Clinical Transplantation最新文献_第8页

Examining the Influence of a General Surgery Resident's Transplant Experience on Their Pursuit of Transplant Surgery Fellowship 研究普通外科住院医师的移植经验对其获得移植手术研究员资格的影响。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-18 DOI: 10.1111/ctr.15398

Mignote Yilma, Audrey E. Brown, Jalen Harvey, Christopher C. Stahl, Ralph C Quillin, Shareef M. Syed, Alexander R. Cortez, the US Resident OPerative Experience (ROPE) Consortium

Background

Transplant surgery has historically been a less desirable fellowship among general surgery graduates. Limited work has been done to understand factors associated with residents’ interest in transplantation. Using a multi-institutional cohort, we examined how the resident experience on transplant surgery may influence their decision to pursue transplant fellowship.

Methods

Individual demographics, program characteristics, and transplant-specific case logs were collected for graduates from 2010 to 2020 at 20 general surgery residency programs within the US Resident OPerative Experience (ROPE) Consortium. Residents who pursued transplant surgery fellowship were compared to those who went directly into practice or pursued a non-transplant fellowship.

Results

Among 1342 general surgery graduates, 52 (3.9%) pursued abdominal transplant fellowship. These residents completed more transplant (22 vs. 9), liver (14 vs. 9), pancreas (15 vs. 11), and vascular access operations (38 vs. 30) compared to residents who did not pursue transplant fellowship (all p < 0.05). Multivariable logistic regression found that residents underrepresented in medicine were three times more likely (95% CI 1.54–6.58, p < 0.01) and residents at a program co-located with a transplant fellowship six times more likely (95% CI 1.95–18.18, p < 0.01) to pursue transplant fellowship. Additionally, a resident's increasing total transplant operative volume was associated with an increased likelihood of pursuing a transplant fellowship (OR = 1.12, 95% CI 1.09–1.14, p < 0.01).

Conclusion

The findings from this multi-institutional study demonstrate that increased exposure to transplant operations and interaction within a transplant training program is associated with a resident's pursuit of transplant surgery fellowship. Efforts to increase operative exposure, case participation, and mentorship may optimize the resident experience and promote the transplant surgery pipeline.

背景：移植手术历来是普外科毕业生不太愿意从事的研究工作。目前了解住院医师对移植手术感兴趣的相关因素的工作还很有限。我们利用一个多机构队列，研究了住院医师在移植手术方面的经验如何影响他们选择移植奖学金的决定：方法：我们收集了美国住院医师实习经验联盟（ROPE）中 20 个普通外科住院医师实习项目 2010 年至 2020 年毕业生的个人人口统计学特征、项目特征和移植特定病例日志。结果显示：在1342名普外科毕业生中，有1342人获得了移植手术研究奖学金：结果：在 1342 名普外科毕业生中，有 52 人（3.9%）获得了腹部移植奖学金。结果：在 1342 名普外科毕业生中，有 52 人（3.9%）获得了腹部移植研究金，与没有获得移植研究金的住院医师相比，这些住院医师完成了更多的移植手术（22 例对 9 例）、肝脏手术（14 例对 9 例）、胰腺手术（15 例对 11 例）和血管通路手术（38 例对 30 例）：这项多机构研究的结果表明，在移植培训项目中更多地接触移植手术和互动与住院医师获得移植手术研究金有关。努力增加手术机会、病例参与和导师指导可优化住院医师的经验并促进移植手术的发展。

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引用次数: 0

Importance of Transplant Era on Post–Heart Transplant Predictive Models: A UNOS Cohort Analysis 移植年代对心脏移植后预测模型的重要性：UNOS 队列分析。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-18 DOI: 10.1111/ctr.15403

Mickaël Lescroart, Evan P. Kransdorf, Maria Francesca Scuppa, Jignesh K. Patel, Guillaume Coutance

Background

The application of posttransplant predictive models is limited by their poor statistical performance. Neglecting the dynamic evolution of demographics and medical practice over time may be a key issue.

Objectives

Our objective was to develop and validate era-specific predictive models to assess whether these models could improve risk stratification compared to non–era-specific models.

Methods

We analyzed the United Network for Organ Sharing (UNOS) database including first noncombined heart transplantations (2001–2018, divided into four transplant eras: 2001–2005, 2006–2010, 2011–2015, 2016–2018). The endpoint was death or retransplantation during the 1st-year posttransplant. We analyzed the dynamic evolution of major predictive variables over time and developed era-specific models using logistic regression. We then performed a multiparametric evaluation of the statistical performance of era-specific models and compared them to non–era-specific models in 1000 bootstrap samples (derivation set, 2/3; test set, 1/3).

Results

A total of 34 738 patients were included, 3670 patients (10.5%) met the composite endpoint. We found a significant impact of transplant era on baseline characteristics of donors and recipients, medical practice, and posttransplant predictive models, including significant interaction between transplant year and major predictive variables (total serum bilirubin, recipient age, recipient diabetes, previous cardiac surgery). Although the discrimination of all models remained low, era-specific models significantly outperformed the statistical performance of non–era-specific models in most samples, particularly concerning discrimination and calibration.

Conclusions

Era-specific models achieved better statistical performance than non–era-specific models. A regular update of predictive models may be considered if they were to be applied for clinical decision-making and allograft allocation.

背景：移植后预测模型的应用因其较差的统计性能而受到限制。忽略人口统计学和医疗实践随时间的动态演变可能是一个关键问题：我们的目标是开发和验证针对不同年龄的预测模型，以评估这些模型与非针对不同年龄的模型相比能否改善风险分层：我们分析了器官共享联合网络（UNOS）数据库，其中包括首次非合并心脏移植（2001-2018年，分为四个移植年代：2001-2005年、2006-2010年、2011-2015年、2016-2018年）。终点是移植后第一年内的死亡或再移植。我们分析了主要预测变量随时间的动态演变，并使用逻辑回归建立了特定时代的模型。然后，我们对时代特异性模型的统计性能进行了多参数评估，并在1000个引导样本（衍生集，2/3；测试集，1/3）中将其与非时代特异性模型进行了比较：共纳入 34 738 例患者，3670 例患者（10.5%）达到了综合终点。我们发现移植年代对供者和受者的基线特征、医疗实践和移植后预测模型有显著影响，包括移植年份与主要预测变量（血清总胆红素、受者年龄、受者糖尿病、既往心脏手术）之间的显著交互作用。虽然所有模型的分辨力仍然较低，但在大多数样本中，特定年代模型的统计性能明显优于非特定年代模型，尤其是在分辨力和校准方面：结论：年代特异性模型比非年代特异性模型具有更好的统计性能。如果要将预测模型应用于临床决策和异体移植分配，可以考虑定期更新模型。

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引用次数: 0

The Impact of Ipsilateral Implantable Cardioverter Defibrillator in Axillary Intra-Aortic Balloon Pump Support as Bridge to Heart Transplantation 同侧植入式心律转复除颤器在腋下主动脉内球囊泵支持中的影响作为心脏移植的桥梁。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-18 DOI: 10.1111/ctr.15404

Ameesh Isath, Rahim Hirani, Avi Levine, Gregg M. Lanier, Aroubah Iqbal, Junichi Shimamura, Alan L. Gass, David Spielvogel, Masashi Kai, Suguru Ohira

Background

The axillary artery (AX) access for intra-aortic balloon pump (IABP) as a bridge to heart transplant (HT) allows mobility while awaiting a suitable donor. As end-stage heart failure patients often have an implantable cardioverter defibrillator (ICD) on the left side, the left AX approach may be avoided due to the perception of difficult access and proximity of two devices. We aimed to evaluate the outcomes of patients bridged to HT with a left-sided AX IABP with or without ipsilateral ICDs.

Methods

We retrospectively reviewed HT candidates at our institution supported by left-sided axillary IABP from November 2019 to February 2024, dividing them into two groups based on the presence (Group ICD, n = 48) or absence (Group No-ICD, N = 19) of an ipsilateral left-sided ICD. The exposure time was defined as the time from skin incision to the beginning of anastomoses of a Dacron graft.

Results

Technical success was achieved in 100% of the cohort, with median exposure times for AX access similar between groups (ICD, 12 [7.8, 18.2] vs. No ICD, 11 [7, 19] min; p = 0.75). The rate of procedural adverse events, such as significant access site bleeding and ipsilateral limb ischemia, did not significantly differ between both groups. Device malfunction rates were comparable (ICD, 29.2% vs. No ICD, 15.8%; p = 0.35). Posttransplant, in-hospital mortality, severe primary graft dysfunction, and stroke rates were comparable in both groups.

Conclusion

The presence of an ipsilateral left-sided ICD does not adversely impact the procedural efficacy, complication rates, or posttransplant outcomes of left-sided AX IABP insertion in HT candidates.

背景：作为心脏移植（HT）的桥梁，主动脉内球囊反搏泵（IABP）的腋动脉（AX）入路允许患者在等待合适供体时进行移动。由于终末期心力衰竭患者的左侧通常装有植入式心律转复除颤器（ICD），因此左侧 AX 入路可能会因难以进入和靠近两个设备而被避免。我们的目的是评估使用左侧 AX IABP（带或不带同侧 ICD）桥接 HT 的患者的预后：我们回顾性审查了我院 2019 年 11 月至 2024 年 2 月期间由左侧腋窝 IABP 支持的 HT 候选人，根据同侧左侧 ICD 的存在（ICD 组，n = 48）或不存在（No-ICD 组，n = 19）将其分为两组。暴露时间定义为从切开皮肤到开始吻合达克隆移植物的时间：结果：100% 的患者获得了技术成功，AX 入路的中位暴露时间组间相似（ICD，12 [7.8, 18.2] 分钟；无 ICD，11 [7, 19] 分钟；P = 0.75）。两组的手术不良事件发生率（如入路部位大量出血和同侧肢体缺血）无显著差异。设备故障率相当（ICD，29.2%；无 ICD，15.8%；P = 0.35）。移植后，两组的院内死亡率、严重原发性移植物功能障碍和中风发生率相当：结论：同侧左侧 ICD 的存在不会对 HT 候选人左侧 AX IABP 植入的手术疗效、并发症发生率或移植后预后产生不利影响。

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引用次数: 0

Uncertainty and Communication Preferences Among Patients Undergoing Lung Transplant Evaluation: A Mixed-Methods Study 肺移植评估患者的不确定性和沟通偏好：混合方法研究。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-18 DOI: 10.1111/ctr.15406

Allison V. Lange, Anuj B. Mehta, Kathleen J. Ramos, Eric G. Campbell, Alice L. Gray, Caroline Tietbohl, Sandra Garcia-Hernandez, David B. Bekelman

Objective

Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians.

Methods

We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33–165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation.

Results

A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants.

Conclusion

Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients’ lives and support patients to cope with uncertainty.

目的：较高的不确定性与较差的生活质量相关，并可能受到临床医生关于未来沟通的影响。我们确定了接受肺移植评估的患者如何体验不确定性以及临床医生对未来的沟通：我们采用横断面调查和半结构式访谈进行了一项收敛平行混合方法研究。在科罗拉多大学和华盛顿大学接受肺移植评估的患者回答了有关未来沟通的问题，并填写了米谢尔疾病不确定性量表-成人（MUIS-A；范围33-165，分数越高表示不确定性越大）。访谈采用内容分析法进行分析。在数据解释过程中整合了调查和访谈结果：共有 101 名患者完成了调查（回复率：47%）。12 名调查参与者完成了访谈。在调查中，大多数患者认为家庭角色的改变很重要（76%），但他们很少与临床医生讨论这个问题（31%）。大多数患者（86%）担心自己未来的生活质量，74%的患者表示，由于不知道未来会发生什么，他们无法制定计划。MUIS-A 的平均得分为 85.5（标准差为 15.3）。访谈揭示了三个主题：（1）未来的不确定性令参与者苦恼；（2）参与者希望从临床医生那里获得实用信息；（3）参与者的沟通偏好各不相同：结论：参与者经历了不确定性带来的痛苦，并希望获得有关未来的信息。对参与者来说重要的沟通主题并不总是能得到医生的关注。临床医生应解决慢性肺病和肺移植如何直接影响患者生活的问题，并支持患者应对不确定性。

{"title":"Uncertainty and Communication Preferences Among Patients Undergoing Lung Transplant Evaluation: A Mixed-Methods Study","authors":"Allison V. Lange, Anuj B. Mehta, Kathleen J. Ramos, Eric G. Campbell, Alice L. Gray, Caroline Tietbohl, Sandra Garcia-Hernandez, David B. Bekelman","doi":"10.1111/ctr.15406","DOIUrl":"10.1111/ctr.15406","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33–165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients’ lives and support patients to cope with uncertainty.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141632879","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

Comparative Analysis of Ischemia-Reperfusion Injury in Heart Transplantation: A Single-Center Study Evaluating Conventional Ice-Cold Storage versus the Paragonix SherpaPak Cardiac Transport System 心脏移植中缺血再灌注损伤的比较分析：评估传统冰冷储存与 Paragonix SherpaPak 心脏转运系统的单中心研究。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-15 DOI: 10.1111/ctr.15397

Dor Lotan, Cathrine M. Moeller, Afsana Rahman, Gal Rubinstein, Daniel Oren, Yonatan Mehlman, Andrea Fernandez Valledor, Ersilia M. DeFilippis, Jayant Raikhelkar, Kevin Clerkin, Justin Fried, David Majure, Yoshifumi Naka, Yuji Kaku, Koji Takeda, Kyung Taek Oh, Adil Yunis, Paolo C Colombo, Melana Yuzefpolskaya, Farhana Latif, Gabriel Sayer, Nir Uriel, Miroslav Sekulic

Background

Since the 2018 allocation system change in heart transplantation (HT), ischemic times have increased, which may be associated with peri-operative and post-operative complications. This study aimed to compare ischemia reperfusion injury (IRI) in hearts preserved using ice-cold storage (ICS) and the Paragonix SherpaPak TM Cardiac Transport System (CTS).

Methods

From January 2021 to June 2022, consecutive endomyocardial biopsies from 90 HT recipients were analyzed by a cardiac pathologist in a single-blinded manner: 33 ICS and 57 CTS. Endomyocardial biopsies were performed at three-time intervals post-HT, and the severity of IRI manifesting histologically as coagulative myocyte necrosis (CMN) was evaluated, along with graft rejection and graft function.

Results

The incidence of IRI at weeks 1, 4, and 8 post-HT were similar between the ICS and CTS groups. There was a 59.3% statistically significant reduction in CMN from week 1 to 4 with CTS, but not with ICS. By week 8, there were significant reductions in CMN in both groups. Only 1 out of 33 (3%) patients in the ICS group had an ischemic time >240 mins, compared to 10 out of 52 (19%) patients in the CTS group. During the follow-up period of 8 weeks to 12 months, there were no significant differences in rejection rates, formation of de novo donor-specific antibodies and overall survival between the groups.

Conclusion

The CTS preservation system had similar rates of IRI and clinical outcomes compared to ICS despite longer overall ischemic times. There is significantly more recovery of IRI in the early post operative period with CTS. This study supports CTS as a viable option for preservation from remote locations, expanding the donor pool.

背景：自 2018 年心脏移植（HT）分配制度改变以来，缺血时间增加，这可能与围手术期和术后并发症有关。本研究旨在比较使用冰冷储存（ICS）和Paragonix SherpaPak TM心脏运输系统（CTS）保存的心脏的缺血再灌注损伤（IRI）：从 2021 年 1 月到 2022 年 6 月，心脏病理学家以单盲方式分析了 90 例 HT 受体的连续心内膜活检组织：其中 33 例为 ICS，57 例为 CTS。心内膜活检在HT后的三次间隔期进行，评估组织学上表现为凝固性心肌细胞坏死（CMN）的IRI严重程度，以及移植物排斥反应和移植物功能：ICS组和CTS组在HT术后第1、4和8周的IRI发生率相似。从第 1 周到第 4 周，CTS 组的 CMN 有 59.3% 的统计学显著下降，而 ICS 组则没有。到第 8 周时，两组的 CMN 都有明显减少。在 33 名 ICS 组患者中，只有 1 人（3%）的缺血时间超过 240 分钟，而在 52 名 CTS 组患者中，有 10 人（19%）的缺血时间超过 240 分钟。在8周至12个月的随访期间，两组患者在排斥率、新的供体特异性抗体的形成和总体存活率方面没有明显差异：结论：尽管CTS保存系统的总体缺血时间更长，但其IRI发生率和临床结果与ICS相似。CTS术后早期的IRI恢复率明显更高。这项研究支持将 CTS 作为保存偏远地区器官的可行方案，从而扩大供体库。

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引用次数: 0

Significant Long-Term Prevention of High Sensitization After Kidney Allograft Failure by Maintaining Calcineurin Inhibitor-Based Immunosuppression 维持基于钙神经蛋白抑制剂的免疫抑制，长期显著预防肾移植失败后的高度致敏。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-12 DOI: 10.1111/ctr.15394

Anna Allesina, Antonio Lavacca, Fabrizio Fop, Roberta Giraudi, Gloria Giovinazzo, Silvia Deaglio, Cristiana Caorsi, Caterina Dolla, Ester Gallo, Alberto Mella, Luigi Biancone

Introduction

Broad national or international programs contribute to mitigating the expected longer waiting list (WL) time for sensitized patients but with minor benefits for highly sensitized subjects. Therefore, strategies to prevent high sensitization are urgently required. In this study, we investigated the risk of developing highly sensitized patients with different immunosuppressive (IS) handling after kidney allograft failure (KAF).

Methods

Data from 185 patients with KAF, retransplanted/relisted from 2010 to 2020 in two regions of Italy that share the same regional WL, were analyzed. Patients were categorized according to IS management at 12 months after KAF as follows: patients maintaining IS with calcineurin inhibitors (CNI) (late withdrawal group [LWG], n = 58) and those who withdrew all IS therapy or were on steroids only (early withdrawal group [EWG], n = 127).

Results

Patients in the LWG showed lower panel reactive antibodies (PRA) at 12 (29.0% vs. 85.5%, p < 0.001) and 24 months (61.0% vs. 91.0%, p = 0.001), reduced risk of high sensitization (PRA ≥90%) at 12 (9.4% vs. 40.7%, p < 0.001, OR = 0.15) and 24 months (25.6% vs. 57.3%, p = 0.001, OR = 0.26) and almost no very high sensitization (PRA ≥ 98%) at 12 months (1.9% vs. 18.6%, p = 0.003, OR = 0.08) after KAF. In the LWG subgroup analysis, patients who maintained IS for up to 24 months after KAF did not show very high sensitization. The LWG showed shorter active WL times (406 vs. 813 days, p = 0.001) without an increased risk of complications.

Conclusions

CNI maintenance for at least 12 months after KAF could be a useful approach to prevent high sensitization and reduce WL times in patients who are offered retransplantation, without a higher burden of complications.

导言：广泛的国家或国际计划有助于缩短致敏患者预期较长的候诊时间（WL），但对高度致敏受试者的益处不大。因此，迫切需要制定预防高度致敏的策略。在这项研究中，我们调查了肾移植失败（KAF）后不同免疫抑制（IS）处理方式下高度致敏患者的发病风险：方法：我们分析了 2010 年至 2020 年期间在意大利两个共享同一地区 WL 的地区进行再移植/再住院的 185 名 KAF 患者的数据。根据KAF术后12个月的IS管理情况将患者分为以下两组：使用降钙素抑制剂（CNI）维持IS的患者（晚期撤药组[LWG]，n = 58）和撤除所有IS治疗或仅使用类固醇的患者（早期撤药组[EWG]，n = 127）：结果：LWG 组患者在 12 个月（29.0% vs. 85.5%，p < 0.001）和 24 个月（61.0% vs. 91.0%，p = 0.001）时面板反应性抗体（PRA）较低，在 12 个月时高度致敏（PRA ≥90%）的风险较低（9.4% vs. 40.7%，p < 0.001，OR = 0.15）和 24 个月（25.6% vs. 57.3%，p = 0.001，OR = 0.26），以及在 KAF 后 12 个月（1.9% vs. 18.6%，p = 0.003，OR = 0.08）几乎没有极度过敏（PRA ≥ 98%）。在 LWG 亚组分析中，在 KAF 后维持 IS 长达 24 个月的患者并未显示出极高的敏感性。LWG显示活跃WL时间较短（406天对813天，P = 0.001），但并发症风险并未增加：结论：在 KAF 后将 CNI 维持至少 12 个月可能是一种有效的方法，可防止高度致敏并缩短再次移植患者的 WL 时间，同时不会增加并发症负担。

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引用次数: 0

Organ Offer Review Cards: Improving Transparency on the Kidney Transplant Waitlist 器官供应审查卡：提高肾移植候选名单的透明度。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-11 DOI: 10.1111/ctr.15388

Husain A. Rasheed, Meridith Pensler, Sarah Diaz, Emily Roney, Meredith Barrett, Elizabeth M. Sonnenberg

Introduction

The 2022 National Academy of Sciences, Engineering, and Medicine report on equity in organ transplantation highlighted limited transparency and accountability for organ offer declines and recommended prioritizing patient engagement in decisions regarding organ offers. Yet, there is no guidance on how to incorporate patients in organ offers. We elected to study the experiences of patients on the waitlist and their perception of a novel Organ Offer Review Card (OORC).

Methods

A prototype OORC was created using Donornet refusal codes. Sixty randomly selected kidney waitlist patients at a single center were asked to participate in a web-based survey focusing on current medical decision-making preferences and perceptions of the prototype OORC.

Results

Among the 43 patients reached, 17 (39.5%) completed the survey. Most participants (88.2%) expressed it was important to be involved in the decision-making about organ offers, with 100.0% of respondents wanting to know why an organ was declined. Regarding the prototype OORC, 94.1% thought it helped them understand the factors and priorities considered when selecting an organ, and 88.2% said it increased their belief that their team was acting in their best interest.

Conclusion

An OORC could increase transparency and communication during the waitlist process while enhancing trust in the transplant team.

导言：2022 年美国国家科学、工程和医学研究院关于器官移植公平性的报告强调了器官供应下降的有限透明度和问责制，并建议优先考虑让患者参与有关器官供应的决策。然而，目前还没有关于如何让患者参与器官提供的指南。我们选择研究候选名单上患者的经历及其对新型器官提供审核卡（OORC）的看法：方法：使用 Donornet 拒绝代码创建了 OORC 原型。方法：使用 Donornet 拒绝代码创建了一个原型 OORC。在一个中心随机抽取了 60 名肾脏候诊患者，要求他们参与一项基于网络的调查，重点是当前医疗决策的偏好以及对原型 OORC 的看法：在 43 名患者中，17 人（39.5%）完成了调查。大多数参与者（88.2%）表示参与器官提供的决策非常重要，100.0% 的受访者希望了解拒绝提供器官的原因。关于 OORC 原型，94.1% 的受访者认为它有助于他们了解选择器官时考虑的因素和优先顺序，88.2% 的受访者表示它增强了他们的信念，即他们的团队是在为他们的最大利益着想：OORC 可以增加等待过程中的透明度和沟通，同时增强对移植团队的信任。

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引用次数: 0

Intravenous Immunoglobulins Alone for the Desensitization of Lung Transplant Recipients with Preformed Donor Specific Antibodies and Negative Flow Cytometry Crossmatch 单用静脉注射免疫球蛋白为预制供体特异性抗体和流式细胞术交叉配型阴性的肺移植受者脱敏。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-09 DOI: 10.1111/ctr.15374

Rayid Abdulqawi, Moheeb Alawwami, Omar Aldosari, Zyad Aldosari, Mohammed Alhuqbani, Rana A. Saleh, Dorina Esendagli, Haifa Aldakhil, Edward B. De Vol, Khaled Alkattan, Kris Ann H. Marquez, Waleed Saleh, Sahar Sandoqa, Eid A. Al-Mutairy

Background

The lack of evidence regarding optimal desensitization strategies for lung transplant candidates with preformed donor specific anti-human leukocyte antigen antibodies (DSAs) has led to varying approaches among centers towards this patient group. Our institution's desensitization protocol for recipients with preformed DSAs and negative flow cytometry crossmatch (FCXM) consists of intravenous immunoglobulin (IVIG) as the sole therapy. The study aimed to determine outcomes using this approach.

Methods

This retrospective study included adults who underwent lung-only transplantation for the first time between January 2015 and March 2022 at a single center. We excluded patients with positive or missing FCXM results. Transplant recipients with any DSA ≥ 1000 MFI on latest testing within three months of transplant were considered DSA-positive, while recipients with DSAs <1000 MFI and those without DSAs were assigned to the low-level/negative group. Graft survival (time to death/retransplantation) and chronic lung allograft dysfunction (CLAD)-free times were compared between groups using Cox proportional hazards models.

Results

Thirty-six out of 167 eligible patients (22%) were DSA-positive. At least 50% of preformed DSAs had documented clearance (decrease to <1000 MFI) within the first 6 months of transplant. Multivariable Cox regression analyses did not detect a significantly increased risk of graft failure (aHR 1.04 95%CI 0.55–1.97) or chronic lung allograft dysfunction (aHR 0.71 95%CI 0.34–1.52) in DSA-positive patients compared to patients with low-level/negative DSAs. Incidences of antibody-mediated rejection (p = 1.00) and serious thromboembolic events (p = 0.63) did not differ between study groups.

Conclusion

We describe a single-center experience of administering IVIG alone to lung transplant recipients with preformed DSAs and negative FCXM. Further studies are required to confirm the efficacy of this strategy against other protocols.

背景：由于缺乏证据证明对已形成供体特异性抗人类白细胞抗原抗体（DSAs）的肺移植候选者采取最佳脱敏策略，因此各中心对这一患者群体采取了不同的方法。我们机构对已形成供体特异性抗人类白细胞抗原抗体且流式细胞术交叉配型（FCXM）阴性的受者采取的脱敏方案包括静脉注射免疫球蛋白（IVIG）作为唯一疗法。该研究旨在确定采用这种方法的疗效：这项回顾性研究纳入了 2015 年 1 月至 2022 年 3 月期间在一个中心首次接受纯肺移植的成人患者。我们排除了FCXM结果呈阳性或缺失的患者。移植受者在移植后三个月内的最近一次检测中任何 DSA≥1000 MFI 均被视为 DSA 阳性，而 DSA 结果为阳性的受者则被视为 DSA 阳性：167 名符合条件的患者中有 36 人（22%）DSA 阳性。至少有 50%的预处理 DSA 有清除记录（下降至结论：我们描述了一个单中心经验，即对DSA阳性和FCXM阴性的肺移植受者单独使用IVIG。还需要进一步研究，以确认该策略对其他方案的疗效。

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引用次数: 0

Assessment of Posttransplant Bacteremia Caused by Extended-Spectrum Beta-Lactamase–Producing Gram-Negative Bacteria Among Kidney Transplant Recipients 评估肾移植受者移植后由产生广谱β-乳酰胺酶的革兰氏阴性菌引起的菌血症。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-08 DOI: 10.1111/ctr.15390

Madeleine S. Tilley, Seth W. Edwards, Matthew L. Brown, Peng Li, Shikha Mehta, Jeremey Walker, Kristofer C. Gutierrez

Background

Extended-spectrum beta-lactamase–producing gram-negative rods (ESBL-GNR) are a rising cause of bacteremia in kidney transplant recipients (KT). The study purpose was to examine patient mortality, allograft survival, estimated glomerular filtration rate (eGFR) at the end of 1 year, and readmission rates while looking at treatment strategies among KTs with ESBL-GNR and non–ESBL-GNR bacteremia at our institution.

Methods

This study was a retrospective, cohort analysis of KTs with gram-negative bacteremia from January 1, 2020, to December 31, 2021. The primary outcome of the study was mortality. Patient outcomes were assessed for 365 days after positive blood cultures.

Results

The study included 63 patients. Of these, 18 (29%) patients had bacteremia caused by an ESBL-GNR and 45 (71%) patients had bacteremia caused by a non–ESBL-GNR. Patient survival at 90 days was 94% in the ESBL-GNR group and 96% in the non–ESBL-GNR group. Ciprofloxacin was the most common antimicrobial therapy at discharge (68.9%) in the non–ESBL-GNR group whereas ertapenem was the most common in the ESBL-GNR group (44.5%). Median eGFR at discharge was 41 mL/min/1.73 m² in the ESBL-GNR group and 48 mL/min/1.73 m² in the non–ESBL-GNR group. Ninety-day readmission occurred in 9 (50%) ESBL-GNR patients and 14 (32%) non–ESBL-GNR patients. None of the above comparisons are statistically significant (p > 0.05). Eleven (61%) ESBL-GNR and 2 (4%) non–ESBL-GNR patients used outpatient parenteral antimicrobial therapy (p < 0.001).

Conclusions

Among KTs with ESBL-GNR bacteremia, no significant difference was detected in mortality or allograft function compared to non–ESBL-GNR bacteremia.

背景：产生广谱β-内酰胺酶的革兰氏阴性杆菌（ESBL-GNR）是导致肾移植受者（KT）菌血症的一个不断上升的原因。本研究旨在探讨本院肾移植受者中ESBL-GNR和非ESBL-GNR菌血症患者的死亡率、异体移植存活率、1年后估计肾小球滤过率（eGFR）和再入院率，同时研究治疗策略：本研究对 2020 年 1 月 1 日至 2021 年 12 月 31 日期间患有革兰氏阴性菌血症的 KT 进行了回顾性队列分析。研究的主要结果是死亡率。在血液培养阳性后的 365 天内，对患者的预后进行评估：研究共纳入 63 名患者。其中，18 例（29%）患者的菌血症由 ESBL-GNR 引起，45 例（71%）患者的菌血症由非 ESBL-GNR 引起。在 90 天的存活率方面，ESBL-GNR 组为 94%，非 ESBL-GNR 组为 96%。非ESBL-GNR组患者出院时最常用的抗菌药物是环丙沙星（68.9%），而ESBL-GNR组患者最常用的抗菌药物是厄他培南（44.5%）。ESBL-GNR 组出院时的中位 eGFR 为 41 mL/min/1.73 m2，非 ESBL-GNR 组为 48 mL/min/1.73 m2。9例（50%）ESBL-GNR患者和14例（32%）非ESBL-GNR患者在90天后再次入院。上述比较均无统计学意义（P > 0.05）。11例（61%）ESBL-GNR患者和2例（4%）非ESBL-GNR患者使用了门诊肠外抗菌治疗（P < 0.001）：结论：与非ESBL-GNR菌血症相比，患有ESBL-GNR菌血症的KT在死亡率或异体移植功能方面没有发现明显差异。

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引用次数: 0

Symptom Distress Before and After Heart Transplantation – A Longitudinal 5-Year Follow-Up 心脏移植前后的症状困扰--一项为期 5 年的纵向随访。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-08 DOI: 10.1111/ctr.15385

Marita Dalvindt, Hannah Lindahl Veungen, Annika Kisch, Shahab Nozohoor, Annette Lennerling, Anna Forsberg

Introduction

Symptom distress after heart transplantation (HTx) is a significant problem causing uncertainty, low self-efficacy, and psychological distress. Few studies have addressed self-reported symptoms. The aim was to explore self-reported symptom distress from time on the waiting list to 5 years after HTx and its association with self-reported psychological well-being, chronic pain, and fatigue in order to identify possible predictors of psychological or transplant specific well-being.

Methods

This multicenter, longitudinal cohort study includes 48 heart recipients (HTRs), 12 women, and 36 men, with a median age of 57 years followed from pretransplant to 5 years post-transplant. Symptom distress was explored by means of four instruments measuring psychological general wellbeing, transplant specific wellbeing, pain, and fatigue.

Results

Transplant specific well-being for the whole improved in a stepwise manner during the first 5 years compared to pretransplant. Heart transplant recipients with poor psychological wellbeing were significantly more burdened by symptom distress, in particular sleep problems and fatigue, for up to 5 years after HTx, and their transplant-specific well-being never improved compared to baseline. The prevalence of pain varied from 40% to 60% and explained a significant proportion of the variance in transplant-specific well-being, while psychological general well-being was mainly predicted by overall symptom distress.

Conclusion

The presence of distressing symptoms explains a significant proportion of poor psychological wellbeing both among HTRs reporting chronic pain and those without pain.

简介心脏移植（HTx）后的症状困扰是一个重要问题，会导致不确定性、自我效能低和心理困扰。很少有研究涉及自我报告的症状。本研究的目的是探讨从候选名单到心脏移植术后5年期间自我报告的症状困扰及其与自我报告的心理健康、慢性疼痛和疲劳之间的关系，以确定心理健康或移植特定健康的可能预测因素：这项多中心纵向队列研究包括 48 名心脏受者（HTR），其中女性 12 人，男性 36 人，中位年龄为 57 岁，从移植前随访到移植后 5 年。研究通过四种工具对症状困扰进行了调查，这四种工具分别测量一般心理健康、移植特定健康、疼痛和疲劳：结果：与器官移植前相比，器官移植受者的整体心理状况在最初的5年中逐步改善。心理健康状况不佳的心脏移植受者在接受心脏移植手术后长达5年的时间里受症状困扰的程度明显加重，尤其是睡眠问题和疲劳，他们的移植具体健康状况与基线相比从未得到改善。疼痛的发生率从40%到60%不等，可以解释移植特定幸福感的很大一部分差异，而心理总体幸福感主要由总体症状困扰预测：结论：无论是报告有慢性疼痛的还是没有疼痛的人类器官移植患者，其心理健康状况不佳的很大一部分原因都在于存在痛苦症状。

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引用次数: 0