Network For Organ Sharing Database Research Articles

Changes in Donor Utilization and Outcomes for Patients Bridged With Durable Left Ventricular Assist Device.

We studied the impact of the 2018 heart allocation policy change on donor characteristics and posttransplant outcomes of left ventricular assist device (LVAD)-bridged heart transplant (HT) recipients. Left ventricular assist device-bridged adult HT recipients from October 2014 to October 2022 in the United Network for Organ Sharing database were categorized into old allocation policy (OAP) and new allocation policy (NAP) cohorts. Baseline characteristics, posttransplant outcomes, and subgroup analyses of unstable and stable LVAD-bridged recipients were assessed. The study included 7,384 HT recipients; 4,345 (58.8%) were transplanted in the OAP era and 3,039 (41.2%) in the NAP era. Old allocation policy recipients were most frequently status 1A at transplantation (71.1%), whereas NAP recipients were most frequently status 3 (40.0%), and status 4 (31.9%). Median donor sequence number (DSN) was higher in the NAP versus OAP era (9 vs. 3, p < 0.001). On multivariable analysis, NAP recipients had 20% higher 1 year mortality compared to OAP (adjusted hazard ratio [aHR] = 1.20 [95% confidence interval {CI}: 1.04-1.40], p = 0.01). Status 1 or 2 recipients had 28% higher 1 year mortality compared to status 1A (aHR = 1.28 [95% CI: 1.01-1.63], p = 0.04). Status 1 and 2 LVAD-supported recipients had higher mortality following the 2018 allocation change, indicating the need for closer surveillance of LVAD-bridged patients who may decompensate on the waitlist.

A Decade of Liver Transplantation in the United States: Drivers of Discard and Underutilization.

Organ shortage remains a major challenge for the field of transplantation. Maximizing utilization and minimizing discard of available organs is crucial to reduce waitlist times. Our aim was to investigate the landscape of liver recovery, discard over the past decade in the United States, and identify areas to reduce organ discard. This study used the Scientific Registry of Transplant Recipients United Network for Organ Sharing database to analyze the rates and associated reasons of discarded organs from 2010 to 2021. All deceased donors were evaluated, and data were analyzed by organ type, year, and region. Organ disposition was analyzed by year and region. Donor demographics and liver biopsy data were also analyzed. The volume of liver transplantation increased steadily, with a 44% increase from 2010 to 2021. Donation after circulatory death transplantation increased by 239%, comprising 10.6% of transplants in 2021, yet discard rates remained high at 30% for this donor subset. For all donor types, the liver discard rate has remained stable around 10% despite a 74% increase in available donors. Seventy percent of liver discards were attributed to organ factors, with biopsy findings accounting for 40% of all discards. Of livers that were biopsied, 70% had macrosteatosis of <30%. Analysis of trends in transplantation and discard allow for identifying areas of underutilization. Donation after circulatory death livers have expanded the pool of transplanted livers but remain discarded at high rates. Significant differences remain in discard rates between geographic regions. We identify several areas to lower the discard rates. The expanding role of machine perfusion may allow for utilization of previously discarded organs.

Live-donor kidney transplant outcome prediction (L-TOP) using artificial intelligence.

Outcome prediction for live-donor kidney transplantation improves clinical and patient decisions and donor selection. However, the concurrently used models are of limited discriminative or calibration power and there is a critical need to improve the selection process. We aimed to assess the value of various artificial intelligence (AI) algorithms to improve the risk stratification index. We evaluated pre-transplant variables among 66914 live-donor kidney transplants (performed between 01/12/2007-01/06/2021) from the United Network of Organ Sharing database, randomized into training (80%) and test (20%) sets. The primary outcome measure was death-censored graft survival. We tested four machine learning models for discrimination (time-dependent concordance index, CTD, and area under the ROC curve) and calibration (integrated Brier score, IBS). We used decision curve analysis to assess the potential clinical utility. Among the models, the deep Cox mixture model showed the best discriminative performance (AUC=0.70, 0.68, and 0.68 at 5, 10, and 13 years post-transplant, respectively). CTD reached 0.70, 0.67, and 0.66 at 5, 10, and 13 years post-transplant. The IBS score was 0.09, indicating good calibration. In comparison, applying the Living Kidney Donor Profile Index (LKDPI) on the same cohort produced a CTD of 0.56 and an AUC of 0.55-0.58 only. Decision curve analysis showed an additional net benefit compared to the LKDPI, 'Treat all' and 'Treat None' approaches. Our AI-based deep Cox mixture model, termed Live-Donor Kidney Transplant Outcome Prediction outperforms existing prediction models, including the LKDPI, with the potential to improve decisions for optimum live donor selection by ranking potential transplant pairs based on graft survival. This model could be adopted to improve the outcomes of paired exchange programs.

National Trends in Utilization of Normothermic Machine Perfusion in DCD Liver Transplantation.

In liver transplantation, advances in ex situ normothermic machine perfusion (NMP) have improved outcomes compared with traditional static cold storage (SCS) in donation after circulatory death (DCD) organs. We aimed to characterize trends in the utilization of NMP versus SCS in DCD liver transplantation in the United States. This retrospective cohort study used data from the United Network for Organ Sharing database to identify recipient-donor adult liver transplant pairs from DCD donors from January 2016 to June 2022. Utilization of NMP and changes in donor risk index (DRI) and components between NMP and SCS were assessed across transplant year eras (2016-2018, 2019-2020, and 2021-2022). Statistical comparisons were made using the Kruskal-Wallis test or the chi-square test. A total of 3937 SCS and 127 NMP DCD donor transplants were included. Utilization of NMP ranged from ~0.4% to 3.5% from 2016 to 2021 and rose significantly to 11.2% in early 2022. Across transplant eras, median DRI increased significantly for SCS and NMP, but the magnitude of the increase was larger for NMP. With NMP DCDs, there were significant increases in median donor age, national share proportion, and "cold ischemic time" over time. Finally, there was a shift toward including higher DRI donors and higher model for end-stage liver disease score transplant recipients with NMP in later transplant eras. In recent years, NMP utilization has increased and expanded to donors with higher DRI and recipients with higher model for end-stage liver disease score at transplant, suggesting increasing familiarity and risk tolerance with NMP technology. As NMP remains a relatively new technique, ongoing study of patient outcomes, organ allocation practices, and utilization patterns is critical.

Indications and outcomes of liver transplantation for liver tumors in the United States

BackgroundWhile hepatocellular carcinoma (HCC) remains the leading cause of liver transplant (LT) for liver tumors, indications have broadened over the years. Data regarding patient characteristics and outcomes of LT for liver tumors are limited. MethodsFrom Jan-2002 to March-2022, 14,406 LT recipients for various liver tumors were identified in United Network for Organ Sharing database. Overall post-transplant survival analysis was performed with Kaplan-Meier method and multivariable Cox proportional-hazards model. ResultsDuring the study period, indications for LT for various hepatic tumors were HCC (88.5 %), benign tumors (5.1 %), cholangiocarcinoma (3.9 %), angiosarcoma (0.7 %), bile duct cancer (0.7 %), secondary tumors (0.5 %) and others (0.7 %). Compared to non-HCC, LT recipients for HCC were older (median age 61 vs 54 years, P < 0.001), more often male (77% vs 48 %, P < 0.001), more often Hispanic (16% vs 8.0 %), had higher BMI (28.2 vs 25.3, P < 0.001) and higher prevalence of Hepatitis C (53% vs 3.9 %, P < 0.001). Donor characteristics across various groups were similar. One-year survival in LT recipients of HCC was higher (HCC: 91.7% vs. non-HCC: 90.3 %) with adjusted Hazard Ratio (aHR) of 0.87; 95 % CI 0.77–0.99, P = 0.033 in a multivariable Cox regression analysis. Compared to HCC, survival outcomes were worse in cholangiocarcinoma (aHR 1.70; 95 %CI 1.43–2.01, P < 0.001), bile duct cancer (aHR 3.03; 95 %CI 2.12–4.33, P < 0.001), secondary tumors including colon cancer and neuroendocrine tumors (aHR 1.88; 95 % CI 1.24–2.85, P = 0.003), with best survival in patients with benign tumors (aHR 0.57; 95 %CI 0.46–0.70, P < 0.001). ConclusionsLT is performed for various liver tumors with variable outcomes among these primary indications.

(913) - Does Ex Vivo Lung Perfusion Mitigate the Detrimental Effects of Primary Graft Dysfunction? A Propensity Matched Analysis of the United Network for Organ Sharing Database

(913) - Does Ex Vivo Lung Perfusion Mitigate the Detrimental Effects of Primary Graft Dysfunction? A Propensity Matched Analysis of the United Network for Organ Sharing Database

(893) - Have Policy Changes Improved Geographical Disparities in Lung Transplantations? An Analysis of the United Network of Organ Sharing Database

(893) - Have Policy Changes Improved Geographical Disparities in Lung Transplantations? An Analysis of the United Network of Organ Sharing Database

Long-Term Survival Following Primary Graft Dysfunction Development in Lung Transplantation

IntroductionPrimary graft dysfunction (PGD) is a known risk factor for early mortality following lung transplant (LT). However, the outcomes of patients who achieve long-term survival following index hospitalization are unknown. We aimed to determine the long-term association of PGD grade 3 (PGD3) in patients without in-hospital mortality. MethodsLT recipients were identified from the United Network for Organ Sharing Database. Patients were stratified based on the grade of PGD at 72 h (No PGD, Grade 1/2 or Grade 3). Groups were assessed with comparative statistics. Long-term survival was evaluated using Kaplan–Meier methods and a multivariable shared frailty model including recipient, donor, and transplant characteristics. ResultsThe PGD3 group had significantly increased length of stay, dialysis, and treated rejection post-transplant (P < 0.001). Unadjusted survival analysis revealed a significant difference in long-term survival (P < 0.001) between groups; however, following adjustment, PGD3 was not independently associated with long-term survival (hazard ratio: 0.972; 95% confidence interval: 0.862-1.096). Increased mortality was significantly associated with increased recipient age and treated rejection. Decreased mortality was significantly associated with no donor diabetes, bilateral LT as compared to single LT, transplant in 2015-2016 and 2017-2018, and no post-transplant dialysis. ConclusionsWhile PGD3 remains a challenge post LT, PGD3 at 72 h is not independently associated with decreased long-term survival, while complications such as dialysis and rejection are, in patients who survive index hospitalization. Transplant providers should be aggressive in preventing further complications in recipients with severe PGD to minimize the negative association on long-term survival.

Predictors of early mortality after lung transplantation for idiopathic pulmonary arterial hypertension.

Lung transplantation remains an important therapeutic option for idiopathic pulmonary arterial hypertension (IPAH),yet short-term survival is the poorest among the major diagnostic categories. We sought to develop a prediction model for 90-day mortality using the United Network for Organ Sharing database for adults with IPAH transplanted between 2005 and 2021. Variables with a pvalue ≤ 0.1 on univariate testing were included in multivariable analysis to derive the best subset model. The cohort comprised 693 subjects, of whom 71 died (10.2%) within 90 days of transplant. Significant independent predictors of early mortality were: extracorporeal circulatory support and/or mechanical ventilation at transplant (OR:3; CI: 1.4-5), pulmonary artery diastolic pressure (OR:1.3 per 10 mmHg; CI: 1.07-1.56), forced expiratory volume in the first second percent predicted (OR:0.8 per 10%; CI: 0.7-0.94), recipient total bilirubin >2 mg/dL (OR:3; CI: 1.4-7.2) and ischemic time >6 h (OR: 1.7, CI: 1.01-2.86). The predictive model was able to distinguish 25% of the cohort with a mortality of ≥20% from 49% with a mortality of ≤5%. We conclude that recipient variables associated with increasing severity of pulmonary vascular disease, including pretransplant advanced life support, and prolonged ischemic time are important risk factors for 90-day mortality after lung transplant for IPAH.

(1346) - Panel Reactive Antibody, Crossmatch Status, and Outcomes in Pediatric Heart Transplant Recipients with Congenital Heart Disease: An Analysis of the United Network for Organ Sharing Database

(1346) - Panel Reactive Antibody, Crossmatch Status, and Outcomes in Pediatric Heart Transplant Recipients with Congenital Heart Disease: An Analysis of the United Network for Organ Sharing Database

The Impact of Local Programmatic Decisions on Outcomes in Transplant-Listed Adults With Congenital Heart Disease

We investigated variables impacting waitlist time and negative waitlist outcomes in adult congenital heart disease (ACHD) orthotopic heart transplant (OHT) candidates following the 2018 allocation change. Adult OHT candidates listed between 10/18/2018-12/31/2022 in the United Network for Organ Sharing database were categorized as ACHD vs. non-ACHD. Waitlist time and time to upgrade for those upgraded into status 1-3 were compared using rank-sum tests. Death/delisting for deterioration was assessed using Fine-Gray sub-distribution hazard ratios (SHRs). Of 15,424 OHT candidates, 589 (3.8%) were ACHD. ACHD vs. non-ACHD candidates had less urgent status at initial listing (4.2% vs. 4.7% listed at status 1; 17.2% vs. 23.7% listed at status 2, p<0.001), but not final listing (5.9% vs. 7.6% final status 1; 35.6% vs. 36.8% final status 2, p<0.001). ACHD vs. non-ACHD candidates upgraded into status 1 (65.0 vs. 30.0 days, p=0.09) and status 2 (113.0 vs. 64.0 days, p=0.003) spent longer on the waitlist. ACHD vs. non-ACHD candidates spent longer waiting for an upgrade into status 1 (51.4 vs. 17.6 days, p=0.027) and status 2 (76.7 vs. 34.7 days, p=0.003). Once upgraded, there was no difference between groups in waitlist time as status 1 (9.7 vs. 5.5 days, p=0.66). ACHD vs. non-ACHD candidates with a final status of 1 (20.0% vs. 8.6%; SHR 2.47 [95%CI=1.19-5.16], p=0.02) and 2 (8.9% vs. 2.3%; SHR 3.59 [95%CI=2.18-5.91], p<0.001) experienced higher death/deterioration. ACHD candidates have longer waitlist times, lower priority status at initial listing, wait longer for upgrade, and have higher mortality at the same final status as non-ACHD candidates, suggesting that they are being upgraded too late.

Is Time Scheduling Important? An Analysis of Donor Heart Cross-clamp Times During Heart Transplantation.

Outcomes in heart transplantation are affected by a variety of variables and patient factors. However, the impact of circadian rhythms, gene expression, and transcription remain underexplored. We thus evaluated the potential role of donor heart cross-clamp times on short-term and long-term outcomes after heart transplantation. A total of 31 713 heart transplants were identified from the United Network for Organ Sharing Database. Patients were first stratified on the basis of time of donor procurement: 12 am to 12 pm or 12 pm to 12 am. To evaluate a possible effect of circadian rhythms, donor time was further divided into 5 groups based on preclinical data: 4 am to 8 am; 8 am to 11 am; 11 am to 5 pm; 5 pm to 10 pm; 10 pm to 4 am. Groups were assessed with comparative statistics. Long-term survival was evaluated using Kaplan-Meier methods and a multivariate Cox proportional hazard model. Patients who received hearts recovered between 12 am and 12 pm had significantly higher survival than those who received hearts recovered between 12 pm and 12 am. This survival difference was observed in both unadjusted (P = 0.002) and adjusted analyses (hazard ratio [HR]: 0.93; 95% confidence interval [CI], 0.89-0.97; P < 0.001). On unadjusted analysis, the survival difference among the 5 groups was insignificant (P = 0.07). Following adjustment, the periods of 11 am to 5 pm (HR: 1.09, 95% CI, 1.02-1.17; P = 0.012), 5 pm to 10 pm (HR: 1.11; 95% CI, 1.04-1.19; P = 0.002), and 10 pm to 4 am (HR: 1.07; 95% CI, 1.01-1.15; P = 0.034), were all independently associated with increased long-term mortality. Notably, the time of 8 am to 11 am was not associated with a change in survival (HR: 1.04; 95% CI, 0.96-1.14; P = 0.3). Given the independent association of donor timing and survival after adjustment in a large national cohort, further investigation into the role of donor circadian rhythm and donor procurement time is warranted in preclinical and clinical studies. Understanding the underlying mechanisms of this observation could potentially lead to the development of effective treatments and donor procurement processes that prepare the organs for transplantation in a better condition.

Trends in survival after heart transplantation based on Social Vulnerability Index in the United States

IntroductionThe association of social vulnerability (SV) and cardiac transplant survival remains poorly defined, particularly related to long-term outcomes. The purpose of this study was to define the impact of SV on survival among heart transplant recipients with at least 1-year of survival post-transplant. MethodsHeart transplant recipients were identified using the United Network for Organ Sharing database between 6/1/06-12/31/20. The Center for Disease Control’s Social Vulnerability Index (SVI) database was used to stratify patients based on SVI into three groups: Low: <25; Average: 26-74; High: 75+. The groups were analyzed with comparative statistics, and unadjusted survival was assessed using Kaplan-Meier methods. To determine the independent association between SVI and survival, a multivariable Cox proportional hazard model was created. ResultsThere were 27,740 recipients identified. High SVI patients more commonly identified as Black individuals and had a higher incidence of diabetes, pre-transplant intensive care unit admission and need for concomitant kidney transplant (p<0.05 for all). Additionally, High SVI patients had the longest length of stay post-transplant (21.4 days) (p<0.05). High and Average SVI patients had inferior 3-year, 5-year, and 10-year survival versus Low SVI patients (p<0.05). After adjustment, Average (hazard ratio [HR]:1.12) and High (HR:1.16) SVI were independently associated with an increased risk of mortality on multivariable analysis (both p<0.001). ConclusionHigh or average SVI is independently associated with increased mortality following heart transplantation in patients with 1-year conditional survival. These findings demonstrate that disparities persist among heart transplant recipients during long-term follow up.

Reversibility of precapillary pulmonary hypertension and outcomes after heart transplantation bridged with left ventricular assist devices: Insight from the United Network for Organ Sharing

BackgroundIn light of the updated lowered threshold for diagnosing pulmonary hypertension (PH), the reversibility of precapillary PH with left ventricular assist device (LVAD) and the associated post-heart transplantation (HT) outcomes remain unclear. MethodsUsing data from the United Network for Organ Sharing database, we aimed to investigate predictors of persistent precapillary PH in HT recipients bridged with LVAD and examine the interrelated post-HT survival using the updated pulmonary vascular resistance (PVR) cutoff of >2 Wood units for precapillary PH. ResultsAmong 2169 HT recipients bridged with LVAD, 1299 had PVR >2 at baseline; 551 (42.4%) of whom normalized their PVR ≤2 and 748 (57.6%) remained with elevated PVR >2 after LVAD implantation. Female sex (adjusted odds ratio [aOR]; 2.22, 95% confidence interval [CI], 1.61-3.07; P < .001) and inotrope treatment at listing (aOR, 1.31; 95% CI, 1.03-1.66; P = .028) were associated with persistently elevated PVR after LVAD. Conversely, longer duration of LVAD support (aOR, 0.74; 95% CI, 0.65-0.84; P < .001) and use of HeartMate II (aOR, 0.74; CI, 0.59-0.93; P = .011) were found to be protective against persistently elevated PVR after LVAD. Persistently elevated PVR >2 after LVAD was associated with increased risk of death compared with those who normalized their PVR (adjusted hazard ratio [aHR], 1.26; 95% CI, 1.01-1.57; P = .037). However, the normalized PVR post-LVAD group had comparable survival with those with PVR ≤2 at baseline (aHR, 0.76; 95% CI, 0.57-1.02; P = .07). ConclusionsMany recipients of HT bridged with LVAD remain with PVR >2 after LVAD implantation, which is associated with increased risk of death after HT compared with patients with normalized PVR after LVAD.

Trends and outcomes of heart transplantation in adults with congenital heart disease.

Heart transplantation for adult congenital heart disease is complicated and associated with challenging pretransplant support, long waiting, and high early post-transplant mortality. We explored if surgical and medical advances, and allocation system changes have affected outcomes. From United Network for Organ Sharing database, adults with congenital heart disease listed for heart transplantation were queried. To explore practice and outcome trends, patients were divided into 4 eras (eras1-3: nearly 3 equal periods from 1992-2018, era-4: after 2018, corresponding with new allocation system). Univariate and multivariable analysis was performed to evaluate outcomes. 2737 patients were listed. There was gradual increase in listed and transplanted patients, along with significant increase in use of mechanical support, simultaneous kidney and liver transplantation. While proportion of transplanted remained constant, there was decrease in proportion delisted/died after listing (p = 0.01) and waiting list duration (p = 0.01), especially in era-4. 30-days post-transplant mortality remains high, however, it has significantly improved starting era-3 (p = 0.01). Current survival at 1-year and 5-years is 85% and 65%, with improvement mainly related to decreased early death. On multivariable analysis, factors associated with survival were lower glomerular filtration rate (HR = 0.99, p = 0.042), bilirubin (HR = 1.17, p < 0.001), and mechanical ventilation (HR = 2.3, p = 0.004). Heart transplantation in adults with congenital heart disease is increasing, along with added complexity, higher usage of pretransplant mechanical support and simultaneous organ transplantation. Despite that, more complex patients don't experience worse outcomes. Early mortality improved but remains high. New donor allocation system allowed shorter waiting time and higher proportion transplanted without altering early mortality.

Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience

BackgroundDonation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. MethodsUsing the United Network for Organ Sharing database, we identified adult multiorgan heart candidates and recipients between 1/1/2020 and 3/31/2023. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD vs. brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. ResultsOf 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4% and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to last follow-up. ConclusionsMultiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.

Use of 50 years or older donors in septuagenarian recipients for liver transplantation: Potential to expand the donor pool: Old livers for old transplant recipients

BackgroundWhile younger donors have better liver transplant (LT) outcomes, the median age of both the donor and recipient pools is rising. The impact of using donors ≥50 years on the LT outcomes of septuagenarians is unknown. MethodsFrom 2011–2021, outcomes in septuagenarian LT recipients from donor livers <50 year-old (DON<50) and donor livers ≥50 year-old (DON≥50) were analyzed using the United Network for Organ Sharing database. Post-LT survival analysis was performed with the Kaplan-Meier method and multivariable Cox proportional-hazards model. A propensity score was utilized to conduct one-to-one matching using 14 recipient variables (1230-pairs). ResultsThere were 2797 septuagenarian deceased-donor LT recipients during the study period. Of these, 1487 (53.2 %) were DON <50 with median age of 34 years and 1310 (46.8 %) were DON ≥50 with median age of 60 years. The number of LT for septuagenarians has increased over the last decade. The causes of donor and recipient deaths were different between two groups. Post-LT one-year survival (DON<50: 89.3 % vs. DON≥50: 88.3 %) and five-year survival (DON<50: 41.4 % vs DON≥50: 42.8 %) were comparable. Multivariable Cox proportional-hazards model showed that donor age ≥50 years is not associated with increased mortality after LT in the matched cohort (HR: 1.04, 95 % CI: 0.88–1.24, P = 0.63). ConclusionsThe utilization of carefully selected donor livers older than 50 years may be a viable option for septuagenarian LT candidates by lowering their waitlist time and can maximize the organ utilization without compromising the outcomes.

The effect of donor–recipient sex matches on lung transplant survival: An analysis of the United Network for Organ Sharing database

ObjectiveTo investigate the impact of donor–recipient (DR) sex matches on survival after lung transplantation while controlling for size difference in the United Network of Organ Sharing (UNOS) database. MethodsWe performed a retrospective study of 27,423 lung transplant recipients who were reported in the UNOS database (January 2005-March 2020). Patients were divided into groups based on their respective DR sex match: male to male (MM), male to female (MF), female to female, (FF), and female to male (FM). Kaplan–Meier curve and Cox regression with log-rank tests were used to assess 1-, 3-, 5-, and 10-year survival. We also modeled survival for each group after controlling for size-related variables via the Cox regression. ResultsKaplan–Meier curves showed overall significance at 1-, 3-, 5-, and 10-year end points (P < .0001). Estimated median survival time based on Kaplan–Meier analysis were 6.41 ± 0.15, 6.13 ± 0.18, 5.86 ± 0.10, and 5.37 ± 0.17 years for FF, MF, MM, and FM, respectively (P < .0001). After we controlled for size differences, FF had statistically significantly longer 5- and 10-year survival than all other cohorts. MF also had statistically significantly longer 5- and 10-year survival than FM. ConclusionsWhen variables associated with size were controlled for, FF had improved survival than other DR groups. A female recipient may experience longer survival with a female donor’s lungs versus a male donor’s lungs of similar size.

Contemporary trends and outcomes after liver transplantation and resection for intrahepatic cholangiocarcinoma

BackgroundLiver transplantation has been shown to be superior to resection in highly selected patients with perihilar cholangiocarcinoma, yet has traditionally been contraindicated for intrahepatic cholangiocarcinoma. Herein, we aimed to examine contemporary trends and outcomes for surgical resection and liver transplantation for intrahepatic cholangiocarcinoma. MethodsThe National Cancer Database was queried for patients presenting with stage I-III intrahepatic cholangiocarcinoma between 2010 and 2018 who underwent resection or liver transplantation. Overall survival was compared with Kaplan-Meier and multivariable Cox proportional hazards methods stratified by management. Secondary analysis of patients undergoing transplant for cholangiocarcinoma was performed with the United Network for Organ Sharing database. ResultsOf 2,565 patients, 2,412 (94.0%) underwent resection and 153 (5.96%) liver transplantation of which 84 (54.9%) received neoadjuvant therapy. Utilization of liver transplantation remained between 3.9-7.8% annually. Unadjusted 5-year overall survival was higher for liver transplantation than resection (59.8% vs 39.9%, p=0.0067). Yet, adjusted analysis revealed no significant difference in mortality (hazard ratio 0.91, 95% confidence interval 0.66-1.27, p=0.58). On secondary analysis including 437 patients with all subtypes of cholangiocarcinoma, unadjusted 5-year overall survival was higher for non-cholangiocarcinoma indications (79% vs 52-54%, p<0.001). ConclusionUtilization of liver transplantation for intrahepatic cholangiocarcinoma remains low and many cases are likely incidental. While partial hepatectomy remains the standard of care for patients with resectable disease, our findings suggest that highly selected patients with unresectable intrahepatic cholangiocarcinoma may achieve favorable outcomes after liver transplantation. Granular, prospective data is needed to identify patients most likely to benefit from transplant and allocate scarce liver grafts.

Pretransplant malignancy in pediatrics is not a risk factor for renal graft failure.

In adults, pretransplant malignancy (PTM) negatively impacts patient survival due to immunosuppression regimens influencing post-transplantation tumor growth. Few reports investigate the outcomes of pediatric kidney transplantation with PTM. We compare transplant outcomes for pediatric patients with PTM to matched controls, including cancer types extending beyond Wilms tumor. The United Network of Organ Sharing Database was queried to identify pediatric transplant recipients with histories of PTM. All PTM patients were matched to non-PTM patients, at a 1:1 ratio, with 0.001 match tolerance. Matching variables included transplant year, recipient age, recipient gender, recipient race, donor type, and prior transplant. Death-censored graft and patient survival were analyzed. All statistics were reported with 95% confidence intervals (CI). After propensity matching, 285 PTM and 285 non-PTM patients were identified, with transplant dates from 1990 to 2020. Median Kidney Donor Profile Index values were comparable between cohorts, 17% and 12%, respectively (p = .065). Kaplan-Meier analysis revealed that PTM patients did not have a significantly different rate of death-censored graft failure, compared to the non-PTM group [HR 0.76; 95% CI (0.54-1.1)]. There was also no difference in the overall survival between the two groups of patients [HR 1.1; 95% CI (0.66-2.0)]. A history of pediatric malignancy has minimal independent effect on their post-transplant survival. Additionally, pediatric patients with PTM demonstrated equivalent rates of graft survival. Thus, in contrast to adults, renal failure in children with history of pediatric malignancies should not be considered a complicating factor for renal transplantation.