Clinical Transplantation最新文献_第9页

Components of Residential Neighborhood Deprivation and Their Impact on the Likelihood of Live-Donor and Preemptive Kidney Transplantation 居民区贫困程度及其对活体肾移植和先期肾移植可能性的影响。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-08 DOI: 10.1111/ctr.15382

Yiting Li, Gayathri Menon, Byoungjun Kim, Maya N. Clark-Cutaia, Jane J. Long, Garyn T. Metoyer, Dinushika Mohottige, Alexandra T. Strauss, Nidhi Ghildayal, Evelien E. Quint, Wenbo Wu, Dorry L. Segev, Mara A. McAdams-DeMarco

Introduction

Adults residing in deprived neighborhoods face various socioeconomic stressors, hindering their likelihood of receiving live-donor kidney transplantation (LDKT) and preemptive kidney transplantation (KT). We quantified the association between residential neighborhood deprivation index (NDI) and the likelihood of LDKT/preemptive KT, testing for a differential impact by race and ethnicity.

Methods

We studied 403 937 adults (age ≥ 18) KT candidates (national transplant registry; 2006–2021). NDI and its 10 components were averaged at the ZIP-code level. Cause-specific hazards models were used to quantify the adjusted hazard ratio (aHR) of LDKT and preemptive KT across tertiles of NDI and its 10 components.

Results

Candidates residing in high-deprivation neighborhoods were more likely to be female (40.1% vs. 36.2%) and Black (41.9% vs. 17.7%), and were less likely to receive both LDKT (aHR = 0.66, 95% confidence interval [CI]: 0.64–0.67) and preemptive KT (aHR = 0.60, 95% CI: 0.59–0.62) than those in low-deprivation neighborhoods. These associations differedby race and ethnicity (Black: aHR_LDKT = 0.58, 95% CI: 0.55–0.62; aHR_{preemptive KT} = 0.68, 95% CI: 0.63–0.73; P_interactions: LDKT < 0.001; Preemptive KT = 0.002). All deprivation components were associated with the likelihood of both LDKT and preemptive KT (except median home value): for example, higher median household income (LDKT: aHR = 1.08, 95% CI: 1.07–1.09; Preemptive KT: aHR = 1.10, 95% CI: 1.08–1.11) and educational attainments (≥high school [LDKT: aHR = 1.17, 95% CI: 1.15–1.18; Preemptive KT: aHR = 1.23, 95% CI: 1.21–1.25]).

Conclusion

Residence in socioeconomically deprived neighborhoods is associated with a lower likelihood of LDKT and preemptive KT, differentially impacting minority candidates. Identifying and understanding which neighborhood-level socioeconomic status contributes to these racial disparities can be instrumental in tailoring interventions to achieve health equity in LDKT and preemptive KT.

导言：居住在贫困社区的成年人面临着各种社会经济压力，阻碍了他们接受活体供肾移植（LDKT）和先期肾移植（KT）的可能性。我们量化了居住区贫困指数（NDI）与接受活体供肾移植/肾脏移植前期治疗的可能性之间的关系，并检测了种族和民族的不同影响：我们研究了 403 937 名成人（年龄≥ 18 岁）KT 候选人（国家移植登记处；2006-2021 年）。在邮政编码水平上对 NDI 及其 10 个组成部分进行了平均。使用病因特异性危险模型来量化不同NDI及其10个分量的LDKT和先期KT的调整危险比（aHR）：居住在高贫困社区的候选者更有可能是女性（40.1% 对 36.2%）和黑人（41.9% 对 17.7%），与居住在低贫困社区的候选者相比，他们接受低密度KT（aHR = 0.66，95% 置信区间 [CI]：0.64-0.67）和抢先 KT（aHR = 0.60，95% 置信区间：0.59-0.62）的可能性更低。这些关联因种族和民族而异（黑人：aHRLDKT = 0.58，95% CI：0.55-0.62；aHR-抢先 KT = 0.68，95% CI：0.63-0.73；平特互动：aHRLDKT = 0.58，95% CI：0.55-0.62；平特互动：aHR-抢先 KT = 0.68，95% CI：0.63-0.73）：结论居住在社会经济贫困的社区与较低的 LDKT 和抢先 KT 可能性有关，对少数族裔候选人的影响不同。识别和了解哪些社区层面的社会经济状况会导致这些种族差异，有助于调整干预措施，以实现 LDKT 和抢先 KT 的健康公平。

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引用次数: 0

Cytology or Multiparameter Flow Cytometry Positivity in the Cerebrospinal Fluid Before Transplantation is Predictive of Poor Outcomes After Allotransplantation in Acute Myeloid Leukemia Patients 移植前脑脊液细胞学或多参数流式细胞术阳性可预测急性髓性白血病患者异体移植后的不良预后。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-05 DOI: 10.1111/ctr.15396

Li-Juan Hu, Guo-Mei Fu, Yuan-Yuan Zhang, Ya-Zhe Wang, Ya-Zhen Qin, Yue-Yun Lai, Hong-Xia Shi, Hao Jiang, Xiao-Hui Zhang, Lan-Ping Xu, Yu Wang, Qian Jiang, Xiao-Jun Huang, Ying Jun Chang

Introduction

Central nervous system leukemia (CNSL) remains a serious complication in patients with acute myeloid leukemia (AML) and an ambiguous prognostic factor for those receiving allo-geneic hematopoiesis stem cell transplantation (allo-HSCT). It is unknown whether using more sensitive tools, such as multiparameter flow cytometry (MFC), to detect blasts in the cerebrospinal fluid (CSF) would have an impact on outcome.

Methods

We retrospectively analyzed the clinical outcomes of 1472 AML patients with or without cytology or MFC positivity in the CSF before transplantation. Abnormal CSF (CSF+) was detected via conventional cytology and MFC in 44 patients at any time after diagnosis. A control group of 175 CSF-normal (CSF−) patients was generated via propensity score matching (PSM) analyses according to sex, age at transplant, and white blood cell count at diagnosis.

Results

Compared to those in the CSF-negative group, the conventional cytology positive and MFC+ groups had comparable 8-year nonrelapse mortality (NRM) (4%, 4%, and 6%, p = 0.82), higher cumulative incidence of relapse (CIR) (14%, 31%, and 32%, p = 0.007), lower leukemia-free survival (LFS) (79%, 63%, and 64%, p = 0.024), and overall survival (OS) (83%, 63%, and 68%, p = 0.021), with no significant differences between the conventional cytology positive and MFC+ groups. Furthermore, multivariate analysis confirmed that CSF involvement was an independent factor affecting OS and LFS.

Conclusion

Our results indicate that pretransplant CSF abnormalities are adverse factors independently affecting OS and LFS after allotransplantation in AML patients.

导言：中枢神经系统白血病（CNSL）仍是急性髓性白血病（AML）患者的一种严重并发症，也是接受异基因造血干细胞移植（allo-HSCT）患者的一个不明确的预后因素。目前尚不清楚使用多参数流式细胞术（MFC）等更敏感的工具检测脑脊液（CSF）中的胚泡是否会对预后产生影响：我们回顾性分析了1472例急性髓细胞性白血病患者在移植前脑脊液中细胞学或MFC阳性与否的临床结果。44例患者在确诊后的任何时间通过常规细胞学和MFC检测到CSF异常（CSF+）。根据性别、移植年龄和诊断时的白细胞计数，通过倾向得分匹配（PSM）分析产生了一个由175名CSF正常（CSF-）患者组成的对照组：与 CSF 阴性组相比，常规细胞学阳性组和 MFC+ 组的 8 年非复发死亡率（NRM）相当（4%、4% 和 6%，P = 0.82），复发累积发生率（CIR）较高（14%、31% 和 32%，P = 0.007）、较低的无白血病生存率（LFS）（79%、63% 和 64%，P = 0.024）和总生存率（OS）（83%、63% 和 68%，P = 0.021），常规细胞学阳性组和 MFC+ 组之间无显著差异。此外，多变量分析证实，CSF受累是影响OS和LFS的独立因素：我们的研究结果表明，移植前CSF异常是独立影响AML患者异体移植后OS和LFS的不利因素。

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引用次数: 0

Comparison Between Black Non-Hispanic and White Non-Hispanic Simultaneous Pancreas-Kidney Transplant Candidates and Recipients 非西班牙裔黑人与非西班牙裔白人胰肾同时移植候选者和受者之间的比较。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-05 DOI: 10.1111/ctr.15392

Shawna M. Green, Aaron C. Spaulding, Emily R. Brennan, Tambi Jarmi

Introduction

This study examined simultaneous pancreas–kidney transplant (SPKt) in Black and White patients to identify disparities in transplantation, days on the waitlist, and reasons for SPKt waitlist removal.

Methods

Using the United Network for Organ Sharing Standard Transplant Analysis and Research file, patients between January 1, 2009, and May 31, 2021, were included. Three cohorts (overall, SPKt recipients only, and those not transplanted) were selected using propensity score matching. Conditional logistic regression was used for categorical outcomes. Days on the waitlist were compared using negative binomial regression.

Results

Black patients had increased odds of receiving a SPKt (OR, 1.25 [95% CI, 1.11–1.40], p < 0.001). White patients had increased odds of receiving a kidney-only transplant (OR 0.48 [95% CI, 0.38–0.61], p < 0.001), and specifically increased odds of receiving a living donor kidney (OR 0.34 [0.25–0.45], p < 0.001).

Conclusion

This study found that Black patients are more likely to receive a SPKt. Results suggest that there are opportunities for additional inquiry related to patient removal from the waitlist, particularly considering White patients received or accepted more kidney-only transplants and were more likely to receive a living donor kidney-only transplant.

简介：本研究调查了黑人和白人患者的同步胰腺-肾脏移植（SPKt）情况：本研究调查了黑人和白人患者的胰腺-肾脏同步移植（SPKt）情况，以确定移植手术、候选天数和SPKt候选名单除名原因方面的差异：使用器官共享联合网络标准移植分析与研究档案，纳入了2009年1月1日至2021年5月31日期间的患者。采用倾向得分匹配法选出了三个队列（总体队列、仅接受 SPKt 的队列和未接受移植的队列）。条件逻辑回归用于分类结果。使用负二项回归比较了候选名单上的天数：黑人患者接受 SPKt 的几率增加（OR，1.25 [95% CI，1.11-1.40]，P 结论：该研究发现，黑人患者接受 SPKt 的几率更高（OR，1.25 [95% CI，1.11-1.40]，P本研究发现，黑人患者接受 SPKt 的几率更高。结果表明，有机会对患者从等待名单中删除的情况进行更多调查，特别是考虑到白人患者接受或接受了更多的纯肾移植，并且更有可能接受纯活体肾移植。

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引用次数: 0

Chronological and Geographical Variations in the Incidence and Acceptance of COVID-19–Positive Donors and Outcomes Among Abdominal Transplant Patients 腹腔移植患者中 COVID-19 阳性捐献者的发生率和接受率及结果的年代和地域差异。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-05 DOI: 10.1111/ctr.15391

Jason Yang, Yutaka Endo, Kazunari Sasaki, Austin Schenk, Timothy M. Pawlik

Introduction

Given the importance of understanding COVID-19–positive donor incidence and acceptance, we characterize chronological and geographic variations in COVID-19 incidence relative to COVID-19–positive donor acceptance.

Methods

Data on deceased donors and recipients of liver and kidney transplants were obtained from the UNOS database between 2020 and 2023. Hierarchical cluster analysis was used to assess trends in COVID-19–positive donor incidence. Posttransplant graft and patient survival were assessed using Kaplan–Meier curves.

Results

From among 38 429 deceased donors, 1517 were COVID-19 positive. Fewer kidneys (72.4% vs. 76.5%, p < 0.001) and livers (56.4% vs. 62.0%, p < 0.001) were used from COVID-19–positive donors versus COVID-19–negative donors. Areas characterized by steadily increased COVID-19 donor incidence exhibit the highest transplantation acceptance rates (92.33%), followed by intermediate (84.62%) and rapidly increased (80.00%) COVID-19 incidence areas (p = 0.016). Posttransplant graft and patient survival was comparable among recipients, irrespective of donor COVID-19 status.

Conclusions

Regions experiencing heightened rates of COVID-19–positive donors are associated with decreased acceptance of liver and kidney transplantation. Similar graft and patient survival is noted among recipients, irrespective of donor COVID-19 status. These findings emphasize the need for adaptive practices and unified medical consensus in navigating a dynamic pandemic.

简介：鉴于了解 COVID-19 阳性捐献者发生率和接受率的重要性，我们描述了 COVID-19 发生率与 COVID-19 阳性捐献者接受率之间的时间和地理差异：我们从 UNOS 数据库中获取了 2020 年至 2023 年间已故肝肾移植供体和受体的数据。采用层次聚类分析评估COVID-19阳性供体发生率的趋势。使用 Kaplan-Meier 曲线评估移植后移植物和患者的存活率：在38 429名已故捐献者中，有1517名COVID-19阳性。与 COVID-19 阴性供体相比，COVID-19 阳性供体使用的肾脏（72.4% 对 76.5%，P < 0.001）和肝脏（56.4% 对 62.0%，P < 0.001）更少。COVID-19供体发生率稳步上升的地区的移植接受率最高（92.33%），其次是COVID-19发生率居中的地区（84.62%）和快速上升的地区（80.00%）（p = 0.016）。无论供体的COVID-19状况如何，移植后受体和患者的存活率相当：结论：COVID-19 阳性捐献者比例增加的地区与肝脏和肾脏移植接受率下降有关。无论供体COVID-19状态如何，受体的移植物存活率和患者存活率相似。这些发现强调，在应对动态流行病时，需要有适应性的做法和统一的医学共识。

{"title":"Chronological and Geographical Variations in the Incidence and Acceptance of COVID-19–Positive Donors and Outcomes Among Abdominal Transplant Patients","authors":"Jason Yang, Yutaka Endo, Kazunari Sasaki, Austin Schenk, Timothy M. Pawlik","doi":"10.1111/ctr.15391","DOIUrl":"10.1111/ctr.15391","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Given the importance of understanding COVID-19–positive donor incidence and acceptance, we characterize chronological and geographic variations in COVID-19 incidence relative to COVID-19–positive donor acceptance.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Data on deceased donors and recipients of liver and kidney transplants were obtained from the UNOS database between 2020 and 2023. Hierarchical cluster analysis was used to assess trends in COVID-19–positive donor incidence. Posttransplant graft and patient survival were assessed using Kaplan–Meier curves.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>From among 38 429 deceased donors, 1517 were COVID-19 positive. Fewer kidneys (72.4% vs. 76.5%, <i>p</i> < 0.001) and livers (56.4% vs. 62.0%, <i>p</i> < 0.001) were used from COVID-19–positive donors versus COVID-19–negative donors. Areas characterized by steadily increased COVID-19 donor incidence exhibit the highest transplantation acceptance rates (92.33%), followed by intermediate (84.62%) and rapidly increased (80.00%) COVID-19 incidence areas (<i>p</i> = 0.016). Posttransplant graft and patient survival was comparable among recipients, irrespective of donor COVID-19 status.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Regions experiencing heightened rates of COVID-19–positive donors are associated with decreased acceptance of liver and kidney transplantation. Similar graft and patient survival is noted among recipients, irrespective of donor COVID-19 status. These findings emphasize the need for adaptive practices and unified medical consensus in navigating a dynamic pandemic.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/ctr.15391","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141533821","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}

引用次数: 0

Changes in Numbers of Glomerular Macrophages Between Two Consecutive Biopsies and the Association With Renal Transplant Graft Survival 两次连续活检之间肾小球巨噬细胞数量的变化及其与肾移植移植物存活率的关系

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-05 DOI: 10.1111/ctr.15384

Salmir Nasic, Johan Mölne, Marie Eriksson, Bernd Stegmayr, Henri Afghahi, Björn Peters

Background

Macrophages are involved in kidney transplants. The aim of the study was to investigate if changes exist in the levels of glomerular macrophage index (GMI) between two consecutive kidney transplant biopsies, and if so to determine their potential impact on graft survival.

Methods

Two consecutive biopsies were performed on the same renal graft in 623 patients. GMI was categorized into three GMI classes: ≤1.8 Low, 1.9–4.5 Medium, and ≥4.6 High. This division yielded nine possible switches between the first and second biopsies (Low-Low, Low-Medium, etc.). Cox-regressions were used and hazard ratios (HR) with 95% confidence interval (CI) are presented.

Results

The worst graft survival was observed in the High-High group, and the best graft survival was observed in the Low-Low and High-Low groups. Compared to the High-High group, a reduction of risk was observed in nearly all other decreasing groups (reductions between 65% and 80% of graft loss). After adjustment for covariates, the risk for graft-loss was lower in the Low-Low (HR = 0.24, CI 0.13–0.46), Low-Medium (HR = 0.25, CI 0.11–0.55), Medium-Low (HR = 0.29, CI 0.11–0.77), and the High-Low GMI (HR = 0.31, CI 0.10–0.98) groups compared to the High-High group as the reference.

Conclusions

GMI may change dynamically, and the latest finding is of most prognostic importance. GMI should be considered in all evaluations of biopsy findings since high or increasing GMI levels are associated with shorter graft survival. Future studies need to consider therapeutic strategies to lower or maintain a low GMI. A high GMI besides a vague histological finding should be considered as a warning sign requiring more frequent clinical follow up.

背景：巨噬细胞与肾移植有关。本研究旨在调查两次连续肾移植活检之间肾小球巨噬细胞指数（GMI）水平是否存在变化，如果存在变化，则确定其对移植物存活率的潜在影响：方法：对 623 名患者的同一肾移植移植物进行了两次连续活检。GMI 被分为三个等级：≤1.8 低、1.9-4.5 中、≥4.6 高。这样划分后，第一次活检和第二次活检之间有九种可能的切换（低-低、低-中等）。采用 Cox 回归分析，并给出了带有 95% 置信区间 (CI) 的危险比 (HR)：结果：高-高组的移植物存活率最差，低-低组和高-低组的移植物存活率最好。与 "高-高 "组相比，几乎所有其他下降组的风险都有所降低（移植物损失率降低了 65% 至 80%）。在对协变量进行调整后，与高-高组相比，低-低组（HR = 0.24，CI 0.13-0.46）、低-中组（HR = 0.25，CI 0.11-0.55）、中-低组（HR = 0.29，CI 0.11-0.77）和高-低 GMI 组（HR = 0.31，CI 0.10-0.98）的移植物丢失风险较低：结论：GMI可能会动态变化，最新发现对预后最重要。在所有活检结果评估中都应考虑 GMI，因为 GMI 水平过高或升高与移植物存活期缩短有关。未来的研究需要考虑降低或维持低 GMI 的治疗策略。除了模糊的组织学发现外，高 GMI 应被视为一个警示信号，需要更频繁地进行临床随访。

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引用次数: 0

Hepatitis B Virus Reactivation in Non-Liver Solid Organ Transplantation: Incidence and Risk Analysis 非肝实体器官移植中的乙型肝炎病毒再激活：发病率和风险分析。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-01 DOI: 10.1111/ctr.15389

Chia-Yu Chiu, Lisa M. Brumble, Holenarasipur R. Vikram, Kymberly D. Watt, Elena Beam

Introduction

Hepatitis B virus reactivation (HBVr) can occur in solid organ transplant (SOT) recipients with previously inactive hepatitis B virus (HBV) infection. Previous studies have reported that HBVr is generally less than 10% in nonliver SOT recipients with past HBV infection.

Methods

We conducted a retrospective study from January 2018 to August 2023 at Mayo Clinic sites in Arizona, Florida, and Minnesota. We examined the antiviral prophylaxis strategy used and the characteristics of HBVr in hepatitis B core antibody-positive (HBcAb +) nonliver SOT adult recipients. Past HBV infection was defined as HBcAb + / hepatitis B surface antigen (HBsAg) –. Chronic HBV infection was defined as HBcAb + / HBsAg +.

Results

A total of 180 nonliver SOT recipients were identified during the study period. Indefinite antiviral prophylaxis was utilized in 77 recipients, and none developed HBVr after transplantation. In 103 recipients without antiviral prophylaxis, the incidence of HBVr was 12% (12/97) and 33% (2/6) in those with past HBV infection and chronic HBV infection. The incidence of HBVr in patients with past HBV infection is 16% (8/50), 15% (3/20), and 5% (1/22) in kidney, heart, and lungs, respectively. HBVr was more frequent in those who received alemtuzumab. Among 14 recipients with HBVr, none had HBV-associated liver failure or death.

Conclusions

Our study observed a higher rate of HBVr (12%) in nonliver SOT recipients with past HBV infection compared to the previous studies. Further studies are needed to identify predictors of HBVr in nonliver SOT recipients and optimize antiviral prophylaxis guidance.

导言：既往未感染乙型肝炎病毒（HBV）的实体器官移植（SOT）受者可能会发生乙型肝炎病毒再激活（HBVr）。以往的研究报告显示，在既往有乙肝病毒感染的非肝脏 SOT 受者中，HBVr 一般低于 10%：我们于 2018 年 1 月至 2023 年 8 月在亚利桑那州、佛罗里达州和明尼苏达州的梅奥诊所进行了一项回顾性研究。我们研究了乙肝核心抗体阳性（HBcAb +）的非肝脏 SOT 成年受者所使用的抗病毒预防策略和 HBVr 的特征。既往 HBV 感染定义为 HBcAb + / 乙肝表面抗原 (HBsAg) -。慢性 HBV 感染定义为 HBcAb + / HBsAg +：研究期间共发现了 180 名非肝脏 SOT 受体。77名受者接受了无限期抗病毒预防治疗，无一人在移植后出现 HBVr。在 103 例未进行抗病毒预防的受者中，HBVr 的发生率为 12%（12/97），在既往感染过 HBV 和慢性 HBV 感染者中，HBVr 的发生率为 33%（2/6）。在既往有 HBV 感染的患者中，肾脏、心脏和肺部的 HBVr 发生率分别为 16%（8/50）、15%（3/20）和 5%（1/22）。HBVr在接受阿仑妥珠单抗治疗的患者中更为常见。在14名HBVr受者中，没有人出现HBV相关性肝衰竭或死亡：我们的研究发现，与之前的研究相比，既往感染过 HBV 的非肝脏 SOT 受者中 HBVr 的发生率更高（12%）。需要进一步研究来确定非肝 SOT 受者中 HBVr 的预测因素，并优化抗病毒预防指导。

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引用次数: 0

Living Donor Decision-Making and the Complex Interplay of Finances and Other Motivators, Barriers, and Facilitators 活体捐献决策与经济及其他动机、障碍和促进因素的复杂相互作用。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-01 DOI: 10.1111/ctr.15377

Abigail R. Smith, Rebecca J. Mandell, Nathan P. Goodrich, Margaret E. Helmuth, Jonathan B. Wiseman, Kimberly A. Gifford, Melissa A. Fava, Akinlolu O. Ojo, Robert M. Merion, Amit K. Mathur

Introduction

The decision to become a living donor requires consideration of a complex, interactive array of factors that could be targeted for clinical, policy, and educational interventions. Our objective was to assess how financial barriers interact with motivators, other barriers, and facilitators during this process.

Methods

Data were obtained from a public survey assessing motivators, barriers, and facilitators of living donation. We used multivariable logistic regression and consensus k-means clustering to assess interactions between financial concerns and other considerations in the decision-making process.

Results

Among 1592 respondents, the average age was 43; 74% were female and 14% and 6% identified as Hispanic and Black, respectively. Among employed respondents (72%), 40% indicated that they would not be able to donate without lost wage reimbursement. Stronger agreement with worries about expenses and dependent care challenges was associated with not being able to donate without lost wage reimbursement (OR = 1.2, 95% CI = 1.0–1.3; OR = 1.2, 95% CI = 1.1–1.3, respectively). Four respondent clusters were identified. Cluster 1 had strong motivators and facilitators with minimal barriers. Cluster 2 had barriers related to health concerns, nervousness, and dependent care. Clusters 3 and 4 had financial barriers. Cluster 3 also had anxiety related to surgery and dependent care.

Conclusions

Financial barriers interact primarily with health and dependent care concerns when considering living organ donation. Targeted interventions to reduce financial barriers and improve provider communication regarding donation-related risks are needed.

简介决定是否成为活体捐献者需要考虑一系列复杂、互动的因素，这些因素可以作为临床、政策和教育干预的目标。我们的目标是评估在这一过程中经济障碍如何与动机、其他障碍和促进因素相互作用：我们从一项评估活体捐献动机、障碍和促进因素的公众调查中获得了数据。我们使用多变量逻辑回归和共识 K-均值聚类来评估决策过程中经济顾虑与其他考虑因素之间的相互作用：在 1592 名受访者中，平均年龄为 43 岁；74% 为女性，14% 和 6% 分别为西班牙裔和黑人。在就业受访者（72%）中，40%的人表示，如果没有工资损失补偿，他们将无法进行捐赠。如果没有工资损失补偿，他们将无法进行捐赠（OR = 1.2，95% CI = 1.0-1.3；OR = 1.2，95% CI = 1.1-1.3）。共确定了四个受访者群组。第 1 组具有强烈的动机和促进因素，障碍极少。第 2 组的障碍与健康问题、紧张和家属照顾有关。第 3 组和第 4 组存在经济障碍。第 3 组还存在与手术和家属护理有关的焦虑：结论：在考虑活体器官捐献时，经济障碍主要与对健康和家属护理的担忧相互影响。需要采取有针对性的干预措施，以减少经济障碍，并改善提供者在捐赠相关风险方面的沟通。

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引用次数: 0

Anticoagulation and Antiplatelet Regimen in Cardiac Transplant. Clinical Characteristics, Outcomes, and Blood Product Transfusion 心脏移植中的抗凝和抗血小板方案。临床特征、疗效和血制品输注。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-01 DOI: 10.1111/ctr.15380

Maria del Val Groba Marco, Pedro Saavedra Santana, Luz Maria Gonzalez del Castillo, Mario Galvan Ruiz, Miguel de Fernandez de Sanmamed, Stefano Urso, Elisabet Guerra Hernández, Laura Quintana Paris, Michelle Tout Castellano, Jose Luis Romero Lujan, Eduardo Jose Caballero Dorta, Luisa Maria Guerra Dominguez, Antonio Garcia Quintana

Background

We aimed to evaluate the characteristics, clinical outcomes, and blood product transfusion (BPT) rates of patients undergoing cardiac transplant (CT) while receiving uninterrupted anticoagulation and antiplatelet therapy.

Methods

A retrospective, single-center, and observational study of adult patients who underwent CT was performed. Patients were classified into four groups: (1) patients without anticoagulation or antiplatelet therapy (control), (2) patients on antiplatelet therapy (AP), (3) patients on vitamin K antagonists (AVKs), and (4) patients on dabigatran (dabigatran). The primary endpoints were reoperation due to bleeding and perioperative BPT rates (packed red blood cells (PRBC), fresh frozen plasma, platelets). Secondary outcomes assessed included morbidity and mortality-related events.

Results

Of the 55 patients included, 6 (11%) received no therapy (control), 8 (15%) received antiplatelet therapy, 15 (27%) were on AVKs, and 26 (47%) were on dabigatran. There were no significant differences in the need for reoperation or other secondary morbidity-associated events. During surgery patients on dabigatran showed lower transfusion rates of PRBC (control 100%, AP 100%, AVKs 73%, dabigatran 50%, p = 0.011) and platelets (control 100%, AP 100%, AVKs 100%, dabigatran 69%, p = 0.019). The total intraoperative number of BPT was also the lowest in the dabigatran group (control 5.5 units, AP 5 units, AVKs 6 units, dabigatran 3 units; p = 0.038); receiving significantly less PRBC (control 2.5 units, AP 3 units, AVKs 2 units, dabigatran 0.5 units; p = 0.011). A Poisson multivariate analysis showed that only treatment on dabigatran reduces PRBC requirements during surgery, with an expected reduction of 64.5% (95% CI: 32.4%–81.4%).

Conclusions

In patients listed for CT requiring anticoagulation due to nonvalvular atrial fibrillation, the use of dabigatran and its reversal with idarucizumab significantly reduces intraoperative BPT demand.

背景：我们旨在评估心脏移植（CT）患者在接受不间断抗凝和抗血小板治疗期间的特征、临床结果和血液制品输注率：我们旨在评估不间断接受抗凝和抗血小板治疗的心脏移植（CT）患者的特征、临床结果和血液制品输注（BPT）率：对接受 CT 的成年患者进行了一项回顾性、单中心和观察性研究。患者分为四组：(1) 未接受抗凝或抗血小板治疗的患者（对照组）；(2) 接受抗血小板治疗的患者（AP 组）；(3) 接受维生素 K 拮抗剂治疗的患者（AVK 组）；(4) 接受达比加群治疗的患者（达比加群组）。主要终点是出血导致的再手术和围手术期BPT率（包装红细胞（PRBC）、新鲜冰冻血浆、血小板）。次要评估结果包括发病率和死亡率相关事件：在纳入的 55 例患者中，6 例（11%）未接受治疗（对照组），8 例（15%）接受了抗血小板治疗，15 例（27%）使用了 AVKs，26 例（47%）使用了达比加群。在再次手术需求或其他继发性发病相关事件方面没有明显差异。手术期间，服用达比加群的患者输注 PRBC（对照组 100%，AP 100%，AVKs 73%，达比加群 50%，P = 0.011）和血小板（对照组 100%，AP 100%，AVKs 100%，达比加群 69%，P = 0.019）的比例较低。达比加群组术中 BPT 的总数量也最少（对照组 5.5 个单位，AP 5 个单位，AVKs 6 个单位，达比加群 3 个单位；p = 0.038）；接受的 PRBC 明显较少（对照组 2.5 个单位，AP 3 个单位，AVKs 2 个单位，达比加群 0.5 个单位；p = 0.011）。泊松多变量分析显示，只有达比加群能减少手术期间的 PRBC 需求，预计减少率为 64.5%（95% CI：32.4%-81.4%）：结论：对于因非瓣膜性心房颤动而需要抗凝治疗的 CT 患者，使用达比加群及伊达珠单抗逆转可显著减少术中 BPT 需求。

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引用次数: 0

Impact of Age of Heart Transplant Program on Patient Survival and Post-Transplant Outcomes 心脏移植项目的年龄对患者存活率和移植后效果的影响。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-01 DOI: 10.1111/ctr.15387

David T. Majure, Gabriel Sayer, Kevin J. Clerkin, Maria G. Karas, Mandisa Jones, Evelyn M. Horn, Yoshifumi Naka, Nir Uriel

Background

The relationship between age of a heart transplant (HT) program and outcomes has not been explored.

Methods

We performed a retrospective cohort analysis of the United Network for Organ Sharing database of all adult HTs between 2009 and 2019. For each patient, we created a variable that corresponded to program age: new (<5), developing (≥5 but <10) and established (≥10) years.

Results

Of 20 997 HTs, 822 were at new, 908 at developing, and 19 267 at established programs. Patients at new programs were significantly more likely to have history of cigarette smoking, ischemic cardiomyopathy, and prior sternotomy. These programs were less likely to accept organs from older donors and those with a history of hypertension or cigarette use. As compared to patients at new programs, transplant patients at established programs had less frequent rates of treated rejection during the index hospitalization (HR 0.43 [95% CI, 0.36–0.53] p < 0.001) and at 1 year (HR 0.58 [95% CI, 0.49–0.70], p < 0.001), less frequently required pacemaker implantations (HR 0.50 [95% CI, 0.36–0.69], p < 0.001), and less frequently required dialysis (HR 0.66 [95% CI, 0.53–0.82], p < 0.001). However, there were no significant differences in short- or long-term survival between the groups (log-rank p = 0.24).

Conclusion

Patient and donor selection differed between new, developing, and established HT programs but had equivalent survival. New programs had increased likelihood of treated rejection, pacemaker implantation, and need for dialysis. Standardized post-transplant practices may help to minimize this variation and ensure optimal outcomes for all patients.

背景：心脏移植（HT）项目的年龄与结果之间的关系尚未得到探讨：我们对器官共享联合网络（United Network for Organ Sharing）数据库中 2009 年至 2019 年期间的所有成人心脏移植手术进行了回顾性队列分析。对于每位患者，我们创建了一个与项目年龄相对应的变量：新患者（结果：在 20 997 例 HT 中，有 8 例为新患者）：在 20 997 例 HT 中，822 例为新项目，908 例为发展中项目，19 267 例为成熟项目。新项目的患者更有可能有吸烟史、缺血性心肌病和胸骨切开术前病史。这些项目不太可能接受年龄较大的捐献者和有高血压或吸烟史的捐献者的器官。与新项目的患者相比，成熟项目的移植患者在指标住院期间发生治疗性排斥反应的频率较低（HR 0.43 [95% CI, 0.36-0.53] p 结论：新项目和成熟项目的患者和供体选择不同：新的移植项目、发展中的移植项目和成熟的移植项目在患者和供体的选择上有所不同，但存活率相当。新项目出现治疗性排斥反应、起搏器植入和透析需求的可能性增加。标准化的移植后实践可能有助于最大限度地减少这种差异，并确保所有患者都能获得最佳治疗效果。

{"title":"Impact of Age of Heart Transplant Program on Patient Survival and Post-Transplant Outcomes","authors":"David T. Majure, Gabriel Sayer, Kevin J. Clerkin, Maria G. Karas, Mandisa Jones, Evelyn M. Horn, Yoshifumi Naka, Nir Uriel","doi":"10.1111/ctr.15387","DOIUrl":"10.1111/ctr.15387","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>The relationship between age of a heart transplant (HT) program and outcomes has not been explored.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We performed a retrospective cohort analysis of the United Network for Organ Sharing database of all adult HTs between 2009 and 2019. For each patient, we created a variable that corresponded to program age: new (<5), developing (≥5 but <10) and established (≥10) years.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 20 997 HTs, 822 were at new, 908 at developing, and 19 267 at established programs. Patients at new programs were significantly more likely to have history of cigarette smoking, ischemic cardiomyopathy, and prior sternotomy. These programs were less likely to accept organs from older donors and those with a history of hypertension or cigarette use. As compared to patients at new programs, transplant patients at established programs had less frequent rates of treated rejection during the index hospitalization (HR 0.43 [95% CI, 0.36–0.53] <i>p</i> < 0.001) and at 1 year (HR 0.58 [95% CI, 0.49–0.70], <i>p</i> < 0.001), less frequently required pacemaker implantations (HR 0.50 [95% CI, 0.36–0.69], <i>p</i> < 0.001), and less frequently required dialysis (HR 0.66 [95% CI, 0.53–0.82], <i>p</i> < 0.001). However, there were no significant differences in short- or long-term survival between the groups (log-rank <i>p</i> = 0.24).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Patient and donor selection differed between new, developing, and established HT programs but had equivalent survival. New programs had increased likelihood of treated rejection, pacemaker implantation, and need for dialysis. Standardized post-transplant practices may help to minimize this variation and ensure optimal outcomes for all patients.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10467,"journal":{"name":"Clinical Transplantation","volume":null,"pages":null},"PeriodicalIF":1.9,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141476115","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

The Spread Pattern of New Practice in Liver Transplantation in the United States 美国肝移植新疗法的传播模式。

IF 1.9 4区医学 Q2 SURGERY

Clinical Transplantation

Pub Date : 2024-07-01 DOI: 10.1111/ctr.15379

Miho Akabane, Yuki Imaoka, Carlos O. Esquivel, W. Ray Kim, Kazunari Sasaki

Background

Introducing new liver transplantation (LT) practices, like unconventional donor use, incurs higher costs, making evaluation of their prognostic justification crucial. This study reexamines the spread pattern of new LT practices and its prognosis across the United States.

Methods

The study investigated the spread pattern of new practices using the UNOS database (2014–2023). Practices included LT for hepatitis B/C (HBV/HCV) nonviremic recipients with viremic donors, LT for COVID-19-positive recipients, and LT using onsite machine perfusion (OMP). One year post-LT patient and graft survival were also evaluated.

Results

LTs using HBV/HCV donors were common in the East, while LTs for COVID-19 recipients and those using OMP started predominantly in California, Arizona, Texas, and the Northeast. K-means cluster analysis identified three adoption groups: facilities with rapid, slow, and minimal adoption rates. Rapid adoption occurred mainly in high-volume centers, followed by a gradual increase in middle-volume centers, with little increase in low-volume centers. The current spread patterns did not significantly affect patient survival. Specifically, for LTs with HCV donors or COVID-19 recipients, patient and graft survivals in the rapid-increasing group was comparable to others. In LTs involving OMP, the rapid- or slow-increasing groups tended to have better patient survival (p = 0.05) and significantly improved graft survival rates (p = 0.02). Facilities adopting new practices often overlap across different practices.

Discussion

Our analysis revealed three distinct adoption groups across all practices, correlating the adoption aggressiveness with LT volume in centers. Aggressive adoption of new practices did not compromise patient and graft survivals, supporting the current strategy. Understanding historical trends could predict the rise in future LT cases with new practices, aiding in resource distribution.

背景：引入新的肝移植（LT）方法，如使用非常规供体，会产生更高的成本，因此评估其预后的合理性至关重要。本研究重新审视了新肝移植方法在美国的传播模式及其预后：本研究利用 UNOS 数据库（2014-2023 年）调查了新做法的传播模式。方法：该研究利用 UNOS 数据库（2014-2023 年）对新实践的传播模式进行了调查。这些实践包括对乙型肝炎/丙型肝炎（HBV/HCV）非病毒血症受者与病毒血症供体的 LT、对 COVID-19 阳性受者的 LT 以及使用现场机器灌注（OMP）的 LT。此外，还对LT术后一年的患者和移植物存活率进行了评估：结果：使用HBV/HCV供体的LT常见于东部地区，而COVID-19受体的LT和使用OMP的LT主要开始于加利福尼亚州、亚利桑那州、德克萨斯州和东北部地区。K-means 聚类分析确定了三个采用群体：采用率较快、较慢和最低的机构。快速采用主要发生在高容量中心，随后在中等容量中心逐渐增加，而在低容量中心几乎没有增加。目前的传播模式并未对患者的存活率产生重大影响。具体而言，对于HCV供体或COVID-19受体的LT，快速增加组的患者和移植物存活率与其他组相当。在涉及 OMP 的 LT 中，快速或缓慢增加组的患者存活率往往更高（p = 0.05），移植物存活率也显著提高（p = 0.02）。讨论：讨论：我们的分析显示，在所有实践中，有三个不同的采用组，采用的积极性与中心的LT量相关。积极采用新方法不会影响患者和移植物的存活率，这支持了当前的策略。了解历史趋势可以预测采用新方法后未来LT病例的增加情况，有助于资源分配。

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引用次数: 0