Torque teno virus (TTV): A gentle spy virus of immune status, predictive marker of seroconversion to COVID-19 vaccine in kidney and lung transplant recipients.

To date, no comprehensive marker to monitor the immune status of patients is available. Given that Torque teno virus (TTV), a known human virome component, has previously been identified as a marker of immunocompetence, it was retrospectively investigated whether TTV viral load may also represent a marker of ability to develop antibody in response to COVID-19-BNT162B2 vaccine in solid organ transplant recipients (SOT). Specifically, 273 samples from 146 kidney and 26 lung transplant recipients after successive doses of vaccine were analyzed. An inverse correlation was observed within the TTV copy number and anti-Spike IgG antibody titer with a progressive decrease in viremia the further away from the transplant date. Analyzing the data obtained after the second dose, a significant difference in TTV copy number between responsive and nonresponsive patients was observed, considering a 5 log10 TTV copies/mL threshold to discriminate between the two groups. Moreover, for 86 patients followed in their response to the second and third vaccination doses a 6 log10 TTV copies/mL threshold was used to predict responsivity to the booster dose. Although further investigation is necessary, possibly extending the analysis to other patient categories, this study suggests that TTV can be used as a good marker of vaccine response in transplant patients.

SARS-COV-2 vaccination with BNT162B2 in renal transplant patients: Risk factors for impaired response and immunological implications.

Solid organ transplant patients are at a higher risk for poor CoronaVirus Disease-2019 (COVID-19)-related outcomes and have been included as a priority group in the vaccination strategy worldwide. We assessed the safety and efficacy of a two-dose vaccination cycle with mRNA-based COVID-19 vaccine (BNT162b2) among 82 kidney transplant outpatients followed in our center in Rome, Italy. After a median of 43 post-vaccine days, a SARS-CoV-2 anti-Spike seroprevalence of 52.4% (n = 43/82) was observed. No impact of the vaccination on antibody-mediated rejection or graft function was observed, and no significant safety concerns were reported. Moreover, no de novo HLA-donor-specific antibodies (DSA) were detected during the follow-up period. Only one patient with pre-vaccination HLA-DSA did not experience an increased intensity of the existing HLA-DSA. During the follow-up, only one infection (mild COVID-19) was observed in a patient after receiving the first vaccine dose. According to the multivariable logistic regression analysis, lack of seroconversion after two-dose vaccination independently associated with patient age ≥60 years (OR = 4.50; P = .02) and use of anti-metabolite as an immunosuppressant drug (OR = 5.26; P = .004). Among younger patients not taking anti-metabolites, the seroconversion rate was high (92.9%). Further larger studies are needed to assess the best COVID-19 vaccination strategy in transplanted patients.

The role of hypothermic machine perfusion in selecting renal grafts with advanced histological score.

BACKGROUND: Few studies explored the role of hypothermic machine perfusion (HMP) in the sub-group of non-standard renal grafts with a biopsy-proven advanced histological impairment. This study aimed to investigate the role of HMP in grafts with a Karpinski Score >3 in terms of the need for dialysis, creatinine reduction ratio at day-7 (CRR7), and 3-year graft survival. METHODS: Twenty-three perfused grafts with Karpinski Score >3 evaluated between November 2017 and December 2018 were retrospectively analyzed and compared with a control group of 32 non-perfused grafts transplanted between January 2014 and October 2017. RESULTS: After transplantation, perfused grafts had fewer cases requiring dialysis (8.7% vs. 34.4%; p = 0.051), a better reduction in serum creatinine (median at 7 days: 2.2 vs. 4.3 mg/dl; p = 0.045), and shorter length of hospital stay (median 11 vs. 15 days; p = 0.01). Three-year death-censored graft survival was better in the perfused cases (91.3% vs. 77.0%; p = 0.16). In perfused grafts, initial renal resistance (RR) had the best predictive value for renal function recovery after the first week, as defined by CRR7 ≤ 70% (AUC = 0.83; p = 0.02). A cut-off value of 0.5 mm Hg/ml/min showed a sensitivity of 82.4%, a specificity of 83.3%, and diagnostic odds ratio = 23.4. After dividing the entire population into a Low-RR (n = 8) and a High-RR Group (n = 15), more cases with CRR7 ≤ 70% were reported in the latter group (86.7 vs. 13.3%; p = 0.03). CONCLUSION: HMP yielded promising results in kidneys with Karpinski Score >3. Initial RR should be of interest in selecting non-standard organs for single kidney transplantation even in impaired histology.

Role of Contrast-Enhanced Voiding Urosonography in the Evaluation of Renal Transplant Reflux - Comparison with Voiding Cystourethrography and a New Classification.

Vesicoureteral reflux (VUR) is a common urological complication in renal transplant patients. THE AIM: of this study is to evaluate the performance of contrast-enhanced voiding urosonography (CEvUS) in the diagnosis and classification of reflux into the renal allograft, to evaluate and classify VUR into the allograft using voiding cystourethrography (VCUG) and CEvUS, to compare the two methods, and to propose a new classification of reflux into the allograft based on CEvUS and VCUG assessment, in line with the international reflux grading system. MATERIALS AND METHODS: From January 2017 to July 2019, 84 kidney transplant patients were enrolled. All patients underwent VCUG and CEvUS. RESULTS: In 76 cases there was agreement between VCUG and CEvUS (90 %) (Kappa = 0.7). The sensitivity of CEvUS using VCUG as the gold standard was 90 %, and the specificity was 92 %. Of the 7 cases diagnosed by VCUG and not by CEvUS, 6 were grade 1 and 1 was grade 2. CONCLUSION: Transplant patients with reflux symptoms should undergo CEvUS. If the outcome is negative, VCUG should be performed. The classification that we propose is better suited to describe VUR in transplant patients, because it is simpler and takes into account whether reflux occurs not only during urination but also when the bladder is relaxed.

The Long-Term Immunogenicity of mRNABNT162b Third Vaccine Dose in Solid Organ Transplant Recipients.

We investigated humoral and T-cell response to a SARS-CoV-2 mRNA vaccine in solid organ transplant recipients (SOT-Rs) and healthy donors (HDs) before (T0) and after two (T1) and twelve months (T2) since the third dose administration. SOT-Rs were stratified according to the transplanted organ and to the time elapsed since the transplant. In SOT-Rs, detectable levels of anti-S antibodies were observed in 44%, 81% and 88% at T0, T1 and T2, respectively. Conversely, anti-S antibody levels were detected in 100% of HD at all time points. Lower antibody titers were observed in SOT-Rs compared to HDs, even stratifying by transplanted organs and the time elapsed since transplant. Lower percentages of responding and polyfunctional T-cells were observed in SOT-Rs as well as in each subgroup of SOT-Rs compared to HDs. At both T0 and T1, in SOT-Rs, a predominance of one cytokine production shortly was observed. Conversely, at T2, a dynamic change in the T-cells subset distribution was observed, similar to what was observed in HDs. In SOT-Rs, the third dose increased the rate of seroconversion, although anti-S levels remained lower compared to HDs, and a qualitatively inferior T-cell response to vaccination was observed. Vaccine effectiveness in SOT-Rs is still suboptimal and might be improved by booster doses and prophylactic strategies.

[Pre-emptive renal transplantation from deceased donor]. / Il trapianto pre-emptive da donatore deceduto.

Preemptive transplantation from deceased donors is an important issue due to its ethical and clinical implications. In this paper, two nephrologists discuss the problem from different angles, expressing their opinion on specific points and highlighting the limitations and advantages. The first point discussed relates to the advantages of preemptive renal transplant from a deceased donor versus dialysis. The second point considers the possibility that the former could reduce the already limited resources for patients on the transplant waiting list. The third point discusses whether preemptive transplant should be reserved for patients with particular background diseases. The last discussion point relates to the possibility that a preemptive program from deceased donors could hamper an already limited living donor program. The ethical aspects are examined separately by a bioethicist who critically evaluates all discussion points and lists some principles that should guide clinicians, before or after starting dialysis, in the proper use of renal transplant, an efficacious but scarce resource.

[Adacolumn apheresis for hepatitis C virus in patients waiting for kidney transplant. Preliminary study]. / Trattamento con Adacolumn leucocitaferesi per la rimozione del virus C nei pazienti in lista per trapianto di rene. Studio preliminare.

Hepatitis C virus (HCV) infection occurs much more frequently in the hemodialysis population than in the general population. Patients with chronic kidney disease with persistent HCV infection may develop serious and progressive chronic liver disease, with associated long-term morbidity and mortality related to cirrhosis and hepatocellular carcinoma. Monocytes and macrophages are known to produce extrahepatic breeding sites and spread the disease. Our aim was to lower the levels of macrophages, granulocytes, monocytes, proinflammatory cells and viremia using an extracorporeal device: the Adacolumn ® leukocyte apheresis system (Otsuka). The Adacolumn is a direct hemoperfusion-type leukapheresis device. The column is a single-use (disposable) polycarbonate column with a capacity of about 335 mL, filled with 220-g cellulose acetate beads of 2 mm in diameter bathed in physiological saline. The carriers adsorb ''activated'' granulocytes and monocytes/macrophages that bear Fc and complement receptors. The patients underwent five 1-hour sessions for five consecutive days. The column was placed in an extracorporeal setting with a perfusion rate of 30 mL/min and a duration of 60 minutes. A reduction of viremia was observed in all patients in association with a decrease in cytokine levels and a proportional decrease in immune cells. Although this study investigated responses in a small number of patients, it was shown that the Adacolumn changed the cellular immunity and promoted early viral response.

[Multimodal treatment for acute antibody-mediated renal transplant rejection: successful rescue therapy with combined plasmapheresis, photopheresis and intravenous immunoglobulin]. / Trattamento multimodale per il rigetto acuto anticorpo-mediato nel trapianto di rene: terapia di salvataggio con plasmaferesi, fotoaferesi e immunoglobuline endovenose.

The fundamental role of antibodies in the development of acute graft rejection has been established recently. Antibody-mediated acute rejection may develop at any time during the post-transplant period. Several therapeutic approaches have been proposed in the last decades. However, there is no standardized therapy. The aim of this study is to report the Sapienza University experience of combined plasma treatment and high-dose intravenous immunoglobulin ± extracorporeal photopheresis. From January 2006 to September 2009, 6 patients were treated at Sapienza University. In 5 cases (83%) complete regression of the acute rejection was observed, followed by stable renal function (median creatinine value at 1-year follow-up: 1.5 mg/dL). No adverse events were reported. Our approach seems to give good results in terms of graft survival and procedure safety. Further studies on a larger number of patients will be needed to confirm the validity of these findings. Moreover, comparison between our protocol and other treatments is necessary.

Effectiveness of Expressive Writing in Kidney Transplanted Patients: A Randomized Controlled Trial Study.

The present study aimed to assess the effectiveness of an expressive writing (EW) intervention on psychological and physiological variables after kidney transplant. The final sample of 26 were randomly assigned to an expressive writing group (EWG) and control group (CG). Outcomes were focused on depression, anxiety, alexithymia, empathy, resilience, locus of control, creatinine, CDK-EPI, and azotemia. Depressive symptoms and alexithymia levels decreased in the EWG, with better adherence. Resilience declined over time in both groups. The EWG showed a significantly higher CDK-EPI, indicating better renal functioning. EW seems an effective intervention to improve the psychological health of transplanted patients, with a possible effect on renal functioning. These findings open the possibility of planning brief psychological interventions aimed at processing emotional involvement, in order to increase adherence, the acceptance of the organ, and savings in healthcare costs.

Contrast Enhanced Ultrasound Compared with MRI and CT in the Evaluation of Post-Renal Transplant Complications.

Renal transplantation (RT) is the treatment of choice for end-stage renal disease, significantly improving patients' survival and quality of life. However, approximately 3-23% of patients encounter post-operative complications, and radiology plays a major role for their early detection and treatment or follow-up planning. CT and MRI are excellent imaging modalities to evaluate renal transplant post-operative course; nevertheless, they are both associated with a high cost and low accessibility, as well as some contraindications, making them not feasible for all patients. In particular, gadolinium-based contrast can lead to the rare condition of nephrogenic systemic fibrosis, and iodine-based contrast can lead to contrast-induced nephropathy (CIN). CT also exposes the patients who may require multiple examinations to ionizing radiation. Therefore, considering the overall advantages and disadvantages, contrast-enhanced ultrasound (CEUS) is presently considered an effective first-line imaging modality for post-operative early and long-term follow-up in RT, reducing the need for biopsies and providing adequate guidance for drainage procedures. Hence, this paper aims to review the updated knowledge on CEUS compared with CT and MRI for the evaluation of RT renal transplant complications; advantages, limitations, and possible recommendations are provided.

Diagnostic Value of Presepsin for Bacterial Infection in Cirrhosis: A Pilot Study.

INTRODUCTION: Presepsin (or sCD14) has been identified as a protein whose levels increase specifically in the blood of patients with bacterial infections. In this study, we evaluated the clinical performance of sCD14 and its usefulness in the early diagnosis of bacterial infection in decompensated cirrhotic patients. MATERIALS: Seventy patients were enrolled in this study. The mean age of patients was 49.5 years, and 21 were women and 49 men. The heparinized whole blood for the PATHFAST test was used in the evaluation of bacterial infection (T0). The test was repeated after 48 hours (T1); at 96 hours (T2); at 144 hours (T3); then at 15 days (T4) to monitor the clinical responses to therapeutic interventions. RESULTS: Forty-nine patients tested positive for sCD14. The mean sCD14 level was 1854 ± 1744 pg/mL. Microbiological findings confirmed the presence of bacterial infections within 84 ± 4.8 h from enrollment in all 49 positive patients. Thirty-eight patients were considered responders to empirical antibiotic therapy with a decrease of presepsin at the different time points, while an increased level of sCD14 was highlighted in 11 patients. When the test was performed, 45% of the patients showed no signs or symptoms of bacterial infection. At 30 days of follow-up 43 patients survived, and 6 patients died from septic shock. CONCLUSIONS: The PATHFAST test highlighted the presence of infection in a very short time (15 minutes), and the presepsin could be considered an early biomarker in patients with cirrhosis. A greater number of patients are necessary to confirm these data.

Expected and Observed Glomerular Filtration Rates in Kidney Transplant Patients Converted to Once Daily Tacrolimus: 10 Years of Follow-up.

The decline of allograft kidney function in the long term remains a significant issue in renal transplantation, with drug nephrotoxicity and cardiovascular complications as important risk factors. Our study aimed to evaluate the estimated glomerular filtration rate (eGFR) trend and metabolic cardiovascular risk factors over 10 years in a cohort of kidney transplant (KT) recipients converted from twice-daily (TD) tacrolimus (Tac) to once-daily (OD)-Tac. We enrolled 55 consecutive KT recipients who had been at the outpatient clinic between 2009 and 2011. Thirty-seven reached the 10-year follow-up. We compared the observed eGFR with the expected eGFR trend described in KT-recipients and monitored blood pressure and metabolic cardiovascular risk factors. The observed eGFR remained stable throughout the complete follow-up (P = .188). The observed decline of eGFR was significantly lower compared with the expected decline for KT patients (P < .001). The blood pressure was maintained within target values. The monitoring of plasma glucose levels demonstrated the stability of median values (P = .686), as well as cholesterol level (P = .250), high-density lipoprotein (HDL) cholesterol (P = .294), and triglycerides (P = .592) throughout the follow-up. The monitoring of tacrolimus plasma level demonstrated that median trough levels remained constant (median values 4.4-5.5 ng/mL) throughout the entire follow-up period (P = .149). We suggest that the reasonable control of metabolic risk factors for cardiovascular disease over long-term follow-up may significantly contribute to the preservation of eGFR compared with the decline expected in KT recipients.

Viremia Negativization After BK Virus Infection in Kidney Transplantation: A National Bicentric Study.

BACKGROUND: BK virus (BKV) infection represents a potentially dreadful complication after kidney transplantation (KT). When BK viremia is detected, the best therapeutic approach remains not entirely clarified. Critical elements of BK viremia treatment are immunosuppression minimization and introduction of drugs like leflunomide, everolimus, and fluoroquinolones. The study aimed to analyze the results of the BK viremia management in 2 collaborative Italian centers. METHODS: Ten patients undergoing KT in the 2 collaborative Italian centers of Sapienza University of Rome and University of L'Aquila from January 2013 to December 2017 and showing a post-KT diagnosis of BK viremia were retrospectively investigated. RESULTS: Mean time from KT to BKV positivity was 7 months (range: 1-19 months). At diagnosis, the mean viral load was 683,842 copies/mL (range: 5800-4,052,415 copies/mL), with an average zenith of 2,428,410 copies/mL (range: 6762-18,022,500 copies/mL). In the 5 patients with BKV nephropathy, we observed a switch from antimetabolite to leflunomide (n = 5), a switch from tacrolimus to everolimus (n = 3), or an introduction of fluoroquinolones (n = 3). BKV clearance was achieved in 3 patients. CONCLUSIONS: Early BKV diagnosis and stepwise minimization of immunosuppression remain the first-line approach in patients with BK viremia. In the presence of BKV nephropathy, a combination of antiviral drugs like leflunomide and fluoroquinolones/everolimus should favor viremia clearance.

Renal Papillary Carcinoma Developed in a Kidney Transplant Recipient With Late IgA-Nephropathy.

With improvements in immunosuppressive therapy, patient and graft survival in renal transplant recipients have been prolonged. Increasing donor age and patient survival rates have been related to an increase in the number of de novo tumors. Posttransplant malignancy in these patients is an important cause of graft loss and death in these patients. Among cancers occurring after a kidney transplant, renal cell carcinoma is the fifth most common malignancy after lymphoproliferative disorders, and skin, gastrointestinal, and lung cancers. When nonmelanoma skin cancers and in situ carcinoma of the cervix are excluded from malignancies, renal cell carcinoma accounts for 2% of all cancers in the general population, which increases to 5% in solid-organ recipients. The majority of renal cell carcinomas found in transplant recipients develop in the recipient 's native kidneys, but only 9% of tumors develop in the allograft itself. Tumors transmitted by donors represent only 0.02% to 0.2% of cases. Most de novo allograft renal cell carcinomas are single tumors. The mechanisms of development of renal cell carcinoma in renal grafts are not completely understood.

Evaluation of pretransplant immunologic status in kidney-transplant recipients by panel reactive antibody and soluble CD30 determinations.

OBJECTIVES: To retrospectively compare the accuracy of pretransplant panel of reactivity antibodies (PRA) and serum level of soluble CD30 (sCD30) in predicting early (< 6 months) acute rejection (AR) in living-donor and deceased-donor kidney-transplant (KT) patients. METHODS: Pretransplant sera of 24 KT recipients were retrospectively tested for sCD30 and compared with PRA. Inclusion criteria were de novo graft patients on calcineurin-inhibitor-based immunosuppression, minimum follow-up of 1 year, alive with a functioning graft, and stable renal function over the last 12 months. Objective measures were incidence of biopsy-proven AR (BPAR) within 6 months of KT and sCD30 and PRA diagnostic indexes. The relative risk (RR) of BPAR for each test was also obtained. RESULTS: Fourteen (58.3%) patients presented at least one episode of BPAR within 6 months of KT. All rejection episodes were responsive to steroid treatment. PRA was positive in six (25%) patients, and four (66.7%) of them presented at least one episode of BPAR. sCD30 tested positive in nine (37.5%) patients, and all these later presented at least one episode of BPAR. sCD30 and PRA diagnostic indexes in predicting early (< 6 months) BPAR were sensitivity 64.2% versus 28.5%; specificity 100% versus 80%; accuracy 79.1% versus 50%; positive predictive value 100% versus 66.6%; and negative predictive value 66.6% versus 44.4%. The RR of early AR was 1.4 in PRA-positive patients and extremely higher in the sCD30-positive group. CONCLUSIONS: Pretransplant sCD30 is a more accurate predictor of AR when compared with PRA. These results support its use in the pretransplant work-up of kidney-graft recipients.

Evaluation of pretransplant immunologic status in kidney-transplant recipients by panel reactive antibody and soluble CD30 determinations.

OBJECTIVES: To retrospectively compare the accuracy of pretransplant panel of reactivity antibodies (PRA) and serum level of soluble CD30 (sCD30) in predicting early (<6 months) acute rejection (AR) in living-donor and deceased-donor kidney-transplant (KT) patients. METHODS: Pretransplant sera of 24 KT recipients were retrospectively tested for sCD30 and compared with PRA. Inclusion criteria were de novo graft patients on calcineurin-inhibitor-based immunosuppression, minimum follow-up of 1 year, alive with a functioning graft, and stable renal function over the last 12 months. Objective measures were incidence of biopsy-proven AR (BPAR) within 6 months of KT and sCD30 and PRA diagnostic indexes. The relative risk (RR) of BPAR for each test was also obtained. RESULTS: Fourteen (58.3%) patients presented at least one episode of BPAR within 6 months of KT. All rejection episodes were responsive to steroid treatment. PRA was positive in six (25%) patients, and four (66.7%) of them presented at least one episode of BPAR. sCD30 tested positive in nine (37.5%) patients, and all these later presented at least one episode of BPAR. sCD30 and PRA diagnostic indexes in predicting early (< 6months) BPAR were sensitivity 64.2% versus 28.5%; specificity 100% versus 80%; accuracy 79.1% versus 50%; positive predictive value 100% versus 66.6%; and negative predictive value 66.6% versus 44.4%. The RR of early AR was 1.4 in PRA-positive patients and extremely higher in the sCD30-positive group. CONCLUSIONS: Pretransplant sCD30 is a more accurate predictor of AR when compared with PRA. These results support its use in the pretransplant work-up of kidney-graft recipients.

Tailoring of immunosuppression in renal and liver allograft recipients displaying donor specific T-suppressor cells.

Although transplantation tolerance cannot be yet reliably achieved in humans, there is evidence that active immunosuppression contributes to the maintenance of quiescence. However, the mechanism that underlies quiescence and the precise identity of regulatory cells are not completely understood. We have demonstrated that allograft recipients who remain rejection-free display allospecific T-suppressor cells (Ts). Ts express the CD8(+) CD28(-) phenotype, recognize major histocompatibility complex (MHC) class I antigens, and suppress the up-regulation of costimulatory molecules induced by CD40 ligation of donor antigen presenting cells. The presence of Ts is inversely correlated with T cell alloreactivity to donor MHC peptides, alloantibody production, and rejection. Monitoring of Ts has been successfully used in our studies for tailoring immunosuppression in kidney and liver allograft recipients.

Color Doppler ultrasound in renal transplant: role of resistive index versus renal cortical ratio in the evaluation of renal transplant diseases.

BACKGROUND/AIMS: Ultrasound (US) and color Doppler are not sensitive enough to detect anomalies in cortical perfusion, which is affected in most graft dysfunctions. The renal cortical ratio (RCR) is a variation in the resistive index (RI) values from the renal artery to cortical vessels, expressed in percent. The aim of this study was to compare the RI and RCR in the differentiation of normal and pathological grafts, to assess the positive predictive value of RCR and show that RCR enables earlier diagnosis than RI. METHODS: Based on clinical, biochemical and histological examinations, 494 renal allografts were divided into 3 groups (normal grafts, acute and chronic pathologies). All patients underwent US color Doppler. RI was measured and RCR calculated. Follow-up confirmed the initial division in groups. Statistical significance was calculated using the two-tailed Student's t test. The positive predictive value was calculated for each group. RESULTS: 24 h after transplant, RCR differentiated normal grafts from acute dysfunctions despite confusing biochemical values and clinical symptoms. In chronic patients, RCR variations occurred later but always before the serum creatinine level increased. CONCLUSION: RCR presented a higher positive predictive value than RI. RCR curves were already altered in the early stages of transplant pathologies. RCR calculation is easy and makes a significant contribution towards a correct early diagnosis.

Ethical considerations on kidney transplantation from living donors.

Our study population consisted of 402 Living Related Donors (LRD)--of which 344 pairs shared 1 haplotype (Group A) and of 209 Living Unrelated Donors (LURD) (Group B): 175 between spouse pairs (Group C)--132 from wife to husband (Group C1) and 43 from husband to wife (Group C2) as well as 32 between relatives in law or emotionally related patients and 2 between members of clergy (Group D). 199 pairs showed 3-6 HLA A B Dr mismatches (MM) with the donor and in 10 cases 0-2 MM. Donor and recipient mean age was 49 +/- 13.4 and 29 +/- 10.3 in Group A and respectively 46 +/- 11.2 and 48 +/- 9.6 in Group B. The post-transplant immunosuppression therapy was based on Cyclosporin A (CsA). Chi2 test was used to assess statistical significance. Donor mortality was 0%; perioperative morbidity was 15.2%. Graft function immediately started after surgery. The actuarial 1 yr, 5 yrs, 10 yrs and 15 yrs graft survival was in Group A: 94%, 86%, 84%, 75% vs. Group B: 89%, 78%, 71%, 70% (NS), Group C1: 90%, 75%, 67%, 69% vs. Group C2: 81%, 74%, 72%, 62% (NS) and Group C: 88%, 78%, 66%, 60% vs. Group D: 91%, 80%, 71%, 61% (NS). There was no statistically significant difference between LURD and LRD as far as graft survival. In conclusion, we certainly agree with the guidelines issued by the International Congress on Ethics in Organ Transplantation (Munich, December 10-13,2002): kidney transplantation from living donors is a safe and effective procedure and should not be discouraged.

A case of portal vein arterialization after a liver transplant.

Hepatic artery thrombosis represents a potentially deadly complication after a liver transplant. Portal vein arterialization recently has been proposed as a bridge approach in patients with hepatic artery thrombosis needing a retransplant. We report the case of a 53-year-old man treated with a liver transplant for a cryptogenetic cirrhosis. One month after a liver transplant, a hepatic artery thrombosis was documented, and a portal vein arterialization as bridge therapy for another liver transplant was performed. After surgery, improvement in the patient's liver functioning was seen. No signs of portal hypertension or hepatic abscesses were documented. Unfortunately, 8 months after the liver transplant, the patient experienced a severe urinary infection caused by a multidrug-resistant Klebsiella and died. An increase in the oxygen supply to the liver parenchyma after portal vein arterializations represents rationale use for managing hepatic artery thromboses. Several cases of treating post liver transplant hepatic artery thromboses have been reported in the literature. Portal vein arterializations can be used as bridge therapy in well-selected situations of post-liver transplant hepatic artery thromboses. Strict surveillance should be used to prevent the onset of complications that can exclude a patient from a transplant. The correct timing for retransplant is not fully known, but we think the shorter the time to retransplant, the better is the patient survival.