Early Post-transplant Outcomes Research Articles

Outcomes of Liver Transplantation for Porto-Pulmonary Hypertension in Model for End-Stage Liver Disease Era

Porto-pulmonary hypertension (POPH), once considered an absolute contraindication for liver transplantation (LT), has become a more accepted indication because of the evolution of treatment with prostacyclin analogues, phosphodiesterase inhibitors and endothelin receptor antagonists. An exception model for end stage liver disease (MELD) score of 22 is assigned to candidates with documentation of effective treatment. We examined the post-transplant outcomes of patients who received LT for POPH with exception. Scientific Registry of Transplant Recipients data on 34,318 adult (≥ 18 years) deceased donor LT recipients transplanted between March 1, 2002 and August 31, 2010 were reviewed. The diagnosis of POPH was ascertained from MELD exception forms. Patients were followed from the time of transplant until the earlier occurrence of death or end of the follow-up period. Cox regression was used to evaluate the predictors of post-LT mortality and graft failure. During the study period, 34,318 patients received deceased donor LT. Seventy eight out of 34,318 patients were transplanted for POPH with MELD exception. The 1-year adjusted risks of patient death and graft failure for patients transplanted under exception rules for POPH were significantly higher than with POPH adult recipients who did not receive exception points (death:hazard ratio [HR] = 2.25, p = 0.005 and graft failure HR = 1.96, p = 0.012). This study of national data suggests that treated POPH continues to be associated with inferior early post-transplant outcomes.

Ventricular assist devices as a bridge-to-transplant improve early post-transplant outcomes in children

The use of ventricular assist devices (VADs) to bridge pediatric patients to transplant or recovery has been expanding. There are few current pediatric data assessing the impact of VAD support on post-transplant survival. We performed a retrospective review of all pediatric (≤18 years old, n = 4,028) transplants performed between 1995 and 2011 and contained within the United Network for Organ Sharing data set. Transplants were divided into three eras: early (1995 to 2002, n = 1,450); intermediate (2003 to 2007, n = 1,138); and recent (2008 to 2011, n = 1,440). VADs were present at transplant in 398 patients (9.8%). Outcomes among patients with and without VADs were assessed and compared across eras. The use of VADs for bridge to transplant has increased (early 1.1%, intermediate 10.5%, recent 17.9%; p < 0.0001). Mean weight among VAD-supported patients (early 63.5 kg, intermediate 42.3 kg, recent 28.8 kg; p < 0.0001) has decreased during this period. VAD patients <10 kg had an increased risk of stroke (odds ratio [OR] = 4.9, 95% confidence interval [CI] 2.1 to 10.8) compared with non-mechanical support patients. In multivariable analyses, extracorporeal VADs were the only type of VAD associated with higher post-transplant mortality (OR = 3.0, 95% CI 0.8 to 10.6). Other types of VAD had lower mortality (OR = 0.5, 95% CI 0.2 to 1.0). Long-term survival was unaffected by the use of a VAD pre-transplant. Pediatric patients bridged to transplantation with VADs are increasingly younger and smaller. Complication rates remain high among patients <10 kg. Early post-transplant survival among intracorporeal and paracorporeal VAD patients is excellent and better when compared with unsupported patients. The use of short-term support devices is associated with higher post-transplant mortality. Long-term survival is unaffected by VAD use.

Autologous and allogeneic mesenchymal stem cells in organ transplantation

Recent developments toward the successful clinical application of autologous and allogeneic mesenchymal stem cells (MSCs) to organ transplantation are summarized with a focus on safety and efficacy. Clinical trials in organ transplantation and other conditions indicate that infusion of autologous or allogeneic MSCs is generally well tolerated. However, new studies also suggest that efficacy may be curtailed by sequestration in the lungs and early elimination. Safety concerns regarding autologous and/or allogeneic MSCs that have recently been investigated include transient proinflammatory effects, influences on opportunistic infections and cancers and alloantibody induction. Animal models indicate that autologous MSCs are likely to be efficacious in preventing or treating early intragraft inflammation and may reduce the risk of acute rejection - observations that have been borne out in a randomized controlled trial of living-donor kidney transplantation. The potential for donor-specific or third-party allogeneic MSCs to promote allograft tolerance is suggested by animal model studies but has not yet been proven in humans. Recent reports on the safety and efficacy of autologous MSCs for early posttransplant outcomes give cause for optimism. Benefits of allogeneic MSCs for long-term allograft survival and of MSCs for chronic transplant injury await clinical validation.

Inferior Early Posttransplant Outcomes for Recipients of Right Versus Left Deceased and Living Donor Kidneys

To the Editor: We read with interest the article by Vacher-Coponat et al 1 demonstrating inferior early posttransplant outcomes for recipients of right versus left deceased donor kidneys in a large registry from Australia and New Zealand. Aside from an increased risk of early failure, the analysis reveals that right kidneys are associated with a greater incidence of delayed graft function and slower decline in serum creatinine. Several small series have previously examined whether right-sided kidneys have a higher risk of graft loss 2, 3. The current report by Vacher-Coponat et al 1 offers ongoing support for a technical etiology. Although donor renal laterality is generally not one of great importance in the allocation decision for deceased donor kidneys, the decision is important for live donor transplantation. In general, the left kidney is selected due to the longer renal vein, particularly in the setting of laparoscopic donor nephrectomy where the renal vein length may be compromised by the method used to secure the vein. We previously tested the hypothesis that right-sided living donor kidneys would have an increased risk of graft loss compared to the left side among a cohort of over 35 000 live donor kidney transplants from the United States 4. Right-sided nephrectomy increased the risk of allograft loss within 90 days of transplant compared to the left (OR = 1.49, p < 0.01). Stratification by procedure type demonstrated that both right laparoscopic (OR 1.58, p < 0.01) and right open donor nephrectomy (OR = 1.38, p = 0.02) were associated with an increased risk of graft failure compared to the left side. Right-sided kidneys, whether procured via laparoscopic or open techniques, had an increased incidence of delayed graft function, indicating that issues related to laparoscopic donation were unlikely contributors to right-sided allograft loss. Additional potential technical explanations for these findings were not discernable from the data. These articles by Vacher-Coponat et al and Hsu et al support a greater risk of allograft loss among both deceased and living right-sided kidneys 1, 4. While the overall magnitude of the hazard is modest, it may be of some importance when selecting the laterality of either a deceased or living donor allograft, may warrant consideration in the statistical evaluation of renal transplant cohorts, and offers opportunities for clinical innovation to reduce risk associated with the right kidney. J. W. Hsu1, P. P. Reese2,3, A. Naji4, M. H. Levine4, and P. L. Abt4,* 1St. Francis Medical Center, Department of Transplantation, Peoria, IL 2Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 3Renal Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 4Division of Solid Organ Transplant, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA *Corresponding author: Peter L. Abt, peter.l.abt@uphs.upenn.edu The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Lower socioeconomic status is associated with worse outcomes after both listing and transplanting children with heart failure

The relationship between SES and outcomes surrounding pediatric cardiac transplantation is complex and influenced by recipient race. Broad-based studies of SES have not been performed. A retrospective review of all 5125 primary pediatric heart transplants performed in the United States between 2000 and 2011. Patients were stratified by SES based on zip code of residence and U.S. census data (low SES: 1637; mid-SES: 2253; high SES: 1235). Survival following listing and transplantation was compared across strata. Risk-adjusted long-term mortality on the waitlist was higher among low SES patients (hazard 1.32, CI 1.07-1.63). The relationship between SES and outcomes varied by race. Early risk-adjusted post-transplant outcomes were worst among high SES patients (10.8% vs. low SES: 8.9%, p<0.05). The incidence of non-compliance was higher among low SES patients (p<0.0001). Long-term risk-adjusted patient survival was poorer among low (hazard 1.41, CI 1.10-1.80) and mid-SES (1.29, 1.04-1.59) groups. Low SES is associated with worse outcomes on both the waitlist and late following transplantation. Higher SES patients had more complex transplants with higher early mortality. Further research should be directed at identifying and addressing underlying causal factors for these disparities.

Pulmonary rehabilitation in lung transplant candidates

While awaiting lung transplantation, candidates may participate in pulmonary rehabilitation to improve their fitness for surgery. However, pulmonary rehabilitation outcomes have not been systematically evaluated in lung transplant candidates. This investigation was a retrospective cohort study of 345 pre-transplant pulmonary rehabilitation participants who received a lung transplant between January 2004 and June 2009 and had available pre-transplant exercise data. Data extracted included: 6-minute walk tests at standard intervals; exercise training details; health-related quality-of-life (HRQL) measures; and early post-transplant outcomes. Paired t-tests were used to examine changes in the 6MW distance (6MWD), exercise training volume and HRQL during the pre-transplant period. We evaluated the association between pre-transplant 6MWD and transplant hospitalization outcomes. The final 6MWD prior to transplantation was only 15 m less than the listing 6MWD (n = 200; p = 0.002). Exercise training volumes increased slightly from the start of the pulmonary rehabilitation program until transplant: treadmill, increase 0.69 ml/kg/min (n = 238; p < 0.0001); biceps resistance training, 18 lbs. × reps (n = 286; p < 0.0001); and quadriceps resistance training, 15 lbs. × reps (n = 278; p < 0.0001). HRQL measures declined. A greater final 6MWD prior to transplant correlated with a shorter length of stay in the hospital (n = 207; p = 0.003). Exercise capacity and training volumes are well preserved among lung transplant candidates participating in pulmonary rehabilitation, even in the setting of severe, progressive lung disease. Participants with greater exercise capacity prior to transplantation have more favorable early post-transplant outcomes.

Inferior Early Posttransplant Outcomes for Recipients of Right Versus Left Deceased Donor Kidneys: An ANZDATA Registry Analysis

Anatomical differences between right and left kidneys could influence transplant outcome. We compared graft function and survival for left and right kidney recipients transplanted from the same deceased organ donor. Adult recipients of 4900 single kidneys procured from 2450 heart beating deceased donors in Australia and New Zealand from 1995 to 2009 were included in a paired analysis. Right kidneys were associated with more delayed graft function (DGF) (25 vs. 21% for left kidneys, p < 0.001) and, if not affected by DGF, a slower fall in serum creatinine. One-year graft survival was lower for right kidneys (89.1 vs. 91.1% for left kidneys, p = 0.001), primarily attributed to surgical complications (66 versus 35 failures for left kidneys). Beyond the first posttransplant year, kidney side was not associated with eGFR, graft or patient survival. Receipt of a right kidney is a risk factor for inferior outcomes in the first year after transplantation. A higher incidence of surgical complications suggests the shorter right renal vein may be contributory. The higher susceptibility of right kidneys to injury should be considered in organ allocation.

Single Kidney Transplantation in Small Children from Small Paediatric Donors

Background: Paediatric single kidney transplantation (sKT) from small pediatric donors (i.e. ≤ 5yrs and/or ≤10Kg) has been seeing with reluctance because of multiple factors (i.e. insufficient nephron mass, high rates of ACR and high rates of vascular and urological complications) which may negatively influence both early and late post-transplant outcome. Therefore small kidneys from paediatric donors have been usually transplanting en-bloc in adults and in children too. Up to date only one series on this topic (sKT from donor ≤ 6 yrs.) has been reported in the Literature. Aim: To analyze our single centre experience with children receiving sKT from paediatric donors < 4 years. Patients and methods: Single centre retrospective analysis of results of sKT in children < 4 years old at UKT between 2004 and 2011. Univariate analysis was performed according to t-Student test and graft/patient survival was estimated by the Kaplan-Mayer method Results: Between 2004-2011, 20 paediatric sKT have been performed at UKT: – 7 from donors ≤4 yrs (Study Group): 6 in small recipients ≤5yrs and 1 in a 16 years old recipient – 13 from donors > 5 yrs Post-operative course in Study Group: – CIT: 16,5±6,4 hours – WIT: 32±7,2 minutes – PGF in 5 – DGF (defined as Creatinine>3 for more than 5POD) in 2 – No patient received post-operative dialysis or vasopressor support – average ICU stay: 5±1,2 days – average hospital stay: 19±4,5 days – postoperative complications according to Dindo-Clavien classification o 5 Grade I-II o 1 Grade III – BPAR was observed in 1 case, successfully treated. – 1 out of the 6 small recipients developed graft loss due to chronic rejection after 6 months. He died one month later due to massive bleeding during implantation of Hickmann-Catheter. -Surival rates (mean follow-up 34 months) -Overall graft and patients survival: 95% -Overall graft and patients survival in group 1: 85,7% Conclusions: Paediatric sKT from small paediatric donors in small recipient is feasible, sure and associated with good outcome. In times of organ paucity, in order to avoid further organ wastage, renal grafts from small paediatric donors should be allocated singularly to different paediatric recipient instead en-bloc for one adult or adolescent.

Kinetics of lactate metabolism during acellular normothermic ex vivo lung perfusion

Plasma lactate has been used as a marker of poor prognosis in clinical conditions. However, the relationship between lactate production and lung function during acellular normothermic ex vivo lung perfusion (EVLP) is unclear. We investigated the kinetics of lactate metabolism during EVLP and the correlation of this marker with outcomes after transplant. Human donor lungs in our clinical EVLP trial (CLs; n = 28) and rejected donor lungs for experimental use (Els; n = 8) were perfused ex vivo using the Toronto technique. Lactate level, lactate/pyruvate (L/P) ratio, and glucose level in the perfusate were measured. In CLs, we examined the relationship between lactate metabolism during EVLP and early post-transplant outcomes. The hypoxia-inducible factor 1 sub-unit 1α (HIF-1α) level in lung tissue was examined in ELs. We performed double-lung EVLP in CLs and single-lung EVLP in ELs. In CLs, the lactate and L/P ratios at the end of EVLP had no correlation with early post-transplant outcomes despite lactate elevation during EVLP. Although lactate elevation was also present in all ELs, we were able to identify 2 groups based on L/P ratio at the end of EVLP. The group with the high L/P ratio had higher airway pressure during EVLP and higher HIF-1α in lung tissue at the end of EVLP. Lactate increases seen in the EVLP perfusate most often represent physiologic lactate production by the lung in a setting with reduced lactate clearance. Thus, patients who underwent transplantation after EVLP had good outcomes despite lactate elevation during EVLP.

Comparative Single-Institute Analysis of Cord Blood Transplantation from Unrelated Donors with Unrelated Bone Marrow or Related Peripheral Blood Stem-Cell Transplants in Elderly Patients with Hematologic Diseases after Reduced Intensity-Conditioning Regimen.

Although cord blood (CB) transplantation with reduced-intensity (RI) conditioning (RICBT) has been widely applied to those who lack available related or unrelated donors and are not eligible for conventional conditioning, indication of RICBT to elderly patients relative to other stem-cell sources is still controversial due to higher early mortality post-transplant and undefined long-term outcome. Since there has been not much data available regarding this issue, we retrospectively reviewed patients aged 55 and older who underwent RI allogeneic stem-cell transplantation at our institute from Nov. 2000 to Dec. 2006 consecutively. The study includes 121 recipients of CB (n=42), unrelated bone marrow (UBM, n=41), and related mobilized peripheral blood (RPB, n=38) for AML / MDS (n=66), ALL (n=11), CML (n=4), ML (n=31), MF (n=3), and AA (n=6). The median age for CB, UBM, and RPB recipients were 61 (range 56–69), 60 (55–70), and 60 (55–66), respectively. CB recipients had more serologically HLA-mismatched grafts (98% vs. 24% vs. 5%, P < .05), were conditioned more frequently with melphalan (90% vs. 34% vs. 32%, P < .05) and with total body irradiation (88% vs. 71% vs. 16%, P < .05), used more tacrolimus (100% vs. 71% vs. 18%, P < .05) and less methotrexate (0% vs. 76% vs. 74%, P < .05) for GVHD prophylaxis, had shorter duration of donor search (median 41 days (14–151) vs. 166 (93–345) vs. 130 (41–311), P < .05), and were transplanted more recently (2005–2006: 71% vs. 56% vs. 37%, P < .05). CB recipients tended to have high-risk disease status (76%) relative to UBM (59%) and RPB (66%) recipients, although not statistically significant. Other characteristics such as sex, diagnosis, and body weight were balanced among three groups. Median follow-up time of survivors was 554 days (25–1132), 667 days (315–1794), and 703 days (57–2214) for CB, UBM, and RPB recipients, respectively. CB recipients tended to show slower neutrophil recovery (median 19 days (12–36) vs. 16 (10–27) vs. 13 days (10–21)), and lower rate of myeloid engraftment (86% vs. 90% vs. 100%), although not statistically significant. The incidence of grades II–IV acute GVHD among evaluable CB recipients (61%) was lower than that of UBM (83%, P < .05) and comparable to that of RPB recipients (50%). The incidences of chronic GVHD for evaluable CB, UBM, and RPB recipients were 45%, 71%, and 71%, respectively (N.S.). The disease-free survival and overall survival (OS) at 2 years post-transplant were 23+/–7% and 33+/–8% for CB, 42+/–8% and 47+/–8% for UBM, and 35+/–9% and 40+/–9% for RPB recipients, respectively (N.S.). Within those who had standard risk diseases, 2-year OS were 67+/–15.7%, 48+/–13%, and 59+/–14% for CB (n=10), UBM (n=17), and RPB (n=13) recipients, respectively (N.S.). These data suggest that CB could be a viable stem-cell source for elderly patients as UBM or RPB, not just expanding opportunity of transplant. A larger-sized, randomized study is needed to further define the position of CB for this population of patients.

Feasibility and Utility of a Lung Donor Score: Correlation With Early Post-Transplant Outcomes

A lung donor score may provide a numerical value of overall donor lung "quality" to allow comparison among different organizations and research protocols. This study aims to develop a simple scoring system and investigate its applicability on predicting donor selection and early post-lung-transplant (LTx) outcomes. Data of all donors referred to our institution in 2001 were initially analyzed to create a LTx donor score. Five domains, age, smoking history, chest X-ray, secretions, and arterial blood gas results, were included. A larger cohort of transplant recipients (years 2002 to 2005) was analyzed to validate the score against early post-LTx outcomes. In the initial 2001 cohort, 36 of 87 (41%) donors were used for 41 LTx (used group) and 51 (59%) were declined for medical (lung-exclusion group, n = 31) and general (general-exclusion group, n = 20) reasons. The median donor scores in the used, general-exclusion, and lung-exclusion groups were 2.0, 2.0, and 10.0, respectively (p < 0.0001). In multivariate analysis of the validation cohort, the donor score in bilateral LTx was significantly associated with post-transplant ratio of arterial oxygen tension and inspired oxygen fraction (coefficient = -16.19, p = 0.002), primary graft dysfunction grade (coefficient = 0.21, p < 0.0001), and intubation hours (coefficient = 0.05, p = 0.04); however, a significant association was not seen in single LTx. A proposed simple donor scoring system, based on five major donor variables available at the time of donor selection, may be useful for data comparison between specific centers, quality control, evaluative research, and clinical decision making in donor selection and management in LTx.

Unilateral radiographic abnormalities after bilateral lung transplantation: Exclusion from the definition of primary graft dysfunction?

Unilateral infiltrates on chest x-ray films are occasionally seen after bilateral lung transplantation. In the primary graft dysfunction grading system, the presence or absence of a radiographic abnormality is crucial in determining the incidence and severity of primary graft dysfunction. However, no consideration is given as to whether unilateral infiltrates have the same impact and relevance as bilateral infiltrates. This study aims to describe the incidence, features, and outcomes of posttransplant unilateral infiltrates and their effect on the novel primary graft dysfunction grading system. Depending on posttransplant radiographic appearance, 144 patients who underwent bilateral lung transplantation were divided into 3 groups: no infiltrates (clear), unilateral infiltrates (unilateral), or bilateral infiltrates (bilateral). Radiographic abnormalities were seen in 43% of donors and 61% of posttransplant recipients (sensitivity = 76%, specificity = 50%). The percentage of recipients in the unilateral, clear, and bilateral groups was 26%, 39%, and 35%, respectively. Lower posttransplant oxygenation (P < .05), longer intubation hours, and more intensive care unit days (P < .0001) were seen in the bilateral compared with the unilateral and the clear groups. A significant difference in the prevalence of primary graft dysfunction (P < .0001) was seen, depending on whether unilateral infiltrates were included or excluded from the primary graft dysfunction grading. The incidence of unilateral infiltrates is relatively high after bilateral lung transplantation. The early posttransplant outcome of the unilateral infiltrates is similar to that in the group having a clear chest x-ray film and significantly better than that in those with bilateral infiltrates. In bilateral lung transplantation, only bilateral infiltrates should be used as part of the definition of primary graft dysfunction.

Early Outcomes Comparing Perfadex, Euro-Collins, and Papworth Solutions in Lung Transplantation

Despite improved surgical techniques and medical management, primary graft dysfunction (PGD) remains a major cause of early morbidity and mortality after lung transplantation. Different types of lung preservation solutions have been developed and applied to clinical use; however, the relative clinical efficacy of these solutions to prevent PGD remains controversial. This study aimed to investigate the effect of the three solutions most commonly used (Perfadex [Vitrolife, Göteborg, Sweden], Papworth, and Euro-Collins [Baxter Healthcare, Old Toongabbie NSW, Australia]) on posttransplant outcomes. Early outcomes from 157 consecutive lung transplants (113 bilateral and 44 single) performed at The Alfred Hospital were compared across three preservation solutions. Posttransplant oxygenation (p = 0.57), pulmonary vascular resistance (p = 0.34), intubation hours (p = 0.66), intensive care unit days (p = 0.34), severe PGD (grade 3) (p = 0.70), 30-day mortality (p = 0.87), and 3-month % predicted forced expiratory volume in 1 second (p = 0.58) were not statistically different; however, Perfadex trended toward superiority among the three solutions. After adjustment of donor, recipient, and operative factors in multivariate analysis, Perfadex was significantly associated with the prevention of moderate to severe PGD (grade 2 to 3) at 48 hours posttransplant (odds ratio = 0.26 [0.10 to 0.72], p < 0.01) compared with Papworth (odds ratio = 0.75 [0.32 to 1.75], p = 0.51) and Euro-Collins (reference) solutions. Although any advantageous effects of Perfadex on early posttransplant outcomes were generally subtle and statistically nonsignificant, Perfadex prevented moderate to severe PGD. Switching preservation solution from Euro-Collins (or Papworth) to Perfadex would appear to usefully contribute to a strategy to reduce PGD in lung transplantation.

Techniques of Reconstruction for Inadequate Donor Left Atrial Cuff in Lung Transplantation

An inadequate donor left atrial (LA) cuff due to an anatomical abnormality of the pulmonary vasculature or technical errors at the time of procurement can exclude the lungs from transplant. This study aims to describe the incidence, efficacy, and various techniques of LA cuff reconstruction in lung transplantation. A total of 637 pulmonary venous anastomosis in 405 consecutive lung transplants from January 1995 to July 2005 were reviewed. Comparison between the patients who required LA cuff reconstruction (reconstruction group) or who did not (no-reconstruction group) was made in posttransplant outcomes. An overall incidence of requirement of LA cuff reconstruction was 2.7% (4% on the right, 1% on the left, p = 0.03). Seventy-one percent of LA inadequacy was corrected using a pericardial patch on the anterior LA cuff wall; the remainder required complicated reconstruction for separated/short pulmonary veins to create a new LA cuff. There was no significant difference between the reconstruction and no-reconstruction groups, respectively, in oxygenation (329 +/- 28, 337 +/- 10, p = 0.81), duration of intubation and intensive care unit stay (p = 0.54, p = 0.89, respectively), 30-day mortality (12%, 6%, p = 0.30), and 5-year survival (57%, 52%, p = 0.80). Inadequate donor LA cuff is an infrequent but potentially serious complication in lung transplantation. Donor LA cuff reconstruction using donor pericardium or pulmonary artery remnant is a useful technique to salvage surgically marginal lungs without affecting early and late posttransplant outcomes. These lungs should not be excluded from transplantation.

The Eurotransplant Study on Twin Lung Transplants (ESOTWIN): 90 paired single-lung transplants from the same donor.

Despite its reduced benefit for a single recipient, the transplantation of two single-lung allografts as opposed to one bilateral lung transplant has the indisputable advantage of maximizing the number of patients that benefit from a single donor. In the period 1997 to 1999, 90 paired single-lung transplants (SLTx) from 45 donors were performed in 16 lung centers in Eurotransplant, with a complete follow-up of 1 year. No significant differences between left- and right-lung allograft recipients were observed regarding age, sex, primary disease, number of human leukocyte antigen mismatches, cold ischemic time, and donor-to-recipient cytomegalovirus match. Early posttransplant outcome, as assessed by oxygenation index at 12, 24, and 48 hr, also did not differ significantly, and there were no differences in time to extubation and time spent in the intensive care unit. In the first month, six left- and three right-lung allograft recipients died. Bronchiolitis obliterans syndrome developed in 5 of 39 left-lung and 10 of 42 right-lung allograft recipients. If the retrieval team was different from the transplanting team, a significantly worse 1-year posttransplant survival rate was seen in patients who underwent left SLTx compared with those who underwent right SLTx (62% vs. 92%, respectively; P=0.04). More fatal posttransplant complications occur in patients undergoing left SLTx compared with right SLTx. A less optimistic assessment of the left lung by the not-implanting retrieval team is warranted.

Prolonged continuous outpatient parenteral inotropic support in heart transplant candidates with reversible pulmonary hypertension

Background: Pulmonary hypertension (PH) in advanced congestive heart failure (CHF) is associated with increased mortality after heart transplantation. Reversibility of elevated transpulmonary gradient (TPG) by pharmacologic agents predicts improved early post-transplant outcome.

THE EARLY AND LONG-TERM GRAFT SURVIVALS OF CADAVERIC KIDNEYS HARVESTED FROM UNCONTROLLLED NON-HEART BEATING DONORS

73 INTRODUCTION; In this clinical communication, the early and long-term posttransplant outcome of 285 renal allografts harvested from uncontolled non-heart beating donors (NHBDs), using in situ cooling technic, and transplanted into recipients treated with ciclosporin or tacrolimus are retrospectively investigated and risk factors affecting renal prognoses are analysed. STUDY SUBJECTS AND METHODS; Between April 1979 and December 1998, 379 kidneys been retrieved from 191 uncontrolled NHBDs using in situ cooling technic at our center. Thirty five kidneys (9.2%) were discarded mainly due to poor arterial perfusion and bacterial contaminations, and 39 kidneys were transplanted into patients treated with azathioprine and steroid. Among the rest, 285 kidneys engrafted before December 1998 and transplanted into recipients treated with ciclosporin or tacrolimus were enrolled. RESULTS; Following transplants, only 46 grafts (16.1%) had immediate graft function, and 17 grafts (6.0%) were lost due to primary non-function. Two hundred twenty two grafts (77.9%) required posttransplant dialysis (PTD) for 13.7 days on the average. The mean values of posttransplant lowest serum creatinine levels (LSCR) was 1.58 mg/dl. The patient survival at one, 3, 5 and 10 years were 97.2%, 95.0%, 93.2% and 89.3%, respectively, and the graft survival at one, 3, 5 and 10 years were 83.3%, 72.0%, 64.7% and 48.6%, respectively. When the donor's age, warm ischemic time (WIT) and total ischemic time (TIT) were analyzed with the LSCR and PTD period, only the donor's age had significant correlation with LSCR and PTD period (p < 0.001 and p < 0.01, respectively). Additionaly, renal grafts from the donors died of cereblovascular disease (CVD) had significantlly higher LSCR than the grafts from non-CVD donors (P < 0.0001). When multivariate analysis was applied for the long-term graft survival, WIT (> 30 min.) and donor age (> 50 years) were significantly independent risk factors (P< 0.001 and P< 0.05, respectively). CONCLUSIONS; The renal grafts harvested from uncontrolled NHBDs using in situ cooling technic can provide good renal functions and promise an acceptable long-term graft survial. Especially when the donor is young or the cause of death is non-CVD, the posttransplant renal function and graft survival will be excellent. We conclude using the kidneys from uncontrolled NHBDs should be one of the way to resolve the severe organ shortage.

Trough blood concentrations in long-term treatment with mycophenolate mofetil

Mycophenolate mofetil (MMF) is routinely administered as a fixed regimen. Contrary to the other immunosuppressive drugs, drug monitoring has not been required to optimise its activity or reduce its toxicity. 1 Fulton B Markham A Mycophenolate mofetil. A review of its pharmacodynamic and pharmacokinetic properties and clinical efficacy in renal transplantation. Drugs. 1996; 51: 278-297 Crossref PubMed Scopus (286) Google Scholar The efficacy of MMF in early post-transplant outcomes 2 European Mycophenolate Mofetil Cooperative Study GroupPlacebo-controlled study of mycophenolate mofetil combined with cyclosporin and corticoids for prevention of acute rejection. Lancet. 1995; 345: 1321-1325 Summary PubMed Google Scholar has led renal transplant physicians to increasingly use this drug for baseline immunosuppression. Despite, however, reduced acute rejection rates, the improvement of 1-year graft survival or incidence of chronic rejection incidence at 3 years has yet to be demonstrated. 3 The International Mycophenolate Mofetil Study Group. A long-term randomized multicenter study of mycophenolate mofetil (MMF) in cadaveric renal transplantation: results at 3 years. XVIth Annual Meeting of the American Society of Transplant Physicians, Chicago, May 11–14, 1997. Google Scholar We looked to see whether time-dependent changes in the pharmacokinetics of MMF could contribute to this absence of long-term efficacy.

IgG T cell flow cytometry crossmatching does not significantly discriminate early post transplant outcome in primary kidney and kidney/pancreas recipients with a negative CDC crossmatch

IgG T cell flow cytometry crossmatching does not significantly discriminate early post transplant outcome in primary kidney and kidney/pancreas recipients with a negative CDC crossmatch