Early Graft Survival Research Articles

Effects of Preoperative Positive Cross-Match and HLA Mismatching on Early Acute Cellular Rejection and Graft Survival in Living Donor Liver Transplantation

BACKGROUND We evaluated the effects of preoperative positive cross-match and HLA mismatching on early acute cellular rejection and graft survival in living donor liver transplantation (LDLT). MATERIAL AND METHODS We retrospectively reviewed data of 286 patients who underwent LDLT from 2008 to 2013. Cross-matching tests were performed by complement-dependent lymphocytotoxicity (CDC) and flow cytometry (FCX) methods. The CDC cross-matching test was performed using the National Institutes of Health (NIH) standard cross-match and antiglobulin (AHG) cross-match methods. RESULTS NIH, AHG, and FCX were positive in T-lymphocytes from 18 (6.3%), 21(7.3%), and 23 (8.0%) patients, respectively. T-CDC (T-NIH or T-AHG) results were positive in 23 (8.0%) patients. CDC and FCX results were positive in B-lymphocytes from 18 (6.3%) and 35 (12.2%) patients. All positive cross-match results were significantly associated with acute cellular rejection. Only a positive T-CDC cross-match was significantly associated with decreased graft survival (P=0.035). In a multivariate analysis, a positive T-CDC cross-match was the only independent risk factor with a decreased graft survival rate (P=0.041). An HLA mismatch was not associated with acute rejection (p=0.468 for HLA-A, p=0.644 for HLA-B, and p=0.811 for HLA-DR), graft survival (p=0.895 for HLA-A, p=0.580 for HLA-B, and p=0.969 for HLA-DR), and overall survival (p=0.862 for HLA-A, p=0.634 for HLA-B, and p=0.917 for DLA-DR). CONCLUSIONS Although a further prospective study with a larger cohort is required, it is not wise nor safe to perform LDLT in the setting of a positive T-CDC cross-match result.

The challenges and outcomes of living donor kidney transplantation in pediatric and adolescent age group in a developing country: A critical analysis from a single center of north India.

Introduction:Renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD). We evaluated the outcome of renal transplantation in the pediatric and adolescent age groups in the perspective of a developing country as compared with developed nations while highlighting the challenges we have faced in a pediatric transplant programme.Materials and Methods:Seventy live related pediatric and adolescent renal transplantations were reviewed retrospectively. Variables analyzed were etiology of ESRD, pre-transplant renal replacement modality, donor relationship, surgical complications, rejection episodes, immuno-suppression regimens, compliance to immunosuppression, graft survival and overall survival.Results:The cohort consisted of 13 (18%) female and 57 male (82%) recipients. The mean age was 14 ± 1.4 years. The etiology of ESRD was chronic glomerulonephritis (n = 43), chronic interstitial nephritis (n = 26) and Alport's syndrome (n = 1). Fifty-six (80%) children were on hemo-dialysis and 10 (14%) on peritoneal dialysis prior to transplantation. 80.5% and 61% patients were strictly compliant to immunosuppresant medications at 1 and 5 years. The 1, 3 and 5 year graft survival rates were 94.3%, 89.2% and 66.8%, respectively. The overall survival rates were 95.7%, 96.4% and 94.1% for 1, 3 and 5 years, respectively.Conclusions:The spectrum of etiology of ESRD differs in our patients from the west, with chronic glomerulonephritis being the most common etiology. Early graft survival is comparable, but the 5-year graft survival is clearly inferior as compared with developed countries.

Pathophysiological aspects of intestinal transplantation (reference review)

Transplantation of the intestine is quite new and most effective treatment for short bowel syndrome (SBS). Improving early graft survival due to the reduction in the rate of acute rejection after transplantation while minimizing toxicity, achieved at the expense of significant progress in immunosuppression. Recently, the multi-visceral transplantation has been applied more and more widely. The article highlights the mechanisms of disorders that occur in bowel transplantation, possible ways to manage side effects with a view to long-term graft survival.

Post-heart transplantation outcome of HeartMate II-bridged recipients requiring unplanned concomitant temporary right ventricular mechanical support.

Second-generation axial-flow left ventricular assist devices (LVADs) have become an established therapy in bridging end-stage heart failure patients to cardiac transplantation. Despite the proven clinical success of these devices, some patients develop right ventricular (RV) failure after LVAD implantation. We sought to determine post-heart transplantation outcomes of HeartMate II (HMII)-bridged patients who developed postimplantation right ventricular failure and received Levitronix CentriMag for RV support in addition to LVAD. This was a single-centre institutional report of 64 patients transplanted during 2007-2013 from a HeartMate II device. Patients were divided into two groups according to whether they received an isolated LVAD (n = 56) or required additional RV mechanical support (n = 8). These two groups were compared for early graft loss (death before discharge or retransplantation), major early post-transplant complications and 3-year graft survival. Early graft loss was 10.7% in isolated HMII and 25% in HMII + RVAD patients (P = 0.26). There were no observed differences in the rates of primary graft dysfunction (7.3 vs 0%, P = NS), renal failure (16.7 vs 12.5%, P = NS) and stroke (11.1 vs 25%, P = 0.273) between the two groups. Pulmonary artery resistance (odds ratio: 3.286, 95% confidence interval: 1.063-10.157, P = 0.039) was identified as a significant predictor for adverse outcome of mechanically-bridged heart transplant recipients. The 3-year graft survival rate was 86 ± 5% in isolated HMII and 75 ± 15% in HMII + RVAD patients, P = 0.326. Our data demonstrate that heart transplant recipients who required unplanned RV mechanical support after LVAD implantation achieved comparable rates of early graft loss, post-transplant renal failure and stroke rate in comparison with patients bridged with an isolated HeartMate II assist device. Three-year graft survival was equivalent between those two groups. Given the small sample size, further studies involving more patients are needed to support or challenge our conclusions.

De-functioning polymorphism in the inhibitory receptor FcγRIIB does not impact upon kidney allograft survival.

De-functioning polymorphism in the inhibitory receptor FcγRIIB does not impact upon kidney allograft survival.

Through a glass darkly: seeking clarity in preventing late kidney transplant failure.

A common lament is that long-term kidney transplant outcomes remain the same despite improvements in early graft survival. To be fair, progress has been made-in both our understanding of chronic injury and modestly, graft survival. However, we are still a long way from actually solving this important and difficult problem. In this review, we outline recent data supporting the existence of several causes of renal allograft loss, the incidences of which peak at different time points after transplantation. On the basis of this broadened concept of chronic renal allograft injury, we examine the challenges of clinical trial design in long-term studies, including the use of surrogate end points and biomarkers. Finally, we suggest a path forward that, ultimately, may improve long-term renal allograft survival.

The Effect of Preservation Solutions for Storage of Liver Allografts on Transplant Outcomes

The objective of this review was to systematically evaluate the evidence comparing preservation fluids for liver allografts on transplant outcomes. Adequate preservation of liver allografts for transplantation is essential for successful transplant outcomes. There are several preservation fluids available that have been specifically designed for the static cold storage of livers. These fluids differ in composition and cost. literature search was performed using MEDLINE, EMBASE, Cochrane Library, Transplant Library, and the International Clinical Trials Registry Platform. Only randomized controlled trials were included. Studies were assessed for methodological quality. Primary outcomes were the risk of early dysfunction, primary nonfunction, retransplantation, patient survival, and graft survival. Secondary outcomes were serum biochemical parameters in the first week and biliary complications. Summary effects were calculated as relative risk and relative log survival with 95% confidence intervals (95% CIs). Sixteen randomized controlled trials met the full inclusion criteria (1619 livers). There is good evidence that the University of Wisconsin and Celsior solutions are associated with the same rates of early dysfunction (relative risk = 1.08, 95% CI = 0.63-1.86, P = 0.77), primary nonfunction (relative risk = 0.73, 95% CI = 0.22-2.40, P = 0.60), patient survival (relative log survival = 0.86, 95% CI = 0.58-1.28, P = 0.46), and graft survival (relative log survival = 0.85, 95% CI = 0.59-1.23, P = 0.39). There was no good evidence of any difference in outcomes when comparing histidine-tryptophan-ketoglutarate with either of the University of Wisconsin or Celsior solution, although data were limited. Data from included studies suggest that preservation of deceased donor livers with the University of Wisconsin or Celsior solution results in equivalent outcomes.

B77 - ABO incompatibility does not have an influence on early kidney graft survival in living related donor transplantation

B77 - ABO incompatibility does not have an influence on early kidney graft survival in living related donor transplantation

S8-3 Hydrogen sulphide: The magic bullet in organ transplantation?

Ischemia reperfusion injury (IRI) is unavoidable in renal transplantation and is associated with increased rates of acute tubular necrosis, delayed graft function and impaired early and long-term graft function and survival. Gasotransmitters, particularly H2S, may be cytoprotective in models of IRI in various tissues including the kidney. We aimed to investigate the utility of H2S in mitigating renal IRI during transplantation, thereby improving subsequent renal graft function and survival compared to current standard clinical practices. Our two main objectives were to characterize the real-time protective properties of supplemental H2S against prolonged periods of warm renal IRI as well as determining its protective role in organ preservation during extremes of cold storage and transplantation in murine models. Our results demonstrated, for the first time, that supplemental H2S treatment during prolonged cold ischemia associated with transplantation dramatically improved renal graft survival and function and mitigated graft injury and inflammation compared to grafts that were preserved in standard University of Wisconsin organ preservation solution. In addition, we found that H2S treatment improved real-time renal vascular flow patterns as well as function and decreased the renal injury and inflammation associated with prolonged warm renal IRI. Overall, exogenous H2S may protect kidneys from both prolonged warm and cold IRI associated with renal transplantation. Considering that more transplant centers are utilizing grafts near the limits of cold and warm ischemic times to accommodate their expanding waiting lists, H2S treatment may represent a novel, potent and cost-effective solution to mitigate transplantation induced IRI.

Cobalt protoporphyrin pretreatment protects human embryonic stem cell-derived cardiomyocytes from hypoxia/reoxygenation injury in vitro and increases graft size and vascularization in vivo.

Human embryonic stem cell-derived cardiomyocytes (hESC-CMs) can regenerate infarcted myocardium. However, when implanted into acutely infarcted hearts, few cells survive the first week postimplant. To improve early graft survival, hESC-CMs were pretreated with cobalt protoporphyrin (CoPP), a transcriptional activator of cytoprotective heme oxygenase-1 (HO-1). When hESC-CMs were challenged with an in vitro hypoxia/reoxygenation injury, mimicking cell transplantation into an ischemic site, survival was significantly greater among cells pretreated with CoPP versus phosphate-buffered saline (PBS)-pretreated controls. Compared with PBS-pretreated cells, CoPP-pretreated hESC-CM preparations exhibited higher levels of HO-1 expression, Akt phosphorylation, and vascular endothelial growth factor production, with reduced apoptosis, and a 30% decrease in intracellular reactive oxygen species. For in vivo translation, 1 × 10(7) hESC-CMs were pretreated ex vivo with CoPP or PBS and then injected intramyocardially into rat hearts immediately following acute infarction (permanent coronary ligation). At 1 week, hESC-CM content, assessed by quantitative polymerase chain reaction for human Alu sequences, was 17-fold higher in hearts receiving CoPP- than PBS-pretreated cells. On histomorphometry, cardiomyocyte graft size was 2.6-fold larger in hearts receiving CoPP- than PBS-pretreated cells, occupying up to 12% of the ventricular area. Vascular density of host-perfused human-derived capillaries was significantly greater in grafts composed of CoPP- than PBS-pretreated cells. Taken together, these experiments demonstrate that ex vivo pretreatment of hESC-CMs with a single dose of CoPP before intramyocardial implantation more than doubled resulting graft size and improved early graft vascularization in acutely infarcted hearts. These findings open the door for delivery of these, or other, stem cells during acute interventional therapy following myocardial infarction or ischemia.

That which does not kill us makes us stronger – Does Nietzsche’s quote apply to islets? A re-evaluation of the passenger leukocyte theory, free radicals, and glucose toxicity in islet cell transplantation

In clinical islet transplantation, isolated islets are embolized into the liver via the portal vein (PV); however, up to 70% of the islets are lost in the first few days after transplantation (i.e., too quickly to be mediated by the adaptive immune system). Part of early loss is due to instant blood-mediated inflammatory reaction, an immune/thrombotic process caused by islets interacting with complement. We have shown that glucose toxicity (GT) also plays a critical role based upon the observation that islets embolized into the PVs of diabetic athymic mice are rapidly lost but, if recipients are not diabetic, the islet grafts persist. Using donor islets resistant to the β-cell toxin streptozotocin, we have shown that intraportal islets engrafted in non-diabetic athymic mice for as little as 3days will maintain normoglycemia when streptozotocin is administered destroying the recipient’s native pancreas β-cells. What is the mechanism of GT in β-cells? Chronic exposure to hyperglycemia over-exerts β-cells and their electron transport chains leak superoxide radicals during aerobic metabolism. Here we reinterpret old data and present some compelling new data supporting a new model of early intraportal islet graft loss. We hypothesize that diabetes stimulates overproduction of superoxide in both the β-cells of the islet grafts and the endothelial cells lining the intraportal microvasculature adjacent to where the embolized islets become lodged. This double dose of oxidant damage stresses both the islets, which are highly susceptible to free radicals because of inherent low levels of scavenging enzymes, and the adjacent hepatic endothelial cells. This, superimposed upon localized endothelial damage caused by embolization, precipitates inflammation and coagulation which further damages islet grafts. Based upon this model, we predict that pre-exposing islets to sub-lethal hyperoxia should up-regulate islet free radical scavenging enzyme levels and promote initial engraftment; reinterpretation of 30years old “passenger leukocyte” data and preliminary new data support this. Other data suggests that pre-exposure of recipients to hyperoxia could up-regulate antioxidant enzymes in the hepatic endothelium. The combination of both effects could markedly enhance early intraportal islet graft survival and engraftment. Finally, if our model is correct, current in vitro and in vivo tests used to test batches of harvested islets for viability and function prior to transplantation are poorly conceived (n.b., it is already well-known that results using these tests often do not predict clinical islet transplantation success) and a different testing paradigm is suggested.

D-MELD as a Predictor of Early Graft Mortality in Adult-to-Adult Living-Donor Liver Transplantation

Ensuring a good match between donor and recipient is critically important to achieve acceptable graft outcomes after living-donor liver transplantation (LDLT). Our objective was to evaluate the product of donor age and Model for End-stage Liver Disease score (D-MELD) as a predictor of graft survival after LDLT. We retrospectively evaluated the records of 355 adults who underwent LDLT for chronic liver disease and explored the relationship between D-MELD and graft outcome. High MELD score and advanced donor age were significantly associated with graft survival; D-MELD had the strongest association with in-hospital mortality. Receiver operating characteristic curve analysis showed that a D-MELD score of 462 had the highest sensitivity for predicting in-hospital mortality. Patients were allocated to three groups based on D-MELD (Class A [≤449; n=142], Class B [450-899; n=163], and Class C [≥900; n=50]) and were found to have stratified cumulative 2-year graft survivals of 94.1%, 85.3%, and 63.1%, respectively (P<0.01). Although D-MELD Class C patients had larger graft volume-to-standard liver volume ratio (P<0.01) and received right lobe grafts more often (P<0.01), they still exhibited significantly higher rates of primary graft dysfunction (P<0.01) and in-hospital mortality (P<0.01). Outcomes in D-MELD Class C were significantly worse in hepatitis C-positive patients (P<0.05). The D-MELD score is a simple and reliable predictor of early graft survival that assists the matching of donors and recipients in LDLT in adults.

Low platelet counts after liver transplantation predict early posttransplant survival: The 60-5 criterion

Platelets play a critical role in liver injury and regeneration. Thrombocytopenia is associated with increases in postoperative complications after partial hepatectomy, but it is unknown whether platelet counts could also predict outcomes after transplantation, a procedure that is often performed in thrombocytopenic patients. Therefore, the aim of this study was to evaluate whether platelet counts could be indicators of short- and long-term outcomes after liver transplantation (LT). Two hundred fifty-seven consecutive LT recipients (January 2003-December 2011) from our prospective database were analyzed. Preoperative and daily postoperative platelet counts were recorded until postoperative day 7 (POD7). Univariate and multivariate analyses were performed to assess whether low perioperative platelet counts were a risk factor for postoperative complications and graft and patient survival. The median pretransplant platelet count was 88 × 10(9) /L [interquartile range (IQR) = 58-127 × 10(9) /L]. The lowest platelet counts occurred on POD3: the median was 56 × 10(9) /L (IQR = 41-86 × 10(9) /L). Patients with low platelet counts on POD5 had higher rates of severe (grade IIIb/IV) complications [39% versus 29%, odds ratio (OR) = 1.09 (95% CI = 1.1-3.3), P = 0.02] and 90-day mortality [16% versus 8%, OR = 2.25 (95% CI = 1.0-5.0), P = 0.05]. In the multivariate analysis, POD5 platelet counts < 60 × 10(9) /L were identified as an independent risk factor for grade IIIb/IV complications [OR = 1.96 (95% CI = 1.07-3.56), P = 0.03)], graft survival [hazard ratio (HR) = 2.0 (95% CI = 1.1-3.6), P = 0.03)], and patient survival [HR = 2.2 (95% CI = 1.1-4.6), P = 0.03)]. The predictive value of platelet counts for graft and patient survival was lost in patients who survived 90 days. In conclusion, after LT, platelet counts < 60 × 10(9) /L on POD5 (the 60-5 criterion) are an independent factor associated with severe complications and early graft and patient survival. These findings may help us to develop protective strategies or specific interventions for high-risk patients.

The “July Effect” Does Not Have Clinical Relevance in Liver Transplantation

In the beginning of the academic year, medical errors are often attributed to inexperienced medical staff. This potential seasonal influence on health care outcomes is termed the "July effect." No study has demonstrated the July effect in liver transplantation. We reviewed retrospectively collected data from the United Network for Organ Sharing for patients who underwent liver transplantation from October 1987 to June 2011 to determine if surgical outcomes were worse in July compared with rest of the year. We found no clinical difference in early graft survival (91.11% vs. 90.72%, p = 0.045) and no difference in early patient survival (94.71% vs. 94.42%, p = 0.057). Survival at 1 year, 3 years, and 5 years was also compared and no notable differences were detected. Because the Model for End-stage Liver Disease (MELD) score implementation in 2002 affected the acuity of liver transplant recipients, we further stratified our data to compare pre- and post-MELD survival to remove subjectivity as a confounding factor. MELD stratification revealed no seasonal difference in outcomes. There was no difference in rate of graft failure and acute and chronic rejection between groups. Our findings show no evidence of the July effect in liver transplantation. Each July, thousands of medical residents take on new responsibilities in patient care. It has been suggested that these new practitioners may produce errors that contribute to worse patient outcomes in the beginning of the academic year-a phenomenon called the "July effect." Currently, there are few research studies with controversial evidence of poorer outcomes in July, and no articles address the effect of new medical staff in the setting of liver transplantation. Our study compares short-, medium-, and long-term graft and patient survival between July and August and the remaining months using national data. We also examine survival before and after the implementation of the MELD scoring system to determine its effect on outcomes in the beginning of the academic year.

Delayed Graft Function: Risk Factors and the Effects of Early Function and Graft Survival

IntroductionDelayed graft function (DGF), a well-known immediate postoperative complication is defined as the need for dialysis during the first week after deceased donor kidney transplantation. It affects 25% to 50% of recipients. In this study we identified risk factors for DGF and its impact on patient and graft survivals. MethodsWe retrospectively analyzed medical records from renal transplant recipients aged above 18 years who received a deceased donor kidney graft between November 2008 and December 2011, excluding kidney losses during the first week. ResultsAmong 137 transplantations, 64 (46.5%) displayed DGF. Multivariate analysis showed secondary renal disease (OR 3.7, CI 1.36–10.30; P = .011), HLA mismatches > 3 (OR 4.4, CI 1.53–12.51; P = .006) and donor urine output ≤ 3000 ml/24h (OR 25.8, CI 3.60–185.70; P = .001) to be significant risk factors for DGF. The hospitalization time was longer in the DGF group (38,2 ± 20,75 vs. 25,6 ± 8,18; P < .001). At 1 month, DGF group showed worse graft function based upon serum creatinine: 207.7 ± 148.52 vs 118.1 ± 36.63 μmol/L (P < .001). At 1 year follow-up, incidence of biopsy-proven acute renal rejection episodes was higher in the DGF (28; 51,9%) vs. the non-DGF group (18; 33,3%; P = .05). The 1-year recipient survival in DGF and no DGF groups were 90% vs 97% respectively (P = .124). With 1-year death censored graft survivals of 92% vs 100% respectively (P = .062). ConclusionSecondary renal disease, HLA mismatches and lower donor urinary output were associated with a greater incidence of DGF, leading to prolonged hospitalizations and an increased risk for an acute rejection episode.

Early lung retrieval from traumatic brain-dead donors does not compromise outcomes following lung transplantation

To determine whether lung retrieval from traumatic donors performed within 24 h of brain death has a negative impact on early graft function and survival after lung transplantation (LT), when compared with those retrieved after 24 h. Review of lung transplants performed from traumatic donors over a 17-year period. Recipients were distributed into two groups: transplants from traumatic donor lungs retrieved within 24 h of brain death (Group A), and transplants from traumatic donor lungs retrieved after 24 h of brain death (Group B). Demographic data of donors and recipients, early graft function, perioperative complications and mortality were compared between both groups. Among 356 lung transplants performed at our institution, 132 were from traumatic donors (70% male, 30% female). Group A: 73 (55%); Group B: 59 (45%). There were 53 single, 77 double, and 2 combined LT. Indications were emphysema in 41 (31%), pulmonary fibrosis in 31 (23%), cystic fibrosis in 38 (29%), bronchiectasis in 9 (7%) and other indications in 13 patients (10%). Donor and recipient demographic data, need or cardiopulmonary bypass, postoperative complications and Intensive Care Unit and hospital stay did not differ between groups. Primary graft dysfunction (A vs B): 9 (16%) vs 13 (26%) P = 0.17. PaO2/FiO2 24 h post-transplant (A vs B): 303 mmHg vs 288 mmHg (P = 0.57). Number of acute rejection episodes (A vs B): 0.93 vs 1.49 (P = 0.01). Postoperative intubation time (A vs B): 99 vs 100 h (P = 0.99). 30-day mortality (A vs B): 7 (10%) vs 2 (3.5%) (P = 0.13). Freedom from bronchiolitis obliterans syndrome (A vs B): 82, 72, 37, 22 vs 78, 68, 42, 15%, at 3, 5, 10 and 15 years, respectively (P = 0.889). Survival (A vs B): 65, 54, 46, 42 and 27 vs 60, 50, 45, 43 and 29% at 3, 5, 7, 10 and 15 years, respectively (P = 0.937). In our experience, early lung retrieval after brain death from traumatic donors does not adversely affect early and long-term outcomes after LT.

Haemoglobin variability in the early post‐transplant period: Association with graft survival and mortality

Haemoglobin (Hb) variability is associated with poor survival in patients with chronic kidney disease. Association of Hb variability after kidney transplantation with patients' and graft survival has not been adequetly studied. This retrospective study used registry data to examine the association between Hb variability in the early post-transplant period (first 6 months) and graft survival after kidney transplantatin. Kaplan-Meier and Cox regression analyses were used for univariate and multivariate associations between mortality, death censored graft survival and the composite outcome of both, in 752 patients after kidney transplantation. Hb values were collected each month during the first 6 months after transplantation, and Hb variavility was calculated using the residual standard deviation method. The highest quartile of Hb variability was associated with inferior graft and patients' survival in univariate (hazard ratio (HR) 2.18; 95% confidence interval (CI) 1.51 to 3.13; P < 0.001) and multivariate models (HR 1.5; 95% CI 1.029 to 2.18; P = 0.035). This association was mainly due to increased death censored graft failure in the high variability group (HR 2.75; 95% CI 1.73 to 4.38; P < 0.001) and (HR 1.67; 95% CI 1.023 to 2.74; P = 0.04) in the univariate and multivariate models, respectively. There was no association between Hb variability and the risk of death (HR 1.51; 95% CI 0.88 to 2.57; P = 0.132). High Hb variability is independently associated with inferior graft survival in patients after kidney transplantation.

Is lung transplantation survival better in infants? Analysis of over 80 infants

There have been >1,600 pediatric lung transplantations (LTx) performed worldwide with a trend toward improved outcomes over the last 25 years. The majority of these LTxs have been in older children and adolescents. Less than 4 infant (defined as ≤ 12 months of age) LTxs per year have been performed over the past 20 years, mostly in the USA. However, infant LTx outcomes have not been well documented in a multi-institutional longitudinal fashion. The United Network of Organ Sharing database was queried from October 1987 to July 2011. Of the 1,003 pediatric LTxs reported, 84 (8%) were infants. All combined transplantations were excluded. Eighty-one infants received 84 LTxs, of which 95% had a bilateral LTx. Median age and weight at LTx was 4 months (range 0 to 11 months) and 5.3 kg (2.7 to 11.8 kg), respectively. Median ischemic time was 5.2 hours (2.0 to 10.8 hours). Overall Kaplan-Meier graft survival was similar for infants compared with other pediatric age group (OPA: >1 to 18 years) LTx recipients (half-life 4.0 years vs 3.4 years, p = 0.7). Conditional 1-year graft survival for infants was significantly higher than OPA (half-life 7.4 years vs 5.0 years, p = 0.024). Early (1987 to 2000, n = 46) and late (2001 to 2011, n = 38) era graft survival was not significantly different. Graft survival in pre-LTx ventilated infants was significantly better than pre-LTx ventilated OPA (half-life 6.1 years vs 0.9 year, p = 0.004) and was not statistically different from pre-LTx infants not on ventilatory support (half-life 6.1 years vs 2.2 years, p = 0.152). Cox regression of 5 variables (weight, donor arterial PO(2), pre-Tx ventilator, organ ischemic time, center experience) showed that survival was associated with increased center experience (p = 0.03). Infants undergoing LTx have outcomes similar to those of all other pediatric LTx patients.

Laparoscopic Donor Nephrectomy for Pediatric Kidney Transplantation: The Short Term Results

Aim: Laparoscopic kidney procurement in adults is safe. However the impact of this procedure on early graft function and survival in pediatric kidney recipient remains unclear. The aim of this study was to determine the surgical and functional outcomes of laparoscopic graft procurement in pediatric renal transplant recipients. Patients and methods: Twelve pediatric laparoscopic living donor renal transplant recipients operated between October 2010 and January 2012 were retrospectively reviewed in terms of demographics, etiology of end stage renal diseases (ESRD), operative complications, length of hospital stay, early graft function, graft and patient survival. Results: The mean age was 11.45±6,3 (range: 1,5-18) years in recipients and was 43,3 ±10,8 (range: 27-61) years in donors. Median donor operation time was 124 minutes (range: 110-135 min). All donors were discharged between 36 to 48 hours after nephrectomy. There was no surgical and medical complication in donors. Etiologies of ESRD were nephrotic syndrome in four, cystinosis in two, vesicoureteral reflux in four, unknown in two patients. The mean of warm ischemia time was 131± 21 seconds and cold ischemia time was 48,0±12,9 minutes. Mean follow up was 7,0 ±3,9 months. The mean serum creatinin levels (mg/dl) on first day after operation was 1,76±1,4, at the time of discharge was 0,72±0,4 and currently is 0,86±0,5. Mean hospitalization time was 10,1±4,8 days. One patient had urinary tract infection. It was controlled by appropriate antibiotic treatment. No acute rejection and surgical complication was observed in recipients. Graft survival rates were 100%. No mortality occurred in the pediatric recipients. Conclusion: Laparoscopic donor nephrectomy seems safe and effective in our group of pediatric kidney transplant recipients.

Predictors of early graft survival after pediatric liver transplantation

The objective of this study was to identify peritransplant predictors of early graft survival and posttransplant parameters that could be used to predict early graft outcomes after pediatric liver transplantation (PLT). The response of children to liver dysfunction after liver transplantation (LT) is poor. No data have been reported for early predictors of poor graft survival, which would potentially be valuable for rescuing children at risk after LT. A retrospective cohort study of 422 PLT procedures performed from 2000 to 2010 at a single center was conducted. Multiple peritransplant variables were analyzed. Univariate and multivariate analyses using receiver operating characteristic curves were performed to identify predictors of early graft loss (ie, at 30, 60, and 90 days). The number needed to treat (NNT) was calculated when the risk factors were identified. Comparisons with the Olthoff criteria for early graft dysfunction in adults were performed. The overall 30-, 60-, and 90-day graft survival rates were 93.6%, 92.6%, and 90.7%, respectively. A recipient age of 0 to 2 or 6 to 16 years, acute liver failure, and a posttransplant day 7 serum bilirubin level > 200 μmol/L were risk factors for graft loss in the 3-strata Cox models. The product of the peak aspartate aminotransferase (AST) level, day 2 international normalized ratio (INR) value, and day 7 bilirubin level [with 30-, 60-, and 90-day areas under the receiver operating characteristic curve (AUROCs) of 0.774, 0.752, and 0.715, respectively] and a day 7 bilirubin level > 200 μmol/L (with 30-, 60-, and 90-day AUROCs of 0.754, 0.661, and 0.635, respectively) provided excellent prediction rates for early graft loss (30-days for Day-7-bilirubin level > 200) in the pediatric population (sensitivity = 72.7%, specificity = 96.6%, positive predictive value = 95.5%, negative predictive value = 78%). The NNT with early retransplantation when the day 7 bilirubin level was >200 μmol/L was 2.17 (unadjusted) or 2.76 (adjusted for graft survival). In conclusion, 2 scores-the product of the peak AST level, day 2 INR value, and day 7 bilirubin level and a posttransplant day 7 bilirubin level > 200 μmol/L-have been identified as clinically valuable tools with high accuracy for predicting early graft loss. A more aggressive attitude to considering early retransplantation in this group may further improve survival after LT.