Post-transplant Survival Rates Research Articles

Waiting list and Post-Transplant Outcome in Sweden after National Centralization of Heart Transplant Surgery

BackgroundPrevious studies have demonstrated an association between the annual transplantation rate per center and post-operative mortality after heart transplantation. In 2011, Sweden centralized heart transplants and waiting lists, reducing the number of centers from three to two. This study aimed to assess the active waiting time and pre- and post-transplant mortality rates before and after centralization. MethodsHeart transplantations performed in Sweden between January 1, 2001, and December 31, 2020, were included. Background and donor organ supply data were collected from national registries (Scandiatransplant, STRAX, and SWEDEHEART) and Scandiatransplant, respectively. The Fine and Gray methods were applied to visualize cumulative incidence curves and conduct competing risk regressions. A Cox model was used to adjust for factors influencing time to post-transplant death across eras. ResultsWhen comparing the 10 years before and after centralization, the median active waiting time increased from 54 to 71 days (p=0.015). A decreased risk of mortality on the waiting list was observed in the later era compared to the first (SHR 0.43; [95% CI 0.25-0.74]; p=0.002). The total number of heart transplantation procedures (including pediatric patients) increased by 53% from 377 (mean, 38/year) to 577 (mean, 58/year) in the second era. There was a statistically significant difference in organ utilization between the time eras (p=0.033; Chi2-test). The 30-day and 1-year survival post-transplant rates for adults increased from 90.8% to 97.8% (p<0.001) and from 87.9% to 94.6% (p<0.001), respectively. An adjusted Cox-regression analysis showed a 63% reduction in 1-year mortality between eras (HR 0.37 95%CI 0.22-0.61). ConclusionsThis nationwide retrospective registry study examined patients listed for and undergoing heart transplantation before and after centralization of waiting lists and surgeries in Sweden. Waiting list mortality decreased, and 1-year post-transplantation survival rates improved.

No Improvement in Intention-to-treat Survival and Increasing Liver Nonutilization Rate During the MELD Era.

Although post liver transplant survival rates have significantly improved during the past 2-3 decades, the trend in intention-to-treat (ITT) survival (survival from waitlist addition) has not been well studied. We conducted a retrospective analysis of Scientific Registry of Transplant Recipients data to determine the trend in ITT survival in liver transplant candidates. Adult (age ≧ 18 y) patients who were on the waitlist between the time period of March 1, 2002, to December 31, 2019 (n = 200 816) and deceased liver donors that were registered between the same time period (n = 152 593) were analyzed. We found a constant increase in posttransplant survival rates; however, the ITT survival rates showed no statistically significant improvement through the study period. We observed significant linear increase in waitlist dropout rates over time. We also observed linear increase in liver nonutilization rate in both entire cases and brain-dead cases. Donor risk index increased significantly over the years; however, it was mostly driven by increase in donation after circulatory death cases; without donation after circulatory death cases, donor risk index was stable throughout the 17 y we observed. The reason of the increased liver nonutilization rate is unclear; however, it is possible that reluctance to use high-risk organ to maintain better posttransplant outcomes contributed to this increase, which also could have led to increase in waitlist dropout rates and no improvements in ITT survival. Further investigation is warranted on the increased nonutilization rates to improve over all contribution of liver transplant to patient care.

Clinical outcomes of liver transplantation in human immunodeficiency virus/hepatitis B virus coinfected patients in China

BackgroundHighly active antiretroviral therapy (HAART) has been able to improve the immune system function and survival of human immunodeficiency virus (HIV) patients. However, Patients coinfected with HIV and hepatitis B virus (HBV) are more likely to develop end-stage liver disease (ESLD) than those infected with HBV alone. Consequently, liver transplantation is often required for these patients. This study evaluates the outcomes of orthotopic liver transplantation (OLT) of HIV-HBV coinfected patients in China.MethodsWe conducted a retrospective analysis on all HIV-HBV coinfected patients that underwent OLT from April 1, 2019 to December 31, 2021 and their outcomes were compared to all HBV monoinfected patients undergoing OLT during the same period. Patient outcomes were determined, including cumulative survival, viral load, CD4 T-cell count and postoperative complications.ResultsThe median follow-up of HIV recipients was 36 months after OLT (interquartile range 12–39 months). Almost all patients had stable CD4 T-cell count (> 200 copies/ul), undetectable HBV DNA levels, and undetectable HIV RNA load during follow-up. The 1-, 2-, and 3-year posttransplant survival rates were 85.7% for the HIV group (unchanged from 1 to 3 years) versus 82.2%, 81.2%, and 78.8% for the non-HIV group. Cumulative survival among HIV-HBV coinfected recipients was not significantly different from the HBV monoinfected recipients (log-rank test P = 0.692). The percentage of deaths attributed to infection was comparable between the HIV and non-HIV groups (14.3% vs. 9.32%, P = 0.665). Post OLT, there was no significant difference in acute rejection, cytomegalovirus infection, bacteremia, pulmonary infection, acute kidney injury, de novo tumor and vascular and biliary complications.ConclusionsLiver transplantation in patients with HIV-HBV coinfection yields excellent outcomes in terms of intermediate- or long-term survival rate and low incidence of postoperative complications in China. These findings suggest that OLT is safe and feasible for HIV-HBV coinfected patients with ESLD.Trial registrationChinese Clinical Trial Registry (ChiCTR2300067631), registered 11 January 2023.

Adult-to-adult right lobe graft living donor liver transplantation for acute-on-chronic liver failure: a single-centre retrospective study in Vietnam.

Acute-on-chronic liver failure (ACLF) has a high mortality rate, and liver transplantation is considered a definite treatment for patients with this condition. This study aims to evaluate the outcomes of living donor liver transplantation (LDLT) in ACLF patients in a single centre in a lower middle-income country, Vietnam. This was a retrospective study at the 108 Military Central Hospital (Hanoi, Vietnam), enroling 51 patients diagnosed with ACLF based on Asian Pacific Association for the Study of the Liver (APASL) criteria who underwent LDLT with a right lobe graft from December 2019 to December 2022. The authors utilize the model for end-stage liver disease (MELD) and APASL ACLF Research Consortium (AARC) scores to evaluate and stratify the severity of ACLF. The average age of all patients was 47.27±13.61, with 88.24% being male. The average BMI was 22.78±2.61. The most common underlying liver disease was chronic viral hepatitis B (88.2%). The average MELD score of the patients was 34.90±5.61, with 33.3% having MELD score greater than or equal to 40. In terms of ACLF severity, five patients (9.8%) had grade I ACLF, 35 patients (68.6%) had grade II ACLF, and 11 patients (21.6%) had grade III ACLF. The average AARC score was 9.43±1.68. The duration of treatment in the ICU was 8.59±7.27 days, and the length of hospital stay was 28.02±13.45 days. The most common post-transplant complication was biliary complication (19.61%). Death occurred in 7 patients (13.7%). The survival rates at 6 months, 1 year, and 3 years were 84%, 81.7%, and 81.7%, respectively. Living donor liver transplantation for ACLF patients is safe and has a high post-transplant survival rate. Multidisciplinary care before, during, and after surgery, and the decision to do a liver transplant early, is essential in saving the lives of ACLF patients.

Waitlist and posttransplant outcomes of pregnancy-related acute liver failure in the United States.

Data on the liver transplant (LT) outcomes of women with acute liver failure (ALF) due to liver diseases unique to pregnancy (P-ALF) are limited. Using United Network of Organ Sharing (UNOS) data (1987-2021), we analyzed waitlist and post-LT outcomes of ALF in women of childbearing age comparing P-ALF versus ALF due to liver diseases not unique to pregnancy. Baseline characteristics were compared between groups at the time of listing for LT. Of 3542 females aged 16-43 years and listed for LT for ALF, 84 (2%) listed for P-ALF were less likely to be Black (11 vs. 21%, p =0.033), have lower international normalized ratio (2.74 vs. 4.53 p <0.002), but more likely to have respiratory failure (56% vs. 41%, p <0.005), be on pressors (58% vs. 43%, p <0.005), and require dialysis (23% vs. 10%, p <0.001). The cumulative 90-day waitlist mortality (WLM) was lower in P-ALF vs. ALF due to liver diseases not unique to pregnancy (7.4 vs. 16.6%, p <0.001). Posttransplant survival rates at 5 years were similar (82% vs. 79%, p =0.89). In a Fine and Gray regression model controlled for listing year and Model for End-Stage Liver Disease score, 90-day WLM was lower in P-ALF with a sub-HR of 0.42 (95% CI: 0.19-0.94, p =0.035). Of 84 women with P-ALF and listed for LT, 45 listed for hemolysis-elevated liver enzymes-low platelets (HELLP) versus 39 for acute fatty liver of pregnancy had higher 90-day WLM (19.3% vs. 5.7% p <0.005). The 90-day WLM was about 10-fold higher in HELLP versus acute fatty liver of pregnancy with a sub-HR of 9.97 (95% CI: 1.64-60.55, p =0.013). In this UNOS database analysis of ALF among women of childbearing age, the waitlist outcome is better in women with P-ALF compared to women with ALF due to liver diseases not unique to pregnancy. Among women with P-ALF, the 90-day WLM is worse for HELLP versus acute fatty liver of pregnancy. Further studies are needed to improve the management of HELLP and prevent the development of ALF in this subgroup population.

Standard Risk Assessment Tools Fall Short to Assess Risk in Transplant Patients

Introduction: The HCT-CI (Hematopoietic Cell Transplantation-specific Comorbidity Index) predicts survival after HCT in patients with hematologic malignancies. HCT-CI ≥3 is associated with higher Non-Relapse Mortality (NRM) and lower overall survival in both allogeneic (allo) and autologous (auto)-HCT patients. The Disease Risk Index (DRI) Assessment Tool is a validated tool to categorize patients undergoing allo- transplant into risk categories based on disease status. It was developed to predict overall survival per disease status. This study was done to understand reasons for increased mortality in transplant patients at our center in 2021 compared to 2020 by comparing HCT-CI and DRI of transplant patients between the two years. Methods: The study was approved by our institution's IRB. A retrospective chart analysis of adult patients who underwent auto- or allo-HCT at Henry Ford Hospital in the years 2020 and 2021 was conducted. Relevant patient demographics, comorbidities, disease characteristics, and transplant-related data were collected. HCT-CI scores were calculated on all patients using the online calculator (https://www.mdcalc.com/calc/3980/hematopoietic-cell-transplantation-specific-comorbidity-index-hct-ci). Patients were also risk stratified based on the DRI Assessment Tool (https://cibmtr.org/CIBMTR/Resources/Research-Tools-Calculators/Disease-Risk-Index-DRI-Assignment-Tool). Data was reviewed and collected by investigators and compiled in a confidential platform. Results: A total of 166 patient records between 2020 and 2021 were reviewed. In 2020, 46 patients underwent auto-HCT and 28 underwent allo-HCT. In 2021, 58 patients underwent auto-HCT and 34 patients underwent allo-HCT. The one-year post transplant survival rates for patients are elucidated in Table 1. The median HCT-CI scores amongst the patients who underwent transplant was 3 in 2020 and 4 in 2021(refer Table 2). When assessing the Disease Risk Index, overall, more patients with higher disease risk were transplanted in 2021 compared to 2020 (refer Table 3). 16 patients (12 in 2021 and 4 in 2020) underwent transplant for diseases that are not included in the DRI assessment tool. Of these, 8 patients in 2021 underwent allo-HCT. These included aplastic anemia (AA), inherited bone marrow failure syndromes (BMF), solid tumors, primary CNS lymphomas, mycosis fungoides and hemophagocytic lymphohistiocytosis (HLH). Conclusion: The HCT-CI and the DRI are both tools used in transplant centers to risk stratify patients pre-transplant. The use of both tools can give a good sense of post-transplant outcomes, combining both individual patient characteristics as well as diseases specific variations. These data are also important for monitoring outcomes at transplant centers. In this study, patients who had an HCT-CI &amp;gt;/3 were similar in both years. The DRI however could not be ascertained in 16 patients, as these diseases are not currently included in the DRI. This makes outcome prediction for these particular patients suboptimal especially if they do not have as many comorbidities but still higher risk diseases. Furthermore, this precludes effective outcome monitoring in and amongst transplant centers. The combination of both the HCT-CI and the DRI would perform better if the DRI tool is revised to become more comprehensive or by creating a DRI that is specific for non-malignant disorders like AA, HLA and BMF. We intend to propose this to CIBMTR for further consideration.

Live slow, die old: larval propagation of slow-growing, stress-tolerant corals for reef restoration

Efforts to restore coral reefs usually involve transplanting asexually propagated fast-growing corals. However, this approach can lead to outplanted populations with low genotypic diversity, composed of taxa susceptible to stressors such as marine heatwaves. Sexual coral propagation leads to greater genotypic diversity, and using slow-growing, stress-tolerant taxa may provide a longer-term return on restoration efforts due to higher outplant survival. However, there have been no reports to date detailing the full cycle of rearing stress-tolerant, slow-growing corals from eggs until sexual maturity. Here, we sexually propagated and transplanted two massive slow-growing coral species to examine long-term success as part of reef restoration efforts. Coral spat were settled on artificial substrates and reared in nurseries for approximately two years, before being outplanted and monitored for survivorship and growth for a further four years. More than half of initially settled substrates supported a living coral following nursery rearing, and survivorship was also high following outplantation with yields declining by just 10 to 14% over four years. At 6-years post-fertilisation over 90% of outplanted corals were reproductively mature, demonstrating the feasibility of restoring populations of sexually mature massive corals in under a decade. Although use of slower growing, stress tolerant corals for reef restoration may provide a longer-term return on investment due to high post-transplantation survival rates, considerable time is required to achieve even modest gains in coral cover due to their relatively slow rates of growth. This highlights the need to use a mix of species with a range of life-history traits in reef restoration and to improve survivorship of susceptible fast-growing taxa that can generate rapid increases in coral cover.

Augmenting the United States transplant registry with external mortality data: A moving target ripe for further improvement

The Organ Procurement and Transplantation Network conducts a robust death verification process when augmenting the United States transplant registry with external sources of data. Process enhancements added over 35,000 externally verified deaths across waitlist candidates and transplant recipients for all organs beginning in April 2022. Ninety-four percent of added posttransplant deaths occurred beyond 5 years posttransplant, and over 74% occurred beyond 10 years. Deceased donor solid organ recipients transplanted from January 1, 2010, through October 31, 2020, were analyzed from January and July 2022 Organ Procurement and Transplantation Network Standard Transplant Analysis and Research and the Scientific Registry of Transplant Recipients Standard Analysis Files to quantify the impact of including vs excluding unverified deaths (not releasable to researchers) on posttransplant patient survival estimates. Across all organs, 1- and 5-year posttransplant survival rates were not substantially impacted; meaningful differences were observed in 10-year survival among kidney recipients. These findings bear important implications for anyone who utilized transplant registry data to examine long-term outcomes prior to the updated verification process. Users of transplant surveillance data should interpret results of long-term outcomes cautiously, particularly differences across subpopulations, and the transplant community should identify ways to improve data quality and minimize the reporting burden on transplant institutions.

Improved waitlist and comparable post-transplant outcomes in simultaneous heart-kidney transplantation under the 2018 heart allocation system

ObjectiveThis study aimed to investigate the clinical trends and the impact of the 2018 heart allocation policy change on both waitlist and post-transplant outcomes in simultaneous heart-kidney transplantation in the United States. MethodsThe United Network for Organ Sharing registry was queried to compare adult patients before and after the allocation policy change. This study included 2 separate analyses evaluating the waitlist and post-transplant outcomes. Multivariable analyses were performed to determine the 2018 allocation system's risk-adjusted hazards for 1-year waitlist and post-transplant mortality. ResultsThe initial analysis investigating the waitlist outcomes included 1779 patients listed for simultaneous heart-kidney transplantation. Of these, 1075 patients (60.4%) were listed after the 2018 allocation policy change. After the policy change, the waitlist outcomes significantly improved with a shorter waitlist time, lower likelihood of de-listing, and higher likelihood of transplantation. In the subsequent analysis investigating the post-transplant outcomes, 1130 simultaneous heart-kidney transplant recipients were included, where 738 patients (65.3%) underwent simultaneous heart-kidney transplantation after the policy change. The 90-day, 6-month, and 1-year post-transplant survival and complication rates were comparable before and after the policy change. Multivariable analyses demonstrated that the 2018 allocation system positively impacted risk-adjusted 1-year waitlist mortality (sub-hazard ratio, 0.66, 95% CI, 0.51-0.85, P < .001), but it did not significantly impact risk-adjusted 1-year post-transplant mortality (hazard ratio, 1.03; 95% CI, 0.72-1.47, P = .876). ConclusionsThis study demonstrates increased rates of simultaneous heart-kidney transplantation with a shorter waitlist time after the 2018 allocation policy change. Furthermore, there were improved waitlist outcomes and comparable early post-transplant survival after simultaneous heart-kidney transplantation under the 2018 allocation system.

Prognosis of patients with systemic sclerosis-related interstitial lung disease on the lung transplant waiting list: a retrospective study

Advanced systemic sclerosis-associated interstitial lung disease (SSc-ILD) can be treated with lung transplantation. There is limited data on lung transplantation outcomes in patients with SSc-ILD, in non-Western populations.We assessed survival data of patients with SSc-ILD, on the lung transplant (LT) waiting list, and evaluated post-transplant outcomes in patients from an Asian LT center. In this single-center retrospective study, 29 patients with SSc-ILD, registered for deceased LT at Kyoto University Hospital, between 2010 and 2022, were identified. We investigated post-transplant outcomes in recipients who underwent LT for SSc-ILD, between February 2002 and April 2022. Ten patients received deceased-donor LT (34%), two received living-donor LT (7%), seven died waiting for LT (24%), and ten survived on the waiting list (34%). Median duration from registration to deceased-donor LT was 28.9 months and that from registration to living-donor LT or death was 6.5 months. Analysis of 15 recipients showed improved forced vital capacity with a median of 55.1% at baseline, 65.8% at 6 months, and 80.3% at 12 months post-transplant. The 5-year survival rate for post-transplant patients with SSc-ILD was 86.2%. The higher post-transplant survival rate at our institute than previously reported suggests that lung transplantation is acceptable in Asian patients with SSc-ILD.

How to Optimize the Results of Liver Transplantation for Acute-on-Chronic Liver Failure.

Cirrhotic patients who developed a decompensation episode requiring an admission to an intensive care unit are not equal in term of prognosis. This led to the definition of a syndrome, acute-on-chronic liver failure (ACLF), marked by the severity of systemic inflammation, the development of organ failures and a high short-term mortality. The most common underlying liver etiology is related to acute alcohol hepatitis in western countries and to HBV or HCV cirrhosis in eastern countries. Twenty-eight and 90-days high mortality rates are well linked to the number of organ failure and defined, merely ten years ago, by a modified SOFA score. ACLF is a dynamic syndrome and grading can vary from hospital admission. ACLF grading between day 3-7 of admission is more accurate for determining outcome. ACLF-3 patients with ≥3 organ failures remain very challenging with >75% mortality rate. Despite recent advances in the medical management of critically ill cirrhotic patients, the prognosis of these patients remains poor. Currently, the main effective treatment is an urgent liver transplantation (LT) which is performed in a very selected patients eligible to transplant given the limited availability of organ donors and the low post-transplant survival rates reported in earlier studies. Recently, large retrospective multicenter studies and registries showed an improved 1-year post-transplant survival rate >83% in several transplant centers. Nevertheless, only few proportions of the ACLF-2 and ACLF-3 patients are transplanted representing 0-10% of most liver transplant programs. A careful selection of these patients (excluding major comorbidities i.e., older age, addictology criteria, severe malnutrition…) and optimal timing for transplant (infection control, hemodynamic stability, low oxygen and vasopressor requirements) are associated with excellent post-transplant survival rate.

Prognostic factors for lung transplant recipients focusing on age and gender: the Japanese lung transplantation report 2022

PurposeTo clarify the impact of donor and recipient characteristics on the survival of recipients before and after lung transplantation in the Japanese population.MethodsPatients’ data were collected for retrospective analysis from all authorized lung transplant centers in Japan. We included 1963 patients listed for lung transplantation by the end of December 2021, comprised of 658 deceased-donor and 270 living-donor lung transplants.ResultsPrimary disease had a significant impact on the mortality of patients waiting for transplantation. The indications for transplant significantly affected the post-transplant survival rate of deceased-donor lung transplant recipients. The recipient’s age also significantly affected the post-transplant survival rate of the deceased-donor and living-donor lung transplant recipients. The recipients of grafts transplanted from donors aged 61 years or older showed a worse post-transplant survival rate (≧60 years old). The survival rate for the combination of a female donor to a male recipient among the deceased-donor lung transplant recipients was the worst among the four combinations.ConclusionThe donor and recipient characteristics significantly impacted the survival of recipients after lung transplantation. The underlying mechanism of the negative impact of the gender mismatch of female donor to male recipient on post-transplant survival needs to be investigated further.

Role of neoadjuvant chemoradiotherapy in liver transplantation for unresectable perihilar cholangiocarcinoma: multicentre, retrospective cohort study

The Mayo protocol for liver transplantation in patients with unresectable perihilar cholangiocarcinoma is based on strict selection and neoadjuvant chemoradiotherapy. The role of neoadjuvant chemoradiotherapy in this scenario remains unclear. The aim of this study was to compare outcomes after transplantation for perihilar cholangiocarcinoma using strict selection criteria, either with or without neoadjuvant chemoradiotherapy. This was an international, multicentre, retrospective cohort study of patients who underwent transplantation between 2011 and 2020 for unresectable perihilar cholangiocarcinoma using the Mayo selection criteria and receiving neoadjuvant chemoradiotherapy or not receiving neoadjuvant chemoradiotherapy. Endpoints were post-transplant survival, post-transplant morbidity rate, and time to recurrence. Of 49 patients who underwent liver transplantation for perihilar cholangiocarcinoma, 27 received neoadjuvant chemoradiotherapy and 22 did not. Overall 1-, 3-, and 5-year post-transplantation survival rates were 65 per cent, 51 per cent and 41 per cent respectively in the group receiving neoadjuvant chemoradiotherapy and 91 per cent, 68 per cent and 53 per cent respectively in the group not receiving neoadjuvant chemoradiotherapy (1-year hazards ratio (HR) 4.55 (95 per cent c.i. 0.98 to 21.13), P = 0.053; 3-year HR 2.07 (95 per cent c.i. 0.78 to 5.54), P = 0.146; 5-year HR 1.71 (95 per cent c.i. 0.71 to 4.09), P = 0.229). Hepatic vascular complications were more frequent in the group receiving neoadjuvant chemoradiotherapy compared with the group not receiving neoadjuvant chemoradiotherapy (nine of 27 versus two of 22, P = 0.045). In multivariable analysis, tumour recurrence occurred less frequently in the group receiving neoadjuvant chemoradiotherapy (HR 0.30 (95 per cent c.i. 0.09 to 0.97), P = 0.044). In selected patients undergoing liver transplantation for perihilar cholangiocarcinoma, neoadjuvant chemoradiotherapy resulted in a lower risk of tumour recurrence, but was associated with a higher rate of early hepatic vascular complications. Adjustments in neoadjuvant chemoradiotherapy reducing the risk of hepatic vascular complications, such as omitting radiotherapy, may further improve the outcome in patients undergoing liver transplantation for perihilar cholangiocarcinoma.

Temporal trends in the use and outcomes of temporary mechanical circulatory support as a bridge to cardiac transplantation in Spain. Final report of the ASIS-TC study

We aimed to describe recent trends in the use and outcomes of temporary mechanical circulatory support (MCS) as a bridge to heart transplantation (HTx) in Spain. Retrospective case-by-case analysis of 1,036 patients listed for emergency HTx while on temporary MCS in 16 Spanish institutions from January 1st, 2010 to December 31st, 2020. Patients were classified in 3 eras according to changes in donor allocation criteria (Era 1: January 2010/May 2014; Era 2: June 2014/May 2017; Era 3: June 2017/December 2020). Over time, the proportion of candidates listed with intra-aortic balloon pumps decreased (Era 1=55.9%, Era 2=32%, Era 3=0.9%; p < 0.001), while the proportion of candidates listed with surgical continuous-flow temporary VADs (Era 1=10.6%, Era 2=32%, Era 3=49.1%; p < 0.001) and percutaneous VADs (Era 1=0.3%, Era 2=6.3%; Era 3=17.2%; p < 0.001) increased. Rates of HTx increased from Era 1 (79.4%) to Era 2 (87.8%), and Era 3 (87%) (p=0.004), while rates of death before HTx decreased (Era 1=17.7%; Era 2=11%, Era 3=12.4%; p=0.037) Median time from listing to HTx increased in patients supported with intra-aortic balloon pumps (Era 1=8 days, Era 2=15 days; p < 0.001) but remained stable in other candidates (Era 1=6 days; Era 2=5 days; Era 3=6 days; p=0.134). One-year post-transplant survival was 71.4% in Era 1, 79.3% in Era 2, and 76.5% in Era 3 (p=0.112). Preoperative bridging with ECMO was associated with increased 1-year post-transplant mortality (adjusted HR=1.71; 95% CI 1.15-2.53; p=0.008). During the period 2010 to 2020, successive changes in the Spanish organ allocation protocol were followed by a significant increase of the rate of HTx and a significant reduction of waiting list mortality in candidates supported with temporary MCS. One-year post-transplant survival rates remained acceptable.

335.6: Long-term Outcomes of Living Donor Versus Deceased Donor Liver Transplantation for Acute Liver Failure in United States

Introduction: Acute Liver Failure (ALF) is rarely encountered but often is associated with high morbidity and mortality. Timely Liver Transplantation is universally the only accepted rescue therapy, but not much is known about the usage of Living Donor (LDLT) versus Deceased Donor (DDLT)Liver Transplantation in the United States for this indication. Method: United Network of Organ Sharing/ Organ Procurement and Transplantation Network (UNOS/OPTN) data was reviewed from January 2002 to December 2020. Adult and pediatric recipients with diagnostic codes for ALF and listed as Status 1 were included in the study. Clinical, laboratory, and demographic characteristics were compared between LDLT and DDLT groups. In addition, Post-transplant survival rates were compared between the two groups. Results: There were a total of 246 LDLT (3.8%) and 6153 DDLT (96.2%) recipients with the diagnosis of ALF (Table 1). There was a difference in age and gender between the groups, with 93.5% of LDLT cases being for pediatric ALF cases versus 45.9% of DDLT cases being for pediatric recipients of age less than 18. There were more female gender in the DDLT group. Race was not different between the two groups. The proportion of patients waiting ≥ 3 days was 64.1% in DDLT compared to 77.2% in the LDLT group (P<0.001). There was no statistical difference between the two groups in terms of sodium, bilirubin, and INR. There were more patients with hepatic encephalopathy, and on renal replacement therapy in the DDLT group compared to LDLT group. Overall, 1, 5 and 10 year overall survival among the DDLT and LDLT groups were also similar, 87.7% vs. 85.5%, 81.1% vs. 81.1%, 74.7% vs. 79.3% (p=0.16) (Figure 1) (Log rank P=0.16). Conclusions: In the US, LDLT constitutes of only 3.8% of all liver transplants for ALF. In addition, LDLT was mostly used among pediatric recipients (93.5%), whereas DDLT was mostly used for adult recipients (54.1%). Signs of decompensation with hepatic encephlopathy, ascites, and on renal replacement therapy were more common in DDLT than LDLT group. LDLT can be carefully considered in a select group of adult ALF cases, in early phases, before further progression into renal failure and advanced encephalopathy.

P11.11: A New Designed Machine Perfusion System to Mimic the Cardiac Cycle’s Heart Function for a Better Hepatic Microcirculation Perfusion

Background: Machine perfusion is a relatively new concept developed for protecting marginal liver transplantation. However, so far, limited studies have reported on liver transplantation donated after cardiac death (DCD). Objective: To establish and verify a novel machine perfusion concept to eliminate these risk factors and recover DCD livers. Methods: To explore a novel hypothermic oxygenated perfusion (HOPE) system, two pumps and an elastic water sac were integrated into the perfusion system to mimic the cardiac cycle’s heart function. Compared to the other two traditional systems (HOPE S1 and S2), the novel HOPE system (HOPE S3) was verified in rats by no injured livers (perfused with methylene blue diluted by UW-G) or DCD livers subjected to 60 min in situ warm ischemia, without application of heparin. Liver perfusion outcomes were compared using macroscopy, microscopy, molecular tests, and orthotopic liver transplantation (OLT). Results: DCD livers, subjected to HOPE systems’ perfusion, disclosed reduced injury and improved survival compared to static cold storage after warm ischemia of 60 min (DCD+SCS). The post-transplantation survival rates of 4 weeks were 0%, 20 and 30% in DCD+SCS, DCD+SCS+HOPE S1, and DCD+SCS+HOPE S2 group, respectively. In contrast, HOPE S3 protected from hepatocyte and non-parenchymal cell injury and led to 60% (6/10) animal survival after 60 min of warm donor ischemia (DCD+SCS+HOPE S3). These data were further demonstrated by monitoring the hepatic sinusoid microcirculation, function morphological, and molecular changes of preserved livers. Conclusion: The newly designed novel machine perfusion system achieved complete and homogeneous liver perfusion and is regarded as a useful tool for resuscitating DCD liver grafts with severe warm ischemic injuries. Key words：Liver transplantation; Hypothermic oxyenated perfusion; Donation after cardiac death; Organ recovery; Perservayion manner; Ischemic reperfusion injury; Static cold storage; Hepatic sinusoidal; Hepatic microcirculation; Inferior vena cava. National Natural Science Foundation of China (Grant No. 81970548). Medical Science Advancement Program (Youth Scholars) of Wuhan University (Grant No. TFZZ2018035). Science and Technology Innovation Cultivation Fund of Zhongnan Hospital of Wuhan University(No.znpy2019041).

Heart Transplant Indications, Considerations, and Outcomes in Fontan Patients: Age-Related Nuances, Transplant Listing, and Disease-Specific Indications.

In the current era, 5%-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure of any mechanism, with a 1-year post-transplant survival rate approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein-losing enteropathy and plastic bronchitis can be expected to resolve post-transplant, and limited data suggest patients with Fontan-associated liver disease who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx, and late referrals and failure to refer adult patients remain problematic. Very little is known about the numbers of patients who are not referred, are turned down following assessment for HTx, or die on the waiting list-numbers that are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality-improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status-listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing adult congenital heart disease transplant centres with expertise that can also offer combined heart-liver transplant when appropriate, and improving single-ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.

Outcomes in Patients With LVADs Undergoing Simultaneous Heart-Kidney Transplantation

Multiple studies have shown better outcomes for simultaneous heart-kidney transplant (sHKT) than for isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable left ventricular assist devices (LVADs) have not been well studied. Patients with durable LVADs and stage 3 or higher CKD (eGFR < 60 mL/min/1.73 m2) undergoing iOHT or sHKT between 2008 and 2020 were identified from the United Network for Organ Sharing registry. A Kaplan-Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival rates. Multivariable modeling was used to identify risk-adjusted predictors of 1 year post-transplant mortality. We identified 4375 patients; 366 underwent sHKT, and 4009 underwent iOHT. The frequency of sHKT increased during the study period. The 1-year post-transplant survival rate was worse in patients after sHKT than in patients after iOHT (80.3% vs 88.3%; P < 0.001) and persisted up to 5 years post-transplant (P = 0.001). sHKT recipients were more likely to require dialysis after transplantation and had longer hospital lengths of stay (P < 0.001). Multivariable analysis showed that sHKT remained an independent risk factor for mortality at 1 year (OR 1.58; P = 0.002). sHKT is becoming more common in patients with durable LVADs. Compared with iOHT, patients with sHKTs have worse short- and long-term survival rates and are more likely to require post-transplant dialysis.

Lung Transplantation in HIV Patients

<h3>Purpose</h3> Limited published data exist on outcomes related to lung transplantation (LTx) in human immunodeficiency virus (HIV)-infected individuals. <h3>Methods</h3> We conducted a multicenter retrospective study of LTx in HIV- infected patients and describe key transplant- and HIV-related outcomes. <h3>Results</h3> We identified 22 HIV-infected LTx recipients across 25 transplant centers from 2007 through 2021. At transplantation, mean age was 53 [46 - 59] years, 55% were male. Two (9%) patients had an history of previous opportunistic infection and AIDS status. Pretransplant CD4 T cell count was 514 [351 - 670] cell/mm3 and RNA viral load was negative in all patients and their values did not change significantly post operatively. Due to calcineurin inhibitor interactions, 3 (15%) patients required an antiretroviral regimen change before LTx. Main indications for LTx were pulmonary arterial hypertension in 7 (32%), fibrosis in 5 (23%) and cystic fibrosis in 3 (14%). LTx procedure was predominantly bilateral-lung transplantation (91%). Immunosupression was giving according to local protocols including induction in 7 (32%) patients. During first post-LTx year, acute cellular rejection, antibody-mediated rejection, and infections requiring hospitalization occurred in 7 (37%), 2 (11%) and 8 (40%), respectively. During the median [range] follow-up of 25 [0.1-172] months, 26% and 14% of patients developed chronic lung allograft dysfunction and malignancy, respectively. Posttransplant survival rates after 1, 3, and 5 years were 79%, 79%, and 79%, respectively. At last news evaluation, 59% of the patients were fully active and independent. <h3>Conclusion</h3> Apart from early infection rates, survival rates and post-operative outcome were similar to their HIV-uninfected LTx recipients. At last follow-up, more than half of the patients had near-normal functional status.

Intra-Aortic Balloon Pump or Impella 5.0/5.5 as a Bridge to Heart Transplantation?

<h3>Purpose</h3> Impella 5.0/5.5 provide superior hemodynamic support and left ventricle unloading compared to intra-aortic balloon pump (IABP) but may be associated with more device-related complications. Limited comparative data exists on their use in patients with advanced heart failure awaiting transplantation. We evaluated patients bridged to transplant (BTT) with IABP versus Impella 5.0 or 5.5 <h3>Methods</h3> A prospective institutional registry identified 142 patients undergoing either IABP (n=77) or Impella 5.0/5.5 (n=65) implantation as BTT between 1/1/2017 and 12/31/2020. Analysis included only patients who were transplanted. Outcomes included 6-months survival, 6-months freedom from cardiac allograft vasculopathy (CAV: stenosis ≥30% by angiography), non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, pacemaker implant, stroke) and treated rejections <h3>Results</h3> The percentage of transplanted patients who were bridged with either Impella 5.0/5.5 or IABP increased from 19% (19/100) in 2017 to 28.6% (30/105) in 2020. Successful transplantation occurred in 75% (49/65) patients bridged with Impella and 68.9% (53/77) bridged with IABP (p=0.39). Among transplanted patients, several baseline characteristics differed between the Impella and IABP groups, including longer device duration, more pre-transplant packed red blood cell (PRBC) transfusions, and more multi-organ transplants in Impella patients (all p<0.05). At 6 months, post-transplant survival and stroke rates were similar (both p>0.5). In patients bridged with IABP, rates of rejections trended lower, while rates of CAV and NF-MACE were numerically higher, primarily driven by higher rates of pacemaker implant (Table) <h3>Conclusion</h3> The use of IABP and Impella 5.0/5.5 as BTT is increasing, with excellent 6-month survival. Registry analysis may help quantify the impact of increased blood product and induction therapy requirement associated with Impella 5.0/5.5 use