This article aims to review unresolved ethical issues and raise additional questions to be answered regarding the use of intraoperative brain monitoring during thoracoabdominal normothermic regional perfusion (TA-NRP). We discuss the following ethical questions, as well as offer preliminary recommendations to advance the discourse around use of brain monitoring during TA-NRP: (1) Does brain monitoring admit violation of the dead donor rule? (2) Which monitoring techniques should be implemented during TA-NRP? (3) How should we manage positive findings? (4) How should we manage ambiguous findings on brain monitoring? (5) What procedural and institutional barriers remain to utilizing intraoperative brain monitoring for TA-NRP on a wider scale? We argue that preventing inadvertent brain reperfusion is central to ensuring TA-NRP complies with ethical standards, and that blood flow monitoring is the most direct monitor for reperfusion. We assess potential brain monitors during TA-NRP and suggest that transcranial doppler (TCD) with cerebral oximetry may be the closest existing tests to an ideal monitor for this application. We likewise review remaining questions regarding diagnostic uncertainty around these tests and the implications of this uncertainty or positive findings of brain reperfusion on the donor, their families, and public trust. To begin addressing these questions, necessary first steps include standardization of surgical protocols to include venting and consolidating data around TA-NRP.
{"title":"Intraoperative Brain Monitoring During Thoracoabdominal Normothermic Regional Perfusion: Practical and Ethical Considerations","authors":"Alexander J. Quan, Brendan S. Parent","doi":"10.1111/ctr.70383","DOIUrl":"10.1111/ctr.70383","url":null,"abstract":"<div>\u0000 \u0000 <p>This article aims to review unresolved ethical issues and raise additional questions to be answered regarding the use of intraoperative brain monitoring during thoracoabdominal normothermic regional perfusion (TA-NRP). We discuss the following ethical questions, as well as offer preliminary recommendations to advance the discourse around use of brain monitoring during TA-NRP: (1) Does brain monitoring admit violation of the dead donor rule? (2) Which monitoring techniques should be implemented during TA-NRP? (3) How should we manage positive findings? (4) How should we manage ambiguous findings on brain monitoring? (5) What procedural and institutional barriers remain to utilizing intraoperative brain monitoring for TA-NRP on a wider scale? We argue that preventing inadvertent brain reperfusion is central to ensuring TA-NRP complies with ethical standards, and that blood flow monitoring is the most direct monitor for reperfusion. We assess potential brain monitors during TA-NRP and suggest that transcranial doppler (TCD) with cerebral oximetry may be the closest existing tests to an ideal monitor for this application. We likewise review remaining questions regarding diagnostic uncertainty around these tests and the implications of this uncertainty or positive findings of brain reperfusion on the donor, their families, and public trust. To begin addressing these questions, necessary first steps include standardization of surgical protocols to include venting and consolidating data around TA-NRP.</p>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145755317","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}
Michael G. Megaly, William C. Miller, Jessica Thul, Peter Gullickson, Abraham J. Matar, Michael Dryden, Matthew Wright, David Mathews, Jessica Fisher, Heidi Sarumi, Levi Teigen, Scott Lunos, Timothy L. Pruett
Sarcopenia is a known predictor of morbidity and mortality after liver transplantation (LT); it has been assessed with computed tomography (CT) derived Psoas Area Index (PAI) and mean Hounsfield units (mHU). While literature is abundant regarding the adverse outcomes of liver transplant in sarcopenic patients, a paucity of data exists describing the change in psoas muscle area and density from pre- to post-liver transplant. One hundred and four adult liver transplant recipients had pre- and post-transplant CT scans analyzed with respect to PAI and mHU. Mean PAI pre-transplant was 7.94 and 6.99 cm2/m2 post-transplant (12% loss). Mean mHU pre-transplant was 35.47 and 33.00 post-transplant (7% reduction). However, stratified by pre-transplant quartiles, PAI reduction was −15%, −12%, and −6% for the upper, mid-two, and lower quartiles, respectively (p value = 0.0028). The mHU stratification was −15%, −8%, and + 12% for the upper, mid-two, and lower quartiles, respectively (p value = 0.0004). No relationship was noted between PAI and mHU. PAI and mHU decreased following liver transplantation; however, the most pronounced decrease in muscle mass and density was in patients with the highest starting muscle mass and density. However, muscle mass (PAI) and composition (mHU) appear to be affected by multiple factors.
{"title":"Decrease in Psoas Muscle Mass and Density Following Liver Transplantation Is Greatest in Patients With the Highest Muscle Quantity and Density Pre-Transplant","authors":"Michael G. Megaly, William C. Miller, Jessica Thul, Peter Gullickson, Abraham J. Matar, Michael Dryden, Matthew Wright, David Mathews, Jessica Fisher, Heidi Sarumi, Levi Teigen, Scott Lunos, Timothy L. Pruett","doi":"10.1111/ctr.70410","DOIUrl":"10.1111/ctr.70410","url":null,"abstract":"<p>Sarcopenia is a known predictor of morbidity and mortality after liver transplantation (LT); it has been assessed with computed tomography (CT) derived Psoas Area Index (PAI) and mean Hounsfield units (mHU). While literature is abundant regarding the adverse outcomes of liver transplant in sarcopenic patients, a paucity of data exists describing the change in psoas muscle area and density from pre- to post-liver transplant. One hundred and four adult liver transplant recipients had pre- and post-transplant CT scans analyzed with respect to PAI and mHU. Mean PAI pre-transplant was 7.94 and 6.99 cm<sup>2</sup>/m<sup>2</sup> post-transplant (12% loss). Mean mHU pre-transplant was 35.47 and 33.00 post-transplant (7% reduction). However, stratified by pre-transplant quartiles, PAI reduction was −15%, −12%, and −6% for the upper, mid-two, and lower quartiles, respectively (<i>p</i> value = 0.0028). The mHU stratification was −15%, −8%, and + 12% for the upper, mid-two, and lower quartiles, respectively (<i>p</i> value = 0.0004). No relationship was noted between PAI and mHU. PAI and mHU decreased following liver transplantation; however, the most pronounced decrease in muscle mass and density was in patients with the highest starting muscle mass and density. However, muscle mass (PAI) and composition (mHU) appear to be affected by multiple factors.</p>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12704402/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145755330","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michael G. Megaly, Todd DeFor, Xianghua Luo, Michael Dryden, Joseph Sushil Rao, Matthew Wright, David Mathews, Karthik Ramanathan, Vanessa Humpreville, Erik B. Finger, Raja Kandaswamy, Abraham J. Matar
Background
Although advances in pancreas transplantation have improved patient survival, prolonged immunosuppression has increased the risk of post-transplant malignancies. This study aimed to examine the incidence, risk factors, and long-term outcomes of solid organ malignancies in pancreas transplant recipients at a single center.
Methods
All adult pancreas transplants between February 1, 1983, and December 31, 2023 at the University of Minnesota were reviewed, including pancreas transplant alone (PTA), simultaneous pancreas-kidney transplants (SPK), and pancreas after kidney transplants (PAK).
Results
1729 pancreas transplant recipients were included with a median follow-up of 23 years. During this period, 152 (8.8%) developed a non-skin, non-hematologic malignancy at a median time of 12.6 years after transplant, with a cumulative incidence of 13% (95% CI 11%–16%) at 30 years post-transplant. The most common malignancies were colorectal (14.1%), renal cell (13.0%), breast (13.0%), and lung (9.7%) cancers. Functioning graft status (HR 0.67, 95% CI 0.47–0.95, p = 0.024), maintenance corticosteroid use (HR 1.51, 95% CI 1.00–2.27, p = 0.051), and transplant era (p = 0.015) were risk factors for development of a solid organ malignancy. Overall survival following malignancy diagnosis was poor, with a 10-year post-diagnosis survival rate of 24% (95% CI 17%–33%). No recipient or transplant-related factors were independently associated with mortality after malignancy diagnosis.
Conclusion
Solid organ malignancies constitute a substantial late complication in pancreas transplant recipients, with corticosteroid exposure and graft longevity as key risk factors. These findings underscore the need for long-term cancer surveillance and tailored immunosuppressive strategies in this population.
尽管胰腺移植技术的进步提高了患者的生存率，但长期的免疫抑制增加了移植后恶性肿瘤的风险。本研究旨在研究单一中心胰腺移植受者实体器官恶性肿瘤的发生率、危险因素和长期预后。方法回顾1983年2月1日至2023年12月31日在明尼苏达大学进行的所有成人胰腺移植手术，包括单独胰腺移植（PTA）、胰肾联合移植（SPK）和肾移植后胰腺移植（PAK）。结果纳入1729例胰腺移植受者，中位随访23年。在此期间，152例（8.8%）患者在移植后12.6年的中位时间内发展为非皮肤、非血液系统恶性肿瘤，移植后30年的累积发病率为13% （95% CI为11%-16%）。最常见的恶性肿瘤是结直肠癌（14.1%）、肾细胞癌（13.0%）、乳腺癌（13.0%）和肺癌（9.7%）。移植物功能状态（HR 0.67, 95% CI 0.47-0.95, p = 0.024）、维持皮质类固醇使用（HR 1.51, 95% CI 1.00-2.27, p = 0.051）和移植时间（p = 0.015）是发生实体器官恶性肿瘤的危险因素。恶性肿瘤诊断后的总体生存率较差，诊断后10年生存率为24% （95% CI 17%-33%）。没有受体或移植相关因素与恶性肿瘤诊断后的死亡率独立相关。结论实体器官恶性肿瘤是胰腺移植患者的重要晚期并发症，皮质类固醇暴露和移植物寿命是主要危险因素。这些发现强调了对这一人群进行长期癌症监测和量身定制的免疫抑制策略的必要性。
{"title":"Solid Organ Malignancy After Pancreas Transplantation: A Four Decade Single-Center Experience","authors":"Michael G. Megaly, Todd DeFor, Xianghua Luo, Michael Dryden, Joseph Sushil Rao, Matthew Wright, David Mathews, Karthik Ramanathan, Vanessa Humpreville, Erik B. Finger, Raja Kandaswamy, Abraham J. Matar","doi":"10.1111/ctr.70381","DOIUrl":"https://doi.org/10.1111/ctr.70381","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Although advances in pancreas transplantation have improved patient survival, prolonged immunosuppression has increased the risk of post-transplant malignancies. This study aimed to examine the incidence, risk factors, and long-term outcomes of solid organ malignancies in pancreas transplant recipients at a single center.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>All adult pancreas transplants between February 1, 1983, and December 31, 2023 at the University of Minnesota were reviewed, including pancreas transplant alone (PTA), simultaneous pancreas-kidney transplants (SPK), and pancreas after kidney transplants (PAK).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>1729 pancreas transplant recipients were included with a median follow-up of 23 years. During this period, 152 (8.8%) developed a non-skin, non-hematologic malignancy at a median time of 12.6 years after transplant, with a cumulative incidence of 13% (95% CI 11%–16%) at 30 years post-transplant. The most common malignancies were colorectal (14.1%), renal cell (13.0%), breast (13.0%), and lung (9.7%) cancers. Functioning graft status (HR 0.67, 95% CI 0.47–0.95, <i>p</i> = 0.024), maintenance corticosteroid use (HR 1.51, 95% CI 1.00–2.27, <i>p</i> = 0.051), and transplant era (<i>p</i> = 0.015) were risk factors for development of a solid organ malignancy. Overall survival following malignancy diagnosis was poor, with a 10-year post-diagnosis survival rate of 24% (95% CI 17%–33%). No recipient or transplant-related factors were independently associated with mortality after malignancy diagnosis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Solid organ malignancies constitute a substantial late complication in pancreas transplant recipients, with corticosteroid exposure and graft longevity as key risk factors. These findings underscore the need for long-term cancer surveillance and tailored immunosuppressive strategies in this population.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739568","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}
Amit Banga, Brandon A. Guenthart, Song Zhang, John W. MacArthur, Gundeep S. Dhillon
Background
The use of donation after circulatory death (DCD) donors has significantly increased in recent years. The current study sought to risk-stratify transplants where DCD donors are utilized.
Methods
We reviewed the UNOS database for adult patients who underwent lung transplantation (LT) using DCD donors between 2017 and 2022 (n = 948, 6.31% of all LT). One-year mortality was the primary dependent variable.
Results
The proportion of DCD donors is increasing (3.7% in 2017 to 7.6% in 2022, p < 0.001) and is associated with significantly higher 1-year mortality (13.9% vs. 10.7% among recipients of brain dead donors; p = 0.003). On Cox proportional hazard analysis with bootstrap validation, recipient age > 65 years (adjusted hazards ratio, 95% CI: 1.51, 1.05–2.2; p = 0.028), admission to the ICU at the time of transplant (2.11, 1.34–3.31; p = 0.001), estimated GFR < 75 mL/min/1.73 m2 at the time of transplant (1.81, 1.23–2.67; p = 0.003), and organ out of body time >7 h (2.02, 1.39–2.94; p < 0.001) are associated with 1-year mortality. A composite variable, the recipient risk score, based on the number of above risk factors, is strongly associated with 1-year mortality.
Conclusions
The utilization of DCD donors is associated with worse 1-year mortality after LT. The recipient risk score based on the four simple-to-use recipient and procedure-related variables strongly predicts outcomes.
背景近年来，循环死亡（DCD）供者捐献的使用显著增加。目前的研究试图对使用DCD供体的移植进行风险分层。方法：我们回顾了UNOS数据库中2017年至2022年间使用DCD供体接受肺移植（LT）的成年患者（n = 948，占所有LT的6.31%）。1年死亡率是主要的因变量。结果DCD供体比例呈上升趋势（2017年为3.7%，2022年为7.6%,p < 0.001），且与较高的1年死亡率相关（脑死亡供体受者为13.9% vs. 10.7%, p = 0.003）。在采用bootstrap验证的Cox比例风险分析中，受者年龄>； 65岁（校正风险比，95% CI: 1.51, 1.05-2.2; p = 0.028）、移植时入住ICU （2.11, 1.34-3.31; p = 0.001）、移植时估计GFR <； 75 mL/min/1.73 m2 （1.81, 1.23-2.67; p = 0.003）、器官出体时间>；7 h （2.02, 1.39-2.94; p < 0.001）与1年死亡率相关。一个复合变量，即基于上述危险因素数量的受者风险评分，与1年死亡率密切相关。结论DCD供体的使用与lt后较差的1年死亡率相关。基于四个简单使用的受体和程序相关变量的受体风险评分强有力地预测了结果。
{"title":"Donation after Circulatory Death Donors Are Associated With Increased 1-Year Mortality After Lung Transplantation: A UNOS-Based Risk Stratification Study","authors":"Amit Banga, Brandon A. Guenthart, Song Zhang, John W. MacArthur, Gundeep S. Dhillon","doi":"10.1111/ctr.70399","DOIUrl":"https://doi.org/10.1111/ctr.70399","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The use of donation after circulatory death (DCD) donors has significantly increased in recent years. The current study sought to risk-stratify transplants where DCD donors are utilized.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We reviewed the UNOS database for adult patients who underwent lung transplantation (LT) using DCD donors between 2017 and 2022 (<i>n</i> = 948, 6.31% of all LT). One-year mortality was the primary dependent variable.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The proportion of DCD donors is increasing (3.7% in 2017 to 7.6% in 2022, <i>p</i> < 0.001) and is associated with significantly higher 1-year mortality (13.9% vs. 10.7% among recipients of brain dead donors; <i>p</i> = 0.003). On Cox proportional hazard analysis with bootstrap validation, recipient age > 65 years (adjusted hazards ratio, 95% CI: 1.51, 1.05–2.2; <i>p</i> = 0.028), admission to the ICU at the time of transplant (2.11, 1.34–3.31; <i>p</i> = 0.001), estimated GFR < 75 mL/min/1.73 m<sup>2</sup> at the time of transplant (1.81, 1.23–2.67; <i>p</i> = 0.003), and organ out of body time >7 h (2.02, 1.39–2.94; <i>p</i> < 0.001) are associated with 1-year mortality. A composite variable, the recipient risk score, based on the number of above risk factors, is strongly associated with 1-year mortality.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>The utilization of DCD donors is associated with worse 1-year mortality after LT. The recipient risk score based on the four simple-to-use recipient and procedure-related variables strongly predicts outcomes.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739570","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}
Organ transport remains a critical determinant of transplant success, with delays during transfer prolonging cold ischemia time (CIT) and increasing the risk of delayed graft function or organ discard. Uncrewed aerial vehicles (UAVs) have emerged as a potential means to enhance the speed, predictability, and resilience of transplant logistics. This scoping review synthesized global evidence from 2010 to 2025 across biomedical, engineering, and regulatory domains, mapping research within six key themes: time sensitivity and clinical evidence, integration with preservation and perfusion technologies, technological and infrastructural readiness, regulatory and ethical frameworks, economic and environmental feasibility, and public and professional preparedness. Case studies from North America, Europe, and Asia demonstrate that UAVs can safely deliver donor organs while maintaining temperature and structural stability, with successful clinical transplantation reported. Their current value lies primarily in short-range transfers where direct routing and rapid handover are feasible; however, advances in heavy-lift aircraft, autonomous traffic management, and connected perfusion systems may soon enable longer, more complex missions. Major barriers include restrictions on beyond-visual-line-of-sight (BVLOS) operation, payload and endurance limitations, uncertain liability frameworks, and incomplete hospital-side infrastructure. Future priorities include comparative clinical and economic trials, harmonized international standards, and certified medical air corridors integrated with national allocation systems. With appropriate regulation, interoperability, and clinical validation, drones could become a safe and sustainable extension of existing transplant networks—improving efficiency, equity, and ultimately, patient survival.
{"title":"Drone-Assisted Organ Transport: A Scoping Review of Clinical, Regulatory, and System Readiness","authors":"Robson G. Gilmour, Mekhola Hoff","doi":"10.1111/ctr.70398","DOIUrl":"https://doi.org/10.1111/ctr.70398","url":null,"abstract":"<p>Organ transport remains a critical determinant of transplant success, with delays during transfer prolonging cold ischemia time (CIT) and increasing the risk of delayed graft function or organ discard. Uncrewed aerial vehicles (UAVs) have emerged as a potential means to enhance the speed, predictability, and resilience of transplant logistics. This scoping review synthesized global evidence from 2010 to 2025 across biomedical, engineering, and regulatory domains, mapping research within six key themes: time sensitivity and clinical evidence, integration with preservation and perfusion technologies, technological and infrastructural readiness, regulatory and ethical frameworks, economic and environmental feasibility, and public and professional preparedness. Case studies from North America, Europe, and Asia demonstrate that UAVs can safely deliver donor organs while maintaining temperature and structural stability, with successful clinical transplantation reported. Their current value lies primarily in short-range transfers where direct routing and rapid handover are feasible; however, advances in heavy-lift aircraft, autonomous traffic management, and connected perfusion systems may soon enable longer, more complex missions. Major barriers include restrictions on beyond-visual-line-of-sight (BVLOS) operation, payload and endurance limitations, uncertain liability frameworks, and incomplete hospital-side infrastructure. Future priorities include comparative clinical and economic trials, harmonized international standards, and certified medical air corridors integrated with national allocation systems. With appropriate regulation, interoperability, and clinical validation, drones could become a safe and sustainable extension of existing transplant networks—improving efficiency, equity, and ultimately, patient survival.</p>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ctr.70398","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739411","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sandesh Parajuli, Adam Bregman, Emily E. Zona, Megan Sokup, Neetika Garg, Weixiong Zhong, Didier Mandelbrot
Background
Microvascular inflammation (MVI) with sum glomerulitis and peritubular capillaritis (g+ptc) ≥ 2 is an integral component of kidney allograft antibody-mediated rejection (AMR). It is unclear what the outcomes are among those with persistent MVI, despite treatment.
Methods
We included all kidney transplant recipients (KTRs) with persistent MVI ≥ 2 on first and second allograft biopsies who had third biopsies within 2 years of the first biopsy. KTRs were categorized into two groups, MVI (+) and MVI (−) on third biopsy. Risk factors for persistent MVI ≥ 2 on third biopsy, and graft survival based on MVI (+) and MVI (−) at last follow-up were outcomes of interest.
Results
A total of 108 KTRs transplanted between 2013 and 2022 fulfilled our selection criteria, 75 (69%) were MVI (+) and 33 (31%) MVI (−). Most baseline characteristics were similar between the groups. In Cox regression analysis, none of the commonly assessed baseline characteristics, Banff scores, or DSA status at first or second biopsy were associated with persistent MVI on the third biopsy. Also, in Cox regression analysis, after adjusting for various characteristics, persistent MVI on third biopsy was not associated with increased or decreased risk for uncensored graft failure (aHR: 0.55, 95% CI: 0.23–1.29; p = 0.17).
Conclusion
The lack of difference in graft outcomes between the AMR patients who were MVI (+) versus MVI (−) on the third biopsy suggests that subsequent response to AMR treatment is less important for prognosis than the initial development of AMR. This reinforces the importance of the prevention of rejection.
{"title":"Outcomes of Persistent Microvascular Inflammation in Repeated Kidney Allograft Biopsies","authors":"Sandesh Parajuli, Adam Bregman, Emily E. Zona, Megan Sokup, Neetika Garg, Weixiong Zhong, Didier Mandelbrot","doi":"10.1111/ctr.70419","DOIUrl":"https://doi.org/10.1111/ctr.70419","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Microvascular inflammation (MVI) with sum glomerulitis and peritubular capillaritis (g+ptc) ≥ 2 is an integral component of kidney allograft antibody-mediated rejection (AMR). It is unclear what the outcomes are among those with persistent MVI, despite treatment.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We included all kidney transplant recipients (KTRs) with persistent MVI ≥ 2 on first and second allograft biopsies who had third biopsies within 2 years of the first biopsy. KTRs were categorized into two groups, MVI (+) and MVI (−) on third biopsy. Risk factors for persistent MVI ≥ 2 on third biopsy, and graft survival based on MVI (+) and MVI (−) at last follow-up were outcomes of interest.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 108 KTRs transplanted between 2013 and 2022 fulfilled our selection criteria, 75 (69%) were MVI (+) and 33 (31%) MVI (−). Most baseline characteristics were similar between the groups. In Cox regression analysis, none of the commonly assessed baseline characteristics, Banff scores, or DSA status at first or second biopsy were associated with persistent MVI on the third biopsy. Also, in Cox regression analysis, after adjusting for various characteristics, persistent MVI on third biopsy was not associated with increased or decreased risk for uncensored graft failure (aHR: 0.55, 95% CI: 0.23–1.29; <i>p</i> = 0.17).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>The lack of difference in graft outcomes between the AMR patients who were MVI (+) versus MVI (−) on the third biopsy suggests that subsequent response to AMR treatment is less important for prognosis than the initial development of AMR. This reinforces the importance of the prevention of rejection.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ctr.70419","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739567","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Laila Fozouni, Giuseppe Cullaro, Ann Lazar, Jennifer C. Lai, Sharad I. Wadhwani
Background
Neighborhood deprivation is associated with adverse outcomes post-liver transplantation in pediatric recipients. We examined the association between neighborhood deprivation index (NDI) and medication level variability index (MLVI), T-cell mediated rejection (TCMR), and graft failure/death in adult liver transplant recipients.
Methods
We conducted a retrospective cohort study of 1485 adult liver-transplant recipients with >1 year follow-up. NDI was calculated at the census tract level. MLVI, the standard deviation of ≥3 sequential tacrolimus troughs, was dichotomized at MLVI > 2. Hospitalization was analyzed as a binary variable.
Results
The median age was 65, and 36% were female. In multivariate regression, increased NDI was associated with 20% increased odds of MLVI > 2 between 1–3 years post-transplant (95% CI 1.1–1.3) but not MLVI > 2 between 3–5 years. NDI was associated with a 2.2 times higher hazard of hospitalization between 1–3 years post-transplant (95% CI 1.1–4.4); but not between 3–5 years (HR 1.9, 95% CI 1.0–3.7). NDI was not significantly associated with increased hazard of rejection or graft failure/death. Adjusting for NDI, MLVI > 2 between 1–3 and 3–5 years was associated with a 30% higher hazard of rejection (95% CI 1.1–1.6), and between 1–3 years, a 40% increased hazard of graft failure/death (95% CI 1.2–1.5). We found geospatial hotspots of rejection with positive autocorrelation at Years 1–3 and 3–5 post-transplant (Geary's C 0.97, p = 0.01).
Conclusions
Efforts to understand why individuals from disadvantaged neighborhoods experience poorer immunosuppression adherence may uncover targeted strategies to improve medication adherence for high-risk groups.
背景：邻里剥夺与儿童肝移植后不良后果相关。我们研究了成人肝移植受者的邻里剥夺指数（NDI）、药物水平变异性指数（MLVI）、t细胞介导的排斥反应（TCMR）和移植物衰竭/死亡之间的关系。方法对1485例成人肝移植受者进行回顾性队列研究，随访1年。NDI按人口普查区水平计算。MLVI，即≥3个序贯他克莫司波谷的标准差，在MLVI >； 2处进行二分类。住院率作为二元变量进行分析。结果中位年龄65岁，女性占36%。在多变量回归中，NDI的增加与移植后1-3年内MLVI >； 2的几率增加20%相关（95% CI 1.1-1.3），但与3-5年内MLVI >； 2无关。移植后1-3年内，NDI与住院风险增加2.2倍相关（95% CI 1.1-4.4）；但在3-5年之间没有（HR 1.9, 95% CI 1.0-3.7）。NDI与排斥反应或移植物衰竭/死亡风险增加无显著相关。调整NDI后，1-3年至3-5年的MLVI >； 2与排斥反应风险增加30%相关（95% CI 1.1-1.6）， 1-3年的移植失败/死亡风险增加40% （95% CI 1.2-1.5）。我们发现，在移植后1-3年和3-5年，排斥反应的地理空间热点具有正自相关（Geary’s C = 0.97, p = 0.01）。结论：努力理解为什么弱势社区的个体免疫抑制依从性较差，可能会发现有针对性的策略来提高高危人群的药物依从性。
{"title":"Neighborhood Deprivation Linked to Medication Level Variability in Liver Transplant Recipients","authors":"Laila Fozouni, Giuseppe Cullaro, Ann Lazar, Jennifer C. Lai, Sharad I. Wadhwani","doi":"10.1111/ctr.70412","DOIUrl":"https://doi.org/10.1111/ctr.70412","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Neighborhood deprivation is associated with adverse outcomes post-liver transplantation in pediatric recipients. We examined the association between neighborhood deprivation index (NDI) and medication level variability index (MLVI), T-cell mediated rejection (TCMR), and graft failure/death in adult liver transplant recipients.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a retrospective cohort study of 1485 adult liver-transplant recipients with >1 year follow-up. NDI was calculated at the census tract level. MLVI, the standard deviation of ≥3 sequential tacrolimus troughs, was dichotomized at MLVI > 2. Hospitalization was analyzed as a binary variable.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The median age was 65, and 36% were female. In multivariate regression, increased NDI was associated with 20% increased odds of MLVI > 2 between 1–3 years post-transplant (95% CI 1.1–1.3) but not MLVI > 2 between 3–5 years. NDI was associated with a 2.2 times higher hazard of hospitalization between 1–3 years post-transplant (95% CI 1.1–4.4); but not between 3–5 years (HR 1.9, 95% CI 1.0–3.7). NDI was not significantly associated with increased hazard of rejection or graft failure/death. Adjusting for NDI, MLVI > 2 between 1–3 and 3–5 years was associated with a 30% higher hazard of rejection (95% CI 1.1–1.6), and between 1–3 years, a 40% increased hazard of graft failure/death (95% CI 1.2–1.5). We found geospatial hotspots of rejection with positive autocorrelation at Years 1–3 and 3–5 post-transplant (Geary's C 0.97, <i>p</i> = 0.01).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Efforts to understand why individuals from disadvantaged neighborhoods experience poorer immunosuppression adherence may uncover targeted strategies to improve medication adherence for high-risk groups.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739569","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}
Deepika Devuni, Katherine M. Cooper, Alexander Wiseman, Marie M. Budev, Ashrith Guha, Bekir Tanriover, Neeraj Singh
This national cross-sectional survey evaluated the roles, responsibilities, compensation, and job satisfaction of medical directors in adult solid organ transplant programs in the United States. Responses were collected from 210 (34.5%) medical directors representing kidney/kidney-pancreas, liver, heart, and lung transplant centers. The findings reveal wide variation in compensation models and medical director duties across organ types. Kidney/kidney-pancreas directors reported lower compensation, despite leading higher-volume programs. Less than half of respondents reported that these duties were adequately recognized in their compensation. Only 40% of participants perceived their total compensation package as fair, and less than 50% understood how their compensation was determined. A third reported decreased job satisfaction compared to post-fellowship levels. Nearly half of respondents reported symptoms of burnout, with higher rates among women. Perceived fairness of compensation, adequate time with patients, and institutional support for non-clinical duties were associated with job satisfaction, while excessive calls and administrative burden were associated with burnout. These findings suggest more transparent and equitable compensation structures are needed. Incorporating the economic value assessment of transplant providers into institutional planning may strengthen justification for fair compensation models. These data provide a foundation for policy development aimed at enhancing workforce satisfaction and stability across transplant disciplines.
{"title":"A Comparison Study of the Roles and Responsibilities, Compensation, and Job Satisfaction of the Medical Directors of Kidney/Kidney-Pancreas, Liver, Lung, and Heart Transplant in the United States","authors":"Deepika Devuni, Katherine M. Cooper, Alexander Wiseman, Marie M. Budev, Ashrith Guha, Bekir Tanriover, Neeraj Singh","doi":"10.1111/ctr.70411","DOIUrl":"https://doi.org/10.1111/ctr.70411","url":null,"abstract":"<div>\u0000 \u0000 <p>This national cross-sectional survey evaluated the roles, responsibilities, compensation, and job satisfaction of medical directors in adult solid organ transplant programs in the United States. Responses were collected from 210 (34.5%) medical directors representing kidney/kidney-pancreas, liver, heart, and lung transplant centers. The findings reveal wide variation in compensation models and medical director duties across organ types. Kidney/kidney-pancreas directors reported lower compensation, despite leading higher-volume programs. Less than half of respondents reported that these duties were adequately recognized in their compensation. Only 40% of participants perceived their total compensation package as fair, and less than 50% understood how their compensation was determined. A third reported decreased job satisfaction compared to post-fellowship levels. Nearly half of respondents reported symptoms of burnout, with higher rates among women. Perceived fairness of compensation, adequate time with patients, and institutional support for non-clinical duties were associated with job satisfaction, while excessive calls and administrative burden were associated with burnout. These findings suggest more transparent and equitable compensation structures are needed. Incorporating the economic value assessment of transplant providers into institutional planning may strengthen justification for fair compensation models. These data provide a foundation for policy development aimed at enhancing workforce satisfaction and stability across transplant disciplines.</p>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145739571","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}
Pedro Caravaca-Pérez, Anthony Salazar Rodriguez, José Jesús Broseta, Eduard Solé Gonzalez, María Ángeles Castel, Juan José Rodriguez, Elena Cuadrado-Payán, Diana Rodriguez-Espinosa, Elena Sandoval, Aleix Cases, Ana García-Álvarez, Marta Farrero
Background
Chronic kidney disease (CKD) is a common but poorly characterized complication in heart transplant (HT) recipients due to limited use of renal damage markers, such as albuminuria. Our aim is to determine CKD prevalence based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, assess CKD risk stratification according KDIGO guidelines, and describe the use of cardiorenal protective drugs in a contemporary HT cohort.
Methods
A cross-sectional, single-center study was conducted in stable HT recipients under follow-up in 2023. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 (using CKD-EPI) and/or albumin-to-creatinine ratio (UACR) ≥ 30 mg/g. Patients were stratified into KDIGO risk categories based on eGFR and UACR thresholds.
Results
Among 207 patients (median age 65 years; 29% women; median time since transplant: 8 years), the median eGFR was 51 mL/min/1.73m2, with 58.9% having an eGFR < 60 mL/min/1.73m2 and median UACR was 45 (8–173) mg/g, with 57% showing elevated UACR. The prevalence of CKD was 79.2%, with 36 (17.4%) patients exhibiting elevated UACR despite an eGFR ≥ 60 mL/min/1.73m2. A total of 23.7%, 19.8%, 21.7%, and 34.8% were classified as low, moderate, high, and very high KDIGO risk categories, respectively. Among patients meeting the CKD criteria, 37.2% were on ACEi/ARBs and 26.2% on SGLT2i.
Conclusions
CKD is highly prevalent in HT recipients, with UACR improving diagnostic accuracy. Over half of patients fell into high-risk KDIGO categories, indicating substantial CKD severity. However, the underuse of renal-protective therapies highlights the need for better alignment with current clinical guidelines.
{"title":"The Role of Albuminuria in Diagnosing and Stratifying Kidney Disease in Heart Transplant Recipients: A KDIGO Criteria-Based Analysis","authors":"Pedro Caravaca-Pérez, Anthony Salazar Rodriguez, José Jesús Broseta, Eduard Solé Gonzalez, María Ángeles Castel, Juan José Rodriguez, Elena Cuadrado-Payán, Diana Rodriguez-Espinosa, Elena Sandoval, Aleix Cases, Ana García-Álvarez, Marta Farrero","doi":"10.1111/ctr.70347","DOIUrl":"10.1111/ctr.70347","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Chronic kidney disease (CKD) is a common but poorly characterized complication in heart transplant (HT) recipients due to limited use of renal damage markers, such as albuminuria. Our aim is to determine CKD prevalence based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, assess CKD risk stratification according KDIGO guidelines, and describe the use of cardiorenal protective drugs in a contemporary HT cohort.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A cross-sectional, single-center study was conducted in stable HT recipients under follow-up in 2023. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m<sup>2</sup> (using CKD-EPI) and/or albumin-to-creatinine ratio (UACR) ≥ 30 mg/g. Patients were stratified into KDIGO risk categories based on eGFR and UACR thresholds.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 207 patients (median age 65 years; 29% women; median time since transplant: 8 years), the median eGFR was 51 mL/min/1.73m<sup>2</sup>, with 58.9% having an eGFR < 60 mL/min/1.73m<sup>2</sup> and median UACR was 45 (8–173) mg/g, with 57% showing elevated UACR. The prevalence of CKD was 79.2%, with 36 (17.4%) patients exhibiting elevated UACR despite an eGFR ≥ 60 mL/min/1.73m<sup>2</sup>. A total of 23.7%, 19.8%, 21.7%, and 34.8% were classified as low, moderate, high, and very high KDIGO risk categories, respectively. Among patients meeting the CKD criteria, 37.2% were on ACEi/ARBs and 26.2% on SGLT2i.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>CKD is highly prevalent in HT recipients, with UACR improving diagnostic accuracy. Over half of patients fell into high-risk KDIGO categories, indicating substantial CKD severity. However, the underuse of renal-protective therapies highlights the need for better alignment with current clinical guidelines.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ctr.70347","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145713576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Moustafa Younis, Christopher I. Mederos, Cecelia. M. Miller, Pooja Kumar, Ariana Ishaq, Amy Mu, Cynthia Gries, Victoria Reams, Mohammad A. Aladaileh, Mindaugas Rackauskas, Vaidehi Kaza, Srinivas Bollineni, Fernando Torres, Amir Emtiazjoo, Irina Timofte
Background
Belatacept use in renal transplant is associated with similar graft survival and elimination of preexisting donor-specific antibodies (DSA). We aim to describe the impact of Belatacept use on de novo DSA in lung transplant (LTx).
Methods
A multi-institutional retrospective review of LTx patients with de novo DSA who received Belatacept (January 2018–August 2023) was performed. The primary outcome is the change in DSA post Belatacept initiation. Changes in mean fluorescence intensity (MFI) before and after Belatacept administration were analyzed using a linear mixed-effects model. Secondary outcomes included antibody-mediated rejection (AMR).
Results
Forty-four patients with DSA received Belatacept. Most DSA were class II (n = 41, 93%), with a median (IQR) MFI of 4000 (2500–7000) at Belatacept initiation. Following Belatacept initiation, DSA resolved in (n = 25, 57%) patients, decreased in (n = 7, 16%), and remained unchanged in (n = 12, 27%). No de novo DSA developed during Belatacept therapy. There was no significant change in MFI pre Belatacept administration (change = −38, 95% CI: −267 to 191, p = 0.745), whereas MFI decreased significantly post Belatacept administration (change = −334, 95% CI: −449 to −219, p < 0.001). A total of (n = 25, 57%) patients experienced AMR prior to initiating Belatacept. None of the patients developed AMR while on Belatacept.
Conclusion
This is the largest cohort to date of LTx patients with DSA who received Belatacept. Belatacept use was associated with a reduction in DSA.
{"title":"Belatacept-Based Immunosuppression and Donor-Specific Antibodies in Lung Transplant: A Multi-Institutional Retrospective Study","authors":"Moustafa Younis, Christopher I. Mederos, Cecelia. M. Miller, Pooja Kumar, Ariana Ishaq, Amy Mu, Cynthia Gries, Victoria Reams, Mohammad A. Aladaileh, Mindaugas Rackauskas, Vaidehi Kaza, Srinivas Bollineni, Fernando Torres, Amir Emtiazjoo, Irina Timofte","doi":"10.1111/ctr.70415","DOIUrl":"10.1111/ctr.70415","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Belatacept use in renal transplant is associated with similar graft survival and elimination of preexisting donor-specific antibodies (DSA). We aim to describe the impact of Belatacept use on de novo DSA in lung transplant (LTx).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A multi-institutional retrospective review of LTx patients with de novo DSA who received Belatacept (January 2018–August 2023) was performed. The primary outcome is the change in DSA post Belatacept initiation. Changes in mean fluorescence intensity (MFI) before and after Belatacept administration were analyzed using a linear mixed-effects model. Secondary outcomes included antibody-mediated rejection (AMR).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Forty-four patients with DSA received Belatacept. Most DSA were class II (<i>n</i> = 41, 93%), with a median (IQR) MFI of 4000 (2500–7000) at Belatacept initiation. Following Belatacept initiation, DSA resolved in (<i>n</i> = 25, 57%) patients, decreased in (<i>n</i> = 7, 16%), and remained unchanged in (<i>n</i> = 12, 27%). No de novo DSA developed during Belatacept therapy. There was no significant change in MFI pre Belatacept administration (change = −38, 95% CI: −267 to 191, <i>p</i> = 0.745), whereas MFI decreased significantly post Belatacept administration (change = −334, 95% CI: −449 to −219, <i>p</i> < 0.001). A total of (<i>n</i> = 25, 57%) patients experienced AMR prior to initiating Belatacept. None of the patients developed AMR while on Belatacept.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>This is the largest cohort to date of LTx patients with DSA who received Belatacept. Belatacept use was associated with a reduction in DSA.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":"39 12","pages":""},"PeriodicalIF":1.9,"publicationDate":"2025-12-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145713582","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}
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