Waiting List Patients Research Articles

Solid Organ Transplantation in the Coronavirus Disease 2019 Era: “The Great Bet” in the North Italy Transplant Program Area

IntroductionSolid organ transplantation is challenging for waitlist patients during the coronavirus disease 2019 (COVID-19) pandemic. AimThis study investigates COVID-19 incidence and mortality in patients transplanted in the North Italy Transplant program (NITp) during the outbreak. Materials and MethodsAll consecutive patients transplanted from February 20 to April 3, 2020 (6 weeks), were included in our cohort and were observed for at least 4 weeks. Survival analyses were performed. ResultsIn this study, 124 patients were transplanted with 12 (9.7%) hearts, 4 (3.2%) lungs, 39 (31.4%) livers, 67 (54%) kidneys, and 2 (1.6%) combined kidney-pancreas. Recipients’ mean age was 51 years (standard deviation [SD] ± 16.6), and 76 of 124 (61%) were men. Five (4%) patients developed COVID-19 after a mean of 13 days (SD ± 6.7), with a cumulative incidence of 4.0% (95% confidence interval [CI], 0.5-7.5). During the follow-up period, 5 of 124 (4%) recipients died; overall mortality was 4.3% (95% CI, 0.6-8.0), with only 1 patient dying of COVID-19, for a COVID-19–related mortality of 0.8% (95% CI, 0-6.0). ConclusionsThis study showed a low COVID-19 incidence and COVID-19–related mortality in patients transplanted during the COVID-19 pandemic. Further studies with a longer follow-up period are mandatory to confirm the safety of transplant procedures.

Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden.

Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden.

Challenges in heart transplantation during COVID-19: A single-center experience

BACKGROUNDOrthotopic heart transplantation (OHT) recipients may be particularly vulnerable to coronavirus disease 2019 (COVID-19). OHT during the pandemic presents unique challenges in terms of feasibility and safety.METHODSChart review was performed for consecutive OHT recipients with COVID-19 and waitlisted patients who underwent OHT from March 1, 2020 to May 15, 2020.RESULTSOf the approximately 400 OHT recipients followed at our institution, 22 acquired COVID-19. Clinical characteristics included median age 59 (range, 49–71) years, 14 (63.6%) were male, and median time from OHT to infection was 4.6 (2.5–20.6) years. Symptoms included fever (68.2%), gastrointestinal complaints (55%), and cough (46%). COVID-19 was severe or critical in 5 (23%). All patients had elevated inflammatory biomarkers. Immunosuppression was modified in 85% of patients. Most (n = 16, 86.4%) were hospitalized, 18% required intubation, and 14% required vasopressor support. Five patients (23%) expired. None of the patients requiring intubation survived. Five patients underwent OHT during the pandemic. They were all males, ranging from 30 to 59 years of age. Two were transplanted at United Network of Organ Sharing Status 1 or 2, 1 at Status 3, and 2 at Status 4. All were successfully discharged and are alive without allograft dysfunction or rejection. One contracted mild COVID-19 after the index hospitalization.CONCLUSIONOHT recipients with COVID-19 appear to have outcomes similar to the general population hospitalized with COVID-19. OHT during the pandemic is feasible when appropriate precautions are taken. Further study is needed to guide immunosuppression management in OHT recipients affected by COVID-19.

HLA and AB0 Polymorphisms Influence SARS-CoV-2 Infection and COVID-19 Severity

Background: SARS-CoV-2 infection is heterogenous in clinical presentation and disease evolution. We investigated whether genetic variability can in of immune response to the virus can be influenced by genetic factors. Specifically, we compared HLA and AB0 frequencies in organ transplant recipients and in waitlisted patients according to the presence or absence of SARS-CoV-2 infection. Methods: A retrospective analysis was performed on an Italian cohort composed by subjects who received organ transplantation and candidates in waiting list in a January 2002-March 2020 time frame. Data from this cohort were merged with the Italian Ministry of Health registry of COVID+ subjects, evaluating infection status of transplanted and waitlisted patients. A total of 56304 cases were studied with the aim of comparing HLA and AB0 frequencies according to the presence (COVID+) or absence (COVID-) of SARS-CoV-2 infection. Findings: The cumulative incidence rate of COVID-19 was 0·112% in the Italian population and 0·462% in waitlisted/transplanted patients (OR=4·2, 95% CI [3·7-4·7], p<0·0001). HLA-B*51 was more frequent in COVID+ (25·1%) compared to COVID- (17·7%: OR=1·6, 95%CI [1·1-2·1]; p=0·004), as well as HLA-DRB1*08 (9·7% and 5·2%: OR=1·9, 95% CI [1·2-3·1]; p=0·003). Conversely, HLA-DRB1*07 showed a protective effect (15·2% in COVID+ vs. 21·6% in COVID-: OR=0·7, 95% CI [0·5-0·9]; p=0·023). In transplant recipients, HLA-DRB1*08 was correlated to mortality (1·9% in living vs 15·2% in deceased: OR=9·4 95% CI [1·9-47·3]; p=0.006). Lastly, blood group A was more frequent in COVID+ (45·5%) than in COVID- patients (39%; OR=1·3, 95% CI [1·0-1·7]; p=0·033). Interpretation: These results show that HLA antigens can influence SARS-CoV-2 infection and clinical evolution of COVID-19. They also confirm that blood group A subjects are at greater risk of infection. Overall, this study provides clues on the different spread of the disease and indications about infection prognosis and vaccination strategies. Funding Statement: Supported by a grant from the Italian Ministry of Education, University and Research-MIUR “Progetto strategico di Eccellenza Dipartimentale” #D15D18000410001 to the Department of Medical Sciences, University of Turin. Declaration of Interests: The authors have no conflicts of interest to declare. Ethics Approval Statement: All patients included in TR consented to registration and use of their data, which were treated and analysed in compliance with the European General Data Protection Regulation (EU GDPR), anonymizing sensitive data and processing aggregate data. ISS Data Protection Officer (DPO) authorized this study.

A change of heart: Preliminary results of the US 2018 adult heart allocation revision.

In 2018, the Organ Procurement and Transplantation Network (OPTN) modified adult heart allocation to better stratify candidates and provide broader access to the most medically urgent candidates. We analyzed OPTN data that included waiting list and transplant characteristics, geographical distribution, and early outcomes 1year before (pre: October 18, 2017-October 17, 2018) and following (post: October 18, 2018-October 17, 2019) implementation. The number of adult heart transplants increased from 2954 pre- to 3032 postimplementation. Seventy-eight percent of transplants in the post era were for the most medically urgent (statuses 1-3) compared to 68% for status 1A in the pre era. The median distance between the donor hospital and transplant center increased from 83 to 216 nautical miles, with an increase in total ischemic time from 3 to 3.4hours (all P<.001). Waiting list mortality was not different across eras (14.8 vs 14.9 deaths per 100 patient-years pre vs post respectively). Posttransplant patient survival was not different, 93.6% pre and 92.8% post. There is early evidence that the heart allocation policy has enhanced stratification of candidates by their medical urgency and broader distribution for the most medically urgent candidates with minimal impact on overall waiting list mortality and posttransplant outcomes.

Use of SARS-CoV-2-infected deceased organ donors: Should we always "just say no?"

In the context of a rapidly evolving pandemic, multiple organizations have released guidelines stating that all organs from potential deceased donors with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection should be deferred, including from otherwise medically eligible donors found to have mild or asymptomatic SARS‐CoV‐2 discovered on routine donor screening. In this article, we critically examine the available data on the risk of transmission of SARS‐CoV‐2 through organ transplantation. The isolation of SARS‐CoV‐2 from nonlung clinical specimens, the detection of SARS‐CoV‐2 in autopsy specimens, previous experience with the related coronaviruses SARS‐CoV and MERS‐CoV, and the vast experience with other common RNA respiratory viruses are all addressed. Taken together, these data provide little evidence to suggest the presence of intact transmissible SARS‐CoV in organs that can potentially be transplanted, specifically liver and heart. Other considerations including ethical, financial, societal, and logistical concerns are also addressed. We conclude that, for selected patients with high waitlist mortality, transplant programs should consider accepting heart or liver transplants from deceased donors with SARS‐CoV‐2 infection.

Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients.

Striking a Balance in Simultaneous Heart Kidney Transplant: Optimizing Outcomes for All Wait-Listed Patients.

Comparison Between Phenotypic Bead Assay and Single Antigen Bead Assay for Determining Specificity of HLA Antibodies in Kidney Transplant Waiting List

ObjectivesThe determination of unacceptable antigens in patients on kidney transplant waiting list is a critical laboratory investigation in sensitized patients. The Luminex single antigen bead (SAB) assay has high sensitivity and accuracy. However, several countries have not yet implemented SAB testing for waitlisted patients because of limited financial resources. In Thailand, specificities of HLA antibodies are identified by using a phenotypic bead assay. The aim of this study was to evaluate the performance of the phenotypic bead assay for determining HLA antibody specificities when compared with the SAB assay. MethodsA total of 254 sera from patients awaiting kidney transplantation were included. Of 254 sera, 206 and 171 were positive for HLA class I and II antibodies, respectively. Antibody specificities of sera that were tested with both phenotypic and SAB assay were analyzed. The performances of the phenotypic bead assay were compared with those of the SAB assay as the gold standard by using estimation of pooling sensitivity, specificity, and accuracy. ResultsThe sensitivity, specificity, and accuracy of the phenotypic bead assay for determining HLA class I antibodies was 53.9%, 93.0%, and 78.1%, respectively. The sensitivity, specificity, and accuracy of the phenotypic bead assay for determining HLA class II antibodies were 57.3%, 94.9%, and 81.4% respectively. ConclusionIn waitlisted kidney transplant patients, the phenotypic bead assay had high specificity and moderate accuracy when compared with the SAB assay. However, the low sensitivity of the test suggests that the use of the phenotypic assay for determining HLA specificities should be applied with caution in sensitized patients.

COVID-19 and lung transplant patients.

COVID-19 is a novel respiratory disease leading to high rates of acute respiratory failure requiring hospital admission. It is unclear if specific patient populations such as lung transplant patients are at higher risk for COVID-19. Some reports suggest that transplant patients may not be at higher risk if proper social distancing and preventive measures are employed. Efforts to ensure the safety of wait-listed patients, transplant recipients, and healthcare workers are underway. Recommendations for the care of lung transplant patients during the COVID-19 pandemic are discussed and will likely change as the pandemic evolves.

Prospective Analysis Regarding Health-Related Quality of Life (HR-QOL) between Morbid Obese Patients Following Bariatric Surgery Versus on a Waiting List.

Major impairment of health-related quality of life (HRQoL) is one of the main reasons why obese patients request surgical treatment. To prospectively analyze the impact of HRQoL between obese patients who underwent surgery and those who were wait-listed. Between April 2017 and March 2018, 70 surgical and 69 wait-listed patients were interviewed twice, at baseline and at the 12-month follow-up. Quality of life was measured by the SF-12v2 and the Impact of Weight on Quality of Life-Lite (IWQoL-Lite) questionnaires. Sociodemographic-, clinical-, and surgical-related variables were collected. One hundred thirty-nine patients were analyzed, showing similar baseline characteristics but differences in HRQoL. Performing more qualified work improved scores on some aspects of the SF-12 survey. In contrast, women scored worse on the self-esteem domain, and men scored worse on the mental health domain. By group, at the 12-month follow-up, statistically significant differences were found among all aspects of the questionnaires between both groups (P < 0.001) and between baseline and postoperative 12-month follow-up in the surgical group (P < 0.001). Furthermore, scores were lower in all domains in the evolution of wait-listed patients, with statistically significant differences among the Bodily Pain, Emotional Role, Mental Health, and Mental Component Summary Domains (P < 0.05). HRQoL is a multimodal concept that allows the identification of factors impacting obese patients' quality of life. It promotes the benefit of surgery against waiting list delays, which can take up to 4years in our hospital. Therefore, HRQoL is an important pillar to justify more resources for reducing unacceptable surgical delays.

Perspectives on donor lung allocation from both sides of the Atlantic: The United States.

Donor lung allocation in the United States focuses on decreasing waitlist mortality and improving recipient outcomes. The implementation of allocation policy to match deceased donor lungs to waitlisted patients occurs through a unique partnership between government and private organizations, namely the Organ Procurement and Transplantation Network under the Department of Health and Human Services and the United Network for Organ Sharing. In 2005, the donor lung allocation algorithm shifted toward the prioritization of medical urgency of waitlisted patients instead of time accrued on the waitlist. This led to the Lung Allocation Score, which weighs over a dozen clinical variables to predict a 1-year estimate of survival benefit, and is used to prioritize waitlisted patients. In 2017, the use of local allocation boundaries was eliminated in favor of a 250 nautical mile radius from the donor hospital as the first unit of distance used in allocation. The next upcoming iteration of donor allocation policy is expected to use a continuous distribution algorithm where all geographic boundaries are eliminated. There are additional opportunities to improve donor lung allocation, such as for patients with high antibody titers with access to a limited number of donors.

Malignancy Prevalence in Waitlisted Potential Kidney Transplant Recipients Is Very Low Relative to Patients After Kidney Transplantation

Kidney transplantation improves quality of life, prolongs survival, and is cost-effective, but bears some serious complications including malignancy.The aim of this study was to assess the prevalence of malignancy in dialyzed patients on the waiting list and in kidney allograft recipients.The cross-sectional study was conducted in 50 prevalent patients on the waiting list and 300 kidney allograft recipients. Patients who had been registered in the cadaver kidney waiting list and kidney allograft recipients did not differ in regard to age, sex, dialysis vintage, and causes of end-stage renal failure. In waitlisted patients, only 3 had a history of malignancy. In kidney allograft recipients, 52 patients developed malignancy. The leading malignancy was skin cancer with 9 cases, followed by post-transplant lymphoproliferative disorder in 5 cases, Kaposi sarcoma in 2 cases, brain cancer in 2 cases, Merkel carcinoma in 2 cases, lung cancer (small cell and non--small cell), unknown origin in 2 cases, and the other 22 malignancies were in single patients (including 1 leukemia and 1 multiple myeloma). Seventeen deaths were recorded in kidney allograft recipients with malignancy mainly in post-transplant lymphoproliferative disorder, Kaposi sarcoma, Merkel carcinoma, sarcoma, and brain cancer.Concluding, waitlisted patients represent a very selected and healthier dialyzed population. Guidelines for cancer screening in both potential transplant recipients and kidney allograft recipients should be developed as nowadays a scarcity of data exists in this matter. Minimization of immunosuppressive regimen should be considered, in particular, in high-risk patients.

Effect of Sacubitril-Valsartan in reducing depression in patients with advanced heart failure

BackgroundDepression is highly prevalent in Heart Failure (HF). Treatment with sacubitril/valsartan improved quality of life and survival in HF patients. Aim of the study was to investigate prospectively the effect of sacubitril/valsartan on depression in advanced HF patients in waiting list for heart transplant (HT). Methods37 consecutive patients with advanced HF in waiting list for HT were treated with sacubitril/valsartan. We analyzed data derived from the assessment performed the year before the beginning of sacubitril/valsartan, at study entry, and at one year of follow-up. Depression was assessed with Beck Depression Inventory II (BDI) scale. Cognitive function were assessed with Mini-Mental State Examination (MMSE). Functioning was evaluated measuring meters at 6 Minute Walking Test (6MWT) and maximum rate of oxygen consumption (VO2 max). ResultsAt baseline, 64.9% of HF patients were in NYHA III and 35.1% NYHA IIIB, BDI was 15.2 ± 5.2 with 59.5% of patients with a score > 13. MMSE was 27.8 ± 2.6. After one year of follow-up NYHA class improved significantly, with 56.8% in NYHA II, 40.5% in NYHA III and 2.7% NYHA in IIIB (p < 0.001). VO2 max and 6MWT increased. Notably, BDI was 9.5 ± 3.9 with 21.6% of patients with a score > 13. MMSE remain stable (28.2 ± 2.1) (p = 0.104). No statistical differences are observed between data collected in the evaluation 1-year before and soon before treatment with sacubitril/valsartan. Multivariate regression analysis demonstrate a relationship between reduction in BDI-II score and improvement in six-minute walking test independently by the effect of sex, age, selective serotonin reuptake inhibitors, VO2 max, NT-proBNP, PAPs, NYHA class differences evaluated at follow-up versus baseline. ConclusionsOur study showed a reduction in depressive symptomatology in heart transplant waiting list patients treated with sacubitril/valsartan. The improvement in depressive symptomatology was paralleled by 6MWT increase in the follow-up.

Listening to music during arteriovenous fistula surgery alleviates anxiety: A randomized single-blind clinical trial.

Both end-stage renal disease and being wait-listed for a kidney transplant are anxiety-causing situations. Wait-listed patients usually require arteriovenous fistula surgery for dialysis access. This procedure is performed under local anesthesia. We investigated the effects of music on the anxiety, perceived pain and satisfaction levels of patients who underwent fistula surgery. To investigate the effect of music therapy on anxiety levels and perceived pain of patients undergoing fistula surgery. Patients who were on a waiting list for kidney transplants and scheduled for fistula surgery were randomized to control and music groups. The music group patients listened to music throughout the fistula surgery. The State-Trait Anxiety Inventory was performed to assess anxiety, additionally visual analog scale was used to evaluate perceived pain, willingness to repeat the procedure and patient satisfaction. Demographic features, comorbidities, surgical history, basic surgical data (location of fistula creation, duration of surgery, incision length) and intra-operative hemodynamic parameters were recorded by an investigator blinded to the study group. An additional trait anxiety assessment was performed following the surgery. There was a total of 55 patients included in the study. However, 14 patients did not fulfill the criteria due to requirement of sedation during surgery or uncompleted questionnaires. The remaining 41 patients were included in the analysis. There were 26 males and 15 females. The control and music groups consisted of 20 and 21 patients, respectively. With regard to basic surgical and demographic data, there was no difference between the groups. Overall patient satisfaction was significantly higher and intra-operative heart rate and blood pressure were significantly lower in the music group (P < 0.05). Postoperative state anxiety levels were significantly lower in the music group. Music therapy can be a complimentary treatment for patients undergoing fistula surgery. It can reduce anxiety and perceived pain, improve intraoperative hemodynamic parameters and enhance treatment satisfaction, thus may contribute to better compliance of the patients.

Clinical judgment versus lung allocation score in predicting lung transplant waitlist mortality.

Canadian lung transplant centers currently use a subjective and dichotomous "Status" ranking to prioritize waitlisted patients for lung transplantation. The lung allocation score (LAS) is an objective composite score derived from clinical parameters associated with both waitlist and post-transplant survival. We performed a retrospective cohort study to determine whether clinical judgment (Status) or LAS better predicted waitlist mortality. All adult patients listed for lung transplantation between 2007 and 2012 at three Canadian lung transplant programs were included. Status and LAS were compared in their ability to predict waitlist mortality using Cox proportional hazards models and C-statistics. Status and LAS were available for 1122 patients. Status 2 patients had a higher LAS compared to Status 1 patients (mean 40.8 (4.4) vs 34.6 (12.5), P=.0001). Higher LAS was associated with higher risk of waitlist mortality (HR 1.06 per unit LAS, 95% CI 1.05, 1.07, P<.001). LAS predicted waitlist mortality better than Status (C-statistic 0.689 vs 0.674). Patients classified as Status 2 and LAS≥37 had the worst survival awaiting transplant, HR of 8.94 (95% CI 5.97, 13.37). LAS predicted waitlist mortality better than Status; however, the best predictor of waitlist mortality may be a combination of both LAS and clinical judgment.

A Share 21 model in liver transplantation: Impact on waitlist outcomes.

With the introduction of Model for End-Stage Liver Disease-Sodium (MELD-Na)-based allocation, the score at which patients benefit from liver transplantation (LT) has shifted from a score of 15 to 21. This study aimed to evaluate waitlist outcomes in patients with MELD-Na scores<21 and explore the utility of replacing "Share 15" with "Share 21." The study uses data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing registry.All adult patients registered for LT after implementation of the MELD-Na-based allocation were evaluated. Waitlist patients with initial and final scores<21 were eligible. Patients with exception scores were excluded. To explore the potential impact of a Share 21 model, patients with an initial MELD-Na score of 6-14 (Group 1) and those with a score of 15-20 (Group 2) were compared for waitlist outcomes. There were 3686 patients with an initial score of 6-14 (Group 1) and 3282 with a score of 15-20 (Group 2). Group 2, when compared to Group 1, showed comparable risk of mortality (adjusted hazard ratio [aHR] 1.00, P=.97), higher transplant probability (aHR 3.25, P<.001), and lower likelihood of removal from listing because of improvement (aHR 0.74, P=.011). Share 21 may enhance transplant opportunities and increase parity for patients with higher MELD-Na scores without compromising waitlist outcomes.

Artificial Intelligence Helps Predict 5-year Mortality and Graft Failure in Patients Undergoing Orthotopic Heart Transplantation

Orthotopic heart transplantation (OHT) is a life-saving procedure for advanced end-stage heart failure patients. Given the conservative allocation policy and mismatch of donors and wait-listed patients, the prediction of post OHT outcomes including survival and graft failure (GF) can help optimize organ allocation. We aimed to develop a risk prediction model using machine learning algorithm to predict survival and GF 5 years after OHT. Using International society of heart and lung transplant (ISHLT) registry data, we retrospectively analyzed 15236 patients who underwent OHT from January 2005 through December 2009. 342 variables including pre/ post OHT, discharge and follow up information were extracted and used to develop a risk prediction model utilizing a gradient boosted classification tree algorithm (GBM) to predict the risk of graft failure and mortality 5 yrs. after hospital discharge. Variables with missing observations were handled internally by the GBM algorithm. A 10 fold cross-validation repeated 5 times was used to estimate the model's external performance. Receiver operator curve (ROC) for GBM model was calculated to predict survival and GF 5 years post OHT. The mean duration of follow up of 4.7 years (median 5 years). The mortality and graft failure 5 years post- OHT was 27.3% (n = 4161) & 28 %( n=4276) respectively. The area under ROC (AUC) to predict 5 yr. mortality and GF are 0.717 (95% CI 0.696- 0.737) & 0.661 (95% CI 0.640-0.683) respectively. Length of stay, recipient and donor age, recipient body mass index and ischemic time had the highest weight in predicting 5-year mortality and graft failure. The subgroup of patients with age>60yrs had a higher AUC for both the models. The GBM model has an excellent accuracy in predicting 5 yr.-mortality and graft failure in patients undergoing OHT.

HCV Seropositive Donors Positively Impact Heart Transplantation Rates and Waitlist Mortality without Compromising Outcomes

Transplant demand continues to exceed supply. With advances in hepatitis C virus (HCV) treatment, HCV+ donors have recently been considered suitable for select recipients; here we investigate the effects of transplantation of HCV+ donors on waitlist mortality and transplant survival. Retrospective review of the Organ Procurement and Transplantation Network database was performed across two time periods - HCV+ donor era (6/'17-6/'19) and control (1/'13-1/'15). UNOS regions 1, 2, 5, 9 and 11 were analyzed as the highest volume HCV+ donor transplantation regions. Baseline characteristics were compared across periods and between transplants from HCV+ donors, as well as outcomes related to waitlist mortality, adverse events, graft failure and patient survival. 3,880 patients were included in the HCV+ donor era, of which 2,007 (51.7%) were transplanted. 232 (11.6%) received organs from HCV+ donors. 3688 patients underwent listing from the control era, of which 2,085 (56.5%) were transplanted. Baseline characteristics across eras demonstrated a greater proportion of HCV+ donor era transplants performed for restrictive cardiomyopathy (9.3% vs. 6.7%, p =0.012) and as multi-organ transplants (10.2% vs. 5.5%, p<0.001). Waitlist mortality at one year was less in the HCV+ donor era than control era (4.9% vs. 9.35%, p<0.001), and median waitlist time was shorter in the HCV+ donor era group (98 vs. 174 days, p=<0.001). Post-transplant adverse event, graft failure and survival outcomes were largely equivalent between HCV+ donor grafts and HCV- donor grafts during the same time period. Transplantation of HCV+ donor hearts safely and effectively expands the donor pool, and shows promise in decreasing both waitlist time and mortality without compromising graft quality. Continued re-assessment is essential to ensure long-term safety and efficacy of utilizing HCV+ donors.

Congenital Heart Disease and a Single Lung: Is Heart Transplantation Alone an Option?

Patients with end-stage heart failure and one functioning (Fx) lung are often referred for combined heart-lung transplantations (HLTx). However, this strategy carries significant waitlist & post-transplant mortality. Between 1987 and 2018, only 37% of the pediatric patients listed for HLTx were actually transplanted. This study aims to evaluate if heart transplant alone (HTx) remains a viable option for this patient population. Using both the Pediatric Health Information System (PHIS) and United Network for Organ Sharing (UNOS) databases, HTx recipients with one Fx lung and congenital heart disease between 2006 and 2015 (n=19) were identified. All other HTx recipients in a merged PHIS-UNOS database during the same period were classified as two Fx lungs (n=2,625). Post-transplantation survival rates for recipients with one and two Fx lungs were compared using Kaplan-Meier analysis. HTx recipients with one Fx lung had lower post-transplantation survival rates than recipients with two Fx lungs (p=0.03) but comparable conditional 60-day survival rates (p=0.56). Recipients with one Fx lung had one- and five-year survival rates of 71% and 40% with 60-day conditional one- and five-year survival rates of 100% and 90%, respectively. Five out of the six deceased HTx recipients with one Fx lung died within 60 post-operative days and before being discharged. Renal dysfunction (GFR<60 mL/min/1.73 m²) at HTx was a significant predictor of mortality for patients with one Fx lung (p=0.03). HTx recipients with one Fx lung can do well but seem to have a high early post-operative mortality that usually indicates high-risk recipients with multiple risk factors. Patient selection and timing of transplantation referral will be key to improving these outcomes. Keeping in mind the low percentage of waitlisted patients who actually make it to HLTx, HTx appears to be the best option for patients with end-stage heart failure and one Fx lung.

The Use of AlloMap and AlloSure in Combined Heart-Kidney Transplantation

Kidney disease is a common comorbidity seen in heart disease, and so the number of patients undergoing combined heart-kidney transplantation (HKT) continues to increase, as well as the number of waitlisted patients for HKT. Recent evidence suggests a favorable immunomodulatory effect for combined HKT, making these patients ideal candidates for non-invasive monitoring for rejection and injury. The use of gene-expression profile testing (AlloMap®) in HKT recipients vs heat transplant (HT) alone has remained uncertain with earlier reports suggesting higher values in HKT, while more recent reports suggesting equivocal results between the two. Additionally, the profile of donor-derived cell-free DNA (dd-cfDNA) (AlloSure®) in HKT has not yet been evaluated. The Utility of dd-cfDNA in Association with Gene Expression Profiling (D-OAR) registry is a prospective, observation study of HT recipients monitored with AlloMap and AlloSure. The D-OAR registry and prospectively collected data from UCLA Medical Center were assessed for patients who underwent HKT with associated AlloSure and AlloMap scores and compared to patients who underwent HT alone. The cumulative distribution functions of AlloMap and AlloSure scores were stratified by HT vs. HKT. Patients with CMV and acute cellular rejection (≥2R) were excluded from the analysis. There were 300 HT recipients and 14 HKT recipients. Baseline characteristics were similar between groups. The median AlloMap and AlloSure scores for HT recipients (N=300) were 29 and 0.09% respectively, while for HKT recipients (N=14) AlloMap and AlloSure scores were 33.5 and 0.41% respectively. See table 1 CONCLUSION: There were slightly higher AlloMap scores in HKT vs HT patients, while AlloSure results in HKT were significantly higher. Further work to establish baseline parameters and understand changes to these parameters during rejection episodes would benefit HKT patients by allowing non-invasive monitoring for rejection and graft injury.