Activation of HMGB1 – TLR4 pathway and Inflammasome contribute to enhanced inflammatory response in extended criteria and kidneys with KDPI ≥ 85% Background. Metrics for evaluating “low-quality” kidneys have failed to predict outcomes or reduce the kidney refusal and discard rates. Kidneys from extended-criteria donors (ECDs) and kidneys with ≥85% kidney donor profile indexes (KDPI) might have different sensitivities to the proinflammatory milieu generated by brain death. We aimed to identify gene expression profile differences in innate immunity pathways between “low-quality” and ideal kidneys. Methods. Preimplantation kidney biopsies from ECD (n=41) and SCD (n=39) were evaluated for real-time quantitative polymerase chain reaction (qPCR) gene expression using the TaqMan Gene Expression Array Plates system for genes TLR4, HMGB1, NFK-β, MyD-88, INF-γ, IL1-β, TNF-α, CASP1, ICAM-1, IL-10, HO-1, HIF-1, MCP-1, TGF-β, TRIF, TRAM, IRF-3, RIP1, INFβ-1 and NLRP3. Gene expression was also evaluated in kidneys with KDPI ≥85. Results. ECD biopsies showed significantly higher expression of IL-10, TLR4, HMGB1, IFN-γ, TRAM, IRF-3, HIF-1, NLRP3, CASP1, and IL-1β (p < 0.05) compared to SCD biopsies. IRF-3, HIF-1 and CASP1 were exclusively upregulated in ECD kidneys. Compared to kidneys with KDPIs <85%, kidneys with KDPIs ≥ 85% had very similar gene transcripts as those observed in ECD kidneys, except that TNF-α and MCP-1 expression were only elevated in kidneys with KDPIs ≥ 85%. Significant positive correlations were found between the different genes upregulated and the increase in KDPIs. Conclusions. Our results showed that TLR4 and inflammasome pathways were enhanced in “low-quality” kidneys, which place improve transplant outcomes and reduce kidney discard rates. + Both authors contributed equally to this manuscript * Corresponding author Funding: This work was supported funding from FAPESP (#2010/12930-4 and #2012/14781-1). Disclosures: The authors declare no funding or conflicts of interest. Author contributions: G.M.S.F: Collection and assembly of data, data analysis and interpretation; H.C.C.: Data analysis and interpretation, administrative support; N.N.G: Collection and assembly of data; G.O.B.E.B: Collection and assembly of data; M.A.S.F.B.: Collection and assembly of data; I.M.M.F.C.: Collection and assembly of data, data analysis and interpretation; M.A.F.: Conception and design, collection and assembly of data, data analysis nd interpretation, manuscript writing, final approval of manuscript. Correspondence: Mario Abbud-Filho MD, PhD, Departamento de Medicina/Nefrologia, Faculdade de Medicina de São José do Rio Preto (FAMERP)- HB/FUNFARME, Laboratório de Imunologia e Transplante Experimental – LITEX, Av. Brigadeiro Faria Lima 5416- 15090-000. São Jose do Rio Preto, SP, Brazil. Phone: +55 173201-5739, Email: mabbud@terra.com.br This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Influence of different partial pressures of oxygen during continuous hypothermic machine perfusion in a pig kidney ischemia-reperfusion autotransplant model. Background: The optimal perfusate partial oxygen pressure (pO2) during hypothermic machine perfusion (HMP) is unknown. The aims of the study were to determine the functional, metabolic, structural and flow dynamic effects of low and high perfusate pO2 during continuous HMP in a pig kidney ischemia-reperfusion autotransplant model. Methods: The left kidneys of a ±40 kg pigs were exposed to 30 minutes of warm ischemia and randomized to receive 22h HMP with either low perfusate pO2 (30% oxygen, HMPO2low)(n=8) or high perfusate pO2 (90% oxygen, HMPO2high)(n=8), prior to autotransplantation. Kidneys stored in 22h standard HMP (n=6) and 22h static cold storage (SCS)(n=6) conditions served as controls. The follow-up after autotransplantation was 13 days. Results: High pO2 resulted in a 3- and 10-fold increase in perfusate pO2 compared with HMPO2low and standard HMP, respectively. Both oxygenated HMP groups were associated with superior graft recovery compared with the control groups. Oxygenation was associated with a more rapid and sustained decrease in renal resistance. Whilst there was no difference in functional outcomes between both oxygenated HMP groups, there were clear metabolic differences with an inverse correlation between oxygen provision and the concentration of major central metabolites in the perfusion fluid but no differences were observed by oxidative stress and metabolic evaluation on preimplantation biopsies. Conclusions: Whilst this animal study does not demonstrate any advantages for early graft function for high perfusate pO2, compared with low perfusate pO2, perfusate metabolic profile analysis suggests that aerobic mechanism is better supported under high perfusate pO2 conditions. Clinical trial notation: not applicable. Disclosure: The authors of this manuscript have conflicts of interest to disclose as described by Transplantation. The LifePort Kidney Transporter, the Perfusion Circuits and the oxygenators were supplied by Organ Recovery Systems (Diegem, Belgium). Several authors (TD, MV, TS, KP, AB, JN, CL, PG, MM) have ongoing research in part funded by Organ Recovery Systems. Funding: Tom Darius received a grant from the "Fondation Saint Luc", the "Fondation Recherche Clinique" and Astellas Belgium. Benoît Ury received funding from "Fonds pour la formation à la Recherche dans l’Industrie et dans l’Agriculture (FRIA)". Correspondence: Tom Darius, MD, Physical mailing address: Dr. Tom Darius, Chirurgie et Transplantation Abdominale, Clinique Universitaire Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium. Email address: tom.darius@uclouvain.be Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

In vivo analysis of human immune responses in immunodeficient rats. Background. Humanized immune system immunodeficient mice have been extremely useful for the in vivo analyses of immune responses in a variety of models, including organ transplantation and GVHD but they have limitations. Rat models are interesting complementary alternatives presenting advantages over mice, such as their size and their active complement compartment. Immunodeficient rats have been generated but human immune responses have not yet been described. Methods. We generated immunodeficient RRGS rats (for Rat Rag-/- Gamma chain-/- hSIRPa-positive) combining Rag1 and Il2rg deficiency with the expression of human SIRPalpha, a negative regulator of macrophage phagocytosis allowing repression of rat macrophages by human CD47-positive cells. We then immune humanized RRGS animals with human PBMCs to set up a human acute GVHD model. Treatment of GVHD was done with a new porcine anti-human lymphocyte serum (LIS1) active through complement-dependent cytotoxicity. We also established a tumor xenograft rejection model in these human PBMCs immune system RRGS animals by subcutaneous implantation of a human tumor cell line. Results. RRGS animals receiving human PBMCs showed robust and reproducible reconstitution, mainly by T and B cells. A dose-dependent acute GVHD process was observed with progressive weight loss, tissue damage and death censoring. LIS1 antibody completely prevented acute GVHD. In the human tumor xenograft model, detectable tumors were rejected upon hPBMCs injection. Conclusions. Human PBMC can be implanted in RRGS animals and elicit acute GVHD or rejection of human tumor cells and these are useful models to test new immunotherapies. Disclosure: Pierre-Joseph Royer, Gwenaelle Evanno and Bernard Vanhove are employees of Xenothera. The other authors declare no conflict of interest. Funding. This work was performed in the context of different programs: Biogenouest by Région Pays de la Loire, IBiSA program, TEFOR (Investissements d’Avenir French Government program, ANRII-INSB-0014), LabCom SOURIRAT project (ANR-14-LAB5-0008), Labex IGO project (Investissements d’Avenir French Government program, ANR-11-LABX-0016-01), IHU-Cesti project (Investissements d’Avenir French Government program, ANR-10-IBHU-005, Nantes Métropole and Région Pays de la Loire) and Fondation Progreffe. TransImm team (E.P.) is supported by LabEx DCBIOL (ANR-10-IDEX-0001-02 PSL and ANR-11-LABX-0043), SIRIC INCa-DGOS-Inserm_12554, Center of Clinical Investigation (CIC IGR-Curie 1428). * corresponding authors: Séverine Ménoret, CRTI, Nantes Université, CHU Nantes, Inserm, CNRS, SFR Santé, Inserm UMS 016, CNRS UMS 3556, 30 Bd Jean Monnet F-44093 Nantes, France. Email: severine.menoret@univ-nantes.fr Ignacio Anegon, CRTI, Nantes Université, CHU Nantes, Inserm, CNRS, SFR Santé, Inserm UMS 016, CNRS UMS 3556, 30 Bd Jean Monnet F-44093 Nantes, France. Email: ianegon@nantes.inserm.fr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

PRETRANSPLANT OPIOID USE AND SURVIVAL AFTER LUNG TRANSPLANTATION Purpose: The impact of opioid use in lung transplant candidates on posttransplant outcomes is unknown. Studies on opioid therapy in kidney and liver transplant candidates have suggested increased risk of graft failure or death. We sought to analyze the relationship between pretransplant opioid use in lung transplant candidates and retransplant-free survival. Method: We retrospectively reviewed adult patients transplanted consecutively between November 2004 and August 2015. The exposure was any opioid use at time of transplant listing and primary outcome was retransplant-free survival, analyzed via Cox regression model adjusted for recipient age, gender, ethnicity, diagnosis and bridging status. Secondary outcomes included duration of ventilation, intensive care unit and hospital length of stay (LOS), 3-month and 1-year survival, continuing opioid use at 1 year and time to onset of chronic lung allograft dysfunction. Results: The prevalence of opioid use at time of listing was 14% (61/425). Median daily oral morphine equivalent dose was 31mg (18-54). Recipient ethnicity was associated with pretransplant opioid use. Opioid use at time of listing did not increase risk of death or retransplantation in an adjusted model (hazard ratio 1.12 [95% confidence interval 0.65-1.83], p=0.6570). Secondary outcomes were similar between groups except hospital LOS (opioid users 35 vs. nonusers 27 days, p=0.014). Continued opioid use at 1-year posttransplant was common (27/56, 48%). Conclusion: Pretransplant opioid use was not associated with retransplant-free survival in our cohort and should not necessarily preclude listing. Further work stratifying opioid use by indication and the association with opioid use disorder would be worthwhile. Author Contributions: SL helped formulate the study, collected data, assisted with analysis, wrote the first draft of the manuscript and approved the final version. DL collected data, helped with analysis and approved the final manuscript version. AH, AK, JW, BL and DL helped formulate the study, contributed to and approved the final manuscript version. KH formulated the study, performed the analysis, and wrote the final draft of the manuscript. The authors declare no conflicts of interest. This study was unfunded. This paper was presented at the 39th Annual Meeting of the International Society for Heart and Lung Transplantation in April 2019 in Orlando, USA. Correspondence: Kieran Halloran, MD, MSc, University of Alberta, 11350 83rd Street, 3-125 Clinical Sciences Building, Edmonton, Alberta, Canada T6G2G3, Telephone: 1-780-492-2691 Fax: 1-780-492-4483, Email: kieran.halloran@ualberta.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Innate immune activation in high risk donor kidneys: an opportunity to intervene? No abstract available

BK nephropathy as a cause of renal dysfunction in an ABO-incompatible liver transplant patient No abstract available

Donor–recipient lymphatic interaction after lung transplantation: not simply a drainage route for water, but a complex pathway regulating intrapulmonary alloimmunity No abstract available

AA Amyloidosis After Renal Transplantation: An Important Cause of Mortality Background: There is limited data on the outcome of transplant recipients with familial Mediterranean fever (FMF)-associated AA amyloidosis. The aim of the present study is to evaluate demographic, clinical, laboratory, prognostic characteristics and outcome measures of these patients. Methods: Eighty-one renal transplant recipients with FMF-associated AA amyloidosis (group 1) and propensity score-matched transplant recipients (group 2, n = 81) with nonamyloidosis etiologies were evaluated in this retrospective, multicenter study. Recurrence of AA amyloidosis was diagnosed in 21 patients (group 1a) and their features were compared with propensity score matched 21 recipients with FMF-amyloidosis with no laboratory signs of recurrence (group 1b). Results: The risk of overall allograft loss was higher in group 1 compared to group 2 [25 (30.9%) vs. 12 (14.8%), p = 0.015 (HR 2.083; 95% CI 1.126 - 3.856)]. Patients in group 1 were characterized by an increased risk of mortality compared group 2 [11 (13.6%) vs 0%, p = 0.001 (HR 1.136; 95% CI 1.058 - 1.207)]. Kaplan Meier analysis revealed that 5-year and 10-year patient survival rates in group 1 (92.5% and 70.4%) were significantly lower than group 2 (100% and 100%; p = 0.026 and p = 0.023, respectively). Although not reaching significance, overall, 5-year and 10-year graft survival rates (57.1%, 94.7% and 53.8%, respectively) in group 1a were worse than group 1b (76.2%, 95% and 77.8%, respectively) (p = 0.19, p = 0.95 and p = 0.27, respectively). Conclusions: AA amyloidosis is associated with higher risk of mortality after kidney transplantation. Inflammatory indicators should be monitored closely, and persistent high levels of acute phase reactants should raise concerns about amyloid recurrence in allograft. Disclosure: The authors declare no funding was received for this study. Disclaimer: All authors declare no conflicts of interest. Clinical Trial Notation: ClinicalTrials.gov, number NCT02704065. Corresponding Author: Yasar Caliskan, MD, Division of Nephrology and Hypertension, Saint Louis University School of Medicine, Floor 9, Desloge Towers, 3635 Vista Ave. St. Louis, Missouri 63110, Phone: +1 314-577-8765, Email: yasar.caliskan@health.slu.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

To thine own self be true1 No abstract available

Pediatric donor glomerulopathy is a possible cause of proteinuria and/or hematuria in adults receiving small pediatric donor kidneys Background: Reports about prognosis of adults receiving small pediatric-donor kidneys (PDK) as compared to those receiving elder pediatric or adult donor kidneys (ADK) are controversial. This study aimed to examine the outcomes of adults receiving small PDK and possible prognostic factors. Methods: The records of adults who received kidneys from donors < 10 years old at our center from July 1, 2011 to June 30, 2018 were reviewed. Results: A total of 121 adults were small PDK recipients. Twenty-three patients received 29 biopsies and/or nephrectomy between 6 and 896 days post transplantation days. Seven patients (30.4%) had pediatric donor glomerulopathy (PDG), which developed from 113 to 615 days post transplantation. The incidence of proteinuria and hematuria were significantly higher in the PDG group. The characteristic pathological finding in PDG was irregular lamination and splintering of the glomerular basement membrane (GBM). Donor age, donor weight, and donor kidney volume were significantly less in PDG cases compared with the non-PDG cases. For the risk factors of PDG, increasing urinary RBC count during follow-up was an independent predictor, while increasing donor age and body weight were protective factors. PDG was not a significant risk factor for Scr increasing of PDKs. Conclusions: PDG is a potential cause of urinary abnormalities in adults receiving small PDKs. The pathological characteristic change of PDG is splitting and lamination of the GBM. Persistent hematuria after transplantation in recipients of PDK is a predictor of PDG development. # Zeying Jiang and Yulin liang contributed equally to this work. Author contributions: WC designed the work; ZJ and YL were responsible for the acquisition of data, and drafted the manuscript; TZ performed the statistical analysis; SY and YC were responsible for the interpretation of data for the work; GH acquired the data of follow up; CW performed the operation and revised the manuscript. All authors approved the final version of the manuscript. Conflict of interest: The authors declare no conflicts of interest. Funding: The study was supported by the grants from the National Natural Science Foundation of China (Grant No.81772701), National Natural Science Foundation of Guangdong Province (Grant No. 2017A030313521), Foundation of Guangdong Special Branch Plans for Young Talent with Scientific and Technological Innovation and Science (Grant No. 2017TQ04R382) and Foundation for The Excellent Youth Scholars of Sun Yat-sen University (No. 17ykpy25). *Correspondence to:Wenfang Chen, Department of Pathology, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Road 2, Guangzhou 510080, China; E-mail: chwfang@mail.sysu.edu.cn; Changxi Wang, Department of organ transplantation, the First Affiliated Hospital of Sun Yat-sen University, 58# Zhongshan Road 2, Guangzhou 510080, China. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.