High-volume Transplant Center Research Articles

IgA nephropathy recurrence after living donor kidney transplantation: a retrospective analysis of postoperative outcomes at a single high-volume transplant center

BackgroundIgA nephropathy (IgAN) is a common primary glomerulonephritis leading to end-stage renal disease. Living donor kidney transplantation (LDKT) is considered a favorable treatment option, but IgAN recurrence rates and the impact on outcome is unclear. In the present study, we retrospectively analyzed the rate of IgAN recurrence, risk factors and clinical outcomes in LDKT recipients.MethodsWe analyzed 193 adult patients who received a LDKT between 2011 and 2017 of which 32 (16.7%) had IgAN as underlying disease. Demographic data and clinical outcomes, especially regarding IgAN recurrence, were evaluated. Mean follow-up period was 102.13 months in the IgAN group vs. 97.27 months in the control group.ResultsAmong the IgAN cohort, five (15.63%) experienced IgAN recurrence. Patients with IgAN underwent LDKT at a significantly younger age (p < 0.001). No significant differences were observed in demographic factors, HLA-mismatches, or AB0-compatibility. Patients receiving an immunosuppressive regimen including Cyclosporine A (60% vs. 7.4%) instead of Tacrolimus (40% vs. 92.6%) were significantly more likely to develop IgAN recurrences (p < 0.001). Moreover, early post-surgery serum creatinine levels were higher in the recurrence group at one week (4.25 vs. 1.65 mg/dl; p < 0.001), one month (2.13 vs. 1.53 mg/dl; p = 0.027) and two years (2.65 vs. 1.34 mg/dl; p = 0.008). Although graft survival displayed a tendency towards inferior outcomes after recurrence, significance was not reached (p = 0.14, log-rank test).ConclusionLiving donor kidney transplantation continues to be recommended as the preferred treatment option for IgAN patients, despite the potential risk of recurrence and graft loss.

Long-term follow-up of kidney transplant recipients admitted to a tertiary care transplant center with SARS-CoV-2.

Kidney transplant recipients (KTR) are at risk of severe coronavirus disease 2019 (COVID-19) disease and mortality after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We predicted that hospitalization for COVID-19 and subsequent admission to the intensive care unit (ICU) would yield worse outcomes in KTRs. To investigate outcomes among KTRs hospitalized at our high-volume transplant center either on the general hospital floor or the ICU. We retrospectively describe all adult KTRs who were hospitalized at our center with their first SARS-CoV-2 infection between 04/2020 and 04/2022 and had at least 12 months follow-up (unless they experienced graft failure or death). The cohort was stratified by ICU admission. Outcomes of interest included risk factors for ICU admission and mortality, length of stay (LOS), respiratory symptoms at admission, all-cause graft failure at the last follow-up, and death related to COVID-19. 96 KTRs were hospitalized for SARS-COV-2 infection. 21 (22%) required ICU admission. The ICU group had longer hospital LOS (21.8 vs 8.6 days, P < 0.001) and were more likely to experience graft failure (81% vs 31%, P < 0.001). Of those admitted to the ICU, 76% had death at last-follow up, and 71% had death related to COVID-19. Risk factors for ICU admission included male sex (aHR: 3.11, 95%CI: 1.04-9.34; P = 0.04). Risk factors for all-cause mortality and COVID-19-related mortality included ICU admission and advanced age at SARS-CoV-2 diagnosis. Mortality was highest within a month of COVID-19 diagnosis, with the ICU group having increased risk of all-cause (aHR: 11.2, 95%CI: 5.11-24.5; P < 0.001) and COVID-19-related mortality (aHR: 27.2, 95%CI: 8.69-84.9; P < 0.001). ICU admission conferred an increased risk of mortality, graft failure, and longer LOS. One-fifth of those hospitalized died of COVID-19, reflecting the impact of COVID-19-related morbidity and mortality among KTRs.

Postoperative Delirium Screening Characteristics in Pediatric Intestinal, Liver, and Renal Transplant Recipients: Single-Center Retrospective Cohort Study.

To describe and compare the results of delirium screening in the immediate post-transplant PICU admission for pediatric intestinal, liver, and renal transplant recipients. We also examined associations with known and suspected risk factors for pediatric delirium (PD). Retrospective analysis of a single-center cohort, 2016-2022. Twenty-four-bed PICU in a high-volume transplant center. All intestinal, liver, and renal transplant recipients under 23 years old admitted between July 2016 and August 2022. We identified 211 pediatric transplant recipients: intestinal (n = 36), liver (n = 78), and renal (n = 97). Results of the Cornell Assessment for PD during the immediate post-transplant PICU admission were reviewed and patients were categorized into screen positive, screen negative, and unscreened. Corresponding data on known and suspected risk factors for PD were also collected. Data on delirium subtypes were not collected. Screens were available for 156 of 211 patients (74%) who were included in the final analysis. The prevalence of a positive screen by transplant category was: intestine 80% (24/30), liver 75% (47/63), and renal 14% (9/63). A positive screen was associated with younger age, greater duration of mechanical ventilation, and greater PICU length of stay (LOS) in bivariate analysis. In multivariable analysis, age and PICU LOS remained strongly correlated with a positive screen (p < 0.05). Deep sedation and agitation as categorized by the State Behavioral Scale was associated with a positive screen, as was significant iatrogenic withdrawal symptoms (p < 0.05). Most patients screened positive by post-transplant days 2 and 3 (58/80 [72%] and 64/80 [80%], respectively). In our 2016 to 2022 experience, we found a high prevalence of positive PD screens in pediatric intestinal and liver transplant recipients in the immediate post-transplant PICU admission. A positive screen was associated with younger age and greater PICU LOS.

Mismatched Postsurgical Opioid Prescription to Liver Transplant Patients: A Retrospective Cohort Study From a Single High-volume Transplant Center.

Improper opioid prescription after surgery is a well-documented iatrogenic contributor to the current opioid epidemic in North America. In fact, opioids are known to be overprescribed to liver transplant patients, and liver transplant patients with high doses or prolonged postsurgical opioid use have higher risks of graft failure and death. This is a retrospective cohort study of 552 opioid-naive patients undergoing liver transplant at an academic center between 2012 and 2019. The primary outcome was the discrepancy between the prescribed discharge opioid daily dose and each patient's own inpatient opioid consumption 24 h before discharge. Variables were analyzed with Wilcoxon and chi-square tests and logistic regression. Opioids were overprescribed in 65.9% of patients, and 54.3% of patients who required no opioids the day before discharge were discharged with opioid prescriptions. In contrast, opioids were underprescribed in 13.4% of patients, among whom 27.0% consumed inpatient opioids but received no discharge opioid prescription. The median prescribed opioid daily dose was 333.3% and 56.3% of the median inpatient opioid daily dose in opioid overprescribed and underprescribed patients, respectively. Importantly, opioid underprescribed patients had higher rates of opioid refill 1 to 30 and 31 to 90 d after discharge, and the rate of opioid underprescription more than doubled from 2016 to 2019. Opioids are both over- and underprescribed to liver transplant patients, and opioid underprescribed patients had higher rates of opioid refill. Therefore, we proposed to prescribe discharge opioid prescriptions based on liver transplant patients' inpatient opioid consumption to provide patient-centered opioid prescriptions.

Small and large bowel anatomy is associated with enteral autonomy in infants with short bowel syndrome: A retrospective cohort study.

Achievement of enteral autonomy (EA) is the ultimate treatment goal in pediatric intestinal failure (IF). We aimed to assess predictors of EA in pediatric short bowel syndrome (SBS) and explore the impact of residual small bowel (SB) and large bowel (LB) length on EA. A retrospective cohort study was performed on infants aged <12 months (n = 367, six centers) with SBS referred between 2010 and 2015. The cohort was stratified based on the achievement of EA. Statistical testing was completed using t-test, chi-square, Cox proportional hazards regression model, and Kaplan-Meier analysis. EA was achieved in 229 patients. In the multivariable analysis, the percentage of residual LB (hazard ratio [HR] = 1.02; 95% CI = 1.01-1.02) and SB (HR = 1.01; 95% CI = 1.01-1.02) length, presence of the ileocecal valve (HR = 2.02; 95% CI=1.41-2.88), and not coming from a high-volume transplantation center (HR = 2.42; 95% CI = 1.68-3.49) were positively associated with EA, whereas a negative association was seen with the presence of stoma at the time when shortest remnant was documented (HR = 0.72; 95% CI = 0.52-1.00). EA achievement was significantly different between the anatomical subgroups (log-rank test P < 0.001) with an EA rate of 80.4% in infants with ≥50% SB and LB (median time 209 days); 62.5% with ≥50% SB and <50% LB (397 days); 58.3% with <50% SB and ≥50% LB (1192 days), and 25.9% with <50% SB and LB. Necrotizing enterocolitis (NEC) was not associated with a better achievement of EA (NEC vs other etiologies: log-rank test P = 0.33). Overall, 62% of infants with IF secondary to SBS achieved EA over a mean time of follow-up of 2.3 years. A colon length of >50% can compensate for the loss of small bowel (<50%) and account for similar EA rates as those in children with residual SB > 50%.

Outcomes after intestinal re-transplant: A detailed, single-center analysis of clinical and technical factors

BackgroundIntestinal transplantation (ITx) has evolved into a viable option for patients suffering from intestinal failure (IF). As graft and patient survival increase, we enter a new era where re-transplantation (re-ITx) is increasingly considered. Re-ITx grafts historically are less successful than their primary counterpart. While re-ITx is challenging for the obvious reasons of a re-do operation, there are potentially modifiable pre-transplant clinical and technical factors which are not yet understood. MethodsWe conducted an in-depth review of our re-ITx experience at a high volume transplant center, and describe unique predictors associated with improved outcomes. ResultsThere were 132 primary ITx performed from 1991-2021; 44 primary ITx failed (33%) and of those, 25 (56%) were re-transplanted within the time of this retrospective review. The median time to re-ITx was 13 months (5 days–6 years). I-ITx recipients were more commonly re-transplanted with liver-inclusive grafts (64%). Re-ITx recipients were more often male (p=0.05), had positive crossmatch (p=0.01), PRA>20% (p=0.03), and underwent ATG-induction (p=0.00). The mean graft survival in months in primary ITx was 74.0 (0.0 - 303.2) and in re-ITx was 60.0 (0.0 - 155.83) (p=0.37). The leading indication for re-ITx was ACR of the primary graft (64%). Successful re-ITx (graft survival >1 year) was significantly associated with ATG-induction (p=0.003). Liver-inclusive grafts demonstrated increased 1-year survival compared with liver-free grafts, but not significantly (primary ITx: 72% vs 55%; re-ITx: 75% vs 57%). Enterectomy of the primary graft prior to re-ITx appeared to increase overall graft survival after re-ITx, but not significantly (70 vs 40 months, p=0.17). Enterocolonic continuity was associated with overall longer graft survival after re-ITx (95 vs 40 months, p=0.03). ConclusionWe demonstrate several factors to consider when evaluating patients for re-ITx, a multicenter study is needed to understand how patient selection, clinical management, and technical modifications can improve outcomes after re-ITx.

Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes.

This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center. This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders. The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity. SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.

Safety attitudes culture remain stable in a transplant center: evidence from the coronavirus pandemic.

We sought to understand how safety culture may evolve during disruption, by using the COVID-19 pandemic as an example, to identify vulnerabilities in the system that could impact patient outcomes. A cross-sectional analysis of transplant personnel at a high-volume transplant center was conducted using the Safety Attitudes Questionnaire (SAQ). Survey responses were scaled and evaluated pre- and post-COVID-19 (2019 and 2021). Two-hundred and thirty-eight responses were collected (134 pre-pandemic and 104 post-pandemic). Represented organ groups included: kidney (N = 89;38%), heart (N = 18;8%), liver (N = 54;23%), multiple (N = 66;28%), and other (N = 10;4%). Responders primarily included nurses (N = 75;34%), administration (N = 50;23%), and physicians (N = 24;11%). Workers had high safety, job satisfaction, stress recognition, and working conditions satisfaction (score >75) both before and after the pandemic with overlapping responses across both timepoints. Stress recognition, safety, and working conditions improved post-COVID-19, but teamwork, job satisfaction, and perceptions of management were somewhat negatively impacted (all p > 0.05). Despite the serious health care disruptions induced by the pandemic, high domain ratings were notable and largely maintained in a high-volume transplant center. The SAQ is a valuable tool for healthcare units and can be used in longitudinal assessments of transplant culture of safety as a component of quality assurance and performance improvement initiatives.

Expanded Criteria Donor Heart Allograft Utilization: National Trends and Outcomes

BackgroundTo examine recent trends in the use of expanded criteria donor organs in heart transplantation, this study assessed center-level variation in acceptance of these allografts and analyzed their posttransplantation outcomes. MethodsAdult (aged ≥18 years) heart transplant recipients between 2011 and 2022 were identified in the Organ Procurement and Transplantation Network database. Expanded criteria allografts were defined using a previously validated risk score. After stratifying centers by cumulative transplantation volume, those centers in the top tertile (≥23/year) were considered high volume. Subsequently, the ratio of transplantations using expanded criteria allografts to total transplantations was calculated for each high-volume center. On the basis of tertiles, centers were then categorized as high-, medium-, and low-use centers. The primary outcome was death after transplantation. ResultsOf 23,290 transplantations performed, 5017 (22%) used expanded criteria donor allografts. High-volume heart transplantation centers performed 72% (3628) of these transplantations—1183 (75%) between 2011 and 2014, 1383 (73%) between 2015 and October 2018, and 1062 (68%) between November 2018 and June 2021. Compared with low-volume programs, undergoing expanded criteria heart transplantation at high-volume centers was associated with a significantly reduced hazard of mortality at 1 year (hazard ratio, 0.78; CI, 0.65-0.94; P = .01) and 5 years (hazard ratio, 0.85; CI, 0.75-0.98; P = .02). During the study period, survival rates 1 year after transplantation were similar across high-volume centers, regardless of their use of expanded criteria allografts. ConclusionsUndergoing heart transplantation with an expanded criteria donor allograft at a high-volume transplantation center provides a significant survival benefit. Further, the use of more expanded criteria criteria organs, in the right clinical settings, does not negatively affect overall patient outcomes at high-volume centers.

Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers.

Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed. RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models. The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience. RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy.

We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes. This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications. Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area. The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

Where to Draw the Line in Ex-Situ Split Liver Transplantation for Adult Recipients? – A Benchmarking Analysis

Abstract Background A comprehensive outcome analysis of ex situ right split liver graft transplantation (RSLT) is currently lacking. Aims Benchmarking outcomes of RSLT against best achievable results from whole LT offers a novel comparative approach. Methods This retrospective study includes all consecutive ex-situ RSLT for adult recipients performed from 2014-2019 at 4 high volume transplant centers (&amp;gt;70 LT/year). Outcomes including overall morbidity expressed by the comprehensive complication index (CCI) and graft related complications were compared to the published benchmark cutoffs for whole graft LT. Results We included 129 ex-situ RSLT with 76% H45678 (n=98) and 24% (n=31) H5678 grafts. The median follow-up was 4.8 years. Overall and severe 1-year morbidity expressed by the CCI were within established whole graft LT benchmarks. Biliary complication rates were slightly higher than the benchmark due to the occurrence of cut-surface leaks. The arterial thrombosis rate was outside the benchmark cutoff (7% vs ≤4.4%) leading to a higher retransplantation rate. However, overall 1-year graft and recipient mortality were well within the benchmark cutoffs, resulting in a 5-year overall recipient survival of 88.5%. Selecting benchmark cases for RSLT defined by low-risk recipient-donor criteria including static cold storage time ≤10h and recipient MELD≤20 points, did not significantly reduce overall morbidity nor arterial complication rate. In contrast, the type of split graft (H45678 vs.H5678) did impact on both arterial and biliary complications. Conclusions This large multicenter series of ex-situ right split grafts disclosed an overall 1-year morbi-mortality comparable to the best achievable results in whole graft LT. The results show that the main morbidity burden in adult RSLT is related to technical criteria rather than graft-recipient matching.

Clonal hematopoiesis of indeterminate potential and outcomes after heart transplantation: A multicenter study

Cardiac allograft vasculopathy (CAV) is a leading cause of late graft failure and mortality after heart transplantation (HT). Sharing some features with atherosclerosis, CAV results in diffuse narrowing of the epicardial coronaries and microvasculature, with consequent graft ischemia. Recently, clonal hematopoiesis of indeterminate potential (CHIP) has emerged as a risk factor for cardiovascular disease and mortality. We aimed to investigate the relationship between CHIP and posttransplant outcomes, including CAV. We analyzed 479 HT recipients with stored DNA samples at 2 high-volume transplant centers, Vanderbilt University Medical Center and Columbia University Irving Medical Center. We explored the association between the presence of CHIP mutations with CAV and mortality after HT. In this case-control analysis, carriers of CHIP mutations were not at increased risk of CAV or mortality after HT. In a large multicenter genomics study of the heart transplant population, the presence of CHIP mutations was not associated with an increased risk of CAV or posttransplant mortality.

Utilization of the emergency department by kidney transplant recipients: a retrospective cohort study from a high-volume transplant center.

This retrospective cohort study targeted patients who underwent renal transplantation at a high-volume transplant centre from 2016 to 2020. The main outcomes of the study were ED visits within 30 days, 31-90 days, 91-180 days, and 181-365 days of transplantation. This study included 348 patients. The median (interquartile range) age of patients was 45.0 years (30.8, 58.2). Over half of the patients were male (57.2%). There was a total of 743 ED visits during the first year after discharge. 19% (n=66) were considered high-frequency users. High-volume ED users tended to be admitted more frequently as compared to those with low frequencies of ED visits (65.2% vs. 31.2%, respectively, P<0.001). As evident by the large number of ED visits, suitable coordination of management through the ED remains a pivotal component of post-transplant care. Strategies addressing prevention of complications of surgical procedures or medical care and infection control are aspects with potential for enhancement.

Do Center-specific Factors Impact Utilization of Organs From COVID-positive Donors in the United States?

Utilization of organs from coronavirus disease 2019–positive (COVID+) donors for solid organ transplantation remains variable across various centers in the United States.1 Despite the good quality of available organs from COVID+ donors and no known transmission of severe acute respiratory syndrome coronavirus 2 to the recipient,1 factors associated with utilization of these organs remain poorly defined. The aim of our study was to investigate the correlation between a transplant center’s use of organs from COVID+ donors, its transplant volume, and its use of hepatitis C virus–positive (HCV+) organs. Retrospective analysis using the United Network of Organ Sharing database between January 2020 to March 2022 was performed. Adult deceased donors for kidney, liver, and heart transplants were included and further separated into COVID–nucleic acid amplification test (NAT) positive (COVID+), COVID-NAT negative (COVID–), HCV-NAT positive (HCV+), and HCV-NAT negative (HCV–) groups. The estimated annual transplant volume (eVolume) was calculated: {12*(total transplants between January-2020 to March-2022)/27}. Centers with eVolume <5 were excluded. Linear regression analysis was performed to evaluate the association between transplants from COVID+ and HCV+ organs and eVolume. A P value of <0.05 was defined as statistically significant. A total of 248 centers that performed 234 kidney, 130 liver, and 131 heart transplants were included in the study. Solid organ transplantation from COVID+ donors was performed in 139 centers (overall 56%), kidney 121 (51.7%), liver 75 (57.7%), and heart 44 (33.6%). A positive association (P < 0.001) was seen between utilization of organs from COVID+ donors and center’s transplant volume as well as utilization of HCV+ organs (Figure 1; Table S1, SDC, https://links.lww.com/TXD/A508; Figures S1 and S2, SDC,https://links.lww.com/TXD/A508). Our results show that transplant centers that used organs from COVID+ donor were less likely to be low-volume centers and were more likely to use organs from HCV+ donors.FIGURE 1.: Correlation between transplant center’s use of organs from COVID-19 positive donors, its transplant volume, and its use of HCV+ organs in the UNOS region: (A) all organs, (B) kidney, (C) liver, and (D) heart. Size of bubble indicates the volume of transplant. UNOS regions are color coded (region 1–11). COVID-19, coronavirus disease 2019; HCV, hepatitis C virus; UNOS, United Network of Organ Sharing.There is a regional and center-wide variation in utilization of organs from various extended-criteria donors, including those with increased infectious risk such as HCV, hepatitis B, concurrent bacterial infections, and now COVID-19.1,2 This variation is likely multifactorial based on waitlist size, organ shortage, waiting times, organ availability, transplant center competition, experience of the transplant team, changes in organ allocation systems, and “risk averseness” of the transplant program.3 Besides these factors, utilization of organs from increased-risk donors requires a strong, team-oriented, multidisciplinary approach along with readily available resources for the pursuit of therapeutics and diagnostics for a novel infectious cause. A high-volume transplant center has been shown to be associated with improved risk-adjusted outcomes across various transplant types.4,5 An increase in baseline success of such a transplant center, along with the local geographic and population-based challenges, often alters the risk–benefit analysis of pursing an individual transplant. This may allow for such centers to be more “aggressive” and accumulate additional experience regarding outcomes in higher-risk recipients or utilization of otherwise increased-risk donors. A significant correlation between utilization of organs from HCV+ and COVID+ donors of a center highlights the existing regional and center-wide variation in transplant practices. Further identification of factors leading to these disparities will help expand the donor pool by decreasing the discard rate and by increasing the safe utilization of organs from COVID+ donors.

The impact of the United Network of Organ Sharing allocation change on waitlist trajectories of inpatients listed with inotropic support: A single-center analysis.

In the United Network of Organ Sharing (UNOS) allocation scheme prior to October 18, 2018, heart transplant (HTx) candidates with extracorporeal membrane oxygenation (ECMO), temporary mechanical circulatory support (MCS), or pulmonary artery (PA) catheter inotropic support all received Status 1A priority. In revised scheme, patients with PA catheter and inotropic support are Status 3 after those on ECMO (Status 1) or temporary MCS (Status 2). We examined the impact of the allocation change on HTx candidates listed Status 1A versus Status 3 at a high-volume transplant center. Between January 2017 and January 2021, 75 patients were listed with a PA catheter and inotropic support prior to the allocation change (Era 1) and 48 were listed after (Era 2). Clinical characteristics and outcomes were compared for these 123 patients. Heart transplant (HTx) candidates in Era 2 had higher median inotrope doses at listing. There was no significant difference in inpatient wait list days (12vs. 20 days, P=.15), transition to temporary MCS (33.3%vs. 22.7%, P=.15), or wait list mortality (6.3%vs. 4.0%, P=.68). There was also no significant difference in survival to transplantation (91.7%vs. 94.7%, P=.71). There were no differences in post-transplant outcomes including 1-year survival (88.6%vs. 93.0%, P=.38). At a high-volume transplant center, the UNOS allocation change did not result in increased wait list time, use of temporary MCS, or mortality on the waitlist or post-transplant for candidates on inotropic support with continuous hemodynamic monitoring.

Deceased donor liver transplantation under Korean MELD score-based liver allocation system at a high-volume transplantation center

Deceased donor liver transplantation under Korean MELD score-based liver allocation system at a high-volume transplantation center

S1307 Provider Perceptions of Code Status for Patients With End-Stage Liver Disease

Introduction: Liver transplantation (LT) is the only curative option for patients with end-stage liver disease (ESLD). Patients with ESLD have high rates of in-hospital mortality and low rates of survival to hospital discharge after in-hospital CPR. As ESLD is one of the few diseases where patients are close to death but also to a total cure, some studies suggest that LT listing and hospice referral should not be mutually exclusive. While many centers require that a patient be “full code” for LT listing or evaluation, this is not a United Network for Organ Sharing (UNOS) mandate. This study aims to assess LT providers’ awareness of organizational policies and their perspectives on code status requirement, with the eventual goal of providing patients with goal-concordant care while balancing the need of ethical solid organ allocation for transplant. Methods: Healthcare providers involved in the LT evaluation process at a high-volume transplant center anonymously completed a 13-question survey. Provider specialties are shown in Table. Answers were displayed using descriptive statistics. Results: Out of 83 providers who filled out the survey, 40% reported that they either often or always discussed code status with patients, often in a hospital setting. 62% were unaware of the institutional protocol that patients had to be full code for LT evaluation or listing, and 95% were unaware that UNOS did not have a full code requirement for the LT process. 93% of participants felt that patients undergoing LT evaluation should discuss code status. 15% felt that patients should remain full code throughout, 54% felt that patient should have their choice of code status during LT evaluation and listing, and 31% felt that patients should have their choice during evaluation but become full code once listed. Conclusion: These results show a need for increased educational initiatives among providers involved in the LT process, as there is a lack of knowledge among providers regarding policy on code status. Among the subset who was aware of a protocol, knowledge of the actual requirements varied. While most providers believe that a discussion regarding code status is necessary for patients who wish to undergo LT, there was a diverse range of opinions on code status requirement throughout the LT evaluation and listing process. Initiatives to further the dialogue of code status and advanced care planning in a high mortality patient population are needed. Table 1. - Description of Survey Respondents Role on LT team Number of Respondents Gastroenterology/Hepatology Attending 6 Critical Care Attending 5 Transplant Surgeon 3 Palliative Medicine Attending 3 Gastroenterology Fellow 9 Internal Medicine Resident 32 Advanced Practice Provider 14 Transplant Coordinator 6 Transplant Selection Committee 1 Social Worker 1 Other 3

Techniques of hepatic arterial reconstruction in liver transplantation.

Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field. In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call "one stay corner suture technique". We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the "one stay corner suture technique" can be easily applied in centers that perform LDLT.

Novel Benchmark Values for Redo Liver Transplantation: Does the Outcome Justify the Effort?

To define benchmark cutoffs for redo liver transplantation (redo-LT). In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT. We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers. Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks. This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources.