Excellent Post-transplant Survival Research Articles

Discussion to: The majority of pediatric Fontan patients have excellent post-transplant survival

Discussion to: The majority of pediatric Fontan patients have excellent post-transplant survival

The majority of pediatric Fontan patients have excellent post-transplant survival

ObjectiveMany pediatric Fontan patients require heart transplant, but this cohort is understudied given the difficulty in identifying these patients in national registries. We sought to characterize survival post-transplant in a large cohort of pediatric patients undergoing the Fontan. MethodsThe United Network for Organ Sharing and Pediatric Health Information System were used to identify Fontan heart transplant recipients aged less than 18 years (n = 241) between 2005 and 2022. Decompensation was defined as the presence of extracorporeal membrane oxygenation, ventilation, hepatic/renal dysfunction, paralytics, or total parenteral nutrition at transplant. ResultsMedian age at transplant was 9 (interquartile range, 5-12) years. Median waitlist time was 107 (37-229) days. Median volume across 32 center was 8 (3-11) cases. Approximately half (n = 107, 45%) of recipients had 1A/1 initial listing status. Sixty-four patients (28%) were functionally impaired at transplant, 10 patients (4%) were ventilated, and 18 patients (8%) had ventricular assist device support. Fifty-nine patients (25%) had hepatic dysfunction, and 15 patients (6%) had renal dysfunction. Twenty-one patients (9%) were dependent on total parenteral nutrition. Median postoperative stay was 24 (14-46) days, and in-hospital mortality was 7%. Kaplan–Meier analysis showed 1- and 5-year survivals of 89% (95% CI, 85-94) and 74% (95% CI, 81-86), respectively. Kaplan–Meier of Fontan patients without decompensation (n = 154) at transplant demonstrated 1- and 5-year survivals of 93% (95% CI, 88-97) and 88% (95% CI, 82-94), respectively. In-hospital mortality was higher in decompensated patients (11% vs 4%, P = .023). Multivariable analysis showed that decompensation predicted worse post-transplant survival (hazard ratio, 2.47; 95% CI, 1.16-5.22; P = .018), whereas older age at transplant predicted superior post-transplant survival (hazard ratio, 0.89/year; 95% CI, 0.80-0.98; P = .019). ConclusionsPediatric Fontan post-transplant outcomes are promising, although early mortality remains high. For nondecompensated pediatric patients at transplant without end-organ disease (>63% of cohort), early mortality is circumvented and post-transplant survival is excellent and similar to all pediatric transplantation.

Hepatocellular Cancer And Liver Transplantation; Is There Any Novelty İn Prognostic Factors For Survival And Recurrence?

Background/Purpose: Hepatocellular cancer constitutes 75-85% of liver cancers, and its treatment requires a multidisciplinary approach. Milan criteria are golden standart candidate selection criteria that ensure excellent posttransplant survival and follow up with low recurrence rate. However, other classifications include histopathological features or biological behaviors may vary survival and recurrence. We examined the parameters that may have prognostic value in out study.
 Methods: 217 patients for recurrence, 226 patients for overall survival, 48 patients for disease free survival, whose explant pathology is hepatocellular carcinoma and data information can be obtained were evaluated. Recurrence and overall survival and disease free survival were statistically analyzed in terms of age, gender, living and cadaveric transplanted patient groups, blood group, BMİ, MELD and Child scores, milan criteria and pathological parameters. All survival rates were evaluated in terms of recurrent organ location, number of organ recurrence, and survival rates.
 Results: There were less recurrence rates in patients, with 0 blood group, inside milan, with less total and maximum tumor diameter. It was also observed that the maximum tumor size affected the overall survival multivariately It was observed that survival was worse in early recurrence and recurrence in the first 24 months. 
 Conclusion: İt is observed that being inside the milan and tumor diameter affect the recurrence and survival, surgery to be performed in localized recurrences and additional systemic treatment will affect survival positively.

How to Optimize the Results of Liver Transplantation for Acute-on-Chronic Liver Failure.

Cirrhotic patients who developed a decompensation episode requiring an admission to an intensive care unit are not equal in term of prognosis. This led to the definition of a syndrome, acute-on-chronic liver failure (ACLF), marked by the severity of systemic inflammation, the development of organ failures and a high short-term mortality. The most common underlying liver etiology is related to acute alcohol hepatitis in western countries and to HBV or HCV cirrhosis in eastern countries. Twenty-eight and 90-days high mortality rates are well linked to the number of organ failure and defined, merely ten years ago, by a modified SOFA score. ACLF is a dynamic syndrome and grading can vary from hospital admission. ACLF grading between day 3-7 of admission is more accurate for determining outcome. ACLF-3 patients with ≥3 organ failures remain very challenging with >75% mortality rate. Despite recent advances in the medical management of critically ill cirrhotic patients, the prognosis of these patients remains poor. Currently, the main effective treatment is an urgent liver transplantation (LT) which is performed in a very selected patients eligible to transplant given the limited availability of organ donors and the low post-transplant survival rates reported in earlier studies. Recently, large retrospective multicenter studies and registries showed an improved 1-year post-transplant survival rate >83% in several transplant centers. Nevertheless, only few proportions of the ACLF-2 and ACLF-3 patients are transplanted representing 0-10% of most liver transplant programs. A careful selection of these patients (excluding major comorbidities i.e., older age, addictology criteria, severe malnutrition…) and optimal timing for transplant (infection control, hemodynamic stability, low oxygen and vasopressor requirements) are associated with excellent post-transplant survival rate.

Evaluation of Fontan-associated Liver Disease and Ethnic Disparities in Long-term Survivors of the Fontan Procedure: A Population-based Study.

Fontan-associated liver disease (FALD) has emerged as a nearly universal chronic comorbidity in patients with univentricular congenital heart disease who undergo the Fontan procedure. There is a paucity of data reporting long-term outcomes and the impact of FALD in this population. Patients who underwent the Fontan procedure between 1992 and 2018 were identified using California registry data. Presumed FALD was assessed by a composite of liver disease codes. Primary outcomes were mortality and transplant. Multivariable regression and survival analyses were performed. Among 1436 patients post-Fontan, 75.9% studied were adults, with a median follow-up of 12.6 (8.4, 17.3) years. The population was 46.3% Hispanic. Overall survival at 20 years was >80%, but Hispanic patients had higher mortality risk compared with White patients [hazard ratio: 1.49 (1.09-2.03), P =0.012]. Only 225 patients (15.7%) had presumed FALD, although >54% of patients had liver disease by age 25. FALD was associated with later deaths [median: 9.6 (6.4-13.2) years post-Fontan] compared with patients who died without liver disease [4.1 (1.4-10.4) years, P =0.02]. Patients with FALD who underwent combined heart liver transplant had 100% survival at 5 years, compared with only 70.7% of patients who underwent heart transplant alone. In this population-based analysis of long-term outcomes post-Fontan, Hispanic ethnicity was associated with increased all-cause mortality. Further, the prevalence of FALD is underrecognized, but our data confirms that its incidence increases with age. FALD is associated with late mortality but excellent posttransplant survival. This emphasizes the need for FALD-specific liver surveillance strategies in patients post-Fontan.

Short Term Outcomes in Case Series of 21 Congenital Heart Disease Recipients of Heart or Dual-Solid Organ Transplants

<h3>Purpose</h3> Heart transplantation for patients with end-stage congenital heart disease (CHD) is considered high risk due to increased peri-operative mortality at index hospitalization. However, survivors have comparable conditional 1-year survival and a superior 15-year survival when compared to non-CHD recipients. Outcomes from a multidisciplinary CHD team caring for this complex population are presented. <h3>Methods</h3> We conducted a retrospective review, at a large volume transplant center from 2017-2021 to identify consecutive patients who underwent single or dual-solid organ transplantation for the indication of end-stage CHD. Overall post-transplant survival at 6 and 12 months for this CHD cohort were compared to the other heart, heart-lung, and heart-liver transplants during the same period. <h3>Results</h3> There were 21 consecutive patients with end-stage CHD who were transplanted during the study period. A total of 12 recipients (57%) had single ventricle physiology with the most common defects being tricuspid atresia and hypoplastic left heart syndrome. Most were male (71%) with a mean age of 29 years (Table 1). There was a high proportion of dual-organ transplants (43%) with the most common being heart-liver (Table 1). Post-transplant survival at 6 and 12 months were 95% and 94%, respectively compared to 97% and 96%, respectively for similar transplant recipients for non-CHD indications. The single mortality in the CHD cohort occurred in a dual-organ transplant recipient (listed status 1A) with single ventricle and died 72 hours post-operatively due to severe, nonspecific graft dysfunction requiring extracorporeal membrane oxygenation support. <h3>Conclusion</h3> This study demonstrates an excellent post-transplant survival (94% at 12 months) for CHD patients can be achieved when a collaborative approach between pediatric and adult transplantation teams with congenital disease expert is employed in the pre-, peri- and post-transplantation period.

Real World Experience with Transmedics Organ Care System in Cardiac Transplantation with Donor Organs Associated with Marginal Risk Factors

<h3>Purpose</h3> Donor organ acceptance is limited by preservation method using cold storage. We sought to evaluate the efficacy of normothermic TransMedics OCS Heart to preserve BD donor organ associated with pre-donation criteria that may increase risk of primary graft dysfunction (expanded criteria). <h3>Methods</h3> All cardiac transplantations between 2017-19 were evaluated in this single-centre, observational analysis. Expanded criteria was defined as: (I) cold ischaemic time between 4-8 hours, (ii) donor age >55 year-old with normal coronary angiography, (iii) reported circulatory down-time > 20mins, (iv) LVEF <50% where impairment is thought to be reversible, and (v) LV hypertrophy (wall thickness 12-16mm). Final transcoronary lactate level < 5 mmol/L at the end of the ex-vivo perfusion period was required for final organ acceptance. Clinical outcomes of interest include: total cold ischaemic time, index hospitalisation length of stay, and all-cause mortality at 90-day. <h3>Results</h3> Between July 2017 and December 2019, the OCS Heart Retrieval team was dispatched on 9 occasions, with 8 cases of ex-vivo organ retrievals. Of the 8 cases, 6 were successfully transplanted. With a total of 43 heart transplants were undertaken, availability of OCS Heart effectively allowed 14% increase in successful transplantation (6/43). Donor organ retrieval using TransMedics OCS Heart was associated with significant reduction in the total cold ischaemic time compared to cold storage (192.4mins vs 80.33mins, p=0.0005). Despite the expanded criteria, donor hearts that were successfully preserved were associated with comparable clinical outcomes: index hospitalization length of stay (P=0.97) and excellent post-transplant survival (Figure). <h3>Conclusion</h3> Normothermic donor heart preservation, with TransMedics OCS, allows comparatively safe transplantation with expanded criteria BD donor organ compared to conventional cold storage method with conservation donor characteristics.

Heart Transplantation for Giant Cell Myocarditis: A Case Series

BackgroundGiant cell myocarditis (GCM) has a poor prognosis without heart transplant, but post-transplant survival is unknown. PurposeTo describe the post-transplant survival of patients with GCM at a large transplant center. MethodsSeven patients underwent heart transplant for histologically confirmed GCM of the explanted heart. The median age was 59 years, and 43% (3 of 7) were female. All patients had cardiogenic shock, multiorgan failure, elevated troponin, and recurrent ventricular tachycardia, and some required mechanical circulatory support. All patients received rabbit antithymocyte globulin (rATG) in the perioperative period at a dose of 1.5 mg/kg daily for 1 to 5 days and 4 received intravenous immunoglobulin 1 g/kg daily for 2 days after rATG. All patients had early initiation of tacrolimus by first to third postoperative day depending on renal function, early mycophenolate, and high dose steroid. All were maintained using tacrolimus, mycophenolate, and prednisone. ResultsOne patient had asymptomatic recurrence of GCM at 3 months, managed by up-titration of tacrolimus, and had asymptomatic 2R cellular rejection at 4 months, managed with steroid bolus. No patient had high-grade rejection. One patient died at 267 days, possibly of GCM. Six of 7 (86%) remain alive at a median of 842 days (2.3 years) post transplant. ConclusionsPatients with GCM have excellent post-transplant survival with use of rATG and triple drug immunosuppressive therapy; however, some patients remain at risk for GCM recurrence after transplant, which may respond to augmented immunosuppression.

Patients and their family members prioritize post-transplant survival over waitlist survival when considering donor hearts for transplantation.

Heart transplant providers often focus on post-transplant outcomes when making donor decisions, potentially at the expense of higher waitlist mortality. This study aimed to assess public opinion regarding the selection of donor hearts and the balance between pre- and post-transplant risk. The authors generated a survey to investigate public opinion regarding donor acceptance. The survey was shared freely online across social media platforms in April-May 2019. A total of 718 individuals responded to the survey, with an equal distribution between patients and family members. Respondents consistently favored post-transplant outcomes over waitlist outcomes. About 83.9% of respondents favored a hospital with longer waitlist times, worse waitlist outcomes, but excellent post-transplant survival over a hospital with short waitlist times, a high waitlist survival, and inferior post-transplant survival. This preference was no different between pediatric and adult populations (P=.7), patient and family members (P=.935), or those with a pre- vs post-transplant perspective (P=.985). Patients and their family members consistently favor improved post-transplant survival over waitlist survival when considering the risks of accepting a donor organ. These findings suggest that current practice patterns of donor selection align with the opinions of patients and family members with heart failure or who have undergone heart transplantation.

VAD infection during bridge-to-transplant, unique aspects of treatment and prevention.

VAD infections remain a frequent complication of VAD care and can markedly affect patient management before and after transplantation. This review highlights the standard-of-care approaches offered by recent guidelines as well as published data that may improve the care for patients with these challenging and often persistent infections. Prevention and management of VAD infections has become more standardized with updated consensus guidelines published in 2017. Unfortunately, advanced devices have not markedly affected the incidence of VAD infection. Efforts to improve, yet streamline, the prevention of VAD-specific infections are ongoing. However, the data provided in the best of recent publications are rarely effectively comparative. Granular data on management strategies are limited to a few studies. Nevertheless, several publications provide more detailed posttransplant outcomes for patients with pretransplant VAD infections and demonstrate overall excellent posttransplant survival. Prevention and management of VAD-specific and VAD-related infections are the ongoing work of all VAD programs. Consensus guidelines are a marker of progress for this field. Despite very good posttransplant outcomes for these patients, more granular data are required to understand how such patients arrive successfully to transplantation and how their posttransplant course is affected.

Stabilisation of acute-on-chronic liver failure patients before liver transplantation predicts post-transplant survival.

Acute-on-chronic liver failure (ACLF) is a severe complication of liver cirrhosis associated with excess short-term mortality rates. Orthotopic liver transplantation (OLT) is a potentially life-saving therapeutic modality for acute-on-chronic liver failure patients, but selection of transplant candidates with an acceptable post-transplant outcome is difficult. To assess the risk of liver transplantation in patients with ACLF, and to determine parameters that predict post-transplant survival in this patient cohort. We retrospectively analysed all 250 patients with cirrhosis who underwent their first liver transplantation between 2009 and 2014 at our institution, and assessed post-transplant outcomes. Of 250 cirrhotic liver transplant recipients, 98 patients fulfilled the diagnostic criteria for acute-on-chronic liver failure in the 3-month pre-transplant period. Compared to non-ACLF patients, ACLF was associated with significantly higher short-term morbidity and mortality after liver transplantation (90-day patient survival 96.1% non-ACLF vs 72.4% ACLF patients, P < 0.0001). Clinical improvement in the pre-transplant period, as defined by recovery of at least one previously failed organ system, was observed in 37 of 98 acute-on-chronic liver failure patients, mostly within several days after diagnosis. Most notably, clinical improvement prior to liver transplantation was associated with excellent post-transplant survival rates that approximated non-ACLF transplant recipients. Following the 90-day post-transplant period, patient survival and long-term graft functions were comparable between ACLF and non-ACLF liver transplant recipients for up to 5 years. Acute-on-chronic liver failure predicts adverse outcome after orthotopic liver transplantation. Given the dismal prognosis without transplantation, however, our results indicate that ACLF patients can be transplanted with comparably good outcomes, in particular patients who improve under conservative therapeutic measures.

Acute Liver Failure, Etiology, and Outcome: An Experience in a Referral Liver Transplant Center

Background and Aims: Acute liver failure (ALF) caused by a sudden loss of liver function in patients without pre-existing liver disease is a rare condition and one of the emergencies in the field of hepatology. The common etiologies of ALF vary in different geographic areas and the course is highly variable among patients with different confounding factors. In this prospective study, ALF patients referred to our tertiary center were followed, and their data were analyzed for determinants of outcome. Methods: From March 2014 through February 2015, all adult and pediatric patients with a diagnosis of ALF, who were admitted to the gastroenterology and hepatology wards of our center with a large liver transplant program, were included in the study. Survivors were followed for at least 3 months after discharge from the hospital. Results: A total number of 45 (23 males) patients were included in the present study. The most common etiology was acute hepatitis A (15.6%), followed by drug induced liver injury (13.3%), and autoimmune hepatitis (11.1%), while most cases were classified as indeterminate ALF (35.6%). Overall survival rate was 71 %; 24.4% (11 patients) died, 46.7% (21 patients) survived without transplant, and 28.9% (13 patients) were transplanted, but 2 of them did not survive. Conclusions: Most cases of ALF in this study had unknown etiology. Acute hepatitis A was the most commonly identified cause. About half of the cases survived without transplantation with very good outcomes after 3 months, one-third received liver transplantation with excellent post-transplant survival.

Downstaging of hepatocellular cancer before liver transplant: long-term outcome compared to tumors within Milan criteria.

We report on the long-term intention-to-treat (ITT) outcome of 118 patients with hepatocellular carcinoma (HCC) undergoing downstaging to within Milan/United Network for Organ Sharing T2 criteria before liver transplantation (LT) since 2002 and compare the results with 488 patients listed for LT with HCC meeting T2 criteria at listing in the same period. The downstaging subgroups include 1 lesion >5 and ≤8 cm (n = 43), 2 or 3 lesions at least one >3 and ≤5 cm with total tumor diameter ≤8 cm (n = 61), or 4-5 lesions each ≤3 cm with total tumor diameter ≤8 cm (n = 14). In the downstaging group, 64 patients (54.2%) had received LT and 5 (7.5%) developed HCC recurrence. Two of the five patients with HCC recurrence had 4-5 tumors at presentation. The 1- and 2-year cumulative probabilities for dropout (competing risk) were 24.1% and 34.2% in the downstaging group versus 20.3% and 25.6% in the T2 group (P = 0.04). Kaplan-Meier's 5-year post-transplant survival and recurrence-free probabilities were 77.8% and 90.8%, respectively, in the downstaging group versus 81% and 88%, respectively, in the T2 group (P = 0.69 and P = 0.66, respectively). The 5-year ITT survival was 56.1% in the downstaging group versus 63.3% in the T2 group (P = 0.29). Factors predicting dropout in the downstaging group included pretreatment alpha-fetoprotein ≥1,000 ng/mL (multivariate hazard ratio [HR]: 2.42; P = 0.02) and Child's B versus Child's A cirrhosis (multivariate HR: 2.19; P = 0.04). Successful downstaging of HCC to within T2 criteria was associated with a low rate of HCC recurrence and excellent post-transplant survival, comparable to those meeting T2 criteria without downstaging. Owing to the small number of patients with 4-5 tumors, further investigations are needed to confirm the efficacy of downstaging in this subgroup.

Serum alpha-fetoprotein level independently predicts posttransplant survival in patients with hepatocellular carcinoma

We aimed to determine whether combining serum alpha-fetoprotein (AFP) level with hepatocellular carcinoma (HCC) tumor burden would allow better stratification of posttransplant survival for patients with HCC undergoing liver transplantation. Adjusting for donor and recipient characteristics, we calculated the risk of posttransplant mortality associated with serum AFP level or HCC tumor burden for all first-time adult liver transplants performed in the United States between 2002 and 2011 (n = 45,267). Serum AFP level, rather than tumor burden, was the tumor characteristic most strongly associated with posttransplant survival. Although recipients with HCC and a serum AFP level ≤ 15 ng/mL at the time of transplantation had no excess posttransplant mortality [adjusted hazard ratio (AHR) = 1.02, 95% confidence interval (CI) = 0.93-1.12], patients with a serum AFP level of 16 to 65 ng/mL (AHR = 1.38, 95% CI = 1.23-1.54), patients with a serum AFP level of 66 to 320 ng/mL (AHR = 1.65, 95% CI = 1.45-1.88), and patients with a serum AFP level > 320 ng/mL (AHR = 2.37, 95% CI = 2.06-2.73) had progressively worse posttransplant mortality in comparison with recipients without HCC. Patients with a tumor burden exceeding the Milan criteria (who are usually excluded from transplantation) had excellent posttransplant survival if their serum AFP level was 0 to 15 ng/mL (AHR = 0.97, 95% CI = 0.66-1.43). In contrast, patients within the Milan criteria (who are routinely considered to be transplant candidates) had poor survival if their serum AFP level was substantially elevated (for a serum AFP level ≥ 66 ng/mL, AHR = 1.93, 95% CI = 1.74-2.15). Changes in serum AFP level while patients were on the waiting list corresponded closely to changes in posttransplant mortality. In conclusion, the absolute serum AFP level and changes in the serum AFP level strongly predict posttransplant survival independently of the tumor burden. We hope that these data, in combination with other factors, can be used to inform future studies and ongoing discussions aimed at improving the eligibility criteria for liver transplantation for patients with HCC.

005 FIFTEEN YEAR EXPERIENCE OF BRIDGING TO HEART TRANSPLANTATION WITH VENTRICULAR ASSIST DEVICES

Background An increasing number of end-stage heart failure patients are being bridged to heart transplant (BTT) with ventricular assist devices (VAD). This is due to a severe shortage of donor hearts. Surgery for VAD explant and heart transplant can be technically demanding. We reviewed a single-centre experience of BTT over a 15 year period with long term follow up. Methods This is a retrospective study of 529 consecutive patients who underwent heart transplantation between 1 April 1997 and 31 July 2012. 466 were standard orthotopic heart transplants (OHT) without prior VAD support and 63 were BTT. The primary outcome was actuarial post-transplant survival. Other outcomes included blood lost within first 24 h, return to theatre, intubation time, renal failure, gastro-intestinal complication, intensive care and total length of hospitalisation. Results The mean age of BTT patients was younger (OHT 49 yo, BTT 41 yo, p Conclusions The use of ventricular assist devices as bridge to transplantation provides excellent posttransplant survival when compared to standard heart transplants. However, surgery for VAD explant and heart transplant can be demanding and is accompanied by higher perioperative morbidity without increasing length of stay.

Fifteen Year Experience of Bridging to Heart Transplantation with Ventricular Assist Devices

Purpose An increasing number of end-stage heart failure patients are being bridged to heart transplant (BTT) with ventricular assist devices (VAD). We reviewed a single-centre experience of BTT over a 15 year period with long term follow up. Methods and Materials This is a retrospective study of 529 consecutive patients who underwent heart transplantation between April 1st, 1997 and July 31st, 2012. 466 were standard orthotopic heart transplants (OHT) without prior VAD support and 63 were BTT. The primary outcome was actuarial post-transplant survival. Other outcomes included blood lost within first 24 hours, return to theatre, intubation time, renal failure, gastro-intestinal complication, intensive care and total length of hospitalization. Results The mean age of BTT patients was younger (OHT 49 yo, BTT 41 yo, p figure 1 ] Conclusions The use of ventricular assist devices as bridge to transplantation provides excellent posttransplant survival when compared to standard heart transplants. However, surgery for VAD explant and heart transplant can be demanding and is accompanied by higher perioperative morbidity without increasing length of stay.

A Large Single Center Cohort of Liver Transplants from HBcAb-Positive Donors: Null Risk of Denovo Hepatitis B Infection and Excellent Post-Transplant Survival

A Large Single Center Cohort of Liver Transplants from HBcAb-Positive Donors: Null Risk of Denovo Hepatitis B Infection and Excellent Post-Transplant Survival

A Large Single Center Cohort of Liver Transplants from HBcAb-Positive Donors: Null Risk of Denovo Hepatitis B Infection and Excellent Post-Transplant Survival

Introduction: The utilization of hepatitis-B core antibody (HBcAb) positive and hepatitis-B surface antigen (HBSAg) negative have been proposed to maximize the donor pool. However, these grafts might carry occult HBV infection, therefore risking potential recipients of developing “de novo” hepatitis B (DNHB) post-transplant. It has also been suspected than these grafts might have inferior post-transplant survival. We designed this study to better understand the safety of this practice and to assess the transplant outcomes of recipients of HbcAb positive/HbsAg negative donors. Methods: From June, 2005 through June, 2010 458 liver transplants in 413 patients were performed at Albert Einstein Hospital in São Paulo, Brazil. We excluded from this analysis: recipients with acute liver failure (n=45) and those who were in need of an urgent retransplant (n=46). All recipients of HbcAb+HbsAg- grafts were kept with life-long prophylaxis for hepatitis B post-transplant: hepatitis B immuneglobulin plus lamivudine when the cause of cirrhosis was hepatitis B (n=13) and lamivudine monotherapy for the other recipients (n=53). Serology for hepatitis B infection and histological evaluation of the graft for at least 6 months post-transplant were used to detect DNHB. Mean follow-up was 27.5 months. Outcomes of transplants from HbcAb+HbsAg-donors were compared to those from other donors. Main endpoints were the incidence of DNHB and post-transplant survival. The Kaplan-Meier and log-rank test method were used to calculate patient and graft survivals; T test and Mann-Whitney were used to compare donors and recipients demographics variables. [PS1] Results: Among 367 patients that were included in the study, the mean MELD score was 25 (ranging from 7 to 40). The mortality for those in the waiting list was 11.1%. We used HbcAb+HbsAg-grafts in 66 transplants (18% of the cohort). Eighty percent of those who receive a HbcAb+HbsAg- allograft did not present cirrhosis due to hepatitis B (n=53). When we compared age, gender, BMI, ICU length of stay and laboratory tests of the donors in both groups, we found that HbcAb+HbsAg-donors were older than the controls (49 vs 42.2 years, p=0.006). In the HbcAb+HbsAg- group, there was no case of DNHB: post-transplant HbsAg test was negative in 88.7% of[PS2] these patients; in 77.3% of these patients, graft biopsy had no signs of VHB injury[PS3]. 1-year patient and graft survival were respectively 86.8% and 79.2% for the HbcAb+ group and 87% and 80.4% for the HbcAb negative graft group, (NS). Conclusion: The use of grafts form HbcAb+HbsAg- donors is safe even in patients who undergone liver transplantation for diseases different than hepatitis B. With proper prophylaxis and follow-up the incidence of DNHB is null. The utilization of HbcAb+HbsAg- donors has no impact on post-transplant survival.

Excellent posttransplant survival for patients with nonalcoholic steatohepatitis in the United States

Because of the ongoing epidemics of obesity and diabetes, nonalcoholic steatohepatitis (NASH) may become a leading indication for liver transplantation. There are concerns about the posttransplant survival of patients with NASH because of associated cardiovascular and metabolic risk factors. We aimed to determine recent trends in the proportion of patients undergoing transplantation for NASH-related cirrhosis in the United States and to estimate their posttransplant survival. We used data provided by the United Network for Organ Sharing for first-time adult cadaveric liver transplants performed in the United States between January 1, 1997 and October 31, 2010 (n = 53,738). The proportion of liver transplants performed for NASH-related cirrhosis increased dramatically from 1.2% in 1997-2003 to 7.4% in 2010 when NASH was the fourth most common indication for transplantation. The posttransplant survival of patients with NASH (n = 1810) at 1 (87.6%), 3 (82.2%), and 5 years (76.7%) was superior to the survival of patients with hepatocellular carcinoma, hepatitis C virus, alcoholic liver disease, acute hepatic necrosis, hemochromatosis, or cryptogenic liver disease and was inferior to the survival of only 4 groups of patients (those with primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis, or hepatitis B virus). In conclusion, NASH-related cirrhosis is increasing rapidly as an indication for liver transplantation in the United States and is associated with excellent posttransplant survival.

Balancing Multiple and Conflicting Allocation Goals: A Logical Path Forward

Balancing Multiple and Conflicting Allocation Goals: A Logical Path Forward