Treatment Of Transplant Patients Research Articles

Surveillance of a Transplant Kidney Harboring a Stable Renal Artery Aneurysm: A Case Report

Renal artery aneurysms (RAA) may occur in patients with transplanted kidneys, either through de-novo development or as a preexisting feature of the donor kidney. How this vascular condition progresses in patients on immunosuppressive therapy after transplantation is poorly understood, and consensus guidelines for treating transplant patients with RAA have not been developed. We present the case of a kidney allograft recipient on triple immunosuppressive therapy in whom post-operative imaging revealed a 13 mm renal artery aneurysm in the renal hilum not amenable to endovascular intervention. We review systemic influences on aneurysm formation and how matrix metalloproteinases may interact with immunosuppressive medications. Surveillance imaging over 5 years has shown a stable aneurysm, and the patient has maintained stable renal function with adequate creatinine levels and no adverse symptoms.

Nonadherence to Immunosuppressants Among Transplant Recipients: Emotional Intelligence as a Predictive Factor During COVID-19 Pandemic.

To evaluate the association between emotional intelligence and fear of COVID-19 on self-reported adherence, based on a cross-sectional design. Transplants recipient of both sexes aged 23-75 years old were evaluated at the Organ Transplant Unit, University Hospital of Catania, Italy. Data were analyzed using frequency, descriptives, Spearman and Pearson correlations, Chi-square goodness of fit test, and linear regression. Self-reported adherence was estimated with the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Emotional intelligence and fear of COVID were, respectively, measured with the Emotional Intelligence Scale (EIS) and Multidimensional Assessment of COVID-19 Related Fears Scale (MAC-RF). This was a cross-sectional study of kidney transplant recipients. In reporting this study the authors followed the STROBE guidelines. A correlation was found between EIS and MAC and between EIS and adherence but there was no correlation between MAC and adherence. A linear regression model was also conducted using a stepwise method, which indicated that EIS was a significant predictor of adherence (p <0.05). This study was found that EIS is a predictor of adherence to treatment in transplant patients. Fear of COVID, while positively correlated to EIS, is not correlated to the adherence's outcome, possibly due to the proper follow-up performed to the patients. Indeed, according to these results, we suggest to provide good follow-ups with recipients, with interviews also based on self-regulation and awareness.

Tuberculosis treatment without rifampin in kidney/kidney-pancreas transplantation: A case series report.

The best approach to tuberculosis (TB) treatment in transplanted patients is still unknown. Current guidelines are based on evidence either extrapolated from other populations or observational. Rifampin-containing regimens have strong pharmacokinetic interactions with immunosuppressive regimens, with high rates of organ dysfunction and ∼20% mortality. This report describes the results obtained using non-rifampin-containing regimens to treat confirmed TB in adult patients with kidney/kidney-pancreas transplantation. Retrospective data analysis from confirmed TB cases in adult kidney/kidney-pancreas transplant recipients (2006-2019), treated "de novo" with non-rifampin-containing regimens. Fifty-seven patients had confirmed TB. Thirty patients were treated "de novo" with non-rifampin-containing regimens. These patients' mean age was 49.24 (±11.50) years. Induction immunosuppression was used in 22 patients. Maintenance immunosuppression was tacrolimus-mycophenolate-steroids in 13 (43%), sirolimus-mycophenolate-steroids in 6 (20%), and other immunosuppressive regimens in 11 (36%). Belatacept was used in four patients. TB localizations: pulmonary 43%; disseminated 23%; extrapulmonary 33%. Twenty-seven (90%) patients completed treatment with isoniazid, ethambutol, and levofloxacin (12 months, 23; 9 months, 3; 6 months, 1); 12 of these patients also received pyrazinamide for the first 2months and were cured with functioning grafts. One patient (3%) lost the graft while on treatment. Two patients (7%) died while on TB treatment. Median (range) follow-up after completion of TB treatment was 32 (8-150) months. No TB relapses were observed. Results with non-rifampin-containing TB treatments in this case series were better (in terms of mortality and graft dysfunction) than those previously described with rifampin-containing regimens in transplanted patients.

Does STING failure affect short-term graft functions in renal transplant patients: a single-center study.

The aim of the present study was to evaluate outcomes of symptomatic VUR treatment in transplant patients, compare open and endoscopic approaches in terms of graft functions, success rates, complications and recurrent UTIs. 67 patients who undergone only STING and STING followed redo UNC due to symptomatic VUR after kidney transplantation were included into the investigation. Patients who had lower urinary tract dysfunctions were excluded from the trial. For 67 patients, baseline and before final surgery and 3rd month creatinine and GFR levels were recorded. Twenty-six of those 67 patients had redo UNC due to failed STING. The data of those patients were compared with the remaining 41 patients who had only STING. In both groups no statistically significant variations in serum creatinine and GFR levels were detected during follow-up (p > 0.05). Serum levels after STING and in the 3rd month of redo UNC were compared. Although variation was observed in serum creatinine levels and in GFR levels, was not statistically significant (p: 0.59 and p: 0.23). The success rate of STING was %61.1 in 67 patients, and was not significantly different when three VUR grade groups (Grade 3 n:17, Grade 4 n:24, Grade 5 n:36) were compared (p > 0.05). The present study revealed that subureteral endoscopic injection is cost effective and safe for the first-line treatment due to its minimally invasive nature, does not cause delay which leads to deterioration of graft functions. Redo-UNC has acceptable morbidity and complication rates, should be considered when STING is failed.

Rapidly Disseminated Strogyloidiasis Following Liver Transplant

Introduction: Strongyloides stercoralis is an intestinal nematode with nonspecific gastrointestinal symptoms. In transplant patients, disseminated strongyloidiasis carries a mortality rate of 80%. Case report: The patient is a 54 year old athlete who underwent liver transplant in 2019. He is normally extremely physically active. He presented one year post-transplant with three days of diffuse gnawing abdominal pain that came in waves. He noted recent ten-pound weight gain and constant fatigue. Labs suggested malnutrition requiring parenteral nutrition. Endoscopies were negative. Rejection and tumor workups were negative. He continued to have diffuse abdominal pain, anorexia and constipation. He began to have hypotension and persistent fevers, but blood cultures were negative. He stayed in bed feeling depressed and “constantly drained”. With worsening bloating and epigastric pain, a repeat endoscopy was performed. Multiple patches of friable erythematous mucosa were noted in the stomach and duodenum. Biopsies demonstrated parasitic worms, confirmed to be Strongyloides. Treatment with Ivermectin was initiated. He had complete resolution of his symptoms within four days, including a dramatic improvement in mood and motivation. It was discovered that a week before the onset of his symptoms, the patient had adopted a dog with no vaccination record, believed to have been a parasitic host. The time from exposure to hospitalization was one week. Conclusions: Disseminated strongyloidiasis is characterized by overwhelming worm burden causing sepsis, shock and gastrointestinal failure. It is important for clinicians to recognize the atypical physical and mental symptoms, as well as the rapid resolution with proper treatment in transplant patients.

Immunomodulatory Properties of Mesenchymal Stromal Cells Can Vary in Genetically Modified Rats.

Mesenchymal Stromal Cells (MSC) have been shown to exhibit immuno-modulatory and regenerative properties at sites of inflammation. In solid organ transplantation (SOT), administration of MSCs might lead to an alleviation of ischemia-reperfusion injury and a reduction of rejection episodes. Previous reports have suggested ‘MSC-preconditioning’ of macrophages to be partly responsible for the beneficial effects. Whether this results from direct cell-cell interactions (e.g., MSC trans-differentiation at sites of damage), or from paracrine mechanisms, remains unclear. Immunosuppressive capacities of MSCs from donors of different age and from genetically modified donor animals, often used for in-vivo experiments, have so far not been investigated. We conducted an in vitro study to compare paracrine effects of supernatants from MSCs extracted from young and old wild-type Wystar-Kyoto rats (WKY-wt), as well as young and old WKY donor rats positive for the expression of green fluorescent protein (WKY-GFP), on bone marrow derived macrophages (BMDM). Expression levels of Mannose receptor 1 (Mrc-1), Tumor necrosis factor α (TNFα), inducible NO synthase (iNos) and Interleukin-10 (IL-10) in BMDMs after treatment with different MSC supernatants were compared by performance of quantitative PCR. We observed different expression patterns of inflammatory markers within BMDMs, depending on age and genotype of origin for MSC supernatants. This must be taken into consideration for preclinical and clinical studies, for which MSCs will be used to treat transplant patients, aiming to mitigate inflammatory and allo-responses.

Letermovir and Maribavir for the Treatment and Prevention of Cytomegalovirus Infection in Solid Organ and Stem Cell Transplant Recipients.

Until recently, available drugs for cytomegalovirus (CMV) prevention and treatment in transplant patients included (val)ganciclovir, foscarnet, and cidofovir. Use of these drugs is limited by toxicity and the development of resistance. The 2017 approval of letermovir for prevention of CMV after stem cell transplant marked the first approval of an anti-CMV agent since 2003. The role of letermovir in treatment of established CMV infection or disease remains largely unstudied, although early reports suggest that a low barrier to resistance will likely limit efficacy as primary therapy for patients with refractory or resistant disease. The investigational agent maribavir has shown promise as preemptive treatment; in patients with refractory or resistant disease the emergence of resistance while on treatment has been observed and ongoing studies will define efficacy in this population. Both agents have unique mechanisms of action limiting cross resistance, and neither exhibit myelotoxicity or nephrotoxicity.

Failure of Achieving Tacrolimus Target Blood Concentration Might Be Avoided by a Wide Genotyping of Transplanted Patients: Evidence from a Retrospective Study.

Precise tacrolimus treatment in transplanted patients is achieved in the clinical setting by performing therapeutic drug monitoring (TDM) and consequently adjusting therapy. The aim of this study was to retrospectively analyze the variability in tacrolimus blood levels throughout 2 years of observation in 75 transplanted patients and to investigate if tacrolimus blood levels correlate with presence of genetic polymorphisms, thus modifying tacrolimus pharmacokinetics. CYP3A5*1 (G6986A), CYP3A4*1B (A392G), CYP3A4*22, ABCB1 (C3435T; C1236T; G2677A/T), SLCO1B1 (T521C), polymorphisms were analyzed. Based on the effect of their genotypes, patients were stratified into 5 groups: (1) reduced tacrolimus metabolism (RM), (2) increased metabolism (IM), (3) transporters polymorphisms (TM), (4) metabolism and transporter polymorphisms (AM) and (5) no mutations (Wild Type, WT). The percentage of the samples out of therapeutic range was significantly higher in the IM group than in the WT group (p = 0.001), as well as compared to the TM group (p = 0.004). Only IM pattern (p = 0.015) resulted as an independent predictor of number of tacrolimus blood levels out of therapeutic range. RM pattern (p = 0.006) was inversely related to the administered dose. Therefore, genotyping could become a standard practice before tacrolimus prescription thus decreasing side effects, increasing efficacy and reducing the economic burden for the national health system.

Renal transplant alıcılarında düşük doz valgansiklovir profilaksisinin etkinliği ve güvenilirliği

Purpose: Cytomegalovirus (CMV) infection is one of the most common infections observed following kidney transplantations. Transplantations between cytomegalovirus (Immunoglobulin G)-seropositive donor and CMV-seropositive recipient (D+/R+) are considered to be of moderate risk. In our study, we investigated the efficacy of low-dose (450 mg/g) valganciclovir in CMV chemoprophylaxis in renal transplant patients over their first post-transplant year.Materials and Methods: A total of 68 consecutive patients aged over 18 years who underwent renal transplantation between January 2016 and June 2019 were included in this retrospective study. All patients were administered valganciclovir 450 mg/g, for 100 days. The efficacy of low-dose valganciclovir was determined by whether the patients developed a CMV disease during their first post-transplant year.Results: Only one patient (n=1/68) (1.5%) developed CMV disease. CMV DNA titer was positive on post-transplant day 134 of the patient who had unexplained loss of GFR. CMV disease-related acute rejection, graft loss, leukopenia, post-transplant diabetes mellitus, opportunistic infection, or patient loss was not observed.Conclusion: There are many studies comparing CMV prophylaxis with low and standard dose (450 vs. 900 mg/g) valganciclovir treatment in transplant patients. The results of this study show that low-dose valganciclovir is sufficient for the prophylaxis of CMV disease in D+/R+ medium-risk patients without leading to any side effects. Further clinical studies with larger patient participation are needed.

Efficiency and Safety of the Sting Operation on Kidney Transplanted Patients with Symptomatic Vesicoureteral Reflux and Neurogenic Bladder Dysfunction

PurposeThe study aimed to evaluate the feasibility and effectiveness of the endoscopic treatment in transplanted patients with neurogenic bladder who complained of symptomatic vesicoureteral reflux (VUR). Material and MethodsFifteen patients with VUR who were previously diagnosed with a neurogenic bladder were included in the study. The Lich-Gregoire technique was used for ureterovesical anastomosis during transplantation, and a double J stent was inserted routinely in the ureter to protect the anastomosis. The sting operation was performed under general anesthesia in the lithotomy position. A 4.8 Fr double J stent (Boston Scientific, Boston, MA) was inserted to prevent the risk of ureteral obstruction. Successful treatment was defined as absent acute glomerulopyelonephritis (AGPN) during follow-up and as absent VUR on radiological evaluation. ResultsClinical success was achieved in 6 of 10 patients (60%) who presented with recurrent febrile urinary tract infection (UTI) and in 4 of 6 (66%) patients who presented with gradually graft function deterioration. In 3 patients, the ureteral neo-orifice could not be localized during the operation owing to severe trabeculation of the bladder wall. The other 2 patients with a previous history of augmented bladder procedures had a hypotension attack during bladder filling; hence, the operation was stopped to prevent further complications. Two patients, whose clinical symptoms did not resolve after the sting procedure, accepted open ureteral reimplantation surgery. ConclusionEndoscopic management of the VUR in the transplant patients with neurogenic bladder function is safe and effective in at least half of the patients in a mid-term follow-up period.

Parameters of the oxidative-reduction system of the homeostasis in female transplant patients with tumors of the reproductive system treated with hyperbaric oxygen therapy

Introduction. Studies on the effects of hyperbaric oxygenation have often been represented as animal model experiments. Currently, the number of studies on the use of hyperbaric oxygen therapy in the post-transplant period in humans is growing. The need in investigating the efficacy of hyperbaric oxygen therapy in the postoperative period in female transplant patient with tumors of the reproductive system is dictated by time.The aim of the study was to evaluate the efficacy of hyperbaric oxygen therapy in the complex treatment of transplant patients at an early stage of the postoperative period.Material and methods. We have studied the course of an early postoperative period in 8 female transplant patients with reproductive system tumors treated in N.V. Sklifosovsky Research Institute for Emergency Medicine, using hyperbaric oxygenation. The hyperbaric oxygen therapy sessions were provided in a single-patient hyperbaric chamber at 1.2–1.6 ATA for 40 minutes. The status of the redox homeostasis system was assessed based on the data of the platinum electrode open circuit potential measured in blood plasma by using the potentiometric method; and the blood plasma antioxidant activity was assessed by cyclic voltammetry.Results. The analysis of the results showed that there was a direct relationship indicating the positive effect of hyperbaric oxygen therapy on the balance status of the pro- and antioxidant systems of the body, and on the improvement of blood counts.Conclusion. The early inclusion of hyperbaric oxygen therapy in the complex treatment of transplant patients with tumors of the reproductive system contributes to a more rapid recovery of pro- and antioxidant systems of the body, blood counts.

Chronic interstitial nephritis in agricultural communities is a toxin-induced proximal tubular nephropathy

Almost 30 years after the detection of chronic interstitial nephritis in agricultural communities (CINAC) its etiology remains unknown. To help define this we examined 34 renal biopsies from Sri Lanka, El Salvador, India and France of patients with chronic kidney disease 2-3 and diagnosed with CINAC by light and electron microscopy. In addition to known histopathology, we identified a unique constellation of proximal tubular cell findings including large dysmorphic lysosomes with a light-medium electron-dense matrix containing dispersed dark electron-dense non-membrane bound "aggregates". These aggregates associated with varying degrees of cellular/tubular atrophy, apparent cell fragment shedding and no-weak proximal tubular cell proliferative capacity. Identical lysosomal lesions, identifiable by electron microscopy, were observed in 9% of renal transplant implantation biopsies, but were more prevalent in six month (50%) and 12 month (67%) protocol biopsies and in indication biopsies (76%) of calcineurin inhibitor treated transplant patients. The phenotype was also found associated with nephrotoxic drugs (lomustine, clomiphene, lithium, cocaine) and in some patients with light chain tubulopathy, all conditions that can be directly or indirectly linked to calcineurin pathway inhibition or modulation. One hundred biopsies of normal kidneys, drug/toxin induced nephropathies, and overt proteinuric patients of different etiologies to some extent could demonstrate the light microscopic proximal tubular cell changes, but rarely the electron microscopic lysosomal features. Rats treated with the calcineurin inhibitor cyclosporine for four weeks developed similar proximal tubular cell lysosomal alterations, which were absent in a dehydration group. Overall, the finding of an identical proximal tubular cell (lysosomal) lesion in CINAC and calcineurin inhibitor nephrotoxicity in different geographic regions suggests a common paradigm where CINAC patients undergo a tubulotoxic mechanism similar to calcineurin inhibitor nephrotoxicity.

Investigation and Standardization on Current Practice of Renal Transplant Pathology in Korea

We need to establish an informative guideline to increase inter-institutional and inter-observer reproducibility of renal transplant diagnosis, and to improve the diagnostic ability of pathologists in Korea. A first nation-wide survey for renal transplant pathology was conducted by Renal Pathology Study Group of the Korean Society of Pathologists in 2016, to provide the continued excellence in the transplantation pathology laboratory, and to improve the diagnostic ability for the best treatment of transplant patients. This survey revealed the significant variations in scale, work load and biopsy indications for the renal transplant pathology in various institutions in Korea. The Banff classification were used by all institutions for the diagnosis of renal transplant pathology, but different formats were used: most institutions (70%) used the “2013 Banff classification” while the others were using “2007 Banff classification” (20%) or even older formats. In daily diagnostic practice of the renal allografts, difficulties that pathologists encounter were quite diverse due to different environments they work in. Most respondents agreed that standardized diagnostic practice guidelines, regular education on renal transplant pathology and convenient ways of consultation are further needed. We are currently working toward the enhancement of the expertise of renal pathologists and to increase inter-institutional and inter-observer reproducibility by 1) development of a set of virtual slides of renal allograft biopsies for the training, 2) validation and gathering expert''s consensus on the core variables of rejection diagnosis by using virtual slides, and 3) continued education by the developed virtual slide atlas.

Monitoring of Renal Allograft Function with Different Equations: What are the Differences?

AbstractIntroduction. Monitoring of graft function by creatinine concentrations in serum and calculated glomerular filtration rate (GFR) is recommended after kidney transplantation. KDIGO recommendations on the treatment of transplant patients advocate usage of one of the existing mathematical equations based on serum creatinine. We compared clinical application of three equations based on serum creatinine in monitoring the function of transplanted kidney. Methods. A total number of 55 adult patients who received their first renal allograft from living donors at our transplant center in between 2011-2014 were included into the study. Renal allograft GFR was estimated by the Cockroft-Gault, Nankivell and MDRD formula, and correlated with clinical parameters of donors and recipients. Results. The mean age of recipients was 35.7±9.5 (range 16-58), and the mean age of donors was 55.5±9.0 (34- 77) years. Out of this group of 55 transplant patients, 50(90.91%) were on hemodialysis (HD) prior to transplantation. HD treatment was shorter than 24 months in 37(74%) transplant patients. The calculated GFR with MDRD equation showed the highest mean value at 6 and 12 months (68.46±21.5; 68.39±24.6, respectively) and the lowest at 48 months (42.79±12.9). According to the Cockroft&amp;Gault equation GFR was the highest at 12 months (88.91±24.9) and the lowest at 48 months (66.53±18.1 ml/min). The highest mean level (80.53±17.7) of the calculated GFR with the Nankivell equation was obtained at 12 months and the lowest (67.81±16.7 ml/min) at 48 months. The values of Pearson’s correlation coefficient between the calculated GFR and the MDRD at 2 years after transplantation according to donor’s age of r=-0.3224, correlation between GFR and the Cockfroft &amp; Gault at 6 and 12 months and donor’s age (r=-0.2735 and r=-0.2818), and correlation between GFR and the Nankivell at 2 years and donor’s age of r=-0.2681, suggested a conclusion that calculated GFR was lower in recipients who had an older donors. Conclusion. Our analysis showed difference in the calculated GFR with different equations at the same time points. Using one mathematical equation during the total post-transplantation period would be a recommended method in order to eliminate the discrepancy in determining the stage of kidney failure.

Plasma C4d+ Endothelial Microvesicles Increase in Acute Antibody-Mediated Rejection.

Antibody-mediated rejection (AMR) is a major cause of kidney allograft loss. Currently, AMR diagnosis relies on biopsy which is an invasive procedure. A noninvasive biomarker of acute AMR could lead to early diagnosis and treatment of this condition and improve allograft outcome. Microvesicles are membrane-bound vesicles released from the cell surface after injury. We hypothesized that because AMR is associated with allograft endothelial injury and C4d deposition, plasma microvesicles positive for endothelial (CD144) marker and C4d are increased in this condition. We studied microvesicle concentration in the plasma of 95 kidney transplant patients with allograft dysfunction and compared with 23 healthy volunteers. Biopsy diagnosis and scoring was performed using Banff classification. In the 28 subjects with AMR, the density of C4d+/CD144+ microvesicles was on average 11-fold (P = 0.002) higher than transplant recipients with no AMR and 24-fold (P = 0.008) than healthy volunteers. Densities of C4d+ and C4d+/annexin V+ (C4d+/AVB+) microvesicles were also increased in AMR patients compared with no AMR and healthy subjects. C4d+/AVB+ microvesicles correlated with AMR biopsy severity. Nine patients with acute AMR that received treatment showed a mean 72% decrease (P = 0.01) in C4d+/CD144+ microvesicle concentration compared with pretreatment values. Quantification of plasma C4d+ microvesicles provides information about presence of AMR, its severity and response to treatment in transplant patients.

Progressive multifocal leukoencephalopathy after liver transplantation can have favorable or unfavorable outcome

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC polyomavirus (JCPyV) in immunocompromised patients, including solid organ transplant recipients. We report 2 cases of PML late after liver transplantation (144 and 204months) and review the few other published cases. The clinical course of PML is characterized by a rapid progressive neurological decline coinciding with the presence of white matter lesions on magnetic resonance images. No direct antiviral therapy is available against the JCPyV. The prognosis is therefore extremely poor. Restoration of the immune response achieved by tapering or ending the immunosuppressive therapy is the basis of treatment in transplanted patients. One of our patients is alive 3years after diagnosis after total withdrawal of immunosuppressive therapy. The other presented severe rejection when tapering immunosuppression and died 26months after diagnosis.

Outcomes of Foot and Ankle Surgery in Diabetic Patients Who Have Undergone Solid Organ Transplantation

Foot and ankle problems are highly prevalent in patients with diabetes mellitus (DM). Increased rates of surgical site infections and noninfectious complications, such as malunion, delayed union, nonunion, and hardware failure, have also been more commonly observed in diabetic patients who undergo foot and ankle surgery. DM is a substantial contributor of perioperative morbidity in patients with solid organ transplantation. To the best of our knowledge, postoperative foot and ankle complications have not been studied in a cohort of diabetic patients who previously underwent solid organ transplantation. The aim of the present study was to evaluate the outcomes of foot and ankle surgery in a cohort of diabetic transplant patients and to compare these outcomes with those of diabetic patients without a history of transplantation. We compared the rates of infectious and noninfectious complications after foot and ankle surgery in 28 diabetic transplant patients and 56 diabetic patients without previous transplantation and calculated the odds ratios (OR) for significant findings. The diabetic transplant patients who underwent foot and ankle surgery in the present cohort were not at an increased risk of overall complications (OR 0.83, 95% confidence interval [CI] 0.33 to 2.08, p = .67), infectious complications (OR 0.54, 95% CI 0.09 to 3.09, p = .49), or noninfectious complications (OR 1.14, 95% CI 0.41 to 3.15, p = .81). Four transplant patients (14.3%) died of non–orthopedic surgery-related events during the follow-up period; however, no deaths occurred in the control group. Diabetic patients with previous solid organ transplantation were not at an increased risk of developing postoperative complications after foot and ankle surgery, despite being immunocompromised. The transplant patients had a greater mortality rate, but their premature death was unrelated to their foot and ankle surgery. Surgeons treating transplant patients can recommend foot and ankle surgery when indicated. However, owing to the increased mortality rate and comorbidities associated with this high-risk group, we recommend preoperative clearance from the transplant team and medical consultations before performing surgery.

Beyond cancer treatment - a review of total lymphoid irradiation for heart and lung transplant recipients.

Immunosuppressive drugs used in the management of heart and lung transplants have a large monetary and quality of life cost due to their side effects. Total lymphoid irradiation (TLI) is one method of minimising the need for or replacing post-operative immunosuppressive drugs. A literature review was conducted on electronic databases using defined search terms. The aim was to establish the indications for the use of TLI, its advantages and disadvantages and the weaknesses associated with the methods used in related research. Eight articles were located that focused on TLI usage in combating organ rejection. These studies identified that the use of TLI resulted in a reduction in early rejection. One study reported a drop in rejection episodes from 0.46 to 0.14 episodes per patient per month once the TLI was complete. While the short-term prognosis is excellent, the long-term outlook is less positive with an increased risk of organ rejection and myelodysplasia 3.5 years post-TLI. This review reminds us that radiation therapy (RT) is not exclusively indicated for cancer treatment. While TLI cannot replace immunosuppressive drug therapy, it can offer a treatment option for people that cannot tolerate immunosuppressive drugs, or when conventional anti-rejection treatment is no longer viable. Reported long-term complications suggest that TLI should be used with caution. However, this modality should not be overlooked in cases of chronic rejection. Further research is required to establish the efficacy of RT in the treatment of transplant patients who are unsuitable for drug-based anti-rejection therapies.

An Unusual Case: Gastric Metastasis of Hepatocellular Carcinoma

Introduction: Gastrointestinal tract involvement of hepatocellular carcinoma (HCC) is a rare entity with a poor prognosis and can occur via hematogenous route or direct invasion. Here we report a case with de novo HCC after liver transplantation who had rising alfa-fetoprotein (AFP) levels and was found to have gastric metastases incidentally. Case: A 62 year old man underwent liver transplantation with a diagnosis of hepatocellular carcinoma Three years after the liver transplantation, bone and liver metastasis developed and palliative treatment plan was made. During follow-up AFP levels began to rise subsequently and computed tomography of chest and abdomen revealed stable liver lesions and a suspicious gastric luminal nodule. Upper endoscopy showed polypoid lesions in stomach and the pathology of the biopsies taken from these lesions were consistent with HCC metastasis. Discussion: Patterns of metastases in patients with recurrent HCC after liver transplantation might be different. Immunsuppressive treatment in transplant patients might have a negative effect on disease biology and may result in more disseminated disease and atypical sites of metastases as in our case. In patients with rising AFP in the absence of progressive disease on radiologic evaluation, gastrointestinal system metastases via hematogenous route should be kept in mind and upper endoscopy should be considered even in the absence of gastric symptoms, particularly if the presence of extrahepatic disease will change treatment decisions.

Isolated Tuberculosis of Transplanted Liver, A Case Report and Review of the Literature

IntroductionRecipients of liver transplantation are prone to different types of infections such as tuberculosis (TB).Case PresentationHerein we report a 59-year-old man with liver transplantation due to HBV cirrhosis who developed isolated hepatic TB, 18 months after OLT (orthotropic liver transplantation). He has been successfully treated with anti-TB regimen and now after 12 months he is completely symptom-free.ConclusionsOrgan transplantation and treatment of transplanted patients with immunosuppressive drugs would prone them to various unusual infections. One of these is unusual primary involvement of liver by tuberculosis which has been extremely rare in the previous reports.