Current Opinion in Organ Transplantation最新文献

Purpose of review: This review summarizes the different instruments for evaluating the psychosocial health of transplant candidates, the evidence demonstrating how these instruments relate to probability of transplant waitlisting and transplant outcomes, and the critical knowledge gaps that exist in the causal pathway between psychosocial health and clinical transplant trajectory.

Recent findings: The current literature reveals that psychosocial assessments are a common reason for racial and ethnic minorities to be denied access to the transplant list. Given evidence that a lack of clinician consensus exists regarding the definition of, importance of, and reproducibility of psychosocial support evaluations, this facet of the holistic evaluation process may create a unique challenge for already vulnerable patient populations. Though recent evidence shows that psychosocial evaluation scores predict select transplant outcomes, these findings remain inconsistent.

Summary: Multiple instruments for psychosocial transplant evaluation exist, though the utility of these instruments remains uncertain. As equity becomes an increasingly urgent priority for the transplant system, rigorous interrogation of the causal pathway between psychosocial health and transplant longevity is still needed.

Purpose of review: Hispanics with limited English proficiency (LEP) face unique challenges in accessing organ transplantation due to limited culturally concordant care and linguistically appropriate resources, leading to disparities in healthcare delivery and transplantation outcomes. This review examines how language barriers affect access to kidney and liver transplant, and highlights the importance of institutional support for quality interpretation services in promoting healthcare equity in transplantation.

Recent findings: Hispanics experience greater disease burden, but are less likely to receive a transplant compared to non-Hispanic Whites. LEP is a significant barrier to transplantation. Culturally and linguistically concordant interventions, such as the "Hispanic Kidney Transplant Program," have demonstrated success in improving transplant-related outcomes among Hispanics. However, limited resources affect widespread implementation, and the broad lack of interpretation services in healthcare settings delay timely care in transplantation.

Summary: Despite some progress demonstrated by culturally and linguistically concordant clinical intervention trials, disparities in transplantation for Hispanics with LEP remain. Enhancing the availability of interpretation services, recruiting and hiring bilingual healthcare professionals, and training healthcare staff to effectively engage with language and interpretation resources are critical to improving health equity. Efforts must prioritize language access and cultural concordance to address the unique challenges faced by Hispanics with LEP.

Purpose of review: Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape in advanced hepatocellular carcinoma and increasingly are being evaluated in earlier stage disease. Herein we explore the role of ICIs pre-liver transplant for liver cancers.

Recent findings: Given the high response rates with combination approaches including locoregional treatments, more patients with liver confined disease, without vascular invasion, who have received ICIs are now being rendered eligible for potential liver transplant. This opportunity to expand the population who may benefit from liver transplant has also come with challenges recognizing the global shortage of organs. Post-liver transplant immunosuppression potentially competes with the immune-stimulating effects of ICIs and graft rejection has been a concern. ICIs may provide an opportunity to maintain patients on the waiting list but an understanding of who is likely to benefit is needed, to circumvent possible toxicities. In addition, ICIs are now considered standard of care, in combination with chemotherapy, for advanced cholangiocarcinoma, where the role of liver transplant is evolving.

Summary: As the eligibility criteria globally for liver transplant in the setting of malignancy continues to expand, the integration of ICIs becomes increasingly important.

Purpose of review: While prior reviews have assessed barriers to transplantation experienced by patients and their families, they have not summarized how these stakeholders feel about whether and how those barriers impact equity in transplantation. We seek to comprehensively present the literature of patients and family perspectives on disparities in transplant access and potential solutions.

Recent findings: Some patients and their families report experiences of discrimination, while others from traditionally marginalized groups feel the system is equitable and do not perceive any different treatment as a result of their race/ethnicity, sex, age, religion, or geography. This summary suggests that not all of the disparities observed in transplant access are attributable to systemic or unconscious bias and may be partially alleviated through enhanced education and communication.

Summary: Lack of understanding and transparency lead to mistrust of organ transplantation, further exacerbating existing disparities. Patient and family engagement is paramount for ensuring the trust of the public who are the source of organs and those who directly benefit from this field. Partnerships between patient advocacy groups, professional societies, and policymakers have the potential to increase transparency while ensuring that the patient voice is represented in any system-level change and assessment.

Purpose of review: Increasing transplant access overall and particularly among historically underserved and marginalized patient groups is a shared goal nationwide. Patient challenges with psychosocial factors, such as social support and health literacy, are recognized as among the top reasons patients may not be referred, evaluated, or waitlisted, key steps along the pathway to transplantation. Yet referring providers' (e.g., dialysis clinics') and transplant centers' processes for measuring, communicating about, and addressing patients' psychosocial challenges are inconsistent, can emphasize measures more relevant to dialysis care than transplant care, and are highly susceptible to implicit bias.

Recent findings: In this article, we illuminate the opportunity to standardize the patient psychosocial information that dialysis clinics and other nephrology care providers share with the transplant center when referring a patient for transplant evaluation. We highlight potential benefits and trade-offs to this approach and describe how regional coalitions comprising patients, caregivers, and community members can support developing and implementing a standardized template for this purpose, as well as the objectives that the coalition's efforts should pursue to this end.

Summary: Standardized templates for psychosocial information sharing at referral represent a key opportunity to improve quality, efficiency, and equity in pretransplant care as well as transplant access outcomes broadly.

Purpose of review: Patients undergoing re-transplantation constitute a growing proportion of annual lung transplants. It is necessary to consider ethical considerations of re-transplantation in parallel with clinical progress.

Recent findings: Most clinical data demonstrate patients undergoing re-transplantation have worse survival outcomes; however, there is limited discussion of the ethical principles surrounding re-transplantation. Ethical guidance in re-transplantation trails clinical advancement.

Summary: The four-box model offers a valuable framework for assessing the ethical considerations in re-transplantation. This includes an analysis of medical indications, patient preferences, quality-of-life and contextual factors to support the ethical use of scarce donor lungs.

Purpose of review: The controversial medical procedure of abortion is the subject of this article. It argues that for transplant patients, including recipients, abortion is ethical.

Recent findings: In June 2022, the United States Supreme Court overturned the long-standing decision of Roe v. Wade. This decision has led to a socio-legal environment where obtaining an abortion is impossible for some patients. However, the moral position relating to patients who have undergone transplants or are on a waiting list has been largely overlooked. End-stage renal, liver, and heart disease presents a hazardous situation for pregnancy, posing risks to both the fetus and the pregnant person. The abortion procedure is medically safer and allows a patient to proceed with a transplant. Limiting access to abortion or preventing it altogether will have a significant negative impact on transplant patients. The ethical analysis of abortion can be likened to compelling a relative or loved one of a transplant recipient to donate an organ to their family member or loved one.

Summary: This article emphasizes the importance of maintaining the legal availability of abortion for transplant patients. Allowing abortions in transplant patients upholds ethical parity, as seen in the analogous situation of live organ donation.

Purpose of review: Primary graft dysfunction (PGD) and chronic lung allograft dysfunction (CLAD) are the leading causes of graft loss in lung transplant recipients. The development of mouse lung transplant models has allowed for the genetic dissection of cellular and molecular pathways that prevent graft survival. This review provides an overview into recent mechanistic insights into PGD and CLAD.

Recent findings: Mouse orthotopic lung transplant models and investigations of human lung transplant recipeints have revealed new molecular and cellular targets that promote PGD and CLAD. Donor and recipient-derived innate immune cells promote PGD and CLAD. PGD is driven by communication between classical monocytes and tissue-resident nonclassical monocytes activating alveolar macrophages to release chemokines that recruit neutrophils. Products of cell damage trigger neutrophil NET release, which together with NK cells, antibodies and complement, that further promote PGD. The development of CLAD involves circuits that activate B cells, CD8 + T cells, classical monocytes, and eosinophils.

Summary: Effective targeted management of PGD and CLAD in lung transplant recipient to improve their long-term outcome remains a critical unmet need. Current mechanistic studies and therapeutic studies in mouse models and humans identify new possibilities for prevention and treatment.

Purpose of review: As one of the early hand transplant programs in the world, we are often asked to educate other programs on the lessons we have learned and on how to set up a successful hand transplantation program.

Recent findings: Two decades of global experience with vascularized composite allotransplantation (VCA) of the upper limb have demonstrated improved functional outcomes and quality of life for carefully screened patients. Despite initial reticence about VCA, over 30 patients in the USA have benefited from hand transplantation, with around 80% long-term successes. We have experience with four bilateral upper extremity patients who have undergone bilateral upper extremity allotransplants. This review article highlights our personal experience and lessons with respect to VCA team assembly, logistics, patient selection, perioperative planning, the operative procedure, and postoperative management.

Summary: Continual learning and critical evaluation are crucial to maintaining a successful upper extremity VCA program. This will ensure that patients who stand to benefit most from this life-enhancing procedure are identified and are others optimized to achieve the best possible outcomes.