6-month Graft Research Articles

Clinical validation of preoperative serum markers for liver fibrosis in living donor liver transplantation recipients.

To validate the reliability of fibrosis markers as predictors of graft survival in living donor liver transplantation (LDLT) recipients. We reviewed data retrospectively, from 163 patients who underwent adult LDLT with preoperative measurements of type IV collagen (CIV), Mac-2 binding protein glycosylation isomer (M2BPGi), and hyaluronic acid (HA). Patients were divided into high and low groups for each biomarker, based on optimal cutoff values, and graft loss within 6months was evaluated in each group. The high CIV level group showed significantly lower 6-month graft survival rates and significantly higher rates of postoperative sepsis and sepsis from pneumonia. However, the groups with high and low M2BPGi levels and those with high and low HA levels did not show significant differences in 6-month graft survival rates or rates of postoperative sepsis. Multivariate analysis revealed that a CIV level ≥ 590 was a significant predictor of graft loss within 6months, postoperative sepsis, and sepsis from pneumonia. Unlike other fibrosis markers, preoperative CIV levels can predict graft survival, postoperative sepsis, and sepsis from pneumonia after LDLT.

The learning curve for modified hand-assisted retroperitoneoscopic living donor nephrectomy

BackgroundWe aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve.MethodsOne hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome.ResultsIn total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (–0.09 case number2) + (12.88 case number) – 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications.ConclusionsOur modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.

Association of the Inlay Structure Used in the Modified Bristow Procedure With Accelerated Bone Union: Comparing the Cuistow and Modified Bristow Procedures.

The Chinese unique inlay Bristow (Cuistow) procedure is a modified Bristow surgery in which an inlay (mortise-and-tenon) structure is added to the contact surface between the coracoid tip and the glenoid. Patients who have undergone the Cuistow procedure have had satisfying clinical performance and excellent postoperative bone healing rates (96.1%). To compare the clinical and radiographic outcomes after the arthroscopic Cuistow procedure and the arthroscopic Bristow procedure. Cohort study; Level of evidence, 3. A total of 91 patients who underwent either the Cuistow or Bristow procedure between January 2017 and March 2018 were selected, and 69 patients (70 shoulders; 35 in the Cuistow group and 35 in the Bristow group) were included. Clinical assessment at minimum 24 months postoperatively, including the visual analog scale for pain and instability, American Shoulder and Elbow Surgeons score, Rowe score, subjective shoulder value score, and active range of motion, was completed by independent observers and compared with values collected preoperatively. Assessment with 3-dimensional computed tomography scans was performed preoperatively; immediately after the operation; at 3, 6, and 12 months postoperatively; and at the final follow-up. A total of 69 patients (70 shoulders) were included, with a mean follow-up duration of 34.41 ± 5.99 months (range, 24-50 months). Both groups saw significant improvement in visual analog scale for pain and instability, American Shoulder and Elbow Surgeons, Rowe, and subjective shoulder value scores at the final follow-up compared with the preoperative values (P < .001 for all), with no significant between-group differences on any clinical outcomes at the final follow-up. The 3-month postoperative graft union rate on computed tomography was significantly higher in the Cuistow group compared with the Bristow group (82.9% vs 51.4%, respectively, P = .003), although the graft union rate at the final follow-up was not significantly different (94.3% vs 85.7%, respectively; P = .449). Patients receiving the Cuistow procedure had equivalent clinical outcomes and a significantly higher bone union rate at 3 months postoperatively than those in the Bristow group. The inlay structure used in the Cuistow procedure was found to be associated with accelerated bone union.

Contrast-Enhanced Ultrasonography Findings Within 3 Days Postoperatively Are Associated With 1-Month Graft Failure After Split Liver Transplantation

Purpose:To evaluate whether Doppler ultrasonography (DUS) and contrast-enhanced ultrasonography (CEUS) within 3 days postoperative can identify 1-month graft failure after split liver transplantation (SLT). Materials and methodsA total of 58 consecutive patients who underwent SLT between February 2022 and September 2023 were included. The DUS and CEUS images and parameters within 3 days postoperatively were analyzed and recorded. The DUS parameters included peak systolic velocity (PSV), resistive index, and systolic acceleration time for the hepatic artery, PSV for the portal vein and hepatic vein. The CEUS qualitative analysis variables included the liver parenchyma enhancement pattern and the posterior enhancement attenuation. Logistic regression and Cox proportional hazard regression were used to evaluate the relationship between DUS/CEUS findings and 1-month graft failure. ResultsSeven of the 58 liver grafts failed within one month. Poor CEUS enhancement (pattern Ⅱ/Ⅲ) was observed in 5 of 7 patients (71.4%) of graft failure, whereas good contrast enhancement (pattern Ⅰ) was found in 47 of the 51 patients (92.1%) in the successful group on postoperative day 3. Multivariate logistic regression analysis revealed that 1-month graft failure was independently predicted by operative time (OR=3.79, 95% CI: 1.27–11.29, p=.017) and CEUS enhancement pattern on postoperative day 3 (OR=90.88, 95% CI: 2.77–2979.56, p=.011). Cox proportional hazard regression showed that operative time ( HR=1.6, 95% CI: 1.15–2.22, p =.005) and CEUS enhancement pattern on postoperative day 3 (HR=11.947, 95% CI: 2.04–69.98, p =.006) were independent predictors for graft failure. ConclusionsPoor CEUS enhancement (pattern Ⅱ/Ⅲ) was associated with 1-month graft failure in SLT recipients. CEUS may serve as a noninvasive, valuable prognostic tool to predict clinical outcomes early after SLT.

442 Prophylactic Peri-Nephric Drain Placement in Renal Transplant Surgery: A Systematic Review and Meta-Analysis

Abstract Aim Usage of prophylactic perinephric drains is variable in renal transplantation, drains are associated with risks, and there is a lack of consensus as to the relative benefit of placing a drain intraoperatively in this patient cohort. This meta-analysis assessed whether prophylactic perinephric drainage reduced the need for postoperative intervention to manage collections. Method This systematic review and meta-analysis was performed using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis and was prospectively registered on PROSPERO (CRD42021255795). A literature search was carried out in June 2023, and titles and s was screened against our pre-defined criteria. Quality assessment was performed using the Newcastle Ottawa Scale. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). Results Literature search revealed 1540 unique titles and s across all four databases. Of these, 4 retrospective cohort studies were selected. Meta-analysis of 3 studies showed no evidence of a significant reduction in reintervention rate with drain placement, OR=0.59 (95%CI: 0.16-2.23, p=0.44). Meta-analysis did not show a significant reduction in perinephric collections with drainage OR=0.55 (95%CI: 0.13-2.37, p=0.42). Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Conclusions Given the lack of current evidence basis supporting the practice of prophylactic perinephric drain placement in renal transplantation, we advocate for a drain-free strategy in this patient cohort. Well-designed, prospective studies to assess the risks and benefits of intraoperative drain placement in these patients is needed.

Perfusion Techniques in Kidney Allograft Preservation to Reduce Ischemic Reperfusion Injury: A Systematic Review and Meta-Analysis.

The limited supply and rising demand for kidney transplantation has led to the use of allografts more susceptible to ischemic reperfusion injury (IRI) and oxidative stress to expand the donor pool. Organ preservation and procurement techniques, such as machine perfusion (MP) and normothermic regional perfusion (NRP), have been developed to preserve allograft function, though their long-term outcomes have been more challenging to investigate. We performed a systematic review and meta-analysis to examine the benefits of MP and NRP compared to traditional preservation techniques. PubMed (MEDLINE), Embase, Cochrane, and Scopus databases were queried, and of 13,794 articles identified, 54 manuscripts were included (n = 41 MP; n = 13 NRP). MP decreased the rates of 12-month graft failure (OR 0.67; 95%CI 0.55, 0.80) and other perioperative outcomes such as delayed graft function (OR 0.65; 95%CI 0.54, 0.79), primary nonfunction (OR 0.63; 95%CI 0.44, 0.90), and hospital length of stay (15.5 days vs. 18.4 days) compared to static cold storage. NRP reduced the rates of acute rejection (OR 0.48; 95%CI 0.35, 0.67) compared to in situ perfusion. Overall, MP and NRP are effective techniques to mitigate IRI and play an important role in safely expanding the donor pool to satisfy the increasing demands of kidney transplantation.

#1645 The role of donor Cystatin-C in posttransplant outcomes in kidney transplantation

Abstract Background and Aims Cystatin-C is an established marker of glomerular filtration rate in kidney disease. High levels of cystatin-C have been associated with unfavorable outcomes (acute kidney injury, cardiovascular morbidity) in critically ill patients. The aim of this study was to evaluate the levels of Cystatin-C in donors after brain (DBD) and circulatory death (DCD) and investigate its association with posttransplant graft function. Method Plasma samples from 303 donors (283 deceased, 20 living donors; LD) were obtained from the Quality in Organ Donation (QUOD) and the Oxford Transplant (OTB) biobanks. QUOD is a national multi-center UK wide bioresource of deceased donor clinical samples collected during donor management and organ procurement. OTB is a living donor biobank established to obtain clinical samples as control cohorts. Only deceased donors with both grafts transplanted were included in the study. Plasma Cystatin-C from LD samples as assessed as an optimal control group. The samples were linked to donor and recipient metadata obtained from the National Transplant Registry (NHSBT). Using Luminex assays, plasma Cystatin-C was quantified in samples collected during donor management (prior to cross clamp in DBDs and LDs and at withdrawal of support in DCDs). We performed descriptive statistics and multivariate linear and logistic analysis to determine the association between Cystatin-C, primary non-function (PNF), delayed graft function (DGF), acute rejection (AR) and 12-month posttransplant graft function. Results Among 303 donors (median age: 50 years), 126 were DCDs, 157 DBDs (20.1% of them were expanded criteria donors, ECD) and 20 LDs. ECDs and DCDs had significantly higher levels of Cystatin-C, compared to DBDs. In a total of 606 recipients, 11 (1.9%) developed PNF, and 128 (21%) developed DGF (24 as pairs, 80 non-pairs). Forty-six recipients (7.6%) experienced at least one AR episode and 60 (10%) donors had lost the graft during follow-up. Donor levels of Cystatin-C were associated with DGF and were further elevated in donors of kidneys which developed PNF (P-value &amp;lt; .0001, Fig. 1). Grafts with acute rejections were retrieved from donors with higher levels of Cystatin-C, but the difference did not meet statistical significance. Cystatin-C levels were significantly lower (P-value &amp;lt; .0001) in donors who offered concordant grafts with optimal 12-month post-transplant function (eGFR &amp;gt;60 ml/min), compared with grafts with intermediate function (GFR 30-60 ml/min) or eGFR &amp;lt;30ml/min (Fig. 2). LDs had significantly lower levels of Cystatin-C compared to deceased donors in all studied outcomes (Figs 1 and 2). Cystatin-C during donor management was an independent risk factor for inferior 12-month paired graft function, after the implementation of three different multivariate models, including donor (β-coef = −11.3, P-value = .001), recipient (β-coef = −16, P-value &amp;lt; .001) and post-transplant characteristics (β-coef = −13.1, P-value = .002). Conclusion In a large cohort of deceased and living donors, we were able to evaluate the circulating levels of Cystatin-C during donor management with the use of high-end performance technology. The concentration of Cystatin-C was notably different among donor types and was significantly higher in donors with kidneys that developed PNF or had suboptimal graft function 12-month posttransplant. Our findings suggest that Cystatin-C may have a role in identifying higher-risk donors during donor management and offers the opportunity for granular assessment of donor kidney quality prior to transplantation.

The reduced function allele SLCO1B1 c.521T>C is of no practical relevance for the renal graft function over the first post-transplant year in patients treated with mycophenolic acid.

It is unclear whether renal transplant recipients treated with mycophenolic acid (MPA) who carry the reduced-function allele at polymorphism SLCO1B1 c.521T>C differ from their wild-type peers regarding renal outcomes and tolerability. We aimed to estimate the effect of this polymorphism on the graft function (estimated glomerular filtration rate, eGFR) over the first 12 post-transplant months in patients on MPA-based maintenance immunosuppression. In a 12-month observational cohort study, consecutive adult patients were repeatedly assessed for eGFR. The SLCO1B1 c.521C>T variant allele carriers (exposed) and wild-type subjects (controls) were balanced on a range of demographic, medical, and genetic variables at baseline, and eGFR trajectory was estimated with further adjustment for time-varying covariates. A subset of patients were assessed for exposure to MPA 5-7 days after the transplantation. The adjusted eGFR slopes from day 1 to day 28 (daily), and from day 28 to day 365 (monthly) were practically identical in exposed (n = 86) and control (n = 168) patients [geometric means ratios (GMR) = 0.99, 95% confidence interval (CI) = 0.92-1.06 and GMR = 0.98, 0.94-1.01, respectively]. The rates of adverse renal outcomes and possible MPA-related adverse effects were low, and similar in exposed and controls [rate ratios (RR) = 0.94, 0.49-1.84 and RR = 1.08, 0.74-1.58, respectively]. The pharmacokinetic analysis did not signal meaningful differences regarding exposure to MPA, overall (exposed n = 23, control n = 45), if cotreated with cyclosporine (n = 17 vs. n = 26) or with tacrolimus (n = 8 vs. n = 17). In patients treated with MPA, variant allele SLCO1B1 c.521T>C appears of no practical relevance regarding the 12-month renal graft function, MPA safety and exposure to MPA at early steady-state.

Prophylactic Peri-Nephric Drain Placement in Renal Transplant Surgery: A Systematic Review and Meta-Analysis.

Renal transplantation is common worldwide, with >25,000 procedures performed in 2022. Usage of prophylactic perinephric drains is variable in renal transplantation; drains are associated with risks, and there is a lack of consensus regarding benefit of routine drain placement in these patients. This meta-analysis assessed whether prophylactic drainage reduced need for reintervention postoperatively. This systematic review and meta-analysis was carried out using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis, and prospectively registered on PROSPERO. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). A systematic literature search in June 2023 revealed 1,540 unique articles across four databases. Of these, four retrospective cohort studies were selected. Meta-analysis of three studies showed no significant reduction in reintervention rate with pre-emptive drain placement, OR = 0.59 (95% CI: 0.16-2.23), p = 0.44. Meta-analysis did not show a significant reduction in perinephric collections with prophylactic drain insertion OR = 0.55 (95% CI: 0.13-2.37), p = 0.42. Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Further work is needed, including well-designed, prospective studies to assess the risks and benefits of drain placement in these patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422685, Identifier PROSPERO CRD42021255795.

Early-onset hepatic veno-occlusive disease after liver transplantation: an institutional experience and analysis of a literature-based cohort.

Hepatic veno-occlusive disease (HVOD) after liver transplantation (LT) is almost always a fatal complication. We assessed the outcomes of HVOD in a single institute and analyzed a literature-based cohort. We reviewed the medical records of recipients of LT performed between 1995 and 2020 at our institute and the literature on HVOD after LT. We then analyzed the clinical features based on a "pooled" cohort of cases identified in our institute and reported in the literature. HVOD was diagnosed in 3 of 331 LT recipients, all of whom died in hospital, on days 164, 12, and 13, respectively. Our comprehensive review of the literature, as well as our cases, identified eight cases of HVOD that developed within 14days after LT (early-onset type). Early-onset HVOD had a significantly worse prognosis than HVOD that developed beyond 2weeks after LT (non-early-onset type), which was identified in 22 cases (25.0% vs. 86.1% of the 3-month graft survival rate). The most common causes of early-onset and non-early-onset types were acute cellular rejection (50%) and drug-induced disease (50%), respectively. Early-onset HVOD developing within 14days after LT has a poor prognosis.

The short and long-term prognostic influences of liver grafts with high bilirubin levels at the time of organ recovery.

Donors with hyperbilirubinemia are often not utilized for liver transplantation (LT) due to concerns about potential liver dysfunction and graft survival. The potential to mitigate organ shortages using such donors remains unclear. This study analyzed adult deceased donor data from the United Network for Organ Sharing database (2002-2022). Hyperbilirubinemia was categorized as high total bilirubin (3.0-5.0mg/dL) and very high bilirubin (≥5.0mg/dL) in brain-dead donors. We assessed the impact of donor hyperbilirubinemia on 3-month and 3-year graft survival, comparing these outcomes to donors after circulatory death (DCD). Of 138622 donors, 3452 (2.5%) had high bilirubin and 1999 (1.4%) had very high bilirubin levels. Utilization rates for normal, high, and very high bilirubin groups were 73.5%, 56.4%, and 29.2%, respectively. No significant differences were found in 3-month and 3-year graft survival between groups. Donors with high bilirubin had superior 3-year graft survival compared to DCD (hazard ratio .83, p=.02). Factors associated with inferior short-term graft survival included recipient medical condition in intensive care unit (ICU) and longer cold ischemic time; factors associated with inferior long-term graft survival included older donor age, recipient medical condition in ICU, older recipient age, and longer cold ischemic time. Donors with ≥10% macrosteatosis in the very high bilirubin group were also associated with worse 3-year graft survival (p=.04). The study suggests that despite many grafts with hyperbilirubinemia being non-utilized, acceptable post-LT outcomes can be achieved using donors with hyperbilirubinemia. Careful selection may increase utilization and expand the donor pool without negatively affecting graft outcome.

Outcomes of living donor liver transplant recipients receiving grafts with the Graft-to-Recipient weight ratio less than 0.6%: A matched pair analysis.

We sometimes experience living donor liver transplantation (LDLT) involving very small grafts with graft-to-recipient weight ratio (GRWR) <0.6% when the actual graft size is smaller than predicted. The outcomes in this situation have not been fully investigated. The present study aimed to determine the graft outcomes of LDLT with GRWR <0.6%. We retrospectively reviewed 280 cases of adult LDLT performed at our institution between January 2000 and March 2021. In our institution, the lower limit for graft volume/standard liver volume ratio was 30%. The patients were divided into two groups according to the cutoff value of 0.6% for actual GRWR. Graft survival and surgical outcomes including small-for-size syndrome (SFSS) were compared between the groups using propensity score matching (PSM) analysis. Risk factors associated with SFSS in recipients with GRWR <0.6% were also evaluated. Fifty-nine patients received grafts with GRWR <0.6%. After PSM, similar graft survival rates were observed for GRWR <0.6% (n=53) and GRWR ≥0.6% (n=53) (p=0.98). However, patients with GRWR <0.6% had a significantly worse 3-month graft survival rate (86.8% vs. 98.1%, p=0.03) and higher incidence of SFSS (p<0.001) than patients with GRWR ≥0.6%. On multivariate analysis, Model for End-Stage Liver Disease score and donor age were associated with SFSS in patients with GRWR <0.6%. The same factors were also associated with graft survival. In conclusions, although similar overall graft survival rates were observed for LDLT with GRWR <0.6% and GRWR ≥0.6%, GRWR <0.6% was associated with an increased risk of SFSS. Appropriate donor and recipient selection is important for successful LDLT with very small grafts.

Comparative analysis of models predicting the risks of early poor outcome of deceased-donor liver transplantation: a retrospective single-center study

Rationale. The risk of early graft loss determines the specifics and plan of anesthesiological assistance, intensive therapy, and overall the feasibility of liver transplantation. Various prognostic models and criteria have become widespread abroad; however, Russian transplant centers have not yet validated them.Objective. To evaluate the applicability and accuracy of the most common models predicting the risks of early adverse outcomes in liver transplantation from deceased donors.Material and methods. A retrospective single-center study included data on 131 liver transplantations from deceased donors performed between May 2012 and January 2023. For each observation, DRI, SOFT, D-MELD, BAR, MEAF, L-GrAFT, and EASE indices were calculated, and compliance with an early allograft dysfunction criteria was verified. Depending on the possibility of calculating the indicators and their values relative to known cutoff points, the study groups were formed, and 1-, 3-, 6-, and 12-month graft survival rates were calculated. The forecast was compared with the actual outcomes, and sensitivity, specificity, F1-score, and C-index were calculated.Results. When assessing the risk of 1- and 3-month graft loss, models using only preoperative parameters demonstrated relatively low prognostic significance: DRI (F1-score: 0.16; C-index: 0.54), SOFT (F1-score: 0.42; C-index: 0.64), D-MELD (F1-score: 0.30; C-index: 0.58), and BAR (F1-score: 0.23; C-index: 0.57). Postoperative indices of MEAF (F1- score: 0.44; C-index: 0.74) and L-GrAFT (F1-score: 0.32; C-index: 0.65) were applicable in 96%, those of ABC (F1-score: 0.29; C-index: 0.71) in 91%, and EASE (F1-score: 0.26; C-index: 0.80) in 89% of cases. The relative risk of 30-days graft loss in case of EAD was 5.2 (95% CI: 3.4-8.1; p&lt;0.0001), F1-score: 0.64, and C-index: 0.84. Using locally established cutoff values for SOFT (11 points) and L-GrAFT (-0.87) scores increased their prognostic significance: F1-score: 0.46 and 0.63, C-index: 0.69 and 0.87, respectively.Conclusion. The analyzed models can be used to assess the risks of early liver graft loss; however, their prognostic significance is not high. Developing a new model in a multicenter Russian study, as well as searching for new objective methods to assess the state of the donor liver are promising directions for future work.

The Case | Crescentic glomerulonephritis in a kidney transplant recipient

A 55-year-old man was referred for acute kidney failure. He had undergone a kidney transplantation for focal segmental glomerulosclerosis 6 months before admission. Medical history consisted of hypertension, hypercholesterolemia, monoclonal gammopathy of unknown significance (IgM λ), and tertiary hyperparathyroidism secondary to chronic kidney disease. After anti-thymocyte globulin induction, the maintenance regimen consisted of azathioprine, tacrolimus, and corticosteroids. His baseline creatinine level was around 150 μmol/L, no proteinuria was detected, and a 3-month protocol graft biopsy was unremarkable. Three months after kidney transplantation, the patient developed primary cytomegalovirus infection despite valganciclovir prophylactic treatment in the setting of donor cytomegalovirus positive and recipient negative. No specific organ involvement was detected, and a ganciclovir-based regimen was started. Because of persistent viremia, 2 months after ganciclovir treatment, cytomegalovirus antiviral resistance testing was performed and a UL97 ganciclovir resistance mutation was detected. I.v. foscarnet treatment was initiated at 100 mg/kg per day.

Donation after circulatory death heart procurement strategy impacts utilization and outcomes of concurrently procured abdominal organs

The impact of donation after circulatory death (DCD) heart procurement techniques on the utilization and outcomes of concurrently procured DCD livers and kidneys remains unclear. Using the United Network for Organ Sharing database, we identified 246 DCD donors whose heart was procured using direct procurement and ex-situ machine perfusion and 128 DCD donors whose heart was procured using in-situ thoracoabdominal normothermic regional perfusion (12/2019-03/2022). We evaluated the transplantation rate of concurrently procured DCD livers and kidneys (defined as the number of organs transplanted/total number of organs available for procurement) and their post-transplant outcomes. The transplantation rate of concurrently procured DCD livers was higher with in-situ perfusion compared to direct procurement (67.1% vs 56.5%, p=0.045). After excluding pediatric, multiorgan, and repeat transplant recipients, there was no difference in 6-month liver graft failure rate (direct procurement 0.9% vs in-situ perfusion 0%, p > 0.99). Recipients of kidneys procured with in-situ perfusion had less delayed graft function (11.3% vs 41.5%, p < 0.0001) shorter length of stay, and lower serum creatinine at discharge (both p < 0.05). Six-month recipient survival in the direct procurement and in-situ perfusion group were similar after DCD liver and kidney transplantation (p=0.24 and 0.79 respectively). Compared to direct procurement, DCD heart procurement with in-situ thoracoabdominal normothermic regional perfusion was associated with increased utilization of DCD livers and a lower incidence of delayed graft function in concurrently procured DCD kidneys. Broader implementation of DCD heart transplantation must maximize the transplant potential of concurrently procured abdominal organs and ensure their successful outcomes.

Utility of Pre-Transplant Bladder Cycling for Patients With a Defunctionalized Bladder. A Randomized Controlled Trial

To study the necessity of pre-transplant programmed bladder cycling (PBC) in patients with defunctionalized bladder (DB). This RCT included renal transplant (RT) candidates with DB. Eligible patients were assigned to two groups, group I underwent PBC before RT and group II underwent direct RT into the DB. The primary outcome was to assess the efficacy of PBC in improving post- RT bladder capacity. Secondly, to compare its impact on early urological complications and 3-month voiding function and 1-year graft function and survival. Graft function was evaluated using serum creatinine and eGFR using MDRD equation. Groups I included 23 patients and group II included 20 patients. The mean ±SD of bladder capacity was 88.7±11.7ml and 90.6 ±9.8ml in both groups, respectively (P= 0.5). In group I, PBC increased bladder capacity to 194.7 ±21.2 ml (P<0.001). Targeted bladder capacity was achieved in 19 (82.6 %) patients and two patients developed UTI. At 3-months, bladder capacity, compliance and bladder contractility index improved significantly in both groups with a significant reduction in maximum detrusor pressure with no significant difference between both groups (P= 0.3,0.4, 0.2 and 0.8, respectively). Urinary leakage occurred in one (4.3%) and three patients (15%) in group 1 and 2, respectively (P=0.2). At 1-year, no statistically significant differences in the median (IQR) serum creatinine (P= 0.05) and eGFR (P= 0.07) between both groups were noted. Pre-transplant PBC for DB-patients provided no clinical advantage concerning postoperative urological complication, urodynamic criteria and graft function and survival.

Validation of risk scores for allograft failure after liver transplantation in Germany: a retrospective cohort analysis.

A growing number of clinical risk scores have been proposed to predict allograft failure after liver transplantation. However, validation of currently available scores in the Eurotransplant region is still lacking. We aimed to analyze all clinically relevant donor and recipient risk scores on a large German liver transplantation data set and performed a retrospective cohort analysis of liver transplantations performed at the Charité-Universitätsmedizin Berlin from January 2007 until December 2021 with organs from donation after brain death. We analyzed 9 previously published scores in 906 liver transplantations [Eurotransplant donor risk index (ET-DRI/DRI), donor age and model for end-stage liver disease (D-MELD), balance of risk (BAR), early allograft dysfunction (EAD), model for early allograft function (MEAF), liver graft assessment following transplantation (L-GrAFT7), early allograft failure simplified estimation (EASE), and a score by Rhu and colleagues). The EASE score had the best predictive value for 3-month, 6-month, and 12-month graft survival with a c-statistic of 0.8, 0.77, and 0.78, respectively. In subgroup analyses, the EASE score was suited best for male recipients with a high-MELD (>25) and an EAD organ. Scores only based on pretransplant data performed worse compared to scores including postoperative data (eg, ET-DRI vs. EAD, p<0.001 at 3-month graft survival). Out of these, the BAR score performed best with a c-statistic of 0.6. This a comprehensive comparison of the clinical utility of risk scores after liver transplantation. The EASE score sufficiently predicted 12-month graft and patient survival. Despite a relatively complex calculation, the EASE score provides significant prognostic value for patients and health care professionals in the Eurotransplant region.

Donor Skeletal Muscle Quality Affects Graft Mortality After Living Donor Liver Transplantation- A Single Center, Retrospective Study.

The recipient muscle status is closely associated with postoperative poor survival in recipients of living donor liver transplantation (LDLT). However, it is uncertain whether LDLT donor muscle quality and quantity affect graft quality. Hence, we analyzed the correlation between donor muscle status and graft function. We measured the skeletal muscle mass index (SMI) and intramuscular adipose tissue content (IMAC) of 380 LDLT donors. We examined the correlation between donor SMI or IMAC and graft mortality, the occurrence rates of small-for-size graft (SFSG) syndrome, and 6-month graft survival rates. The donor SMI had no effect on the occurrence of SFSG syndrome and graft survival, while a high IMAC in both male and female donors was significantly correlated with the rate of SFSG syndrome [high vs low: (male donors) 15.8% vs. 2.5%, p = 0.0003; (female donors) 12.8% vs. 3.1%, p = 0.0234] and 6-month graft survival rates [(male donors) 87.7% vs 95.9%, p = 0.02; (female donors) 83.0% vs. 99.0%, p < 0.0001]. Multivariate analysis revealed that a high donor IMAC (HR; 5.42, CI; 2.13-13.8, p = 0.0004) was an independent risk factor for 6-month graft survival, and the donor IMAC is useful for donor selection for high-risk recipients.

De novo posttransplant membranous nephropathy following BNT162b2 mRNA COVID-19 vaccine in a kidney transplant recipient

To the Editor: Mass COVID-19 vaccination programs in kidney transplant patients (KTRs) have demonstrated an excellent safety profile, without increased rates of ensuing alloimmune events. However, autoimmune diseases may seldom occur after vaccination. We report the case of a KTR who presented de novo posttransplant membranous nephropathy (MN) following administration of COVID-19 vaccine. A 66-year-old patient underwent first kidney transplantation for autosomal-dominant polycystic-kidney-disease-related end-stage kidney disease in June 2020. His medical history included hypertension and left nephrectomy in 2016. After basiliximab induction, the maintenance regimen consisted of tacrolimus, mycophenolic acid, and steroids. His baseline creatinine level was 100 μmol/L, and he remained free of proteinuria during the posttransplant course. A 3-month protocol graft biopsy was unremarkable. Immunohistochemistry (IHC) C4d staining was negative (Figure 1A,B). The patient received the second injection of the BNT162b2 mRNA COVID-19 vaccine (Pfizer-BioNTech) in March 2021. Subsequent serology tests showed negative results, consistent with a blunted antibody response to the vaccine, as widely reported in KTRs. Eight weeks after the second vaccine dose, the patient underwent a 1-year protocol graft biopsy. Concurrent creatinine level and proteinuria were 120 μmol/L and negative, respectively. Light microscopy showed normal glomeruli and ruled out subclinical rejection(Figure 1D). However, C4d staining revealed the presence of granular staining along the glomerular basement membrane consistent with stage 1 MN (Figure 1E). Anti-phospholipase-A2-receptor (PLA2R) immunochemistry analysis showed strong positive staining on the glomerular capillary walls (Figure 1F). Circulating PLA2R antibodies were negative. Notably, IHC staining for PLA2R and C4d was retrospectively negative in the 3-month protocol graft biopsy (Figure 1E) and in the native kidney specimen (nephrectomy). The residual renal parenchyma on the native kidney contained non-sclerotic glomeruli. We retrospectively performed Jones staining which did not show irregularities of the glomerular basement membrane suggestive of membranous nephropathy. There was no available frozen sample on the renal parenchyma. Hence, the diagnosis of de novo posttransplant MN was firmly established. Screening for malignancy and infections remained negative, excluding secondary causes of MN. COVID-19 tests remained also negative (SARS-CoV-2 PCR was negative at MN diagnosis and 3 months after the diagnosis. Anti-Spike IgG were negative 1 and 2 months after the diagnosis). This is the first case of de novo posttransplant MN following mRNA COVID-19 vaccine. Interestingly, cases of de novo or relapsing MN after COVID-19 vaccine have recently been reported.1Aydin MF Yildiz A Oruc A et al.Relapse of primary membranous nephropathy after inactivated SARS-CoV-2 virus vaccination.Kidney Int. 2021; 100 (doi:10.1016/j.kint.2021.05.001): 464-465Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 2Da Y Goh GH Khatri P A case of membranous nephropathy following Pfizer-BioNTech mRNA vaccination against COVID-19.Kidney Int. 2021; 100 (doi:10.1016/j.kint.2021.07.016): 938-939Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Gueguen L Loheac C Saidani N Khatchatourian L Membranous nephropathy following anti-COVID-19 mRNA vaccination.Kidney Int. 2021; S0085-2538 (doi:10.1016/j.kint.2021.08.006): 00752-00757Google Scholar Additionally, rare cases of MN (including one PLA2R+ case) have been described after COVID-19 infection.4Nasr SH Alexander MP Cornell LD et al.Kidney biopsy findings in patients with COVID-19, kidney injury, and proteinuria.Am J Kidney Dis. 2021; 77 (doi:10.1053/j.ajkd.2020.11.002): 465-468Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The temporality between COVID-19 vaccination and PLA2R+ MN in a patient without history of MN and in whom the etiological workup has remained otherwise negative, supports a causal link. However, we must acknowledge that a coincidental association could not be ruled out. Given the lack of proteinuria, no specific treatment was introduced. The subclinical presentation of MN may be related to the mitigating effects of maintenance immunosuppressive therapy. In conclusion, auto-immune reactivity and MN may occur after mRNA COVID-19 vaccine. This report will raise awareness of nephrologists for the need to closely monitor patients with primary MN, following COVID-19 vaccination, including KTRs. If proteinuria occurs after vaccination, a graft biopsy should be promptly performed to firmly establish the diagnosis. We would like to thank Ms. Roberta Vellve for the English language review. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation. Additional supporting information can be found online in the Supporting Information section at the end of this article. Download .docx (.03 MB) Help with docx files Appendix S1

Comparison of Outcomes in High Donation after Circulatory Death Liver Transplantation Usage Centers in the Acuity Circles Era

INTRODUCTION: The recent acuity circles (AC) liver allocation policy has increased rates of donation after circulatory death (DCD) liver transplantation. We hypothesize that transplant centers with high-volume DCD graft usage may have differing outcomes. METHODS: All adult DCD transplant recipients in the United Network for Organ Sharing (UNOS) STAR file from January 11, 2016, to September 30, 2021, were included. Living liver grafts, pediatric, and nonkidney simultaneous transplantation were excluded. The top decile of DCD transplant centers by volume per year were identified. Six-month and 1-year patient and liver graft survival were compared with bottom 90% usage centers by using propensity score–matched fine gray regression models. Outcomes were stratified by pre-AC (January 11, 2016 to February 3, 2020) and post-AC (February 4, 2020 to September 30, 2020) eras (Figure). Transplant recipients that cross eras were censored on the last day of the pre-AC era. RESULTS: Included in this study were 2,299 DCD liver transplantation recipients : 2012 in pre-AC and 287 in post-AC eras. High DCD volume (top decile) centers had significantly improved 6-month (hazard ratio 0.32, 95% CI 0.11 to 0.91, p = 0.033) and 1-year (hazard ratio 0.42, 95% CI 0.17 to 0.98, p = 0.043) patient survival in the post-AC era compared with bottom 90% centers by volume. No significant differences were noted in 6-month or 1-year liver graft survival in either era. CONCLUSION: The top decile DCD transplantation volume centers have improved 6-month and 1-year patient survival compared with the lower volume centers with the introduction of the AC policy.Figure