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.

Donor-Host Lymphatic Anastomosis after Murine Lung Transplantation Background. Establishing lung lymphatic drainage is thought to be important for successful lung transplantation. To date, there has been a complete absence of knowledge of how lymphatic connections are reestablished after lung transplant, despite evidence suggesting that this does indeed occur. The present study aimed to elucidate whether and how lymphatic anastomosis occurs after lung transplant. Methods. An orthotopic murine model of lung transplant using lymphatic reporter mice and whole mount immunohistochemistry was used to evaluate the lymphatic vasculature and donor-host connections after lung transplantation. Results. Immunohistochemistry of transplanted lungs demonstrated robust lymphatic vessels, and functional assays demonstrated lymphatic drainage in the transplanted lung that was comparable to that in native lungs. Lymphatic vessels in the donor lung exhibited active sprouting toward the host at the anastomosis within the first 3 days after lung transplantation, with more numerous and complex lymphatic sprouting developing thereafter. Donor lymphatic vessels were numerous at the site of anastomosis by day 14 after lung transplantation and formed physical connections with host lymphatic vessels, demonstrating a mechanism by which lymphatic drainage is reestablished in the transplanted lung. Conclusions. Lymphatic drainage after lung transplantation is established by active sprouting of donor lymphatic vessels towards the host and the formation of donor-host lymphatic connections at the level of the transplant anastomosis. Disclosure Statement:The authors of no conflicts of interest to disclose. Funding:This study was supported by NIAID grant 5R01AI123241 (to W.W.H.), NIH R01 HL121650 (to M.L. Kahn), and by T32HL007586-32 (to H. Outtz Reed). Authorship:HOR designed and performed experiments, performed data analysis, and prepared manuscript, LW performed lung transplantation procedures. MLK provided assistance with experimental design and writing of manuscript. WWH provided assistance and oversight with lung transplant experiments. Corresponding Author: Hasina Outtz Reed, MD PhD, 1300 York Avenue, Room 323, New York, NY 10065, ho2001@med.cornell.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Toward Deciphering the Code of Pediatric Donor Glomerulopathy No abstract available

Delayed Implantation of Pumped Kidneys Decreases Renal Allograft Futility in Combined Liver-Kidney Transplantation Background: Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT. Methods: A retrospective analysis (UCLA [n=145], TMH [n=79]) was performed of all adults receiving CLKT at 2 high-volume transplant centers from February 2004 through January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT. Results: 63 patients (28.1%) underwent delayed implantation of pumped kidneys (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys (eCLKT). Most recipients were high-acuity with median biologic MELD 35 for dCLKT and 34 for eCLKT (p=ns). Pretransplant, dCLKT had longer ICU stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-yr patient and kidney survival (p=0.02) and decreased length of stay (p=0.001), kidney allograft failure (p=0.012), and dialysis duration (p=0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 months posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (p=0.013). Conclusions: Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients. * Indicates corresponding author FUNDING: We would like to thank the Houston Methodist Institution of Academic Medicine for their generous funding contributions. DISCLOSURE: The authors of this manuscript have no conflicts of interests to disclose as described by Transplantation. CORRESPONDING AUTHOR:: A. Osama Gaber, MD, J.C. Walter Jr. Distinguished Endowed Chair, Director, Houston Methodist J.C. Walter Jr. Transplant Center, Professor of Surgery, Weill Cornell Medical College, Vice Chair Administration & Faculty Affairs, Department of Surgery, 6550 Fannin Street, Suite 1661, Houston, TX 77030, Email: AOGaber@houstonmethodist.org Office: 713-441-6174, Fax: 713-790-6839 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

OUTCOMES OF PATIENTS SUSPENDED FROM THE NATIONAL KIDNEY TRANSPLANT WAITING LIST IN THE UNITED KINGDOM BETWEEN 2000 AND 2010. Background: In the UK, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) are suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described. Methods: We linked patient records from the UK Transplant Registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HR) that compared mortality and graft survival between those who had experienced a suspension event and those who had not. Results: Between Jan 1, 2000, and Dec 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. 48.0% (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (aHR: 1·79, 1·64-1·95) and from the time of transplantation (aHR: 1·20, 1.06-1.37, p=0005). Graft survival was also poorer in those who had been suspended (aHR: 1·13, 1·01-1·28, p=0·04). Conclusions: Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritisation of patients at risk of experiencing a suspension event may improve their outcomes. * Joint first authors Declaration of interests: The authors declare no competing interests. All authors have given final approval for this manuscript to be submitted to Transplantation. Correspondence: Mr Roberto Cacciola, Organ Donation and Transplantation, NHS Blood Transplant, Fox Den Road, Stoke Gifford, Bristol, UK: Roberto.cacciola@nhs.net, Tel No: 07789 864155 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Liver retransplantation associated with kidney transplantation for end stage liver graft disease and renal insufficiency: a morbid procedure on a unique subgroup of patients. Background: Chronic renal disease (CKD) jeopardizes the long-term outcomes of liver transplant recipients. In patients with end-stage liver graft disease and CKD, liver retransplantation associated with kidney transplantation (ReLT-KT) might be necessary. Yet, this specific subset of patients remains poorly described. Methods: Indications, perioperative characteristics, and short and long-term outcomes of patients undergoing ReLT-KT at 2 transplantation units from 1994 to 2012, were analyzed. Risk factors for postoperative mortality and long-term survivals were evaluated. Results: Among 3060 patients undergoing liver transplantation (LT), 45 (1.5%) underwent ReLT-KT. The proportion of ReLT-KT among LT recipients continuously grew throughout the study period from 0.3% to 2.4% (p<0.001). Median time from primary LT to ReLT-KT was 151.3 (7.5-282.9) months. The most frequent indications for liver retransplantation were recurrence of the primary liver disease and cholangitis in 15 (33.3%) cases each. CKD was related to calcineurin inhibitors toxicity in 38 (84.4%) cases. Twelve (26.7%) patients died postoperatively. D-MELD (donor age*recipients’ MELD) was associated with postoperative mortality (HR: 8.027; 95% CI: 2.387-18.223; p=0.026) and optimal cut-off value was 1039 (AUC: 0.801; p=0.002). Overall 1, 3 and 5 years survivals were 68.8%, 65.9% and 59.5%, respectively. D-MELD > 1039 was the only factor associated with poor survival (p=0.021). Conclusions: ReLT-KT is a highly morbid increasingly performed procedure. Refinements in the selection of grafts and transplant candidates are required in order to limit the postoperative mortality of these patients. Disclosure: The authors declare no conflicts of interest Funding: None Corresponding author:François Cauchy, Department of HPB and liver transplantation surgery, Hôpital Beaujon, 100, Boulevard du Général Leclerc, 92110, Clichy, France. Tel: + 33 (1) 40.87.58.95, E-mail: fafatoubib@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.