According to the ISHLT registry, the survival outcome of heart transplantation recipients is ever improving. Infection, however, is still a serious complication after heart transplantation, even if a new antibiotic has been developed and viral infection or fungal infection is being treated safely. As the recipients of heart transplant receive immunosuppressive therapy, the frequency of infection varies based on the difference in immunosuppressive agents. These patients are susceptible to infection caused by true pathogens, which are able to overwhelm the natural defense mechanisms of a non immunocompromised host, and non-pathogens which do not present a risk to a normal host, but to which immunocompromised patients are susceptible. While symptomatic infection is a significant cause of morbidity and mortality, surprisingly, even asymptomatic infections are independent risk factors for overall mortality and reduced survival. Infection with cytomegalovirus has been implicated in cardiac graft vasculopathy and Epstein-Barr virus infection is associated with malignant disease. Post-transplant infection is expected to decrease by improvement of infection control and immunosuppressive agents; conversely, ventricular assist devices are a recent option for patients with heart failure awaiting cardiac transplantation, and some studies reported that pre-transplant ventricular assist device infection correlated with a high incidence of bacteremia following heart transplantation and decreased survival. There is concern that it will become a further problem in the near future.

Since the revised Japanese Organ Transplant Act was issued in 2010, brain dead organ donation from children (<15 years of age) has been able to be performed and 26 pediatric heart transplantations were done before the end of 2017. In regard to infection after pediatric heart transplantation: 1, children are not exposed to as many kinds of pathogenic organisms prior to transplantation as adults; 2, there many infectious factors in daily life circumstances around children; and 3, different management methods depending on the age are required to prevent and control infection. To manage infection after heart transplantation in children, education of family and school officials is as important as medical strategies.

Heart transplantation is the gold standard of therapy for end-stage heart failure. Because of the extreme shortage of donor hearts, the need for prolonged support with a continuous-flow ventricular assist device (VAD) has increased and more patients are at risk for VAD-specific and VAD-related infections. Although the duration of VAD support prior to heart transplantation does not directly affect the outcomes of heart transplantation, the presence of active VAD-specific infections is an independent risk factor for increased severity of early postoperative infection in heart transplantation recipients. To date, there is no ideal prophylactic antibiotic regimen for patients undergoing heart transplantation after long-term VAD support. However, if infecting organisms are isolated from the recipient before transplantation, then the perioperative antibiotics regimen should be tailored to treat the isolated microorganisms.

Immunosuppressants including calcineurin-inhibitors rapidly developed from the 1980s have produced splendid results for heart transplantation. Under the post-transplant immunosuppressive condition, which lasts many years, attention should be paid to many kinds of infections including opportunistic infection such as cytomegalovirus and Epstein-Barr viruses, fungi, and parasites.

In order to maintain quality of life in each patient after heart transplantation, prevention of any infections not only from the public but also from themselves is needed.

【Objective】 The utilization of grafts from donors after cardiac death (DCD) would greatly contribute to the expansion of the donor organ pool. However, the implementation of such a strategy requires the development of novel kidney preservation methods to recover from an ischemic injury.

【Design】 The aim of this study was to evaluate the effectiveness of using oxygenated rewarming machine perfusion for preserving porcine DCD kidney grafts for transplantation.

【Methods】 Porcine kidneys were perfused with an original machine perfusion (MP) system. The kidneys were procured after 0 or 60 min. of warm ischemic time (WIT) and were perfused for 2 hours with modified UW-gluconate solution after 2 hours of simple cold storage. Group 1: The grafts with a WIT of 0 min were preserved using hypothermic MP (HMP). Group 2: The grafts with a WIT of 60 min were preserved using HMP. Group 3: The grafts with a WIT of 60 min were preserved using rewarming MP (RMP) at up to 25°C without oxygenation. Group 4: The grafts were preserved with a WIT of 60 min using oxygenated RMP.

【Results】 In Group 4, the effluent levels of the lactate dehydrogenase (LDH), but not CPK, were lower than those observed in Group 2. The vascular resistance (renal resistance; RR) was remarkably lower in Group 4 (p<0.01). A positive correlation was observed between RR and LDH.

【Conclusion】 Oxygenated subnormothermic preservation with rewarming may help in recovering the function of DCD kidney grafts.

A man in his 60s with autosomal dominant polycystic kidney disease developed massive ascites 3 years after kidney transplantation. Although massive ascites was observed, the size of the spleen and liver function were within normal limits. MRI revealed that his inferior vena cava was severely compressed by an enlarged polycystic liver, and we concluded that direct compression of the inferior vena cava was the cause of his ascites. Since the ascites became resistant to medical treatment with diuretics, his renal function gradually deteriorated. To reduce the direct compression by the enlarged polycystic liver, we firstly considered partial hepatectomy or surgical fenestration of the liver cysts. But surgical revisions were thought an unsuitable option for his treatment. So he underwent the placement of a Denver peritoneo-venous shunt. Ascites was managed without any complications and impaired renal graft function was improved promptly due to appropriate circulating plasma volume.

We herein report two cases of pneumatosis intestinalis (PI) after lung transplantation. The first case was a 50-year-old woman who underwent left single-lung transplantation due to interstitial pneumonia derived from drug injury. At her annual checkup six years after lung transplant, PI was identified on computed tomography (CT) ; however, she had reported feeling abdominal pain before the CT session. We followed up her PI because there were no symptoms of perforation or necrosis of the colon. Her symptoms disappeared within several days, and CT one year later revealed that the PI had resolved. The next case was a 20-year-old woman who underwent double-lung transplantation due to idiopathic pulmonary arterial hypertension. She had diabetes mellitus due to several sessions of steroid pulse therapy for allograft dysfunction. We identified PI on CT five years after lung transplantation; however, she did not have any symptoms in the abdomen, so we followed up her PI with oxygen inhalation therapy as recommended by a gastroenterologist. After two months, her PI had disappeared. Recipients of lung transplant have many risk factors for PI, such as steroid therapy and diabetes mellitus. We therefore need to be alert for PI in lung transplant patients.

Although a pancreatic pseudocyst following acute pancreatitis is infrequent after renal transplantation, it has been reported to become severe once occurred. We present a case of pancreatic pseudocyst ruptured into the stomach following acute pancreatitis in a renal transplantation recipient from a brain-dead donor after long-term hemodialysis.

In this case, a secondary hyperparathyroidism and pre-operative use of sodium valproate in addition to an administration of prednisolone were thought to be the cause of acute pancreatitis, and a pancreatic microcirculatory disorder due to Mönckeberg-type arteriosclerosis would lead to a rupture of pancreatic pseudocyst into the stomach.

It is important to diagnose early and to treat quickly a pancreatic pseudocyst ruptured into the stomach of a long-term dialyzed and transplanted patient.

This clinical report describes two rare cases of Alagille syndrome (AGS) in which visceral aneurysms were diagnosed after living-donor liver transplantation (LDLT). The first patient is a 22-year-old man who underwent LDLT in 2009 and had two aneurysms subsequently identified in 2015-one was 12×14.5×15 mm on the inferior pancreaticoduodenal artery (IPDA) and the other 6×7×9 mm on the splenic artery (SPA). Because the IPDA aneurysm displayed a course of progression, coil embolization via interventional radiology (IVR) was performed in 2016. The other patient is a 17-year-old woman who underwent initial LDLT in 2001 followed by re-LDLT in 2002 due to intractable hepatic venous stenosis. In 2016 a fusiform aneurysm with a dimension of 7.5×7.5×17 mm was found in the superior mesenteric artery (SMA) ; however, due to its location in the main trunk of the SMA along with its fusiform nature, the patient was placed on follow-up observation as opposed to aggressive intervention. While identifying the specific causes of aneurysm development in AGS has been an elusive feat, recent studies have suggested the involvement of mutations in JAG1 or NOTCH2 which result in disruptions during smooth muscle differentiation. Given the propensity of AGS patients to develop visceral aneurysm, patients are relegated to continuous imaging examinations and IVR treatment where deemed appropriate throughout the remainder of their lifetimes.

For extension of organ transplantation, deepening of people’s comprehension is necessary. The aim of this study was investigation of citizens’ opinions on organ transplantation in Ibaraki Prefecture.

We surveyed the opinion of organ transplantation by questionnaires of the citizens who gathered in festivals held in Ibaraki Prefecture from October 2014 to November 2015. Questions consisted of 13 items concerning organ transplantation and donation. The analysis was performed with the X2 Goodness-of-fit Test.

One thousand one hundred thirty-one citizens responded. The rate of citizens who had already expressed their intention to donate organs was 25% for those in their 30s, which was higher than for other generations. The ratio of the citizens who intended to donate was 39%. The citizens who had an interest in organ transplantation outnumbered the persons without interest. Half of the citizens who had an interest had already discussed organ transplantation with their family. On the other hand, 77% of citizens without interest did not obtain any information about organ transplantation.

From this survey in Ibaraki Prefecture it is suggested that it is effective to provide an opportunity to think about the organ transplantation in the families of citizens 20-30 years of age.

【Objective】 Acute graft-versus-host disease (GVHD) in pancreas transplant is a rare but lethal complication. Most of the reported cases have died of sepsis or multiple organ failure within a few months of onset. Because of its rarity, the risks of GVHD have not been well understood. Recently, a few reports successfully showed treated cases of GVHD after pancreatic transplant for the first time in the last 20 years. This is a review of GVHD cases in pancreas transplant with particular emphasis on the clinical importance of donor-dominant human leukocyte antigen (HLA) one-way 0-mismatch.

【Data Source and Data Extraction】 We queried PubMed in search of articles describing GVHD in pancreas transplant. The reported cases of the past 20 years were reviewed. We summarized the data on baseline characteristics, treatment, and mortality of GVHD in pancreas transplant.

【Results】 Fourteen cases were reviewed; nine patients were deceased and five survived. Among 10 cases with reported HLA combinations, three (30%) were donor-dominant HLA one-way 0-mismatched cases, and all three cases were fatal regardless of type of treatment.

【Conclusion】 Accumulation of GVHD cases in pancreas transplant contributed to a better understanding of the postoperative morbidity and treatment. Still, the presence of donor-dominant HLA one-way 0-mismatch seems to be a risk factor of GVHD and poor treatment response. The application of pancreas transplant for those patients should be carefully determined.