Clinical Transplantation最新文献_第3页

Procurement Trends, Indications, and Outcomes of Heart–Lung Transplantation in the Contemporary Era 当代心肺移植的采购趋势、适应症和结果。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-09-03 DOI: 10.1111/ctr.15447

John A. Treffalls, Ahmet Bilgili, Zachary Brennan, Omar M. Sharaf, Elaine M. Griffeth, Qiudong Chen, Kelly Pennington, Philip J. Spencer, Mauricio A. Villavicencio, Richard C. Daly, Sahar A. Saddoughi

Background

Evolving trends in organ procurement and technological innovation prompted an investigation into recent trends, indications, and outcomes following combined heart–lung transplantation (HLTx).

Methods

The United Network for Organ Sharing database was queried for all adult (≥18 years) HLTx performed between July 1, 2013 and June 30, 2023. Patients with previous transplants were excluded. The primary endpoint was the effect of donor, recipient, and transplantation characteristics on 1- and 5-year survival. Secondary analyses included a comparison of HLTx at high- and low-volume centers, an assessment of HLTx following donation after circulatory death (DCD), and an evaluation of HLTx volume over time. Cox proportional-hazards models were used to assess factors associated with mortality. Temporal trends were evaluated with linear regression.

Results

After exclusions, 319 patients were analyzed, of whom 5 (1.6%) were DCD. HLTx volume increased from 2013 to 2023 (p < 0.001). One- and 5-year survival following HLTx was 84.0% and 59.5%, respectively. One-year survival was higher for patients undergoing HLTx at a high-volume center (88.3% vs. 77.9%; p = 0.012). After risk adjustment, extracorporeal membrane oxygenation support 72 h posttransplant and predischarge dialysis were associated with increased 1-year mortality (HR = 3.19, 95% CI = 1.86–5.49 and HR = 3.47, 95% CI = 2.17–5.54, respectively) and 5-year mortality (HR = 2.901, 95% CI = 1.679–5.011 and HR = 3.327, 95% CI = 2.085–5.311, respectively), but HLTx at a high-volume center was not associated with either.

Conclusions

HLTx volume has resurged, with DCD HLTx emerging as a viable procurement strategy. Factors associated with 1- and 5-year survival may be used to guide postoperative management following HLTx.

背景：器官获取和技术创新的发展趋势促使人们对心肺联合移植（HLTx）的最新趋势和结果进行调查：器官获取和技术创新的发展趋势促使我们对心肺联合移植（HLTx）的最新趋势、适应症和结果进行调查：方法：查询器官共享联合网络数据库，了解 2013 年 7 月 1 日至 2023 年 6 月 30 日期间进行的所有成人（≥18 岁）心肺联合移植手术。曾接受过移植手术的患者不包括在内。主要终点是供体、受体和移植特征对1年和5年存活率的影响。次要分析包括对高容量中心和低容量中心的 HLTx 进行比较、对循环死亡（DCD）后捐献的 HLTx 进行评估，以及对随着时间推移的 HLTx 容量进行评估。采用 Cox 比例危险模型评估与死亡率相关的因素。使用线性回归评估了时间趋势：排除后，分析了 319 例患者，其中 5 例（1.6%）为 DCD。从2013年到2023年，HLTx的数量有所增加（p 结论：HLTx的数量有所恢复：HLTx数量再次上升，DCD HLTx已成为一种可行的采购策略。与 1 年和 5 年生存率相关的因素可用于指导 HLTx 术后管理。

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引用次数: 0

Strategy and Outcomes of Cardiac Surgery in Patients With Cirrhosis: Comprehensive Approach With Liver Transplant Program 肝硬化患者心脏手术的策略和结果：肝移植计划的综合方法。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-09-02 DOI: 10.1111/ctr.15451

Junichi Shimamura, Kenji Okumura, Ryosuke Misawa, Roxana Bodin, Seigo Nishida, Sooyun Tavolacci, Ramin Malekan, Steven Lansman, David Spielvogel, Suguru Ohira

<div> <section> <h3> Background</h3> <p>Cardiac surgery is considered a contraindication in patients with advanced liver cirrhosis (LC) due to increased mortality and morbidity. There are limited data on the treatment strategy and management of this population. We aimed to present our strategy and evaluate the clinical outcome of cardiac surgery in patients with LC.</p> </section> <section> <h3> Methods</h3> <p>Our strategy was (i) to list patients for liver transplant (LT) at the time of cardiac surgery; (ii) to maintain high cardiopulmonary bypass (CPB) flow (index up to 3.0 L/min/m<sup>2</sup>) based on hyper-dynamic states due to LC; and (iii) to proceed to LT if patients’ liver function deteriorated with an increasing model for end-stage liver disease Na (MELD-Na) score after cardiac surgery. Thirteen patients (12 male and 1 female [mean age, 63.0]) with LC who underwent cardiac surgery between 2017 and 2024 were retrospectively analyzed.</p> </section> <section> <h3> Results</h3> <p>Six patients were listed for LT. Indications for cardiac surgery included coronary artery disease (<i>N</i> = 7), endocarditis (<i>N</i> = 2), and tricuspid regurgitation (<i>N</i> = 1), tricuspid stenosis (<i>N</i> = 1), mitral regurgitation (<i>N</i> = 1), and hypertrophic obstructive cardiomyopathy (<i>N</i> = 1). The Child–Pugh score was A in five, B in six, and C in one patient. The procedure included coronary artery bypass grafting (<i>N</i> = 6), single valve surgery (mitral valve [<i>N</i> = 2] and tricuspid valve [<i>N</i> = 1]), concomitant aortic and tricuspid valve surgery (<i>N</i> = 2), and septal myectomy (<i>N</i> = 1). Two patients had a history of previous sternotomy. The perfusion index during CPB was 3.1 ± 0.5 L/min/m<sup>2</sup>. Postoperative complications include pleural effusion (<i>N</i> = 6), bleeding events (<i>N</i> = 3), acute kidney injury (<i>N</i> = 1), respiratory failure requiring tracheostomy (<i>N</i> = 2), tamponade (<i>N</i> = 1), and sternal infection (<i>N</i> = 1). There was no in-hospital death. There was one remote death due to COVID-19 complication. Preoperative and postoperative highest MELD-Na score among listed patients was 15.8 ± 5.1 and 19.3 ± 5.3, respectively. Five patients underwent LT (1, 5, 8, 16, and 24 months following cardiac surgery) and one patient remains on the list. Survival rates at 1 and 3 years are 100% and 75.0%, respectively.</p> </section> <section> <h3> Conclusion</h3> <p>Cardiac surgery maintaining high CPB flow with LT backup is a feasible strategy in an otherwise inoperable patient population with an acceptable early and midterm survival when performed in a center with an exp

背景：由于死亡率和发病率增加，心脏手术被认为是晚期肝硬化（LC）患者的禁忌症。有关这一人群的治疗策略和管理的数据十分有限。我们旨在介绍我们的策略，并评估肝硬化患者心脏手术的临床效果：我们的策略是：(i) 在心脏手术时将患者列入肝移植（LT）名单；(ii) 基于 LC 导致的高动力状态，维持高心肺旁路（CPB）流量（指数高达 3.0 L/min/m2）；(iii) 如果患者肝功能恶化，且心脏手术后终末期肝病模型 Na（MELD-Na）评分增加，则进行 LT。对2017年至2024年间接受心脏手术的13例LC患者（12男1女[平均年龄63.0岁]）进行了回顾性分析：6名患者被列为LT患者。心脏手术指征包括冠状动脉疾病（7 例）、心内膜炎（2 例）、三尖瓣反流（1 例）、三尖瓣狭窄（1 例）、二尖瓣反流（1 例）和肥厚型梗阻性心肌病（1 例）。5 名患者的 Child-Pugh 评分为 A，6 名患者为 B，1 名患者为 C。手术包括冠状动脉旁路移植术（6 例）、单瓣膜手术（二尖瓣 [2 例] 和三尖瓣 [1 例]）、主动脉瓣和三尖瓣联合手术（2 例）以及室间隔肌层切除术（1 例）。两名患者曾进行过胸骨切开术。CPB 期间的灌注指数为 3.1 ± 0.5 L/min/m2。术后并发症包括胸腔积液（6 例）、出血事件（3 例）、急性肾损伤（1 例）、呼吸衰竭（2 例）、气管插管（1 例）和胸骨感染（1 例）。无院内死亡病例。有1例因COVID-19并发症导致的远程死亡。所列患者术前和术后的最高 MELD-Na 评分分别为（15.8 ± 5.1）和（19.3 ± 5.3）。五名患者接受了LT治疗（心脏手术后1、5、8、16和24个月），一名患者仍在名单上。1年和3年的存活率分别为100%和75.0%：结论：在心脏外科和LT项目经验丰富的中心进行心脏手术时，维持高CPB流量和LT备用是一种可行的策略，对于无法手术的患者群体来说，其早期和中期存活率都是可以接受的。

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引用次数: 0

Measuring the Impact of Postsimultaneous Pancreas–Kidney Transplantation Complications: Comparing the Comprehensive Complication Index and Clavien–Dindo Classification 衡量同期胰肾移植术后并发症的影响：比较综合并发症指数和克拉维恩-丁多分类法

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-30 DOI: 10.1111/ctr.15440

Yeqi Nian, Lu Hu, Yu Cao, Zhen Wang, Hui Wang, Gang Feng, Jie Zhao, Jianming Zheng, Wenli Song

Introduction

The Clavien–Dindo classification (CDC) is commonly used for assessing postoperative complications; however, it may not be comprehensive. A comprehensive complication index (CCI) was introduced to address this limitation. This study aimed to compare the effectiveness of the CCI and CDC in evaluating the complications after simultaneous pancreas–kidney (SPK) transplantation.

Methods

Data were collected from patients who underwent SPK transplantation at our center between February 2018 and February 2021. Complications encountered during hospitalization were assessed using both the CDC and CCI. Linear regression analyses were performed to identify the factors related to postoperative length of stay (PLOS).

Results

Overall, 125 patients were included, with an average age of 46.87 years. Type 2 diabetes was present in 79% of the recipients. Among them, 117 patients experienced postoperative complications of CDC grades I (2.4%), II (57.6%), IIIa (8.0%), IIIb (9.6%), IVa (14.4%), IVb (0.8%), and V (0.8%) postoperative complications. The median CCI for the entire cohort was 37.2. Spearman's correlation analysis revealed significant associations between the CDC and PLOS and the CCI and PLOS. Notably, CCI exhibited a stronger correlation with PLOS (CCI: ρ = 0.698 vs. CDC: ρ = 0.524; p = 0.024).

Conclusion

The CCI demonstrated a stronger correlation with PLOS than CDC. Our finding suggests that the CCI may be a useful tool for comprehensively assessing complications following SPK transplantation.

导言：Clavien-Dindo 分类法（CDC）常用于评估术后并发症，但可能并不全面。综合并发症指数（CCI）的引入正是为了解决这一局限性。本研究旨在比较 CCI 和 CDC 在评估同步胰肾（SPK）移植术后并发症方面的有效性。方法收集2018年2月至2021年2月期间在本中心接受SPK移植的患者数据。使用 CDC 和 CCI 评估住院期间遇到的并发症。进行线性回归分析以确定与术后住院时间（PLOS）相关的因素。结果共纳入 125 名患者，平均年龄为 46.87 岁。79%的受术者患有 2 型糖尿病。其中，117 名患者出现了 CDC I 级（2.4%）、II 级（57.6%）、IIIa 级（8.0%）、IIIb 级（9.6%）、IVa 级（14.4%）、IVb 级（0.8%）和 V 级（0.8%）术后并发症。整个组群的 CCI 中位数为 37.2。斯皮尔曼相关性分析表明，CDC 和 PLOS 以及 CCI 和 PLOS 之间存在显著相关性。值得注意的是，CCI 与 PLOS 的相关性更强（CCI：ρ = 0.698 vs. CDC：ρ = 0.524; p = 0.024）。结论 CCI 与 PLOS 的相关性强于 CDC。我们的发现表明，CCI 可能是全面评估 SPK 移植后并发症的有用工具。

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引用次数: 0

Regional Disparities in Kidney Transplant Allocation in Brazil: A Retrospective Cohort Study 巴西肾移植分配的地区差异：回顾性队列研究

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-30 DOI: 10.1111/ctr.15446

Daniela Ferreira Salomão Pontes, Gustavo Fernandes Ferreira, Dorry Segev, Allan B. Massie, Macey Levan, Abner Mácola Pacheco Barbosa, Naila Camila da Rocha, Luis Gustavo Modelli de Andrade

Background

Brazil has a large public transplant program, but it remains unclear if the kidney waitlist criteria effectively allocate organs. This study aimed to investigate whether gender, ethnicity, clinical characteristics, and Brazilian regions affect the chance of deceased donor kidney transplant (DDKT).

Methods

We conducted a retrospective cohort study using the National Transplant System/Brazil database, which included all patients on the kidney transplant waitlist from January 2012 to December 2022, followed until May 2023. The primary outcome assessed was the chance of DDKT, measured using subdistribution hazard and cause-specific hazard models (subdistribution hazard ratio [sHR]).

Results

We analyzed 118 617 waitlisted patients over a 10-year study period. Male patients had an sHR of 1.07 ([95% CI: 1.05–1.10], p < 0.001), indicating a higher chance of DDTK. Patients of mixed race and Yellow/Indigenous ethnicity had lower rates of receiving a transplant compared to Caucasian patients, with sHR of 0.97 (95% CI: 0.95–1) and 0.89 (95% CI: 0.95–1), respectively. Patients from the South region had the highest chance of DDKT, followed by those from the Midwest and Northeast, compared to patients from the Southeast, with sHR of 2.53 (95% CI: 2.47–2.61), 1.21 (95% CI: 1.16–1.27), and 1.10 (95% CI: 1.07–1.13), respectively. The North region had the lowest chance of DDTK, sHR of 0.29 (95% CI: 0.27–0.31).

Conclusion

We found that women and racial minorities faced disadvantages in kidney transplantation. Additionally, we observed regional disparities, with the North region having the lowest chance of DDKT and longer times on dialysis before being waitlisted. In contrast, patients in the South regions had a chance of DDKT and shorter times on dialysis before being waitlisted. It is urgent to implement approaches to enhance transplant capacity in the North region and address race and gender disparities in transplantation.

背景巴西有一个庞大的公共移植项目，但肾脏等待名单标准是否能有效分配器官仍不清楚。本研究旨在探讨性别、种族、临床特征和巴西地区是否会影响死亡供体肾移植（DDKT）的机会。方法我们利用巴西国家移植系统数据库（National Transplant System/Brazil database）进行了一项回顾性队列研究，该数据库包括从 2012 年 1 月至 2022 年 12 月肾移植等待者名单上的所有患者，并跟踪至 2023 年 5 月。评估的主要结果是 DDKT 的几率，采用亚分布危险模型和特定病因危险模型（亚分布危险比 [sHR]）进行测量。结果我们对 10 年研究期间的 118 617 名候补患者进行了分析。男性患者的亚分布危险比为 1.07（[95% CI：1.05-1.10]，p < 0.001），表明 DDTK 的几率更高。与白种人相比，混血儿和黄种人/土著人接受移植的几率较低，sHR 分别为 0.97（95% CI：0.95-1）和 0.89（95% CI：0.95-1）。与来自东南部的患者相比，来自南部地区的患者发生 DDKT 的几率最高，其次是来自中西部和东北部的患者，sHR 分别为 2.53（95% CI：2.47-2.61）、1.21（95% CI：1.16-1.27）和 1.10（95% CI：1.07-1.13）。北部地区出现 DDTK 的几率最低，sHR 为 0.29（95% CI：0.27-0.31）。结论我们发现，女性和少数种族在肾移植中处于不利地位。此外，我们还观察到地区间的差异，北部地区的 DDKT 机率最低，在列入等待名单之前的透析时间较长。与此相反，南部地区患者的 DDKT 机率较高，等待肾移植之前的透析时间较短。当务之急是采取措施提高北部地区的移植能力，并解决移植中的种族和性别差异问题。

{"title":"Regional Disparities in Kidney Transplant Allocation in Brazil: A Retrospective Cohort Study","authors":"Daniela Ferreira Salomão Pontes, Gustavo Fernandes Ferreira, Dorry Segev, Allan B. Massie, Macey Levan, Abner Mácola Pacheco Barbosa, Naila Camila da Rocha, Luis Gustavo Modelli de Andrade","doi":"10.1111/ctr.15446","DOIUrl":"https://doi.org/10.1111/ctr.15446","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Brazil has a large public transplant program, but it remains unclear if the kidney waitlist criteria effectively allocate organs. This study aimed to investigate whether gender, ethnicity, clinical characteristics, and Brazilian regions affect the chance of deceased donor kidney transplant (DDKT).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a retrospective cohort study using the National Transplant System/Brazil database, which included all patients on the kidney transplant waitlist from January 2012 to December 2022, followed until May 2023. The primary outcome assessed was the chance of DDKT, measured using subdistribution hazard and cause-specific hazard models (subdistribution hazard ratio [sHR]).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We analyzed 118 617 waitlisted patients over a 10-year study period. Male patients had an sHR of 1.07 ([95% CI: 1.05–1.10], <i>p</i> < 0.001), indicating a higher chance of DDTK. Patients of mixed race and Yellow/Indigenous ethnicity had lower rates of receiving a transplant compared to Caucasian patients, with sHR of 0.97 (95% CI: 0.95–1) and 0.89 (95% CI: 0.95–1), respectively. Patients from the South region had the highest chance of DDKT, followed by those from the Midwest and Northeast, compared to patients from the Southeast, with sHR of 2.53 (95% CI: 2.47–2.61), 1.21 (95% CI: 1.16–1.27), and 1.10 (95% CI: 1.07–1.13), respectively. The North region had the lowest chance of DDTK, sHR of 0.29 (95% CI: 0.27–0.31).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>We found that women and racial minorities faced disadvantages in kidney transplantation. Additionally, we observed regional disparities, with the North region having the lowest chance of DDKT and longer times on dialysis before being waitlisted. In contrast, patients in the South regions had a chance of DDKT and shorter times on dialysis before being waitlisted. It is urgent to implement approaches to enhance transplant capacity in the North region and address race and gender disparities in transplantation.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142100086","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

Assessing the Role of Primary Heart Failure Etiology on Cardiac Transplant Outcomes 评估原发性心力衰竭病因对心脏移植结果的影响

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-30 DOI: 10.1111/ctr.15450

Ahad Firoz, Roh Yanagida, Mohammed Kashem, Yoshiya Toyoda, Eman Hamad

Background

There are diverse indications for heart transplantation (HTx), often categorized into ischemic (ICM) and nonischemic (NICM) cardiomyopathy. Although there is extensive research comparing the outcomes for these disease processes following certain therapeutic interventions, there are limited data on how recipient etiology impacts post-HTx survival. Our investigation seeks to identify this relationship.

Methods

We conducted a retrospective analysis using adult HTx patients from the United Network for Organ Sharing database between 2000 and 2021. Patients with a combined heart–lung transplant or previous HTx were excluded. ICM included coronary artery disease (CAD) and ischemic dilated cardiomyopathy. NICM included nonischemic dilated (NIDCM), hypertrophic (HCM), and restrictive (RCM) cardiomyopathy. Overall survival was analyzed using Kaplan–Meier curves, log-rank tests, and multivariable Cox regression models.

Results

A total of 42 268 patients were included in our study. Recipients with ICM were older and more likely to be males, obese, diabetics, and smokers. We found that patients with ICM had an increased incidence of transplant CAD (OR = 1.23, p < 0.001) and risk of mortality (hazard ratio [HR] = 1.22, p < 0.001) compared to NICM. When NICM was expanded, RCM had a similar hazard risk compared to ICM (HR = 1.03, p = 0.650), whereas both NIDCM (HR = 0.81, p < 0.001) and HCM (HR = 0.70, p < 0.001) had improved survival.

Conclusion

Our study provides evidence to suggest that ICM has decreased survival when compared to NICM. When NICM was expanded, RCM was found to have an increased mortality risk similar to ICM, whereas NIDCM and HCM both had superior outcomes. The clinical implication of this investigation will allow clinicians to better understand the prognosis of certain patient groups.

背景心脏移植（HTx）的适应症多种多样，通常分为缺血性（ICM）和非缺血性（NICM）心肌病。尽管有大量研究比较了这些疾病过程在接受某些治疗干预后的结果，但关于受体病因如何影响心脏移植后存活率的数据却很有限。我们的调查旨在确定这种关系。方法我们利用 2000 年至 2021 年期间器官共享联合网络数据库中的成人 HTx 患者进行了一项回顾性分析。排除了合并心肺移植或既往接受过 HTx 的患者。ICM 包括冠状动脉疾病（CAD）和缺血性扩张型心肌病。NICM包括非缺血性扩张型（NIDCM）、肥厚型（HCM）和限制型（RCM）心肌病。采用 Kaplan-Meier 曲线、对数秩检验和多变量 Cox 回归模型对总生存率进行了分析。结果本研究共纳入 42 268 例患者。ICM 受体年龄较大，男性、肥胖、糖尿病患者和吸烟者较多。我们发现，与 NICM 相比，ICM 患者的移植 CAD 发生率（OR = 1.23，p < 0.001）和死亡风险（危险比 [HR] = 1.22，p < 0.001）均有所增加。当 NICM 扩大时，RCM 的危险风险与 ICM 相似（HR = 1.03，p = 0.650），而 NIDCM（HR = 0.81，p <0.001）和 HCM（HR = 0.70，p <0.001）的生存率均有所提高。结论我们的研究提供的证据表明，与 NICM 相比，ICM 的存活率更低。在扩大 NICM 的范围后，发现 RCM 的死亡风险增加与 ICM 相似，而 NIDCM 和 HCM 的预后均优于 ICM。这项研究的临床意义将使临床医生更好地了解某些患者群体的预后。

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引用次数: 0

Eculizumab as Salvage Treatment for Thrombotic Microangiopathy After Lung Transplantation 将 Eculizumab 作为肺移植术后血栓性微血管病的挽救疗法

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-29 DOI: 10.1111/ctr.15443

Hernando Trujillo, Ana Huerta, Rodrigo Alonso, Maria Luisa Serrano, Myriam Aguilar, Enrique Morales, Teresa Cavero

Background

Thrombotic microangiopathy (TMA) is a rare complication after lung transplantation (LT) that has seldom been characterized in detail. Recent evidence has linked TMA other than primary atypical hemolytic uremic syndrome (aHUS) with hyperactivation of the complement alternative pathway. The focus of this investigation was to analyze the treatment response with eculizumab in TMA after LT.

Methods

Case series where we have studied 11 patients with TMA after LT from 2 Spanish tertiary healthcare centers. Clinical data and response rates to eculizumab are provided.

Results

The main indication for lung transplant was chronic obstructive pulmonary disease (COPD) (36%) and most cases (82%) received bilateral LT. The median time to TMA diagnosis was 11.6 months (4.7–28.9) and the TMA trigger in the majority of cases (73%) was immunosuppressive drugs. Platelet and hemoglobin nadir were 58 × 10³/µL (24–108) and 7.7 g/dL (7.1–7.9), respectively. All cases presented acute kidney injury (AKI) with a median creatinine of 4 mg/dL (3.2–4.8) and 54.5% required acute dialysis. Eculizumab was started after a median time of 8 days (6–14) with a median duration of 3 weeks (2–8). Complete TMA response was observed in 7 (63.6%) cases and hematologic response in 10 (90.9%). The time to hematologic and renal response was 23 days (13–29) and 28 days (14–46), respectively.

Conclusions

TMA after LT is infrequent but potentially devastating. Our findings suggest that short cycles of eculizumab may be effective for severe TMA after LT.

背景血栓性微血管病（TMA）是肺移植（LT）后的一种罕见并发症，很少有详细的描述。最近有证据表明，除原发性非典型溶血性尿毒综合征（aHUS）外，血栓性微血管病还与补体替代途径的过度激活有关。本研究的重点是分析依库珠单抗对 LT 后 TMA 的治疗反应。方法我们对来自西班牙两家三级医疗中心的 11 名 LT 后 TMA 患者进行了病例系列研究。提供了临床数据和对依库珠单抗的反应率。结果肺移植的主要适应症是慢性阻塞性肺病（COPD）（36%），大多数病例（82%）接受了双侧LT。TMA诊断的中位时间为11.6个月（4.7-28.9个月），大多数病例（73%）的TMA诱因是免疫抑制剂。血小板和血红蛋白最低值分别为 58 × 103/µL (24-108) 和 7.7 g/dL (7.1-7.9)。所有病例均出现急性肾损伤（AKI），肌酐中位数为 4 mg/dL (3.2-4.8)，54.5% 的病例需要急性透析。开始使用依库珠单抗的中位时间为 8 天（6-14 天），中位持续时间为 3 周（2-8 周）。7例（63.6%）观察到完全的TMA反应，10例（90.9%）观察到血液学反应。血液学和肾脏反应时间分别为 23 天（13-29 天）和 28 天（14-46 天）。结论 LT 后的 TMA 并不常见，但可能具有破坏性。我们的研究结果表明，短周期的依库珠单抗可能对LT后的严重TMA有效。

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引用次数: 0

Review–Long-Term Care of Kidney Transplant Patients 回顾--肾移植患者的长期护理

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-27 DOI: 10.1111/ctr.15441

Ron Shapiro

引用次数: 0

Determining Predictors of Actual Living Kidney Donation Based on Potential Donor Characteristics 根据潜在捐献者的特征确定实际活体肾脏捐献的预测因素。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-27 DOI: 10.1111/ctr.15439

Andrea M. Meinders, Edward A. Graviss, Duc T. Nguyen, Jonathan Daw, Krista L. Lentine, John Devin Peipert, Ahmed Osama Gaber, David A. Axelrod, Francis L. Weng, Amy D. Waterman

Background

Living donor kidney transplantation is the optimal treatment for end-stage kidney disease; however, few living donor candidates (LDCs) who begin evaluation actually donate. While some LDCs are deemed medically ineligible, others discontinue for potentially modifiable reasons.

Methods

At five transplant centers, we conducted a prospective cohort study measuring LDCs’ clinical and psychosocial characteristics, educational preparation, readiness to donate, and social determinants of health. We followed LDCs for 12 months after evaluation to determine whether they donated a kidney, opted to discontinue, had modifiable reasons for discontinuing, were medically ineligible, or had other recipient-related reasons for discontinuing.

Results

Among 2184 LDCs, 18.6% donated, 38.2% opted to or had modifiable reasons for discontinuing, and 43.2% were deemed ineligible due to medical or recipient-related reasons. Multivariable analyses comparing successful LDCs with those who did not complete donation for modifiable reasons (N = 1241) found that LDCs who discussed donation with the recipient before evaluation (OR, 2.31; 95% CI, 1.54–3.46), had completed high school (OR, 2.01; 95% CI, 1.21–3.35), or were a “close relation” to their recipient (OR, 1.89; 95% CI, 1.33–2.69) were more likely to donate. Conversely, LDCs who reported religion as important (OR, 0.55; 95% CI, 0.38–0.80), were Non-White (OR, 0.70; 95% CI, 0.49–1.00), or had overall higher anxiety scores (OR, 0.92; 95% CI, 0.86–0.99) were less likely to donate.

Conclusion

With fewer than a fifth of LDCs donating, developing programs to provide greater emotional support and facilitate open discussions between LDCs and recipients earlier may increase living donation rates.

背景：活体肾移植是治疗终末期肾病的最佳方法；然而，开始评估的活体肾移植候选者（LDC）中，真正捐献者寥寥无几。有些活体捐献者在医学上被认为不符合捐献条件，有些则因潜在的可改变原因而中止捐献：我们在五个移植中心开展了一项前瞻性队列研究，测量 LDC 的临床和社会心理特征、教育准备情况、捐献准备情况以及健康的社会决定因素。我们在评估后对 LDC 进行了为期 12 个月的跟踪调查，以确定他们是否捐献了肾脏、是否选择中止捐献、中止捐献的原因是否可以改变、是否不符合医疗条件或是否有其他与受者相关的中止捐献原因：在 2184 名当地捐献者中，18.6% 的人捐献了肾脏，38.2% 的人选择停止捐献或有可改变的原因而停止捐献，43.2% 的人因医疗或与受捐者相关的原因而被认为不符合捐献条件。将成功捐赠的 LDC 与因可修改原因而未完成捐赠的 LDC（N = 1241）进行多变量分析后发现，在评估前与受捐者讨论过捐赠事宜（OR，2.31；95% CI，1.54-3.46）、已完成高中学业（OR，2.01；95% CI，1.21-3.35）或与受捐者 "关系密切"（OR，1.89；95% CI，1.33-2.69）的 LDC 更有可能捐赠。相反，认为宗教很重要（OR，0.55；95% CI，0.38-0.80）、非白人（OR，0.70；95% CI，0.49-1.00）或总体焦虑评分较高（OR，0.92；95% CI，0.86-0.99）的最不发达国家捐赠的可能性较低：结论：由于只有不到五分之一的遗体捐献者进行了捐献，因此制定相关计划，为遗体捐献者和受捐者提供更多的情感支持并促进他们尽早进行公开讨论，可能会提高活体捐献率。

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引用次数: 0

Association of Frailty With Clinical and Financial Outcomes Following Liver Transplantation 肝移植后体弱与临床和财务结果的关系

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-27 DOI: 10.1111/ctr.15438

Giselle Porter, Sara Sakowitz, Saad Mallick, Amulya Vadlakonda, Joanna Curry, Konmal Ali, Jeffrey Balian, Peyman Benharash

Introduction

Frailty, a measure of physiological aging and reserve, has been validated as a prognostic indicator of mortality in patients with cirrhosis. However, large-scale analyses of the independent association of frailty with clinical and financial outcomes following liver transplantation (LT) are lacking.

Methods

Adults (≥18 years) undergoing LT were identified in the 2016–2020 National Readmissions Database. Frailty was defined using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable linear and logistic regression models were developed to evaluate the independent association of frailty with in-hospital mortality, perioperative complications, and costs.

Results

Of an estimated 34 442 patients undergoing LT, 8265 (24%) were frail. After adjustment, frailty was associated with greater odds of mortality (adjusted odds ratio [AOR] 1.80; 95% Confidence Interval [CI]: 1.49–1.18), postoperative length of stay (β + 11 days; 95% CI: +10, +12), and hospitalization costs (+$86 880; 95% CI: +75 660, +98 100), as well as a two-fold increase in relative risk of nonhome discharge (AOR 2.17, 95% CI: 1.90–2.49).

Conclusions

Frailty is associated with an increased risk of in-hospital mortality, complications, and resource utilization among LT recipients. As the proportion of frail LT patients continues to rise, our findings underscore the need for novel risk-stratification and individualized care protocols for such vulnerable patients.

简介虚弱是一种衡量生理衰老和储备的指标，已被证实是肝硬化患者死亡率的预后指标。然而，目前还缺乏对虚弱与肝移植（LT）后临床和财务结果的独立关联的大规模分析：方法：从2016-2020年全国再入院数据库中识别出接受肝移植的成人（≥18岁）。采用二元约翰霍普金斯调整临床组虚弱指标对虚弱进行定义。建立了多变量线性和逻辑回归模型，以评估虚弱与院内死亡率、围手术期并发症和费用的独立关联：在约 34 442 名接受腰椎间盘突出症手术的患者中，有 8265 人（24%）体弱。经调整后，体弱与死亡率（调整赔率[AOR]1.80；95% 置信区间[CI]：1.49-1.18）、术后住院时间（β + 11 天；95% CI：+10，+12）和住院费用（+86 880 美元；95% CI：+75 660，+98 100）相关联，且非居家出院的相对风险增加了两倍（AOR 2.17，95% CI：1.90-2.49）：体弱与LT患者院内死亡率、并发症和资源使用风险的增加有关。随着体弱的LT患者比例持续上升，我们的研究结果凸显了对这类易感患者进行新的风险分级和个体化护理方案的必要性。

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引用次数: 0

Risk Factors and Outcomes Associated With the Development of Persistent Acute Kidney Injury in Non-Renal Solid Organ Transplant Recipients: Systematic Review and Meta-Analysis 非肾脏实体器官移植受者发生持续性急性肾损伤的相关风险因素和结果：系统回顾与元分析》。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-08-27 DOI: 10.1111/ctr.15444

Ivan E. Saraiva, Natsumi Hamahata, Ankit Sakhuja, Xinlei Chen, John S. Minturn, Pablo G. Sanchez, Ernest G. Chan, David J. Kaczorowski, Ali Al-Khafaji, John A. Kellum, Hernando Gómez

Persistent acute kidney injury (pAKI), compared with acute kidney injury (AKI) that resolves in <72 h, is associated with worse prognosis in critically ill patients. Definitions and prognosis of pAKI are not well characterized in solid organ transplant patients. Our aims were to investigate (a) definitions and incidence of pAKI; (b) association with clinical outcomes; and (c) risk factors for pAKI among heart, lung, and liver transplant recipients. We systematically reviewed the literature including PubMed, Embase, Web of Science, and Cochrane from inception to 8/1/2023 for human prospective and retrospective studies reporting on the development of pAKI in heart, lung, or liver transplant recipients. We assessed heterogeneity using Cochran's Q and I². We identified 25 studies including 6330 patients. AKI (8%–71.6%) and pAKI (2.7%–55.1%) varied widely. Definitions of pAKI included 48–72 h (six studies), 7 days (three studies), 14 days (four studies), or more (12 studies). Risk factors included age, body mass index (BMI), diabetes, preoperative chronic kidney disease (CKD), intraoperative vasopressor use, and intraoperative circulatory support. pAKI was associated with new onset of CKD (odds ratio [OR] 1.41–11.2), graft dysfunction (OR 1.81–8.51), and long-term mortality (OR 3.01–13.96), although significant heterogeneity limited certainty of CKD and graft dysfunction outcome analyses. pAKI is common and is associated with worse mortality among liver and lung transplant recipients. Standardization of the nomenclature of AKI will be important in future studies (PROSPERO CRD42022371952).

持续性急性肾损伤（pAKI）与急性肾损伤（AKI）相比，后者可在 2 个月内缓解。我们确定了 25 项研究，包括 6330 名患者。AKI（8%-71.6%）和pAKI（2.7%-55.1%）的差异很大。pAKI 的定义包括 48-72 小时（6 项研究）、7 天（3 项研究）、14 天（4 项研究）或更长时间（12 项研究）。风险因素包括年龄、体重指数 (BMI)、糖尿病、术前慢性肾病 (CKD)、术中使用血管加压药和术中循环支持。pAKI 与新发 CKD（几率比 [OR] 1.41-11.2）、移植物功能障碍（OR 1.pAKI在肝脏和肺脏移植受者中很常见，并且与死亡率下降有关。在未来的研究中，AKI命名的标准化将非常重要（PROSPERO CRD42022371952）。

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引用次数: 0