Case Reports in Transplantation http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Diffuse Hepatic Epithelioid Hemangioendothelioma Developed in a Patient with Hepatitis C Cirrhosis Mon, 08 Sep 2014 05:39:54 +0000 http://www.hindawi.com/journals/crit/2014/694903/ Hepatic epithelioid hemangioendothelioma (HEHE) is an infrequent vascular tumor of endothelial origin that primarily occurs in women in the mid-fifth decade of life without underlying chronic liver disease or cirrhosis. Liver transplant should be the first-line of therapy in patients with large or diffuse unresectable tumors even in the presence of metastatic disease due to the favorable long-term outcome. We report the case of a 48-year-old female who complained of abdominal pain and weight loss. She has a history of cirrhosis secondary to chronic hepatitis C (HCV) and was treated with interferon and ribavirin with sustained virological response. Her work-up revealed multiple confluent infiltrating bilobar liver masses diagnosed as HEHE. She underwent a successful liver transplant without evidence of recurrent HCV infection. She developed cervical spine (C4-C6) HEHE metastases 4 years after transplant. She underwent surgical resection and local radiotherapy after resection with good clinical response. To the best of our knowledge, this is the first report of HEHE that developed in a patient with HCV cirrhosis successfully treated with antiviral therapy before transplant and liver transplant with good allograft function without evidence of recurrent liver tumor or HCV infection but developed metastases to the cervical spine 4 years after transplant. Pedro W. Baron, Thomas Amankonah, Robert F. Cubas, Arputharaj H. Kore, Arvand Elihu, Michael E. de Vera, and Mia C. N. Perez Copyright © 2014 Pedro W. Baron et al. All rights reserved. Acute Demyelinating Polyneuropathy after Lung Transplantation: Guillain-Barré Syndrome or Tacrolimus Toxicity? Mon, 11 Aug 2014 11:42:56 +0000 http://www.hindawi.com/journals/crit/2014/685010/ Guillain-Barré syndrome (GBS) has been described after solid organ and bone marrow transplantation mostly due to viral infections and possibly calcineurin inhibitors. Incidence after bone marrow transplant is 0.3–0.7%, though incidence in other transplants is not well known. We present the first description of tacrolimus associated GBS in lung transplant recipients in the English language literature. The pathophysiology of tacrolimus-induced polyneuropathy is not known, but some have hypothesized that tacrolimus induces an inflammatory phenomenon by differential effects on T cell subsets. Diagnosis of association may be challenging and requires high index of suspicion. The optimal treatment of GBS-associated with tacrolimus after lung transplantation is unknown, although drug discontinuation may result in improvement in some patients, while some reports suggest that the use of IVIG and/or plasmapheresis may be helpful and safe in organ transplant recipients with severe symptoms. Nirmal S. Sharma, Keith M. Wille, Charles W. Hoopes, and Enrique Diaz-Guzman Copyright © 2014 Nirmal S. Sharma et al. All rights reserved. Alemtuzumab Plus Cyclosporine Treatment of the Autoimmune Hemolytic Anemia in an Adult Bowel Transplant Mon, 11 Aug 2014 06:54:41 +0000 http://www.hindawi.com/journals/crit/2014/262953/ An adult male underwent a bowel transplant for tufting enteropathy, receiving alemtuzumab, tacrolimus, and steroids as immunosuppressants. Five years later, he developed an autoimmune hemolytic anemia (AIHA), anti-IgG positive, with reduced reticulocyte count, leukopenia, and thrombocytopenia with antiplatelet antibodies. After an unsuccessful initial treatment with high dose steroids, reduction in tacrolimus dose, and intravenous immunoglobulin (IVIG), a bone marrow biopsy revealed absence of erythroid maturation with precursor hyperplasia. The patient was switched to sirolimus and received four doses of rituximab plus two courses of plasmapheresis, which decreased his transfusion requirements. After a febrile episode one month later, the AIHA relapsed with corresponding decreases in platelet and leukocyte count: cyclosporine A (CsA) was started with a second course of rituximab and IVIG without response, even though repeat bone marrow biopsy did not reveal morphology correlated to an acquired pure red cell aplasia (APRCA). Considering the similarity in his clinical and laboratory findings to APRCA, alemtuzumab was added (three doses over a week) with CsA followed by steroids. The patient was eventually discharged transfusion-independent, with increasing hemoglobin (Hb) levels and normal platelet and leukocyte count. One year later he is still disease-free with functioning graft. A. Lauro, M. Stanzani, C. Finelli, C. Zanfi, M. C. Morelli, E. Pasqualini, A. Dazzi, M. Ravaioli, M. Di Simone, V. Giudice, L. Pironi, and A. D. Pinna Copyright © 2014 A. Lauro et al. All rights reserved. Vascular Fluorescence Imaging Control for Complex Renal Artery Aneurysm Repair Using Laparoscopic Nephrectomy and Autotransplantation Sun, 10 Aug 2014 08:29:45 +0000 http://www.hindawi.com/journals/crit/2014/563408/ Intraoperative fluorescent imaging using indocyanine green enables vascular surgeons to confirm the location and states of the reconstructed vessels during surgery. Complex renal artery aneurysm repair involving second order branch vessels has been performed with different techniques. We present a case of ex vivo repair and autotransplantation combining the advantages of minimally invasive surgery and indocyanine green enhanced fluorescence imaging to facilitate vascular anatomy recognition and visualization of organ reperfusion. Matteo Tozzi, Luigi Boni, Gabriele Soldini, Marco Franchin, and Gabriele Piffaretti Copyright © 2014 Matteo Tozzi et al. All rights reserved. Yersinia enterocolitica Infection Simulating Lymphoproliferative Disease, after Liver Transplant Mon, 14 Jul 2014 07:15:49 +0000 http://www.hindawi.com/journals/crit/2014/923058/ We describe a 14-year-old girl, who was 13 y after liver transplantation for biliary atresia with an unremarkable postoperative course. She presented with fever of up to 40°C, extreme fatigue, malaise, anorexia, and occasional vomiting. On physical examination the only finding was splenomegaly. Lab results showed hyperglobulinemia and an elevated sedimentation rate. Liver function tests were normal except for mild elevation of γGTP. Abdominal U/S and CT demonstrated an enlarged spleen with retroperitoneal and mesenteric lymph nodes enlargement. An exhaustive evaluation for infectious causes, autoimmune conditions, and malignancy was negative. A full recovery after 5 months prompted testing for self-limited infectious etiologies. Yersinia enterocolitica infection was diagnosed. E. Jakobovich, B. Koplewitz, E. Marva, and E. Granot Copyright © 2014 E. Jakobovich et al. All rights reserved. Cutaneous Metastases from Primary Hepatobiliary Tumors as the First Sign of Tumor Recurrence following Liver Transplantation Thu, 10 Jul 2014 07:48:20 +0000 http://www.hindawi.com/journals/crit/2014/838949/ Cutaneous metastasis from hepatobiliary tumors is a rare event, especially following liver transplantation. We report our experience with two cases of cutaneous metastases from both hepatocellular carcinoma and mixed hepatocellular/cholangiocarcinoma following liver transplantation, along with a review of the literature. Adam T. Hauch, Joseph F. Buell, Margit McGowan, Parisha Bhatia, Eleanor Lewin, Mary Killackey, Nathan J. Shores, Luis A. Balart, Martin Moehlen, Bob Saggi, and Anil S. Paramesh Copyright © 2014 Adam T. Hauch et al. All rights reserved. Successful Management of Repetitive Urinary Obstruction and Anuria Caused by Double J Stent Calculi Formation after Renal Transplantation Sun, 06 Jul 2014 08:16:26 +0000 http://www.hindawi.com/journals/crit/2014/245724/ This report firstly describes an extremely rare case of repetitive double J stent calculi formation after renal transplantation caused by the antihyperparathyroidism (HPT) drug calcitriol. In 2012, a woman initially presented to our hospital for anuria with lower abdominal pain. She was diagnosed with allograft hydronephrosis and double J stents obstruction by calculi formation after transplantation and treated with triplicate stents replacements in another hospital without clinical manifestations improvements. Through detailed exploration of medical history, we conclude that the abnormal calculi formation is due to the calcitriol (1,25-dihydroxyvitamin D3) administration, a drug which can increase renal tubular reabsorption of calcium for treating posttransplant HPT bone disease. After discontinuing calcitriol, the patient was stone-free and had a good recovery without severe complications during the 9-month follow-up. Our novel findings may provide an important clue and approach to managing formidable repetitive double J stent calculi formation in the clinical trial. Zongyao Hao, Li Zhang, Jun Zhou, Xiansheng Zhang, Haoqiang Shi, Yifei Zhang, Pengfei Wei, and Chaozhao Liang Copyright © 2014 Zongyao Hao et al. All rights reserved. Differing Tales of Two Patients after Receiving a Kidney Transplant from a Donor with Disseminated Intravascular Coagulation Mon, 30 Jun 2014 12:04:07 +0000 http://www.hindawi.com/journals/crit/2014/754256/ In order to decrease the time on the deceased donor kidney wait list and to have more organs available, criteria for acceptable organs for transplant could be made less stringent. There are reports of successful recipient outcomes using kidney donors presenting with disseminated intravascular coagulation (DIC). We report a unique circumstance where two patients received kidneys from the same deceased donor who had DIC; one patient developed thrombotic microangiopathy (TMA) while the other did not. This difference in outcome may indicate that both donor and recipient factors contribute to the development of posttransplant TMA. Pradeep V. Kadambi, Ann K. Gamilla-Crudo, Mohammad Almiani, Michelle A. Josephson, and W. James Chon Copyright © 2014 Pradeep V. Kadambi et al. All rights reserved. ABO-Incompatible Living Donor Liver Transplantation from Hepatitis B Core Antibody Positive Donor to Hepatitis C Liver Cirrhosis Recipient: A Case Report Sun, 22 Jun 2014 07:01:10 +0000 http://www.hindawi.com/journals/crit/2014/507621/ Herein, we describe an extremely rare experience of a patient with liver cirrhosis from hepatitis C virus (LC-HCV) who underwent an ABO-incompatible living donor liver transplantation (ABO-I-LDLT) using a hepatitis B core antibody (HBc-Ab) positive donor’s liver graft. A 47-year-old Japanese woman with end stage LC-HCV, as a recipient, was preoperatively administered rituximab, mycophenolate mofetil, and steroids without plasma exchange. A routine ABO-I-LDLT procedure was applied using her daughter’s HBc-Ab positive liver graft. Prophylaxis of the hepatitis B virus (HBV) infection using hepatitis B immunoglobulin (HBIG) and entecavir had been properly administered. Three months after the ABO-I-LDLT, HCV hepatitis relapsed. To date, this patient has been under antiviral therapy and prophylaxis of HBV infection using HBIG, while entecavir has been continued. The cognitions and techniques with regard to ABO-I-LDLT, prophylaxis of HBV cross infection, various patterns of immunosuppression, and antiviral therapy for HCV relapse are indispensable in managing a transplant recipient. According to the prophylaxis of HBV cross infection under ABO-I-LDLT, it may be very important to keep the HBs-Ab titer higher than usual for HBV naïve recipients, because severe systemic immunosuppression can cause de novo hepatitis. Akira Umemura, Hiroyuki Nitta, Akira Sasaki, Takeshi Takahara, Yasushi Hasegawa, and Go Wakabayashi Copyright © 2014 Akira Umemura et al. All rights reserved. Case of Acute Graft Failure during Suspected Humoral Rejection with Preserved Ejection Fraction, but Severely Reduced Longitudinal Deformation Detected by 2D-Speckle Tracking Wed, 11 Jun 2014 14:17:38 +0000 http://www.hindawi.com/journals/crit/2014/173589/ This case displays limited utility of left ventricular ejection fraction to detect acute graft failure due to microvascular vasculopathy and suspected humoral rejection. Despite severe and progressive graft failure, clinically and by right heart catheterizations, left ventricular ejection fraction remained unchanged, indicating need of more reliable noninvasive methods for graft function surveillance. Global longitudinal strain relates to clinical heart failure, filling pressure, and cardiac index during suspected humoral rejection and microvascular dysfunction in this HTX patient. We suggest routine monitoring of graft function by global longitudinal strain as supplement to routine left ventricular ejection fraction and diastolic Doppler measurements. Tor Skibsted Clemmensen, Hans Eiskjær, Pernille B. Kofoed-Nielsen, Søren Høyer, and Steen Hvitfeldt Poulsen Copyright © 2014 Tor Skibsted Clemmensen et al. All rights reserved. Salvage with a Secondary Infrahepatic Cavocavostomy of the Occluded Modified Piggyback Anastomosis during Split Liver Transplantation: A Case Report Wed, 21 May 2014 06:28:06 +0000 http://www.hindawi.com/journals/crit/2014/740802/ Hepatic venous outflow obstruction following liver transplantation is rare but disastrous. Here we described a 14-year-old boy who underwent a split right lobe liver transplantation with modified (side-to-side) piggyback technique which resulted in hepatic venous outflow obstruction. When the liver graft was lifted up, the outflow drainage returned to normal but when it was placed back into the abdomen, the outflow obstruction recurred. Because reanastomosis would have resulted in hepatic reischemia, alternatively, a second infrahepatic cavocavostomy was planned without requiring hepatic reischemia. During this procedure, the first assistant hung the liver up to provide sufficient outflow and the portal inflow of the graft continued as well. We only clamped the recipient’s infrahepatic vena cava and the caudal cuff of the graft cava. After the second end-to-side cavocaval anastomosis, the graft was placed in its orthotopic position and there was no outflow problem anymore. The patient tolerated the procedure well and there were no problems after three months of follow-up. A second cavocavostomy can provide an extra bypass for some hepatic venous outflow problems after piggyback anastomosis by avoiding hepatic reischemia. Erdem Kinaci, Cuneyt Kayaalp, Sezai Yilmaz, and Emrah Otan Copyright © 2014 Erdem Kinaci et al. All rights reserved. Beneficial Effect of Conversion to Belatacept in Kidney-Transplant Patients with a Low Glomerular-Filtration Rate Sun, 18 May 2014 12:44:52 +0000 http://www.hindawi.com/journals/crit/2014/190516/ Belatacept has been found to be efficient at preserving good kidney function in maintenance kidney-transplant patients. Herein, we report on the use of belatacept as a rescue therapy for two kidney-transplant patients presenting with severe adverse events after treatment with calcineurin inhibitors (CNIs) and mammalian target-of-rapamycin (mTOR) inhibitors. Two kidney-transplant patients developed severely impaired kidney function after receiving CNIs. The use of everolimus was associated with severe angioedema. Belatacept was then successfully used to improve kidney function in both cases, even though estimated glomerular-filtration rate before conversion was <20 mL/min. These case reports show that belatacept can be used as a rescue therapy, even if kidney function is very low in kidney-transplant patients who cannot tolerate CNIs and/or mTOR inhibitors. Julie Belliere, Céline Guilbeau-Frugier, Arnaud Del Bello, Laure Esposito, Caroline Capuani, Isabelle Cardeau-Desangles, Lionel Rostaing, and Nassim Kamar Copyright © 2014 Julie Belliere et al. All rights reserved. Concurrent Hepatic Artery and Portal Vein Thrombosis after Orthotopic Liver Transplantation with Preserved Allografts Thu, 10 Apr 2014 08:52:03 +0000 http://www.hindawi.com/journals/crit/2014/384295/ In contrast to early HAT, late HAT has an insidious clinical presentation. Nevertheless, biliary and vascular reconstructions in this late setting are unlikely to improve outcome. Patent portal flow makes an important contribution to the viability of liver in case of late HAT while the allograft reconstitutes intrahepatic arterial flow through neovascularization. Concurrent HAT with PVT without immediate graft necrosis is extremely rare, and allograft and patient survival are seemingly impossible without retransplantation. In fact, hepatopetal arterial and portal venous neovascularization are known albeit obscure phenomena that can preserve posttransplant hepatic function under the extenuating circumstances of complete interruption of blood flow to the graft. We describe two such cases that developed combined HAT and PVT more than six months after OLT with perfect preservation of graft function. The survival of allografts in our cases was due to extensive hepatopetal arterial and portal venous collateralization. Simultaneous HAT and PVT after OLT are rare events and almost uniformly fatal, if they occur early. Due to paucity of such cases, however, underlying mechanisms and etiology remain elusive, and despite radiological diagnosis of these complications, there is no way to predict these events in the wake of stable graft function. Arshad Khan, P. Park, Jose Oberholzer, Ivo Tzvetanov, Raquel Garcia Roca, Ron C. Gaba, Enrico Benedetti, and Hoonbae Jeon Copyright © 2014 Arshad Khan et al. All rights reserved. Graft-versus-Host Disease after Living-Unrelated Kidney Transplantation Wed, 09 Apr 2014 08:46:42 +0000 http://www.hindawi.com/journals/crit/2014/971426/ Graft-versus-host disease (GVHD) is a rare complication after solid organ transplantation and consists of a reaction of donor derived immune cells directed against host tissues. The vast majority of cases reported in the literature involve liver, small intestine and pancreas transplantation. We report a case of GVHD in a 48-year-old man after living-unrelated kidney transplantation at another center. Six months postoperatively he developed a skin rash, anorexia, and diarrhea that resulted in malnutrition and a 90 pound weight loss. At this point he was transferred to our center with a BMI of 16 and severe cachexia. Intravenous hyperalimentation was initiated and an extensive work-up for an infectious etiology was performed and was negative. An esophagogastroduodenoscopy was performed and revealed nodularity of the gastric mucosa, atrophy, and edema in the first and second portion of his duodenum. Biopsy findings were consistent with GVHD. Aggressive immunosuppressive therapy was instituted with a good response. The anorexia and diarrhea resolved, and he was discharged on hospital day 20. Three months later, there had been no recurrence of the diarrhea, the patient had gained an additional 40 pounds, BMI of 25, and a repeat upper endoscopy revealed complete resolution of the initial endoscopic abnormalities. N. Zacharias, M. H. Gallichio, and D. J. Conti Copyright © 2014 N. Zacharias et al. All rights reserved. Isolated Aspergillosis Myocardial Abscesses in a Liver-Transplant Patient Sun, 23 Feb 2014 00:00:00 +0000 http://www.hindawi.com/journals/crit/2014/418357/ Cardiac abscess is an uncommon and fatal complication after transplantation. We report a case of an initially isolated aspergillosis myocardial abscess diagnosed by cardiac magnetic resonance imaging (CMRI). At that time, there was no other biological evidence or other extracardiac manifestations. A three-month course of dual antifungal therapy followed by a single antifungal therapy was empirically given. Six month after admission, Aspergillus fumigatus was isolated for the first time and the patient deceased from a disseminated aspergillosis. Kim-Diêp Dang-Tran, Valérie Chabbert, Laure Esposito, Céline Guilbeau-Frugier, Fabrice Dédouit, Lionel Rostaing, Hervé Rousseau, Phillippe Otal, and Nassim Kamar Copyright © 2014 Kim-Diêp Dang-Tran et al. All rights reserved. Point of Care Perioperative Coagulation Management in Liver Transplantation and Complete Portal Vein Thrombosis Thu, 06 Feb 2014 10:04:13 +0000 http://www.hindawi.com/journals/crit/2014/487364/ Liver transplantation (LT) is a serious hemostatic challenge in patients with portal vein thrombosis (PVT). Advances in monitoring systems have improved surgery in this setting. We report the successful application of a point-of-care (POC) rotational viscoelastic thromboelastometry-guided (TEM) testing system (ROTEM) which allowed management of coagulation during LT in a 64-year-old cirrhotic patient with a model for end-stage liver disease (MELD) score of 16. Perioperatively, the patient showed complete PVT, hepatomegaly, splenomegaly, recanalization of the umbilical vein, and portosystemic shunt. Macroscopic liver and spleen adherences with collateral circulation were evident. Coagulation factors and fibrinolysis were assessed preoperatively and at graft reperfusion to evaluate the need of hemostatic therapy. Based on ROTEM findings, the patient received 16 g of human fibrinogen concentrate, half preoperatively (with prothrombin complex concentrate 2000 IU, tranexamic acid 1 g, and platelets 2 IU), and two doses of 4 g before and after graft reperfusion; we achieved normalization of all monitored parameters. No ischemia-reperfusion syndrome was present. Postoperatively portal vein flux at Color-Doppler ultrasonography was normal. After a 3-day ICU stay, the patient was moved to the Department of Surgery and discharged on day 14. The postoperative course was uneventful and did not require any further haemostatic therapy. Cristiano Piangatelli, Lucia Faloia, Claudia Cristiani, Ilaria Valentini, and Marco Vivarelli Copyright © 2014 Cristiano Piangatelli et al. All rights reserved. Leukocytoclastic Vasculitis as a Complication of Recombinant Granulocyte Colony-Stimulating Factor Therapy in a Heart Transplant Patient Thu, 30 Jan 2014 11:09:22 +0000 http://www.hindawi.com/journals/crit/2014/160407/ Recombinant granulocyte colony-stimulating factor (rG-CSF) is a myeloid growth factor that is widely used in haematology to recover neutropenia secondary to myelosuppressive chemotherapy. Leukocytoclastic vasculitis is an acknowledged side effect of the above therapy. Its pathogenesis involves many mechanisms that collectively induce an increase in neutrophil function and a subsequent release of cytokines. Here, we report a case of leukocytoclastic vasculitis proven by skin biopsy, following the use of rG-CSF in a heart transplant patient with leukopenia secondary to immunosuppressive therapy. Giovanbattista Ippoliti, Marco Paulli, Marco Lucioni, Marinella Lauriola, and Andrea Maria D'Armini Copyright © 2014 Giovanbattista Ippoliti et al. All rights reserved. Markedly Increased High-Mobility Group Box 1 Protein in a Patient with Small-for-Size Syndrome Wed, 29 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/crit/2014/272498/ Background. Small-for-size syndrome (SFSS) occurs in the presence of insufficient liver mass to maintain normal function after liver transplantation. Murine mortality following 85% hepatectomy can be reduced by the use of soluble receptor for advanced glycation end products (sRAGE) to scavenge damage-associated molecular patterns and prevent their engagement with membrane-bound RAGE. Aims. To explore serum levels of sRAGE, high-mobility group box-1 (HMGB1) protein, and other soluble inflammatory mediators in a fatal case of SFSS. Methods. Serum levels of HMGB1, sRAGE, IL-18, and other inflammatory mediators were measured by ELISA in a case of SFSS, and the results were compared with 8 patients with paracetamol-induced acute liver failure (ALF) and 6 healthy controls (HC). Results. HMGB1 levels were markedly higher in the SFSS patient (92.1 ng/mL) compared with the ALF patients (median (IQR) 11.4 (3.7–14.8) ng/mL) and HC (1.42 (1.38–1.56) ng/mL). In contrast, sRAGE levels were lower in the SFSS patient (1.88 ng/mL) compared with the ALF patients (3.53 (2.66–12.37) ng/mL) and were similar to HC levels (1.40 (1.23–1.89) ng/mL). Conclusion. These results suggest an imbalance between pro- and anti-inflammatory innate immune pathways in SFSS. Modulation of the HMGB1-RAGE axis may represent a future therapeutic avenue in this condition. Darren G. Craig, Patricia Lee, E. Anne Pryde, Ernest Hidalgo, Peter C. Hayes, Stephen J. Wigmore, Stuart J. Forbes, and Kenneth J. Simpson Copyright © 2014 Darren G. Craig et al. All rights reserved. Torsion of the Retroperitoneal Kidney: Uncommon or Underreported? Thu, 16 Jan 2014 13:45:06 +0000 http://www.hindawi.com/journals/crit/2014/561506/ Vascular torsion in a renal allograft after placement in the retroperitoneum is rare and has only been reported twice in the literature. It is an extrinsically mediated process that occurs at the vascular pedicle resulting in graft compromise and potential loss. Rapid diagnosis and immediate surgical intervention may salvage allograft function. Herein, we present a unique case of a 42-year-old male that developed renal allograft torsion following a second kidney transplant placed in the retroperitoneum. Immediate detorsion did not resolve allograft dysfunction, and a biopsy revealed acute cellular mediated rejection. After antithymocyte globulin treatment, allograft function was salvaged. A review of the current literature shows that the incidence, morbidity, and long term allograft function of intraperitoneal and extraperitoneal torsion are different. As such, torsion of the retroperitoneal kidney demonstrates encouraging allograft salvage rates. Only the third case reported to date, this serves as a contribution to the growing body of literature in retroperitoneal renal torsion and reviews the risks, medication considerations, diagnostic tests, and treatment modalities in a unique disease process. Michael Sosin, Wuya Lumeh, and Matthew Cooper Copyright © 2014 Michael Sosin et al. All rights reserved. Drug Interaction between Sirolimus and Ranolazine in a Kidney Transplant Patient Thu, 02 Jan 2014 14:01:28 +0000 http://www.hindawi.com/journals/crit/2014/548243/ Purpose. The case of a kidney transplant recipient who experienced a probable drug interaction between sirolimus and ranolazine is reported. Summary. The narrow therapeutic window of immunosuppressive therapy in transplant recipients requires close monitoring for potential drug-drug interactions. The patient, a 57-year-old Caucasian male kidney transplant recipient, was stable for years on sirolimus as his primary immunosuppressive agent and had a history of chronic angina, for which he was prescribed ranolazine. Upon addition and dose escalation of ranolazine, whole blood sirolimus levels more than tripled, rising to immeasurably high concentrations. After holding sirolimus on multiple occasions and reducing dosage more than 50%, blood levels returned to therapeutic range, while continuing ranolazine. Conclusion. Since ranolazine is a documented P-GP and CYP3A inhibitor, and sirolimus a known substrate for both pathways, it is proposed that ranolazine inhibition of P-GP and CYP3A4 contributed to the significant elevation in sirolimus exposure. No alternative causes for the rise in sirolimus exposure were found, and assessment with the Drug Interaction Probability Scale finds this interaction to be probable. Clinicians should be aware of the potential for this interaction to cause elevated sirolimus exposure and subsequent increase in clinical effect or toxicity, in this case overimmunosuppression. Joanna C. Masters, Mita M. Shah, and Ashley A. Feist Copyright © 2014 Joanna C. Masters et al. All rights reserved. Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft Wed, 25 Dec 2013 10:17:04 +0000 http://www.hindawi.com/journals/crit/2013/171807/ We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population. Nirmit Desai, Sagar Patel, Chinyere Nwosu, Lok Sung, Carl Tack, Jonathan M. Buscaglia, Edward P. Nord, and Nand K. Wadhwa Copyright © 2013 Nirmit Desai et al. All rights reserved. Renal Transplantation in Secondary Amyloidosis Associated with Tuberculosis Wed, 25 Dec 2013 09:08:55 +0000 http://www.hindawi.com/journals/crit/2013/353529/ Although end-stage renal disease (ESRD) related to AA amyloidosis nephropathy secondary to tuberculosis is most common in our country, there are limited data concerning patient and graft outcome after renal transplantation (RTx). To the best of our knowledge, this is the first report of RTx in ESRD patient with secondary amyloidosis due to tuberculosis from India. A 30-year-old female with past history of pulmonary tuberculosis 3 years back was admitted with complaint of gradually progressive pedal oedema and nausea for 3 months. Renal biopsy was suggestive of secondary renal amyloidosis with vascular involvement and chronic tubulointerstitial involvement. She was transplanted with kidney from her 28-year-old brother with 3/6 human leukocyte antigen match. She had immediate good graft function without any perioperative complications (cardiovascular, infections, rejection and delayed graft function). She was discharged with serum creatinine of 0.8 mg/dL. Her last serum creatinine level was 0.9 mg/dL with cyclosporine level of 100 mg/dL at 9-month followup without any medical or surgical complication. The quality of life also improved after transplantation. With careful selection, ESRD patients with secondary amyloidosis due to tuberculosis are eligible for RTx with favorable outcome and improved quality of life. Vivek B. Kute, Aruna V. Vanikar, Himanshu V. Patel, Manoj R. Gumber, Pankaj R. Shah, Pranjal R. Modi, and Hargovind L. Trivedi Copyright © 2013 Vivek B. Kute et al. All rights reserved. Single-Lobe Living Donor Liver Transplant in a Morbidly Obese Cirrhotic Patient Preceded by Laparoscopic Sleeve Gastrectomy Tue, 10 Dec 2013 18:03:04 +0000 http://www.hindawi.com/journals/crit/2013/279651/ Nonalcoholic steatohepatitis (NASH) is a stage of nonalcoholic fatty liver disease (NAFLD), and, in most patients, it is associated with obesity and metabolic syndrome with progression to end-stage liver disease in about 20% of patients (McCullough (2004); Matteoni et al. (1999); Liou and Kowdley (2006)). It has been estimated that between 20 and 30% of patients with end-stage cirrhosis referred for liver transplantation (LT) evaluation and 30 to 70% of LT recipients exhibit some degree of obesity (Muñoz and ElGenaidi (2005)). Management of obesity in chronic liver disease patients is not only difficult but also preludes them from undergoing major bariatric surgery due to associated high morbidity and mortality. Here, we present a case report of a morbidly obese patient who underwent laparoscopic sleeve gastrectomy followed by single-lobe living donor liver transplantation (LDLT) with a successful outcome. We believe that this is the first report of successful LDLT following planned weight loss to facilitate LDLT. Sunil Taneja, Subash Gupta, Manav Wadhawan, and Neerav Goyal Copyright © 2013 Sunil Taneja et al. All rights reserved. Acute Liver Failure Occurring during the First Trimester of Pregnancy Successfully Treated with Living Donor Liver Transplantation Wed, 04 Dec 2013 18:39:27 +0000 http://www.hindawi.com/journals/crit/2013/309545/ Acute liver failure (ALF) during pregnancy remains difficult to treat, and despite advances in treatment, liver transplantation must be selected as treatment option in certain cases. We report a 30-year-old woman with ALF of unknown etiology, occurring during the first trimester of pregnancy. Her condition was complicated by consciousness disturbance and coagulopathy due to ALF, but she was successfully treated with living donor liver transplantation 7 days after dilatation and curettage. At 9-month followup, she was in good medical condition. Liver transplantation has been reported as one of the treatment options for ALF during pregnancy with the prognosis varying depending on the trimester, from living donor or deceased donor liver transplantation. Of importance is that clinicians always think of emergent liver transplantation as a therapeutic option in ALF even in the first trimester of pregnancy. Naoya Kanogawa, Tatsuo Kanda, Masayuki Ohtsuka, Masato Nakamura, Tatsuo Miyamura, Shin Yasui, Makoto Arai, Hitoshi Maruyama, Keiichi Fujiwara, Makio Shozu, Shigeto Oda, Masaru Miyazaki, and Osamu Yokosuka Copyright © 2013 Naoya Kanogawa et al. All rights reserved. Tacrolimus-Related Cerebral Microbleeds after Lung Transplantation Mon, 02 Dec 2013 11:57:10 +0000 http://www.hindawi.com/journals/crit/2013/708961/ Posterior reversible encephalopathy syndrome is a well-known complication of treatment by tacrolimus. We report 2 cases of lung transplant recipients treated with tacrolimus who developed cerebral microbleeds on T2*-weighted sequences in the acute setting of posterior reversible encephalopathy syndrome. Cerebral microbleeds may be a marker of tacrolimus-induced vasculopathy that may be detected earlier by neuropsychological and magnetic resonance imaging monitoring in transplant recipients treated with tacrolimus. L. Mechtouff, F. Piegay, J. Traclet, F. Philit, P. Boissonnat, M. Hermier, I. Durieu, T.-H. Cho, N. Nighoghossian, and J.-F. Mornex Copyright © 2013 L. Mechtouff et al. All rights reserved. A Case of Alport Syndrome with Posttransplant Antiglomerular Basement Membrane Disease despite Negative Antiglomerular Basement Membrane Antibodies by EIA Treated with Plasmapheresis and Intravenous Immunoglobulin Mon, 02 Dec 2013 11:54:42 +0000 http://www.hindawi.com/journals/crit/2013/164016/ Posttransplant antiglomerular basement membrane (anti-GBM) disease occurs in approximately 5% of Alport patients and usually ends in irreversible graft failure. Recent research has focused on characterizing the structure of the anti-GBM alloepitope. Here we present a case of a 22-year-old male with end-stage renal disease secondary to Alport syndrome, with a previously failed renal allograft, who received a second deceased-donor kidney transplant. Six days after transplantation, he developed acute kidney injury. The serum anti-GBM IgG was negative by enzyme immunoassay (EIA). On biopsy, he had crescentic glomerulonephritis with linear GBM fixation of IgG. With further analysis by western blotting, we were able to detect antibodies to an unidentified protein from the basement membrane. This patient was treated with plasmapheresis twice per week and monthly intravenous immunoglobulin (IVIG) for a total of five months. At the end of treatment, these unknown antibodies were no longer detected. His renal function improved, and he has not required dialysis. We conclude that anti-GBM disease in patients with Alport Syndrome may be caused by circulating antibodies to other components of the basement membrane that are undetectable by routine anti-GBM EIA and may respond to treatment with plasmapheresis and IVIG. Sumiko I. Armstead, Thomas Hellmark, Jorgen Wieslander, Xin J. Zhou, Ramesh Saxena, and Nilum Rajora Copyright © 2013 Sumiko I. Armstead et al. All rights reserved. Renal Mucormycosis: A Rare and Potentially Lethal Complication of Kidney Transplantation Tue, 22 Oct 2013 10:08:18 +0000 http://www.hindawi.com/journals/crit/2013/915423/ Renal mucormycosis is a rare and potentially lethal complication of kidney transplantation. We describe two cases of renal mucormycosis following deceased donor kidney transplantation. This is the second report of renal mucormycosis following kidney transplantation in the United States, and the first case of renal mucormycosis infection presumed to be of recipient origin. Case A had an early presentation of mucormycosis isolated to the kidney allograft. He had an unexpected rise in serum creatinine and leukocytosis necessitating allograft biopsy which showed mucormycosis. He underwent transplant nephrectomy on posttransplant day 11, was treated with amphotericin B, and discharged home on posttransplant day 22. Case B had a late presentation of renal mucormycosis, preceded by a cutaneous manifestation. One year after kidney transplantation he had a nonhealing knee ulcer which on biopsy showed cutaneous mucormycosis. Treatment included aggressive debridement and amphotericin B. Allograft biopsy showed mucormycosis, necessitating transplant nephrectomy. He was discharged to a rehabilitation facility and died from noninfectious causes. Review of the published literature of renal mucormycosis cases following kidney transplantation reveals a mortality rate of more than 50%. The key to successful outcome is early recognition, prompt institution of surgical debridement of all infected tissue, and appropriate antifungal therapy. SreyRam Kuy, Chun He, and David C. Cronin II Copyright © 2013 SreyRam Kuy et al. All rights reserved. Intra-Abdominal Localisation of a Buschke-Lowenstein Tumour: Case Presentation and Review of the Literature Wed, 18 Sep 2013 18:27:35 +0000 http://www.hindawi.com/journals/crit/2013/187682/ Giant condyloma acuminatum or Buschke-Lowenstein tumour is a very rare disease which usually is located in the genital, anorectal, and perianal regions. It is regarded as a type of verrucous carcinoma occurring on anogenital mucosal surfaces where it is locally invasive but displays a benign cytology. We describe a case of a 24-year-old woman with persisting condyloma acuminata progressing to a large intra-abdominal Buschke-Lowenstein tumour. To our knowledge such an advanced stage has only been reported once before. The severity and extent of the tumour both determine the treatment and patient outcome. Treatment was impeded by cachexia, an immunosuppressive state after kidney transplantation and difficulties in establishing a reliable diagnose. Interferon treatment was started which initially led to tumour reduction but was complicated by an interferon-induced pancreatitis, pneumonia, and fasciitis necroticans resulting in death. We present a literature overview on the treatment options for a Buschke-Lowenstein tumour, with emphasis on interferon therapy, with all the advantages and disadvantages. N. E. Wester, E. M. Hutten, C. Krikke, and Robert A. Pol Copyright © 2013 N. E. Wester et al. All rights reserved. Liver Transplantation Using a Graft from a Donor with Situs Inversus Totalis: A Case Report and Review of the Literature Tue, 10 Sep 2013 15:48:07 +0000 http://www.hindawi.com/journals/crit/2013/532865/ It is critical to effectively use every available organ to meet the increasing demands for liver transplantation. Situs inversus is a rare congenital anomaly caused by obstruction of viscus rotation during embryonic development. Situs inversus was once regarded as a contraindication to liver transplantation because of the technical difficulties associated with the unique vascular anatomy and concern about achieving accurate graft positioning. Here, we present a successful case of liver transplantation using a graft from a donor with situs inversus totalis. The related experience will contribute to opening up new realms for the use of such rare organ resources. Xu-Yong Sun, Ke Qin, Jian-Hui Dong, Hai-Bin Li, Liu-Gen Lan, Ying Huang, Song Cao, and Zhuang-Jiang Li Copyright © 2013 Xu-Yong Sun et al. All rights reserved. Successful Kidney Transplantation for End-Stage Renal Disease in Marfan's Syndrome Wed, 04 Sep 2013 15:27:58 +0000 http://www.hindawi.com/journals/crit/2013/809613/ Marfan’s syndrome is a systemic disorder of the connective tissue caused by mutations in the extracellular matrix protein fibrillin-1, with aortic dissection and aneurysm being its most life-threatening manifestations. Kidney transplantation for end-stage renal disease (ESRD) in patients with Marfan’s syndrome has not been reported in the literature, and the rate of the incidence of dissection or aneurysm in the iliac artery is unknown. Here, we present a patient with Marfan’s syndrome with ESRD due to severe renal ischemia caused by massive bleeding from thoracoabdominal aortic dissection leading to transplant surgery of a living kidney procured from the patient’s mother. After kidney transplantation, the renal function normalized without vascular complications, and stable graft function along with negative results for both microhematuria and proteinuria continued for two years. Also, vascular complication such as aneurysm or dissection of the iliac artery was not observed using ultrasonography during the follow-up period. ESRD patients with Marfan’s syndrome might be suitable for kidney transplantation, but long-term and careful observations are needed. Makoto Ryosaka, Kazuya Omoto, Taiji Nozaki, Kazuhiko Yoshida, Yugo Sawada, Hajime Hirano, Tomokazu Shimizu, Hideki Ishida, and Kazunari Tanabe Copyright © 2013 Makoto Ryosaka et al. All rights reserved.