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Malignant melanoma represents the most common tumour responsible for donor-derived post transplan-tation malignancies. We report the varied presentation and outcome of three graft recipients (two kidney and hepatic) who developed metastatic melanoma following cadaveric organ transplantation from a single multiorgan donor. Two of the recipients presented with symptomatic metastatic lesions and the third patient , despite being carefully monitored, developed evidence of metastatic cutaneous melanoma. Two of the patients died as a direct result of their melanomas. The recipients of corneal and cardiac grafts remain disease-free. We conclude that despite careful screening , donor-derived tumours remain a not uncommon clinical entity. The identification of a lesion in one recipient should prompt immediate examination and investigation of the remaining recipients of multiorgan donations. A 42-year-old Caucasian female who had died in a local hospital from a subarachnoid haemorrhage was the organ donor. The donor HLA type was HLA A: 1,2; B: 60,14; DR: 4,13. The donor had a diagnosis of grade II cervical intraepithelial neoplasia 8 years previously, however , clinical examination was unremarkable at the time of donation. Her family consented for multiorgan trans-plantation including the kidneys, liver, heart and corneas. At the time of organ retrieval no intra-abdominal or in-trathoracic abnormalities were noted and no autopsy was performed. Recipient 1 The recipient of the first kidney, a 55-year-old Caucasian female with a lifelong history of pyelonephritis, had been maintained on haemodialysis for 2 years before transplan-tation. Her tissue type was HLA A: 2,3; B: 7,44; DR: 4,13 and the mismatch was 1 : 2 : 0. Postoperatively she experienced good immediate graft function and received immunosuppression with tacrolimus (Prograf ® , Fujisawa, Osaka, Japan)-based triple therapy (tacrolimus, azathio-prine and prednisolone). No antibody induction therapy was instituted. At 3 months post-transplantation the patient had normal renal function and the protocol renal biopsy performed was reported as normal. However 6 months post-transplantation, the patient had an emergency admission with severe abdominal pain and vomiting. Routine haematological and biochemical investigations were unremarkable as was a plain abdominal X-ray. Upper and lower gastrointestinal endoscopy were performed with no abnormalities visualized. During the admission the patient became increasingly confused , however, the CT scans of the head and thorax and abdomen performed were nondiagnostic. In view of the persisting symptoms a laparoscopy was performed which demonstrated numerous black plaques on the peri-toneal surface of the abdominal wall and on the omentum. Multiple biopsies were taken and the histological examination was compatible with metastatic melanoma. Post-operatively the patient's skin and mucosal surfaces were reexamined but no site of primary melanoma was identified. The antitumour management consisted of the withdrawal of immunosuppression...

To elucidate the biological importance of intrahepatic hepatitis D virus antigen, its expression was correlated with biochemical and histological inflammatory activity in 98 biopsy specimens from 68 patients seropositive for total antibody to the virus. Seventy five specimens were positive for intrahepatic nuclear antigen for HDV antigen accompanied by cytoplasmic HDV antigen in only one biopsy specimen. This group had significantly higher serum transaminase activities and inflammatory activity than the remaining cases that were negative for HDV antigen. Among the group positive for HDV antigen, there was no correlation between the proportion of hepatocytes containing HDV antigen and either serum transaminase activity or histological inflammatory indices.In 22 HDV antigen positive patients who had follow up biopsy specimens taken at a median of two years, the proportion with cirrhosis increased from 36% to 73%. Serum transaminase activities remained the same during this period, but the proportion of HDV antigen positive cells dropped. Follow up of 51 patients showed that 21 died or underwent liver transplantation within three years.The absence of an association between intrahepatic HDV antigen expression and progression of histological liver damage does not support the view that HDV is directly cytopathic to hepatocytes. Immune mediated mechanisms may have a role in the pathogenesis of chronic liver disease related to HDV infection.

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