Clinical Transplantation最新文献

Antibiotic allergy labels (AALs) are common and often incorrect. They have many potential impacts, including the use of broader-spectrum antibiotics and suboptimal treatment of infections. The impact of inaccurate allergy labels on post-transplant outcomes in the solid organ transplant population is not well described. We performed a retrospective review of 2,373 consecutive solid organ transplants occurring between 2011 and 2021, to analyze the impact of AALs, specifically penicillin, on outcomes in the first year after transplantation. Three hundred and twenty-two patients (13.6%) had a penicillin allergy label, while 572 patients (24%) had at least one antibiotic allergy label. Patients with a penicillin allergy label were more likely to have a positive Clostridioides difficile test (p = 0.021). Patients with allergy labels also had significantly more utilization of alternative antimicrobial agents (p < 0.001) and longer inpatient hospital durations (p = 0.013). This study suggests that AALs may be a risk factor for inferior outcomes after solid organ transplantation and could represent a modifiable target for pre-transplant optimization.

Background: Liver transplant (LT) anesthesiology has evolved alongside rising LT volumes in the United States. The formation of dedicated LT anesthesia teams (LTATs), formalization of director of LT anesthesia (DLTA), and standardization of LT anesthesia programs (LTAPs) have advanced the field. However, the current post-COVID-19 state of these initiatives remains poorly characterized.

Methods: From May 1 to June 31, 2024, we conducted a national electronic survey of 101 DLTAs representing 151 active adult LT programs in the U.S., excluding pediatric programs and programs without identifiable DLTA contacts. The survey assessed LTAT structure, clinical practices, professional perceptions, and anticipated future challenges.

Results: The response rate was 32.7% (33 of 101), predominantly from academic institutions (90.9%). Estimated number of LTATs averaged 6.6 members, with 38% fellowship-trained in transplant anesthesia, 27% in cardiothoracic anesthesia, and 23% in critical care. Overall 52% received institution-specific training. Forty two percent of LTAPs offered one-year LT anesthesiology fellowship. Most (82%) LTATs operated at 1:1 (including solo anesthesiologist in 15%) vs. 1:2 (7%) staffing ratios, involving residents (91% of cases), fellows (52%), and CRNAs (9%). Nearly all programs (94%) anticipated staffing changes, with 20 programs projecting 22 net hires. Approximately half of DLTAs (52%) considered their workforce adequate, while 36% reported a need for additional LT anesthesiologists. Overall, 76% of DLTAs were satisfied with their role, though increased workload (45%) and supply-demand mismatches (41%) were challenges.

Conclusion: Addressing workforce expansion and workload-related challenges may support LT anesthesia programs in meeting the demands of increasing national transplant volumes.

Background: Preserving health and quality of life are priorities of care for living liver donors (LLDs) due to their altruistic contribution to recipients. No study has examined the role of multimodal prehabilitation for living donor liver transplantation (LDLT). Prior to determining the efficacy of prehabilitation in LLDs, a feasibility study is required.

Methods: The objective of this feasibility randomized controlled trial (RCT) was to assess the feasibility of conducting a large-scale RCT of prehabilitation prior to LDLT. Thirty LLDs at Toronto General Hospital were randomized 2:1 to receive multimodal prehabilitation or usual care, respectively. The prehabilitation intervention comprised: (1) exercise, (2) nutrition support, (3) psychological counselling, and (4) LLD peer mentor sessions. The primary outcome was feasibility via rates of recruitment, retention, adverse events, adherence, and healthcare provider engagement. Clinical, patient-reported, and physical fitness outcomes were collected at baseline, preoperatively, and at 4 and 12 weeks postoperatively. Qualitative interviews were used to assess feasibility and satisfaction with the intervention.

Results: Sixty-three patients were eligible and 30 enrolled (48%). Participants' mean age was 42 ± 8 and 67% were female. There were no intervention-related adverse events. Attrition was 33% and adherence across each of the components of prehabilitation was ≥75%. Interviews demonstrated satisfaction with the prehabilitation intervention and areas for improvement for a Phase III RCT.

Conclusions: This study demonstrates a Phase III RCT of prehabilitation versus usual care may be feasible in LLDs. The Phase III trial will confirm the preliminary and exploratory physical and psychosocial benefit reported in this study.

Trial registration: ClinicalTrials.gov identifier: NCT0543136.

Introduction: Liver transplantation (LT) significantly improves survival and quality of life for patients with end-stage liver disease. Whilst it is believed that need for LT vastly exceeds organ supply, quantifying the demand accurately is challenging. The performance metrics of the transplant system, such as waitlist mortality, may be misleading as they capture only patients who are referred, evaluated and listed for LT. Although means of increasing organ availability are available, they have financial costs and may be technically and ethically challenging (such as live donation and normothermic regional perfusion). The imperative to embrace these techniques can be obscured if the waitlist is assumed to be representative of the actual demand for transplantation.

Methods: An international comparative analysis of transplantation, donation and waitlist outcomes versus measures of demand for LT was performed using publicly available data.

Results: The comparative analysis revealed no correlation between disease prevalence and waitlist metrics across jurisdictions internationally, suggesting that waitlisting practices are largely independent of actual LT demand and are constrained by other factors.

Conclusion: Adult LT systems globally are supply driven and uncorrelated to demand, implying that all jurisdictions are unable to meet the demand of their community and are limited by the supply of viable organs. The study underscores the inadequacy of waitlist data in representing true demand and highlights the need for improved data to inform LT policy and practice to improve access to this life-enhancing and life-saving treatment.

Background: As survival following solid organ transplantation (SOT) improves, attention has shifted to survivorship and quality of life (QoL) outcomes. Sexual function is an important component of women's health in transplant recipients. In the general population, sexual distress affects approximately 10%-15% of midlife women. Female SOT recipients may experience additional risk for sexual dysfunction related to surgery, body image, and immunosuppression. However, sexual health in this population remains understudied. This study assessed sexual function and its impact on QoL among female SOT recipients by menopausal status.

Methods: A cross-sectional study of female SOT recipients aged ≥ 18 years was conducted at a single tertiary transplant center from 2018 to 2023. Participants were within five years of kidney, liver, or pancreas transplantation. Validated questionnaires included female sexual function index (FSFI), female sexual distress scale (FSDS), menopause rating scale (MRS), linear analog scale assessment (LASA). Respondents were categorized as premenopausal or peri/postmenopausal. Sexual function, distress, and QoL were compared between groups, with exploratory analyses stratified by current sexual activity status.

Results: The survey response rate was approximately 30%. Among 277 respondents, peri/postmenopausal patients were less likely to be sexually active (48.9% vs 69.4%, p = 0.002). They reported lower desire, arousal, and lubrication scores, and higher sexual distress than premenopausal SOT recipients. While overall QoL was rated highly across both groups, sexual distress negatively correlated with QoL across menopausal groups. Among the entire cohort, most women (≈74%) had not been asked about sexual health by any provider in the past year.

Conclusion: Sexual dysfunction is common among female SOT recipients and is associated with menopausal status, with higher rates observed than those reported in the general population. These findings highlight the importance of integrating sexual health into posttransplant survivorship care.

Introduction: Although advanced age is no longer a contraindication for renal transplantation, real-world data on elderly transplant recipients remain limited.

Methods: This multicenter, prospective study enrolled de novo kidney transplant recipients aged 60 years or older receiving once-daily tacrolimus immunosuppression, following recovery of renal function and referral to the transplant clinic. The primary objective was to describe clinical characteristics and post-transplant outcomes over a 12-month follow-up. Secondary objectives included assessing changes in quality of life and the relationship between biopsy-proven acute rejection (BPAR) and tacrolimus levels.

Results: Of 280 evaluable patients, 239 completed the 12-month follow-up (mean recipient age: 69.8 years; mean donor age: 69.1 years) and 41 (14.6%) terminated due to graft loss (13, 31.7%), tacrolimus termination (12, 29.3%), death (10, 24.4%), loss to follow-up (3, 7.3%), other (2, 4.9%), and temporary tacrolimus interruption (1, 2.4%). BPAR occurred in 8.2% of patients who showed significantly higher tacrolimus levels vs those without BPAR over the follow-up (9.8 ng/mL vs. 8.9 ng/mL; p = 0.01). Opportunistic infections were reported in 78.3% patients with BPAR vs 58.8% without BPAR (p = 0.07). Quality of life improved across different domains of the Kidney Transplant Questionnaire and the ESRD-SCL.

Conclusion: This study monitored clinical outcomes during the first year post-transplant in older de novo kidney transplant recipients receiving grafts from older donors and under a once-daily tacrolimus-based immunosuppressive regimen. The incidence of BPAR, graft loss, and mortality was low, and patients generally experienced an improvement in quality of life, indicating an effective and safe procedure in this population.

Introduction: The anti-CD52 monoclonal antibody alemtuzumab is used as an induction agent in kidney transplantation (KT) but remains understudied in septuagenarian recipients. The study purpose was to analyze the safety and efficacy of single-dose alemtuzumab induction in septuagenarian deceased donor (DD) KT recipients.

Methods: Single center retrospective nonrandomized cohort review of septuagenarian DDKT recipients stratified by induction immunosuppression (single dose alemtuzumab versus multi-dose rabbit anti-thymocyte globulin [ATG]). Standardized management algorithms were used, and all patients received maintenance immunosuppression with tacrolimus/mycophenolate/steroids.

Results: From November 2003 to December 2024, 359 DDKTs were performed in septuagenarian recipients with either alemtuzumab (n = 270) or ATG induction (n = 89). Donor and recipient characteristics were largely comparable between the two groups. Five-year patient (70.3% alemtuzumab versus 82.9% ATG, p = 0.054), graft (60.2% alemtuzumab versus 74.7% ATG, p = 0.04) and death-censored graft survival (80.0% alemtuzumab versus 89.1% ATG, p = 0.11) rates favored the ATG cohort.

Conclusion: ATG induction was associated with improved survival outcomes in our cohort and may be the preferred induction agent in septuagenarians undergoing DDKT versus alemtuzumab. Given the findings of our study, caution is warranted with the use of alemtuzumab in elderly KT patients receiving triple maintenance immunosuppression.

Background: Hematopoietic stem cell transplantation (HSCT) is widely used in both malignant and non-malignant diseases in children. This study aimed to evaluate long-term endocrine complications in pediatric HSCT survivors.

Methods: Children who underwent HSCT between April 2010 and October 2014 were retrospectively assessed. Data included demographics, growth and nutritional status, thyroid function, bone health, pubertal development, and gonadal function.

Results: Seventy-five patients (45 males, 30 females; mean current age 18.8 ± 3.9 years) were included. The mean follow-up duration after HSCT was 9.7 ± 1.2 years, and at least one endocrine disorder was identified in 40 patients (53.3%). At the last follow-up, 23 patients (30.6%) were underweight, and 17 (18.6%) had short stature. Growth impairment was more frequent in patients with non-malignant diseases. Hypothyroidism was observed in 6 patients (8%), and low bone mineral density (BMD)/osteoporosis in 17 (22.6%). Short stature, malnutrition, low BMD, and vitamin D deficiency were more prevalent among those who underwent HSCT at ≥10 years of age. Hypogonadism was detected in 12 females (40%) and 11 males (24%) and showed no association with age at HSCT, pubertal stage, primary diagnosis, or conditioning regimen.

Conclusions: These findings underscore the importance of long-term endocrine surveillance in HSCT survivors, particularly in those transplanted at ≥10 years of age.