Baseline Characteristics Of Recipients Research Articles

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.

Synchronous Donor Heart and Lung Procurement Does Not Impair Outcomes After Heart Transplant.

Donor hearts frequently originate from donors whose lungs are also recovered for transplant. Synchronous heart and lung procurement is more complex than procurement ofthe heart alone, and the effects on outcomes are debated. This study examines the effect of synchronous procurement on outcomes in heart transplant recipients. This single-center study included patients who received a heart transplant from September 2010 to June 2022. Main outcomes were overall mortality and mortality at 30 days, 3 months, 1 year, and 3 years and morbidity within the first year. We analyzed overall mortality using KaplanMeier survival analysis. Logistic regression was used for the remaining outcomes, adjusting for covariates. P < .05 was considered significant. Our study included 253 heart transplant recipients (72.3% male, mean age 55.0 years), of which 184 patients (72.7%) received hearts from donors of heart and lung, and 69 (27.3%) received hearts from donors of only hearts. Heart-and-lung donors were younger than heart-only donors (43.2 vs 47.2 years; P = .017). Transplant recipient baseline characteristics were not different between the 2 groups. Receipt of hearts from heart-and-lung donors was not associated with higher overall mortality (P = .33) or mortality at 3 months (P = .199), 1 year (P = .348), or 3 years (P = .375), and even showed better 30-day survival than receipt of hearts from heart-only donors (p=0.035). Recipients of hearts from heart-and-lung donors did not have higher rates of postoperative mechanical circulatory support, resternotomy, or pacemaker implantation within the first year. Our study confirms that synchronous heart and lung procurement for transplant is not associated with worse outcomes in heart transplant recipients and that hearts originating from heart-andlung donors may even be associated with improved outcomes.

2123. The Impact of Staphylococcus aureus Peri-transplant Cultures on Six-Month Outcomes in Lung Transplantation

Abstract Background Staphylococcus aureus (S. aureus) infections post-lung transplant lead to increased mortality. The impact of S. aureus peri-transplant respiratory cultures on post-transplant outcomes is unknown as is the optimal duration of peri-transplant antibiotics. We compared lung transplant recipients with and without S. aureus growth on peri-transplant cultures and the impact on 6-month outcomes including rejection, survival, and occurrence of S. aureus infections. Methods A single-center, retrospective study of lung transplant recipients between January 2017 and April 2021 was performed. Donor/recipient characteristics, microbiologic data, antibiotics, and 6-month outcomes were analyzed. Results In this 4.5-year study period, 229 patients underwent lung transplant. 121 (53%) had S. aureus growth on peri-transplant cultures, of which 84 (69%) were methicillin-susceptible (MSSA), 30 (25%) methicillin-resistant (MRSA), and 7 (6%) had MSSA and MRSA. Median duration of antibiotics post-transplant was 28-days in the S. aureus group. 67% of non-S. aureus recipients received S. aureus targeting antibiotics (p = &amp;lt; 0.001) for other indications for a median of 13-days. In the S. aureus cohort, donors were younger (median age 33 vs 38 years, p = 0.027) and more donors died from drug intoxication (50% vs 31%, p = 0.005) [Table 1]. Recipient baseline characteristics and median length of hospitalization were similar in both cohorts. There were no statistically significant differences in 6-month outcomes, including rates of rejection or survival [Figure 1]. Having grown S. aureus in peri-transplant cultures was not associated with a higher incidence of post-transplant S. aureus infections (10% vs 13%, p = 0.534). Patients who had a S. aureus infection post-transplant had lower 6-month survival that was not statistically significant (85% vs 93%, p = 0.131). Conclusion The growth of S. aureus on peri-transplant respiratory cultures with a median 4-week antibiotic course does not increase the risk of having a S. aureus infection post-transplant and is not associated with increased mortality or rejection at 6-months. The impact of a shorter duration of peri-transplant antibiotics on recurrence of infection and outcomes needs to be further studied. Disclosures Nicolas C. Issa, MD, AiCuris: Grant/Research Support|Merck: Grant/Research Support.

Predictors of Grade 3 Primary Graft Dysfunction in Lung Transplant Recipients

<h3>Purpose</h3> Primary graft dysfunction (PGD) remains a feared complication and contributes to significant morbidity and mortality following lung transplantation. The goal of this study was to evaluate factors associated with grade 3 PGD at a large volume lung transplant center. <h3>Methods</h3> We conducted retrospective review of all adult lung transplant recipients performed at University of California Los Angeles from January 1999 to August 2021, including data on donor and recipient baseline characteristics, laboratory values, and operative variables. The primary outcome was grade 3 PGD at 48 or 72 hours after lung transplantation. Donor and recipient factors associated with grade 3 PGD were examined with multivariable logistic regression. <h3>Results</h3> Of 1230 lung transplants performed during the study period with adequate PGD data, grade 3 PGD at 48 or 72 hours occurred in 86(7.0%) recipients. Recipients who developed grade 3 PGD were less likely male(49% vs 60%, p<0.04), white(56% vs 69%, p=0.04), and diagnosis groups A(15% vs 21%, p<0.01) and C (1% vs 5%, p<0.01). They were more likely to be diabetic(31% vs 22%, p=0.04), receive double lungs(65% vs 53%, p=0.04), and be completed on cardiopulmonary bypass(76% vs 64%, p=0.04). Recipients who developed grade 3 PGD also had higher BMI(27±4 vs 25±4 kg/m², p<0.01), PA pressures (50±21 vs 41±16 mmHg systolic and 21±10 vs 18±8 mmHg diastolic, p<0.01) and longer ischemic times (5.4±1.7 vs 4.7±1.3 hours, p<0.01). The grade 3 PGD group also had a lower proportion of male donors(52% vs 66%, p<0.01). On multivariable logistic regression, factors associated with increased odds of grade 3 PGD were recipient BMI (aOR 1.11, 95% CI 1.04-1.17), increasing PA systolic pressure (aOR 1.02 per mmHg, 95% CI 1.01-1.03), and increasing ischemic time (aOR 1.40 per hr, 95% CI 1.19-1.64). Male donors (aOR 0.49, 95% CI 0.30-0.79) were associated with lower odds of grade 3 PGD. The c-statistic for the multivariable model was 0.73. <h3>Conclusion</h3> Increasing recipient BMI, PA systolic pressures, and ischemic time were associated with developing grade 3 PGD 48 or 72 hours after lung transplantation, whereas male donors were protective in our single center study. These variables may help inform donor and recipient selection to reduce the risk of PGD following lung transplantation.

306.6: Importing Pancreata for Transplantation: An 18-year Single Center Experience

Introduction: Pancreatic Transplant (PTX) is a safe surgical procedure offered to diabetic patients with or without chronic kidney disease. With the new allocation system in the US, more pancreas offers are coming from beyond one’s donor service area (DSA), and region. Whether transplanting grafts from beyond one’s DSA or region is a safe practice is unknown. In this study, we analyzed our experience with importing pancreata according to DSA and UNOS region source and distance from the donor hospital to the transplant center, resembling the newest changes mandated by UNOS allocation policies. Methods: We analyzed primary PTXs performed between January 2000 and December 2018. Recipients of simultaneous pancreas and kidney (SPK), primary solitary pancreas (PAN) including pancreas after kidney (PAK) and pancreas transplant alone (PTA) transplants were analyzed. Two separate analyses were performed: i) based on graft origin (local, regional and national) and ii) based on nautical mile (NM) distances form the (< 250 NM, 250 and 750 NM and > 750 NM) which were retrospectively determined. Primary outcome was DC-graft survival (DC-GS), overall and stratified by transplant type and geographical source. DC-GS survival was analyzed using Kaplan-Meier analyses. All grafts were enterically drained with systemic venous drainage. Results: There were 884 PTXs; 676 underwent SPK and 208 PAN. Of these, 152 underwent PTA and 56 PAK. Donor PDRI and recipient baseline characteristics were similar between groups. Evaluating all PTX together, we observed no statistical differences in the DC-GS based on local, regional or national organ source; nor did we see a difference based on NM distance. Analyzing by graft origin (local vs regional vs national): the 5-year DC-GS rates for SPK were similar at 83% vs 83% vs 85% (p=0.50) and the 5-year DC-GS rates for PAN were 82% vs 64% vs 75% (p=0.17). The 5-year DC-GS rates were also similar across locales for both PTA (83% vs 60% vs 77%; p=0.14) and PAK (78% vs 73% vs 69%; p=0.55). Based on the NM distance from donor to transplant hospital (<250NM, 250-750NM and >750NM): the 5-year DC-GS rates for SPK were similar across distances at 83% vs 84% vs 89% (p=0.69). The 5-year DC-GS rates for PAN were not different from one another at 73% vs 72% vs 78% (p=0.96). The 5-year DC-GS rates across distances for PTA (71% vs 73% vs 81%; p=0.79) and PAK (76% vs 70% vs 67%; p=0.65) were not statistically different from one another. Conclusions: With greater sharing mandated by new UNOS allocation policies, we aim to demonstrate the utility of importing selected pancreata from non-local regions and DSAs and from > 250NM from the transplant center. This experience emphasizes the possibility of importing pancreatic grafts to increase organ utilization, increase center transplant rates and reduce waiting times for patients.

Abstract 13053: Cardiac Allograft Vasculopathy Following Donation After Circulatory-Determined Death Heart Transplantation

Introduction: Cardiac allograft vasculopathy (CAV) remains a major problem for heart transplant (HTx) recipients, limiting their long-term survival. Our centre has performed the world’s largest series of donation after circulatory-determined death (DCD) HTx. Five-year survival is equivalent to donation after brainstem-determined death (DBD) HTx. However, there is no information on CAV in DCD HTx recipients. We sought to evaluate the incidence of CAV in our cohort of DCD HTx recipients. Methods: All DCD HTx recipients at our centre between February 2015 and December 2019 who had undergone CAV screening were included. They were compared with all DBD recipients during the same period who had undergone CAV screening. Angiograms were retrospectively assigned an ISHLT CAV grade by two independent observers. Results: Thirty-six DCD and 70 DBD HTx recipients were included in the study. Median time to first imaging of coronary arteries was 621 days and 572 days for DCD and DBD cohorts respectively. There was a higher proportion of male donors in the DCD cohort (p= 0.03) but no other significant differences between donor baseline characteristics. DCD recipients had a lower median pre-transplant pulmonary vascular resistance (p=0.03) but there were no other significant differences in recipient baseline characteristics. The two cohorts had similar rates of pre-operative durable LVAD use, post-transplant mechanical circulatory support and post-transplant immunosuppression regimes. There was no significant difference in the rates of CAV between the DBD and DCD groups (p=0.41) (Figure 1). When adjusted for standard risk factors for development of CAV (including donor factors, CMV status and rejection) there remained no significant difference between rates of CAV between groups (OR 1.48, p=0.41, 95% CI 0.58-3.78). Conclusions: DCD HTx recipients have similar rates of CAV when compared to a contemporary population of DBD HTx recipients.

Alcoholic liver disease has more bleeding tendency during liver transplant operation

Alcohol liver disease (ALD) includes a wide clinical spectrum from acute alcoholic hepatitis to severe cirrhosis and/or hepatocellular carcinoma. Until now, there was no report to reveal the bleeding tendency of ALD compared to other diseases in liver transplantation (LT). Thus, we analyzed the blood loss and transfusion amount during operation according to the etiologies of liver disease and model for end stage liver disease (MELD) score. Out of 874 recipients who underwent LT, a total of 146 patients were excluded by our exclusion criteria. We compared 728 recipient's baseline characteristics, operation time, blood loss, and transfusion amounts between ALD and non-ALD according to MELD score. The number of patients in ALD groups was 130 (17.9%), and 598 (82.1%) in non-ALD group. ALD group showed younger age, higher MELD score, and more proportion of deceased donor liver transplantation than non-ALD group. Overall blood loss, RBC, FFP, Platelets transfusion of ALD group were significantly higher than non-ALD group. When we divided the patients into two group according to the MELD score 20, ALD group showed significant blood loss, RBC, and FFP transfusion in both higher and lower MELD groups even though there were no significant differences of INR and PLT counts between two groups in the higher MELD subgroup. ALD showed more bleeding tendency than non-ALD during LT operation. These findings imply that transplant surgeon need to prepare for blood loss during operation for ALD patients regardless of the MELD score.

THE KOREAN ORGAN TRANSPLANTATION REGISTRY (KOTRY): FIRST OFFICIAL KIDNEY TRANSPLANTATION REPORT

Korean Organ Transplantation Registry Study Group. Korean Organ Transplantation Registry (KOTRY), a first prospective-deigned national transplantation registry in Korea, was launched in 2014. This is an initial report on the status of patients received kidney transplants over the past 4 years. A total of 4839 kidney transplants (KTs) from 32 transplant centers were collected from April 2014 to December 2018. Among these, 3039 patients received kidneys from living donors, and 1800 patients received kidneys from deceased donors. We analyzed baseline characteristics of recipients and donors, and short-term post-transplantation outcomes. Among 4839 KTs, 3039 patients (62.8%) received kidneys from living donors (LDs), and 1800 patients (37.2%) received kidneys from deceased donors (DDs). The average recipient age was 48 years; there were 1774 (58.4%) male recipients. The mean age of patients undergoing LD kidney transplantation was 4 years younger than that of patients undergoing DD kidney transplantation. Even though glomerulonephritis was the most common cause of end-stage renal disease (33.3%), the number of diabetic nephropathy was increasing. At the time of transplantation, 10.9% and 29.8% of KTs had cardiovascular disease and diabetes, respectively. The average donor age was 47 years; there was 2593 (53.6%) male donors. The mean age of LD was 2 years younger than that of DD. Expanded criteria donors (30.8%) were frequently used. During follow-up period, new-onset cardiac events and NODAT were identified in 9.4% and 8.4% of the recipients, respectively. The overall 1- and 4-year patient survival rates were 98.4% and 96.9%, respectively. During the follow-up period, 84 KTs died, and the most common cause of death was infection (47.6%). The overall 1- and 4-year graft survival rates were 97.1% and 93.0%, respectively, and the most common cause of graft loss was rejection (43.5%). The overall 1- and 4-year rejection-free survival rates were 81.8% and 72.2%, respectively. In multivariate analysis, older recipients, history of cardiovascular disease, an increasing number of HLA mismatch, bortezomib induction, cyclosporine use at discharge, no anti-metabolite at discharge, an increase serum creatinine at discharge, and long cold ischemic time were significantly associated with death after transplantation. And no anti-metabolite at discharge, an increase serum creatinine at discharge and long cold ischemic time were significantly associated with graft loss after transplantation. With the establishment of KOTRY, it is possible to present the first nationwide epidemiological data of Korean kidney transplantation. KOTRY will provide better understanding regarding nationwide epidemiological data for kidney transplantation in Korea. Novartis Korea, Ltd.. Research of Korea Centers for Disease Control and Prevention (2014-ER6301-00, 2014-ER6301-01, 2014-ER6301-02, 2017-ER6301-00, 2017-ER6301-01).

P1648CLINICAL OUTCOMES OF LIVING DONOR KIDNEY TRANSPLANTATION FROM MARGINAL DONORS

Abstract Background and Aims Evidence demonstrating the outcomes of living donor kidney transplantation (LDKT) from marginal donors (MDs) is limited. We retrospectively investigated the clinical outcomes of LDKT from MDs in both recipients and donors. Method Clinical data on patients who received LDKT in Jichi Medical University Hospital between 2006 and 2019 were extracted from the medical records. Based on the Japanese guideline for preoperative conditions of donors, they were classified as standard donors (SDs) or MDs, the latter including the elderly and patients with obesity, hypertension, diabetes mellitus, and reduced renal function. Multivariate Cox proportional hazard regression analysis for graft survival was performed using explanatory variables of the donor conditions (MD vs SD) and recipient conditions, including age, gender, duration of dialysis, ABO compatibility, and presence of donor specific antibodies. The estimated glomerular filtration rates (eGFRs) of the donors were compared using an unpaired t-test. Results Of the 293 donors, 195 were SDs and 98 were MDs. Demographics and baseline characteristics of recipients and donors Recipients of kidney transplants from MDs were associated with a higher incidence of death-censored graft loss than recipients of kidney transplants from SDs. Kaplan-Meier plots for overall and death-censored graft survival. Multivariate Cox proportional hazard regression analyses for overall and death-censored graft survival The eGFRs of MDs before transplantation were significantly lower than those of SDs, while no significant differences were observed between the two groups 3- and 5-years after transplantation. Comparison of estimated glomerular filtration rates of donors Conclusion While the renal prognosis of recipients of kidneys from MDs is poorer than that of recipients from SDs, donating a kidney has no adverse effects on the renal health of MDs. The present study is the most comprehensive study that examined that the outcomes of LDKT from MDs according to the Japanese guideline.

Development of the Asian Transplant Registry Under the Asian Society of Transplantation

IntroductionIn the Asian region, no international organ transplantation registry exists. Individual centers maintain their own database, or some countries developed a national registration system. To promote collaboration among Asian transplantation societies, the Asian Society of Transplantation (AST) has developed an international transplantation registry for the Asian countries that has been named as the Asian Society Transplant Registry (ASTREG). MethodsIn 2017, the AST council formed a registry committee to develop 2 kinds of databases: ASTREG-N (nationwide level), which collects yearly aggregated data of participating countries, and ASTREG-H (hospital level), which collects the data of transplant recipients and donors from individual centers. ResultsASTREG-N collects each country’s aggregate data of solid-organ transplantation, such as the total number of transplantations and deceased donors. ASTREG-H collects 5 transplant domains, namely recipient baseline characteristics, immunosuppression, post-transplant event, annual post-transplant evaluation, and donor traits. For the ASTREG-H project, South Korea, Philippines, Mongolia, and Myanmar are the current participants. A web-based secure data entry platform with real-time data visualization and automated data verification systems is currently available. Any participating centers can run this platform as their own data collection system. ConclusionThe ASTREG is a collaborative project that will be the representative solid-organ transplantation database in the Asian region. It can aid in the harmonization of transplantation data in the Asian region.

Utilization of New Heart Preservation Technology in the Era of New Organ Allocation and Extended Ischemic Times

Current ice bag heart preservation technique is associated with wide fluctuations of organ temperature, resulting in sub-optimal preservation and freeze injury. These shortcomings may be particularly impactful with increased ischemic times given increasing retrieval distances associated with new organ allocation. In comparison, the SherpaPakTM Cardiac Transport System is designed for the static hypothermic preservation of donor hearts within a controlled temperature range. This method avoids excess cooling and optimizes preservation during transportation. The purpose of this study is to assess the outcomes of heart transplantation using the static hypothermic preservation (SHP) system as compared with conventional ice bag preservation (IP). Retrospective cohort analysis was performed on adult patients undergoing heart transplantation between 6/30/2018 and 09/02/2019 at a single institution. Donor and recipient baseline characteristics and post-transplant outcomes were compared between patients receiving organs with SHP versus IP for donor heart transport. Patients who underwent multiple organ transplantation were excluded. Of 48 consecutive patients undergoing heart transplantation, 20 (41.7%) organs were transported using SHP and 28 (58.3%) using IP. SHP was used for older recipients (61.5 vs 57.5 years, p=0.02), and longer donor heart cold ischemic times (4.35 vs 3.49 hours, Figure1, p=0.018). There were no 30-day mortalities. Despite longer ischemic times, there was no difference in the incidence of any primary graft dysfunction (PGD) (14.3% vs 15.0%, p=1) or severe PGD requiring extracorporeal membrane oxygenation (10.7% vs 5.0%, Table1, p=0.63) between SHP and IP. There was no worsening in clinical outcomes with SHP despite longer ischemic times and older recipient ages. With new heart allocation changes, SHP may be beneficial in cases with further transport distances, by mitigating the effect of prolonged ischemic times.

The impact of hepatitis C viremic donor lung allograft characteristics on post-transplantation outcomes

There is a low utilization rate of donated donor lungs. Historically, transplantation of lungs from hepatitis C-viremic donors to hepatitis C (HCV) negative recipients was avoided due to concern for worse graft survival. In the past few years with the advent of direct acting antiviral (DAA) therapy, there are emerging data suggesting the safety and efficacy of transplanting thoracic organs from HCV-viremic donors. This study assessed the differences in donor characteristics and allograft-specific clinical features at the time of organ offer and investigated whether these variables differed in HCV-viremic versus HCV-negative donors and impacted recipient outcomes. We conducted a single-center, retrospective cohort study of adult patients who underwent a lung transplant at Brigham and Women's Hospital between March 2017 and October 2018. Patients were stratified based on their donor HCV status (HCV-viremic versus HCV-negative). Donor and allograft-specific characteristics and clinical features including chest imaging and bronchoscopy reports, respiratory cultures, and the donor's oxygenation as measured by the arterial partial pressure of oxygen (PaO2) were collected as well as recipient baseline characteristics and transplant outcomes. During the study period, 42 and 57 lung transplants were performed from HCV-viremic and HCV-negative donors, respectively. Donor age was similar in both cohorts. More HCV-viremic donors died from drug intoxication (71% versus 19%, P=0.0001) and had a history of cigarette use (83% versus 5%, P=0.0001) and drug use (76% versus 49%, P=0.007). There were differences in the baseline recipient characteristics including a lower median lung allocation score in the HCV-viremic cohort. The organ-specific clinical characteristics including the terminal PaO2, chest imaging and bronchoscopy findings, and evidence of pulmonary infection were similar between the two cohorts. The recipient outcomes overall were excellent and did not differ significantly in both cohorts in terms of graft and patient survival at 6 and 12 months. Despite a greater proportion of HCV-viremic donors being increased risk with a history of drug and cigarette use and having died as a result of drug intoxication, the quality of the HCV-viremic donor organs did not differ from the HCV-negative donor organs or impact graft and recipient survival. Due to an increasing number of transplants from increased risk donors and in order to develop safe and effective protocols to perform lung transplants from HCV-infected donors, further characterization of the donor and allograft-specific clinical features and longer-term recipient outcomes is greatly needed.

Clinical outcome of donor heart with prolonged cold ischemic time: A single-center study.

Due to the shortage of donor pool, there has been a need for organs with prolonged cold ischemic time. This study aims to evaluate the short-term results of different cold ischemic times in orthotopic heart transplantation based on a single-center experience in China. We retrospectively analyzed outcomes of the heart transplant patients from 1January 2015 to 31December 2017. The recipient population was divided into four groups. Group 1: cold ischemic time greater than 8 hours; group 2: the cold ischemic time between 6 and 8 hours; group 3: the cold ischemic time between 4 and 6 hours; and group 4: cold ischemic time less than 4 hours. Efficacy indicators included after transplant survival, infection rate, rejection rate, and complications. The four groups have similar donor and recipient baseline characteristics (P > .05). Cold ischemic time greater than 8 hours had more cardiopulmonary bypass (CPB) time (127.62 ± 50.23 minutes; P = .003), CPB-assist time (86.14 ± 36.74 minutes; P = .047), and higher intra-aortic balloon pump (IABP) usage rate postoperatively (47.36%; P = .010). Cold ischemic time greater than 8 hours witnessed a relatively higher mortality rate compared with the other three groups (P = .115, P = .078, and P = .114) during the 2-year follow-up. Survival rates of 1 and 2 years for the four groups were 78.95%, 87.13%, 87.32%, and 87.50% and 68.42%, 85.14%, 85.92%, and 83.93%, respectively. Cold ischemic time less than 8 hours can be reasonably applied to expand the heart transplantation donor pool. Cold ischemic time greater than 8 hours might result in longer CPB time, CPB-assist time, and higher IABP usage postoperatively. It might also affect the in-hospital and 2-years survival rate.

Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: A systematic review and meta-analysis

ObjectiveEx vivo lung perfusion (EVLP) is reportedly a useful strategy that permits marginal donor lungs to be evaluated and reconditioned for successful lung transplantation (LTx). This systematic review and meta-analysis was performed to evaluate the outcomes of EVLP conducted for marginal donor lungs. MethodsWe searched PubMed, the Cochrane Library, and Embase to select studies describing the results of LTx following EVLP for marginal donor lungs compared with standard LTx without EVLP. We performed a meta-analysis to examine donor baseline characteristics, recipient baseline characteristics, and postoperative outcomes. ResultsOf 1380 studies, 8 studies involving 1191 patients met the inclusion criteria. Compared with the non-EVLP group (ie, standard LTx without EVLP), the EVLP group (ie, EVLP of marginal donors following LTx) had similar donor age and sex and recipient baseline age, sex, body mass index, bridge by ventilator/extracorporeal life support/extracorporeal membrane oxygenation, and rate of double LTx but more abnormal donor lung radiographs (P = .0002), a higher smoking history rate (P = .03), and worse donor arterial oxygen tension/inspired oxygen fraction (P < .00001). However, there were no significant differences in outcomes between the EVLP and non-EVLP groups with respect to the length of postoperative intubation, postoperative extracorporeal life support/extracorporeal membrane oxygenation use, length of intensive care unit stay, length of hospital stay, 72-hour primary graft dysfunction of grade 3, 30-day survival, or 1-year survival (all P values > .05). ConclusionsPosttransplant outcomes were similar between EVLP-treated LTx and standard LTx without EVLP, although the quality of donor lungs was worse with EVLP-treated LTx.

Effect of Recipient Race on Quality of Donors Allocated to Heart Transplant Recipients

Purpose Black heart transplant (HT) recipients have worse overall survival than other ethnic groups. It is unknown if subconscious racial bias affects the quality of donors that are allocated to black HT recipients. This study aims to investigate if the quality of donors allocated to HT recipients differs based on the race of the recipient. Methods We queried the Scientific Registry of Transplant Recipients (SRTR) dataset from 2006-2015. Patients were stratified into groups by race: black, white, Hispanic and other. Baseline characteristics of recipients were recorded in addition to independent donor variables including: donor age, ischemic time, creatinine, and size mismatch of greater than 20% difference in height or weight. Race-mismatch was not used as a variable due to disproportionate distribution of donor race in the population studied. We then compared these continuous variables across different racial groups. Results A total of 19171 HT recipients were included in the analysis: 3811 black, 13059 white, 1487 Hispanic, and 814 other. Black patients received donors with a significantly lower ischemic time (min) compared to white patients (188.9 ± 1.9 vs. 194.8 ± 1.1, p<0.001), and a significantly higher creatinine (mg/dL) than white patients (1.41 ± 0.09 vs 1.35 ± 0.04, p<0.001). In addition, white patients received donors of significantly older age (yr) than black and Hispanic patients (31.95 ± 0.4 vs 31.56 ± 0.7; 30.6 ± 1.1, respectively, p< 0.001) and "other" race was a significant risk for size mismatch compared to blacks, whites and Hispanics (39 ± 6.7% vs 35 ± 3%; 33 ± 1.6%; 31 ± 4.7% respectively, p<0.001). However, no other significant trends were noted. Conclusion Though there were some statistically significant results, most notably, our study did not find any meaningful clinically significant differences in the quality of donors allocated to HT recipients based on race. Though black HT recipients have worse outcomes than other ethnic groups, this effect may not be related to racial bias in organ allocation. Black heart transplant (HT) recipients have worse overall survival than other ethnic groups. It is unknown if subconscious racial bias affects the quality of donors that are allocated to black HT recipients. This study aims to investigate if the quality of donors allocated to HT recipients differs based on the race of the recipient. We queried the Scientific Registry of Transplant Recipients (SRTR) dataset from 2006-2015. Patients were stratified into groups by race: black, white, Hispanic and other. Baseline characteristics of recipients were recorded in addition to independent donor variables including: donor age, ischemic time, creatinine, and size mismatch of greater than 20% difference in height or weight. Race-mismatch was not used as a variable due to disproportionate distribution of donor race in the population studied. We then compared these continuous variables across different racial groups. A total of 19171 HT recipients were included in the analysis: 3811 black, 13059 white, 1487 Hispanic, and 814 other. Black patients received donors with a significantly lower ischemic time (min) compared to white patients (188.9 ± 1.9 vs. 194.8 ± 1.1, p<0.001), and a significantly higher creatinine (mg/dL) than white patients (1.41 ± 0.09 vs 1.35 ± 0.04, p<0.001). In addition, white patients received donors of significantly older age (yr) than black and Hispanic patients (31.95 ± 0.4 vs 31.56 ± 0.7; 30.6 ± 1.1, respectively, p< 0.001) and "other" race was a significant risk for size mismatch compared to blacks, whites and Hispanics (39 ± 6.7% vs 35 ± 3%; 33 ± 1.6%; 31 ± 4.7% respectively, p<0.001). However, no other significant trends were noted. Though there were some statistically significant results, most notably, our study did not find any meaningful clinically significant differences in the quality of donors allocated to HT recipients based on race. Though black HT recipients have worse outcomes than other ethnic groups, this effect may not be related to racial bias in organ allocation.

Characteristics and Short-Term Outcomes of Hepatitis C Antibody Positive Organs for Heart Transplantation: UNOS Analysis

Purpose Heart transplant centers are increasingly utilizing organs from donors infected with Hepatitis C virus (HCV). Aside from single-center experiences, there is little existing data regarding the characteristics of recipients of HCV Antibody (Ab)+ organs as well as short-term outcomes and graft survival. Methods We analyzed the United Network for Organ Sharing registry from January 2016 and March 2018 to include adults ≥18 who had undergone heart transplantation with a HCV Ab+ donor. Information regarding nucleic acid amplification testing (NAT) was also available. Results Between January 2016 and March 2018, 159 recipients underwent heart transplantation with HCV Ab+ donors. When comparing recipients of HCV+ to HCV- hearts, there were no differences between recipient age (53.4 vs 53.6 years, p =0.86), donor age (33.2 vs 31.9 years, p =0.055), female donor (26.0 vs 27.7%, p =0.64), body mass index (27.3 vs 27.6, p =0.47), and serum creatinine at transplant (1.4 vs 1.4, p = 0.36). There were no differences in the use of ventricular assist devices at time of transplant between groups. Recipients of HCV+ organs were more likely to be Blood Type O (55.3% vs 38.9%, p Conclusion While recipient baseline characteristics were similar between those receiving HCV+ and HCV- transplants, recipients of HCV+ organs had significantly longer ischemic times with longer distances from the donor hospital to the transplant center. Short-term survival appears similar between groups.

Interaction of Donor and Recipient Age: Do Older Heart Transplant Recipients Require Younger Hearts?

Older patients (aged 60 years or more) awaiting heart transplant often have comorbidities that may limit overall survival independent of cardiac status. We hypothesized that these comorbidities have a more-limiting impact on survival than age of donor heart and that older allografts might be utilized in these patients without compromising outcomes. We identified all transplant recipients aged more than 60 years in the United Network for Organ Sharing database. Local regression analysis detected the point above which increasing donor age incurred increasing risk of mortality, above and below which two cohorts were defined. Kaplan-Meier analysis compared cumulative 5-year survival between groups. Cox proportional hazard modeling was then used to determine the hazards of death in the two groups. An inflection point in posttransplant survival was detected near donor age 50 years. Of 14,113 older recipients studied, 86% received younger donor hearts (less than 50 years of age), and 14% received advanced age allografts (50 years of age or more). Baseline characteristics were comparable between groups except more recipients had left ventricular assist devices at time of transplant in the younger donor group (15% versus 9%, p< 0.001). Five-year survival was significantly lower among recipients receiving advanced age hearts compared with those receiving younger hearts (67% versus 73%, log rank p < 0.001). Adjusting for relevant recipient baseline characteristics, patients receiving advanced age hearts were 30% more likely to die by 5 years compared with patients receiving younger hearts. Transplant recipients aged 60 years and more who receive advanced age donor hearts (50 years ormore) have a significantly increased risk of mortality. With careful allograft selection, use of donor hearts to age 50 may be acceptable among older transplant recipients.

Cardiac transplantation for older patients: Characteristics and outcomes in the septuagenarian population

With increasing age of patients with heart failure, it is important to understand the potential role for orthotopic heart transplant (OHT) in elderly patients. We examined recipient and donor characteristics and long-term outcomes of older recipients of OHT in the United States. Using the United Network for Organ Sharing database, we identified OHT recipients from the years 1987-2014 and stratified them by age 18-59 years old, 60-69 years old, and ≥70 years old. We compared baseline characteristics of recipients and donors and assessed outcomes across groups. During this period, 50,432 patients underwent OHT; 71.8% (n = 36,190) were 18-59 years old, 26.8% (n = 13,527) were 60-69 years old, and 1.4% (n = 715) were ≥70 years old. Comparing the ≥70 years old group and 60-69 years old group, older patients had higher rates of ischemic etiology (53.6% vs 44.9%) and baseline renal dysfunction (61.4% vs 56.4%) and at the time of OHT were less likely to be currently hospitalized (45.0% vs 50.9%) or supported with left ventricular assist device therapy (21.0% vs 28.3%). Older recipients received organs from older donors (median age 36 years old vs 30 years old) who were more likely to have diabetes and substance use. After OHT, the median length of stay was similar between groups. At 1 year, of patients alive, patients ≥70 years old had fewer rejection episodes (17.8%) compared with patients 60-69 years old (29.5%). The 5-year mortality was 26.9% for recipients 18-59 years old, 29.3% for recipients 60-69 years old, and 30.8% for recipients ≥70 years old. Despite advanced age and less ideal donors, OHT recipients in their 70s had similar outcomes to recipients in their 60s. Selected older patients should not routinely be excluded from consideration for OHT.

Extracorporeal Life Support in "Awake" Patients as a Bridge to Lung Transplant.

Traditionally, patients on extracorporeal membrane oxygenation (ECMO) are sedated and mechanically ventilated, which increases risk of complications related to immobility and mechanical ventilation. The purpose of this study was to assess the feasibility and highlight the benefits of a bridge to lung transplant (LTx) using "awake ECMO" support. The peripheral venovenous or venoarterial ECMO was implanted at a bedside. A retrospective study of patients undergoing LTx between January 2007 and March 2013 was performed. Outcomes in patients supported on ECMO as a bridge to LTx and kept "awake" (Group 1) were compared with the rest of the LTx patients (Group 2). In this period, 249 LTx were performed and in them 7 patients were bridged to LTx using "awake ECMO" strategy. Two patients were awake at ECMO implantation and throughout the therapy, and two patients were on ventilator support at the time of ECMO implantation who were extubated later and maintained awake until LTx. The remaining three patients were awake for some time during the ECMO. There was no statistically significant difference in most donor characteristics and recipient baseline characteristics as well as post-LTx parameters between the two groups. One-year survival estimate was not different between the groups: Group 1, 85.7% vs. Group 2, 86.3% (log rank p = 0.99). In end-stage lung disease, the ECMO can be commenced in "awake" patients and patients can be awakened on ECMO. The "awake ECMO" strategy may avoid complications related to mechanical ventilation, sedation, and immobilization and provide comparable outcomes in the high-risk LTx patients.

Incidence and Risk Factors for Pulmonary Mycosis in Kidney Transplantation

Introduction Pulmonary mycosis, a severe complication following kidney transplantation, is associated with a high rate of mortality. The incidence of and independent risk factors for its development have not been well studied. Methods We retrospectively reviewed 2573 kidney transplant recipients. Patients were divided into case and control groups based on a diagnosis of pulmonary mycosis. The recipient baseline characteristics, posttransplant complications, immunosuppressive regimens and antibiotic usages were analyzed to identify independent risk factors. Results The total incidence of pulmonary mycosis among kidney recipients was 2.1%. Upon univariate analysis, patients in the case group differed significantly from the controls based upon: older age, higher retransplantation rate, longer dialysis time, induction with ATG or anti-CD25 monoclonal antibodies, maintenance treatment with FK506 or MMF, broad-spectrum antibiotics, higher incidences of acute rejection episodes, DGF, impaired liver function, leukopenia, cytomegalovirus infection, and delayed incisional healing ( P < .05). Multivariate analysis showed that older age, retransplantation, ATG induction, FK506/MMF, broad-spectrum antibiotics, leukopenia, and delayed incisional healing were independent risk factors for pulmonary mycosis. Conclusions The use of more potent immunosuppressive regimens seems to increase the rate of pulmonary mycosis. Patients who have five or more independent risk factors are at high risk for developing pulmonary mycosis.