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Pancreas transplant recipient obesity has been associated with increased risk of perioperative complications, graft failure, and death. The imperative to maximize organ utility must be balanced against the need to maintain equity of access, including for the increasing number of obese diabetic patients.We compared the outcomes of pancreas transplant recipients with body mass index (BMI) greater than 30 kg/m(2) (n=60, mean ± SD BMI 32.1 ± 1.7 kg/m(2)) to those with BMI less than 30 kg/m(2) (n=308, mean ± SD BMI 24.5 ± 2.7 kg/m(2)) between 1996 and 2013.There were no differences in the pretransplant recipient or donor characteristics apart from BMI. The BMI greater than 30 group were more likely to suffer a rejection episode (43% vs. 29%; P = 0.03). The median time to first rejection was shorter (1 vs. 6 months; P = 0.04), and wound infection was more common in the BMI greater than 30 group (P = 0.03). There was no difference in the rate of patient, pancreas, or kidney graft survival or difference in graft function between the two groups.The obese recipients in this study were in the lower range of the obese category. Although there was an increased risk of rejection and wound infection in the obese group, there was no difference in patient or graft survival. This finding, when compared with previous reports, may be related to stringent recipient selection and posttransplant care particularly with respect to cardiovascular disease.

Colonic pseudo-obstruction (CPO) is characterized by colonic distention in the absence of mechanical obstruction or toxic megacolon. Concomitant secretory diarrhea (SD) with hypokalemia (SD-CPO) due to gastrointestinal (GI) loss requires further characterization.To perform a systematic review of SD-CPO, report a case study, and compare SD-CPO with classical CPO (C-CPO).We performed a search of MEDLINE, EMBASE, Cochrane, and Scopus for reports based on a priori criteria for CPO, SD and GI loss of potassium. An additional case at Mayo Clinic was included.Nine publications met inclusion criteria, with a total of 14 cases. Six studies had high, three moderate, and our case high methodological quality. Median age was 74 years (66-97), with 2:1 male/female ratio. Kidney disease was present in 6/14 patients. Diarrhea was described as profuse, watery, or viscous in 10 patients. Median serum, stool, and urine potassium concentrations (mmol/L) were 2.4 (range: 1.9-3.1), 137 (100-180), and 17 (8-40), respectively. Maximal diameter of colon and cecum (median) were 10.2 cm and 10.5 cm, respectively. Conservative therapy alone was effective in five out of 14 patients. Median potassium supplementation was 124 mEq/d (40-300). Colonic decompression was effective in three out of six patients; one had a total colectomy; three out of 14 had died. The main differences between SD-CPO and C-CPO were lower responses to treatments: conservative measures (35.7% vs 73.6%, P=.01), neostigmine (17% vs 89.2%, P.001), and colonic decompression (50% vs 82.4%, P=.02).SD-CPO is a rare phenotype associated with increased fecal potassium and is more difficult to treat than C-CPO.

BACKGROUND There is a paucity of contemporary data describing the results of pancreas retransplantation (PRT). As a measure of utility, we wished to determine whether PRT could produce equivalent short-term and long-term recipient outcomes to primary pancreas after kidney (PAK) transplantation. METHODS Retrospective analysis of 96 consecutive pancreas only transplants performed from 2003 to May 2012. Primary PAK transplants (n = 78) were compared to PRT (n=18). RESULTS Donor and recipient demographics were similar. Pancreas graft survival was similar for PAK and PRT at 1 year (88.2% vs. 100%) and 3 years (85.1% vs. 85.1%). Pancreas graft failure occurred in 14 PAK and two PRT patients with a mean follow-up of 61.6 ± 38.7 and 37.8 ± 26.1 months, respectively. There were no differences in postoperative length of stay (9.9 days vs. 8.7 days; P = 0.9) or postoperative complications in the first 3 months (47.4% vs. 38.9%, P = 0.6). At 3-year follow-up, both groups had comparable HBA1c (0.06 vs. 0.05; P = 0.8), serum creatinine (116.6 μmol/L v 131.7 μmol/L; P = 0.09), and oral glucose tolerance tests. CONCLUSION Pancreas retransplantation is a safe and effective therapy for select recipients after graft loss. Pancreas retransplantation is associated with the same risk of postoperative complications and has similar intermediate-term graft survival compared to primary PAK transplantation.

An ischemic-type biliary stricture (ITBS) is a common feature after liver transplantation using donation after cardiac death (DCD) grafts. We compared sequential subnormothermic ex vivo liver perfusion (SNEVLP; 33°C) with cold storage (CS) for the prevention of ITBS in DCD liver grafts in pig liver transplantation (n = 5 for each group). Liver grafts were stored for 10 hours at 4°C (CS) or preserved with combined 7-hour CS and 3-hour SNEVLP. Parameters of hepatocyte [aspartate aminotransferase (AST), international normalized ratio (INR), factor V, and caspase 3 immunohistochemistry], endothelial cell (EC; CD31 immunohistochemistry and hyaluronic acid), and biliary injury and function [alkaline phosphatase (ALP), total bilirubin, and bile lactate dehydrogenase (LDH)] were determined. Long-term survival (7 days) after transplantation was similar between the SNEVLP and CS groups (60% versus 40%, P = 0.13). No difference was observed between SNEVLP- and CS-treated animals with respect to the peak of serum INR, factor V, or AST levels within 24 hours. CD31 staining 8 hours after transplantation demonstrated intact EC lining in SNEVLP-treated livers (7.3 × 10(-4) ± 2.6 × 10(-4) cells/μm(2)) but not in CS-treated livers (3.7 × 10(-4) ± 1.3 × 10(-4) cells/μm(2) , P = 0.03). Posttransplant SNEVLP animals had decreased serum ALP and serum bilirubin levels in comparison with CS animals. In addition, LDH in bile fluid was lower in SNEVLP pigs versus CS pigs (14 ± 10 versus 60 ± 18 μmol/L, P = 0.02). Bile duct histology revealed severe bile duct necrosis in 3 of 5 animals in the CS group but none in the SNEVLP group (P = 0.03). Sequential SNEVLP preservation of DCD grafts reduces bile duct and EC injury after liver transplantation.

Regard its values with suspicion, especially when they do not agree with the patient’s blood glucose levels.

Background Cytomegalovirus (CMV) is a major pathogen affecting solid organ transplant (SOT) recipients. Prophylactic strategies have decreased the rate of CMV infection/disease among SOT. However, data on the effect of current prophylactic strategies for simultaneous pancreas–kidney (SPK) or pancreas after kidney (PAK) transplant remain limited. We report our experience of CMV prophylaxis in SPK/PAK recipients. Methods A total of 130 post-SPK/PAK patients were analyzed retrospectively for the rate of CMV and the risk factors associated with the acquisition of CMV. All patients received antiviral prophylaxis. The follow-up period was one yr post-transplant or until death. Results The rate of CMV post-SPK/PAK transplant was 24%, 44%, and 8.2% among the whole cohort, the D+/R− and the R+ groups, respectively. Median time of prophylaxis was 49 (0–254) d. In the whole cohort, risk factors for CMV infection/diseases were D+/R− CMV status (odds ratio [OR] = 16.075), preceding non-CMV (infection caused by bacteria or fungi and other viruses) infection (OR = 6.362) and the duration of prophylaxis (OR = 0.984). Among the CMV D+/R− group, non-CMV infection was the only risk factor for CMV disease (OR = 10.7). Conclusions Forty-four per cent (25/57) of the D+/R− recipients developed CMV infection/disease despite CMV prophylaxis. Current CMV prophylaxis failed to prevent CMV infection/disease in this group of patients.

Introduction Bacterial infections are major causes of early morbidity and mortality after liver transplantation. Selective digestive decontamination (SDD) can be used pre-operatively for living-donor liver transplant (LD-LT), but its role in this setting remains controversial. Methods To evaluate this strategy, we retrospectively analyzed a cohort of consecutive LD-LTs performed in our center from March 2007 to February 2011 and compared the incidence and nature of early infectious complications, length of intensive care unit stay and hospitalization, antibiotic use, and emergence of resistant bacteria in patients with or without SDD prophylaxis. Results Of 148 LD-LTs in the study period, 111 received SDD prophylaxis while 37 did not. In a multivariate model, the independent factors associated with an increased risk of early post-transplant infections were length of postoperative mechanical ventilation (for every additional day odds ratio [OR] = 2.37, 95% confidence interval [CI] 1.4–4.0; P = 0.002), and choledochojejunostomy (OR = 4.5, 95% CI 1.95–10.5; P

Learning Point for Clinicians Clinicians must consider schwannomas in acute paraparesis in young people. Prompt diagnostic imaging is critical for early intervention. Surgical decompression can result in significant improvement and favorable outcomes, especially when performed early. A thorough neurologic examination will allow proper anatomic localization and guide further investigations. Schwannomas are neoplasms that arise from schwann cells of the posterior spinal root, cranial nerves or peripheral nerves. They account for up to 30% of all spinal tumors and have roughly the same incidence as meningiomas. They may involve multiple spinal compartments (intradural extramedullary 72%, extradural 13%, intradural and extradural 13% and intramedullary 1%).1 Classification of these tumors uses location and extent and entails five distinct classes.2 Class V has been described almost exclusively in the lumbosacral spine and as intrascaral lesions.2,3 However, rare reports have described giant thoracic schwannomas.4 We report the case of a patient with type V thoracic schwannoma mimicking acute …

Background Controversy persists over the safety and efficacy of pancreas transplantation in patients with insulin-dependent diabetes mellitus who have received a prior kidney transplant. Methods We compared the outcomes of recipients who received either Synchronous-Pancreas Kidney-Transplantation (SPK, n=123) or Pancreas-After-Kidney-Transplants(n=49)at our institution between August 2002 to January 2010. Results Donor and recipient demographics were similar. Time interval between kidney and pancreas transplantation was 5.9 ± 3.8 (4.8 [1.6-12.2]) years. The majority of kidney-recipients in PAK group were transplanted at outside institutions and referred to us for PAK. Most patients received thymoglobulin induction and were maintained on tacrolimus, MMF, and prednisone. For SPK versus PAK recipients, there was no difference in median of length of hospital stay or incidence of overall complications. All PAK recipients are alive with functioning kidney grafts, whereas the 1-, 3-, and 5-year SPK patient survival rates were 98%,96%,and 94%, P=0.09. The 1-,3-, and 5-yr uncensored pancreas survival rates for SPK versus PAK were 93% vs. 90%, 90% vs. 90%, and 82% versus 85%, respectively (P=0.4). Conclusion Glycemic control and intermediate survival outcomes were similar in both groups. Pancreas-graft outcomes in SPK and PAK were equivalent in our study, but our specific population entailed among other factors a long K to PAK time interval; PAK could be a comparable option to SPK for patients with access to kidney grafts.

We compared cold static with acellular normothermic ex vivo liver perfusion (NEVLP) as a novel preservation technique in a pig model of DCD liver injury. DCD livers (60 min warm ischemia) were cold stored for 4 h, or treated with 4 h cold storage plus 8 h NEVLP. First, the livers were reperfused with diluted blood as a model of transplantation. Liver injury was determined by ALT, oxygen extraction, histology, bile content analysis and hepatic artery (HA) angiography. Second, AST levels and bile production were assessed after DCD liver transplantation. Cold stored versus NEVLP grafts had higher ALT levels (350 ± 125 vs. 55 ± 35 U/L; p < 0.0001), decreased oxygen extraction (250 ± 65 mmHg vs. 410 ± 58 mmHg, p < 0.01) and increased hepatocyte necrosis (45% vs. 10%, p = 0.01). Levels of bilirubin, phospholipids and bile salts were fivefold decreased, while LDH was sixfold higher in cold stored versus NEVLP grafts. HA perfusion was decreased (twofold), and bile duct necrosis was increased (100% vs. 5%, p < 0.0001) in cold stored versus NEVLP livers. Following transplantation, mean serum AST level was higher in the cold stored versus NEVLP group (1809 ± 205 U/L vs. 524 ± 187 U/L, p < 0.05), with similar bile production (2.5 ± 1.2 cc/h vs. 2.8 ± 1.4 cc/h; p = 0.2). NEVLP improved HA perfusion and decreased markers of liver duct injury in DCD grafts.

Background Thymoglobulin (ATG) and basiliximab induction therapies are used by the majority of centers for pancreas transplantation today. Although both strategies have different mechanisms, there is a paucity of studies comparing them. We compared the efficacy and side effects of both methods in simultaneous pancreas-kidney (SPK) transplantation. Methods We analyzed 128 SPKs at our institution between January 2001 and August 2008. Forty-nine patients received basiliximab (40 mg), whereas 79 patients had ATG (5 mg/kg). Graft function, complications, rejection, and survival rates were analyzed. Results ATG versus basiliximab therapy was associated with decreased 3-month (6% vs. 21%; P=0.01) and 1-year (14% vs. 27%; P=0.049) rejection rate. Steroid-resistant rejections were decreased with ATG (3%) vs. basiliximab (14%) (P=0.01). In a univariate regression analysis, basiliximab induction was a risk factor for rejection (HR, 7.1; CI, 3.8-13). No differences were observed regarding complications and graft function up to 5 years. ATG versus basiliximab therapy resulted in identical 1-year (90% vs. 93%), 3-year (87% vs. 89%), and 5-year (78% vs. 83%) pancreas survival (P=0.7). No difference was observed in kidney survival after 1 year (99% vs. 98%), 3 years (97% vs. 98%), and 5 years (95% vs. 95%) (P=0.4). Conclusions ATG versus basiliximab induction therapy results in decreased acute cellular rejection in the first year after SPK with similar side effects. Long-term graft function and survival are not affected by induction regimen.

268 www.thelancet.com/infection Vol 15 March 2015 but similar to what has been described in other extrahepatic manifestations related to HEV infection. In all reported cases thus far, HEV RNA in the cryoprecipitate was not assessed. In view of the growing interest in HEV infection and prevention, especially in immunosuppressed patients, more studies are needed to further delineate the HEV extrahepatic manifestations and their immunopathogenesis.

To the Editor, We read with interest the recent report by Festa et al. [1], regarding acute fulminant hepatitis (AFH) with hepatitis E virus (HEV) genotype 3e, and appreciate the opportunity to comment and discuss our opinion. In their report, the authors deduce a diagnosis of end-stage liver disease (ESLD) from radiological fi ndings (e.g. mild hepatic and splenic enlargement, irregularity of the liver profi le, non-homogenous liver parenchyma, and portal vein enlargement), as well as the presence of mild thrombocytopenia. However, hepatic surface nodularity is commonly seen in AFH, and it re fl ects alternating confl uent regenerative nodules and necrosis [2]. Moreover, mild hepatic and splenic enlargement are nonspecifi c features that could be encountered in acute hepatitis, as well as in ESLD. Similarly, portal hypertension and portal vein enlargement are described in AFH, and are related to the severity of liver damage and the presence of ascites [3]. Thrombocytopenia has also been described in AFH, and may result from decreased platelet produc-tion, increased destruction or sequestration [4].There-fore, ESLD diagnosis is best made by biopsy when feasible, and hepatic venous pressure gradient could be measured through the transjugular approach. Additionally, pancreatic head enlargement could occur in the setting of AFH-related pancreatitis [5], although pancreatic hyperenzymemia was not docu-mented in this report. Although the antiviral treatment of this patient may not differ in either case, this distinction becomes relevant in the United States if transplantation was needed, as AFH receives higher listing priority according to the United Network for Organ Sharing (UNOS), in turn decreasing the chances of receiving a life-saving transplant if chronic liver illness was determined. HEV infections continue to emerge in non-endemic regions, and this has led to rising interest in its epidemiology and prevention [6]. We believe that more interesting aspects of this infection will appear in the future, along with the need for research in its pathogenesis, diagnosis, and therapies. Declaration of interest

Liver transplantation with grafts obtained after cardiac death-current advances in mastering the challenge

To the Editor: Serious cardiac toxicity following ropivacaine infusion is rare. Side effects that responded to lipid infusions have been described [1]. A 57-year-old man with impaired liver function and end-stage renal disease (ESRD) was admitted for an belowknee amputation. Postoperatively, ropivacaine catheters were placed. Later, the patient became lethargic, and bradycardic, with tinnitus, dysgeusia, and hallucinations. EKG showed widened QRS and prolonged QT without ST changes (Supplementary Figure 1a, b). Echocardiography revealed an ejection fraction (EF) of 20 % without wall motion abnormality. Peak troponin-I-ES = 4.3. We estimated the infusion to be 1,540 mg ropivacaine. A total of 2,480 ml intralipids 20 %, and one round of plasmapheresis, were given with transient response. The patient ultimately died of cardiac arrest (Supplementary Table 1.) Cardiac toxicity has been reversed using infusion of lipids in animal models. Reports have suggested its clinical efficacy in humans [1]. The mechanism of lipid rescue is thought to be a combination of reduced tissue binding by reestablished equilibrium in a plasma lipid phase and a beneficial energetic-metabolic effect. Ropivacaine may be less responsive to lipid rescue therapy because of its decreased lipophilicity. Slow accumulation into tissues may be more difficult to reverse than a sudden bolus [2]. We have evidence of ropivacaine toxicity considering the Naranjo algorithm score of 6, which correlates to the category of a probable adverse drug reaction. The pharmacokinetics are not affected by renal failure, and the liver accounts for the majority of clearance [3]. In this patient, the impaired liver was further hypoperfused, considering myocardial depression. This report suggests the failure of lipid rescue.