Transplantation Rates Research Articles

HCC in the Rio Grande Valley: Outcomes in a predominant Latino community.

550 Background: Hepatocellular carcinoma (HCC) has slowly increased in the U.S. in recent years, with a higher incidence among racial and ethnic minorities, particularly Latinos. This retrospective study examines the different etiologies, presentation of diagnosis, management, and outcomes of patients presented in a multidisciplinary-liver tumor board in the Rio Grande Valley, home of 1.3 million Latinos. Methods: A retrospective chart review was conducted on patients with HCC diagnosis who were presented at the Liver Tumor Board of DHR Health Transplant Institute between 2017 and 2023. The data collected was extracted from the EHR, including medical history, laboratory results, and radiological studies required for staging, transplant eligibility assessments, clinical characteristics, and treatments. Results: A total of 250 cases were reviewed, and 70 patients with complete clinical data and a diagnosis of HCC were included in the study. Of those, 98.5% were identified as White/ Hispanic. The median age at diagnosis was 64.4 ± 9.2 years, with 72.9% male and 11.4% uninsured. The average BMI was 31.5 kg/m 2 , metabolic-associated liver disease (MALD) was present in 28.6% of patients, 25.7% were alcohol-related, and 38.6% presented multiple etiologies. A descriptive analysis of this population is found in the table. Ablative therapy was used in 68 (97.1%) of the patients. The number of patients sent for liver transplant evaluation was 31 (44%), and only 3 (4.2%) patients received a liver transplant. Barriers to transplant included lack of transportation, inadequate social support, underinsurance, and fear of the transplant itself. Conclusions: Our data by staging aligns with the national distribution of incidence cases from 2012-2022 per SEER program. The rate of transplantation at our institution is below the national average, highlighting the need to bridge this disparity and address race-specific barriers to transplant within the Latino community. Sociodemographic data. Parameter Stage IAN=15 (21.4%) Stage IBN=20 (28.6%) Stage IIN=10 (14.3%) Stage IIIAN=8 (11.4%) Stage IIIBN=9 (12.9%) Stage IVAN=5 (7.1%) Stage IVBN=3 (4.3%) All StagesN=70 (100%) Child Pugh A 7 (46.7%) 8 (40.0%) 5 (50.0%) 4 (50.0%) 2 (22.2%) 2 (40.0%) 1 (33.3%) 29 (41.4%) Child Pugh B 6 (40.0%) 6 (30.0%) 5 (50.0%) 2 (25.0%) 5 (55.6%) 2 (40.0%) 2 (66.7%) 28 (40.0%) Child Pugh C 2 (13.3%) 6 (30.0%) 0 (0.0%) 2 (25.0%) 2 (22.2%) 1 (20.0%) 0 (0.0%) 13 (18.6%) MELD-Na mean, (min-max) 12.8(7.0-21.0) 13.6(6.0-23.0) 12.8(6.0-20.0) 12.3(5.0-17.0) 13.6(8.0-26.0) 13.0(10.0-19.0) 11.3(7.0-14.0) 13.6(6.0-26.0) Therapy*:Ablative (TACE, Y90, Radiation, other) 15 21 10 6 8 6 2 Surgery (including transplant)** 1 1 2 2 2 0 0 Systemic 2 6 5 4 6 3 1 Overall Survival (months) 29.5 26.8 34.7 17.5 24.1 17.3 14.9 25.3 *Several patients received one or more types of therapy. **All transplant patients received ablation therapy.

It's Getting Better All the Time: Decreased Cumulative Incidence of Waitlist Mortality in Pediatric Candidates Following 2018 Heart Allocation Policy Change.

In October 2018, the OPTN changed adult heart transplant (HT) allocation policy, increasing the number of adult candidates that had higher priority than pediatric candidates, potentially disadvantaging pediatric waitlist registrants. To understand the impact of this policy change, we used SRTR data to identify 1469 pre-policy (7/2016-9/2018) and 2901 (10/2018-12/2022) post-policy pediatric (< 18 years) HT registrants. We quantified mortality and transplant risks using weighted cause-specific hazard models, and then using weighted competing risks regression. We further stratified these analyses by age to understand risks for those in direct competition with adults for organs (≥ 12 years). Post-policy, patients were more likely to need VAD prior to HT. There were no changes in post-policy access to HT (weighted hazard ratio [wHR] = 0.96 1.03 1.11, p = 0.43). Mortality risk censoring for transplantation declined by 20% post-policy (wHR = 0.64 0.80 1.02, p = 0.05). When accounting for competing risks of transplantation, post policy, mortality decreased by 24% compared to pre-policy (weighted subdistribution HR [wSHR] = 0.61 0.76 0.94, p = 0.02). Post policy, 1-year transplant rate did not change in those < 12years (68.2%-71.0%, p = 0.77), but in those ≥ 12years, transplant rate increased (77.3%-81.0%, p = 0.003). Mortality on the waitlist decreased and access to HT for pediatric registrants did not decline following the 2018 policy change. The decreased mortality rate may reflect changes in patient casemix and/or improved patient care. Continued surveillance is important in ensuring equity in pediatric, and adult, HT.

Larsucosterol for the Treatment of Alcohol-Associated Hepatitis.

Larsucosterol is a DNA methyltransferase inhibitor in development for alcohol-associated hepatitis (AH), a disease for which there is no approved therapy. In this phase 2b trial, patients with severe AH were randomly assigned 1:1:1 to receive 30 mg or 90 mg of larsucosterol or placebo; a second dose was administered after 72 hours if the patient remained hospitalized. All patients received supportive care as determined by investigators. Patients in the placebo group, if prescribed, received 32 mg of methylprednisolone, while patients in the larsucosterol groups received matching placebo capsules. The primary end point was 90-day mortality or liver transplant (LT) rate. The key secondary end point was 90-day mortality. We prespecified the reporting of U.S. results separately. Among 307 enrolled patients, 301 received at least one treatment dose. The difference in 90-day mortality or LT between the 30-mg or 90-mg larsucosterol and placebo groups did not reach statistical significance. Ninety-day mortality in the placebo and the 30-mg and 90-mg groups was 25 out of 103, 15 out of 102, and 17 out of 102, respectively. Among U.S. patients (76% of all enrolled patients), there were 21 deaths and 4 LTs among 77 patients in the placebo group, 8 deaths and 5 LTs among 73 patients in the 30-mg larsucosterol group, and 10 deaths and 8 LTs among 77 patients in the 90-mg larsucosterol group. In patients who were treated within less than 10 days of hospitalization (75%), mortality in the placebo group was 20 out of 79 (U.S. patients 17/57), mortality in the 30-mg larsucosterol group was 7 out of 74 (U.S. patients 4/57), and mortality in the 90-mg larsucosterol group was 13 out of 77 (U.S. patients 9/66). Most adverse events arising during treatment were attributable to hepatic disease, and there was no imbalance in adverse events that could not be ascribed to liver disease. The trial did not meet the primary end point of showing a beneficial effect of larsucosterol on 90-day mortality or LT in patients with severe AH. Equipoise has been established for a further trial of larsucosterol on AH survival. (The trial was funded by the DURECT Corporation; its ClinicalTrials.gov number is NCT04563026.).

Prognostic Factors, FLT-3 Mutations, and Treatment Outcomes with pediatric inspired protocols in adolescent and young adults (AYA) and adult patients with Acute Lymphoblastic Leukemia.

The treatment protocols of adolescent and young adults (AYA) patients with acute lymphoblastic leukemia (ALL) have evolved, with the advent of pediatric-based regimens, measurable residual disease monitoring and mutation analysis. Among the latter, previous reports have identified FLT-3 mutations in up to 5% of pediatric patients, however the full clinical significance of these mutations in the non-pediatric population is still uncertain. Our cohort includes AYA patients with ALL treated with the NY-II and BFM protocols at different time periods, allowing analysis of prognostic factors and survival outcomes. Additionally, we analyzed DNA samples for FLT-3 mutations, focusing on the potential prognostic implications and treatment responses within our cohort. No significant differences were found in overall survival (OS) or progression-free survival (PFS) between the two treatment protocols. However, a higher rate of hematopoietic stem-cell transplantation (HSCT) was noted in the NY-II patients. Older age and high WBC count at presentation were identified as adverse prognostic factors using multivariate analysis. FLT-3 mutations were identified in 4 patients (5%) of the cohort, with only one patient having FLT-3 internal tandem duplication (ITD) mutation and three patients having FLT-3-tyrosine kinase domain (TKD) mutations. The low rate and variability of FLT-3 mutations in an Israeli cohort precludes broad conclusions regarding their prognostic significance. In our cohort, age and WBC count, but not treatment protocol or FLT-3 mutations influenced survival.

Systematic Sex-Based Inequity in the MELD Score-Based Allocation System for Liver Transplantation in Germany

In liver allocation systems based on the Model for End-stage Liver Disease (MELD) score, sex inequities have been identified in countries with high organ donation rates. Whether similar inequities exist in regions with average to low donation rates remained unclear. We assessed the impact of sex on transplantation rates, waiting list mortality and post-transplant survival in 25,943 patients waitlisted for liver transplantation in Germany between 2003 and 2017 using competing risk analysis. Women are currently underrepresented on the waiting list (33.3%) and among transplant recipients (31.1%) compared to their proportion of severe liver disease cases (35.1%). The introduction of MELD-based allocation has worsened this disadvantage [HR before: 0.89 (0.81–0.98), after: 0.77 (0.74–0.81)]. Three key factors contribute to this disparity: Women have lower creatinine levels despite worse renal function, reducing their MELD score (median 1, 0–3). Second, exceptional MELD points are more frequently granted to men [HR 1.61 (1.54–1.69) compared to regular allocation]. Third, the small height of women has the highest impact on the probability of not being transplanted [adjusted HR 0.85 (0.81–0.9)]. Even in countries with lower organ donation rates, MELD-based allocation leads to sex inequity. Measures are needed to ensure sex-neutral liver allocation in MELD-based systems worldwide.

Metabolic and Bariatric Operation and the Path to Kidney Transplantation.

Obesity is a significant barrier to kidney transplantation for patients with end-stage renal disease (ESRD). We aimed to evaluate the long-term impact of metabolic and bariatric surgery (MBS) on kidney transplantation access and outcomes in individuals with obesity and ESRD patients. A retrospective cohort study using data from 64 US healthcare organizations included 132,989 individuals with obesity (BMI ≥30kg/m²) and ESRD requiring dialysis, of whom 6,263 (4.6%) underwent MBS. Propensity score matching produced 1:1 matched groups of 6,238 patients each, analyzed over 10 years. Primary outcomes included rates of kidney transplant waitlist placement, transplantation, and overall mortality. Secondary outcomes focused on 22,979 transplant recipients, including 1,701 (7.4%) MBS patients, to evaluate post-transplant adverse events. Over a median follow-up of 33.3 months (MBS) and 28.5 months (controls), MBS patients demonstrated higher rates of waitlist placement (19.12% vs 10.53%, HR=1.800, 95%CI=1.636-1.980, p<0.001) and transplantation (27.06% vs 16.09%, HR=1.712, 95%CI=1.584-1.852, p<0.001) at 10 years, with benefits evident within 1-month postoperation. Mortality was lower in the MBS group (30.55% vs 36.44%, HR=0.768, 95%CI=0.723-0.817, p<0.001). In transplant recipients, MBS patients had lower cardiovascular complications (37.3% vs 40.6%, RR=0.92, p=0.007) and all-cause mortality (16.70% vs 20.88%, HR=0.82, p<0.001), with no significant differences in graft rejection or failure. MBS significantly improves access to kidney transplantation and long-term survival for obese ESRD patients. Patients who underwent MBS demonstrated notable improvements in cardiovascular health, potentially leading to a better quality of life and survival.These findings suggest that MBS should be considered as part of the comprehensive care for this high-risk population.

Impact of Type of Vascular Access on Clinical Outcomes in Peritoneal Dialysis Patients Transitioning to Haemodialysis: An ANZDATA Study

Abstract Background Vascular access on haemodialysis corresponds with long term outcomes. However, the effect of access on haemodialysis transfer for peritoneal dialysis (PD) patients has not been fully explored. Methods Retrospective cohort study of incident adult PD patients from the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry who transferred to haemodialysis between 2004-2022. Associations between vascular access on transfer (central venous catheter [CVC] or arterio-venous access [AVA]) and clinical outcomes (all-cause mortality, cause-specific mortality, kidney transplantation and return to PD) were compared using Cox proportional hazards analysis and competing risk models. Results Of 6,824 patients, 65% used a CVC on transfer and 35% an AVA. Variability of access type at transfer between centres was high (range 13% to 98% for CVC). AVA transfer was associated with a longer PD vintage (1.6 versus 1.2 years, P&amp;lt;0.001) and inadequate PD as a cause of transfer (29% versus 15%, P&amp;lt;0.001). All-cause mortality was lower for AVA transfer compared to a CVC (hazard ratio (HR) 0.71, 95% confidence intervals (CI) 0.66- 0.77). The risk was lowest for infection-related mortality (HR 0.59, 95%CI 0.45- 0.77) Kidney transplantation was more likely in AVA transfer compared to a CVC (HR 1.18, 95%CI 1.05- 1,33), but return to PD was less likely (HR 0.67, 95%CI 0.59- 0.71). Results remained consistent in the competing risk analysis. Conclusions Patients who transferred with an AVA, compared to a CVC, showed better survival and kidney transplantation rates, but were less likely to return to PD.

P0281 Comparison of disease characteristics and disease course between paediatric and adult onset Primary Sclerosing Cholangitis and Inflammatory Bowel Disease

Abstract Background Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease that frequently coexists with inflammatory bowel disease (IBD). Data comparing the paediatric- and adult-onset PSC-IBD are lacking. We compared disease characteristics and the clinical course of PSC-IBD between Canadian children and adults. Methods This was a multi-center retrospective cohort study including eight paediatric centers from different provinces across Canada including (Ontario, Alberta, Nova Scotia, Manitoba) and four adult centers from the province of Ontario, including patients diagnosed with PSC-IBD from 1985-2023. Patient and disease characteristics and outcome data were extracted from the clinical charts. We compared patient demographics, disease course, laboratory and imaging results, and complications including liver transplant among paediatric- and adult-onset PSC-IBD. Continuous data were reported as median (Q1-Q3) and compared with the Wilcoxon Rank Sum test, and categorical data were reported as number (%) and compared with chi-square or Fisher exact tests. We compared the time to transplant with the log-rank test. Results We included 521 patients (228 children, median follow-up 3.3 (Q1-Q3 1.5-5.8) years; 293 adults, median follow-up 9.8 (Q1-Q3 4.3-16.0) years (Table-1). The interval between PSC and IBD diagnosis was longer in adults. Small duct disease and PSC with autoimmune hepatitis (AIH) features were more common in children, with corresponding higher ALT and more frequently positive autoantibodies. Rates of portal hypertension at PSC diagnosis were similar in both groups. Ulcerative colitis predominated in both groups with more IBD-unclassified in children. Colitis was most severe in the right colon in a third of children and adults. Children were more often treated with ursodeoxycholic acid, vancomycin, corticosteroids and immunomodulators. Adult patients experienced a higher proportion of adverse liver events over the entire follow-up duration, but time to event analysis showed similar rates of progression to liver transplant (log-rank p=0.075; 2- and 5-year survival with native liver in paediatric vs. adult: 97% and 90% vs. 94% and 84%). (Figure-1) Conclusion In this large Canadian multi-center cohort of PSC-IBD, paediatric-onset disease was characterized by more frequent small duct disease and features of AIH. The interval between IBD and PSC diagnosis was far longer in adults. Although a greater proportion of adult-onset patients experienced adverse liver outcomes overall, rates of transplant at 2 and 5 years were similar between groups, suggesting that PSC progression may in fact be similar.

Abdominal and intra-abdominal fibromatoses: Outcomes over time.

Abdominal wall and intra-abdominal fibromatoses are locally aggressive, nonmetastasizing neoplasms. Surgery has been the mainstay of local control, but new forms of therapy have been developed that may influence the clinical course and morbidity. We studied the clinical features and outcomes of patients with abdominal and intra-abdominal fibromatoses over time. Ninety-one patients-46 with abdominal wall and 45 with intra-abdominal fibromatosis-treated in our hospital systems between 2009 and 2023 were included. The patients were allocated to 1 of 2 groups based on the year of their initial treatment: before and including 2016 vs 2017-2023. Medical records and available histologic slides were reviewed. Forty-six patients were treated between 2009 and 2016, and 45 patients were treated between 2017 and 2023. Patient ages ranged from 1 to 85 years (median, 39 years), and most patients (70%) were women (2:2 men to women). Patients self-reported as Hispanic (49%), followed by White (28%), Black (20%), and Asian (3%). A subset (21%) had familial adenomatous polyposis (FAP)/Gardner syndrome. Individuals with intra-abdominal fibromatoses (37%) were more likely to have FAP than individuals with abdominal wall fibromatosis (4%) (P < .0001). The most common initial treatment before and during vs after 2016 was surgical excision (78% and 51% respectively; P = .02), followed by active surveillance with other medical intervention (9% and 18%, respectively; P = .28) and use of tyrosine kinase inhibitors (0% and 18%, respectively; P = .014). The rate of multivisceral transplant in patients with FAP/Gardner syndrome was 47% vs 4% in patients with sporadic disease (P < .001); most transplants (92%) were performed before and during 2016. The overall tumor recurrence/persistence rate in patients who had undergone surgery was 31%. The recurrence/persistence rate in patients treated before and during 2016 was 39% (median follow-up, 24 months), which fell to 13% (median follow-up, 18 months) in individuals treated after 2016 (P = .032). The overall recurrence/persistence rate in patients with FAP/Gardner syndrome was 64% vs 21% in patients with sporadic disease (P = .002). In patients with sporadic disease, there were recurrences in 29% of patients treated before and during 2016 and in 9% of patients treated thereafter (P = .086). Intra-abdominal vs abdominal wall lesions in patients with FAP and in patients with sporadic disease were more likely to recur (26% vs 10% and 16% vs 5%), but this occurrence did not reach statistical significance (P = .15). Most recurrent tumors were treated by surgical re-excision in both groups. Our data suggest that a combination of less morbid surgical approaches and the addition of nonsurgical approaches (active disease surveillance, use of tyrosine kinase inhibitors and other interventions) have resulted in substantially fewer surgical interventions over time for intra-abdominal and abdominal wall fibromatoses treated between 2009 and 2023. The overall probability of recurrences, however, in patients treated surgically remains similar.

Long-term outcomes of corneal transplantation: a review of 8,378 patients

PurposeTo analyze the outcomes of corneal transplantation procedures over a 13-year period at Farabi Eye Hospital, Tehran, Iran, to identify trends and determinants influencing the frequency and success of primary and re-transplantations.MethodsUtilizing a comprehensive dataset from the hospital’s Hospital Information System, the study reviewed the records of 8,378 patients who underwent corneal transplants between 2009 and 2022. This analysis included demographic information, surgical details, and follow-up data. Statistical methods were applied to assess the impact of variables such as age, gender, surgeon experience, and surgical techniques on the likelihood of re-transplantation.ResultsOf the 8,378 transplants, 7,660 (91.4%) were primary procedures while 718 (8.6%) involved re-transplantation. The most common primary transplant was penetrating keratoplasty (PKP, 50.3%), followed by Descemet’s stripping endothelial keratoplasty (DSAEK, 29.3%), and deep anterior lamellar keratoplasty (DALK, 18.5%). Analysis revealed no significant association between re-transplantation rates and patient gender or nationality. Older recipient age correlates with higher re-transplantation rates, likely due to reduced regenerative capacity and increased comorbidities in older patients. Pre-transplant comorbidities (e.g., keratoconus, ulcers), concurrent surgeries (e.g., vitrectomy), and prior procedures (e.g., glaucoma surgeries, IOL implantation) significantly increase re-transplantation risk, likely due to additional ocular stress and inflammation.ConclusionThe study highlights the importance of patient age, surgeon experience, and the choice of surgical technique in the success rates of corneal transplants. These factors are crucial for optimizing patient outcomes and minimizing the necessity for re-transplantations.

Real-world trends and future projections of the prevalence of cirrhosis and hepatic encephalopathy among commercially and Medicare-insured adults in the United States.

Describing cirrhosis and hepatic encephalopathy (HE) burden over time can inform clinical management and resource allocation. Using health care claims data, this observational study examined recent trends in the prevalence of cirrhosis and HE and associated health care resource utilization among commercially and Medicare-insured adults in the United States (US). Data from the MarketScan Commercial Claims and Encounters Database and 100% Medicare Research Identifiable Files were analyzed (2007-2020). Annual prevalence of cirrhosis, HE, overt HE (OHE) hospitalizations, and rifaximin ± lactulose use, and costs per hospitalization per year were calculated. Average year-over-year (YOY) changes in prevalence of cirrhosis and HE were estimated. Trends were extrapolated to 2030 using ordinary least-squares regression. From 2007 to 2020, the prevalence of cirrhosis increased by an average of 4.6% YOY in the Commercial population and 8.1% in the Medicare population; the prevalence of HE increased by 4.3% and 2.5%, respectively. Rates of OHE hospitalizations decreased from 27.5% to 5.5% (Commercial) and from 26.2% to 9.5% (Medicare), and rates of liver transplantation increased. Average payer costs (Commercial) and provider charges (Medicare) per OHE hospitalization increased (from $40,881 to $77,699 and from $45,913 to $74,894, respectively). Use of rifaximin ± lactulose showed an increasing trend during the observation period whereas lactulose use declined steadily. The health care burden of cirrhosis and HE in the US is increasing. Trends are projected to continue unless action is taken, such as improving medication access and developing policies addressing the contributing factors.

Cost-effectiveness Analysis of Uterus Transplantation versus Gestational Carrier for Treatment of Absolute Uterine Factor Infertility.

Patients with uterine factor infertility (UFI) have few options for family building. Uterus transplant is a feasible treatment for some patients; however, cost remains a significant concern. To compare the cost effectiveness of treatment for patients with absolute uterine factor infertility to achieve 1-2 singleton births by gestational carrier or uterus transplant DESIGN: Decision analysis from the United States healthcare sector perspective, with time horizons to achieve one or two singleton births. Gestational carrier or uterus transplant MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratios, comparing the costs (2020 U.S. Dollars) and effectiveness (quality-adjusted life years, QALYs, and live births) to achieve one or two births by gestational carrier and uterus transplant. In the base case of one singleton birth, the overall cost using a gestational carrier was $97,712.90 ($56,985.20-$153084.20) compared $116,137.20 ($67,142.88-$182,290.86) after uterus transplant. QALYs were higher in the gestational carrier arm (0.93) compared to uterus transplant (0.90) and overall rates of live birth were also higher in the gestational carrier arm (94%) compared to the uterus transplant arm (77%). Costs of the gestational carrier and uterus transplant recipient were the most significant cost variables in the model. Monte Carlo simulation showed that uterus transplant had a 37% chance of being the cost-effective strategy for a single live birth at a willingness to pay of $150,000/QALY. In the case of two singleton births, the cost using a gestational carrier was $186,278.56 ($103,597.81-$296,010.27) compared to $164,276.84 ($111,961.91-$229,394.43) after uterus transplant. QALYs were again higher in the gestational carrier arm (0.93) compared to uterus transplant (0.89). Overall rates of two live birth were also higher in the gestational carrier arm (86%) compared to the uterus transplant arm (66%). Monte Carlo simulation showed that uterine transplant has a 62% chance of being the cost-effective strategy for two live births at a willingness to pay of $150,000/QALY. Treatment of uterine factor infertility with a gestational carrier is likely the most cost-effective approach for patients delivering a single child. However, the absolute costs associated uterus transplant were 14% less than a gestational carrier for those having two live singleton births.

Early versus late nephrology referral and patient outcomes in chronic kidney disease: an updated systematic review and meta-analysis

BackgroundNephrology referral has been recognized as a modifiable factor influencing patient outcomes. The study aimed to compare clinical outcomes among patients referred early versus late to nephrologists.MethodsWe searched online database from inception to June 1, 2022, to obtain all eligible literature reporting outcomes of patients referred early versus late to nephrologists. The early and late referral was defined by the time at which patients were referred to nephrologists before dialysis onset.ResultsSeventy-two studies with over 630,000 patients met the inclusion criteria. A lower likelihood of all-cause mortality (HR = 0.67, 95% CI: 0.62–0.72) was achieved among patients referred early to nephrologists. The survival advantage of early referral was apparent in the first 6 months and extended to the 5th year after dialysis onset (6 months: HR = 0.52, 95% CI: 0.40–0.68; 5 years: HR = 0.67, 95% CI: 0.60–0.74). The early referral was associated with shorter durations of initial hospitalization, a higher rate of kidney transplantation (RR = 1.41, 95% CI: 1.12–1.78), a lower likelihood of emergency start (RR = 0.39, 95% CI: 0.28–0.54), a higher likelihood of permanent access creation (RR = 3.34, 95% CI: 2.43–4.59), increased initial use of permanent access (RR = 2.60, 95% CI: 2.18–3.11), and reduced initial catheter use (RR = 0.43, 95% CI: 0.32–0.58).ConclusionsOur study showed a lower risk of mortality, shorter lengths of initial hospitalization, and better preparations for renal replacement therapy among patients referred early to nephrologists. Early nephrology care should be promoted to improve the management of advanced chronic kidney disease.

Artificial Liver Support Systems in Acute Liver Failure and Acute-on-Chronic Liver Failure: Systematic Review and Meta-Analysis.

To systematically review the safety and efficacy of nonbiological (NBAL) or biological artificial liver support systems (BAL) and whole-organ extracorporeal liver perfusion (W-ECLP) systems, in adults with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Eligible NBAL/BAL studies from PubMed/Embase searches were randomized controlled trials (RCTs) in adult patients with ALF/ACLF, greater than or equal to ten patients per group, reporting outcomes related to survival, adverse events, transplantation rate, and hepatic encephalopathy, and published in English from January 2000 to July 2023. Separately, we searched for studies evaluating W-ECLP in adult patients with ALF or ACLF published between January1990 and July 2023. Two researchers independently screened citations for eligibility and, of eligible studies, retrieved data related to study characteristics, patients and interventions, outcomes definition, and intervention effects. The Cochrane Risk of Bias 2 tool and Joanna Briggs Institute checklists were used to assess individual study risk of bias. Meta-analysis of mortality at 28-30 days post-support system initiation and frequency of at least one serious adverse event (SAE) generated pooled risk ratios (RRs), based on random (mortality) or fixed (SAE) effects models. Of 17 trials evaluating NBAL/BAL systems, 11 reported 28-30 days mortality and five reported frequency of at least one SAE. Overall, NBAL/BAL was not statistically associated with mortality at 28-30 days (RR, 0.85; 95% CI, 0.67-1.07; p = 0.169) or frequency of at least one SAE (RR, 1.15; 95% CI, 0.99-1.33; p = 0.059), compared with standard medical treatment. Subgroup results on ALF patients suggest possible benefit for mortality (RR, 0.67; 95% CI, 0.44-1.03; p = 0.069). From six reports of W-ECLP (12 patients), more than half (58%) of severe patients were bridged to transplantation and survived without transmission of porcine retroviruses. Despite no significant pooled effects of NBAL/BAL devices, the available evidence calls for further research and development of extracorporeal liver support systems, with larger RCTs and optimization of patient selection, perfusion durability, and treatment protocols.

Epidemiology and outcomes of alpha-1 antitrypsin deficiency in Sweden 2002-2020: A population-based cohort study of 2286 individuals.

To estimate the incidence, prevalence, and outcomes of patients with diagnosed alpha-1-antitrypsin deficiency (AATD) in Sweden, 2002-2020. The Swedish National Patient Registry was utilized to identify patients with a first diagnosis of AATD between 2002 and 2020. Each patient was matched with up to 10 comparators from the general population. AATD incidence and prevalence were estimated. Causes of death and rates of mortality, transplantation, lung disease, liver cirrhosis, and previous neonatal cholestasis were estimated. The incidence rate of AATD was 1.83 (95% confidence interval [CI] 1.58-2.11) per 100,000 person-years and the total prevalence was 21.04 (95%CI=20.17-21.94) per 100,000 persons at the end of 2020. Mortality was 3.55 times higher (95%CI=3.15-3.99) for patients with AATD. Rates of liver-(hazard ratio [HR]=22.95, 95%CI=12.61-41.75), lung-(HR=12.09, 95%CI=8.87-16.47), and cardiovascular (HR=1.90, 95%CI=1.45-2.90) related death were higher in patients with AATD. The cumulative incidence after 10 years of follow-up was 1.69% (95%CI=1.15-2.41) for liver transplantation and 4.14% (95%CI=3.20-5.26) for lung transplantation. About 20% of patients were estimated to be alive without lung disease or liver cirrhosis 20 years after an AATD diagnosis. Neonatal cholestasis codes were found in 3.0% of AATD patients and 0.5% of comparators (odds ratio 6.28, 95%CI=3.81-10.36). In this population-based cohort study on AATD in Sweden, an increasing incidence was observed, and significantly higher rates of death from liver, lung, and cardiovascular causes compared to the general population were found. Only a minority of diagnosed AATD patients were estimated to be free of liver cirrhosis and lung disease after 20 years.

Impact of the lung allocation system score modification by blood type on US lung transplant candidates.

The lung continuous distribution system was modified on September 27, 2023, with the goal of increasing transplant access for blood-type-O candidates after an error was discovered in the simulation used to support the development of the initial allocation policy. This retrospective observational study compares national waitlist outcomes (transplant rate, waitlist mortality) under continuous distribution before (3/10/23-9/26/23; premodification) and after (9/27/23-4/14/24; postmodification) the blood-type score modification. We fit adjusted Poisson regression models of the transplant rate and mortality rate. The transplant rate was lowest for type-O candidates in both eras, but significantly increased after the score modification, from a premodification adjusted rate ratio (95% CI) of 0.40 (0.36, 0.45) to postmodification 0.52 (0.45, 0.59), relative to premodification type-A candidates. The adjusted mortality incidence (95% CI) decreased in type-O candidates from 3.6% (3.0%, 4.3%) premodification to 3.2% (2.6%, 3.8%) postmodification. In an exploratory analysis, we estimated there would have been the same number of waitlist deaths (approximately 105) if the modified score had been adopted at the start of continuous distribution; however, transplants would have shifted towards type-O candidates (57.8 [95% CI: 35.1, 80.9] additional transplants) and deaths would have shifted away from type-O candidates (4.6 [95% CI: 2.7, 6.8] fewer deaths).

Demographic Profile and Clinical Characteristics of Fuchs Endothelial Corneal Dystrophy in Thai Patients: A Retrospective Cohort in a Tertiary Referral Center.

To describe the demographic profile, clinical characteristics, and treatment trends of Fuchs endothelial corneal dystrophy (FECD) in Thai patients, reflecting the evolving landscape of corneal transplantation in this region. This retrospective cohort study included 900 patients (1,743 eyes) diagnosed with FECD at a tertiary referral center in Thailand between January 2017 and June 2023. Demographic, clinical, and surgical data were analyzed, focusing on best-corrected visual acuity (BCVA), central corneal thickness (CCT), endothelial cell density (ECD), surgical interventions, and graft survival rate. The mean age was 63.9 years, with 77.2% of patients being female. Most eyes were classified as Adamis grade I (83.7%). Diabetes mellitus and hypertension were prevalent in 17.4% and 38.6% of patients, respectively. The rate of corneal transplantation was 8.1%, with DMEK accounting for 69.3% of transplants. Graft survival rates were 94.3% at 1 year and 76.2% at 5 years. The average post-operative ECD declined from 1667.8 ± 668.0 cells/mm² at 1 year to 1140.7 ± 684.4 cells/mm² at 5 years.Cataract surgery was performed in 20.4% of phakic eyes, with only 2.2% requiring corneal transplantation within five years. FECD in Thailand, as reflected by this large cohort, predominantly presents at an early stage, allowing for conservative management. The growing use of DMEK highlights the shift towards less invasive procedures, mirroring global trends in Southeast Asia. These findings emphasize the importance of advancing surgical techniques and improving eye banking practices in the region.

Low rates of positive evaluation and early liver transplantation (LT) for acute-on-chronic liver failure (ACLF) in a European tertiary referral center

Low rates of positive evaluation and early liver transplantation (LT) for acute-on-chronic liver failure (ACLF) in a European tertiary referral center

Circulating factors, in both donor and ex-vivo heart perfusion, correlate with heart recovery in a pig model of DCD

BackgroundHeart transplantation with donation after circulatory death and ex-situ heart perfusion offers excellent outcomes and increased transplantation rates. However, improved graft evaluation techniques are required to ensure effective utilization of grafts. Therefore, we investigated circulating factors, both in-situ and ex-situ, as potential biomarkers for cardiac graft quality. MethodsCirculatory death was simulated in anesthetized male pigs with warm ischemic durations of 0, 10, 20, or 30 min. Hearts were explanted and underwent ex-situ perfusion for 3h in an unloaded mode, followed by left ventricular loading for 1h, to evaluate cardiac recovery (outcomes). Multiple donor blood and ex-situ perfusate samples were used for biomarker evaluation with either standard biochemical techniques or nuclear magnetic resonance spectroscopy. ResultsCirculating adrenaline, both in the donor and at 10 min ex-situ heart perfusion, negatively correlated with cardiac recovery (p <0.05 for all). We identified several new potential biomarkers for cardiac graft quality that can be measured rapidly and simultaneously with nuclear magnetic resonance spectroscopy. At multiple timepoints during unloaded ex-situ heart perfusion, perfusate levels of acetone, betaine, creatine, creatinine, fumarate, hypoxanthine, lactate, pyruvate and succinate (p <0.05 for all) significantly correlated with outcomes; the optimal timepoint being 60 min. ConclusionsIn heart donation after circulatory death, circulating adrenaline levels are valuable for cardiac graft evaluation. Nuclear magnetic resonance spectroscopy is of particular interest, as it measures multiple metabolites in a short timeframe. Improved biomarkers may allow more precision and therefore better support clinical decisions about transplantation suitability.

Association between regional cardiac rehabilitation and heart transplantation rates in France (2014–2022)

Association between regional cardiac rehabilitation and heart transplantation rates in France (2014–2022)