibodies and rejection

Antibody-mediated rejection (AMR) is acknowledged and defined in kidney transplantation, but where do we stand as far as pancreas transplantation is concerned? Here we appraise the most recent findings in pancreatic AMR and give suggestions for future research in the field by addressing currently unresolved issues. Five main topics are discussed: chronological assessment of all literature on biopsy-proven pancreatic AMR; role of C4d and recent development in other markers; the use of sentinel organs, such as kidney biopsies and duodenal patch biopsies for diagnosis of pancreatic AMR; studies addressing islet pathology and its relevance in AMR; and protocol and follow-up pancreas biopsy practice in relation to pancreas transplant management and survival. Antibody-mediated processes play a role in pancreas transplantation. However, sensitive markers, pathophysiological understanding, and adequate interventions have not yet been established. Much data are still lacking and we believe that studying protocol and follow-up biopsies along with serial donor-specific antibody data may improve pancreas transplant patient management and outcomes.

Pancreas and Islet Transplantation

Pancreas and Islet Transplantation

Pancreas-After-Kidney Versus Synchronous Pancreas-Kidney Transplantation

Controversy persists over the safety and efficacy of pancreas transplantation in patients with insulin-dependent diabetes mellitus who have received a prior kidney transplant. We compared the outcomes of recipients who received either Synchronous-Pancreas Kidney-Transplantation (SPK, n=123) or Pancreas-After-Kidney-Transplants(n=49)at our institution between August 2002 to January 2010. Donor and recipient demographics were similar. Time interval between kidney and pancreas transplantation was 5.9 ± 3.8 (4.8 [1.6-12.2]) years. The majority of kidney-recipients in PAK group were transplanted at outside institutions and referred to us for PAK. Most patients received thymoglobulin induction and were maintained on tacrolimus, MMF, and prednisone. For SPK versus PAK recipients, there was no difference in median of length of hospital stay or incidence of overall complications. All PAK recipients are alive with functioning kidney grafts, whereas the 1-, 3-, and 5-year SPK patient survival rates were 98%,96%,and 94%, P=0.09. The 1-,3-, and 5-yr uncensored pancreas survival rates for SPK versus PAK were 93% vs. 90%, 90% vs. 90%, and 82% versus 85%, respectively (P=0.4). Glycemic control and intermediate survival outcomes were similar in both groups. Pancreas-graft outcomes in SPK and PAK were equivalent in our study, but our specific population entailed among other factors a long K to PAK time interval; PAK could be a comparable option to SPK for patients with access to kidney grafts.

Drug Interaction with Pristinamycin in a Kidney and Pancreas Transplant Patient

We report the case of a 49-year-old renal and pancreatic female transplant recipient, who presented a drug interaction between tacrolimus, warfarin and pristinamycin. Three days after oral pristinamycin 1000 mg bid administrations, the patient presented nausea, vomiting, abdominal pain and violent headaches that required hospitalization. Tacrolimus trough level was 5 times higher (34.9 μg/l) than the target required (5-8 μg/l) and the INR was at 5.8 (therapeutic index between 2 and 3) despite a stable kidney function (serum creatinine 130 μmol/L) and no other organic disorders. Five days following discontinuation, drug monitoring revealed adequate tacrolimus plasma trough concentrations (8.9 μg/l) and the INR subsequently decreased. Pristinamycin is an antibiotic effective against the majority of Gram positive bacteria. This drug is an inhibitor of the multidrug transporter P-glycoprotein (P-gp) that could lead to the accumulation of tacrolimus. Moreover, pristinamycin IIA is the active metabolite of quinupristin/dalfopristin which, is known to be an inhibitor of cytochrome P450 3A4 (CYP 3A4). Our case supposes that pristinamycin is also an inhibitor of CYP 3A4 that can lead to an increase of tacrolimus levels. This case report brings to light potential drug interactions of pristinamycin with narrow therapeutic index drugs such as tacrolimus and warfarin.

Measurement of transplanted pancreatic volume using computed tomography: reliability by intra- and inter-observer variability

Unlike other solid organ transplants, pancreas allografts can undergo a substantial decrease in baseline volume after transplantation. This phenomenon has not been well characterized, as there are insufficient data on reliable and reproducible volume assessments. We hypothesized that characterization of pancreatic volume by means of computed tomography (CT) could be a useful method for clinical follow-up in pancreas transplant patients. To evaluate the feasibility and reliability of pancreatic volume assessment using CT scan in transplanted patients. CT examinations were performed on 21 consecutive patients undergoing pancreas transplantation. Volume measurements were carried out by two observers tracing the pancreatic contours in all slices. The observers performed the measurements twice for each patient. Differences in volume measurement were used to evaluate intra- and inter-observer variability. The intra-observer variability for the pancreatic volume measurements of Observers 1 and 2 was found to be in almost perfect agreement, with an intraclass correlation coefficient (ICC) of 0.90 (0.77-0.96) and 0.99 (0.98-1.0), respectively. Regarding inter-observer validity, the ICCs for the first and second measurements were 0.90 (range, 0.77-0.96) and 0.95 (range, 0.85-0.98), respectively. CT volumetry is a reliable and reproducible method for measurement of transplanted pancreatic volume.

Early findings of prospective anti‐HLA donor specific antibodies monitoring study in pancreas transplantation: Indiana University Health Experience

The significance of donor-specific antibodies (DSA) is not well known in the setting of pancreas transplantation. Since December 2009, we prospectively followed pancreas transplant patients with single-antigen-luminex-bead testing at one, two, three, six, and then every six months for the first two yr. Thirty-five of the 92 patients that underwent pancreas transplantation (13 pancreas-alone [PTA], 20 with a kidney [SPK], and two after a kidney [PAK]) agreed to participate in study. Median age at transplant was 45 yr and follow-up was 23 months. Majority were Caucasian (n = 33) and male (n = 18). Rabbit anti-thymocyte globulin induction was used. Median HLA-mismatch was 4.2 ± 1.1. Eight patients (7SPK, 1PAK) developed post-transplant DSA at median follow-up of 76 d (26-119), 1 SPK had pre-formed DSA. Seven patients had both class I and class II DSA, one with class I and one with class II only. Mean peak class I DSA-MFI was 3529 (±1456); class II DSA-MFI was 5734 (±3204) whereas cumulative DSA MFI (CI + CII) was 9264 (±4233). No difference was observed in the patient and donor demographics among patients with and without DSA. One patient in non-DSA group developed acute cellular rejection of pancreas. From our data it appears that post-transplant DSA in pancreas allograft recipients may not impact the early-pancreatic allograft outcomes. The utility of prospective DSA monitoring in pancreatic transplant patients needs further evaluation and long-term follow-up.

Outcomes of Pancreas Allografts Procured Simultaneously With an Isolated Intestine Allograft

Simultaneous procurement of pancreas and isolated intestine allografts from the same donor may compromise one graft or both given the shared vasculature between these two organs. This study reports the transplant outcomes for pancreas allografts procured simultaneously with an intestine graft. Separate analyses are reported from (1) 10-year US national data obtained from the United Network for Organ Sharing database including all donors from 2000 to 2010 in whom both the pancreas and isolated intestine were procured and transplanted into separate recipients and (2) local, single-center data for all donors of simultaneous pancreas and isolated intestine procurement. Scientific Registry of Transplant Recipients reference data are provided for comparison. Nationally, there were 159 simultaneous pancreas and intestine donors. The mean pancreas transplant graft and patient survival rates for this cohort were 75% and 93%, respectively. There were 34 isolated intestine allografts procured by our center during the study period. There were 14 cases (41%) in which the pancreas was transplanted. The reasons for nontransplantation of the pancreas in the other 20 donors included donor age (n=12), graft quality (n=4), and anatomic or surgical issues (n=4). For the 14 transplanted grafts, 1-year pancreas allograft survival rate was 100%. These results suggest that pancreas allografts procured simultaneously with an isolated intestine graft, although technically more challenging, do not have significantly inferior survival outcomes.

Endoscopic Botulinum Toxin Injection for the Treatment of Diabetic Gastropathy in Pancreas and Islet-cell Transplant Patients

Gastroparesis is a well-recognized, long-term complication of diabetes. Prokinetic drugs are often not effective, prompting the development of alternative therapies. We report our experience of using one such alternative, endoscopic botulinum toxin injection, to ameliorate diabetic gastropathy in association with pancreas and islet-cell transplant patients. Three male diabetic patients aged 42 to 55 years had been treated with botulinum toxin in our center. Two patients were both after-simultaneous pancreas-kidney transplant and 1 was awaiting islet-cell transplant after pancreatectomy. Mechanical gastric outlet obstruction was first excluded by radiological and endoscopic studies. Between 100 and 200 IU of toxin were then injected in the prepyloric region using an endoscopic technique. A subjective scoring scale was used to assess symptoms before and after botulinum therapy. Improvement in subjective symptom severity scoring was seen in all patients, with a posttreatment improvement from 55% to 91%. Such improvement was temporary in 2 patients and long-lasting in 1 patient. The time for improvement of gastric autonomic function after pancreas or islet-cell transplantation remains unclear. Some patients may continue to be symptomatic, leading to increasing morbidity. However, endoscopic botulinum injections may provide short-term relief while waiting for improvement and spare patients the morbidity associated with more-invasive therapies.

Posttransplant Lymphoproliferative Disorder in Kidney Transplant Patients: A Report of 68 Cases

Abstract 2662Posttransplant Lymphoproliferative Disorder (PTLD) is a rare complication of kidney transplantation that often arises due to reactivation of the Epstein-Bar Virus (EBV). Given the rarity of this disease, a full understanding of its presentation and optimal therapies has yet to be determined. Out of the 3160 patients who received a kidney transplant at the Hospital of the University of Pennsylvania between October 1987 and December 2010, we provide a retrospective analysis of 68 patients who developed PTLD. These patients were 82% Caucasian, 62% male, and 9% combined kidney and pancreas transplant patients. The most common underlying diseases leading to transplantation were glomerulonephritis (26%) and diabetes mellitus (17%). Most patients received a kidney from an unrelated donor (74%) and experienced one or more rejection episodes prior to PTLD diagnosis (59%). The median age at PTLD diagnosis was 48 yrs (range 17–76 yrs), and the median time from transplantation to diagnosis was 3 yrs (range 6 days– 25 yrs). PTLD histology consisted of 48% monomorphic, 37% polymorphic, 7% plasmacytoma, 4% T cell, and 3% Hodgkin lymphoma. At diagnosis, patients were taking steroids (96%), cyclosporine (53%), tacrolimus (35%), azathioprine (52%), and/or mycophenolate mofetil (28%). Common initial PTLD symptoms include fever (48%), pain (42%), weight loss (33%), fatigue (33%), and mass (24%). The disease commonly presented in lymph nodes (38%), kidney allograft (29%), and/or GI tract (18%). Most PTLD cases were diagnosed at stage 1 (43%) or stage 4 (31%). Laboratory analyses reveal that 62% of patient tumors tested positive for EBV and 61% of patients had elevated LDH levels. Common PTLD therapies included reduction of immunosuppression (88%), treatment with rituximab (31%), surgery (29%), and/or radiation therapy (9%). Reduction of immunosuppression alone led to CR (50%), PR (8%), SD (4%), and PD (38%). Of the 68 patients, 21 (31%) ultimately died a PTLD related death.Interestingly, PTLD patients under age 40 were more likely to have allograft involvement (p=0.007) and a polymorphic histology (p=0.007). Furthermore, allograft involvement tended to occur sooner after transplant (p=0.0001) and those with allograft involvement were more likely to present with allograft failure (p= 0.0001). Compared to monomorphic PTLD, polymorphic PTLD was more likely to be EBV positive (82% vs 51%, p=0.03) and have a lower chance of PTLD-related death (15% vs 40%, p=0.03). Finally, patients with allograft PTLD were more likely to have a polymorphic histology (80%, p<0.001). In summary, PTLD occurs in about 2% of kidney recipients and is typically EBV-associated. EBV positive PTLD is more common in younger recipients, frequently presenting with polymorphic histology in the allograft and appears to have a better prognosis. Disclosures:No relevant conflicts of interest to declare.

Impact of Cytomegalovirus Disease in D+/R– Kidney Transplant Patients Receiving 6 Months Low-Dose Valganciclovir Prophylaxis

Late-onset cytomegalovirus (CMV) disease remains common in CMV serology naïve kidney transplant patients of CMV serology positive organs (D+/R-) despite the use of antiviral prophylaxis. We studied clinical efficacy of 6-month low-dose valganciclovir (VGCV) prophylaxis, risk factors for late-onset CMV disease and its impact on kidney transplant outcomes. Between October 2005 and December 2009, 166 consecutive D+/R- kidney alone and simultaneous pancreas and kidney transplant patients received VGCV 450 mg daily for 6 months after transplantation. After a median follow-up of 3.2 years, 30 cases of CMV disease occurred within the first 2 years after transplantation with a cumulative incidence of 11.5 and 18.1% at 1 and 2 years, respectively. The use of an induction agent with rabbit antithymocyte globulin and older donor age were factors associated with the risk of late-onset CMV disease (AHR 2.91, 95% CI 1.18-7.20, p = 0.021 and AHR 1.03, 95% CI 1.01-1.06, p = 0.016, respectively). Late-onset CMV disease was associated with increased risk for death-uncensored graft loss (AHR 2.95, 95% CI 1.15-7.61, p = 0.025). In conclusion, late-onset CMV disease continues to negatively impact kidney transplant outcome despite 6-month low-dose VGCV prophylaxis. Investigations focusing on novel preventive approaches should be emphasized.