Selection Of Patients For Transplantation Research Articles

Prognostic Significance of FDG-PET/CT on Determining Upfront Autologous Stem Cell Transplantation for the Treatment of Peripheral T Cell Lymphomas

Purpose: The clinical role of 18F-fluorodeoxyglucose (FDG)-positron emission tomography-computed tomography (PET/CT) in performing upfront high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) remains unclear in peripheral T cell lymphomas (PTCLs). This study investigated the prognostic relevance of interim and final FDG-PET/CT in predicting the outcome of upfront ASCT for the treatment of PTCLs.Method: The study conducted newly diagnosed 96 patients with PTCLs who aged under 65 years between January 2005 and December 2016 from two independent institutions. For making a comparison of clinical outcome between transplant and non-transplant patients according to interim or final FDG- PET/CT, 37 transplanted and 59 non-transplanted patients with the same populations were evaluated as a comparative group (non-ASCT). The enrolled patients were treated with mainly anthracycline-based chemotherapy except patients with NK/T cell lymphoma who were treated with non-anthracycline-based. If achieved complete or partial remission after primary treatment, patients proceeded to upfront ASCT. FDG-PET/CT was performed at the time of diagnosis, interim, and after primary treatment. The response of interim or final FDG-PET/CT was analyzed by visual assessment using Deauville five-point scale (5-PS).Results: The characteristics of transplant patients were similar to non-transplant patients except two features (IPI score, CT response). Final FDG-PET/CT response (P<0.001, Hazard ratio (HR) 3.51), CT response (P<0.001, HR 2.11) and age (P=0.005, HR 1.07) were significant prognostic factors of progression-free survival (PFS) in transplant patients on multivariate analysis. In non-ASCT patients, final FDG-PET/CT response (P<0.001, HR 9.65), prognostic index for T-cell lymphomas (PITs) score (P=0.001, HR 5.24), and CT response (P<0.001, HR 2.34) were prognostic for PFS. After a median follow-up of 60.8 months, 5-year PFS rates of ASCT and non-ASCT patients according to interim FDG-PET/CT response were 75.5 vs 74.5% of Deauville score 1-2, 20% vs 22.2% of Deauville score 3 and 33.3% vs 42.2% of Deauville score 4, respectively (P=0.092, P=0.005; Figure 1A, 1C). 5-year PFS rates according to final FDG-PET/CT response of ASCT and non-ASCT patients were 70.2% vs 80.5% of Deauville score 1-2, 22.2% vs 25% of Deauville score 3 and 0% vs 0% of Deauville score 4, respectively (P<0.001, P<0.001; Figure 1B, 1D).Conclusion: Final FDG-PET/CT response based on Deauville 5-PS had prognostic significance on the treatment outcome of PTCLs regardless of upfront ASCT. However, patients with ≥ 3 of Deauville score assessed by interim or final FDG-PET/CT had poor prognosis even though performing upfront ASCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Impact of donor and recipient cytomegalovirus serology on long-term survival of heart transplant recipients.

Some studies have shown that pre-transplant cytomegalovirus (CMV) serostatus is associated with heart transplant patient survival while others have not. We analyzed the relationship between pre-transplant donor/recipient CMV serostatus and long-term mortality in a retrospective cohort of heart transplant recipients at our center. Adult (Age >17years) heart recipients transplanted between July 1985-December 2015 were analyzed. Variables included age, sex, pre-transplant donor (D)/recipient (R) serostatus [D-/R-, D-/R+, D+/R+, D+/R-], CMV infection within 2years of transplant and transplant eras divided by changes in CMV prevention strategies: Era 1 (Pre-ganciclovir, July 1985-April 1998), Era 2 (Oral ganciclovir, May 1998-December 2004), Era 3 (Valganciclovir, January 2005-December 2015). Survival analysis and Cox regression were performed at 10years. A total of 620 heart transplants were included in our analysis; 20% were CMV mismatched pre-transplant. Thirty-eight percent of patients were infected with CMV within the first two post-transplant years. Survival analysis showed D/R CMV serostatus did not significantly impact survival of heart recipients at 10years (P=0.11). Survival was significantly different across eras for D-/R+, D+/R+, and D+/R+ (P=0.043) but not D-/R- patients (P=0.8). Cox regression revealed that patients transplanted in the valganciclovir era have an estimated 29% reduced risk of death (P=0.047) compared to patients transplanted in the pre-ganciclovir era after controlling for age at transplantation, D/R CMV serostatus and CMV infection. Our review of the impact of CMV managed differently across eras suggests in heart transplantation there is no influence of D/R CMV serostatus on 10year survival.

The Concerted Action of Multiple Mechanisms to Induce and Sustain Transplant Tolerance

Transplant tolerance has been achieved in experimental models using immune intervention strategies. Yet, their clinical translation remains unsuccessful and requires further optimization of immunotherapeutic regimens based on a deeper understanding of the cellular and molecular mechanisms at play in the induction and maintenance phases of immune tolerance. Intensive investigations have shed the light on the tolerogenic networks underlying graft survival and have unraveled their complexity, which may depend on several parameters such as intrinsic features of the transplant itself (organs/tissues/cells), the type of immunotherapy and the therapeutic window used. Although it is now fairly well-established that Foxp3+ regulatory T lymphocytes (Tregs) play a central role in these networks, a wealth of evidence points to multiples mechanisms, including alloreactive T cell depletion and T cell anergy that, in addition to Treg-mediated suppression, are all engaged and cooperate in a timely manner to tip the balance from rejection towards robust and sustained tolerance. All this supports the fact that the clinical development of tolerance-inducing therapies may reside in the triggering of these multiple pathways to achieve long-term graft survival in transplanted patients while minimizing/withdrawing immunosuppression.

Incidence and Survival Rate of de novo Tumors in Liver Transplants

IntroductionThe greater survival of transplanted patients is accompanied by an increase in the rate of de novo malignancies (NM), which are the most frequent late-onset complication. We can distinguish between non-melanoma skin cancers (NMSC), post-transplant lymphoproliferative disorders (PTLD) and solid organ cancers (SOC). Our objective is to determine the incidence of the different types of NM, the time elapsed until diagnosis and survival rates in our setting. MethodsWe conducted a retrospective study of 1071 liver transplant patients from 1990 to 2015 at our center. We analyzed the demographic variables, incidence of NM and survival. Results184 NM developed in 1071 transplant patients (17%), specifically 19% of the males and 13% of the females (P=.004). The most frequent NM were NMSC (29%), lung (18%), head and neck (16%), PTLD (10%) and gastrointestinal (8%). The median time of diagnosis was 7.9 years in NMSC, 3.9 years in PTLD and 9.8 years in SOC. Patients with NMSC had significantly better survival than those with PTLD or SOC. The incidence of de novo tumors (excluding NMSC) was 1889/100,000 transplants/year. By gender, lung cancer was the most common TOS in men and breast cancer in women. ConclusionIn our setting, excluding NMSC, the incidence is 8.8 times greater than estimations for the general population, with a high rate of lung cancer, so we should implement preventive and diagnostic strategies.

Resultados del retrasplante pulmonar por disfunción crónica del injerto pulmonar en un centro trasplantador: Hospital Vall D’Hebron de Barcelona

IntroductionLong-term survival of lung transplantation (LT) patients is mainly limited by the development of chronic lung allograft dysfunction (CLAD). Lung retransplantation (LR) is an alternative for a selected population. The aim of this study was to review the LR experience in our center. Patients and methodsWe conducted a retrospective study of patients undergoing LR between August 1990 and July 2017. ResultsFourteen LR out of a total of 998 (1.4%) LT were performed. Twelve patients (85.7%) underwent LR due to CLAD: 10 (71.4%) because of bronchiolitis obliterans syndrome and 2 (14.3%) due to restrictive allograft syndrome. LR was performed in 2 patients within 30 days of the first LT. In those who underwent LR due to CLAD, mean time between the first LT and LR was 48 months, and mean duration of invasive mechanical ventilation was 32 days. The increase in FEV1 after LR was 24±18%. The best spirometry values were observed after 7.3 months. Mean survival of the cohort was 43.8 months. In patients with bronchiolitis obliterans syndrome, mean survival was 63.4 months, while in those with restrictive allograft syndrome, it was 19.5 months. Only 1 of the 2 early LR patients survived. ConclusionLR is a therapeutic option in selected patients with CLAD, with acceptable survival. Indication for LR early after LT shows poor outcomes.

Impact of donor and recipient cytomegalovirus serology on long-term survival of lung transplant recipients.

Pre-transplant cytomegalovirus (CMV) serostatus has been associated with lung transplant patient survival. We retrospectively analyzed the relationship between pre-transplant donor/recipient CMV serostatus and long-term mortality in a cohort of lung transplant recipients at our center. Adult (Age >17years) lung recipients transplanted between July 1985-December 2015 were analyzed. Variables included age, sex, pre-transplant donor (D)/recipient (R) serostatus [D-/R-, D-/R+, D+/R+, D+/R-], CMV infection within 2years of transplant and transplant eras divided by changes in CMV prevention strategies: Era 1 (pre-ganciclovir, July 1985-April 1998), Era 2 (oral ganciclovir, May 1998-December 2004), Era 3 (valganciclovir, January 2005-December 2015). Survival analysis and Cox regression were performed at 10years. A total of 652 lung recipients were analyzed. Twenty percent were CMV mismatched pre-transplant and 45% had CMV infection within 2years post-transplant. Survival at 10years appeared worse in D+ transplants (P=0.027). D-/R- lungs did not have significantly different survival across eras (P=0.76), but survival of D-/R+, D+/R+, D+/R- lungs improved (P<0.001). Cox regression revealed that transplantation in the valganciclovir era reduced risk of death in lung transplants by an estimated 52% (P<0.001) compared to transplantation in the pre-ganciclovir era after controlling for age at transplant, D/R CMV serostatus and CMV infection. Age at transplant and CMV infection were also significant predictors of mortality in lung transplants (P<0.001 and 0.033 respectively). Our review of the impact of CMV managed differently across eras suggests in lung transplantation there is no independent influence of D/R CMV serostatus on 10-year survival.

Allograft and patient survival after sequential HSCT and kidney transplantation from the same donor-A multicenter analysis.

Tolerance induction through simultaneous hematopoietic stem cell and renal transplantation has shown promising results, but it is hampered by the toxicity of preconditioning therapies and graft‐versus‐host disease (GVHD). Moreover, renal function has never been compared to conventionally transplanted patients, thus, whether donor‐specific tolerance results in improved outcomes remains unanswered. We collected follow‐up data of published cases of renal transplantations after hematopoietic stem cell transplantation from the same donor and compared patient and transplant kidney survival as well as function with caliper‐matched living‐donor renal transplantations from the Austrian dialysis and transplant registry. Overall, 22 tolerant and 20 control patients were included (median observation period 10 years [range 11 months to 26 years]). In the tolerant group, no renal allograft loss was reported, whereas 3 were lost in the control group. Median creatinine levels were 85 μmol/l (interquartile range [IQR] 72‐99) in the tolerant cohort and 118 μmol/l (IQR 99‐143) in the control group. Mixed linear‐model showed around 29% lower average creatinine levels throughout follow‐up in the tolerant group (P < .01). Our data clearly show stable renal graft function without long‐term immunosuppression for many years, suggesting permanent donor‐specific tolerance. Thus sequential transplantation might be an alternative approach for future studies targeting tolerance induction in renal allograft recipients.

Incidencia y supervivencia de los tumores de novo en el trasplante hepático

IntroductionThe greater survival of transplanted patients is accompanied by an increase in the rate of de novo malignancies (NM), which are the most frequent late-onset complication. We can distinguish between non-melanoma skin cancers (NMSC), post-transplant lymphoproliferative disorders (PTLD) and solid organ cancers (SOC). Our objective is to determine the incidence of the different types of NM, the time elapsed until diagnosis and survival rates in our setting. MethodsWe conducted a retrospective study of 1071 liver transplant patients from 1990 to 2015 at our center. We analyzed the demographic variables, incidence of NM and survival. Results184 NM developed in 1071 transplant patients (17%), specifically 19% of the males and 13% of the females (P=.004). The most frequent NM were NMSC (29%), lung (18%), head and neck (16%), PTLD (10%) and gastrointestinal (8%). The median time of diagnosis was 7.9 years in NMSC, 3.9 years in PTLD and 9.8 years in SOC. Patients with NMSC had significantly better survival than those with PTLD or SOC. The incidence of de novo tumors (excluding NMSC) was 1889/100,000 transplants/year. By gender, lung cancer was the most common TOS in men and breast cancer in women. ConclusionIn our setting, excluding NMSC, the incidence is 8.8 times greater than estimations for the general population, with a high rate of lung cancer, so we should implement preventive and diagnostic strategies.

Kidney Transplant with Multi-organ and Mono-Organ Donor in Argentina 2007-2015. Results

Purpose To analyze both patient and graft survival in Argentina in the last 9 years, in relation to mono-organ donors (kidney donor – KD) and multiorgan donor (multiorgan donor – MOD) and other associated variables. Materials and Methods 5788 patients older than 18 were assessed at the time of transplant (Tx) between January 1, 2007 and December 31, 2015 The variables used in the multivariate model were cause of death of the donor, donor type, donor´s age and gender, (CVA, TBI, Others), cold ischemia time (CIT), years on waiting list to transplant (< o > 3), years on dialysis to transplant (< o > 6), etiology at the time of listing, delayed graft function (DGF) defined as the need for dialysis within a 7-day period after transplant. Results The study included 5788 patients, 4.6% of the transplant procedures used mono-organ donors. The etiology of the patients undergoing transplantation was unknown (28%), glomerulonephritis (20%), nephroangiosclerosis (15%), diabetic nephropathy (8%), renal polycystic disease (12%) and Others (17%). Mean recipient and donor´s age was 51.6 years (CI 95% 51.0-52.0) and 45.9 years (CI 95% 45.3-46.6) respectively.Fifty six percent of the patients AND 58% of the donors were male10% of the patients, 578, required dialysis within the first 7 days after transplantation. Transplant patients receiving a kidney from a KD had DGF (11.1%), and 9% of the transplant patients receiving a kidney from a MOD had DGF, was not statistically significant. Mean time in years on waiting list was 2.9 (CI 95% 2.8 -3.0) and the mean time on dialysis to transplant was 6.3 (CI 95% 6.1-6.4). The main causes of donor´s death were CVA (56%) and TBI (36%). Post – transplant patient survival at one year with KD and MOD was 89.4% and 90.7%, at 3 years, 83.9% and 85.5%, at 5 years 78.9 % and 81.5%, and at 9 years 67.5% and 66.6%, respectively. Post- transplant graft survival with KD and MOD was 83.4 and 86.6% at one year; 74.1% and 78.2% at 3 years, 66.0% and 71.0% at 5 years, and 42.8% and 51.5% at 9 years, respectively. After comparing graft survival curves (log rank test) a P= 0.0002 was obtained. In the multivariate analysis: both donor and recipient ´s age, the time on dialysis and etiologies such as nephroangiosclerosis and diabetic nephropathy and DGF had a statistically significant association with post- transplant mortality. As for graft survival, the variables that were negatively associated were: donor and recipient´s age, diabetic nephropathy, years on dialysis before transplant and DGF. As for causes of death, TBI and Others were considered statistically significant as a protecting factor for graft loss in the post-transplant period. Conclusions The type of retrieval, although the Kaplan Meier curve shows a slightly improved survival for patients receiving a kidney from a MOD as compared to those receiving a kidney from a KD, is not statistically significant for patients; however, it is statistically significant for the graft.

Viral infections directly involved in kidney allograft function.

Modern immunosuppressive therapy has dramatically reduced the incidence of acute rejection and improved graft survival in kidney transplant patients. However, infectious complications remain an important issue. Amongst the various pathogens, viruses such as adenovirus and polyomavirus BK can directly cause acute or chronic graft dysfunction. Adenovirus mainly causes haemorrhagic cystitis and tubulointerstitial nephritis in kidney transplant patients. While patients show apparent clinical symptoms such as fever, dysuria, gross haematuria, frequency and urgency of urination, and most patients show acute graft dysfunction, these symptoms and graft dysfunction are reversible. Polyomavirus BK infection, however, is asymptomatic but graft outcome is poor if the patient develops tissue-invasive nephropathy confirmed by graft biopsy. Recently, an attempt to create a pathological classification for predicting the clinical course has been made by the Banff Working Group on Polyomavirus Nephropathy. With regards to treatment, the basic strategy is a reduction of calcineurin inhibitor and/or antimetabolites, and the effectiveness of several adjunct treatments has been investigated in several clinical trials. There are other unresolved issues, such as the diagnosis of subsequent acute rejection, the definition of remission, methods of resuming immunosuppression and long-term follow-up. Most of all, development of effective vaccines and novel drug discovery are necessary to prevent the development and progression of BKV-associated nephropathy.

Acute Rejection and Short-Term Outcomes in Highly Sensitized Kidney Transplant Recipients

Introduction Highly sensitized patients with end-stage renal disease are less likely to receive a kidney transplant and have a higher risk of acute rejection (AR) and graft loss compared to non-sensitized candidates. We design a retrospective cohort study to evaluate the incidence of acute rejection as well as patient and graft survival in kidney transplants performed in highly immunized patients. We also evaluated efficacy and safety of the immunosuppressive treatments used. Material and Methods We collected clinical and laboratory data from highly sensitized patients who received a kidney transplant in our hospital between 2007 and 2015. Only those with preformed donor-specific antibodies (DSA) or a panel reactive antibody (PRA) above 50% were considered highly sensitized. Results and Discussion Of the 361 patients who received a kidney transplant in that period of time, 27 were highly sensitized recipients. In addition to thymoglobulin, tacrolimus, mycophenolic acid and steroids, 70.4% (n=18) received intravenous immunoglobulin +/- plasmapheresis as induction treatment. Fourteen patients (51.9%) presented biopsy-proven acute rejection (78.6% of them were antibody-mediated rejections), with a median presentation of 13 days. In patients with PRA> 50%, incidence of AR was 42.9% (n=9) compared to 83.3% in patients with DSA (n=5). Mean creatinine at diagnosis was 3.8 mg/dl (SD=2) and proteinuria was 4.1 g/day. 85.7% of the patients had a positive response to rejection treatment: mean creatinine was 1.7 mg/dl (SD=1) and proteinuria was 0.59 g/day one month after the episode. Median follow-up was 4 years. There were two graft losses in the group of patients with AR (7.4%) and none in the group without rejection. Death-censored graft survival was 92.6% (100% in the group without AR vs 85.7% in the group with AR, ns). Patient survival was 95% (100% in the group without AR vs 92,9% in the group with AR, ns). Patients with AR had a higher incidence of serious bacterial infections (66.7% vs 33.3%, ns), CMV infection (57.1% vs 42.9%, ns) and significant leukopenia (58.3% vs. 41.7%, ns) than patients without acute rejection. There was a similar incidence of BK virus replication. Conclusions The incidence of AR in highly sensitized patients was 51.9%, with a favorable response to treatment in 85.7% of cases. The incidence of graft loss was 7.4%, lower than that described in other series. Patient and graft survival was 95% and 92.6% respectively. There was a high rate of complications associated with the treatment of rejection in this patients.

MELD based Allocation Deteriorates Patient Survival without Improving Waiting List Mortality in a Low Donor Area

The MELD-based allocation system has been implemented in Germany in 2006 in order to decrease waiting list mortality in patients with end stage liver disease. However, the MELD score not only reflects the probability to die within 3 months, but simultaneously represents a major risk factor for post transplantation patient survival. Purpose of this study is to evaluate post transplant results and waiting list mortality since the introduction of MELD-based allocation. Liver transplant patients were assessed retrospectively from 2005 -2015 using our own center as well as open access Eurotransplant data. In our department 1172 liver transplantations were performed from 2005 to 2015. The median Match-MELD at time of transplantation increased from 16 to 26 (Pearson r=0.69, p= 0.019). Concomitantly, 3-year patient survival decreased from 85% in 2005 to 70% in 2012 (Pearson r=-0.78, p= 0.022). Similarly, in the Eurotransplant area the average 3-year patient survival decreased from 78% to 70%. In these years on average 57 percent of all liver transplantations were performed in Germany. During this time period donor age increased from 48 to 54 to overcome organ shortage. Simultaneously the number of transplantations per year dramatically decreased from 158 in 2005 to 79 in 2015 at our center. At the same time the ratio of waiting list mortality/active-listed patients increased significantly from 2007 to 2016 (Pearson r=0.69, p= 0.019), indicating an increased waiting list mortality. The combination of increasing organ scarcity and MELD based allocation may require reconsideration of the current allocation policy and the inclusion of prognostic outcome factors should be discussed.

Lung Transplantation in Cystic Fibrosis and the Impact of Extracorporeal Circulation

IntroductionLung disease is the major cause of death among cystic fibrosis (CF) patients, affecting 80% of the population. The impact of extracorporeal circulation (ECC) during transplantation has not been fully clarified. This study aimed to evaluate the outcomes of lung transplantation for CF in a single center, and to assess the impact of ECC on survival. MethodsWe performed a retrospective observational study of all transplanted CF patients in a single center between 1992 and 2011. During this period, 64 lung transplantations for CF were performed. ResultsFive- and 10-year survival of transplanted patients was 56.7% and 41.3%, respectively. Pre-transplantation supplemental oxygen requirements and non-invasive mechanical ventilation (NIMV) do not seem to affect survival (P=.44 and P=.63, respectively). Five- and 10-year survival among patients who did not undergo ECC during transplantation was 75.69% and 49.06%, respectively, while in those did undergo ECC during the procedure, 5- and 10-year survival was 34.14% and 29.87%, respectively (P=.001). PaCO2 is an independent risk factor for the need for ECC. ConclusionsThe survival rates of CF patients undergoing lung transplantation in our hospital are similar to those described in international registries. Survival is lower among patients receiving ECC during the procedure. PaCO2 is a risk factor for the need for ECC during lung transplantation.

Extracorporeal Photopheresis Improves Survival in Hematopoietic Cell Transplant Patients with Bronchiolitis Obliterans Syndrome without Significantly Impacting Measured Pulmonary Functions

We carried out the first matched retrospective cohort study aimed at studying the safety and efficacy of extracorporeal photopheresis (ECP) for bronchiolitis obliterans syndrome (BOS) after allogeneic hematopoietic cell transplantation (HCT). Medical records of 1325 consecutive adult patients who underwent HCT between 2005 and 2015 were reviewed. Seventy-four patients (median age, 51 years) with a diagnosis of BOS were included in the study. After propensity-score matching for BOS severity, 26 patients who underwent ≥3 months of ECP were matched to 26 non–ECP-treated patients, who were assigned an index date corresponding to the ECP start date for their matched pairs. The rate of decline in FEV1 percentage predicted (FEV1PP) decreased after ECP initiation (and after index date in the non-ECP group), with no significant difference between the 2 groups (P = .33). On a multivariable analysis that included baseline transplant and pulmonary function test variables, matched related donor HCT (HR, .1; 95% CI, .03 to .5; P = .002), ECP (HR, .1; 95% CI, .01 to .3; P = .001), and slower rate of decline in FEV1PP before the ECP/index date (HR, .7; 95% CI, .6 to .8; P = .001) were associated with a better overall survival. At last follow-up, non–ECP-treated patients were more likely to be on >5 mg daily dose of prednisone (54% versus 23%; P = .04) and had a greater decline in their Karnofsky performance score (mean difference, −9.5 versus −1.6; P = .06) compared with ECP-treated-patients. In conclusion, compared with other BOS-directed therapies, ECP was found to improve survival in HCT patients with BOS, without significantly impacting measured pulmonary functions. These findings need prospective validation in a larger patient cohort.

Duration of ECMO Support Predicts Survival in Transplant Patients

Duration of ECMO Support Predicts Survival in Transplant Patients

Survival and Graft Function in Heart Transplant Patients Receiving Adverse Risk Profile Donor Hearts

To determine if use of older donors or donors with adverse cardiovascular risk profile (ACRP) is associated with impaired graft function and adverse longterm outcome in heart transplant recipients.

Quality of life on long-term parenteral nutrition: can it be an indication for intestinal transplantation?

Long-term outcomes in patients with intestinal failure and following intestine transplantation have improved significantly over the last decade. With these improvements, listing criteria for intestine transplantation are reevaluated and the role of quality of life (QoL) in patients' outcome is increasingly studied and emphasized. Here, we review the recent literature on QoL before and after intestine transplantation and discuss whether QoL should be considered as a listing criterion for intestine transplantation. Patients on home parenteral nutrition, experience lower QoL compared with healthy population and equal or lower QoL than patients with other chronic diseases. After transplantation, QoL improves and is comparable in some QoL domains to that of the general population. These findings are limited by heterogeneous study designs and sample size. Although QoL improves after intestine transplantation, long-term survival of patients receiving HPN surpass postintestine transplantation survival. Poor QoL is not associated with an increased mortality in patients receiving HPN. Current survival outcomes of intestine transplantation do not justify poor QoL as a single listing criterion for intestine transplantation. However, intestine transplantation should be considered in patients with unique circumstances of extremely poor QoL. This approach may change once postintestine transplantation patient survival will further improve.

Effects of Older Donor Age and Cold Ischemic Time on Long-Term Outcomes of Heart Transplantation

Using older donor hearts in cardiac transplantation may lead to inferior outcomes: older donors have more comorbidities that reduce graft quality, including coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia. Shorter cold ischemic times might overcome the detrimental effect of older donor age. We examined the relationship between donor allograft age and cold ischemic time on the long-term outcomes of heart transplant recipients. rom 1994 through 2010, surgeons at our hospital performed 745 heart transplantations. We retrospectively classified these cases by donor ages of <50 years (younger) and ≥50 years (older), then by cold ischemic times of <120 min (short), 120 to 240 min (intermediate), and >240 min (long). Endpoints included recipient and graft survival, and freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, and rejection. For intermediate ischemic times, the 5-year recipient survival rate was lower when donors were older (70% vs 82.6%; P=0.02). This was also true for long ischemic times (69.8% vs 87.6%; P=0.09). For short ischemic times, we found no difference in 5-year recipient or graft survival rates (80% older vs 85.6% younger; P=0.79), in freedom from nonfatal major adverse cardiac events (83.3% vs 91.5%; P=0.46), or in freedom from cardiac allograft vasculopathy (50% vs 70.6%; P=0.66). Rejection rates were mostly similar. Long-term graft survival in heart transplantation patients with older donor allografts may improve when cold ischemic times are shorter.

Does recipient work status pre-transplant affect post–heart transplant survival? A United Network for Organ Sharing database review

Recipient-related factors, such as education level and type of health insurance, are known to affect heart transplantation outcomes. Pre-operative employment status has shown an association with survival in abdominal organ transplant patients. We sought to evaluate the effect of work status of heart transplant (HTx) recipients at the time of listing and at the time of transplantation on short- and long-term survival. We evaluated the United Network for Organ Sharing (UNOS) registry for all adult HTx recipients from 2001 to 2014. Recipients were grouped based on their work status at listing and at heart transplantation. Kaplan-Meier estimates illustrated 30-day, 1-year, 5-year, and 10-year survival comparing working with non-working groups. The Cox proportional hazards regression model was applied to adjust for covariates that could potentially confound the post-transplantation survival analysis. Working at listing for HTx was not significantly associated with 30-day and 1-year survival. However, 5- and 10-year mortality were 14.5% working vs 19.8% not working (p < 0.0001) and 16% working vs 26% not working (p < 0.0001), respectively. Working at HTx appeared to be associated with a survival benefit at every time interval, with a trend toward improved survival at 30 days and 1 year and a significant association at 5 and 10 years. Kaplan-Meier analysis demonstrated a 5% and 10% decrease in 5- and 10-year mortality, respectively, for the working group compared with the group not working at transplantation. The Cox proportional hazards regression model showed that working at listing and working at transplantation were each associated with decreased mortality (hazard ratio [HR] = 0.8, 95% confidence interval [CI] 0.71 to 0.91; and HR = 0.76, 95% CI 0.65 to 0.89, respectively). This study is the first analysis of UNOS STAR data on recipient work status pre-HTx demonstrating: (1) an improvement in post-transplant survival for working HTx candidates; and (2) an association between working pre-HTx and longer post-HTx survival. Given that work status before HTx may be a modifiable risk factor for better outcomes after HTx, we strongly recommend that UNOS consider these important findings for moving forward this patient-centered research on work status. Working at listing and working at HTx are associated with long-term survival benefits. The association may be reciprocal, where working identifies less ill patients and also improves well-being. Consideration should be given to giving additional weight to work status during organ allocation. Work status may also be a modifiable factor associated with better post-HTx outcomes.

Pediatric Renal Transplantation in Oman: A Single-center Experience.

This study sought to report 22 years experience in pediatric kidney transplantation in Oman. Electronic charts of all Omani children below 13 years of age who received a kidney transplant from January 1994 to December 2015 were reviewed. Data collected included patient demographics, etiology of end-stage kidney disease, modality and duration of dialysis, donor type, complication of kidney transplantation (including surgical complications, infections, graft rejection) graft and patient survival, and duration of follow-up. During the study period transplantation from 27 living related donors (LRDs), 42 living unrelated donors (LURDs), also referred to as commercial transplant, and one deceased donor were performed. The median age at transplantation was nine years for both groups. The most common primary diagnosis was congenital anomalies of the kidney and urinary tract in 32.8% of patients followed by familial nephrotic syndrome in 20.0% and polycystic kidney disease in 18.5%. Almost half the patients were on hemodialysis before transplantation, 35.7% were on peritoneal dialysis, and 14.2% received preemptive renal transplantation. Children who received LURD kidneys had high surgical complications (42.8%) compared to the LRDs group (17.8%). Five patients from LURDs group had early graft nephrectomy and four patients developed non-graft function or delayed graft function. In addition, patients in the LURDs group had a higher incidence of hypertension and acute rejection. Graft and patient survival were both better in the LRDs than the LURDs group. Although our pediatric kidney transplant program is a young program it has had successful patient outcomes comparable to international programs. Our study provides evidence that in addition to legal and ethical issues with commercial transplant, it also carries significantly higher morbidity and reduced graft and patient survival.