Favorable Posttransplant Outcomes Research Articles

(440) - Second Opinion Heart Transplantation After a Previous Contra-Indication in Another Center is Associated with Favorable Post-Transplant Outcomes. A Single High-Volume Center Experience

(440) - Second Opinion Heart Transplantation After a Previous Contra-Indication in Another Center is Associated with Favorable Post-Transplant Outcomes. A Single High-Volume Center Experience

Distinct clinical profiles and post-transplant outcomes among kidney transplant recipients with lower education levels: uncovering patterns through machine learning clustering

Background Educational attainment significantly influences post-transplant outcomes in kidney transplant patients. However, research on specific attributes of lower-educated subgroups remains underexplored. This study utilized unsupervised machine learning to segment kidney transplant recipients based on education, further analyzing the relationship between these segments and post-transplant results. Methods Using the OPTN/UNOS 2017–2019 data, consensus clustering was applied to 20,474 kidney transplant recipients, all below a college/university educational threshold. The analysis concentrated on recipient, donor, and transplant features, aiming to discern pivotal attributes for each cluster and compare post-transplant results. Results Four distinct clusters emerged. Cluster 1 comprised younger, non-diabetic, first-time recipients from non-hypertensive younger donors. Cluster 2 predominantly included white patients receiving their first-time kidney transplant either preemptively or within three years, mainly from living donors. Cluster 3 included younger re-transplant recipients, marked by elevated PRA, fewer HLA mismatches. In contrast, Cluster 4 captured older, diabetic patients transplanted after prolonged dialysis duration, primarily from lower-grade donors. Interestingly, Cluster 2 showcased the most favorable post-transplant outcomes. Conversely, Clusters 1, 3, and 4 revealed heightened risks for graft failure and mortality in comparison. Conclusions Through unsupervised machine learning, this study proficiently categorized kidney recipients with lesser education into four distinct clusters. Notably, the standout performance of Cluster 2 provides invaluable insights, underscoring the necessity for adept risk assessment and tailored transplant strategies, potentially elevating care standards for this patient cohort.

Transient decrease in B-type natriuretic peptide level after liver transplantation does not ensure favorable post-transplant 30-day outcomes.

High B-type natriuretic peptide (BNP) levels within the first 3 postoperative days (postBNPPOD3) after liver transplantation (LT) are greatly predictive of the 30-day mortality. We evaluated clinical impact of transient decrease in postBNPPOD3 compared to pretransplant BNP (preBNP) level on mortality and major adverse cardiac event (MACE) within 30 days after LT. We retrospectively evaluated 3,811 LT patients who measured delta BNP (deltaBNP), defined by serial postBNPPOD3 minus preBNP. Thirty-day all-cause mortality and MACE were estimated in patients with deltaBNP < 0 (n = 594, 15.6%) and > 0 (n = 3,217, 84.4%), respectively. Kaplan-Meier survival and multivariable Cox regression analysis were used. Within 30 days, 100 (2.6%) of all patients died. Unexpectedly, 30-day mortality rate (6.1% [95% CI: 4.2-8.4%] vs. 2.0% [95% CI: 1.5-2.5%], P < 0.001) and MACE (24.2% [95% CI: 20.4-28.5%] vs. 15.3% [95% CI: 14.0-16.7%], P < 0.001) were higher in patients with deltaBNP < 0 compared to those with deltaBNP > 0, respectively. Patients with deltaBNP < 0 had higher preBNP level (median [interquartile range], 251 [118, 586] vs. 43 [21, 92] pg/ml, P < 0.001) and model for end-stage liver disease score (26 [14, 37] vs. 14 [9, 23], P < 0.001) and more transfused intraoperatively. DeltaBNP < 0 remained significant after adjustments for potential confounders in multivariable analysis of 30-day mortality and MACE. DeltaBNP < 0 within the first 3 postoperative days is mainly attributed to pre-LT severe liver and cardiac disease status, therefore, transient decrease in BNP level after LT does not ensure favorable post-LT 30-day outcomes.

Outcomes of Lung Transplantation in Patients With Combined Pulmonary Fibrosis and Emphysema: A Single-Center Experience

Combined pulmonary fibrosis and emphysema (CPFE) is a distinct clinical entity that can progress to end-stage lung disease. Patients with CPFE may develop pulmonary hypertension and face a predicted 1-year mortality of 60%. Lung transplantation is the only curative therapeutic option for CPFE. This report describes our experience after lung transplantation in patients with CPFE. This retrospective, single-center study describes short- and long-term outcomes for adult patients who underwent lung transplant for CPFE. The study included 19 patients with explant pathology-proven diagnosis of CPFE. The patients were transplanted between July 2005 and December 2018. Sixteen recipients (84%) had pulmonary hypertension before transplant. Of the 19 patients, 7 (37%) had primary graft dysfunction at 72 hours post-transplant. 1-, 3-, and 5-year freedom from bronchiolitis obliterans syndrome was 100%, 91% (95% CI, 75%-100%), and 82% (95% CI, 62%-100%), respectively. One-, 3-, and 5-year survival was 94% (95% CI, 84%-100%), 82% (95% CI, 65%-100%), and 74% (95% CI, 54%-100%), respectively. Our experience demonstrates the safety and feasibility of lung transplant for patients with CPFE. Significant morbidity and mortality without lung transplant coupled with favorable post-transplant outcomes merit prioritization of CPFE in the Lung Allocation Score algorithm for lung transplant candidacy.

Prioritizing the Sickest Among the Sickest: A Matter of Tact and Moderation, but the Game Is Worth the Candle.

Prioritizing the Sickest Among the Sickest: A Matter of Tact and Moderation, but the Game Is Worth the Candle.

Textbook Outcome: Definition and Analysis of a Novel Quality Measure in Lung Transplantation.

To define textbook outcome (TO) for lung transplantation (LTx) using a contemporary cohort from a high-volume institution. TO is a standardized, composite quality measure based on multiple postoperative endpoints representing the ideal "textbook" hospitalization. Adult patients who underwent LTx at our institution between 2016 and 2019 were included. TO was defined as freedom from intraoperative complication, postoperative reintervention, 30-day intensive care unit or hospital readmission, length of stay >75th percentile of LTx patients, 90 day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, postoperative extracorporeal membrane oxygenation, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Recipient, operative, financial characteristics, and post-transplant outcomes were recorded from institutional data and compared between TO and non-TO groups. Of 401 LTx recipients, 97 (24.2%) achieved TO. The most common reason for TO failure was extubation >48 hours post-transplant (N = 119, 39.1%); the least common was mortality (N = 15, 4.9%). Patient and graft survival were improved among patients who achieved versus failed TO (patient survival: log-rank P < 0.01; graft survival: log-rank P < 0.01). Rejection-free and chronic lung allograft dysfunction-free survival were similar between TO and non-TO groups (rejection-free survival: log-rank P = 0.07; chronic lung allograft dysfunction-free survival: log-rank P = 0.3). On average, patients who achieved TO incurred approximately $638,000 less in total inpatient charges compared to those who failed TO. TO in LTx was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer providers and patients new insight into transplant center quality of care and highlight areas for improvement.

Living-donor lobar lung transplantation.

Living-donor lobar lung transplantation (LDLLT) has become an important life-saving option for patients with severe respiratory disorders, since it was developed by a group in the University of Southern California in 1993 and introduced in Japan in 1998 in order to address the current severe shortage of brain-dead donor organs. Although LDLLT candidates were basically limited to critically ill patients who would require hospitalization, the long-term use of steroids, and/or mechanical respiratory support prior to transplantation, LDLLT provided good post-transplant outcomes, comparable to brain-dead donor lung transplantation in the early and late phases. In Kyoto University, the 5- and 10-year survival rates after LDLLT were reported to be 79.0% and 64.6%, respectively. LDLLT should be performed under appropriate circumstances, considering the inherent risk to the living donor. In our transplant program, all living donors returned to their previous social lives without any major complications, and living-donor surgery was associated with a morbidity rate of <15%. Both functional and anatomical size matching were preoperatively performed between the living-donor lobar grafts and recipients. Precise size matching before surgery could provide a favorable pulmonary function and exercise capacity after LDLLT. Various transplant procedures have recently been developed in LDLLT in order to deal with the issue of graft size mismatching in recipients, and favorable post-transplant outcomes have been observed. Native upper lobe-sparing and/or right-to-left inverted transplantation have been performed for undersized grafts, while single-lobe transplantation has been employed with or without contralateral pneumonectomy and/or delayed chest closure for oversized grafts.

Efficacy of Three-Dimensional Computed Tomography Volumetry for Recipients in Downsizing Oversized Grafts in Brain-Dead Donor Lung Transplantation

Purpose Brain-dead donor lung transplantation frequently requires reduction in the size of oversized lung grafts for patients with a small chest cavity. We focused on the role of three-dimensional computed tomography (3D-CT) volumetry for recipients on downsizing oversized lung grafts. Methods We performed 53 brain-dead donor bilateral lung transplantations, including 15 lobar lung transplants (Lobar group) and 38 standard lung transplants with full-sized grafts (Full group), between December 2010 and December 2018. Recipient chest volume before transplantation was measured using 3D-CT volumetry, and donor lung volume was evaluated by predicted total lung capacity. Post-transplant outcomes and pulmonary function were retrospectively compared between the groups. Results The ratio of the recipient chest volume to the donor lung volume was significantly lower in the Lobar group (0.42±0.15) than in the Full group (0.77±0.30, P Conclusion Brain-dead donor lobar lung transplantation showed favorable post-transplant outcomes. The assessment of recipient chest cavity volume using 3D-CT volumetry may help surgeons precisely downsize oversized lung grafts prior to transplantation.

Ex vivo lung perfusion in lung transplantation.

Lung transplantation is an established life-saving intervention for patients with end-stage lung diseases. The success of lung transplantation mainly depends on the quality and function of the implanted donor lungs, which are frequently subject to brain-death-induced lung injuries and intensive care unit (ICU)-related complications before transplantation. Recent innovations, particularly the development of ex vivo lung perfusion (EVLP), in which donor lungs are ventilated and perfused under normothermic conditions outside the body, have allowed clinicians to more accurately assess the donor lung function prior to transplantation. Therefore, EVLP has been successfully translated into clinical practice with the expansion of the donor lung pool, leading to favorable post-transplant outcomes in a growing number of transplant centers worldwide. The EVLP system and techniques, following the Toronto protocol, have recently been applied for the assessment of extended criteria brain-death donors in clinical lung transplantation in Japan. The advancement of EVLP from organ assessment to organ treatment will be the next challenging stage not only to expand donor lung pool, but also to improve graft survival and long-term outcomes after transplantation.

Efficacy of three-dimensional computed tomography volumetry for recipients in downsizing oversized grafts in brain-dead donor lung transplantation.

ObjectiveBrain-dead donor lung transplantation frequently requires reduction in the size of oversized lung grafts for patients with a small chest cavity. We focused on the role of three-dimensional computed tomography (3D-CT) volumetry for recipients on downsizing oversized lung grafts.MethodsWe performed 53 brain-dead donor bilateral lung transplantations, including 15 lobar lung transplants (Lobar group) and 38 standard lung transplants with full-sized grafts (Full group), between December 2010 and December 2018. Recipient chest volume before transplantation was measured using 3D-CT volumetry, and donor lung volume was evaluated by predicted total lung capacity. Post-transplant outcomes and pulmonary function were retrospectively compared between the groups.ResultsThe ratio of the recipient chest volume to the donor lung volume was significantly lower in the Lobar group (0.42 ± 0.15) than in the Full group (0.77 ± 0.30, P < 0.01). The calculated size matching between the donor and recipient after downsizing the grafts was significantly correlated to the ratio of the recipient chest volume to the donor lung volume (Spearman r = 0.69; P < 0.01). Early post-transplant outcomes did not significantly differ between the groups. Although the Full group showed slightly better pulmonary function after transplantation, the 1-, 3-, and 5-year overall survival rates were similar to the Lobar group (100%, 93%, and 81% in the Lobar group vs. 92%, 78%, and 70% in the Full group; P = 0.50).ConclusionsBrain-dead donor lobar lung transplantation showed favorable post-transplant outcomes. The assessment of recipient chest cavity volume using 3D-CT volumetry may help surgeons precisely downsize oversized lung grafts prior to transplantation.

Definition and Analysis of Textbook Outcome: A Novel Quality Measure in Kidney Transplantation.

"Textbook outcome" (TO) is a novel composite quality measure that encompasses multiple postoperative endpoints, representing the ideal "textbook" hospitalization for complex surgical procedures. We defined TO for kidney transplantation using a cohort from a high-volume institution. Adult patients who underwent isolated kidney transplantation at our institution between 2016 and 2019 were included. TO was defined by clinician consensus at our institution to include freedom from intraoperative complication, postoperative reintervention, 30-day intensive care unit or hospital readmission, length of stay > 75th percentile of kidney transplant patients, 90-day mortality, 30-day acute rejection, delayed graft function, and discharge with a Foley catheter. Recipient, operative, financial characteristics, and post-transplant patient, graft, and rejection-free survival were compared between patients who achieved and failed to achieve TO. A total of 557 kidney transplant patients were included. Of those, 245 (44%) achieved TO. The most common reasons for TO failure were delayed graft function (N = 157, 50%) and hospital readmission within 30days (N = 155, 50%); the least common was mortality within 90days (N = 6, 2%). Patient, graft, and rejection-free survival were significantly improved among patients who achieved TO. On average, patients who achieved TO incurred approximately $50,000 less in total inpatient charges compared to those who failed TO. TO in kidney transplantation was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer transplant centers a detailed performance breakdown to identify aspects of perioperative care in need of process improvement.

Post-Transplant Outcomes of Novel Surgical Procedures to Deal with Graft Size Mismatch in Living-Donor Lobar Lung Transplantation

Various living-donor lobar lung transplant (LDLLT) procedures have been developed in order to resolve the serious issue of graft size mismatch. The purpose of this study was to compare the outcomes of newly developed transplant techniques with those of the standard LDLLT approach. In Kyoto University, the procedures of "native upper lobe-sparing transplant" and "right-left inverted transplant" have been employed as strategies for managing undersized grafts, and single lobar transplant has been used to manage oversized grafts. Between June 2008 and May 2018, we performed 47 standard LDLLT procedures (Standard group), 22 native upper lobe-sparing transplants and/or right-left inverted transplants for undersized grafts (Under group), and 11 single lobar transplants for oversized grafts (Over group). The LDLLT patients showed great early post-transplant outcomes: the ECMO requirement rate was 8.8%, 30-day mortality was 2.5%, and hospital mortality was 5.0%. The pulmonary function at 1 year after LDLLT was similar among the three groups: %FVC of 59%±22% in the Standard group, 63%±19% in the Under group and 61%±21% in the Over group (P = 0.81), and %FEV1 of 59%±20% in the Standard group, 62%±15% in the Under group and 58%±20% in the Over group (P = 0.84). The LDLLT patients had a favorable exercise capacity at 1 year after transplant, as demonstrated by the 6-minute walking distance (Standard: 474±132 m; Under: 525±114 m; Over: 399±81 m, P = 0.08). The incidence of CLAD per graft did not differ markedly among the groups (Standard: 17.4%; Under: 14.3%; Over: 20%, P = 0.87). The overall 5-year survival rate of LDLLT was 79%, and each group showed an excellent 5-year survival rate (Standard: 77%; Under: 74%; Over: 91%, P = 0.67). These novel LDLLT procedures may have resolved the critical size-matching problems between living-donor lobar lungs and recipients, demonstrating favorable post-transplant outcomes.

Increased Posttransplant Mortality for Autoimmune Hepatitis Compared With Other Autoimmune Liver Diseases.

We sought to compare posttransplant outcomes between autoimmune liver disease. Autoimmune liver diseases, namely primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), and autoimmune hepatitis (AIH) generally have favorable posttransplant outcomes. PSC is known to require more retransplantation compared with PBC, however, comparisons to AIH are lacking. We sought to compare graft survival and the need for retransplant in AIH compared with other autoimmune liver disease. We compared posttransplant graft survival among the 3 entities using Cox regression and competing for risk analyses using the United Network for Organ Sharing (UNOS) database. We found AIH is associated with significantly decreased graft survival compared with PBC [hazard ratio: 0.86; 95% confidence interval (CI): 0.77-0.96] and PSC (hazard ratio: 0.89; 95% CI: 0.8-0.99) after controlling for potential confounders. This is mainly driven by posttransplant death. On competing for risk analysis, AIH was associated with higher risk of death compared with PBC [subdistribution hazard ratio (SHR): 0.79; 95% CI: 0.7-0.89] and PSC (SHR: 0.72; 95% CI: 0.64-0.82) and lower risk of retransplant compared with PSC (SHR: 1.48; 95% CI: 1.19-1.8). As prior studies have shown the similar risk of disease recurrence in AIH and PSC, our study indicates at least part of the increased posttransplant mortality in AIH may be due lower retransplantation rate in this population.

The Systemic Metabolic Profile Early after Allogeneic Stem Cell Transplantation: Effects of Adequate Energy Support Administered through Enteral Feeding Tube.

Patients undergoing allogeneic stem cell transplantation usually require nutritional support. There is no consensus on whether enteral support through tube feeding should be preferred. A recent randomized study could not detect any difference between enteral and parenteral feeding with regard to post-transplant outcomes, whereas 2 retrospective studies described an association between enteral feeding and a favorable post-transplant outcome. We compared pre- and post-transplant plasma metabolomic profiles for 10 patients receiving mainly enteral nutritional support and 10 patients receiving mainly parenteral support. Samples were collected before conditioning and 3 weeks post-transplant; 824 metabolites were analyzed using mass spectrometry. The pretransplant metabolite profiles showed a significant overlap between the 2 groups. Post-transplant samples for both patient groups showed an increase of secondary bile acids and endocannabinoids, whereas reduced levels were seen for food preservatives, plasmalogens, and retinol metabolites. The main post-transplant differences between the groups were decreased levels of fatty acids and markers of mitochondrial activation in the control group, indicating that these patients had insufficient energy intake. A significant effect was also seen for heme/bilirubin metabolism for the parenteral support. To conclude, allotransplant recipients showed altered metabolic profiles early after transplantation; this was mainly due to the conditioning/transplantation/reconstitution, whereas the type of nutritional support had minor effects.

Predictors of Favorable Outcome in Patients Bridged to Transplant with Temporary Mechanical Circulatory Support Devices

Purpose Revisions to the US heart allocation system are expected to increase the number of patients bridged to transplant with temporary mechanical circulatory support (TMCS). However, the presence of TMCS at time of transplantation can lead to higher risk of post-transplant mortality. We sought to identify clinical variables associated with favorable post-transplant outcome in patients bridged to transplant with TMCS. Methods We examined data in the ISHLT Thoracic Transplant Registry. We included subjects transplanted between 2005 and 2016 with known use of MCS. Pre-transplant recipient, donor and transplant-specific variables were abstracted. The primary outcome was patient survival at 1 year post transplant in patients bridged with various types of MCS. Cox regression analyses were performed to identify predictors of survival and Cox regression coefficients were used to construct a patient survival calculator. Results There were 6,528 patients bridged to transplant with the following types of MCS: continuous flow LVAD (HeartMate II, HeartMate 3, HeartWare, Jarvik 2000; n=6,206), ECMO (n=134), percutaneous temporary LVAD (P-VAD: Impella 2.5, CP, 5.0, TandomHeart; n=75), surgically implanted temporary LVAD (T-LVAD: CentriMag LVAD; n=38) or BiVAD (T-BiVAD: CentriMag BiVAD; n=75). Kaplan Meier survival among the 5 subgroups is shown in Figure 1A. In a multivariable model, bridging with ECMO or P-VAD was associated with higher risk of mortality. Additional risk factors included older donor age, female/male donor-recipient match, older recipient age, higher recipient body mass index and higher recipient creatinine . We created a calculator that quantifies predicted patient survival at 1 year post-transplant based on donor and recipient characteristics at transplant (Figure 1B). Conclusion The calculator is a novel tool to assist providers in refining the selection of transplant candidates with TMCS with the hopes of improving post-transplant outcomes.

A Direct Heart-Transplantation Strategy in Selected Patients on Extra-Corporeal Membrane Oxygenation Achieved Favorable Post-Transplant Outcomes

Purpose To analyze post-heart transplantation (HTx) outcomes in selected patients on ECMO support. Our local strategy is to transplant ECMO-patients without mechanical ventilation or kidney failure (creatinine clearance ≤ 30 mL/min or dialysis). In addition, specific pre-transplant (intra-aortic balloon pump, reperfusion canula) and post-transplant strategies (maintaining ECMO after HTx) were applied. Methods We performed a restrospective study in a high ECMO and HTx volume center. We included all-consecutive patients with a first non-combined HTx performed between 2012 and 2016. We aimed to compare outcomes between patients with or without ECMO support at the time of HTx. The primary outcome was all-cause mortality after HTx. Secondary outcomes included death-censored rejection-free survival and complications of ECMO (infection, vascular complications). Risk factors for death were identified using Cox proportional hazard model. Results We analyzed 415 patients, including 118 patients (28.4%) under ECMO support at the time of HTx. Median follow-up post-transplant was 20.7 months. Median time on ECMO before HTx was 9 days (IQR = 5-15). Post-transplant survival in ECMO-patients was not significantly different from non-ECMO patients (see figure, p=0.12). In the overall cohort, only recipient age (HR = 1.22 per 10-year increment), recipient BMI (HR = 3.93 for BMI Conclusion A direct heart transplantation strategy in selected patients on ECMO support achieved favorable post-transplant outcomes.

Pre-heart transplantation ECMO support achieved favorable post-transplant outcomes in selected patients.

Pre-heart transplantation (HTx) ECMO support has been associated with poor short-term post-transplant outcomes. To analyze post-HTx outcomes in patients under ECMO support at our center. Our local strategy is to associate an intra-aortic ballon pump to ECMO, to maintain ECMO after HTx and to propose HTx to selected patients with “isolated cardiac failure” (without mechanical ventilation; creatinine clearance > 40 mL/min). We performed a restrospective single-center observational study. We included all consecutive patients with a first non-combined HTx performed at our center between 2012 and 2016. We aimed to compare outcomes between patients under ECMO support at the time of HTx to patients without. The primary outcome was all-cause mortality after HTx. Four hundred and fifteen patients met the inclusion criteria, including 118 patients (28.4%) under ECMO support at the time of HTx. Patients were mostly males (79%) and mean age was 50.8 ± 12.4 years. ECMO patients were younger but had a longer ischemic time compared to other patients. Median time under ECMO before HTx was 9 days (IQR = 5–15). Survival was similar between both groups (see Fig. 1 , 1 and 3 years survival was respectively 85 and 80% in the ECMO-group compared to 81 and 72% in the no-ECMO-group). Only recipient age (HR = 1.22 per 10-year increment), recipient BMI (HR = 3.93 for BMI < 18.5 compared to BMI 18.5 to 25 kg/m 2 ), creatinine clearance (HR = 2.35 for clearance between 30 and 60 mL/min; HR = 3.73 for clearance < 30 mL/min compared to clearance ≥ 90 mL/min) and ischemic time (HR = 1.03 per 1-hour increment) were independent risk factors for all-cause mortality. Rejection-free survival was comparable between groups. ECMO-related local wound infection was the most prevalent complication (37% of patients). HTx in selected patients under ECMO support at the time of transplantation achieved favorable outcomes in selected “isolated cardiac failure” patients.

Invited Commentary

Invited Commentary

P4222Pre-heart transplantation ECMO support achieved favorable post-transplant outcomes in selected patients

P4222Pre-heart transplantation ECMO support achieved favorable post-transplant outcomes in selected patients

Acute alcoholic hepatitis as indication for liver transplantation

Until recently, severe acute alcoholic hepatitis that is refractory to medical therapy was a disease with extremely high mortality and no viable treatment options. A landmark trial of early liver transplantation in highly selected patients demonstrated a clear survival benefit and favorable posttransplant outcomes. Since then, new findings regarding medical therapy for alcoholic hepatitis, outcomes of early transplant, and ethical considerations as well as public perception of this intervention have been published. Glucocorticoids remain the best initial medical therapy for severe acute alcoholic hepatitis, but liver transplantation can be an acceptable and effective therapy for those who fail to respond to steroids. Recurrence of harmful drinking is a valid concern, and has been observed in long-term follow-up of patients transplanted for alcoholic liver disease. Public perception of early liver transplant for severe acute alcoholic hepatitis is overall positive. Liver transplantation for refractory severe acute alcoholic hepatitis is a life-saving intervention and should be judiciously employed in highly selected individuals who are at low risk of recidivism.