Clinical Transplantation最新文献

Background

Post-lung transplantation (LTx) fluid accumulation can lead to dilution of serum creatinine (SCr). We hypothesized that fluid accumulation might impact the diagnosis, staging, and outcome of posttransplant acute kidney injury (AKI).

Methods

In this retrospective study, we analyzed data from 131 adult LTx patients at a single German lung center between 2005 and 2018. We assessed the occurrence of AKI within 7 days posttransplant, both before and after SCr-adjustment for fluid balance (FB), and investigated its impact on all-cause mortality. Transient and persistent AKIs were defined as return to baseline kidney function or continuation of AKI beyond 72 h of onset, respectively.

Results

AKI was diagnosed in 58.8% of patients according to crude SCr values. When considering FB-adjusted SCr values, AKI severity was underestimated in 20.6% of patients, that is, AKI was detected in an additional 6.9% of patients and led to AKI upstaging in 23.4% of cases. Patients initially underestimated but detected with AKI only after FB adjustment had higher mortality compared to those who did not meet AKI criteria (hazard ratio [HR] 2.98; 95% confidence interval [CI] 1.06, 8.36; p = 0.038). Persistent AKI was associated with higher mortality than transient AKI, regardless of using crude or adjusted SCr values (p < 0.05). Persistent AKI emerged as an independent risk factor for mortality (HR 2.35; 95% CI 1.29, 4.30; p = 0.005).

Conclusion

Adjusting for FB and evaluating renal recovery patterns post-AKI may enhance the sensitivity of AKI detection. This approach could help identify patients with poor prognosis and potentially improve outcomes in lung transplant recipients.

Trial Registration

ClinicalTrials.gov identifier: NCT03039959, NCT03046277.

Background

There is a lack of information on the waitlist performance and post-transplant outcomes of lung transplants in elderly recipients in Korea.

Methods

We retrospectively reviewed and analyzed data from the Korean Network for Organ Sharing database between March 2010 and August 2023.

Results

In total, 2574 patients were listed for lung transplantation during the study period, with 511 (19.9%) of them being over 65 years of age. Among these, 188 patients (36.8%) underwent transplantation, while 184 patients (36%) passed away without undergoing transplantation at the time of data extraction. The most prevalent underlying disease on the waitlist was idiopathic pulmonary fibrosis, accounting for 68.1%. The 1-year survival rate was significantly lower in the elderly compared to that in the nonelderly (65.4 vs. 75.4%; p = .004). In the multivariate Cox analysis, elderly (hazard ratio [HR], 1.49; 95% CI, 1.14–1.97; p = .004) and a high urgent status at registration (HR, 1.83; 95% CI, 1.40–2.40; p < .001) were significantly associated with post-transplant 1-year mortality. Kaplan–Meier curves demonstrated a significant difference in post-transplant mortality based on the urgency status at enrollment (χ² = 8.302, p = .016). Even with the same highly urgent condition at the time of transplantation, different prognoses were observed depending on the condition at listing (χ² = 9.056, p = .029).

Conclusion

The elderly exhibited worse transplant outcomes than nonelderly adults, with a highly urgent status at registration identified as a significant risk factor. Unprepared, highly urgent transplantation was associated with poor outcomes.

Background

The number of living kidney donors in the United States has declined since 2005, with variations based on the donor–recipient relationship. The reasons for this decline are unclear, and strategies to mitigate declined donations remain elusive. We examined the change in donor number monthly (within-year) versus annually (between-years) to inform potentially modifiable factors for future interventions.

Methods

In this registry-based cohort analysis of 141 759 living kidney donors between 1995 and 2019, we used linear mixed-effects models for donor number per month and year to analyze between-year and within-year variation in donation. We used Poisson regression to quantify the change in the number of donors per season before and after 2005, stratified by donor–recipient relationship and zip-code household income tertile.

Results

We observed a consistent summer surge in donations during June, July, and August. This surge was statistically significant for related donors (incidence rate ratio [IRR] range: 1.12–1.33) and unrelated donors (IRR range: 1.06–1.16) across donor income tertiles.

Conclusion

Our findings indicate lower rates of living kidney donation in non-summer months across income tertiles. Interventions are needed to address barriers to donation in non-summer seasons and facilitate donations throughout the year. Since the Organ Donor Leave Law provides a solid foundation for supporting year-round donation, extending the law's provisions beyond federal employees may mitigate identified seasonal barriers.

Objective and Background

Sinusoidal obstruction syndrome (SOS) is a life-threatening complication in hematopoietic stem cell transplantation (HSCT) patients. However, the related risk factors in pediatric and young adult HSCT recipients remain unclear. Thus, we conducted this meta-analysis to identify potential risk factors for SOS in children and young adults undergoing HSCT.

Method

We acquired related articles through searching PubMed, EMBASE, and the Cochrane Library up to May 31, 2024. We calculated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) to identify potential risk factors.

Results

A total of 12 studies with 7644 HSCT recipients were included. Bone marrow transplantation (OR = 1.35, 95% CI: 1.03–1.77, I² = 0%), busulfan (BU) (OR = 3.63, 95% CI: 1.78–7.38, I² = 70%), and fludarabine (FLU) (OR = 1.55, 95% CI: 1.09–2.21, I² = 16%) were risk factors for SOS after HSCT in children and young adults.

Conclusion

Bone marrow transplantation and the use of BU or FLU might be risk factors for SOS after HSCT in children and young adults.

Introduction

Sarcopenia is common in children after liver transplantation (LTx). Resistance training (RT) may be effective in combating sarcopenia.

Objectives

The purpose of the study was to test the feasibility and impact of a 12-week RT program on skeletal muscle mass (SMM), muscle strength, physical performance (PP), and child–parent perspectives about RT.

Methods

Children (6–18 years) post-LTx and healthy controls (HC) underwent progressive RT using resistance bands. SMM and adipose tissue (MRI: abdomen and thigh), muscle strength (handgrip, push-ups, sit-to-stand), and PP (6-minute walk test [6MWT], timed-up-and-down-stair test [TUDS]) were measured before and after 12-weeks of RT.

Results

Ten children post-LTx (11.9 ± 3.5 years) and 13 HC (11.7 ± 3.9 years) participated. LTx children significantly increased abdominal SM-index (+4.6% LTx vs. a −2.7% HC; p = 0.01) and decreased visceral adipose tissue-index (−18% LTx vs. −0.8% HC; p = 0.04) compared to HC. No thigh SMI changes were noted. Significant increases in 6MWT distance (LTx; p = 0.04), number of push-ups (p = 0.04), and greater reduction times for TUDS (−10.6% vs. +1.7%; p = 0.05) occurred after 12 weeks. Higher thigh muscle-fat content was associated with worse physical performance. These results were impacted by adherence (≥75% vs. <75%) and family engagement.

Conclusions

RT in children post-LTx is feasible and effective. RT in children post-LTx may alleviate adverse outcomes associated with sarcopenia.

Purpose

The aim of the study was to determine outcomes after heart transplantation for cytomegalovirus (CMV) mismatched patients (D⁺/R⁻) who underwent a surveillance and preemptive therapy protocol, compared to nonmismatch patients.

Methods

A review of patient records from January 2010 to December 2020 with follow-up to October 2023 was done. The protocol consisted weekly surveillance with CMV PCR starting 4 weeks after transplant continuing up until the patient seroconverts or up to 3 months posttransplant if the patient does not seroconvert. Valganciclovir was given for 2 weeks to those who seroconverted.

Results

Two hundred and twenty-one patients were included, and 23% were mismatched patients. Overall survival was not different between CMV groups (p = NS). Causes of death and morbidities were also not significantly different (p = NS). Sixty-six percent of mismatch patients seroconverted, and there was also a significantly older donor age in the seroconverted patients compared to nonseroconverted patients (41 ± 11 vs. 29 ± 12 years, p < 0.005), indicating a higher risk donor profile. A multivariate Cox regression including donor age showed that there was no increase in mortality in the seroconverted mismatches compared to nonmismatch patients (p = NS).

Conclusions

There is no significant increased mortality or morbidity using a CMV surveillance and preemptive therapy protocol. The effect of donor age on seroconversion of mismatches requires further validation.

Background

The 2018 UNOS allocation policy change deprioritized geographic boundaries to organ distribution, and the effects of this change have been widespread. The aim of this investigation was to analyze changes in donor transplant center distance for organ travel and corresponding outcomes before and after the allocation policy change.

Methods

The UNOS database was utilized to identify all adult patients waitlisted for heart transplants from 2016 to 2021. Transplant centers were grouped by average donor heart travel distance based on whether they received more or less than 50% of organs from >250 miles away. Descriptive statistics were provided for waitlisted and transplanted patients. Regression analyses modeled waitlist mortality, incidence of transplant, overall survival, and graft survival.

Results

Centers with a longer average travel distance had a higher mean annual transplant volume with a reduction in total days on a waitlist (86.6 vs. 149.2 days), an increased cold ischemic time (3.6 vs. 3.2 h), with no significant difference in post-transplant overall survival or graft survival.

Conclusions

The benefits of reducing waitlist time while preserving post-transplant outcomes extend broadly. The trends observed in this investigation will be useful as we revise organ transplant policy in the era of new organ procurement and preservation techniques.

Introduction

Simultaneous pancreas–kidney transplantation (SPK) is the preferred treatment for individuals with type-1 diabetes and end-stage renal disease. However, a limited supply of “Ideal Pancreas Donors” contributed to a growing disparity between available organs and recipients. Even though SPK outcomes from pediatric donors match those from adult donors, unclear guidelines on minimum age and weight criteria for extra small pediatric pancreas donors lead to hesitancy among several transplant centers to utilize these grafts due to concerns about inadequate islet mass, technical challenges, and increased risk of allograft thrombosis.

Methods

This report details the successful outcomes of SPK transplantations performed at the study center between December 2021 and January 2024, using four extra small pediatric brain-dead donors (ESPDs). Each donor was aged ≤5 years and weighed <20 kg.

Results

All SPK recipients achieved immediate posttransplant euglycemia without requiring insulin. None of the recipients experienced graft pancreatitis, graft thrombosis, allograft rejection, or required re-exploration. During a 5–27-month follow-up period, all ESPD recipients maintained optimal graft function, as evidenced by normal glucose tolerance tests and HbA1c (4.9%–5.2%), with 100% graft and patient survival.

Conclusion

This report examines the usage of ESPDs in SPK transplantation, highlighting their potential to expand the donor pool and reduce wait times in areas with scarce deceased organ donations, thereby increasing the number of available organs for transplantation with acceptable outcomes. Revising donor selection guidelines to reflect the diverse risk–benefit profiles of waitlisted individuals is crucial to addressing geographical disparities and reducing organ discard rates.

Purpose

Evaluate cytomegalovirus (CMV) post-prophylaxis surveillance in high-risk (D+/R-) kidney and liver transplant recipients.

Methods

Adult D+/R- patients were included if transplanted between 6/1/15 and 11/30/22 and divided into a pre-CMV-stewardship-era (6/1/15–5/31/18), CMV-stewardship-era (6/1/18–6/30/20), and a surveillance-era (7/1/2020–11/30/2022) then followed through 12 months. The primary objective was to evaluate CMV-related outcomes. The secondary objective was to assess graft and patient survival by era.

Results

There were 328 patients in the study period; 133 in the pre-stewardship-era, 103 in the stewardship-era, and 92 in the surveillance-era.

Replication rates in the surveillance-era were significantly higher, as anticipated due to increased sampling (pre 38.4%, stewardship 33.0%, surveillance 52.2%, p = 0.02). Time from transplant to first replication was similar (pre 214.0 ± 79.0 days, stewardship 231.1 ± 65.5, surveillance 234.9 ± 61.4, p = 0.29). CMV viral load (VL) at first detection, maximum-VL, and incidence of VL > 100 000 IU/mL were numerically lower in the surveillance era, although not statistically significant. CMV end-organ disease (p < 0.0001) and ganciclovir-resistance (p = 0.002) were significantly lower in the surveillance era than in both previous eras.

Rejection was not different between eras (p = 0.4). Graft (p = 0.0007) and patient survival (p = 0.008) were significantly improved in the surveillance era.

Conclusions

Post-prophylaxis surveillance significantly reduced CMV end-organ disease and resistance. Despite observing increased replication rates in the surveillance era, rejection was not significantly different and there was no graft loss or patient mortality at 12 months.