National Transplant Program Research Articles

High malignancy rate in the absence of viral prophylaxis after kidney transplantation in Sudan.

Kidney transplantation in Sudan is funded by the government. Cytomegalovirus prophylaxis is provided for patients who receive biological induction or have recipient-negative donor-positive cytomegalovirus serology. Doctor Selma Center for Kidney Diseases joined the national kidney transplant program in May 2019. Since then, we observed the frequent occurrence of cancer in patients who received modest immunosuppression without viral prophylaxis. We retrospectively divided kidney transplant recipients between 2019 and 2021 into two groups according to cytomegalovirus prophylaxis and compared tumor occurrence rates. The first group included 77 patients who did not receivebiological induction or cytomegalovirus prophylaxis. The second group included 92 patients who received valganciclovir for 3-6months. There was no other antiviral treatment except entecavir for chronic hepatitis B virus infection in eight patients. Five patients in the first group developed malignancy. The first patient presented eight months post-transplant with Kaposi sarcoma of the stomach and responded to treatment with sirolimus. The second patient presented nine months post-transplant with cutaneous Kaposi sarcoma and also responded to sirolimus. Two patients presented two and four months post-transplant with aggressive non-cutaneous Kaposi sarcoma that involved the gastrointestinal tract and lymphatic system and died soon afterwards. The fifth patient presented three years post-transplant with non-Hodgkin lymphoma of the duodenum and is currently receiving chemotherapy. Malignancy rate (6.5% vs 0.0%, P = 0.02) and Kaposi sarcoma rate (5.2% vs 0.0%, P = 0.04) were significantly higher in the first group. In Sudan, omitting valganciclovir prophylaxis after kidney transplantation was associated with a high rate of virus-induced malignancy.

Examining a 12-year experience within Kazakhstan’s national heart transplantation program

Kazakhstan has one of the lowest heart transplantation (HTx) rates globally, but there are no studies evaluating the outcomes of HTx. This study aimed to provide a comprehensive analysis of the national HTx program over a 12-year period (2012–2023). Survival analysis of the national HTx cohort was conducted using life tables, Kaplan‒Meier curves, and Cox regression methods. Time series analysis was applied to analyze historical trends in HTx per million population (pmp) and to make future projections until 2030. The number of patients awaiting HTx in Kazakhstan was evaluated with a regional breakdown. The pmp rates of HTx ranged from 0.06 to 1.08, with no discernible increasing trend. Survival analysis revealed a rapid decrease in the first year after HTx, reaching 77.0% at 379 days, with an overall survival rate of 58.1% at the end of the follow-up period. Among the various factors analyzed, recipient blood levels of creatinine and total bilirubin before surgery, as well as the presence of infection or sepsis and the use of ECMO after surgery, were found to be significant contributors to the survival of HTx patients. There is a need for public health action to improve the HTx programme.

Evaluation of liver transplantation services in Kazakhstan from 2012 to 2023

There is a scarcity of publications evaluating the performance of the national liver transplantation (LTx) program in Kazakhstan. Spanning from 2012 to 2023, it delves into historical trends in LTx surgeries, liver transplant centers, and the national cohort of patients awaiting LTx. Survival analysis for those awaiting LTx, using life tables and Kaplan–Meier, is complemented by time series analysis projecting developments until 2030. The overall per million population (pmp) LTx rate varied from 0.35 to 3.77, predominantly favoring living donor LTx. Liver transplant center rates ranged from 0.06 to 0.40. Of 474 LTx patients, 364 on the waiting list did not receive transplantation. The 30-day and 1-year survival rates on the waiting list were 87.0% and 68.0%, respectively. Viral hepatitis and cirrhosis prevalence steadily rose from 2015 to 2023, with projections indicating a persistent trend until 2030. Absent targeted interventions, stable pmp rates of LTx and liver transplant centers may exacerbate the backlog of unoperated patients. This study sheds light on critical aspects of the LTx landscape in Kazakhstan, emphasizing the urgency of strategic interventions to alleviate the burden on patients awaiting transplantation.

(280) - Ukrainian National Transplant Program During Active Military Invasion

(280) - Ukrainian National Transplant Program During Active Military Invasion

Clinical Characteristics, Etiology, and Prognostic Scores in Patients with Acute Decompensated Liver Cirrhosis.

Chronic liver disease and cirrhosis contribute significantly to global mortality, with limited improvements despite medical advancements. This study aims to evaluate acute decompensation of liver cirrhosis characteristics, etiology, and survival outcomes in Oman. In addition, we examined the accuracy of prognostic scores in predicting mortality at 28 and 90 days. We conducted a retrospective analysis of 173 adult patients with acute decompensation of liver cirrhosis at Sultan Qaboos University Hospital in Oman. We collected demographic, clinical, and biochemical data, including etiology, prognostic scores (CTP, MELD-Na, CLIF-C), and health outcomes. Alcohol (29.5%), hepatitis C (27.75%), and hepatitis B (26.74%) were the predominant causes of liver cirrhosis in our cohort. Hepatic encephalopathy, mechanical ventilation, and admission to the intensive care unit were strongly associated with an increased mortality rate. The 1-year readmission rate stood at 42.2%. Liver transplantation was performed in 4.1% of cases. The overall mortality rate was approximately 40% during the follow-up period, and the cumulative 28-days and 90-days mortality rates were 20.8% and 25.4%, respectively. Prognostic scores (CTP, MELD-Na, CLIF-C) effectively predicted 28- and 90-day mortality, with CLIF-C demonstrating superior performance (AUROC 0.8694 ± 0.0302 for 28-day mortality and AUROC 0.8382 ± 0.0359 for 90-day mortality). Alcohol and viral hepatitis are the leading causes of liver cirrhosis in our study. Hepatic encephalopathy is a significant predictor of poor outcomes. Prognostic scores (CTP, MELD-Na, CLIF-C) have valuable predictive abilities for short-term mortality. These findings highlight the importance of public strategies to reduce alcohol consumption and the need for the comprehensive management of liver cirrhosis in Oman. Early diagnosis and intervention can improve clinical outcomes and support the establishment of a national organ transplantation program to address the healthcare challenge effectively.

The National Organ Donation and Transplantation Program in Greece: Gap Analysis and Recommendations for Change.

Greece has fallen far behind many comparable European countries in the field of organ donation and transplantation and has made little progress over the past decade. Despite efforts to improve its organ donation and transplantation program, systemic problems persist. In 2019, the Onassis Foundation commissioned a report to be prepared by the London School of Economics and Political Science that focused on the state of the Greek organ donation and transplantation program and proposed recommendations for its improvement. In this paper, we present our analysis of the Greek organ donation and transplantation program together with an overview of our specific recommendations. The analysis of the Greek program was undertaken in an iterative manner using a conceptual framework of best practices developed specifically for this project. Our findings were further developed via an iterative process with information provided by key Greek stakeholders and comparisons with case studies that featured successful donation and transplantation programs in Croatia, Italy, Portugal, Spain, and the United Kingdom. Because of their overall complexity, we used a systems-level approach to generate comprehensive and far-reaching recommendations to address the difficulties currently experienced by the Greek organ donation and transplantation program.

"Let's Live Life - Let's Give Life”: Donor Program Improvement as the Key to Transplantation Success in 21<sup>st</sup> Century - A Croatian Experience

Transplantation is a widely accepted and successful life-saving treatment for hundreds of thousands of patients. However, transplant medicine still faces a number of obstacles. One of the most significant is the large disparity between the number of donors and recipients and the growing need for re-transplantation. In the last two decades, the improvement and organization of the national transplantation program in Croatia have resulted in a steadily increasing donor rate and therefore the transplantation numbers. As the key points of the donor program's success, I would single out the appointment of hospital and national transplant coordinators, the financial reimbursement model for additional medical staff engaged with the donors, the adoption of new legislation, public awareness campaigns and international cooperation with Eurotransplant.

The impact of islet mass, number of transplants, and time between transplants on graft function in a national islet transplant program

The UK islet allotransplant program is nationally funded to deliver one or two transplants over 12 months to individuals with type 1 diabetes and recurrent severe hypoglycemia. Analyses were undertaken 10 years after program inception to evaluate associations between transplanted mass; single versus two transplants; time between two transplants and graft survival (stimulated C‐peptide >50 pmol/L) and function. In total, 84 islet transplant recipients were studied. Uninterrupted graft survival over 12 months was attained in 23 (68%) single and 47 (94%) (p = .002) two transplant recipients (separated by [median (IQR)] 6 (3–8) months). 64% recipients of one or two transplants with uninterrupted function at 12 months sustained graft function at 6 years. Total transplanted mass was associated with Mixed Meal Tolerance Test stimulated C‐peptide at 12 months (p < .01). Despite 1.9‐fold greater transplanted mass in recipients of two versus one islet infusion (12 218 [9291–15 417] vs. 6442 [5156–7639] IEQ/kg; p < .0001), stimulated C‐peptide was not significantly higher. Shorter time between transplants was associated with greater insulin dose reduction at 12 months (beta −0.35; p = .02). Graft survival over the first 12 months was greater in recipients of two versus one islet transplant in the UK program, although function at 1 and 6 years was comparable. Minimizing the interval between 2 islet infusions may maximize cumulative impact on graft function.

Perspective on Macroscale Complexity in the National Transplant System

We present a perspective of the national transplant program based on organizational theory and complexity theory, framing the system’s allocation of donor organs as an interorganizational directed multiplex of agents with diverse belief formation in a cooperative‐competitive environment. Simulation and analysis of this macroscale complexity may help explain known behavioural variations across member organizations. However, the transplant community still relies on system‐scale simulations since effective macroscale methodologies are not well established. Therefore, we offer this perspective of the national transplant program as a means to stimulate new methods that capture macroscale impacts of policy development for deceased donor organ allocation.

Setting up of a national liver transplant programme for neuroendocrine tumour liver metastases in UK and Ireland: opportunities for clinical study and research

Setting up of a national liver transplant programme for neuroendocrine tumour liver metastases in UK and Ireland: opportunities for clinical study and research

Multidisciplinary Development Issues of Hematopoietic Stem Cell Transplantation Program in Ukraine: Role of Auxiliary Cryopreservation Technologies

Hematopoietic stem cell transplantation (HSCT) is a life-saving medical technology for many serious diseases. Active international exchange of transplant material is ensured through productive cooperation of world international donation, transplantation, cell therapy organizations, along with their associations. Analysis of the experience of many countries has allowed the development of key recommendations from the Worldwide Network for Blood and Marrow Transplantation for establishing HSCT programs. According to them, to make the most effective use of the capabilities of this medical technology, the creation of new transplant programs requires both sufficient investment and the presence of specialized professional teams for multidisciplinary support of the entire process.&#x0D; This article discusses prospects for the development of the national transplant program in Ukraine. In particular, the role of Ukrainian national scientific and practical traditions detailed in the creation of cellular processing technologies and cryopreservation as part of the team support providing components of transplantation medical technology. It is looked forward that the development of the HCST program in Ukraine will take place through continuous improvement in order to meet the criteria of the highest quality and safety. Its serious basis is the solid scientific traditions, historical and modern experience of many directions that provide the field.

The impact of the COVID‒19 pandemic on organ donation and transplantation in Hungary in 2020

The spread of the SARS-CoV-2 pandemic has resulted in drastic changes in day-to-day patient care, which has also affected the field of organ donation and transplantation, thus reducing the number of donations and transplants from living and deceased donors worldwide. In addition to the reduction in the number of cases, additional safety measures had to be introduced to protect transplanted and implicatively immunosuppressed patients. The aim of the study was to demonstrate the impact of the COVID-19 epidemic on domestic donation and transplantation activity in 2020, compared to the previous year. We also compared the Hungarian results with the data of the Eurotransplant and the European Union member states. In terms of population-weighted, registered COVID-19 infection and mortality, we did not find a significant difference in Hungary in 2020 compared to the Eurotransplant member states. The national organ donation potential did not diminish in the period under review, however, the number of brain-dead organ donors decreased by 38.33% in Hungary, while in the Eurotransplant it did by 8.64% on average and in 23 reporting European countries by 17.55%. The number of organ transplants from the deceased decreased by 29.27%, especially regarding heart and liver transplants. Both the number and the proportion of organs received from abroad increased by 21.13% and 12.34%, respectively. The number of living donor kidney transplants did not change. In 2020, 25% fewer new patients were registered than in 2019 and the mortality on waiting list increased by 28% compared to the previous year, especially among those waiting for a kidney transplant. The national organ transplantation program is safe: donor-derived SARS-CoV-2 transmission did not occur in Hungary. In addition to the organ donation potential and the COVID-19 pandemic, organ donation and transplantation activity decreased significantly in Hungary from March 2020 until the end of the year. Transient and smaller reductions in organ donation rates have been reported in most European countries. The number of organ transplants did not decrease as much as the number of donors, because more donor organs arrived in Hungary from the Eurotransplant than we sent abroad. Orv Hetil. 2021; 162(23): 890-896.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

P1841THE JOURNEY OF KIDNEY TRANSPLANTATION IN EGYPT: STILL EXTRA-MILES TO GO

Abstract Background and Aims Kidney transplantation is the renal replacement therapy of choice for patients with end-stage kidney disease. Egypt is a developing country with social, religious and demographic characteristics having enormous impact on the development and progress of its own national transplant program. Method A web-based review of relevant bibliography: articles and textbooks, reporting the progress in the transplant practice in Egypt and its legislations was conducted. Results Kidney transplantation started in Egypt about 43 years ago when the first transplant was performed at Mansoura Urology and Nephrology Center (UNC) in March 1976. The practice of kidney transplantation in Egypt has then evolved over the years. While about ten thousand transplants were performed from 1976 to 2011, the annual mean number of kidney transplantation between 2011 and 2016 increased to 1100 cases/year. The number of transplant centers has also grown from 12 in 1997 to 35 currently licensed centers. However, Egypt is still lacking a national transplant registry data. The legal framework developed over the last decade towards establishing a national transplant program. Until 2010, organ transplantation was only regulated by the professional code of ethics and conduct of the Egyptian Medical Syndicate. Representatives of the Istanbul Declaration met with the Egyptian Minister of Health and Egyptian Society of Nephrology leaders in Cairo in October 2008; since then, Egypt has been working to terminate illegal practices associated with organ transplantation, organ trafficking and transplant tourism. The first legislation for a national organ transplant program “The executive list for law number 5 of the year 2010 regarding regulating human organ transplants” was then issued after approval by the parliament. The law established “The Higher Committee for Organ Transplants” which includes 7 - 11 experts and is responsible for regulating and supervising all organ and tissue transplant procedures in the country. The new law criminalizes organ trafficking and set strict penalties for physicians, hospitals and medical facilities performing illegal organ transplant procedures. In 2017, the legislation has been further modified to make the penalties even harsher “Law number 142 of the year 2017 modification of some articles in law number 5 of the year 2010 regarding regulating human organ transplants”. Transplantation practice is still limited to live transplants. The cadaveric transplant program has not yet been put into action despite the new 2010 legislation has set the legal framework, yet lacking a clear definition of the legal death. Cadaveric transplantation was performed twice in Egypt in 1992 at Cairo (kasr El Aini hospital) from 2 criminals after execution in Alexandria. This was faced with social anger and rejection which led to legal restrictions for non-living organ procurement at that time. Barriers to establishment of a national transplant program in Egypt include cultural and religious rejection of deceased donation, organ shortage, and long waiting time in national transplant centers. Conclusion Despite the recent ameliorations in the current Egyptian transplant practice, the overall progress has been slow. This can be attributed to a complex interaction between social, religious and financial factors. Further advances are vital to reduce the burden implied by the state-funded dialysis therapy and to demolish organ trafficking and transplant tourism. As such, state efforts would continue to further improve the living donor and to implement the deceased donor transplantation programs.

P1662COMMERCIAL KIDNEY TRANSPLANTATION: PARTICIPANTS' ATTITUDES AND PERCEPTIONS

Abstract Background and Aims Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. The national diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program and to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant. Method A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 28 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. Results One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program. Conclusion Even considering the ongoing ethical debates, number of patients undergoing commercial transplantation is on the rise. The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from cadaveric sources.

Characterization of pre-transplant psychosocial burden in an integrated national islet transplant program

ABSTRACT The psychological burden experienced by people with diabetes prior to islet transplantation is recognized but has not been studied comprehensively, especially in relation to glycemia. Therefore, we conducted a rigorous pre-operative psychosocial profile of UK islet transplant recipients, and compared groups with higher/lower HbA1 c to test the null hypothesis that pre-transplant hypoglycemia awareness and psychosocial burden would not be related to baseline HbA1 c in this high-risk cohort. Pre-transplant, recipients (n = 44) completed validated hypoglycemia awareness questionnaires and generic/diabetes-specific measures of psychological traits and states. Scores were compared in groups, dichotomized by HbA1 c (≤8% versus >8%). Participants were aged (mean±SD) 53 ± 10 years; 64% were women; with HbA1 c 8.3 ± 1.7%. Median rate of severe hypoglycemia over the preceding 12 months was 13 events/person-year and 90% had impaired awareness of hypoglycemia (Gold/Clarke score ≥4). Participants had elevated fear of hypoglycemia (HFS-II Worry), impaired diabetes-specific quality of life (DQoL) and low generic health status (SF-36; EQ-5D). One quarter reported scores indicating likely anxiety/depression (HAD). Dispositional optimism (LOT-R) and generalized self-efficacy (GSE) were within published ‘norms.’ Despite negative perceptions of diabetes (including low personal control), participants were confident that islet transplantation would help (BIPQ). Hypoglycemia awareness and psychosocial profile were comparable in lower (n = 24) and higher (n = 20) HbA1 c groups. Islet transplant candidates report sub-optimal generic psychological states (anxiety/depressive symptoms), health status and diabetes-specific psychological states (fear of hypoglycemia, diabetes-specific quality of life). While their generic psychological traits (optimism, self-efficacy) are comparable with the general population, they are highly optimistic about forthcoming transplant. HbA1 c is not a proxy measure of psychosocial burden, which requires the use of validated questionnaires to systematically identify those who may benefit most from psychological assessment and support.

Progressive improvement in short‐, medium‐ and long‐term graft survival in kidney transplantation patients in Ireland – a retrospective study

It is often quoted that while short-term graft survival in kidney transplantation has improved in recent years, it has not translated into a commensurate improvement in long-term graft survival. We considered whether this was true of the entire experience of the national kidney transplant program in Ireland. A retrospective analysis of the National Kidney Transplant Service (NKTS) database was undertaken to investigate patient and graft survival for all adult first deceased donor kidney transplant recipients in Ireland, 1971-2015. Three thousand two hundred and sixty recipients were included in this study. Kaplan-Meier methods were used to estimate survival at each time period post transplant for the various eras of transplantation. Uncensored graft survival has improved over the course of the program in Ireland at various time points despite risk factors for graft failure progressively increasing over successive eras. For example the graft survival at 15years post transplant has increased from 10% in 1971-1975 to 45% by 1996-2000. Ireland has experienced a progressive improvement in long-term graft survival following kidney transplantation. Whether these trends are attributable to biological or nonbiological factors is unclear but likely involves a combination of both.

Transplantation Tourism and Recipients Perspectives and Experience

Background and Objectives Kidney transplantation is the gold standard for patients with end- stage kidney disease (ESKD). In view of shortages of available organs, long wait times for possible transplantation and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for ESKD patients to elect for commercial transplant. Design, Setting, Participants & Measurements A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. Results One hundred fifty patients were approached to participate and 106 agreed to participate. Of the participantsConclusions The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from deceased sources. All western ethical arguments turn out to become of vital importance in developing countries, because transplantation is the cheapest renal replacement therapy. However, it must be emphasized that commercial transplants should not be an alternative to building a national transplant initiative. National diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation.

Development of the National Transplant Program Has Significantly Decreased but Not Ended Transplant Tourism in Montenegro

Organ transplantation has prolonged and improved the lives of many patients around the world. However, a widespread shortage of donors remains the main factor that has led to organ trafficking and transplant tourism. To stop transplant tourism and to provide optimal treatment for its citizens with end-stage renal disease, Montenegro started performing renal transplantations in September 2012. Thirty-five transplantations have been performed since that time, 34 from living donors and only 1 from a deceased donor. This practice has significantly decreased but not ended transplant tourism in Montenegro.

Implementation of telehealth is associated with improved timeliness to kidney transplant waitlist evaluation

Introduction The United States Department of Veterans Affairs (VA) National Transplant Program has made efforts to improve access by introducing Web-based referrals and telehealth. The aims of this study were to describe the programmatic implementation and evaluate the effectiveness of new technology on the timeliness to kidney transplant evaluation at a VA medical centre. Methods Between 1 January 2009 and 31 May 2016, 835 patients were approved for evaluation. Monthly data were summarized as: number of applications, median days to evaluation, and median percentage of evaluations that occurred within 30 days. Temporal trends were analysed using non-parametric comparisons of medians between three eras: Pre Web-based submission, Web-based submission, and Web-based submission with videoconference (VC) telehealth. Results The number of applications did not vary between eras (p = 0.353). The median time to evaluation and the median percentage of patients with appointments within 30 days improved significantly in the Web-based submission with VC era when compared with the Web-based and Pre Web-based eras (37 vs. 260 and 116 days, respectively, p < 0.001; 100% vs. 8% and 0%, respectively, p < 0.001). Discussion We have been able to markedly improve the timeliness to kidney transplant waitlist evaluation with the addition of telehealth.