Multiorgan Transplantation Research Articles

CARC20: Intra-operative Use of Intra-aortic Balloon Pump to Generate Pulsatile Flow During Heart Transplantation

Introduction: The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. One method of generating PF during CPB is to use an intra-aortic balloon pump (IABP). Maintaining the IABP during CPB to produce a state of PF for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for short-term graft function and immediate post-operative outcomes. Methods: A single-center retrospective cohort study of adult patients bridged to HT with IABP was conducted between January 2018 and December 2022. Patients were excluded if they were <18 years old, not bridged to HT with IABP, or underwent simultaneous multi-organ transplant. For patients bridged to HT with IABP, beginning in May 2022 the IABP was allowed to continue inflating and deflating during CPB. Upon initiation of CPB, the IABP was set on an internal rate of 80 beats per minute. Patients who underwent HT with IABP turned off while on CPB (IABP-Off) and patients maintained on IABP during HT (IABP-On) were propensity matched according to age, organ ischemia time, and intraoperative dobutamine dose (mcg/kg/min). Results: A total of 70 patients bridged to HT with IABP were propensity matched into IABP-Off (n=12) versus IABP-On (n=12) groups. IABP-Off and IABP-On groups were similar with respect to age (p=0.93), sex (p=0.54), race (p=0.68), BMI (p=0.37), previous sternotomy (p=0.27), and waitlist time (p=0.31). IABP-Off and IABP-On groups had similar organ ischemia times (166.9±40.3 vs. 165.8±55.0 minutes, p=0.96), similar CPB times (109.3±20.6 vs. 111.3±29.7 minutes, p=0.43), and similar case lengths (449.5±108.7 vs. 449.4±115.3 minutes, p=0.50). The groups received similar amounts of intraoperative products and fluids. IABP-Off and IABP-On groups were matched on intraoperative dobutamine dose (2.85±1.73 vs. 3.09±1.76, p=0.74) and received similar doses of other intraoperative inotropes, with the IABP-Off group trending towards a higher norepinephrine dose that did not reach statistical significance. There was no difference in the first measured post-operative lactate between groups, although patients in the IABP-On group had significantly lower peak lactates in the first 24 hours post-transplant (2.39±1.17 vs. 4.31±2.95, p=0.02). There was no difference between groups with respect to post-operative creatinine or length of stay or mortality. Conclusion: Patients maintained on IABP had lower peak lactates in the first 24 hours post-transplant compared to patients in whom IABP was turned off and trended to require less norepinephrine. This limited preliminary data suggests that maintaining pulsatility during CPB may result in improved end-organ perfusion. Table 1. Characteristics of the IABP-Off and IABP-On Cohorts

Letter to the Editor: Acute rejection after liver transplantation with machine perfusion versus static cold storage: A systematic review and meta-analysis.

1Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China 2Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health; Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Zhejiang Province, Hangzhou 310003, China Funding: None. Correspondence Yu Nie MD, Department of Hepatobiliary Surgery II, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China. Email: [email protected]

Reduced incidence of cardiac rejection in multi-organ transplants: A propensity matched study.

Rejection remains a primary cause of graft loss after heart transplant (HT). Recognizing the immunomodulation of multi-organ transplant can enhance our understanding of the mechanisms of cardiac rejection. This retrospective cohort study identified patients from the UNOS database with isolated heart (H, N=37 433), heart-kidney (HKi, N=1516), heart-liver (HLi, N=286), and heart-lung (HLu, N=408) transplants from 2004 to 2019. Propensity score matching reduced baseline differences between groups. Outcomes included risk of rejection prior to transplant hospital discharge and within 1 year, and mortality within 1 year of transplant. In the propensity score matched data, the relative risk of being treated for rejection prior to transplant hospital discharge was 61% lower for HKi (RR .39, 95% CI .29, .53) and 87% lower for HLi (RR .13, 95% CI .05, .37) compared to H. Similarly, the probability of being treated for rejection in the first year after transplant remained lower in HKi (RR .45, 95% CI .35, .57) and HLi (RR .13, 95% CI .06, .28) compared to H. The 1-year survival analysis revealed an equivalent risk of death in HKi (HR .84, 95% CI .68, 1.03) and HLi (HR 1.41, 95% CI .83, 2.41) compared to H, while HLu had a higher risk of death in the first year after transplant (HR 1.65, 95% CI 1.17, 2.33). Recipients of HKi and HLi experience a reduced risk of rejection when compared to H, but an equivalent risk of 1yr mortality. These findings have important implications for the future of HT medicine.

Outcomes of Bebtelovimab Therapy in Patients With Solid Organ Transplantation With Mild and Moderate COVID-19.

Solid organ transplant recipients (SOTRs) are at greaterrisk of poorer outcomes from coronavirus disease 2019 (COVID-19) as compared to the general population. Because of significant drug-drug interactions between nirmatrelvir-ritonavir and immunosuppressive agents as well aslogistical challenges of outpatient administration of remdesivir, anti-severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) monoclonal antibodies (mAbs) had been the mainstay of outpatient treatment of COVID-19 among SOTRs, with bamlanivimab, casirivimab-imdevimab, and sotrovimab having been previously granted emergency use authorization by the Food and Drug Administration (FDA). The challenge with the ongoing use of these monoclonal antibodies is the loss of efficacy against emerging variants of SARS-CoV-2. Bebtelovimab, which retained efficacy against early subvariants of Omicron, was granted emergency use authorization by the Food and Drug Administration when Omicron BA.4 and BA.5 became the predominant variants in the United States. However, the study based on which bebtelovimab was authorized by the FDA did not include SOTRs. The only available safety and efficacy data on these patients are from retrospective studies. In our retrospective analysis of 62 SOTRs who received bebtelovimab infusion between May 11, 2022, and October 11, 2022, 28 had a kidney transplant, 18 had a liver transplant, 10 had a heart transplant, and six had multi-organ transplants (liver/kidney: 4, heart/kidney: 2). None of the patients reported infusion-associated adverse reaction. Only one (1.6%)patient developed progression of COVID-19, requiring subsequent treatment with remdesivir, steroids, and oxygen supplementation. The rateof need for intensive care and death from COVID-19 during the 30-dayfollow-up period was 0%.

Normal Saline vs Plasma-Lyte A Use Intra- and Post-Operatively in Adult Kidney Transplant Recipients

Fluid management intra- and post-operatively for kidney transplant recipients (KTR) is essential to maintain adequate perfusion to the kidney. 0.9% normal saline (NS) is commonly used, but it can cause hyperchloremic metabolic acidosis, which may result in hyperkalemia and lead to delayed graft function (DGF). Plasma-Lyte A (PA) is an alternative option that has a lower amount of chloride and a neutral pH, which may offset the risk of hyperkalemia. The aim of this study is to determine the incidence of DGF in KTRs comparing NS vs PA use intra- and initially post-operatively. This single-center, retrospective cohort study in adult KTRs from January 1, 2016 to February 1, 2021 consisted of two cohorts, those receiving NS vs PA. Multi-organ transplant recipients were excluded. The primary outcome was the incidence of DGF. A total of 244 KTRs in the NS group and 263 KTRs in the PA group were included. There was no significant difference in incidence of DGF between the groups, (NS 23.4% vs PA 25.9%, p = 0.537). The logistic regression for only deceased donors were not significantly different (OR 1.369 (0.819-2.288). There was no difference in the incidence of DGF when comparing NS vs PA.

Clinical case report - The first successful simultaneous heart and kidney transplantation in Vietnam

Abstract: Simultaneous heart and kidney transplantation is quite a popular type of multiorgan transplant in the world, considered an optimum treatment for end stage cardiorenal syndrome. This report presents first successful simultaneous heart-kidney transplant in Vietnam. A 37-year-old male patient with 10 years of chronic disease: end-stage heart failure due to dilated cardiomyopathy with 15-25% of left ventricular systolic function, and renal failure due to IgA nephropathy completely depended on dialysis. The patient underwent a simultaneous heart-kidney transplant from a brain-dead multiorgan donor on February 15, 2023 at Viet Duc University hospital. He had quick recovery of all cardiac and renal functions on 5 days afters transplant. This is the 2nd successful case of multiorgan transplant at Viet Duc hospital, but the first heart-kidney transplantation.

Simultaneous heart and kidney transplantation: Our first experience

The gold standard treatment for end-stage heart and kidney failure is simultaneous heart and kidney transplantation. The global number of recipients on the waiting list and performed organ transplants increases annually. However, there is a lack of well-defined selection criteria for multi-organ transplants, leading to variations based on geographic region and local protocols.&#x0D; In this study, we present our initial experience with simultaneous heart and kidney transplantation in Patient P, a 51-year-old individual with severe calcification of the mitral valve and end-stage chronic kidney disease. Surgical correction was not possible, and thus the patient underwent orthotopic simultaneous heart and kidney transplantation. During the early postoperative period, the patient experienced acute renal failure in the transplanted kidney, which was managed through courses of hemodialysis.&#x0D; The findings of this clinical observation represent the first experience of multi-organ transplantation in Ukraine. Our clinical observation illustrates the successful feasibility of simultaneous orthotopic heart and kidney transplantation, showcasing promising immediate and medium-term follow-up results.

Influence of chronic kidney disease and other risk factors pre-heart transplantation on malignancy incidence post-heart transplantation.

Chronic kidney disease (CKD) pre-heart transplantation (HTx) has been proposed as a risk factor for malignancy risk post-HTx. Using multicenter registry data, our aim was to calculate the death-adjusted annual incidence of malignancies post-HTx, corroborate the association between CKD pre-HTx and malignancy risk post-HTx, and determine other risk factors for post-HTx malignancies. We used data from patients transplanted in North American HTx centers between January 2000 and June 2017 and registered in the International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry. We excluded recipients with missing data on post-HTx malignancies, heterotopic heart transplant, retransplantation, multi-organ transplantation, and patients with a total artificial heart pre-HTx. Overall, 34,873 patients were included to determine the annual incidence of malignancies, 33,345 patients were included in the risk analyses. The incidence of any malignancy, solid-organ malignancy, post-transplant lymphoproliferative disease (PTLD), and skin cancer adjusted for death 15 years post-HTx, was 26.6%, 10.9%, 3.6%, and 15.8% respectively. Besides widely acknowledged risk factors, CKD stage ≥4 pre-HTx was associated with the development of all malignancies post-HTx (HR 1.17 compared to CKD stage 1, p = 0.023), as well as solid-organ malignancies (HR 1.35, p = 0.01), but not for PTLD (HR 0.73, p = 0.057), and skin cancer (HR 1.06, p = 0.59). Risk of malignancy post-HTx remains high. CKD stages ≥4 pre-HTx was associated with an increased risk for any malignancy and solid-organ malignancy post-HTx. Strategies to mitigate the impact of pre-HTx patient factors on the risk of post-HTx malignancy are needed.

(514) Clinical Utility of Donor Derived Cell-Free DNA in the Multiorgan Transplantation

(514) Clinical Utility of Donor Derived Cell-Free DNA in the Multiorgan Transplantation

(540) Multi-Organ Transplantation in Hiv-Positive Recipients - Patient Characteristics and Outcomes

(540) Multi-Organ Transplantation in Hiv-Positive Recipients - Patient Characteristics and Outcomes

(195) Comparison of CAV Development in Simultaneous Multi-Organ and Isolated Heart Transplant Recipients in the United States

(195) Comparison of CAV Development in Simultaneous Multi-Organ and Isolated Heart Transplant Recipients in the United States

Do vasoactive medications impact donor hearts clinical outcomes in pediatric heart transplantation?

There is limited data examining donor vasopressor and/or inotrope medications (vasoactives) on pediatric orthotopic heart transplant (OHT) outcomes. We aim to evaluate the effects of vasoactives on pediatric OHT outcomes. The United Network for Organ Sharing database was retrospectively reviewed from January 2000 to March 2018 for donor hearts. Exclusion criteria included multiorgan transplants and recipient age >18. Donors receiving vasoactives at the time of procurement were compared to donors not on vasoactives, including the number of vasoactives and the type. End-points of interest were survival at 30 days and 1year as well as post-transplant rejection at 1year. Logistic and Cox models were used to quantify survival end-points. Of 6462 donors, 3187 (49.3%) were receiving at least one vasoactive. Comparing any vasoactive medication versus none, there was no difference in 30-day survival (p= .27), 1 year survival (p= .89), overall survival (p= .68), or post-transplant rejection (p= .98). There was no difference in 30-day survival for donors receiving 2 or more vasoactive infusions (p= .89), 1 year survival (p= .53), overall survival (p= .75), or post-transplant rejection at 1year (p= .87). Vasopressin was associated with decreased 30-day mortality (OR=0.22; p= .028), dobutamine with decreased 1-year mortality (OR=0.37; p= .036), overall survival (HR=0.51; p= .003), and decreased post-transplant rejection (HR=0.63; p= .012). There is no difference in pediatric OHT outcomes when the cardiac donor is treated with vasoactive infusions at procurement. Vasopressin and dobutamine were associated with improved outcomes. This information can be used to guide medical management and donor selection.

A42 LIVE DONOR LIVER TRANSPLANTATION IN PRIMARY SCLEROSING CHOLANGITIS: AN INDICATOR OF AN ORGAN ALLOCATION SYSTEM NOT ADDRESSING PATIENT NEED

Abstract Background Liver transplantation is frequently lifesaving for people living with primary sclerosing cholangitis (PSC). However, patients are waitlisted for liver transplant (LT) according to the MELD-Na score, which may not accurately reflect the burden of living with PSC. Purpose We sought to describe and analyze the clinical trajectory for patients with PSC referred for LT, in a mixed deceased donor/live donor transplant programme. Method This was a retrospective cohort study from November 2012 to December 2019 including all patients with PSC referred for assessment at the University Health Network Liver Transplant Clinic. Patients who required multiorgan transplant or re-transplantation were excluded. Liver symptoms, hepatobiliary malignancy, MELD-Na progression, and death were abstracted from chart review. Competing Risk analysis was used for timing of LT, transplant type, and death. Result(s) Of 172 PSC patients assessed, 144 (84%) were listed, of whom 106/144 (74%) were transplanted. Mean age was 47.6 years and 66% were male. During follow-up through to 2021, 23/144 (16%) were removed from the waitlist due to infection, clinical deterioration, liver-related mortality or new cancer; 3 had clinical improvement. At the time of listing, 118/144 (81.95%) had a potential Living Donor (pLD) of whom 94 were transplanted: 64 live donor and 30 deceased donor. Patients with pLD had 79% lower mortality (p&amp;lt;0.001), and higher rates of transplantation (80% vs 46%). Exception points were granted to 13/172 (7.5%) patients. Conclusion(s) In a high-volume North American liver transplant centre, most patients with PSC assessed for transplant were listed and subsequently transplanted. However, this was a consequence of patients engaging in live donor transplantation. Our findings support the concern from patients with PSC that MELD-Na allocation does not adequately address their needs. Please acknowledge all funding agencies by checking the applicable boxes below CIHR, Other Please indicate your source of funding; This study was supported by PSC Partners Canada, Canadian Institutes of Health Research (CIHR), Toronto General and Western Hospital Foundation. Disclosure of Interest None Declared

Donation after circulatory death heart procurement strategy impacts utilization and outcomes of concurrently procured abdominal organs

The impact of donation after circulatory death (DCD) heart procurement techniques on the utilization and outcomes of concurrently procured DCD livers and kidneys remains unclear. Using the United Network for Organ Sharing database, we identified 246 DCD donors whose heart was procured using direct procurement and ex-situ machine perfusion and 128 DCD donors whose heart was procured using in-situ thoracoabdominal normothermic regional perfusion (12/2019-03/2022). We evaluated the transplantation rate of concurrently procured DCD livers and kidneys (defined as the number of organs transplanted/total number of organs available for procurement) and their post-transplant outcomes. The transplantation rate of concurrently procured DCD livers was higher with in-situ perfusion compared to direct procurement (67.1% vs 56.5%, p=0.045). After excluding pediatric, multiorgan, and repeat transplant recipients, there was no difference in 6-month liver graft failure rate (direct procurement 0.9% vs in-situ perfusion 0%, p > 0.99). Recipients of kidneys procured with in-situ perfusion had less delayed graft function (11.3% vs 41.5%, p < 0.0001) shorter length of stay, and lower serum creatinine at discharge (both p < 0.05). Six-month recipient survival in the direct procurement and in-situ perfusion group were similar after DCD liver and kidney transplantation (p=0.24 and 0.79 respectively). Compared to direct procurement, DCD heart procurement with in-situ thoracoabdominal normothermic regional perfusion was associated with increased utilization of DCD livers and a lower incidence of delayed graft function in concurrently procured DCD kidneys. Broader implementation of DCD heart transplantation must maximize the transplant potential of concurrently procured abdominal organs and ensure their successful outcomes.

Transplantation in paediatric patients with MMA requires multidisciplinary approach for achievement of good clinical outcomes

BackgroundAs modern medicine is advancing, younger, small, and more complex children are becoming multi-organ transplant candidates. This brings up new challenges in all aspects of their care.MethodsWe describe the first report of a small child receiving a simultaneous liver and kidney transplant and abdominal rectus sheath fascia transplant on the background of Williams syndrome and methylmalonic acidaemia. At the time of transplantation, the child was 3 years old, weighed 14.0 kg, had chronic kidney disease stage V, and had not yet started any other form of kidney replacement therapy.ResultsThere were many anaesthetic, medical, metabolic, and surgical challenges to consider in this case. A long general anaesthetic time increased the risk of cardiac complications and metabolic decompensation. Additionally, the small size of the patient and the organ size mis-match meant that primary abdominal closure was not possible. The patient’s recovery was further complicated by sepsis, transient CNI toxicity, and de novo DSAs.ConclusionsThrough a multidisciplinary approach between 9 specialties in 4 hospitals across England and Wales, and detailed pre-operative planning, a good outcome was achieved for this child. An hour by hour management protocol was drafted to facilitate transplant and included five domains: 1. management at the time of organ offer; 2. before the admission; 3. at admission and before theatre time; 4. intra-operative management; and 5. post-operative management in the first 24 h. Importantly, gaining a clear and in depth understanding of the metabolic state of the patient pre- and peri-operatively was crucial in avoiding metabolic decompensation. Furthermore, an abdominal rectus sheath fascia transplant was required to achieve abdominal closure, which to our knowledge, had never been done before for this indication. Using our experience of this complex case, as well as our experience in transplanting other children with MMA, and through a literature review, we propose a new perioperative management pathway for this complex cohort of transplant recipients.

The teammate trial: Study design and rationale tacrolimus and everolimus against tacrolimus and MMF in pediatric heart transplantation using the major adverse transplant event (MATE) score

Currently there are no immunosuppression regimens FDA-approved to prevent rejection in pediatric heart transplantation (HT). In recent years, everolimus (EVL) has emerged as a potential alternative to standard tacrolimus (TAC) as the primary immunosuppressant to prevent rejection that may also reduce the risk of cardiac allograft vasculopathy (CAV), chronic kidney disease (CKD) and cytomegalovirus (CMV) infection. However, the two regimens have never been compared head-to-head in a randomized trial. The study design and rationale are reviewed in light of the challenges inherent in rare disease research. The TEAMMATE trial (NCT03386539, IND 127980) is the first multicenter randomized clinical trial (RCT) in pediatric HT. The primary purpose is to evaluate the safety and efficacy of EVL and low-dose TAC (LD-TAC) compared to standard-dose TAC and mycophenolate mofetil (MMF). Children aged <21 years at HT were randomized (1:1 ratio) at six months post-HT to either regimen, and followed for 30 months. Children with recurrent rejection, multi-organ transplant recipients, and those with an estimated glomerular filtration rate (eGFR) <30 ml/min/1.73m2 were excluded. The primary efficacy hypothesis is that, compared to TAC/MMF, EVL/LD-TAC is more effective in preventing 3 MATEs: acute cellular rejection (ACR), CKD and CAV. The primary safety hypothesis is that EVL/LD-TAC does not have a higher cumulative burden of 6 MATEs (antibody mediated rejection [AMR], infection, and post-transplant lymphoproliferative disorder [PTLD] in addition to the 3 above). The primary endpoint is the MATE score, a composite, ordinal surrogate endpoint reflecting the frequency and severity of MATEs that is validated against graft loss. The study had a target sample size of 210 patients across 25 sites and is powered to demonstrate superior efficacy of EVL/LD-TAC. Trial enrollment is complete and participant follow-up will be completed in 2023. The TEAMMATE trial is the first multicenter RCT in pediatric HT. It is anticipated that the study will provide important information about the safety and efficacy of everolimus- vs tacrolimus-based regimens and will provide valuable lessons into the design and conduct of future trials in pediatric HT.

Heart-liver-kidney transplantation for AL amyloidosis using normothermic recovery and storage from a donor following circulatory death: Short-term outcome in a first-in-world experience

AL amyloidosis is a rare condition characterized by the overproduction of an unstable free light chain, protein misfolding and aggregation, and extracellular deposition that can progress to multiorgan involvement and failure. To our knowledge, this is the first worldwide report to describe triple organ transplantation for AL amyloidosis and triple organ transplantation using thoracoabdominal normothermic regional perfusion recovery with a donation from a circulatory death (DCD) donor. The recipient was a 40-year-old man with multiorgan AL amyloidosis with a terminal prognosis without multiorgan transplantation. An appropriate DCD donor was selected for sequential heart, liver, and kidney transplants via our center's thoracoabdominal normothermic regional perfusion pathway. The liver was additionally placed on an ex vivo normothermic machine perfusion, and the kidney was maintained on hypothermic machine perfusion while awaiting implantation. The heart transplant was completed first (cold ischemic time [CIT]: 131 minutes), followed by the liver transplant (CIT: 87 minutes, normothermic machine perfusion: 301 minutes). Kidney transplantation was performed the following day (CIT: 1833 minutes). He is 8 months posttransplant without evidence of heart, liver, or kidney graft dysfunction or rejection. This case highlights the feasibility of normothermic recovery and storage modalities for DCD donors, which can expand transplant opportunities for allografts previously not considered for multiorgan transplantations.

Does donor treatment with inotropes and/or vasopressors impact post-transplant outcomes?

The purpose was to evaluate the effects of the most commonly used cardiac donor inotropes/vasopressors on subsequent post-heart transplant survival. Adult heart transplant recipients from January 2000 to June 2022 were identified in the United Network for Organ Sharing (UNOS) database. Exclusion criteria included: multiorgan transplants, donor age<15, and recipient age<18. Donors receiving vasoactive medications at the time of procurement were compared to donors not receiving these medications. Those on vasoactive medications were stratified by medication: phenylephrine, dopamine, dobutamine, norepinephrine and epinephrine, the combination of these agents, and the concomitant administration of vasopressin with any single agent alone or in combination. The primary area of interest was short-and-long-term survival. Survival at 30 days, 1 year, and long-term (Median=13.6 years) was compared using logistic and Cox models to quantify survival endpoints. A total of 45,198 donors met inclusion criteria and had data on the use of vasoactive agents available. Mean donor age was 32.3 years with 71% male. Vasoactive medications and potential combinations included phenylephrine in 8156 donors (18.0%), dopamine in 9550 (21.1%), dobutamine in 718 (1.6%), epinephrine in 332 (.73%), and norepinephrine in 4854 (10.7%). A total of 25,856 donors (57.2%) were receiving vasopressin at the time of procurement. There was no impact of donor inotropes on 30-day survival. Donors receiving one inotrope and no vasopressin were associated with increased 1 year mortality (OR 1.14; p=.021), as were donors receiving 2+ inotropes and no vasopressin (OR 1.26; p=.006). For individual agents, 1 year mortality was increased for dopamine (OR 1.11; p=.042) and epinephrine (OR 1.59; p=.004). There is no difference in heart transplant recipient survival at 30 days when the donor is receiving inotropes without vasopressin at the time of procurement. Inotropic support without vasopressin is associated with greater 1 year mortality. The impact of donor inotropic support on long term heart transplant survival, and the interaction with vasopressin warrants further study.

Efficacy of pre-emptive kidney transplantation for adults with end-stage kidney disease: a systematic review and meta-analysis

Background Pre-emptive kidney transplantation (PEKT), i.e., transplantation performed before initiation of maintenance dialysis, is considered an ideal renal replacement therapy because there is no exposure to long-term dialysis therapy. Therefore, we summarized advantages/disadvantages of PEKT to assist in deciding whether kidney transplantation should be performed pre-emptively. Methods This study was registered with PROSPERO, CRD42021269163. Observational studies comparing clinical outcomes between PEKT and non-PEKT were included; those involving only pediatric recipients or simultaneous multi-organ transplantations were excluded. The PubMed/MEDLINE, Cochrane Library, and Ichushi-Web databases were searched on 1 August 2021. Studies were pooled using the generic inverse-variance method with random effects model, and risk of bias was assessed using ROBINS-I. Results Seventy-six studies were included in the systematic review (sample size, 23–121,853; enrollment year, 1968–2019). PEKT patients had lower all-cause mortality (adjusted HR: 0.78 [95% CI 0.66–0.92]), and lower death-censored graft failure (0.81 [0.67–0.98]). Unadjusted RRs for the following outcomes were comparable between the two patient groups: cardiovascular disease, 0.90 (0.58–1.40); biopsy-proven acute rejection, 0.75 (0.55–1.03); cytomegalovirus infection, 1.04 (0.85–1.29); and urinary tract infection, 0.89 (0.61–1.29). Mean differences in post-transplant QOL score were comparable in both groups. The certainty of evidence for mortality and graft failure was moderate and that for other outcomes was very low following the GRADE classification. Conclusions The present meta-analysis shows the potential benefits of PEKT, especially regarding patient and graft survival, and therefore PEKT is recommended for adults with end-stage kidney disease.

Indian society of organ transplantation: New Era

Dear Esteemed colleagues, I am writing this column after taking over as ISOT president being supported by the proactive executive committee. Former president Prof. Sunil Shroff had provided new initiatives in 2021–2022, which have gone above and beyond in leading by example with regard to team working, cross-specialty collaboration, and raising awareness of how the social determinants of health such as organ donation drive affect and save many lives. I congratulate his leadership for these endless efforts. Prof. Manisha Sahay editor-in-chief of the Indian Journal of Transplantation has commendably published every edition suitably representing the broad spectrum of scientific literature. As she demits editorship, I say a big thank you, as she hands over the reins of the journal to Prof. Narayan Prasad. As we are all aware of the lacunae in transplantation immunology, transplant-related infections, and appropriate transplant-related multiple organ biopsy interpretation, I convened a zoom meeting of Prof. Dolly Daniel (Immunologist), Prof. Priscilla Rupoli (Infectious disease), and Prof. Seethalakshmi (Pathologist) with Prof. Vivek Kute last week to form subcommittees. These three will work 24 × 7 through the website to give timely support to all transplant facilities across India. I express my thanks for their commitment. Having been the organizing chairman for ISOT 1997 and 2015 in Chennai, I understand how pressurized is our transplantation landscape. I request our trainee nephrologists, urologists, Pathologists, infectious disease people, other multi-organ transplant physicians, and surgeons to join the society to strengthen our society and be beneficiaries. The collaborative efforts undertaken by ISOT, the British Transplant Society, and the European Society of Transplantation on a mutually respectable platform will accelerate our efforts in terms of the exchange of knowledge. Short-term and long-term fellowship programs and other exchanges should be utilized to the best of our efforts. Our young members in the executive and membership are exemplary value to the society. They are an absolutely vital part of our commitment to encourage upcoming youngsters to develop an active role in future issues that matter to them in our influencing work. The pandemic greatly disrupted our work. Nevertheless, Prof. Vivek Kute and other colleagues put in extraordinary efforts to show the transplant community across the world of our challenges and solutions through publications. They deserve special appreciation. Although we lost some patients during the first and second waves, we gained much-desired experience in the management of our patients. As the misinformation and paucity of information and unnecessary hype created by some media demoralized our eminent doctors and uncalled punishment action by certain government authorities falling prey to misinformed advice, we have to stand together as a responsible body to take and deal with these challenges effectively. The discussion highlighting legal issues by Prof. Sanjay Agarwal along with ISN and facing the media in a previous incident was highly educative. We require a strong legal cell to protect our doctors. I also look forward to bidding for a future WCT in India. I take this opportunity to congratulate the three Indians Prof. Manikkam Suthanthiran, Dr. Gomathy Narasimhan, and Prof. Vivek Kute for receiving prestigious awards by TTS at the WCT in Buenos Aires, Argentina. They are the face of India. I wish you all a Happy New Year. Figure 1 is the picture of Prof. Krishna Menon, President BTS; Gabriel Oniscu, President ESOT; and myself.Figure 1: Gabriel Oniscu, Georgi Abraham, Krishnan Menon