Allograft artery mycotic aneurysm after kidney transplantation: A case report and review of literature

Perspectives on donor-derived infections from Germany

AIM

Often, organ transplantation is the only option to improve the life expectancy and quality of life of patients with terminal organ failure. Despite improved donor and organ assessment, a residual risk remains for transmitting infection, tumor, or other disease from the donor to recipients. Analysis, reporting, and managing of donor-derived diseases through a vigilance and surveillance system (V&S) is mandatory in many countries. We report on suspected and proven/probable donor-derived infections (DDI) in Germany over a period of 8 years (2016-2023).

METHODS

All incoming serious-adverse-event and serious-adverse-reaction (SAE/SAR) reports from 01.01.2016 to 31.12.2023 were evaluated for suspected DDI. Analysis of imputability followed the definition of the US Disease Transmission Advisory Committee (DTAC). Only probable and proven cases according to DTAC classification were defined as DDI.

RESULTS

During the study period, 9771 donors in Germany donated post-mortem organs to 27 919 recipients. In that period 612 SAE/SAR cases were reported, 377 (62%) involved infections. 41 cases were proven/probable DDI affecting 58 recipients (seven recipients died, 12%). Suspected infections were bacterial (182/377, 48%), fungal (135/377, 36%), viral (55/377, 15%), and parasitic (5/377, 1%). In case of bacterial DDI, no recipient died, but organ loss occurred in six recipients. In case of fungal or viral DDI, 19% (3/16) and 21% (3/14) of the recipients died, respectively.

CONCLUSIONS

DDI are rare in solid organ transplantation (58/27 919, 0.21%), but when they occur, they are associated with high morbidity and mortality in affected recipients. Careful and detailed donor evaluation and a reliable V&S help improve recipient safety.

A Rare Case of Gas Forming Enterobacter cloacae Leading to Bleeding Mycotic Pseudoaneurysm of Transplant Renal Artery Culminating in Graft Nephrectomy

Enterobacter cloacae belongs to Enterobacter genus. It is a common gram-negative, facultative anaerobic, rod-shaped organism. It causes a variety of nosocomial infections including urinary tract infection, pneumonia, wound infection, osteomyelitis and endocarditis. Over time Enterobacter cloacae complex (ECC) has developed to be resistant to antibiotics including carbapenem. It has been rarely reported to cause gas gangrene and never been reported to cause pseudoaneurysm (PA) of transplant renal artery. We report and share our experience with this rare case of gas forming and muti-drug resistant ECC which led to mycotic PA of transplant renal artery, complicated by bleeding and infected hematoma and which resulted in graft nephrectomy.

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.

Successful Endovascular Repair of Infectious External Iliac Artery Anastomotic Pseudoaneurysm With Graft Preservation Post-Kidney Transplantation: Case Report and Review of Literature

BACKGROUND

Allograft artery-infected pseudoaneurysm (PA) represents a rare but life-threatening complication of kidney transplantation (KT). A review of the literature, showed that nearly all these cases ended resulted in graft loss. We presented a case of post-KT-infected external iliac artery anastomotic PA successfully managed by endovascular stenting with graft preservation. Additionally, we reviewed the pertinent literature.

METHOD

In this article, we described a hypertensive, 47-year-old man who presented 1 month post-cadaveric KT with acute kidney injury and gram-negative bacteremia secondary to a large infectious anastomotic PA of the external iliac artery.

RESULTS

Because of favorable anatomy, successful arterial angio-stent fixation of the main renal artery PA, sparing the lower polar artery, was performed after 1 week of antibiotic and fungal coverage.

CONCLUSION

Patient was discharged after 2 weeks with functioning graft. Graft function was stable after 3 months.