M. K. Heer

Effect of immunosuppression for primary renal disease on the risk of cancer in subsequent renal transplantation: a population-based retrospective cohort study.

Background To measure the risk of cancer in renal transplantation for recipients who had previously been treated with immunosuppressive agents for primary renal disease. Methods A retrospective population-based cohort study of 5970 renal transplant recipients in Australia registered on the Australia and New Zealand Dialysis and Transplant Registry between 1982 and 1997 and followed until 2007. Data about the incidence of a range of cancer types from this Registry were compared with cancer incidence data for the general population matched for cancer type, year of incidence, age, and gender derived from national cancer records. Outcome measures for each cancer group with or without pretransplantation immunosuppression were cancer-specific standardized incidence ratios and a multivariate hazard ratio (HR) standardized to 1. Results For those treated with pretransplantation immunosuppression, the risks for four cancer groups during renal transplantation were significantly increased: anogenital cancer (HR, 3.13; confidence interval [CI], 1.92–5.11; P<0.0001), non–Hodgkin’s lymphoma (HR, 2.37; CI, 1.53–3.68; P=0.0001), breast cancer (HR, 2.52; CI, 1.13–5.61; P=0.024), and urinary tract cancer (excluding kidney) (HR, 1.84; CI, 1.13–3.01; P=0.015). However, the risks of cancer in the oral cavity and pharynx, kidney, thyroid, colon, leukemia, lung, melanoma, prostate, and stomach were not significantly increased. Conclusions Pretransplantation immunosuppression for primary renal disease increases the risks of four cancer types in renal transplantation while sparing the others. Patients in whom this treatment is being considered should be informed of these risks.

Malignant melanoma of the pancreas

A 50-year-old patient was admitted for surgical management of cancer of gastric cardia. His past medical history and preoperative clinical examination were unremarkable. He underwent gastroesophagectomy/splenectomy. Post-operative course was uneventful. Seven days after discharge, the patient was admitted to the emergency department with acute respiratory distress, reporting a progressively aggravating muscular weakness. He was intubated and supported by mechanical ventilation. Clinicolaboratory/imaging evaluation showed diffuse lung inflammation. Neurological evaluation showed weaknesses of upper and lower extremities and repeal of tendons reflexes. Based on this clinical presentation and celebrospinal fluid examination, the diagnosis of Guillain–Barré syndrome (GBS) was established. The patient remained intubated for 3 weeks. After extubation, intensive physiotherapy was performed for the next 2 months. About 3.5 months after his admission to the ICU, the patient showed an almost complete improvement, proved with electomyograph and neurophysiologic examination, and he returned to his normal activities. GBS is an acute monophasic paralyzing illness, synonymous with acute demyelinating polyneuropathy; its median annual incidence is 1.3/100 000. Very rarely (<5%), GBS may occur post-operatively and its dramatic clinical manifestations may cause significant diagnostic problems and concerns to the surgeon and to patient and his/her family. Immune responses against peripheral nerve components (triggered by a preceding bacterial/viral infection) are involved in its pathogenesis. Post-operative GBS may be secondary to anaesthesia or metabolic changes induced by surgery. The patient complains of weakness of distal limb muscles and /or distal numbness, progressively ascending over several days. In 20% of cases, the respiratory and facial muscles are affected, the patient may become paralyzed, and intubation and mechanical support may be needed. Diagnosis is based on a careful history, physical examination, nerve conduction studies and cerebrospinal fluid analysis. Management is supportive and may include intubation and mechanical respiratory support, intravenous g-globulin, and potentially plasmapheresis.

Successful renal transplantation in a patient with cold agglutinin disease

Cold agglutinin disease is a rare cause of acute graft loss after renal transplantation. A 71‐year‐old female with end stage renal failure was diagnosed to have cold agglutinin disease when investigated for recurrent clotting of hemodialysis circuits. Kidney transplantation was a major challenge due to unavoidable exposure of the transplant kidney to cold temperatures. Large volume plasma exchange given pre‐transplant and infusion of warm saline prior to anastomosis resulted in successful renal transplantation with good graft function despite initial delayed graft function. This challenging case illustrates the complete removal of cold agglutinin antibodies with therapeutic large volume plasma exchange. J. Clin. Apheresis 32:56–58, 2017.

TN05 NATURAL HISTORY OF TRANSPLANT RENAL ARTERY STENOSIS

Introduction  Integrity of Transplant Renal Artery is crucial for long term survival of the graft. Literature regarding the evolution of Transplant Renal Artery Stenosis (TRAS) is scant.