Case Reports in Transplantation The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Rupture of Renal Transplant Wed, 21 Jan 2015 13:36:02 +0000 Background. Rupture of renal allograft is a rare and serious complication of transplantation that is usually attributed to acute rejection, acute tubular necrosis, or renal vein thrombosis. Case Presentation. LD, a 26-year-old male with established renal failure, underwent deceased donor transplantation using kidney from a 50-year-old donor with acute kidney injury (Cr 430 mmol/L). LD had a stormy posttransplant recovery and required exploration immediately for significant bleeding. On day three after transplant, he developed pain/graft swelling and another significant haemorrhage with cardiovascular compromise which did not respond to aggressive resuscitation. At reexploration, the renal allograft was found to have a longitudinal rupture and was removed. Histology showed features of type IIa Banff 97 acute vascular rejection, moderate arteriosclerosis, and acute tubular necrosis. Conclusion. Possible ways of avoiding allograft rupture include use of well-matched, good quality kidneys; reducing or managing risk factors that would predispose to delayed graft function; ensuring a technically satisfactory transplant procedure with short cold and warm ischemia times; and avoiding large donor-recipient age gradients. Shona Baker, Maria Popescu, and Jacob A. Akoh Copyright © 2015 Shona Baker et al. All rights reserved. Staged Hand-Assisted Bilateral Native Nephrectomy for Management of Posttransplant Polyuria in an Adult with Dent’s Disease Sun, 11 Jan 2015 14:04:27 +0000 Polyuria after kidney transplantation causes graft dysfunction and increased thrombotic risk. We present a case of a polyuric adult with Dent’s disease who underwent staged bilateral native nephrectomies, the first operation before transplant and the second four months after transplant. This led to improved allograft function maintained during four years of follow-up. The retroperitoneal laparoscopic approach was well tolerated and allowed continuation of peritoneal dialysis before transplantation. A staged approach helps regulate fluid balance perioperatively and may be tailored to individual need according to posttransplant urine output. This novel approach should be considered for polyuric patients with tubular dysfunction including Dent’s disease. Rosa M. Montero, Rachel Hilton, and Jonathon Olsburgh Copyright © 2015 Rosa M. Montero et al. All rights reserved. Delayed Gastric Emptying after Living Donor Hepatectomy for Liver Transplantation Thu, 25 Dec 2014 11:29:39 +0000 Delayed gastric emptying is a significant postoperative complication of living donor hepatectomy for liver transplantation and may require endoscopic or surgical intervention in severe cases. Although the mechanism of posthepatectomy delayed gastric emptying remains unknown, vagal nerve injury during intraoperative dissection and adhesion formation postoperatively between the stomach and cut liver surface are possible explanations. Here, we present the first reported case of delayed gastric emptying following fully laparoscopic hepatectomy for living donor liver transplantation. Additionally, we also present a case in which symptoms developed after open right hepatectomy, but for which dissection for left hepatectomy was first performed. Through our experience and these two specific cases, we favor a neurovascular etiology for delayed gastric emptying after hepatectomy. Hanjay Wang, Adam D. Griesemer, Ronald F. Parsons, Jay A. Graham, Jean C. Emond, and Benjamin Samstein Copyright © 2014 Hanjay Wang et al. All rights reserved. A Symptomatic De Novo Pheochromocytoma 23 Years after Liver Transplantation: A Case Report and Review of the Literature Sun, 14 Dec 2014 09:03:29 +0000 We report a case of subacute onset of headaches and tremors with a newly discovered adrenal pheochromocytoma 23 years after an orthotopic liver transplantation and provide a review of the scarce literature regarding endocrine malignancies in liver transplant recipients. We describe the clinical presentation, diagnostic work-up, and management. This is the second case report in the literature of a de novo pheochromocytoma after solid organ transplantation. It shows that new-onset common symptoms in transplant recipients are always challenging and deserve a very thorough work-up until the cause of the symptoms is elucidated. A broad differential diagnosis should always be included in the study of any abnormalities in this patient population. M. I. Montenovo, F. G. Jalikis, B. Hoch, and R. Bakthavatsalam Copyright © 2014 M. I. Montenovo et al. All rights reserved. Replacement of Vena Cava up to the Right Atrium during Living Donor Liver Transplantation for Echinococcus alveolaris Thu, 20 Nov 2014 00:00:00 +0000 Management of advanced stage of Echinococcus alveolaris is a very difficult procedure. Surgical treatment like resection and liver transplantation is accepted procedure nowadays. Here we presented a case report of Echinococcus alveolaris which invaded the inferior vena cava up to the right atrium and surrounding tissues. This patient underwent living donor liver transplantation with replacement of inferior vena cava up to the right atrium with cryopreserved cadaveric aortic graft. This procedure is very difficult but it is a life-saving chance for patients in advanced cases of Echinococcus alveolaris. Fahri Yetişir, S. Murad Dogan, Ruslan Mamedov, Cuneyt Kayaalp, and Sezayi Yilmaz Copyright © 2014 Fahri Yetişir et al. All rights reserved. Cardiac Failure after Liver Transplantation Requiring a Biventricular Assist Device Sun, 09 Nov 2014 09:15:40 +0000 Increased hepatic iron load in extrahepatic organs of cirrhotic patients with and without hereditary hemochromatosis portends a poorer long term prognosis after liver transplant. Hepatic as well as nonhepatic iron overload is associated with increased infectious and postoperative complications, including cardiac dysfunction. In this case report, we describe a cirrhotic patient with alpha 1 antitrypsin deficiency and nonhereditary hemochromatosis (non-HFE) that developed cardiogenic shock requiring mechanical circulatory support for twenty days after liver transplant. Upon further investigation, she was found to have significant iron deposition in both the liver and heart biopsies. Her heart regained complete and sustained recovery following ten days of mechanical biventricular support. This case highlights the importance of preoperatively recognizing extrahepatic iron deposition in patients referred for liver transplantation irrespective of etiology of liver disease as this may prevent postoperative complications. Rita Jermyn, Eiei Soe, David D’Alessandro, Julia Shin, William Jakobleff, Daniel Schwartz, Milan Kinkhabwala, and Paul J. Gaglio Copyright © 2014 Rita Jermyn et al. All rights reserved. Methicillin-Resistant Staphylococcus aureus Prostatic Abscess in a Liver Transplant Recipient Mon, 20 Oct 2014 11:26:18 +0000 Prostatic abscesses are usually related to gram-negative bacilli. However, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a substantial cause of prostatic abscesses in recent years. Herein, we report the case of a 31-year-old man with a history of orthotopic liver transplantation 10 years ago who presented with acute onset dysuria and abdominal pain and was diagnosed with a MRSA prostatic abscess. To our knowledge, this is the first case describing a prostatic abscess in a liver transplant recipient and the first reporting MRSA as the causative organism of a prostatic abscess in a solid organ transplant recipient. Tanima Jana, Jorge D. Machicado, Giovanni E. Davogustto, and Jen-Jung Pan Copyright © 2014 Tanima Jana et al. All rights reserved. A Case of Continuous Negative Pressure Wound Therapy for Abdominal Infected Lymphocele after Kidney Transplantation Wed, 08 Oct 2014 14:11:16 +0000 Lymphocele is a common complication after kidney transplantation. Although superinfection is a rare event, it generates a difficult management problem; generally, open surgical drainage is the preferred method of treatment but it may lead to complicated postoperative course and prolonged healing time. Negative pressure wound therapy showed promising outcomes in various surgical disciplines and settings. We present a case of an abdominal infected lymphocele after kidney transplantation managed with open surgery and negative pressure wound therapy. Marco Franchin, Matteo Tozzi, Gabriele Soldini, and Gabriele Piffaretti Copyright © 2014 Marco Franchin et al. All rights reserved. Early Introduction of Everolimus Immunosuppressive Regimen in Liver Transplantation with Extra-Anatomic Aortoiliac-Hepatic Arterial Graft Anastomosis Sun, 21 Sep 2014 05:47:52 +0000 Liver transplantation is the treatment of choice for patients with acute and chronic end-stage liver disease, when no other medical treatment is possible. Despite high rates of 1- to 5-year survival, long-term adverse effects of immunosuppressant agents remain of major concern. Current research and clinical efforts are made to develop immunosuppressant agents that minimize adverse effects along with a low rate of graft rejection. Tailoring immunosuppressive therapy to individual patients by the use of proliferation signal inhibitors seems to be the best way to minimize toxicity and increase efficacy. Recently everolimus has been introduced in clinical practice; among its adverse effects an increased incidence of arterial graft thrombosis in renal transplants, vascular anastomosis leakage, impaired wound healing, and thrombotic microangiopathy have been reported. We present the case of a 54-year-old patient submitted to liver transplantation for end-stage liver disease treated by an extra-anatomic aortoiliac-hepatic arterial graft anastomosis and early postoperative introduction of everolimus for acute renal failure. Postoperative period was characterized by two abdominal collections and reactivation of cytomegalovirus infection that were treated by percutaneous drainage and antiviral therapy, respectively; the patient is well after 8-month followup with patency of the arterial conduit and no leakage. Emanuele Felli, Giovanni Vennarecci, Marco Colasanti, Roberto Santoro, Edoardo de Werra, Andrea Scotti, Mirco Burocchi, Giovanni B. Levi Sandri, Alessandra Campanelli, Pasquale Lepiane, and Giuseppe M. Ettorre Copyright © 2014 Emanuele Felli et al. All rights reserved. Diffuse Hepatic Epithelioid Hemangioendothelioma Developed in a Patient with Hepatitis C Cirrhosis Mon, 08 Sep 2014 05:39:54 +0000 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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.