Early Graft Survival Research Articles

Long-term outcomes of the octogenarian donor liver recipient: The era of the new centurion.

Studies have suggested transplantation using older donor livers results in similar short-term outcomes as younger donor livers; however, little data exist on long-term patient/graft outcomes of the octogenarian liver recipient. Retrospective data were collected from 2 centers, (Valencia, Spain and Rochester, MN, USA) of all recipients of octogenarian donor liver allografts from 2000 to 2011 with follow-up to 2016. The aim was to compare long-term patient/graft survival as well as metabolic outcomes of the recipient with the octogenarian liver vs younger than 60years donor. 78 recipients of older liver allografts were compared to 78 matched controls. No difference in 10-year patient mortality was demonstrated (P=0.074). Octogenarian livers were associated with 3-fold higher likelihood of graft failure (P=0.002) but no increase in the risk of post-LT cardiovascular disease (P=0.60), hypertension (P=0.33), vascular complications (P=0.53), or malignancy (P=0.14). In multivariate analysis, elder livers remained a significant factor associated with rejection (P=0.034) with a trend not reaching statistical significance for graft failure (P=0.052). For appropriately selected recipients, receiving an octogenarian liver does not clearly influence patient survival but does impact early graft survival with a notable increase in early posttransplant rejection rates and re-transplantation. Over 1.5 decades, older allografts have not adversely affected metabolic outcomes.

Donor Small-Droplet Macrovesicular Steatosis Affects Liver Transplant Outcome in HCV-Negative Recipients.

Background No data are available on liver transplantation (LT) outcome and donor liver steatosis, classified as large droplet macrovesicular (Ld-MaS), small-droplet macrovesicular (Sd-MaS), and true microvesicular (MiS), taking into account the recipient Hepatitis C virus (HCV) status. Aim We investigate the impact of allograft steatosis reclassified according to the Brunt classification on early graft function and survival after LT. Methods We retrospectively reviewed 204 consecutive preischemia biopsies of grafts transplanted in our center during the period 2001-2011 according to recipient HCV status. Results The median follow-up after LT was 7.5 years (range: 0.0-16.7). In negative recipients (n=122), graft loss was independently associated with graft Sd-MaS, in multivariable Cox regression models comprehending only pre-/intraoperative variables (HR=1.03, 95%CI=1.01-1.05; P=0.003) and when including indexes of early postoperative graft function (HR=1.04, 95%CI=1.02-1.06; P=0.001). Graft Sd-MaS>15% showed a risk for graft loss > 2.5-folds in both the models. Graft Sd-MaS>15% was associated with reduced graft ATP content and, only in HCV- recipients, with higher early post-LT serum AST peaks. Conclusions In HCV-negative recipients, allografts with >15% Sd-MaS have significantly reduced graft survival and show low ATP and higher AST peaks in the immediate posttransplant period. Donors with >15% Sd-MaS have significantly higher BMI, longer ICU stays, and lower PaO2.

Machine preservation of donor kidneys in transplantation.

With increasing demands for 'less than ideal' kidneys for transplantation, machine perfusion of kidneys has been utilized to improve the preservation of kidneys during storage. Hypothermic machine perfusion (HMP) of renal allografts has been shown to reduce delayed graft function rates in both expanded criteria and donation after cardiac death renal allografts. However, the beneficial impact upon long-term graft function is unclear. There has been emerging evidence that both subnormothermic (room temperature) and normothermic machine perfusion (NMP) of allografts have beneficial effects with regards to early graft function, survival and injury in pre-clinical and early clinical studies. Additionally, machine perfusion allows functional assessment of the organ prior to transplantation. Ultimately, the greatest benefit of machine perfusion may be the ability to treat the organ with agents to protect the graft against ischemia reperfusion injury, while awaiting transplantation.

Ees Estimation Using Machine Learning Approach during Ex Vivo Heart Perfusion to Predict Early Graft Survival: A Preliminary Study in Porcine Model

Purpose Ex vivo heart perfusion (EVHP) provides a means to assess cardiac function before heart transplantation . End-systolic elastance (E es ) has been proposed as a relative load-insensitive index of cardiac function. However, due to the difficulties to obtain multiple stable pressure-volume (PV) loops at different preload conditions in EVHP, accurate prediction of organ viability using E es is limited. In this study, Ees estimation on single-beat basis prior to heart transplantation was used to predict early stage graft survival in a porcine model. Methods Single-beat determination of Ees was developed by employing end systolic pressure (P es ), end systolic volume (V es) and volume axis intercept of Ees (V0): Ees=Pes/(Ves-V0). V0 was estimated using machine learning method (support vector regression). 20 EVHP experiments using pig hearts were performed to train the Ees estimation model. The trained Ees estimation model was then used to predict early post transplantation outcomes in 6 experiments where donor pig hearts were procured and perfused ex vivo for 4 hours before transplant. Hearts were transitioned into working mode for functional assessment during the 4th hour perfusion and Ees was derived using the proposed single-beat method. Linear regression was performed to study the correlation between E es and post-transplant cardiac index. Results In the first 20 EVHP experiments, 10 parameters (Table 1) were selected as inputs of the machine learning model. Ees determined by single-beat method aligned well with conventional multi-beat estimates obtained by occlusion process (R=0.959, p Conclusion Determination of Ees from a single, steady-state beat using machine learning technology could provide an effective approach to predict early post-transplant outcomes in porcine model.

The Changing Face of Liver Transplantation in the United States: The Effect of HCV Antiviral Eras on Transplantation Trends and Outcomes.

BackgroundHepatitis C virus (HCV) cirrhosis is the leading indication for liver transplantation in the United States, although nonalcoholic steatohepatitis (NASH) is on the rise. Increasingly effective HCV antivirals are available, but their association with diagnosis-specific liver transplantation rates and early graft survival is not known.MethodsThe Scientific Registry of Transplant Recipients database records were retrospectively stratified by HCV antiviral era: interferon (2003-2010), protease inhibitors (2011-2013), and direct-acting antivirals (2014 to present). Kaplan-Meier, χ2, and multivariable Cox proportional hazards regression models evaluated the effects of antiviral era and etiology of liver disease on transplantation rates and graft survival over 3 years.ResultsLiver transplants for HCV decreased (35.3% to 23.6%), whereas those for NASH and alcoholic liver disease increased (5.8% to 16.5% and 15.6% to 24.0%) with each advancing era (all P < 0.05). Early graft survival improved with each advancing era for HCV but not for hepatitis B virus, NASH, or alcoholic liver disease (multivariable model era by diagnosis interaction P < 0.001). Era-specific multivariable models demonstrated that the risk of early graft loss for NASH was 22% lower than for HCV in the interferon era (hazard ratio, 0.78; 95% confidence interval, 0.64-0.96; P = 0.02) but risks associated with these diagnoses did not differ significantly in the protease inhibitor (P = 0.06) or direct-acting antiviral eras (P = 0.08).ConclusionsIncreasing effectiveness of HCV antivirals corresponds with decreased rates of liver transplantation for HCV and improved early graft survival. As the rates of liver transplant for NASH continue to increase, focus will be needed on the prevention and effective therapies for this disease.

Renal Transplant and Its Outcomes: Single-Center Experience From India.

Improvements in early graft survival and long-term graft function have made kidney transplant a more cost-effective alternative to dialysis. We aimed to assess renal transplant outcomes over a 9-month follow-up of recipients in a cost-limited setting (a tertiary care center in India). Included patients in this prospective observational study were those who underwent renal transplant from July 2016 to February 2017 (8 months) and followed for 9 months. Of 122 included patients, 20 (16.4%) were women and 102 (83.6%) were men (mean age 35.61 ± 10.64 y), with 92 (75.4%) from a lower socioeconomic status. Kidneys were from first-degree relatives for 52 patients (42.6%), from spousal donors for 34 (27.9%), from deceased donors for 24 (19.7%), and from second/third degree relative donors for 12 (9.8%). All patients underwent only complementdependent cytotoxicity crossmatch due to financial constraints. Fifty patients (41%) had history of packed red blood cell transfusion. Induction was thymoglobulin in 60 patients (49.2%), basiliximab in 8 (6.6%), and no induction in 54 (44.3%). Forty patients (30.1%) underwent biopsy for graft dysfunction, and 32 (26.2%) had graft rejection: 18 (14.8%) with antibodymediated rejection, 5 (4.1%) with T-cell-mediated rejection, and 9 (7.4%) with both. Opportunistic infections were shown in 24.5% of patients, including primarily cytomegalovirus (10.7%), tuberculosis (5.7%), and aspergillosis (3.3%). Twenty-nine patients (24%) had new-onset diabetes posttransplant. At end of follow-up, 93 patients (76.2%) had normal graft function, 21 (17.2%) had chronic graft dysfunction, 3 (2.4%) had graft loss, and 5 (4.1%) died. History of blood transfusion (P = .001) predicted the occurrence of antibody-mediated rejection, and induction used showed trend toward prediction (P = .083). With high rejection rates, it would be prudent to include proper immunologic testing, even in cost-limited settings, pretransplant. The high infection and death rates are also concerning.

Frequency of Hepatotropic Viruses Leading To Deranged Liver Function Tests in Renal Transplant Recipients.

The preferred modality for renal replacement therapy is renal transplantation. Marked improvements in early graft survival and long-term graft function have made renal transplantation a more cost-effective alternative to dialysis. The presence of liver disease in the posttransplant period adversely affects graft function and survival. Determining the cause of deranged liver function tests can be helpful in treating the underlying cause, leading to improved graft survival and overall quality of life in patients after renal transplant. Here, we determined the frequency of hepatotropic viral infections leading to deranged liver function tests in renal transplant recipients. Our study included 132 patients with deranged liver function tests who had undergone renal transplant within the past 6 months. Reactivity and nonreactivity of hepatotropic viruses leading to deranged liver function tests were recorded. Average age of patients was 37.17 ± 8.75 years. There were 84 male (63.64%) and 48 female (36.36%) patients. Rates of hepatitis C virus antibodies and hepatitis B surface antigen were 62.88% (83/132) and 37.12% (49/132), respectively, whereas no patients had hepatitis E virus immunoglobulin M antibodies or hepatitis A virus immunoglobulin M antibodies. Among the hepatotropic viral infections leading to deranged liver function tests in renal transplant recipients, hepatitis B virus accounted for a small fraction. In contrast, hepatitis C virus was highly prevalent in transplant recipients who developed deranged liver function tests. Renal transplant recipients with hepatic viral infections have worse patient and allograft survival after transplant compared with noninfected renal transplant recipients. We recommend that transplant candidates be screened for hepatitis B and C virus infection, thus allowing increased graft survival and improved quality of life in renal transplant recipients.

Low platelet counts after liver transplantation: validation of the 60-5 criterion

Background: Platelets play a critical role in hepatic ischemia-reperfusion injury and regeneration. In a single-centre cohort of liver transplanted patients (derivation cohort), platelet counts <60x109/L at postoperative day 5 (POD5) (the 60-5 criterion) were shown to be an independent predicting factor for severe postoperative complications and early graft and patient survival. The aim of this study was to validate those findings using a validation cohort containing prospective data. Methods: The validation cohort comprised prospectively collected data on donors, recipients, perioperative laboratory values, graft function, complications and survival from 285 liver transplantations between 2008 and 2014. The primary outcome was grade IIIb/IV complications, secondary outcomes were graft and patient survival. Results: Mean patient and donor ages were 57 ±11.6 and 51 ±18.3 years respectively. The average MELD score was 18 ± 10.6. Patients with POD5 platelet counts <60 x109/L had higher rates of severe (grade IIIb/IV) complications [27.8% versus 16.8%, odds ratio (OR) 1.9 (95% CI 1.1-3.5), p<0.05] and worse 90-day mortality [6.1% versus 1.3%, OR 5.0 (95% CI 1.0-24.6), p<0.05]. The 1-, 3-, and 5-year graft and overall survival rates were similar in both groups. Conclusion: This study validates the 60-5 criterion as a predictor of severe complications and 90-day mortality after liver transplantation. These findings may help in developing protective strategies or interventions early after liver transplantation in high-risk patients.

Low Platelet Counts After Liver Transplantation: Validation of the 60-5 Criterion

Background: Platelets play a critical role in hepatic ischemia-reperfusion injury and regeneration. In a single-centre cohort of liver transplanted patients (derivation cohort), platelet counts <60x109/L at postoperative day 5 (POD5) (the 60-5 criterion) were shown to be an independent predicting factor for severe postoperative complications and early graft and patient survival. The aim of this study was to validate those findings using a validation cohort containing prospective data. Methods: The validation cohort comprised prospectively collected data on donors, recipients, perioperative laboratory values, graft function, complications and survival from 285 liver transplantations between 2008 and 2014. The primary outcome was grade IIIb/IV complications, secondary outcomes were graft and patient survival. Results: Mean patient and donor ages were 57 ±11.6 and 51 ±18.3 years respectively. The average MELD score was 18 ± 10.6. Patients with POD5 platelet counts <60 x109/L had higher rates of severe (grade IIIb/IV) complications [27.8% versus 16.8%, odds ratio (OR) 1.9 (95% CI 1.1-3.5), p<0.05] and worse 90-day mortality [6.1% versus 1.3%, OR 5.0 (95% CI 1.0-24.6), p<0.05]. The 1-, 3-, and 5-year graft and overall survival rates were similar in both groups. Conclusion: This study validates the 60-5 criterion as a predictor of severe complications and 90-day mortality after liver transplantation. These findings may help in developing protective strategies or interventions early after liver transplantation in high-risk patients.

Donor liver apoptosis is associated with early allograft dysfunction and decreased short-term graft survival after liver transplantation.

The clinical significance of apoptosis in assessing the quality of donor liver grafts remains unknown. This study aimed to determine whether apoptosis in a donor liver is predictive of early allograft dysfunction (EAD) and graft survival after liver transplantation (LT). Donor liver specimens were analyzed for apoptosis using TUNEL assays. The prognostic factors for EAD were identified through logistic regression analyses, and a nomogram was developed. The apoptosis index of donor livers in EAD patients was significantly higher than that of donors livers in non-EAD patients (median 5.3; interquartile range [IQR] 3.4 vs 3.5; 3.6, P<0.001). Multivariate analyses identified the apoptosis index of the donor liver (HR=6.927, P<0.001) and five other characteristics as independent predictors of EAD. A nomogram built on these predictive variables showed good calibration and discriminatory abilities, with a c-index value of 0.847. The 30-day graft survival rates in the high apoptosis index (apoptosis index >4.4%) group were significantly lower than those in the low apoptosis index (apoptosis index ≤4.4%) group (84.4% vs 97.6%, P=0.004). Donor liver apoptosis plays a significant role in predicting EAD after LT. Furthermore, a high apoptosis index in the donor liver was associated with inferior graft survival in the short-term.

Use of donors at age extremes for simultaneous pancreas-kidney transplant

Introduction: There is a shortage of optimal pancreatic donors for simultaneous pancreas and kidney transplant (SPKT), as such there is interest in utilizing donors at extremes of age to expand the donor pool. We sought to evaluate outcomes in SPKT from pediatric donors (PDs) to older donors (ODs). Patients and Methods: We identified patients who underwent simultaneous pancreas and kidney transplant at a single, high-volume institution from 1988–2013. We evaluated for differences in transplant organ function (estimated glomerular filtration rate [GFR], serum glucose, and urine amylase), early (technical) graft loss, and patient and graft survival. Results: A total of 729 SPKT were performed during the study, with 32 PDs, 652 standard donors (SDs), and 45 ODs. Renal function was slightly worse in OD. Otherwise, graft function was similar between all three groups at up to 5 years. There was no difference in censored survival analyses for both kidney and pancreas allografts. There was comparable short-term and long-term patient survival among all groups. Conclusions: Overall, the use of pancreas from pediatric and ODs for SPKT has comparable outcome to SDs. Kidneys from donors above 50 may have lower GFR, but otherwise, have comparable long-term patient and graft survival.

Biomarkers and Pharmacogenomics in Kidney Transplantation.

This review is focused on present and future biomarkers, along with pharmacogenomics used in clinical practice for kidney transplantation. It aims to highlight biomarkers that could potentially be used to improve kidney transplant early and long-term graft survival, but also potentially patient co-morbidity. Future directions for improving outcomes are discussed, which include immune tolerance and personalising immunosuppression regimens.

Better Graft Survival with no Ischemic Cholangiopathy in DCD Liver Transplantation in the UK using Normothermic Regional Perfusion (NRP)

Background Normothermic regional perfusion, whereby the donor is placed on an extracorporeal circuit to circulate oxygenated blood to the abdominal viscera after death, is increasingly being used in controlled donation after circulatory death (DCD) donation. We evaluated the joint experience of the two centres pioneering this technique in the UK and compared NRP DCD liver transplants to non-NRP DCD livers transplanted at each centre in the same period. Methods Between 1/1/2011 and 31/5/17, 44 patients underwent liver transplantation following NRP; these were compared to 185 DCD liver transplants without NRP performed in the same period. NRP was performed for a median 123 (IQR 101-130) minutes before in-situ cold perfusion. Results Table 1 summarises the results. There was no significant difference in the recipient age (58 vs 61) or UK End Stage Liver disease (UKELD) score (55.7 NRP vs 54.3 non-NRP) between groups. 90 day patient survival was similar (100% NRP vs 96.7% non-NRP). There was a significant reduction in ischemic cholangiopathy and early allograft dysfunction with a better graft survival at 90 days. Conclusion Livers from DCD donors undergoing NRP have a lower incidence of primary non function and early allograft dysfunction, fewer biliary complications, and significantly better early graft survival.

Comparison of Histidine-Tryptophan-Ketoglutarate and University of Wisconsin preservation solutions inpediatric liver transplantation.

UW and HTK solutions are the two primary organ preservation solutions most used in the United States. This study analyzes use of the two solutions in all pediatric liver transplants performed at a single center between 2001and 2017. Outcome measures included early graft function, as well as graft and patient survival. Bile duct complications were reviewed. Operative technique, immunosuppressive protocols, and donor acceptance criteria remained uniform among participating surgeons throughout the study period. There were 104 pediatric liver transplants with complete data during the study period, 75 preserved with HTK (68%) and 29 with UW (26%). Demographics were similar. Cold and warm ischemia times were similar. Peak ALT post-transplant was higher in the UW group at both peak and post-transplant day 3. The peak TB levels were similar. Bile duct strictures were more common in the UW group (44% vs 16%, P<.01). Early graft survival was statistically similar at 7-, 90- and 365-days post-transplant. Cox regression graft survival was similar at 10-years. This study suggests that use of HTK in pediatric liver transplantation is safe with outcomes similar to UW, though bile duct stricture rates may be lower with HTK.

Outcomes of Pediatric Liver Transplantation: Deceased Donor Liver Transplantation vs Living Donor Liver Transplantation

BackgroundThe use of pediatric donor liver for pediatric liver transplantation (LT) remains controversial and few studies have focused on pediatric deceased donors. To address this issue, we decided to perform a retrospective research, trying to compare the clinical effects between deceased donor LTs (DDLTs) and living donor LTs (LDLTs). MethodsA retrospective review of pediatric LTs using grafts from deceased donors and living donors from June 2013 to August 2016 was performed. The children were divided into a DDLT group and a LDLT group based on their donor styles. The incidence of early vascular complications (VC), biliary complications, and graft and patient survival rates were observed between the 2 groups. ResultsThere were 217 cases of pediatric LTs performed in our hospital from June 2013 to August 2016 (83 DDLTs and 134 LDLTs). The 1-year cumulative survival rates of grafts and recipients were 89.16% and 91.57% in DDLTs, and 95.47% and 95.52% in LDLTs, respectively (P > .05). The incidence of early VC was lower in LDLTs than that in DDLTs (3.7% vs 19.3%, P < .001). The incidence of HAT in children aged less than 1 year was significantly higher in the DDLT group (P < .001) and can be up to 31.82%. The incidence of biliary complications was similar in the 2 groups (8.4% vs 13.5%, P = .285). ConclusionsPediatric DDLTs have similar graft and patient survival rates with LDLT. The incidence of early VC was higher in DDLTs, and children aged less than 1 year are at a higher risk of developing HAT.

Pretransplant Amiodarone Use and Post-transplant Outcomes in Pediatric Heart Transplant: A Propensity Score Analysis of the ISHLT Transplant Registry

Amiodarone is used in children awaiting transplant who have or develop arrhythmias. An association between pre-transplant amiodarone use and worse early post-transplant graft survival in adult heart transplantation has been established. There are no studies investigating associations of pre-transplant amiodarone and post-transplant outcomes in pediatric heart transplantation

The Treatment of Antibody-Mediated Rejection in Kidney Transplantation: An Updated Systematic Review and Meta-Analysis.

Current treatments for antibody-mediated rejection (AMR) in kidney transplantation are based on low-quality data from a small number of controlled trials. Novel agents targeting B cells, plasma cells, and the complement system have featured in recent studies of AMR. We conducted a systematic review and meta-analysis of controlled trials in kidney transplant recipients using Medline, EMBASE, and CENTRAL from inception to February 2017. Of 14 380 citations, we identified 21 studies, including 10 randomized controlled trials, involving 751 participants. Since the last systematic review conducted in 2011, we found nine additional studies evaluating plasmapheresis + intravenous immunoglobulin (IVIG) (two), rituximab (two), bortezomib (two), C1 inhibitor (two), and eculizumab (one). Risk of bias was serious or unclear overall and evidence quality was low for the majority of treatment strategies. Sufficient RCTs for pooled analysis were available only for antibody removal, and here there was no significant difference between groups for graft survival (HR 0.76; 95% CI 0.35-1.63; P = 0.475). Studies showed important heterogeneity in treatments, definition of AMR, quality, and follow-up. Plasmapheresis and IVIG were used as standard-of-care in recent studies, and to this combination, rituximab seemed to add little or no benefit. Insufficient data are available to assess the efficacy of bortezomib and complement inhibitors. Newer studies evaluating rituximab showed little or no difference to early graft survival, and the efficacy of bortezomib and complement inhibitors for the treatment of AMR remains unclear. Despite the evidence uncertainty, plasmapheresis and IVIG have become standard-of-care for the treatment of acute AMR.

Results of Renal Transplant From Deceased Anti-hepatitis C Virus Donors, Poland 1998-2012

Kidney transplant (KTx) is the best method of renal insufficiency treatment. In dialyzed patients, mortality rises with the time on dialysis. There is a continuing shortage of organs for transplantation, hence a propensity to expand the donor pool with expanded-criteria donors, anti-hepatitis C virus-positive included. In the above case a transmission of hepatitis C virus (HCV) genotype to recipient is present. It has been proven that contamination with more than 1 HCV genotype did not worsen KTx outcomes. There are 2.6% anti-HCV(+) donors in Poland. Use is only possible in cases of anti-HCV(+) and anti-HCV RNA(+) recipients. MethodsRetrospective analysis covered 8675 deceased donors (1998-2012 Polish data from Poltransplant). The early (after 12 months) and late (after 60 months) graft and patient survival was assessed in KTx recipients, with documented recipient and donor data spanning at least 1 year after KTx. In comprehensive analysis, 7016 KTx recipients with known anti-HCV status were included according to anti-HCV profile of recipient and donor. The results are in absolute and percentage values and P < .05 assessed with χ2 test. ResultsTwelve-month survival: recipient (R) (95%), graft (G) (89%), total; R (95% vs 89%, P < .001), G (88 vs 79, P < .001) in HCV(−) to HCV(+/−) vs HCV(+) to HCV(+); R (95 vs 94, P = .2), G (88 vs 83, P < .001), HCV(−) to HCV(−) vs HCV(−) to HCV(+); R (93 vs 95, P = .004), G (82 vs 89, P < .001) in HCV(+/−) to HCV(+) vs HCV(−) to HCV(−); R (95 vs 89, P < .001), G (88 vs 79, P < .001) in HCV(−) to HCV(−) vs HCV(+) vs HCV (+). Sixty-month survival: R (86%), G (75%), total; R (84 vs 88, P = .01), G (63 vs 71, P = .001) in HCV(+/−) to HCV(+) vs HCV(−) to HCV(−); R (88 vs 80, P = .003) in HCV(−) to HCV(−) vs HCV(+) to HCV(+). ConclusionsThe worst anti-HCV serological profile was HCV(+) to HCV(+), although transplanting HCV(+) to HCV(+) did not worsen outcomes in that group. Worse KTx outcomes of HCV(+) over HCV(−) donors can be attributed to HCV(+) status of the recipient.

Coexistence of Bilirubin ≥10 mg/dL and Prothrombin Time-International Normalized Ratio ≥1.6 on Day 7: A Strong Predictor of Early Graft Loss After Living Donor Liver Transplantation.

Early allograft dysfunction (EAD) defined by serum total bilirubin (TB) of 10 mg/dL or greater or prothrombin time-international normalized ratio (PT-INR) of 1.6 or greater on postoperative day 7 (POD 7) or aminotransferase greater than 2000 IU/L within the first week, is associated with early graft loss after deceased-donor liver transplantation. We aimed to determine the prognostic impact of the EAD definition in living-donor liver transplantation (LDLT). We analyzed the validity of the EAD definition and its impact on early graft survival in 260 adult recipients who underwent primary LDLT. Eighty-four (32.3%) patients met the EAD criteria; 59 (22.7%) and 46 (17.7%) patients had TB of 10 mg/dL or greater and PT-INR of 1.6 or greater on POD 7, respectively, and 22 (8.5%) patients satisfied both criteria. Graft survival differed significantly when stratified according to TB of 10 mg/dL or greater and PT-INR of 1.6 or greater (P < 0.0001). PT-INR of 1.6 or greater resulted in higher graft mortality (risk ratio [RR], 3.87; P < 0.0001 at 90 days; RR, 2.97; P < 0.0001 at 180 days), as did TB of 10 mg/dL or greater (RR, 1.89; P = 0.027 at 90 days; RR, 1.91; P = 0.006 at 180 days). Coexistence of TB of 10 mg/dL or greater and PT-INR of 1.6 or greater was strongly associated with early graft loss (59.1%, RR, 6.97 at 90 days; 68.2%; RR, 5.75 at 180 days). In Cox regression analysis, PT-INR of 1.6 or greater and TB of 10 mg/dL or greater on POD 7 were significant risk factors for early graft loss (hazard ratio, 4.10; 95% confidence interval, 2.35-7.18; P < 0.0001, and hazard ratio, 2.43; 95% confidence interval, 1.39-4.24; P = 0.0018, respectively). TB of 10 mg/dL or greater and/or PT-INR of 1.6 or greater on POD 7 predicted early graft loss after LDLT, and their coexistence worsened patient outcomes.

The effect of inhalational anaesthesia during deceased donor organ procurement on post-transplantation graft survival.

Many deceased by neurologic criteria donors are administered inhalational agents during organ recovery surgery-a process that is characterised by warm and cold ischaemia followed by warm reperfusion. In certain settings, volatile anaesthetics (VA) are known to precondition organs to protect them from subsequent ischaemia-reperfusion injury. As such, we hypothesised that exposure to VA during organ procurement would improve post-graft survival. Lifebanc (organ procurement organisation [OPO] for NE Ohio) provided the investigators with a list of death by neurologic criteria organ donors cared for at three large tertiary hospitals in Cleveland between 2006 and 2016-details about the surgical recovery phase were extracted from the organ donors' medical records. De-identified data on graft survival were obtained from the United Network for Organ Sharing (UNOS). The collated data underwent comparative analysis based on whether or not VA were administered during procurement surgery. Records from 213 donors were obtained for analysis with 138 exposed and 75 not exposed. Demographics, medical histories, and organ procurement rates were similar between the two cohorts. For the primary endpoint, there were no significant differences observed in either early (30-day) or late (five-year) graft survival rates for kidney, liver, lung, or heart transplants. Our findings from this retrospective review of a relatively small cohort do not support the hypothesis that the use of VA during the surgical procurement phase improves graft survival. Reviews of larger datasets and/or a prospective study may be required to provide a definitive answer.