世界移植杂志最新文献

Background: Living donor kidney transplantation (LDKT) is considered the gold standard for treating end-stage kidney disease. Previous studies have highlighted the impact of donor and recipient demographics in influencing post-transplant outcomes. We believe that patient and graft outcomes in a tertiary university hospital setting will have no difference between pairs of standard criteria vs pairs of extended criteria (EC) donors and recipients in LDKT.

Aim: To investigate the outcomes of allocating EC donation (ECD) kidneys to EC recipients (ECR) in LDKT and compare them to standard and mixed standard and EC pair counterparts.

Methods: We collected data from adult LDKTs conducted between April 2017 and April 2022. Donor-recipient pairs were grouped based on criteria as follows: (1) Group 1: Standard criteria donor (SCD) to standard criteria recipient (SCR); (2) Group 2: SCD to ECR; (3) Group 3: ECD to SCR; and (4) Group 4: ECD to ECR.

Results: A total of 149 living donor transplants were analysed over a 5-year period. Graft survival, patient survival, and graft function were similar across all four groups. The incidence of common postoperative complications was as follows: (1) Perioperative bleeding (5.6%); (2) Surgical site infection (6.8%); and (3) Incisional hernia (7.4%). No statistically significant differences were found in patient or graft outcomes amongst the four groups. Multivariate analysis showed that group 4 recipients might experience inferior 5-year graft function (β = -11.8, P = 0.037) when compared with group 1.

Conclusion: In LDKT, long-term patient and graft outcomes are comparable amongst different combinations of standard vs EC donors and recipients. These findings show the primary potential of living donor ECD to ECR kidney transplantation with satisfying outcomes.

Background: Liver transplantation (LT) is the preferred treatment for end-stage liver diseases. Early allograft failure (EAF) can result in death or retransplantation. One of the key factors predicting EAF is the degree of graft injury, which is typically assessed by elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. Aminotransferase levels exceeding 5000 U/L within 48 hours of LT are indicative of poor short-term graft survival.

Aim: To investigate outcomes in liver transplant recipients with peak aminotransferase levels exceeding 5000 U/L and to identify predictors of EAF.

Methods: Adult patients who underwent LT from a deceased (brain-dead) donor between 2011 and 2024 at Hospital de Clínicas de Porto Alegre were screened. Patients with peak AST or ALT levels > 5000 U/L post-LT were included, excluding those with vascular thrombosis. EAF was defined as death or re-transplantation within 90 days. A receiver operating characteristic curve were generated for each EAF predictor to determine the area under the curve (AUC). Sensitivity, specificity, negative predictive value, and positive predictive value were calculated for each predictor's best cutoff, as defined by the Youden Index. Survival curves were plotted using the Kaplan-Meier method.

Results: Between 2011 and 2024, 341 patients underwent LT. Of these, 29 (8.5%) patients had AST and/or ALT levels exceeding 5000 U/L within the first 48 hours post-LT. Four patients were excluded due to vascular thrombosis, resulting in a study cohort of 25 patients. EAF were also observed in 11 patients. One-year and five-year graft survival rates were 51.7% and 42.6%, respectively. For patients without EAF, one-year and five-year graft survivals were 92.3% and 76.2%, respectively. The key predictors of EAF included serum factor V and arterial lactate levels on postoperative day (POD) 1, with AUCs of 0.936 and 0.919, respectively. The optimal cutoff for EAF prediction were 26.2% for serum factor V and 9 mmol/L for arterial lactate.

Conclusion: Aminotransferase levels > 5000 U/L were associated with high EAF risk. However, favorable graft function indicators on POD 1 were associated with long-term survival comparable to that of general LT recipients. Serum factor V and arterial lactate levels emerged as valuable prognostic markers.

Background: In France, nitazoxanide is available through compassionate use authorization, as there is no summary of product characteristics for this medication. However, it has been marketed in the United States for several years, with evidence supporting its use in the treatment of chronic norovirus infections in immunocompromised individuals. Due to its limited use, data on the efficacy and safety of this drug remain sparse.

Case summary: We report the case of a 79-year-old immunocompromised patient, a renal transplant recipient undergoing treatment with mycophenolate mofetil and tacrolimus, who developed toxic agranulocytosis, as absolute neutrophil count dropped from 2.93 G/L to 0.09 G/L within 17 days following the introduction of nitazoxanide for the treatment of chronic diarrhea caused by norovirus infection. Clinical and laboratory findings suggest a toxic mechanism, most likely attributable to nitazoxanide.

Conclusion: This case highlights the potential of nitazoxanide to induce dose-dependent toxic agranulocytosis. While this adverse effect does not necessarily contraindicate reintroduction of the drug, it underscores the necessity for close hematological monitoring in such cases.

Background: Incisional hernia (IH) is a common complication following liver transplantation (LT), contributing to significant morbidity and impaired quality of life. The interplay of transplant-specific factors, patient comorbidities, surgical complexity, and immunosuppression presents considerable challenges in hernia repair, often accompanied by substantial risks.

Aim: To assess the incidence, risk factors, and outcomes of IH repair in LT recipients.

Methods: A systematic literature search was conducted across MEDLINE, EMBASE, Scopus, CINAHL, the Cochrane Library, Google Scholar, and PubMed, yielding 493 results. In accordance with PRISMA guidelines, 39 studies reporting on IH following LT were included in the final analysis. Studies involving paediatric populations, hernias unrelated to transplant incisions, living liver donors, non-LT, and multi-organ transplants were excluded. Meta-analysis was performed using Cochrane RevMan software. The study has been registered with PROSPERO (CRD42024563398).

Results: A review of 39 studies revealed incidence of post-LT IH ranging from 1.7% to upto 42.8%. Pooled analysis showed comparable demographics among groups and post-LT IH incidence was higher in older age recipients [mean difference (MD) = 2.39, 95%CI: 1.15-3.63, P < 0.001], male gender (relative risk = 1.42, 95%CI: 1.18-1.72, P < 0.001), high body mass index (BMI) (MD = 1.06, 95%CI: 0.82-1.29, P < 0.001), Mercedez-Benz incision type [odds ratio (OR) = 0.45, 95%CI: 0.21, 0.96, P = 0.04], and need for re-laparotomy (OR = 2.49, 95%CI: 1.05-5.93, P = 0.04). No significant differences were found in recurrence rates or wound complications between open and laparoscopic IH repairs.

Conclusion: Older recipient age, male gender, high BMI, Mercedes-Benz incision, and re-laparotomy after LT are significant risk factors for IH. In contrast, model for end-stage liver disease score, pre-LT ascites, acute rejection, and mammalian target of rapamycin inhibitor therapy do not appear to influence IH development. While open repair remains the predominant approach post-LT, no significant differences in recurrence or wound complication rates have been observed between open and laparoscopic repairs. However, open repair is associated with a shorter operative time.

Chronic heart failure (CHF) is a complex clinical syndrome characterized by impaired cardiac function and neurohormonal dysregulation. While CHF has traditionally been regarded as a hemodynamic disorder, growing evidence highlights the pivotal role of autonomic nervous system (ANS) dysfunction in its progression and prognosis. The ANS, comprising sympathetic and parasympathetic branches, exerts significant control over cardiac function, including heart rate, contractility, and vascular tone. In CHF, sympathetic overactivation coupled with parasympathetic withdrawal contributes to adverse cardiac remodeling, arrhythmogenesis, and further deterioration of cardiac performance. This minireview summarizes current knowledge on the role of autonomic dysfunction in CHF and heart transplantation. It focuses on how sympathetic nervous system imbalance contributes to CHF progression and explores the impact of autonomic dysregulation on post-transplant outcomes. By synthesizing existing evidence, the review highlights ANS modulation as a key therapeutic target for improving cardiac function and patient prognosis in both clinical settings.

Background: Aorto-hepatic conduits (AHCs) are an effective revascularization method for liver allografts when the native hepatic artery is unusable. Various studies have confirmed that outcomes with AHCs are inferior to those with native hepatic artery inflow.

Aim: To investigate the published evidence on the outcomes according to different inflow site for AHCs.

Methods: A systematic search was conducted for studies reporting on AHCs in liver transplantation over the last 10 years (January 2014 onwards). Two independent reviewers selected articles, assessed quality, and evaluated bias in the included systematic reviews. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale. The protocol was registered with PROSPERO (CRD42024545810). Review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis statement standards.

Results: Fourteen studies identified a total of 32486 deceased donor liver transplants, of which 1136 (3.5%) required AHCs. The most frequent indications for AHC use included poor arterial flow, intimal dissections, and hepatic artery thrombosis. Among all AHCs, 207 (18.2%) were supra-coeliac (SC) AHCs, 738 (65.0%) infra-renal (IR) AHCs, 25 (2.2%) iliac artery conduits, and 166 (14.6%) had unspecified origins. Pooled analysis revealed comparable demographic characteristics. The median follow-up duration ranged from 18 to 52 months. There were no significant differences in early occlusions of AHCs [odds ratio (OR) = 0.94 (0.48, 1.84); P = 0.86], late occlusions of AHCs [OR = 0.46 (0.16, 1.32); P = 0.15], early allograft dysfunction [OR = 0.82 (0.46, 1.47); P = 0.51], biliary complications [OR = 1.10 (0.69, 1.76); P = 0.68], post-transplant renal replacement therapy (RRT) requirement [OR = 1.12 (0.72, 1.72); P = 0.62], and major surgical complications (Clavien-Dindo > 3b) [OR = 1.06 (0.70, 1.61); P = 0.79]. The median duration for graft occlusion was approximately 142 days, ranging from 13 to 3313 days. One-year graft and patient survival rates for SC conduits were 77% to 81.1% and 80% to 85.1%, respectively. For IR conduits, one-year graft and patient survival rates were 66% to 79.1% and 73% to 88.3%, respectively. Five-year graft and patient survival rates for SC conduits were 53.9% to 67% and 67.8% to 74%, respectively. For IR conduits, five-year graft and patient survival rates were 50% to 56% and 56% to 64.9%, respectively.

Conclusion: Considering these findings, there is no significant difference in early and late outcomes between SC and IR AHCs, although there is a discernible tendency towards higher late occlusion rates in the IR group.

Background: Kidney transplantation is increasingly more common due to the ongoing shortage of deceased donors. However, anatomical challenges, such as a short renal artery, can complicate surgical procedures and increase complication risk, including thrombosis and anastomotic stenosis. To address these issues and optimize graft outcomes, innovative surgical techniques are essential.

Case summary: We present a case of kidney transplantation complicated by a short donor renal artery. To address the discrepancy between arterial length and diameter mismatch, the recipient's inferior epigastric artery was used as a cuff interposition for arterial reconstruction. Following standard laparoscopic donor nephrectomy, vascular reconstruction was performed on the back table. The use of the inferior epigastric artery as a cuff allowed for successful elongation and size matching of the donor renal artery, enabling a tension-free anastomosis to the recipient's external iliac artery. Postoperative Doppler ultrasound and angiography confirmed excellent graft perfusion. The patient experienced an uneventful recovery with immediate graft function and maintained stable renal function at 6 months post-transplant. To our knowledge, this is the first reported use of the inferior epigastric artery as a cuff interposition in renal artery reconstruction, offering a novel and effective technique for managing short renal arteries in kidney transplantation.

Conclusion: Interposition of the epigastric artery offers an innovative technique for managing short donor renal arteries, reducing the risk of early thrombosis and long-term complications as size mismatch and intimal hyperplasia.

In recent years, the use of new biomarkers in different phases of the diagnosis and treatment of several diseases has allowed substantial improvement in clinical practice. The use of donor-derived cell-free DNA (dd-cfDNA) in organ transplantation has led to significant progress in the treatment of post-transplant outcomes, particularly after kidney transplantation. In addition, the use of dd-cfDNA in organ transplantation has led to significant advancements in post-transplant outcome monitoring. The aim of this study is to review many of the recent studies on the use of this biomarker and to evaluate its most relevant advantages and limitations. dd-cfDNA is released from several types of cells of the transplanted organ, most often from endothelial cells and this happens in the case of organ damage, most often rejection. Its presence in the bloodstream of the recipients is an important sign of graft damage; its principal advantage is in the avoidance of invasive tools such as renal biopsy. Additionally, several studies reported that the finding of dd-cfDNA in the serum may precede histological abnormalities; its utility in the diagnosis of subclinical rejection is extremely important. Among the principal limitations of this tool are the difficulty in distinguishing different forms of graft damage. According to several studies this tool has several limitations in diagnosing T-cell mediated rejection. In addition, particular care should be taken in distinguishing dd-cfDNA from recipient-derived cfDNA.

Alcohol-associated liver disease (ALD) is a rapidly increasing indication for liver transplantation (LT) globally with a significant rise in transplants for ALD with limited sobriety including patients with alcohol-associated hepatitis (AH). This evolution challenges the older paradigm that mandates prolonged periods of alcohol abstinence prior to LT. Due to the limited armamentarium of effective pharmacotherapy to treat severe AH, the mortality rates are significantly higher when LT is not available. In the patients who are transplanted for ALD with limited sobriety including AH, patient and graft survival are equivalent, if not better, compared to patients transplanted for other etiologies. However, due to the risk of alcohol relapse and other psychosocial factors, public opinion regarding early LT may continue to impact how the field moves forward particularly regarding organ stewardship and the need for equitable allocation of organs. Numerous tools for psychosocial evaluations have been developed to assist liver transplant teams to identify appropriate patients in a more uniform manner. In this review, we aim to assess the available evidence to support early LT for alcohol AH and propose directions for the future as the field continues to evolve.

Background: The pathophysiology behind gastroesophageal reflux disease and its association with poor outcomes after lung transplantation is incompletely understood. The physiologic impact of lung transplantation on pulmonary function, intrathoracic pressures, and vagal innervation may affect esophageal motility, bolus clearance and reflux risk. However, the effect of changes in esophageal function after lung transplantation on the risk of poor post-transplant outcomes remains unclear.

Aim: To evaluate the association between change in esophageal motility pre-/post-lung transplantation and rejection outcome.

Methods: This was a retrospective cohort study of lung transplant recipients who underwent both pre-and post-transplant esophageal testing including high resolution manometry (HRM) at a tertiary center. Acute cellular rejection (ACR) was defined histologically per International Society for Heart and Lung Transplantation criteria. Univariate analyses were performed using student's t-test, χ ² test, and Spearman's correlation where appropriate. Multivariable time-to-event analysis using Cox proportional hazards model was applied. Subjects not meeting ACR outcome were censored at death or date of last clinic visit.

Results: 55 subjects (65% men, mean age: 61, median follow-up: 840 days) were included, with 17 (31%) experiencing ACR. Increase in failed swallows correlated with lower baseline total lung capacity (TLC) (R = -0.32, P = 0.05) and decreased post-transplant esophageal bolus clearance (R = -0.45, P = 0.004). On multivariable analysis, post-transplant hypomotility independently predicted increased ACR (HR: 3.62, 95%CI: 1.11-11.8; P = 0.03). Kaplan-Meier analysis demonstrated increased ACR for subjects with increased vs unchanged failed swallows post-transplant (P = 0.048). On Cox regression, a 20% elevated risk of ACR was found for every 10% increase in failed swallows, after controlling for confounders including reflux severity.

Conclusion: Esophageal hypomotility, specifically an increase in failed swallows on HRM, from pre- to post-lung transplantation was independently associated with ACR. Additionally, lower baseline TLC correlated with increase in failed swallows, suggesting restrictive lung disease may be associated with post-transplant esophageal hypomotility. Lung transplantation may affect esophageal function and contribute to rejection outcomes. Routine esophageal function testing may help identify patients at higher risk for poor lung transplantation outcomes.