Waiting Time For Transplantation Research Articles

Wait Times in Pediatric Heart Transplant Candidates: Impact of Size and Blood Type Following the 2016 Allocation Policy Revision

Purpose To describe wait times for pediatric heart transplant (HT) candidates following new allocation policies in 2016. Methods The OPTN database was queried for pediatric HT candidates listed for HT between 7/2016 and 4/2019. Wait times were analyzed by listing status (1A, 1B, 2), blood type, and recipient weight. Candidates were analyzed by days spent at each listing status, classified as transplanted only in their final listing status, and censored in the analysis for any other statuses in which they spent time listed. Wait list outcomes were analyzed using a competing risk analysis and a proportional subdistribution hazards regression model was used to compare associations between predictors and outcomes. Results The study included 1,789 candidates listed for HT under the new allocation system. 65% underwent HT, 14% died or were removed for clinical deterioration, 8% were removed for other reasons including clinical improvement, and 13% were still waiting at the end of the study period. The majority of children were listed as status 1A at the time of HT (81%), while 16% were listed as status 1B and 2.6% were status 2 at the time of HT. Candidates Conclusion Wait times for pediatric HT candidates are highly variable, with listing status, size, and blood type contributing to wait time and likelihood of HT. Children less than 25 kg, particularly those who are blood type O, experience longer wait times and higher wait list mortality. Advanced heart failure therapies should be selected with these longer wait times in mind.

Heart Transplant Waitlist Outcomes and Wait Time by Center Volume: Where Should You List?

Purpose With new devices and policy changes in the heart transplantation, patients are faced with increasingly complex management options. Among one of the decisions they must make is which transplant center they can and should list under. Here we explored waitlist outcomes by transplant center volume. Methods We performed a retrospective analysis of adults listed for primary heart transplantation from 2008 to 2018 using the UNOS Database. Transplant centers were split into low ( 30 HTx/year) volume. Multivariable Cox Proportional Hazards analysis identified predictors of death prior to transplantation; Cox model was adjusted for age at listing, transpulmonary gradient, and use of LVAD while on the waitlist. Results Of the 37,779 patients included in our study, only 24,285 (64.3%) underwent transplantation. Of the remaining 13,494, 6,687 (49.6% of non-transplanted patients) died before receiving transplantation. Of the 140 centers, 51 were low volume (1,412 HTx), 64 were medium volume (11,687 HTx), and 25 were high volume (11,186 HTx); 118 patients were listed at centers which did not perform any transplants in the years analyzed. LVAD utilization (at listing or while listed) was 20.2% for low, 31.8% for medium, and 25.1% for high volume centers. Of the 3,192 patients listed in low-volume centers, only 1,412 (44.2%) underwent transplantation, while 800 (25.1%) died prior to transplant; of the 18,538 listed in medium volume centers, 11,687 (63.0%) underwent transplantation, while 3,343 (18.0%) died prior to transplant; of the 15,931 listed in high volume center, 11,186 (70.2%) underwent transplantation, while 2,503 (15.7%) died prior to transplant. Average time on waitlist was 328.7 + 453.7 days for low-volume, 358.5+469.8 for medium-volume, and 313.7+484.6 for high-volume centers (p = NS). Cox proportional hazards analysis demonstrated listing at a higher volume center to be an independent predictor of lower death rate while on transplant waitlist (HR 0.89, P Conclusion Survival to transplantation was higher for patients listed in higher volume centers. This may be associated with higher utilization rates of LVADs which was also associated with improved waitlist outcomes, or possibly better management of advanced heart failure in centers more experienced with this patient population.

Impact of carfilzomib-based desensitization on heart transplantation of sensitized candidates

Allosensitization in heart transplant candidates is associated with longer transplant wait times and post-transplant complications. We summarize our experience with desensitization using carfilzomib, an irreversible proteasome inhibitor that causes plasma cell apoptosis. One cycle of desensitization consisted of plasmapheresis and carfilzomib 20 mg/m2on days 1, 2, 8, 9, 15, and 16 with intravenous immune globulin 2 g/kg after carfilzomib on day 16. Patients underwent repeat cycles as indicated. We compare calculated panel-reactive antibody (cPRA) for neat combined Class I and II IgG and C1q pre- and post-treatment using a cutoff for cPRA entry of ≥ 4000 and 500 MFI, respectively. From June 2013 to October 2019, 9 patients underwent 20 cycles of carfilzomib-based desensitization. Each cycle resulted in an average cPRA decrease of 24% (95% CI: 6-42) for IgG and 36% (95% CI: 17-55) for C1q. From treatment start to finish, mean cPRA fell from 76% to 40% (p = 0.01) for IgG and 56% to 4% (p = 0.017) for C1q. Six of 9 patients have been transplanted with 5 of the transplanted hearts crossing preoperative donor-specific antibodies. During a median follow-up of 35.1 months, all transplanted patients have survived with only 1 occurrence of treated rejection. Side effects of desensitization included acute kidney injury (67%) and thrombocytopenia (33%) with all episodes self-resolving. A carfilzomib-based desensitization strategy among heart transplant candidates reduces the level of HLA antibodies and complement binding, facilitates successful transplantation, and is associated with excellent outcomes at 3 years.

Racial Disparities in Eligibility for Preemptive Waitlisting for Kidney Transplantation and Modification of eGFR Thresholds to Equalize Waitlist Time.

Patients may accrue wait time for kidney transplantation when their eGFR is ≤20 ml/min. However, Black patients have faster progression of their kidney disease compared with White patients, which may lead to disparities in accruable time on the kidney transplant waitlist before dialysis initiation. We compared differences in accruable wait time and transplant preparation by CKD-EPI estimating equations in Chronic Renal Insufficiency Cohort participants, on the basis of estimates of kidney function by creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys). We used Weibull accelerated failure time models to determine the association between race (non-Hispanic Black or non-Hispanic White) and time to ESKD from an eGFR of ≤20 ml/min per 1.73 m2. We then estimated how much higher the eGFR threshold for waitlisting would be required to achieve equity in accruable preemptive wait time for the two groups. By eGFRcr, 444 CRIC participants were eligible for waitlist registration, but the potential time between eGFR ≤20 ml/min per 1.73 m2 and ESKD was 32% shorter for Blacks versus Whites. By eGFRcys, 435 participants were eligible, and Blacks had 35% shorter potential wait time compared with Whites. By the eGFRcr-cys equation, 461 participants were eligible, and Blacks had a 31% shorter potential wait time than Whites. We estimated that registering Blacks on the waitlist as early as an eGFR of 24-25 ml/min per 1.73 m2 might improve racial equity in accruable wait time before ESKD onset. Policies allowing for waitlist registration at higher GFR levels for Black patients compared with White patients could theoretically attenuate disparities in accruable wait time and improve racial equity in transplant access.

An evaluation of the current status of kidney transplant in terms of the type of receipt among Iranian patients

IntroductionWith the increasing prevalence and incidence of chronic renal failure leading to advanced kidney disease (ESRD), the use of renal transplant therapy is increasing globally. The aim of this study was to determine the status of kidney transplant in patients during a period of 4–5 years.Materials and methodsIn this retrospective, analytical study, patients undergoing renal transplant at one of the hospitals in northern Iran were studied. The data was collected using a checklist assessing the required information, including the age, sex, place of residence, source of the kidney for transplant (living related, living non-related, deceased), kidney receiving method (donated, purchased), and wait time for a kidney transplant.ResultsA total of 228 patients were included in the study, of which 73.7% were male and 26.3% were female. The average wait time for kidney transplant was 386.22 days. The mean age of patients was 32.7 ± 10.7 years. In addition, living non-related (66.2%) and deceased (14%) were the most and least frequent sources of kidney transplant, respectively. Moreover, 51.8% of all transplanted kidneys were purchased.ConclusionOver the past 5 years, there has been a decrease in wait time for kidney transplant in Rasht, Iran. Factors, such as being female, lower age, and living in urban areas, are related to a shorter wait time for kidney transplant. The most common types of kidney transplant are from non-related donors and purchased.

Regional Report on Organ Transplantation in Trinidad and Tobago.

Regional Report on Organ Transplantation in Trinidad and Tobago.

Predictors of long-term employment among patients with cystic fibrosis undergoing lung transplantation.

Lung transplantation is an established therapy in selected patients with advanced cystic fibrosis lung disease. Resumption of employment after lung transplantation is generally supported. In Switzerland, there are no data on long-term employment in people with cystic fibrosis undergoing lung transplantation. In a single-centre, cross-sectional study at a Swiss university hospital, clinical data from lung transplant recipients with cystic fibrosis, covering the transplantation period from January 1996 to December 2016, were analysed retrospectively. The potential influence of pre-lung transplantation factors (age, sex, lung function, body mass index, six-minute walk test distance, lung transplantation wait list time, paid employment on the wait list, education, relationship status, housing situation) and post-lung transplantation factors (chronic allograft dysfunction [CLAD], dialysis, cancer diagnosis [except skin cancer]) on paid employment and work percentage after lung transplantation were investigated using mixed logistic and linear regression models. Descriptive analyses of paid employment were performed for various periods after lung transplantation (<1, 1–3, 3–5, 5–10, >10 years). Data are reported as odds ratios (ORs) or coefficients (β) with their 95% confidence intervals (CIs). Eighty-four subjects (46.4% female) with a mean ± SD age of 29.9 ± 8.4 years were included in the study. Mean wait time for lung transplantation was 42.7 ± 40.2 weeks. The number (percentage) of subjects employed <1 year, 1–3 years, 3–5 years, 5–10 years and >10 years after lung transplantation was n = 23 (28%), n = 51 (65%), n = 44 (75%), n = 30 (68%) and n = 21 (75%), respectively. In mixed logistic regression models, pre-lung transplantation paid employment (OR 24.03, 95% CI 6.08 to 164.39, p <0.0001), academic education (OR 7.81, 95% CI 1.66 to 48.66, p = 0.01) and time post lung transplantation (on log scale, OR 5.81, 95% CI 3.15 to 12.78, p <0.0001) were the main factors influencing post-lung transplantation paid employment status. In mixed linear regression models, pre-lung transplantation paid employment (β = 21.40, 95% CI 10.98 to 31.81, p = 0.00014), academic education (β = 12.54, 95% CI 0.48 to 24.55, p = 0.05) and time post lung transplantation (on log scale, β = 8.96, 95% CI 6.17 to 11.82, p <0.0001) were the main factors influencing work percentage post lung transplantation. No evidence for an influence of clinical factors such as CLAD, cancer or dialysis on post-lung transplantation employment and work percentage was found. Pre-transplant employment is the dominant factor influencing lung transplantation employment in people with cystic fibrosis. People with cystic fibrosis undergoing lung transplantation should be encouraged to work for as long as their health status permits. Professional reintegration after successful lung transplantation should be supported by a multi-disciplinary lung transplant team.

Cardiac donation after circulatory determination of death: protocol for a mixed-methods study of healthcare provider and public perceptions in Canada

IntroductionCardiac transplantation remains the best treatment for patients with end-stage heart disease that is refractory to medical or device therapies, however, a major challenge for heart transplantation is the persistent...

Heart and kidney transplant: should they be combined or subsequent?

AimsEnd‐stage heart failure patients often present with severe kidney failure and have limited treatment options. We compared the clinical characteristics and outcomes among end‐stage heart and kidney failure patients who underwent combined heart and kidney transplant (HKTx) with those who underwent kidney transplant after heart transplant (KAH).Methods and resultsAll patients from 2007–2016 who underwent combined HKTx (n = 715) and those who underwent KAH (n = 130) using the United Network for Organ Sharing database were included. Kaplan‑Meier curves and Cox models compared survivals and identified predictors of death. Number of combined HKTx performed annually in United States increased from 59 in 2007 to 146 in 2016 whereas KAH decreased from 34 in 2007 to 6 in 2016. Among KAH patients, average wait time for kidney transplant was 3.0 years, time to dialysis or to kidney transplant after heart transplant did not differ with varying severity of kidney disease at baseline (P for both >0.05). Upon follow‐up (mean 3.5 ± 2.7 years), 151 patients died. In multivariable models, patients who underwent combined HKTx had 4.7‐fold greater risk of death [95% confidence interval (CI) 2.4–9.4) than KAH patients upon follow up. A secondary analysis using calculation of survival only after kidney transplant for KAH patients still conferred higher risk for combined HKTx patients [hazard ratio (HR) 2.6 95% CI 1.33–5.15]. In subgroup analyses after excluding patients on dialysis (HR 3.99 95% CI 1.98–8.04) and analysis after propensity matching for age, gender, and glomerular filtration rate (HR 3.01 95% CI 1.40–6.43) showed similar and significantly higher risk for combined HKTx patients compared with KAH patients. Lastly, these results also remained unchanged after excluding transplant centres who performed only one type of procedure preferentially, i.e. HKTx or KAH (HR 4.70 95% CI 2.35–9.42).ConclusionsNational registry data show continual increase in combined HKTx performed annually in the United States but inferior survival compared with KAH patients. Differences in patient characteristics or level of kidney dysfunction at baseline do not explain these poor outcomes among HKTx patients compared with KAH patients. Consensus guidelines are greatly needed to identify patients who may benefit more from dual organ transplants.

P1662COMMERCIAL KIDNEY TRANSPLANTATION: PARTICIPANTS' ATTITUDES AND PERCEPTIONS

Abstract Background and Aims Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. The national diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program and to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant. Method A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 28 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. Results One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program. Conclusion Even considering the ongoing ethical debates, number of patients undergoing commercial transplantation is on the rise. The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from cadaveric sources.

The Natural History of Pre-Existing Donor Specific Antibody and Amnestic Responses after Heart Transplantation

Sensitized patients have prolonged wait times for heart transplant and often low-level donor specific antibodies (DSA) will be crossed when accepting a donor heart. The purpose of this study was to determine if positive low-level DSA at the time of transplant increase in strength post transplant and increase the risk of antibody mediated rejection (AMR). We reviewed 72 heart transplant patients between 2010 and 2018 in whom low-level DSA were crossed. DSA strength, as measured by mean fluorescence intensity (MFI) and AMR on biopsy was assessed at 1, 3, 6, 12 months post transplant. Other outcomes assessed: freedom from first-year rejection (acute cellular rejection (ACR), any treated rejection (ATR)), freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), and freedom from graft dysfunction (LVEF ≤40%). Patients were compared to a contemporaneous control group conditional to 1-year survival without DSA at transplant. Approximately one-third of patients with pre-existing DSA at transplant demonstrated an increase in DSA strength. Patients with pre-existing DSA had decreased freedom from ATR and AMR but no differences in freedom from CAV, graft dysfunction, or ACR compared to the control group. Crossing low-level DSA may increase the risk of AMR, but there is no difference in clinically important sequelae such as CAV or graft dysfunction. Thus, accepting low-level DSA at the time of transplant appears feasible and could broaden the donor pool.

Carfilzomib for Heart Transplant Desensitization

Allosensitization in heart transplant (HT) candidates is associated with longer transplant wait times and post-transplant complications. We summarize our experience with desensitization using carfilzomib (CFZ), an irreversible proteasome inhibitor that causes plasma cell apoptosis. One cycle of desensitization consisted of plasmapheresis and CFZ 20mg/m2 on days 1, 2, 8, 9, 15, and 16 with intravenous immune globulin 2g/kg after CFZ on day 16. Patients underwent repeat cycles as indicated. We summarize treatment impact by depicting calculated PRA (cPRA) for neat combined Class I and II IgG and C1q pre- and post-treatment using a cutoff for cPRA entry of ≥ 4000 and 500 MFI, respectively. We fit a linear mixed model to evaluate treatment effect. From June 2013 to October 2019, 9 patients underwent 20 cycles of CFZ with 6 requiring multiple cycles. Each cycle of CFZ resulted in an average cPRA decrease of 33% (95% CI: 16-50) for combined IgG and 36% (95% CI: 17-55) for C1q. An example is shown in Figure 1. From treatment start to finish, mean cPRA fell from 76% to 35% (p=0.005) for combined IgG and 56% to 4% (p=0.017) for C1q (Table 1). Six of 9 patients have been transplanted with 5 of the transplanted hearts crossing historical antibodies. HT survival at 1 year was 100%. Patient 6 has not been transplanted due to obesity. Patients 3 and 4 only received 4 doses of CFZ due to acute kidney injury, which resolved. Neutropenia, thrombocytopenia, neuropathy, and hepatotoxicity did not occur. CFZ, as part of a desensitization regimen, appears to be safe and effective in sensitized patients awaiting HT. The number of cycles may depend on the HLA antibody titer prior to treatment.

DONOR SELECTION IN PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES

As limited donor hearts can lead to a prolonged wait time for heart transplantation (HTX), many candidates undergo implantation of durable left ventricular assist device (LVAD) as a bridge to HTX. We hypothesize that due to high surgical complexity of LVAD explant with HTX, transplant programs may

SAT-297 KIDNEY TRANSPLANTATION RECIPIENTS’ EXPERIENCE IN ORGAN TRAFFICKING

Kidney transplantation is the gold standard for patients with end-stage kidney disease. In view of shortages of available organs, long wait times for possible transplantation, and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for patients with end-stage kidney disease to elect for commercial transplant. A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. One hundred and fifty patients were approached to participate and 106 agreed. Of the participants, 60% were male with an average age of 41.5 (SD 14.8) years and ranged from 18 to 83 years. The majority (82%) of our participants were educated ranging from primary to college level. The major reason (71%) for these participants to obtain commercial transplants was stated as the unavailability of a live related donor. Thirteen percent stated that they objected to getting a kidney donated from a family member, and 9% stated that they were worried about taking a kidney from a family member. Finally, 3% of participants stated that they needed prompt transplant and could not wait for a long time for transplant investigations and the workup associated with this program. The study showed that patients often travel outside their country border to seek medical treatment for ESKD through organ transplantation due to the lack of a strong health system that provides all necessary tools of care. Oman, similar countries in the regions, and various other countries around the world must empower their citizens, provide the care required to improve their lives, and preserve dignity and human values. Efforts must therefore be directed towards strengthening the national program with full logistic, financial, and strong legislation to protect human lives locally, regionally, and globally and must collaborate with international efforts to combat organ trafficking and commercialism and to encourage the notion of humanity’s best interest.

Patient’s Perspectives of Experimental HCV-Positive to HCV-Negative Renal Transplantation: Report from a Single Site

Background: With growing transplant wait times, clinical trials are evaluating the safety and efficacy of transplanting HCV-infected donor (HCV+) organs into HCV-noninfected recipients (HCV D+/R-). Such transplants raise ethical questions about safety, consent, and access to organs. Methods: We interviewed eight of the ten total HCV D+/R- transplant recipients enrolled in a pilot clinical trial examining the safety and feasibility of these novel transplants regarding their experiences in the trial, including their decision-making and perceptions of the informed consent process. Results: All interviewees reported positive experiences and expressed confidence regarding their decision to participate. Participants accepted an HCV + organ based on their assessments of the risks and potential benefits of HCV D+/R- transplants. For many, the risks of HCV were minimal compared to the risks of not receiving a transplant. All participants recalled providing informed consent, reporting that the process was thorough and that all their questions were addressed. Participants did not regret receiving an HCV D+/R- transplant and did not report experiencing stigma. However, given their understanding of HCV cure rates in the general population and the survival benefit associated with kidney transplantation, participants may have conflated research regarding HCV D+/R- transplantation with clinical care, suggesting a potential therapeutic misconception. Conclusions: Recipients of experimental HCV D+/R- transplants generally seemed to recognize the risks and benefits of these novel transplants and did not regret participating. Such salutary reported experiences are important in assessing the appropriateness of further research into the feasibility of HCV D+/R- transplants.

Journal Club - Endobronchial Valve Bronchoscopic Lung Volume Reduction.

It is estimated that approximately 3.5 million American adults have been diagnosed with emphysema, an irreversible destruction of the alveolar lung parenchyma. In advanced cases, the lung damage is so severe that significant air trapping occurs and does not improve with the use of bronchodilators and other conventional medicines used for chronic obstructive pulmonary disease (COPD). Viable surgical options include bullectomy, lung volume reduction surgery (LVRS), and lung transplantation but many patients may not be appropriate candidates for these procedures and/or there are long wait times for transplantation. Recently, the U.S. Food and Drug Administration (FDA) approved the Zephyr® endobronchial valve (EBV) (Zephyr Valve EBV; Pulmonx Corporation, Redwood City, California) for bronchoscopic lung volume reduction for patients with severe emphysema who are not responsive to medical therapy. This 1-way valve, the size of a pencil eraser, is inserted into the targeted diseased portion of the lung. Typically, 4 to 8 valves are inserted into the chosen emphysematous lobe and will allow air to escape out of that region but prevent any further air from entering, leading to deflation, and ultimately, total lobar collapse over a matter of weeks. An earlier study with the Zephyr® valves, the “Endobronchial Valve for Emphysema Palliation Trial, (VENT)” study,1 was a multicenter trial with 321 participants (220 with EBV insertion) that demonstrated statistically significant improvements in forced expiratory volume in 1 second (FEV1) and the 6-minute walk distance test (6MWD) between EBV and standard of care (SoC) groups but these were not clinically meaningful differences (mean change in FEV1 was 60 mL and median difference from baseline 6MWD 19.1 m).1 Post hoc analysis indicated that the best responders were those who demonstrated the following criteria: little to virtually no collateral ventilation to ipsilateral adjacent lobes, complete lobar occlusion achieved with the correct occlusive positioning of the valves in all segmental and sub-segmental airways and complete intact fissures between lobes.2,3 With this information, Pulmonx developed a unique technology-- Chartis (Pulmonx Corporation, Redwood City, California) a device that tests for collateral ventilation to judge the appropriateness of valve insertion.4 The Chartis system consists of a console connected to a balloon catheter with a central channel that is used to occlude the target lobe and to subsequently measure pressure and flow to calculate resistance to airflow and hence to quantify collateral ventilation in that lobe.4 More recently, advanced computed tomography (CT) scan analysis techniques have been developed that can virtually eliminate the need for testing with the Chartis system.5,6 Advanced CT analysis techniques have become a key element of deciding on the appropriateness of candidates. This has been confirmed with several short-term single center studies.2,7,8 The FDA actually granted the Zephyr® valve “breakthrough device” designation, allowing the FDA to provide guidance on efficient device development and to expedite evidence generation and review of the device. This designation generally signals the recognition that there are relatively few viable options for treating the targeted patient population. Indeed, the first study we review by Criner and colleagues, LIBERATE (below) is the first large, prospective, randomized controlled, multicenter study to evaluate the effectiveness, safety and durability of the benefit out to 12 months in patients with severe heterogeneous emphysema and with little to no collateral ventilation in the target lung. In order to expedite approval, the FDA required that, compared to previous studies, the primary endpoints show a greater magnitude of difference between Zephyr valve insertion and SoC versus a sham procedure and then SoC. In this Journal Club we will review this pivotal study that led to the approval of the Zephyr® valve in the United States and other recent studies that have evaluated the efficacy and safety of this device. Note: Abstracts are presented in their original, published format and have not been edited to match JCOPDF style.

Abstract 17340: Disparities in Wait Times for Heart Transplant by Racial and Ethnic Minorities

Introduction: Although wait times vary widely across geographic regions and blood type under the current allocation system, it is unclear if minority patients have longer waitlist times. Hypothesis: We hypothesized that racial/ethnic minority patients experience longer wait times to transplant, even after accounting for age, gender, blood type, heart failure severity defined by UNOS status, and region. Methods: Patients listed for first transplant from 2005-2016 in the UNOS database were analyzed by racial/ethnic groups: African-American (AA), Hispanic, White (Non-Hispanic) and Other. We estimated median time to transplant for each group by year of listing using cumulative incidence functions and accounted for competing risks of waitlist mortality and delisting. For 2015-2016, we performed multivariable cause-specific Cox regression modeling accounting for age, gender, UNOS status urgency (status 1A, 1B, 2, 7) ABO blood type, and region by organ procurement organization. The reference population was Whites. Results: A total of 36,801 patients (21.5% AA, 7.8% Hispanic, 4.0% Other and 66.6% White) were available for analysis. Since 2005, the proportion of AAs on the waitlist has increased slightly, while the proportion of Whites has decreased. Wait times increased to a peak in 2014 for all ethnic/racial groups, but were disproportionally increased for AAs. In 2015-2016 this disparity persisted but was less pronounced compared to prior years. ( Figure ) After multivariable adjustment, the Hazard Ratio for time to transplant in AAs was 0.90 (95% CI 0.83 – 0.96) compared to Whites, with no prolonged time to transplant for other minorities. Conclusions: AAs experience disproportionally long wait times for heart transplant, which could not be explained by traditional determinants of time to transplant. How the new allocation system implemented in 2018 will impact this disparity should be a focus for ongoing population health research.

Transplantation Tourism and Recipients Perspectives and Experience

Background and Objectives Kidney transplantation is the gold standard for patients with end- stage kidney disease (ESKD). In view of shortages of available organs, long wait times for possible transplantation and strict regulation, many patients opt for commercial transplantation. This study elicits the reasons and motivations for ESKD patients to elect for commercial transplant. Design, Setting, Participants & Measurements A questionnaire-based evaluation was conducted during the period from July 2015 until late December 2015. It consisted of 29 multiple choice questions and was distributed to all patients who underwent commercial kidney transplantation. Results One hundred fifty patients were approached to participate and 106 agreed to participate. Of the participantsConclusions The study showed that the most common underlying cause for seeking commercial transplantation is the unavailability of a national transplant program, particularly transplantation from deceased sources. All western ethical arguments turn out to become of vital importance in developing countries, because transplantation is the cheapest renal replacement therapy. However, it must be emphasized that commercial transplants should not be an alternative to building a national transplant initiative. National diseased program must be a priority with full financial and administrative support. All government agencies including religious affairs must work together to support the program to provide the citizens with a good transplantation service and ameliorate the impact of commercial transplantation.

Transplantation of hepatitis C virus infected kidneys into hepatitis C virus uninfected recipients.

Long wait times for kidney transplant and the high risk of mortality on dialysis have prompted investigation into strategies to increase organ allocation and decrease discard rates of potentially viable kidneys. Organs from hepatitis C virus (HCV) antibody positive donors are often rejected; nearly 500 HCV-infected kidneys are discarded annually in the United States. Due the opioid epidemic, the number of HCV-infected donors has increased because of a rise in both new HCV infections and drug-related deaths. In the past 5 years, HCV has been transformed into a curable illness with direct-acting antiviral therapies (DAAs) that are effective in >95% of patients treated and are extremely well tolerated. Recent data has shown several direct-acting antiviral combinations are safe and effective after kidney transplant, and can achieve the same high cure rate seen in the general population and without increasing the rate of acute rejection. Because of this, strategies to decrease discard of HCV-infected organs have been devised. Two recent studies have transplanted HCV-uninfected dialysis patients with kidneys from donors actively infected with HCV; recipients were treated with DAA in the peri-transplant period. More research is needed to determine the safety and efficacy of this approach, but it has the potential to dramatically increase the donor pool of available kidneys, shorten waitlist times and ultimately decreases mortality in patients waiting for kidney transplant.

Trends in Characteristics of Patients Listed for Liver Transplantation Will Lead to Higher Rates of Waitlist Removal Due to Clinical Deterioration.

Changes in the epidemiology of end-stage liver disease may lead to increased risk of dropout from the liver transplant waitlist. Anticipating the future of liver transplant waitlist characteristics is vital when considering organ allocation policy. We performed a discrete event simulation to forecast patient characteristics and rate of waitlist dropout. Estimates were simulated from 2015 to 2025. The model was informed by data from the Organ Procurement and Transplant Network, 2003 to 2014. National data are estimated along with forecasts for 2 regions. Nonalcoholic steatohepatitis will increase from 18% of waitlist additions to 22% by 2025. Hepatitis C will fall from 30% to 21%. Listings over age 60 years will increase from 36% to 48%. The hazard of dropout will increase from 41% to 46% nationally. Wait times for transplant for patients listed with a Model for End-Stage Liver Disease (MELD) between 22 and 27 will double. Region 5, which transplants at relatively higher MELD scores, will experience an increase from 53% to 64% waitlist dropout. Region 11, which transplants at lower MELD scores, will have an increase in waitlist dropout from 30% to 44%. The liver transplant waitlist size will remain static over the next decade due to patient dropout. Liver transplant candidates will be older, more likely to have nonalcoholic steatohepatitis and will wait for transplantation longer even when listed at a competitive MELD score. There will continue to be significant heterogeneity among transplant regions where some patients will be more likely to drop out of the waitlist than receive a transplant.