Rhizomucor hepatosplenic abscesses in a patient with renal and pancreatic transplantation

Fungal infections are generally observed in immunosuppressed patients only, with a diagnostic challenge due to non-specific symptoms. For this reason, appropriate management may be delayed. This case report concerns a 36-year-old man with history of pancreas and kidney transplantation. He had chemotherapy for post-transplant B-cell lymphoma and presented with left upper abdominal pain and fever. Multiple investigations led to a final diagnosis of disseminated abdominal mucormycosis with multiple Rhizomucor abscesses in the liver, spleen and kidney transplant. Treatment was antifungal therapy and laparotomy with splenectomy, wedge resection of two fungal abscesses in segments II and IVb, and segmental left colic resection.

BK Polyomavirus-Specific 9mer CD8 T Cell Responses Correlate With Clearance of BK Viremia in Kidney Transplant Recipients: First Report From the Swiss Transplant Cohort Study

BK polyomavirus (BKPyV) causes premature kidney transplant (KT) failure in 1-15% of patients. Because antivirals are lacking, most programs screen for BKPyV-viremia and, if positive, reduce immunosuppression. To evaluate the relationship of viremia and BKPyV-specific immunity, we examined prospectively cryopreserved plasma and peripheral blood mononuclear cells at the time of transplantation (T0) and at 6 mo (T6) and 12 mo (T12) after transplant from 28 viremic KT patients and 68 nonviremic controls matched for the transplantation period. BKPyV IgG seroprevalence was comparable between cases (89.3%) and controls (91.2%; p = 0.8635), but cases had lower antibody levels (p = 0.022) at T0. Antibody levels increased at T6 and T12 but were not correlated with viremia clearance. BKPyV-specific T cell responses to pools of overlapping 15mers (15mer peptide pool [15mP]) or immunodominant CD8 9mers (9mer peptide pool [9mP]) from the early viral gene region were not different between cases and controls at T0; however, clearance of viremia was associated with stronger 9mP responses at T6 (p = 0.042) and T12 (p = 0.048), whereas 15mP responses were not informative (T6 p = 0.359; T12 p = 0.856). BKPyV-specific T cells could be expanded in vitro from all patients after transplant, permitting identification of 78 immunodominant 9mer epitopes including 50 new ones across different HLA class I. Thus, 9mP-responses may be a novel marker of reconstituting CD8 T cell function that warrants further study as a complement of plasma BKPyV loads for guiding immunosuppression reduction.

CRTC2 polymorphism as a risk factor for the incidence of metabolic syndrome in patients with solid organ transplantation

Metabolic syndrome after transplantation is a major concern following solid organ transplantation (SOT). The CREB-regulated transcription co-activator 2 (CRTC2) regulates glucose metabolism. The effect of CRTC2 polymorphisms on new-onset diabetes after transplantation (NODAT) was investigated in a discovery sample of SOT recipients (n₁=197). Positive results were tested for replication in two samples from the Swiss Transplant Cohort Study (STCS, n₂=1294 and n₃=759). Obesity and other metabolic traits were also tested. Associations with metabolic traits in population-based samples (n₄=46'186, n₅=123'865, n₆>100,000) were finally analyzed. In the discovery sample, CRTC2 rs8450-AA genotype was associated with NODAT, fasting blood glucose and body mass index (P_corrected<0.05). CRTC2 rs8450-AA genotype was associated with NODAT in the second STCS replication sample (odd ratio (OR)=2.01, P=0.04). In the combined STCS replication samples, the effect of rs8450-AA genotype on NODAT was observed in patients having received SOT from a deceased donor and treated with tacrolimus (n=395, OR=2.08, P=0.02) and in non-kidney transplant recipients (OR=2.09, P=0.02). Moreover, rs8450-AA genotype was associated with overweight or obesity (n=1215, OR=1.56, P=0.02), new-onset hyperlipidemia (n=1007, OR=1.76, P=0.007), and lower high-density lipoprotein-cholesterol (n=1214, β=-0.08, P=0.001). In the population-based samples, a proxy of rs8450G>A was significantly associated with several metabolic abnormalities. CRTC2 rs8450G>A appears to have an important role in the high prevalence of metabolic traits observed in patients with SOT. A weak association with metabolic traits was also observed in the population-based samples.

Differential role of naïve and memory CD4 T-cell subsets in primary alloresponses

The T cell response to major histocompatibility complex (MHC) alloantigens occurs via two main pathways. The direct pathway involves the recognition of intact allogeneic MHC:peptide complexes on donor cells and provokes uniquely high frequencies of responsive T cells. The indirect response results from alloantigens being processed like any other protein antigen and presented as peptide by autologous antigen-presenting cells. The frequencies of T cells with indirect allospecificity are orders of magnitude lower and comparable to other peptide-specific responses. In this study, we explored the contributions of naïve and memory CD4(+) T cells to these two pathways. Using an adoptive transfer and skin transplantation model we found that naive and memory CD4(+) T cells, both naturally occurring and induced by sensitization with multiple third-party alloantigens, contributed equally to graft rejection when only the direct pathway was operative. In contrast, the indirect response was predominantly mediated by the naïve subset. Elimination of regulatory CD4(+)CD25(+) T cells enabled memory cells to reject grafts through the indirect pathway, but at a much slower tempo than for naïve cells. These findings have implications for better targeting of immunosuppression to inhibit immediate and later forms of alloimmunity.

Treg-therapy allows mixed chimerism and transplantation tolerance without cytoreductive conditioning

Establishment of mixed chimerism through transplantation of allogeneic donor bone marrow (BM) into sufficiently conditioned recipients is an effective experimental approach for the induction of transplantation tolerance. Clinical translation, however, is impeded by the lack of feasible protocols devoid of cytoreductive conditioning (i.e. irradiation and cytotoxic drugs/mAbs). The therapeutic application of regulatory T cells (Tregs) prolongs allograft survival in experimental models, but appears insufficient to induce robust tolerance on its own. We thus investigated whether mixed chimerism and tolerance could be realized without the need for cytoreductive treatment by combining Treg therapy with BM transplantation (BMT). Polyclonal recipient Tregs were cotransplanted with a moderate dose of fully mismatched allogeneic donor BM into recipients conditioned solely with short-course costimulation blockade and rapamycin. This combination treatment led to long-term multilineage chimerism and donor-specific skin graft tolerance. Chimeras also developed humoral and in vitro tolerance. Both deletional and nondeletional mechanisms contributed to maintenance of tolerance. All tested populations of polyclonal Tregs (FoxP3-transduced Tregs, natural Tregs and TGF-beta induced Tregs) were effective in this setting. Thus, Treg therapy achieves mixed chimerism and tolerance without cytoreductive recipient treatment, thereby eliminating a major toxic element impeding clinical translation of this approach.

[Hypertension in solid organ transplants]

Hypertension is highly prevalent in transplantation and affects all type of organs. With the introduction of calcineurin inhibitors as immunosuppressive drugs, acute allograft rejection episodes have been significantly reduced and hence patient and allograft survival rates have dramatically improved. However, cardiovascular complications have become an important cause of morbidity and mortality. Treating cardiovascular risk factors such as diabetes, dyslipidemia and hypertension seems obvious, however in this population, there is little evidence for specific blood pressure targets, or for the best strategy to achieve blood pressure control. The aim of this article is to review the epidemiology and physiopathology of hypertension in transplant recipients as well as its clinical management.

[Pregnancy in patients with underlying renal disease]

Pregnancy has generally been regarded as very high risk in women with chronic renal insufficiency. In this review, we describe the physiologic changes in systemic and renal haemodynamics during pregnancy, as well as the nature and severity of possible maternal and foetal complications in the setting of underlying renal disease. The risks are proportional to the degree of functional renal impairment, the presence or not of proteinuria and/or arterial hypertension at the time of conception, and are related to the type of underlying nephropathy or systemic disease in the mother. Furthermore, if the renal disease has been diagnosed before pregnancy, a better planning of the moment of conception, as well as a tight follow-up, allow for a better maternal and obstetrical outcome.

Phenotypic and genotypic risk factors for cardiovascular events in an incident dialysis cohort

Cardiovascular disease (CVD) remains the major cause of death in patients with end-stage renal disease (ESRD). Traditional risk factors do not explain the high prevalence of CVD in this population, and other non-traditional cardiovascular (CV) risk markers have now been described. Therefore, the potential relationship between CVD and phenotypic and genotypic risk markers was investigated prospectively in incident dialysis patients cohort. The 279 patients (244 on hemodialysis, 35 on peritoneal dialysis) within the Diamant Alpin Dialysis Cohort Study were investigated. Phenotypic and genotypic parameters were determined at dialysis initiation, patients monitored over a 2-year period, and CV events (morbidity and mortality) recorded. Globally, 82 CV events occurred and 26 patients (9.3%) died from CVD, whereas 28 (10%) died from non-CV causes. Previous CV events were strongly predictive of CV events occurrence, whatever patients had had one (hazard ratio (HR) 2, 95% confidence intervals (CI) 1.1-3.5) or more (HR 3.9, 95% CI 2.1-7.1) CV accidents before starting dialysis. Both lipoprotein(a) (HR 1.67, 95% CI 1-2.5) and total plasma homocysteine at cutoff 30 micromol/l (HR 1.7, 95% CI 1.1-2.8) were independent predictors of CV events outcome. In the subgroup of patients with homocysteine < 30 micromol/l, methylenetetrahydrofolate reductase (MTHFR) TT was the sole biological parameter predictive of CV event outcome (HR 2.5, 95% CI 1.1-10, P = 0.03). ESRD patients who enter chronic dialysis with a previous CV event, high total homocysteinemia levels, or MTHFR 677TT genotype must be considered at high risk of incident CV events.

[Clinical and genetics aspects of Alport syndrome]

Microscopic haematuria of glomerular origin, without known aetiology, should raise the suspicion of Alport Syndrome IASI in children as well as in adults. The genetic mutations causing AS lie in the genes encoding for the alpha3, alpha4 and alpha5 chains of the collagen type IV, the main constituent of glomerular basement membranes (GBM). The various mutations and modes of transmission of the disease account for the heterogeneous clinical presentations. No specific treatment of AS is currently available. However, a better understanding of the GBM's ultrastructure, in particular of type IV collagen, will hopefully enable the identification of novel therapeutic targets.

[Epidemiology of end-stage renal failure: comparison between 2 Swiss cantons]

Since a previous survey in the Valais Canton had shown a disparity in the prevalence of chronic dialysis patients compared to the national mean, an epidemiological survey was conducted in the cantons of Valais (VS) and Vaud (VD) among all the dialysis units (VS 6, VD 6) and all adult dialysis patients (VS 130, VD 187). The survey confirms the disparity in prevalence: VS 476, VD 340 and Switzerland 329 per million inhabitants (p.m.h.). This disparity also exists among different parts of the VS canton: Haut-Valais 316, Valais Central 650 and Bas-Valais 409 per million d'habitants. The mean age at start of therapy and at the time of the survey are comparable: 57 +/- 17 vs 55 +/- 15 years and 62 +/- 15 vs 61 +/- 14 respectively. Among the different etiological diseases, vascular nephropathies are less frequent and hereditary diseases more frequent in the VS canton. Co-morbidity factors were comparable. In VS there are less patients on peritoneal dialysis (6 vs 19%) and on the transplant waiting list (12 vs 16%). Globally, disparities exist in the prevalence of dialysis patients between the 2 cantons; they can be explained by both medical factors (type of nephropathies) and different options in the treatment modalities.

Incidence and prognostic value of electrocardiographic abnormalities after heart transplantation

BACKGROUND

The improvement of surgical techniques and the use of immunosuppressive drugs within the past 15 years has made heart transplantation an increasingly performed procedure and an accepted treatment for end-stage cardiac failure.

HYPOTHESIS

The aim of this study was to describe the changes of the 12-lead electrocardiogram (ECG) after heart transplantation and to determine their prognostic value on complications such as rejection or graft coronary artery disease during follow-up.

METHODS

The ECGs of 62 consecutive patients were analyzed for 5 years at follow-up periods of 1, 2, 3, 6 months and yearly after transplantation.

RESULTS

The most prevalent abnormality was the presence of complete or incomplete right bundle-branch block (RBBB). New RBBB appeared in 69% (43/62) of the patients, mainly during the first month (21/43). There was no left bundle-branch block. We detected nine episodes of supraventricular arrhythmias: one atrial fibrillation, six atrial flutter, one junctional tachycardia, one orthodromic tachycardia on a Wolff-Parkinson-White syndrome; all appearing during the first 3 months. Three of the six episodes of atrial flutter occurred during an episode of acute rejection. There was no relation between RBBB and the gender and age of recipients and donors, nor with the graft ischemic time and the pretransplantation hemodynamic values. Right bundle-branch block was not associated with acute rejection nor with graft coronary artery disease.

CONCLUSION

The ECG abnormalities after heart transplantation have no predictive value on the long-term evolution. Right bundle-branch block is very frequent and is not associated with adverse prognosis.