Candida albicans arteritis transmitted by conservative liquid after renal transplantation: a report of four cases and review of the literature

Assessing the impact of positive cultures in preservation fluid on renal transplant outcomes: a scoping review

BACKGROUND

Infection following kidney transplantation is a significant risk factor for adverse outcomes. While the donor may be a source of infection, microbiological assessment of the preservation fluid (PF) can mitigate potential recipient contamination and help curb unnecessary antibiotic use. This scoping review aimed to describe the available literature on the association between culture-positive preservation fluid, its clinically relevant outcomes, and management.

METHODS

Following the Joanna Briggs Institute's scoping review recommendations, a comprehensive search in databases (EMBASE, MEDLINE, and gray literature) was conducted, with data independently extracted by two researchers from selected studies.

RESULTS

We analysed 24 articles involving 12,052 samples, predominantly published post-2000, 91% of which retrospective. The prevalence of culture-positive preservation fluid varied from 0.86 to 77.8%. Coagulase-negative staphylococci emerged as the most frequently isolated pathogen in 14 studies. The presence of ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species), observed in two studies involving 1074 donors, was significantly associated with an increased risk of probable donor-derived infections (p-DDI). Of the reviewed articles, 14 reported on probable donor-derived infections, while 19 addressed the topic of preemptive antibiotic therapy.

CONCLUSIONS

Routine culturing of preservation fluid is crucial for the identification of pathogenic organisms, facilitates targeted treatment and prevents probable donor-derived infections. Furthermore, this approach helps avoid the treatment of low-virulence contaminants, thereby reducing unnecessary antimicrobial use and the risk of antibiotic resistance. In cases where ESKAPE or Candida species are detected, preemptive therapy appears to be an important strategy. Given that the current evidence primarily stems from retrospective studies, there is a pressing need for large-scale, prospective trials to corroborate these recommendations. This scoping review currently represents the most thorough compilation of evidence on how contamination of preservation fluids affects kidney transplant management.

Clinical impact of preservation fluid contamination on kidney transplant patients

BACKGROUND

Kidney transplantation is associated with a high risk of infectious complications due to immunosuppressive therapy. Although infections may be transmitted from donor to transplant recipient through contaminated preservation solution (PS), the clinical impact of this is not well-understood.

METHODS

We retrospectively evaluated PS contamination rates in a series of 339 patients who underwent cadaveric renal transplant at our centre. All patients with a positive culture received targeted preemptive therapy (PET).

RESULTS

Of the 339 PS samples, 136 (40.1%) were positive for a microorganism, mainly coagulase-negative staphylococci (CoNS; n = 89;60.5%), gram-negative bacilli (n = 31;21.1%), non-CoNS gram-positive cocci (n = 18;12.2%), and Candida spp (n = 2;1.4%). Of the 136 positive cases, 42 (30.9%) received PET (12.4% of the cohort). No cases of urinary tract infection, surgical site infection, or graft loss were observed. Overall, our findings indicate that PS contamination, mainly by saprophytic skin flora (CoNS) is common. Only 8% of patients required antibiotic or antifungal therapy.

CONCLUSION

The infection transmission rate from donors to recipients was negligible (0%), perhaps due to the early initiation of a targeted PET after isolation of a recognized pathogen. More data from large, prospective studies are needed to confirm these findings.

Invasive Fungal Infections after Liver Transplantation

Invasive fungal infections represent a major challenge in patients who underwent organ transplantation. Overall, the most common fungal infections in these patients are candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Several risk factors have been identified, which increase the likelihood of an invasive fungal infection developing after transplantation. Liver transplant recipients constitute a high-risk category for invasive candidiasis and aspergillosis, and therefore targeted prophylaxis is favored in this patient population. Furthermore, a timely implemented therapy is crucial for achieving optimal outcomes in transplanted patients. In this article, we describe the epidemiology, risk factors, prophylaxis, and treatment strategies of the most common fungal infections in organ transplantation, with a focus on liver transplantation.

Utility of deceased donor cultures in solid organ transplantation in preventing donor-derived bacterial and fungal infectious diseases transmission

Deceased donor and organ perfusion fluid cultures are obtained in order to inform recipient antimicrobial management and therefore reduce the risk of donor-derived bacterial and fungal infections. However, important heterogeneity exists in laboratory practice across organ procurement organizations and clinical management of culture results across transplant centers. While not standardized, the clinical approach to donors with positive bacterial and/or fungal cultures should be informed by the risk of donor-derived infection (DDI) and the consequence of organ non-utilization and account for potential unintended effects of antimicrobial use in the recipient. In this review, we summarize the literature on bacterial and fungal DDIs, describe the significance of positive cultures by anatomic site, and summarize current guidance on the management of positive cultures from donors or preservation fluids.

Donor-Derived Infection's Prevention and Control in Kidney Transplantation

BACKGROUND

The study aimed to summarize the experience of donor selection and recipient therapy in the face of potential donor-derived infections and improve the quality of donor organ utilization, which would help reduce the risk of infection after recipient operation and decrease the risk of loss or even death of recipient kidney transplantation.

METHODS

In this study, 132 kidneys from 70 donors and their recipients who underwent surgery between July 2017 and January 2021 were studied to perform a retrospective analysis of their etiologic examination results and treatment process.

RESULTS

In the 70 donors, only 25 had negative etiologic examination results, accounting for 35.71%. Among the 132 recipients, 31.82% had positive culture results, 3 (2.27%) experienced donor-derived infections, and one died.

CONCLUSIONS

Although infection in the donor before the donation is quite common, the incidence of donor-derived infections is relatively low. The targeted and preventive application of adequate sensitive antibiotics in the whole course of therapy was the cornerstone for treating recipients at potential risk of potential donor-derived infection. The changes in infection indicators in the recipient should be closely monitored, which would guide medication adjustments timely. These measures could, to a great degree, ensure the prognosis of the recipient, in turn reducing the adverse events caused by donor-derived infections.

The impact of preservation fluid culture on graft site arteritis: A systematic review and meta-analysis

BACKGROUND

The role of culturing the graft preservation fluid (PF) is controversial and its impact on graft arteritis development remains unclear.

METHODS

Systematic literature search retrieving observational studies comparing solid organ transplant (SOT) recipients with culture-positive PF versus culture-negative PF. The quality of included studies was independently assessed according to the ROBINS-I tool for observational studies. Meta-analysis was performed using Mantel-Haenszel random-effect models. Graft site arteritis within 180 days from transplant was selected as the primary outcome.

RESULTS

Twenty-one observational studies (N = 2208 positive PF vs. 4458 negative) were included. Among positive PF, 857 (38.8%) were classified as high-risk group pathogens and 1351 (61.2%) as low-risk pathogens. Low-risk and negative PF showed similar odds ratios. A significant higher risk of graft arteritis was found in SOT recipients with a PF yielding a high-risk pathogen (odds ratio [OR] 18.43, 95% confidence interval [CI] 7.83-43.40) compared to low-risk and negative PF, with low heterogeneity (I² = 2.24%). Similar results were found considering separately high-risk bacteria (OR 12.02, 95%CI 4.88-29.60) and fungi (OR 71.00, 95%CI 28.07-179.56), with no heterogeneity (I² = 0%), and in the subgroup analyses of the liver (OR 16.78, 95%CI 2.95-95.47) and kidney (OR 19.90, 95%CI 4.78-82.79) recipients. However, data about diagnostic features of graft arteritis were very limited, indeed for only 11 of the 93 events histological or microbiological results were reported.

CONCLUSIONS

Our results may support the performance of PF culturing and a preemptive diagnostic or therapeutic management upon isolation of high-risk pathogens. Further studies based on a reliable diagnosis of graft arteritis are needed.

Management of early graft candidiasis in a kidney transplant recipient

Balancing adequate immunosuppression with the risk of infection after renal transplantation remains a challenge. The presence of comorbidities adds to the challenge. Although infrequent, invasive fungal infections result in high morbidity and mortality risk in renal transplant recipients. This can be attributed to the intense immunosuppression in the first 6 months after renal transplantation, minimal symptomatology and the high mortality associated with fungal infections.

Due to minimal available evidence, clinical judgement guides management of graft candidiasis. There is a need to develop evidence-based management guidelines for the treatment of fungal infections in renal transplants. Here, we report a case of early-onset candidiasis in a transplanted kidney and present the histological findings, multidisciplinary discussions and treatment given.

Infective Artery Rupture of Renal Allografts: A Single-Center Retrospective Study in China

OBJECTIVE

This study investigated the composition of pathogenic microorganisms, clinical features, and therapeutic strategies of infective artery rupture of renal allografts in recipients receiving deceased donor (DD) kidneys.

METHODS

We retrospectively studied the clinical data of the DD kidney transplant recipients with donor-associated infection at Tongji Hospital, Wuhan, China from January 1, 2015 to December 31, 2018, related recipients and corresponding donors. We collected the entire results of pathogenic microorganisms cultured from these related ruptured kidneys and then analyzed their distribution and differences.

RESULTS

A total of 1440 kidney transplants from DD were performed in our center. The total incidence of infective artery rupture in kidney transplants was about 0.76% (11/1440), and the annual incidence ranged from 0.25% to 1.03%. The microbial culture results revealed that 11 recipients suffered from infective artery rupture and 3 recipients who accepted the kidney from same donor had the donor-associated pathogens, including 9 fungal strains (28.1%) and 23 bacterial strains (71.9%). There were 4 recipients infected with multi-drug-resistant Staphylococcus and Klebsiella pneumoniae from the above 11 recipients, of which, 10 recipients underwent graft loss, and one died of septic shock. The microbial cultures of the remaining 3 recipients who received appropriate anti-infective regimens turned negative eventually, and the patients were discharged successfully without significant complications.

CONCLUSION

Renal recipients with infections derived from DDs were at high risk of artery rupture, graft loss, or even death. Appropriate anti-infective treatment is essential to reduce the incidence of artery rupture and mortality.

Renal artery infectious (mycotic) pseudoaneurysms in renal transplantation recipients

INTRODUCTION

Infection of the artery at or around the anastomotic site is an ominous complication commonly presenting as a leak and/or local dissolution of the arterial wall.

MATERIAL AND METHODS

Narrative review based on relevant PubMed, EMBASE, and Scielo indexed English or Spanish-written articles for the period January 2000-December 2019. A pooled analysis regarding etiology was performed. Based on the results obtained with this approach, a diagnostic/therapeutic algorithm is suggested in order to optimize its clinical management.

FINDINGS

Arterial pseudoaneurysms are pseudocapsuled contained hematomas generated as the result of an arterial leaking. They are infrequent (<1% of cases), mostly related with infection (contamination of preservation fluid or sepsis) and located at the arterial anastomotic site in renal transplantation recipients. Although they are frequently diagnosed in symptomatic patients days/weeks after transplantation, they may remain unnoticed for long periods being diagnosed incidentally. Color coded-Doppler ultrasound confirms the clinical suspicion. Angio CT-scan and angiography are used for surgical planning or endovascular treatment, respectively. The etiological diagnosis is made on a basis of excised tissue culture. The decision-making process regarding the treatment approach, mostly relies on clinical presentation and anatomical location. Therapeutic options include ultrasound-guided percutaneous thrombin injection, endovascular treatment, and surgery.

CONCLUSIONS

Mycotic pseudoaneurysms in renal transplantation recipients may pose a significant challenge in cases of spontaneous rupture, given the risk for massive bleeding and death. Adequate management requires accurate diagnosis. Early endovascular stenting remains the treatment of choice in hemodynamically unstable patients. Percutaneous injection and vascular reconstruction present variable success rates in preserving graft function.

Candida Contamination in Kidney and Liver Organ Preservation Solution: Does It Matter?

INTRODUCTION

Fungal infections remain a major challenge affecting outcomes after kidney (KT) and liver transplantation (LT).

METHODS

In this retrospective single center study, the incidence of Candida contamination in renal and hepatic graft preservation solution (PS) was evaluated. In addition, Candida associated infections in recipients and related complications were analyzed.

RESULTS

Overall, the PS of 1248 hepatic and 1273 renal grafts were evaluated. The incidence of fungal contamination in the PS of hepatic and renal grafts was 1.2% and 0.86%, respectively. Additionally, the hepatic PS of one patient who underwent a combined liver-kidney transplant had Candida contamination. Candida albicans was the most common organism (70.4%) and 65.4% of the patients received antifungal treatment. Candida-associated complications in the recipients was 19%. Complications in LT patients included Candida peritonitis and Candida sepsis. Two KT recipients with contaminated PS developed a mycotic aneurysm at the anastomotic site resulting in severe bleeding. The 1-year mortality in patients with PS contamination for LT and KT recipients was 33% and 18%, respectively. Although the incidence of fungal contamination of PS was low, contaminated PS was associated with a high mortality.

CONCLUSION

The results of the study suggest that PS should be evaluated for fungal growth.

Renal artery infectious (mycotic) pseudoaneurysms in renal transplantation recipients

INTRODUCTION

Infection of the artery at or around the anastomotic site is an ominous complication commonly presenting as a leak and/or local dissolution of the arterial wall.

MATERIAL AND METHODS

Narrative review based on relevant PubMed, EMBASE, and Scielo indexed English or Spanish-written articles for the period January 2000-December 2019. A pooled analysis regarding etiology was performed. Based on the results obtained with this approach, a diagnostic/therapeutic algorithm is suggested in order to optimize its clinical management.

FINDINGS

Arterial pseudoaneurysms are pseudocapsuled contained hematomas generated as the result of an arterial leaking. They are infrequent(<1% of cases),mostly related with infection(contamination of preservation fluid or sepsis) and located at the arterial anastomotic site in renal transplantation recipients. Although they are frequently diagnosed in symptomatic patients days/weeks after transplantation, they may remain unnoticed for long periods being diagnosed incidentally. Color coded-Doppler ultrasound confirms the clinical suspicion. Angio CT-scan and angiography are used for surgical planning or endovascular treatment, respectively. The etiological diagnosis is made on a basis of excised tissue culture. The decision-making process regarding the treatment approach, mostly relies on clinical presentation and anatomical location. Therapeutic options include ultrasound-guided percutaneous thrombin injection, endovascular treatment, and surgery.

CONCLUSIONS

Mycotic pseudoaneurysms in renal transplantation recipients may pose a significant challenge in cases of spontaneous rupture, given the risk for massive bleeding and death. Adequate management requires accurate diagnosis. Early endovascular stenting remains the treatment of choice in hemodynamically unstable patients. Percutaneous injection and vascular reconstruction present variable success rates in preserving graft function.

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience

OBJECTIVE

This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis.

METHODS

Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate.

RESULTS

Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) at two years.

CONCLUSION

Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.

Candida sp. Infections in Patients with Diabetes Mellitus

Candidiasis has increased substantially worldwide over recent decades and is a significant cause of morbidity and mortality, especially among critically ill patients. Diabetes mellitus (DM) is a metabolic disorder that predisposes individuals to fungal infections, including those related to Candida sp., due to a immunosuppressive effect on the patient. This review aims to discuss the latest studies regarding the occurrence of candidiasis on DM patients and the pathophysiology and etiology associated with these co-morbidities. A comprehensive review of the literature was undertaken. PubMed, Scopus, Elsevier’s ScienceDirect, and Springer’s SpringerLink databases were searched using well-defined search terms. Predefined inclusion and exclusion criteria were applied to classify relevant manuscripts. Results of the review show that DM patients have an increased susceptibility to Candida sp. infections which aggravates in the cases of uncontrolled hyperglycemia. The conclusion is that, for these patients, the hospitalization periods have increased and are commonly associated with the prolonged use of indwelling medical devices, which also increase the costs associated with disease management.

Donor-Derived Candida dubliniensis Resulting in Perigraft Abscesses in a Liver Transplant Recipient Proven by Whole Genome Sequencing: A Case Report

BACKGROUND

The transmission of fungi via transplant, although well-known, has not often been molecularly proven. We describe a case of donor-derived candidiasis verified by whole genome sequencing.

CASE DESCRIPTION

The multiorgan donor was a 42-year-old woman with subdural hemorrhage. Procurement of the thoracic organs was performed followed by the abdominal organs. Tissue from the left bronchus grew Candida dubliniensis. The liver recipient was a 63-year-old woman with cryptogenic liver cirrhosis. She was noted to have worsening leukocytosis on postoperative day (POD) 9. Computed tomography of the abdomen and pelvis showed multiple rim-enhancing collections around the graft. Percutaneous drainage was performed. Fluid cultures grew C dubliniensis. C dubliniensis isolated from the donor's left bronchus and the liver recipient's abscesses were verified to be related by whole genome sequencing. We postulate that C dubliniensis colonizing the donor's transected trachea could have contaminated the inferior vena cava when the former was left open after explant of the donor's lungs. A portion of the donor's contaminated inferior vena cava was transplanted along with the liver graft, resulting in the infected collections in the recipient.

CONCLUSIONS

Our case report highlights the importance of maintaining a sterile field during organ procurement, especially in a multiorgan donor whose organs are explanted in succession.

Perioperative antibiotic prophylaxis in renal transplantation: a single-center comparison between two regimens and a brief survey among the Eurotransplant renal transplantation centers

BACKGROUND

Perioperative antibiotic prophylaxis (PAP) is an integral part of kidney transplantation to prevent surgical site infections (SSI). In July 2015, we changed our standard from a multiple-dose to a single-dose (SD) prophylaxis. Here, we report on results with both regimens and a related survey among Eurotransplant renal transplantation centers.

METHODS

From July 2015, all kidney graft recipients of our center were scheduled to receive SD i.v. cefazolin (group SD, n = 107). They were compared to patients, transplanted since January 2014, receiving our previous standard (i.v. piperacillin/flucloxacillin) until postoperative day (POD) 7, plus oral sultamicillin until POD 10 (group MD, n = 105). The primary endpoint was the number of SSIs during a 3-month observational period.

RESULTS

The frequency of SSI episodes was generally low (group SD vs. MD: 2 vs. 4, p = 0.40). Of note, urinary tract infections occurred in 40 SD vs. 36 MD patients, respectively (p = 0.60). Urinary tract infections were caused by Escherichia coli in 36.8%. Female gender was the only independent risk factor on multivariate analysis (p = 0.002). In addition, 12 episodes of urosepsis in both groups occurred. All-cause infection with multi-resistant bacteria occurred less frequently in SD vs. MD patients (3.7% vs. 8.6%, p = 0.16). A majority of Eurotransplant centers used i.v. single-dose cephalosporins (36.9%), although substances and duration varied remarkably.

CONCLUSION

Single-dose cefazolin was equally effective and less expensive compared to our previous MD regimen. Based on these findings, we conclude that future prospective studies should be designed to confirm the non-inferiority of single-dose antibiotic regimens.

Transplant tourism and invasive fungal infection

BACKGROUND

Deceased and live-related renal transplants (RTXs) are approved procedures that are performed widely throughout the world. In certain regions, commercial RTX has become popular, driven by financial greed.

METHODS

This retrospective, descriptive study was performed at the Royal Hospital from 2013 to 2015. Data were collected from the national kidney transplant registry of Oman. All transplant cases retrieved were divided into two groups: live-related RTX performed in Oman and commercial-unrelated RTX performed abroad. These groups were then divided again into those with and without evidence of fungal infection, either in the wound or renal graft.

RESULTS

A total of 198 RTX patients were identified, of whom 162 (81.8%) had undergone a commercial RTX that was done abroad. Invasive fungal infections (IFIs) were diagnosed in 8% of patients who had undergone a commercial RTX; of these patients, 76.9% underwent a nephrectomy and 23.1% continued with a functioning graft. None of the patients with RTXs performed at the Royal Hospital contracted an IFI. The most common fungal isolates were Aspergillus species (including Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, and Aspergillus nigricans), followed by Zygomycetes. However, there was no evidence of fungal infection including Aspergillus outside the graft site. Computed tomography (CT) findings showed infarction of the graft, renal artery thrombosis, aneurysmal dilatation of the external iliac artery, fungal ball, or just the presence of a perigraft collection. Of the total patients with IFIs, 23.1% died due to septic shock and 53.8% were alive and on hemodialysis. The remaining 23.1% who did not undergo nephrectomy demonstrated acceptable graft function.

CONCLUSIONS

This is the largest single-center study on commercial RTX reporting the highest number of patients with IFI acquired over a relatively short period of time. Aspergillus spp were the main culprit fungi, with no Candida spp being isolated. A high index of suspicion might be the most reasonable means to reduce the possible very poor outcomes. Improving legal transplant programs and strengthening the associated laws could prevent commercial transplant tourism.

Colonization of preservation solution in kidney transplantation: Clinical impact and risk of secondary acute graft pyelonephritis

INTRODUCTION

Bacterial colonization of preservative solutions (PS) remains poorly described in renal transplantation. We investigated the bacterial colonization of the PS and its influence on graft pyelonephritis within one year from the renal transplantation.

PATIENTS AND METHODS

We cultured 2 samples of PS from 424 patients who underwent a renal transplantation. The follow-up period was one year. An acute graft pyelonephritis was defined as a positive bacteriological urine analysis, with temperature higher than 38.5°C or graft pain.

RESULTS

In total, 424 samples of PS were tested and 195 were positive for colonization (46%). Forty-five patients developed an acute graft pyelonephritis during the follow-up period (10.6%), of which, 21 (46.7%) showed a colonization of their PS. Twenty-four had no colonization (53.3%). This difference was not significant (P=0.697).

DISCUSSION

Our data suggest that the bacterial colonization of PS samples does not seem to increase the risk of acute graft pyelonephritis in renal transplant recipients.

LEVEL OF EVIDENCE

-3.

Mycotic Pseudoaneurysm After Kidney Transplantation: Two Case Reports

BACKGROUND

Vascular complications after kidney transplantation may cause allograft loss. Here, we describe 2 patients with extrarenal mycotic pseudoaneurysm after kidney transplantation.

PATIENTS

Patient 1 was a 54-year-old man who developed pseudoaneurysm 60 days after transplantation, and patient 2 was a 48-year-old woman who was diagnosed with a pseudoaneurysm 5 months after transplantation.

RESULTS

Patient 1 had a deceased-donor kidney transplant with end-to-side external iliac arterial anastomosis that was reconstructed 8 days after transplantation owing to rupture and major bleeding. At 60 days after transplantation, he had high serum creatinine level and Doppler ultrasonography showed a pseudoaneurysm of the arterial graft anastomosis and postanastomotic renal artery stenosis. Treatment included surgical excision of the pseudoaneurysm, vascular reconstruction, and fluconazole, with mycologic culture of the resected pseudoaneurysm showing Candida albicans. Patient 2 developed nondisabling intermittent claudication at 5 months after kidney transplantation, with a pseudoaneurysm subsequently observed on Doppler ultrasonography and computerized tomographic angiography. Treatment included renal artery thrombectomy and common iliac bypass to the hilar donor renal artery with inverted ipsilateral long saphenous vein. Operative samples showed C albicans, and she was treated with fluconazole. Both patients had satisfactory outcomes, and both kidney allografts were preserved.

CONCLUSIONS

Extrarenal mycotic pseudoaneurysms after kidney transplantation require a high index of suspicion for early diagnosis, and preservation of the kidney graft may be achieved with the use of surgical treatment and antifungal therapy.

Fifty-one cases of fungal arteritis after kidney transplantation: A case report and review of the literature

Fungal arteritis affecting graft arteries is a rare but life-threatening complication in kidney transplantation (KT). Here, we report the case of a patient with Aspergillus arteritis who experienced renal artery rupture 8 days after KT. We also reviewed 50 other reported cases of fungal arteritis after KT. We found that fungal contamination can occur during kidney graft harvest, preservation, and/or transplantation. Typically, early diagnosis, timely antifungal treatment, and emergency surgery seem crucial for avoiding life-threatening vascular complications.

Development of Graft-Site Candidiasis in 3 Solid Organ Transplant Recipients from the Same Donor

Case series

Patient: Female, 61 • Female, 33 • Female, 58

Final Diagnosis: Candida arteritis

Symptoms: Severe bleeding

Medication: —

Clinical Procedure: —

Specialty: Infectious Diseases

Donor Derived Candida stellimalicola in a Clinical Specimen: Preservation Fluid Contamination During Pancreas Procurement

We report here a case of possible donor-derived Candida stellimalicola infection after pancreas transplantation. Candida stellimalicola, an environmental non-filamentous yeast, was isolated from both the peritoneal fluid of the graft donor and the preservation fluid of the transplanted pancreas. Interestingly, this strain exhibited high minimum inhibitory concentrations to azoles. These results justified the use of echinocandins as therapy instead of fluconazole. This switch permitted a favorable outcome. To our knowledge, this is the first report of C. stellimalicola from clinical samples and therefore the first reported case of a possible human infection. This case report highlights the need for standardized microbiological procedures in solid organ transplant settings. Moreover, it underlines the importance of using molecular identification technique when routine techniques do not allow successful identification of the pathogen. It is of utmost importance to determine sensitivity profile, even in the absence of species-level identification, because resistance to fluconazole is not uncommon, especially in emergent species.

Infection in Organ Transplantation

The prevention, diagnosis, and management of infectious disease in transplantation are major contributors to improved outcomes in organ transplantation. The risk of serious infections in organ recipients is determined by interactions between the patient's epidemiological exposures and net state of immune suppression. In organ recipients, there is a significant incidence of drug toxicity and a propensity for drug interactions with immunosuppressive agents used to maintain graft function. Thus, every effort must be made to establish specific microbiologic diagnoses to optimize therapy. A timeline can be created to develop a differential diagnosis of infection in transplantation based on common patterns of infectious exposures, immunosuppressive management, and antimicrobial prophylaxis. Application of quantitative molecular microbial assays and advanced antimicrobial therapies have advanced care. Pathogen-specific immunity, genetic polymorphisms in immune responses, and dynamic interactions between the microbiome and the risk of infection are beginning to be explored. The role of infection in the stimulation of alloimmune responses awaits further definition. Major hurdles include the shifting worldwide epidemiology of infections, increasing antimicrobial resistance, suboptimal assays for the microbiologic screening of organ donors, and virus-associated malignancies. Transplant infectious disease remains a key to the clinical and scientific investigation of organ transplantation.

Successful Kidney and Lung Transplantation From a Deceased Donor With Blunt Abdominal Trauma and Intestinal Perforation

The number of organ donors is limited by many contraindications for donation and poor quality of potential organ donors. Abdominal infection is a generally accepted contraindication for donation of abdominal organs. We present a 43-year-old man with lethal brain injury, blunt abdominal trauma, and intestinal perforation. After withdrawal of life-sustaining treatment and circulatory arrest, a minilaparotomy confirmed abdominal contamination with intestinal content. After closure of the abdomen, organs were preserved with in situ preservation with an aortic cannula inserted via the femoral artery. Thereafter, the kidneys were procured via bilateral lumbotomy to reduce the risk of direct bacterial contamination; lungs were retrieved following a standard practice. There was no bacterial or fungal growth in the machine preservation fluid of both kidneys. All organs were successfully transplanted, without postoperative infection, and functioned well after 6 months. We hereby show that direct contamination of organs can be avoided with the use of in situ preservation and retroperitoneal procurement. Intestinal perforation is not an absolute contraindication for donation, although the risk of bacterial or fungal transmission has to be evaluated per case.

Clinical impact of bacterial contamination of perfusion fluid in kidney transplantation

Contamination of perfusion fluid (PF) could lead to serious infections in kidney transplant recipients. Preemptive therapy (PE-T) in case of yeast contamination of PF is mandatory. The usefulness of PE-T in presence of bacteria remains unclear. In this study we evaluated the incidence of PF bacterial contamination and the impact of PE-T on clinical outcome. Microbiological data of 290 PF and clinical data of the corresponding recipients collected in our hospital from January 2010 and December 2012 were analyzed. Recipients with bacterial contaminated PF (101) were divided in 3 groups: group 1 (n = 52) PE-T treated bacteria resistant to perioperative antibiotic prophylaxis (PAP), group 2 (n = 28) bacteria sensitive to PAP, group 3 (n = 21) PE-T-untreated bacteria resistant to PAP. Incidence of positive PF was 34.8 %, 50.4 % staphylococci, 9.9 % C. albicans. No significant differences in the rate of PF-related infections between the three groups were found. In conclusion, although PF contamination is frequent, the incidence of PF-related infections is very low. In addition, in this study PE-T did not help to reduce the rate of PF-related infection suggesting that a resonable reduction in the use of antibiotic terapy could be made. However, waiting for largest and prospective clinical trials to confirm our findings, a closely clinical and microbiologic monitoring of the recipient is highly recommended in case of PF contamination.

Fungal complications after Candida preservation fluid contamination in liver transplant recipients

Donor-derived fungal infections can be associated with severe complications in transplant recipients. Donor-derived candidiasis has been described in kidney transplant recipients where contamination of the preservation fluid (PF) was a commonly proposed source. In liver transplantation, these fungal infections have been less explored. The aim of this study was therefore to determine the incidence and clinical relevance of Candida contamination of preservation fluid in the context of liver transplantation. A 5-year (2008-2012) retrospective multicentre study involving six French liver transplantation centers was performed to determine the incidence of Candida PF contamination. Postoperative clinical features, outcomes in recipients, and risk factors for Candida-related complications of liver transplantation were studied. Candida sp. was isolated from 28 of 2107 preservation fluid samples (1.33%). Candida albicans was the most common yeast (n = 18, 64%). Twenty-two recipients (78.5%) received antifungal therapy (echinocandins in 68%) for 7-37 days. Eight patients developed yeast-related complications (28.6%) including hepatic artery aneurysms (n = 6) and Candida peritonitis (n = 2). The 1-year mortality rate among patients after a yeast-related complication was 62.5%. The incidence of Candida PF contamination was low, but was associated with dramatic postoperative complications and high mortality. Close radiological follow-up may enable early recognition of the arterial complications associated with PF contamination by Candida.

Candida arteritis in kidney transplant recipients: case report and review of the literature

Multi-organ procurement is a risk factor for contamination of preservation fluid with intestinal flora including fungi (e.g., Candida). Transmission of fungal species to the graft vessel can cause mycotic arteritis. This is a very rare but life-threatening complication of renal transplantation. We present 2 cases of renal transplant recipients from the same multi-organ donor. Both recipients suffered from severe hemorrhages from renal graft anastomosis and renal artery pseudoaneurysm due to Candida albicans arteritis (CAA). The culture of the preservation fluid revealed growth of Escherichia coli, but neither preservation fluid nor multiple routine blood cultures performed before hemorrhagic complications revealed fungal growth (media non-selective for fungal growth were applied). The first recipient suffered from sudden severe hemorrhage in the area of graft anastomosis on day 10 post surgery (without any preceding clinical or radiological symptoms). This led to urgent surgery and graftectomy, which was complicated by cardio-respiratory arrest with resuscitation in the operating room; despite resuscitation, irreversible brain damage, and subsequent death occurred in the intensive care unit (ICU) 2 weeks later (on day 24 after transplantation). The second patient underwent urgent vascular surgery on day 22 (after transplantation), because of hemorrhage from a pseudoaneurysm of the graft artery. She required repeated vascular operations, extended antimicrobial and antifungal therapy, and ICU monitoring and, despite these interventions, she died on day 80 after transplantation as a result of Pseudomonas aeruginosa sepsis. Arteritis of the renal artery in both patients was caused by C. albicans. This was confirmed by histopathology: infiltration of renal artery with budding yeast forming pseudohyphae (Case 1), and the presence of C. albicans in the culture of the renal artery and surrounding tissue (Case 2). We conclude that organ preservation solution should be cultured with use of media selective for fungal growth. As soon as the positive culture is detected, appropriate measures protecting patients against CAA should be undertaken.

Selecting suitable solid organ transplant donors: Reducing the risk of donor-transmitted infections

Selection of the appropriate donor is essential to a successful allograft recipient outcome for solid organ transplantation. Multiple infectious diseases have been transmitted from the donor to the recipient via transplantation. Donor-transmitted infections cause increased morbidity and mortality to the recipient. In recent years, a series of high-profile transmissions of infections have occurred in organ recipients prompting increased attention on the process of improving the selection of an appropriate donor that balances the shortage of needed allografts with an approach that mitigates the risk of donor-transmitted infection to the recipient. Important advances focused on improving donor screening diagnostics, using previously excluded high-risk donors, and individualizing the selection of allografts to recipients based on their prior infection history are serving to increase the donor pool and improve outcomes after transplant. This article serves to review the relevant literature surrounding this topic and to provide a suggested approach to the selection of an appropriate solid organ transplant donor.

Candida species contamination of preservation fluid-outcome of renal transplantation in 6 patients

BACKGROUND

Fungal infections are a rare but important cause of morbidity and mortality in kidney transplantation. Fungal contamination of the kidney preservation fluid may, sometimes, be the cause of these infections. However, the clinical consequences of fungal contamination of this fluid are not completely understood and literature on this topic is controversial. The purpose of this study was to determine the incidence of preservation fluid contamination by fungi and its clinical consequences.

METHODS

From June 2010 to September 2011, a prospective cohort analysis was conducted at our center, enrolling all patients who received a renal allograft and whose perfusion fluid was analyzed for microbiology sterility. Patients with perfusion fluids positive for fungi were further studied: the patients' status was assessed during regular visits and data were recorded, including clinical characteristics, infections, graft function, immunosuppressive regimen and outcomes.

RESULTS

Microbiologic, cultures of 70 kidney perfusion fluids using specific mycologic media, obtained from 74 cadaveric renal transplants (4 fluids were unsuitable for analysis), were evaluated. Six samples were positive for yeasts (8.6%), with 4 isolates of Candida albicans and 2 isolates of Candida glabrata. Four patients had no evidence of fungal infection during the follow-up period (median 321 days); conversely, 2 patients developed severe mycotic vascular complications leading to transplantectomy.

CONCLUSIONS

Perfusion fluid contamination by fungi is an elusive situation that can lead either to an unremarkable clinical course or to graft loss life-threatening situations. Routine culture of kidney perfusion fluid is critical for prompt diagnosis and early implementation of appropriate treatment.

Donor-derived fungal infections in organ transplant recipients: guidelines of the American Society of Transplantation, infectious diseases community of practice

Donor-derived fungal infections can be associated with serious complications in transplant recipients. Most cases of donor-derived candidiasis have occurred in kidney transplant recipients in whom contaminated preservation fluid is a commonly proposed source. Donors with cryptococcal disease, including those with unrecognized cryptococcal meningoencephalitis may transmit the infection with the allograft. Active histoplasmosis or undiagnosed and presumably asymptomatic infection in the donor that had not resolved by the time of death can result in donor-derived histoplasmosis in the recipient. Potential donors from an endemic area with either active or occult infection can also transmit coccidioidomycosis. Rare instances of aspergillosis and other mycoses, including agents of mucormycosis may also be transmitted from infected donors. Appropriate diagnostic evaluation and prompt initiation of appropriate antifungal therapy are warranted if donor-derived fungal infections are a consideration. This document discusses the characteristics, evaluation and approach to the management of donor-derived fungal infections in organ transplant recipients.

Invasive fungal infections in solid organ transplant recipients

Invasive fungal infections are a major problem in solid organ transplant (SOT) recipients. Overall, the most common fungal infection in SOT is candidiasis, followed by aspergillosis and cryptococcosis, except in lung transplant recipients, where aspergillosis is most common. Development of invasive disease hinges on the interplay between host factors (e.g., integrity of anatomical barriers, innate and acquired immunity) and fungal factors (e.g., exposure, virulence and resistance to prophylaxis). In this article, we describe the epidemiology and clinical features of the most common fungal infections in organ transplantation. Within this context, we review recent advances in diagnostic modalities and antifungal chemotherapy, and their impact on evolving prophylaxis and treatment paradigms.

Outcomes of transplantation using organs from a donor infected with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae

Transmission of pathogens from donor to recipient is a potential complication of organ transplantation. Herein, we describe the clinical course and outcomes of 4 transplant recipients who received tissues from a donor with multi-organ infection with Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae. Recipient 1 underwent simultaneous liver and kidney transplantation for alpha-1 antitrypsin deficiency and alcohol-related cirrhosis, and acute tubular necrosis, respectively. Soon after transplantation, he developed an infected hematoma and peritonitis due to KPC-producing K. pneumoniae despite receiving tigecycline prophylaxis. He was treated with a prolonged course of tigecycline, amikacin, and meropenem, in conjunction with surgical evacuation and percutaneous drainage of the infected fluid collections. Recipient 2 underwent living-donor liver transplantation for cholangiocarcinoma and primary sclerosing cholangitis using vein graft from the donor infected with KPC-producing K. pneumoniae. Culture of the preservation fluid containing the vein graft was positive for KPC-producing K. pneumoniae. The patient received preemptive amikacin and tigecycline, and he did not develop any infection (as evidenced by negative surveillance blood cultures). The isolates from the donor and Recipients 1 and 2 were indistinguishable by pulsed-field gel electrophoresis. Recipients 3 and 4 underwent kidney and heart transplantation, respectively; both patients received perioperative tigecycline prophylaxis and did not develop infections due to KPC-producing K. pneumoniae. All transplant recipients had good short-term outcomes. These cases highlight the importance of inter-institutional communication and collaboration to ensure the successful management of recipients of organs from donors infected with multidrug-resistant organisms.

Invasive Candida infections in solid organ transplant recipient children

Solid organ transplantation (SOT) is now an accepted therapy for many end-stage organ disorders and fungal infections are the principal cause of infection-related mortality in SOT recipients. Among invasive fungal infections, Candida species are the most common pathogens identified, associated with high mortality rates. The epidemiology and clinical manifestations of Candida infections vary with the type of organ transplantation. This article reviews invasive Candida infections in pediatric SOT recipients.

Contamination of preservation fluid in kidney transplantation: single-center analysis

INTRODUCTION

Contamination of preservation fluid is common, with a reported incidence of 2.2% to 28.0%, and may be a major cause of early morbidity after transplantation. Herein, we report our experience with routine examination of preservation fluid collected just before implantation, focusing on the rate of contamination and the clinical consequences to recipients.

MATERIALS AND METHODS

We analyzed 62 samples of preservation fluid for microbial and fungal contamination.

RESULTS

Twenty-four samples (38.7%) were contaminated with at least 1 organism. Bacterial contamination alone was observed in 18 samples; all patients received prophylactic treatment with intravenous piperacillin/tazobactam, 4.5 g/d for 10 days, without clinical sequelae. Six samples were contaminated with Candida species; all patients received prophylactic treatment with fluconazole, 100 mg/d for 3 months. One patient developed reversible acute renal failure due to ureteral obstruction by fungus balls at 30 days after transplantation.

CONCLUSION

Contamination of preservation fluid occurs frequently after kidney transplantation. Bacterial contamination evolved without symptoms in most patients treated with prophylactic antibiotic therapy. Fungal contamination may be potentially life-threatening. However, graft nephrectomy is not mandatory if the involved Candida species is identified correctly and appropriate antifungal therapy is rapidly prescribed.

Aspergillus infection limited to the anastomosed artery following renal transplantation: a report of 4 cases

We present 4 cases of Aspergillus fumigatus infection limited to the anastomosed artery following renal transplantation. All grafts were nephrectomized. Two patients received 2 weeks of itraconazole therapy; both showing recurrence of pseudoaneurysms following discontinuation of therapy. Another 2 patients received 3 months of itraconazole therapy without recurrence of pseudoaneurysms. Surgical interventions were life saving. Resection of infected tissues and 3 months of antifungal therapy seemed to give better results than shorter antifungal strategies.

Evidence that graft-site candidiasis after kidney transplantation is acquired during organ recovery: a multicenter study in France

BACKGROUND

Infections of renal grafts with Candida species can induce life-threatening complications in the recipient.

METHODS

A 9-year retrospective study involving all of the transplant centers in France was designed to determine the incidence, origin, characteristics, and outcome of graft-site candidiasis that occurred after kidney transplantation. Yeasts cultured from preservation or drainage solutions and graft specimens were recorded.

RESULTS

Among 18,617 kidney grafts, 18 recipients corresponding to 12 donors developed culture-confirmed graft-site candidiasis (incidence, 1 case per 1000 grafts) a median of 25 days after the graft procedure. Clinical presentations included 14 cases of renal arteritis (13 were complicated by aneurysm), 1 urinoma, 2 graft site abscesses, and 1 surgical site infection. Candida albicans was involved in 13 cases. A unique C. albicans genotype or a single rare Candida species was involved in each episode. Together with the clinical history, these findings demonstrate that organ contamination followed by transmission to the recipient occurred during recovery. Therapeutic management varied from simple monitoring in 1 case to a combination of surgery (nephrectomy in 9 cases and arterial bypass in 9 cases) and antifungal therapy (14 cases). Overall, 3 of 18 kidney transplant recipients died, and 9 had their graft surgically removed.

CONCLUSION

Graft-transmitted candidiasis that ends most often in fungal arteritis is associated with high morbidity and mortality after kidney transplantation and is related to organ contamination during recovery in the donor.

[Mycotic aneurysm and renal transplant. A case report]

The arterial aneurysm secondary to Candida is a rare but frightening complication of renal transplant. We report the case of a 58-year-old patient who developed an arterial aneurysm secondary to a Candida infection in 3 weeks of a third renal transplant. Candida albicans was isolated from the preservation solution. The treatment consisted of a transplant nephrectomy, aneurysm excision and an iliac bypass with cryopreserved iliac homograft. All of bacteriologic culture was positive for Candida. The positive bacteriologic culture for Candida in preservation solution requires antifongic treatment. In case of arterial aneurysm, a surgical treatment is necessary but majority of kidney transplant had to be removed.

Early conservative intervention for candida contamination of preservative fluid without allograft nephrectomy

BACKGROUND

Fungal contamination of kidney allograft preservative fluid can lead to renal arteritis and arterial wall rupture.

METHODS

We have evaluated a conservative management strategy based onearly antifungal therapy, rigorous morphological monitoring of the graft artery and surgical second look (SSL). Since November 2004, preservative fluid was routinely cultured on specific media for all kidney transplant recipients.

RESULTS

In 8/474 cases, results were positive for Candida (albicans 5, glabrata 2, tropicalis 1). Two patients also had candida infection of drainage fluid leading to the diagnosis of operative site infection. Radiological and surgical examinations of the renal graft artery were normal in all cases and nephrectomy was not required. At 12 months, all patients were alive with a functioning allograft.

CONCLUSION

Early antifungal therapy with microbiological and morphological follow-up should be recommended as soon as contamination is detected, but SSL is advised only in patients with risk factors for arterial anomalies.