Clinical Transplantation最新文献

Background

The optimal management of incidental coronary artery disease (CAD) for renal transplant candidates is not well-defined. This study examined transplant and survival outcomes in patients undergoing coronary artery bypass grafting (CABG) for asymptomatic CAD.

Methods

A retrospective review of patients undergoing CABG solely to facilitate renal transplant was conducted at four tertiary centers. Exclusion criteria were symptoms or acute coronary syndrome (ACS). The primary outcomes were successful renal transplant and survival analyzed using Kaplan-Meier curves with log-rank testing, compared to US Renal Data System (USRDS)-predicted life expectancy matched for age and gender.

Results

86 patients (59.0 [IQR 51.0,65.0] years, 88% male) were identified. At follow-up of 4.41 (2.74,6.04) years, 19.8% (n = 17) had successful renal transplant; 29.1% (n = 25) were never listed, 44.2% (n = 38) listed but removed (29 permanently, 9 temporarily), 7.0% (n = 6) awaiting transplant. Pre- and intraoperative characteristics were similar between those transplanted and not. For the entire cohort, CABG was associated with worse 1-year survival, similar 5-year survival, and better 8-year survival compared to USRDS-predicted life expectancy (log-rank p = 0.027).  Considering those not transplanted, 8-year survival was similar to USRDS (log-rank p = 0.94).

Conclusions

In patients with Stage V CKD and asymptomatic CAD, renal transplant rates are low. Whether surgical revascularization offers survival benefit due to successful renal transplant or due to revascularization remains an area of future study. Longer follow-up, study of patient/procedural factors, and multidisciplinary efforts may improve patient selection and transplantation rates.

Background

Acute graft-versus-host disease (aGVHD) remains a major complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Identifying reliable biomarkers for early prediction of aGVHD could enable timely interventions and improve patient outcomes.

Objective

This study aims to assess whether levels of specific cytokines can serve as predictive markers for the onset and severity of aGVHD.

Methods

Plasma levels of IL-6, IFN-γ, TNF-α, sST2, CD25, and REG3α were measured via ELISA in 50 allo-HSCT patients (20 with aGVHD and 30 without aGVHD) on Days +7, +14, and +21 post - transplantation. Receiver operating characteristic (ROC) curves and area under the curve (AUC) analyses were used to assess the predictive performance of these biomarkers.

Results

Among the six biomarkers analyzed, sST2 demonstrated the highest predictive accuracy for aGVHD. Elevated sST2 levels at Days +14 and +21 posttransplantation significantly correlated with aGVHD occurrence (AUC = 0.7092 at Day +21) and gastrointestinal aGVHD (AUC = 0.8007 at Day +14). sST2 also showed strong predictive performance for severe aGVHD (Grade II-IV), with AUC values of 0.8125 at Day +7 and 0.8021 at Day +14. Other biomarkers, including IL-6, REG3α, CD25, and TNF-α, exhibited dynamic changes but lacked robust predictive value for aGVHD onset or severity. These findings support sST2 as a promising biomarker for early risk stratification of aGVHD.

Conclusion

SST2 is a promising biomarker for the early prediction of aGVHD, offering potential for guiding proactive therapeutic strategies in allo-HSCT patients.

Background

We sought to characterize adaptive changes to the revised UNOS donor heart allocation policy in 2018 and estimate long-term survival trends for heart transplant (HTx) recipients with respect to inotropic support.

Methods

Patients listed for HTx between July 18, 2014, and July 18, 2016 (prepolicy revision) and between October 18, 2018, and October 18, 2020 (postpolicy revision) were identified from the UNOS database. Sub-analyses examined trends in device progression where patients listed on inotropes were later transplanted on inotropes and/or on extracorporeal membranous oxygenator (ECMO), durable left ventricular assist device (LVAD), temporary mechanical circulatory support (tMCS), or intra-aortic balloon pump (IABP). Survival data post-HTx were calculated and plotted.

Results

Overall, 3,189 patients were waitlisted (pre: 1,408; post: 1,781). Patient demographics differed only by cardiac output, mean PCWP, cigarette use, ventilatory support, and time on the waitlist. Policy revisions were associated with an increase in patients transplanted while supported with IABP (p < 0.01), tMCS (p < 0.01), and ECMO (p < 0.01). In contrast, postpolicy, fewer patients were transplanted while on inotropes (p < 0.01) or an LVAD (p < 0.01), and 57.4% patients progressed from inotropes to another form of support (27.4% prepolicy, p < 0.01). Additionally, waitlisted patients in the postpolicy period were more likely to be transplanted (pre: 78.9% vs. post: 89.8%, p < 0.01) and more likely to survive (mortality, pre: 26.9% vs. post: 19.1, p < 0.01).

Conclusions

Allocation policy revisions have contributed to increased utilization of temporary support (ECMO, tMCS, and IABP) and decreased utilization of others such as durable LVADs. Additionally, revisions have led to improved survival and increased transplantation for patients waitlisted on inotropes, yet similar survival for each individual form of temporary support.

Background

Heart re-transplantation (re-HT) is the last treatment option for end-stage graft failure, with cases due to severe cardiac allograft vasculopathy (CAV) showing a better prognosis compared to other indications. However, the effects of restrictive cardiac allograft physiology (RCP), classified as severe CAV, on re-HT outcomes remain unclear.

Methods

We assessed patients with severe CAV who underwent re-HT between 2010 and 2024. RCP was defined as symptomatic heart failure with restrictive echocardiographic values (E-to-A velocity ratio >2 and deceleration time <150 ms) or hemodynamic values (mean right atrial pressure >12 mmHg, pulmonary capillary wedge pressure >25 mmHg, and cardiac index <2.0 L/min/m²). The primary outcome was death or third re-HT.

Results

We included 86 patients; 34 patients were complicated with RCP and 52 patients were without RCP. During the follow-up period, two patients underwent a third re-HT, and 16 died. The most frequent cause of death among those with and without RCP was malignancy and cardiovascular death, respectively. The probability of survival from all-cause death or third re-HT was significantly worse for those with RCP than for those without RCP (p = 0.021). Additionally, RCP was independently associated with an increased risk of death or third re-HT (hazard ratio: 3.36; 95% confidence interval: 1.16–9.75; p = 0.026).

Conclusions

Among patients with severe CAV, those with RCP appear to have a worse prognosis after re-HT compared to those without RCP. This finding might be considered in the candidate selection for re-HT.

Introduction

Medication adherence is critical to improve quality of life, reduce transplant-related complications, and increase survival. Nonadherent health behaviors after heart transplantation lead to increased morbidity and mortality, decreased quality of life, increased medical costs, and overuse of healthcare services in heart transplant patients (HTR).

This study examined the relationship between heart transplant recipients' medication adherence, dietary practices, and physical activity.

Methods

This cross-sectional study was conducted at a university hospital's Heart and Lung Transplant Outpatient Clinic. The sample included adult HTR who had undergone transplantation at least 6 months prior. Data were collected using the Basel Assessment of Adherence to Immunosuppressive Medication Scale, a Nutritional Behaviors Questionnaire, and the International Physical Activity Questionnaire Short Form Statistical analyses using SPSS 24.0, with significance set at p < 0.05.

Results

Among 70 participants, 42.85% were non-adherent to immunosuppressive medications. Factors influencing adherence included age and time since transplantation. Dietary assessments revealed that while most patients practiced washing fruits and vegetables, adherence to other food safety measures was low. Physical activity levels indicated that 50% of participants were physically inactive, with high body mass index significantly correlating with lower activity levels. Patients with medication adherence had higher physical activity levels.

Conclusion

The study highlights the critical need for targeted interventions to improve medication adherence, dietary practices, and physical activity among HTR. Addressing these factors is essential for enhancing patient outcomes, reducing morbidity and mortality, and improving quality of life posttransplant. Further research is warranted to explore the barriers and facilitators influencing these health behaviors in diverse populations.

Introduction

The number of patients on heart transplant waitlists is growing globally, with an insufficient number of organ offers to meet this growing demand. To help improve patient outcomes, in the United Kingdom (UK), orthotopic cardiac transplantation (OCTx) can occur using hearts donated following donor brain death (DBD) or donor circulatory death (DCD). The aim of this paper was to compare outcomes between groups of DBD and DCD OCTx patients at Harefield Hospital.

Methods

44 DCD patients (transplanted between 2012 and 2023) were matched (with outcomes blinded, by age and gender) with 33 DBD patients (transplanted between 2015 and 2023). Short-term outcomes (up until 1-year posttransplants, including outcomes such as primary graft dysfunction [PGD] and length of intensive care unit [ICU] stay) and midterm outcomes (up until 5 years posttransplant, including outcomes such as all-cause-mortality, episodes of rejection and graft left ventricular function) were assessed.

Results

Overall, no significant differences were noted with regard to baseline characteristics, and outcome measures (both short and mid-term outcomes) between the matched DCD and DBD cohorts. Event-free survival with regard to all-cause mortality also remained not significantly different between both groups (log-rank p < 0.756).

Conclusion

In conclusion, our single-center UK data did not demonstrate any differences in outcomes between DCD and DBD OCTx patients. We add to growing literature that would support DCD organ use in heart transplantation, in an effort to reduce growing organ demand worldwide.

Purpose

There are limited data regarding outcomes of a new heart allocation policy on recovering brain-death donors (DBD) from extended distances.

Methods

From May 6, 2014, to March 31, 2023, the United Network for Organ Sharing database was queried where 1885 cases (8.3%) out of 22 806 isolated heart transplants received donor hearts from extended distances (ED) greater than 500 miles. Patients were divided into groups based on the transplanted date before or after the policy change (October 18, 2018): old (N = 443) versus new (N = 1383). A total of 439 pairs were matched utilizing propensity score matching.

Results

The utilization of hearts from ED in the new system increased 2.7 times. Before matching, characteristics that differed included new group recipients with higher usage of temporary mechanical circulatory support devices and donors with more anoxia as the cause of death (new, 47% vs. old, 37%; p < 0.001). In the matched cohort, the incidences of dialysis (14% vs. 11%, p = 0.18), stroke (3.9% vs. 2.7%, p = 0.44), or pacemaker implantation (3.0% vs. 2.5%, p = 0.83) were similar. Both groups showed similar 1-year recipient survival (90.9% vs. 90.4%, p = 0.79) and graft survival (90.7% vs. 90.2%, p = 0.8).

Conclusion

In the new allocation policy, the utilization of hearts from ED has increased approximately three-fold compared to the period before the policy change without affecting transplant outcomes.

Background and Aims

One strategy to minimize the risk of posttransplant lymphoproliferative disorder (PTLD) is to avoid an Epstein–Barr Virus (EBV) mismatch through kidney paired donation. We aimed to estimate the incidence of PTLD in EBV-negative kidney transplant recipients with EBV-positive donors (D+/R−) and evaluate the excess risk of death following the occurrence of PTLD.

Methods

We included adult patients in OPTN database who underwent kidney transplants between 2012 and 2022. Cox regression analysis was employed to evaluate the impact of EBV serostatus on the development of PTLD, and to assess mortality following PTLD diagnosis in D+/R− individuals.

Results

A total of 179 068 patients were included, with 92.8% in the R+, 6.4% in the D+/R−, and 0.8% in the D−/R− group. D+/R− exhibited a significantly higher risk of PTLD compared to R+ and D−/R− groups. D+/R− had a greater risk of PTLD when compared to D−/R− recipients (aHR: 3.82; p < 0.001). Among D+/R− recipients, those who developed PTLD had a significantly higher risk of mortality (aHR: 2.28; p < 0.001 in deceased donor kidney transplant [DDKT] and aHR: 5.22; p < 0.001 in living donor kidney transplant [LDKT]).

Conclusions

D+/R− recipients have nearly a fourfold higher risk of PTLD compared to D−/R− recipients, suggesting that choosing an EBV D−/R− transplant could reduce the PTLD risk by about 73%. This data is crucial for counseling EBV-negative patients considering kidney paired donation to avoid an EBV serostatus mismatch.