Donor Liver Transplant Recipients Research Articles

Outcomes of Living Donor Liver Transplantation in Recipients Colonized with Carbapenem-Resistant Enterobacterales

Outcomes of Living Donor Liver Transplantation in Recipients Colonized with Carbapenem-Resistant Enterobacterales

#2741 The interplay between donor & recipient factors, outcomes, and transplant artery flow volume as measured by phase-contrast magnetic resonance imaging

Abstract Background and Aims Cardiovascular health and kidney transplant health are inter-connected [1]. Phase-contrast magnetic resonance imaging (PC-MRI) is a non-invasive means of quantifying blood flow volume within vasculature. Its utility for the assessment of blood flow volumes within the transplant renal artery has not been explored. The aims of this study were to determine if: (A) flow in the transplant artery is influenced by donor and recipients factors, (B) flow in the transplant artery is related to or influences clinical outcomes for transplant recipients. Method Analysis of PC-MRI sequences obtained during 218 kidney transplant magnetic resonance angiograms (MRA) performed at a single centre between 2019 and 2021 was undertaken. All scans were clinically indicated and requested by clinicians to investigate for transplant renal artery stenosis (TRAS). Baseline clinical and demographic data and subsequent clinical outcome data were collected for all study participants. Median follow up was 49 (IQR 40–54) months. For Kaplan-Meier survival analyses, comparison of clinical outcomes by interquartile range of flow volumes was performed, whereby quartile one comprised subjects with the lowest transplant artery blood flow volumes. Statistical analysis was performed using MedCalc Statistical Software version 22.013. Results In this study of 218 subjects, 49 (22.4%) had features of possible TRAS identified on initial MRA. TRAS was subsequently confirmed via intra-arterial digital subtraction angiography in 19 (8.7%) cases. The majority of participants were male 150/218 (68.8%). The commonest cause of ESKD was diabetic kidney disease at 71/218 (32.6%). Living donor transplant recipients were 35/218 (11.5%) of the study population. The median donor age was 55 (IQR 44–65) years. The median time from ESKD to transplantation was 25 (IQR 9–53) months. The median time from transplantation to PC-MRI for all participants was 322 (IQR 81–1744) days; for participants who were ultimately diagnosed with TRAS it was 169 (IQR 76–262) days. The median age of recipients at time of PC-MRI was 56 (IQR 45–64) years. Overall, the mean transplant artery flow volume was 0.41 L/min (95% CI 0.39–0.45 L/min). Rank correlation between age of donor and flow in the transplant artery (L/min) showed r = −0.25 (95% CI −0.37 - −0.12) P = 0.0002. Rank correlation between age of recipient at time of PC-MRI and flow in the transplant artery (L/min) showed r = −0.37 (95% CI −0.48 to −0.25) P ≤ 0.0001. Rank correlation between flow in the transplant artery (L/min) and estimated glomerular filtration rate (mL/min/1.73 m2) showed r = 0.43 (95% CI 0.31–0.53) P < 0.0001. Univariable linear regression analysis of flow in the transplant artery (L/min) and estimated glomerular filtration rate (mL/min/1.73 m2) was R2 0.14, DF regression = 1 DF residual = 214, F = 34.7, P < 0.0001 (Fig. 1). Overall, 35 (16.1%) participants experienced kidney transplant failure and 42 (19.3%) participants died within the study follow up period. Kaplan-Meier analysis showed no significant difference in kidney transplant survival between four groups categorized according to transplant artery flow volumes, logrank test P = 0.93 (Fig. 2A). Subjects in the first quartile were at greater risk of death, logrank test P = 0.01, HR 4.36 (95% CI 1.77–10.74) compared with fourth quartile (Fig. 2B) Conclusion This study has demonstrated that both older donor age and older recipient age negatively correlate with transplant artery flow, and that transplant artery flow is positively correlated and predicts estimated glomerular filtration rate. Finally, recipients with low transplant artery flow volume are at greater risk of death. Neither cause nor effect of low blood flow volume have been elucidated in this study. However, improving transplant blood flow by optimising cardiovascular health may have a positive impact on outcomes for people with kidney transplants and warrants further study.

A2/A2B to B deceased donor kidney transplantation in the Kidney Allocation System era

Kidney transplantation from blood type A2/A2B donors to type B recipients (A2→B) has increased dramatically under the current Kidney Allocation System (KAS). Among living donor transplant recipients, A2-incompatible transplants are associated with an increased risk of all-cause and death-censored graft failure. In light of this, we used data from the Scientific Registry of Transplant Recipients from December 2014 until June 2022 to evaluate the association between A2→B listing and time to deceased donor kidney transplantation (DDKT) and post-DDKT outcomes for A2→B recipients. Among 53 409 type B waitlist registrants, only 12.6% were listed as eligible to accept A2→B offers ("A2-eligible"). The rates of DDKT at 1-, 3-, and 5-years were 32.1%, 61.4%, and 72.1% among A2-eligible candidates and 14.1%, 29.9%, and 44.1% among A2-ineligible candidates, with the former experiencing a 133% higher rate of DDKT (Cox weighted hazard ratio (wHR) = 2.192.332.47; P < .001). The 7-year adjusted mortality was comparable between A2→B and B-ABOc (type B/O donors to B recipients) recipients (wHR 0.780.941.13, P = .5). Moreover, there was no difference between A2→B vs B-ABOc DDKT recipients with regards to death-censored graft failure (wHR 0.771.001.29, P > .9) or all-cause graft loss (wHR 0.820.961.12, P = .6). Following its broader adoption since the implementation of the kidney allocation system, A2→B DDKT appears to be a safe and effective transplant modality for eligible candidates. As such, A2→B listing for eligible type B candidates should be expanded.

Center use of technical variant grafts varies widely and impacts pediatric liver transplant waitlist and recipient outcomes in the United States.

To assess the impact of technical variant grafts (TVGs) [including living donor (LD) and deceased donor split/partial grafts] on waitlist (WL) and transplant outcomes for pediatric liver transplant (LT) candidates, we performed a retrospective analysis of Organ Procurement and Transplantation Network (OPTN) data on first-time LT or liver-kidney pediatric candidates listed at centers that performed >10 LTs during the study period, 2004-2020. Center variance was plotted for LT volume, TVG usage, and survival. A composite center metric of TVG usage and WL mortality was developed to demonstrate the existing variation and potential for improvement. Sixty-four centers performed 7842 LTs; 657 children died on the WL. Proportions of WL mortality by center ranged from 0% to 31% and those of TVG usage from 0% to 76%. Higher TVG usage, from deceased donor or LD, independently or in combination, significantly correlated with lower WL mortality. In multivariable analyses, death from listing was significantly lower with increased center TVG usage (HR = 0.611, CI: 0.40-0.92) and LT volume (HR = 0.995, CI: 0.99-1.0). Recipients of LD transplants (HR = 0.637, CI: 0.51-0.79) had significantly increased survival from transplant compared with other graft types, and recipients of deceased donor TVGs (HR = 1.066, CI: 0.93-1.22) had statistically similar outcomes compared with whole graft recipients. Increased TVG utilization may decrease WL mortality in the US. Hence, policy and training to increase TVG usage, availability, and expertise are critical.

OPTN/SRTR 2021 Annual Data Report: Kidney

The year 2021 marked both successes and challenges for the field of kidney transplantation, in the context of the ongoing COVID-19 pandemic and broader geographic organ distribution. The total number of kidney transplants in the United States reached a record count of 25,487, driven by growth in deceased donor kidney transplants. The total number of candidates listed for deceased donor kidney transplant rose slightly in 2021 but remained below 2019 listing levels, with nearly 10% of candidates having been waiting 5 years or longer. Pretransplant mortality declined slightly among candidates of Black, Hispanic, and other races, in parallel with increasing numbers of Black and Hispanic transplant recipients. In the context of broader organ sharing, there is growing disparity in pretransplant mortality among non-metropolitan compared with metropolitan residents. The proportion of deceased donor kidneys recovered but not used for transplant (nonuse rate) rose to a high of 24.6% overall, with greater nonuse among biopsied kidneys (35.9%), kidneys from donors aged 55 years or older (51.1%), and kidneys with kidney donor profile index (KDPI) of 85% or greater (66.6%). Nonuse of kidneys from donors who are hepatitis C virus (HCV) anti-body positive only slightly exceeded that of HCV antibody–negative donors. Disparities in access to living donor kidney transplant persists, especially for non-White and publicly insured patients. Delayed graft function continues an upward trend and occurred in 24% of adult kidney transplants in 2021. Five-year graft survival after living compared with deceased donor transplant was 88.6% versus 80.7% for recipients aged 18-34 years, and 82.1% versus 68.0% for recipients aged 65 years or older. The total number of pediatric kidney transplants performed increased to 820 in 2021, the highest number since 2010. Despite numerous efforts, living donor kidney transplant remains low among pediatric recipients, with continued racial disparities. The rate of deceased donor transplants among pediatric candidates recovered in 2021 from a low in 2020. Congenital anomalies of the kidney and urinary tract remain the leading primary kidney disease diagnosis among pediatric candidates. Most pediatric deceased donor recipients receive a kidney from a donor with KDPI less than 35%. Graft survival continues to improve, with superior outcomes for living donor transplant recipients.

HLA-DQ Mismatches Lead to More Unacceptable Antigens, Greater Sensitization, and Increased Disparities in Repeat Transplant Candidates.

In single-center studies, HLA-DQ mismatches stimulate the most pathogenic donor-specific antibodies. However, because of limitations of transplant registries, this cannot be directly confirmed with registry-based analyses. We evaluated patients in the Scientific Registry of Transplant Recipients who were relisted after renal graft failure with new, unacceptable antigens corresponding to the HLA typing of their previous donor (UA-PD) as a proxy for donor-specific antibodies. Linear regression was applied to estimate the effects of HLA mismatches on UA-PD and the effects of UA-PD on calculated panel reactive antibody (cPRA) values for 4867 kidney recipients from 2010 to 2021. Each additional HLA-DQ mismatch increased the probability of UA-PD by 25.2% among deceased donor transplant recipients and by 28.9% among living donor transplant recipients, significantly more than all other HLA loci (P<0.05). HLA-DQ UA-PD increased cPRA by 29.0% in living donor transplant recipients and by 23.5% in deceased donor transplant recipients, significantly more than all loci except for HLA-A in deceased donor transplant recipients (23.1%). African American deceased donor transplant recipients were significantly more likely than Hispanic and White recipients to develop HLA-DQ UA-PD; among living donor transplant recipients, African American or Hispanic recipients were significantly more likely to do so compared with White recipients. Models evaluating interactions between HLA-DR/DQ mismatches revealed largely independent effects of HLA-DQ mismatches on HLA-DQ UA-PD. HLA-DQ mismatches had the strongest associations with UA-PD, an effect that was greatest in African American and Hispanic recipients. cPRA increases with HLA-DQ UA-PD were equivalent or larger than any other HLA locus. This suggests a need to consider the effects of HLA-DQ in kidney allocation.

P8.012: The Impact of a Positive B-Cell Flow Crossmatch in Living Donor Renal Transplant Recipients

Background: The aim of this study is to determine the incidence of early acute rejection and graft outcomes in living donor renal transplants with an isolated positive B-Cell Flow-Cytometry Crossmatch (B-FCXM). Methods: We performed a retrospective analysis of graft outcomes in 152 adults who received living donor renal transplants between January 2019 and March 2021 at Mount Sinai Hospital in New York CIty. Pre-transplant histocompatibility was assessed with flow cytometric crossmatch (FCXM) and Luminex single-antigen beads. Positive B- FCXM is was defined as median channel shift of ≥ 40. A mean fluorescence intensity (MFI) ≥ 1400 defined positive donor-specific HLA Class I and/or II antibody (DSA). Most patients received induction immunosuppression consisting of rabbit anti-thymocyte globulin, steroids and intravenous immunoglobulin. Estimated glomerular filtration rate (eGFR) and biopsy-proven rejection at six months’ post-transplant were compared between patients with and without a positive B-FCXM, and positive and negative DSA. Results: Of 152 patients, 89 (59%) were males and 63 (41%) females; the mean age was 44 years (SD ± 13.8). 45 donor B-FCXMs (30%) were positive and 107 (70%) were negative. 42 (28%) positive donor B-FCXM had no DSA and 3 (2%) had DSA. 91 (85%) negative donor B-FCXMs did not have DSA, and 16 (15%) had DSA. Thirty-six (80%) out of 45 patients with positive donor B-FCXM, including the 3 patients with DSA, received intravenous-immunoglobulin (IVIG) as part of induction immunosuppression. None of the patients with both positive donor B-FCXM and DSA had rejection. eGFR and rejection rate at 6 months were similar between patients with positive and negative donor B-FCXM [median 58.9 (IQR= 50.2-70.8) vs 57.6 (48.8-76.6), p=0.88; 6.8% vs 5.6%, p=0.7, respectively]. Comparison by combination of donor B-FCXM and DSA status (B-FCXM- DSA-, B-FCXM- DSA+, B-FCXM+ DSA-, B-FCXM+ DSA+) did not show statistically significant differences in eGFR or rejection rate at 6 months [median 57.4 (IQR= 48.5-74.3) vs 59.3 (52.6-83.3) vs 58.2 (50.1-70.8) vs 76.6 (58.3-102.5) p=0.4; 3.3% vs 18.7% vs 7.3% vs 0% p=0.09, respectively]. Conclusion: In our cohort, there was no statistical difference in early acute rejection and graft function at 6 months between living donor transplant recipients with positive and negative donor B-FCXM even after accounting for DSA status. Peri-transplant treatment with IVIG for a positive donor B-FCXM might be a helpful adjunct in this setting.

401.1: Impact of HLA-A,B DR and DQ on Living Kidney Transplant Outcomes in the Tacrolimus/MMF Era: An Artificial Intelligence Approach

Introduction: One of the biological barriers that can impact outcomes among Living donor kidney transplantation is HLA mismatch. The aim of our study is to assess the effect of HLA mismatches on acute rejection rates and graft survival in the Tacrolimus era. Moreover, to assess factors affecting survival. Methodology: All Living donor kidney transplant patients registered in UNOS database between 01/01/2005 and 01/12/2019 were retrospectively reviewed. Inclusion criteria: Living donor transplant recipients that were discharged on Tacrolimus/Mycophenolate Mofetil. Exclusion criteria: multiple organ transplants, previous kidney transplants, recipient age<18 years old, deceased donor transplants, missing data about induction therapy, missing HLA mismatch or ABO incompatible transplant. We used double-selection lasso (least absolute shrinkage and selection operator) logistic regression model to assess for acute rejection rates at one-year post-transplant. Variables of interest were HLA-A,B,DR and DQ mismatch. Variables Lasso selected from were: recipient characteristics (age, sex, BMI, ethnicity, diabetes, recipient/donor CMV status, pre-transplant dialysis), donor characteristics (age,ethnicity, diabetes and hypertension) and transplant characteristics (induction therapy, steroid intake, cold ischemia time, delayed graft function, PRA). Acute rejection was defined as biopsy proven or clinically suspected rejection. For survival analysis, we fit a penalised Cox model after choosing best alpha. Cross-validated grid-search was used to evaluate the best alpha. The variables included in the penalised cox model donor, recipient and transplant factors plus HLA mismatches. Results: 28,736 patients were included in our study. Worse acute rejection rates at one-year post-transplant were noted with incremental increase in HLA-DQ (Two HLA-DQ: OR=1.29, P<0.01, 95%CI:1.08-1.54; One HLA DQ:OR=1.22,P=0.01, 95%CI:1.05-1.44), HLA-DR mismatches (Two HLA-DR: OR=1.85, P<0.01, 95%CI:1.48-2.31; One HLA-DR: OR=1.51,p<0.01, 95%CI:1.23-1.85),HLA-B mismatches(Two HLA-B OR=1.33, P=0.01,95%CI:1.05-1.69; One HLA-B mismatch: OR=1.21,P=0.09) and HLA-A mismatch (OR:1.19, P<0.01). In the penalized cox regression model, None of the HLA types (A,B,DR or DQ) were associated with worse graft survival (P>0.05 for every type). The factors that were associated with worse outcomes are: Recipient black ethnicity (HR 1.2, P<0.01, 95%CI:1.10-1.31); delayed graft function (HR=1.54, p<0.01, 95%CI:1.31-1.81), pre-transplant dialysis (HR=1.19,P<0.01, 95%CI:1.12-1.26) and donor Black ethnicity(HR=1.21, P<0.01, 95%CI:1.10-1.33). Conclusion: HLA-DQ, DR,B and A mismatches play a vital role in the occurrence of acute rejection among Living donor kidney transplant recipients. However, HLA mismatches have no significant effect on graft survival. Delayed graft function, pre-transplant dialysis recipient and donor black ethnicity, play an important role in determining graft survival.

Textbook Outcome as a Quality Metric in Living and Deceased Donor Kidney Transplantation.

BACKGROUND:Quality in kidney transplantation is measured using 1-year patient and graft survival. Because 1-year patient and graft survival exceed 95%, this metric fails to measure a spectrum of quality. Textbook outcomes (TO) are a composite quality metric offering greater depth and resolution. We studied TO after living donor (LD) and deceased donor (DD) kidney transplantation.STUDY DESIGN:United Network for Organ Sharing data for 69,165 transplant recipients between 2013 and 2017 were analyzed. TO was defined as patient and graft survival of 1 year or greater, 1-year glomerular filtration rate of greater than 40 mL/min, absence of delayed graft function, length of stay of 5 days or less, no readmissions during the first 6 months, and no episodes of rejection during the first year after transplantation. Bivariate analysis identified characteristics associated with TO, and covariates were incorporated into multivariable models. Five-year conditional survival was measured, and center TO rates were corrected for case complexity to allow center-level comparisons.RESULTS:The national average TO rates were 54.1% and 31.7% for LD and DD transplant recipients. The hazard ratio for death at 5 years for recipients who did not experience TO was 1.92 (95% CI 1.68 to 2.18, p ≤ 0.0001) for LD transplant recipients and 2.08 (95% CI 1.93 to 2.24, p ≤ 0.0001) for DD transplant recipients. Center-level comparisons identify 18% and 24% of centers under-performing in LD and DD transplantation. High rates of TO do not correlate with transplantation center volume.CONCLUSION:Kidney transplant recipients who experience TO have superior long-term survival. Textbook outcomes add value to the current standards of 1-year patient and graft survival.

Expedited evaluation for liver transplantation: A critical look at processes and outcomes.

Most patients are listed for liver transplant (LT) following extensive workup as outpatients ("conventional evaluation"). Some patients undergo urgent evaluation as inpatients after being transferred to a transplant center ("expedited evaluation"). We hypothesized that expedited patients would have inferior survival due to disease severity at the time of transplant and shorter workup time. Patients who underwent evaluation for LT at our institution between 2012 and 2016 were retrospectively reviewed. The expedited and conventional cohorts were defined as above. Living donor LT recipients, combined liver-kidney recipients, acute liver failure patients, and re-transplant patients were excluded. We compared patient characteristics and overall survival between patients who received a transplant following expedited evaluation and those who did not, and between LT recipients based on expedited or conventional evaluation. Five-hundred and nine patients were included (110 expedited, 399 conventional). There was no difference in graft or patient survival at 1year for expedited versus conventional LT recipients. In multivariable analysis of overall survival, only Donor Risk Index (HR 1.97, CI 1.04-3.73, P=.037, per unit increase) was associated with increased risk of death. Patients who underwent expedited evaluation for LT had significant demographic and clinical differences from patients who underwent conventional evaluation, but comparable post-transplant survival.

Portal Vein Stent Placement in Anastomotic Stenosis After Deceased Donor Liver Transplantation: A Case Report

Vascular complications (VCs) after liver transplantation (LT) frequently result in graft and patient loss. The smaller vessels and the insufficient length for reconstruction in living donor LT and pediatric transplantation predispose patients to a higher incidence of VCs. Herein we present a case of portal vein stenosis (PVS) in an adult deceased donor LT recipient with portal vein thrombosis requiring extended thrombectomy at the time of LT. He presented with ascites 4 months after LT, was diagnosed with PVS, and was successfully treated with percutaneous transhepatic venoplasty and placement of a portal stent. This case highlights the importance of Doppler ultrasound as a screening modality for detection of VCs after LT and the pivotal role of endovascular repair as a first-line treatment for PVS.

Oral/oesophageal candidiasis is a risk factor for severe infection after kidney transplantation.

AimBacterial and fungal infections are serious, life‐threatening conditions after kidney transplantation. The development of oral/oesophageal candidiasis after kidney transplantation is not a reported risk factor for subsequent severe infection. This study was performed to investigate the relationship between oral/oesophageal candidiasis after kidney transplantation and the development of subsequent infection requiring hospitalization.MethodsThis retrospective study included 522 consecutive patients who underwent kidney transplantation at Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital from 1 January 2010 to 1 February 2019. Ninety‐five percentage of patients were living donor transplant recipients. Visual examination was performed to detect oral candidiasis, beginning immediately after kidney transplantation; upper gastrointestinal endoscopy was performed 8–10 months after kidney transplantation. Twenty‐five patients developed candidiasis (Candida‐onset group) and 497 did not (non‐Candida‐onset group). The follow‐up periods were 67 (37–86) months in the Candida‐onset group and 55 (34–89) months in the non‐Candida‐onset group. Severe infection was defined as bacterial or fungal infection requiring hospitalization; viral infections were excluded.ResultsSevere infection developed in 9/25 (36%) patients in the Candida‐onset group and in 77/497 (15%) patients in the non‐Candida‐onset group (p = .006). Binomial logistic analysis revealed that Candida infection (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.06–6.06; p = .037) and use of rituximab (OR 1.81, 95% CI 1.12–2.93; p = .016) were significant predictors of subsequent severe infection.ConclusionOral/oesophageal candidiasis is a risk factor for severe infection after kidney transplantation and suggests an over‐immunosuppressive state, which should prompt evaluation of immunosuppression.

Intranodal Sirolimus Induces Regulatory T Cells in Human Hepatic Lymph Nodes via Interleukin 10 Signaling.

Intranodal Sirolimus Induces Regulatory T Cells in Human Hepatic Lymph Nodes via Interleukin 10 Signaling.

Developing a Novel Scoring System for Risk Stratification in Living Donor Liver Transplantation.

Background: We aimed to develop a novel scoring system for risk stratification specific to living donor liver transplantation (LDLT) recipients, to improve the accuracy of predicting short-term outcomes. Methods: The sequential organ failure assessment (SOFA) score at postoperative day 7 was collected and simplified by dichotomization, and these categories and other clinical factors were subjected to univariate and multivariate logistic regression analyses to select independent risks in constructing a “graft-to-recipient weight ratio (GRWR)-SOFA” scoring system. Results: We enrolled 519 patients who underwent LDLT. The GRWR-SOFA score comprises a sum of six factors: cardiovascular (mean arterial pressure < 70 mmHg, scored 3), coagulation (serum platelet < 50 × 103/μL, scored 2), renal (creatinine > 1.2 mg/dL, scored 2), liver (serum total bilirubin > 5.9 mg/dL, scored 5), neurological (Glasgow coma scale < 15, scored 2), and GRWR < 0.8, scored 2. The GRWR-SOFA contained four classes: The early mortality rate at 3 months and 1 year after LDLT was 1.3% and 6.9% for class I (scores of 0–4), 9.1% and 16.7% for class II (scores of 5–8), 25.5% and 34% for class III (scores of 9–10), and 61.3% and 67.7% for class IV (scores ≥ 11), respectively. The area under the receiver operating characteristic curve of GRWR-SOFA in the 3-month mortality prediction was 0.881 (95% confidence interval (CI): 0.818–0.944). Conclusions: The GRWR-SOFA model demonstrates superior discriminatory power for predicting short-term mortality. It enables clinicians to identify the right level of care for distinct subgroups of patients receiving LDLT.

POS-753 LONG TERM BENEFITS OF PRESERVED GRAFT FUNCTIONS AFTER LATE WITHDRAWAL OF CALCINEURIN INHIBITORS IN LIVE DONOR KIDNEY TRANSPLANT RECIPIENTS.

With the use of calcineurin inhibitors (CNI) and induction therapy , graft survival has reached over 90% at 1 year. Despite short and medium term improvement , long term graft survival has not shown proportionate improvement. There is debate about role of CNI induced nephrotoxicity and long term graft dysfunction and there is no uniformity in renal outcome after CNI minimization or withdrawal 1 year after transplantation, especially in live donor transplants and well matched kidneys. This retrospective data analyses the long term outcome of patient and graft survival after CNI withdrawal from triple drug therapy of CNI, prednisolone and azathioprine /mycophenolate mofetyl (MMF) Twenty two adults (M:F- 16: 6) who had kidney from live donor and no rejections with stable renal function at one year after transplant were evaluated in this retrospective study. 6 recipients for financial reasons opted for CNI withdrawal which was done over 8 weeks. In the transition period prednisolone and azathioprine dose was stepped up. In another 12 patients CNI was withdrawn over 1-2 years post transplantation for gradually rising serum creatinine. In the remaining 4 patients CNI was withdrawn after graft biopsy revealed no evidence of rejection and histological changes suggestive of CNI toxicity,48-140 months( mean 90 +/-40) after transplant.Patients were followed up regularly for estimation of renal functions. Withdrawal of CNI after 12 months and even in late withdrawal did not result in graft rejection and all patients tolerated the intervention well. At time of early withdrawal at 12 months in 6 patients(Group A) serum creatinine ranged from 1.12 –1.6 mg/dl (Mean1.28 +/-0.16) and eGFR of 65.16 +/-12.81ml/mt. In12 patients (Group-B) in whom CNI was withdrawn between12-24 months serum creatinine ranged from 1.3-1.75 mg/dl (mean 1.51+/- 0.15) and eGFR 56.16 +/-7.1 ml/mt. In remaining 4 patients (group 3) who had evidence of toxicity,CNI was withdrawn 48 to140 months after transplant.Their serum creatinine was1.3 -1.75 mg/dl (mean 1.57+/-0.19) and eGFR 47+/-7.63ml/mt. At the end of follow up ranging from 60-348 months (mean 170+/-72 months ) all the patients had well preserved renal functions with their mean GFR of 65, 56 and 47 ml/mt in respective group with serum creatinine1.02 to 5.2 mg/dl (mean 1.86 +/- 0.99) There were 9 deaths after a follow up of 82-300 months (mean 200 +/- 75.2 )months.Three patients had carcinoma tongue of whom one had achieved prolonged remission after therapy but during follow up along with 2others reached ESRD and were initiated on hemodialysis.Cardiovascular events in 3 and infections in other 2 patients accounted for their mortality. Recipients of kidney from live donors with at least 1 haplo match and who did not have rejections in the1st year of transplant had excellent long term graft survival with 2 drugs only without CNI.In selected live donor transplant recipients who do not have rejection in first year calceinurin inhibitors can safely be withdrawn at least one year after transplant which helps in ameliorating CNI induced renal injury and prevents further deterioration of renal functions. In patients with graft dysfunction with histological features of CNI toxicity this beneficial effect of CNI withdrawal can sometimes be seen even many years after transplantation.

Doppler-derived renal resistive index helps predict acute kidney injury in patients undergoing living-related liver transplantation.

Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients. We performed a single-center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non-AKI groups for comparison. Fifty patients were included in the study (mean age, 44years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of≥0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline. Doppler-derived RRI is a rapid, non-invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.

Adult to Adult Living Donor Liver Transplantation in Recipients with Low MELD: A Strategy Intended to Overcome Donor Shortage.

Recent series have demonstrated advantages of living donor over deceased donor liver transplantation, with particular benefit for those with low model for end-stage liver disease score. The logic underlying the transplantation of patients before they become too sick is intuitive. It reduces mortality and drop outs from the waiting list and makes transplant surgery less demanding. Those principles have to be balanced with donor safety and transplant benefit for the recipient avoiding early, futile transplantation. The authors report a case of adult to adult right lobe living donor liver transplantation performed for a recipient affected by primary biliary cirrhosis with MELD score of 15, in a transplant center located in an area of Europe characterized by chronic organ shortage.

Renal Transplantation in Mansoura, Egypt.

Renal Transplantation in Mansoura, Egypt.

Is Body Mass Index a Significant Independent Risk Factor for Graft Failure and Patient Death in the Modern Immunosuppressive Era?

ObjectivesPrevious studies have shown that kidney transplant recipients with a high body mass index (BMI) have inferior graft and patient outcomes compared to patients with a lower BMI. We hypothesized that there would be secular improvements in outcomes among high BMI recipients. We used data from the United Network for Organ Sharing (UNOS) to determine whether obesity affects patient and graft outcomes following kidney transplantation in the modern immunosuppressive era. MethodsThe study sample consisted of 69,749 recipients from 1987 to 1999 and 197,986 recipients from 2000 to 2016. BMI values were categorized into 11 tiers: below 18 kg/m2, from 18 to 36 kg/m2 at 2 kg/m2-unit increments, and above 36 kg/m2. We created multivariate models to evaluate the independent effect of BMI on graft and patient outcomes, adjusting for factors known to affect graft success and patient survival. ResultsOverall graft and patient survival has improved for all BMI categories. Cox regression modeling hazard ratios showed that the relative risk for graft loss, patient death, and patient death with a functioning graft in the modern immunosuppressive era (2000 to 2016) has significantly decreased compared to the earlier era (1987 to 1999), especially for living kidney transplant recipients. ConclusionsThe relative risk of graft failure and patient death with increasing BMI has appreciably decreased in the modern immunosuppressive era, especially for living donor transplant recipients. Withholding transplantation from patients with higher BMIs may no longer be justifiable on grounds of worse clinical outcomes.

Temporal Changes and Regional Variation in Acceptance of Hepatitis C Virus-Viremic Livers.

The high efficacy of current hepatitis C virus (HCV) therapy and increased numbers of HCV-infected deceased donors have changed the paradigm of HCV in liver transplantation (LT). Modeling studies have been performed to evaluate the optimal timing of HCV treatment (before versus after LT) in HCV-infected patients and to assess the cost-effectiveness of transplanting HCV-infected livers into HCV- patients. However, these models rely on historical data and have not quantified the temporal changes in the median Model for End-Stage Liver Disease (MELD) score at transplant of recipients of an HCV-infected liver across geographic areas. We performed a retrospective cohort study of Organ Procurement and Transplantation Network/United Network for Organ Sharing (UNOS) data of nonstatus 1 deceased donor LT recipients from January 1, 2016, to December 31, 2018, and we calculated the difference in allocation MELD score in recipients of HCV nucleic acid test (NAT)- versus NAT+ livers by year and UNOS region. We used Pearson correlation coefficients to assess the relationship between MELD score difference in recipients of HCV NAT+ versus HCV NAT- livers and the proportion of non-HCV recipients of HCV NAT+ livers. Nationally, the allocation MELD score difference at LT in recipients of HCV NAT+ versus NAT- livers did not change (4-point difference). This stability was seen in regions 3, 5, and 10. In regions 1, 7, 8, 9, and 11, the MELD score difference decreased, which is a diminishing advantage. However, in regions 2 and 4, it increased, which is a rising advantage. In 2018, recipients of HCV NAT+ livers had a lower MELD score in 9/11 regions, and the MELD score advantage of accepting HCV NAT+ livers had a moderate inverse correlation with the regional use in non-HCV patients (r=-0.53). These data should be used to inform clinicians of the pre- and post-LT trade-offs of HCV treatment.