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Optimizing the pediatric transplant candidate. 优化儿科移植候选者。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-10-12 DOI: 10.1097/MOT.0000000000001115
James E Squires, Vikram K Raghu, George V Mazariegos

Purpose of review: Advances in pediatric transplant parallel those in adult populations; however, there remain critical unique considerations and differences that require specialized knowledge and a specific skill set to optimize care afforded to the pediatric transplant candidate. We introduce general themes regarding optimization of the transplant candidate that are unique to children.

Recent findings: The pathologies leading to pediatric organ transplant candidacy differ from adults and a precise understanding of the physiologies and natural histories of such diseases is critical for optimized care. Regardless of etiology, comorbidities including malnutrition, sarcopenia, and developmental delay are seen and often require disease and organ specific approaches to management. Additionally, an understanding of the concepts of developmental immunology and their relevance to transplant is critical.

Summary: When looking to optimize pretransplant care, awareness of the pediatric-specific challenges by the transplant community in addition to organ- and age-specific management strategies enable the best outcomes for children awaiting solid organ transplantation.

综述的目的:儿童移植的进展与成年人群的进展相似;然而,仍然存在关键的独特考虑和差异,需要专业知识和特定技能来优化为儿科移植候选人提供的护理。我们介绍了儿童特有的关于优化移植候选者的一般主题。最近的发现:导致儿童器官移植候选的病理学与成人不同,准确了解这些疾病的生理学和自然史对于优化护理至关重要。无论病因如何,包括营养不良、少肌症和发育迟缓在内的合并症都是常见的,通常需要疾病和器官特异性的治疗方法。此外,了解发育免疫学的概念及其与移植的相关性至关重要。摘要:在寻求优化移植前护理时,除了器官和年龄特定的管理策略外,移植社区对儿科特定挑战的认识也能为等待实体器官移植的儿童带来最佳结果。
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引用次数: 0
Controlling infections in hospitalized pretransplant candidates. 控制住院移植前患者的感染。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-11-14 DOI: 10.1097/MOT.0000000000001120
Marian G Lacy, Evgenii Filippov, Saman Nematollahi

Purpose of review: Infections in hospitalized patients awaiting solid organ transplantation can pose complicated diagnostic and therapeutic challenges. Goals of management include stabilizing the patient, treating or controlling infections, and decreasing the risk of reactivation of infection after transplant.

Recent findings: Groups such as The Organ Procurement and Transplantation Network, American Society of Transplantation Infectious Diseases Community of Practice and the European Society of Clinical Microbiology and Infectious Diseases have updated their guidelines on screening and treatment of infection in transplant candidates. There are also recent developments in therapeutic options for tuberculosis, COVID-19, Clostridioides difficile colitis, bloodstream infections, and other common infections.

Summary: Ideally, antimicrobial therapy should be complete prior to transplantation. In situations in which completion of therapy prior to transplant is not feasible, therapy may need to be prolonged or modified. In most situations, infections can be managed similarly to the general population, although some infections, particularly fungal and mycobacterial, require a different management approach. We review disease- and organ-specific management.

回顾目的:等待实体器官移植的住院患者感染可能带来复杂的诊断和治疗挑战。管理目标包括稳定患者,治疗或控制感染,降低移植后感染再激活的风险。最近的发现:器官获取和移植网络、美国移植传染病实践协会和欧洲临床微生物学和传染病学会等组织已经更新了他们关于移植候选人感染筛查和治疗的指南。最近在结核病、COVID-19、艰难梭菌结肠炎、血液感染和其他常见感染的治疗方案方面也有进展。总结:理想情况下,在移植前应完成抗菌治疗。在移植前完成治疗不可行的情况下,治疗可能需要延长或修改。在大多数情况下,感染可以类似于一般人群的管理,尽管一些感染,特别是真菌和分枝杆菌感染,需要不同的管理方法。我们回顾疾病和器官特异性管理。
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引用次数: 0
Optimizing cardiac status in the preliver transplant candidate. 优化肝脏移植候选者的心脏状态。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-11-14 DOI: 10.1097/MOT.0000000000001119
Maxine W Stachel, Eugene C DePasquale

Purpose of review: Liver transplant is a widely accepted therapy for end-stage liver disease. With advances in our understanding of transplant, candidates are increasingly older with more cardiac comorbidities. Cardiovascular disease also represents a leading cause of morbidity and mortality posttransplant.

Recent findings: Preoperative cardiac risk stratification and treatment may improve short-term and long-term outcomes after liver transplant. Importantly, the appropriate frequency of surveillance has not been defined. Optimal timing of cardiac intervention in end-stage liver disease is likewise uncertain.

Summary: The approach to risk stratification of cardiovascular disease in end-stage liver disease is outlined, incorporating the AHA/ACC scientific statement on evaluation of cardiac disease in transplant candidates and more recent expert consensus documents. Further study is needed to clarify the ideal timing and approach for cardiovascular interventions.

综述目的:肝移植是一种被广泛接受的治疗终末期肝病的方法。随着我们对移植理解的进步,候选人年龄越来越大,心脏合并症也越来越多。心血管疾病也是移植后发病和死亡的主要原因。最新发现:术前心脏风险分层和治疗可改善肝移植术后的短期和长期预后。重要的是,监测的适当频率尚未确定。终末期肝病心脏干预的最佳时机同样不确定。总结:本文概述了终末期肝病患者心血管疾病风险分层的方法,并结合了AHA/ACC关于移植候选者心脏病评估的科学声明和最新的专家共识文件。需要进一步的研究来阐明心血管干预的理想时机和方法。
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引用次数: 0
Treating rare tumors with liver transplantation. 肝移植治疗罕见肿瘤。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-10-18 DOI: 10.1097/MOT.0000000000001118
Andrew Melehy, Vatche Agopian

Purpose of review: The success of liver transplantation (LT) in treating unresectable hepatocellular carcinoma (HCC) has resulted in interest in LT for other oncologic conditions. Here, we discuss the role of LT for rare oncologic indications including metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs), hepatic epitheliod hemangioendothelioma (HEHE), fibrolamellar hepatocellular carcinoma (FLC), and hepatic angiosarcoma (HAS).

Recent findings: Conditions reviewed have been documented indications for LT in the available literature. We summarize the experience of LT for these indications and proposed management guidelines.

Summary: GEP-NETs with isolated metastases to the liver can be treated with LT with excellent long-term outcomes (10-year survival 88%) if strict selection criteria are used (low-intermediate grade, Ki-67% < 20%, complete resection of primary tumor, stable disease for 6 months, <50% hepatic involvement). HEHE is a rare hepatic tumor for which LT can be performed with reported 10-year survival around 70%. FLC is a distinct clinical entity to HCC and is optimally treated with surgical resection though experience with LT is described in observational series (5-year survival 50%, recurrence in 10%). HAS is a rapidly progressive tumor with a dismal prognosis with or without treatment, including LT.

综述目的:肝移植(LT)在治疗不可切除的肝细胞癌(HCC)方面的成功引起了人们对LT治疗其他肿瘤学疾病的兴趣。在此,我们讨论了LT在罕见肿瘤适应症中的作用,包括转移性胃肠胰神经内分泌肿瘤(GEP-NETs)、肝上皮样血管内皮瘤(HEHE)、纤维板层肝细胞癌(FLC)和肝血管肉瘤(HAS)。我们总结了LT治疗这些适应症的经验,并提出了管理指南。总结:如果使用严格的选择标准(低-中级,Ki-67%<20%,原发肿瘤完全切除,疾病稳定6个月,
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引用次数: 0
Innovative surgical techniques in the intestine and multivisceral transplant. 创新的肠道和多器官移植手术技术。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-10-30 DOI: 10.1097/MOT.0000000000001098
Phillipe Abreu, Joao Manzi, Rodrigo Vianna

Purpose of review: This timely review delves into the evolution of multivisceral transplantation (MVT) over the past six decades underscoring how advancements in surgical techniques and immunosuppression have driven transformation, to provide insight into the historical development of MVT, shedding light on its journey from experimentation to a valuable clinical approach.

Recent findings: The review presents contemporary enhancements in surgical methods within the context of intestinal transplantation. The versatility of MVT is emphasized, accommodating diverse organ combinations and techniques. Both isolated intestinal transplantation (IIT) and MVT have seen expanded indications, driven by improved parenteral nutrition, transplantation outcomes, and surgical innovations. Surgical techniques are tailored based on graft type, with various approaches for isolated transplantation. Preservation strategies and ostomy techniques are also covered, along with graft assessment advancements involving donor-specific antibodies.

Summary: This review's findings underscore the remarkable evolution of MVT from experimental origins to a comprehensive clinical practice. The progress in surgical techniques and immunosuppression has broadened the spectrum of patients who can benefit from intestinal transplant, including both IIT and MVT. The expansion of indications offers hope to patients with complex gastrointestinal disorders. The detection of donor-specific antibodies in graft assessment advances diagnostic accuracy, ultimately improving patient outcomes.

综述目的:这篇及时的综述深入探讨了过去60年来多器官移植(MVT)的演变,强调了外科技术和免疫抑制的进步是如何推动变革的,以深入了解MVT的历史发展,揭示其从实验到有价值的临床方法的历程。最近的发现:这篇综述介绍了肠移植手术方法的当代改进。MVT的多功能性被强调,适应不同的器官组合和技术。由于肠外营养、移植结果和手术创新的改善,分离式肠移植(IIT)和MVT的适应症都有所扩大。手术技术是根据移植物类型量身定制的,有各种单独移植的方法。还涵盖了保存策略和造口术技术,以及涉及供体特异性抗体的移植物评估进展。综述:这篇综述的发现强调了MVT从实验起源到全面临床实践的显著演变。外科技术和免疫抑制的进步拓宽了可以从肠移植中受益的患者范围,包括IIT和MVT。适应症的扩大为患有复杂胃肠道疾病的患者带来了希望。移植物评估中供体特异性抗体的检测提高了诊断的准确性,最终改善了患者的预后。
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引用次数: 0
Hemodynamic monitoring in liver transplantation 'the hemodynamic system'. 肝移植血流动力学监测“血流动力学系统”。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-11-30 DOI: 10.1097/MOT.0000000000001125
Sherif Kandil, Ashraf Sedra

Purpose of review: The purpose of this article is to provide a comprehensive review of hemodynamic monitoring in liver transplantation.

Recent findings: Radial arterial blood pressure monitoring underestimates the aortic root arterial blood pressure and causes excessive vasopressor and worse outcomes. Brachial and femoral artery monitoring is well tolerated and should be considered in critically ill patients expected to be on high dose pressors. The pulmonary artery catheter is the gold standard of hemodynamic monitoring and is still widely used in liver transplantation; however, it is a highly invasive monitor with potential for serious complications and most of its data can be obtained by other less invasive monitors. Rescue transesophageal echocardiography relies on few simple views and should be available as a standby to manage sudden hemodynamic instability. Risk of esophageal bleeding from transesophageal echocardiography in liver transplantation is the same as in other patient populations. The arterial pulse waveform analysis based cardiac output devices are minimally invasive and have the advantage of real-time beat to beat monitoring of cardiac output. No hemodynamic monitor can improve clinical outcomes unless integrated into a goal-directed hemodynamic therapy. The hemodynamic monitoring technique should be tailored to the patient's medical status, surgical technique, and the anesthesiologist's level of expertise.

Summary: The current article provides a review of the current hemodynamic monitoring systems and their integration in goal-directed hemodynamic therapy.

综述目的:本文旨在对肝移植血流动力学监测进行综述。最近发现:桡动脉血压监测低估了主动脉根动脉血压,导致血管加压过度和更糟糕的结果。肱动脉和股动脉监测耐受性良好,应考虑在危重患者预期高剂量的压力。肺动脉导管是血流动力学监测的金标准,目前仍广泛应用于肝移植;然而,它是一种高侵入性监护仪,有可能出现严重并发症,其大部分数据可以通过其他侵入性较小的监护仪获得。抢救经食管超声心动图依赖于几个简单的视图,应作为处理突发性血流动力学不稳定的备用。肝移植患者经食管超声心动图显示食管出血的风险与其他患者相同。基于动脉脉冲波形分析的心输出量装置具有微创性和实时监测心输出量的优点。没有血流动力学监测可以改善临床结果,除非整合到目标导向的血流动力学治疗。血流动力学监测技术应根据患者的医疗状况、手术技术和麻醉师的专业水平进行调整。摘要:本文综述了当前血流动力学监测系统及其在目标导向血流动力学治疗中的应用。
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引用次数: 0
Pushing the limits of treatment for hepatocellular carcinoma. 推动肝细胞癌治疗的极限。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-11-30 DOI: 10.1097/MOT.0000000000001123
Michelle Jones-Pauley, David W Victor, Sudha Kodali

Purpose of review: We review existing and newer strategies for treatment and surveillance of hepatocellular carcinoma (HCC) both pre and postliver transplantation.

Summary: HCC is rising in incidence and patients are often diagnosed at later stages. Consequently, there is a need for treatment strategies which include collaboration of multiple specialties. Combinations of locoregional, systemic, and surgical therapies are yielding better postliver transplantation (post-LT) outcomes for patients with HCC than previously seen. Tumor biology (tumor size, number, location, serum markers, response to therapy) can help identify patients who are at high risk for HCC recurrence posttransplantation and may expand transplant eligibility for some patients.

综述目的:我们回顾了肝移植前后肝细胞癌(HCC)的治疗和监测的现有和更新的策略。摘要:HCC的发病率正在上升,患者往往在晚期才被诊断出来。因此,需要制定包括多专业合作在内的治疗策略。局部、全身和手术联合治疗肝癌患者肝移植后(后lt)的预后比以前所见的更好。肿瘤生物学(肿瘤大小、数量、位置、血清标志物、对治疗的反应)可以帮助识别移植后HCC复发的高危患者,并可能扩大一些患者的移植资格。
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引用次数: 0
Molecular profiling in the management of hepatocellular carcinoma. 分子分析在肝细胞癌治疗中的应用。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-12-01 DOI: 10.1097/MOT.0000000000001124
Nadine Soliman, Ashish Saharia, Maen Abdelrahim, Ashton A Connor

Purpose of review: The purpose of this review is to both summarize the current knowledge of hepatocellular carcinoma molecular biology and to suggest a framework in which to prospectively translate this knowledge into patient care. This is timely as recent guidelines recommend increased use of these technologies to advance personalized liver cancer care.

Recent findings: The main themes covered here address germline and somatic genetic alterations recently discovered in hepatocellular carcinoma, largely owing to next generation sequencing technologies, and nascent efforts to translate these into contemporary practice.

Summary: Early efforts of translating molecular profiling to hepatocellular carcinoma care demonstrate a growing number of potentially actionable alterations. Still lacking are a consensus on what biomarkers and technologies to adopt, at what scale and cost, and how to integrate them most effectively into care.

综述的目的:本综述的目的是总结当前肝细胞癌分子生物学的知识,并提出一个框架,其中前瞻性地将这些知识转化为患者护理。这是及时的,因为最近的指南建议增加使用这些技术来推进个性化的肝癌治疗。最近的发现:本文所涵盖的主要主题是最近在肝细胞癌中发现的种系和体细胞遗传改变,这主要归功于下一代测序技术,以及将这些技术转化为当代实践的初步努力。摘要:早期将分子谱分析转化为肝细胞癌治疗的努力表明,越来越多的潜在可行的改变。对于采用何种生物标志物和技术,采用何种规模和成本,以及如何最有效地将它们整合到护理中,目前仍缺乏共识。
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引用次数: 0
Optimizing the prelung transplant candidate. 优化肺移植前候选者。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-11-07 DOI: 10.1097/MOT.0000000000001116
John Pagteilan, Scott Atay

Purpose of review: Lung transplant outcomes are impacted by multiple modifiable risk factors. Candidate deterioration on the wait list remains problematic. Innovative technology and strategies to identify and impact pretransplant morbidity have improved short- and long-term outcomes. We focus our review on recent advances in pretransplant recipient assessment and optimization.

Recent findings: Advancements in recipient management have focused on risk factor identification for adverse outcomes and the development of a lung transplant specific frailty assessment. Early surgical correction of gastroesophageal reflux disease (GERD), including the use of partial fundoplication in the setting of esophageal dysmotility, leads to improvements in graft function/longevity. New evidence supports expanding criteria for extracorporeal life support as a bridge to transplant.

Summary: Candidate optimization requires early intervention to limit functional deterioration potentially contributing to adverse outcomes. Frailty can be identified with a transplant specific frailty assessment, and positively impacted with dedicated rehabilitation. Pretransplant frailty is reversible following transplant and should be considered in the context of overall fitness at the time of candidate selection. Invasive support modes including extracorporeal membrane oxygenation (ECMO) are appropriate to preserve strength and mobility, with awake, ambulatory ECMO preferred. The deleterious effect of GERD on graft function can be managed with early fundoplication over medical management alone.

综述目的:肺移植的结果受到多种可改变的危险因素的影响。候选人在等待名单上的恶化仍然是个问题。识别和影响移植前发病率的创新技术和策略改善了短期和长期结果。我们重点回顾了在转运前受体评估和优化方面的最新进展。最近的发现:受体管理的进展集中在不良结果的风险因素识别和肺移植特异性虚弱评估的发展上。胃食管反流病(GERD)的早期手术矫正,包括在食管运动障碍的情况下使用部分胃底折叠术,可以改善移植物的功能/寿命。新的证据支持扩大体外生命支持作为移植桥梁的标准。总结:候选优化需要早期干预,以限制可能导致不良结果的功能恶化。虚弱可以通过移植特异性虚弱评估来识别,并通过专门的康复来产生积极影响。移植前的虚弱在移植后是可逆的,在选择候选人时应考虑整体健康状况。包括体外膜肺氧合(ECMO)在内的有创支持模式适用于保持力量和机动性,优选清醒、动态ECMO。胃食管反流术对移植物功能的有害影响可以通过早期胃底折叠术来控制,而不是单独进行药物治疗。
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引用次数: 0
Ethical issues in solid organ transplantation: transfusion-free transplantation in Jehovah's witness patients. 实体器官移植的伦理问题:耶和华见证人患者的无输血移植。
IF 2.2 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-02-01 Epub Date: 2023-12-06 DOI: 10.1097/MOT.0000000000001128
Rick Selby, Taylor Selby-Medical, Michael Richman

Purpose of review: Jehovah's Witnesses do not accept transfusion of major allogeneic blood fractions. Successful solid organ transplantation is challenging for Jehovah's Witnesses when anemia, coagulation disturbances, and difficult technical aspects co-exist, and key blood bank resources cannot be utilized. Organ availability for transplantation is limited and demand exceeds supply for all organ types. Historically, the likelihood of poor outcomes in Jehovah's Witnesses patients placed ethical limitations on transplant candidacy for this population violating the precept of maximal utilization of a limited resource. The review's purpose is to describe advancements and strategies that make Jehovah's Witnesses transplant outcomes comparable to transfusion-eligible patients and allay the ethical concerns of their candidacy.

Recent findings: Immunomodulation from allogeneic transfusion is a cause of significant postop morbidity. Blood conservation strategies have led to improved outcomes across different medical and surgical cohorts and set the stage for expanded utility in Jehovah's Witnesses with organ insufficiency.Published single-center series with descriptions of specific peri-operative strategies describe the path to major blood product avoidance.

Summary: Comparable outcomes in solid organ transplantation for Jehovah's Witnesses without allogeneic transfusion are possible when inclusion-exclusion criteria are respected, and blood conservation strategies employed.

审查目的:耶和华见证会不接受输注主要的异体血液成分。当贫血、凝血障碍和困难的技术问题同时存在,且无法利用关键的血库资源时,成功进行实体器官移植对耶和华见证会来说是一项挑战。可供移植的器官有限,所有类型的器官都供不应求。从历史上看,耶和华见证会患者可能出现不良预后,这就从伦理上限制了这一人群的移植候选资格,违反了最大限度利用有限资源的原则。这篇综述的目的是介绍使耶和华见证会患者的移植结果与符合输血条件的患者相媲美的先进技术和策略,并消除对他们作为移植候选者的伦理顾虑:最新研究结果:异体输血引起的免疫调节是导致术后严重发病的原因之一。最近的研究结果:异体输血引起的免疫调节是导致术后严重发病的原因之一。血液保存策略改善了不同内科和外科组群的治疗效果,并为在器官功能不全的耶和华见证会患者中推广使用奠定了基础。已发表的单中心系列研究描述了避免使用主要血液制品的具体围手术期策略。
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引用次数: 0
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Current Opinion in Organ Transplantation
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