UNOS Data Research Articles

Single and Double Redo Lung Transplantation: A Review of UNOS Data

Single and Double Redo Lung Transplantation: A Review of UNOS Data

Impact of center volume and the adoption of laparoscopic donor nephrectomy on outcomes in pediatric kidney transplantation.

Reports for pediatric kidney transplant recipients suggested better outcomes for ODN compared to LDN. Contemporary outcomes stratified by donor type and center volume have not been evaluated in a national dataset. UNOS data (2000-2014) were analyzed for pediatric living donor kidney transplant recipients. The primary outcome was GF; secondary outcomes were DGF, rejection, and patient survival. Live donor nephrectomies for pediatric recipients decreased 30% and transitioned from ODN to LDN. GF rates did not differ for ODN vs LDN (P=.24). GF was lowest at high volume centers (P<.01). Donor operative approach did not contribute to GF. LDN was associated with less rejection than ODN (OR 0.66, CI 0.5-0.87, P<.01). Analysis of the 0- to 5-yr recipient group showed no effect of ODN vs LDN on GF or rejection. For the contemporary era, there was no association between DGF and LDN in the 0- to 5-yr group (OR 1.12, CI 0.67-1.89, P=.67). Outcomes of kidney transplants in pediatric recipients following LDN have improved since its introduction and LDN should be the approach for live donor nephrectomy regardless of recipient age. The association between case volume and improved outcomes highlights future challenges in organ transplantation.

Psychosocial predictors of medication adherence in pediatric heart and lung organ transplantation.

Few studies have identified the psychosocial characteristics of those children and their families associated with future non-adherence to immunosuppressive medications following a heart or lung transplant. UNOS data and medical records information were used to test the association between patient and family psychosocial characteristics and medication adherence. Medication adherence outcomes were obtained using the physician assessments in the UNOS data and measured through patient-level standard deviation scores of immunosuppressive medication blood levels. Complete data were collected on 105 pediatric heart and lung transplant recipients and their families. Multivariate, stepwise analyses were conducted with each adherence outcome. Physician reports of adherence were associated with age of the child at transplantation, parental education, two-parent families, significant psychosocial problems, and the pretransplant life support status of the child. The resulting model (χ2 =28.146, df=5, P<.001) explained approximately 39.5% of the variance in physician reports of adherence (Nagelkerke r2 =.395). Blood level standard deviation scores were predicted by age at transplant (F=5.624, P=.02, r2 =.05). Results point to the difficulties experienced by children and families when undergoing a heart or lung transplantation. Efforts to develop standardized and evidence-based pretransplant psychosocial assessments in pediatric populations are suggested, especially those surrounding familial risk factors.

Patterns and Outcomes Associated with Patient Migration for Liver Transplantation in the United States.

BackgroundTraveling to seek specialized care such as liver transplantation (LT) is a reality in the United States. Patient migration has been attributed to organ availability. The aims of this study were to delineate patterns of patient migration and outcomes after LT.Study DesignAll deceased donor LT between 2008–2013 were extracted from UNOS data. Migrated patients were defined as those patients who underwent LT at a center in a different UNOS region from the region in which they resided and traveled a distance > 100 miles.ResultsMigrated patients comprised 8.2% of 28,700 LT performed. Efflux and influx of patients were observed in all 11 UNOS regions. Regions 1, 5, 6, and 9 had a net efflux, while regions 2, 3, 4, 7, 10, and 11 had a net influx of patients. After multivariate adjustment for donor and recipient factors, graft (p = 0.68) and patient survival (p = 0.52) were similar between migrated and non-migrated patients.ConclusionA significant number of patients migrated in patterns that could not be explained alone by regional variations in MELD score and wait time. Migration may be a complex interplay of factors including referral patterns, specialized services at centers of excellence and patient preference.

Body Mass Index (BMI) and Survival After Liver Transplantation LT): Influence of the Extremes of BMI.

BACKGROUND: The effect of BMI on post-LT survival is controversial. There are mixed data on the effect of obesity on post-LT survival, while BMI<18 is associated with poorer post-LT survival. Non-alcoholic steatohepatitis (NASH) LT recipients overall weigh more than those transplanted for other indications, but their survival by BMI has not been well described. METHODS: We performed a retrospective cohort study of adult LT recipients between 3/1/02-12/31/11, using UNOS data. BMI at listing was defined by the following categories: 1 (<20), 2 (20-24.9), 3 (25-29.9), 4 (30-34.9), 5 (35-39.9), and 6 (≥40 kg/m2). The association between BMI category and post-LT survival was evaluated with Cox regression. RESULTS: 41,036 LT recipients (median follow-up time 2.9 years, IQR 0.98-5.13) were included; 30.7% were female, 73.3% white, and 10.5% had NASH. Median BMI was higher in NASH vs non-NASH patients (32 vs 28; p≤0.001). BMI ≥40 was more prevalent in NASH vs non-NASH recipients (10.3 vs 2.6%; p≤0.001). Severity of ascites was similar in all BMI categories. When adjusted for age, gender, race, MELD, HCC, PVT, and DRI, all BMI categories except BMI 30-34.9 were associated with poorer post-LT survival, compared to BMI 25-29.9 (Table). In NASH patients, BMI <20 and 20-24.9 were strongly associated with poorer post-LT survival (HR 1.25 and 1.10, respectively), but BMI >35 was not a predictor of post-LT death. Change in BMI (≥2 kg/m2) or BMI category from listing to transplant had no impact on post-LT survival. CONCLUSIONS: Normal weight and underweight are independently associated with worse post-LT survival in both the non-NASH and NASH LT populations. In contrast to the non-NASH LT population, BMI>40 does not predict post-LT death in patients with NASH. Table. Multivariable cox regression, adjusted for age, gender, race, HCC, PVT, MELD, DRI, year of LT.Table: No Caption available.

A Composite Donor and Recipient Risk Factor Analysis Predicts Outcomes and Supports the Utilization of Marginal Donor Organs in Patients With Higher Co-Morbidities.

Introduction: Because organ discard rates remain high with lower quality organs having the highest likelihood of discard, quantifying the survival benefit of these organs across a range of recipient characteristics is important for clinical decision-making. Methods: We used UNOS data from 1995-2010 to examine outcomes among 138,717 first-time, adult deceased donor renal transplant recipients. Organ quality was assessed by KDPI quintiles (e.g., 0-20%/excellent to 81-100%/poor). We created a composite recipient risk profile score for the hazard of death from a Cox model using a randomly-selected cohort analyzing 15 clinical covariates, which were then applied in a validation set to candidates and recipients. Risk scores were divided into quintiles by probability of death (Very Low(VL), Low(L), Medium(M), High(H), Very High(VH)), and Kaplan-Meier methods were used to estimate survival by risk profile score and organ quality. Results: Factors most predictive of recipient mortality included race, age, and cause of ESRD (p<0.0001). Five-year survival was better in transplant recipients compared to matched, wait-listed candidates with similar risk profile scores (i.e., 5-year survival for transplant/waitlist: VL-91.2%/78.7%, L-86.7%/83.5%, M-83.4%/61.9%, H-76.2%/54.5%, VH-63.4%/45.4%; p<0.0001 for all transplant/waitlist comparisons). Moreover, when sub-analyzing recipient survival by organ quality, recipients of poor quality organs derived a survival benefit from transplant, a finding that remained true across all risk profile scores (survival difference: VL-12.6%, L-15.7%, M-15.8%, H-15.7%, VH-9.6%). Conclusion: In our analysis, renal transplantation with poor quality organs provides a survival advantage even in patients with higher morbidity and mortality burden.

Influence of Recipient Age On Long-Term Simultaneous Pancreas Kidney Transplants: An Analysis of UNOS Data.

Background The influence of recipient age in simultaneous pancreas kidney (SPK) transplantation was inconclusive. Accordingly, using UNOS data, we assessed recipient age in relation to long-term graft survival among SPK recipients after adjustments for recipient, donor, and transplant factors Methods We used the data of 10,592 adults who received deceased-donor primary-only SPK transplants performed between January 1995 and December 2011. Our analysis included follow-up information received through July 2012. We classified recipients into five age groups: recipients who were 19-30 years old, those 31-40, those 41-50, those 51-60, and recipients older than 61. We used Kaplan-Meier methods to calculate liver graft survival rates, and Cox proportional hazard models to estimate the influence of recipient age adjusted for confounding factors. Results Three-year graft survival rates were significantly higher among recipients 31-40 years old, 41-50, and 41-50 (respectively, 77.4%, 78.2%, and 76.7%) than among recipients 19-30 years old and those older than 61 (74.8% and 68.8%).Figure: No Caption available.When censored for survival more than one year, graft survival rates showed a similar trend for the three recipient age groups from 31 to 60 years old. After adjusting for confounders—and using recipients 19-30 years old as the reference group—five-year survival was significantly better for those three age groups: the hazard ratio (HR) for recipients 31-40 years old was 0.68, 95% CI (0.58-0.80); for those 41-50 years old the HR was 0.65, 95% CI (0.55-0.78); and for recipients 51-60 the HR was also 0.65, 95% CI (0.51-0.82). The survival rate for recipients older than 61 (HR, 0.97, 95% CI, 0.48-2.00) was similar to that for the reference group recipients 19-30 years old. Conclusion Recipient age is indeed a factor in survival after SPK transplant, with better survival for those between 31 and 60 years old than for recipients who are younger or older.

(255) - Heart Transplantation Outcomes in Patients with Continuous Flow Left Ventricular Assist Device Related Complications

(255) - Heart Transplantation Outcomes in Patients with Continuous Flow Left Ventricular Assist Device Related Complications

(254) - De Novo DQ Donor-Specific Antibodies Are Associated With Chronic Lung Allograft Dysfunction

s S99 Device related complications (DRC) raise acuity of illness allowing patients to be listed as status 1A. We sought to study HTx outcomes of status 1A patients supported with CF LVADs with (DRC+) or without (DRC-) device related complications. Methods: UNOS data (2006 to 2012), on adult HTx patients listed as status 1A with CF LVADs at HTx was analyzed. Outcomes were compared between DRC+ and DRCgroups. Data on DRC+ group was further analyzed under five UNOS categories (B1 = Thromboembolism, B2 = Device related infections, B3 = Mechanical failure, B4 = Ventricular arrhythmia, B5 = other). Results: During the study period 6799 patients received HTx under 1A listing, of which 2113 (31%) were supported with CF LVADs (Fig). Substantially more patients are supported with CF LVADs under 1A listing, 11.4% in 2006 to 41.5% in 2012. Alarming number of CF LVAD patients are added to 1A listing for DRC, 20% in 2006 to 55% in 2012, p = 0.0001. Majority of DRC are in B2 category54% followed by B117.4%. Demographics and perioperative variables between DRC+ and DRCwere comparable except DRC+ had longer wait times (330 ± 323 days vs 168 ± 298 days), more blood group O (57% v 40%) and higher BMI (29 ± 5.5 vs 27± 5). Post HTx survival for DRC+ was significantly inferior compared to DRCgroup both at 1 yr (85.6% vs 89.4%, p = 0.01) and 3 yrs (78% vs 82.7%, p = 0.01). Among DRC+ subgroups, 1 and 3 yr survival was inferior only for B2 category (85% and 77%, p = 0.01). Conclusion: Increasing number of patients receiving HTx under 1A listing are supported with CF LVADs. DRC are steadily increasing, majority of them from B2 category. Longer wait times, blood group O and higher BMI are associated with DRC. Post HTx survival in the DRC+ group is inferior, primarily for B2 category. Benefits of CF LVADs for patients awaiting HTx need to be weighed against the development of DRC and inferior post HTx survival.

Outcomes among older adult liver transplantation recipients in the model of end stage liver disease (MELD) era.

Since 2002, the Model of End Stage Liver Disease (MELD) score has been the basis of the liver transplant (LT) allocation system. Among older adult LT recipients, short-term outcomes in the MELD era were comparable to the pre-MELD era, but long-term outcomes remain unclear. This is a retrospective cohort study using the UNOS data on patients age ≥ 50 years who underwent primary LT from February 27, 2002 until October 31, 2011. A total of 35,686 recipients met inclusion criteria. The cohort was divided into 5-year interval age groups. Five-year over-all survival rates for ages 50-54, 55-59, 60-64, 65-69, and 70+ were 72.2%, 71.6%, 69.5%, 65.0%, and 57.5%, respectively. Five-year graft survival rates after adjusting for death as competing risk for ages 50-54, 55-59,60-64, 65-69 and 70+ were 85.8%, 87.3%, 89.6%, 89.1% and 88.9%, respectively. By Cox proportional hazard modeling, age ≥ 60, increasing MELD, donor age ≥ 60, hepatitis C, hepatocellular carcinoma (HCC), dialysis and impaired pre-transplant functional status (FS) were associated with increased 5-year mortality. Using Fine and Gray sub-proportional hazard modeling adjusted for death as competing risk, 5-year graft failure was associated with donor age ≥ 60, increasing MELD, hepatitis C, HCC, and impaired pre-transplant FS. Among older LT recipients in the MELD era, long-term graft survival after adjusting for death as competing risk was improved with increasing age, while over-all survival was worse. Donor age, hepatitis C, and pre-transplant FS represent potentially modifiable risk factors that could influence long-term graft and patient survival.

Lung allograft tolerance in non-human primates following delayed donor bone marrow transplantation

METHODS: We used UNOS data from 1995-2012 to analyze all adult deceased-donor kidney transplant recipients (N1⁄4155,367), excluding prior, multi-organ, and en-bloc transplants. Recipient age andKDPIs were divided into deciles. Kaplan-Meier survival estimates were used to measure the effect of KDPI on median graft survival. Given the high rate of survival among age cohorts, we compared time to death at the 75th percentile rather thanmedian time to death.

Centers for Disease Control ‘High-Risk’ Donors and Thoracic Organ Transplantation: Expanding the Donor Pool

Purpose A shortage of thoracic organs remains a significant barrier for patients with end stage cardiac or pulmonary disease awaiting transplantation. Increased use of Centers for Disease Control(CDC) high risk donors represents an opportunity for access to more organs, however post-transplant outcomes using these organs have not been previously studied. Methods and Materials We retrospectively reviewed the United Network for Organ Sharing database including adult( Results Among 10,314 OHT recipients during the study period, 937 (9.1%) received a CDC high risk organ; of 8,027 LTx patient, 564 (7.0%) received CDC high risk organs. For both OHT and LTx, with few exceptions, demographics and markers of acuity were evenly matched among patients receiving CDC high risk and Non-CDC high risk organs. In OHT and LTx using CDC high risk organs, there were more male recipients, longer ischemic times, younger donors, and annual average transplant center volume was higher. Postoperative infection, stroke, and dialysis rates were similar. Risk-adjusted Cox proportional hazards regression revealed equivalent risk of 1-year mortality when comparing CDC high risk and Non-CDC high risk organs. KM 1-year survival was unaffected by use of CDC high risk organs. Conclusions According to UNOS data, use of CDC high risk donor organs does not negatively affect 1-year survival among OHT or LTx recipients. With current organ shortages, expanding the donor pool with more use of CDC high risk donors may improve access to transplantation.

A review of the United States experience with combined heart-liver transplantation

Since first described by Starzl, combined heart and liver transplantation (CHLT) has been a relatively rare event, although utilization has increased in the past decade. This study was undertaken to review the United States experience with this procedure; UNOS data on CHLT was reviewed. CHLT was compared with liver transplantation alone and heart transplantation alone in terms of acute rejection within 12 months, graft survival, and patient survival. Survival was calculated according to Kaplan-Meier and Cox proportional hazards. Continuous variables were compared using Student's t-test and categorical variables with chi-squared. Between 1987 and 2010, there were 97 reported cases of CHLT in the United States. Amyloidosis was the most common indication for both heart (n = 26, 26.8%) and liver (n = 27, 27.8%) transplantation in this cohort. Liver graft survival in the CHLT cohort at 1, 5, and 10 years was 83.4%, 72.8%, and 71.0%, whereas survival of the cardiac allograft was 83.5%, 73.2%, and 71.5%. This was similar to graft survival in liver alone transplantation (79.4%, 71.0%, 65.1%; P = 0.894) and heart transplantation alone (82.6%, 71.9%, 63.2%; P = 0.341). CHLT is a safe and effective procedure, with graft survival rates similar to isolated heart and isolated liver transplantation.

601 Listing Requirements for a Prospective Crossmatch in Pediatric Heart Transplantation: Analysis of UNOS Data from 1996 to 2009

601 Listing Requirements for a Prospective Crossmatch in Pediatric Heart Transplantation: Analysis of UNOS Data from 1996 to 2009

Overweight and obesity in pediatric liver transplant recipients: Prevalence and predictors before and after transplant, United Network for Organ Sharing Data, 1987–2010

Obesity is extremely common in adult liver transplant recipients and healthy U.S. children. Little is known about the prevalence or risk factors for post-transplant obesity in pediatric liver transplant recipients. UNOS data on all U.S. liver transplants 1987-2010 in children 6 months-20 yr at transplant were analyzed. Subjects were categorized as underweight, normal weight, overweight, or obese by CDC guidelines. Predictors of weight status at and after transplant were identified using multivariate logistic regression. Of 3043 children 6-24 months at transplant, 14% were overweight. Of 4658 subjects 2-20 yr at transplant, 16% were overweight and 13% obese. Children overweight/obese at transplant were more likely to be overweight/obese at one, two, and five yr after transplant in all age groups after adjusting for age, ethnicity, primary diagnosis, year of transplant, and transplant type. Weight status at transplant was not associated with overweight/obesity by 10 yr after transplant. The prevalence of post-transplant obesity remained high in long-term follow-up, from 20% to 50% depending on age and weight status at transplant. Weight status at transplant is the strongest predictor of post-transplant overweight/obesity. To optimize long-term outcomes in pediatric liver transplant recipients, monitoring for obesity and its comorbidities is important.

Outcomes of liver transplantation for glycogen storage disease: a matched‐control study and a review of literature

The clinical characteristics and outcomes of patients with glycogen storage disease (GSD) who undergo liver transplantation (LT) have not been well defined. In this study, our objective was to determine the outcome of LT in patients with GSD and compare it with a comparable group of patients without GSD (matched controls). UNOS data from 1986 to 2007 were used for this study. For each GSD patient (n = 95; men 62%) who was transplanted, three patients (n = 285, men 60%) without GSD (case controls) matched for age ± five yr, year of transplantation and donor risk index (DRI) ± 0.2 were identified from the UNOS database in a random manner. Unadjusted patient survival was determined by Kaplan-Meier survival analysis and significance determined by log-rank test. The mean age of the group was 17.9 yr. GSD patients had lower BMI (22 vs. 24, p = 0.002), lower serum bilirubin (2.7 vs. 13.5 mg/dL, p < 0.0001), higher serum albumin (3.7 vs. 3.1 g/dL, p < 0.0001), and higher wait-list time (239 vs. 74 d, p < 0.0001) compared to case controls. Recipient age and DRI were similar between the groups. Tumors were more common in GSD group (13.7% vs. 5%). Patient survival was significantly better (p = 0.024) in GSD group at one, five, and 10 yr (82%, 76%, and 64%) than non-GSD (73%, 65%, and 59%) group. In this matched-control study, patients who underwent LT for GSD had a better long-term survival than a comparable group of patients without GSD.

71-P Trends in kidney transplantation across a positive crossmatch: The UNOS data

71-P Trends in kidney transplantation across a positive crossmatch: The UNOS data

Estimating the Potential Pool of HIV-Infected Deceased Organ Donors in the United States

Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation. For HIV-infected patients, HIV-infected deceased donors (HIVDD) could attenuate the organ shortage and waitlist mortality. However, this practice would violate United States federal law. The goal of this study was to estimate the potential impact of legalizing transplantation of HIV-infected organs by quantifying the potential pool of HIVDD. Using Nationwide Inpatient Sample (NIS) data, HIV-infected deaths compatible with donation were enumerated. Using HIV Research Network (HIVRN) data, CD4 count, plasma HIV-1 RNA level, AIDS-defining illnesses and causes of death were examined in potential HIVDD. Using UNOS data, evaluated donors who later demonstrated unanticipated HIV infections were studied. From NIS, a yearly average of 534 (range: 481-652) potential HIVDD were identified, with 63 (range: 39-90) kidney-only, 221 (range: 182-255) liver-only and 250 (range: 182-342) multiorgan donors. From HIVRN, a yearly average of 494 (range: 441-533) potential HIVDD were identified. Additionally, a yearly average of 20 (range: 11-34) donors with unanticipated HIV infection were identified from UNOS. Deceased HIV-infected patients represent a potential of approximately 500-600 donors per year for HIV-infected transplant candidates. In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful.

241 Association Between Lower Graft Survival and Kidneys from Donors Aged 40-49 Years with Co-Morbidities

ASSOCIATION BETWEEN LOWER GRAFT SURVIVAL AND KIDNEYS FROM DONORS AGED 40-49 YEARS WITH CO-MORBIDITIES Anita Patel, Mohamad Al-Abed, Mariella Goggins, Lauren Malinzak, Vanji Karthikeyan, Department of Internal Medicine and Transplant Institute, Henry Ford Hospital, Detroit, MI, United States Several recipient (R) and donor (D) risk factors are associated with inferior graft survival (GS). Outcomes of recipients (R) receiving kidneys from standard criteria donors (SCD) aged 40-49 years with risk factors of ECD criteria coined compromised SCD donors (CSCD) were compared with SCDR using UNOS data from1995 to 2010. Patient survival (PS) and GS were studied. Median follow up was 4 years. On Kaplan Meier survival analysis, both PS and GS appeared to be significantly superior for SCDR compared to CSCDR. However, on Cox regression analysis, there appeared to be a marginally significant decrease in PS (Hazard ratio [HR] 1.089 [95% confidence interval 1.010-1.174]); p=0.02) in CSCDR. In this group, GS was significantly lower (HR:1.109 [CI 1.031-1.192]; p=0.0053). However, patient survival was not significantly different. In conclusion, GS appears to be strongly influenced by donor risk factors in age group 40-49 years. It is possible that duration and severity of co-morbidities and effective renal reserve influence graft outcomes in this age group of standard criteria donors. Whether the same influence exists in donors less than 40 years of age or healthy donors over age 50 years is being invested. Influence of other risk factors including components of the metabolic syndrome is also being studied.

M1027 Utility of Nuclear Bone Scan and Head and Thoracic Computed Tomography to Detect Metastases During Pre-Liver Transplant Workup of Hepatocellular Carcinoma Patients

methods. Using pre-transplant variables, our series of ANNs allow us to optimize the UNOS data for predictive purposes and correctly classify patients according to post-transplant survival. The relative significance of certain variables in the UNOS database are now better understood as well. Improved database input (SRTR data) has been obtained and will provide increased accuracy in the near future.