Transplant International最新文献

Cytomegalovirus (CMV) infection following solid organ transplant (SOT) is associated with increased mortality risk. In the phase 3 SOLSTICE study (NCT02931539), more transplant recipients achieved CMV clearance after 8 weeks with maribavir than investigator-assigned therapy (IAT). In SOLSTICE, SOT recipients with refractory CMV infection were randomized 2:1 to receive maribavir or IAT for 8 weeks. This post hoc analysis assessed the impact of CMV clearance at Week 8 on mortality at Week 20. Patients who achieved CMV clearance at Week 8 were categorized as responders, and patients without CMV clearance, or who received maribavir rescue or alternative treatment, were categorized as nonresponders. All-cause mortality was assessed at Week 20 for responders and nonresponders using the Kaplan-Meier method with log-rank test. The analysis included 211 SOT recipients: 97 responders and 114 nonresponders. Week 20 all-cause mortality was significantly higher in nonresponders than responders (p = 0.0024). No deaths were reported in the responder group, and 10 deaths were reported in the nonresponder group (3 receiving IAT, 7 receiving maribavir). Median (range) time from treatment start to death was 30.5 (3-123) days. This analysis is consistent with other studies showing an increased risk of mortality with post-SOT CMV infection.

The rising prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and Hepatocellular Carcinoma in the elderly population has increased the demand for liver transplantation (LT) in patients over 70 years. Advanced age, however, is still considered an independent risk factor. This study aims to evaluate post-transplant oucomes in patients aged over 70 years, traditionally viewed as an age limit for transplant. We retrospectively analyzed 584 LT recipients (36 aged ≥70, 548 aged <70). Viral cirrhosis was more frequent in the younger group (36.1% vs. 13.1%), while MASLD was more common in those over 70 (25% vs. 13.1%) (p = 0.013). Model for End-Stage Liver Disease (MELD) scores were lower in patients over 70 (13, IQR 9-17) compared to the younger group (15, IQR 10-23) (p = 0.032). Propensity score matching (3:1 ratio, without replacement) was performed based on MELD and cirrhosis etiology. After matching, no significant differences were found in postoperative outcomes, overall survival, or graft survival. Our findings demonstrate that carefully selected patients over 70 can achieve post-transplant outcomes comparable to younger patients. Advanced age alone should not be considered an absolute contraindication; instead, a comprehensive, multidimensional assessment is essential to identify suitable candidates.

Atypical hemolytic uremic syndrome (aHUS) is a rare cause of end stage kidney disease (ESKD) associated with a high rate of recurrence in kidney transplants causing a post-transplant thrombotic microangiopathy (TMA). Prophylactic eculizumab can prevent disease recurrence in select patients. Treating at the time of post-transplant TMA occurrence is the only option if the diagnosis of aHUS is not established pre-transplant. We report our experience of using eculizumab at the point of post-transplant TMA in those with a diagnosis or suspicion of aHUS. We conducted a case note review of 26 patients treated with eculizumab for post-transplant TMA. Screening for complement pathway defects included testing for variants in genes of the complement pathway and anti-factor H autoantibodies. 34.6% of recipients had an identified complement pathway defect. Median time to presentation with post-transplant TMA was 8.4 months. Death-censored graft survival 12 months after starting eculizumab was 68% for the cohort and was worse in those presenting >12 months post-transplant where this figure was 42.9%. The outcome is poor despite eculizumab treatment for those presenting >12 months after transplantation with TMA.

Muslim-majority countries differ in socio-cultural behavior and economic development but share a similar high burden of organ failure. Due to this heterogeneity, mapping organ donation and transplantation activity is of interest for future healthcare provision. Data was analyzed for 50 Muslim-majority countries (defined as Muslims comprising >50% of the population). Organ donation/transplantation rates were obtained from global registries between 2013-2023. Supplementary socio-economic and health data were obtained from open-source data repositories. Muslim-majority countries population increased from 1.53 billion to 1.88 billion between 2013-2023. Organ donation/transplant activity was only reported for 21/50 countries. Most organ donations came from living people rather than deceased donors (resulting in kidney and liver transplantation being the most common procedures). Other transplant activity rates were low. Poisson regression analyses identified multiple socioeconomic indicators to be associated with deceased- or living-donor activity, while negative binomial analyses comparing Muslim-majority to other countries within the region showed Muslim countries had lower deceased donation rates. Our study shows access to transplantation is lacking in many Muslim-majority countries. While socio-economic factors play a role, other challenges like religious and/or cultural barriers must be appreciated. With such global heterogeneity, bespoke country-specific interventions are warranted to improve transplantation opportunities in Muslim-majority countries.

The aim was to compare intraoperative, postoperative and functional outcomes of patients undergoing living donor RAKT versus OKT. A retrospective analysis of all living donor's kidney transplantation performed in a tertiary center between 2013 and 2024 comparing RAKT with OKT was performed. All recipients in the OKT group were eligible for a RAKT. A total of 400 patients (200 RAKT and 200 OKT) were included. Recipients were younger in the RAKT cohort (48.0 versus 51.5 years, p = 0.045). Median operative time was significantly longer in the RAKT group (185.5 versus 120.0 min, p < 0.0001). Intraoperative complications rate was similar in both study group. A significantly higher proportion of recipients receiving OKT undergone post-operative surgical complications (p < 0.0001) and major post-operative complications (8.0% versus 19.5%, p = 0.001). Seven patients required graft nephrectomy during the early post-operative period (of whom all were in the RAKT group). Median length of hospitalization was significantly longer in the OKT group (7.0 versus 9.0 days, p < 0.0001). 1-, 3- and 5-years patient and graft survival were comparable between the RAKT and OKT cohorts. The postoperative opioid requirement was not evaluated. Our analysis confirms the safety and efficacy of RAKT in the setting of living donors, in comparison to conventional OKT.

Intensive care to facilitate organ donation (ICOD) is being discussed internationally without reaching a consensus. The aim of this paper is to share with the community the recently published French ICOD guidelines, focusing on two main ethical issues: the ethical acceptability of antemortem interventions during the ICOD process, and the ethical acceptability of considering controlled donation after circulatory death during the ICOD process. These issues raised by the tension between end-of-life care and the possibility of OD deserve to be addressed as they challenge the consideration of ICOD as a routine part of end-of-life care.

This study explores the impact of using kidneys from very-aged donors to address the organ shortage, focusing on risk factors for graft loss and delayed graft function (DGF), independent of recipient factors. Data were sourced from the French multicentric prospective DIVAT cohort and retrospectively analyzed. The study included adult recipients transplanted between 2007 and 2018 receiving kidneys from brain-deceased donors over 70. The primary endpoint was death-censored graft survival, and secondary endpoint DGF. Among 1036 patients with a median follow-up of 3.96 years (2.01-6.31), donor hypertension (HR 1.46 95% CI (1.09-1.95), cold ischemia time (HR 1.03 per hour 95% CI (1.01-1.06) and HLA mismatches (after adjustment on DGF, HR 1.98 (1.45-2.71)) were significant risk factors for graft loss. Considering DGF, donor serum creatinine (HR 1.01 95% CI (1.01-1.01) per μmol/L), warm and cold ischemia times (HR 1.01 95% CI (1.0-1.01) per minute and HR 1.05 95% CI (1.02-1.08) per hour) and the use of SCOT preservation solution (HR 3.90 95% CI (1.26-11.84)) were deleterious, while hypothermic perfusion machine was protective (HR 0.65 95% CI (0.43-0.99)). The findings emphasize the paucity of modifiable variables associated with long-term outcomes in very-aged donors and the need for peri-transplant preservation strategies.

Using biomarkers to tailor immunosuppressive therapy after kidney transplantation was proposed to improve clinical care. Timely and individual adaptions of immunosuppression could reduce therapy-related side effects, such as infections, cardiovascular morbidity and malignancy, and further lower the risk of allograft rejection. Despite promising preliminary studies, evidence for implementing such a biomarker in clinical care is insufficient. Prominent candidates for immunologic monitoring after kidney transplantation include donor human leukocyte antigen-specific antibodies, donor-derived cell-free DNA, urinary chemokines and peripheral transcriptomics. In addition, the quantification of Torque Teno virus, a highly prevalent and non-pathogenic virus that was shown to associate with outcomes linked to immunocompetence, has been proposed for immunologic monitoring. This review summarises the prospects and limitations of Torque Teno virus for immunologic risk stratification after kidney transplantation in the context of current state-of-the-art. It will focus on cut-off values of plasma Torque Teno virus load that might be useful to guide immunosuppression in the clinical care of kidney transplant recipients, and highlights recently proposed indications of Torque Teno virus-guided immunosuppression.