Transplantation最新文献

Background: Acquired diaphragmatic hernia (DH) is a rare and potentially fatal complication after living donor hepatectomy (LDH). This study aimed to assess the incidence and clinical outcomes of DH after LDH.

Methods: Four thousand fourteen living donors who underwent LDH at Asan Medical Center, Seoul, between September 2013 and August 2023 were retrospectively reviewed. We analyzed the incidence of DH before and after the introduction of the bipolar irrigated sealer (BIS). Multivariate logistic regression analysis was used to identify the risk factors for DH.

Results: Postoperative DH occurred in 18 patients (0.40%). Seventeen patients underwent right LDH and developed right-sided DH, whereas 1 patient underwent left LDH and developed left-sided DH. The incidence of DH was 0.22% in the pre-BIS period and >6-fold to 1.36% in the post-BIS period. The median time of postoperative DH occurrence was 11 (range, 3-95) mo. Ten patients underwent elective surgery for DH repair, whereas 8 patients with severe abdominal pain or bowel obstruction underwent emergency surgery, 1 of whom underwent small bowel resection and anastomosis due to severe bowel incarceration. Using BIS was the only significant risk factor for developing DH (p < 0.001; odd ratio, 6.28; 95% confidence interval, 2.43-16.25).

Conclusions: Early recognition and surgical repair of DH after LDH should be considered in living donors with unexplained abdominal or thoracic symptoms. Caution is advised when using peridiaphragmatic hemostasis with BIS in liver surgery. We recommend extending the postoperative follow-up of living donors to at least 3 y, including routine imaging screenings for DH.

Background: Normothermic machine perfusion (NMP) enables pretransplantation assessment of donor liver viability to increase donor liver utilization. However, unambiguous objective criteria to determine integrated liver function during NMP to decide upon acceptance are still lacking. This study investigates whether the indocyanine green (ICG) elimination test can be applied to assess liver function during NMP.

Methods: Donor livers underwent dual-hypothermic oxygenated machine perfusion and NMP. The ICG elimination test was improved during an optimization phase (n = 10) and tested against current functional perfusion parameters and posttransplantation outcomes in clinically perfused livers (n = 32).

Results: The ICG plasma disappearance rate (PDR) during NMP was dependent on perfusion blood flow and liver weight. The corrected PDR (NMP-PDR) was correlated to the hepatic extraction rate (R = 0.923; P > 0.001) and ATP content in liver biopsies at 2 h of NMP (R = 0.692; P = 0.027). In the clinical phase, the length of the functional warm ischemia time in the donation process was inversely correlated to the NMP-PDR (P = 0.042). Both individual acceptance criteria (lactate clearance, ability of self-regulate pH, Δbicarbonate, and ΔpH) and overall hepatocellular and cholangiocellular acceptance criteria were correlated to the NMP-PDR. The NMP-PDR was higher in the cohort accepted for transplantation (n = 18; 18.1%/L·kg [14.0% to 22.7%/L·kg]) than in the nontransplanted cohort (n = 14; 11.8%/L·kg [8.8% to 12.9%/L·kg]; P < 0.0001). Furthermore, the NMP-PDR correlated with the liver graft assessment following transplantation at 7 d score posttransplantation (R = -0.551; P = 0.027).

Conclusions: We demonstrate that the NMP-PDR correlates with both liver function during NMP and short-term posttransplantation outcomes. This simple objective test has the potential to increase donor liver utilization rate, while preventing hepatocellular dysfunction posttransplantation.

Background: Deciphering the impact of invasive percutaneous core needle biopsy of the kidney allograft on diagnostic biomarkers may help guide their clinical usage.

Methods: We prospectively enrolled 39 adult kidney allograft recipients (patients) who underwent 41 clinically indicated, ultrasound-guided, percutaneous core needle biopsies. Pre- and post-biopsy urines were analyzed for urinary cell 3-gene signature score (UroMap), and the bloods for peripheral blood gene expression score (AlloMap Kidney) and plasma donor-derived cell-free DNA percentage (dd-cfDNA). We performed statistical analyses to compare pre- and post-biopsy values.

Results: Median A260/A280 ratios of RNA from pre- and post-biopsy urines were 1.99 and 2.01, respectively; RNA yield, 0.78 versus 0.76 micrograms; and transcript copies of 18S rRNA, TGFβ1, CD3ε, CXCL10, and UroMap score were similar (all P > 0.05, Wilcoxon matched-pairs signed-rank test). The pre- and post-scores were very strongly correlated (Spearman's correlation coefficient [rs]: 0.83, P < 0.0001). AlloMap Kidney scores in pre- and post-biopsy peripheral blood were similar (P > 0.05) and strongly correlated (rs = 0.70, P < 0.0001). dd-cfDNA in post-biopsy plasma was higher than in pre-biopsy plasma (0.61% versus 0.26%, P = 0.004). The higher post-biopsy percentage was replicated in an independent cohort of 119 post-biopsy plasma collected from 105 patients with no rejection biopsies. To normalize the biopsy-associated increase, a correction factor of -0.36% was derived by subtracting the pre-biopsy dd-cfDNA percent from the post-biopsy percent.

Conclusions: UroMap and AlloMap Kidney scores are not affected by the biopsy procedure. However, dd-cfDNA increases following the biopsy procedure and could be normalized using the correction factor identified in this study.

Background: The number of deceased donor kidney transplants has been increasing and is at a record high, yet nonuse of kidneys recovered for transplantation has risen to 25.8% following circular kidney allocation system based on 250-nautical-mile circles implemented on March 15, 2021 (KAS250).

Methods: Using Scientific Registry of Transplant Recipients data, we studied all deceased donor kidneys recovered for transplant from March 15, 2019, to January 31, 2023. We calculated the association of multiple factors with kidney nonuse, including increasing recovery of kidneys from nonideal donors, delays in offer acceptance observed under KAS250, and impacts of COVID-19.

Results: In the 2 y before KAS250, the nonuse rate was 21.2%. Had this rate continued, 2334 more kidneys would have been transplanted through January 2023. We estimated that about 769 of these nonused kidneys (33%) were associated with offer acceptance delays under KAS250; about 994 of these nonused kidneys (43%) were associated with increased prevalence of nonideal donors: donation after circulatory death donors, older donors, and donors with elevated peak serum creatinine; and about 542 of these nonused kidneys (23%) were associated with an otherwise unexplained gradual upward trend in nonuse of recovered kidneys across the pre-KAS250 and KAS250 eras. The overall impact of COVID-19 on the nonuse rate was not significant.

Conclusions: The rise in kidney nonuse rate was significantly associated with both increased recovery of nonideal donors, and with KAS250 allocation complexity and delays. Increasing recovery of kidneys from nonideal donors benefits patients because recovering more kidneys increases the number of kidneys available for transplant.

Background: There are few interventional studies using CMV cell-mediated immunity (CMI) to guide antiviral prophylaxis. We assessed the Quantiferon-CMV (QTF-CMV) assay to guide CMV prophylaxis duration in high-risk organ transplant recipients.

Methods: A single-arm, multicenter, prospective interventional study including high-risk kidney, pancreas, liver, and heart transplant recipients who were either donor CMV-seropositive, recipient-seronegative (D + /R - ) or recipient-seropositive with antithymocyte globulin (R + /ATG) induction. CMI testing was performed using the QTF-CMV assay at months 3, 4, 5, and 6 posttransplant. Prophylaxis was discontinued for a positive CMI but continued for a negative result up to a maximum of 6 mo. The primary endpoint was CMV viremia ≥1000 IU/mL up to 1 y posttransplant.

Results: One hundred eight patients were included, comprising kidney (n = 89), kidney-pancreas (n = 7), liver (n = 10), and heart (n = 2) transplants. Eighty-nine patients (82.4%) completed the study protocol (n = 39 D + /R - and n = 50 R + /ATG). In the D + /R - group, only 1 of 39 patients (2.6%) had a positive QTF-CMV result. In the R + /ATG group, 33 of 50 patients (66%) had a positive QTF-CMV result before 6 mo, allowing for early discontinuation of prophylaxis (28 at month 3, 4 at month 4, and 1 at month 5). During the follow-up, CMV viremia ≥1000 IU/mL occurred in only 4 of 33 patients (12.1%) who discontinued prophylaxis early compared with 6 of 17 patients (35.3%) with negative QTF-CMV results and continued prophylaxis (hazard ratio 0.31; 95% confidence interval, 0.09-1.09; P  = 0.07). No R + patient developed CMV disease.

Conclusions: QTF-CMV-guided prophylaxis appears useful in R + patients who may benefit from a tailored duration of prophylaxis. This strategy does not appear to be useful in D + /R - patients.

Background: Few studies have examined the long-term outcomes of recipients in minimally invasive donor hepatectomies, particularly comparing robotic and laparoscopic donor procedures. Understanding these outcomes is crucial for optimizing surgical approaches and improving the overall success of living donor liver transplantation. This study aimed to compare the feasibility and safety of robotic donor right hepatectomy (RDRH) and laparoscopic donor right hepatectomy (LDRH) by evaluating total follow-up patient outcomes.

Methods: This retrospective, single-center study included 117 and 118 donors who underwent RDRH and LDRH between March 2016 and June 2023, respectively. After performing 1:1 propensity score matching, 71 donor-recipient pairs were included in each group. Donor and recipient complications were divided into early (within 90 d) and late (after 90 d) biliary and vascular complications.

Results: In the matched cohort, major complication rates of donors were similar in both groups. Bile duct (BD) variation was not significantly different; however, the rates of multiple BD openings (26.8% versus 54.9%; P  =   0.001) and major biliary complications in recipients were higher in the LDRH group (22.5% versus 42.3%; P  =   0.012). The cumulative biliary complication rate was significantly higher in the LDRH group. Early biliary complications were not significantly different; however, the rate of late biliary complications was higher in the LDRH group (11.3% versus 23.9%; P  =   0.047).

Conclusions: RDRH demonstrated comparable postoperative complications to LDRH in donors but showed fewer recipient biliary complications. This could be attributed to the precision of robotic dissection and BD division, resulting in fewer multiple BD openings.