Primary Transplant Patients Research Articles

Repeat pediatric heart transplantation: A united network for organ sharing database analysis.

A history of congenital heart disease and previous transplantation are each independently associated with worse survival following pediatric heart transplantation. This study aimed to evaluate the characteristics and outcomes of children undergoing repeat heart transplantation in the United States based on the underlying diagnosis. The United Network for Organ Sharing database was used to identify 8111 patients aged<18 years undergoing isolated heart transplantation from 2000 to 2021, including 435 (5.4%) repeat transplants. Restricted cubic spline analysis assessed the non-linear relationship between inter-transplant interval and the primary outcome of all-cause mortality or re-transplantation. Multivariable Cox regression assessed the impact of re-transplantation on the primary outcome. Median follow-up was 5.0 (interquartile range 1.9-9.9) years. Repeat transplant patients were older (median age 12vs. 4 years; p<.001), and less likely to be in UNOS status 1A (66.0%, n=287vs. 81.0% n=6217; p<.001) than primary transplant patients. Freedom from the primary outcome was 51.4% (95% confidence interval [CI] 45.5-57.2) among repeat transplants and 70.5% (95% CI 69.2-71.8) among primary transplants at 10 years (p<.001). Among repeat transplant patients, the relative hazard of the primary outcome became non-significant when the inter-transplant interval>3.6 years. Congenital heart disease was an independent predictor of mortality among primary (HR 1.8, 95% CI 1.6-1.9) but not repeat transplant (HR 1.1, 95% CI .8-1.6) patients. Long-term outcomes remain poor for patients undergoing repeat heart transplantation, particularly those with an inter-transplant interval<3.6 years. Underlying diagnosis does not impact outcomes after repeat transplantation, after accounting for other risk factors.

Beneficial Effect of Moderately Increasing Hypothermic Machine Perfusion Pressure on Donor after Cardiac Death Renal Transplantation.

Background:Vascular resistance and flow rate during hypothermic machine perfusion (HMP) of kidneys is correlated with graft function. We aimed to determine the effects of increasing HMP pressure versus maintaining the initial pressure on kidney transplantation outcomes.Methods:We retrospectively reviewed the data of 76 primary transplantation patients who received HMP-preserved kidneys from 48 donors after cardiac death between September 1, 2013, and August 31, 2015. HMP pressure was increased from 30 to 40 mmHg (1 mmHg = 0.133 kPa) in kidneys with poor flow and/or vascular resistance (increased pressure [IP] group; 36 patients); otherwise, the initial pressure was maintained (constant pressure group; 40 patients). Finally, the clinical characteristics and transplantation outcomes in both groups were assessed.Results:Delayed graft function (DGF) incidence, 1-year allograft, patient survival, kidney function recovery time, and serum creatinine level on day 30 were similar in both groups, with improved flow and resistance in the IP group. Among patients with DGF, kidney function recovery time and DGF duration were ameliorated in the IP group. Multivariate logistic regression analysis revealed that donor hypertension (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.02–2.06, P = 0.035), donor terminal serum creatinine (OR: 1.27, 95% CI: 1.06–1.62, P = 0.023), warm ischemic time (OR: 3.45, 95% CI: 1.97–6.37, P = 0.002), and terminal resistance (OR: 3.12, 95% CI: 1.76–6.09, P = 0.012) were independent predictors of DGF. Cox proportional hazards analysis showed that terminal resistance (hazard ratio: 2.06, 95% CI: 1.32–5.16, P = 0.032) significantly affected graft survival.Conclusion:Increased HMP pressure improves graft perfusion but does not affect DGF incidence or 1-year graft survival.

Lung Retransplantation for Chronic Rejection: A Single-Center Experience

Chronic lung allograft dysfunction (CLAD) is nonreversible and remains the biggest obstacle to long-term survival after lung transplantation (LTx). Retransplantation is the sole definitive therapeutic option for CLAD. We analyzed our single-center experience with retransplantation as a treatment option for CLAD. From March 1, 2010, to May 31, 2016, 419 consecutive patients underwent LTx at our institution; 29 of these procedures were retransplantations for CLAD. We analyzed demographic characteristics, lung allocation score, operation type, length of stay, and perioperative outcomes. Actuarial survival was estimated using Kaplan-Meier survival curves. In total, 29 of 419 patients (6.9%) underwent retransplantation for CLAD. Median time from primary LTx to retransplantation was 1,163 days (range: 304 to 3,971 days). Patients undergoing retransplantation were younger and had higher lung allocation scores than primary transplantation patients. Most LTx procedures were bilateral (93% of retransplantations, 95% of primary LTx). Rates of cardiopulmonary bypass, extracorporeal membrane oxygenation support for severe primary graft dysfunction, and re-exploration for bleeding were higher in retransplantation patients (p= 0.010, p= 0.019, and p= 0.029, respectively). One- and 5-year survival rates in the retransplantation group were similar to those of the primary LTx group (89.2% and 64.3% versus 89.7% and 58.2%, respectively; p= 0.79). Lung retransplantation is a viable treatment option for CLAD after LTx. In this study, retransplantation patients were younger, had higher lung allocation scores, and were more likely to require cardiopulmonary bypass and postoperative extracorporeal membrane oxygenation support than primary LTx patients. Postoperative length of stay and short- and mid-term survival were comparable with those of primary LTx patients.

451 Cardiac Retransplantation is a Valuable Option for End-Stage Coronary Artery Vasculopathy

Retransplantation is done in only 2% to 3% of primary transplant recipient. Most of these patients have advanced coronary vasculopathy at the time of retransplantation. We report our experience with cardiac retransplantation since 1983. We reviewed all cases of patients who underwent heart retransplantation for end-stage coronary artery vasculopathy. From April 1983 to March 2011, we performed 377 cardiac transplantations. Ten (2.6%) were retransplantations. All primary cardiac transplant recipients at our institution served as the control group. Time to event analyses included comparisons of patients undergoing primary transplantation versus patients undergoing retranplantation for patient survival, rejection and infection analyses. There were 7 male and 3 female patients ranging from 14 to 69 years (mean, 37 ± 17 years). Indication for second transplantation was end-stage coronary vasculopathy in all cases. The Kaplan-Meier survival curves comparing our primary transplantation group with the retransplantation group are identical. The 30-day and the one year survival averaged 90 % ± 9 and 88 % ± 8 in retransplantation patients compared with 92 % ± 1 and 85 % ± 2 (p = 0.71) in primary transplant patients. The freedom rates from acute rejection (51 % ± 3 and 39 % ± 17, respectively) and from infection (48 % ± 3 and 39 % ± 17) were similar in both groups (p = 0.65 and p = 0.97) at ten year follow-up. Patients who underwent cardiac retransplantation for endstage coronary artery vasculopathy have similar outcomes when compared to primary heart transplant patients.

Lung Retransplantation in Children: Appropriate When Selectively Applied

Lung retransplantation (re-LTx) in children has been associated with lower survival rates compared with primary lung transplantation. However, improving survival for primary LTx has led to more patients presenting for re-LTx. Therefore, an analysis of the UNOS (United Network of Organ Sharing) database to evaluate the effectiveness of pediatric lung retransplantation in the United States was completed. The UNOS registry was queried for pediatric re-LTx patients from May 1988 to May 2008. There were 81 (10%) re-LTx out of a total 802 pediatric lung transplants. Median age and weight at re-LTx were 14 (range, 0 to 18) years and 32 (4 to 58) kg. Indications for re-LTx were obliterative bronchiolitis in 50 patients (62%), primary graft failure in 8 (10%), and other in 23 (28%). The Kaplan-Meier graft survival for re-LTx patients was worse than for primary transplant patients (p < 0.001, graft half-life 0.9 vs 4.0 years), especially if re-LTx was done less than 1 year after primary transplant (graft half-life 0.25 years). Graft survival in patients who underwent re-LTx greater than 1 year after primary transplant was not statistically different than for primary LTx patients (p = 0.21; graft half-life 2.8 vs 4.0 years), and if re-LTx greater than 1 year posttransplant occurred in patients who were not ventilator dependent, survival was further improved (p = 0.68; graft half-life 4.7 vs 4.0 years). Pediatric lung retransplantation within the first year after primary transplant does not appear advisable. Pediatric re-LTx greater than 1 year after primary transplantation may be a reasonable strategy for end-stage graft failure. Patients greater than 1 year posttransplant and not ventilator dependent appear an even more compelling group in which to consider lung retransplantation.

Repeat Heart–Lung Transplantation Outcome in the United States

This study compared risk-adjusted survival between primary and repeat heart-lung transplantation. Data for 799 primary heart-lung and 19 repeat heart-lung transplants were extracted from the United Network Organ Sharing (UNOS) registry. Analyses were based on propensity score matching in which 1, 2, and 3 primary transplant patients were matched with 19 repeat transplant patients. The matching variables were sex of recipient and donor, ethnicity, race, age of recipient and donor, cytomegalovirus status, ABO match, human leukocyte antigen mismatch, medical condition (hospitalized), ventilator, employment status, functional status, UNOS transplant status, and ischemic time. Propensity score matching revealed incomplete overlap of covariate distributions between primary and repeat transplant patients. The 19 repeat heart-lung transplant patients were more severely impaired at the time of transplant, and 4 did not have an adequate primary transplant match. For 15 repeat transplant patients, survival time was not significantly different from matched primary transplant controls. For repeat transplant patients, being Hispanic, having longer ischemic time, poor functional status (needing assistance), being hospitalized, and requiring ventilator support were all associated with decreased survival time; however, only being on a ventilator was statistically significant. By contrast, being female, and younger were associated with increased survival, but were not statistically significant. When matched for a set of potential confounding variables, no difference in survival benefit was observed between primary and repeat heart-lung transplant patients. The only predictor significantly associated with decreased survival time among repeat transplant patients was being on a ventilator.

Comparison of Survival in Primary and Repeat Heart Transplantation From 1987 Through 2004 in the United States

The purpose of this study was to identify predictors for survival after primary and repeat heart transplantations, and to compare their survival. The United Network for Organ Sharing database provided 20,787 primary heart transplants and 594 repeat heart transplants (for those patients who had previously undergone a primary heart transplant). Cox regression models were used to separately determine predictors of survival in primary and retransplant patients and to compare their survival distributions. Propensity score matching was then used to compare the survival between primary and retransplant patients adjusted for potential confounders. Similar predictors of survival were found for primary and retransplant patients. The overall increased risk of death was 71% higher for retransplant versus primary transplant patients. Propensity score analysis showed that, in patients with characteristics most similar to primary transplant patients, the increased risk of death was 133%; however, for patients with characteristics most like retransplant patients, the increased risk of death was only 34%. Survival after retransplantation is significantly reduced relative to survival after primary transplantation. The difference in survival between primary and repeat transplants is smallest among recipients who fit the profile of the typical repeat transplant patient. In general, these are younger patients with better functional status prior to listing, who received an organ from a younger donor.

Renal graft survival is not influenced by a positive flow B‐cell crossmatch

The influence of a positive B-cell crossmatch on graft outcome in renal transplantation is controversial. We analyzed graft survival using Kaplan-Meier estimates for recipients of deceased donor kidneys who were either regraft transplant patients (n = 198) from 1990 to August 20, 2004, or primary transplant patients (n = 361) from December 15, 2000 to August 8, 2004, each of whom had a flow T- and B-cell IgG crossmatch performed before transplantation. The flow B-cell crossmatch (FBXM) was not used to decide whether or not to transplant. Graft survival was analyzed by whether the patient's FBXM was positive or negative. We also evaluated creatinine levels and graft survival of 131 transplant patients (June 1, 2004 to July 1, 2005) by their FBXM result and by their HLA class II flow-defined IgG PRA. One- and three-yr graft survival for the primary transplant patient group with a positive FBXM (98% and 84%) was not significantly different from the group with a negative FBXM (96% and 93%) (log-rank = 0.9). Similarly, graft survival at one, five, and 10 yr for the regraft transplant group whose FBXM was positive (91%, 76%, and 61%) was not significantly different from the group whose FBXM was negative (91%, 79%, and 77%) (log-rank = 0.4). Creatinine levels in the group of patients whose FBXM was positive (1.4 +/- 0.4 mg/dL; n = 76) were not significantly different from the group with a negative FBXM (1.4 +/- 0.4 mg/dL; n = 42). Even in the presence of class II PRA, a positive FBXM did not impact a patient's creatinine levels or graft outcome. Neither short nor long-term graft survival of deceased donor kidneys is influenced by a positive flow B-cell IgG crossmatch, even when caused by HLA class II antibody.

Cardiac retransplantation in children

Background Experience with pediatric cardiac retransplantation is limited. Outcomes should be inspected to insure proper use of donor hearts. Methods Of 152 pediatric heart transplantations, we performed 20 retransplants in 17 children (3 had a second retransplant). The retransplant children were older than the primary transplant children (11.1 ± 4.4 years versus 7.1 ± 6.0 years; p = 0.005). Excluding 1 early retransplant, the interval from primary transplant to retransplant was 5.5 ± 3.3 years (range, 1.1 to 11.1). The retransplant patients were clinically more ill than the primary transplant patients (United Network for Organ Sharing status I, 75% versus 63%; mechanical circulatory support or dialysis, 20% versus 3.8%). Results Donor ischemia time (188 versus 165 minutes) and cardiopulmonary bypass time (127 versus 127 minutes) were not significantly different for the retransplant patients. Excluding 1 retransplant patient who required a tracheostomy, days on the ventilator (2.7 versus 2.7), days on inotropic support (3.0 versus 3.2), intensive care unit days (7.2 versus 6.7), and hospital days (15.9 versus 13.8) were similar in the retransplant group. Freedom from rejection at 90 days and 1 year was not different in the retransplant patients. Actuarial patient survival in the patients undergoing first retransplant was similar to the primary transplant patients at 30 days (95% versus 94.7%), 1 year (94.1% versus 80.7%), and 3 years (78.4% versus 73.1%). Two of 3 children receiving a third transplant died within 1 year of redo retransplantation. Conclusions Cardiac retransplantation can be performed in children with results comparable with those for primary transplantation despite increased clinical acuity. These early results suggest that cardiac retransplantation in children is a reasonable therapeutic option. Children with repeat retransplantation do not fare as well.

Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study

Background Cardiac retransplantation is a controversial procedure due to the disparity between donor heart demand and supply. Methods Of 7,290 patients undergoing primary cardiac transplantation between January 1990 and December 1999 at 42 institutions contributing to the Cardiac Transplant Research Database (CTRD), 106 patients later underwent a second and 1 patient a third cardiac transplant procedure. Results The actuarial freedom from retransplantation was 99.2% and 96.8% at 1 and 10 years, respectively. Reasons for retransplantation included early graft failure ( n = 34), acute cardiac rejection ( n = 15), coronary allograft vasculopathy (CAV, n = 39), non-specific graft failure ( n = 7), and miscellaneous ( n = 10). The only risk factor associated with retransplantation was younger age, reflecting the policy of preferential retransplantation of younger patients. Survival after retransplantation was inferior to that after primary transplantation (56% and 38% at 1 and 5 years, respectively). Risk factors associated with death after retransplantation included retransplantation for acute rejection ( p = 0.0005), retransplantation for early graft failure ( p = 0.03), and use of a female donor ( p = 0.005). Survival after retransplantation for acute rejection was poorest (32% and 8% at 1 and 5 years, respectively) followed by retransplantation for early graft failure (50% and 39% at 1 and 5 years, respectively). Survival after retransplantation for CAV has steadily improved with successive eras. Conclusions The results of retransplantation for acute rejection and early graft failure are poor enough to suggest that this option is not advisable. However, retransplantation for CAV is currently associated with satisfactory survival and should continue to be offered to selected patients.

Decision for Retransplantation of the Liver

Objective To determine the patient factors affecting patient outcome of first liver retransplantation at a single center to help in the decision process for retransplantation. Summary Background Data Given the critical organ shortage, one of the most controversial questions is whether hepatic retransplantation, the only chance of survival for patients with a failing first organ, should be offered liberally despite its greater cost, worse survival, and the inevitable denial of access to primary transplantation to other patients due to the depletion of an already-limited organ supply. The authors’ experience of 139 consecutive retransplantations was reviewed to evaluate the results of retransplantation and to identify the factors that could improve the results. Methods From 1986 to 2000, 1,038 patients underwent only one liver transplant and 139 patients underwent a first retransplant at the authors’ center (first retransplantation rate = 12%). Multivariate analysis was performed to identify variables, excluding intraoperative and donor variables, associated with graft and patient long-term survival following first retransplantation. Lengths of hospital and intensive care unit stay and hospital charges incurred during the transplantation admissions were compared for retransplanted patients and primary-transplant patients. Results One-year, 5-year, and 10-year graft and patient survival rates following retransplantation were 54.0%, 42.5%, 36.8% and 61.2%, 53.7%, and 50.1%, respectively. These percentages were significantly less than those following a single hepatic transplantation at the authors’ center during the same period (82.3%, 72.1%, and 66.9%, respectively). On multivariate analysis, three patient variables were significantly associated with a poorer patient outcome: urgency of retransplantation (excluding primary nonfunction), age, and creatinine. Primary nonfunction as an indication for retransplantation, total bilirubin, and factor II level were associated with a better prognosis. The final model was highly predictive of survival: according to the combination of the factors affecting outcome, 5-year patient survival rates varied from 15% to 83%. Retransplant patients had significantly longer hospital and intensive care unit stays and accumulated significantly higher total hospital charges than those receiving only one transplant. Conclusions These data confirm the utility of retransplantation in the elective situation. In the emergency setting, retransplantation should be used with discretion, and it should be avoided in subgroups of patients with little chance of success.