Retransplantation Rate Research Articles

Trends in Kidney Allograft Failure Among First-Time Transplant Recipients in the United States

Rationale & ObjectiveThe management and outcomes of kidney transplant recipients have evolved over the past three decades. This study of U.S patients whose first kidney allograft failed sought to understand long-term trends in subsequent waitlisting, re-transplantation, and all-cause mortality. Study DesignRetrospective cohort study. Setting & ParticipantsPatients recorded in the United States Renal Data System (USRDS) whose first kidney allograft failed between 1990 and 2019. ExposureThe 5-year period in which the allograft failure occurred: 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014, or 2015-2019. Outcomes1) Waitlisting for re-transplantation, 2) re-transplantation, and 3) all-cause mortality following first allograft failure. Analytical ApproachCompeting risk survival analyses using the approach described by Fine and Gray were used for the outcomes of waitlisting and re-transplantation. Cox proportional hazards models were used for the outcome of all-cause mortality. ResultsThe absolute number of patients whose allograft failed and started dialysis increased from 3,197 in 1990 to 5,821 in 2019. Compared to 1990-1994, the rate of waitlisting for a second transplant increased with each subsequent 5-year period, peaking between 2005-2009 before decreasing again subsequently. The rate of re-transplantation following allograft failure decreased by 9%, 14%, 18%, 7%, and 11% in the sequential 5-year eras; and the mortality rate was 25% lower in 2015-2019 (HR=0.75, 95% CI, 0.72-0.77) compared to 1990-1994. Women had a reduced rate of waitlisting (HR 0.93, 95% CI 0.91-0.95) and lower rate of re-transplantation (HR 0.93, 95% CI 0.91, 0.95) compared to men. Compared to White patients, African-American and Hispanic patients had significantly lower rates of waitlisting, re-transplantation, and mortality. LimitationsRetrospective data that lacks granular clinical information. ConclusionsDuring the past three decades, among patients whose first kidney allograft failed and subsequently initiated dialysis, the rates of waitlisting for re-transplantation increased while the rates of re-transplantation and mortality decreased. Race-, ethnicity-, and sex-based disparities in waitlisting and re-transplantation were observed and warrant further investigation.

Failure to Rescue Pediatric Recipients of Living Donor Liver Transplantation: A Single-Center Study of Technical Complications in 500 Primary Grafts.

The concept of failure to rescue (FTR) has been used to evaluate the quality of care in several surgical specialties but has not been well-studied after living donor liver transplantation (LDLT) in children. This study retrospectively reviewed 500 pediatric LDLT performed at a single center between 1993 and 2022. The recipient outcomes were assessed by means of patient and graft survival rates, retransplantation rates, and arterial/portal/biliary complication rates. Graft and patient losses secondary to these complications were calculated regarding FTR for patients (FTRp) and grafts (FTRg). Overall 1- and 5-year patient survival rates were 94.5% and 92.1%, respectively, the corresponding figures for graft survival being 92.7% and 89.8%. One-year hepatic artery complication rate was 3.6% (n = 18 cases), the respective rates for portal vein complications and biliary complications being 5.7% (n = 57) and 15.6% (n = 101). One-year FTRp rates for hepatic artery thrombosis, portal vein thrombosis, anastomotic biliary stricture, and intrahepatic biliary stricture were 28.6%, 9.4%, 3.6%, and 0%, respectively. The corresponding FTRg rates being 21.4%, 6.3%, 0%, and 36.4%. Such novel analytical method may offer valuable insights for optimizing quality of care in pediatric LDLT.

Incidence and risk factors for chronic rejection in pediatric liver transplantation.

Chronic rejection (CR) is a progressive immunological injury that frequently leads to long-term liver allograft dysfunction and loss. Although CR remains an important indication for retransplantation, as transplant immunosuppression has evolved, its prevalence in adults undergoing liver transplantation (LT) has declined. However, the incidence and factors that lead to CR in pediatric LT are poorly defined. Therefore, we sought to systematically measure CR's incidence and assess both the risk factors for developing CR and outcomes in a large cohort of pediatric recipients of LT. In this single-center study, we retrospectively analyzed and compared relevant recipient characteristics, surgical details, immunosuppression, graft, and patient survival in the CR and control groups over a 17-year period. After a median time of 1.9 years after LT, 19/356 recipients of LT (5.3%) developed CR in our cohort. Posttransplant lymphoproliferative disorder ( p = 0.01), infections ( p = 0.02), autoimmune liver diseases (HR = 7.3, p = <0.01), Black race (HR = 11.5, p = 0.01), and 2 or more episodes of T cell mediated rejection (HR = 5.1, p = <0.01) were associated with CR development. The retransplantation rate among CR cases was 15.8% at a median follow-up time of 4.1 years. Overall, patient survival was lower in the CR group (78.9%) versus controls (91.1%). While CR incidence in our pediatric cohort was lower than previously reported rates of >12%, the CR group had a higher graft failure rate that required retransplantation and lower overall patient survival. Thus, identifying risk factors may warrant specialized immunosuppression protocols and closer posttransplantation monitoring to reduce the risk of morbidity and mortality from CR.

Ileal pouch-anal anastomosis and end ileostomy result in equivalent graft survival following liver transplantation for inflammatory bowel disease-primary sclerosing cholangitis.

Patients with inflammatory bowel disease and primary sclerosing cholangitis may require both liver transplantation and colectomy. There are concerns about increased rates of hepatic artery thrombosis, biliary strictures, and hepatic graft loss in patients with ileal pouch-anal anastomosis compared to those with end ileostomy. We hypothesized that graft survival was not negatively affected by ileal pouch-anal anastomosis compared to end ileostomy. A tertiary center's database was searched for patients meeting the criteria of liver transplantation because of primary sclerosing cholangitis and total proctocolectomy with ileal pouch-anal anastomosis or end ileostomy because of ulcerative colitis. Primary endpoints were hepatic graft survival and post-transplant complications. Fifty-five patients met the inclusion criteria between January 1990 and December 2022. Of these, 46 (84%) underwent ileal pouch-anal anastomosis, and 9 (16%) underwent end ileostomy. The average age at total proctocolectomy (41.5 vs. 49.1years; p = 0.12) and sex distribution (female: 26.1% vs. 22.2%; p = 0.99) were comparable. The rates of re-transplantation (21.7% vs. 22.2%; p = 0.99), hepatic artery thrombosis (10.8% vs. 0; p = 0.58), acute rejection (32.6% vs. 44.4%; p = 0.7), chronic rejection (4.3% vs. 11.1%; p = 0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p = 0.99), and biliary strictures (19.6% vs. 33.3%; p = 0.36) were similar between the ileal pouch-anal anastomosis and end ileostomy groups, respectively. None of the end ileostomy patients developed parastomal varices. The log-rank tests for graft (p = 0.97), recipient (p = 0.3), and combined graft/recipient survival (p = 0.73) were similar. Ileal pouch-anal anastomosis did not negatively affect graft, recipient, and combined graft/recipient survival, or the long-term complications, compared to end ileostomy.

Survival after live donor versus deceased donor liver transplantation: propensity score-matched study.

For individuals with advanced liver disease, equipoise in outcomes between live donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) is uncertain. A retrospective cohort study was performed using data extracted from the Scientific Registry of Transplant Recipients. Adults who underwent first-time DDLT or LTDL in the United States between 2002 and 2020 were paired using propensity-score matching with 1:10 ratio without replacement. Patient and graft survival were compared using the model for end-stage liver disease (MELD) score for stratification. After propensity-score matching, 31 522 DDLT and 3854 LDLT recipients were included. For recipients with MELD scores ≤15, LDLT was associated with superior patient survival (HR = 0.92; 95% c.i. 0.76 to 0.96; P = 0.013). No significant differences in patient survival were observed for MELD scores between 16 and 30. Conversely, for patients with MELD scores >30, LDLT was associated with higher mortality (HR 2.57; 95% c.i. 1.35 to 4.62; P = 0.003). Graft survival was comparable between the two groups for MELD ≤15 and for MELD between 21 and 30. However, for MELD between 16 and 20 (HR = 1.15; 95% c.i. 1.00 to 1.33; P = 0.04) and MELD > 30 (HR = 2.85; 95% c.i. 1.65 to 4.91; P = 0.001), graft survival was considerably shorter after LDLT. Regardless of MELD scores, re-transplantation rate within the first year was significantly higher after LDLT. In this large propensity score-matched study using national data, comparable patient survival was found between LDLT and DDLT in recipients with MELD scores between 16 and 30. Conversely, for patients with MELD > 30, LDLT was associated with worse outcomes. These findings underscore the importance of transplant selection for patients with high MELD scores.

Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers.

Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplant (post-LT) outcomes in Europe. Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years, with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%). LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.

Lithium-Associated Kidney Failure: Predictors and Outcomes

Despite the widespread use of lithium for bipolar disorders and depression, little is known about the characteristics of patients with lithium-associated kidney failure receiving kidney replacement therapy (KRT). We conducted a retrospective study using the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) to investigate the predictors and outcomes of patients with lithium-associated kidney failure receiving KRT. A total of 437 patients with lithium-associated kidney failure were compared to 1280 ANZDATA allocated controls of patients with kidney failure not associated with lithium. Patients with lithium-associated kidney failure commenced KRT at significantly older age (62 ± 10 vs. 58 ± 15 years; P< 0.001) and were more likely to be European (93% vs. 68%, P< 0.001), to be female (63% vs. 40%, P< 0.001), and to live in a postcode with a higher socioeconomic status (SES) (P< 0.001). In patients with lithium-associated kidney failure, there were lower rates of coronary artery disease (17% vs. 37%, P< 0.001), peripheral vascular disease (7% vs. 25%, P< 0.001), cerebrovascular disease (8% vs. 14%, P= 0.004) and diabetes mellitus (16% vs. 47%, P< 0.001). There were no differences between first KRT modality, although kidney transplantation and retransplantation rates were lower (21% vs. 27%, P= 0.008; 0.2% vs 3%, P= 0.001) with shorter wait-times to first transplantation (20 months vs. 29 months, P= 0.02) in the patients with lithium-associated kidney failure. Rates of at least 1 rejection episode was comparable (21% vs. 22%, P= 0.85) between the 2 groups. In addition, there were no survival differences regardless of KRT modality between the 2 groups. Lithium-associated kidney failure represents a unique cohort which is predominantly older, female, European, with a higher SES and less comorbidities. Despite this, there are no differences in survival. Given the lower rate of transplantation, barriers to transplantation need further exploration.

P358 Impact of end-ileostomy versus ileal pouch-anal anastomosis on graft-survival following liver transplantation for primary sclerosing cholangitis

Abstract Background IBD-PSC patients may require both liver transplantation and ileoanal pouch (IPAA) construction. Recently, concerns have been raised regarding an increased rates of hepatic artery thrombosis, biliary strictures, and graft loss in individuals who underwent IPAA after liver transplantation compared to those who underwent end-ileostomy (EI). We hypothesized that graft survival was not negatively affected by IPAA compared with EI. Methods A prospectively maintained database from a large tertiary center was searched for patients meeting the inclusion criteria for liver transplantation, primary sclerosing cholangitis, ulcerative colitis, and total colectomy with IPAA or EI. Univariate analysis and Kaplan-Meier survival curves were calculated. Results Between January 1990 and December 2023, 55 patients met inclusion criteria. Of these, 46 (83.6%) underwent IPAA, and 9 (16.4%) underwent EI. The average age at colectomy (41.7 vs. 45.7 years; p=0.44), sex distribution (female: 26.1% vs. 22.2%, p=1), and MELD score before transplantation (20.3 vs. 14; p=0.06) were comparable between patients with IPAA and EI patients. The rates of re-transplantation (21.7% vs. 22.2%; p=1), hepatic artery thrombosis (8.7% vs. 0; p=1), episodes of acute rejection (32.6% vs. 44.4%; p=0.7), chronic rejection (4.3% vs. 11.1%; p=0.42), recurrence of primary sclerosing cholangitis (23.9% vs. 22.2%; p=1), and biliary complications (21.7% vs. 33.3%; p=0.43) were similar between the IPAA and EI groups, respectively. None of the EI patients developed parastomal varices. Survival analyses for time to re-transplantation (p=0.97), overall survival (p=0.3), and time to graft loss or mortality (p=0.73) were similar. Conclusion In contrast to a previous study, we observed similar rates of liver transplant graft loss, biliary complications, and recurrent PSC after IPAA compared to those after end-ileostomy. IPAA may be associated with an increased rate of hepatic artery thrombosis.

Utility of nifedipine use for Doppler ultrasound early after liver transplantation to predict short-term complications and long-term outcomes.

To evaluate the response to nifedipine administration measured by changes in hepatic arterial (HA) flow on post-operative Doppler ultrasound (US) to predict short-term complications and long-term outcomes in liver transplant (LT) patients. Patients who underwent LT with post-operative Doppler US within 3days between 1 January 2005 and 31 December 2015 were included in this retrospective single center study. The patients who received and did not receive nifedipine during the Doppler US comprised the study and control groups, respectively. A positive response to nifedipine was defined as the detection of HA flow when none was present initially or a reduction in HA resistive index (RI) ≥ 0.1 after nifedipine administration. The rates of re-transplantation, re-operation, percutaneous intervention (PCI), and overall survival (OS) were recorded. Cox proportional hazards regression was used to evaluate the association of clinic-demographic variables and Doppler findings with the outcome measures. 444 LT patients (305M/139F, mean age 51.7 ± 17.4years, mean interval between LT-Doppler US 1.12 ± 0.9days) are presented. 220 patients comprised the nifedipine study group [n = 157/220 (71.4%) responder, n = 63/220 (28.6%) nonresponder] and 224 patients comprised the control group. There was no difference in re-transplantation or PCI rates between the groups (all p-values ≥ 0.2 and ≥ 0.08, respectively). The responder group had a lower rate of re-operation vs. the control group (15.9% vs. 24.1%, p = 0.03) and nonresponder group (15.9% vs. 31.8%, p = 0.004). 1-year and 2-year OS were similar between the groups (all p-values > 0.37). Short-term complication rates and long-term outcomes for patients with liver transplant who responded to nifedipine administration on Doppler US are similar to those who did not require nifedipine administration. A lack of response to nifedipine was associated with a higher re-operation rate.

Indications and outcomes of liver retransplantation in three medical centers.

retransplantation is the only viable treatment for patients with irreversible graft loss. The objective of this study was to analyze the indications and outcomes of liver retransplantation in three medical centers. a total of 66 patients who underwent liver retransplantation from September 1991 to December 2021 were included in the study. A retrospective analysis was performed evaluating patients demographic, clinical, primary diagnosis, indications for and time interval to retransplantation, complications and patient survival. from a total of 1293 primary liver transplants performed, 70 required one or more liver retransplant. The main indication for primary transplant was hepatitis C cirrhosis (21,2%). Hepatic artery thrombosis was the main cause of retransplantation (60,6%), with almost half (46,9%) of retransplants having occurred within 30 days from initial procedure. The average survival time after a repeat liver transplant, was 89,1 months, with confidence interval from 54 to 124,2. The 1-,5- and 10- year survival rate following liver retransplant were 48,4%, 38% and 30,1%, respectively. Male gender, primary non function as the cause for retransplant, prolonged operative time and higher MELD were associated with higher mortality. operative mortality and morbidity rates of liver retransplantation are higher than those of the first transplantation. Male gender, primary non function, prolonged operative time and higher MELD were associated with less favorable outcomes.

Predictors of graft function and survival in second kidney transplantation: A single center experience.

The increasing kidney retransplantation rate has created a parallel field of research, including the risk factors and outcomes of this advanced form of renal replacement therapy. The presentation of experiences from different kidney transplantation centers may help enrich the literature on kidney retransplantation, as a specific topic in the field of kidney transplantation. To identify the risk factors affecting primary graft function and graft survival rates after second kidney transplantation (SKT). The records of SKT cases performed between January 1977 and December 2014 at a European tertiary-level kidney transplantation center were retrospectively reviewed and analyzed. Beside the descriptive characteristics, the survivals of patients and both the first and second grafts were described using Kaplan-Meier curves. In addition, Kaplan-Meier analyses were also used to estimate the survival probabilities at 1, 3, 5, and 10 post-operative years, as well as at the longest follow-up duration available. Moreover, bivariate associations between various predictors and the categorical outcomes were assessed, using the suitable biostatistical tests, according to the predictor type. Out of 1861 cases of kidney transplantation, only 48 cases with SKT were eligible for studying, including 33 men and 15 women with a mean age of 42.1 ± 13 years. The primary non-function (PNF) graft occurred in five patients (10.4%). In bivariate analyses, a high body mass index (P = 0.009) and first graft loss due to acute rejection (P = 0.025) were the only significant predictors of PNF graft. The second graft survival was reduced by delayed graft function in the first (P = 0.008) and second (P < 0.001) grafts. However, the effect of acute rejection within the first year after the first transplant did not reach the threshold of significance (P = 0.053). The mean follow-up period was 59.8 ± 48.6 mo. Censored graft/patient survival rates at 1, 3, 5 and 10 years were 90.5%/97.9%, 79.9%/95.6%, 73.7%/91.9%, and 51.6%/83.0%, respectively. Non-immediate recovery modes of the first and second graft functions were significantly associated with unfavorable second graft survival rates. Patient and graft survival rates of SKT were similar to those of the first kidney transplantation.

Impact of Ischemia and Preservation Times on Survival in Transplant Recipients From After Circulatory Death Donors

The limitation of ischemia times, which damages the organs and impacts transplant outcomes, is a drawback of controlled donation after circulatory death. The aim of the study was to analyze the influence of preservation and ischemia times on overall survival and both censured graft survival and overall graft survival. This was an observational and retrospective study of patients undergoing liver transplantation with grafts from controlled donation after circulatory death between November 2013 and November 2022. Sixty-five patients were included in the study. Twenty percent (12 patients) developed early graft dysfunction according to Olthoff's classification, and 7 patients (11.6%) scored ≥7 points according to the Model for Early Allograft Function Scoring scale. Five patients (7.6%) met the criteria for primary graft failure. The retransplantation rate was 9.2% (6 cases). Fifty patients (76.9%) remained alive, and 15 patients (23.1%) died. When analyzing overall survival based on the main preservation and ischemia times, we observed that the best results occurred in the group with a functional warm ischemia time <12 minutes, with a survival rate at 1, 3, and 5 years of 95.8%, 87.1%, and 87.1%, respectively (P=.043). Regarding the analysis of censured graft survival based on the main preservation and ischemia times, we found that the worst results occurred in the group with a cold ischemia time ≥6 hours, with a survival rate of around 48% at 3 and 5 years (P=.047). High-risk patients have lower overall and graft survival in the short and long term in grafts from controlled donation after circulatory death.

Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies.

Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.

Life after a pediatric kidney transplant

Introduction and objectivesThere is currently no doubt that a kidney transplant with good function is the best treatment we can offer a child with severe kidney failure, improving their growth, development and life in general. But there are few works that follow these patients over the years to find out what their life is like as adults, their achievements and if there are any difficulties that may have arisen from their illness. That has been the objective of this work. Material and methodsWe have collected the evolution of 287 patients who received at least one kidney transplant in pediatric age, analyzing not only the survival of grafts and recipients but, fundamentally, their current quality of life. ResultsOver a 40-year period (1979−2019), 345 kidney transplants were performed in 287 pediatric recipients, with a rate of retransplantation before reaching the age of majority of 16.7%. Survival, both of patients and grafts, has improved remarkably in the last 20 years. The survival of transplanted patients in the period from 1979 to 1996 at 10, 20 and 25 years after the intervention was 83%, 76% and 65% respectively, and 94% and 82% at 10 and 20 years respectively in those transplanted in the period from 1997 to 2019. Graft survival in the period from 1979 to 1996 at 10 and 20 years was 39% and 18%, increasing in the second period to 68% and 34% respectively. Survival of the first living donor graft (LD) at 5 and 10 years was 94% and 89%. Currently 150 of these patients are adults. Of these, 32% have a stable partner and 6.6% have children. The level of training is lower than that of the general population and many of them have other comorbidities. ConclusionsThe life expectancy of pediatric patients with kidney failure transplanted during childhood has improved markedly in recent decades, as has graft survival, being better with a living donor. In general, they consider themselves satisfied with their lives, with great acceptance of their illness and limitations, but -analyzing their testimonies- we conclude that they lack social support, both for themselves and their families, to achieve a higher level of education and better quality of life.

Survival after LDLT in recipients ≥70 years old in the United States. An OPTN/UNOS liver transplant registry analysis.

Living donor liver transplantation (LDLT) in the elderly population is currently not well studied. There are single-center studies indicating that patient age should not be a barrier to LDLT, with similar outcomes compared to younger recipients. Using UNOS/STAR data from 2010 to 2022 we retrospectively analyzed patients ≥70 years old receiving a living donor graft (LDLT ≥70y group) versus a deceased donor graft (DDLT ≥70y group). In addition, we compared recipients ≥70 years old undergoing LDLT versus patients 18-69 years old also undergoing LDLT. Donor and recipient baseline characteristics, as well as postoperative outcomes including graft and patient survival were analyzed and compared between groups. Recipients in the LDLT ≥70y group showed less disease burden and spent significantly less time on the waitlist when compared to recipients in the DDLT ≥70y group (102 [49-201] days versus 170 [36-336] days) respectively; p=.004. With the exception of a longer length of stay (LOS) in the LDLT ≥70y group (p≤.001), postoperative outcomes were comparable with recipients in the DDLT ≥70y group, including similar graft and patient survival rates at 1-, 3-, and 5-years. When compared to younger recipients of a graft from a living donor, patients in the LDLT ≥70y group had similar post-transplant functional status, re-transplant rates and similar causes contributing to graft failure. However, significantly lower graft and patient survival rates were observed. LDLT for recipients aged 70 or greater represents a faster access to transplantation in a safe and feasible manner when compared to similar- aged recipients undergoing DDLT.

Long-Term Outcomes of Permanent Pacemaker Implantation in Bicaval Heart Transplant Recipients

BackgroundPermanent pacemakers (PPMs) may be necessary in up to 10% of patients after heart transplantation (HT). ObjectivesThe purpose of this study was to evaluate long-term outcomes and clinical courses of heart transplant recipients who received PPM. MethodsAll patients who required PPM after bicaval HT at Columbia University between January 2005 and December 2021 were included. Cases were compared to matched heart transplant recipients by age, sex, and year of transplantation. Patient and device characteristics including complications and device interrogations were reviewed. Outcomes of re-transplantation or graft failure/death were compared between groups. ResultsOf 1,082 heart transplant recipients, 41 (3.8%) received PPMs. The median time from transplantation to PPM was 118 days (IQR: 18-920 days). The most common indications were sinus node dysfunction (60%, n = 25) and atrioventricular (AV) nodal disease (41.5%, n = 17). Post-implantation complications included pocket hematoma (n = 3), lead under-sensing (n = 2), and pocket infection requiring explant (n = 1). Rates of death and re-transplantation at 10 years post-HT were similar between groups. In multivariable analysis, after adjustment for mechanical circulatory support, pretransplantation amiodarone use, donor ischemic time and age, only older donor age was associated with increased risk of PPM implantation (P = 0.03). There was a significant decrease in PPM placement after 2018 (1.2% vs 4.4%, P = 0.02), largely driven by a decline in early PPM placement. There were no differences in mortality or need for re-transplantation between groups. ConclusionsPPMs are implanted after HT for sinus and atrioventricular node dysfunctions with low incidence of device-related complications. Our study shows a decrease in PPM implantation after 2018, likely attributable to expectant management in the early postoperative period.

Results of liver retransplantations

Aim. To present the results of repeated liver transplantations performed in a federal center. Materials and methods. The results of 268 orthotopic full-liver postmortem transplantations in 248 patients since 1998 were analyzed. Retransplantation was performed in 20 patients (8.1%) – 10 men and 10 women, 18-64 years old (median age 44.4 years). The median MELD score was 21 (19-24). Observations before 2006 were analyzed retrospectively. Early hepatic artery thrombosis and late biliary complications due to insufficient arterial blood supply to the graft indicated the retransplantation in the majority of patients. Results. The duration of preservation stages was comparable to the primary transplantation. Significant differences were found in the duration of the anhepatic period, the volume of hemotransfusion, the duration of the surgery, the rate of complications and the hospital mortality rate. Currently, 9 of the 20 patients (45%) are alive, with a follow-up period of 7-140 months. Graft function was satisfactory in most recipients. Hospital mortality accounted for 35%. Conclusion. Liver retransplantation is accompanied by considerable technical difficulties, as well as by an increase in surgery duration, volume of blood transfusion, time of stay in the intensive care unit, and incidence of postoperative complications. Infectious complications were the main cause of death. With successful retransplantation, long-term results and survival rates were comparable to those of primary transplantation.

Blood component requirements in liver transplantation: effect of 2 thromboelastometry-guided strategies for bolus fibrinogen infusion—the TROMBOFIB randomized trial

BackgroundA low plasma fibrinogen level influences blood component transfusion. Thromboelastometry provides clinical guidance for fibrinogen replacement in liver transplantation (LT). ObjectivesWe hypothesized that infusions of fibrinogen concentrate to reach an A10FibTem value of 11 mm during LT could reduce red blood cell (RBC) and other component and fluid requirements in comparison to standard care. MethodsThis randomized, blinded, multicenter trial in 3 hospitals enrolled 189 LT-scheduled patients allocated to an intervention target (A10FibTem, 11 mm) or a standard target (A10FibTem, 8 mm); 176 patients underwent LT with fibrinogen replacement. Data were analyzed by intention-to-treat (intervention group, 91; control group, 85). Blood was extracted, and fibrinogen kits were prepared to bring each patient’s fibrinogen level to the assigned target at the start of LT, after portal vein clamping, and after graft reperfusion. The main outcome was the proportion of patients requiring RBC transfusion during LT or within 24 hours. ResultsThe proportion of patients requiring RBCs did not differ between the groups: intervention, 74.7% (95% CI, 65.5%-83.3%); control, 72.9% (95% CI, 62.2%-82.0%); absolute difference, 1.8% (95% CI, −11.1% to 14.78%) (P = .922). Thrombotic events occurred in 4% of the patients in both groups; reoperation and retransplantation rates and mortality did not differ. Nearly 70% of the patients in both groups required fibrinogen concentrate to reach the target. Using an 11-mm A10FibTem target increased the maximum clot firmness without affecting safety. However, this change provided no clinical benefits. ConclusionThe similar low plasma fibrinogen concentrations could explain the lack of significant between-group outcomes.

Survival outcomes in adult recipients using pediatric deceased donor liver grafts. A PSM analysis from the OPTN/UNOS liver transplant registry

BackgroundThe use of pediatric donor grafts in adult recipients is a viable option to help address persistent organ shortages. Existing data is inconclusive regarding outcomes of pediatric-to-adult liver transplantation. Materials and methodsUsing the UNOS-STAR database, adults receiving a whole liver graft in the US between 2010 and 2019 were retrospectively identified. Patients were divided into two groups depending on whether they received a graft from a pediatric-donor (≤12y) or an adult-donor (≥18y). The groups were further matched using propensity-score matching (PSM) in a 1:1 ratio. Liver grafts disposition trends from pediatric donors ≤12y, as well as usage patterns of these grafts for adult recipients across UNOS regions were analyzed. The primary outcomes of this study were graft and patient survival. Secondary outcomes included LOS and need for re-transplantation. ResultsThere were 4,798 deceased donors ≤12 years during the study period. Of those, 3476 liver grafts were recovered for transplant, 203/3,476 were discarded and 3,273/3,476 transplanted. Twenty percent of those recipients were adults ≥18y. PSM created a cohort of 642 patients, (pediatric-donor group n = 321, adult-donor group n = 321). Survival analyses revealed no difference in graft survival (p = 0.64) or overall patient survival (p = 0.74) between pediatric-donor and adult-donor groups. Likewise, secondary outcomes were comparable between groups. Although not statistically significant, adults in the pediatric-donor group showed a trend toward higher rates of re-transplantation (4.4%) vs those in the adult-donor group (1.9%) (p = 0.07). A subgroup PSM analysis including only recipients with MELD score >18 further demonstrated comparable results including similar LOS, re-transplantation rates, graft failure (log-rank p-value = 0.57) and patient mortality (log rank p-value = 0.38). ConclusionPediatric-to-adult liver transplantation could represent a safe and effective option in the event that a pediatric graft is available and declined by all potential pediatric recipients, particularly if performed under careful patient selection, and in centers with pediatric liver transplant and/or LDLT. Our results are in favor of utilizing pediatric-donor livers in adult patients since there is no significant difference in mortality or graft survival and could potentially increase organ utilization by avoiding discard of these grafts.

Combination prophylaxis in CMV high risk heart transplant recipients: A single center experience.

Cytomegalovirus (CMV) is the most clinically relevant infectious agent following heart transplantation (HTX). Data on the beneficial effects of prophylactic use of CMV immunoglobulins (CMVIG) are scarce. In this single-center, retrospective study, we reported patient outcomes following cardiac transplantation using prophylactic CMV treatment, including CMVIG. Distinct clinically relevant outcomes were compared across different CMV risk groups (CMV D-/R-, CMV D-/R+, CMV D+/R+, and CMV D+/R- or CMV high risk group). We included 272 heart transplant procedures, performed between 1/1/2009 and 1/11/2020. Sixty-one (22%) procedures belonged to the CMV high risk group, while 96 (35%), 50 (18%), and 65 (24%) were CMV D-/R-, CMV D-/R+, and CMV D+/R+, respectively. Baseline donor and recipient characteristics (sex, age, body mass index, cause of death, indication for HTX), ischemia times and baseline immunosuppressive regimens were similar across the different CMV risk groups, yet fewer patients were bridged with a mechanical circulatory support in the CMV D+/R- group. CMV disease following cardiac transplantation was more common in the CMV D+/R- risk group (n=40 or 66.7%; p<.001), yet mortality and re-transplantation rates, cardiac allograft vasculopathy (CAV) severity, rejection episodes, and development of donor-specific antibodies (DSA), post-transplant lymphoproliferative diseases (PTLD), and EBV infections were similar across all four CMV risk groups. High risk CMV D+/R- patients had a similar survival compared to low and intermediate CMV risk groups using a prophylactic strategy combining CMVIG and viral DNA polymerase inhibitors. This may be related to a number of factors unrelated to prophylaxis strategy as two out of three CMV D+/R- recipients developed CMV primary infection after prophylaxis was discontinued.