Daratumumab Use Prior to Kidney Transplant and T Cell-Mediated Rejection: A Case Report.

There is growing interest in daratumumab in the solid organ transplant realm owing to the potential immunomodulatory effects on CD38-expressing cells, primarily plasma cells, as they have a key role in antibody production. In particular there is interest in use of daratumumab for desensitization and potential treatment for antibody-mediated rejection. However, ongoing investigation with daratumumab has shown potential immunologic concerns in vitro, with a significant increase in populations of CD4-positive cytotoxic T cells and CD8-positive helper T cells in both peripheral blood and bone marrow that could lead to acute T cell-mediated rejection in the solid organ transplant patient. To date, there are no published reports of an association with daratumumab use and T cell-mediated rejection in vivo. In this case report we present what is to our knowledge the first documented case of an early severe T cell-mediated rejection in a low-immunologic-risk living-donor kidney transplant recipient who received daratumumab for multiple myeloma maintenance prior to transplant.

Correlation of preoperative imaging characteristics with donor outcomes and operative difficulty in laparoscopic donor nephrectomy.

This study aimed to understand the relationship of preoperative measurements and risk factors on operative time and outcomes of laparoscopic donor nephrectomy. Two hundred forty-two kidney donors between 2010 and 2017 were identified. Patients' demographic, anthropomorphic, and operative characteristics were abstracted from the electronic medical record. Glomerular filtration rates (GFR) were documented before surgery, within 24 hours, 6, 12, and 24 months after surgery. Standard radiological measures and kidney volumes, and subcutaneous and perinephric fat thicknesses were assessed by three radiologists. Data were analyzed using standard statistical measures. There was significant correlation between cranio-caudal and latero-lateral diameters (P < .0001) and kidney volume. The left kidney was transplanted in 92.6% of cases and the larger kidney in 69.2%. Kidney choice (smaller vs. larger) had no statistically significant impact on the rate of change of donor kidney function over time adjusting for age, sex and race (P = .61). Perinephric fat thickness (+4.08 minutes) and surgery after 2011 were significantly correlated with operative time (P ≤ .01). In conclusion, cranio-caudal diameters can be used as a surrogate measure for volume in the majority of donors. Size may not be a decisive factor for long-term donor kidney function. Perinephric fat around the donor kidney should be reported to facilitate operative planning.

The Volume-outcome Relationship in Deceased Donor Kidney Transplantation and Implications for Regionalization.

OBJECTIVE: The aim of this study was to investigate the volume-outcome relationship in kidney transplantation by examining graft and patient outcomes using standardized risk adjustment (observed-to-expected outcomes). A secondary objective was to examine the geographic proximity of low, medium, and high-volume kidney transplant centers in the United States. SUMMARY OF BACKGROUND DATA: The significant survival benefit of kidney transplantation in the context of a severe shortage of donor organs mandates strategies to optimize outcomes. Unlike for other solid organ transplants, the relationship between surgical volume and kidney transplant outcomes has not been clearly established. METHODS: The Scientific Registry of Transplant Recipients was used to examine national outcomes for adults undergoing deceased donor kidney transplantation from January 1, 1999 to December 31, 2013 (15-year study period). Observed-to-expected rates of graft loss and patient death were compared for low, medium, and high-volume centers. The geographic proximity of low-volume centers to higher volume centers was determined to assess the impact of regionalization on patient travel burden. RESULTS: A total of 206,179 procedures were analyzed. Compared with low-volume centers, high-volume centers had significantly lower observed-to-expected rates of 1-month graft loss (0.93 vs 1.18, P<0.001), 1-year graft loss (0.97 vs 1.12, P<0.001), 1-month patient death (0.90 vs 1.29, P=0.005), and 1-year patient death (0.95 vs 1.15, P=0.001). Low-volume centers were frequently in close proximity to higher volume centers, with a median distance of 7 miles (interquartile range: 2 to 75). CONCLUSIONS: A robust volume-outcome relationship was observed for deceased donor kidney transplantation, and low-volume centers are frequently in close proximity to higher volume centers. Increased regionalization could improve outcomes, but should be considered carefully in light of the potential negative impact on transplant volume and access to care.

Preemptive VAE-An Important Tool for Managing Blood Loss in MVT Candidates With PMT.

Explantation of native viscera in multivisceral transplant candidates, particularly in those with extensive portomesenteric thrombosis (PMT), carries considerable morbidity due to extensive vascularized adhesions. Preemptive visceral angioembolization has been previously described as a technique to minimize excessive blood loss during mobilization of the native viscera but is not well described specifically in patients with extensive PMT. METHODS: In a series of 5 patients who underwent mutivisceral transplant for PMT from June 2015 to November 2018, we performed preoperative superior mesenteric, splenic, and hepatic artery embolization to reduce blood loss during explanation and evaluated the blood loss and blood product utilization, as well as 30-day rates of infectious complications. RESULTS: Following preemptive embolization, median total blood loss was 6000 mL (range 800-7000 mL). The median transfusion requirements were as follows: 16 units packed red blood cells (range 2-47), 14 units fresh frozen plasma (range 0-29), 2 units cryoprecipitate (range 1-14), 4 units platelets (range 2-10), and 500 mL cell saver autotransfusion (range 0-1817). In the first 30 postoperative days, 2 out of 5 patients developed positive blood cultures and 3 out of 5 developed complex intra-abdominal infections. Two patients developed severe graft pancreatitis resulting in mycotic aneurysm of the aortic conduit; bleeding from the aneurysm led to 1 patient mortality. CONCLUSIONS: Preoperative embolization is an effective modality to mitigate exsanguinating blood loss during multivisceral transplant in patients with portomesenteric thrombosis; however, it is unclear if the resultant native organ ischemia during explant carries clinically relevant consequences.

Metastatic Urothelial Carcinoma from Transplanted Kidney with Complete Response to an Immune Checkpoint Inhibitor.

BACKGROUND: Donor-derived malignancy is a rare complication in patients who undergo organ transplant. Approaches to treatment have largely been individualized based on clinical circumstances given the lack of evidence-based guidelines, with therapeutic options ranging from discontinuation of immunosuppression and transplantectomy to the addition of chemotherapy or radiotherapy. Case Presentation. Herein, we describe a 60-year-old woman with metastatic donor-derived upper tract urothelial carcinoma (UTUC) discovered nine years postrenal transplant. Molecular diagnostic studies using polymerase chain reaction amplification of short tandem repeat alleles and HLA tissue typing proved that the urothelial carcinoma originated from donor tissue. She achieved sustained complete remission with transplant nephroureterectomy, retroperitoneal lymphadenectomy, immunosuppression withdrawal, and immunotherapy with pembrolizumab. Routine radiologic surveillance has demonstrated 15-month progression-free survival to date off pembrolizumab, and she is now under consideration for retransplantation. CONCLUSIONS: Immunotherapy using checkpoint inhibitors can serve as a novel treatment option for patients in the clinical predicament of having a solid organ transplant and simultaneous metastatic malignancy. In this report, we also discuss the oncogenic potential of BK virus, the use of checkpoint inhibitors in urothelial carcinoma, and the feasibility of retransplant for this patient population.

Autologous gastrointestinal reconstruction: review of the optimal nontransplant surgical options for adults and children with short bowel syndrome.

Short bowel syndrome (SBS) results in loss of absorptive capacity of the development of gut, leading to malabsorption due to protein, energy, fluid, and electrolyte loss and imbalance while on enteral diet alone. Various nonsurgical and surgical therapeutic options that have emerged improve the survival outcome following SBS in both children and adults. An individualized, complex multidisciplinary approach to medical and surgical intestinal rehabilitation is needed to provide an opportunity for enteral autonomy to be possible in a patient with SBS. The remnant bowel plays a very pivotal role in autologous gastrointestinal reconstruction (AGIR) surgery. Intestinal transplantation, although promising and potentially life-saving for SBS, should be reserved for patients with failed AGIR or those who have no prospect for autologous enteral autonomy. This article reviews the evolution of nontransplant surgical management of patients with SBS.

Benign metastasizing leiomyoma: a rare cause of multiple pulmonary nodules.

Benign metastasizing leiomyoma (BML) is a rare cause of pulmonary nodules that occurs when uterine leiomyomas metastasize to the lung. The management of these lesions varies from resection and hysterectomy to nonsurgical treatments such as hormonal therapy. We report a case of a 45-year-old woman with multiple nodules of the right lung identified during preoperative imaging before her hysterectomy for uterine fibroids.