Transplantation Direct最新文献

Background: Gastroparesis (GP) is a chronic disorder of the stomach characterized by delayed gastric emptying and frequently associated with longstanding diabetes. This is a single-center retrospective analysis designed to establish the prevalence and assess the impact on posttransplant outcomes of GP among pancreas transplant recipients.

Methods: Medical records for all recipients of pancreas transplants performed between January 2003 and December 2023 were reviewed. GP was defined by abnormal gastric-emptying scintigraphy or other motility study or a history of symptoms. Primary outcomes included graft loss and patient death. Clinical outcomes included length of stay after transplant and readmissions, including specifically for GP symptoms.

Results: Of 731 recipients, 156 (21%) were diagnosed with GP before transplant. Patients with GP were younger and more likely to be female individuals. Posttransplant, there was no difference in length of stay, graft survival, or patient survival. Patients with GP were more likely to be readmitted and to be specifically admitted for GP symptoms. Requirement for interventions was more common in patients with GP.

Conclusions: GP is identified with increased frequency among the specific patient population referred for pancreas transplant, and although it does not seem to affect allograft or patient survival, it does seem to have an impact on readmissions and the need for interventions.

Background: Augmentation of hepatic venous outflow is crucial in living donor liver transplantation (LDLT) to maximize functional graft size and prevent venous complications. We present details of our outflow augmentation technique for left lobe grafts (LLG) in adult LDLTs, which uses all recipient 3 hepatic veins and venoplasty of graft left and middle hepatic veins. This study examines the effectiveness of our technique in preventing outflow complications and the correlation between anatomical variations of the graft hepatic veins and surgical outcomes.

Methods: We retrospectively reviewed 88 patients who underwent LLG-LDLT between 2012 and 2023. The patients were classified into 3 groups based on the graft hepatic vein anatomy and usage of venoplasty: group 1 (n = 10, common trunk without venoplasty), group 2 (n = 62, common trunk with venoplasty), and group 3 (n = 16, no common trunk with venoplasty).

Results: No patient developed clinically significant venous outflow complications or graft loss related to venous outflow. There were no significant differences in complication rates or ascites production among the groups. Five-year graft survival was comparable among the groups (P = 0.43). Multiple regression analysis revealed that the model for end-stage liver disease score was the only independent risk factor for increased ascites after transplant (standardized beta, 0.546; t value,4.20; P < 0.001; 95% confidence interval, 0.287-0.804), but anatomical variations of the graft hepatic veins did not influence ascites output.

Conclusions: The recipient 3 hepatic vein outflow augmentation technique with graft venoplasty can be applied to various graft hepatic venous anatomy and effectively prevents outflow-related graft loss in LLG-LDLT.

Background: In Qatar, the Committee for Oversight of Living Donation (COLD) was established at Hamad Medical Corporation in 2014 to provide standardized, multidisciplinary psychosocial evaluation (PE) for prospective living kidney donors (PLKDs) and ensure appropriate care throughout evaluation, donation, and postdonation follow-up, consistent with legal and ethical standards. We describe the COLD protocol and report PE outcomes of PLKDs in Qatar.

Methods: A retrospective observational cross-sectional study was conducted using case file data of PLKDs assessed at Hamad Medical Corporation between August 2014 and December 2022. Descriptive statistics analyzed demographics and outcomes of COLD evaluation.

Results: Eight hundred ninety-eight PLKDs (54% men) were enlisted for 545 transplant candidates. Four hundred forty-seven PLKDs (49.8%) were Qatari; the remainder were noncitizen residents representing 43 nationalities. Most 680 PLKDs (76%) claimed a genetic relationship with recipients; 20% were emotionally related and 4.34% were unrelated. Of those who proceeded with evaluation, 88% (n = 788) were accepted, 7.5% were declined, and 4.8% dropped out. Of those who were declined (n = 67), 81% were noncitizen residents; 42% claimed an emotional relationship with the intended recipient, whereas 34% were unrelated and 24% were genetically related. The main reasons for declining a PLKD were insufficient socioeconomic support, psychological unfitness, and coercion by employers or family.

Conclusions: Standardized structured PE has been effective in identifying and addressing risk factors across various PLKD demographics in Qatar. This study highlights the importance of comprehensive evaluation for all PLKDs, regardless of nationality or relationships with recipients. The COLD protocol could serve as a valuable tool for PE of PLKDs in other countries.

Background: Sex disparities in solid organ transplantation are well documented. Relative changes in sex-based outcome disparities after the 2017 standardization of simultaneous liver-kidney (SLK) listing criteria in the United States have not been reported. We hypothesized that this policy's objective measures of kidney dysfunction may differentially affect SLK patients by sex and that the use of MELD 3.0 in the SLK population might provide unique benefit to female transplant candidates.

Methods: Organ Procurement and Transplantation Network data were retrospectively analyzed comparing 2013-2016 with 2018-2021 SLK listings. Waitlist outcomes and Model for End-stage Liver Disease (MELD) 3.0 reclassifications were compared by sex and listing period.

Results: There were 2626 and 2609 male patients and 1670 and 1919 female patients pre- and post-policy changes, respectively. The proportion of female SLK listings post-policy change (42.4%) was higher than both female SLK listings pre-policy change (38.9%) and female single-organ liver listings post-policy change (36.8%; P < 0.01). A statistically significant interaction between sex and listing group (pre- versus post-policy change) was present in multivariable analysis (P = 0.02). Female patients were more likely to have a higher MELD 3.0 score than the listing MELD/MELD-Na score when the listing MELD score was <30 (P < 0.01). Among all patients who died on the waitlist, female patients were nearly twice as likely to be underrepresented by listing MELD compared with MELD 3.0 (23% female and 13% male patients; P < 0.01).

Conclusions: Waitlist outcomes were changed differentially between male and female patients after the 2017 SLK policy change. The application of MELD 3.0 to SLK patients is likely to benefit female patients.

Background: Individuals from socioeconomically disadvantaged neighborhoods may be at risk of inequitable access to the liver transplant (LT) waitlisting (WL), but mechanisms mediating this relationship are not well understood. We assessed whether area deprivation index (ADI), a measure of neighborhood socioeconomic deprivation, was associated with LT WL and assessed whether caregiver support, a potentially modifiable factor, mediated this relationship.

Methods: We performed a single-center retrospective cohort study of adults referred for LT evaluation from January 2015 to December 2021. First, we assessed the association between ADI and LT WL using univariate and multivariable logistic regression analyses. Second, we analyzed caregiver support as a potential mediator through mediation analysis.

Results: During the study period, 2574 patients were referred for LT, 2057 patients initiated evaluation, and 622 patients were waitlisted. Residence in the highest ADI quartile was associated with lower probability of WL (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.52-0.99) after adjusting for individual medical and sociodemographic factors, and distance from the transplant center. In adjusted mediation analysis, caregiver support did not mediate the relationship between ADI and LT WL (OR, 0.90; 95% CI, 0.80-1.01), and highest ADI quartile also did not have significant direct effects on LT WL (OR, 0.95; 95% CI, 0.72-1.26).

Conclusions: ADI may be useful as a screening tool to identify candidates who could benefit from early intervention in the LT process when individual social needs information is not available. Caregiver support did not mediate the ADI and LT WL association. Additional work is needed to understand which modifiable factors may mediate this association to inform potential interventions for this population.

Background: Liver transplantation is essential for many people with primary sclerosing cholangitis (PSC). People with PSC are less likely to receive a deceased donor liver transplant compared with other causes of chronic liver disease. This disparity may stem from the inaccuracy of the model for end-stage liver disease (MELD) in predicting waitlist mortality or dropout for PSC. The broad applicability of MELD across many causes comes at the expense of accuracy in prediction for certain causes that involve unique comorbidities. We aimed to develop a model that could more accurately predict dynamic changes in waitlist outcomes among patients with PSC while including complex clinical variables.

Methods: We developed 3 machine learning architectures using data from 4666 patients with PSC in the Scientific Registry of Transplant Recipients (SRTR) and tested our models on our institutional data set of 144 patients at the University Health Network (UHN). We evaluated their time-dependent concordance index (C-index) for mortality prediction and compared it against MELD-sodium and MELD 3.0.

Results: Random survival forest (RSF), a decision tree-based survival model, outperformed MELD-sodium and MELD 3.0 in both the SRTR and the UHN test data set using the same bloodwork variables and readily available demographic data. It achieved a C-index of 0.868 (SD 0.020) and 0.771 (SD 0.085) on the SRTR and UHN test data, respectively. Training a separate RSF model using the UHN data with PSC-specific achieved a C-index of 0.91. In addition to high MELD score, increased white blood cells, time on the waiting list, platelet count, presence of Autoimmune hepatitis-PSC overlap, aspartate aminotransferase, female sex, age, history of stricture dilation, and extremes of body weight were the top-ranked features predictive of the outcomes.

Conclusions: Our RSF model offers more accurate waitlist outcome prediction in PSC. The significant performance improvement with the inclusion of PSC-specific variables highlights the importance of disease-specific variables for predicting trajectories of clinically distinct presentations.

Background: Ex vivo lung perfusion (EVLP) offers a novel platform for delivering targeted therapies directly to donor lungs before transplantation, potentially reducing systemic side effects. Our study evaluated the feasibility and safety of rituximab delivery to donor lungs from Epstein-Barr virus (EBV)-seropositive donors for transplantation into EBV-seronegative recipients (D⁺/R^-) to reduce the risk of EBV-associated posttransplant lymphoproliferative disorder (PTLD), which remains a major obstacle in the transplant setting.

Methods: A pilot study was conducted involving 5 EBV-seronegative lung transplant recipients. Donor lungs were perfused with 500 mg rituximab during EVLP for 3-4 h. Primary outcomes included safety and feasibility, assessed by monitoring lung function during perfusion, posttransplant complications, and graft dysfunction. Secondary outcomes included EBV DNAemia, PTLD incidence, peripheral B-cell frequencies, EBV blood transcripts, and rituximab serum levels.

Results: Rituximab delivery via EVLP was feasible and safe, with no significant deviations in lung function or adverse events linked to treatment. One patient experienced primary graft dysfunction. Peripheral B-cell counts were reduced immediately posttransplant and remained low in some patients, whereas others rebounded over the weeks posttransplant, and serum rituximab levels were undetectable after 2 wk. Three patients developed EBV DNAemia and 2 developed PTLD within 2 y, although PTLD lesions were not observed in transplanted lungs.

Conclusions: EVLP-based rituximab delivery is a feasible and promising strategy for targeting donor-transmitted EBV with minimal systemic exposure. Although the findings suggest potential clinical benefit, the development of PTLD in extrathoracic sites underscores the need for further optimization and larger studies to evaluate efficacy and refine the intervention.

Background: Liver transplantation (LT) is the standard treatment for liver failure secondary to alcohol-associated liver disease, but limited literature and best practices exist for post-LT treatment of alcohol use disorder (AUD). This study explores current AUD management practices and providers' perceived barriers to effective post-LT AUD management.

Methods: A 45-item survey on post-LT AUD treatment practices was distributed to members of the American Society of Transplant Surgeons, the Association of Consult/Liaison Psychiatry Transplant Special Interest Group, and both the American Society of Transplantation's Liver and Intestine Community of Practice and Psychosocial and Ethics Community of Practice discussion boards, between December 2021 and April 2022. Univariate analysis of categorical variables was performed using the chi-square test. Data were analyzed using center volume tertiles, country region, and provider professional activity.

Results: Two hundred thirty-two respondents from 70 LT centers across all 11 United Network for Organ Sharing regions completed the survey. Half of the them were attending physicians and 16.4% were nurse coordinators. Most centers (84%) aimed for alcohol abstinence for all post-LT patients. Perceived barriers to AUD treatment efficacy included ongoing desire to drink (18%), denial about alcohol misuse (14.9%), and lack of posttransplant support (14%). Additionally, 62.1% of centers had no policy for prescribing medication-assisted therapy to treat AUD, and 32.7% of centers reported no center-level changes in AUD care. Providers identified primary needs as hiring additional mental health professionals (30.8%), dedicating specific staff to AUD care (24.7%), and standardizing psychiatric/psychological care in transplant clinics (17.2%).

Conclusions: Despite the increasing volume of LT for alcohol-associated liver disease, significant perceived barriers to effective AUD treatment remain.

Background: Focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30%-50% of recipients. Recurrence is associated with early graft loss in up to 60% of cases. This study aimed to assess the efficacy of therapeutic plasma exchange (TPE) combined with rituximab (RTX) in preventing early FSGS recurrence within 1 y post-KT.

Methods: This single-center, retrospective cohort study included patients receiving KT for idiopathic FSGS between June 2013 and August 2021. In May 2016, a preventative FSGS protocol was implemented where KT recipients with idiopathic FSGS received perioperative sessions of TPE followed by a dose of RTX with or without IVIG. The incidence of recurrent FSGS within the first year posttransplantation was assessed between the FSGS protocol cohort versus the historical group of patients who did not undergo prophylactic treatment.

Results: A total of 65 patients received KT for idiopathic FSGS during the study period. Forty patients were included in the FSGS protocol cohort and 25 in the control cohort. When assessing clinical recurrence with proteinuria, there were significantly fewer cases in the FSGS protocol cohort versus the control cohort, 1 versus 5 patients (3% versus 20%, P = 0.03). There were no instances of death-censored graft loss at 1 y in the protocol cohort versus 2 cases in the control cohort (0% versus 8%, P = 0.14).

Conclusions: TPE combined with RTX may prevent early FSGS recurrence without significant rates of infection.

Background: Donation after circulatory death liver transplantation (DCD LT) is underused given historical outcomes fraught with ischemic cholangiopathy (IC). We aimed to assess 6-mo IC in LT from DCD via normothermic regional perfusion (NRP) compared with DCD via static cold storage (SCS).

Methods: A retrospective review of adult Maastricht-III DCD liver donors and recipients at the University of Colorado Hospital from January 1, 2017, to August 27, 2024, was performed. The 6-mo IC rate was compared between NRP and SCS. Secondary outcomes included biochemical assessments of accepted versus declined NRP liver allografts and allograft and patient survival for NRP and SCS groups.

Results: One hundred sixty-two DCD LTs (SCS = 79; NRP = 97) were performed and 150 recipients (SCS = 74; NRP = 86) reached 6-mo follow-up. Six-month IC was lower for NRP compared with SCS (1.2% versus 9.5%, P = 0.03). The Donor Risk Index (2.44 [2.02-2.82] versus 2.17 [1.97-2.30], P = 0.002) and UK DCD Risk Score (4.2 ± 2.9 versus 3.2 ± 2.3, P = 0.008) were higher for NRP versus SCS. The Liver Graft assessment Following Transplantation score was less for NRP compared with SCS (-3.3 versus -3.1, P < 0.05). There were several differences in median biochemical parameters during NRP between accepted and declined livers, including higher terminal biliary bicarbonate (22.7 [20.9-29.1] versus 10.8 [7.6-13.1] mEq/L, P = 0.004). There were no significant differences in 12-mo allograft or patient survival for NRP versus SCS.

Conclusions: NRP is a disruptive innovation that improves the utilization of DCD livers. Despite higher-risk donor-recipient pairing for NRP compared with SCS, we demonstrate a decrease in IC for NRP. These data facilitate benchmarking of thoracoabdominal NRP DCD LT and support further protocol development.