Epidemiological and Immunological Characteristics of HIV-Infected Patients on the Cadaveric Kidney Donor Waiting List at the Johannesburg Renal Transplant Program.

HIV infection was previously considered an exclusion criterion for renal dialysis and transplant. Recent research has prompted policy changes, allowing for transplantation in this subgroup of patients. Theoretical risks with transplantation include the immune dysregulation associated with post-transplantation immunosuppression and immune activation with possible organ rejection. Assessments for eligibility to renal transplantation rely on a point system, which allocates points based on a patient's age, previous transplants, and time on the waiting list as well as panel reactive antibodies among other parameters. This study aimed at quantifying and defining the clinically relevant characteristics of HIV-infected patients on the cadaveric donor waiting list on the Johannesburg renal transplant program. Clinical records for patients on the transplant list from November 2016 to October 2017 were accessed from existing databases and clinical records. A total of 248 patients were analyzed during the study period. There were a total of 215 HIV-uninfected patients, and 33 HIV-infected patients were on the waiting list. The median age for patients at listing was 39 years (interquartile range 29-47). There were no significant differences in the median age of listing between the HIV-infected and HIV-uninfected groups (p = .7). Hypertension was the most common cause of renal failure in both study groups. The study did not show any significant differences in age or immunological characteristics between the HIV-infected and HIV-uninfected groups. This suggests that for immunological risk stratification purposes, these two groups of patients could be considered equivalent. A possible explanation for this could be that antiretroviral therapy has a significant role in mitigating the effect of the virus on the immune system. Further studies looking at a larger study population are required to corroborate these findings. These data do provide reassurance that HIV-infected patients are suitable candidates for transplantation.

Chronic pancreatitis in a patient with malnutrition due to anorexia nervosa.

CONTEXT: Both acute and chronic pancreatitis are associated with eating disorders, including malnutrition found in anorexia, bulimia, and major depression. CASE REPORT: We report a case of a female patient suffering from severe malnutrition and anorexia with repeated attacks of pancreatic pain and an enlarging cystic lesion in the pancreatic head. Due to a progressively enlarging lesion on CT, a pancreaticoduodenectomy was performed. Histology demonstrated chronic pancreatitis. CONCLUSIONS: The pathogenesis of chronic pancreatitis remains to be well defined. There is evidence that an imbalance between oxidative stress and antioxidant capacity results in pancreatic inflammation and activation of periacinar myofibroblasts. It has been demonstrated that protein energy malnutrition is associated with increased levels of proinflammatory cytokines as well as pancreatic acinar cell damage and ductal disruption. Furthermore, it has been shown that protein energy malnutrition including anorexia nervosa is associated with a depleted antioxidant status. Thus there is a possible pathogenic basis for severe malnutrition leading to chronic pancreatitis. Our patient underwent surgery based on the presumption that she had a symptomatic cystic neoplasm. Chronic pancreatitis was demonstrated. Patients presenting with malnutrition and recurrent epigastric pain should be investigated for pancreatic pathology and the possibility of pancreatitis and the presence of pseudocysts entertained.

Paediatric liver transplantation in Johannesburg revisited: 59 transplants and challenges met.

BACKGROUND: A paediatric liver transplant programme was started at the Wits Donald Gordon Medical Centre, Johannesburg, South Africa (SA), in November 2005. We reported on the first 29 patients in 2012. Since then we have performed a further 30 transplants in 28 patients, having met the major challenge of donor shortage by introducing a living related donor programme and increasing the use of split liver grafts. OBJECTIVE: To review the Wits Donald Gordon Medical Centre paediatric liver transplant programme to date. We describe how the programme has evolved and specifically compare the outcomes of the first cohort with the most recent 28 patients. METHODS: Case notes of all paediatric liver transplants performed between 14 November 2005 and 30 June 2014 were retrospectively reviewed. Data were analysed for age and weight at transplantation, indication and type of graft. Morbidity and mortality were documented, specifically biliary and vascular complications. Comparison was made between Era 1 (November 2005 - October 2012) and Era 2 (November 2012 - June 2014). RESULTS: A total of 59 transplants were performed in 57 patients. Age at transplantation ranged from 9 months to 213 months (mean 82.39 months) and weight ranged from 5 kg to 62 kg (mean 21 kg). A total of 23 whole livers, 10 reduced-size grafts, 14 split liver grafts and 12 living donor liver transplants (LDLTs) were performed. Eight patients were referred with fulminant hepatic failure (FHF), all in Era 2. Of these, three patients were successfully transplanted. Of the 57 patients, 45 are alive and well with actuarial 1-year patient and graft survival of 85% and 84%  and 5-year patient and graft survival of 78% and 74%, respectively. Sixteen (25.42%) biliary complications occurred in 15 of our 59 transplants. Seven patients developed significant vascular complications. Comparing Era 1 with Era 2, mean age at transplant decreased from 100.86 months to 64.73 months, mean weight from 25.2 kg to 16.9 kg, and type of graft utilised changed with a trend away from the use of whole livers and reduced-sized grafts to split livers and segment 2,3 LDLT grafts. CONCLUSION: Initially limited by a shortage of donor organs, we aggressively explored optimal utilisation, splitting liver grafts from deceased donors as often as possible and establishing an LDLT programme. This increased access to donor livers allowed us to include patients with FHF and to perform retransplantation in recipients with early graft failure. It remains to offer liver transplantation to the entire paediatric community in SA, in conjunction with the only other established paediatric liver transplant unit, at Red Cross War Memorial Children's Hospital in Cape Town.