Transplant International最新文献

Grade 3 primary graft dysfunction at 72 h (PGD3-T72) is a severe complication following lung transplantation. We aimed to develop an intraoperative machine-learning tool to predict PGD3-T72. We retrospectively analyzed perioperative data from 477 patients who underwent double-lung transplantation at a single center between 2012 and 2019. Data were structured into nine chronological steps, and supervised machine-learning models (XGBoost and logistic regression) were trained to predict PGD3-T72, with hyperparameters optimized via grid search and cross-validation. PGD3-T72 occurred in 83 patients (17.3%). XGBoost outperformed logistic regression, achieving peak performance at second graft implantation with an AUROC of 0.84 IQR: 0.065, p < 0.001, with a sensitivity of 0.81 and a specificity of 0.68. The top predictors included extracorporeal membrane oxygenation (ECMO) use, blood lactate levels, PaO2/FiO2 ratio, and total lung capacity mismatch. Subgroup analyses confirmed robustness across ECMO and non-ECMO cohorts. PGD3-T72 can be reliably predicted intraoperatively, offering potential for early intervention.

Controlled donation after the circulatory determination of death (cDCDD) is currently one of the most promising ways to increase organ availability. In France, a national cDCDD protocol requiring abdominal normothermic regional perfusion (A-NRP) has been in place since 2015. The recent consideration of heart procurement from cDCDD donors has reignited clinical and ethical debates within the critical care community. This position paper, endorsed by the two French intensive care societies, provides a critical care perspective on this evolving practice. Two key challenges are identified. First, heart procurement may require the withdrawal of life-sustaining measures (WLSM) to occur in or near the operating room, in contrast with French current practice where WLSM mostly takes place in the ICU. Intensivists strongly advocate maintaining ICU-based WLSM whenever possible, and ensuring continuity of care and end-of-life support when relocation is unavoidable. Second, the use of NRP raises concerns about the permanence of death and compliance with the dead donor rule. These concerns can be addressed through targeted biomedical research and a robust ethical framework affirming that death is declared prior to NRP and that no return to life is possible thereafter. Transparent engagement with these challenges is essential to sustain trust in the cDCDD pathway.

Improved biomarkers are needed to enhance prognostication in kidney transplantation. We evaluated urinary Epidermal Growth Factor (uEGF) as a predictor of long-term allograft loss. We conducted a prospective, single-center cohort study of 290 adult kidney transplant recipients with uEGF measured 3 months post-transplant. The primary outcome was allograft loss, defined as return to dialysis or pre-emptive re-transplantation. Multivariable cause-specific Cox models assessed the independent association between uEGF and allograft loss. Model performance was compared to the iBox prediction model using 7-year time-dependent AUC and Akaike Information Criterion (AIC), with internal validation via bootstrap resampling. Temporal validation was performed in an independent cohort of 203 patients. uEGF correlated with markers of chronic injury, including eGFR, donor age, and interstitial fibrosis. After a median 8.8-year follow-up, lower uEGF was independently associated with allograft loss (adjusted HR 0.19; 95% CI, 0.11-0.32). Adding uEGF to the iBox improved discrimination (AUC 0.72 vs. 0.63) and reduced AIC (383 vs. 394). While results were robust to internal validation, temporal validation did not show an independent association of uEGF with allograft loss. These findings suggest uEGF may provide independent prognostic value, but further studies in larger and more diverse cohorts are needed to confirm its clinical utility.

Strain echocardiography (SE) may be used for surveillance in patients after heart transplantation (HTx); however, data on atrial strain are lacking. We aimed to compare the significance of ventricular and atrial strain with respect to an associated acute cellular rejection (ACR). Patients who underwent an endomyocardial biopsy (EMB) within 1 year after HTx were eligible for this retrospective analysis. The relationship between SE and ACR was assessed. EMB results of 52 patients (median age, 53 years; 63% male) at a median of 181 days post-HTx were identified. Mild ACR was present in 19 patients and ≥ moderate ACR in 6 patients. ACR ≥ moderate was associated with right ventricular free wall strain (OR 1.20, 95%CI 1.02-1.46, P = 0.04) and right atrial contraction strain (RASct; OR 1.55, 95%CI 1.18-2.43, P = 0.01). The RASct cut-off value of -9.3% had a sensitivity of 100% and a specificity of 79% for ≥ moderate ACR. None of these associations were observed for left ventricular or left atrial strain. A validation analysis was performed on another group of 23 HTx patients, which yielded similar results with regard to the specified RASct cut-off value. Our comprehensive strain analysis confirmed the association between reduced right ventricular strain and ACR and further identified robust associations between RASct and ACR. Right atrial strain analysis may be a promising method for excluding subclinical ACR after HTx.

We compared the long-term outcomes of pediatric kidney transplants from DCD and DBD donors over a 33-year period in the USA. Data were retrieved and analysed on kidney transplants from deceased donors in paediatric recipients in 1994-2020 from the OPTN. Data were compared between those receiving kidney transplants from DBD and DCD donors. There were 11,071 paediatric kidney transplants from deceased donors including 350 from DCD donors. DCD transplants were more likely to have delayed allograft function (20.1% vs. 11.9%, p < 0.01). However, there was no significant difference in allograft or patient survival between transplants from DBD and DCD donors at 10 years (56% vs. 55%, p = 0.76 and 90% vs. 91%, p = 0.89). We describe the largest cohort of pediatric DCD kidney transplant recipients in the literature. We showed that despite higher rates of delayed allograft function in DCD transplants, long-term outcomes were not significantly different. Kidney transplants from DCD donors are a viable option and should be offered to children comparable to DBD kidneys as their long-term outcomes do not differ. DCD transplantation is illegal in some countries, however, it offers an opportunity to increase the number of transplants for children; this data should be considered in ongoing policy discussions.