Clinical Transplantation最新文献_第10页

Higher Hospitalization Costs and Fewer Routine Discharges in the Medicaid Expansion Era for Lung Transplant Recipients 肺移植受者在医疗补助扩展时代的住院费用更高，常规出院次数更少。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-11 DOI: 10.1111/ctr.70017

Andrew Kalra, Jessica M. Ruck, Alice L. Zhou, Armaan F. Akbar, Albert Leng, Bin You, Alfred J. Casillan, Jinny S. Ha, Christian A. Merlo, Errol L. Bush

Background

In January 2014, states expanded Medicaid access under the Affordable Care Act. We studied the financial implications of this policy on lung transplantation, a costly procedure.

Methods

Lung transplant (LT) hospitalizations were identified within the National Inpatient Sample (2005–2020). Recipients were categorized as “pre-expansion” (1/2005–12/2013) versus “post-expansion” (1/2014–12/2020) of Medicaid and as being in “expander” versus “non-expander” regions. We calculated difference-in-differences estimates comparing pre- and post-expansion eras in expander versus non-expander regions for inflation-adjusted hospitalization costs and for discharge disposition. We evaluated total hospitalization costs using multivariable generalized linear regression, adjusting for recipient demographics, Charlson Comorbidity Index, single versus double-lung transplant, and extracorporeal membrane oxygenation (ECMO), ex-vivo lung perfusion (EVLP), and mechanical ventilation usage.

Results

Of the 29 225 LT recipients identified, 14 085 were pre-expansion and 15 140 were post-expansion. More recipients were insured by Medicaid in expander n = 735 (9%) versus non-expander n = 220, (3%) regions (p = 0.01) post-expansion. Hospitalization costs increased post- versus pre-expansion by $20 948 (95% CI = $8713–$33 183, p < 0.001) more in expander versus non-expander regions even after adjustment for risk factors associated with increased costs. Within expander regions, recipients post- versus pre-expansion were less likely to be discharged routinely (n = 2625, 28% vs. n = 3959, 44%) and more likely to be discharged to care facilities (n = 2045, 22% vs. n = 1045, 12%, p < 0.001).

Conclusions

Although Medicaid expansion resulted in greater access to care, it was associated with increased hospitalization costs and fewer routine discharges for LT recipients. Further research is warranted to identify the reasons that underpin the financial sequelae of Medicaid expansion, including changes in access to care for sicker patients.

背景：2014 年 1 月，各州根据《平价医疗法案》扩大了医疗补助的使用范围。我们研究了这一政策对肺移植这一昂贵手术的财务影响：在全国住院病人样本（2005-2020 年）中确定了肺移植（LT）住院病例。受助者被分为医疗补助 "扩张前"（1/2005-12/2013）和 "扩张后"（1/2014-12/2020），以及 "扩张 "地区和 "非扩张 "地区。我们计算了通货膨胀调整后的住院费用和出院处置的差异估计值，比较了扩张前和扩张后地区与非扩张地区的差异估计值。我们使用多变量广义线性回归评估了住院总费用，并对受者人口统计学、查尔森疾病指数、单肺移植与双肺移植、体外膜肺氧合（ECMO）、体外肺灌注（EVLP）和机械通气的使用情况进行了调整：在已确认的 29 225 名长期肺移植受者中，有 14 085 人是肺移植扩展前的受者，15 140 人是肺移植扩展后的受者。在扩大医保范围后，扩大医保范围地区的 735 人（9%）与非扩大医保范围地区的 220 人（3%）相比（P = 0.01），扩大医保范围地区的医疗补助受保人更多。扩展后与扩展前相比，住院费用增加了 20 948 美元（95% CI = 8713-33 183 美元，p 结论：尽管医疗补助扩展使更多的人获得了医疗补助，但医疗补助的使用率却有所下降：虽然医疗补助计划的扩大使人们获得了更多的医疗服务，但却增加了住院费用，减少了长期住院患者的常规出院次数。有必要开展进一步研究，以确定扩大医疗补助计划后产生财务后遗症的原因，包括病情较重的患者在获得医疗服务方面的变化。

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引用次数: 0

Kidney Transplantation From Donors With Malignant Renal Masses: A Systematic Review 恶性肾肿块供体的肾移植：系统回顾。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-08 DOI: 10.1111/ctr.70020

Vincenzo Villani, Rupak D. Kulkarni, Jeffrey H. Fair, Kumaran Shanmugarajah

Background

Small malignant renal tumors can be found in up to 1.3% of kidney donors. Several studies have investigated the use of these kidneys for transplantation, after ex vivo resection of the malignant mass.

Methods

We performed a systematic review of the literature on PubMed, Embase, and Web of Science of studies including reports of malignant renal masses excised from kidney grafts prior to transplantation. Articles including benign pathology only were excluded.

Results

Our search strategy identified 226 patients over 32 studies. Pathology included 107 clear cell carcinomas, 27 papillary renal cell carcinomas (RCCs), 84 other types of RCCs, and 8 transitional cell carcinomas. The majority of cancers were grade 1 or 2 (81.6%). Average tumor size was 12.6 mm. Clavien–Dindo ≥ 3 complication rate was 22%. Mean follow-up was 39.9 months. The 1-year, 3-year, and 5-year overall survival rate for recipients of living donor grafts was 95.8%, 92.1%, and 75.1%. The 1-year, 3-year, and 5-year living donor death-censored graft survival rate was 90.8, 85.2%, and 64.8%. Of the 226 patients, 6 (2.7%) experienced a malignant recurrence. The average time to recurrence was 36.1 months.

Conclusions

Transplantation of kidney grafts after resection of small cancerous masses is relatively safe and has low rates of recurrent malignancy. In the case of a living donor, appropriate counseling on partial nephrectomy versus donor nephrectomy should be provided, ideally by a surgeon who is not part of the transplant team. Recipients of these grafts should be carefully selected and counseled regarding the additional potential technical and oncological risks.

背景：在多达 1.3% 的肾脏捐献者中可发现小的恶性肾肿瘤。有几项研究调查了这些肾脏在体外切除恶性肿块后用于移植的情况：我们在 PubMed、Embase 和 Web of Science 上对有关移植前从肾脏移植物中切除恶性肾肿块的研究报告进行了系统性回顾。结果：我们的搜索策略在 32 项研究中发现了 226 名患者。病理结果包括107例透明细胞癌、27例乳头状肾细胞癌（RCC）、84例其他类型的RCC和8例过渡细胞癌。大多数癌症为 1 级或 2 级（81.6%）。肿瘤平均大小为 12.6 毫米。克拉维恩-丁多并发症≥3级的比例为22%。平均随访时间为 39.9 个月。活体移植物受者的 1 年、3 年和 5 年总生存率分别为 95.8%、92.1% 和 75.1%。活体移植物接受者的 1 年、3 年和 5 年存活率分别为 95.8%、92.1% 和 75.1%，活体移植物接受者的 1 年、3 年和 5 年死亡剪除存活率分别为 90.8%、85.2% 和 64.8%。在226例患者中，有6例（2.7%）恶性肿瘤复发。平均复发时间为36.1个月：结论：切除小癌块后进行肾移植相对安全，恶性肿瘤复发率较低。对于活体捐献者，应就肾部分切除术和捐献者肾切除术提供适当的咨询，最好由不属于移植团队的外科医生提供咨询。应谨慎选择这些移植物的受体，并就潜在的额外技术和肿瘤风险提供咨询。

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引用次数: 0

Transition of Care of Stable Kidney Transplant Patients to Referring Nephrologists: A Survey of U.S. Transplant Program Staff 将病情稳定的肾移植患者转诊给肾科医生：美国移植项目工作人员调查。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-08 DOI: 10.1111/ctr.15484

Prince Mohan Anand, Kenneth J. Woodside, Neeraj Singh, Tarek Alhamad, Roy D. Bloom, Gaurav Gupta, Gary Singer, Mona Doshi, Darshana M. Dadhania, Bekir Tanriover, Ronald F. Parsons, Caroline Wagner, Huiling Xiao, Krista L. Lentine, the Graduating Kidney Transplant Patients Controversies Workgroup

Background and Objectives

We conducted a national survey to assess the opinions and experiences of transplant center staff related to processes of care graduation.

Methods

Following IRB approval, medical staff at U.S. adult kidney transplant programs were surveyed using the Qualtrics survey platform (4/5/2022–10/05/2022). Respondents were invited via email and listservs of professional societies. If > 1 survey was submitted for a program, a selection hierarchy was utilized (e.g., prioritizing nephrologists’ responses).

Results

Respondents provided data from 46.7% of active programs (N = 92), representing 67% of the national kidney transplant volume. Most respondents (70%) were nephrologists. Full graduation to referring nephrologists was reported by 39% of transplant programs, with an additional 48% reporting partial graduation with ongoing co-management. Rationales for graduation were multifactorial, most commonly including patient travel distance (64%), maintenance of referral base (58%), continuity of care (58%), and center and/or patient burden (54%). Common reasons cited by programs for postgraduation return of care to the transplant center included worsening renal function (82%), malignancy (66%), opportunistic infection (63%), limited local nephrologist availability (60%), and pregnancy planning (57%). Additional coordinators and clinic staff were cited as needed to make transplant center perpetual care feasible by 78% of programs, with 71% stating that more clinicians are needed, while half thought more physical space or telemedicine are required.

Conclusions

Graduation of kidney transplant patients is common, with half of programs using a joint-care approach and another third reporting full return of care to the referring nephrologist. Expanded opportunities related to transplant care for the broad nephrology community are essential.

背景和目标：我们在全国范围内开展了一项调查，以评估移植中心工作人员对护理毕业流程的看法和经验：我们开展了一项全国性调查，以评估移植中心员工对护理毕业流程的看法和经验：在获得 IRB 批准后，我们使用 Qualtrics 调查平台对美国成人肾移植项目的医务人员进行了调查（4/5/2022-10/05/2022）。通过电子邮件和专业协会列表邀请受访者。如果一个项目提交的调查超过 1 份，则采用分层选择法（例如，优先考虑肾脏科医生的答复）：受访者提供的数据来自 46.7% 的活跃项目（N = 92），占全国肾移植总量的 67%。大多数受访者（70%）是肾病专家。有 39% 的移植项目报告称，转诊肾脏病学家完全分级，另有 48% 的项目报告称，部分分级并持续共同管理。分级的理由是多方面的，最常见的包括患者的旅行距离（64%）、转诊基础的维护（58%）、护理的连续性（58%）以及中心和/或患者的负担（54%）。毕业后返回移植中心接受治疗的常见原因包括肾功能恶化（82%）、恶性肿瘤（66%）、机会性感染（63%）、当地肾病专家有限（60%）和怀孕计划（57%）。78%的项目认为需要增加协调员和诊所工作人员，以使移植中心的永久护理可行，71%的项目表示需要更多临床医生，而半数项目认为需要更多物理空间或远程医疗：结论：肾移植患者的分级治疗非常普遍，半数项目采用联合护理方法，另有三分之一的项目报告称将护理工作完全交还给了转诊的肾科医生。为广大肾脏病学界提供更多与移植治疗相关的机会至关重要。

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引用次数: 0

Novel Scoring System for Ranking Hematopoietic Stem Cell Transplantation 造血干细胞移植排名的新评分系统。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-08 DOI: 10.1111/ctr.15478

Lee Ann Baxter-Lowe, Tao Wang, Michelle Kuxhausen, Stephen R. Spellman, Martin Maiers, Stephanie Lee, Jennifer Saultz, Esteban Arrieta-Bolaños, Shahinaz M. Gadalla, Yung-Tsi Bolon, Brian C. Betts

Background

When human leukocyte antigen (HLA)-matched donors are not available for hematopoietic stem cell transplants (HSCT), there are no well-accepted guidelines for ranking 7/8 HLA-matched unrelated donors to achieve optimal transplant outcomes. A novel scoring system for ranking HLA mismatches for these donors was investigated.

Methods

High-resolution HLA types were used to determine amino acid mismatches located in the HLA antigen-recognition domain. The location and physicochemical properties of mismatched amino acids were used to assign scores for peptide binding, T-cell receptor docking, and HLA structure/function. The scores were tested using a cohort of 2319 patients with leukemia or myelodysplastic syndrome who received their first unrelated donor transplant using conventional graft-versus-host disease (GVHD) prophylaxis between 2000 and 2014. Donors were 7/8 HLA-matched with a single HLA Class I mismatch. Primary outcomes were overall survival and acute GVHD.

Results

The scores did not significantly (p < 0.01) associate with transplant outcomes, although a Peptide Score = 0 (i.e., no differences in peptide binding; N = 146, 6.3%) appears to have lower transplant-related mortality (TRM) compared to higher scores (p = 0.019). HLA mismatches with Peptide Score = 0 were predominately HLA-C*03:03/03:04 (62%), previously reported to be a permissive mismatch, and a group of 28 other HLA mismatches (38%) that showed similar associations with TRM.

Conclusions

This study suggests that HLA mismatches that do not alter peptide binding or orientation (Peptide Score = 0) could expand the number of permissive HLA mismatches. Further investigation is needed to confirm this observation and to explore alternative scoring systems for ranking HLA mismatched donors.

背景：当没有人类白细胞抗原（HLA）匹配的供者进行造血干细胞移植（HSCT）时，没有公认的指南对7/8 HLA匹配的非亲属供者进行排序，以获得最佳移植结果。方法：利用高分辨率HLA分型确定位于HLA抗原识别结构域的氨基酸错配。利用错配氨基酸的位置和理化性质为肽结合、T 细胞受体对接和 HLA 结构/功能分配分数。2000年至2014年期间，2319名白血病或骨髓增生异常综合征患者接受了首次非亲缘供体移植，并采用了传统的移植物抗宿主病（GVHD）预防措施。供体有7/8个HLA匹配，只有一个HLA I类不匹配。主要结果是总生存率和急性GVHD：结果：得分无明显差异（P这项研究表明，不改变肽结合或取向的 HLA 错配（肽得分 = 0）可增加允许的 HLA 错配的数量。需要进一步调查以证实这一观察结果，并探索对 HLA 错配供体进行排序的其他评分系统。

{"title":"Novel Scoring System for Ranking Hematopoietic Stem Cell Transplantation","authors":"Lee Ann Baxter-Lowe, Tao Wang, Michelle Kuxhausen, Stephen R. Spellman, Martin Maiers, Stephanie Lee, Jennifer Saultz, Esteban Arrieta-Bolaños, Shahinaz M. Gadalla, Yung-Tsi Bolon, Brian C. Betts","doi":"10.1111/ctr.15478","DOIUrl":"10.1111/ctr.15478","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>When human leukocyte antigen (HLA)-matched donors are not available for hematopoietic stem cell transplants (HSCT), there are no well-accepted guidelines for ranking 7/8 HLA-matched unrelated donors to achieve optimal transplant outcomes. A novel scoring system for ranking HLA mismatches for these donors was investigated.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>High-resolution HLA types were used to determine amino acid mismatches located in the HLA antigen-recognition domain. The location and physicochemical properties of mismatched amino acids were used to assign scores for peptide binding, T-cell receptor docking, and HLA structure/function. The scores were tested using a cohort of 2319 patients with leukemia or myelodysplastic syndrome who received their first unrelated donor transplant using conventional graft-versus-host disease (GVHD) prophylaxis between 2000 and 2014. Donors were 7/8 HLA-matched with a single HLA Class I mismatch. Primary outcomes were overall survival and acute GVHD.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The scores did not significantly (<i>p</i> < 0.01) associate with transplant outcomes, although a Peptide Score = 0 (i.e., no differences in peptide binding; <i>N</i> = 146, 6.3%) appears to have lower transplant-related mortality (TRM) compared to higher scores (<i>p</i> = 0.019). HLA mismatches with Peptide Score = 0 were predominately HLA-C*03:03/03:04 (62%), previously reported to be a permissive mismatch, and a group of 28 other HLA mismatches (38%) that showed similar associations with TRM.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>This study suggests that HLA mismatches that do not alter peptide binding or orientation (Peptide Score = 0) could expand the number of permissive HLA mismatches. Further investigation is needed to confirm this observation and to explore alternative scoring systems for ranking HLA mismatched donors.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"38 11","pages":""},"PeriodicalIF":1.9,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142603616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Beyond Borders: International Immunosuppression Practices in Pediatric Lung Transplantation 超越国界：小儿肺移植中的国际免疫抑制实践。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-08 DOI: 10.1111/ctr.70016

Erica Wong, Jake Brockmeyer, Christian Benden, Nicholas Avdimiretz

Introduction

Current recommendations for lung transplantation immunosuppression do not explicitly target children, and many pharmacotherapies used in pediatrics are extrapolated from adults.

Methods

Data were collected from an anonymous survey distributed to International Pediatric Lung Transplant Collaborative (IPLTC) members from November 2023 to February 2024. Eligible participants included pediatric lung transplant physicians, pharmacists, or others with expertise in their lung transplant center's protocols. Participant and program demographics were surveyed, including location and transplant volume. Seventeen multiple-choice questions, text responses, and Likert scale statements covered the following: induction immunosuppression, maintenance immunosuppression, drug monitoring, dose optimization, and expert guidance available in current literature.

Results

Among the 23 pediatric lung transplant healthcare professionals who responded, 13 respondents (57%) preferred using basiliximab as their standard induction immunosuppression. 3 (13%) prefer rabbit anti-thymocyte globulin (rATG), while 7 (30%) consider either rATG or basiliximab for induction. Of 22 responses with 100% completion, 21 of 22 (95.2%) respondents reported a combination of tacrolimus, mycophenolate mofetil (MMF), and corticosteroids (CCS) as their preferred maintenance immunosuppression regimen, reflecting the suggested preferred regimen for pediatric lung transplantation. Feedback on the perception of available evidence-based or established guidelines revealed the majority (90.0%) of respondents found them to be insufficient for pediatrics.

Conclusion

This international survey highlights the variability in immunosuppression practices across pediatric lung transplant programs around the world. The findings underscore a gap in unified, evidence-based practice guidelines. With strong consensus among respondents on the lack of established guidelines, there is a clear directive for future research to establish standardized practices in pediatric lung transplantation.

导言：目前关于肺移植免疫抑制的建议并未明确针对儿童，许多用于儿科的药物疗法都是从成人那里推断而来：目前关于肺移植免疫抑制的建议并没有明确针对儿童，许多用于儿科的药物疗法都是从成人中推断出来的：方法：从 2023 年 11 月至 2024 年 2 月向国际儿科肺移植协作组（IPLTC）成员发放的匿名调查中收集数据。符合条件的参与者包括儿科肺移植医生、药剂师或其他在肺移植中心方案方面具有专业知识的人员。对参与者和项目的人口统计数据进行了调查，包括地点和移植量。17道多选题、文本回答和李克特量表陈述涉及以下内容：诱导免疫抑制、维持免疫抑制、药物监测、剂量优化和当前文献中提供的专家指导：结果：在回答问题的 23 位小儿肺移植医护人员中，13 位受访者（57%）倾向于使用巴利昔单抗作为标准诱导免疫抑制剂。3位受访者（13%）倾向于使用兔抗胸腺细胞球蛋白（rATG），而7位受访者（30%）则考虑使用rATG或巴利昔单抗作为诱导免疫抑制剂。在 22 份 100% 完成率的回复中，有 21 份（95.2%）回复者称他克莫司、霉酚酸酯 (MMF) 和皮质类固醇 (CCS) 组合是他们首选的维持性免疫抑制方案，这反映了建议的小儿肺移植首选方案。对现有循证指南或既定指南的看法反馈显示，大多数受访者（90.0%）认为这些指南对儿科而言不够充分：这项国际调查凸显了世界各地小儿肺移植项目在免疫抑制实践方面的差异。调查结果显示，在统一的循证实践指南方面存在差距。由于受访者对缺乏既定指南达成了强烈共识，因此未来研究的明确方向是建立小儿肺移植的标准化实践。

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引用次数: 0

Changes in Donor-Derived Cell-Free DNA Before and After Rejection and De Novo DSA Detection in Primary and Repeat Kidney Transplant Recipients 初次和再次肾移植受者排斥反应前后供体来源细胞游离 DNA 的变化以及新的 DSA 检测。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-05 DOI: 10.1111/ctr.70019

Sandesh Parajuli, Neetika Garg, Ban Dodin, Isabel Breyer, Emily Zona, Shree Patel, Kevin Pinney, Didier Mandelbrot

Background

Serial monitoring of dd-cfDNA and change from baseline can provide meaningful information beyond absolute thresholds. We describe dd-cfDNA trajectories from the baseline before and after acute rejection (AR) and de novo donor-specific antibodies (dnDSA) detection in kidney transplant recipients (KTRs).

Methods

We included KTR from 02/2019 to 03/2022 with serial dd-cfDNA. The primary analysis compared the time-varying change in dd-cfDNA from baseline in KTR first AR on biopsy [AR] to patients with no-AR on biopsy [no-AR].

Results

151 KTR were analyzed (AR = 56 KTR, no-AR = 95 KTRs). In the AR group, dd-cfDNA rose ahead of diagnosis: median rise from baseline was 75% at −3 months, 32% at −2 months, and 325% at −1 month before biopsy. At the time of biopsy, the median rise in dd-cfDNA from baseline was 291% (IQR [interquartile range] 88%–1081%) in AR and 17% (IQR 0%– 194%) in no-AR (p < 0.0001). Following treatment, dd-cfDNA values fell in the AR group with a median change from baseline of 94.7% at +1 month, 10.5% at +2 months, and 0% at +3 months. These trajectories were not observed in the no-AR group. Similarly, there were no significant differences in eGFR (estimated glomerular filtration rate) trajectories between the two groups. The median change from baseline to dnDSA detection was 141% (IQR 112%–574%). In KTRs with persistent rejection, median dd-cfDNA was 0.95% (IQR 0.44–1.8) compared to 0.19% (IQR 0.12–0.31) in subjects with no rejection on follow-up (p < 0.001).

Conclusion

The significant changes from baseline observed before and after AR show how serial monitoring enhances dd-cfDNA utility and allows for earlier identification of evolving injury and monitoring treatment response.

背景：连续监测dd-cfDNA和与基线相比的变化可提供绝对阈值以外的有意义信息。我们描述了肾移植受者（KTR）在急性排斥反应（AR）和新供者特异性抗体（dnDSA）检测前后从基线开始的dd-cfDNA变化轨迹：我们纳入了2019年2月至2022年3月期间连续检测dd-cfDNA的KTR。主要分析比较了活检时首次出现 AR 的 KTR [AR] 与活检时未出现 AR 的患者 [no-AR] 的 dd-cfDNA 从基线开始的时变变化：分析了 151 例 KTR（有 AR = 56 例 KTR，无 AR = 95 例 KTR）。在有AR组中，dd-cfDNA在确诊前就已上升：活检前-3个月时，与基线相比的中位上升率为75%，-2个月时为32%，-1个月时为325%。活检时，有基因突变者 dd-cfDNA 从基线上升的中位数为 291%（IQR [四分位数间距] 88%-1081%），无基因突变者为 17%（IQR 0%- 194%）（P 结论：有基因突变者的 dd-cfDNA 从基线上升的中位数比无基因突变者高：AR 前后观察到的与基线相比的重大变化表明，连续监测可提高 dd-cfDNA 的效用，并能更早地识别不断发展的损伤和监测治疗反应。

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引用次数: 0

Hospitalization and Hospitalized Delirium Are Associated With Decreased Access to Kidney Transplantation and Increased Risk of Waitlist Mortality 住院和住院谵妄与肾移植机会减少和候诊死亡率风险增加有关。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-11-05 DOI: 10.1111/ctr.70018

Jane J. Long, Jingyao Hong, Yi Liu, Akanksha Nalatwad, Yiting Li, Nidhi Ghildayal, Emily A. Johnston, Jordan Schwartzberg, Nicole Ali, Eric Oermann, Michal Mankowski, Bruce E. Gelb, Emily L. Chanan, Joshua L. Chodosh, Aarti Mathur, Dorry L. Segev, Mara A. McAdams-DeMarco

Background

Kidney transplant (KT) candidates often experience hospitalizations, increasing their delirium risk. Hospitalizations and delirium are associated with worse post-KT outcomes, yet their relationship with pre-KT outcomes is less clear. Pre-KT delirium may worsen access to KT due to its negative impact on cognition and ability to maintain overall health.

Methods

Using a prospective cohort of 2374 KT candidates evaluated at a single center (2009–2020), we abstracted hospitalizations and associated delirium records after listing via chart review. We evaluated associations between waitlist mortality and likelihood of KT with hospitalizations and hospitalized delirium using competing risk models and tested whether associations differed by gerontologic factors.

Results

During a median of 1.8 years after listing, 735 (31.0%) candidates had ≥1 hospitalizations. Candidates with less education, frailty, depressive symptoms, and lower extremity function impairment were more likely to be hospitalized. Hospitalization was associated with higher waitlist mortality (aSHR = 3.65, 95% CI: 2.99–4.45) and a lower likelihood of KT (aSHR = 0.74, 95% CI: 0.66–0.84). Among candidates who were hospitalized, 80 (11%) had ≥1 delirium episodes. Candidates who were older, frail, and impaired in lower extremity function were more likely to have delirium, which was associated with higher waitlist mortality (aSHR = 4.87, 95% CI: 3.42–6.93) and a lower likelihood of KT (aSHR = 0.45, 95% CI: 0.27–0.74). The association between hospitalization and KT differed by candidate age (p_interaction < 0.001), with those aged ≥65 having a 61% lower likelihood of KT.

Conclusion

Hospitalization and delirium are associated with worse pre-KT outcomes and have serious implications on candidates’ access to KT. Providers should work to reduce preventable instances of delirium.

背景：肾移植（KT）候选者经常住院，这增加了他们谵妄的风险。住院和谵妄与较差的 KT 后预后有关，但它们与 KT 前预后的关系却不太清楚。KT前谵妄可能会对认知能力和维持整体健康的能力产生负面影响，从而影响KT的获得：方法：我们利用一个前瞻性队列（2009-2020 年），对在一个中心接受评估的 2374 名 KT 候选人进行了调查，并通过病历审查抽取了他们的住院和相关谵妄记录。我们使用竞争风险模型评估了候选者死亡率和 KT 与住院及住院谵妄的可能性之间的关联，并检验了不同老年学因素之间的关联是否存在差异：735名候选者（31.0%）在被列入名单后的中位数1.8年内住院≥1次。受教育程度较低、体弱、有抑郁症状和下肢功能障碍的候选人更有可能住院。住院与较高的候选者死亡率（aSHR = 3.65，95% CI：2.99-4.45）和较低的 KT 可能性（aSHR = 0.74，95% CI：0.66-0.84）相关。在住院的候选人中，有 80 人（11%）谵妄发作次数≥1 次。年龄较大、体弱且下肢功能受损的候选者更有可能出现谵妄，这与较高的候选者死亡率（aSHR = 4.87，95% CI：3.42-6.93）和较低的 KT 可能性（aSHR = 0.45，95% CI：0.27-0.74）有关。住院与 KT 之间的关联因候选者年龄而异（pinteraction 结论）：住院和谵妄与更差的 KT 前预后有关，对候选者获得 KT 有严重影响。医疗服务提供者应努力减少可预防的谵妄情况。

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引用次数: 0

Persistent Chronic Active T-Cell-Mediated Rejection After Kidney Transplantation Is Associated With Poor Allograft Survival 肾移植后持续的慢性活性 T 细胞介导的排斥反应与异体移植存活率低有关。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-10-30 DOI: 10.1111/ctr.70011

Hiroshi Noguchi, Yuta Matsukuma, Kenji Ueki, Akihiro Tsuchimoto, Kei Nishiyama, Toshiaki Nakano, Shinsuke Kubo, Yu Sato, Keizo Kaku, Yasuhiro Okabe, Masafumi Nakamura

Introduction

Histopathological findings of chronic active T-cell-mediated rejection (CA-TCMR) have been reported to potentially improve with treatment. However, whether this improvement is associated with a better renal prognosis remains unclear. This study was performed to analyze the impact of the histological response to therapy on kidney allograft survival in patients with CA-TCMR.

Methods

The data of patients diagnosed with CA-TCMR between January 2018 and May 2023 were retrospectively reviewed. A composite graft endpoint was defined as a two-fold increase in the serum creatinine level or the development of end-stage kidney disease.

Results

Thirty-seven patients with CA-TCMR underwent 46 follow-up biopsies. Eleven patients who were diagnosed with CA-TCMR at the last biopsy were classified as the persistent group, while the remaining 26 patients were classified as the transient group. Both before and after treatment, there were no significant changes in serum creatinine, estimated glomerular filtration rate, or proteinuria in either group. However, the transient group showed a significant reduction in interstitial fibrosis and tubular atrophy without a specific etiology (IFTA). This improvement was attributed to better histopathological Banff scores after treatment. Patients with persistent CA-TCMR had significantly worse graft survival than those with transient CA-TCMR (p = 0.002), even after adjusting for significant clinical factors (hazard ratio: 11.4; 95% CI: 1.1–120.0; p = 0.043).

Conclusion

Our findings suggest that the persistence of histopathologic evidence of CA-TCMR after treatment is a significant risk factor for allograft loss compared with transient CA-TCMR.

导言：据报道，慢性活动性 T 细胞介导的排斥反应（CA-TCMR）的组织病理学结果可能会随着治疗而改善。然而，这种改善是否与更好的肾脏预后相关仍不清楚。本研究旨在分析组织学治疗反应对 CA-TCMR 患者肾移植存活率的影响：回顾性回顾了2018年1月至2023年5月期间确诊为CA-TCMR患者的数据。复合移植物终点定义为血清肌酐水平升高两倍或出现终末期肾病：37 名 CA-TCMR 患者接受了 46 次随访活检。最后一次活检确诊为 CA-TCMR 的 11 名患者被归为持续组，其余 26 名患者被归为短暂组。治疗前后，两组患者的血清肌酐、估计肾小球滤过率和蛋白尿均无明显变化。不过，短暂组患者的间质纤维化和无特殊病因的肾小管萎缩（IFTA）明显减少。这种改善归因于治疗后组织病理学 Banff 评分的提高。持续性CA-TCMR患者的移植物存活率明显低于短暂性CA-TCMR患者（p = 0.002），即使在调整了重要的临床因素后也是如此（危险比：11.4；95% CI：1.1-120.0；p = 0.043）：我们的研究结果表明，与一过性 CA-TCMR 相比，治疗后 CA-TCMR 组织病理学证据的持续存在是导致同种异体移植损失的重要风险因素。

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引用次数: 0

Survey of Post-Prophylaxis Delayed-Onset Cytomegalovirus Management Strategies Among Transplant Providers 器官移植提供者对预防后延迟发病巨细胞病毒管理策略的调查。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-10-30 DOI: 10.1111/ctr.70015

Lemuel R. Non, Chen Sabrina Tan, Dilek Ince, Raymund R. Razonable

Background

Preventive strategies for cytomegalovirus (CMV) in the posttransplant period have changed the pattern of CMV infections, now more commonly manifesting as late-onset occurrences known as post-prophylaxis delayed-onset CMV disease (PPDOC). We conducted a survey to investigate provider practices in managing PPDOC.

Methods

A web-based provider survey on the management of PPDOC was developed using Research Electronic Data Capture (REDCap). It was distributed to the online forums of the American Society of Transplantation communities of practice (COP) for Infectious Diseases (IDCOP), Kidney and Pancreas (KPCOP), Liver and Intestinal (LICOP), and Thoracic and Critical Care (TCCOP). The survey was posted twice within a span of a month.

Results

Fifty-six respondents, comprising 50 (89%) transplant physicians and 6 (11%) transplant pharmacists, from 46 distinct transplant centers, completed the survey. Universal antiviral prophylaxis (UAP) was the predominant preventive approach for both high-risk (85%) and moderate-risk (85%) transplant recipients. Out of 56, 51 respondents completed the questions regarding management of PPDOC. Regular surveillance with nucleic acid amplification tests (NAAT) (88%) was the most commonly used approach in high-risk recipients, while symptom monitoring (73%) was the most common strategy in moderate-risk recipients. Immunologic monitoring was used only by a few respondents who found it moderately useful in high-risk recipients.

Conclusion

Management of PPDOC was highly variable among providers and strategies differed based on patient risk profile. These findings could help shape future studies and guidelines to harmonize CMV management.

背景：移植后巨细胞病毒（CMV）的预防策略改变了 CMV 感染的模式，现在更多的表现为晚期发病，即预防后迟发 CMV 病（PPDOC）。我们开展了一项调查，研究医疗服务提供者在管理 PPDOC 方面的做法：方法：我们使用研究电子数据采集（REDCap）开发了一项关于 PPDOC 管理的网络医疗服务提供者调查。该调查表被发布到美国移植学会传染病实践社区（IDCOP）、肾脏和胰腺实践社区（KPCOP）、肝脏和肠道实践社区（LICOP）以及胸腔和重症监护实践社区（TCCOP）的在线论坛上。调查在一个月内发布了两次：来自 46 个不同移植中心的 56 名受访者完成了调查，其中包括 50 名（89%）移植医生和 6 名（11%）移植药剂师。普遍抗病毒预防（UAP）是高风险（85%）和中度风险（85%）移植受者的主要预防方法。在 56 位受访者中，有 51 位完成了有关 PPDOC 管理的问题。使用核酸扩增检测（NAAT）进行定期监测（88%）是高风险受者最常用的方法，而症状监测（73%）是中度风险受者最常用的策略。只有少数受访者使用免疫学监测，他们认为这种方法对高危受者的作用一般：结论：医疗服务提供者对 PPDOC 的管理存在很大差异，根据患者的风险状况采取的策略也不尽相同。这些研究结果有助于制定未来的研究和指南，以协调 CMV 管理。

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引用次数: 0

Single Lung Transplantation in a Highly Selected Patient With End-Stage Chronic Thromboembolic Pulmonary Hypertension 为一名经过严格筛选的终末期慢性血栓栓塞性肺动脉高压患者进行单肺移植。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-10-29 DOI: 10.1111/ctr.15483

Nunzio Davide de Manna, Khalil Aburahma, Sophie Kruszona, Philipp Wand, Murat Avsar, Thorsten Derlin, Karen M. Olsson, Arjang Ruhparwar, Christian Kühn, Marius M. Hoeper, Mark Greer, Jawad Salman, Fabio Ius

引用次数: 0