Background. Antibody-mediated rejection (AMR) is a leading cause of morbidity and mortality after kidney transplantation. Early diagnosis and treatment of subclinical AMR based on the donor-specific antibody (DSA) testing may result in better outcomes. Methods. We tested this hypothesis in 220 kidney transplant recipients who underwent an indication or DSA-based surveillance protocol biopsies between March 1, 2013 and December 31, 2016. Patients were divided into 3 groups: clinical AMR (n = 118), subclinical AMR (n = 25), or no rejection on protocol biopsy (controls; n = 77). Results. Both clinical and subclinical AMR groups underwent similar treatment including plasmapheresis, pulse steroids, IVIG, and rituximab (P = ns). Mean follow-up after AMR was 29.5 ± 16.8 months. There were 2 (3%), 2 (8%), and 54 (46%) death-censored graft failures in the control, subclinical, and clinical AMR groups, respectively (P < 0.001). Graft outcomes were similar in the subclinical rejection and control groups. In adjusted Cox regression analysis, only clinical rejection (hazards ratio [HR], 4.31; 95% confidence interval [CI], 1.01-18.94; P = 0.05) and sum chronicity scores (HR, 1.16; 95% CI, 1.01-1.35; P = 0.03) were associated with increased risk of graft failure, while estimated glomerular filtration rate at time of biopsy (HR, 0.98; 95% CI, 0.96-0.99; P = 0.01) was associated with decreased risk of graft failure. Conclusions. Our study suggests that early diagnosis and treatment of subclinical AMR using DSA monitoring may improve outcomes after kidney transplantation.

Introduction Donor-specific antibodies (DSAs) are considered an important risk factor for graft injury and failure. However, there is limited information on long-term outcomes for kidney transplant recipients with positive DSAs in the absence of rejection on biopsy. Methods We evaluated all patients at the University of Wisconsin who underwent a kidney allograft biopsy between January 1, 2013, and December 31, 2016. All patients with clinical indication or protocol biopsies that were negative for acute rejection and lacked significant acute pathological features were included in the study and divided into 2 groups based on DSAs at the time of biopsy. There were a total of 1102 kidney biopsies during the study period of which 587 fulfilled our selection criteria (DSA+, n = 192, and DSA−, n = 395). The incidence of subsequent rejection and death-censored graft failure (DCGF) were outcomes of interest. Results There was no difference in acute (i + t + v + c4d + ptc + g = 0 in both groups) or chronic (ci + ct + cv + cg = 2.4 ± 2.2 vs. 2.7 ± 2.4; cg = 0.12 ± 0.48 vs. 0.13 ± 0.48) Banff scores in the index biopsy. Patients were followed for a mean of 33.1 ± 16.8 months. Kaplan-Meier analyses demonstrated a higher incidence of DCGF in DSA− group ( n = 83) but this was not observed for subsequent rejection ( n = 76). In multivariate Cox regression analyses, the interval from transplant to biopsy, de novo DSA, and younger age remained independently associated with increased risk of subsequent rejection. Notably, there was no association between subsequent rejection or DSA (pretransplant, de novo , persistant, Class I/II, MFI sum , or MFI max ) and graft failure. Conclusion This study suggests that in the absence of biopsy-proven rejection and acute inflammation, human leukocyte antigen (HLA) DSAs are not associated with increased risk of graft failure.

Neuroendocrine tumors (NET) are a heterogeneous group of cancers, with indolent behavior. The most common primary origin is the gastro-intestinal tract but can also appear in the lungs, kidneys, adrenals, ovaries and other organs. In general, NET is usually discovered in the metastatic phase (40%-80%). The liver is the most common organ involved when metastases occur (40%-93%), followed by bone (12%-20%) and lung (8%-10%).A number of different therapeutic options are available for the treatment of hepatic metastases including surgical resection, transplantation, ablation, trans-arterial chemoembolization, chemotherapy and somatostatin analogues. Recently, molecular targeted therapies have been used, usually in combination with other treatment options, to improve outcomes in patients with metastases. This article emphasizes on the role of surgery in the treatment of liver metastases from NET.

Although liver transplantation cannot be considered a first-line treatment, it is a valid therapeutic option in selected patients who are not amenable to resection. Only 0.17% of the transplants in the United States are performed for this indication, with satisfying long-term results. Age was an independent predictor of patient survival. Further studies are needed to better understand the role of liver transplantation in the treatment of BSLT.

Takotsubo cardiomyopathy (TTC) is a transient systolic dysfunction of the left ventricle which is usually seen in elderly women, often following a physical or emotional stressful event. Little is known about the prognostic factors affecting the recovery of systolic function. Thirty-six patients diagnosed with TTC from January 2006 to January 2017 at our hospital were included. Median time to recovery of ejection fraction (EF) was calculated to be 25 days. Early recovery of ejection fraction was defined as less than or equal to 25 days (group 1) and late recovery was defined as more than 25 days (group 2). Demographic and clinical factors were compared between the groups. Fifty percent patients had early recovery of EF with a mean time to recovery of 7.11 days and 50% had late recovery of ejection fraction with a mean time to recovery of 58.38 days. Younger age at presentation was associated with early recovery of systolic function (58.83 ± 2.7 years . 67.33 ± 2.7 years, = 0 .032). Presence of an identifiable triggering event was associated with early recovery (83% in group 1 . 50% in group 2, = 0.034). Generalized anxiety disorder was seen more commonly in the group with early recovery (78% in group 1 . 45% in group 2, = 0.040). In conclusion, younger age, generalized anxiety disorder and presence of triggering event were seen more commonly in patients with early recovery of left ventricular systolic function in Takotsubo cardiomyopathy.

A previously healthy 25-year-old Caucasian male with past medical history significant only for nephrolithiasis presented to Monmouth Medical Center with complaints of palpitations for the past one day. The patient has no known cardiac history, no other risk factors for atrial fibrillation, non smoker, no illicit drug use, occasional alcohol drinker. Approximately, two days prior to his presentation the patient started consuming an over the counter pre-workout energy supplement . He stated that he had started to consume this supplement for better concentration and to increase his stamina for his workout. On the day of admission, the patient had gone out for a fishing trip in the morning after consuming another two capsules of the same pre-workout supplement. He developed palpitations and shortness of breath at the fishing trip and was concerned about his symptoms. He presented himself to the Emergency Department (ED) for further evaluation and treatment.On admission, he denied any further complaints. His vitals were stable except for his rapid heart rate of 140 bpm which was irregularly irregular. He was not in acute distress and his Electrocardiogram showed atrial fibrillation with rapid ventricular response, rate of 123 bpm, normal axis, and no ST-T wave changes [Table/ Fig-2]. Physical examination was remarkable for were unremarkable, his thyroid functions were in the normal range, urine and serum toxicology screen were negative for any drugs or illicit substances. Concerning the Electrocardiogram and physical examination findings a diagnosis of new onset atrial fibrillation with rapid ventricular response was made.The patient was administered intravenous diltiazem boluses in the ED and was started on a diltiazem infusion for rate control of his atrial fibrillation. Heart rate was continuously monitored on telemetry. The patient eventually converted into normal sinus rhythm, 9 hours after initiation of diltiazem infusion. The patient eventually had an echocardiogram which showed LVEF 66%, normal left ventricular size, trace mitral regurgitation and trace tricuspid regurgitation and no other significant valvular pathology. Given the patient's unremarkable echocardiogram, unremarkable labwork and absent cardiac history along with no other risk factors for atrial fibrillation the cause of his new onset atrial fibrillation was attributed to his consumption of over the counter energy capsules. His CHADS2 VASc score was 0 and hence the patient was eventually discharged home with regular scheduled outpatient follow-up visits. DISCUSSIONOver the counter stimulants are easily available in the form of pills, energy drink, liquid capsules and energy shots. One of the major constituents of these preparations is caffeine. The amount of caffeine present in these over the counter energy supplements are in excess compared to the standard FDA approved guidelines for quantities' of caffeine [Table/ Fig-1]. These are widely aimed at the teenagers and young adults. Several studies suggest that energy drinks may serve as a gateway...

A 44-year-old woman who intentionally ingested brodifacoum was successfully treated with phytonadione, PCC, and FFP.

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