Kidney failure is a common complication in recipients of nonkidney solid organ transplants (NKSOT), often stemming from prolonged calcineurin inhibitor (CNI) exposure or perioperative insults. Although haemodialysis (HD) remains the predominant renal replacement therapy (RRT), peritoneal dialysis (PD) offers advantages such as better quality of life, haemodynamic stability and preservation of residual renal function. Concerns about infection risk, technical feasibility and respiratory complications have curtailed its broader use. We present the first reported case of successful PD in a liver and double-lung transplant recipient. The patient, a 30-year-old male with cystic fibrosis, extensive abdominal surgery and immunosuppression, was initially deemed unsuitable for PD due to surgical complexity and potential complications in a transplant recipient. A multidisciplinary team (MDT) review at our liver and kidney transplant specialist centre ultimately supported PD based on clinical suitability and lifestyle preferences. Laparoscopic catheter insertion was achieved despite significant intra-abdominal adhesions, and the patient remained on PD for 18 months without complications. This case underscores that with meticulous surgical planning and MDT input, PD can be a safe and viable option in complex NKSOT recipients. It challenges prevailing biases against PD in this population and suggests that prior transplantation should not preclude its consideration.
Infections are a significant cause of morbidity and mortality in kidney transplant patients. The clinical presentation can be atypical, and establishing the diagnosis in a timely manner can be challenging. We describe a 55-year-old woman who received a kidney transplant and developed severe anaemia with very high ferritin levels, abnormal liver function tests and no evidence of bleeding. Initial screening for parvovirus infection with IgG and IgM antibodies was negative, but blood DNA polymerase chain reaction (PCR) for parvovirus was strongly positive with a high viral load. Treatment with reduction in immunosuppressive therapy and a course of intravenous immunoglobulin resulted in sustained improvement in haemoglobin levels and a reduction in viral load. This case report highlights the diagnostic and management challenges of parvovirus infection in a kidney transplant recipient.
Heart transplantation remains the gold standard treatment for end-stage heart failure. However, the persistent shortage of donor organs continues to limit the number of procedures performed worldwide. Several strategies have been developed to expand the donor pool, including the reuse of a previously transplanted cardiac graft, which represents a rare alternative. We report the first case of cardiac graft reuse performed in France, and the ninth case described worldwide. A 61-year-old man with end-stage dilated cardiomyopathy and cardiogenic shock underwent urgent heart transplantation using a graft that had been previously transplanted into another recipient, who subsequently developed brain death. Pretransplant evaluation confirmed preserved graft function, allowing for retransplantation. The postoperative course was initially complicated by vasoplegic shock but evolved favorably. At the 3-year follow-up, the patient remained in a good functional status with preserved cardiac function.
Background:Mycobacterium haemophilum is an uncommon nontuberculous mycobacterium that primarily affects immunocompromised hosts and may present with cutaneous and musculoskeletal manifestations that mimic inflammatory or infectious disorders. Its specialized growth requirements often delay diagnosis, particularly in solid organ transplant recipients. Case Presentation:A 59-year-old man with a history of deceased donor kidney transplantation presented with progressive bilateral ankle pain, lower extremity swelling, and painful nodular skin lesions. Initial evaluation suggested erythema nodosum and inflammatory arthritis, with nondiagnostic musculoskeletal imaging and arthrocentesis. Corticosteroid therapy resulted in only transient improvement. Persistent low-titer serum cryptococcal antigenemia with negative cerebrospinal fluid studies further complicated the diagnostic evaluation and prompted empiric fluconazole therapy. Progressive disease led to recurrent hospitalization and inability to bear weight. Initial synovial fluid aspiration demonstrated acid-fast bacilli, whereas repeat bilateral aspirations demonstrated concomitant monosodium urate crystals and acid-fast bacilli. Skin biopsy demonstrated rod-shaped acid-fast organisms with negative fungal staining. Routine cultures were unrevealing, but independent polymerase chain reaction testing performed at two reference laboratories identified M. haemophilum. Mycophenolate mofetil was withheld because of active infection, whereas tacrolimus therapy was continued with therapeutic drug monitoring. Prolonged multidrug antimicrobial therapy was individualized according to susceptibility testing and medication tolerance. Despite treatment-related complications, the patient experienced substantial clinical improvement with healing of cutaneous lesions, restoration of mobility, and preservation of kidney allograft function. Conclusion:This case highlights the diagnostic complexity of M. haemophilum infection in kidney transplant recipients. Simultaneous erythema nodosum-like lesions, crystal arthropathy, and persistent serum cryptococcal antigenemia obscured the diagnosis, whereas conventional microbiologic studies remained largely unrevealing. Early consideration of opportunistic nontuberculous mycobacterial infection and the use of molecular diagnostics may facilitate timely diagnosis and appropriate management in immunocompromised patients.
Phaeohyphomycoses are a heterogeneous group of diseases caused by several genera of pigmented fungi, also called dematiaceous fungi. These organisms are increasingly recognized as emerging opportunistic pathogens in immunocompromised patients, particularly solid organ transplant recipients. Among them, Alternaria is the most frequently associated genus, with clinical manifestations ranging from superficial to disseminated infections. Treatment options are limited and often complicated by toxicity and drug interactions, particularly in the posttransplant setting. We report what is, to our knowledge, the first case of disseminated alternariosis in a liver transplant recipient in Uruguay, successfully treated with isavuconazole. This case highlights the importance of early recognition and tailored antifungal therapy in transplant patients presenting with unusual cutaneous and pulmonary manifestations.
De novo inflammatory bowel disease (IBD) is a rare but important cause of diarrhea after kidney transplantation (KT). Experience with newer biological agents in the management of IBD among KT recipients remains limited. Vedolizumab is an α4β7 integrin antagonist that selectively blocks a subset of gastrointestinal-homing lymphocytes, which limits systemic immunosuppression and, compared to other biologic agents or novel molecules, may reduce the risk of overimmunosuppression in the setting of KT. We report the case of a KT recipient with IgA nephropathy as the underlying cause of chronic kidney disease, who developed de novo ulcerative colitis after KT and was successfully treated with vedolizumab without experiencing adverse reactions during the 29 months of follow-up.
Exostosin-2 (EXT2)-associated membranous nephropathy (MN) represents a subgroup of immune complex-mediated renal diseases, where transplantation may facilitate clearance of immune deposits. We present a successful kidney transplantation from a 19-year-old deceased donor with previously undiagnosed EXT2-associated MN into a 75-year-old male recipient. Despite significant pretransplant donor proteinuria (> 300 mg/dL) and hypoalbuminemia, renal biopsies at procurement demonstrated well-preserved renal architecture with minimal interstitial fibrosis. Clinical follow-up showed improvement in recipient renal function, with serum creatinine decreasing from 3.56 mg/dL preoperatively to 0.96 mg/dL (reference range: 0.7-1.3 mg/dL) within 2 months posttransplant. Proteinuria, initially nephrotic-range, progressively resolved to subnephrotic by 4 months. At 6 months, the recipient had normalized renal function and sustained resolution of proteinuria. This case demonstrates that removing a kidney from its native pro-inflammatory environment, coupled with immunosuppression, can facilitate resolution of immune complex-mediated glomerulopathy.
A kidney transplant recipient developed spindle cell sarcoma within an abdominal aortic aneurysm following prior endovascular aneurysm repair (EVAR). The patient had undergone EVAR for abdominal aortic aneurysm before successful living-donor kidney transplantation and maintained stable graft function under immunosuppressive therapy. Two years after transplantation, he presented with back pain, elevated inflammatory marker, and aneurysm enlargement, initially suspected as an infected aneurysm. Despite antibiotic therapy, the lesion progressed. Positron emission tomography demonstrated increased fluorodeoxyglucose uptake, and computed tomography-guided biopsy revealed undifferentiated spindle cell sarcoma with unclear lineage differentiation. Surgical resection was not feasible, and systemic chemotherapy was initiated; however, disease progression continued, and the patient died 7 months after admission. Aortic sarcoma following EVAR is rare and may mimic infection or inflammatory complications. Clinicians should consider malignant etiologies when transplant recipients with prior EVAR present with atypical aneurysm enlargement or persistent inflammatory findings, and early tissue diagnosis may be necessary.
Hepatitis E virus (HEV) infection is an increasingly recognized cause of acute and chronic hepatitis in immunosuppressed individuals, including solid organ transplant recipients. Although typically self-limited in immunocompetent hosts, HEV infection in transplant recipients may lead to persistent viremia, accelerated fibrosis, and graft dysfunction. We report the case of a 47-year-old man who underwent deceased donor liver transplantation for decompensated metabolic-associated steatohepatitis cirrhosis. Five months post-transplant, he was found to have rising liver enzymes during routine monitoring. Imaging and two liver biopsies showed no evidence of acute cellular rejection. Subsequent evaluation revealed positive HEV IgM and detectable HEV RNA with a viral load of 5.5 million IU/mL. Reduction of immunosuppression and initiation of ribavirin therapy resulted in rapid biochemical improvement and complete viral clearance. HEV RNA remained undetectable at the end of therapy and during extended follow-up. This case highlights the importance of early consideration of HEV infection in liver transplant recipients with unexplained liver enzyme abnormalities. Prompt diagnosis and guideline-concordant management can prevent progression to chronic infection and preserve graft function.
Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of solid organ transplantation. While usually Epstein-Barr virus (EBV)-positive PTLD, EBV-negative PTLD is a distinct, typically late-onset, and aggressive entity. A 66-year-old man developed progressive abdominal distension and anemia 11 years after bilateral lung transplantation for idiopathic pulmonary fibrosis. Paracentesis with flow cytometry of ascitic fluid revealed a monoclonal B-cell population (CD10, CD19, and CD20 positive). EBV PCR and EBER chromogenic in situ hybridization confirmed EBV negativity, establishing EBV-negative PTLD. Mycophenolate mofetil was discontinued, and tacrolimus levels were maintained at 6-8 ng/mL. Five additional EBV-negative PTLD cases after lung transplantation were identified in the literature; most occurred beyond 1 year, were diagnosed by biopsy, and had high mortality. EBV-negative PTLD is rare and often fatal. Ascitic fluid cytology can facilitate early, minimally invasive diagnosis, warranting high clinical suspicion in transplant recipients with unexplained ascites.
Renal replacement lipomatosis is a rare benign diagnosis described as the total replacement of the renal parenchyma with fibrous and fatty tissue. It usually affects one kidney, and it is usually associated with conditions such as renal calculus or pyelonephritis. Histopathological findings of reported cases have shown severe atrophy and destruction of the renal parenchyma. In the present study, we report a rare case of total renal allograft replacement lipomatosis and its surgical treatment after kidney transplantation.
Despite prompt initiation of oral ivermectin, her clinical course progressed with diffuse alveolar hemorrhage (DAH) and purpuric skin lesions. Bronchoalveolar lavage (BAL) and skin biopsy demonstrated filariform larvae. Severe ileus prompted the emergency use of subcutaneous ivermectin under an FDA Investigational New Drug (IND) application. The cutaneous eruption improved rapidly, and the clearance of parasites from stool exam was achieved after prolonged therapy. The patient completed a 40-day course of ivermectin with clinical recovery. This case highlights the potential for donor-derived Strongyloides transmission even in nonendemic regions and illustrates the role of subcutaneous ivermectin in select clinical cases. It also highlights how recently implemented universal donor screening policies may prevent similar adverse outcomes. We report a case of donor-derived S. stercoralis infection resulting in progression to hyperinfection syndrome with dissemination following orthotopic heart transplantation. A 62-year-old woman with end-stage nonischemic cardiomyopathy and a remote history of Hodgkin’s lymphoma treated with radiation and ABVD chemotherapy underwent orthotopic heart transplantation in 2024. Pretransplant serologic screening, including Strongyloides IgG, was negative. Travel history was limited to a brief trip to Mexico over 20 years prior. Immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone, with valganciclovir and trimethoprim–sulfamethoxazole prophylaxis. Two months after transplantation, she developed progressive nausea, vomiting, abdominal pain, and odynophagia. Laboratory evaluation revealed leukopenia (3.7×103/μL) with marked eosinophilia (43%). Stool pathogen testing, blood cultures, and cytomegalovirus (CMV) and Epstein–Barr virus (EBV) DNA levels were negative. Upper endoscopy demonstrated erosive gastropathy, and duodenal biopsy revealed Strongyloides organisms. Oral ivermectin was initiated. Given the negative pretransplant serology, donor-derived transmission was suspected and promptly reported to the Organ Procurement Organization (OPO). Investigation revealed another recipient from the same donor—originally from Central America—had also developed Strongyloides infection, confirming donor transmission. Despite treatment, the patient’s condition deteriorated. She developed fever, diffuse abdominal tenderness, and a maculopapular rash that evolved into purpura. Blood cultures grew ESBL Enterobacter cloacae, treated with meropenem. On hospital Day 7, she required ICU admission for hypoxic respiratory failure. Computed tomography (CT) showed diffuse pulmonary opacities, and BAL revealed DAH with numerous Strongyloides larvae, consistent with hyperinfection syndrome. Severe ileus developed with progressive abdominal distension and inability to tolerate enteral intake, raising concern for impaired enteral absorption of ivermectin. Triggers prompting escalation to parenteral therapy included worsening ileus with placement of nasogastric tube (NGT) for decompression and initiation of continuous suction. The patient also remained critically ill after several days of oral therapy, with serious complications from infection including acute respiratory distress syndrome (ARDS), gram-negative bacteremia, and septic shock requiring vasopressor support. An emergency single-patient IND request was submitted to the FDA, coordinated through the hospital investigational pharmacy. Approval was obtained within 24 h after submission of clinical justification, dosing and monitoring plan, and informed consent documentation. The single-patient IND application for subcutaneous ivermectin required a prespecified dosing and monitoring plan with clear treatment endpoints: subcutaneous ivermectin was administered while enteral absorption was unreliable, with stool ova and parasite examinations obtained every 3 days to assess parasitic clearance, and transition back to oral ivermectin once the patient was tolerating enteral nutrition and gastrointestinal absorption was expected to be adequate. Veterinary-grade subcutaneous ivermectin (200 μg/kg every 48 h) was procured and compounded by the inpatient compounding pharmacy. Following parenteral therapy, the purpuric lesions—most prominent in the periumbilical region, flanks, and proximal thighs—began fading within 48 h. Skin biopsy confirmed filariform larvae within dermal collagen bundles, consistent with disseminated strongyloidiasis and periumbilical parasitic thumbprint purpura. The hospital course was complicated by vancomycin-resistant Enterococcus faecium meningitis, treated with linezolid. Serial stool ova and parasite examinations became initially negative after 13 days of subcutaneous ivermectin. Therapy continued for a total of 40 days until multiple consecutive stool O&P samples were negative, confirming parasite clearance. Treatment was successful and she was ultimately discharged on hospital Day 63.
Allogeneic hematopoietic cell transplants (HCTs) offer a curative option for patients with life-threatening hematologic diseases. While stem cell infusion reactions are common, they are generally not severe and typically do not affect engraftment. We present a rare case of isolated secondary cold agglutinin syndrome (CAS) in a donor, complicating the graft infusion and causing poor graft function (PGF) in a recipient. The 27-year-old recipient, diagnosed with refractory T-cell acute lymphoblastic leukemia (ALL), underwent a 9/10 HLA-mismatched unrelated peripheral blood stem cell transplant. The donor developed an upper respiratory infection 1 week before the donation, and cold agglutinin antibodies were detected in the donor's stem cell product. During infusion, the patient developed fever, tachycardia, and hypertension. Despite initial neutrophil engraftment and full donor chimerism, the patient remained transfusion-dependent, indicating PGF. A subsequent CD34-selected stem cell boost from the same donor on Day +108 posttransplant, confirmed to be CAS-negative, resulted in successful platelet engraftment and recovery. This case highlights the potential complications of CAS in donors, emphasizing the need for comprehensive donor evaluation and management strategies to mitigate adverse effects on recipients.
Hepatitis E virus (HEV) is a common but often underdiagnosed cause of hepatitis in both the general population and transplant patients. Diagnosis is usually made by detecting IgM anti-HEV antibodies, with immunosuppressed individuals being at higher risk for chronic infection. We present the case of a 56-year-old man who developed asymptomatic liver cytolysis 4 months after a kidney transplant, with no significant physical findings or relevant epidemiological history. Abdominal ultrasound revealed hepatic steatosis. Drug-induced liver injury was suspected, prompting the discontinuation of potential causative agents. However, liver enzymes worsened asymptomatically after 2 weeks, prompting further medication adjustments. Testing for Hepatitis B and C, as well as IgM for Toxoplasma, was negative. Serologies for herpes simplex and varicella zoster were positive for IgG and negative for IgM, and CMV viral load was undetectable. HEV serologies were negative for IgG and IgM. A liver biopsy revealed nonspecific acute hepatitis without fibrosis. The positive HEV plasma viral load was suggestive of Hepatitis E. As the patient was asymptomatic with no further analytical worsening, targeted treatment was not initiated. The patient achieved spontaneous viral clearance in less than 12 weeks, despite his immunocompromised condition. This case report highlights the diagnostic challenges of HEV hepatitis in immunosuppressed patients, as detection may rely solely on viral load testing due to potential serological negativity. This case also highlights that despite the patient's immunosuppressed condition, viral clearance is possible without the need for targeted antiviral therapy.
Introduction:Kidney transplant recipients are at increased risk of malignancy due to chronic immunosuppression. Although rare (≈0.3%), bladder cancer in this population tends to be aggressive and may present with atypical symptoms. We report a case of muscle-invasive bladder cancer in a patient with prior simultaneous pancreas-kidney transplantation, successfully managed by fully intracorporeal robot-assisted radical cystoprostatectomy and urinary diversion. Presentation:A 46-year-old male with a history of a simultaneous pancreas and kidney transplantation presented with persistent storage lower urinary tract symptoms. Cystoscopy revealed a necrotic, atypical lesion with associated inflammatory changes. Preoperative CT urography showed thickening of the bladder dome, with peripheral enhancement and a calcified component. The patient underwent robot-assisted radical cystoprostatectomy with intracorporeal ileal conduit involving the transplanted kidney. Clinical Discussion:This rare case highlights the importance of thorough urological evaluation in transplant recipients presenting with atypical urinary symptoms. Conclusion:This case demonstrates the feasibility and safety of fully intracorporeal robot-assisted cystoprostatectomy with urinary diversion in a patient with a simultaneous pancreas-kidney transplant.
Emphysematous pyelonephritis is an acute, severe infection of the kidneys with gas accumulation in the kidneys and adjacent tissues, which is associated with significant morbidity and mortality. Primarily seen in native kidneys, it is relatively rare in renal allograft, despite the immunosuppressed state of transplant recipients and is associated with a high risk of graft loss. Risk factors include urinary tract abnormalities, urological procedures, diabetes mellitus, female gender, and the postmenopausal state. We report a transplant recipient with rapid progression of acute pyelonephritis to emphysematous pyelonephritis and eventually required a transplant nephrectomy. Management is geared towards early detection, judicious antibiotic therapy, repeat imaging, and timely intervention.
Background:Postcardiotomy cardiogenic shock (PCCS) is a critical condition with high mortality. When biventricular dysfunction occurs, veno-arterial ECMO alone may not provide adequate unloading. Paracorporeal BiVAD can offer balanced support as a bridge to heart transplantation. Case:A 61-year-old woman developed PCCS following bioprosthetic aortic valve replacement. Despite VA-ECMO and intra-aortic balloon pump support, biventricular failure persisted. A paracorporeal BiVAD was implanted, achieving rapid hemodynamic and pulmonary improvement. After 7 days of BiVAD support, she underwent successful orthotopic heart transplantation. At 1-year follow-up, the patient remains alive without graft rejection or vasculopathy. Conclusion:Early conversion from VA-ECMO to BiVAD may improve outcomes in refractory PCCS with biventricular failure, serving as an effective bridge to transplantation.
Portal vein thrombosis (PVT) is common among liver transplant candidates, affecting up to 26% of patients awaiting liver transplant. Despite the suspected negative impact of PVT on liver transplant outcomes, consensus recommendations remain lacking. Thrombus circumvention is most commonly achieved with eversion portal thromboendovenectomy or venous jump graft. We present a novel hybrid approach addressing PVT in a patient with acute hepatic decompensation and worsening clot burden extending to the superior mesenteric and splenic veins. This patient underwent a transjugular intrahepatic portosystemic shunt (TIPS) placement and endovascular thrombectomy of the splanchnic veins less than 24 h prior to undergoing an orthotopic liver transplant with the graft maintained on normothermic machine perfusion. Three-month postoperative scans demonstrated a patent portal venous system with trace residual clot burden. This is the first reported case utilizing a hybrid approach for a portal vein thrombus extending into the superior mesenteric and splenic veins with subsequent orthotopic liver transplant.
Acute kidney injury (AKI) is common in kidney transplant recipients, and the etiology varies depending on the time since transplantation. We present an uncommon case of AKI from obstructive uropathy 7 years posttransplant in a 47-year-old Caucasian male with moderate intellectual disability and end-stage kidney disease secondary to glomerulonephritis who received a deceased donor kidney transplant. He presented with abdominal pain, lethargy, hypercalcemia, and AKI. However, though his serum calcium level improved with intravenous fluid resuscitation, the AKI did not improve. Kidney transplant ultrasound showed hydronephrosis of the transplant ureter, and a noncontrast abdominal and pelvic computed tomography scan showed fecal impaction as the cause of obstruction of the transplanted ureter. The patient underwent fecal disimpaction resulting in the resolution of his hydronephrosis and return of his kidney function to baseline. Although a few case reports have been published of fecal impaction causing AKI due to obstruction of native ureters, to our knowledge, this is the first case describing AKI from fecal impaction in an adult kidney transplant recipient.
