Kidney transplantation is considered the preferred treatment option to promote physical and psychosocial growth for paediatric patients with deteriorating renal function and end-stage renal disease. For this pool of patients, the reality is that more than one kidney transplant will be required in their lifetime. One cause of allograft failure is the development of de novo donor-specific antibodies (dnDSA) which is strongly associated with transplant nephropathy and kidney allograft failure. Subsequent transplantation is then hampered because of sensitisation, with the consequence being a longer wait time for a second transplant. This is often combined with poorer graft survival rates. Current literature supports the realisation that HLA-DR mismatching at first transplant leads to greater sensitisation because of eplet mismatches, and that some human leukocyte antigens (HLA) mismatches pose a greater risk for transplant glomerulonephropathy than others, by virtue of the eplet mismatch load. This case study follows the journey of one such child through a desensitisation schedule of plasma exchange therapy, rituximab and intravenous immunoglobulin (IVIg) treatments, which enabled the child a greater chance of receiving a second kidney transplant that would not be rejected by pre-existing antibodies. It tracks the events prior to receiving a second renal transplant from a deceased donor and includes progress during the first year following transplantation. It highlights the significance of the question, “should donor selection be further modified to capture eplet mismatching?”

Background
Renal transplantation would provide the best treatment option for Indigenous people of Northern Australia living in remote communities. However, the number of Indigenous Australians receiving a renal transplant is low. Poor graft and patient survival rates are common. We have observed that a significant number of patients do well. This study assessed factors contributing to the difference between those with favourable and unfavourable outcomes.
Study design
We performed a descriptive case review study of 14 Indigenous Australians who received a renal transplant between 1998 and 2013. Patients were divided into favourable (graft survival ≥5 years) and unfavourable outcomes groups (graft survival <5 years). We extracted data for potential influential factors: age; gender; renal diagnosis; co-morbidities; donor; cold ischaemia time; delayed graft function; post-operative complications; rejection episodes and treatment; cancers; socio-economic status; dialysis modality and vintage; human leucocyte antigen matching; induction and maintenance immunosuppression; renal biopsies; infections and outcomes.
Results
There were seven patients in each group. Those with unfavourable outcomes tended to be younger at the time of transplantation, have shorter dialysis vintage (length of time on dialysis), higher numbers of human leucocyte antigen mismatches, stronger induction immunosuppression, more episodes of rejections, more episodes of infections, delayed graft function, shorter cold ischaemia time and were from an urban environment.
Conclusion
Northern Territory Indigenous Australians can do well with renal transplants. There are potential predictors for both favourable and unfavourable outcomes which can potentially be identified before listing and at the time of transplantation. Performing prospective studies with appropriate sample sizes can identify these factors.

Background
From 2004 to 2015, over 2000 transplants were carried out from deceased donors. The potential donors were usually notified to the National Organ Transplant Unit (NOTU) by inpatient departments when the patients have passed away. There are no existing pathways to refer potential donors from the emergency department (ED). We aimed to characterise potential tissue or organ donors who present to the ED.
Methods
This is a retrospective observational study at a major tertiary hospital in Singapore. We identified potential donors among patients who died in the ED from 1 January 2015 – 31 December 2015. Patients were cross-referenced with the NOTU list of organ donation objectors. As the Human Organ Transplant Act (HOTA) only applies to citizens and permanent residents of Singapore, only this group of patients were analysed.
Results
A total of 240 patients passed away in the ED. One hundred and seventy-three patients were recruited into the study. The participants consisted of 114 (65.9%) males, 141 (65.9%) were Coroner cases and 135 (78.0%) were of Chinese descent. One hundred and eighteen (68.2%) patients were above the age of 65, while 6 (3.5%) were aged 20 or younger. Visit diagnoses consisted of: 12 (6.9%) had non-specific cardiac arrest; 106 (61.3%) cardiovascular-related causes; 17 (9.8%) were cancer-related; and 12 (6.9%) were others. One (0.6%) was an objector to organ transplant and 2 (1.2%) voluntarily pledged to donate their organs upon death.
Conclusion
A large majority of the patients were elderly Chinese males, and triaged as P1/P1F (immediate care needed). Most patients were non-objectors to organ transplant. The ED provides a pool of potential donors that transplant coordinators can tap. However, more research is needed on the reasons why the non-objectors and pledgers did not have their organ/tissue donated.