Ten Years of Kidney Paired Donation at Mayo Clinic: The Benefits of Incorporating ABO/HLA Compatible Pairs Background: We examined the 10 year experience of Mayo Clinic’s kidney paired donation (KPD).We aimed to determine the benefits for the recipients of enrolled ABO/HLA compatible pairs and determine the factors associated with prolonged KPD waiting time. Methods: We performed a retrospective study of 332 kidney transplants facilitated by the Mayo 3-site KPD program from 9/2007- 6/2018. Results: The median (IQR) time from KPD entry to transplantation was 89(42-187) days. The factors independently associated with receiving a transplant > 3 months after KPD entry included recipient blood type O and cPRA (calculated panel reactive antibodies) ≥ 98%. Fifty-four ABO/HLA compatible pairs participated in KPD for the following reasons: CMV mismatch [18.5 %(10/54)], EBV mismatch (EBV) [9.3 %(5/54)], age/size mismatch [51.9 %(28/54)] or altruistic reasons [20.3 %(11/54)]. CMV and EBV mismatch was avoided in 90 %(9/10) and 100 %(5/5) of cases. Recipients who entered KPD for age/size mismatch and altruistic reasons received kidneys from donors with lower Living Kidney Donor Profile Index (LKDPI) scores than their actual donor [median (IQR) 31.5(12.3, 47) p<.001, and 26(-1, 46), p=0.01 points lower, respectively]. Median time to transplant from KPD entry for compatible pair recipients was 70(41-163) days, and 44.4 %(24/54) of these transplants were preemptive. All chains/swaps incorporating compatible pairs included ABO/HLA incompatible pairs. Conclusion: KPD should be considered for all living donor/recipient pairs because the recipients of these pairs can derive personal benefit from KPD while increasing the donor pool for difficult to match pairs. Disclosures: The authors declare no conflicts of interest. Funding: This publication was supported by Clinical and Translational Science Awards Grant Number KL2 TR002379 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Correspondence: Arpita Basu MD, MPH, Emory Transplant Center, 1365 Clifton Road NE, Clinic Bldg B- Suite 6100, Atlanta, GA 30322, Email: arpita.basu@emory.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Challenges with the Cardiac Evaluation of Liver and Kidney Transplant Candidates Cardiovascular events are among the leading cause of mortality in kidney and liver transplant recipients. Thus, screening for cardiovascular disease and risk stratification for cardiovascular events constitute an important part of the pretransplant evaluation. In this overview, we first summarize current guidelines in the cardiac risk assessment of kidney and liver transplant candidates. We then elaborate on the limitations of these guidelines, summarize the current knowledge gaps and narrow down a spectrum of six themes that serves as challenges to research and practice development. This spectrum pertains to understanding the disease itself which is challenging due to the altered cardiac physiology in these patients and that current guidelines do not adequately account for nonischemic diseases and events. We then describe the challenges in assessing these patients, their symptoms, and individualizing their risk of cardiovascular events with a special consideration for non traditional risk factors. We also explore the limitations of the current and novel diagnostic tests and the lack of evidence of therapeutic efficacy in intervening in patients with asymptomatic disease. The transplant procedure itself can be a potential modifiable risk factor for cardiovascular events i.e. surgical technique, type of donor and induction immunosuppression. Lastly, we describe the potential issues with the current literature when defining cardiac diseases and events across different studies and shortcomings of extrapolating data from the nontransplant literature. We conclude by proposing research and practice implications of our discussion and that there is a need for evidence to guide the revision of current guidelines. Part of this manuscript was presented at the 27th International Congress of the Transplantation Society (Madrid June 30 – July 5, 2018) Disclosure: The authors declare no conflicts of interest Acknowledgments: This work was supported using clinical research funding from the Department of Medicine at the McGill University Health Center. Corresponding author: Marcelo Cantarovich, Royal Victoria Hospital Glen Site, D05-7176, 1001 boul. Decarie, Montreal, QC, Canada. H4A 3J1, Tel: (514) 934-1934 ext. 35203. Fax: (514) 938-7050. Email: marcelo.cantarovich@muhc.mcgill.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Re: Distinguishing between Sex and Gender is Critical for Research in Transplantation No abstract available

Distinguishing between Sex and Gender is Critical for Research in Transplantation No abstract available

Hepatitis C Infection in Kidney Donors: A Call to Re-examine its Relevance as a Predictor of Transplant Outcomes No abstract available

PCSK9 Inhibitor Use in Heart Transplant Recipients: A Case Series and Review of the Literature No abstract available

Constrictive Pericarditis after Lung Transplantation Background: Constrictive pericarditis is a rare, but increasingly recognized long-term post-operative complication of lung transplantation. Heightened clinical suspicion, improved diagnostic imaging and effective surgical treatment of the disease have led to progressive awareness of the pathology. We present our institutional experience with constrictive pericarditis after lung transplant in an effort to investigate the etiology and natural history of the disease. Methods: From October 2005 to October 2018, 1,234 patients underwent orthotopic lung transplantation at Duke University Hospital. An institutional database was queried to identify incident patients and determine baseline clinical data. At a median of 11.2 months (IQR 4.6-28.6 months), 10 patients (0.8%) developed constrictive pericarditis. Simple descriptive statistics were used to describe cohort characteristics and identify variables associated with constrictive pericarditis after lung transplantation. Results: The indication for transplantation at index operation was idiopathic pulmonary fibrosis in 8 of 10 patients (1.2% of the 760 restrictive lung disease patients transplanted in the same time period). All ten patients presented with worsening dyspnea and pleural effusions. Right heart catheterization confirmed constrictive physiology in all cases. Eight patients underwent pericardiectomy with improvement in cardiovascular hemodynamics and resolution of symptoms with no 30-day mortality. Conclusions: Diagnosis of constrictive pericarditis should be considered in patients with new onset heart failure symptoms and/or recurrent pleural effusions within 2 years of lung transplantation. Idiopathic pulmonary fibrosis may be associated with increased risk for constrictive pericarditis. Pericardiectomy is a safe and effective treatment for post-transplant constrictive pericarditis. Financial Disclosure: The authors declare no funding sources for this project. Conflict of Interest: The authors declare no conflicts of interest Corresponding Author: Charles M. Wojnarski, MD, Department of Surgery, Duke University Medical Center, Durham, NC 27705, USA. Email: charles.wojnarski@duke.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alterations In NKG2A and NKG2C Subsets Of Natural Killer Cells following Epstein Barr Virus Reactivation In CTLA4Ig Based Haploidentical Transplantation Is Associated With Increased Chronic Graft-Versus-Host Disease Background: The impact of newer approaches to haploidentical transplantation on Epstein Barr virus (EBV) is largely unknown. Methods: We prospectively evaluated the incidence of EBV reactivation and its impact on transplantation outcomes in 71 patients undergoing haploidentical transplantation with post-transplantation cyclophosphamide (PTCy) in combination with CTLA4Ig based T-costimulation blockade (COSBL). Results: Eight patients developed EBV reactivation at a median of 96 days with no incidence of lymphoproliferative disorder (LPD). There was no impact of EBV reactivation on acute GVHD, non-relapse mortality, progression-free or overall survival. Despite an overall incidence of 19%, there was a significant increase in chronic GVHD following EBV reactivation (62.5% vs 8%, p=0.01). NKG2Apos subset of CD56dim NK cells increased substantially and persisted following EBV reactivation and chronic GVHD, with a reciprocal decrease in NKG2Cpos subset, whereas the reverse was witnessed in those without chronic GVHD (p< 0.01). Increase in NKG2Cpos subset and a decrease in the NKG2Apos subset was witnessed within 3 months of subsidence of chronic GVHD. Conclusion: Thus, CTLA4Ig based haploidentical transplantation was associated with a low incidence of EBV reactivation without EBV-LPD. However, EBV reactivation was associated with a sustained alteration in NKG2A and NKG2C subsets of CD56dim NK cells which might have a pathogenic role in chronic GVHD. Financial Disclosure: None Authorship Contribution: SRJ, and SC designed and performed the study. SRJ and PB performed the experiments. GB, HMA and PB collected the data and SRJ and SC analysed the data; SRJ, AC and SC wrote the manuscript. All the co-authors reviewed and approved the manuscript. Acknowledgments: We thank all the patients and family members who participated in this study. We also thank each and every member of our department for their help in patient care and execution of the study. Financial disclosure: The authors have no conflicts of interest to disclose. Funding: None to declare ADDRESS FOR CORRESPONDENCE: Sarita Rani Jaiswal, Program Director, Department of Blood and Marrow Transplantation & Hematology, Dharamshila Narayana Superspeciality Hospital and Research Centre, Vasundhara Enclave, New Delhi-110096, India. Email: drsaritaranij@gmail.com; Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Implications of NKG2A in EBV reactivation and chronic graft-versus-host disease following allogeneic hematopoietic stem cell transplantation No abstract available

Immunosuppression and Graft Rejection in Living-Related HLA-Identical Renal Transplantation: The RADOVFULL Study Purpose We aimed to describe the immunosuppressive regimens and graft rejection rates in living-related HLA-identical (LR HLAid) renal transplantation. Methods We performed a retrospective multicenter analysis of the French national database for LR HLAid renal transplantations performed between 2002 and 2012. Univariate and multivariate analysis were performed to determine risk factors for graft rejection in LR HLAid recipients. Results 27.218 renal transplantations were performed of whom 163 had a LR HLAid donor. Concerning immunosuppressive treatment, less than 60% of the cohort had induction therapy with polyclonal or monoclonal antibodies, 28% did not receive calcineurin inhibitors and 36% did not receive steroids in maintenance. Biopsy-proven acute rejection was diagnosed in 21 patients (12.9%). Rejection occurred on an average of 24 months after transplantation, in 28.5% of the cases after minimization of immunosuppression. Factors associated with rejection were age of recipient (OR = 0.91[0.84-0.96], p=0.003), the body mass index of donors (OR = 1.22[1.04-1.46], p=0.01) and minimization of immunosuppression (OR = 26.2[5.48-166.6], p < 0.001). Overall and graft survival rates were not statistically different according to rejection at 1, 5 and 10 years post transplantation. Conclusion Minimization of immunosuppression should be done with caution in LR HLAid renal transplantations. Disclosures The authors have no conflicts of interest to disclose relevant to the contents of this paper. Funding: The authors have received no financial support for the publication of this article. Corresponding author: Dr Rim OSSMAN, Urgences Néphrologiques et Transplantation Rénale – Hôpital Tenon – APHP, 4 rue de Chine, 75020 Paris, France. Phone: 33 6 73 32 99 91, Fax: 33 1 56 01 79 68, E-mail: rimossman@hotmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.