Older Recipients Research Articles

‘I worry about you more’: insights from older care recipients’ experiences during the Israel-Hamas war

Objectives This study explored the experiences and challenges of older adults with functional disabilities in Israel during the ongoing Israel-Hamas war, particularly those receiving care from migrant live-in carers. The main objectives were to identify their main concerns and coping strategies during this period. Method A qualitative methodology was employed, involving face-to-face interviews with 13 older adults (mean age 91.33, SD = 5.31). All participants liveded in separate housesholds with the assistance of migrant live-in carers. They were recruited through purposive and snowball sampling techniques. The interviews were analyzed using thematic content analysis. Results Two main themes emerged from data analysis: 1) Concerns for others affected by the war and concerns for oneself, and 2) Coping strategies, including utilizing personal resources such as optimism and distraction, seeking connections with family members and carers, and contributing to the community. Conclusion The study highlights the interplay between the vulnerabilities and strengths of older adults during wartime. Their ability to mobilize both internal and external coping strategies reflects an active approach to managing the stress and uncertainties of war, underscoring their resilience and agency and challenging the perception of older adults as passive recipients of care.

Assessing Long-Term Adverse Outcomes in Older Kidney Transplant Recipients: A Propensity Score-Matched Comparison of Early Steroid Withdrawal Versus Continuous Steroid Immunosuppression Using a Large Real-World Database.

Steroids are widely used in maintenance immunosuppression treatment in kidney transplant recipients. Older individuals undergo age-related immunosenescence that consequently decreases their ability to process and evoke a response to foreign antigens. Thus, steroids may not be necessary in preventing allograft rejection and may consequently increase older recipients' risk of long-term steroid-related adverse effects. The objective of this study was to analyze the adverse outcomes of long-term steroid immunosuppression in older kidney transplant recipients using real-world electronic medical record data. The TriNetX database "US Collaborative Network" was utilized to perform a propensity score-matched case-control study comparing 1-year, 3-year, and 5-year adverse effects of steroid immunosuppression in older adults (aged ≥65 years) kidney transplant recipients who underwent either an early-steroid withdrawal (ESW) maintenance regimen or a steroid continuous immunosuppression (SCI) regimen between 31 December, 2010 and 31 December, 2020. Early-steroid withdrawal was defined as tacrolimus plus mycophenolate mofetil maintenance with no prednisone after the seventh day post-transplant. Steroid continuous immunosuppression was defined as tacrolimus plus mycophenolate mofetil plus prednisone maintenance. Cohorts were matched on age, race/ethnicity, and risk factors for adverse steroid-related outcomes and rejection. Outcomes included post-transplant diabetes mellitus, dyslipidemia osteoporosis/fractures, myocardial infarction, glaucoma/cataract, stroke, pulmonary embolism, and malignancy. Secondary outcomes analyzed incidences of infection-related outcomes, graft-related outcomes, and recipient mortality. After matching, there were 304 recipients in each group (ESW, SCI). Mean age at the time of transplant was 69.2±3.7 years (ESW) and 69.2±3.4 years (SCI, p=0.96). The Kaplan-Meier analysis showed recipients who underwent SCI had increased incidences of post-transplant diabetes mellitus at 1 year (22.36% vs 30.37%, p=0.01) and 3 years (34.89% vs 44.29%, p=0.01), but this became non-significant at 5 years post-transplant (41.97% vs 42.6%, p=0.34). Incidences of acute pancreatitis were higher for the SCI cohort at 3 years (p=0.02) as well as incidences of acute myocardial infarction at 5 years post-kidney transplant (6.75% vs 14.39%, p<0.01). No difference was found for other adverse outcomes. Early-steroid withdrawal recipients experienced significantly fewer infection-related outcomes, such as cytomegalovirus, BK virus, sepsis/bacteremia, and fungal infections, compared with SCI recipients. Last, recipients who underwent ESW experienced fewer incidences of rejection and death-censored graft failure at 5 years post-transplant. There is currently no standard maintenance immunosuppression protocol for older kidney transplant recipients. Death-censored graft survival, rejection, and patient survival were improved with ESW. Steroid minimization may be beneficial in this population given that it lowers the risk of drug-induced adverse effects.

Association of Senescence Markers with Age and Allograft Rejection in Renal Transplant Recipients.

Renal transplantation is the treatment of choice for patients with end-stage renal disease. In the last decade, the number of older renal transplant recipients has significantly increased. However, these patients are at a higher risk of developing post-transplant complications. Therefore, identifying the suitable biomarkers to predict which older patients are at risk of complications is crucial. Cellular senescence could provide insights into the increased vulnerability in this population and guide personalized post-transplant care. This preliminary study involved biopsies from 25 patients with renal allograft rejection and 18 patients without rejection, further divided into older (50-65 years) and younger (29-40 years) groups. Biopsies were collected at different time points after transplantation, and rejection was classified according to the histological Banff 07 criteria. Additionally, immunohistochemistry for the markers of cellular senescence, p27kip1 and p16INK4a, was performed. We observed that the number of p27kip1-positive glomeruli was higher in the older patients with rejection compared to the younger patients with rejection, and a similar pattern was found in the patients without rejection. However, the number of p27kip1-positive tubules was higher in the older patients with rejection compared to the younger patients with rejection, as well as compared to both the older and younger patients without rejection. Tubular p16INK4a expression was not significantly different in the older patients with rejection compared to the younger patients with rejection, and the same pattern was observed in the patients without rejection. However, it was increased in the older patients with rejection in comparison to the older patients without rejection. Our preliminary data suggest the strong potential of both p16INK4a and p27kip1 as biomarkers of renal graft rejection, particularly in older renal transplant recipients.

Renal transplantation in older adults: retrospective cohort study to examine the impact of the new 2019 kidney offering scheme on older adult transplant recipients.

In 2019, a new kidney offering scheme was launched in the United Kingdom, aiming to better match estimated patient survival and graft life expectancy. The scheme's impact on older patients undergoing kidney transplantation (KT) is unknown. This study aims to compare the outcomes of older adult KT recipients before and after introduction of the 2019 scheme. A retrospective observational cohort study of older adults who underwent KT was undertaken. Group 1 were transplanted between 1 September 2017 and 31 August 2019 (2006 allocation scheme) and group 2 between 1 September 2019 and 31 August 2021 (2019 offering scheme). An older adult was any person ≥60 years old at the time of KT. Univariable binary logistic regression analysis was performed to determine odds ratios (OR) and 95% confidence intervals (CI). There were 107 older adult deceased donor KT recipients, 62 from group 1 and 45 from group 2. Median age at transplantation was 68 (interquartile range [IQR] 62-71) and 67 (IQR 64-73) years, respectively. Univariable analysis showed that re-intervention (OR 6.486, 95% CI 1.306-32.216, p = 0.022) and critical care admission (OR 5.619, 95% CI 1.448-21.812, p = 0.013) were significantly more likely in group 2. Group 2 recipients were significantly more likely to have a level 4 human leucocyte antigen (HLA) mismatch (OR 4.667, 95% CI 1.640-13.275, p = 0.004) and to have undergone previous KT (OR 4.691, 95% CI 1.385-15.893, p = 0.013). The introduction of the 2019 offering scheme was associated with re-intervention and critical care admission for older KT recipients. We also observed less-favourable HLA matches but more KT in difficult-to-match groups.

Modified Peritoneal Fenestration as a Preventive Method for Lymphocele after Kidney Transplantation: A Preliminary Report.

Background: We aimed to assess the safety of a modified peritoneal fenestration technique with clipping of the window edges during kidney transplantation (KTx) and to determine its impact on reducing lymphocele following KTx. We compared the outcomes of this modified method with those of peritoneal fenestration without clipping. Methods: Among 430 consecutive KTxs performed between 2015 and 2019, preventive peritoneal fenestration and clipping of the margins were performed in 25 patients. These patients were compared with 75 matched patients in whom the margins were not clipped. Postoperative lymphocele formation and other patient data were compared between these two groups. Results: The rate of clinically relevant lymphocele decreased by 2.7% after peritoneal fenestration with clipping, although this decrease was not statistically significant (p = 0.829). There was no significant increase in the rate of other complications in the modified fenestration group (p = 0.067). The incidence of clinically significant lymphocele formation was notably higher in patients with a body mass index greater than 25 kg/m2 (p = 0.028). Univariate analysis indicated that older recipients, individuals with a history of previous abdominal surgery, those receiving the kidney from deceased and older donors were at increased risk of developing a clinically relevant lymphocele. Conclusions: Our preliminary results suggest that peritoneal fenestration with clipping may be as effective as the conventional fenestration technique in preventing lymphocele formation. Further clinical trials with larger sample sizes are required to determine the exact role of preventive peritoneal fenestration with clipping in preventing clinically relevant lymphocele after KTx.

Reexamining Transplant Outcomes in Acute Kidney Injury Kidneys Through Machine Learning.

Despite many people awaiting kidney transplant, kidney allografts from acute kidney injury (AKI) donors continue to be underutilized. We aimed to cluster kidney transplant recipients of AKI kidney allografts using an unsupervised machine learning (ML) approach. Using Organ Procurement and Transplantation Network-United Network for Organ Sharing (OPTN/UNOS) data, a consensus clustering cohort analysis was performed in 12356 deceased donor kidney transplant recipients between 2015 and 2019 in whom donors had a terminal serum creatinine ≥1.5mg/dL. Significant cluster characteristics were determined, and outcomes were compared. The median donor terminal creatinine was 2.2 (interquartile range [IQR] 1.7-3.3) mg/dL. Cluster analysis was performed on 12356 AKI kidney recipients, and three clinically distinct clusters were identified. Young, sensitized kidney re-transplant patients characterized Cluster 1. Cluster 2 was characterized by first-time kidney transplant patients with hypertensive and diabetic kidney diseases. Older diabetic recipients characterized Cluster 3. Clusters 1 and 2 donors were young and met standard kidney donor profile index (KDPI) criteria; Cluster 3 donors were older, more likely to have hypertension or diabetes, and meet high KDPI criteria. Cluster 1 had a higher risk of acute rejection, 3-year patient death, and graft failure. Cluster 3 had a higher risk of death-censored graft failure, patient death, and graft failure at 1 and 3 years. Cluster 2 had the best patient-, graft-, and death-censored graft survival at 1 and 3 years. Compared to non-AKI kidney recipients, the AKI clusters showed a higher incidence of delayed graft function (DGF, AKI: 43.2%, 41.7%, 45.3% vs. non-AKI: 25.5%); however, there were comparable long-term outcomes specific to death-censored graft survival (AKI: 93.6%, 93.4%, 90.4% vs. non-AKI: 92.3%), patient survival (AKI: 89.1%, 93.2%, 84.2% vs. non-AKI: 91.2%), and overall graft survival (AKI: 84.7%, 88.2%, 79.0% vs. non-AKI: 86.0%). In this unsupervised ML approach study, AKI recipient clusters demonstrated differing, but good clinical outcomes, suggesting opportunities for transplant centers to incrementally increase kidney utilization from AKI donors.

Variation in Quality of Life in Frail, Older Transplant Recipients: Mixed-Methods Results from the Kidney Transplantation in Older People (KTOP) Study

Variation in Quality of Life in Frail, Older Transplant Recipients: Mixed-Methods Results from the Kidney Transplantation in Older People (KTOP) Study

79 - Study Design and Baseline Characteristics of Older Medicaid Recipients Enrolled in the Incontinence Helping Others Manage at Home (Incon@Home) Implementation Study

79 - Study Design and Baseline Characteristics of Older Medicaid Recipients Enrolled in the Incontinence Helping Others Manage at Home (Incon@Home) Implementation Study

Healthcare system navigation difficulties among informal caregivers of older adults: a logistic regression analysis of social capital, caregiving support and utilization factors

BackgroundInformal caregivers of older adults play a vital role in improving the degree to which older adults access community and healthcare services in a seamless and timely manner. They are fulfilling important navigation and support roles for their older care recipients. However, there is still little knowledge of the most significant facilitators and barriers to effective and efficient system navigation among caregivers. This paper aims to fill these knowledge gaps through investigation of the key factors (i.e., social capital/cohesion, caregiving supports, and utilization factors) affecting navigation difficulties faced by informal caregivers of older adults.MethodsThe Behavioural-Ecological Framework of Healthcare Access and Navigation (BEAN) model is used to frame the study. Using the General Social Survey on Caregiving and Care Receiving 2018, we analyzed 2,733 informal caregivers whose primary care recipients were aged 65 or older. Hierarchical logistic regression was conducted to identify the relationship between system navigation difficulties among informal caregivers and four sequentially ordered blocks of predictors: (1) sociodemographic (2), social capital/cohesion (3), caregiving supports, and (4) healthcare demand.ResultsThe fully adjusted model showed that the probability of reporting navigation difficulties was lower for caregivers with social capital/cohesion compared to those without social capital/cohesion. In comparison, the probability of reporting navigation difficulties was higher among caregivers with caregiving support and among caregivers whose care receivers use a higher amount of health service use. Several sociodemographic covariates were also identified.ConclusionOur findings support certain aspects of the BEAN model. This study extends our understanding of potential facilitators and barriers that informal caregivers of older adults face while navigating complex community and health systems. There is a need to implement coordinated schemes and health policies especially for older adults with mental/neurological issues to address the challenges of their caregivers given the specific vulnerability identified in this study. The need for further research using different approaches to examine the disproportionate impact of COVID-19 on caregivers’ system navigation experience is crucial.

Comprehensive Geriatric Assessment (CGA) and Optimisation Services before Kidney Transplantation in Older Potential Recipients: Results from the First UK-Wide Transplant Centre Survey Study

Comprehensive Geriatric Assessment (CGA) and Optimisation Services before Kidney Transplantation in Older Potential Recipients: Results from the First UK-Wide Transplant Centre Survey Study

The Society of Thoracic Surgeons Intermacs 2024 Annual Report: Focus on Outcomes in Younger Patients

The 15th Annual Report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) includes 29,634 continuous-flow left ventricular assist devices (LVAD) from the 10-year period between 2014 through 2024. The outcomes reported here demonstrate continued improved survival in the current era of fully magnetically levitated (Mag-Lev) devices, with a significantly higher 1-year (85.7% versus 78.4%) and 5-year (59.7% versus 43.7%) survival than those receiving non-Mag-Lev devices. Mag-Lev recipients are experiencing a lower incidence of adverse events, including freedom from GI bleeding (72.6%), device malfunction (82.9%) and stroke (86.7%) at 5 years. Additionally, a focus on a subgroup of patients less than 50 years of age have demonstrated superior outcomes in both survival (91.6% survival at 1 year and 72.6% survival at 5 years) and decreased incidence of adverse events compared to older recipients. This younger cohort also demonstrated more tolerance to the characteristics of sex, race, ethnicity and psychosocial indicators that are associated with worse outcomes following heart transplantation (HT). Based upon these data, a potential net prolongation of life may be realized by considering prolonged LVAD support prior to HT in this population. These analyses provide preliminary data that could positively influence adoption of LVAD technology in groups previously not seen as candidates for this therapy, while providing a more responsible donor allocation strategy for advanced heart failure patients.

Outcomes of Older Primary Kidney Transplant Recipients by Induction Agent and High-risk Viral Discordance Status in the United States.

The impact of induction type or high-risk viral discordance on older kidney transplant recipients is unclear. Herein, we analyzed the association between induction type, viral discordance, and outcomes for older recipients. We analyzed the Scientific Registry of Transplant Recipients standard analysis file for all primary kidney transplant recipients older than 55 y who were transplanted between 2005 and 2022. All transplants were crossmatch negative and ABO-compatible. Recipients were discharged on tacrolimus and mycophenolate ± steroids. Recipients were categorized into 3 groups by induction received: rabbit antithymocyte globulin (r-ATG; N = 51 079), interleukin-2 receptor antagonist (IL-2RA; N = 22 752), and alemtuzumab (N = 13 465). Kaplan-Meier curves were generated for recipient and graft survival, and follow-up was censored at 10 y. Mixed-effect Cox proportional hazard models examined the association between induction type, high-risk viral discordance, and outcomes of interest. Models were adjusted for pertinent recipient and donor characteristics. Induction type did not predict recipient survival in the multivariable model, whereas Epstein-Barr virus high-risk discordance predicted 14% higher mortality (1.14 [1.07-1.21], P < 0.01). In the multivariable model for death-censored graft survival, alemtuzumab, but not IL-2RA, was associated with an increased risk of graft loss (1.18 [1.06-1.29], P < 0.01) compared with r-ATG. High-risk cytomegalovirus discordance predicted 10% lower death-censored graft survival (1.10 [1.01-1.19], P < 0.02). Live donor and preemptive transplantation were favorable predictors of survival. In this large cohort of older transplant recipients, alemtuzumab, but not IL-2RA, induction was associated with an increased risk of graft loss compared with r-ATG. Cytomegalovirus and Epstein-Barr virus high-risk viral discordance portended poor graft and recipient survival, respectively.

Trends in de toereikendheid van de langdurige zorg onder ouderen in de periode van de hervorming van de langdurige zorg

Due to population ageing and rising healthcare costs, Dutch long-term care was reformed in 2015. Important measures were stricter admission requirements for nursing homes and decentralization of home care to municipalities. The consequences of these changes for the perceived quality of care are still unknown. We examined to which extent the sufficiency of care as experienced by older people has changed during this period. We also examined the relationship with individual characteristics, such as care needs, care use, and wishes regarding care. Data from older care recipients at four observations from the Longitudinal Aging Study Amsterdam (LASA) between 2012 and 2022 (N= 1316) were used. Multilevel logistic regression analysis were performed. Perceived care sufficiency decreased after the healthcare reforms in the years 2015 and 2018, but recovered in 2022. There appeared no difference based on living region, but care sufficiency was higher in less urban areas. In addition, care needs, use of public care, and education level were strongly associated with care sufficiency. However, use of publicly paid care appeared to be the type of care that contributed least to care sufficiency; a lack of perceived control over care may be an explanatory factor.

P.166: Outcomes of kidney transplantation in older recipients: Is age just a number?

P.166: Outcomes of kidney transplantation in older recipients: Is age just a number?

Single vs Double Lung Transplantation in Older Adults: A Propensity-Matched Analysis

BackgroundSingle lung transplantation (SLT) is associated with worse long-term outcomes than bilateral lung transplantation (BLT) but is often performed for older adults at risk of not tolerating BLT. Research QuestionHow do the outcomes of SLT and BLT compare among older adult recipients? Study Design and MethodsThe Scientific Registry of Transplant Recipients database (2005-2022) was queried for lung transplant recipients aged ≥65 years. Patients were stratified by whether they underwent BLT or SLT, and propensity matched. Baseline characteristics and morbidity were compared with frequentist statistics. Survival was analyzed via Kaplan-Meier estimation. Risk factors for mortality were identified with Cox regression. ResultsOf 9,904 included patients, 4,829 (48.8%) underwent SLT. SLT patients had lower lung allocation scores (39.6 v. 40.6, p<0.001), more interstitial lung disease (74.4% v. 64.6%, p<0.001) and lower rates of bridging (0.7% v. 2.4%, p<0.001). Groups did not differ significantly by sex, body mass index, or donor characteristics. Propensity matching resulted in 2,539 patients in each group. On matched analysis, SLT patients had shorter lengths of stay (14 v. 18 d), lower reintubation rates (14.7% v. 19.8%), and less postoperative dialysis use (4.2% v. 6.4%) (all p<0.001). SLT patients had comparable survival at 30-days (97.6% v. 97.3%, p=0.414) and 1-year (85.5% v. 86.3%, p=0.496), but lower survival at 5-years (45.4% v. 53.4%, p<0.001) on matched analysis. SLT was a risk factor for 5-year mortality (adjusted hazard ratio: 1.19, p<0.001). InterpretationIn older adults, SLT is associated with less morbidity and comparable early survival relative to BLT, but lower five-year survival. SLT is reasonable to perform in older adults at high risk for BLT.

Understanding the daily life needs of older public assistance recipient subgroups in Japan: A qualitative study.

Transition from individual-level treatment to social-level intervention should be made to improve peoples daily living conditions for reducing health inequality, which is a major global public health concern. Older public assistance recipients in Japan are socially vulnerable and require healthcare, long-term care, daily living, and social care support. Understanding the diverse daily living needs among public assistance recipient subgroups would prompt the development of novel support measures in the welfare sector. Therefore, this study aimed to understand the daily life needs of older recipient subgroups (segments) created quantitatively in our previous study. We interviewed four caseworkers at municipal welfare offices in 2021; the interview data were analyzed using a qualitative descriptive method to describe the daily life needs of the five older recipient segments for each sex. Five themes of daily life needs were demonstrated: i) housing, ii) financial, iii) welfare service, iv) healthcare, and v) no daily life needs. Consequently, we identified the daily life needs of some older recipient segments, indicating the necessity for support interventions. Future research would help interview other professionals from various backgrounds to further understand the daily life needs of older recipient segments.

Does Age Influence Immunosuppressant Drug Pharmacokinetics in Kidney Transplant Recipients?

The pharmacokinetics of immunosuppressant drugs may change with advancing age, potentially affecting patient outcomes. To characterise the effects of age on the pharmacokinetic and exposure parameters of tacrolimus, mycophenolate, and prednisolone. Pharmacokinetic profiling, involving whole blood tacrolimus, total and free plasma mycophenolic acid (MPA), total plasma mycophenolic acid glucuronide (MPAG), and total and free plasma prednisolone, was performed in an older and younger adult cohort. Thirteen samples were drawn on a single occasion, pre-oral dose and then at 0.25, 0.5, 0.75, 1, 1.25, 1.5, 2, 3, 4, 6, 9, and 12h post-dose. Non-compartmental analysis was conducted using the PKNCA package, and pharmacokinetic and exposure parameters were compared between age groups using a Mann-Whitney test. A regression analysis was conducted for free MPA and MPAG using significant variables of interest. This exploratory study included 21 older and 18 younger adults. Dose-adjusted tacrolimus, total MPA and free prednisolone pharmacokineticparameters were not different between age groups; however, for free MPA and MPAG, older recipients had significantly greater minimum and maximum concentrations, trough concentrations, and half-life. There was a two-fold increase in free MPA exposure in older adults (median dose-adjusted AUC0-12: 1284 vs. 684μgh/L, p<0.0001); MPAG exposure similarly increased. Age was significantly associated with free MPA and MPAG exposure, and free MPA exposure was associated with haematocrit (p<0.05). Differences in MPA were found with advancing age and may be due to altered kidney function, haematocrit, plasma protein binding and/or drug absorption. Future research should explore specific covariate contributions to this further.

Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange, and non-directed donor graft allocation.

In the United States, living donor liver transplant (LDLT), from both directed and nondirected living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation (LT), shorten waiting times for a life-prolonging LT surgery, and reduce LT waitlist mortality. The LT community's focus on LDLT expansion in the United States is fostering discussions around future opportunities, which include the safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include using donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from an LT, but may otherwise have limited access (ie, lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced HCC beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience, and technical advances in the United States, the LT community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.

Association of pneumococcal conjugate vaccination with SARS-CoV-2 infection among older adult recipients of COVID-19 vaccines: a longitudinal cohort study.

Pneumococcal carriage is associated with increased acquisition and duration of SARS-CoV-2 infection among adults. While pneumococcal conjugate vaccines (PCVs) prevent carriage of vaccine-serotype pneumococci, their potential impact on COVID-19 related outcomes remains poorly understood in populations with prevalent immunity against SARS-CoV-2. We undertook a retrospective cohort study of adults aged ≥65 years in the Kaiser Permanente Southern California (KPSC) healthcare system who had received ≥2 COVID-19 vaccine doses, comparing risk of SARS-CoV-2 infection between 1 January, 2021 and 31 December, 2022 among recipients and non-recipients of PCV13. We estimated adjusted hazard ratios via Cox proportional hazards models, employing multiple strategies to mitigate bias from differential test-seeking behavior. The adjusted hazard ratio (aHR) of confirmed SARS-CoV-2 infection comparing PCV13 recipients to non-recipients was 0.92 (95% confidence interval: 0.90-0.95), corresponding to prevention of 3.9 (2.6-5.3) infections per 100 person-years. Following receipt of 2, 3, and ≥4 COVID-19 vaccine doses, aHRs were 0.85 (0.81-0.89), 0.94 (0.90-0.97), and 0.99 (0.93-1.04), respectively. The aHR for persons who had not received COVID-19 vaccination in the preceding 6 months was 0.90 (0.86-0.93), versus 0.94 (0.91-0.98) within 6 months after receipt of any dose. Similarly, the aHR was 0.92 (0.89-0.94) for persons without history of documented SARS-CoV-2 infection, versus 1.00 (0.90-1.12) for persons with documented prior infection. Among older adults who had received ≥2 COVID-19 vaccine doses, PCV13 was associated with modest protection against SARS-CoV-2 infection. Protective effects of PCV13 were greater among individuals expected to have weaker immune protection against SARS-CoV-2 infection.

Allogeneic blood or marrow transplantation using haploidentical grandchildren donors and post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis.

High-dose post-transplant cyclophosphamide allows safe and effective use of allografts from haploidentical relatives (siblings, parents and children) in patients undergoing allogeneic blood or marrow transplant (alloBMT). More recently, second- and third-degree relatives have also been shown to be safe allograft donors. An increasing number of older patients undergoing alloBMT have been receiving allografts from haploidentical donors. However, older patients are more likely to have older siblings and children, and older donor age is associated with worse outcomes. In the current study, we report the safety and utility of grandchildren as haploidentical donors and compared with children as donors in patients undergoing alloBMT. We compared characteristics and outcomes of alloBMT patients aged 55 years and older with children older than 30 years as donors (C group; n = 276) and those with grandchildren as donors (GC group; n = 40). Because many important baseline characteristics predict outcomes after alloBMT, we performed propensity score matched analysis based on recipient age, alloBMT year, disease, graft source and haematopoietic cell transplantation comorbidity index (HCT-CI). The median age of recipients was 67 years (range 55-79) in the C group and 73 years (range 57-78) in the GC group. More than 70% of recipients in the GC group were older than 70 years, compared with 27% in the C group. The median donor age was 37 years (range 31-52) in the C group and 20 years (range 14-34) in the GC group. More patients in the GC group had HCT-CI scores ≥3 than in the C group (32.5% vs. 23%, p = 0.27). Two-year overall survival did not differ between the two groups (GC 62% vs. C 60%, hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.53-1.75, p = 0.90) despite recipients of allografts from grandchildren being older. The 2-year RFS was 55% in the C group compared with 50% in the GC group (HR 1.05, 95% CI 0.62-1.77, p = 0.85). Non-relapse mortality subdistribution [SD] (SDHR 1.36, 95% 0.70-2.63, p = 0.36), relapse (SDHR 0.72, 95% CI 0.33-1.58, p = 0.42) or relapse-free survival (HR 1.05, 95% CI 0.62-1.77, p = 0.85). Propensity score matching analysis showed no significant differences in 2-year overall survival (GC 64% vs. C 53%; HR 0.77, 95% CI 0.42-1.42, p = 0.40), non-relapse mortality (SDHR 1.26, 95% 0.66-2.41, p = 0.48), relapse (SDHR 0.57, 95% CI 0.21-1.52, p = 0.26) or relapse-free survival (HR 0.94, 95% CI 0.57-1.54, p = 0.81). Our results indicate that outcomes of alloBMT patients with grandchild donors are similar to those with child donors, despite recipients' older age and higher comorbidities in the GC group. Grandchildren should be considered when selecting a donor for older alloBMT recipients.