Pancreatic Stromal Tumor of Nerve Sheath Origin Treated by Pancreatoduodenectomy

A pancreatic sarcoma of nerve sheath origin is reported in a 28-year-old female patient, who presented with melaena. Preoperative imaging showed an 8.5 cm diameter mass in the head of pancreas. There was bleeding from the papilla of Vater at endoscopy and a highly vascular lesion on arteriography. The patient was submitted to proximal pancreatoduodenectomy and remains symptom-free at 1 year follow-up

Current preventive strategies and management of Epstein-Barr virus-related post-transplant lymphoproliferative disease in solid organ transplantation in Europe. Results of the ESGICH Questionnaire-based Cross-sectional Survey

There is limited clinical evidence on the utility of the monitoring of Epstein-Barr virus (EBV) DNAemia in the pre-emptive management of post-transplant lymphoproliferative disease (PTLD) in solid organ transplant (SOT) recipients. We investigated current preventive measures against EBV-related PTLD through a web-based questionnaire sent to 669 SOT programmes in 35 European countries. This study was performed on behalf of the ESGICH study group from the European Society of Clinical Microbiology and Infectious Diseases. A total of 71 SOT programmes from 15 European countries participated in the study. EBV serostatus of the recipient is routinely obtained in 69/71 centres (97%) and 64 (90%) have access to EBV DNAemia assays. EBV monitoring is routinely used in 85.9% of the programmes and 77.4% reported performing pre-emptive treatment for patients with significant EBV DNAemia levels. Pre-emptive treatment for EBV DNAemia included reduction of immunosuppression in 50.9%, switch to mammalian target of rapamycin inhibitors in 30.9%, and use of rituximab in 14.5% of programmes. Imaging by whole-body 18-fluoro-deoxyglucose positron emission tomography (FDG-PET) is used in 60.9% of centres to rule out PTLD and complemented computer tomography is used in 50%. In 10.9% of centres, FDG-PET is included in the first-line diagnostic workup in patients with high-risk EBV DNAemia. Despite the lack of definitive evidence, EBV load measurements are frequently used in Europe to guide diagnostic workup and pre-emptive reduction of immunosuppression. We need prospective and controlled studies to define the impact of EBV monitoring in reducing the risk of PTLD in SOT recipients

Long-term outcomes of dual kidney transplantation (DKT) from aged donors

Dual kidney transplantation (DKT) from marginal donors is increasingly used at many centers to help cope with the organ shortage problem. The disadvantages of DKT consist in longer operating times and the risk of surgical complications. DKT can be performed in two ways, i.e. using monolateral or bilateral procedures. From October 1999 to June 2005, 58 DKTs were performed at our unit. In 29 cases (group I), the kidneys were extraperitoneally placed bilaterally in the iliac fossae via two separate incisions; as of June 2003, monolateral kidney placement was preferred in 29 cases, whenever compatible with the recipient's morphological status (group II). After a mean follow-up of 51 +/- 19 months for group I and 15 +/- 7 months for group II, all patients are alive with 1-year graft survival rates of 93% and 96%, respectively. Mean operating times were 351 +/- 76 min in group I and 261 +/- 31 min in group II (P = 0.0001). The mean S-creatinine levels in groups I and II were 132 +/- 47 and 119 +/- 36 mumol/l, respectively, at 1 year. We observed eight surgical complications in group I and seven in group II. Both techniques proved safe, with no differences in surgical complication rates. The monolateral procedure has the advantage of a shorter operating time and the contralateral iliac fossa remains available for further retransplantation procedures

Glomerular C4d Immunoreactivity in Acute Rejection Biopsies of Renal Transplant Patients

In renal transplant patients, glomerulitis may be present in all types of acute rejection, often accompanied by diffuse C4d staining of peritubular capillaries: C4d3 positivity in more than 50% of peritubular capillaries. It may progress to chronic transplant glomerulopathy, characterized by capillary basement membrane multilayering, proteinuria, and progressive loss of renal function. While C4d3 is a recognized marker of an antibody-mediated reaction, the significance of glomerular C4d (GlC4d) staining is unknown. The aim of this study was to evaluate GlC4d immunoreactivity and its correlation with C4d3 in acute rejection biopsies. Paraffin-embedded acute rejection biopsies from 90 renal transplant patients were evaluated according to the Banff classification. Biopsies showing C4d-positive endothelial cells in more than 50% of glomeruli were considered GlC4d-positive. C4d3-positive staining prevalence was 23%. GlC4d-positive staining showed an 89% concordance rate (r = 0.81, P < .0001; Cohen's k = 0.80, P < .0001). GlC4d detection sensitivity was 0.80 and specificity 0.97. C4d3 and GlC4d immunoreactivity was significantly associated with glomerulitis (P < .006 and P < .03, respectively) and with proteinuria at the time of biopsy (P < .03 and P < .01, respectively). Interestingly, GlC4d positivity correlated better than C4d3 positivity with the presence of posttransplant circulating anti-human leukocyte antigen alloantibodies (P < .04 and P = .7, respectively). Patients with C4d3- or GlC4d-positive acute rejections underwent graft loss due to interstitial fibrosis and tubular atrophy more frequently than those with C4d0- or GlC4d-negative rejections (P < .0001 and P < .005, respectively), whereas no differences were observed in graft loss due to death. In conclusion, C4d3 and GlC4d stains showed a high correlation rate. Compared with C4d3, GlC4d staining demonstrated good sensitivity and excellent specificity. Our results suggested that GlC4d staining may indicate glomerular endothelial damage and be of prognostic value

LAPAROSCOPIC VERSUS LAPAROTOMIC LIVING DONOR NEPHRECTOMY: ASSESSMENT OF GRAFT RENAL FUNCTION BY MEANS OF 99MTC-MAG3 DYNAMIC RENAL SCINTIGRAPHY

Laparoscopic living donor nephrectomy (LLDN) has been claimed to induce an increased risk of acute tubular necrosis for the transplanted kidney as compared to laparotomic living donor nephrectomy (OLDN). LLDN is characterized by longer surgery time, longer warm ischemia time, higher risk of vascular damage and vasoconstriction due to the traction on the vessels during the laparoscopic dissection and prolonged venous compression due to pneumoperitoneum. 99mTc Mag3 scintigraphy has been used to compare graft function between LLDN and OLDN groups. Material and Methods: The immediate post-operative results and the effects of the ischemic insult, in 22 grafts derived from LLDN, transplanted between 2001 to 2006, were evaluated in terms of incidence of delayed graft function (DGF), graft survival, serum creatinine and were compared with 38 grafts derived from OLDN performed between 1992 to 2006. The uptake (corrected for graft depth) of 99mTcMAG3 between first and second minute after injection, acquired on the 5th-7th postoperative day, was used to estimate effective renal plasma flow (ERPF) in both groups. Being the variables not normally distributed (shapiro wilk test), two sample Wilcoxon test (Mann Whitney) have been used to assess differences between groups. Results: Kidneys of the LLDN group suffered a mean of 160 \ub1 35 seconds of warm ischemia time (compared with 22 \ub1 11 sec in OLDN group, p<0.0001) and the mean operating time was 213 \ub1 36 min (vs 270 \ub1 41 min in the OLDN group, p<0.001). Only one PNF occurred in the LLDN group. The incidence of DGF was 4.5% in LLDN vs 2.6% in OLDN. Mean serum creatinine at 1 week post-op was 201 \ub1 164 in the LLDN vs 200 \ub1 119 \ub5mol/L in the OLDN (p=0.49). No difference (p= 0.66) in ERPF mean values between LLDN and OLDN group was demonstrated by a twosample Wilcoxon test. Renal time concentration curve suggested tubular necrosis in 4/22 (18.2%) LLDN patients and in 4/38 (10.5%) OLDN patients. Conclusions: Despite the limited experience at our center in LLDN and the small number of procedures performed per year, the LLDN technique seems to be as safe as OLDN, providing a similar early post-transplant renal function and showing significative difference in the incidence of DGF. The slight difference in the number of acute tubular necrosis between the groups, demonstrated by 99mTc-MAG3 renography, could be due to the low number of patients and should be further investigate