Annals of Transplantation最新文献

BACKGROUND Living donor liver transplantation (LDLT) is an established treatment for end-stage liver disease, where donor safety remains a top priority. Pulmonary embolism (PE) is an unpredictable but serious complication following liver donor hepatectomy (LDH), contributing significantly to postoperative morbidity and mortality. CASE REPORT This article reports 4 cases of PE in living donors following LDH, discussing their clinical presentations, diagnosis, and treatment, and reviewing the relevant literature. Patient 1 was a 46-year-old man who underwent laparotomy right hepatectomy and developed PE on postoperative day (POD) 2. Patient 2 was a 42-year-old woman who donated the left half liver for her son. On POD 8, she was diagnosed with PE by enhanced computed tomography (CT) scan. Patient 3 was a 65-year-old man with 2 years history of hypertension. He underwent a laparotomy right hepatectomy and developed PE on POD 2. Patient 4 was a 57-year-old woman who underwent laparotomy left hepatectomy with the middle hepatic vein. On POD 3, the patient suddenly developed dyspnea after ambulation, and the enhanced CT of pulmonary arteries showed extensive PE in both lungs. All donors developed symptoms such as dyspnea and hypoxemia postoperatively, and were diagnosed with PE through imaging studies. Prompt anticoagulation therapy led to favorable outcomes in all cases. CONCLUSIONS Although PE is a rare and serious complication after LDH, early recognition and timely intervention are crucial to prevent catastrophic outcomes for the donor. Improving perioperative management is key to enhancing donor safety.

BACKGROUND The standard conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) is 200 mg/m² of melphalan (Mel200). Dosing is reduced by 30% (Mel140) in frail patients. Studies comparing the performance of these regimens report inconsistent findings, mainly confounded by non-consecutive patient inclusion, missing data, and heterogenous practices. The largest study reported an increased risk of death with Mel200 among patients with very good partial remission, or better, before ASCT. This retrospective study from a single center compared outcomes of patients with a first ASCT for myeloma treated with melphalan 140 mg/m² or 200 mg/m². MATERIAL AND METHODS This was a retrospective real-world analysis from a single center. Data from 159 consecutive, first, single ASCTs for MM between 2012 and 2021 were included. Mel200 and Mel140 were administered to 131 and 28 patients, respectively. Primary and secondary objectives were overall survival (OS) and progression-free survival (PFS), respectively. RESULTS Median follow-up was 5.8 years. Over 90% received bortezomib-based induction, and over 76% achieved at least very good partial remission (VGPR) before ASCT in either group. PFS estimates were similar between groups (P=0.49). OS was longer with Mel200 (HR=0.42, P=0.002). Mel200 maintained OS superiority in all relevant subgroups. CONCLUSIONS In a homogenous population of patients with MM, Mel200 was associated with longer OS, likely reflecting the physiological state of patients and tolerance to subsequent treatments. Concerns reported from EBMT data regarding the association of Mel200 with mortality among patients with VGPR or better before ASCT are not supported by this study's findings.

BACKGROUND The present study assessed medication adherence to immunosuppressive therapy in pediatric patients following heart transplantation at a tertiary care center. MATERIAL AND METHODS A cross-sectional interview-based study combined with immunosuppressant level monitoring was conducted to encompass all pediatric patients who underwent heart transplants at King Abdulaziz Medical City-Central Region over a period of 5 months from January to May 2024. RESULTS More than 95% of patients' parents completed the questionnaire and were included in the final analysis. Among the pediatric post-heart transplant patients, 12 (60%) were males, aged from 6 to 18 years. Most patients (85%) were on tacrolimus, while 15% were on tacrolimus and sirolimus. Using the average blood serum drug levels and the ITAS, the prevalence of non-adherence was found to be 10% and 5%, respectively. Almost 95% of parents reported that they "Never forget about taking immunosuppressive medication". However, a small percentage reported occasional carelessness and missing administration of immunosuppressive medication to their children (5%). One reason given for stopping or missing medication were due to the child feeling worse in overall health (5%). CONCLUSIONS The results of this study indicate generally good adherence among pediatric post-heart transplant patients. Most participants demonstrated acceptable adherence behaviors. Continuous monitoring, support, and education are still necessary to maintain optimal adherence.

BACKGROUND Acute liver failure (ALF) remains a critical concern, accounting for about 8% of all liver transplants, with acetaminophen overdose contributing to nearly half of these cases. Besides synthetic toxins, natural toxins such as phallotoxin from Amanita phalloides mushrooms also lead to severe hepatocyte damage. This study investigates the outcomes of liver transplantation (LT) as a life-saving intervention in patients suffering from ALF due to acetaminophen and Amanita phalloides poisoning. MATERIAL AND METHODS We conducted a retrospective analysis of 39 patients who underwent LT for ALF induced by acetaminophen (n=18) or A. phalloides (n=21) poisoning at the Medical University of Warsaw. Various statistical analyses, including logistic regression, Mann-Whitney-U, and chi-squared tests, were employed. Survival rates were determined using Kaplan-Meier analysis. RESULTS The cohort included 24 females and 15 males, with a median age of 41. The 90-day mortality rate was 22.2% for acetaminophen poisoning and 38.1% for A. phalloides poisoning (P=0.284), with an estimated 5-year survival rate of 59.6%. Key factors associated with increased 90-day mortality included the number of red blood cells transfused (OR 1.574 per unit; P=0.011), fresh frozen plasma units (OR 1.346 per unit; P=0.003), acute kidney failure requiring hemodialysis (OR 13.50; P=0.021), and days from listing to LT (OR 2.289 per day; P=0.013). CONCLUSIONS Liver transplantation for ALF, though inherently high-risk, offers substantial survival benefits. Outcomes are largely influenced by the patient's condition at the time of transplant, organ availability, and intraoperative management. Despite significant mortality risks, LT remains a crucial intervention for ALF due to acetaminophen and Amanita phalloides toxicity.

BACKGROUND Infection is a cause of morbidity and mortality in solid-organ transplantation (SOT). We evaluated a new score that is applied during the first month after transplantation. The score comprises biomarkers of innate and acquired immunity to predict infections in SOT. MATERIAL AND METHODS Prospectively collected blood samples from 377 heart, liver, or kidney recipients were analyzed at 2 centers in Madrid (Spain) and Lima (Peru). Biomarkers were tested before transplantation and at days 7 and 30 after transplantation. During the first 6 months after transplantation, 183 (48.5%) patients developed severe infections (bacterial infections and/or CMV disease). Risk for severe infection was assessed using logistic regression analysis. We designed a score, the routine immunity score (RIS2020), which is based on the sum of the hazard ratios (HRs) of each biomarker. RESULTS The risk factors for severe infection were as follows: Moderate IgG hypogammaglobulinemia (IgG <600 mg/dL at days 7 or 30, HR 2.07, 95% CI 1.37-3.12, p=0.0005, 2 points), CD4 <400 cells/uL at day 30 (HR 1.76, 95% CI 1.03-3.04, p=0.039, 2 points), C3 <80 mg/dL at day 30 (HR 2.18, 95%CI 1.16-4.06, p=0.014, 2 points), and CRP >3 mg/dL at day 30 (HR 2.11, 95% CI 1.12-3.97, p=0.02, 2 points). In patients with ≥4 points, the HR for infection was 5.18 (95% CI 3.06-8.75; p<0.001). RIS2020 was an independent predictor of severe infection in multivariate models. CONCLUSIONS An immunological score combining moderate IgG hypogammaglobulinemia and other parameters of innate and acquired immunity could better identify the risk for severe infection in SOT.

BACKGROUND We previously reported that the Model for End-stage Liver Disease (MELD) score and donor age are risk factors for small-for-size syndrome in adult living donor liver transplantation (LDLT) involving small grafts. Since April 2021, we have performed splenectomy as a portal inflow modulation in LDLT using small grafts according to the presence of risk factors. In this study, we evaluated the validity of our splenectomy strategies for optimizing graft outcomes. MATERIAL AND METHODS We retrospectively reviewed patients who underwent primary LDLT using left lobe grafts with the middle hepatic vein from January 2005 to January 2024 at our institution. We also compared the graft outcomes between recipients who underwent LDLT beginning in April 2021 (current policy group) and those who underwent LDLT in the era when splenectomy as portal modulation was not indicated (previous policy group). RESULTS In total, 173 consecutive LDLTs (current policy group: n=15) involving left lobe grafts were analyzed. Splenectomy was performed in 9 of 15 (60.0%) patients in the current policy group. All 15 patients in the current policy group remained alive for a median follow-up of 20.5 months. The rate of early allograft dysfunction was significantly lower, and the rate of small-for-size syndrome tended to be lower in the current policy group than in the previous policy group (13.3% vs 39.2%, P=0.047 and 20.0% vs 36.1%, P=0.211, respectively). CONCLUSIONS LDLT with splenectomy for high-risk patients may expand the availability of small left lobe grafts and optimize graft outcomes.

BACKGROUND Recipient hepatic arteries are generally used for arterial reconstructions in living donor liver transplantation. When the hepatic arteries are not feasible, the right gastroepiploic artery is one of the options for arterial reconstructions. In this study, we evaluate the feasibility of using the right gastroepiploic artery and report the analyzed retrospective patient outcomes. MATERIAL AND METHODS We included 324 patients who underwent primary living donor liver transplantation between August 1997 and December 2023. The rates of complications and surgical outcomes for different arteries used for reconstruction were compared between the groups. RESULTS For primary arterial reconstruction, the right gastroepiploic artery was used in 18 patients. The incidence of arterial complications and biliary strictures was higher than in the remaining 306 patients (P=0.01 and P=0.21, respectively). The 1-year and 5-year graft survival rates were 83.3% and 77.8% in the right gastroepiploic artery group, and 83.7% and 70.1% in the hepatic artery group, respectively (P=0.58). Eleven patients underwent arterial re-reconstruction secondary to arterial complications. The right gastroepiploic artery was used for the first time in 7 of these patients because the hepatic arteries were not reusable. Arterial complications after arterial re-reconstruction occurred in 4 patients (36.4%). CONCLUSIONS Arterial reconstruction using the right gastroepiploic artery was an effective option when the hepatic arteries were not suitable options, as it offered graft outcomes comparable to those of hepatic artery reconstruction, despite an increased risk of arterial and biliary complications.

BACKGROUND Despite its surgical complexity, kidney transplantation (KT) with multiple renal arteries (MRA) is comparable in performance to KT with a single renal artery (SRA). This study aimed to evaluate the effect of MRA and to investigate risk factors for graft loss in living-donor KT with MRA. MATERIAL AND METHODS This study included living-donor KT recipients who underwent KT in our hospital from February 2002 to March 2023. The primary outcome was whether MRA decreased the prognosis of transplanted kidneys. The secondary outcomes were the risk factors for graft loss in KT with MRA, such as recipients' characteristic. RESULTS Out of 197 recipients, 47 (23.8%) received kidneys with MRA. In inverse probability of treatment weighting, the risk of graft loss did not increase in KT with MRA, as compared to that in KT with SRA (hazard ratio [HR]: 1.46; 95% confidence interval [CI]: 0.68-3.14). MRA were associated with graft loss in ABO blood-incompatible KT (HR: 5.09, 95% CI: 1.75-14.7). CONCLUSIONS In ABO blood-incompatible KT, MRA can increase risk of graft loss.

BACKGROUND Acute respiratory distress syndrome (ARDS) due to coronavirus 2019 (COVID-19) can result in severe disease requiring mechanical ventilatory support. A subset of these patients, however, demonstrate refractory hypoxemia/hypercarbia requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO) as adjunctive therapy. The primary goal of V-V ECMO is a "bridge" to recovery of native lung function; however, patients may progress to irreversible pulmonary damage requiring lung transplantation. MATERIAL AND METHODS We conducted a retrospective review of patients with refractory COVID-19 ARDS/pulmonary fibrosis that required a V-V ECMO bridge to lung transplantation at our institution from May 2021 to December 2022. Data for analysis included patient demographics, pre/post-transplantation course, and 1-year outcomes. RESULTS Nine patients (6 male, 3 female) with an average age of 44.6±12.1 years required V-V ECMO support for COVID-19 and subsequently underwent lung transplantation. The median number of ECMO days was 57 (IQR 53-78). At listing, these patients had a median lung allocation score (LAS) of 91.86 (IQR 89.05-92.13). The median hospital length-of-stay was 89 days (IQR 54-144) with the longest hospital stay at 255 days. All patients were discharged home and survived to 1-year post-transplant. CONCLUSIONS Our case series shows that patients with COVID-19 ARDS/pulmonary fibrosis had no meaningful difference in overall survival compared to our institution's overall 1-year lung transplant survival rate. Our results suggest that with careful selection and care, long-term lung transplantation outcomes can be equivalent for those requiring a bridge to transplantation with V-V ECMO support despite the severity of illness in the peri-transplant period.

BACKGROUND Medical accessibility is important in liver transplantation (LT) because of the risk of infections associated with the use of immunosuppressants and complications that require continuous treatment, such as biliary stenosis. However, the effect of medical accessibility on LT success rates has yet to be scrutinized. The aim of this retrospective observational study is to determine whether medical accessibility affects LT outcomes. MATERIAL AND METHODS We enrolled patients who had undergone LT at Samsung Medical Center between January 2017 and December 2021. The level of medical access was divided into 2 categories (difficult and easy) based on a cutoff of a 120-min commute on public transportation to access LT. Baseline characteristics were calibrated with propensity score matching. The outcomes (overall survival and graft survival) and severity of emergency center visits according to medical accessibility were also investigated. RESULTS A total of 486 patients was included in this study. The median time to reach the hospital by public transportation was 135 min. Sex, Child-Pugh classification, Model for End-stage Liver Disease score, presence of hepatocellular carcinoma, and donor type were calibrated with propensity score matching, and each group consisted of 186 patients. The overall survival (88.3% vs 86.2%, P=0.67, 5-year) and graft survival (98.6% vs 95.4%, P=0.086, 5-year) showed no significant differences between the difficult-to-access and easy-to-access groups. While severity of emergency center visits differed between the difficult group (27.6%) and the easy group (15.5%), the difference was not statistically significant. CONCLUSIONS Medical access to LT did tend to increase emergency center presentation severity but did not affect long-term outcomes.