Date Of Transplantation Research Articles

Skin cancer in renal transplant recipients: outcomes from a safety net hospital in Boston.

Renal transplant recipients (RTRs) are prone to skin cancer due to the immunosuppression required to maintain graft function. Existing studies of skin cancer in RTRs focus on patients with Fitzpatrick skin types I-II, with limited documentation of incidence in skin types III-VI. This study seeks to better characterize skin cancers in RTRs with skin types III-VI. Compare the incidence of skin cancer in RTRs of skin types I-II with skin types III-VI. Explore the association between the development of skin cancer and other contributing factors in RTRs of skin types I-VI. Retrospective chart review of RTRs at a single institution between January 1, 2000 and December 31, 2022. Patients were followed from the date of transplant to the last clinical follow-up or death. 777 RTRs were included in the study, including 245 patients with Fitzpatrick skin types I-II and 532 with skin types III-VI. A total of 48 patients developed NMSCs, 2 patients developed melanoma, and 3 patients developed Kaposi sarcoma. There is a higher incidence of skin cancer in RTRs with Fitzpatrick skin types III-VI compared to the reported incidence among non-transplant recipients of the same skin types, but the incidence remains considerably lower compared to RTR of skin types I-II.

Four decades of progress in heart-lung transplantation: Two hundred seventy-one cases at a single institution

ObjectiveThe objective of this study is to evaluate survival for combined heart-lung transplant (HLTx) recipients across 4 decades at a single institution. We aim to summarize our contemporary practice based on more than 271 HLTx procedures over 40 years. MethodsData were collected from a departmental database and the United Network for Organ Sharing. Recipients younger than age 18 years, those undergoing redo HLTx, or triple-organ system transplantation were excluded, leaving 271 patients for analysis. The pioneering era was defined by date of transplant between 1981 and 2000 (n = 155), and the modern era between 2001 and 2022 (n = 116). Survival analysis was performed using cardinality matching of populations based on donor and recipient age, donor and recipient sex, ischemic time, and sex matching. ResultsBetween 1981 and 2022, 271 HLTx were performed at a single institution. Recipients in the modern era were older (age 42 vs 34 y; P < .001) and had shorter waitlist times (78 vs 234 days; P < .001). Allografts from female donors were more common in the modern era (59% vs 39%; P = .002). In the matched survival analysis, 30-day survival (97% vs 84%; P = .005), 1-year survival (89% vs 77%; P = .041), and 10-year survival (53% vs 26%; P = .012) significantly improved in the modern era relative to the pioneering era, respectively. ConclusionsLong-term survival in HLTx is achievable with institutional experience and may continue to improve in the coming decades. Advances in mechanical circulatory support, improved maintenance immunosuppression, and early recognition and management of acute complications such as primary graft dysfunction and acute rejection have dramatically improved the prognosis for recipients of HLTx in our contemporary institutional experience.

Pretransplant malignancy in pediatrics is not a risk factor for renal graft failure.

In adults, pretransplant malignancy (PTM) negatively impacts patient survival due to immunosuppression regimens influencing post-transplantation tumor growth. Few reports investigate the outcomes of pediatric kidney transplantation with PTM. We compare transplant outcomes for pediatric patients with PTM to matched controls, including cancer types extending beyond Wilms tumor. The United Network of Organ Sharing Database was queried to identify pediatric transplant recipients with histories of PTM. All PTM patients were matched to non-PTM patients, at a 1:1 ratio, with 0.001 match tolerance. Matching variables included transplant year, recipient age, recipient gender, recipient race, donor type, and prior transplant. Death-censored graft and patient survival were analyzed. All statistics were reported with 95% confidence intervals (CI). After propensity matching, 285 PTM and 285 non-PTM patients were identified, with transplant dates from 1990 to 2020. Median Kidney Donor Profile Index values were comparable between cohorts, 17% and 12%, respectively (p = .065). Kaplan-Meier analysis revealed that PTM patients did not have a significantly different rate of death-censored graft failure, compared to the non-PTM group [HR 0.76; 95% CI (0.54-1.1)]. There was also no difference in the overall survival between the two groups of patients [HR 1.1; 95% CI (0.66-2.0)]. A history of pediatric malignancy has minimal independent effect on their post-transplant survival. Additionally, pediatric patients with PTM demonstrated equivalent rates of graft survival. Thus, in contrast to adults, renal failure in children with history of pediatric malignancies should not be considered a complicating factor for renal transplantation.

Twelve Thousand Kidney Transplants Over More Than 55 Y: A Single-center Experience.

Kidney transplant outcomes have dramatically improved since the first successful transplant in 1954. In its early years, kidney transplantation was viewed more skeptically. Today it is considered the treatment of choice among patients with end-stage kidney disease. Our program performed its first kidney transplant in 1966 and recently performed our 12 000th kidney transplant. Here, we review and describe our experience with these 12 000 transplants. Transplant recipients were analyzed by decade of date of transplant: 1966-1975, 1976-1985, 1986-1995, 1996-2005, 2006-2015, and 2016-2022. Death-censored graft failure and mortality were outcomes of interest. Of 12 000 kidneys, 247 were transplanted from 1966 to 1975, 1147 from 1976 to 1985, 2194 from 1986 to 1995, 3147 from 1996 to 2005, 3046 from 2006 to 2015, and 2219 from 2016 to 2022 compared with 1966-1975, there were statistically significant and progressively lower risks of death-censored graft failure at 1 y, 5 y, and at last follow-up in all subsequent eras. Although mortality at 1 y was lower in all subsequent eras after 1986-1995, there was no difference in mortality at 5 y or the last follow-up between eras. In this large cohort of 12 000 kidneys from a single center, we observed significant improvement in outcomes over time. Kidney transplantation remains a robust and ever-growing and improving field.

The effect of oral chronic graft-versus-host disease on bodyweight: A cohort study.

This retrospective cohort study aimed to evaluate the association between body weight and oral cGVHD (chronic graft versus host disease). Patients with oral cGVHD were compared with an age and gender-matched non-GVHD cohort in terms of demographic information, body mass index (BMI), date of transplant, length of hospitalization, and oral complications. Weight was stratified in pre-and post-transplant weight, mean weight after acquiring cGVHD for the first year, and post-oral cGVHD BMI. Each patient was matched and compared with two controls at a 1:2 ratio. Firth's penalized likelihood logistic regression was used to investigate the association between oral complications and weight loss greater than 5% in the oral cGVHD group. This study included 137 patients (n = 42 oral cGVHD, n = 12 non oral-cGVHD and n = 83 non-GVHD). The oral cGVHD cohort had a 1.44 times higher risk (RR) of being underweight (BMI<18.5 kg/m2) compared to the non-GVHD cohort. Oral mucositis was an independent predictor of weight loss above 5% in the oral cGVHD cohort (p < 0.001). The weight loss was more prevalent among oral cGVHD, and oral mucositis was linked to significant weight loss. Weight loss may indicate the need to initiate early and aggressive symptomatic oral cGVHD treatment.

Development of a Pipeline for Removing Allergy Labels in Patients Undergoing Hematopoietic Stem Cell Transplantation

Penicillin allergy is reported by 10-20 % of patients, but when evaluated only 1-2% may have a true allergy. Patients undergoing HSCT have a high likelihood of requiring beta-lactam antibiotics due to increased infection risk, which can be limited by a penicillin allergy label. When a penicillin allergy is recorded, alternatives are needed including more-expensive, broader-spectrum antibiotics, with increases in drug-resistant bacteria, longer hospital stays, higher expenditures, and increases in nosocomial infections such as C. difficile colitis. This group of patients already has extensive pre-treatment testing, and would particularly benefit from allergy de-labeling. This study aimed to develop a self-sustaining, low-cost pipeline between a HSCT clinic and an allergy clinic to identify and successfully de-label low-risk patients who endorse an allergy to penicillin, amoxicillin, amoxicillin-clavulanate, piperacillin-tazobactam, or ampicillin before admission to the hospital. We developed a survey to triage allergy risk, identified key stakeholders in building the pipeline, and underwent four plan, do, study, act (PDSA) cycles. Changes were made in each of the PDSA cycles to minimize cost and uncompensated provider time as well as increase patient retention throughout the pipeline by increasing appointment availability and decreasing reliance on patients to independently progress through the pathway. Of the 410 patients with planned HSCT who were screened over 11 months, we found that 89 (21.7%) patients were listed as having penicillin and/or beta lactam allergy. 98.5% (n=66/67) of participants completed the survey accurately when confirmed by an allergist, and the survey was 100% accurate in predicting de-labeling success in low-risk patients. Of eligible patients, 43.8% (n=39) were successfully de-labeled before their transplant date and 97.4% (n=38) have undergone HSCT to date. This pipeline is maintained by approximately 5 hours of work per week (1 hour of allergy physician time, 4 hours of nurse and/or clinical coordinator time) and no other direct costs. There is an estimated direct savings of at least $1,914.93 per patient de-labeled. We successfully designed and implemented a pipeline between the HSCT clinic and the allergy clinic as a quality improvement initiative to identify and address high rates of reported beta-lactam allergies. We identified and addressed patient-based factors, logistical, temporal, and financial barriers that impacted patient retention and sustainability. This model is expected to have significant and sustained cost-savings for the healthcare system as well as improve patient outcomes, and this hypothesis is currently undergoing formal analysis. We anticipate that this model can be used to create a similar pipeline in other healthcare systems for HSCT patients as well as other clinical settings such as oncology and CAR-T therapy.

Real-World Outcomes of Pfts in Screening for Lung Involvement in Chronic Gvhd Post-Allogeneic Stem Cell Transplant: A Retrospective Study of 387 Patients in British Columbia, Canada

Introduction: Lung involvement in chronic graft versus host disease (cGVHD) is an uncommon but potentially devastating complication with significant morbidity and mortality in patients who have received an allogeneic hematopoietic stem cell transplant (alloHSCT). Unfortunately, early detection remains difficult as early lung cGVHD tends to be asymptomatic or present with nonspecific symptoms such as cough or mild shortness of breath. In British Columbia (BC), Canada, routine pulmonary function tests (PFTs) have been employed in the screening of lung cGVHD in this population at an interval of every 3-4 months for the first 2-3 years after alloHSCT. However, it is unknown whether routine screening 1) improves detection of lung cGVHD, and 2) enables earlier intervention to lead to better outcomes. We aimed to assess the real-world outcomes of lung cGVHD screening and compared the characteristics and clinical results of patients who had lung cGVHD detected via routine PFT screening, versus those who were detected after development of symptoms. Methods: A retrospective chart review was conducted on all adult patients who underwent an alloHSCT at BC, Canada between June 2017 and January 2021. Patients were followed until August 2022. Patients were excluded if they had primary graft failure or if they died within 100 days after transplant. All types of pulmonary GVHD were included analysis and cases were established by the treating clinician in the clinical record. NIH consensus criteria were used to grade cGVHD severity. Statistical significance was calculated using the Chi square test for categorical variables and T-test for continuous variables. Results: Among 387 eligible consecutive patients who underwent alloHSCT, 189 (49%) developed cGVHD, with 33 (9%) cases of lung involvement. The mean time to diagnosis of lung cGVHD from the date of transplant was 13 ± 8 months. There were 16 cases of lung cGVHD (48%) that were initially detected by routine screening, while 17 cases (52%) were first detected due to clinical symptoms that developed in between screening visits or after the screening period ended (two patients developed symptoms at 27 months and 43 months respectively). Patient characteristics are presented on Table 1. Lung involvement was the first cGHVD sign in 17/33 (51%) of patients, with 5 (15%) detected by routine screening and 12 (36%) due to symptoms. At time of diagnosis of lung involvement, 12/33 (36%) of patients were already on systemic immunosuppression for cGVHD with 9 (56%) of these cases detected from screening and 3 (18%) from symptoms (p=0.02). All patients had a maximum overall cGVHD severity by NIH criteria of 2-3. Sixteen of 33 (48%) patients had a lung cGVHD score by NIH criteria of 2-3 at diagnosis, with a mean FEV1 of 54% ± 15, compared to 17 (52%) patients with a score of 1 and mean FEV1 of 78% ± 12. The NIH score at diagnosis was not significantly different between those picked up by routine screening versus symptoms (p=0.76). Eighteen of 33 (55%) patients had a maximum lung cGVHD score by NIH criteria of 2-3, with the mean lowest FEV1 of 52% ± 15, compared to 15 patients (45%) with a maximum lung cGVHD score of 1, with the mean lowest FEV1 of 77% ± 10. Similarly, the maximum NIH lung cGVHD score were not significantly different between those picked up by routine screening versus symptoms (p=0.08). However, patients picked up on screening were more likely to have significant clinical improvements in lung function (4/16 [25%] versus 0/17 [0%], p=0.03), and less likely to die from lung cGVHD (0/16 [0%] versus 5/17 [29%], p=0.02). Conclusions: Routine screening PFTs are effective for early diagnosis of asymptomatic lung cGVHD, and are associated with improved outcomes compared to patients who were diagnosed after symptoms developed. Since a significant number of these patients were not previously receiving immunosuppression for other cGVHD, this suggests a potential benefit in screening all patients every 3 months, regardless of prior GVHD status.

Increasing Palliative Care Team Involvement in Pediatric Hematopoietic Stem Cell Transplant Patients

Background/Objectives: Palliative care facilitates communication, helps with physical and psychological symptom management, and assists in goals of care and advance care planning discussions. Multiple organizations including the World Health Organization, American Academy of Pediatrics and the American Society of Clinical Oncology encourage palliative care involvement. Palliative care involvement with hematopoietic stem cell transplant (HSCT) patients has been shown to be beneficial as HSCT is associated with a high degree of morbidity and possible mortality. We sought to increase the frequency of palliative care consultations for patients planning to undergo HSCT for targeted diagnoses. The outcome measure was percentage of patients who underwent HSCT for a targeted diagnosis who had a Palliative Care Team (PaCT) consult. Baseline data revealed 48 patients underwent HSCT from July 2020 to July 2022, 25 of whom had a targeted diagnosis. PaCT met 12 of the 25 patients (48%). Our goal is to increase the number of PaCT consults for patients receiving HSCT for our targeted diagnoses from 48% to 75% by December 2023. Methods: Chart review was conducted for patients who underwent HSCT from July 2020 to July 2022. Demographics documented included reason for HSCT, if PaCT was consulted, date of transplant, date of PaCT consult and living status. A targeted diagnosis list was compiled based on which patients were felt to benefit most from palliative care involvement: relapsed or refractory leukemias and lymphomas, myelodysplastic syndrome, high risk acute myeloid leukemia and metabolic disorders, such as Hurler syndrome. The first plan-do-study-act (PDSA) cycle included discussion of the project at division meetings, posting flyers in the clinic provider workrooms, and education regarding palliative care and evidence of its involvement in HSCT patients. The second PDSA cycle implemented involved revision of the HSCT referral form to include the question “Is PaCT consulted.” If the provider answers “no,” further elaboration is requested. Results: From 1/1/23 to 7/31/23 ten patients with a targeted diagnosis underwent HSCT. Five patients (50%) received a PaCT consult prior to HSCT. Conclusions: Palliative care involvement in pediatric oncology is well established, but its role in HSCT patients continues to be explored. As HSCT patients receive more intense therapy, have frequent deaths in intensive care units and can have limited opportunity for end of life planning due to rapidly changing clinical courses, early integration of PaCT could allow for decreased symptom burden and distress for both patients and families. Future PDSA cycle interventions include adding PaCT consultation to the transplant evaluation order set in the electronic medical record and review of the comments on the completed HSCT referral forms to identify possible barriers in the PaCT consultation process.

Pre-Transplant Levels of Multiparametric Flow-Cytometry Measurable Residual Disease (MFC-MRD) Predict Outcomes in Children with Acute Myeloid Leukemia Given Allogeneic Hematopoietic Stem Cell Transplantation

Background: Measurable residual disease assessed by multiparametric flow-cytometry (MFC-MRD) is largely used in trials for childhood de novo acute myeloid leukemia (AML) in the early phase of treatment, to stratify patients into different risk groups and to tailor treatment. Despite this, unlike acute lymphoblastic leukemia, the impact of MFC-MRD before allogeneic hematopoietic stem cell transplantation (HSCT) on patients' outcomes has yet to be established. The aim of this study was to evaluate the prognostic role of MFC-MRD before HSCT in a cohort of children with AML treated in centers belonging to Associazione Italiana Ematologia/Oncologia Pediatrica (AIEOP) cooperative group. Patients and Methods: We analyzed MFC-MRD in 208 pediatric patients affected by de novo AML who underwent a first allo-HSCT after a myeloablative conditioning regimen in an AIEOP Centre between 12/2011 and 12/2021. Assessment of MFC-MRD was performed on BM sample within 60 days from the transplantation date. Analysis of 5-10 color-panel MFC-MRD was centrally performed at the Laboratory of Diagnosis and Research, University of Padova, according to standardized operating procedures previously described (Buldini et al., BJH 2017). We defined MFC-MRD positivity as the presence of at least 50 leukemic events of 500,000 acquired nucleated cells. Five-year overall (OS) and event-free survival (EFS) were estimated using Kaplan and Meier method and differences between groups were tested using the log-tank test; the cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) were calculated using the Fine&amp;Gray method to take into account the respective competitive risks. Results: Median age at HSCT of these 208 patients was 7.8 years (range 0.4-23.3); 168 patients (80.8%) were transplanted in CR1, 30 (14.4%) in CR2 and 10 (4.8%) in CR3 or more advanced disease. Forty-eight patients (23.1%) were transplanted from a matched family donor, 85 (40.9%) from an unrelated donor (59 fully-matched and 26 mismatched), while 75 (36%) from a partially matched family donor. The source of stem cells was bone marrow in 117 patients (56.2%), peripheral blood in 81 (39%) and cord blood in 10 (4.8%). Median time from MRD evaluation and HSCT was 22 days (range, 6-57). Overall,168 out of 208 (78.9%) patients were MFC-MRD negative in the pre-HSCT BM, while 44/208 (21.1%) showed a positive MFC-MRD. Among those, MFC-MRD was &amp;lt; 0.1% in 12/44 (27%) patients, 0.1-&amp;lt;1% in 16 patients (36.5%) and ≥ 1% in 16 patients (36.5%). The 5-year OS and EFS of the whole cohort were 79.2% and 65.7%, respectively, while CIR and NRM were 24.7% and 8.6%. Notably, patients with negative MFC-MRD had a significantly better 5-yr OS and EFS (Fig.A) as compared to those with any MFC-MRD positivity (OS 86.3% vs 50.2%; EFS 71.6% vs 42.4%, p &amp;lt;0.0001 in both analysis). CIR significantly differed between patients with MFC-MRD negative and positive (21.1% vs 43.9%, p=0.001) (Fig.B). We also observed a higher NRM in patients with MFC-MRD positivity (13.6%) as compared to those with negative MFC-MRD (7.2%), although this was not statistically significant (p=0.1). Disease status (CR1 vs CR2 vs other CR) did also influence EFS (69.9% vs 55.6% vs 23.3%, p&amp;lt;0.001), OS (83.2% vs 66.6% vs 40.6%, p=0.02) and CIR (21.1% vs 37.7% vs 66.6%, p&amp;lt;0.001), while other variables (including year of HSCT, type of donor and stem cell source employed) did not. In a multivariable model for OS, EFS and CIR, including MFC-MRD, disease status and year of HSCT, MFC-MRD (pos vs neg) remained statistically significant (HR for OS 3.5, p=0.0004; HR for EFS 2.38, p=0.003; HR for CIR 2.14, p=0.02). In addition, advanced disease phase was an independent risk factor for CIR (HR 1.81, p=0.008). Conclusion: These data document the independent prognostic value of MFC-MRD before HSCT in a large cohort of pediatric AML patients, using a centralized evaluation by 5-10 color MFC. Patients with negative MFC-MRD before HSCT have a significantly lower risk of treatment failure. In light of these results, we recommend monitoring MFC-MRD before HSCT in pediatric AML patients as a critical tool for therapy-intervention decision before or after HSCT (e.g., additional treatment for improving leukemia control or less intensive/shorter GvHD prophylaxis) with the aim to improve patients' outcomes.

Association of p16, a Biomarker of Cellular Senescence, with Receipt of Therapy for Plasma Cell Disorders

Introduction Multiple myeloma (MM) and immunoglobulin light chain (AL) amyloidosis are clonal plasma cell disorders (PCDs) of aging, with median ages at diagnosis of 69 and 76 years, respectively. The care of adults with these disorders is often challenging due to the higher prevalence of vulnerabilities with advancing age. We examined patterns of senescence biomarkers and associations with therapy receipt among adults treated for plasma cell disorders. Methods Adults undergoing treatment for PCDs were recruited to a longitudinal observational study (NCT03717844) from 2018 to 2020. Study participants provided blood samples and completed study assessments at pre-specified intervals. Cellular senescence was quantified by measuring mRNA expression of p16 in peripheral blood T lymphocytes. Expression of p16 is reported as log2 arbitrary units. A linear regression formula previously derived from p16 expression in 633 subjects was utilized to translate p16 expression levels into an age equivalent. These values were used to calculate the p16AgeGap, a difference between an individual's p16 expression and their chronological age. Subjects with p16 levels below the age-appropriate population mean have a negative p16AgeGap, and those with p16 above the population mean have a positive p16AgeGap. Exposures included both treatment receipt and duration of therapy. Treatment was assessed via categorical classification of treatment intensity, and treatment duration was quantified from diagnosis to time of p16 blood draw. Descriptive statistics were calculated for baseline demographic and disease characteristic variables. The p16 and p16AgeGap variables were summarized in terms of means and 95% confidence intervals (CI). The significance of associations between p16/p16AgeGap and categorical variables was assessed via Kruskal-Wallis or Wilcoxon rank-sum tests. Associations between continuous variables were assessed via calculation of Pearson correlation coefficients. Results The cohort consisted of 109 individuals (88 with multiple myeloma and 21 with other plasma cell disorders). Mean age was 68 years (range 39-91). The sample was predominantly male (56.9%) and White (70.6%). Samples for p16 were drawn prior to any treatment in 20 subjects. The remainder had received prior therapy and 36 had relapsed/refractory disease. There was a significant association between the treatment receipt and p16 as well as between the treatment receipt and p16AgeGap (Figure 1). We observed a significant modest positive correlation between the duration of treatment and p16 (correlation coefficient 0.27, p=0.007) and p16AgeGap (0.22, p=0.03). Among those who had undergone transplant, we observed higher mean p16 (mean 12.84 [95% CI 12.46-13.23] vs 11.81 [11.51-12.11] for non-recipients, p=0.0001) and p16AgeGap (mean 50.6 [39.6-61.6] vs 16.9 [8.4-25.4], p &amp;lt;0.0001). There was a significant association between receipt of bortezomib-containing regimens with both p16 levels p16AgeGap, with higher mean p16 &amp; mean p16AgeGap for those who did not receive bortezomib. For the subset of patients with transplant date before the p16 collection date (N=38), there was no significant association between time since transplant and either p16 level or p16AgeGap. Conclusion This study elucidates the relationship between markers of cellular senescence, specifically p16 levels and the p16AgeGap, and the impact of treatment receipt and duration in a cohort of patients undergoing treatment for plasma cell disorders. There was a clear significant association between the receipt of treatment and both markers of senescence, along with a modest positive correlation between the duration of treatment and these markers. Further analyses involving this cohort will evaluate the relationship between these biomarkers and patient-centered endpoints, including disease-related symptoms and functional outcomes.

Considering Older Patients As Candidates for Auto Stem Cell Transplants: A Comprehensive Study on Toxicities and Survival Analysis

Introduction: High-dose chemotherapy and autologous stem cell transplantation (ASCT) are commonly used for relapsed/refractory (R/R) Hodgkin (HL) and non-Hodgkin lymphoma (NHL). However, concerns about treatment-related mortality (TRM) and toxicity limit its use in older patients (pts). Existing evidence suggests higher rates of complications and inferior overall survival (OS) in older pts, but conflicting findings suggest that outcomes may be influenced by comorbidities rather than age ( Lahoud O, Curr Oncol Rep. 2015). Our study comparing ASCT outcomes and toxicities in lymphoma pts in younger and older age groups. Methods: In this retrospective study, we analyzed lymphoma pts who underwent ASCT at the Princess Margaret Cancer Centre from January 2015 to December 2019. After Institutional Review Board approval, clinical data was collected from institutional databases and patient charts. The hematopoietic cell transplantation comorbidity index (HCT-CI) and Charlson Comorbidity Index (CCI) were retrospectively calculated. Response assessment was done by Lugano 2014 classification. Grade 3-5 nonhematologic toxicities were collected from admission to day 100 using Common Terminology Criteria for Adverse Events version 5. Overall survival (OS) and progression-free survival (PFS) were calculated from date of transplant to death or disease progression. OS and PFS assessed via Kaplan-Meier; log rank tests and Cox regression performed. The patients were divided into two age groups: Group A (&amp;lt;65 years) and Group B (≥65 years). Results: There were 334 pts who underwent ASCT. 332 pts were analyzed; 2 pts were lost to follow-up and 16 pts were day 1 transfers, making acute toxicity data unavailable. The median age was 53 (range: 18-71), 17% of pts being aged ≥65. The majority of pts (69%) had NHL (table 1). The Eastern Cooperative Oncology Group (ECOG) performance status was ≤1 for 91%. Group B had a higher proportion of pts with ECOG score =2 (18% vs 7%, p &amp;lt; 0.001 ) and higher CCI (88% vs 27% , p &amp;lt; 0.001). NHL and mantle cell lymphoma (MCL) were more prevalent in Group B (93%, 23% vs 68%, 12% respectively, p&amp;lt; 0.001). Thirteen percent of NHL pts were transformed disease. Both groups had similar percentage of pts with central nervous system (CNS) lymphoma (~ 5%). Conditioning regimens varied based on lymphoma type: most of the HL/aggressive lymphomas: Etoposide+Melphalan (ML), CNS lymphoma: Thiotepa based regimen, and MCL Cytarabine + ML+/- Total Body Irradiation. The majority (83%) were treated for R/R disease, while 17% received it as first-line treatment. Prior to transplant, 76% of pts were in CR. Median follow-up was 38 months. Median OS was not reached for Group A, and 73 months for Group B. Five year OS were 82% and 74% respectively (p = 0.05). Median PFS was 75.2 months for Group A and 43.0 months for Group B, with 5-year PFS of 54% and 47% respectively (p = 0.2). Twenty percent of pts died during follow-up, with only 4% being NRM. From the entire cohort 3% of patients died within 100 days post-transplant, with no difference between groups. Three pts died within 100 days of ASCT with 2 deaths from sepsis (Group A) and 1 death from Respiratory failure (Group B). Common transplant-related toxicities did not differ significantly between groups (figure 1). Group B had significantly higher rates of Renal (7%vs 18%), Respiratory (16% vs 6%), and Metabolism abnormalities (14% vs 5%) (p = 0.021-0.028). Group B needed more blood product transfusions by 100 days post-transplant: Packed Cells (mean) 1.7 vs 1.1 units (p 0.08), Platelets (mean) 3 vs 1.9 units (p 0.002). Group B had a longer average length of stay 18 days vs. 14 days (p &amp;lt; 0.001). About 6% of pts required ICU admission, and 4% were discharged to rehabilitation/long-term care facilities, with no group differences. Conclusions: The study concludes that ASCT can be safely performed in appropriately selected elderly pts. TRM rates were not significantly higher in older compared to younger pts with lymphoma. However, older pts did experience higher rates of specific toxicities including renal failure, pulmonary complications, metabolism abnormalities, longer hospital stays, and increased transfusion requirements. In the multivariate analysis, older pts exhibited shorter OS, influenced by lymphoma type and treatment response. Further research is needed to develop risk stratification and geriatric assessments to improve toxicity prediction in elderly pts undergoing ASCT.

Eliminating Racial Disparities Among Transplant Patients in Multiple Myeloma after Referral to a Tertiary Center

Introduction: Autologous stem-cell transplantation (ASCT) remains an integral part of therapy for many newly diagnosed and relapsed multiple myeloma (MM) patients. Most tertiary centers rely on age, ECOG status, and multi-organ function evaluation to determine eligibility for ASCT. African Americans (AA) have a higher incidence of monoclonal gammopathy of undetermined significance (MGUS), higher incidence of MM and higher mortality rates than their Caucasian counterparts, mainly due to lower access to care. Furthermore, AA patients are also underrepresented in clinical trials. Studies have shown AA patients have similar to improved progression-free survival (PFS) and overall survival (OS) compared to Caucasian patients when similar therapies are offered to both groups; however, lower rates of transplantation are reported among AA patients. This is likely multifactorial in origin, with varying risk factors, biological influences, and social hindrances leading to racial disparity. We sought to examine the differences in rates of ASCT among African Americans vs Caucasian patients. Methods: We conducted a retrospective chart review of all patients with myeloma referred to our center between 2018 and 2022. Information regarding demographics, referral information, insurance and transplant status obtained for all patients referred and/or transplanted at our center were obtained from this chart review. The diagnosis date was obtained from referral records if they were referred from an outside institution. All patients received therapy at the discretion of treating physicians. Statistics are descriptive. Results: 206 AA patients were referred to our center for transplant evaluation, of which 138 underwent autologous transplantation (67%). Additionally, 141 Caucasian patients were referred to us for transplant evaluation, 98 of which underwent ASCT (69%). The transplant rates were similar across both genders among AA patients, with female AA patients accounting for 49% of all AA transplants. Among Caucasian patients, female patients accounted for 37% of all Caucasian transplants. The median referral delay time was 104 days among AA patients and 85 days among Caucasian patients. The median time from the date of referral to transplant was 128 days for AA patients and 124 days for Caucasian patients. The reasons for non-transplant varied between the two races. For African Americans, the most common reason was medical contraindication followed by patient disinterest in contrast to Caucasian patients, which was patient disinterest followed by medical contraindication. Conclusion: Once referred to a tertiary center, we observed no racial disparities among transplants in AA and Caucasian patients. While the median time from the date of referral to the date of transplant was similar across both groups, we noted an increased referral delay among AA patients.

2706. Effectiveness and Safety of Shingrix Vaccination in Solid Organ Transplant Recipients at a Large Urban Transplant Center

Abstract Background The varicella zoster virus (VZV) recombinant subunit vaccine, Shingrix, was found to be safe in solid organ transplant recipients (SOTR) and is now approved and recommended for all immunocompromised patients. Given limited efficacy data, we preferred a single center retrospective study to demonstrate safety and effectiveness of the Shingrix vaccine in solid organ transplant recipients. Methods After IRB approval, clinical data from all SOTR at Northwestern Memorial Hospital (NMH) who received the Shingrix vaccine after their transplant, between January 1, 2017 and March 1, 2022 was collected from our Enterprise Data Warehouse (EDW). Extracted data includes age, race, ethnicity, date of transplant, organ transplanted, and date(s) of vaccine administration(s). Clinical outcomes were assessed by diagnosis of acute allograft rejection and/or HZ made post-vaccine administration. Descriptive statistics were utilized. This project is supported by the IDSA G.E.R.M. program. Results 309 of 338 eligible SOTR were included in the analysis of this study (characteristics and reasons for exclusion in Table 1). Only 1 (0.32%) patient experienced a new episode of acute allograft rejection within 3 months of Shingrix administration. 18/309 (5.8%) were diagnosed with HZ after vaccination with Shingrix. This represents a reduction in VZV reactivation events compared to the 9.1% incidence found in the 2021 meta-analysis of HZ in the general solid organ transplant population [Kwon, Transpl Infect Dis., 2021].Table 1.Characteristics of 338 solid organ transplant patients who received Shingrix vaccine. Conclusion The Shingrix vaccine, when administered to SOTR post-transplant, is safe and likely effective in reducing the rate of herpes zoster. This data supports the current recommendation to vaccinate all SOTR with Shingrix. Larger, multi-center data are needed to inform the true efficacy of the vaccine in SOTRs. Disclosures All Authors: No reported disclosures

Pneumocystis Pneumonia After Allogeneic Hematopoietic Cell Transplantation: A Case-Control Study on Epidemiology and Risk Factors on Behalf of the Infectious Diseases Working Party of the European Society for Blood and Marrow Transplantation

Pneumocystis pneumonia (PCP) is a life-threatening complication after allogeneic hematopoietic cell transplantation (allo-HCT). However, allo-HCT procedures have evolved toward older patients, unrelated donors, and reduced-intensity conditioning, possibly modifying the risks. Polymerase chain reaction (PCR), widely used nowadays, is more sensitive than microscopy diagnostic methods. This study aimed to assess the factors associated with PCP in allo-HCT recipients within 2 years of HCT and managed according to current procedures. This multicenter, nested case-control study included PCP cases diagnosed by PCR, cytology, or immunofluorescence on bronchoalveolar lavage fluid between 2016 and 2018. Two controls per case were selected from the ProMISe registry and matched for the center, transplant date, and underlying disease. Fifty-two cases and 104 controls were included among the 5452 patients who underwent allo-HCT in the participating centers. PCP occurred at a median of 11.5 months after transplantation. The mortality rate was 24% on day 30 after the PCP diagnosis and 37% on day 90. The clinical presentation and mortality rates of the 24 patients diagnosed using only PCR were not different from those diagnosed with microscopy methods. Our study demonstrates a substantial incidence of, and mortality from, PCP, after allogeneic HCT despite well-established prophylactic approaches. In our experience, PCP nowadays occurs later after transplant than previously reported, justifying the prolongation of prophylaxis after six months in many cases. Allo-HCT recipients diagnosed with PCR as the only PCP marker should benefit from specific treatment as for other patients.

Marked differences in ICD therapy frequencies between phenotypes

Abstract Background Implantable cardioverter defibrillators (ICD) are implanted due to a broad range of cardiac conditions according to guidelines. Purpose The aim of this study was to compare the distribution of ICD therapies across different cardiac diseases. Methods In this descriptive study, we included patients from Eastern Denmark with an ICD implanted up until November 2021. Data was obtained from the national ICD registry and the diagnosis leading to implantation of the ICD was registered. ICD interrogations and number of episodes of appropriate ICD therapies (shock/anti-tachycardia pacing (ATP)) were obtained. End of follow-up was November 8, 2021 or date of death or heart transplantation. Cumulated numbers of therapies were calculated for each patient during the follow-up period (shock/ATP therapies per 1,000 patients per year). Results Data on 3,068 patients (median (IQR) age at implantation 65 years (56-72)) across 10 cardiac disorders was obtained (Figure). A total of 1,403 patients had the ICD implanted as primary prophylaxis and 1,554 as secondary prophylaxis and in 111 patients it was unclear. Mean follow-up time of 595 years per diagnostic subgroup (210-12,911 years). The median (IQR) shock/ATP rate per 1,000 patients per year was 1.47 (0.70-2.62). The numerically highest shock/ATP rate of 28.9 therapies per 1,000 patients per year was seen in patients with arrhythmogenic right ventricle cardiomyopathy and the lowest shock/ATP rate of 0.05 therapies per 1,000 patients per year was seen in patients with ischemic heart disease. In patients with ischemic heart disease, the shock/ATP rate per year was 0.06 in patients with an ICD implanted as primary prophylactic and 0.15 in patients with an ICD as secondary prophylactic. Conclusion The frequency of ICD shock/ATP therapy varies several-fold between cardiac disorders, with the highest rate in patient with arrhythmogenic right ventricle cardiomyopathy and the lowest rate in the major group of patients, i.e. patients with ischemic heart disease. These findings may indicate a need for adjustments of patient selection for ICD implantation.

Should children receive a kidney transplant before 2 years of age?

The optimal age of kidney transplantation for infants and toddlers with kidney failure is unclear. We aimed to evaluate the patient survival associated with kidney transplantation before 2 years of age versus remaining on the waitlist until ≥2 years. We used the Scientific Registry of Transplant Recipients to identify all children added to the deceased-donor waitlist before 2 years of age between 1/1/2000 and 4/30/2020. For each case aged <2 years at transplant, we created a control group comprising all candidates on the waitlist on the case's transplant date. Patient survival was evaluated using sequential Cox regression. Dialysis-free time was defined as graft survival time for cases and the sum of dialysis-free time on the waitlist and graft survival time for controls. We observed similar patient survival for posttransplant periods 0-3 and 4-12 months but higher survival for period >12 months for <2-year decreased-donor recipients (aHR: 0.32; 95% CI: 0.13-0.78; p = .01) compared with controls. Similarly, patient survival was higher for <2-year living-donor recipients for posttransplant period >12 months (aHR: 0.21; 95% CI: 0.06-0.73; p = .01). The 5-year dialysis-free survival was higher for <2-year deceased- (difference: 0.59 years; 95% CI: 0.23-0.93) and living-donor (difference: 1.84 years; 95% CI: 1.31-2.25) recipients. Kidney transplantation in children <2 years of age is associated with improved patient survival and reduced dialysis exposure compared with remaining on the waitlist until ≥2 years.

Abstract 18088: Survival After Ventricular Tachycardia Onset in Left Ventricular Assist Device Recipients

Introduction: Left Ventricular Assist Devices (LVADs) revolutionized the care of patients with heart failure. However, the burden of ventricular tachycardia (VT) increases after LVAD insertion. The role of ablation in treating VT in LVAD recipients is unclear. Hypothesis: The incidence of VT following LVAD insertion is associated with worse survival, but this association is ameliorated by VT ablation. Methods: This is a single-center retrospective review of 549 LVAD recipients. LVADs implanted elsewhere, LVADs prior to 2011, and patients with inadequate follow up were excluded. Endpoints were transplantation, explantation, and last date of follow up. Event failure was defined as patient death. Cox and Kaplan-Meier survival analysis was performed with STATA and reported as hazard ratio with 95% confidence interval (HR [95% CI]). Results: Pre-LVAD VT was seen in 52% of patients: 33% had a prior ICD shock and 12% had a prior VT ablation. At study conclusion, 57% had died, 22% were transplanted, 9% were explanted, and 12% remained alive. Regardless of VT incidence, worse survival was seen in ischemic cardiomyopathy (HR 2.0 [1.5-2.7]), RV failure necessitating RVAD (HR 2.6 [1.9-3.6]), and pre-LVAD ICD shocks (HR 1.3 [1.0-1.7]). While post-LVAD VT overall was not associated with worse survival (HR 1.1 [0.8-1.3]), VT within 1 year of LVAD insertion demonstrated worse survival (HR 1.9 [1.3-2.6]; Figure 1). Incremental years between LVAD insertion and VT onset improved survival (HR 0.8 [0.7-0.9]). Among those with post-LVAD VT, ablation was not associated with a survival difference (IRR 0.9 [0.6-1.4]) regardless of the timing of ablation or VT onset. Conclusions: The incidence of VT within 1 year of LVAD insertion is associated with worse survival. However, mortality was not improved by VT ablation. This study is limited by its retrospective design, and further prospective studies would better determine the impact of VT ablation on survival in LVAD recipients.

Impact of Race on Progression-Free Survival and Overall Survival in Patients with Multiple Myeloma

Background: Multiple myeloma (MM) is a disorder of plasma cells. Management typically includes induction therapy, autologous stem-cell transplantation (ASCT) and maintenance therapy. Despite significant progress in treatment modalities and improved survival and response rates in patients diagnosed with MM, it remains an incurable disease with a poor outcome, especially in high-risk groups. Black patients have been shown to have a higher incidence of MM than white patients. Multiple studies have been done to examine racial disparities among white and black patients, specifically in overall survival (OS) and progression free survival (PFS). However, data has been overall inconclusive with some studies suggesting there is a difference in survival based on race, while other studies suggesting the opposite. Thus, racial disparities among white and black patients' needs to be further investigated. In our retrospective chart review we reviewed all adult patients with advanced MM within Henry Ford Cancer Institute in the last 10 years to determine the impact of maintenance therapy on PFS and overall survival OS. Methods: We conducted a retrospective chart review of adult patients with MM who underwent autologous stem cell transplantation (ASCT) between January 1, 2012 to December 31, 2022. Those who received maintenance chemotherapy after transplant were included in the study. Patients who were lost to follow-up or who had largely incomplete records were excluded. Data points including age, gender, race, date of transplant, maintenance chemotherapy regimen, last follow-up, and date of death (if applicable) were recorded. Kaplan-Meier plots were used to illustrate overall survival and time to relapse between various races. Statistical significance was set at p&amp;lt;0.05. Results: There were 158 patients included in the study. Of the 158 patients, 82 (51.9%) were male, and 76 (48.1%) were female. The average age of patients included was 61.66 + 9.30 years, spanning from 32 to 78 years old. There were 71 (44.9%) White patients, 76 (48.1%) Black patients, and 11 (7.0%) patients that were of another race. There was no statistical significance in PFS and OS between Black, White and Other race categories. Conclusions: We did not see a difference in outcome based on race and believe all patients would derive equal benefit from maintenance therapy. Further prospective studies are warranted to examine racial disparities in patients with multiple myeloma.

Direct and indirect impact of the COVID-19 pandemic on the survival of kidney transplant recipients: A national observational study in France

During the pandemic period, health care systems were substantially reorganized for managing COVID-19 cases. Corresponding consequences on persons with chronic diseases remain insufficiently documented. This observational cohort study investigated the direct and indirect impact of the pandemic period on the survival of kidney transplant recipients (KTR). Using the French National Health Data System, incident persons with end-stage kidney disease between 2015 and 2020, and who received a kidney transplant during this period were included and followed up from their transplantation date to December 31, 2021. The survival of KTR during the prepandemic and pandemic periods was investigated using Cox models with time-dependent covariates. There were 10 637 KTR included in the study, with 324 and 430 deaths observed during the prepandemic and pandemic periods, respectively. The adjusted risk of death during the pandemic period was similar to that observed during the prepandemic period (hazard ratio [HR] [95% confidence interval]: 0.92 [0.77-1.11]), COVID-19–related hospitalization was associated with an increased risk of death (HR: 10.62 [8.46-13.33]), and a third vaccine dose was associated with a lower risk of death (HR: 0.42 [0.30-0.57]). The pandemic period was not associated with an indirect higher risk of death in KTR with no COVID-19–related hospitalization.

Association of state Medicaid expansion policies with pediatric liver transplant outcomes

Children from minoritized/socioeconomically deprived backgrounds suffer disproportionately high rates of uninsurance and graft failure/death after liver transplant. Medicaid expansion was developed to expand access to public insurance. Our objective was to characterize the impact of Medicaid expansion policies on long-term graft/patient survival after pediatric liver transplantation. All pediatric patients (<19 years) who received a liver transplant between January 1, 2005, and December 31, 2020 in the US were identified in the Scientific Registry of Transplant Recipients (N = 8489). Medicaid expansion was modeled as a time-varying exposure based on transplant and expansion dates. We used Cox proportional hazards models to evaluate the impact of Medicaid expansion on a composite outcome of graft failure/death over 10 years. As a sensitivity analysis, we conducted an intention-to-treat analysis from time of waitlisting to death (N = 1 1901). In multivariable analysis, Medicaid expansion was associated with a 30% decreased hazard of graft failure/death (hazard ratio, 0.70; 95% confidence interval, 0.62, 0.79; P < .001) after adjusting for Black race, public insurance, neighborhood deprivation, and living in a primary care shortage area. In intention-to-treat analyses, Medicaid expansion was associated with a 72% decreased hazard of patient death (hazard ratio, 0.28; 95% confidence interval, 0.23-0.35; P < .001). Policies that enable broader health insurance access may help improve outcomes and reduce disparities for children undergoing liver transplantation.