Transmission of synovial sarcoma from a single multi-organ donor to three transplant recipients: case report

Background Transmission of malignancy is a notable problem that cannot always be absolutely predicted at the time of transplantation. In particular, donor-derived transmission of synovial sarcoma in solid-organ transplantation is a rare but catastrophic event. Case presentation We are the first to report three cases of synovial sarcoma transmitted from a single multi-organ donor in China. The donor died of respiratory failure caused by an intrathoracic tumor, which was diagnosed as benign at the time of donation. All three recipients developed synovial sarcoma 3–13 months after transplantation; all three cases were confirmed to be donor transmitted. The liver transplant recipient died of tumor metastasis after partial-allograft hepatectomy. The two renal-transplant recipients survived after comprehensive therapy, including allograft nephrectomy, withdrawal of immunosuppressants and targeted therapy with anlotinib. Conclusions This report highlights the importance of detailed donor assessment, close follow-up and timely treatment of unexpected donor-transmitted malignancy. Although pathology is the most important evidence for the exclusion of donors for malignant potential, it should be combined with tumor type, tumor size and speed of growth. Organs from donors with malignant potential should be discarded. Allograft nephrectomy should be considered after confirmation of renal-allograft synovial sarcoma. Anlotinib for synovial sarcoma seems to be effective and well tolerated during long-term follow-up.

EP.WE.962Pre-emptive arterial stenting with covered vascular stents to prevent mycotic haemorrhage in infected fields following failed kidney and pancreas transplants prior to graft explant

Aims Allograft nephrectomy and pancreatectomy present a significant surgical challenge in contaminated surgical fields, with risks of post-operative pseudoaneurysms and mycotic bleeds. We report on our experience of prophylactic endovascular stenting shortly before or after allograft nephrectoym and pancreatectomy to reduce the risk of subsequent pseudoaneurysm formation from the donor arterial conduit. Methods A retrospective analysis of all patients undergoing arterial stenting by interventional radiology prior to graft explant in our unit was performed. Results Twelve patients were identified, 6 of whom had undergone kidney transplant and 6 simultaneous pancreas kidney transplant (SPK) with an average age of 46. Iliac stenting was prophylactic in 7 patients, for pseudoaneurysm (28%), graft pancreatitis (28%), acute rejection (28%), enteric anastomotic leak (16%) and transplant pyelonephritis (14%). Therapeutic stenting was performed in 5 patients, all of whom had ruptured pseudoaneurysms. Post-operative 30-day mortality occurred in 1 patient resulting from an acute on chronic limb ischaemia and subsequent sepsis and death. Of the remaining patients, none experienced complications from stenting. 9 of the 12 stented patients remain alive, with the 3 mortalities resulting from other pathology not relating to stenting. Conclusion Prophylactic iliac stenting around the time of graft excision in inflamed or infected fields provides a safe and effective technique to completely exclude the donor arterial stump, with no subsequent vascular complications reported within our series. Preventing mycotic aneurysm formation in this way may mitigate the risk of potentially catastrophic post-operative mycotic arterial bleeds.

Accelerated cellular rejection with prominent interstitial hemorrhage following cemiplimab treatment: How can we approach a renal transplant recipient under anti-PD1 therapy?

The development of immune checkpoints from which tumor cells escape has revolutionized oncology in the past decade. However, its use is not indicated for solid organ transplant (SOT) recipients who wish to develop a state of immune tolerance to preserve the graft. The dysregulation of the immune system furthermore poses these patients at a higher risk of developing malignancies. Given the lack of therapeutic alternatives and the vital risk associated with oncological disease, the use of immunotherapy has been indicated in some cases for SOTR patients. Case reports confirm the imminent risk of rejection, especially cellular, which is higher with anti-PD1 relative to anti CTLA-4. This suggests a fundamental role for PD-1 in the development of graft tolerance. In light of these results, the use of anti-PD-1 would seem incompatible with graft survival; however, some cases have been reported describing the use of anti-PD-1 without loss of the renal graft. We present a case of accelerated allograft cell rejection with cemiplimab (anti-PD1) that required an allograft nephrectomy and briefly review the different immunosuppressive strategies used in kidney transplant recipients who received antiPD-1.

Incidentally detected isolated Aspergillus fumigates infection of the renal allograft

Fungal infection represents 5% of the infections of post renal transplant recipients. The frequency of invasive Aspergillus ranges from 0.5% to 2.2% with a mortality rate of 88%. In renal transplantation, Aspergillus infection usually affects primarily the lungs with occasional dissemination and the central nervous system. Involvement of a renal allograft in the isolated form is rare. A-35-year-old male post-renal transplant patient presented in our institute for routine follow up examination. Ultrasound and computed tomography (CT) were conducted in our radiology department, suggestive of abscess formation in mid pole of transplanted kidney. The patient did not have any clinical symptoms. His serum creatinine level was also within normal limit. Diagnosis of Aspergillus fumigates was made by aspiration of pus. Treatment started according to culture and sensitivity report. Ultimately graft nephrectomy was performed to control infection. Aspergillus infection of a renal allograft remains a key issue for nephrologists and infection specialists. For diagnosis of fungal infection, a high index of suspicious is necessary. In the present case, the infected allograft nephrectomy and the elimination of immune-compromised state and the prompt administration of antifungal therapy, made recovery possible. However, early diagnosis remains difficult.

Management of patients with a failed kidney transplant: what should we do?

The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. Moreover, the risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. The management of these patients present several controversial opinions and clinical guidelines are lacking. This article aims to review the leading evidence on the main issues in the management of patients with failed transplant, including the ideal timing and modality of dialysis reinitiation, the indications for an allograft nephrectomy or the correct management of immunosuppression during graft failure. In summary, retransplantation is a feasible option that should be considered in patients with graft failure and may help to minimize the morbidity and mortality risk associated with dialysis reinitiation.