Progress in Transplantation最新文献

Introduction: Lymphocele is a common complication post-kidney transplantation, influenced by various factors including surgical technique, graft vessel count, operator experience, body mass index, ischemia time, and immunotherapy regimens.

Project aims: The purpose of this study was to evaluate lymphocele risk factors, particularly focusing on the role of end-stage kidney disease.

Design: A retrospective study was conducted on renal transplant recipients from a single center (March 2020 to December 2022). Patients were categorized into those developing lymphocele and those without during the postoperative period. Data, including sociodemographic, personal history, graft-related variables, intervention, and postoperative outcomes, were collected from electronic medical records.

Results: Out of 291 renal transplant recipients, 57 (19.6%) developed postoperative lymphocele, with 15 (5.1%) being symptomatic. Patients with body mass index <24.9 kg/m2 have lower risk of developing lymphocele with an Odds Ratio of 0.538 (P=0.046). Higher lymphocele prevalence was noted in patients with chronic tubulointerstitial nephritis (46.2%; OR 3.815; P=0.024). Focal segmental glomerulosclerosis patients showed no lymphocele (0.0%; OR 0.123; P=0.048). Other factors, including autosomal dominant polycystic kidney disease, did not exhibit significant differences in lymphocele prevalence.

Conclusion: The etiology of end-stage kidney disease can serve as a significant predictor of lymphocele development during the postoperative period following renal transplantation. Further larger prospective studies are required to comprehensively assess risk factors and explore end-stage kidney disease potential role in predicting lymphocele formation.

Introduction: Gaps exist in the understanding of the etiology of poor sleep quality after lung transplantation. Research Question: What factors are associated with poor sleep quality in lung transplant recipients?

Design: A quantitative, single-site, cross-sectional study used an anonymous survey based on 3 scales. The Pittsburgh Sleep Quality Index scale with scores dichotomized to poor versus good sleepers based on the cutoff score > 8. The Hospital Anxiety and Depression Scale evaluated symptoms of anxiety and depression, and the Short Form-12 measured health-related quality of life using the mental and physical component scores. Additional self-reported data included demographic and transplant-related variables.

Results: The response rate was 38.4% (61/158), and 52.5% of the sample (32/61) evidenced a Pittsburgh Sleep Quality Index score > 8, suggestive of poor sleep quality. Bivariate analyses demonstrated that poor sleep was significantly related to symptoms of depression (P < .01), anxiety (P < .01), stressors of hospitalization (P < .05), and treatment of acute rejection (P < .05). Multivariate analysis demonstrated that anxiety was significantly associated with poor sleep (odds ratio = 1.34, P < .05).

Conclusion: Poor subjective sleep quality remains prevalent in lung transplant recipients. Individuals with anxiety symptoms were at a greater risk for poor sleep. Guidance for strategies to improve sleep quality requires further in-depth exploration before implementation of interventions.

Introduction: Life expectancy for pediatric liver transplant patients has increased over the past decade. Different stages of the transplant process can impact patients' quality of life (QOL) and create psychological and physical stressors. This study explored whether age at transplant affected adolescents' feelings of anxiety, depression, and QOL. Design: In this cross-sectional quantitative study, data were collected on 22 adolescent patients aged 13-18 who received a transplant at least 12 months before enrollment. This cohort was divided into 2 groups based on their age at transplant: Group 1 (0-5 years) and Group 2 (6-18 years). To assess transplant-related anxiety, depression, and QOL, participants completed 3 surveys: the Generalized Anxiety Disorder-7 (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), and the Pediatric Quality of Life Inventory™ Transplant Module (PedsQL TM). Results: Group 1 experienced less anxiety and fewer problems based on GAD-7 scores but reported stronger feelings of depression based on PHQ-9 scores. Based on the PedsQL TM scale, Group 1 had higher mean scores compared to Group 2 across all components (mean difference range: 7.2- 27.3; Cohen's d range: 0.27 - 1.13). The largest difference between the 2 groups was observed on the PedsQL TM scale's How I Look (Group 1 mean 81.1 vs. Group 2 mean 53.8; Cohen's d: 1.13; P = 0.015), Conclusion: In this cohort, age at transplant affected adolescents' feelings of anxiety, depression, and QOL. Awareness of these findings can help clinicians screen for and address mental health issues.

Introduction: Some family members who previously made the decision to donate a family member's organs support the organ procurement organization (OPO) through volunteer work. Volunteers were asked to describe their family's organ donation story to educate the general and medical communities about organ donation. This study explored the transformative learning experienced by volunteers during and following the organ donation consent process and throughout their volunteer work. Methods/Approach: A narrative inquiry research methodology and transformative learning theoretical framework was used and 6 volunteers were recruited to participate. Two semistructured virtual interviews were conducted. Interviews were transcribed, radically reduced, and subjected to holistic-content and holistic-form narrative analysis. Findings: Participants experienced strong emotional responses during and after the loss of their family member, characterized as a period of disorientation, which lasted for an extended period preventing transformative learning. After the OPO contacted participants regarding the opportunity to volunteer, participants experienced a period of self-examination when they reengaged with the topic of organ donation. Critical reflection occurred through the act of storytelling about their family's organ donation story during their volunteer work. Storytelling to the community facilitated making meaning of their loss and transformations. Conclusion: Volunteering for an OPO played an important role by initiating self-examination and critical reflection of their prior assumptions. Through storytelling, participants reflected on their roles and made meaning of their organ donation experiences. The act of inviting donor families to reengage with the topic of organ donation through volunteer work fostered positive permanent meaningful transformations.

Introduction: The antioxidant effects of vitamins may attenuate the oxidative stress on organs imposed by ischemia-reperfusion injury during the process of organ transplantation from brain-dead donors. Circulating levels of vitamins A, C, and E-α in donors after brain death and their relationships to donor demographics, management, organ utilization, and recipient outcomes are largely unknown.

Methods: An observational, prospective, cohort study of 84 consecutive brain-dead organ donors managed at a single organ procurement recovery center was conducted. Vitamin levels were drawn immediately prior to procurement.

Results: Levels of serum vitamins A and E-α and plasma vitamin C were below normal in 80%, 85%, and 92% of donors and deficient in 40%, 62%, and 63%, respectively. Vitamin C deficiency was associated with a longer time between death and specimen collection (P = .004). Death from head trauma and stroke were associated with lower levels of vitamin A than from anoxic causes (P = .003) and smokers had greater vitamin C deficiency (P = .03). During donor management, vitamin C deficiency was associated with longer vasopressor support (P = .03) and normal levels of vitamin E-α were associated with reaching a lower alanine transferase compared to those with subnormal levels (P < .05). Donors deficient in vitamin E-α were less likely to have a liver recovered for transplantation (P = .005). Vitamin levels were not associated with the recipient outcomes examined.

Conclusion: Circulating vitamins A, C, and E-α is profoundly low in brain-dead organ donors, associated with relevant demographic features of the donor, and may influence donor management and organ utilization.

Introduction: An inverse relationship has been identified between tacrolimus serum concentrations and donor-derived cell-free DNA (dd-cfDNA) levels after lung transplant, but limited data exists on this relationship in the kidney transplant population. Project Aim: The purpose of this evaluation was to examine the relationship between high tacrolimus variability and elevated dd-cfDNA levels in kidney and simultaneous pancreas-kidney transplant recipients at a single center. Design: Single-center, retrospective, descriptive comparative evaluation of kidney and pancreas-kidney transplant recipients who received longitudinal ddcfDNA surveillance. Intrapatient tacrolimus variability was assessed using the coefficient of variation (%CV) measured between 1 and 12 months posttransplant. Pediatrics, retransplant or multiorgan transplant recipients, and pregnant recipients were excluded. Results: One hundred fifteen recipients with 518 dd-cfDNA levels and 3028 tacrolimus troughs were assessed. Pancreas-kidney recipients had significantly higher median dd-cfDNA (0.29% vs. 0.18%, P = .034) and were excluded from analysis. Ninety-nine kidney transplant recipients were included for analysis. Recipients with tacrolimus %CV ≥30 (N = 66) had significantly higher median dd-cfDNA than %CV <30 (0.22% vs. 0.17%, P = .031). Tacrolimus %CV ≥30 demonstrated higher median peak dd-cfDNA than %CV <30, though this was not statistically significant (0.36% vs. 0.28%, P = .058). Conclusion: These data demonstrated that high intrapatient tacrolimus variability may be associated with elevated dd-cfDNA in the first year after kidney transplant.

Introduction: Patients are at risk of hospital readmission after kidney and liver transplantation due to the complexity of posttransplant care. Currently, clinical practice relies on providers' prediction since there is a lack of specific strategies. However, the accuracy of clinicians' ability to predict readmissions using clinical judgment alone is unknown. Research Question: What is the accuracy of clinicians' ability to predict readmissions after transplantation using clinical judgment alone? Design: In 2019, clinical providers at a large, urban transplant center were electronically surveyed. Primary surgeons, nephrologists, transplant pharmacists, hepatologists, and nurses were asked, within 24 h of any kidney or liver transplant recipient discharge, to predict whether a patient would be readmitted within 30 days, and the suspected causes of readmission. Prediction accuracy was assessed by sensitivity, specificity, positive and negative predictive value, and F-score. Kappa scores were calculated to assess agreement between transplant surgeons and other providers. Results: Overall, N = 34 unique providers were surveyed about 148 kidney and 63 liver transplant recipients, and 27.0% of kidney recipients and 25.4% of liver recipients were readmitted within 30 days. The positive predictive values were low among clinical providers, ranging from 0.25 to 0.55. Agreements between providers were weak, but higher among kidney transplant providers (range: 0.42-0.44) than for liver transplant providers (range: -0.02-0.26). Conclusion: Clinical judgment alone to predict readmission among transplant recipients may not be sufficient and a combination of clinicians' predictions, multitiered discharge surveillance strategies and data-based predictive models may better identify high-risk patients and guide interventions to reduce readmission.

Alcoholic liver disease (ALD) and alcohol-induced deaths have increased dramatically over the last 2 decades. Patients are often referred to liver transplant programs critically ill with a life expectancy of less than 6 months. Historically, less than 6 months sobriety has been an absolute contraindication for transplant listing as ALD is stigmatized as a choice, as patients are responsible for their condition because they did not stop drinking. It has been recommended that 6 months of sobriety should not be considered the determining factor for access to transplantation. However, changing years of clinical practice involves developing new protocols, finding available resources, reworking systems, transforming team, and institutional culture. Steps taken by a large, urban, academic liver transplant program to develop a program for patients with end stage ALD with less than 6 months of sobriety are outlined.

Introduction: Kidney Allocation System (KAS) was implemented by United Network for Organ Sharing in 2014 to reduce allocation disparities. Research Questions: Outcomes of highly sensitized patients (calculated panel reactive antibody (cPRA) ≥ 97%) before and after KAS were compared to low-risk recipients (cPRA <10%) in the post-KAS era were examined. The impact on racial disparities was determined. Design: This was a retrospective study of national registry data. Two cohorts of adult candidates waitlisted for deceased donor transplantation during 3-year periods before and after KAS were identified. Results: Highly sensitized patients (N = 1238 and 4687) received a deceased donor kidney transplant between January 1, 2011 and December 31, 2013 and between January 1, 2015 and December, 31, 2017. Racial disparity for highly sensitized patients improved, yet remained significant (P < 0.001), with Black patients comprising 40% and 41% of the highly sensitized candidates and 28% and 34% of the recipients pre- and post-KAS. While posttransplant death-censored graft failure for highly sensitized recipients was similar overall, post-KAS was associated with improved graft survival in the first year after transplant (HR 0.56, 95% CI 0.40-0.78). When compared to contemporaneous lowrisk recipients, both death-censored and all-cause graft failure were similar for highly sensitized recipients and was associated with increased risk for death-censored graft failure beyond the first year (HR 1.39, 95% CI 1.11-1.73). Conclusion: The allocation system led to an increase in transplantation in highly sensitized candidates without compromising outcomes. Although KAS has led to more balanced transplant rates between highly sensitized Black and White patients, racial inequalities persist.