Short-term Post-transplant Outcomes Research Articles

Multimodal prehabilitation improves short-term post-transplant outcomes while not increasing costs for heart transplant recipients

Multimodal prehabilitation improves short-term post-transplant outcomes while not increasing costs for heart transplant recipients

Multimodal Prehabilitation in Heart Transplant Recipients Improves Short-Term Post-Transplant Outcomes without Increasing Costs

(1) Background and aim: This study aimed to investigate the impact of prehabilitation on the postoperative outcomes of heart transplantation and its cost-effectiveness. (2) Methods: This single-center, ambispective cohort study included forty-six candidates for elective heart transplantation from 2017 to 2021 attending a multimodal prehabilitation program consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative course was compared to a control cohort consisting of patients transplanted from 2014 to 2017 and those contemporaneously not involved in prehabilitation. (3) Results: A significant improvement was observed in preoperative functional capacity (endurance time 281 vs. 728 s, p < 0.001) and quality-of-life (Minnesota score 58 vs. 47, p = 0.046) after the program. No exercise-related events were registered. The prehabilitation cohort showed a lower rate and severity of postoperative complications (comprehensive complication index 37 vs. 31, p = 0.033), lower mechanical ventilation time (37 vs. 20 h, p = 0.032), ICU stay (7 vs. 5 days, p = 0.01), total hospitalization stay (23 vs. 18 days, p = 0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p = 0.009). A cost-consequence analysis showed that prehabilitation did not increase the total surgical process costs. (4) Conclusions: Multimodal prehabilitation before heart transplantation has benefits on short-term postoperative outcomes potentially attributable to enhancement of physical status, without cost-increasing.

Heart transplantation from donation after circulatory death: Impact on waitlist time and transplant rate

The effect of using donation after circulatory death (DCD) hearts on waitlist outcomes has not been substantiated. We retrospectively analyzed 184 heart transplant (HT) candidates at our institution from 2019 to 2021. Patients were stratified into 2 observation periods centered on September 12, 2020, when the adult DCD HT program officially began. The primary outcome was a comparison of transplant rate between period 1 (pre-DCD) and period 2 (post-DCD). Secondary outcomes included waitlist time-to-transplant, waitlist mortality rate, independent predictors of incidence of HT, and posttransplant outcomes. A total of 165 HTs (n = 92 in period 1 and n = 73 in period 2) were performed. The median waitlist time-to-transplant decreased from 47.5 to 19 days in periods 1 and 2, respectively (P = .004). The transplant rate increased from 181 per 100 patient-years in period 1 to 579 per 100 patient-years in period 2 (incidence rate ratio, 1.87; 95% CI, 1.04-3.38; P = .038). There were no statistical differences in waitlist mortality rate (P = .566) and 1-year survival (P = .699) between the 2 periods. DCD HTs (n = 36) contributed to 49.3% of overall HT activity in period 2. We concluded that utilization of DCD hearts significantly reduced waitlist time and increased transplant rate. Short-term posttransplant outcomes were comparable between the pre-DCD and post-DCD periods.

Effects of Intraoperative Support Strategies on Endothelial Injury and Clinical Lung Transplant Outcomes

In lung transplantation, postoperative outcomes favor intraoperative use of extracorporeal membrane oxygenation (ECMO) over cardiopulmonary bypass (CBP). We investigated the effect of intraoperative support strategies on endothelial injury biomarkers and short-term posttransplant outcomes. Adults undergoing bilateral lung transplantation with No-Support, veno-arterial (V-A) ECMO, or CPB were included. Plasma samples pre- and post-transplant were collected for Luminex assay to measure endothelial injury biomarkers including syndecan-1 (SYN-1), intercellular adhesion molecule-1 (ICAM-1), and matrix metalloprotease-9. 55 patients were included for analysis. The plasma level of SYN-1 at arrival in the intensive care unit was significantly higher with CPB compared to V-A ECMO and No-Support (p<0.01). The rate of primary graft dysfunction grade 3 (PGD3) at 72hr was 60.0% in CPB, 40.1% in V-A ECMO, and 15% in No-Support (p=0.01). Post-operative plasma levels of SYN-1 and ICAM-1 were significantly higher in recipients who developed PGD3 at 72hr. SYN-1 levels were also significantly higher in patients who developed acute kidney injury and hepatic dysfunction after transplant. Postoperative, SYN-1 upon intensive care arrival was found to be a significant predictive biomarker of PGD3, acute kidney injury, and hepatic dysfunction following lung transplantation. CPB is associated with higher plasma concentrations of SYN-1, a marker of endothelial glycocalyx degradation, upon arrival to the intensive care unit. Higher levels of SYN-1 are predictive of end-organ dysfunction following lung transplantation. Our data suggests that intraoperative strategies aimed at modulating endothelial injury will help improve lung transplantation outcomes.

Utilization of COVID-19 positive donors for heart transplantation and associated short-term outcomes

The safety and efficacy of using COVID-19 positive donors in heart transplantation (HT) are increasingly relevant, but not well established. The present study evaluated the characteristics and utilization of such donors and associated post-HT outcomes. All adult (≥18 years old) potential donors and HT recipients in the United States from April 21, 2020 to March 31, 2022 were included. Donor COVID-19 status was defined by the presence (or absence) of any positive test within 21 days of organ recovery. Donor and recipient characteristics and post-HT outcomes, including a primary composite of death, graft failure, and re-transplantation, were compared by donor COVID-19 status. Of 967 COVID-19(+) potential donors, 19.3% (n=187) were used for HT compared to 26.7% (n=6277) of COVID-19(-) donors (p < 0.001). Transplanted COVID-19(+) vs COVID-19(-) donors were younger, but otherwise were similar. Recipients of hearts from COVID-19+ vs COVID-19(-) donors less frequently received pre-HT inotropes (24.1% vs 31.7%, p=0.023) and ventricular assist device therapy (29.7% vs 36.8%, p=0.040). There were no significant differences in any post-HT outcome by donor COVID-19 status, including the primary composite outcome at 90 days (5.4% vs 5.6%, p=0.91). Among COVID-19(+) donors, the presence of a subsequent negative test prior to transplant was not associated with posttransplant outcomes. Our results suggest that carefully selected COVID-19 positive donors may be used for HT with no difference in short-term post-transplant outcomes. Additional data regarding donor and recipient treatments and impact of vaccination should be collected to better inform our use of organs from COVID(+) donors.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Lung Transplantation for COVID-19-related Lung Disease: Clinical Experience and Call for a Global Registry.

Marginal Cardiac Donors and Transplant Outcomes: An 11-Year Experience

<h3>Purpose</h3> Heart transplantation is the gold standard treatment for end-stage heart failure. However, the number of available organs is numerically inadequate to address this problem. One potential way to overcome the organ shortage is to broaden criteria for acceptable donations to include a sub-pool of marginal donors. This study aims to assess our outcomes for patients receiving marginal cardiac transplants compared to their counterparts. The analysis is particularly important as our centre has recently begun to utilise the XVIVO hypothermic perfusion machine for organ storage, challenging accepted definitions of organ marginality based on ischaemic time. <h3>Methods</h3> We conducted a single-centre retrospective cohort study to identify all heart transplant recipients from 2010-2021. Patients who received a combined heart-lung transplant were excluded, as were organs obtained through the donation after circulatory death (DCD) pathway. We identified all marginal donors meeting any of the accepted criteria; donor age >60 years, donor LVEF <55%, use of T3 in the donor, or donor ischemic time >6hrs or >4hrs if donor age >40 years. <h3>Results</h3> 371 patients met our inclusion criteria for this study. Based on accepted criteria, 120 (32%) of donors were identified as marginal. Of these 120 marginal donors, 64 (53%) met the prolonged ischaemic time criteria. Overall mean donor age was 37.2 years +/- 12.6 and mean donor ischaemic time was 225 minutes +/- 67 minutes. Utilisation of extra-corporeal membrane oxygenation (ECMO) was higher in the marginal donor group (33 patients, 28%) compared to the non-marginal group (35 patients, 14%), p=0.002. There was no difference in new renal failure, requirement for dialysis or post-operative length of stay. 14 patients (6%) in the non-marginal group died within 30-days of their transplant, compared to 5 patients (4%) in the marginal group, p=0.56). <h3>Conclusion</h3> Our centre's experience indicates that carefully selected marginal donors demonstrate similar short term post-transplant outcomes when compared to their non-marginal counterparts. Furthermore, our utilisation of the XVIVO hypothermic perfusion organ storage device is likely to further challenge the accepted definition of marginal cardiac donors by allowing for longer periods of donor ischaemic time and may improve post-operative ECMO rates in the marginal donor group.

Impact of Donation After Circulatory Death Heart Transplantation on Waitlist Outcomes and Transplantation Activity

<h3>Purpose</h3> To assess the impact of increased availability of donor hearts from donors after circulatory death on waiting list and heart transplantation activity. <h3>Methods</h3> We compared changes in waitlist activity and transplant volumes in patients before and after we adopted DCD heart transplantation into our program. Outcomes of patients who were on the waiting list between January and August 2020 (Period 1) were compared to those listed between January and August 2021 (Period 2). <h3>Results</h3> Waitlist volumes were 10.6 patients listed per month in Period 1 (N = 85) and 7.5 patients in Period 2 (N = 60). The median waitlist time to transplant decreased from 339 days in Period 1 to 77 days in Period 2 (<i>P</i> = .035). The transplant rate increased from 92 per 100 patient-years in Period 1 to 186 per 100 patient-years in Period 2 (<i>P</i> = .004). No status 5 and 6 recipients were transplanted in Period 1 as opposed to 13% in Period 2 (Figure 1). Waitlist mortality rate, hospital stay post-transplantation, and post-transplant mortality did not differ significantly between the time periods. <h3>Conclusion</h3> This single-center retrospective analysis suggests that the use of DCD donor hearts may result in a reduced HTx waitlist time and an increased transplant rate. DCD increases organ availability to recipients in lowers status categories. In addition, transplanting DCD donor hearts can provide comparable short-term post-transplant outcomes to DBD. Figure 1. Transplant activity stratified by recipient status.

Allogeneic Hematopoietic Cell Transplantation for Acute Myeloid Leukemia in First Complete Remission after 5-Azacitidine and Venetoclax: A Multicenter Retrospective Study

The therapeutic landscape for acute myeloid leukemia (AML) has evolved in recent years with the introduction of hypomethylating agents (HMA) and venetoclax in patients previously deemed unfit for curative - intent treatment. Some of these patients undergo allogeneic hematopoietic cell transplant (alloHCT), yet there are scarce data regarding transplantation outcomes.We conducted a multicenter nationwide retrospective cohort study to evaluate outcomes of patients with AML who underwent alloHCT in first CR (CR1) after frontline treatment with 5-azacitidine plus venetoclax (aza-ven group). In addition, we collected a historical control group of patients who achieved CR1 following first line intensive chemotherapy followed by alloHCT (intensive group).24 patients in the aza-ven group were transplanted between 2019 and 2021. Compared to the intensive group, patients in the aza-ven group were older (median age 71.7 vs. 58.4 years, p <0.001), had higher incidence of therapy related AML and AML with antecedent hematologic disorder (p <0.001) and had more often adverse cytogenetics (p=0.022). They had a higher percentage of allografts from matched unrelated donors, and reduced intensity conditioning was more commonly used (Table 1).Median follow up was 8 (range, 0 to 25) months in the aza-ven group and 23 (range, 4 to 56) months in the intensive group. Estimated 12 months non relapse mortality was 19.1% in the aza-ven group and 11.8% in the intensive group (p=0.492). The estimated median relapse free survival (RFS) was not reached in the aza-ven group and was 19.3 months (CI 95% 1-38) in the intensive group. There was no difference between the two groups in 12 months RFS (58% and 54% in the aza-ven group and intensive group, respectively, p = 0.892). The estimated median survival of the aza-ven group was not reached and the 12 months overall survival (OS) rate was 63.2%. The estimated median survival of the intensive group was 50 months (CI 95% 5 - 96) and the 12 months OS rate was 70.8%. There was no statistical differences between the two groups regarding OS (p = 0.58).In a subgroup Cox regression analysis of the aza-ven group, adverse ELN 2017 risk category and HCT-CI score ≥3 were predictive of decreased RFS, both in univariate analysis (UVA) and in multivariate analysis (MVA) (HR 10.56, CI 95%1.64-68.1, p=0.013 and HR 6.43, CR 95% 1.34-30.75, p=0,02, respectively). Graft source (alternative vs. matched donor) and HCT-CI score ≥3 were predictive of decreased OS in UVA (HR 19.45, CI 95% 1.66-228.13, p= 0.018 and HR 5.93, CI 95% 1.13-31.05, p=0.03], yet in MVA neither of these factors retained their predictive value.The cumulative incidence of acute GVHD at 6 months was similar between groups: 58% in the aza-ven group vs. 62% in the intensive group (p=0.39). Likewise, there was no difference in the cumulative incidence of chronic GVHD at 12 months: 40% vs 42%, respectively (p=0.747)In conclusion, our data suggests that alloHCT for AML patients achieving first CR with aza-ven appears feasible, with short term post-transplant outcomes comparable to those expected after traditional intensive chemotherapy. Our results were collected in the real world setting, and patients in the aza-ven group were older and had inherently worse leukemia characteristics, including more secondary AML and more adverse cytogenetic features. Future research is warranted to decipher the true spectrum of AML patients who could benefit from remission induction with this less intensive regimen prior to alloHCT. [Display omitted] DisclosuresRam: Gilead: Honoraria; Novartis: Honoraria. Wolach: Janssen: Consultancy; Abbvie: Consultancy, Honoraria, Research Funding; Astellas: Consultancy; Amgen: Research Funding; Novartis: Consultancy; Neopharm: Consultancy. Yeshurun: Astellas: Consultancy; Janssen: Consultancy.

Allogeneic hematopoietic cell transplantation for acute myeloid leukemia in first complete remission after 5-azacitidine and venetoclax: a multicenter retrospective study.

The combination of hypomethylating agents and venetoclax has revolutionized the therapeutic landscape of acute myeloid leukemia (AML), especially for patients previously deemed unfit for curative-intent treatment. Some of these patients undergo allogeneic hematopoietic cell transplant (alloHCT); yet, there are scarce data regarding transplantation outcomes. We conducted a multicenter nationwide retrospective cohort study, including patients with AML who underwent alloHCT in CR1 after frontline treatment with azacitidine plus venetoclax only (aza-ven group). We collected a historical control group of patients who achieved CR1 after first-line intensive chemotherapy only, followed by alloHCT (intensive group). Patients in the aza-ven group (n = 24) were transplanted between 2019 and 2021. Compared to the intensive group, patients in the aza-ven group were older (median age 71.7 vs. 58.4years), had higher incidence of therapy-related AML and AML with antecedent hematologic disorder and had more often adverse cytogenetics. They had a higher percentage of allografts from matched-unrelated donors, and reduced intensity conditioning was more commonly used. The estimated 12months non relapse mortality was 19.1% in the aza-ven group and 11.8% in the intensive group. The estimated 12months relapse-free survival and overall survival were 58% and 63% in the aza-ven group and 54% and 70% in the intensive group, respectively. The cumulative incidence of acute GVHD at 6months and of chronic GVHD at 12months were 58% and 40% in the aza-ven group and 62% and 42% in the intensive group, respectively. Analysis of the aza-ven group revealed that HCT-CI score and ELN risk category were predictive of RFS in both univariate analysis as well as multivariate analysis. Our data suggests that alloHCT for AML patients achieving first CR with aza-ven appears feasible, with short-term post-transplant outcomes similar to those expected after traditional intensive chemotherapy.

Strategy for Selective Middle Hepatic Vein Reconstruction in Living Donor Liver Transplantation Using Right Lobe Graft: A Retrospective Observational Study

The aim of this study was to verify the safety and feasibility of our selection criteria for middle hepatic vein (MHV) reconstruction in living donor liver transplantation (LDLT) using right lobe grafts. A total of 153 LDLTs were performed using right lobe grafts in a tertiary hospital from 2006 to 2016. Among them, 52 cases without MHV reconstruction were compared with 101 recipients who underwent LDLT using right lobe graft with MHV reconstruction. Both groups were compared regarding indications for reconstruction, short-term and long-term complications, operative details, and outcomes. The two groups differed only in cold ischemic time (108.19 ± 49.81 minutes vs 146.37 ± 58.74 minutes) preoperatively. Short-term posttransplant outcomes, long-term overall survival, and long-term disease-free survival showed no significant differences between the 2 groups. After propensity score matching for both groups with and without MHV reconstruction to eliminate selection bias, the 2 groups were comparable. We found that our selection criteria for performing MHV reconstruction in LDLT using right lobe graft were feasible and safe. A routine MHV reconstruction is not necessary if the right lobe graft graft-to-recipient weight ratio is ≥1.0, right hepatic vein draining territory volume is ≥0.8, and recipient Model for End-Stage Liver Disease score is <20.

Recent Changes in Durable Left Ventricular Assist Device Bridging to Heart Transplantation.

This study evaluates the impact of the recent United Network for Organ Sharing (UNOS) allocation policy change on outcomes of patients bridged with durable left ventricular assist devices (LVADs) to orthotopic heart transplantation (OHT). Adults bridged to OHT with durable LVADs between 2010 and 2019 were included. Patients were stratified based on the temporal relationship of their OHT to the UNOS policy change on October 18, 2018. The primary outcome was early post-OHT survival. In total, 9,628 OHTs were bridged with durable LVADs, including 701 (7.3%) under the new policy. Of all OHTs performed during the study period, the proportion occurring following durable LVAD bridging decreased from 45% to 34% (p < 0.001). The more recent cohort was higher risk, including more extracorporeal membrane oxygenation bridging (2.6% vs. 0.3%, p < 0.001), more mechanical right ventricular support (9.7% vs. 1.4%, p < 0.001), greater pretransplant ICU admission (22.8% vs. 8.7%, p < 0.001) more need for total functional assistance (62.8% vs. 53.0%, p < 0.001), older donor age (33.3 vs. 31.7 years, p < 0.001), and longer ischemic times (3.38 vs. 3.13 hours, p < 0.001). Despite this, early post-OHT survival was comparable at 30 days (96.1% vs. 96.0%, p = 0.89), 90 days (93.7% vs. 94.0%, p = 0.76), and 6 months (91.0% vs. 93.0%, p = 0.96), findings that persisted after risk-adjustment. In this early analysis, OHT following bridging with durable LVADs is performed less frequently and in higher risk recipients under the new allocation policy. Despite this, short-term posttransplant outcomes appear to be unaffected in this patient cohort in the current era.

Cardiac Transplantation in Danon Disease

PurposeDanon disease is a rare X-linked dominant cardioskeletal myopathy caused by mutations in the lysosome-associated membrane protein-2 (LAMP-2) gene. Currently, there are no disease modifying therapies for Danon disease. The purpose of this study is to characterize individuals with Danon disease who undergo cardiac transplantation and describe their outcomes.MethodsRetrospective data of individuals with Danon disease who underwent cardiac transplantation (N=16) were obtained from 6 centers. Post-transplantation outcomes included survival, re-transplantation, and episodes of acute rejection within the first year. Analysis of preoperative patient characteristics was stratified by sex. Because the study was not limited to adults, z-scores were calculated for echocardiographic parameters to allow for comparisons between groups.ResultsMedian follow up time in this dataset was 2.35 years (IQR: 0.8 years - 8.3 years). Males had higher preoperative AST and ALT (p=0.02) compared to females and were more likely than females to have muscular symptoms (p=0.037). From a cardiac perspective, pre-transplant EF was lower in females compared to males (p=0.047), while left ventricular hypertrophy was more prominent in males compared to females (p<0.001). [TABLE] There was 1 death (female) in the entire cohort (occurred 5 days post-transplant) and no re-transplants. At 1 year, there were no episodes of antibody mediated rejection, and 5 episodes of acute cellular rejection (33%) in those who survived to discharge after transplantation.ConclusionDanon disease is a progressive multisystem disease. Understanding the individuals who undergo cardiac transplantation and their outcomes is critical for informing patient selection and guiding decisions regarding organ allocation. Short term post-transplant outcomes are acceptable in Danon disease and suggest that cardiac transplantation is a treatment option for these patients. Danon disease is a rare X-linked dominant cardioskeletal myopathy caused by mutations in the lysosome-associated membrane protein-2 (LAMP-2) gene. Currently, there are no disease modifying therapies for Danon disease. The purpose of this study is to characterize individuals with Danon disease who undergo cardiac transplantation and describe their outcomes. Retrospective data of individuals with Danon disease who underwent cardiac transplantation (N=16) were obtained from 6 centers. Post-transplantation outcomes included survival, re-transplantation, and episodes of acute rejection within the first year. Analysis of preoperative patient characteristics was stratified by sex. Because the study was not limited to adults, z-scores were calculated for echocardiographic parameters to allow for comparisons between groups. Median follow up time in this dataset was 2.35 years (IQR: 0.8 years - 8.3 years). Males had higher preoperative AST and ALT (p=0.02) compared to females and were more likely than females to have muscular symptoms (p=0.037). From a cardiac perspective, pre-transplant EF was lower in females compared to males (p=0.047), while left ventricular hypertrophy was more prominent in males compared to females (p<0.001). [TABLE] There was 1 death (female) in the entire cohort (occurred 5 days post-transplant) and no re-transplants. At 1 year, there were no episodes of antibody mediated rejection, and 5 episodes of acute cellular rejection (33%) in those who survived to discharge after transplantation. Danon disease is a progressive multisystem disease. Understanding the individuals who undergo cardiac transplantation and their outcomes is critical for informing patient selection and guiding decisions regarding organ allocation. Short term post-transplant outcomes are acceptable in Danon disease and suggest that cardiac transplantation is a treatment option for these patients.

Impact of Donor Lung Pathogenic Bacteria on Post-Transplant Outcomes after Lung Transplantation

Purpose Immediate post-transplant complications such as primary graft dysfunction (PGD), acute kidney injury (AKI), infections and acute rejection affect overall graft survival. Our study aims to determine the impact of donor lung pathogenic bacteria on immediate and short-term post-transplant outcomes, including development of AKI, PGD, duration of mechanical ventilation and overall mortality, as, such literature is scarce. Methods We performed a retrospective chart review of patients who underwent lung transplantation between July 2015 and December 2019. All patients above the age of 18 years were included. Multi-organ transplants and re-transplants were excluded. We collected the demographic data, pre and post-transplant clinical variables, donor and recipient cultures. The primary outcome was incidence of AKI with secondary outcomes being the incidence of PGD at 24 hours, length of stay (LOS) and 30- and 90-days mortality. Results Between July 2015 and December 2019, 100 lung transplants were performed, of which 5 were not eligible for the study. 95 patients were analyzed. Of those patients, 66% were male, 91% Caucasian, and the mean transplant age was 56.7 years. 52.6% of patients had interstitial lung disease and 30.5% had an obstructive disease. On cultures, 46% (N=44) had gram positive (GPB) bacteria, 4% (N=4) had gram negative (GNB) bacteria, 12% (N=11) had combined GPB and GNB, 38% (N=36) had no bacterial infection and 26% (N=25) were positive for fungi. 23% (N=22) of patients had AKI. Patients with GNB had the highest incidence of AKI (33.3%) followed by fungal (28%), followed by combined GPB and GNB (27.3%), and the lowest in patients with GPB (23.6%). However, this difference was not statistically significant.12.6% (N=12) had PGD at 24 hours, the highest incidence noted in the cohort with GNB (20%) followed by the combined cohort (18.2%), and the lowest incidence in the fungal cohort (12%). There was no significant difference in the 30- and 90-day mortality between the cohorts. Patients with GNB and GPB had the highest mean hospital LOS (42 days). Conclusion We noticed a trend towards an increase incidence of AKI and PGD in patients with GNB, though it did not reach a statistical significance. Larger studies are required to further assess the impact of donor lung pathogenic bacteria on post-transplant outcomes.

Two Years after the Removal of Donation Service Area from Lung Allocation in the US

<h3>Purpose</h3> The Organ Procurement and Transplantation Network (OPTN) US lung allocation policy was altered in 2017 by changing the first geographic unit of lung allocation from the donation service area (DSA) to a 250 nautical mile (NM) radius around the donor hospital. <h3>Methods</h3> OPTN data on lung candidates and recipients age gt; 11 was analyzed pre (11/26/2015- 11/24/2017) and post allocation policy change (11/25/2017- 11/24/2019). Cohorts were compared to study the differences. <h3>Results</h3> An increase was seen in the match lung allocation score (LAS) at transplant from pre to post era (mean pre=47.25 vs. post=49.79, p < 0.001) and a similar increase in the volume of transplants for candidates with an LAS over 50 (pre=1,260; post=1,702). The waiting list mortality and transplant rate did not change when examined by LAS and diagnosis group except for LAS group 60-70 which saw a significant increase in transplant rate (pre= 429 (95% CI: 357, 512) vs. post=642 (95%CI: 558, 734)). The distance between the donor hospital and transplant center increased (median pre=109NM vs. post=166NM, p < 0.001) and subsequent increase in ischemic time (mean pre=5.3 hrs. vs. post=5.7 hrs., p < 0.001). Despite the increase in distance and ischemic time the discard rate for non-DCD and non-perfused lungs remained stable (pre=3.6 vs. post=4.0, p=0.15). Unadjusted 6-month patient post-transplant survival is unchanged (93.5% pre vs. 93.2% post). <h3>Conclusion</h3> Under the current system, lungs are being placed to sicker candidates with similar short-term post-transplant outcomes compared to the older allocation system. The next step for the lung allocation system in the US is a move to the Continuous Distribution framework to avoid hard boundaries in geography and other clinical classifications. The OPTN Lung Transplantation Committee is using these results and additional analyses to make evidence-based decisions for allocating lungs under the new framework.

Impact of tacrolimus versus cyclosporine on one-year renal transplant outcomes: A single-centre retrospective cohort study

Background:Calcineurin inhibitors are the cornerstone of maintenance immunosuppression after kidney transplant. While studies on predominantly Caucasian populations recommend tacrolimus over cyclosporine, the effects on Singapore’s local population remain unclear.Objectives:This study aimed to compare the impact of tacrolimus against cyclosporine on post-transplant outcomes in our local kidney transplant population.Methods:A single-centre retrospective chart review was conducted on ABO- and human leucocyte antigen (HLA)-compatible kidney transplantations between 1 January 2011 and 15 August 2018. Patients who received basiliximab induction, prednisolone, mycophenolate and either tacrolimus or cyclosporine were included and followed up for at least one year. Recipients of transplantations at other institutions or other immunosuppressive regimens were excluded. Patient and graft outcomes and adverse effects were collected.Results:Overall, 120 patients on tacrolimus and 49 on cyclosporine were included. Patients on tacrolimus were older. This group had more deceased donor transplants, a higher proportion with donor-specific antibodies (DSAs) present and more HLA mismatches. There were no differences in patient and graft survival, graft function and acute rejections at one year, despite adjusting for age, transplant type, presence of DSAs and total HLA mismatches. The tacrolimus group had more infectious admissions (odds ratio=0.27, 95% confidence interval 0.098–0.73, p=0.01) after adjusting for age, transplant type, HLA mismatches, presence of DSAs and acute rejections, with increased severity and more opportunistic infections. More patients on cyclosporine required a change to alternative immunosuppressants (p=0.003).Conclusion:Our study demonstrated comparable short-term post-transplant outcomes between cyclosporine and tacrolimus. Tacrolimus appears more tolerable but may be associated with infection risks.

Elevated Plasma Levels of Mitochondria-Derived Damage-Associated Molecular Patterns during Liver Transplantation: Predictors for Postoperative Multi-Organ Dysfunction Syndrome.

The systemic cytokine response during surgery has been reported to be stimulated by the molecules released from damaged cells, called damage-associated molecular patterns (DAMPs). The relationship between DAMPs and liver transplantation has not been reported. We aimed to clarify the relationship between the plasma levels of DAMPs and the short-term post-transplant outcomes, including mortality and postoperative multi-organ dysfunction syndrome (MODS). This retrospective cohort study enrolled 61 patients who underwent liver transplantation. Mitochondrial DNA fragments, as mitochondria-derived DAMPs (mtDAMPs), were isolated from frozen plasma obtained at the start and the end of transplantation and were quantified by polymerase chain reaction. The short-term post-transplant outcomes were compared among the groups categorized based on the median value of the intraoperative fluctuation of mtDAMPs levels. The mtDAMPs levels were increased from the start to the end of transplantation in 52 recipients (85.2%, n = 61). Regarding mortality, no significant differences were noted between the high group (n = 30) and the low group (n = 31). The higher plasma levels of mtDAMPs were correlated with the longer duration of postoperative vasopressor support (P < 0.05). Importantly, the rate of MODS on post-operative day 1 was significantly higher in the high group (high vs. low group: 21 patients [70%] vs. 11 patients [35.1%], P < 0.01). In conclusion, mtDAMPs were increased in plasma during liver transplantation in most recipients. This elevation was not associated with mortality, but associated with the post-transplant recovery. Measuring plasma mtDAMPs may be helpful for predicting posttransplant recovery among liver-transplant recipients.

Pediatric deceased donor kidney transplant outcomes under the Kidney Allocation System.

The Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This had prompted concerns that post-pDDKT outcomes may worsen. To study this, we used SRTR data to compare the outcomes of 953 pre-KAS pDDKT (age <18years) recipients (December 4, 2012-December 3, 2014) with the outcomes of 934 post-KAS pDDKT recipients (December 4, 2014-December 3, 2016). We analyzed mortality and graft loss by using Cox regression, delayed graft function (DGF) by using logistic regression, and length of stay (LOS) by using negative binomial regression. Post-KAS recipients had longer pretransplant dialysis times (median 1.26 vs 1.07years, P=.02) and were more often cPRA 100% (2.0% vs 0.1%, P=.001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.35 0.540.83 , P=.005) but no statistically significant differences in mortality (HR: 0.29 0.721.83 , P=.5), DGF (odds ratio: 0.93 1.321.93 , P=.2), and LOS (LOS ratio: 0.96 1.061.19 , P=.4). After adjusting for donor-recipient characteristics, there were no statistically significant post-KAS differences in mortality (adjusted HR: 0.37 1.042.92 , P=.9), DGF (adjusted odds ratio: 0.94 1.412.13 , P=.1), or LOS (adjusted LOS ratio: 0.93 1.041.16 , P=.5). However, post-KAS pDDKT recipients still had less graft loss (adjusted HR: 0.38 0.590.91 , P=.02). KAS has had a mixed effect on short-term posttransplant outcomes for pDDKT recipients, although our results are limited by only 2years of posttransplant follow-up.

Successful Utilization of Extended Criteria Donor (ECD) Hearts for Transplantation - Results of the OCS™ Heart EXPAND Trial to Evaluate the Effectiveness and Safety of the OCS Heart System to Preserve and Assess ECD Hearts for Transplantation

Purpose The OCS Heart EXPAND Trial is a prospective, multi-center trial to evaluate the effectiveness of the OCS™ to resuscitate, preserve and assess donor hearts that may not meet current standard donor heart criteria for transplantation to potentially improve donor heart utilization for transplantation. Methods Donor hearts were eligible if they met any of the following characteristics: expected total ischemic time ≥ 4 hours or expected total ischemic time ≥ 2 hours plus at least one of the following risk factors: LVH, EF 40-50%, downtime ≥ 20 minutes, and age >55 yo. Hearts were perfused and assessed on OCS Heart System from donor to recipient. Hearts were eligible for transplantation if the following criteria were met: final OCS Heart arterial lactate Results 93 eligible donor hearts with a mean UNOS match run of 66 declines were assessed on OCS Heart. Donor categories were as follows: x-clamp time ≥ 4 hours 37%, LVH 23%, EF 40-50% were 23%, downtime ≥ 20 minutes 28%, older age 13% and 33% met multiple inclusion criteria. 75 of the 93 donor hearts were successfully transplanted resulting in a utilization rate of 81%. Mean OCS perfusion time was 6.35 hours. Incidence of severe LV or RV PGD at 24 hours was 10.7%. 30-day and 6-month survival were 94.7% and 88% respectively. Conclusion The use of OCS™ Heart System resulted in high utilization of ECD hearts with excellent short-term post-transplant outcomes, most notably a low rate of PGD. These results provide clinical evidence supporting its use in ECD heart preservation and assessment, and may significantly increase donor utilization for transplantation.

Strategy for selective middle hepatic vein reconstruction in living donor liver transplantation using right lobe graft

Introduction: In living donor liver transplantation (LDLT) using right lobe(RL) graft, the standardized technique for procuring the graft does not include middle hepatic vein (MHV) trunk and is left to the donor side. This procedure may increase the congestion area in the graft after reperfusion. To overcome such difficulties, MHV reconstruction is widely being performed at the bench procedure. However in the basis of sufficient right hepatic vein territory(RHV) this procedure can be extravagant. The aim of this study is to verify the safety and feasibility of our policy for MHV reconstruction in LDLT using RL graft. Method: 153 LDLTs, using right hemiliver grafts were performed in a tertiary hospital from 2006 to 2016. Among them, 52 selected cases where MHV reconstruction was not performed were compared with 101 recipients who underwent LDLT using right lobe graft with MHV reconstruction. Both groups were compared regarding indications for reconstruction, short-term and long-term complications and operative details and outcomes Result: Two groups differed only in cold ischemic time (108.19 49.81 versus 146.37 58.74 minutes), preoperatively. Also, no statistical difference was seen, regarding short-term post-transplant outcomes and long-term overall and disease-free survival rates. After propensity score matching in both groups with and without MHV reconstruction to annihilate selection bias, two groups were comparable. Conclusion: We found that our selection criteria, whether to reconstruct MHV in LDLT, using right hemiliver graft is feasible and safe.