Journal of Transplantation最新文献

Background: With population aging and increasing prevalence of kidney disease, a greater number of older patients could benefit from a kidney transplant. Organ shortage has led to expanding the pool of potential donors, including both kidneys from the same donor as dual transplants into a single recipient. At present, there is no consistent criteria for determining suitability for single versus dual transplant.

Methods: We performed a retrospective analysis of the Organ Procurement and Transplantation Network database of all recipients undergoing single or dual kidney transplants from deceased donors from December 4, 2014, to March 31, 2024, excluding en bloc donors. We examined patient and graft survival rates and graft function in dual versus single kidney transplantation. In addition, we analyzed potential survival differences between using a single kidney transplantation over dual transplantation.

Results: During the study period, there were a total of 1015 dual kidney transplant recipients and 134,933 single kidney recipients. The donors of the dual transplants were older, had higher KDRI, and had increased rates of glomerulosclerosis, with > 20% glomerulosclerosis seen in 20% of the kidneys. Using 3:1 propensity matching, we did not observe a significant difference in overall patient survival. We did observe a significant increase in graft survival with dual transplants. Transplanting all dual kidneys as single kidneys could result in a 0.9% increase in overall successful transplants and a 3% reduction in waitlist deaths.

Conclusion: Careful donor and recipient matching are crucial to optimize outcomes in this population. More emphasis needs to be placed on maximizing survival benefit from each donor kidney.

Background: Increasing numbers of older patients are undergoing kidney transplantation. While there is evidence for both sex- and age-related immunological variations increasing the risks of immunosuppression (IS), few centers enforce age- or sex-specific IS adjustments.

Methods: We investigated outcomes of 148 kidney transplants performed in our center between April 2009 and March 2019 in recipients aged > 60 years and compared them to outcomes in 272 younger recipients (divided into age groups 18-34, 35-49, and 50-60 years), matched for degree of human leukocyte antigen (HLA) sensitization (calculated reaction frequency, cRF), number of donor-recipient HLA mismatches, and cytomegalovirus (CMV) serostatus, all treated with the same IS protocol. Outcomes were time to (i) first episode of biopsy-proven acute rejection (BPAR), (ii) first CMV viremia within the first 6 months, (iii) incidence of any new-onset malignancy, and (iv) development of donor-specific anti-HLA antibodies (DSAs).

Results: Overall rates of BPAR were highest in the recipients under the age of 35, but with no evidence of a difference between older age groups. Conversely, the risk of CMV viremia and malignancy was significantly higher in older recipients; in the > 60-year-old group, CMV viremia HR: 2.66 (95% CI: 1.49-4.75), and malignancy HR: 7.3 (95% CI: 1.7-31.10) versus the youngest group with little evidence was confounded by comorbidity or donor factors on multivariate analysis. The risk of CMV infection was most marked in the oldest female group, while the risk of malignancy was greatest in older males. The development of DSA was equal across all age groups.

Conclusion: Our data indicate that older recipient age is associated with increased risk of CMV viremia and malignancy after transplantation, suggesting an age-associated vulnerability to IS, with the risk occurring mostly in older women and older men, respectively. These data support the need to develop age- and sex-specific protocol adjustments.

Deceased organ donation is the greatest source of transplantable whole organs, but registration rates are a limiting factor because they remain low among certain populations. A stratified, nonprobability survey was used to identify population characteristics associated with nonregistration in the United States (N = 11,083). Latent profile analysis (LPA) was used to identify multivariate patterns of demographic, socioeconomic, and health-related factors associated with registration. LPA yielded three distinct profiles, which all reported similar average percentages of driver's license possession, medical insurance coverage, and income, indicating that profiles were not distinguished by these variables. Meaningful differences across the profiles included access to healthcare services, satisfaction with those services, general health and well-being, and age; those who are both healthy and young (mean age = 25.9 years) reported the lowest percentage of organ donation registration (35.3%). For this group, 71.48% listed either low priority or distrust in the donation process as the top reasons for nonregistration. Importantly, age as a standalone variable was not uniformly associated with donation and was conditionally dependent upon health status; poorer health in young adults was associated with greater registration. These findings reveal previously unidentified opportunities for tailoring donor registration campaigns to populations with a high potential for registration behavior change.

Background: Live kidney donation is increasingly common due to the shortage of organs. Surgeons prefer the left kidney due to easier access and longer renal vein. There are conflicting reports about the outcomes of right versus left kidney transplants. The objective of this study was to compare the immediate and long-term outcomes of right and left kidney recipients in live donor kidney transplants. Methods: A retrospective analysis of 215 live kidney donors from 2021 to 2023 was conducted to compare outcomes between the recipients of right and left kidneys. Data were collected on donor and recipient demographics, surgical outcomes, and complications. Baseline values were summarized using descriptive statistics, with the quantitative and qualitative data reported as means, medians, interquartile ranges, standard deviations, and frequencies. Differences between the groups were analyzed using the Chi-square test and t-test. Results: Among the 215 donors, 141 (65.6%) were male and 74 (34.4%) were female, with a mean nuclear GFR of 105.89 ± 10.91 mL/min. Left kidneys were donated in 176 cases (81.9%), and right kidneys in 39 cases (18.1%). The most common complications were delayed graft function (DGF) in 15 cases (6.9%), hematoma in six cases (2.7%), seroma in nine cases (4.2%), and rejection in 10 cases (4.7%). There were no significant differences between the groups for gender, cold ischemia time, operation time, hospital stay, intraoperative hemorrhage, blood transfusion, re-exploration, hematoma, seroma, urine leak, or the presence of donor-specific antibodies (DSA), BK or cytomegalovirus viremia, rejections, or death-censored graft loss. Right nephrectomies and re-exploration were identified as independent predictors of DGF. Creatinine levels and estimated glomerular filtration rates at discharge, 6 months, 1 year, and 2 years did not differ significantly between the recipients of the right and left kidneys. Conclusion: Laparoscopic left and right donor nephrectomies show comparable long-term outcomes with no significant differences in creatinine levels at 6 months, 1 year, and 2 years post-transplantation. Despite more DGF in right kidney recipients, both kidneys are suitable for transplantation without compromising long-term outcomes. These findings highlight the feasibility of utilizing the right kidney for donation when required.

Background: The COVID-19 pandemic impacted how health services were delivered for patients with chronic pulmonary conditions. To our knowledge, perceptions of patients with lung transplant (LT) and their providers on access to care and service delivery during the COVID-19 pandemic have not been explored in our context of Alberta, Canada. Our objective was to explore LT patient and provider perspectives on the impact of the COVID-19 pandemic on healthcare access and service delivery. Methods: We used interpretive description, a qualitative approach with the end-goal of informing decisions and actions in clinical practice. Interviews were conducted virtually and confidentially transcribed verbatim. Data generation and analysis occurred concurrently. Analysis was informed by Braun and Clarke's six phases of reflexive thematic analysis. Strategies to enhance rigor and trustworthiness of the findings were utilized. Results: We completed 17 interviews: 8 with patients and 9 with providers. Four key themes were generated: (1) "COVID-19 created a relational wall;" (2) "Determining how care should be delivered was a juggling act;" (3) "Balancing supply and demand;" and (4) "The unique costs of being immunocompromised during a global pandemic." The pandemic impacted social relationships for LT patients, especially through the use of virtual care. Several factors hindered access to care for LT patients. Provider participants highlighted how there were less transplants during the pandemic which created a backlog in transplant surgeries. Fear of COVID-19 meant that some LT patients were hesitant to seek healthcare services, resulting in later-term health consequences. A need for mental health services was identified among this population despite an apparent lack of available services. Participants highlighted the gap in COVID-19 resources that now exists for this population since testing and treatments are no longer as readily available. Conclusions: In conclusion, provider participants did the best that they could with the circumstances they faced to provide high-quality care to LT patients. However, while patient participants were generally understanding of circumstances, LT care suffered as a result of the COVID-19 pandemic. Care for this population generally needs to be in-person, but there is nuance surrounding this recommendation due to LT patients' immunocompromised nature. Health system leaders can leverage our findings to implement learnings from the pandemic and continue to improve services for the ever-growing LT population.

Introduction: Donor-derived cell-free DNA (dd-cfDNA) in the peripheral blood of allograft recipients has shown to early identify allograft injury. In this study, we assessed the factors that influence the amount of circulating dd-cfDNA during the first month postkidney transplant as well as its longitudinal trend. Materials and Methods: A consecutive series of 98 adult kidney transplant recipients at a single center between July 2018 and January 2020 were included in this study. All demographic and operative details were collected for donors and recipients of the organ transplant. Median eGFR, dd-cfDNA, and serum creatinine were calculated at 1, 2, 3, 6, and 12 month posttransplant. Descriptive statistics were used for patient demographics. Nonparametric comparisons of dd-cfDNA cumulative distributions between dichotomized groupings were evaluated using Kruskal-Wallis or Mann-Whitney U tests. Results: The median age of recipients was 54.5 years (IQR: 42.7-62.2). The cause of ESRD among recipients was hypertension (43%) and Type II diabetes mellitus (29%). Eighty-two percentage of patients received a deceased donor allograft, 14% received a living unrelated allograft, and 4% received a living related allograft. Sixteen percentage of recipients experienced delayed graft function (DGF). Median creatinine level at 1 month posttransplant was 1.75 mg/dL (IQR: 1.34-2.26) and median eGFR at 1 month posttransplant was 49.6 mL/min/1.73 m² (IQR: 35-65). The median dd-cfDNA score at 1 month posttransplant for all recipients was 0.4% (IQR: 0.15-5.3). Donor sex was a statistically significant differential for dd-cfDNA score. Recipients from male donors had a significantly higher median dd-cf DNA score at 1 month posttransplant versus those who received a female kidney (0.57% vs. 0.28%, p < 0.01). Highest median score was recorded at the first month posttransplant (0.4%, IQR: 0.26-0.74), and a sustained downward trend was observed through Month 2 (0.19%, IQR: 0.17-0.31) and Month 3 (0.19%, IQR: 0.15-0.26). Correlation between 1-, 2-, 3-, 6-, and 12-month posttransplant median dd-cfDNA scores between deceased donor and living donor (LRD and LURD) cohorts was not statistically significant. Conclusion: This study provides further insight into donor and recipient variables' effects on dd-cfDNA in the early posttransplant phase by analyzing a more diverse cohort of patients and adds to the knowledge around interpreting dd-cfDNA scores with clinical correlation for posttransplant management.

Background: Right heart remodeling is noted in patients with severe COVID-19-associated acute respiratory distress syndrome (ARDS). There is limited information regarding right heart recovery following lung transplantation in this cohort. Methods: Retrospective review of institutional transplant database from June 2020 to June 2022 was performed at Northwestern University in Chicago, Illinois. Demographic, laboratory, histopathologic, lung transplant outcomes, and pre- and postoperative echocardiographic data were recorded and analyzed. Results: Of the 42 patients who underwent lung transplantation for COVID-19-related ARDS, 6 patients were excluded due to having either a single-lung transplant (n = 2), lobar transplant (n = 1), or dual-organ transplant (n = 1) or for missing postoperative TTE data (n = 2) and 36 were included in the study; there were no 90-day deaths, and the 1-year survival rate was 88.8%. Intraoperative hemodynamics data showed a mean pulmonary artery pressure of 49 ± 23 mm Hg. Preoperative echocardiography was evaluated at a median of 15.5 (10-34.3) (IQR) days preoperatively and 140 (108-201) days (IQR) postoperatively. RV size grade improved from an average of 1.7 ± 0.85 to 1.3 ± 0.6 (p < 0.05), while RV function improved from an average of 2.2 ± 1.2 to 1 ± 1 (p < 0.05). There was a reduction in RVSP from 46.5 ± 18 mmHg to 30.1 ± 7.8 mmHg (p < 0.05) and RV free wall strain showed improvement from -13.9 ± 6.1% to -18.5 ± 5.4% (p < 0.05). Conclusions: The results showed that the RV size and systolic function demonstrate improvement with normalization in a relatively short period following lung transplantation for patients with COVID-19-associated ARDS.

Background: Pneumatosis intestinalis (PI) and pneumoperitoneum are some of the complications after lung transplantation (LT). But only limited reports are published. The purpose of this study is to review our experience and perform a systematic review to discuss the possible causes, risk factors, and management. Methods: We reviewed the characteristics, management, and outcome of the patients who developed PI or pneumoperitoneum after LT in our institution from 2013 to 2022. We also performed a systematic review to discuss the management and outcome. Results: PI and pneumoperitoneum were found in 15 out of 729 patients (2.06%) in our institution. We also found 50 patients in the systematic review. Tracheostomy was performed in 40% and gastrointestinal procedures were performed in 55.6%. Laparotomy was performed in 23.4%. A total of 44.6% of patients had benign physical exams or no symptoms. Rejection was seen in 42.9%. A total of 28.6% of patients died during follow-up periods. Conclusions: This report has the largest number of patients so far with PI and pneumoperitoneum after LT. These conditions have a high rejection and high mortality rate. Mechanical ventilation, tracheostomy, gastrointestinal procedure, CMV infection, Clostridium difficile (C. difficile) infection, and immunosuppression can be the risk factors, and the management includes laparotomy or conservative management. It is generally recommended to proceed with laparotomy if patients have portal venous gas, elevated white blood cell count, elevated lactic acid level, decreased bicarbonate level, elevated amylase level, metabolic acidosis, abdominal tenderness, or abdominal distension. Otherwise, most of the patients recover with conservative management with nil per os (NPO), metronidazole, ganciclovir, antibiotics, high-flow oxygen, and holding mycophenolate mofetil (MMF).

Background: In robotic donor hepatectomy (RDH), hepatic duct division (HDD) and its stump closure technique are of paramount importance in avoiding postoperative biliary complications in both donors and recipients. We describe our novel triple C ("clip-clamp-cut") technique of HDD. Methods: Out of 4016 living donor liver transplant (LDLT) (2004-October 2023), we have performed 208 RDH cases since December 2019. This study is a retrospective analysis of the first 160 RDH cases. After excluding the first 20 RDH cases (learning curve) and 3 left-sided RDH cases, 137 cases with no exclusion criteria were included. We divided these 137 donors into the "cut and suture" (CS) group (n = 33) and the "triple C" technique group (n = 104). We compared intraoperative details and postoperative outcomes. Results: All 137 robotic donors and 128/137 recipients are currently well. Donor biliary leak rate was significantly lower among the triple C group (n = 3, 2.9%) compared to the CS group (n = 5, 15.2%) (p=0.009). No other differences in postdonation morbidity were observed among the two groups. Recipient biliary complication rate was lower in the triple C group than in the CS group although not statistically significant (10.6% vs. 15.1%; p=0.537), despite more multiple biliary anastomoses in the former. No significant differences in post-transplant recipient morbidity and mortality were observed. Conclusions: Our simple yet novel triple C technique enables clean, precise, bloodless HDD resulting in lower donor and potentially recipient biliary complication rates. The ease and reproducibility make it ideal for widespread adoption.

Introduction: Few studies have evaluated the impact of psychological trauma (mental, emotional, or physical) on liver transplant (LT) candidacy and outcomes.

Methods: We performed a single center retrospective analysis of patients who completed routine LT evaluation between October 2017 and June 2021. We identified the prevalence of psychological trauma history in men and women LT candidates and evaluated the association between trauma history and LT access. The primary outcome measure was listing for LT.

Results: A total of 463 patients completed LT evaluation, of which 17% (n = 79) reported a history of trauma: 49 of 159 women and 30 of 304 men. Trauma history was significantly more common in women than in men (31% vs. 10%, p < 0.001). Women with trauma history were less likely to be listed for LT (80% vs. 93%, p = 0.016). Women with trauma history were also more likely to be removed from the LT waitlist (26% vs. 12%, p = 0.045); this persists when excluding patients removed for transfer to another center or for medical improvement (22% vs. 7%, p = 0.020). In contrast, listing for LT (87% vs. 86%, p = 0.973) and waitlist removal (12% vs. 10%, p = 0.766) did not differ in men with and without trauma history. In those that received a LT (n = 107), post-LT relapse, rejection, readmissions, and death did not differ in patients with (n=13)and without (n=94) trauma history.

Conclusions: Trauma history is associated with reduced access to LT in women but not men with chronic liver disease. Further studies are needed to understand the impact of psychological trauma on LT access and post-LT outcomes.