Fatal Allograft Rejection and Cardiac Allograft Vasculopathy After Treatment With Pembrolizumab for Metastatic Melanoma in a Heart Transplant Recipient: A Case Report.

Checkpoint inhibitors decrease the progression of many cancers. However, the experience in immunosuppressed patients is limited, with reports of possible serious adverse events. We present a heart transplant recipient treated with pembrolizumab for metastatic melanoma who developed fatal rejection. The patient was a 29 year-old man who underwent heart transplantation at the age of 10 years for congenital heart disease. Seventeen years after transplant, he was diagnosed with scalp melanoma pT3a, N2a, M0, Stage IIIA, positive for BRAF V600E mutation treated with excision, which metastasized to his lungs and brain a year later. Dabrafenib and trametinib were started with transient response. Additional options and their risks were discussed, and pembrolizumab was started 4 months later due to the incomplete response to previous therapy. Five days after initiation the patient presented with moderate cellular rejection and possible antibody mediated rejection (ISHLT Grade 2R, pAMR 1H). Pembrolizumab was discontinued, and he was treated with steroids. Seven months later he presented in cardiogenic shock and severe coronary allograft vasculopathy. Biopsy was negative for cellular rejection, but suspicious for antibody mediated rejection (ISHLT Grade 0R, pAMR 1H), and he had a new serum alloantibody. Despite steroids and plasmapheresis he remained in refractory cardiogenic shock and died of cardiac arrest.

Evaluating a Change in Surgical Antibiotic Prophylaxis in Kidney Transplant Recipients.

The purpose of this study was to retrospectively evaluate if a change in practice from January 2013 to August 2015 affected the rate of surgical-site infections following kidney transplantation at the single academic medical center. More patients were found to have a surgical-site infection when surgical antibiotics were only given intra-operatively despite a lower incidence of risk factors identified in the literature when compared to the cohort who received antibiotics intra-op and post-op for 24 hours.

Effect of donor kidney volume on recipient outcome: does the "dose" matter?

BACKGROUND: The effect of donor kidney volume on recipient kidney function has not been fully evaluated. METHODS: We performed a prospective analysis of 125 consecutive living kidney donor/recipient pairs. Donor kidney volume was calculated from pretransplantation computed tomography angiograms using a three-dimensional computerized volume method. Cortical volume was calculated from arterial phase and total volume from delayed phase. Because weight is a surrogate marker for metabolic demands, we looked at the "volume dose" by calculating the ratio of donor kidney volume to recipient weight. Recipient kidney function was assessed by calculating the estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration formula. Logistic regression models were used to evaluate odds of developing eGFR of <60 mL/min per 1.73m(2) (eGFR<60) at 12 months. RESULTS: Because cortical and total volumes were correlated (R=0.734, P<0.001), we used total kidney volume to evaluate the dose effect. The mean donated volume dose (SD) was 2.13 (0.62) mL/kg. The mean recipient eGFR at 12 months was 63.6 (17.3) mL/min per 1.73 m, and it correlated with volume dose (r=0.341, P<0.001). Compared with the lowest tertile, those in the highest tertile of donor kidney volume to recipient weight had lower odds ratio of developing eGFR of less than 60 mL/min per 1.73 m(2) (odds ratio, 0.23; 95% confidence interval, 0.07-0.81) in a multivariate logistic regression model. Spline regression suggested that a volume dose greater than 2.5 mL/kg was associated with lowest risk of eGFR of less than 60 mL/min per 1.73 m(2) at 12 months. CONCLUSIONS: Donor kidney volume dosing is an important determinant of recipient graft outcomes and may predict recipient kidney function in kidney transplantation.