Simultaneous Kidney Transplantation Research Articles

Desensitizing With Temporary Donor Splenic Transplant: Hope for the Sensitized Patients on Pancreas and Kidney -Pancreas Transplant Waitlist

Sensitized patients on a waitlist with donor specific antibodies (DSA) or positive flow cytometry cross match (FXM) to deceased donor organ have few pretransplant desensitization options due to increasing graft cold ischemia time. Herein, sensitized simultaneous kidney/pancreas recipients received temporary splenic transplant from the same donor under the hypothesis that spleen would function as a DSA graveyard and provide a safe immunologic window for transplant. We analyzed presplenic and postsplenic transplant FXM and DSA results of 8 sensitized patients who underwent simultaneous kidney and pancreas transplantation with temporary deceased donor spleen between November 2020 and January 2022. Pre-splenic transplant, 4 sensitized patients were both T-cell and B-cell FXM positive; one was only B-cell FXM positive and 3 were DSA positive/FXM negative. Post-splenic transplant, all were FXM negative. Pre-splenic transplant class I and class II DSA were detected in 3 patients, only class I DSA in 4 patients, and only class II DSA in 1 patient. Postsplenic transplant, class I DSA was eliminated in all patients. Class II DSA persisted in 3 patients; all showed a marked decrease in DSA mean fluorescence index. Class II DSA was eliminated in one patient. Donor spleen functions as a DSA graveyard and provides an immunologically safe window for kidney-pancreas transplantation.

Outcomes of Simultaneous Heart and Kidney Transplantation

BackgroundSimultaneous heart-kidney transplantation has been increasingly performed in end-stage heart failure patients with concurrent kidney dysfunction despite limited evidence supporting its indications and utility. ObjectivesThe purpose of this study was to investigate the effects and utility of simultaneously implanted kidney allografts with various degrees of kidney dysfunction during heart transplantation. MethodsUsing the United Network for Organ Sharing registry, long-term mortality was compared in recipients with kidney dysfunction who underwent heart-kidney transplantation (n = 1,124) vs isolated heart transplantation (n = 12,415) in the United States between 2005 and 2018. In heart-kidney recipients, contralateral kidney recipients were compared for allograft loss. Multivariable Cox regression was used for risk adjustment. ResultsLong-term mortality was lower among heart-kidney recipients than among heart-alone recipients when recipients were on dialysis (26.7% vs 38.6% at 5 years; HR: 0.72; 95% CI: 0.58-0.89) or had a glomerular filtration rate (GFR) of <30 mL/min/1.73 m2 (19.3% vs 32.4%; HR: 0.62; 95% CI: 0.46-0.82) and GFR of 30 to 45 mL/min/1.73 m2 (16.2% vs 24.3%; HR: 0.68; 95% CI: 0.48-0.97) but not in GFR of 45 to 60 mL/min/1.73 m2. Interaction analysis showed that the mortality benefit of heart-kidney transplantation continued up to GFR 40 mL/min/1.73 m2. The incidence of kidney allograft loss was higher among heart-kidney recipients than among contralateral kidney recipients (14.7% vs 4.5% at 1 year; HR: 1.7; 95% CI: 1.4-2.1). ConclusionsHeart-kidney transplantation relative to heart transplantation alone provided superior survival for dialysis-dependent recipients and non–dialysis-dependent recipients up to a GFR of approximately 40 mL/min/1.73 m2 but at the cost of almost twice the risk of kidney allograft loss than contralateral kidney allograft recipients.

State of the Retina and Visual Functions before and after Pancreatic Transplantation (Clinical Case)

In this report, we reflected a clinical case of the course of the proliferative stage of diabetic retinopathy in a patient suffering from type 1 diabetes mellitus (DM) and end-stage diabetic nephropathy (DN) before and after simultaneous pancreas and kidney transplantation. As a result of successful surgical treatment of DM and DN was achieved physiological normoglycemia (change in fasting blood glucose from 11 to 5.1 mmol/l, glycated hemoglobin level from 9.2 to 5.7 %) and relief of uremic syndrome (change in serum creatinine from 632 to 77,5 µmol/l, urea from 13 to 6 mmol/l, glomerular filtration rate from 7.1 to 83.5 ml/min/1.73 m2). By the end of the first year of the post-transplantation period according to ophthalmoscopy data on the fundus no regression of the initial and addition of new diabetic changes was recorded and according to special instrumental methods of research was recorded a partial improvement hemoperfusion in superficial (an increase in the whole perfusion density: OD — from 24 to 35 %; OS — from 23 to 33 %) and deep (increase in the whole perfusion density: OD — from 5 to 13 %; OS — from 4 to 6 %) capillary plexus, a decrease in the central thickness of the retina (OD — from 269 to 257 µm; OS — from 271 to 253 µm) with resorption of intraretinal fluid in the right eye, improvement of the visual acuity (OD — from 0.5 to 0.7; OS — 0.6 to 0.7) and light sensitivity (macula light sensitivity threshold: OD — from 16.5 to 21.8 dB; OS — from 22.1 to 25.4 dB) of both eyes.

Simultaneous split liver/kidney transplantation: a national and single center experience report

Background: End-stage liver disease (ESLD) and end-stage renal disease (ESRD) both remain prevalent diseases for which the definitive treatment is transplantation. The increasing number of patients with concurrent ESLD and ESRD has led to the increasing advent of simultaneous liver and kidney transplantations. With a limited organ supply, strategies to maximize organ availability has led to increasing rates of split liver transplantations for ESLD patients. Therefore, simultaneous split liver and kidney transplantations (SSLK) for patients with ESLD and ESRD could represent a treatment option for these patients. However, current practice and outcomes after SSLK are unknown. We aim to report our experience, as well as national trends on transplant recipients undergoing SSLK.

Pancreas Transplantation Alone for Brittle Diabetes Mellitus

Only about 8% of all pancreas transplants for insulin-dependent diabetes mellitus are performed in the Pancreas Transplant Alone (PTA) category. PTAs are primarily performed in diabetic, non-uremic patients with unstable glucose control, hypoglycemia unawareness, and an increased risk of diabetes-related mortality, and who have failed all of the more traditional approaches to glycemic control. Tremendous, yet not widely noticed, progress in PTA outcome has been made over the past two decades. PTA is a very safe procedure with 1-and 5-year patient survival rates of 98.3% and 90.5% according to International Pancreas Transplant Registry (IPTR) data. Since the introduction of tacrolimus and mycophenolate mofetil maintenance therapy in the 1990s and the use of depleting antibody induction therapy, PTA graft survival rates at 1-and 5-years posttransplant are 87.2% and 65.0%. To avoid the need for a future kidney after pancreas (KAP) transplant due to impaired pretransplant native kidney function and the posttransplant use of calcineurin inhibitors, the estimated Glomerular Filtration Rate (eGFR) of PTA candidates should be well within the normal range and preferably &gt; 80 mL/min/1.73m². PTAs with stable, long-term function have been shown to have a positive impact on secondary complications of diabetes mellitus. Considering the significantly improved outcome results, PTA should become the pancreas transplant option of choice before the manifestation of devastating secondary complications (kidney failure, cardio-cerebrovascular events, and blindness) that require simultaneous pancreas and kidney (SPK) transplants in qualified candidates, but with higher morbidity and mortality risks. It is important for diabetologists, endocrinologists, and other health professionals involved in the care of diabetic patients to learn about these positive PTA outcome results. Despite improvements in intensive insulin therapy, insulin-delivering devices, bioartificial pancreas, and islet transplantation, a successful PTA is the only treatment option for patients with brittle diabetes that consistently restores normal glucose homeostasis long-term without exposing recipients to the risks of severe hypoglycemia and prevents, halts, or reverses the development or progression of secondary diabetes complications.

Hepatorenal syndrome: new insights about treatment (part III)

Hepatorenal syndrome is a common and serious complication in cirrhotic patients, leading to significant morbidity and mortality. Although pharmacological treatments have shown mortality benefit, the ideal hepatorenal syndrome treatment option is liver transplantation with or without simultaneous kidney transplantation. Further research is required to optimize pharmacologic and nonpharmacologic approaches to treatment. An analysis of literature reviews, clinical studies, experimental research, clinical recommendations from PubMed / Medline and ELIBRARY databases was carried out for 7 keywords according to the review topic.

Hypercrystalluria as a Factor in the Development of Urine Stone Disease, Diagnosis and Directions of Treatment

Under the action of exogenous, androgenic, genetically determined factors, the metabolism of stone-forming salts of calcium, phosphorus, magnesium, oxalates, uric acid in the blood serum and their active excretion by the kidneys to the state of hypersaturation (oversaturation) is disturbed) urine is formed. When the level of crystallization inhibitors is disturbed, a saturated salt solution crystallizes with the formation of microliths. The formation of stones in the kidneys is possible only in the presence of «building material» – supersaturated saturated urine, therefore, hyperoxaluria is a pre-stone condition. Treatment measures should be aimed at correcting mineral metabolism in the body after establishing the type of hyperoxaluria using laboratory tests: salt transport, calcium load, dietary test – low-calcium diet, thiazide test and determination of the mineral composition of the removed (removed) stone. Genetically consequential conditions (10–15%) count about 30 varieties in which the main sign or symptom in the manifestation of the disease is urolithiasis. Unfortunately, congenital tubulopathies are not sufficiently studied, so the treatment is symptomatic, in some cases simultaneous kidney and liver transplantation options are possible. Clinically, 4 main forms of hypercrystalluria are distinguished: hypercalciuria, hyperoxaluria, hyperuricuria, phosphaturia and mixed forms of crystalluria. Acquired forms of hypercrystalluria, of which they are absorptive (type II intestinal hyperabsorption – absorptive hypercalciuria and absorptive hyperoxaluria), are of main clinical interest, which is characteristic of the course of calcium-oxalate urolithiasis. Metaphylaxis of calcium-oxalate urolithiasis is formed on the basis of these data.

212. Outcomes of Weekly Fluconazole Antifungal Prophylaxis in Pancreas Transplant Recipients

Abstract Background Fungal infections following pancreas transplantation carry significant morbidity and mortality with an estimated incidence of 3 to 28%. The American Society of Transplantation (AST) suggests considering fluconazole prophylaxis in pancreas transplant recipients (PTR) at high-risk of invasive candidiasis (IC). However, optimal dosage and duration of prophylaxis is unclear. Weekly fluconazole for prevention of IC has been previously reported in liver and bone marrow transplant recipients. We analyzed outcomes of once weekly fluconazole prophylaxis in PTR. Methods We retrospectively reviewed all pancreas transplants performed at our institution from January 2017 through September 2021. PTR at high-risk for IC were defined per AST criteria as those with enteric drainage, vascular thrombosis, and post-perfusion pancreatitis. Patients received once weekly oral fluconazole 200 mg for 12 weeks post-transplant for IC prophylaxis. We analyzed incidence of breakthrough IC within the first 6 months post-transplant. Results We identified a total of 22 PTR, all of whom received simultaneous kidney transplantation from deceased donors. Of these, 12/22 (55%) were male and 11/22 (50%) were African American. Median age at the time of transplantation was 39 years (IQR 34-46). The most common indication for transplantation was type 1 diabetes mellitus (17/22, 21%) with associated nephropathy. No donor organ cultures were positive for fungi and all pancreas transplants were performed using enteric drainage. Notably, one patient developed pancreas allograft thrombosis while another developed pancreatitis. No patients required early discontinuation of fluconazole due to intolerance or side effects and none developed breakthrough IC within 6 months post-transplant (Table 1). Table 1. Conclusion Weekly fluconazole prophylaxis has not been previously studied in PTR. In our cohort, this approach was well tolerated, with no cases of IC at 6 months post-transplantation in patients at high-risk. Randomized controlled clinical trials are needed to define the optimal strategy in this population. Disclosures M. Rizwan Sohail, MD, Aziyo Biologics: Honoraria|Boston Scientific Corporation: Honoraria|Medtronic: Grant/Research Support|TRYX: Grant/Research Support.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Simultaneous Living Kidney And Liver Transplantation in a Young Male From Two Living Donors.

Simultaneous kidney and liver transplantation (SKLT) is the surgical treatment modality for combined liver and kidney failure. Although it is a challenging procedure, but has got theadded advantage of a single procedure and common immunosuppression therapy. Recently, the practice of deceased donors SKLT has increased dramatically in the West. However, it is less frequently performed with living donors. Here, we describe a successful SKLT procedure from two separate living donors in a 31-year male, who presented with end-stage renal disease secondary to hypertensive nephropathy and decompensated chronic liver disease secondary to hepatitis C infection. The patient had a smooth recovery and on 1-year follow-up, he is stable. Key Words: Simultaneous, Liver, Kidney, Transplantation.

Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience.

We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p=.438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p=.459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p=.027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p=.119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p=.164 and p=.47, respectively). In multivariable analysis, Amylase levels>270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p=.040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.

"Creating Blue Skies Overhead for All" Introduction of the 2022 Recipient of the Medawar Prize of the Transplantation Society: Professor Jeremy Chapman.

"Creating Blue Skies Overhead for All" Introduction of the 2022 Recipient of the Medawar Prize of the Transplantation Society: Professor Jeremy Chapman.

Cytomegalovirus Graft Duodenitis Diagnosed by Transanal Double-Balloon Endoscopy Technique in an Enteric-Drained Pancreas Transplant Recipient: A Case Report

Duodenal graft complications are not uncommon after pancreas transplant (PTx). Although direct visualization and biopsy of the duodenal graft are important for accurate diagnosis and management, endoscopic access is often limited in cases of enteric-drained PTx. Herein, we present a case of cytomegalovirus (CMV) graft duodenitis that was successfully diagnosed by transanal endoscopy using the double-balloon technique. The patient was a 54-year-old woman who underwent simultaneous pancreas and kidney transplant for type 1 diabetes mellitus and end-stage kidney disease. Enteric drainage was established by anastomosing the graft duodenum to her ileum. One month after the transplant, she developed fever and complained of lower abdominal pain. Graft duodenitis was suspected by laboratory test and imaging study results. Transanal double-balloon endoscopy was performed, and the biopsy specimen of the mucosa of the graft duodenum revealed CMV duodenitis without histopathologic findings of acute rejection. The postendoscopy course was uneventful. Treatment with ganciclovir was promptly initiated, and the CMV duodenitis was resolved with good function of the pancreas graft. In patients who undergo PTx with establishment of exocrine drainage by enteroanastomosis to the recipient ileum, transanal double-balloon endoscopy might be a feasible and safe technique for the surveillance of duodenal graft complications, including CMV duodenitis.

Simultaneous heart and kidney transplantation in middle-aged women with cardiac amyloidosis

Simultaneous heart and kidney transplantation in middle-aged women with cardiac amyloidosis

Evolution of simultaneous pancreas and kidney transplant program in PGIMER Chandigarh

Evolution of simultaneous pancreas and kidney transplant program in PGIMER Chandigarh

Impact of pancreas donor risk index on pancreas graft survival after simultaneous pancreas and kidney transplantation

Impact of pancreas donor risk index on pancreas graft survival after simultaneous pancreas and kidney transplantation

Infections following rejection therapies in kidney and liver transplant recipients.

Infections are known complications of solid-organ transplant. Treatment for rejection may increase risk of infection. We aimed to study frequency of infection and identify the risk factors for infections in solid organ transplant (SOT) (liver and kidney) recipients treated for rejection. This is a retrospective chart review of all liver and kidney transplant recipients treated for rejection at our institution from 2014 to 2020. We collected information on episodes of acute rejection in the first year of transplant and infections within 6 months following rejection treatment. We identified 257 transplant patients treated for rejection. One hundred twelve (43.6%) developed infections, with a total of 226 infections. Urinary tracts infections were the most common, 72 (31.9%), followed by cytomegalovirus viremia in 37 (16.4%), bacteremia in 24 (10.6%), and BK virus in 14 (6.2%). Female sex (p = .047), elevated neutrophil count at rejection (p = .002), and increased number of rejection episodes (p = .022) were predictors of infection in kidney and simultaneous liver-kidney recipients. No specific type of induction or rejection therapy was identified as a risk factor for infection, likely due to the prophylaxis protocols at our institution. Infection post rejection treatment was associated with higher graft loss (p = .021) and mortality (p = .031) in kidney transplant recipients. Infections are common complications after treatment of SOT rejection. Female gender, higher neutrophil at time of rejection, and increased numbers of rejection episodes were predictors of infections after rejection in simultaneous liver-kidney and kidney transplant patients. Infections were predictors of graft loss at 6 months and mortality at any point in follow-up in kidney transplant patients.

Abstract 13448: Time Course and Predictors of Renal Function Decline After Pediatric Heart Transplantation: A PHTS Multi-Institutional Analysis

Introduction: Decline in renal function can impact both the management and outcomes of pediatric heart transplantation (HTx). Initial renal function decline may be subclinical and underappreciated. We sought to identify the time course and predictors of decline in renal function and the impact of these changes on HTx outcomes. Methods: The Pediatric Heart Transplant Society (PHTS) database was queried to identify HTx recipients at participating centers from 1996 to 2019 with at least 1 year of follow-up. Patients with simultaneous or previous kidney transplant were excluded. Renal function was measured by modified Schwartz formula eGFR on annual follow-up forms and stratified into eGFR groups by National Kidney Foundation chronic kidney disease staging guidelines. “Initial renal function decline” was defined as the initial drop by at least one eGFR group relative to stage at 1 year post transplant (“baseline”). Results: Of the 5,250 patients who met inclusion criteria, initial renal function decline occurred, relative to baseline, in 7.4%, 18.7%, and 55.7%, by 1, 5, and 10 years of follow up, respectively (Figure A). eGFR group distribution for the cohort progressively worsened over the follow up period (Figure B). On multivariate Cox modeling, risk factors for renal function decline were increased BSA at 1 year post-transplant (HR 1.24 [1.02, 1.52]), acute rejection with hemodynamic compromise (HR 1.24 [1.10, 1.39]), and Black race (HR 1.21 [1.08, 1.36]) with the use of tacrolimus (vs cyclosporine) being protective (HR 0.77 [0.69, 0.85]). Patients whose eGFR was &lt; 30 mL/min at 1 year follow up had an increased risk of graft loss (P &lt; 0.0001 compared to all other groups). Conclusions: Decline in renal function occurs progressively, affecting over 50% of HTx recipients in long term follow up, independent of renal condition at the time of HTx. Avoidance of potentially nephrotoxic events and medications must be considered at all times in the long term management of pediatric HTx.

Immunology of simultaneous liver and kidney transplants with identification and prevention of rejection.

Simultaneous liver and kidney (SLK) transplantation is considered the best treatment modality among selected patients with both chronic kidney disease (CKD) and end-stage liver disease (ESLD). Since the first SLK transplant in 1983, the number of SLK transplants has increased worldwide, and particularly in the United States since the implementation of the MELD system in 2002. SLK transplants are considered a relatively low immunological risk procedure evidenced by multiple studies displaying the immunomodulatory properties of the liver on the immune system of SLK recipients. SLK recipients demonstrate lower rates of both cellular and antibody-mediated rejection on the kidney allograft when compared to kidney transplant-alone recipients. Therefore, SLK transplants in the setting of preformed donor-specific HLA antibodies (DSA) are a common practice, at many centers. Acceptance and transplantation of SLKs are based solely on ABO compatibility without much consideration of crossmatch results or DSA levels. However, some studies suggest an increased risk for rejection for SLK recipients transplanted across high levels of pre-formed HLA DSA. Despite this, there is no consensus regarding acceptable levels of pre-formed DSA, the role of pre-transplant desensitization, splenectomy, or immunosuppressive management in this unique population. Also, the impact of post-transplant DSA monitoring on long-term outcomes is not well-studied in SLK recipients. In this article, we review recent and relevant past articles in this field with a focus on the immunological risk factors among SLK recipients, and strategies to mitigate the negative outcomes among them.

Racial Differences in Trends and Survival After Simultaneous Heart and Kidney Transplantation in the United States

Racial Differences in Trends and Survival After Simultaneous Heart and Kidney Transplantation in the United States