Selection Of Transplant Candidates Research Articles

The Intersection of Aging and Lung Transplantation: its Impact on Transplant Evaluation, Outcomes, and Clinical Care.

Older adults (age ≥ 65 years) are the fastest growing age group undergoing lung transplantation. Further, international consensus document for the selection of lung transplant candidates no longer suggest a fixed upper age limit. Although carefully selected older adults can derive great benefit, understanding which older adults will do well after transplant with improved survival and health-related qualiy of life is key to informed decision-making. Herein, we review the epidemiology of aging in lung transplantation and its impact on outcomes, highlight selected physiological measures that may be informative when evaluating and managing older lung transplant patients, and identify directions for future research. In general, listing and transplanting older, sicker patients has contributed to worse clinical outcomes and greater healthcare use. Emerging evidence suggest that measures of physiological age, such as frailty, body composition, and neurocognitive and psychosocial function, may better identify risk for poor transplant outcomes than chronlogical age. The evidence base to inform transplant decision-making and improvements in care for older adults is small but growing. Multipronged efforts at the intersection of aging and lung transplantation are needed to improve the clinical and patient centered outcomes for this large and growing cohort of patients. Future research should focus on identifying novel and ideally modifiable risk factors for poor outcomes specific to older adults, better approaches to measuring physiological aging (e.g., frailty, body composition, neurocognitive and psychosocial function), and the underlying mechanisms of physiological aging. Finally, interventions that can improve clinical and patient centered outcomes for older adults are needed.

Out of the Frying-Pan and into the Fire: Transplant Candidate Selection in Acute Lung Failure Due to SARS-CoV-2 Infection

PurposeThe COVID-19 pandemic led to unprecedented rates of acute lung failure (ALF), and a rise in lung transplantation (LTx) referrals. Data on LTx in ALF is limited to LTx outcomes, and the unpredictable course of SARS-CoV-2 makes candidate selection challenging. This study summarizes our experiences, in both patients transplanted and those we declined.MethodsLTx referrals for ALF due to SARS-CoV-2 between 01Apr20-01Oct21 were reviewed. Set parameters were collected prospectively. Acceptance criteria reflected previous guidance. Cases were discussed at our multi-disciplinary meeting and suitable candidates evaluated at source before transfer for consent and listing. Internal follow-up and external data from declined patients were retrospectively analysed, with survival to discharge and length of hospital stay as end-points.Results45 patients were referred (78% male). Median age was 55.8 [IQR 47.6-59.8] years. 36 (80%) required both mechanical ventilation and vvECMO, of median duration 46 [31-82] and 34 [24-72] days respectively. Consolidation was the commonest CT finding (47%). Bacterial colonisation (23/45, 51%), coagulopathy (21/45, 47%) and hepatic dysfunction (11/45, 24%) were common. Twenty-two patients were conscious, of whom 21 were evaluated. Five patients died during evaluation, from either sepsis or bleeding. One failed evaluation, and one withdrew consent. Six patients improved, making urgent LTx unnecessary, with 5 attending our review clinic. Of the 8 patients successfully evaluated, one died unexpectantly awaiting transfer, one improved at listing and a further patient died of sepsis after listing. Three patients underwent LTx, all being discharged home at 3 months post-LTx.ConclusionLTx candidate selection in critically ill SARS-CoV2 patients is challenging. Late recovery, particularly in non-fibrotic ALF is not unusual. Decision-making needs to include “acceptable morbidity” as a prelude to delayed evaluation and perhaps listing. More data is needed about declined candidates, particularly unweanable sedated patients with single-organ failure. Even successful awake recipients may experience significant psychological injury, underlining previous arguments in sedated patients. Equity to all candidates needs consideration, given the extraordinary demands on organ availability and care resources.

VAD as Bridge to Transplant Decision in Nine-Year-Old Child with Duchenne Muscular Dystrophy

<h3>Introduction</h3> Overall survival and quality of life has been improving in patients with Duchenne Muscular Dystrophy (DMD) in recent years in the setting of increased treatment with steroids and non-invasive positive pressure. Cardiac disease is now the primary cause of death. Given this shift, advanced cardiac therapies such as ventricular assist devices (VADs) and transplantation are being increasingly considered in selected individuals. <h3>Case Report</h3> A 9-year-old, ambulatory male with DMD, treated with prednisone and eteplirsen (exon-skipping agent), had rapid progression of ventricular dysfunction over a 6 month period. Given the patient's young age, additional work-up was done to rule out secondary causes. Viral myocarditis labs were unremarkable, but cardiac MRI demonstrated diffuse fibrosis consistent with DMD cardiomyopathy. Despite optimized oral medications, he was hospitalized twice for decompensated heart failure, ultimately requiring intravenous inotropic support. Given that his cardiomyopathy was rapidly progressive and out of proportion to his skeletal muscle disease (remained ambulatory with minimal respiratory muscle weakness), the family opted for VAD implantation with the possibility of subsequent transplant. For successful device placement, a subdiaphragmatic Gore-Tex pericardial pocket extension was created intraoperatively to fit the HeartMate3 LVAD given his small size (45 kg, BSA 1.35/m²). He was extubated on POD#1 and on baseline nocturnal BiPAP by POD#2. He was discharged with improved exercise tolerance and remains ambulatory. The patient was listed for heart transplant 3 months after VAD placement and had no unplanned readmissions. <h3>Summary</h3> In a carefully selected population of muscular dystrophy patients, even at small size and age, VAD placement can be safely performed with good outcomes. VAD support can be used as destination therapy, or in some cases, as bridge to transplantation. Transplantation may be appropriate for those DMD patients with cardiac disease out of proportion to skeletal and respiratory muscle disease, particularly if they are expected to have reasonable longevity from a non-cardiac standpoint. VAD support may allow for full evaluation of these non-cardiac co-morbidities in the absence of heart failure and thus may be helpful in the proper selection of appropriate transplant candidates.

When to consider lung transplantation?

Pulmonary transplantation remains the ultimate therapeutic option for selected patients with an advanced pulmonary disease and terminal respiratory insufficiency when all other therapeutic options have been exhausted. The optimal time-frame to proceed to a first discussion and evaluation about lung transplantation may be difficult to determine. This article describes the pathway of a patient towards lung transplantation and summarizes the criteria, which may help to timely identify eligibility for this therapeutic modality. We will focus mainly on the 2021 update of the International Society for Heart and Lung Transplantation (ISHLT) recommendations for the selection of lung transplant candidates.

Pitfalls and Successes in Trials in Older Transplant Patients with Hematologic Malignancies.

Recent medical advances have allowed a greater number of older patients to undergo hematopoietic stem cell transplantation (HSCT) and participate in HSCT trials. In this review, we outline recent advances in HSCT that have made this possible, general setbacks, and their effects on the landscape of HSCT trials in older adults. Reduced-intensity conditioning regimens and a more physiological approach to transplant candidate selection have given older patients an opportunity to participate in HSCT trials. However, difficulties in allogeneic donor selection, post-transplant complications, and the misalignment of trial goals with patient goals may pose challenges for future trial recruitment and success. While increasing amounts of evidence show that older adults may benefit from participation in HSCT trials, clinicians, investigators, and patients must carefully weigh the benefits with potential repercussions.

Current trends in candidate selection, contraindications, and indications for lung transplantation.

Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.

Obesity Management in Kidney Transplant Candidates: Current Paradigms and Gaps in Knowledge.

In this review, we discuss the increasing prevalence of obesity among people with chronic and end-stage kidney disease (ESKD) and implications for kidney transplant (KT) candidate selection and management. Although people with obesity and ESKD receive survival and quality-of-life benefits from KT, most KT programs maintain strict body mass index (BMI) cutoffs to determine transplant eligibility. However, BMI does not distinguish between visceral adiposity, which confers higher cardiovascular risks and risks of perioperative and adverse posttransplant outcomes, and muscle mass, which is protective in ESKD. Furthermore, requirements for patients with obesity to lose weight before KT should be balanced with the findings of numerous studies that show weight loss is a risk factor for death among patients with ESKD, independent of starting BMI. Data suggest that KT is associated with survival benefits relative to remaining on dialysis for candidates with obesity although recipients without obesity have higher delayed graft function rates and longer transplant hospitalization durations. Research is needed to determine the optimal body composition metrics for KT candidacy assessments and risk stratification. In addition, ESKD-specific obesity management guidelines are needed that will address the neurologic, behavioral, socioeconomic, and physical underpinnings of this increasingly common disease.

Lung transplantation: challenges in the COVID-19 era, a review of the literature

: The severe acute respiratory syndrome coronavirus 2 pandemic poses unique challenges for lung transplant recipients. The optimal management of these patients is not known and the risk of transmission of the SARS-CoV-2 during lung transplantation is a major concern. Clear guidelines for selection of lung transplant candidates due to chronic pulmonary disease due to COVID-19 are urgently needed. The objective of this study is to review the available evidence on the diagnosis and treatment of the coronavirus disease 2019 in lung transplant recipients, as well as current recommendations regarding the screening of potential organ donors and recipients and the implementation of the COVID-19 vaccine in patients both on the waitlist and after lung transplantation. We performed an electronic search of the literature in the PubMed, MedRxiv COVID-19 SARS-Cov-2, LitCovid-NCBI-NLM-NIH, and Medline databases, From December 2019 to January 22, 2021. The following keywords with and without Boolean operators were used: “covid-19”, “SARS-CoV-2” in combination with “lung transplantation”, “solid organ transplant”, and “immunosuppression”. Articles in the English and Spanish languages were extracted. Web sites of the Center for Disease Control (CDC), International Society for Heart & Lung Transplantation, National Institute of Health, Infectious Diseases Society of America (IDSA), and the Federal Drug Administration were reviewed. A total of 168 reports and websites references were used for this review. Lung transplant recipients with COVID-19 are at increased risk for severe illness and death. Management should be similar as the general population but immunosuppression must be adjusted. Lung transplant recipients should receive the COVID-19 vaccine 2 to 3 months after transplantation. Extreme care must be taken to precent transmission of the SARS-CoV-2 during transplantation. The number of patients with post COVID-19 chronic respiratory failure referred for lung transplantation is expected to increase in the near future. There is much to be known regarding the management of lung transplant recipients with COVID-19. Protocols are needed to prevent transmission of the SARS-CoV-2 during transplantation and clear guidelines are needed to define the criteria for lung transplant in patients with residual severe pulmonary disease post COVID-19 infection.

Selected Articles from This Issue

A prior cancer diagnosis is common among solid organ transplant candidates, and immunosuppressive medications administered to transplant recipients may increase recurrence risk. Engels and colleagues used data from the United States transplant registry and 13 cancer registries to assess cancer-specific survival among 10,524,326 cancer patients, 5425 of whom (0.05%) subsequently underwent transplantation. Transplantation was not associated with decreased cancer-specific survival for any cancer site. Protective associations were observed for patients with breast cancer, non-Hodgkin lymphoma, and myeloma. These results partly reflect careful transplant candidate selection and do not demonstrate a detrimental effect of immunosuppression on cancer-specific survival, supporting current management strategies.Chang and colleagues analyzed BOp. data across 3,460 adults in Wave 1 of the PATH Study, including current exclusive smokeless tobacco (ST) use among never smokers (primary ST users) and former smokers (secondary ST users), exclusive cigarette smokers, dual users of ST and cigarettes, former smokers, and never tobacco users. BOPH concentrations among primary ST users were similar to never tobacco users and former smokers. Dual users had significantly higher sICAM-1, IL-6, and F2-isoprostane compared to never tobacco users, but looked similar to exclusive smokers. ST use alone and in combination with smoking may affect levels of inflammatory and oxidative stress levels.Recruitment of stromal cells into the tumor microenvironment may influence disease progression and prognosis in breast cancer. By applying machine learning algorithms to digitized H&amp;E-stained sections for 2,084 breast cancer patients from China, Poland, and the United States, Abubakar and colleagues characterized tumor-associated stromal cellular density (SCD) as the percentage of tumor-stroma that is occupied by nucleated cells. The authors found increasing SCD to be independently predictive of poor clinical outcomes among patients with hormone receptor-positive breast cancer from all three study populations. The findings suggest that SCD assessment on H&amp;E-stained sections, which are routinely performed and widely available, could help refine prognostic assessment and treatment decision-making for patients with hormone receptor-positive breast cancer.Many women undergo risk-reducing oophorectomy (RRO) for ovarian cancer prevention at the time of hysterectomy. The abrupt decline in circulating hormones after RRO may impact body composition, particularly in premenopausal women. In this diverse national sample of women, Karia and colleagues observed higher total and regional (trunk, arms, legs) fat mass and lower lean mass among women with hysterectomy and RRO than those with hysterectomy alone or no surgery. Point estimates were stronger among women &lt;45 years at surgery and those with a normal BMI. Longitudinal studies are needed to assess changes in body composition after RRO and to test interventions to mitigate these effects.

Liver transplantation in acute liver failure: Dilemmas and challenges.

Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage

MO923PREDICTING POST-TRANSPLANT HRQOL TO OPTIMIZE OUTCOMES IN OLDER KIDNEY TRANSPLANT RECIPIENTS

Abstract Background and Aims Kidney transplantation (KT) is the optimal treatment for older patients in need for kidney replacement therapy, with favorable outcomes both on survival, and health-related quality of life (HRQoL). Given the current organ scarcity, allocation of transplants should prioritize patients who are expected to benefit most from KT and identifying reliable predictors of post-transplant HRQoL outcomes is essential to optimize the selection process. Method Patients ≥ 65 years, who were enlisted for KT between January 2013 and November 2016 at the Norwegian national transplant center, were asked to participate. Self-reported HRQoL was assessed using the Kidney-Disease Quality of Life Short Form version 1.3 (KDQOL-SF) survey. Pre-transplant comorbidity was assessed by the Liu comorbidity index (LCI). Linear mixed-effect models were used to detect HRQoL changes over time (pre-KT, at -6, -12 and -36 months post-KT), and to identify pre-transplant predictors of post-transplant outcomes. Results By November 2020, 220 (76%) out of 289 enrolled participants, were transplanted. The mean age at KT was 71.8 (4.1) years, 154 (70%) were males, 57 (26%) were transplanted pre-emptively and 30 (13.6%) received a transplant from a living donor. Longer dialysis vintage was independently associated with impaired physical function post-transplantion (Figure 1). Pre-transplant LCI score ≥ 7 consistently predicted poorer HRQoL outcomes at baseline and after 3-years, compared with LCI score &amp;lt; 7 (Figure 2). At 3- years post-transplant, increasing LCI score was lineary associated with decreasing SF-36 scores. Recipients on dialysis for ≥ 1 year with LCI ≥ 7 experienced the worst outcomes, with a marked and sustained post-transplant physical deterioration (Figure 3). Conclusion Older wait-listed candidates either on dialysis for &amp;gt;1 year or with elevated pre-transplant LCI are at high risk for impaired HRQoL post-transplant outcomes and should be re-evaluated with respect to transplantability on a regular basis. The identification of criteria to optimize the selection of older transplant candidates should be the scope of future studies

Mycobacteria: Selection of Transplant Candidates and Post-lung Transplant Outcomes.

Mycobacterium is a large, clinically relevant bacterial genus made up of the agents of tuberculosis and leprosy and hundreds of species of saprophytic nontuberculous mycobacteria (NTM). Pathogenicity, clinical presentation, epidemiology, and antimicrobial susceptibilities are exceptionally diverse between species. Patients with end-stage lung disease and recipients of lung transplants are at a higher risk of developing NTM colonization and disease and of severe manifestations and outcomes of tuberculosis. Data from the past three decades have increased our knowledge of these infections in lung transplant recipients. Still, there are knowledge gaps to be addressed to further our understanding of risk factors and optimal treatments for mycobacterial infections in this population.

COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health.

The COVID‐19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID‐19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID‐19 as many are dialysis‐dependent and have comorbid conditions. We examined factors associated with COVID‐19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID‐19 mortality. There were 131 659 candidates during the study period with 3534 all‐cause deaths and 384 denoted a COVID‐19 cause (5.00/1000 person years). Factors associated with increased COVID‐19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43–2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46–4.66) had higher COVID‐19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19–3.12, relative to post‐graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26–2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28–2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID‐19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID‐19 mortality.

Long-Term Clinical and Hemodynamic Outcomes after Heart Transplantation in Patients Pre-Treated with Sildenafil.

ResumoFundamento A resistência vascular pulmonar elevada ainda é um grande problema na seleção de candidatos ao transplante cardíaco.Objetivo Nosso objetivo foi avaliar o efeito da administração de sildenafila pré-transplante cardíaco em pacientes com hipertensão pulmonar fixa.Métodos O estudo retrospectivo, de centro único, incluiu 300 candidatos a transplante cardíaco consecutivos tratados entre 2003 e 2013. Destes, 95 pacientes tinham hipertensão pulmonar fixa e, dentre eles, 30 pacientes foram tratados com sildenafila e acabaram passando pelo transplante, formando o Grupo A. O Grupo B incluiu 205 pacientes sem hipertensão pulmonar que passaram pelo transplante cardíaco. A hemodinâmica pulmonar foi avaliada antes do transplante, 1 semana e 1 ano após o transplante. A taxa de sobrevivência foi comparada entre os grupos. Neste estudo, um P valor < 0,05 foi considerado estatisticamente significativo.Resultados Após o tratamento com sildenafila, mas antes do TxC, a RVP (-39%) e a PAPs (-10%) diminuíram significativamente. A PAPs diminuiu após o TxC em ambos os grupos, mas permaneceu significativamente alta no grupo A em relação ao grupo B (40,3 ± 8,0 mmHg versus 36,5 ± 11,5 mmHg, P=0,022). Um ano após o TxC, a PAPs era 32,4 ± 6,3 mmHg no Grupo A versus 30,5 ± 8,2 mmHg no Grupo B (P=0,274). O índice de sobrevivência após o TxC 30 dias (97% no grupo A versus 96% no grupo B), 6 meses (87% versus 93%) e um ano (80% versus 91%) após o TxC não foi estatisticamente significativo (Log-rank P=0,063). Depois do primeiro ano, o índice de mortalidade era similar entre os dois grupos (sobrevivência condicional após 1 ano, Log-rank p=0,321).Conclusão Nos pacientes com HP pré-tratados com sildenafila, a hemodinâmica pós-operatória inicial e o prognóstico são numericamente piores em pacientes sem HP, mas depois de 1 ano, a mortalidade em médio e longo prazo são semelhantes. (Arq Bras Cardiol. 2021; 116(2):219-226)

Arterial abnormalities identified in kidneys transplanted into children during the COVID-19 pandemic.

Graft artery stenosis can have a significant short- and long-term negative impact on renal graft function. From the beginning of the COVID-19 pandemic, we noticed an unusual number of graft arterial anomalies following kidney transplant (KTx) in children. Nine children received a KTx at our center between February and July 2020, eight boys and one girl, of median age of 10years. Seven presented Doppler features suggesting arterial stenosis, with an unusual extensive pattern. For comparison, over the previous 5-year period, persistent spectral Doppler arterial anomalies (focal anastomotic stenoses) following KTx were seen in 5% of children at our center. We retrospectively evidenced severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in five of seven children with arterial stenosis. The remaining two patients had received a graft from a deceased adolescent donor with a positive serology at D0. These data led us to suspect immune postviral graft vasculitis, triggered by SARS-CoV-2. Because the diagnosis of COVID-19 is challenging in children, we recommend pretransplant monitoring of graft recipients and their parents by monthly RT-PCR and serology. We suggest balancing the risk of postviral graft vasculitis against the risk of prolonged dialysis when considering transplantation in a child during the pandemic.

Management of lung transplantation in the COVID-19 era-An international survey.

It is unknown if solid organ transplant recipients are at higher risk for severe COVID-19. The management of a lung transplantation (LTx) program and the therapeutic strategies to adapt the immunosuppressive regimen and antiviral measures is a major issue in the COVID-19 era, but little is known about worldwide practice. We sent out to 180 LTx centers worldwide in June 2020 a survey with 63 questions, both regarding the management of a LTx program in the COVID-19 era and the therapeutic strategies to treat COVID-19 LTx recipients. We received a total of 78 responses from 15 countries. Among participants, 81% declared a reduction of the activity and 47% restricted LTx for urgent cases only. Sixteen centers observed deaths on waiting listed patients and eight centers performed LTx for COVID-19 disease. In 62% of the centers, COVID-19 was diagnosed in LTx recipients, most of them not severe cases. The most common immunosuppressive management included a decreased dose or pausing of the cell cycle inhibitors. Remdesivir, hydroxychloroquine, and azithromycin were the most proposed antiviral strategies. Most of the centers have been affected by the COVID-19 pandemic and proposed an active therapeutic strategy to treat LTx recipients with COVID-19.

Clinical Relevance of Kidney Biopsy in Patients Qualified for Liver Transplantation and After This Procedure in the Model for End-stage Liver Disease (MELD) Era: Where Are We Today?

Chronic kidney disease (CKD) has been recognized as an increasingly common complication of liver transplantation (OLTx). Post-transplant renal dysfunction contributes to long-term morbidity and mortality following OLTx and is a very important issue in the management of liver transplant recipients. Its etiology is multifactorial and can be determined by kidney biopsy, which is too rarely done in this patient group. In the clinical context of patients with liver cirrhosis, accurate and reliable evaluation of the renal injury is crucial.We performed a review of kidney biopsies in patients with symptoms of CKD (proteinuria/hematuria/elevated creatinine) before and after liver transplantation in the published literature.Kidney biopsies were performed either before or after liver transplantation using percutaneous technique. There are few reports on transjugular kidney biopsy. Biopsy results prevented unnecessary modification of immunosuppressive therapy or selection of candidates for liver transplantation.In our opinion, kidney biopsy is a clinically relevant diagnostic approach to recognize kidney disease before and after liver transplantation, it also helps with the management of kidney disease in this population, and it is safe. Kidney biopsy should be offered more often in liver transplant patients to ensure appropriate therapy in concomitant CKD in this population. Our decisions today will impact clinical outcomes in the future.

Findings and recommendations from the organ transplant caregiver initiative: Moving clinical care and research forward.

Lay-caregivers are essential to the continuum of care in adult organ transplantation. However, we have a limited understanding of the experiences, exigencies, and outcomes associated with lay-caregiving for organ transplant patients. While much discussion and debate has focused on caregiver requirements in relation to transplant candidate selection, little focus has been given to understanding the needs of caregivers themselves. In response to this, the Organ Transplant Caregiver Initiative was created, and a meeting was held during October 6-7, 2019. Transplant healthcare professionals, researchers, and lay-caregivers discussed the experiences, educational needs, existing research, and research recommendations to improve the experience of lay-caregivers for adult organ transplant patients. In this report, we summarize the Organ Transplant Caregiver Initiative and meeting findings, providing a preliminary action plan to improve education, research, and advocacy for organ transplant caregivers.

Donor and transplant candidate selection for solid organ transplantation during the COVID-19 pandemic.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a novel coronavirus responsible for a worldwide pandemic has forced drastic changes in medical practice in an alarmingly short period of time. Caregivers must modify their strategies as well as optimize the utilization of resources to ensure public and patient safety. For organ transplantation, in particular, the loss of lifesaving organs for transplantation could lead to increased waitlist mortality. The priority is to select uninfected donors to transplant uninfected recipients while maintaining safety for health care systems in the backdrop of a virulent pandemic. We do not yet have a standard approach to evaluating donors and recipients with possible SARS-CoV-2 infection. Our current communication shares a protocol for donor and transplant recipient selection during the coronavirus disease 2019 (COVID-19) pandemic to continue lifesaving solid organ transplantation for heart, lung, liver, and kidney recipients. The initial results using this protocol are presented here and meant to encourage dialogue between providers, offering ideas to improve safety in solid organ transplantation with limited health care resources. This protocol was created utilizing the guidelines of various organizations and from the clinical experience of the authors and will continue to evolve as more is understood about SARS-CoV-2 and how it affects organ donors and transplant recipients.

Liver Transplantation for Extended Criteria Hepatocellular Carcinoma Using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria

Introduction: Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (IN_MC) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUT_MC) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology. Methods: OUT_MC patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUT_MC patients required (IN_MUC): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with IN_MC tumors served as control and internal validation cohort. Results: 31 of 170 liver transplant candidates were OUT_MC. Of these, 8 dropped out. The remaining 23 patients met the selection criteria and underwent transplantation. Recurrence-free survival was higher in patients transplanted IN_MC compared to those OUT_MC IN_MUC (92.2% vs. 70.8%; p = 0.026) after 5 years of follow-up. Overall survival showed no significant difference (p = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the IN_MC patients as internal validation cohort (c-index: 0.896; CI 0.588–0.981, p = 0.005). Conclusion: Dynamic selection criteria for the stratification of patients with OUT_MC HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to IN_MC patients.