Value of original and modified pathological scoring systems for prognostic prediction in paraffin-embedded donor kidney core biopsy.

BACKGROUND: No study has validated, compared and adapted scoring systems for prognosis prediction based on donor kidney core biopsy (CB), with less glomeruli than wedge biopsy. METHODS: A total of 185 donor kidney CB specimens were reviewed using seven scoring systems. The association between the total score, item scores, score-based grading, and allograft prognosis was investigated. In specimens with less than ten glomeruli (88/185, 47.6%), scoring systems were modified by adjusting weights of the item scores. RESULTS: The Maryland aggregate pathology index (MAPI) score-based grading and periglomerular fibrosis (PGF) associated with delayed graft function (DGF) (Grade: OR = 1.59, p < 0.001; PGF: OR = 1.06, p = 0.006). Total score, score-based grading and chronic lesion score in scoring systems associated with one-year and 3-year eGFR after transplantation. Total-score-based models had similar predictive capacities for eGFR in all scoring systems, except MAPI and Ugarte. Score of glomerulosclerosis (GS), interstitial fibrosis (IF), tubular atrophy (TA), and arteriolar hyalinosis (AH) had good eGFR predictive capacities. In specimens with less than ten glomeruli, modified scoring systems had better eGFR predictive capacities than original scoring systems. CONCLUSIONS: Scoring systems could predict allograft prognosis in paraffin-embedded CB with ten more glomeruli. A simple and pragmatic scoring system should include GS, IF, TA and AH, with weights assigned based on predictive capacity for prognosis. Replacing GS scores with tubulointerstitial scores could significantly improve the predictive capacity of eGFR. The conclusion should be further validated in frozen section.

Small-For-Size Syndrome and Graft Inflow Modulation Techniques in Liver Transplantation.

BACKGROUND: Partial liver transplantation has recently been proposed to alleviate organ shortages. However, transplantation of a small-for-size graft is associated with an increased risk of posttransplant hepatic dysfunction, commonly referred to as small-for-size syndrome (SFSS). This review describes the etiology, pathological features, clinical manifestations, and diagnostic criteria of SFSS. Moreover, we summarize strategies to improve graft function, focusing on graft inflow modulation techniques. Finally, unmet needs and future perspectives are discussed. SUMMARY: In fact, posttransplant SFSS can be attributed to various factors such as preoperative status of the recipients, surgical techniques, donor age, and graft quality, except for graft size. With targeted improvement measures, satisfactory clinical outcomes can be achieved in recipients at increased risk of SFSS. Given the critical role of relative portal hyperperfusion in the pathogenesis of SFSS, various pharmacological and surgical treatments have been established to reduce or partially divert excessive portal inflow, and recipients will benefit from individualized therapeutic regimens after careful evaluation of benefits against potential risks. However, there remain unmet needs for further research into different aspects of SFSS to better understand the correlation between portal hemodynamics and patient outcomes. KEY MESSAGES: Contemporary transplant surgeons should consider various donor and recipient factors and develop case-specific prevention and treatment strategies to improve graft and recipient survival rates.

Nestin+ Mesenchymal Precursors Generate Distinct Spleen Stromal Cell Subsets and Have Immunomodulatory Function.

Mesenchymal stromal cells (MSCs) are known to be widespread in many tissues and possess a broad spectrum of immunoregulatory properties. They have been used in the treatment of a variety of inflammatory diseases; however, the therapeutic effects are still inconsistent owing to their heterogeneity. Spleen stromal cells have evolved to regulate the immune response at many levels as they are bathed in a complex inflammatory milieu during infection. Therefore, it is unknown whether they have stronger immunomodulatory effects than their counterparts derived from other tissues. Here, using a transgenic mouse model expressing GFP driven by the Nestin (Nes) promoter, Nes-GFP+ cells from bone marrow and spleen were collected. Artificial lymphoid reconstruction in vivo was performed. Cell phenotype, inhibition of T cell inflammatory cytokines, and in vivo therapeutic effects were assessed. We observed Nes-GFP+ cells colocalized with splenic stromal cells and further demonstrated that these Nes-GFP+ cells had the ability to establish ectopic lymphoid-like structures in vivo. Moreover, we showed that the Nes-GFP+ cells possessed the characteristics of MSCs. Spleen-derived Nes-GFP+ cells exhibited greater immunomodulatory ability in vitro and more remarkable therapeutic efficacy in inflammatory diseases, especially inflammatory bowel disease (IBD) than bone marrow-derived Nes-GFP+ cells. Overall, our data showed that Nes-GFP+ cells contributed to subsets of spleen stromal populations and possessed the biological characteristics of MSCs with a stronger immunoregulatory function and therapeutic potential than bone marrow-derived Nes-GFP+ cells.

Systemic Immune-Inflammation Index Is a Prognostic Predictor in Patients with Intrahepatic Cholangiocarcinoma Undergoing Liver Transplantation.

BACKGROUND: It was reported that systemic immune inflammation index (SII) was related to poor prognosis in a variety of cancers. We aimed to investigate the ability of the prognostic predictors of SII in patients with intrahepatic cholangiocarcinoma (iCCA) undergoing liver transplantation (LT). METHODS: The 28 iCCA patients who underwent LT at our hospital between 2013 and 2018 were reviewed. Kaplan-Meier survival curves and Cox regression analyses were used to evaluate the prognostic significance of SII. Patients were divided into the high and low SII groups according to the cut-off value. RESULTS: The 1-, 3-, and 5-year OS rates were significantly lower in the high SII group (85.7%, 28.6%, and 21.4%, respectively) than in the low SII group (92.9%, 71.4%, and 57.2%, respectively; P = 0.009). The 1-, 3-, and 5-year RFS rates were, respectively, 57.1%, 32.7%, and 21.8% in the high SII group and 85.7%, 61.1%, and 61.1% in the low SII group (P = 0.021). SII ≥ 447.48 × 109/L (HR 0.273, 95% CI 0.082-0.908; P = 0.034) was an independent prognostic factor for OS. CONCLUSIONS: Our results showed that SII can be used to predict the survival of patients with iCCA who undergo LT.

Transplantation of a single kidney from pediatric donors less than 10 kg to children with poor access to transplantation: a two-year outcome analysis.

BACKGROUND: Access to kidney transplantation by uremic children is very limited due to the lack of donors in many countries. We sought to explore small pediatric kidney donors as a strategy to provide transplant opportunities for uremic children. METHODS: A total of 56 cases of single pediatric kidney transplantation and 26 cases of en bloc kidney transplantation from pediatric donors with body weight (BW) less than 10 kg were performed in two transplant centers in China and the transplant outcomes were retrospectively analyzed. RESULTS: The 1-year and 2-year death-censored graft survival in the en bloc kidney transplantation (KTx) group was inferior to that in the single KTx group. Subgroup analysis of the single KTx group found that the 1-year and 2-year death-censored graft survival in the group where the donor BW was between 5 and 10 kg was 97.7 and 90.0%, respectively. However, graft survival was significantly decreased when donor BW was ≤5 kg (p < 0.01), mainly because of the higher rate of thrombosis (p = 0.035). In the single KTx group, the graft length was increased from 6.7 cm at day 7 to 10.5 cm at 36 months posttransplant. The estimated glomerular filtration rate increased up to 24 months posttransplant. Delayed graft function and urethral complications were more common in the group with BW was ≤5 kg. CONCLUSIONS: Our study suggests that single kidney transplantation from donors weighing over 5 kg to pediatric recipients is a feasible option for children with poor access to transplantation.

Risk factors and outcomes of prolonged recovery from delayed graft function after deceased kidney transplantation.

OBJECTIVE: We aimed to evaluate the effect of prolonged recovery from DGF on outcomes, using a new definition of DGF recovery time, among deceased donor kidney transplant recipients with DGF, and to examine the risk factors for prolonged recovery. METHODS: From 2007 to 2016, 91 deceased donor kidney transplant recipients with DGF were retrospectively analyzed. DGF recovery time was defined as the time from transplantation to achieve a stable estimated glomerular filtration rate (eGFR). Recipients with a DGF recovery time greater than or equal to the median were assigned to the prolonged recovery group, while the others were assigned to the rapid recovery group. RESULT: The median DGF recovery time was 27 days. Donor terminal eGFR was significantly lower in the prolonged recovery group (n = 46) compared with the rapid recovery group (n = 45) (median 24.9 vs. 65.4 ml/min/1.73m2, p = 0.004). The eGFR at 1 year post-transplant in the prolonged recovery group was significantly lower than that in the rapid recovery group (50.6 ± 20.0 vs. 63.5 ± 21.4 ml/min/1.73m2, p = 0.005). The risk of adverse outcomes (acute rejection, pneumonia, graft failure, and death) was significantly greater in the prolonged recovery group (hazard ratio 2.604, 95% confidence interval 1.102-6.150, p = 0.029) compared with the rapid recovery group. CONCLUSION: Decreased donor terminal eGFR is a risk factor for prolonged recovery from DGF after deceased kidney transplantation. Prolonged DGF recovery time is associated with reduced graft function at 1-year post-transplant, and poor transplant outcome.

Glomerular Parietal Epithelial Cells Infection Is Associated With Poor Graft Outcome in Kidney Transplant Recipients With BK Polyomavirus-Associated Nephropathy.

BACKGROUND: The purpose of this study was to investigate the effect of BK polyomavirus (BKPyV infection of glomerular parietal epithelial cells (GPECs) on graft outcome in kidney transplant recipients with BKPyV-associated nephropathy (BKPyVAN). METHODS: A total of 152 kidney transplant recipients with BKPyVAN were divided into 31 with (GPEC-positive group) and 121 without (GPEC-negative group) BKPyV-infected GPECs. Clinicopathological characteristics and allograft survival were compared between the groups. RESULTS: The GPEC-positive group had more patients with advanced-stage BKPyVAN than the GPEC-negative group (P < .001). At the last follow-up, the GPEC-positive group had a significantly higher serum creatinine level than the GPEC-negative group. The graft loss rate in the GPEC-positive group was higher than that in the GPEC-negative group (32.3% vs 12.4%; P = .008). Kaplan-Meier analysis showed that the graft survival rate in the GPEC-positive group was lower than that in the GPEC-negative group (log-rank test, P = .004). Multivariate Cox regression analysis demonstrated that BKPyV infection of GPECs was an independent risk factor for graft survival (hazard ratio, 3.54; 95% confidence interval, 1.43-8.76; P = .006). CONCLUSIONS: GPEC infection in patients with BKPyVAN indicates more-severe pathological damage and a rapid decline in renal function. BKPyV infection of GPECs is an independent risk factor for allograft loss.

Systematic external evaluation of published population pharmacokinetic models of mycophenolate mofetil in adult kidney transplant recipients co-administered with tacrolimus.

AIMS: Various mycophenolate mofetil (MMF) population pharmacokinetic (popPK) models have been developed to describe its PK characteristics and facilitate its optimal dosing in adult kidney transplant recipients co-administered with tacrolimus. However, the external predictive performance has been unclear. Thus, this study aimed to comprehensively evaluate the external predictability of published MMF popPK models in such populations and investigate the potential influencing factors. METHODS: The external predictability of qualified popPK models was evaluated using an independent dataset. The evaluation included prediction- and simulation-based diagnostics, and Bayesian forecasting. In addition, factors influencing model predictability, especially the impact of structural models, were investigated. RESULTS: Fifty full PK profiles from 45 patients were included in the evaluation dataset and 11 published popPK models were identified and evaluated. In prediction-based diagnostics, the prediction error within ±30% was less than 50% in most published models. The prediction- and variability-corrected visual predictive check and posterior predictive check showed large discrepancies between the observations and simulations in most models. Moreover, the normalized prediction distribution errors of all models did not follow a normal distribution. Bayesian forecasting demonstrated an improvement in the model predictability. Furthermore, the predictive performance of two-compartment (2CMT) models incorporating the enterohepatic circulation (EHC) process was not superior to that of conventional 2CMT models. CONCLUSIONS: The published models showed large variability and unsatisfactory predictive performance, which indicated that therapeutic drug monitoring was necessary for MMF clinical application. Further studies incorporating potential covariates need to be conducted to investigate the key factors influencing model predictability of MMF.

The Association of obesity with vascular complications after liver transplantation.

BACKGROUND: Because of the growing number of obese patients undergoing liver transplantation (LT), it is important to investigate the impact of obesity on post-transplant outcomes. Vascular complications are rare, but serious causes of morbidity and mortality after LT. It is not known if pre-transplant obesity is associated with an increased incidence of post-LT vascular complications. METHODS: Medline, Embase, and Cochrane Library databases were searched in September 2017. The primary outcome was the impact of obesity on the vascular complication rate in adult LT recipients. Survival and biliary complications rates were also analyzed. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to compare pooled data between groups with a body mass index (BMI) ≥ 30 kg/m2 and < 30 kg/m2. RESULTS: Six retrospective cohort studies with a total of 987 patients with a BMI ≥ 30 kg/m2 (high BMI group) and 2911 patients with a BMI < 3 0 kg/m2 (control group) were included in the analysis. All studies had Newcastle-Ottawa Scale scores ≥4. The vascular complication rates were similar between the high BMI group and control group (RR = 1.13, 95% CI: 0.87-1.47, P = 0.27), as were the patient survival, graft survival, and biliary complication rates. In subgroup analysis, there was no difference in the vascular complication rates between BMI ≥ 35 vs. BMI < 25 kg/m2; BMI 30-35 vs. BMI 18-25 kg/m2; BMI ≥ 30 vs. BMI 18-25 kg/m2; and BMI ≥ 35 vs. BMI < 35 kg/m2. No difference was found in subgroup analysis when BMI was adjusted for ascites. However, recipients whose primary disease was alcoholic liver disease, those with a BMI ≥ 30 kg/m2 had higher incidence of vascular complications than those with a BMI < 30 kg/m2 (RR = 1.55, 95% CI: 1.07-2.25, P = 0.02) . CONCLUSIONS: BMI does not affect incidence of vascular complications after LT. High pre-transplant BMI is not a risk factor for patient survival and biliary complications after LT.

Partial ALPPS versus complete ALPPS for staged hepatectomy.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can induce a stronger regenerative ability than traditional 2-stage hepatectomy (TSH). ALPPS has become popular for achieving fast hypertrophy in patients with an insufficient future liver remnant (FLR). However, ALPPS is associated with high morbidity and mortality. Partial ALPPS is a variation that may decrease the morbidity and mortality. The purpose of this study was to perform a meta-analysis comparing outcomes of ALLPS and partial ALLPS. METHODS: PubMed, Embase, and Cochrane Library databases were searched for studies comparing partial ALPPS and complete ALPPS up to April 2019. Included studies were assessed by the Newcastle-Ottawa Scale (NOS). Weighted mean difference (WMD)/standard mean difference (SMD) and odds ratios (OR) with 95% confidence intervals (CIs) were calculated to compare FLR, time interval between stages, postoperative complications, and mortality between partial and complete ALPPS. RESULTS: Four studies including 124 patients were included. FLR hypertrophy of partial ALPPS was comparable to complete ALPPS (p = 0.09). The time interval between stages was not different between the 2 procedures (p = 0.57). The postoperative complications rate of partial ALPPS was significantly lower than that of complete ALPPS (OR = 0.38; p = 0.03). The mortality rate of partial ALLPS (4.9%) was lower than that of complete ALLPS (18.9%), but the difference was not significant (OR = 0.37; p = 0.12). CONCLUSIONS: Partial ALLPS is associated with similar FLR hypertrophy and time interval between stages as complete ALLPS, and a lower complication rate. Further studies are needed to examine patient selection and outcomes of the 2 procedures.

Once-daily prolonged-release tacrolimus versus twice-daily tacrolimus in liver transplantation.

OBJECTIVE: For patients who have received a kidney transplant, studies have shown that once-daily prolonged-release tacrolimus (TAC) has similar efficacy and safety to standard twice-daily dosing. The purpose of this study was to perform a meta-analysis to compare the effectiveness and safety of daily TAC (TAC qd) versus standard twice-daily TAC (TAC bid) administration in liver transplantation (LT). DESIGN: Meta-analysis. SETTING AND PARTICIPANTS: We systematically searched the PubMed/MEDLINE, Web of Science, and Cochrane Library databases for studies comparing outcomes of LT patients who received TAC qd versus TAC bid. OUTCOME MEASURES: Results were reported as odds ratios (ORs) with 95% CIs. RESULTS: Six studies, which included 5179 LT recipients (TAC qd = 951; TAC bid = 4228) were included in the analysis. The TAC qd group had a low 1-year graft loss rate (OR 0.70 [95% CI 0.54-0.91], P = 0.008) and lower rate of biopsy-proven acute rejection (BPAR) at 90 days (OR 0.46 [95% CI 0.24-0.89], P = 0.02) compared with the TAC bid group. There was no significant difference in 1-year mortality or the incidence of adverse events after LT between the 2 groups. CONCLUSIONS: Current evidence suggests that TAC qd is safe and effective for LT patients during the first year after transplantation. Longer-term follow-up studies are necessary to determine if TAC qd is safe and effective beyond the first year after LT.

The early outcomes of candidates with portopulmonary hypertension after liver transplantation.

BACKGROUND: Portopulmonary hypertension (PPH) was once regarded as a contraindicaton to liver transplantation (LT). However, growing evidence has indicated that PPH patients undergoing LT may show similar outcomes compared to those without PPH, and researchers have recommended it not be an absolute contraindication. Given this controversy, we aimed to identify and review the current evidence on this topic and to provide a comparison of the outcomes after LT between candidates with PPH and those without. METHODS: We systematically searched the MEDLINE, EMBASE and Cochrane Library databases for all studies that compared the outcomes of PPH patients and those without PPH after LT. All studies reporting outcomes of PPH patients versus those without PPH (Control) were further considered for inclusion in this meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare the pooled data between PPH and Control groups. RESULTS: Eleven retrospective trials and one prospective, randomized, controlled trial, involving 37,686 transplant recipients were included. The PPH patients had increased 1-year mortality with an OR of 1.59 (95% CI = 1.26-2.01, P = 0.0001) compared to the control group. There was no significant difference in graft loss and 30-day mortality after LT between the two groups. CONCLUSIONS: Patients with PPH who underwent LT had increased 1-year mortality compared to those without PPH, while graft loss and 30-day mortality were similar. Nevertheless, LT may be a reasonable therapeutic option for some patients with PPH, but further studies are needed to identify those select patients with PPH who would benefit most from LT.

Transplantation for infantile nephronophthisis with loss-of-function mutation in NPHP3: Lesson from a case.

The choice of KT only or CLKT for infantile NPHP with mild liver fibrosis is understudied. A 5-year-old girl was transferred to our center for KT due to ESRD. Her primary disease was infantile NPHP with compound heterozygous NPHP3 mutations: c.458A>C(p.Q153P)/missense mutation and c.2032A>T(p. K678X)/nonsense mutation. The patient had elevated liver enzymes and biopsy-proven liver fibrosis. As liver synthesis was acceptable, only KT was performed. However, liver fibrosis progressed at 1.5 years after transplantation, manifested with portal hypertension and hypersplenism. Common causes for portal hypertension were excluded, and the progression was attributed to NPHP. AMR attacked allograft at about 2 years post-transplant. To solve both the liver and the kidney problems, CLKT was performed. Her liver and kidney function recovered initially, but she unfortunately died of pneumonia and subsequent intracranial hemorrhage two weeks later. Nonsense mutation in NPHP3 gene may be correlated with rapid progression of liver disease in infantile NPHP. More studies are required to determine the role of CLKT in these cases; however, combined transplantation may improve long-term graft and patient survival.

Dendritic cells that highly express SOCS1 induce T-cell hypo-responsiveness and prolong islet allograft survival.

The capability of dendritic cells (DCs) to induce an immune response or immune tolerance is dependent on their status. Suppressor of cytokine signaling 1 (SOCS1) is a pivotal regulator that participates in negative feedback of the JAK-STAT pathway, which plays a key role in the differentiation, activation, and maturation of DCs. DCs that highly express SOCS1 may modulate DCs, and induce immune anergy or immune tolerance. In this study, we transduced DCs with the recombinant adenovirus Ad5F35 to highly express SOCS1. The mechanisms by which DC-SOCS1 induces T-cell hypo-responsiveness were analyzed in vivo and in vitro. The data demonstrate that recipients treated with DC-SOCS1 had long islet allograft survival times, with a reduction of Th1 and Tc1 in both spleen and draining lymph nodes in vivo. In vitro assay revealed that DCs transduced with SOCS1 had low expression of major histocompatibility and costimulatory molecules, and potentiated the ability of DC-SOCS1 to induce T-cell hypo-responsiveness. Therefore, genetic modification of DCs with SOCS1 affects DC activation and maturation, inhibits T-cell proliferation and induces hypo-responsiveness, and prolongs islet allograft survival.

En bloc kidney transplantation from infant donors younger than 10 months into pediatric recipients.

Early graft loss and poor graft function limit the use of kidneys from infant donors. Six en bloc kidney transplantations were performed from infant donors younger than 10 months into pediatric recipients between November 2012 and September 2015 at our center. We retrospectively analyzed recipient and donor demographics, surgery procedures, complications, graft function and size, and patient and graft survival with a follow-up of 6-39 months (median 15.5 months). Donor age ranged from 1 to 10 months with weight ranging from 3.5 to 10 kg. Recipient age ranged from 10 to 16 years with weight ranging from 30 to 39 kg. One kidney was removed due to arterial thrombosis during surgery, while the other kidney of this en bloc graft remained viable. Urine leak followed by bilateral ureteral obstruction occurred in one recipient. All of the recipients showed immediate graft function. The size of the en bloc kidney increased from 4.2±0.6 cm to 7.6±0.6 cm 6 months after surgery. Patient and graft survival were both 100% at the last follow-up. Our results show that en bloc kidney transplantation from infant donors younger than 10 months into pediatric recipients is effective under the condition of experienced surgical techniques and perioperative management.

Trichinella spiralis infection changes immune response in mice performed abdominal heterotopic cardiac transplantation and prolongs cardiac allograft survival time.

Allograft rejection has been an obstacle for long-term survival of patients for many years. Current strategies for transplant rejection are not as optimal as we expected, especially for long-term treatments. Trichinella spiralis, a nematode parasitized in mammalian muscle and as an invader, maintains harmonious with host in the long term by evading host immune attack. To determine whether T. spiralis infection impacts on allograft rejection, we performed mice cardiac allograft transplantation model by using BALB/c (H-2(b)) mice as donors and C57BL/6 (H-2(b)) mice orally infected with 300 muscle larvae for 28 days as recipients. Graft survival was monitored by daily palpation of the abdomen; histologic change was observed by H&E stain; and CD4(+), CD8(+), CD4(+)IFN-γ(+), and CD4(+)IL-17(+) T cells and regulatory T cells were examined with the use of flow cytometry. Serum cytokine levels were measured by Luminex. Finally, we found that mean survival time of cardiac allografts in T. spiralis group was 23.40 ± 1.99 days, while the vehicle control group was 10.60 ± 0.75 days. Furthermore, we observed alleviated histological changes in the heart allograft, decreased corresponding CD8(+) T cells, suppressed Th1 and Th17 responses, and increased regulatory T cell frequency in a murine cardiac transplantation model at day 7 post-transplantation in experimental group. These data suggest that T. spiralis infection resulted in prolonged allograft survival following murine cardiac transplantation, with suppressed Th1/Th17 responses and augmented regulatory T cells.

[Analysis of BK viruria on the long term graft survival in renal transplant recipients].

OBJECTIVE: To observe the clearance of BK viruria and long-term graft survival in renal transplant recipients with BK virus (BKV) infection under the protocol of our center. METHODS: Urine was taken from 229 renal transplant recipients,who were transplanted between March 2006 to October 2008, for BKV cytological testing and real-time PCR for BKV DNA at 1, 3, 6, 9, and 12 months after transplantation. Graft biopsies were analyzed for SV40-T by immunohistochemical method. Recipients were treated according to the BKV infection protocol of our center and were monitored for BKV and graft function. All the patients were followed for at least 5 years. RESULTS: By 1 year post-transplant, urinary decoy cells, BK viruria, and BKV associated nephropathy (BKVAN) occurred in 78, 99, and 7 patients, respectively. The median followed-up time was 63.6 (3.0-88.0) months. After reduction of immunosuppression, 81 (81.8%) patients cleared BK viruria with a mean time of (12.1 ± 1.9) months. When compared with non-BKVAN patients, BKVAN patients had a higher median peak level of BK viruria (2.07 × 109 vs 9.28 × 105 copies/ml, P=0.002), lower frequency of clearance (3/7 vs 78/92, P=0.006), longer BK viruria clearance time ((45.4 ± 6.4) vs (8.7 ± 1.5) months, P=0.001). The 1, 3, 5-year graft survival in BK viruria patients were 99.0%, 95.9% and 89.6% respectively, which were not significantly different from those in non-BK viruria patients (97.7%, 95.5% and 93.7%, P=0.289). Graft function of BK viruria patients were not statistical significance compared with non-BK viruria patients (serum creatinine level 5 years post-transplant: (105.7 ± 30.9) vs (111.3 ± 4.6) µmol/L, P=0.322). Graft function of BKVAN patients at 5 years post-transplant was stable without significantly difference from non-BKVAN patients (serum creatinine level: (127.6 ± 41.0) vs (108.3 ± 39.3) µmol/L, P=0.204). CONCLUSION: On the premise of intensively and regularly BKV monitoring and preemptive reduction of immunosuppression, BK viruria and BKVAN can not impact on the long-term graft survival in renal transplant recipients.

[Analysis on BK virus associated nephropathy related risk factors in renal transplant recipients].

OBJECTIVE: To analyze the risk factors affecting BK virus associated nephropathy (BKVAN) after kidney transplantation. METHODS: Three screening methods for BKVAN including quantitative PCR assay for BK virus (BKV) DNA load in urine and plasma and quantitative assay of urine cytology concurrently with renal transplant biopsies for the evaluation of 615 patients from January 2006 to December 2014 were used. The renal allograft biopsy specimens were analyzed by routine histologic examination, immunohistochemistry and classified into three categories of BKVAN. Potential variables were analyzed by Logistic regression model multivariate analysis to assess and rank BKVAN related risk factors. RESULTS: The positive rate of urine decoy cell , BKV viruria and viremia in 615 renal recipients were 13.7% (84/615), 29.3% (180/615), and 8.8% (54/615), respectively. BKVAN were diagnosed in 49 recipients. The incidence and the median level of the number of the decoy cell, BK viral load in urine and plasma were higher in the BKVAN group than those in non-BKVAN group (all P<0.05). Tacrolimus (Tac) combined with mycophenolic acid (MPA) protocol (OR=12.4, P=0.001) and severe pneumonia post-transplant (OR=3.7, P=0.001) were the independent risk factors impacting on BKVAN in renal recipients. CONCLUSIONS: The renal recipients with high level of BKV replication, whose immunosuppressant protocol include Tac and MPA, should be suspected the diagnosis of BKVAN.

En bloc dual kidney transplantation from pediatric donors after cardiac death: initial experience in China.

OBJECTIVE: To report 9 cases of en bloc kidney transplantation from pediatric donors in China and share the clinical experience. METHODS: From February 2010 to February 2014, 9 pediatric donors (aged 5 months to 6 years) were assigned to us by the modern donation and allocation system after cardiac death. The en bloc kidneys were recovered in all 9 patients. The inferior vena cava and aorta of the donors were anastomosed to the external vein and artery of the recipients (7 adults and 2 children). Alprostadil or enoxaparin sodium was used for anticoagulation. RESULTS: The kidneys attained immediate perfusion after vascular anastomosis, except for one renal artery that developed thrombosis several minutes later, necessitating nephrectomy of the unilateral graft. The other eight en bloc grafts maintained normal function during the follow-up period of 1-50 months and all the patients survived. There were no rejections or other complications. Based on ultrasonography, the grafts increased in size during the follow-up period. CONCLUSIONS: These results indicate that en bloc renal transplantation from pediatric donors is an acceptable procedure, and more widespread use could increase the number of potential donors. Splitting of pediatric donor en bloc kidneys for transplantation into two recipients may also be feasible in well-matched cases.

Kidney transplantation and gut microbiota.

Kidney transplantation is an effective way to improve the condition of patients with end-stage renal disease. However, maintaining long-term graft function and improving patient survival remain a key challenge after kidney transplantation. Dysbiosis of intestinal flora has been reported to be associated with complications in renal transplant recipients. The commensal microbiota plays an important role in the immunomodulation of the transplant recipient responses. However, several processes, such as the use of perioperative antibiotics and high-dose immunosuppressants in renal transplant recipients, can lead to gut dysbiosis and disrupt the interaction between the microbiota and the host immune responses, which in turn can lead to complications such as infection and rejection in organ recipients. In this review, we summarize and discuss the changes in intestinal flora and their influencing factors in patients after renal transplantation as well as the evidence related to the impact of intestinal dysbiosis on the prognosis of renal transplantation from in vivo and clinical studies, and conclude with a discussion of the use of microbial therapy in the transplant population. Hopefully, a deeper understanding of the function and composition of the microbiota in patients after renal transplantation may assist in the development of clinical strategies to restore a normal microbiota and facilitate the clinical management of grafts in the future.