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Cardiac Sarcoidosis (CS) is a chronic granulomatous disease that can recur in transplanted hearts. There are currently no standardized guidelines for management of CS in heart transplant recipients. A 58-year-old male with end-stage NICM (presumed chemotherapy-related cardiotoxicity) presented with shortness of breath, and persistent low flow alarms on his HVAD. His past medical history was significant for leukemia (treated with doxorubicin), non-sustained VT s/p ICD and HVAD as bridge-to-transplant (2016). RHC showed evidence of cardiogenic shock. He was upgraded to UNOS Status 2 and underwent orthotropic heart transplant (OHT) on 7/30/21. He received standard induction (Basiliximab) and maintenance (Tacrolimus, MMF, prednisone) immunosuppression regimen. Unexpectedly, his explanted heart was noted to have non-necrotizing granulomatous myocarditis consistent with CS. He was switched from MMF to Sirolimus at 7 months post-OHT after TTE showed normal biventricular function and surveillance biopsy revealed 0R, AMR0. He was weaned off prednisone at 8 months. Subsequent cardiac biopsy showed recurrence of non-necrotizing granulomas with focal infiltrates (Fig A), suggesting recurrence of CS and mild acute cellular rejection (1R, AMR0). Patient remained asymptomatic with normal biventricular function. He was restarted on high dose prednisone and switched from Sirolimus to MMF. Tacrolimus goal was kept at 8-10. Five months following CS recurrence, cardiac PET showed no evidence of CS on Tacrolimus, MMF and low-dose prednisone. Recurrent CS in a transplanted heart is rare and usually manifests itself once immunosuppression is weaned. While there are no standard guidelines for its management, standard dose MMF plus low-dose prednisone in addition to Tacrolimus was effective in preventing further recurrence in our patient. Routine monitoring for recurrence is important for early detection and prevention of life-threatening complications. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Laryngeal transplantation is a possibility for patients with irreversible laryngeal disease, such as complex trauma and larynx cancer. The objective of performing this procedure was to solve problems that these patients face with a laryngectomy. The medical literature has reviews about larynx transplantations, but almost nothing about the larynx donor. The following is our experience on management of these donors. Materials and Methods: Selection criteria was as follows: (1) 18–50 years old; (2) gender and ABO blood type matched between donor and recipient; (3) No abuse of tobacco, cocaine, and marijuana, (4) tracheal intubation time <3 days; and (5) time in the intensive care unit <7 days. The preservation was simple hypothermia with larynx infusion via the carotid artery with University of Wisconsin solution. Results: Between 2001 and 2006, we managed 25 donors, among whom 12 grafts were discarded. The 13 larynx donors were of average age 27.2 +− 7.9 years and their cause of death was head trauma. Each was of male and 12 were multiorgan donors. Three donors had previous consumption of tobacco and 2 donors of marijuana. There were 2 cases of acute rejection episodes. Graft survival rate at 2 years was 90%. Discussion: These donors may have differences from other multiorgan donors: (1) they do not require strict fluid management; (2) vasoactive agents may be used in higher doses than in organ donors, and (3) the larynx tolerates hemodynamic instability. It was necessary to use some donors who had used addictive substances, showing that some selection criteria may be flexible. There was no conflict between thoracic surgeons and larynx surgeons. The priority always was for life-saving organs. Family consent was sometimes difficult because of the retrieval times and body donor reconstruction. The larynx surgery retrieval demanded an additional 2–5 hours during routine multiorgan donor surgery, and always the family asked about body reconstruction. The body appearance was always preserved. [Copyright &y& Elsevier]

Abstract: We described a case of allograft kidney dysfunction associated with renal parenchymal infection with amastigotes of Trypanosoma cruzi. The patient was diagnosed as being chronically infected prior to transplantation. The infection was probably acquired by blood transfusion. He could not complete antiparasitic treatment due to drug toxicity. He was transplanted from a cadaver who showed a negative test for Chagas’ disease. One year after transplantation the serum creatinine progressively increased. Histological examination of renal biopsy revealed intracytoplasmic amastigotes of T cruzi. No evidence of other specific alterations in the graft was detected. It was unknown whether graft dysfunction was only due to parasitic infection. The present case confirmed that T cruzi can infect kidney grafts and that immunosuppression in kidney transplantation is potentially a cause of dissemination of Chagas’ disease. [Copyright &y& Elsevier]

The purpose of our study was to evaluate short- and long-term results of transplants from cadaver donors who have died of poisoning by various substances.The actuarial survival rate of organs from intoxicated donors was calculated using the Kaplan-Meier method.Among the 507 donors between January 1998 and December 2002, 5 (0.98%) had a cause of brain death of poisoning, namely, organo-phosphates (n = 2), methanol (n = 1), cyanide (n = 1) and acetylsalicilic acid(n = 1), from whom were procured 10 kidneys, 1 liver, 2 corneas, and 1 set of bones. The follow up for patients receiving solid organs was 15.2 months (range, 0–48 months). At 3 months, 90% of kidneys had normal function. No delayed graft function rejection episodes or major complications were reported in any recipient. None showed evidence of acute or chronic poisoning. Two died, 1 early mortality was due to anesthetic complications and the other at 17 months to an unknown cause. Actuarial kidney survival rates were 90% and 80% at 12 and 24 months, respectively. The liver recipient was well at the end of follow up.Using organs of poisoned donors is feasible with comparable graft survival rates to other recipient. [Copyright &y& Elsevier]

Autochthonous microorganisms [a consortium of arbuscular-mycorrhizal (AM) fungi and Bacillus thuringiensis ( Bt )] were assayed and compared to Rhizophagus intraradices ( Ri ), Bacillus megaterium ( Bm ) or Pseudomonas putida ( Psp ) and non-inoculation on Trifolium repens in a natural arid soil under drought conditions. The autochthonous bacteria Bt and the allochthonous bacteria Psp increased nutrients and the relative water content and decreased stomatal conductance, electrolyte leakage, proline and APX activity, indicating their abilities to alleviate the drought stress. Mycorrhizal inoculation significantly enhanced plant growth, nutrient uptake and the relative water content, particularly when associated with specific bacteria minimizing drought stress-imposed effects. Specific combinations of autochthonous or allochthonous inoculants also contributed to plant drought tolerance by changing proline and antioxidative activities. However, non-inoculated plants had low relative water and nutrients contents, shoot proline accumulation and glutathione reductase activity, but the highest superoxide dismutase activity, stomatal conductance and electrolyte leakage. Microbial activities irrespective of the microbial origin seem to be coordinately functioning in the plant as an adaptive response to modulated water stress tolerance and minimizing the stress damage. The autochthonous AM fungi with Bt or Psp and those allochthonous Ri with Bm or Psp inoculants increased water stress alleviation. The autochthonous Bt showed the greatest ability to survive under high osmotic stress compared to the allochthonous strains, but when single inoculated or associated with Ri or AM fungi were similarly efficient in terms of physiological and nutritional status and in increasing plant drought tolerance, attenuating and compensating for the detrimental effect of water limitation. [ABSTRACT FROM AUTHOR]

Purpose Adequate health insurance coverage is necessary for heart transplantation (HT) candidates. Prior studies have suggested inferior outcomes post HT with public health insurance. We sought to evaluate the effects of insurance type on transplantation rates, listing status and mortality prior to HT. Methods Patients ≥ 18 years old with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between Jan 2010 and Dec 2017, with follow-up through March 2018. Patients were grouped based on the type of insurance Private/self-pay (PV), Medicare (MC) and Medicaid (MA) at the time of listing. We conducted multivariable competing risks regression analysis on listing status and mortality on the waiting list, stratified by insurance type at the time of listing. Results We identified 2,604 patients listed in status 1A (PV: 51.4%, MC: 32.1%, MA:16.5%). MA patients were younger (43.5 vs. 56.4 for MC vs. 51.5 for PV, p<0.001), less frequently white (p<0.001). The cumulative incidence of HT did not differ among the three insurance types (PV: 74.8%, MC 76.3%, MA 71.1%, P=0.14). The cumulative mortality on the waiting list prior to HT was not different among groups (PV: 29.3%, MC 26.3%, MA 21.8%, p=0.94). The reasons for removal from the transplant list is showed in Figure 1. Conclusion We did not detect any disparities in listing status and mortality among different insurance types. The proportion of patients removed because of death was higher among private insurance. In Medicaid patients clinical improvement was the most frequent reason for removal. [ABSTRACT FROM AUTHOR]

We examined whether N-terminal pro-brain natriuretic peptide (NT-proBNP) can serve as a noninvasive marker of filling pressures in ambulatory patients with continuous flow left ventricular assist devices. We retrospectively identified patients who had an outpatient right heart catheterization and NT-proBNP performed the same day between 01/01/2012 and 12/18/2018 at our institution. We evaluated the correlations between NT- proBNP and right atrial pressure (RA), pulmonary artery pressure (PA) and pulmonary capillary wedge pressure (PCWP). The best cut off for NT-proBNP to predict patients that were hemodynamically optimized (CVP<15 and PCWP<18) was derived as the value that minimized the square of the difference between sensitivity and specificity A total of 40 patients were included in the study, Patients characteristics are shown in Table 1. The median NT-proBNP was 1114 pg/mL(IQR 553-2056). The correlations between NT-proBNP and RA (r = 0.58;p<0.001; Coefficient of variation (CV) = 37%); PA(r = 0.34;p=0.03; CV = 26%) and PCWP (r = 0.45;p=0.004; CV = 32%) are shown in figure 1 panels A, B and C respectively. NT-proBNP ≥1168 pg/mL had a 60 %sensitivity and 61% specificity in identifying non-optimum hemodynamics.(Figure 1 panel D). NT-proBNP level is elevated in ambulatory patients with continuous flow left ventricular assist devices and has a moderate correlation with filling pressures. The best cutoff value identified to predict need of hemodynamic optimization had low sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Purpose Evaluate the prevalence, temporal trends and outcomes of patients with left ventricular assist devices and inotropes at the time of listing for heart transplantation. Methods Patients ≥ 18 years old with an LVAD implanted and listed with 1A status were identified in the United Network for Organ Sharing (UNOS) registry between Jan 2010 and Dec 2017, with follow-up through March 2018. Patients were grouped according to the presence or absence of inotropes at the time of listing. The primary outcomes were mortality on the waiting list or transplantation. Since the occurrence of one of the outcomes will prevent the other from manifesting, we accounted for this by use of competing risks regression. Variables that were adjusted for include age, gender, race, BMI, diabetes, prior cardiac surgery, dialysis-dependent, cerebrovascular disease and presence of an implanted defibrillator. Results A total of 2,714 patients were included in the study. The temporal trend of LVAD patients on inotropic therapy at the time of listing and at the time of transplant is shown in figure 1. Patients on inotropes are younger(49.8 (14.0) vs 52.5 (12.4) p<0.001), less likely to be white(56.7% vs 62.2% p=0.01) and have higher wedge pressure (24.1mmHg (8.4)vs 17.7mmHg (9.5) p <0.001) and higher mean pulmonary arterial pressure (33.8mmHg (10.0) vs 27.0mmHg (10.2)p<0.001). Patients on LVAD and inotropes at the time of listing had higher risk of dying in the waiting list sub-hazard ratio (SHR) =1.48 (95% CI=1.14, 1.90), p=0.002 and were less likely to be transplanted SHR= 0.70 (95% CI=0.63, 0.78), p<0.001 after adjusting for described confounders. Conclusion Approximately 1 in 5 patient on LVAD support is on inotropic therapy at the time of listing for heart transplantation. Patients on LVAD and inotropes have worse outcomes in term of survival and chances of being transplanted. The impact of the new allocation system in these patients remains to be seen. [ABSTRACT FROM AUTHOR]

To determine the accuracy of non-invasive blood mean blood pressure (MAP) assessment in patients with continuous flow left ventricular assist devices. Systematic electronic search was performed on four online databases (PubMed, Scopus, Embase, and Web of Knowledge) for the terms "Blood Pressure" AND ("Heart-Assist Devices" OR "Left ventricular Assist Devices"). Only studies where a non-invasive blood pressure measurement was compared with intra-arterial blood pressure recording were included. A total of 12 studies with 502 participants were included, of those 402 had intra-arterial blood pressure measurement. The median number of participants per study was 30.5 (range: 5-154). The mean age of participants was 53 years old and 77% were male. All were single center prospective studies and intra-arterial blood pressure recordings were performed in the context of routine medical care in the Intensive Care Unit. Characteristics of the included studies are shown in figure 1. Intra-arterial recording was obtained using fluid filled catheter in all studies. Statements regarding the leveling and calibration of transducer 6 (50%) studies. Simultaneous recording occurred in 4 (30%) studies. The correlations between non-invasive and intra-arterial recordings are shown in Figure 2 Standardization of quality of signal acquisition and assessment of pulsatility was variable among studies. Non-invasive MAP has variable accuracy and this may adversely influence patients outcomes. [ABSTRACT FROM AUTHOR]

The goal of this article is to present the experience of a new liver transplant team.This review includes all patients who received a liver transplant between March 15, 2000 and March 15, 2003.We performed 87 transplantations on 84 patients; 39 were females and 45 were males of average age 43.6 years, including 6 children. The majority of the patients were from Colombia with time on the waiting list of less than 1 month. The average donor age was 26.7 years. The preservation solutions included Wisconsin, HTK-Brettschneider (Custodiol), and Corpaúl (similar to Henn-Ross). In this study, 95.4% were whole livers, with 97.7% using the piggyback method. We placed 23 arterial grafts and 2 venous grafts for vascular reconstructions; 95.4% were duct-to-duct anastomosis (95.4%). Among the cohort, 8.3% experienced acute rejection and 1.2% experienced chronic rejection. Two patients required retransplantation due to hepatic artery thrombosis with biliary tree necrosis.We consider that we have passed the crisis of beginning a new program with a reduction in postoperative complications and improving patient and graft survival. At present, we are a center that performs liver transplantations in adults and children, with a good organ donation culture in our city that allows us to offer a waiting time on the list less than one month. Neither a veno-venous bypass nor a T-tube were necessary for our cases. We also have developed a new, less expensive form of perfusing the liver in the donor. [Copyright &y& Elsevier]

Abstract: We performed a multivariate analysis to evaluate the importance of histologic parameters in donor kidney biopsies as predictors of graft outcome. Methods: Wedge protocol biopsies from a single center were analyzed for glomerulosclerosis (GS), interstitial fibrosis (IF), tubular atrophy (TA), arteriosclerosis (AS), and arteriolar hyalinosis (AH). Alterations were quantified as percentage (GS, IF) or semiquantified according to Banff criteria (IF, TA, AS, AH). We calculated creatinine clearance (CrCl) at 1, 2, and 3 years posttransplant. Donor data included age, gender, and type: non–heart-beating donor or brain dead donors. Recipient data included age, gender, cold ischemia time, number of HLA mismatches, peak level of the panel reactive antibody (PRA), number of acute rejection episodes (ARE), and presence or absence of cytomegalovirus (CMV) disease. Univariate and multivariate analyses were performed. Follow-up range was 1 to 4.2 years. Results: GS, IF, TA, and AH were associated with graft survival in the multivariate analysis. The histologic parameters were associated with CrCl at several posttransplant time intervals, but the significance of association was lost in the multivariate analysis. Donor age showed a better correlation with graft function. In the univariate analyses adjusting for donor age, only IF and AH were associated with graft function. Conclusions: Histologic parameters showed a modest association with graft function. In our study, donor age is the better predictor of graft function. IF and AH may be similar to or better than GS as predictors of graft outcome. [Copyright &y& Elsevier]

Abstract: Recently in Latin America, there has been a strong influence of the “Spanish model” of organ procurement. In 2001, The “Punta Cana Group” was created by Latin American transplantation coordinators with the objective of registering and improving the system of donation and procurement. In many countries there is no universal financial support from the government for medical treatment, including dialysis and transplantation. In other countries there is complete financial support for all of the population, including immunosuppressive drugs. Practically all countries have transplantation laws that follow ethical concepts, such as brain death diagnosis criteria, forms of consent, criteria of allocation, and inhibition of commerce. The rate of potential donors notified in countries that perform transplantations with deceased donors varied from 6 to 47 per million population yearly (pmp/y); The rate of effective donors varied from 1 to 20 pmp. In 2004, the mean rate of effective donors in Latin America was 5.4 pmp. The family refusal rate for the donation of organs varied from 28% in Uruguay to 70% in Peru. In some countries, such as Puerto Rico, Uruguay, and Cuba, it was more than 15 pmp, whereas in others countries deceased donors were practically not used. The number of patients on the waiting list for solid organ transplants in 12 Latin American countries is 55,000. Although the donation rate has increased by 100% during the last 10 years, it is lower than that in Europe (15 pmm/y) or the United States (20 pmp/y). [Copyright &y& Elsevier]

Abstract: Introduction: We have observed expanded glomeruli in biopsies of kidneys from non–heart-beating donors (NHBDs). We sought to determine the differences in glomerular size between NHBDs and brain-dead donors and to assess whether glomerular size impacted graft outcome. Methods: We estimated the glomerular area using the maximal planar area (MPA) method in 198 pretransplant biopsies from 119 donors: 54 (45.4%) NHBDs and 65 (54.6%) brain-dead donors. Donor data and graft outcomes were correlated with MPA and percentage of glomerulosclerosis. The range of follow-up was 1 to 3 years. Uni- and multivariate analyses were performed. Results: MPA was larger among NHBDs. MPA and GS both significantly correlated with donor age. The association between MPA and age was independent of nephron loss (ie; GS). Increased glomerular size was only observed among donors younger than 50 years. Graft survival and function were not independently associated with MPA. Donor age was a better predictor of graft outcome. Conclusions: The perfusion pressure used in NHBDs may expand the glomeruli, but this maneuver does not have any effect on graft outcome. Among donors without severe changes, glomerular size increment shows a limit around the sixth decade of life. In our study, MPA was not an independent predictor of graft survival or function. [Copyright &y& Elsevier]