Potential Transplant Candidates Research Articles

Humoral and cellular response after varicella vaccination in VZV IgG seronegative kidney transplant candidates

BackgroundIn immunocompromised patients, primary infection with VZV may have a disastrous clinical course. Vaccination of VZV-seronegative patients on the waiting list for renal transplantation may prevent severe disease. However, the immunologic response of end-stage renal disease patients to peptide vaccines is far from optimal. Our question was whether end-stage renal disease patients with undetectable VZV-IgG levels were able to mount an adequate humoral and cellular response to a live attenuated varicella vaccine. MethodsKidney transplant candidates with undetectable VZV levels were vaccinated twice with a live attenuated varicella vaccine at an interval of 6weeks. VZV IgG levels were analysed till 2years after vaccination. The VZV-specific T-cell reactivity was determined prior to vaccination and after transplantation. ResultsSeventy-seven percent (40/52) of the vaccinees reached positive VZV-IgG levels after vaccination (responders). Eighty-two percent (9/11) showed an increase in VZV-specific CD4+ memory T-cells (both central and effector memory cells). The percentage VZV-specific CD8+ memory T-cells did not increase. None of the non-responders suffered from primary VZV after transplantation. No severe vaccine-related adverse events were reported, only spontaneously resolving local skin irritation. ConclusionThe live attenuated varicella vaccine evokes positive VZV IgG-levels and VZV-specific memory T-cells in VZV-seronegative potential kidney transplant candidates.

Should quality of the liver transplant candidate evaluation be measured?

Should quality of the liver transplant candidate evaluation be measured?

Feasibility of exercise stress echocardiography for cardiac risk assessment in chronic kidney disease patients prior to renal transplantation.

Pharmacologic stress testing is utilized in preference to exercise stress echocardiography (ESE) for cardiac risk evaluation in potential renal transplant recipients due to the perceived lower feasibility of ESE for achieving adequate workload and target heart rate (THR) in this population. Consecutive patients referred for cardiac risk evaluation prior to potential kidney transplantation were evaluated. All patients attempted ESE before pharmacologic testing was considered. Treadmill ESE utilized BRUCE protocol to maximum capacity. THR was defined as >85% of the maximum predicted heart rate (220-age). Functional capacity was assessed by metabolic equivalents (METs) and the rate pressure product (RPP). Of 535 patients (349 male, age 56±11), 372(70%) reached THR. Mean METs were 10±3 with 531(99%) achieving ≥4METs and 87% ≥7METs. Mean RPP was 25821±5820bpm×mm Hg (83% achieving >20000bpm×mm Hg). On multivariate analysis, independent predictors of failure to reach THR were rate-control medication and diabetes; failure to reach 7METs: females, diabetics, age≥65, and previous cardiac disease; failure to reach RPP>20000: rate-control medication. There were 97% of ESE completed to physiologic endpoints. In unselected potential renal transplant candidates, cardiac assessment by ESE is well tolerated, with 9-in-10 exercising to satisfactory functional capacity. ESE should be considered a feasible alternative to pharmacologic testing in this population.

Increasing Access.

Increasing Access.

(117) - Changes in Smoking Habits in Potential Lung Transplant (LTx) Candidates

(117) - Changes in Smoking Habits in Potential Lung Transplant (LTx) Candidates

Prevalence, Severity, and Prognostic Effect of Hepatopulmonary Syndrome in Liver Transplant Candidates.

Hepatopulmonary syndrome (HPS) is commonly encountered in the setting of end-stage liver disease (ESLD). Past studies have reported conflicting results in terms of demonstrating an association between HPS and mortality. The aim of this study was to determine the prevalence of HPS in patients with ESLD referred for assessment of transplantation suitability. In addition, we investigated survival rates in the setting of HPS, with and without liver transplantation. The medical records of 524 consecutive patients with ESLD evaluated for potential liver transplantation were retrospectively reviewed. HPS was defined by a reduced partial pressure of oxygen or an elevated alveolar-arterial oxygen gradient and the presence of intrapulmonary vascular dilatation on contrast-enhanced echocardiography. In total, 57 subjects (12%) fulfilled the diagnostic criteria of HPS; 88% of these had mild to moderate HPS. For patients with HPS, the overall survival rates at 1 and 3 years were 95% and 92%, respectively. Liver transplants were received by 245 patients (53%), 26 of whom had HPS. For transplant recipients with HPS, the overall survival rates at 1 and 3 years were 96% and 91%, respectively, compared to 85% and 80% in subjects without HPS. Post-transplantation survival in patients with and without HPS did not differ significantly (HR=0.489, 95% CI: 0.153-1.564; p=0.228). This study demonstrated a high prevalence of IPVD and HPS among patients who were potential candidates for liver transplantation. HPS was mild to moderate in the majority of those affected and had no significant effect on overall survival.

Treat chronic hepatitis C virus infection in decompensated cirrhosis - pre- or post-liver transplantation? the ironic conundrum in the era of effective and well-tolerated therapy.

The management of hepatitis C virus (HCV) infection in patients with decompensated cirrhosis has evolved dramatically over the past few years mainly due to the availability of all-oral antiviral regimens. The currently approved all-oral direct-acting antivirals (DAA) containing sofosbuvir, ledipasvir, daclatasvir and ribavirin, in various combinations, have shown to be safe and effective in patients with decompensated cirrhosis with sustained virological response (SVR) rates nearly comparable to those with well-compensated liver disease. Unique issues yet remain such as the challenges with renal insufficiency, tolerability of ribavirin and risk of further hepatic decompensation with a protease inhibitor-based regimen. While most patients who achieve SVR have demonstrated improvement in hepatic synthetic function over the short course of follow, the long-term beneficial effects are unknown. Further, the baseline predictors of improvement in hepatic function have not been well delineated and thus have left us in a quandary as to what we might expect with successful therapy and thus we are at a loss to well educate our patients. The major concern, in potential liver transplant candidates, is of unintended 'harm' by achieving SVR but without improvement in hepatic function to an extent where the patients might function well. As HCV therapies are as effective in liver transplant recipients, there is a growing sentiment in some of the transplant quarters that those with decompensated liver disease and awaiting liver transplant be treated for HCV after liver transplant. This strategy would thus eliminate any concern of leaving a patient in 'no person's' land by treating HCV successfully pretransplant but not to the point of functional normalcy, while also would maintain the risk of HCC. Yet a contrarian view would be that not all patients have access to liver transplantation (LT), cannot bear the cost, have comorbidities or contraindications to LT. While the debate continues, it is essential that we develop robust predictors of improvement in liver function so that we can carefully select our patients for therapy in the context of liver transplantation.

Solid Organ Transplantation in HIV+ Recipients: Italian Experience

IntroductionAccording to current estimates, there are about 540,000 patients who are infected with HIV in Western Europe, of which about 3100 are potential candidates for organ transplantation. In Italy, there are currently 85 HIV patients on the transplant list. MethodsOrgan transplantation activity in HIV recipients from 2002 to December 2014 was assessed from the database provided by the Transplant Center of Modena until the year 2011. For the years 2012 to 2014, data are from the Transplant Information System (SIT). The follow-up data have been extracted from the function “Quality” of the SIT. ResultsThe transplant centers on Italian territory that meet the requirements according to national protocol are in total 29: 11 for the liver, 9 for the kidney including 1 pediatric, 3 for the heart, 3 for the lungs, and for 3 for the combined kidney–pancreas. Since 2002, 257 organ transplantations were carried out, including 185 liver, 59 kidney, 5 combined liver–kidney, 5 combined kidney–pancreas, 2 heart, and 1 double lung. The first cause of death is represented by co–hepatitis C virus infection, in particular in 26 liver recipients (37%) and in 3 kidney recipients (20%). ConclusionsThe analysis showed that transplantation activity in HIV is on the rise, especially in the last 2 years, with an outcome similar to that reported in the literature.

Prognostic Utility of Calcium Scoring as an Adjunct to Stress Myocardial Perfusion Scintigraphy in End-Stage Renal Disease

Coronary artery calcium score (CACS) is a strong predictor of adverse cardiovascular events in the general population. Recent data confirm the prognostic utility of single-photon emission computed tomographic (SPECT) imaging in end-stage renal disease, but whether performing CACS as part of hybrid imaging improves risk prediction in this population is unclear. Consecutive patients (n = 284) were identified after referral to a university hospital for cardiovascular risk stratification in assessment for renal transplantation. Participants underwent technetium-99m SPECT imaging after exercise or standard adenosine stress in those unable to achieve 85% maximal heart rate; multislice CACS was also performed (Siemens Symbia T16, Siemens, Erlangen, Germany). Subjects with known coronary artery disease (n = 88) and those who underwent early revascularization (n = 2) were excluded. The primary outcome was a composite of death or first myocardial infarction. An abnormal SPECT perfusion result was seen in 22% (43 of 194) of subjects, whereas 45% (87 of 194) had at least moderate CACS (>100 U). The frequency of abnormal perfusion (summed stress score ≥4) increased with increasing CACS severity (p = 0.049). There were a total of 15 events (8 deaths, and 7 myocardial infarctions) after a median duration of 18 months (maximum follow-up 3.4 years). Univariate analysis showed diabetes mellitus (Hazard ratio [HR] 3.30, 95% CI 1.14 to 9.54; p = 0.028), abnormal perfusion on SPECT (HR 5.32, 95% CI 1.84 to 15.35; p = 0.002), and moderate-to-severe CACS (HR 3.55, 95% CI 1.11 to 11.35; p = 0.032) were all associated with the primary outcome. In a multivariate model, abnormal perfusion on SPECT (HR 4.18, 95% CI 1.43 to 12.27; p = 0.009), but not moderate-to-severe CACS (HR 2.50, 95% CI 0.76 to 8.20; p = 0.130), independently predicted all-cause death or myocardial infarction. The prognostic value of CACS was not incremental to clinical and SPECT perfusion data (global chi-square change = 2.52, p = 0.112). In conclusion, a perfusion defect on SPECT is an independent predictor of adverse outcome in potential renal transplant candidates regardless of the CACS. The use of CACS as an adjunct to SPECT perfusion data does not provide incremental prognostic utility for the prediction of mortality and nonfatal myocardial infarction in end-stage renal disease.

Prospective validation of ab initio liver transplantation in hepatocellular carcinoma upon detection of risk factors for recurrence after resection

A decade ago we proposed to enlist for transplantation those patients with resected hepatocellular carcinoma in whom pathology registered pejorative histological markers (microvascular invasion and/or satellites; ab initio indication) and not wait for the appearance of recurrence. This study evaluates the outcome of this approach. From 1995 to 2012, 164 patients with hepatocellular carcinoma underwent resection. Eighty-five patients were potential candidates for liver transplantation and were considered for it upon detection of pejorative histological markers. Patients without these markers were followed, and salvage liver transplantation was considered upon development of tumor recurrence/liver function impairment. Thirty-seven patients were at high risk and 48 at low risk of recurrence at pathology. Twenty-three out of 37 high-risk patients recurred during follow-up, but in nine of them the tumor burden extent contraindicated liver transplantation. Seventeen were finally transplanted: 10 of them presented recurrence at imaging/explant. After a median posttransplant follow-up of 50.9 months, hepatocellular carcinoma had recurred in two patients and five patients had died, the 5-year survival being 82.4%. Twenty-six of the 48 low-risk patients developed recurrence, and 11 of them were transplanted. After a median posttransplant follow-up of 59 months, two patients developed recurrence and five died, their 5-year survival being 81.8%. Enlistment of patients at high risk of HCC recurrence after resection but before recurrence development seems a valid strategy and is associated with excellent long-term outcome; as early (<6 months) recurrence reflects an aggressive tumor behavior leading to tumor extent exceeding transplant criteria, we propose to wait at least 6 months before enlistment; however, once included on the waiting list, priority strategies should be implemented in order to reach effective transplantation prior to the appearance of recurrence.

Impact of Treatment on Overall Survival (OS) in Higher-Risk Myelodysplastic Syndromes (MDS): A Report from the Erasme Study

Introduction: Treatment of MDS has undergone a dramatic change in recent years with the emergence of demethylating agents; however, there are limited data on the impact of these agents on OS in the "real-world" setting. The aim of this study is to evaluate the use and outcomes of different therapies in patients (pts) with International Prognostic Scoring System (IPSS)-defined Intermediate-2- and High-risk (higher-risk) MDS.Methods: The ERASME study (CEL-SMD-2012-01) is an observational, prospective study of pts with either MDS or chronic myelomonocytic leukemia (CMML); pts were defined using the 2008 World Health Organization (WHO) classification system. Initial pt management strategy was classified into 3 groups: active therapy (AT), such as chemotherapy or treatment with azacitidine (AZA), lenalidomide (LEN), etc.; allogeneic hematopoietic cell transplantation (HCT), which included those pts receiving other therapies before transplantation; and observation and support (OB&SP), which included red blood cell and platelet transfusions, and growth factors. OS rates of higher-risk pts are presented using the Kaplan-Meier method.Results: A total of 160 pts with higher-risk MDS were recruited between Jan 2013 and Feb 2015. Median follow-up was 8.6 months (interquartile range [IQR] 4.0-11.8). Pt characteristics are described in the Table. AT was the first therapeutic decision in 83 (52%) pts, HCT in 43 (27%), and OB&SP in 34 (21%). Within the AT group, 75 (90%) pts received AZA alone, 5 (6%) AZA plus chemotherapy, and 3 (4%) received other options; most pts (n = 78; 94%) were treated with a 7-day regimen. Among the 43 potential HCT candidates, 40 (93%) had received prior therapy: 25 (58%) with AZA alone, 8 (19%) with chemotherapy, 6 (14%) with AZA plus chemotherapy, and 1 (2%) with LEN; 3 (7%) had not received prior therapy. Of the potential HCT candidates, 20 had undergone transplantation within a median of 8 months (IQR 4.1-13.3); 7 (16%) pts died before transplantation and 16 (37%) are still awaiting transplantation. The main reasons for OB&SP being the initial pt strategy were disease risk (100%), age (95%), comorbidities (60%), and symptomatology (44%). At last follow-up, 70 of 160 pts (44%) had died after a median of 6 months (IQR 2.9-11.8): 34 (41%), 14 (32%), and 22 (65%) pts undergoing AT, HCT, and OB&SP, respectively (log-rank 6.9; P = 0.032). Median OS in pts who received AT, HCT, and OB&SP was 18.60 months (95% confidence interval [CI] 13.1-21.8), 14.92 months (95% CI 11.6-not reached), and 8.44 months (95% CI 4.3-13.4), respectively. Median OS was significantly longer in the AT group compared with the OB&SP group (hazard ratio [HR] 1.9; 95% CI 1.1-3.3; P = 0.0197). No statistically significant difference was observed in OS between pts treated with AT and those considered potential HCT candidates (HR 0.9; 95% CI 0.5-17.7; P = 0.8).Conclusions: The preliminary data from this observational, prospective study indicate that AT significantly prolongs OS compared with OB&SP when treating pts with higher-risk MDS in a real-world setting. AZA was the most common treatment in the AT group.Abstract presented on behalf of the ERASME Study Investigators Group.TableBaseline characteristics of the MDS population (N = 160)CharacteristicAge, median (IQR), years73 (64.5-79.0)Male, n (%)86 (53.8)Bone marrow blast count, median (IQR), %12 (7.5-16.3)Hemoglobin level, median (IQR), g/dL9.55 (8.0-10.6)Platelet count, median (IQR), × 109/L64.75 (41.0-121.0)ANC, median (IQR), × 109/L1 (0.47-2.20)Cytogenetic risk (by IPSS-R), n (%)Low64 (40.0)Intermediate9 (5.6)High27 (16.9)Very High39 (24.4)Missing data21 (13.1)WHO classification, n (%)RCMD17 (10.6)RAEB type 128 (17.5)RAEB type 294 (58.8)Unclassified2 (1.3)Missing1 (0.6)AML 20-30% blasts18 (11.3)IPSS risk classification, n (%)Intermediate-286 (53.8)High71 (44.4)Missing3 (1.9)IPSS-R risk classification, n (%)Very Low4 (2.5)Low28 (17.5)Intermediate20 (12.5)High40 (25.0)Very High46 (28.8)Missing22 (13.8)AML, acute myeloid leukemia; ANC, absolute neutrophil count; FAB, French-American-British; IPSS-R, Revised-IPSS; RAEB, refractory anemia with excess blasts; RCMD, refractory anemia with multilineage dysplasia. DisclosuresOff Label Use: Azacitidine was used to treat patients who are potential hematopoietic stem cell transplant candidates. Ramos:GlaxoSmithKline: Honoraria; Janssen-Cilag: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria; Celgene Corporation: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria. Rafel:Celgene Corporation: Employment. Valcárcel:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Guidelines for the diagnosis and management of adult aplastic anaemia.

Sally B. Killick (Writing Group Chair), Nick Bown, Jamie Cavenagh, Inderjeet Dokal, Theodora Foukaneli, Peter Hillmen, Robin Ireland, Austin Kulasekararaj, Ghulam Mufti, John A Snowden, Sujith Samarasinghe, Anna Wood (BCSH Task Force Member), Judith C.W. Marsh on behalf of the British Society for Standards in Haematology. The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Northern Genetics Service, Newcastle upon Tyne, St Bartholomew’s Hospital, Barts Health NHS Trust, London, Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, Addenbrooks Hospital, University of Cambridge, Cambridge, Leeds Teaching Hospitals, Leeds, Kings College Hospital NHS Foundation Trust, London, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield Great Ormond Street Hospital for Children NHS Foundation Trust, London, West Hertfordshire NHS Trust, Watford.

Potts Shunt and Pediatric Pulmonary Hypertension: What We Have Learned

A Potts shunt has been proposed as effective palliative therapy in children with severe pulmonary hypertension (PH) who have suprasystemic right ventricular pressures. A retrospective single-center study was performed to assess outcomes in 5 children who underwent a Potts shunt for severe PH. All 5 children were in World Health Organization functional class IV. Only 3 children were classified as having idiopathic pulmonary arterial PH. Preoperatively, 4 children were receiving intravenous prostacyclins, and 3 were placed on intravenous inotropes for acute right-side heart failure. Three children were potential lung transplant candidates. All but 1 child had evidence for suprasystemic right heart pressures immediately before their operation. All 5 children survived the procedure without significant complications. Four of the 5 children were successfully discharged from the hospital and have had sustained clinical improvement with follow-up ranging from approximately 5 to 16 months. The child who did not have suprasystemic right-side heart pressures before the operation did not benefit from the Potts shunt. The Potts shunt can be an effective palliation for children with severe PH. Our results further suggest that (1) a Potts shunt should be considered early in a child's clinical course, before right ventricular deterioration develops; (2) a Potts shunt should be considered in any child with severe, intractable PH regardless of etiology; (3) one might consider a Potts shunt in lieu of intravenous prostacyclins; and (4) a Potts shunt should be considered before lung transplantation and does not preclude future transplantation candidacy.

Aging induced loss of stemness with concomitant gain of myogenic properties of a pure population of CD34+/CD45− muscle derived stem cells

Aging is accompanied by the functional decline of cells, tissues, and organs, as well as, a striking increase in susceptibility to a wide range of diseases. Within a tissue, both differentiated cells and adult stem cells are susceptible to intrinsic and extrinsic changes while aging. Muscle derived stem cells (MDSCs) are tissue specific stem cells which have been studied well for their multipotential nature. Although there are reports relating to diminished function and regenerative capacity of aged MDSCs as compared to their young counterparts, not much has been reported relating to the concomitant gain in unipotent nature of aged MDSCs. In this study, we report an inverse correlation between aging and expression of adult/mesenchymal stem cell markers and a direct correlation between aging and myogenecity in MDSCs. Aged MDSCs were able to generate a greater number of dystrophin positive myofibres, as compared to, the young MDSCs when transplanted in muscle of dystrophic mice. Our data, therefore, suggests that aging stress adds to the decline in stem cell characteristics with a concomitant increase in unipotency, in terms of, myogenecity of MDSCs. This study, hence, also opens the possibilities of using unipotent aged MDSCs as potential candidates for transplantation in patients with muscular dystrophies.

Cardiovascular Screening and Management Among Kidney Transplant Candidates in Hungary

IntroductionCardiovascular disease is a major cause of morbidity and mortality in end-stage renal disease patients on dialysis and the most common cause of death in the immediate post-transplantation period. The aim of our study was to describe a novel approach of cardiovascular screening and management of dialysis patients evaluated for the transplant waiting list. MethodsTwenty-eight patients with end-stage renal disease put on the waiting list between July 2013 and July 2014 were subjected to a prespecified cardiovascular screening protocol utilizing noninvasive and/or invasive tests. Patients were subsequently divided into 3 strata in terms of their estimated cardiovascular risk. Each of these groups were then prescribed interventions aiming to improve their cardiovascular condition. ResultsAccording to our prespecified protocol of cardiovascular screening studies, 15 (54%) patients were identified as low, 5 (18%) as intermediate, and 8 (28%) as high risk. Four (14%) patients were current smokers. In the low-risk group, we initiated a patient education program involving counseling on regular exercise such as swimming or cycling to improve their functional capacity. In the high-risk group revascularization was done in 5 cases (63%), including 3 percutaneous transluminal coronary angioplasties (PTCA) with stents for single-vessel disease, and coronary artery bypass graft surgeries (CABG) for triple-vessel disease in 2 cases. In the medium-risk group medical management was opted for, including introduction of beta-blockers, inhibitors, statins, and ezetimibe, as well as efforts to optimize anemia management, indices of bone-mineral disease, and fluid status. ConclusionIn our regional transplant program, we introduced a comprehensive multidisciplinary approach to treat potential transplant candidates according to cardiovascular risk stratification based on a prespecified screening protocol. Further studies are needed to correlate this novel strategy with post-transplantation outcomes.

Effect of pulmonary vascular resistance before left ventricular assist device implantation on short- and long-term post-transplant survival

ObjectivesPulmonary hypertension is often considered a contraindication to orthotopic heart transplantation. Left ventricular assist device support may improve pulmonary hypertension by unloading the left ventricle, making patients eligible for transplantation. We sought to investigate the effect of continuous-flow left ventricular assist device support on pulmonary hypertension and compare post-transplantation outcomes in patients with preexisting pulmonary hypertension. MethodsBetween March 2004 and December 2013, 256 potential orthotopic heart transplantation candidates underwent continuous-flow left ventricular assist device implantation at Columbia University. Preimplantation right heart catheterization data were available for 227 patients. Patients were divided into 2 groups on the basis of preimplantation pulmonary vascular resistance: low (<5 Wood units) (n = 182) and high (≥5 Wood units) (n = 45). Postimplantation and post-transplantation outcomes were compared between the groups. ResultsPulmonary vascular resistance in the high resistance group decreased significantly during left ventricular assist device support (P < .001). Post-transplantation in-hospital mortality was significantly higher in patients with high vascular resistance (P < .05). However, 3-year survival after transplantation was similar between groups (85.0% and 79.0% for low and high vascular resistance, respectively; P = .45). ConclusionsContinuous-flow left ventricular assist device therapy reduced pulmonary vascular resistance. Subsequent orthotopic heart transplantation in patients with significantly elevated pulmonary vascular resistance resulted in higher in-hospital mortality but similar 3-year survival.

Peak panel reactive antibody, cancer, graft, and patient outcomes in kidney transplant recipients.

High levels of pretransplant panel reactive antibodies (PRA) are known to be associated with detrimental effects on graft outcomes, but the association between pretransplant PRA levels and long-term patient outcomes is unclear. Using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), we assessed the risk of rejection, graft failure, mortality and cancer in kidney transplant recipients with varying peak PRA levels. In 7,118 kidney transplant recipients between 1997 and 2009, there were a total of 3,171 (44.6%), 3,306 (46.4%), 323 (4.5%), and 318 (4.5%) recipients with peak PRA levels of 0%, 1% to 50%, 51% to 80%, and greater than 80%, respectively. Compared to recipients with 0% peak PRA level, recipients with peak PRA levels greater than 80% were at increased risk of acute rejection (odds ratio, 1.81, 95% confidence interval [95% CI], 1.30-2.35; P < 0.001), death censored graft failure (hazard ratio [HR], 2.06; 95% CI, 1.46-2.91; P < 0.001), all-cause mortality (HR, 1.56; 95% CI, 1.15-2.11; P < 0.001) and cancer (HR, 1.94; 95% CI, 1.26-2.97; P = 0.002) in the adjusted models independent of human leukocyte antigen mismatches and initial immunosuppression. Highly sensitized kidney transplant recipients with peak PRA greater than 80% had a greater risk of rejection, graft failure, cancer and death independent of age and time on dialysis. Strategies to reduce transplant waiting time and avoidance of sensitization in all potential transplant candidates are imperative to improve the overall graft and patient survival.

Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative

BackgroundThe shortage of organs is a major hurdle in kidney transplantation, and one solution to the problem is to extend the age of the donor. However, organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis. A possible solution to avoid this wastage of kidneys potentially suitable for transplantation could be the performance of preemptive kidney transplantation (PKT) in carefully selected elderly patients. PKT improves graft and patient survival compared to other renal replacement therapy options. There is no information about PKT in elderly patients receiving kidneys from elderly deceased donors. MethodsFrom 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis. ResultsMean age of recipients was 74.3±2.9 years and mean age of donors was 73.8±4.1 years. Induction immunosuppression was similar in both groups. Death-censored graft survival was 96% in the PKT group and 68% in the control group (p=0.02), at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group (p=0.005). Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%, p=0.043). At the end of follow-up time 35.5±20.1 months, the glomerular filtration rate was similar in both groups (42.2±11.7 vs 41.7±11.2ml/min, p-value=0.72). Patient survival was similar in the two groups. ConclusionsElderly patients with end stage of renal disease non-dialysis may benefit from PKT elderly deceased donors whose kidneys were to be discarded for there are not patients in the waiting list.

Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative

BackgroundThe shortage of organs is a major hurdle in kidney transplantation, and one solution to the problem is to extend the age of the donor. However, organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis. A possible solution to avoid this wastage of kidneys potentially suitable for transplantation could be the performance of preemptive kidney transplantation (PKT) in carefully selected elderly patients. PKT improves graft and patient survival compared to other renal replacement therapy options. There is no information about PKT in elderly patients receiving kidneys from elderly deceased donors. MethodsFrom 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis. ResultsMean age of recipients was 74.3±2.9 years and mean age of donors was 73.8±4.1 years. Induction immunosuppression was similar in both groups. Death-censored graft survival was 96% in the PKT group and 68% in the control group (p=0.02), at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group (p=0.005). Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%, p=0.043). At the end of follow-up time 35.5±20.1 months, the glomerular filtration rate was similar in both groups (42.2±11.7 vs 41.7±11.2ml/min, p-value=0.72). Patient survival was similar in the two groups. ConclusionsElderly patients with end stage of renal disease non-dialysis may benefit from PKT elderly deceased donors whose kidneys were to be discarded for there are not patients in the waiting list.

Neurocognitive status is associated with all-cause mortality among psychiatric, high-risk liver transplant candidates and recipients.

Judicious selection of potential liver transplant candidates and close monitoring of progress are essential to successful outcomes. Pretransplant psychosocial evaluations are the norm, but the relationship between psychosocial (and neurocognitive status) and longer term medical outcomes is understudied. This exploratory study sought to examine the relationship between objective measures of pretransplant psychosocial and neurocognitive status and service utilization, transplant status, and all-cause mortality. This retrospective chart review examined outcomes among 108 psychiatric, high-risk liver transplant candidates up to four years following initial evaluation. Predictor variables of outcomes included demographic, medical, neurocognitive, psychological, and mental health treatment variables. Transplant status and neurocognitive functioning were independently associated with all-cause mortality. None of the other variables were associated with outcomes. Better neurocognitive functioning in high-risk liver transplant candidates may allow for greater involvement in medical care and/or compliance with treatment recommendations. More aggressive assessment and management of neurocognitive dysfunction may improve outcomes. Objective measures identified significant psychopathology typical of liver transplant candidates but were not associated with outcomes; engagement in specialized mental health care may have attenuated this relationship. Further study is needed to better understand the relationship between psychosocial functioning and outcomes.