1. First Multivisceral Transplant following Successful Anti-Retroviral Therapy in HIV-Infected Patient with Short Gut Syndrome A Khanna,C Koval,A Pallotta,B Eghtesad,M Fujiki,K Hashimoto,A Bennett,K Abu-Elmagd OBJECTIVES MATERIALS AND METHODS RESULTS CONCLUSIONS  The continual improvement in outcomes with HAART and Visceral Transplantation (VT) triggered our interest in lifting HIV infection as contraindication for VT.  Unpredictable pretransplant absorptive capacity with short gut syndrome (SGS) may limit HAART efficacy. Post-transplantation, inherent allograft immunogenicity may provoke destructive alloimmune response.  This report is the first to describe VT in a patient with HIV infection with antiretroviral management strategy, technical and immunologic challenges.  A 37 year-old male presented with acute abdomen due to severe Clostridium difficile colitis. He was found to have HIV-1 (CD4 641 cells/mm 3, viral load 105,000 copies/ml, no AIDS defining illness) and underwent total colectomy with midgut resection due to mesenteric venous infarction. Massive peristomal variceal hemorrhage ensued and TIPS was placed resulting in diffuse PMVT. He developed endstage liver failure and AKI requiring dialysis. Patient was accepted for multivisceral transplantation. He was successfully treated with HAART and achieved undetectable viral load  Multivisceral transplantation (stomach, intestine, liver, pancreas) + kidney without induction was performed: Steroid bolus, Tacrolimus intravenous started day +1 Post Transplant Course (Figure 1)  Antiviral therapy: Day +7: raltegravir, abacavir and 3TC by J-tube : HIV VL <20 c/ml; CD4 45-83 cells/ul (27-34%)  4 documented episodes of intestinal rejection (Figure 2) Day +16: steroid bolus, Day +50: steroid bolus, rATG x 2, Day +71: steroid bolus, rATG, alemtuzumab  A total of 23 total intestinal biopsies were performed and most of the histopathologic features were of cellular rejection with occasional microvascular capillary thrombosis (Figure-3-inset).  Intraoperative culture grew Candida albicans, VREF that required multiple abdominal explorations with continuation of daptomycin and tigecycline therapy. Candida parapsilosis, Candida dublienensis, multidrug resistant Citrobacter freundii, and Pseudomonas aeruginosa were isolated from drained intra-abdominal collections and Pseudomonas aeruginosa pneumonia from left lung despite optimal colistin and meropenem therapy.  The patient died from disseminated Citrobacter freundii and Pseudomonas aeruginosa infection. Introduction of a novel HAART regimen with achievement of undetectable HIV viral load in the presence of SGS is a seminal contribution to the field. VT, contrary to solid organs, may carry a higher risk of HIV reactivation due to the high lymphophylic affinity of the virus. The witnessed unsuccessful outcome is the result of technical and immunologic challenges that include robust gut alloimmune response and the immune dysregulations associated with HIV infection. It remains to be proven if the HIV-associated repertoire of gut lymphocytes combined with altered microbiota disrupts the intestinal mucosal barrier with increased risk of bacterial infections 473