Wait Listing Research Articles

481 Social Deprivation Does Not Affect Pediatric Kidney Transplant Wait Listing

481 Social Deprivation Does Not Affect Pediatric Kidney Transplant Wait Listing

Abstract 15192: The Impact of Fontan Circulatory Failure on Heart Transplant Survival: A 20 Center Study

Introduction: Fontan circulatory failure (FCF) is a chronic state in palliated single ventricle heart disease with high morbidity and mortality including heart failure, multisystem end-organ disease, and need for heart transplant (HT). Specific FCF morbidities have not been rigorously defined limiting study of how FCF morbidities impact pre- and post-HT outcomes. Hypothesis: FCF-specific morbidities affect survival from HT waitlisting (WL) through 1-year post-HT. Methods: This 20-center, retrospective cohort study collected demographic, medical/surgical history, WL data, and peri- and post-HT data in Fontan patients WL since 2008. Using Delphi methodology, investigators defined FCF-specific morbidities and collected data. Appropriate univariate 2-group statistics compared surviving individuals with those who 1) died anytime from WL to 1-year post-HT, 2) died on the WL, 3) died within 1-year post-HT. Multivariable logistic regression determined independent risk factors for mortality between WL and 1-year post-HT. Results: Of 409 WL patients, 24 (5.9%) died on the WL. Of the 316 (77%) who underwent HT, 27 (8.5%) did not survive to 1-year. Univariate risk factors for WL death included higher aortopulmonary collateral burden, > 1 hospitalizations in prior year, younger age, sleep apnea, higher NYHA class, non-enrollment in school or work, and single-parent home. Risk factors for 1-year post-HT mortality included HLHS diagnosis, patent fenestration, anatomic Fontan obstruction, clinical cyanosis (pulse oximetry < 90%), polycythemia, portal variceal disease, psychiatric disease requiring treatment, and higher HLA class II PRA. For the 15% of patients not surviving from WL to 1-year post-HT, independent risk factors for mortality included >1 hospitalization in the year prior to WL (aOR 2.0, p=0.05) and clinical cyanosis (aOR 5.0, p=0.002). Notably, some FCF morbidities did not impact post-WL survival including protein-losing enteropathy, plastic bronchitis, and kidney disease. Conclusions: Fontan-palliated patients continue to have high mortality from WL through HT. Among FCF specific morbidities, cyanosis is associated with worsened survival and needs further study. Continued study of FCF phenotype is possible via this dataset.

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Contextual Vulnerability Should Guide Fair Subject Selection in Xenotransplantation Clinical Trials

Balancing Waitlist Dropout in Pancreas Transplantation

The time a patient spends on the waiting list for a Simultaneous Pancreas-Kidney (SPK) transplant depends on several donor and recipient-specific factors. The average wait-list time for SPK in the United States has been about 1 to 3 years, significantly shorter than the average wait time for kidney-only transplantation. A single-center retrospective analysis of SPK waitlisted candidates was performed to determine the implication of wait-list time on dropout from the wait-list due to death or poor health. We analyzed all deceased donor Simultaneous Pancreas-Kidney wait-listed candidates between Jan 1994 and June 2021. Waitlisted candidates who got transplanted (TG) were compared to those who dropped out from the wait list due to death or poor health (DPHG). In the study period, 297 candidates were waitlisted for SPK transplants. Eight candidates were removed, as transplantation was not needed due to improvement in health while on the waiting list. Fourteen wait-listed candidates transferred to another center were also excluded from the study group. Two hundred and thirty wait-listed candidates were transplanted (TG). Forty-five patients were delisted due to death or poor health (DPHG). The mean body mass index of candidates in TG and DPHG were 25.1 and 24.9, respectively. The mean age at dropout in DPHG was 40.7, similar to the mean age at transplant in TG (39.4). The mean age of diabetes onset was slightly lower in TG (17.4) compared to 20.02 in DPHG. The mean days spent by the candidates on the waitlist in DPHG were significantly higher than those in TG (821 days vs 252 days). Eight of the 45 patients (17.7%) in DPHG had 1 or more organ transplants before listing compared to 1 of 230 patients (0.43%) in TG. Despite low wait times for SPK transplants, increased wait times can account for a dropout from the waitlist due to death or poor health. Centers should exercise caution in wait listing SPK candidates with prior organ transplants.

A prospective cohort study of operative outcomes in laparoscopic cholecystectomy using operative difficulty grade-adjusted CUSUM analysis.

The development of a learning health system requires a shift from intermittent retrospective review of outcomes to continuous data-driven understanding of surgical processes and patient outcomes. Doing so will require the routine prospective capture of high-quality structured data. This lack of structured data has been a significant impediment to the development of surgical data science1,2. Laparoscopic cholecystectomy, a high-volume procedure, represents an opportunity to address this, but application of these data will require a paradigm shift in outcome reporting. As part of a systems-wide quality-improvement programme an end-to-end perioperative electronic workflow solution was refined and implemented at Christchurch Hospital, a tertiary referral centre, in 20133. This system allows for end-to-end data capture, including wait listing, operation booking, synoptic operation note documentation, and prospective capture of surgical complications and outcomes. Coupled with this, Christchurch Hospital has undertaken a department-wide initiative to standardize processes in laparoscopic cholecystectomy to optimize outcomes and prevent bile duct injury (BDI)4. Integration of prospective data capture into the clinical workflow allows for the possibility of real-time outcome monitoring and quality improvement.

Non-Renal Factors Associated with Simultaneous Liver-Kidney Transplant in Patients with End-Stage Liver Disease and Stage 3-5 Chronic Kidney Disease Not Requiring Dialysis

We aimed to identify the non-renal risk factors for simultaneous liver-kidney transplantation (SLKT) vs. liver transplantation alone (LTA) in end-stage liver disease (ESLD) patients with estimated glomerular filtration rate (eGFR) <60 ml/min, not on dialysis. Using organ procurement and transplantation network data, we studied adult ESLD patients who received deceased-donor SLKT or LTA in July 2002-Mar 2016 with a 4-point modification of renal disease (MDRD) equation-estimated glomerular filtration rate (eGFR) stratified into chronic kidney disease stage 3 (CKD-3): 30-59 ml/min, CKD stage 4 (CKD-4): 15-29 ml/min, and CKD stage 5 (CKD-5): <15 ml/min) and not on maintenance dialysis (NOD). The outcome of the study was identification of non-renal risk factors predicting likelihood of SLKT vs. LTA. We reported the odds ratio (OR) and 95% confidence interval (CI) for SLKT vs. LTA associated with important clinical variables. Strong non-renal (non-creatinine-associated) risk factors for SLKT were WL-time >2 yrs. and 1-2 yrs. (OR = 3.80, CI = 2.94-4.91; OR = 3.20, CI = 2.58-3.97; respectively), African American or Hispanic recipient race/ethnicity (OR = 2.93, CI = 2.45-3.51; OR = 1.46, CI = 1.24-1.72; respectively), liver repeat transplant (OR = 1.66, CI = 1.39-1.99), and diabetes (OR = 1.53, CI = 1.36-1.72). Factors associated with lower likelihood of SLKT were donor age >60 years (OR = 0.25, CI = 0.19-0.32), female recipient sex (OR = 0.48, CI = 0.43-0.54), hepatocellular carcinoma (OR = 0.53, CI = 0.35-0.81), and transplant center procedure volume tercile ranks 3<sup>rd</sup> (OR = 0.74, CI = 0.62-0.89) and 2<sup>nd</sup> (OR = 0.78, CI = 0.64-0.95). Model for end-stage liver disease scores have varying associations with SLKT vs. LTA, depending on calculation time: at wait listing or transplant. CKD-5 and -4 at wait listing (WL) and transplant were the risk factors with highest point estimates for SLKT vs. LTA. In patients with ESLD and CKD stage 3-5, not on dialysis, strong non-renal risk factors favoring SLKT versus LTA include: prolonged waitlist time, African American or Hispanic race/ethnicity, previous liver transplant, and diabetes. Some novel associations found between risk factors and likelihood of SLKT need further study for confirmation. Lack of uniform criteria for SLK allocation during the period studied is a major limitation of the study.

Heart Transplantation Strategies In Arrhythmogenic Right Ventricular Cardiomyopathy: The Johns Hopkins Experience

<h3>Background</h3> End stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre- and peri-transplant management given predominantly right ventricle (RV) failure and propensity for ventricular arrhythmias. We utilized a tertiary ARVC referral and heart transplant center experience to describe management of patients with ARVC undergoing heart transplantation. <h3>Methods</h3> We queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and studied the subset undergoing transplantation at Johns Hopkins. Patient demographics, clinical characteristics, and pre-transplant clinical course were obtained from the registry and medical records. <h3>Results</h3> Of the 532 patients in the ARVC Registry, 63 underwent heart transplantation. Nine (3 female) patients had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital from 2006 to 2020; 5 occurred after the 2018 allocation system revision. Plakophilin-2 (<i>PKP2</i>) pathogenic or likely pathogenic variant was present in 6 (67%) patients; the others were gene elusive. Six patients had a history of catheter ablation for ventricular arrhythmia (5 had at least 3 ablations). All 9 patients had significant right ventricular failure as demonstrated in <b>Figure</b>. Transplant evaluation occurred at a mean age of 42±14 years and was typically initiated within 1 year of developing heart failure. Initial waitlist status was 2 (old system) or 6 (revised system) in 7 (78%) patients; 1 patient underwent transplant at this status, the remaining required upgraded status because of clinical worsening. Bridge to transplant support included inotropes (n=3) and ECMO (n=2). Percutaneous RV mechanical support was unsuccessful in 2 patients due to severe RV dilation. Contraindication to inotropes or left ventricle mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy. <h3>Conclusion</h3> Heart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmia and RV predominant pathology, patients require unique considerations in regards to timing of evaluation, hemodynamic support options and wait listing qualification.

The predictive utility of functional status at discharge: a population-level cohort analysis

BackgroundFunctional status is a patient-important, patient-centered measurement. The utility of functional status measures to inform post-discharge patient needs is unknown. We sought to examine the utility of routinely collected functional status measures gathered from older hospitalized patients to predict a panel of post-discharge outcomes.MethodsIn this population-based retrospective cohort study, Adults 65+ discharged from an acute hospitalization between 4 November 2008 and 18 March 2016 in Ontario, Canada and received an assessment of functional status at discharge using the Health Outcomes for Better Information and Care tool were included. Multivariable regression analysis was used to determine the relationship between functional status and emergency department (ED) re-presentation, hospital readmission, long term care facility (LTCF) admission or wait listing (‘LTCF readiness’), and death at 180 days from discharge.ResultsA total of 80 020 discharges were included. 38 928 (48.6%) re-presented to the ED, 24 222 (30.3%) were re-admitted, 5 037 (6.3%) were LTCF ready, and 9 047 (11.3%) died at 180 days. Beyond age, diminished functional status at discharge was the factor most associated with LTCF readiness (adjusted Odds Ratio [OR] 4.11 for those who are completely dependent for activities of daily living compared to those who are independent; 95% Confidence Interval [CI]: 3.70-4.57) and death (OR 3.99; 95% CI: 3.67-4.35). Functional status also had a graded relationship with each outcome and improved the discriminability of the models predicting death and LTCF readiness (p<0.01) but not ED re-presentation or hospital re-admission.ConclusionRoutinely collected functional status at discharge meaningfully improves the prediction of long term care home readiness and death. The routine assessment of functional status can inform post-discharge care and planning for older adults.

Heart transplantation strategies in arrhythmogenic right ventricular cardiomyopathy: a tertiary ARVC centre experience.

AimsEnd‐stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre‐transplant and peri‐transplant management given their predominantly right ventricular (RV) failure and propensity for ventricular arrhythmias. We sought to utilize a tertiary ARVC referral and heart transplant centre experience to describe management of a series of patients with ARVC undergoing heart transplantation at our centre.Methods and resultsWe queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and further studied the subset undergoing transplantation at the Johns Hopkins Hospital. Patient demographics, clinical characteristics, and pre‐transplant clinical course were obtained from the registry and electronic medical records. Of the 532 patients in the ARVC Registry, 63 (12%) underwent heart transplantation. Nine (six male) of these patients both had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital between 2006 and 2020 at a mean age of 42 ± 14 years old. Pathogenic ARVC genetic variants were identified in six (67%) patients, all of whom had variants in the plakophilin‐2 (PKP2) gene. RV failure was universal with median right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio of 1.4 [interquartile range (IQR) 1.2–1.5] and median right ventricular stroke work index (RVSWI) of 0 g·m/m2/beat (IQR 0–0.3). Six had a history of catheter ablation for ventricular arrhythmia with five of the six having at least three ablations. Transplant evaluation was initiated an average of 344 ± 407 days after first developing heart failure symptoms. The most common bridge to transplant support included inotropes (n = 3) and extracorporeal membrane oxygenation (ECMO) (n = 2). Contraindication to inotropes or mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy.ConclusionsHeart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmias and RV predominant pathology, patients require unique considerations in regard to timing of evaluation, haemodynamic support options, and wait listing qualification.

Hepatorenal dysfunction assessment with the Model for End-Stage Liver Disease Excluding INR score predicts worse survival after heart transplant in pediatric Fontan patients

BackgroundFontan physiology results in multiorgan dysfunction, most notably affecting the liver and kidney. We evaluated the utility of Model for End-Stage Liver Disease Excluding INR (MELD-XI) score, a score evaluating the function of both liver and kidney to identify Fontan patients at increased risk for morbidity and mortality post–heart transplant. MethodsThe Pediatric Heart Transplant Society database was queried to identify Fontan patients listed for heart transplant between January 2005 and December 2018. MELD-XI scores were calculated at listing and heart transplant. A multivariable analysis was conducted to identify risk factors for post–heart transplant mortality. Demographic, clinical characteristics, and survival differences were evaluated and compared between the high and low MELD-XI score cohorts. The impact of changing MELD-XI scores during the waitlist period on post–heart transplant outcomes was also evaluated. ResultsOf 565 Fontan patients who underwent transplantation, 524 (93%) had calculable MELD-XI scores at the time of heart transplant: 421 calculable at listing and 392 calculable at listing and at heart transplant. On multivariable analysis, only MELD-XI score (squared) (hazard ratio, 1.007), history of protein-losing enteropathy (hazard ratio, 2.1), and ventricular assist device use at transplant (hazard ratio, 3.4) were risk factors for early phase post–heart transplant mortality. Patients with high MELD-XI scores at heart transplant had inferior survival post–heart transplant (P = .02); those in the high MELD-XI score cohort at wait listing and heart transplant tend to have the worst post–heart transplant survival; however, this was not significant (P = .42). ConclusionsThe MELD-XI, an easily calculated score, serves as a valuable aid in identifying pediatric Fontan patients at increased risk for post–heart transplant mortality.

Ventricular Assist Device Technology and Black-White Disparities on the Heart Transplant Wait List.

Heart transplantation is the definitive treatment for end-stage heart failure. Left ventricular assist devices (LVADs) are a continually improving technology that extends life for some candidates on the heart transplant waiting list. Research Questions: Our objective is to compare Black-White differences in LVAD implantation and heart transplant outcomes during a period of technological innovation when the pulsatile flow LVAD was largely replaced by the continuous flow LVAD between 1999-2014. We used transplant registry data from the United Network for Organ Sharing (N = 5,550) to identify Black and White patients with heart failure who used an LVAD as a bridge-to-transplant (BTT). Using logistic regression, we compared Black-White differences in access to newer LVAD technology and timing of implantation relative to wait listing for heart transplantation. We used competing-risks event history models to predict transplant outcomes across race, LVAD type, and timing of LVAD implantation. Black and White candidates were equally likely to receive newer continuous flow LVADs, but Black candidates received LVADs later in the disease course (i.e. after transplant listing). This later timing of technological intervention contributed to poorer wait list outcomes among black transplant candidates, including lower likelihood of receiving a heart transplant and greater likelihood of being removed from the wait list due to worsening health. Delayed LVAD implantation is more common among Black patients and is associated with poorer transplant outcomes.

Abstract 15778: The Impact of Health Insurance Status on Heart Transplant Recipients

Introduction: Gaps in insurance coverage have been associated with diminished access to health care for children with chronic illness. Continuity of coverage is associated with improved long-term clinical outcomes among adolescent heart transplant (HT) recipients, but the relationship between insurance status and post-transplant outcomes has not been described across all pediatric HT recipients. Hypothesis: HT recipients with changes in insurance status will have worse outcomes as opposed to those with continuous coverage. Methods: We queried the United Network for Organ Sharing (UNOS) registry for patients age 0-18 receiving isolated HT or heart re-transplant between 2006 and 2019 and included them in the analysis if they survived at least one year post-transplant. Patients were categorized by insurance coverage at wait listing, HT, and one year follow-up. Cox proportional hazards models were used to characterize the association between coverage pattern and long-term patient survival. Results: Among the 3,247 patients in the analysis, insurance coverage patterns included continuous private (37%), continuous public (46%), gain of private (6%), and loss of private (11%). Patients who had continuous public insurance were more likely to be Black or Hispanic, adolescent, and require ICU care. In a multivariate Cox model, continuous public insurance was associated with increased mortality risk (HR = 1.46, P = 0.014), while loss of private insurance trended towards increased risk (HR = 1.14, P = 0.014). Figure 1 illustrates Kaplan-Meier conditional survival curves according to insurance trajectory. Multivariate sub-group analysis by Black race demonstrated no differences in outcomes by coverage pattern. Conclusions: In comparison to those with continuous private insurance, having continuous public insurance is associated with higher risk of adverse outcomes in pediatric HT recipients, but it does not account for disparate outcomes in Black patients.

Major Variation across Local Transplant Centers in Probability of Kidney Transplant for Wait-Listed Patients.

Geographic disparities in access to deceased donor kidney transplantation persist in the United States under the Kidney Allocation System (KAS) introduced in 2014, and the effect of transplant center practices on the probability of transplantation for wait-listed patients remains unclear. To compare probability of transplantation across centers nationally and within donation service areas (DSAs), we conducted a registry study that included all United States incident adult kidney transplant candidates wait listed in 2011 and 2015 (pre-KAS and post-KAS cohorts comprising 32,745 and 34,728 individuals, respectively). For each center, we calculated the probability of deceased donor kidney transplantation within 3 years of wait listing using competing risk regression, with living donor transplantation, death, and waiting list removal as competing events. We examined associations between center-level and DSA-level characteristics and the adjusted probability of transplant. Candidates received deceased donor kidney transplants within 3 years of wait listing more frequently post-KAS (22%) than pre-KAS (19%). Nationally, the probability of transplant varied 16-fold between centers, ranging from 4.0% to 64.2% in the post-KAS era. Within DSAs, we observed a median 2.3-fold variation between centers, with up to ten-fold and 57.4 percentage point differences. Probability of transplantation was correlated in the post-KAS cohort with center willingness to accept hard-to-place kidneys (r=0.55, P<0.001) and local organ supply (r=0.44, P<0.001). Large differences in the adjusted probability of deceased donor kidney transplantation persist under KAS, even between centers working with the same local organ supply. Probability of transplantation is significantly associated with organ offer acceptance patterns at transplant centers, underscoring the need for greater understanding of how centers make decisions about organs offered to wait-listed patients and how they relate to disparities in access to transplantation.

Changes in health-related quality of life in older candidates waiting for kidney transplantation.

There is limited available knowledge regarding health-related quality of life (HRQoL) in older patients with chronic kidney disease. We aimed to describe HRQoL in renal transplant candidates 65 years or older at transplant acceptance, and during the first year on the waiting list. A nationwide prospective observational study in Norway was conducted. HRQoL was evaluated at baseline (wait listing) and after 6 and 12 months using the patient self-reported Kidney Disease and Quality of Life Short form version 1.3. Intra-individual scores at different times were evaluated. Generic HRQoL was compared with scores from an age-matched Norwegian population. From January 2013 to November 2016, 261 patients ≥65 years accepted for deceased donor kidney transplantation were included. Mean age at inclusion was 71.1 years, 67% male and 69% were on dialysis. HRQoL sum scores significantly decreased during the first year on the waiting list. Physical, mental and kidney disease component summary score reduced from 39.6 to 38.1 (P = 0.045), 48.8 to 44.7 (P < 0.001) and 72.1 to 70.2 (P = 0.03), respectively. When evaluating each domain separately, only the decrease in social function was clinically significant. Age and being on dialysis were the most important predictors for low HRQoL. Compared to the age-matched general population, males had significant lower HRQoL scores. Females were comparable to the general female population at baseline except in general health and vitality. HRQoL in older patients waiting for kidney transplantation decreases during the first year on the waiting list, but only the change in social function is clinically significant.

Expanding clarity or confusion? Volatility of the 5-tier ratings assessing quality of transplant centers in the United States.

Outcomes of patients receiving solid organ transplants in the United States are systematically aggregated into bi-annual Program-Specific Reports (PSRs) detailing risk-adjusted survival by transplant center. Recently, the Scientific Registry of Transplant Recipients (SRTR) issued 5-tier ratings evaluating centers based on risk-adjusted 1-year graft survival. Our primary aim was to examine the reliability of 5-tier ratings over time. Using 10 consecutive PSRs for adult kidney transplant centers from June 2012 to December 2016 (n=208), we applied 5-tier ratings to center outcomes and evaluated ratings over time. From the baseline period (June 2012), 47% of centers had at least a 1-unit tier change within 6 months, 66% by 1 year, and 94% by 3 years. Similarly, 46% of centers had at least a 2-unit tier change by 3 years. In comparison, 15% of centers had a change in the traditional 3-tier rating at 3 years. The 5-tier ratings at 4 years had minimal association with baseline rating (Kappa 0.07, 95% confidence interval [CI] -0.002 to 0.158). Centers had a median of 3 different 5-tier ratings over the period (q1=2, q3=4). Findings were consistent for center volume, transplant rate, and baseline 5-tier rating. Cumulatively, results suggest that 5-tier ratings are highly volatile, limiting their utility for informing potential stakeholders, particularly transplant candidates given expected waiting times between wait listing and transplantation.

Long-term outcomes and transmission rates in hepatitis C virus-positive donor to hepatitis C virus-negative kidney transplant recipients: Analysis of United States national data.

The use of kidneys from hepatitis C virus (HCV)-positive (D+) deceased donors for HCV-negative recipients (R-) might increase the donor pool. We analyzed the national Organ Procurement and Transplant Network (OPTN) registry from 1994 to 2014 to compare the outcomes of HCV D+/R- (n=421) to propensity-matched HCV-negative donor (D-)/R- kidney transplants, as well as with waitlisted patients who never received a transplant, in a 1:5 ratio (n=2105, per matched group). Both 5-year graft survival (44% vs 66%; P<.001) and patient survival (57% vs 79%; P<.001) were inferior for D+/R- group compared to D-/R-. Nevertheless, 5-year patient survival from the time of wait listing was superior for D+/R- when compared to waitlisted controls (68% vs 43%; P<.001). Of the 126 D+/R- with available post-transplant HCV testing, HCV seroconversion was confirmed in 62 (49%), likely donor-derived. Five-year outcomes were similar between D+/R- that seroconverted vs D+/R- that did not (n=64). Our analysis shows inferior outcomes for D+/R- patients although detailed data on pretransplant risk factors was not available. Limited data suggest that HCV transmission occurred in half of HCV D+/R- patients, although this might not have been the primary factor contributing to the poor observed outcomes.

Outcomes and Trends of Ventricular Assist Device Selection in Children with End-Stage Heart Failure.

We aimed to examine trends in ventricular assist device (VAD) selection, continuous flow devices (CFD) versus pulsatile flow devices (PFD), and their associated outcomes in children eligible for both device types. To accomplish this, the United Network for Organ Sharing database was reviewed for pediatric patients listed for heart transplant (HT) from January 2007 to June 2014. Patients were included if a durable VAD was present at wait listing or when removed from the waiting list and who met size eligibility for a CFD (BSA > 1.0 m). In total, 253 patients met inclusion criteria, 144 (57%) CFD and 109 (43%) PFD. Device type varied significantly based on year with CFD increasing from 11% in 2007 to 88% in 2014 (p < 0.01). PFD patients were younger, had a lower BSA, and an increased rate of extracorporeal membrane oxygenation and biventricular assist device support at listing. Survival to transplant or recovery was similar for CFDs and PFDs (96 vs. 94%; p = 0.57), as was the post-HT survival, 95% for both device types. Despite PFD patients having more risk factors for a poor outcome, survival was similar between device types. Even so, there is a dramatic trend toward CFD utilization in patients who are large enough to support one.

Adverse outcomes associated with pulmonary hypertension in chronic obstructive pulmonary disease after bilateral lung transplantation

BackgroundThe impact of pulmonary hypertension (PH) in chronic obstructive pulmonary disease (COPD) on survival after lung transplantation (LTx) is not known. Material and methodsFirst-time adult LTx recipients with COPD transplanted between May 2005 and September 2013 were identified in the United Network for Organ Sharing Registry database, and tracked from transplant date until death or censoring. Right heart catheterization (RHC) measurements at time of wait listing were used to predict all-cause mortality after LTx, with multivariable analyses stratified by transplant type. ResultsOf 3362 COPD LTx recipients, 3105 were included in the analytic sample, with multiple imputation used to complete missing data on covariates. Multivariable analysis found the hazard of death to increase with a 10 mmHg increase in mean pulmonary artery pressure (mPAP) among recipients of bilateral LTx (HR = 1.12; 95% CI = 1.01, 1.24; p = 0.032), but not among recipients of single LTx (HR = 0.92; 95% CI = 0.80, 1.06; p = 0.234). ConclusionPH prior to bilateral LTx in patients with COPD is associated with higher mortality risk.

Ten-years trends in renal replacement therapy for end-stage renal disease in mainland France: Lessons from the French Renal Epidemiology and Information Network (REIN) registry

BackgroundThe incidence rate of renal replacement therapy (RRT) for end-stage renal disease (ESRD) is decreasing in several countries, but not in France. We studied the RRT trends in mainland France from 2005 to 2014 to understand the reasons for this discrepancy and determine the effects of ESRD management changes. MethodsData were extracted from the French Renal Epidemiology and Information Network registry. Time trends of RRT incidence and prevalence rates, patients’ clinical and treatment characteristics were analysed using the Joinpoint regression program and annual percentage changes. Survival within the first year of RRT was analysed using Kaplan-Meier estimates for 4 periods of time. ResultsThe overall age- and gender-adjusted RRT incidence rate increased from 144 to 159 individuals per million inhabitants (pmi) (+0.8% per year; 95% CI: 0.5–1.2) and the prevalence from 903 to 1141 pmi (+2.4% per year; 95% CI: 2.2–2.7). This increase concerned exclusively ESRD associated with type 2 diabetes (+4.0%; 3.4–4.6) and mostly elderly men. Despite patient aging and increasing comorbidity burden and a persistent 30% rate of emergency dialysis start, the one-year survival rate slightly improved from 82.1% (81.4–82.8) to 83.8% (83.3–84.4). Pre-emptive wait listing for renal transplantation and the percentage of wait-listed patients within one year after dialysis start strongly increased (from 5.6% to 15.5% and from 29% to 39%, respectively). ConclusionKidney transplantation and survival significantly improved despite the heavier patient burden. However, the rise in type 2 diabetes-related ESRD and the stable high rate of emergency dialysis start remain major issues.

Health Insurance Trajectories and Long-Term Survival After Heart Transplantation.

Health insurance status at heart transplantation influences recipient survival, but implications of change in insurance for long-term outcomes are unclear. Adults aged 18 to 64 receiving first-time orthotopic heart transplants between July 2006 and December 2013 were identified in the United Network for Organ Sharing registry. Patients surviving >1 year were categorized according to trajectory of insurance status (private compared with public) at wait listing, transplantation, and 1-year follow-up. The most common insurance trajectories were continuous private coverage (44%), continuous public coverage (27%), and transition from private to public coverage (11%). Among patients who survived to 1 year (n=9088), continuous public insurance (hazard ratio =1.36; 95% confidence interval 1.19, 1.56; P<0.001) and transition from private to public insurance (hazard ratio =1.25; 95% confidence interval 1.04, 1.50; P=0.017) were associated with increased mortality hazard relative to continuous private insurance. Supplementary analyses of 11 247 patients included all durations of post-transplant survival and examined post-transplant private-to-public and public-to-private transitions as time-varying covariates. In these analyses, transition from private to public insurance was associated with increased mortality hazard (hazard ratio =1.25; 95% confidence interval 1.07, 1.47; P=0.005), whereas transition from public to private insurance was associated with lower mortality hazard (hazard ratio =0.78; 95% confidence interval 0.62, 0.97; P=0.024). Transition from private to public insurance after heart transplantation is associated with worse long-term outcomes, compounding disparities in post-transplant survival attributed to insurance status at transplantation. By contrast, post-transplant gain of private insurance among patients receiving publicly funded heart transplants was associated with improved outcomes.