Donor Risk Index Research Articles

Warm ischemic time as a critical risk factor of graft failure from donors after cardiac death: A single‐center experience over three decades in the Kidney Donor Profile Index/Kidney Donor Risk Index era in Japan

To evaluate the prognostic value of the warm ischemic time and the validity of the Kidney Donor Profile Index/Kidney Donor Risk Index for predicting the survival of donors after cardiac death grafts. We retrospectively assessed 315 kidneys retrieved from donors after cardiac death at Fujita Health University Hospital, Toyoake, Aichi, Japan. The Kidney Donor Profile Index/Kidney Donor Risk Index was calculated and the grafts were enrolled. The median follow-up period was 11.9years. The Kidney Donor Profile Index had a markedly asymmetric distribution (median 94%), and the Kidney Donor Risk Index had high index rates (0.79-2.94, median 1.70). The overall 5-, 10- and 15-year graft survival rates were 67.5%, 52.1% and 38.9%, respectively. The Kidney Donor Profile Index correlated with graft survival. The 5-, 10- and 15-year graft survival rates for the Kidney Donor Profile Index <1.2 were 87.7%, 73.5% and 59.2%; those for the Kidney Donor Risk Index >2.0 were 55.0%, 34.7% and 22.1%, respectively. A Cox multivariate analysis identified the Kidney Donor Risk Index (hazard ratio 2.06, 95% confidence interval 1.48-2.86, P<0.0001) and warm ischemic time (hazard ratio 1.21, 95% confidence interval 1.09-1.34, P=0.0010) as independent risk factors for graft loss. The addition of warm ischemic time >30min had a significant effect, as measured by the C-index (0.708-0.731, P=0.032), improving the net reclassification improvement score (0.256, P=0.0039) and integrated discrimination improvement score (0.042, P=0.0022). The Kidney Donor Profile Index/Kidney Donor Risk Index is a good prognostic tool for determining the outcomes of donors after cardiac death grafts. However, the warm ischemic time should also be included in the allocation system for donors after cardiac death grafts.

Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change.

Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR=3.49 3.69 3.89 ) and a 2.2-fold higher rate of DDLT postpolicy (aHR=2.09 2.21 2.34 ). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR=0.54 0.63 0.73 ) and a comparable risk of mortality/dropout postpolicy (asHR=0.81 0.95 1.11 ). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.

Association of Kidney Donor Risk Index with the Outcome after Kidney Transplantation in the Eurotransplant Senior Program.

BackgroundWe evaluated the Kidney Donor Risk Index (KDRI) scoring system for kidney transplantation in the Eurotransplant Senior Program (ESP) that allocates kidneys from older donors to older recipients (≥65 years).Material/MethodsWe retrospectively analyzed data of 37 kidney transplant recipients and 36 kidney donors who participated in kidney transplantation program according to the ESP at our center from January 2004 until December 2013.ResultsMean recipient and donor age was 67.9±2.6 and 70.5±4.0 years respectively. The mean KDRI score was 1.7±0.27. Uncensored graft survival after 1 year and 5 years was 64.2% and 53.7% respectively. Subgroup analysis showed that in kidney transplantation with KDRI >1.83, graft survival was significantly reduced compared to lower KDRI subgroups. KDRI was significantly correlated with serum creatinine level at discharge (r=0.4).ConclusionsESP kidneys represent a group of high-risk grafts with high KDRI scores. Higher KDRI scores in ESP kidneys was associated with reduced postoperative short-term and long-term graft outcomes. KDRI might be useful in decision-making for selecting donors for ESP kidney transplantation.

The Impact of Deceased Donor Liver Extraction Time on Early Allograft Function in Adult Liver Transplant Recipients.

In liver transplantation, both cold and warm ischemia times are known to impact early graft function. The extraction time is a period during the initial phase of organ cooling which occurs during deceased donor procurement. During this time, the organ is at risk of suboptimal cooling. Whether donor extraction time, the time from donor aortic cross-clamp to removal of the donor organ from the body cavity has an effect on early graft function is not known. We investigated the effect of donor extraction time on early graft function in 292 recipients of liver grafts procured locally and transplanted at our center between June 2012 and December 2016. Early graft function was assessed using the model of early allograft function score in a multivariable regression model including donor extraction time, cold ischemia time, warm ischemia time, donor risk index, and terminal donor sodium. Donor extraction time had an independent effect on early graft function measured by the model of early allograft function score (coefficient, 0.021; 95% confidence interval, 0.007-0.035; P < 0.01; for each minute increase of donor extraction time). Besides donor extraction time, cold ischemia time, warm ischemia time, and donor risk index had a significant effect on early graft function. We demonstrate an independent effect of donor extraction time on graft function after liver transplantation. Efforts to minimize donor extraction time could improve early graft function in liver transplantation.

Lymphocyte depletion and risk of acute rejection in renal transplant recipients at increased risk for delayed graft function.

Delayed graft function (DGF) is a risk factor for acute rejection (AR) in renal transplant recipients, and KDIGO guidelines suggest use of lymphocyte-depletion induction when DGF is anticipated. We analyzed the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) database to assess the impact of induction immunosuppression on the risk of AR in deceased kidney recipients based on pretransplant risk of DGF using a validated model. Recipients were categorized into 4 groups based upon the induction immunosuppression: (1) Rabbit anti-thymocyte globulin (rATG); (2) Alemtuzumab (C1H); (3) IL2-receptor antagonists (IL2-RA; basiliximab or daclizumab), and (4) No antibody induction. The primary endpoint for analysis was a composite endpoint of treated AR or graft failure by 1-year posttransplantation. Compared to no antibody induction, rATG and C1H had consistently lower adjusted odds of the composite endpoint across all risk strata for DGF risk, whereas IL2-Ra was associated with increased adjusted odds of the composite endpoint with increasing DGF risk. When the induction agents were compared, rATG and C1H were associated with decreasing adjusted odds for the composite endpoint with increasing risk of DGF, especially at the higher risk spectrum of DGF. Consideration must be given to use of lymphocyte-depletion induction when the anticipated risk of DGF is increased.

Morbidity of liver transplantation in patients with multiorgan failure in the intensive care unit

Background: The mean MELD-Na at the time of liver transplant (LT) varies widely across the 11 regions in the United States (US), due to organ supply versus demand issues, from 22 to as high as 35. Utilizing marginal donors on very sick patients has become more commonplace in some regions of the US but it has not been determined as to which patients are “too sick” to undergo LT. The purpose of our study was to determine if the use of Methods: A retrospective review comparing LT in patients from home (n = 40) to patients from the ICU (n = 44) between 2009–2016 with a MELD-Na >25. Preoperative variables included: demographics, etiologies, MELD-Na, and ICU risk factors (mechanical ventilation, vasopressors, hemodialysis, blood transfusions, length of stay (LOS)). Intraoperative variables included: transfusions, organ ischemia, donor risk index, operative time, and complications. Postoperative outcomes included: LOS, mechanical ventilation, re-operation, biliary complications, infection, short and long term renal dysfunction, 30-day readmission, liver biopsy, graft and patient 1 year survival. Results: We found that in in patients who underwent LT from the ICU versus those from home: median MELD-Na 43 vs 36 (p < 0.05), 1 year graft survival of 86.7% vs 90% (p = 0.74), 1 year patient survival of 86.7% vs 92.5% (p = 0.49). Conclusion: LT in the ICU patient continues to face challenges, especially when considering the severe organ shortage in the US. We found that in carefully selected ICU patients, even with multiorgan dysfunction, 1 year graft and patient survival are similar to outpatients.

Identification and Validation of the Predictive Capacity of Risk Factors and Models in Liver Transplantation Over Time.

Outcome after liver transplantation (LT) is determined by donor, transplant and recipient risk factors. These factors may have different impact on either patient or graft survival (outcome type). In the literature, there is wide variation in the use of outcome types and points in time (short term or long term). Objective of this study is to analyze the predictive capacity of risk factors and risk models in LT and how they vary over time and per outcome type. All LTs performed in the Netherlands from January 1, 2002, to December 31, 2011, were analyzed with multivariate analyses at 3-month, 1-year, and 5-year for patient and (non-)death-censored graft survival. The predictive capacity of the investigated risk models was compared with concordance indices. Recipient age, model for end-stage liver disease sodium, ventilatory support, diabetes mellitus, hepatocellular carcinoma, previous malignancy, hepatitis C virus antibody, hepatitis B virus antibody, perfusion fluid, and Eurotransplant donor risk index (ET-DRI) had significant impact on outcome (graft or patient survival) at 1 or multiple points in time. Significant factors at 3-month patient survival (recipient age, model for end-stage liver disease sodium, ventilatory support) were used to compose a concept model. This model, had a higher c-index than the balance-of-risk score, DRI, ET-DRI, donor-recipient model and simplified recipient risk index for long-term patient and non-death-censored graft survival. In this study, the effects of recipient risk factors and models on different outcome types and time points were shown. Short-term patient survival mainly depends on recipient risk factors, long-term graft survival on donor risk factors and is more difficult to predict. Next to the concept model, the donor-recipient model has a higher predictive capacity to other risk models for (long-term) patient and non-death-censored graft survival. The DRI and ET-DRI best predicted death-censored graft survival. Knowledge about risk factors and models is critical when using these for waitlist management and/or help in organ allocation and decision-making.

Procurement Biopsy Findings Versus Kidney Donor Risk Index for Predicting Renal Allograft Survival.

Efforts to maximize transplantation by matching organ quality to recipient longevity require reliable tools. The US kidney allocation system uses the Kidney Donor Risk Index (KDRI) for this purpose, and many centers additionally rely on donor biopsies. The Leuven score combines donor age with procurement histology (glomerulosclerosis and interstitial fibrosis/tubular atrophy) to predict allograft survival. We compared KDRI with Leuven scores for associations with kidney discard, delayed graft function, and allograft function and survival. We used Cox, modified Poisson, and linear regression to calculate risks based on KDRI and (separately) Leuven scores, adjusting for important transplant and recipient variables. From 890 donors, 1729 kidneys were procured and biopsied. Five hundred eighty-five (34%) kidneys were discarded. Median donor age was 53 years (interquartile range [IQR], 44-61 years). Median KDRI and Leuven scores were 1.56 (IQR, 1.28-1.90) and 59 (IQR, 49-69). Relative risk for discard was 1.21 (95% confidence interval [CI], 1.17-1.24) per 0.2-unit increase in KDRI and 1.38 (1.31-1.46) per 10-unit increase in Leuven score. Adjusted relative risks for delayed graft function were 0.98 (95% CI, 0.94-1.02) and 0.94 (95% CI, 0.90-0.99), adjusted hazard ratios for graft failure were 1.10 (95% CI, 1.04-1.16) and 1.11 (95% CI, 1.02-1.21), and adjusted linear regression coefficients for 3-year estimated glomerular filtration rate were -3.88 (-4.63 to -3.13) and -5.18 (-6.19 to -4.18). In kidneys clinically selected for procurement biopsy, the Leuven score was more strongly associated with discard but performed similarly to KDRI for predicting transplant outcomes, suggesting the need to reevaluate current procurement biopsy practices. Given modest associations for both tools; however, neither KDRI nor the Leuven score should be used in isolation for individual organ acceptance decisions.

Who can tolerate a marginal kidney? Predicting survival after deceased donor kidney transplant by donor-recipient combination.

The impact of donor quality on post-kidney transplant (KT) survival may vary by candidate condition. Characterizing this variation would increase access to KT without sacrificing outcomes. We developed a tool to estimate post-KT survival for combinations of donor quality and candidate condition. We studied deceased donor KT recipients (n=120818) and waitlisted candidates (n=376272) between 2005 and 2016 by using the Scientific Registry of Transplant Recipients. Donor quality and candidate condition were measured by using the Kidney Donor Profile Index (KDPI) and the Estimated Post Transplant Survival (EPTS) score. We estimated 5-year post-KT survival based on combinations of KDPI and EPTS score using random forest algorithms and waitlist survival by EPTS score using Weibull regressions. Survival benefit was defined as absolute reduction in mortality risk with KT. For candidates with an EPTSscore of80, 5-year waitlist survival was 47.6%, and 5-year post-KT survival was 78.9% after receiving kidneys with a KDPIof20 and was 70.7% after receiving kidneys with a KDPIof80. The impact of KDPI on survival benefit varied greatly by EPTS score. For candidates with low EPTS scores (eg, <40), the KDPI had limited impact on survival benefit. For candidates with middle or high EPTS scores (eg, >40), survival benefit decreased with higher KDPI but was still substantial even with a KDPIof100 (>16 percentage points). Our prediction tool (www.transplantmodels.com/kdpi-epts) can support individualized decision-making on kidney offers in clinical practice.

Evaluation of Graft Effluent High Mobility Group Box-1 (HMGB-1) for Prediction of Outcome After Liver Transplantation.

BackgroundPre-transplant assessment of the graft for liver transplantation is crucial. Based on experimental data, this study was designed to assess both nuclear high mobility group box-1 (HMGB-1) protein and arginine-specific proteolytic activity (ASPA) in the graft effluent.Material/MethodsIn a non-interventional trial, both HMGB-1 and ASPA were measured in the effluent of 30 liver grafts after cold storage before transplantation. Values of HMGB-1 and ASPA levels were compared with established prognostic parameters such as the donor risk index, balance of risk score, and Donor-Model for End-Stage Liver Disease.ResultsThe early allograft dysfunction (EAD) was best predicted by recipient age (p=0.026) and HMGB-1 (p=0.031). HMGB −1 thresholds indicated the likelihood for initial non-function (1608 ng/ml, p=0.004) and EAD (580 ng/ml, p=0.017). The multivariate binary regression analysis showed a 21-fold higher (95% CI: 1.6–284.5, p=0.022) risk for EAD in cases with levels exceeding 580 ng/ml. The ASPA was lower in cases of initial non-function (p=0.028) but did not correlate with the rate of EAD (p=0.4).ConclusionsThis study demonstrates the feasibility of HMGB-1 detection in the graft effluent after cold storage. Along with conventional prognostic scores, it may be helpful to predict the early fate of a graft in human liver transplantation.

Donor Risk Index could be a Predictor of “Resistant to Flow” Liver Grafts

Introduction The Donor Risk Index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. The measurement of intraoperative arterial hepatic flow and clearance of indocyanine green (PDR-ICG) are variables in the intraoperative time that reflects graft perfusion and they could be influenced by the quality of the grafts. Aim To analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function tests (PDR-ICG). Materials and Methods We propose an observational study of a single center cohort (n = 228). The measurement of the intraoperative flows is made with a flow meter VeriQ). ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated by the previously validated formula. Unless otherwise stated, data were expressed as mean (SD, standard deviation) or n (%). When data were normally distributed (based on the Kolmogorov-Smirnov test) they were compared using the t-Student test. The qualitative variables and risk measurement was analyzed using the chi-square test. Kaplan Meir curves were used to show survival analysis. Results DRI mean value ??was 1.58 ± 0.31. DRI> 1.7 group was considered grafts of poor quality had an intraoperative arterial flow 234.2 ± 121.35 ml / min compared with DRI <1.70 group with an intraoperative arterial flow of 287, 24 ± 156.84, p = 0.02. DRI > 1,7 grafts showed a increase risk to test a low arterial flow less than 180 ml/min. (OR: 1,89 95% confidence interval [95% CI], 1,35-3,35).p<0.04). DRI> 1.70 group had a 60min ICG-PDR of 14.75 ± 6.52% / min compared with DRI <1.70 group with a 60min ICG-PDR of 16.68 ± 6.47% / min, p = 0.09. DRI > 1,7 grafts showed a increase risk to test a low ICG-PDR 60 min less than 10 ml/min. (OR: 2,15 95% confidence interval [95% CI], ( 1,07-4,31), p= 0,03. Conclusion DRI considers variables such as elderly donors and prolonged cold ischemia time. Poor quality grafts have a greater susceptibility to ischemia reperfusion damage. A decrases in the measure of intraoperative hepatic artery flow and ICG-PDR could be translating an increase of intrahepatic resistance. To identify grafts “Resistant to Flow” previous to transplant them in new machine perfusion devise could be the aim of posterior studies.

Matching Graft Life Expectancy with Patient Life Expectancy

NSHBT Kidney Advisory Group. Introduction One of the key recommendations following a review of the current UK Kidney Allocation Scheme was to match graft life expectancy with patient life expectancy more effectively in order to maximise the lifetime of kidneys transplanted and reduce the incidence of offer declines. Material and Methods Data from the UK Transplant Registry held by NHS Blood and Transplant on 7,628 first adult kidney only recipients of adult deceased donor kidney transplants in the UK 2006-2012 were analysed. Donor factors potentially influencing graft outcome and recipient factors potentially influencing graft and patient outcomes were investigated using Cox regression. A Kidney Donor Risk Index (DRI) and a Kidney Recipient Risk Index (RRI) were derived from the models and validated on an independent dataset. Both indices were divided into quartiles and the combinations of the four donor and four recipient quartiles were used to investigate offer decline rates and post-transplant survival. Results and Discussions Donor factors found to significantly predict poor graft outcome included; older age, shorter height, a history of hypertension, positive CMV result, longer hospital stay before death, lower eGFR at time of offering and male donors. Recipient factors found to significantly predict poor transplant outcome (time to graft failure or death) included; older age, on dialysis at point of registration, diabetic and longer time on dialysis. A DRI based on the 7 significant factors and a RRI based on the 4 significant factors were derived and confirmed to be prognostic of outcome in a validation cohort (concordance statistic 0.64 for both models). Using the combination of the DRI and RRI quartiles it was observed that the poorest donors with the best recipients had the highest offer decline rate (64%) and the best donors with the best recipients had the lowest offer decline rate (23%). For kidneys transplanted from the best donors into the best recipients, 15-year patient survival was 86% compared with 70% graft survival, suggesting that patients are likely to outlive their grafts. Conversely, for the best donors with the poorest recipients, patient survival was 37% compared with 73% graft survival, suggesting that patients are likely to die with a functioning graft (Figure 1). These extreme examples demonstrate the importance of matching graft and patient life expectancies.Conclusions A Kidney Donor Risk Index alongside a Kidney Recipient Risk Index provides a clinically useful tool that can be used in allocation schemes to maximise the lifetime of kidneys transplanted and reduce the incidence of offer declines.

Revascularization Time Matters in Liver Transplantation

Background In the era of marginal organ utilization, the impact of revascularization time (RT) on outcomes in liver transplantation (LT) has not been reported. Methods All primary LT performed in Birmingham between 2009 and 2014 (n=678) with portal reperfusion first were stratified according to RT (<44 vs. ≥44 min) and graft quality (SLG, Donor risk index [DRI]<2.3 vs. MLG, DRI≥2.3). Results Compared to RT<44, a significantly greater incidence of early allograft dysfunction (EAD) (29% vs. 47%, p=<0.001), post-transplant acute kidney injury (AKI) (39% vs. 60%, p=<0.001) and new-onset AKI after LT (37% vs. 56%, p=<0.001) occurred after RT≥44. RT≥44 was also associated with adverse long-term outcome (3-year graft survival 92% vs. 83%, p=0.001; 3-year patient survival 87% vs. 79%, p=0.004). RT≥44 independently predicted EAD, renal dysfunction and overall graft but not patient survival. The cumulative effect of prolonged revascularization in marginal grafts (MLGRT≥44) resulted in the worst transplant outcome compared to all other groups which could be mitigated by rapid revascularization (SLGRT<44, SLGRT≥44, MLGRT<44 vs. MLGRT≥44, EAD 24%, 39%, 39% vs. 69%, respectively; p=<0.001 and 3-year graft survival 94%, 87%, 88% vs. 70%, respectively; p=<0.001)(Figure 1). Conclusions Prolonged graft revascularization places outcomes particularly of marginal liver grafts at risk, and this is a modifiable variable that relies on the expertise of the implanting surgeon and also has implications for transplant surgical training.

2. Reversible non-ischemic cardiomyopathy after orthotopic liver transplantation: a report of case series from single-center experience

Background: Non-ischaemic cardiomyopathy (NIC) is an early complication of liver transplantation (LT). Patients undergoing LT at our institution from September 2014 to April 2018. Patients who developed NIC were identified. Data collected included demographic and clinical data. Case Summary: A total 31 transplants were performed in this period and three patients developed NIC. Pretransplant dobutamine stress echocardiography was negative and Ejection fraction showed good LV systolic function. 25 patients (82%) were severely malnourished and required nutritional support. Median time to onset was 2 days post-transplant (range, 0–20). Echocardiograms showed global left ventricular hypokinesis and a decrease in ejection fraction (EF) from a median of 74% (range, 66–78) pretransplant to a median of 30% (range, 30–35). There was no significant difference between recipients with NIC vs. recipients without cardiomyopathy regarding donor age, donor risk index, and cold and warm ischemia time. Recovery of cardiac function occurred in all 3 patients, with a median EF of 60% (range, 58–62%) at the time of discharge. One-year survival of NIC patients was 100%. Conclusion: patients who developed NIC were individuals who had advanced liver disease with a high MELD score. The etiology of NIC is unknown, but it is most likely multifactorial. Although NIC is a rare complication of LT, and in most cases it is reversible, it can also cause significant post-operative morbidity requiring significant physiological support, a prolonged hospital stay, or mortality. Conclusions: Recognition of individuals at risk of NIC in the pre- or immediately post-LT period may be beneficial in reducing cardiovascular complications and may improve outcomes. The authors have none to declare.

A National Registry Analysis of Aortic versus Dual in Situ Perfusion for Retrieval of the DBD Liver

Introduction In situ perfusion of preservation fluid during donation after brain death (DBD) liver retrieval can be conducted via the aorta alone, or aorta and portal vein (dual perfusion). There is considerable disagreement in the literature with regards to the comparative efficacy of each perfusion route for both normal and expanded criteria liver donors, and the few existing studies are disadvantaged by low patient numbers and short periods of follow-up. Materials/Methods DBD whole liver transplants (initial) in Australia were included from 2007-2016, and stratified by aortic (n = 957) or dual (n = 425) perfusion routes. Data points were obtained from the Australia and New Zealand (ANZ) Liver Transplant Registry, the ANZ Organ Donation Registry, and a national survey of senior donor surgeons. University of Wisconsin (UW) solution was given via the aorta and/or portal vein, followed by organ transport in the same fluid. Missing data was handled by multiple imputations. Graft and patient survival were compared using Kaplan-Meier curves and Cox proportional hazards. Causes of graft loss, including primary non-function (PNF), hepatic artery (HAT) and portal vein thrombosis (HAT), biliary complications (BC) and acute rejection (AR) were compared using logistic regression. Results Baseline characteristics between study groups were similar, except for a lower mean cold ischemic time (CIT; 6.3 vs 7.0 hrs), mean secondary warm ischemic time (SWIT; 37.8 vs 45.4 mins), and median recipient MELD score (14 vs 18) in the dual-perfused patient cohort compared to the aortic-only perfusion group (p < 0.001). Actuarial 5-year graft and patient survivals in aortic and dual perfusion cohorts were 80.1% vs 84.6% (p = 0.066, univariate log-rank test), and 82.6% vs 87.8% (p = 0.026, univariate log-rank test), respectively. Multivariate Cox proportion hazards models, accounting for CIT, SWIT, MELD, and other donor/recipient factors with a p-value < 0.1 in univariate analyses, showed that graft survival after aortic vs dual perfusion was not significantly different (HR 0.81, 95% CI 0.60-1.11, p = 0.188). Similarly, overall patient survival was not different between the aortic and dual groups (HR 0.74, 95% CI 0.52-1.05, p = 0.087). There were no significant differences between aortic and dual perfusion groups with respect to causes of graft loss, including PNF, HAT, PVT, BC, and AR. Discussion After accounting for confounders, there were no significant differences in causes of graft loss, graft survival, and patient survival between liver transplants performed after aortic-only or dual in situ liver perfusion at retrieval. Subgroup analyses will need to be conducted to compare high-risk donors. Conclusion The retrieval technique employed does not impact outcomes for standard risk donors. Future RCTs should focus on the efficacy of either technique in liver donors with a high donor risk index, and also consider the impact on other organs, in particular the pancreas. Royal Australasian College of Surgeons.

Surgical Categorization Improve Outcomes and Organ Utilization in Liver Transplantation

Background Liver transplant (LT) varies greatly in technical complexity due to factors such as prior surgery, obesity, and portal vein thrombosis (PVT). In addition, our program often evaluates ‘orphan livers’ that require a quick, effective and accurate recipient selection. This must be taken into account when considering organ offers. In 2015, we began using an A/B/C stratification of predicted surgical complexity based on surgical history and cross-sectional imaging, as reviewed by faculty surgeons. The scores are assigned at waitlist addition and are integral to on-call workflow at the time of the liver offer. Methods Four-hundred consecutives LT recipients (Jan-15 to Dec-16) were prospectively categorize at the time of listing according with their surgical complexity in Group A: Low (n=268) LT alone, absence-moderate obesity; patent PV, no upper abdomen surgeries (except lap chole); Group B: Moderate (n=91) combined LKT, moderate–severe obesity, upper abdomen operations, PV thrombosis; and Group C: High (n=41) retransplantation, previous HB surgery or gastric bypass, PV cavernous transformation. Analysis were performed using Student t-test and Fisher exact test. Survival curves were obtained by Kaplan Meier method and log rank test. Results are in Mean + SD and Mead IQ 1-3. Results Recipients in group A had lower MELD (19.5+8.3 vs. 20.4+9.3 vs. 24.8+9.6 P=0.001) while recipients in group B had higher BMI (27.2+5.4 vs. 33.1+8 vs. 26.9+5.1 p=0.002) and high proportion of HCC (32% vs. 46% vs. 17% p=0.02). Group C had the higher incidence of previous LT (2.4% vs. 1.1% vs. 26.8% p<0.001), PV thrombosis (7.8% vs. 12% vs. 29% p=0.002) and its operation time was longer (5.3+1.6 vs. 5.5+1.3 vs. 6.4+2.1 p<0.001), ICU stay (median, IQ 2, 2-4 vs. 2.8, 2-4 vs. 3, 2-5 days p=0.001) and hospital stay (Median IQ 6, 6-14 vs. 11, 7-18 vs. 12, 8-28 days, p=0.001). All three groups had similar cold ischemia time (33.2+96 vs. 317+84 vs. 312.5+89.9 min, p=0.8) but compared with group B, group A received a higher proportion of livers from out our donor service area (57.8% vs. 43.9% vs. 58.9% p=0.001). In addition, group A received more DCD livers (12.7% vs. 5.5% vs. 0% p=0.02) and higher donor risk index livers (1.6+0.4 vs. 1.4+0.4 vs. 1.3+0.2 p<0.001). Donor liver steatosis, incidence of early allograft dysfunction and, biliary and vascular complications were similar in all 3 groups. One-year graft and patient survival were 91.8% vs. 87.9% vs. 78.1% (p=0.006) and 93.3% vs. 91.2% vs. 78.1% (p=0.001) for groups A, B, C respectively. Conclusion Pre LT categorization by surgical complexity at the time of listing correctly stratified patients’ surgical risk. Surgical complexity ranking is a tool that allows better recipient selection, recipient-donor matching and resource utilization that result in increase acceptance of liver offers.

Validation of the Prognostic Kidney Donor Risk Index (KDRI) Scoring System of Deceased Donors for Renal Transplantation in the Netherlands: Erratum.

Validation of the Prognostic Kidney Donor Risk Index (KDRI) Scoring System of Deceased Donors for Renal Transplantation in the Netherlands: Erratum.

Risk Factors for Fungal Infections After Liver Transplantation

Introduction Fungal infections after transplantation are associated with high morbidity and mortality. Awareness of the treating physicians and thereby early detection is key to successful treatment. Aim of the present study was to identify risk factors for fungal infections in a cohort of liver transplant recipients in the MELD era. Patients and Methods Out of 579 adult patients transplanted from 01/2012-12/2016, 33 (5.6%) patients developed fungal infections after liver transplantation. These 33 patients (mean age 48 years; LabMELD 22) were matched with 99 patients (mean age 50 years; LabMELD 22) without fungal infections after transplantation by MELD score and age. Standard donor and recipient and procedural factors were analyzed and correlated with occurrence of fungal infections and outcomes by univariable/multivariable statistics. Fungal prophylaxis is not administered at our center. Results After adjustment by multivariable analysis the Donor Risk Index (p=0.02) and dialysis after transplantation (p=0.01) were independently associated with occurrence of fungal infections. 30-day and 12-month survival in patients with fungal infections were 63.6% and 48.5%, respectively, while patients without fungal infections demonstrated 30-day and 12 month survival rates of 85.9% and 76.7%, respectively (p<0.01). Conclusions Rates of fungal infections are low after liver transplantation in the modern MELD era. Indeed, outcome is significantly diminished if fungal infections occur. Patients requiring hemodialysis after liver transplantation are under high risk of this dangerous complication and should therefore be monitored carefully.

A New Risk Stratification Score for Deceased Donor Kidneys in Korea

Organ shortages have led to expansions in the criteria for deceased donors. Although the expanded criteria donor (ECD)/standard criteria donor (SCD) dichotomous criteria have been useful for making decisions about accepting organ offers, several studies reported that these criteria are too simple to predict prognosis sufficiently. The Kidney Donor Risk Index (KDRI) is based on 10 donor factors, therefore providing a finely granulated evaluation of donor kidney quality. Kidney Donor Profile Index (KDPI) that was derived from KDRI, was newly adopted as an alternative to ECD/SCD in the US. However, the KDPI based on US data may not have similar prognostic values in other countries. Here, we developed a Korean risk stratification score for deceased donor kidney using data obtained from the KONOS (Korean Network for Organ Sharing) and KOTRY (Korean Organ Transplantation RegistrY), and investigated its prognostic values. We analyzed 5,524 first-time, deceased donor adult kidney transplants between 2000 and 2016. A Cox regression model was used to find out independent risk factors among donor and transplant-related factors for graft failure, adjusted for recipient characteristics. There were 426 deaths and 483 graft loss during median follow-up of 49 months. The mean age of donors were 44 years old, and 32% of donor were females. Nine hundred seventeen donors had history of hypertension, and the cause of death was cerebrovascular event in 2,597 donors. Fifty-three donated organ after cardiac death, and mean cold ischemic time was 322 minutes. Twenty-three percent belonged to ECD. Median KDRI was 1.18 and KDPI was 67. A New Korean Kidney Donor Risk Index (K-KDRI) includes 6 donor and transplant factors, each found to be independently associated with graft failure: donor age, weight, history of diabetes, serum creatinine, cerebrovascular cause of death, and HLA mismatch. Median K- KDRI was 1.5. A New Korean Kidney Donor Profile Index (K-KDPI) is a remapping of the K-KDRI onto a cumulative percentage scale. The lowest K-KDPI group (<20%) showed better graft survival than the higher K-KDPI groups (20-80%, ≥80%, respectively) (p<0.001). Even within the ECD group, higher K-KDPI values were significantly associated with lower graft survival rate. In contrast, in the same K-KDPI group, there was no difference in graft survival rate between ECD and SCD. These data suggested that K-KDPI is a better prognostic tool for graft outcomes than the previous ECD/SCD criteria. The new K-KDPI criteria based on the Korean data are expected to give better information about graft prognosis and assist decision making for deceased donor kidney utilization in Korea. KONOS (Korean Network for Organ Sharing). KOTRY (Korean Organ Transplantation Registry).

A Donor Quality Index for liver transplantation: development, internal and external validation

Organ shortage leads to using non-optimal liver grafts. Thus, to determine the graft quality, the Donor Risk Index and the Eurotransplant Donor Risk Index have been proposed. In a previous study we showed that neither could be validated on the French database. Our aim was then dedicated to propose an adaptive Donor Quality Index (DQI) using data from 3961 liver transplantation (LT) performed in France between 2009 and 2013, with an external validation based on 1048 French LT performed in 2014. Using Cox models and three different methods of selection, we developed a new score and defined groups at risk. Model performance was assessed by means of three measures of discrimination corrected by the optimism using a bootstrap procedure. An external validation was also performed in order to evaluate its calibration and discrimination. Five donor covariates were retained: age, cause of death, intensive care unit stay, lowest MDRD creatinine clearance, and liver type. Three groups at risk could be discriminated. The performances of the model were satisfactory after internal validation. Calibration and discrimination were preserved in the external validation dataset. The DQI exhibited good properties and is potentially adaptive as an aid for better guiding decision making for LT.