En Bloc Liver Kidney Transplantation Using Donor Splenic Artery as Inflow to the Kidney: Report of Two Cases.

The number of simultaneous liver-kidney transplants has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time for the renal allograft. Two patients listed for liver-kidney transplant at our center underwent en bloc combined liver-kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization that was complicated by a bleeding pseudoaneurysm of the right external iliac artery that required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. In this paper, we described a novel technique of en bloc liver-kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful for decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant that can be used in patients with severe disease of the iliac arteries.

Many de novo donor-specific antibodies recognize ß2 -microglobulin-free, but not intact HLA heterodimers.

Solid-phase single antigen bead (SAB) assays are standard of care for detection and identification of donor-specific antibody (DSA) in patients who receive solid organ transplantation (SOT). While several studies have documented the reproducibility and sensitivity of SAB testing for DSA, there are little data available concerning its specificity. This study describes the identification of antibodies to ß(2) -microglobulin-free human leukocyte antigen (ß(2) -m-fHLA) heavy chains on SAB arrays and provides a reassessment of the clinical relevance of DSA testing by this platform. Post-transplant sera from 55 patients who were positive for de novo donor-specific antibodies on a SAB solid-phase immunoassay were tested under denaturing conditions in order to identify antibodies reactive with ß(2) -m-fHLA or native HLA (nHLA). Antibodies to ß(2) -m-fHLA were present in nearly half of patients being monitored in the post-transplant period. The frequency of antibodies to ß(2) -m-fHLA was similar among DSA and HLA antigens that were irrelevant to the transplant (non-DSA). Among the seven patients with clinical or pathologic antibody-mediated rejection (AMR), none had antibodies to ß(2) -m-fHLA exclusively; thus, the clinical relevance of ß(2) -m-fHLA is unclear. Our data suggests that SAB testing produces false positive reactions due to the presence of ß(2) -m-fHLA and these can lead to inappropriate assignment of unacceptable antigens during transplant listing and possibly inaccurate identification of DSA in the post-transplant period.

Sclerosing pancreatitis presenting as a periampullary tumour.

BACKGROUND: Sclerosing lesions of the pancreatic duct are rare and may be secondary to primary sclerosing cholangitis (PSC) or the result of a primary sclerosing process (the recently described lymphoplasmacystic sclerosing pancreatitis, LSP). Occasionally this process may present as a mass lesion. CASE OUTLINE: A 21 -year-old man presented with abdominal pain and jaundice, giving a high index of suspicion for a periampullary malignancy. There were minimal symptoms suggestive of PSC. The resected head of the pancreas demonstrated changes of chronic pancreatitis with a fibro-inflammatory process of the pancreatic duct suggesting an underlying ductal sclerosing process. DISCUSSION: Clinical presentation and imaging characteristics of PSC involving the pancreas are often misleading and may suggest a neoplasm as the underlying disorder. Conclusive diagnosis is usually not determined until after surgical intervention. Although racial differences in pancreatic duct involvement have been suggested, the underlying histopathology is the same as in PSC involving the biliary ducts.