Transplantation proceedings最新文献

Background

Contrast-enhanced T1-weighted magnetic resonance cholangiography (CE-T1-MRC) after gadoxetate disodium administration can be used for preoperative evaluation of the bile ducts in live liver donors. This study aimed to determine whether CE-T1-MRC with 3-hour delayed imaging improves bile duct visualization both qualitatively and quantitatively compared with 20-minute delayed imaging in potential living liver donors.

Methods

We retrospectively identified 33 potential living liver donors (mean age, 30.1 years; 18 men and 15 women) who underwent preoperative CE-T1-MRC with both 20-minute delayed and 3-hour delayed imaging in a single session. The radiologist scored biliary visualization for right and left hepatic ducts (RHD and LHD), their secondary confluences and segmental bile ducts, common hepatic duct (CHD), and cystic duct (CD), and measured relative contrast ratio (rC) and relative signal intensity (rS) for RHD, LHD, and CHD. The data were analyzed using Wilcoxon's signed-rank test and paired t-test.

Results

In qualitative analysis, duct visualization scores for RHD and LHD, their secondary confluences and segmental bile ducts, CHD, and CD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P ≤ .046). In quantitative analysis, both rC and rS of RHD, LHD, and CHD were significantly higher on CE-T1-MRC with 3-hour delayed imaging than with 20-minute delayed imaging (all, P < .001).

Conclusions

CE-T1-MRC with 3-hour delay imaging improves bile duct visualization both qualitatively and quantitatively in potential living liver donors.

Background

Most institutions apply the criteria for controlled donation after cardiac death (cDCD) lung retrieval identical to the criteria for donation after brain death (DBD). The availability of extended criteria donor (ECD) in lung transplants from cDCD remains unclear.

Methods

The United Network for Organ Sharing (UNOS) database was queried for adult lung transplants from cDCD, from May 03, 2005, to March 15, 2022. ECDs were defined by one or more items at variance from standard criteria: age 55 years or more, PaO₂:FiO₂ 300 or less, smoking 20 pack-years or more, diabetes, or purulent secretions upon bronchoscopy. Recipients were divided into the standard criteria donor (SCD) group and the ECD group, and assessed for short- and long-term survival and postoperative events.

Results

Among 827 records, the SCD and ECD group showed no differences in 5-year (P = .56) survival. No significant differences were found in 30-day, 90-day, 1-year mortality and postoperative outcomes before discharge, whether in length of hospital stay, rate of ventilator support for >48 hours or reintubation, incidence of grade 3 PGD 72 hours posttransplant, acute rejection, or dialysis. None of the 5 donor factors used as criteria for lung retrieval was independently associated with cDCD recipient survival.

Conclusions

Using donor lungs that extend the DBD criteria may be a safe strategy in cDCD lung transplantation. However, the current criteria may not be a perfect fit for cDCD lung retrieval. The specific DCD criteria for standard lung retrieval need to be determined.

Background

Anemia is a risk factor for increased morbidity and mortality in multiple medical conditions, yet the impact of pretransplant anemia in patients with advanced lung disease on post-transplant outcomes remains under-explored. We sought to determine whether pretransplant anemia serves as a marker of altered inflammation in the host and associates with short-term outcomes following lung transplantation.

Study Design and Methods

We performed a single-center, retrospective analysis of 238 lung transplant recipients. We assessed for risk factors of pretransplant anemia and identified associations with short-term post-transplant outcomes.

Results

Pretransplant anemia was associated with increased intraoperative transfusion of packed red blood cells and a trend towards increased index hospital length of stay and 1-year mortality. Conversely, pretransplant anemia was associated with a decreased incidence of acute cellular rejection.

Conclusion

These preliminary data suggest that anemia may be a biomarker of altered inflammation in the host recipient and influences post-transplant outcomes.

Objective

To explore the effect of enhanced recovery after surgery nursing on the recovery in patients after liver transplantation.

Methods

This study was performed in 128 patients underwent liver transplantation in our hospital. According to the random number table, these patients were divided into the control group (n = 64) and the experimental group (n = 64). Patients in the control group received traditional nursing, while those in the experimental group received enhanced recovery after surgery nursing. Completion time of the operation, the amount of infused red blood cells during operation, intraoperative anhepatic period, intensive care unit (ICU) stay, the total length of hospitalization, the number of patients reintubated after surgery, the survival rate within 1 year after surgery, and the incidence of postoperative complications were compared between the two groups.

Results

Intraoperative anhepatic period and the amount of infused red blood cells during operation in the experimental group were lower than those in the control group (both P < .05). Postoperative ICU stay, the total length of hospitalization, and the number of patients reintubated after surgery in the experimental group were decreased when compared with the control group, while postoperative ventilator weaning time was increased (all P < .05). The survival rates at 3 months, 6 months, and 1 year after surgery in the experimental group were higher than those in the control group (all P < .05). Compared with the control group, the total incidence of complications in the experimental group was reduced (P < .05).

Conclusion

The application of enhanced recovery after surgery nursing in liver transplantation patients contributes to the accelerated recovery of body function, shortened total length of hospitalization and ICU stay, declined complications, and increased survival rate within 1 year.

Background

Mucorales infections continue to cause significant morbidity and mortality in immunocompromised hosts despite the advent of new approaches for diagnosis and treatment of fungal infections. We aimed to evaluate risk factors and outcomes of Mucorales infection in solid organ transplant, hematopoietic cell transplant, and chimeric antigen receptor T-cell therapy recipients.

Methods

This single-center retrospective study included solid organ transplant, hematopoietic cell transplant, and chimeric antigen receptor T-cell patients with cultures positive for Mucorales.

Results

Forty-three patients were included for analysis; 34 solid organ transplant (79%) and 9 hematopoietic stem cell transplant or chimeric antigen receptor T-cell (21%). Infection with Mucorales occurred a median of 184 days after transplant. At the time of diagnosis, 36 patients were on antifungal prophylaxis with the majority receiving posaconazole (53%). Thirty-three had clinically significant disease; 30 received definitive anti-Mucorales therapy and 3 empiric antifungal therapy. Isavuconazole was the most common azole used for treatment in monotherapy recipients. All-cause mortality was 64% and, of these deaths, 18 (75%) were directly related to Mucormycosis. The highest mortality was seen in disseminated and intra-abdominal disease (100%), followed by pulmonary disease (50%). There was no significant association with mortality and transplant type or number of immunosuppressive agents.

Conclusion

Mucormycosis is an important cause of morbidity and mortality in immunocompromised patients. Breakthrough infection was not uncommon in this study. Data regarding the incidence of infection at approximately 6 months after transplantation can inform prophylaxis and treatment regimens. The spectrum of antifungal regimens used reflects the lack of consensus on ideal regimens for these organisms and a need for more studies.

Background

Medication nonadherence (MNA) in organ transplant recipients is associated with increased risk of rejection, allograft loss, patient death, and higher healthcare costs. Various approaches have been used in an attempt to reduce MNA. A patient support program (PSP) can be an invaluable tool for improving patient outcomes. The aim of this study was to analyze available data of PSP for kidney transplant recipients.

Methods

A total of 3352 patients from all over the country were prospectively enrolled in the Parichay PSP between January 2021 and April 2023. Baseline demographic details were recorded. A monthly call was made thereafter. Data were analyzed for demographic details, compliance rate, dropouts, and tacrolimus levels when available.

Results

The Parichay PSP had enrolled a total of 1371 kidney transplant patients in 2021, 1620 in 2022, and 361 in 2023 (January-April) from different parts of India (North, 25%; East, 35%; South, 26%; West, 14%). (n=2626) Of the 2626 patients who received tacrolimus (Tacrograf), 2158 (82%) were male, with a mean age of 42 years. The majority of patients (61%) were age 28 to 48 years. A patient compliance rate of >90% was maintained for longer than 13 months (n = 1920; April 2022 to April 2023). Of the 3352 patients, 250 (7.4%) dropped out of the study. Thus, use of PSP ensured a compliance rate of 92.6% in this study.

Conclusions

This analysis demonstrates that participation in a PSP can be a useful tool for monitoring compliance and tacrolimus therapeutic drug monitoring in kidney transplant recipients.

Background

Tacrolimus is the core basic immunosuppressant after transplantation. Cytochrome P450 3A5 (CYP3A5) is the main enzyme involved in tacrolimus metabolism, and rs776746A>G is the most frequently studied polymorphism in the CYP3A5 gene. The aim of this study was to investigate the effect of CYP3A5 gene polymorphisms on tacrolimus blood concentrations and acute graft versus host disease (GVHD) in patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT).

Methods

This study included adult patients who received allo-HSCT at the First Affiliated Hospital of Wannan Medical College from January 2021 to June 2022, and received postoperative treatment with tacrolimus. Tacrolimus blood levels were obtained by fully automatic chemiluminescence immunoassay analyzer. Polymerase chain reaction/restriction fragment length polymorphism was used to genotype for CYP3A5*3 allelic variants.

Results

In a total of 50 transplant patients, 30 patients were detected with CYP3A5*3/*3 genotype, 15 patients with CYP3A5*1/*3 genotype, and 5 patients with CYP3A5*1/*1 genotype. The initial tacrolimus blood concentrations in allo-HSCT patients with CYP3A5*1/*1, *1/*3, and *3/*3 genes were 7.75, 8.61, and 10.19 ng/mL, respectively; The initial blood concentration/dose (C/D) ratios were 4.08, 4.42 and 5.66 ng/(mL·mg), respectively. The C/D ratios of allo-HSCT patients carrying CYP3A5*1/*1, *1/*3, and *3/*3 genes were 4.35 and 4.71 and 5.58, 4.19, 4.56 and 5.71 ng/(mL·mg) in the second and 3rd weeks after operation. These results showed that the blood concentration and C/D ratio of tacrolimus in patients with CYP3A5*3/*3 genotype were significantly higher than those in patients with CYP3A5*1/*3 or CYP3A5*1/*1 genotype. Moreover, the incidence of acute GVHD after allo-HSCT in patients with CYP3A5*1/*1 genotype was significantly higher than that in patients with CYP3A5*1/*3 or CYP3A5*3/*3 genotype.

Conclusions

Most patients carry the mutant allele CYP3A5*3. CYP3A5 gene polymorphisms affect tacrolimus blood concentrations and acute GVHD after allo-HSCT.

Objective

To explore the clinical application value of flow-through anterolateral thigh perforator (ALTP) flaps in replantation of complex severed limbs.

Methods

Thirteen severe vascular, nerve injury, and skin or soft tissue defects in patients with complex severed limbs from August 2017 to January 2019 were enrolled in this retrospective study. The skin flap has covered the wound by using the flow-through ALTP flap technique. The main vascular defect was repaired by using the descending branch of the lateral circumflex femoral artery, and the blood supply of the transplanted limb was reconstructed. The blood supply of the flap and wound healing observed were observed after the operation. Regular follow-up was performed to observe the survival and functional recovery of the replanted limb.

Results

Eleven cases of replanted limb and perforator flap survived completely. Limb shortening occurred in 3 patients owing to bone defects caused by distal amputation. After the second stage of bone transplantation, the limb length and function of those 3 patients recovered well. One case showed necrosis of the little finger after replantation of the severed palm. One case showed that the crushed forearm was severed completely. The anastomotic vascular inflammatory embolism was caused by infection and necrosis of soft tissue after replantation for 2 weeks, and then the stump wound was covered with a survived skin flap in the second stage.

Conclusion

The flow-through ALTP flap technique has a good therapeutic effect on the functional reconstruction of complex severed limbs with severe skin and vascular injuries.

To resolve the critical donor shortage worldwide, enlarging the potential donor pool to include expanded criteria donors is necessary. Despite numerous attempts to establish new preservation solutions, no dramatic innovation has occurred since University of Wisconsin (UW) solution displaced Euro Collins’ solution; UW solution remains the global gold standard. We previously developed a heavy water (D₂O)–containing organ storage solution, Dsol, which is effective for livers subjected to extended cold storage (CS), and reported its effectiveness. Dsol is a modified UW solution; however, the substances or conditions that exhibit a synergistic or additive effect with D₂O are unclear. Here we made UWD solution by removing hydroxyethyl starch (HES) from and adding 30%-D₂O to UW solution, and compared the effects of these solutions. After 48 hours of CS, the livers were reperfused at 37 °C on an isolated perfused rat liver apparatus, and their perfusion kinetics, functions, and injuries were compared. In the UW group, portal vein resistance significantly increased and the oxygen consumption rate and bile production decreased; in contrast, these changes were suppressed in the UWD group. Organ expansion and liver damage progressed in both groups. These results confirmed that the removal of HES from and addition of D₂O to the UW solution reduced CS-induced cellular function impairments and microcirculatory disorders. However, to reduce injury during reperfusion after CS, it is necessary to provide conditions that inhibit injury progression after reperfusion.

Background

Disparity in waiting time to kidney transplantation led to new policy (KAS250). Our aims were to identify variables associated with long wait time (LWT); assess the impact of KAS250 on WT; and analyze modifiable transplant center behaviors correlated with WT.

Methods

SRTR data for adult deceased donor kidney transplants were analyzed. Time-periods from 8/1/2018-7/31/2019 and 5/1/2021-4/30/2022 were chosen for pre- and post-KAS250 analyses. Transplant centers were categorized as LWT or SWT centers depending on whether pre-KAS250 median center waiting times were greater or less than the national pre-KAS250 median waiting time of 57.8 months.

Results

In multivariate analysis, transplantation with HCV NAT negative kidneys was associated with an additional 21.3 months of WT (CI: 18.5-24.2, P < .0001), and transplantation with KDPI <85% kidneys was associated with an additional 10.8 months (CI: 8.2-13.3, P < .0001). Post-KAS250 national kidney transplant waiting time decreased from 61-58 months (P < .0001) and waiting time at LWT centers decreased from 74-69 months (P < .0001). Cold ischemic times (CIT) increased (20.2 hours vs 18.3 hours, P < .0001) and DGF rates also increased (32.7% vs 31.0%, P < .0001). Centers generally displayed more aggressive transplantation practices post-KAS250 however significant differences in DCD utilization, organ offer acceptance ratios and tolerance for long CIT persist between SWT and LWT centers.

Conclusion

KAS250 has reduced waiting time disparities between SWT and LWT centers at the cost of increased CIT and DGF and reduced allocation efficiency. Significant differences in transplant practice persist between SWT and LWT centers.