Chimeric antigen receptor T cells (CAR‐T) are genetically modified T cells with a chimeric antigen receptor directed against a specific tumor‐associated antigen like CD19 in lymphoma. CAR‐T cells have shown encouraging activity against recurrent and refractory diffuse large B cell lymphomas (DLBCL). However concurrent use of immunosuppressive agents was prohibited in most CAR‐T trials effectively excluding patients with prior solid organ transplantation (SOT) and posttransplant lymphoproliferative disorders (PTLD). We report the outcomes for three patients with PTLD refractory to immunochemotherapy 10‐20 years after SOT who received CAR‐T therapy between January 2018 and December 2019. One patient had an orthotopic heart transplant, the second had a deceased donor kidney transplant, and the third had a pancreas after kidney transplant (PAK). All patients developed complications of CAR‐T therapy such as cytokine release syndrome, immune effector cell‐associated neurotoxicity syndrome, and acute kidney injury requiring renal replacement therapy in the two out of three patients. All patients expired after withdrawal of care due to lack of response to CAR‐T therapy. In addition, the PAK patient developed acute pancreatitis after CAR‐T therapy. This case series identifies the challenges of using CAR‐T therapy to manage refractory PTLD in SOT recipients and its possible complications.

Kidney transplantation is the best treatment modality for end-stage kidney disease, leading to improvement in a patient’s quality and quantity of life. With significant improvements in short-term outcomes, prolonging long-term allograft and patient survival remain ongoing challenges. The ability to monitor allograft function, immune tolerance and predict rejection accurately would enable personalization and better prognostication during post-transplant care. Though kidney biopsy remains the backbone of transplant diagnostics, emerging biomarkers can help detecting kidney allograft injury early enough to prevent permanent damage and detect injury before it is clinically apparent. In this review, we summarize the recent biomarkers that have shown promise in the prediction of acute rejection with a focus on antibody-mediated rejection in kidney transplantation.

Introduction: Multiorgan dysfunction involving the kidneys is not uncommon in patients with end stage heart and liver disease. Simultaneous heart-liverkidney transplants (HLK) are less commonly performed than simultaneous heart-kidney or liver-kidney transplants due to the complex nature of the surgery and challenges with patient selection. 19 HLK were performed in the US from 2008 to 2020, out of which 8 were performed at our center. Given the limited availability of organs for transplant and the lack of standardized qualifying criteria for these patients, it is imperative to understand the factors involved in better outcomes, to optimize utilization of scarce resources. Method: We performed a retrospective review of all HLK recipients at the University of Chicago medical center between 2008-2020 using Epic EMR. We evaluated their renal outcomes, infection rates, number of hospitalizations, and mortality over a 12-month period post transplantation. Results: Baseline characteristics are summarized in the table 1. 4(50%) were between the ages of 50-64, 2(25%) were between the ages of 35-49, and 2(25%) were between the age of 18-34. Four (50%) were Caucasians, 3(37.5%) were African Americans, and 1(12.5%) was Asian Indian. 6 (75%) had pre-transplant GFR between 30-40 ml/min, 1(12.5%) had GFR between 15-30 ml/min, and 1(12.5%) had GFR <15 ml/min. The etiology of CKD was as follows, 5(62.5%) were cardiorenal, 2(25%) were diabetic, 1(12.5%) was acute interstitial nephritis. All had Kidney Donor Profile Index (KDPI) below 20%. All had GFR above 50 ml/min at 3 months post-transplant, out of which 5 (62.5%) had GFR above 60 ml/min. At 6 months and 1 year, 3 (37.5%) had GFR above 60 ml/min, 3 (37.5%) were between 45-60 ml/min, and 2 (25%) had GFR between 30-45 ml/min. Only 1 patient developed delayed graft function requiring 2 sessions of dialysis post-transplant. All 8 were alive with intact kidney allograft function at 12 months after transplant. Only 2(25%) required a hospitalization within the 1st year of transplant for infection related reason. 2(25%) developed BK viremia and 2(25%) developed CMV viremia. Conclusion: Our experience suggests that with careful selection of patients, simultaneous HLK can lead to successful patient outcomes at one year post transplantation. Longer follow up of these patients is needed to define long term allograft and patient survival which will help to standardize selection and allocation criteria of this subset of patients.

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