Waitlist Time Research Articles

Long surgical waiting list times are associated with an increased rate of negative ureteroscopies.

Negative ureteroscopy (NURS) is "a ureteroscopy in which no stone is found during the procedure." We aimed to determine the association between the surgical waiting list time (WLT) and the NURS rate. We retrospectively analyzed all patients scheduled for ureteroscopy in our center between January 2017 and July 2019. The inclusion criterion was unilateral, semirigid ureteroscopy for a single ureteral stone; exclusion criteria were renal-only stones, incomplete ureteroscopy, and stones >10 mm. We analyzed age; gender; body mass index; stone size, density, and location; presence of a temporary double-J (DJ) stent; use of medical expulsive therapy; and WLT. Complications while waiting for surgery were also collected and analyzed. We included 219 patients, 41 (18.7%) of whom had NURS. The median WLT was 74 days (interquartile range [IQR] 45-127). Variables protective against NURS were large stone size (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.66-0.93), presence of a temporary DJ stent (OR 0.43, 95% CI 0.2-0.8), and radiopaque stones (OR 0.44, 95% CI 0.21-0.88). A long WLT ((≥60 days) increased the risk of NURS (OR 2.18, 95% CI 1.02-4.61). Complications requiring emergency department visits while waiting for surgery were documented in 58/137 (42.3%) patients with indwelling DJ stents; nonetheless, a WLT greater than the median was not associated with an increased risk of complications (p=0.38). Long WLT has an independent, direct, and linear correlation with NURS rates. Patients at higher risk of NURS, may be offered preoperative re-evaluation with a computed tomography scan in a resource-limited setting.

Equity in kidney transplant allocation - North American perspective.

Seven years have passed since the implementation of the kidney allocation policy by the Organ Procurement and Transplantation Network in the United States, the purpose of this article is to review the impact of these policy changes in addressing disparity and inequities in access to transplantation as well as to assess future directions needed in achieving equity in kidney transplantation. The 2014 kidney allocation system policy aimed to improve access to transplantation through various approaches by reducing organ/recipient longevity mismatches, prioritizing highly sensitized patients, and backdating waitlist time to start of dialysis. The policy however did not improve utilization of high-kidney donor profile index kidneys or decrease kidney discard rate. Although the supply-to-demand gap for waitlisted patients has decreased there are several areas that need further investigation, including geographic disparity, barriers in referral for transplantation, evaluating the impact of transplant education, and transplant center waitlist practices on inequities that exist in the prewaitlist stage that impact access to transplantation.

Gender and racial disparities in lung transplantation in the United States

Lung transplant (LT) allocation utilizes a scoring system to prioritize patients, although data evaluating the access by gender and race remains limited. The study objective was to determine whether gender and racial disparities exist in patients listed for LT.This was a retrospective analysis using the Organ Procurement and Transplant Network database of patients listed for a LT from 1984 until 2019. Nominal multivariate logistic regression analysis was performed to evaluate LT allocation by gender, race, and primary lung disease. Kaplan-Meier curves were constructed to compare rates of mortality over time.Sixty thousand eight hundred and forty-seven patients were listed between February 1984 and September 2019. Males comprised the majority of listed and transplanted patients at 51.7% and 55.8% respectively. In the LAS era, the median waiting list time for transplanted males was 43 days (interquartile range [IQR] 13-126), and females waited a median of 80 days (IQR 24-233) (p < .001). Persons of White race accounted for 82.6% and 84.3% of listed and transplanted patients respectively. Logistic regression analysis found that in the LAS era, males had an increased odds for LT allocation (OR 1.19, CI 1.12-1.27, p < .001) compared to females, and persons of White race (OR 1.23, CI 1.16-1.32, p < .001) compared to all other races combined.The majority of listed and transplanted patients in the United States were males and persons of White race. Also, being a male or person of White race had an outcome favoring lung transplant allocation compared to an appropriately matched person of another gender or race.

Neutrophil-to-Lymphocyte Ratio Predicts High-Risk Explant Features and Waitlist Survival But Is Not Independently Associated With Recurrence or Survival Following Liver Transplantation for Hepatocellular Carcinoma.

We assessed the prognostic significance and the clinical stability of the neutrophil-to-lymphocyte ratio (NLR) before liver transplantation (LT) in a large cohort of patients with hepatocellular carcinoma (HCC) from a region with a long waitlist time. A high preoperative NLR ≥5 has been reported to predict poor outcomes following LT for HCC, and the NLR has been incorporated into several prognostic models. We evaluated 758 patients with HCC with Model for End-Stage Liver Disease exceptions and listed for LT from 2002 to 2015 at a single LT center, of which 505 underwent LT and 253 dropped out before LT. The NLR was collected in all patients at LT and, if available, between 15 and 90days before LT (NLR2) or at dropout. An NLR≥5 was associated with microvascular invasion (MVI), poorer tumor differentiation, and more advanced pathology on explant. Patients with an NLR≥5 exhibited no differences in alpha-fetoprotein, tumor burden at listing, or number of locoregional therapies compared with patients with an NLR<5. After a median post-LT follow-up of 4.7years, overall survival and recurrence rates were similar for patients with an NLR≥5 versus patients with an NLR<5. The NLR changed frequently, and 47% of patients whose NLR2 was≥5 had an NLR<5 by LT. The NLR was≥5 in 47.6% of patients at dropout compared with 14.9% of patients undergoing LT. Although the NLR at LT correlated with MVI and tumor stage at explant, the NLR did not predict post-LT survival or HCC recurrence. The NLR appeared to be a relatively unstable inflammatory marker during the immediate 3 months before LT for HCC.

HLA Desensitization in Solid Organ Transplantation: Anti-CD38 to Across the Immunological Barriers.

The presence of anti-human leucocyte antigen (HLA) antibodies in the potential solid organ transplant recipient’s blood is one of the main barriers to access to a transplantation. The HLA sensitization is associated with longer waitlist time, antibody mediated rejection and transplant lost leading to increased recipient’s morbidity and mortality. However, solid organ transplantation across the HLA immunological barriers have been reported in recipients who were highly sensitized to HLA using desensitization protocols. These desensitization regimens are focused on the reduction of circulating HLA antibodies. Despite those strategies improve rates of transplantation, it remains several limitations including persistent high rejection rate and worse long-term outcomes when compare with non-sensitized recipient population. Currently, interest is growing in the development of new desensitization approaches which, beyond targeting antibodies, would be based on the modulation of alloimmune pathways. Plasma cells appears as an interesting target given their critical role in antibody production. In the last decade, CD38-targeting immunotherapies, such as daratumumab, have been recognized as a key component in the treatment of myeloma by inducing an important plasma cell depletion. This review focuses on an emerging concept based on targeting CD38 to desensitize in the field of transplantation.

Bridging With Extracorporeal Membrane Oxygenation Under the New Heart Allocation System: A United Network for Organ Sharing Database Analysis.

The effect of the new donor heart allocation system on survival following bridging to transplantation with venous-arterial extracorporeal membrane oxygenation remains unknown. The new allocation system places extracorporeal membrane oxygenation-supported candidates at the highest status. The United Network for Organ Sharing database was queried for adults bridged to single-organ heart transplantation with extracorporeal membrane oxygenation from October 2006 to February 2020. Association between implementation of the new system and recipient survival was analyzed using Kaplan-Meier estimates, Cox proportional hazards models, and propensity score matching. Of 364 recipients included, 173 and 191 were transplanted under new and old systems, respectively. Compared with the old system, waitlist time was halved under the new system (5 versus 10 days, P<0.01); recipients also demonstrated lower rates of prior cardiac surgery (32.9% versus 44.5%, P=0.03) and preoperative ventilation (30.6% versus 42.4%, P=0.02). Unadjusted 180-day survival was 90.2% (95% CI, 84.7%-94.2%) and 69.6% (95% CI, 62.6%-76.1%) under the new and old systems, respectively. Cox proportional hazards analysis demonstrated listing and transplantation under the new system to be an independent predictor of post-transplant survival (adjusted hazard ratio, 0.34 [95% CI 0.20-0.59]). Propensity score matching demonstrated a similar trend (hazard ratio, 0.36 [95% CI, 0.19-0.66]). Candidates listed under the new system were significantly less likely to experience waitlist mortality or deterioration (subhazard ratio, 0.38 [95% CI, 0.25-0.58]) and more likely to survive to transplant (subhazard ratio, 4.29 [95% CI, 3.32-5.54]). Recipients transplanted following extracorporeal membrane oxygenation bridging to transplantation under the new system achieve greater 180-day survival compared with the old and demonstrate less preoperative comorbidity. Waitlist outcomes have also improved significantly under the new allocation system.

DONOR CHARACTERISTICS AND RECIPIENT OUTCOMES AFTER HEART TRANSPLANTATION IN ADULT CONGENITAL HEART DISEASE

Background Patients with adult congenital heart disease (ACHD) experience long waitlist times for heart transplantation (HTx) while a large proportion of donor hearts are refused. The goal of this ...

Current opinion in pediatric heart transplantation.

Cardiac transplant remains the most effective therapy for children with end-stage heart disease. Outcomes remain better than any alternative therapy for this condition, but its use is limited by donor organ availability. As a result, waitlist times and mortality on the waiting list remain unacceptably high. Novel approaches are necessary to address this problem. Organ Procurement and Transplant Network/United Network for Organ Sharing readjusted the pediatric heart allocation system in 2016 to prioritize children at highest risk of mortality, encourage judicious listing, and improve appropriate donor organ utilization. Subsequent studies have aligned with these priorities to help risk-stratify patients at the time of listing and identify the importance that should be assigned to donor-specific factors. In addition, many authors are advocating for increased utilization of hearts donated after cardiac death. Pediatric Ventricular Assist Device (VAD) application has also been increasing to help decrease waitlist mortality. Although results have significantly improved, there remain important limitations to widespread use of VADs in the pediatric population. This has prompted novel techniques such as pulmonary artery banding to improve cardiac function and, in some cases, promote recovery. The demand for cardiac replacement continues to increase with an ageing population of patients with congenital heart disease, presenting new challenges and stressors to the system. Pediatric cardiac transplant outcomes are excellent but remain plagued by the limited supply of donor organs. Recent strategies to combat this problem have focused on judicious listing, maximal utilization of available donor organs, and safely extending the lives of patients on the waitlist. New demands on the organ supply chain will continue to stress the system, making these efforts of the highest importance.Clinical Trial Registry Number not applicable.

Percutaneous transcystic removal of gallbladder and common bile duct stones: a narrative review.

The incidence of gallstone-related complications is rising, thus leading to increases in waiting list times for elective laparoscopic cholecystectomy (LC). Percutaneous cholecystostomy (PC) provides immediate biliary drainage and may be used as an emergency option in a critically unwell patient as a bridge to surgery, or as the management option of a patient who is not fit for surgery. However, a significant number of these patients may be readmitted after PC with recurrent acute cholecystitis or pancreatitis, leading to significant morbidity and mortality. The aim of the present review was to analyze the available literature surrounding the use of the transcystic approach, including the extraction and balloon expulsion method, in the management of patients with gallbladder stones and/or common bile duct (CBD) stones. The full text of 18 articles were reviewed, of which four were included in this review. Results showed an overall success rate of CBD stone extraction in 118 of 139 patients (84.9%), gallbladder stone extraction in 97 of 114 (85.0%), and CBD stone expulsion in 27 of 29 (93.1%). Percutaneous CBD and gallbladder stone extraction may be a safe management option for elderly or co-morbid patients who are not appropriate for surgical intervention. However, the evidence base surrounding this is very limited; therefore, further research is required in order to evaluate this in more detail.

Untreated dental disease and lung transplant waitlist evaluation time for individuals with cystic fibrosis.

Dental clearance is typically part of the evaluation process prior to placement on the lung transplant waiting list. Individuals with cystic fibrosis (CF) are thought to be at low risk for dental disease. We hypothesized that individuals with CF in need of lung transplantation would have lower dental disease prevalence and shorter waitlist evaluation time than individuals with non-CF lung diseases. We conducted a retrospective study of individuals who received a lung transplant between 2011 and 2017 at the University of Washington (Seattle, WA, USA) (N=280). Untreated dental disease was assessed by the individual's dentist. Waitlist evaluation time was defined as the time, in days, from the initial evaluation by a transplant pulmonologist to placement on the lung transplant waiting list. We used logistic and linear regression models for hypothesis testing. The prevalence of untreated dental disease did not differ by CF status (p=0.99). There was no difference in waitlist evaluation time for transplant recipients by CF status (p=0.78) or by dental disease status (p=0.93). Our findings provide further evidence that individuals with CF are not at low risk for dental disease. Ensuring optimal oral health is important for all individuals with lung diseases.

Taking a Closer Look at Distance: Does Increasing the Maximal Donor Distance Range Shorten Waitlist Times in Pediatric Heart Transplant Candidates?

<h3>Purpose</h3> Data suggest that pediatric heart transplant (HT) centers can reduce waitlist time by expanding donor catchment vis expanded parameters including the maximal donor weight range. Contrary to donor weight ranges, little is known about the effect of increasing the donor distance (DD) range. We sought to determine whether increasing the DD range can reduce waitlist time and how well actual DD predicts ischemic time (IT). <h3>Methods</h3> All US children <18 years listed for HT at centers with ≥20 HT since 2007 were identified using OPTN data. Center variation in maximal DD range, defined as the median value of a center's maximal DD range, was analyzed and compared to actual DD. Pearson correlation was used to examine the correlation between actual DD and IT. Cox proportional hazards analysis was used to determine whether maximal DD range is associated with waitlist time. <h3>Results</h3> Among 4,240 children who met study criteria, the median age was 2 (IQR 0, 11) years, weight 12 (6, 35) kg, 53% had CHD. Centers varied considerably in their maximal DD range (1000-10,000 miles); median 1500 miles (Figure A). Overall, 86% of donors originated from ≤500 miles; 97% ≤1,000 miles (Figures A & B) with sharp drop-offs at 500 and 1000 miles (Figure B). After adjusting for patient factors, maximal DD range was associated with a shorter waitlist time. The correlation between actual DD and IT is fair (R=0.69) but explains only half (R²=0.49) of the variability in IT. <h3>Conclusion</h3> Pediatric HT centers vary considerably in their maximal donor distance ranges, though most donors still fall within 500-1000 miles of recipients. Increasing the maximal DD range appears is associated with a shorter waitlist time. Actual DD explains only half of the variability in IT. Further research is needed to understand the optimal regional sharing distance for organ allocation and whether contemporary navigational software could better predict IT than the linear distance to the donor hospital.

Bridge to Transplant Outcomes with Axillary Intra-Aortic Balloon Pump versus Durable Left Ventricular Assist Device in the Current UNOS Heart Allocation System

Purpose Since the 2018 UNOS Allocation system for heart transplantation change there has been concern for increased wait times for patients with durable left ventricular assist devices (LVAD) as bridge to transplantation (BTT). Furthermore, there are increasing trends to utilize axillary intra-aortic balloon pumps (Ax-IABP) to optimize cardiac unloading while maintaining ambulatory status in listed hospitalized patients. BTT outcomes data for Ax-IABP patients is limited. Understanding risks vs benefits of prolonged support with Ax-IABP vs LVAD in the current UNOS allocation environment is imperative. Methods We performed a single center retrospective review from October 18, 2017 to October 18, 2019 for all patients who underwent heart transplant. Waitlist times based on device (Ax-IABP or LVAD) to transplant were assessed in addition to time from transplant to discharge. Intraoperative cardiopulmonary bypass time, transfusion requirements and post-operative vasoactive support was also compared. Results 59 heart transplants occurred during our review period. 8 bridged with Ax-IABP (13%) and 22 with LVAD (37%). Average age in both groups was 53 with 75% and 68% males in the IABP and LVAD groups respectively. More LVAD as BTT were transplanted prior to the UNOS change (13 vs. 9). All Ax-IABP patients were transplanted after the UNOS change. Waitlist time for LVAD was higher than Ax-IABP patients (109d vs. 575d, p=0.0003). Waitlist time before and after UNOS change was not statistically different among LVAD patients, but did increase (497d vs 688d, p=0.176). Cardiopulmonary bypass time was longer in LVAD patients, but not significant, despite similar UNOS Status at transplant. More PRBC transfusions in the LVAD group (7.5u, IQR 0u - 24u) compared to the Ax-IABP group (2.6u, IQR 0u - 6u, p=0.0012). Time from transplant to discharge was 25 days for LVAD group and 13 for Ax-IABP group (p=0.075). Conclusion Waitlist time and transfusion requirements are statistically increased in LVAD as compared to Ax-IABP as BTT. In the current listing schema for heart transplant, risk vs. benefit of increased waiting time, perioperative hemodynamic compromise and increased transfusions in the LVAD population pose significant concerns. Further prospective studies with larger cohorts may be needed to better evaluate this trend.

A Case of Occult Myocarditis Causing Fatal Arrhythmia in a Cystic Fibrosis Patient Subjected to Retransplantation

Introduction Myocarditis is an inflammatory process that is caused by several factors including infection, systemic disease and/or exposure to drugs and toxins. Its clinical course is extremely variable, ranging from lack of symptoms to sudden cardiac death. Here we report a case of viral myocarditis in a cystic fibrosis (CF) patient subjected to retransplantation for chronic lung allograft dysfunction (CLAD). Case Report The patient was a 42-year-old male who had undergone his first lung transplant 18 years earlier for cystic fibrosis. He was referred for retransplantation for CLAD. The cardiac tests performed at the time of re-listing, as well as those repeated during waiting list time were unremarkable. Intraoperatively, during the first pneumonectomy, the patient developed an episode of ventricular fibrillation (VF), without recurrence after a single intrathoracic defibrillation. Due to the risk of hemodynamic instability, he was put on veno-arterial extracorporeal membrane oxygenation (ECMO). The remainder of the procedure was uneventful, and, after careful monitoring, ECMO cannulae were removed. Soon after skin closure, however, the patient first experienced multiple episodes of VF that required cardioversion, after which he quickly became asystolic. After one hour of advanced cardiac arrest treatments - including norepinephrine, cardiac massage, reopening of the chest and epicardial pacing - the patient was pronounced dead. At autopsy, coronary artery disease was excluded; the only pathological finding was the presence of multifocal acute myocarditis with fibrosis. Tissue molecular analysis detected high viral copies of Epstein Barr virus and Parvovirus B19. Summary In the present case, most probably, a surgery-induced systemic inflammatory response syndrome, with massive cytokine release, was responsible for precipitating an unsuspected preexisting condition of myocarditis. Recipients who undergo retransplantation for CLAD are severely immunocompromised and at risk of getting different forms of infections. Based on this experience, we suggest that cardiac magnetic resonance imaging be added to the preoperative workup of patient candidates for retransplantation for CLAD, so as to be able to detect potentially life-threatening pathologies of the myocardium with higher sensitivity.

A Multicentric Evaluation of Pediatric Lung Transplantation in Italy

Purpose Pediatric lung transplantation is performed only in high-experienced centers due to the peculiarity of these patients.This has often discussed only by limited case-series; moreover in the international register the data do not frequently report peculiarities of single countries.The purpose of this study was to analyze the results of pediatric lung transplantation in Italy. Methods The multicentric retrospective analysis was carried out on 110 pediatric patients ( Results The population was composed of 44 males and 66 females with a median age of 15 years. The most frequent indication was cystic fibrosis (83%) with a median waiting list time of 235 days.Pre-operatively, 42% of patients were transplanted in emergency setting, assisted by ECMO and/or mechanically ventilation. Median donor Oto Score was 1 while median donor age 15 years with 43% adults (age>= 18 years).A predominance of bilateral transplantation was recorded (98%); in 17% of patients a graft reduction for size mismatch was performed, with lobectomy in 78% of them. Post-operatively, PGD 3 at 72 h was found in 15% of patients while median time for mechanical ventilation, ICU and intra-hospital stay were 48 hours, 11 days and 35 days, respectively. Anastomotic complications were observed in 6.5% of patients.Thirty-days mortality was 6% and 1,5 and 10-years survival 72%, 52% and 33% respectively with a best FEV1 of 84%. 34% of patients experienced chronic rejection with a 5-year CLAD-free survival of 77%; 12.7% of subjects required retransplantation mainly due to CLAD (71%).The univariate analysis for mortality risk factors revealed a direct correlation with Oto Score and BMI. No other influences were observed in particular for graft reduction and donor age. Conclusion This multicentric analysis shows that pediatric lung transplantation in Italy presents results comparable with data reported in the current literature.Particular care should be considered with BMI recipient and donor Oto score. Conversely, adult donors and volumetric graft reductions can be safely used in order to expand the pool of donors, reducing waiting list time and mortality.

Heart Transplantation in Dextrocardia-Heterotaxy Syndrome

Purpose Heart transplantation in infants with dextrocardia-heterotaxy syndrome (HS) presents significant surgical challenges. There is limited data on surgical strategies to accomplish heart transplantation in these children. We report surgical strategy and outcomes of 5 patients with HS who underwent orthotopic heart transplant (HT). Methods Heart transplantation in children with HS between 2017-2020 in a tertiary care children's hospital were reviewed. Perioperative characteristics and post-operative outcomes of these 5 patients were obtained. All patients underwent pre-transplant volumetric analysis with chest computerized tomography scan to predict maximum donor size and orthotopic HT with the donor heart placed in a levoposition. Furthermore, recipient systemic veins were routed to the donor heart using extra-cardiac conduits and baffle techniques. Outcomes were compared with 10 size-matched HT patients who had no HS. Results For HS patients the median age at HT was 439 days (IQR:89-716), median weight was 8.4 kg (IQR: 4.1-10.8). For HS pts; waitlist time was 43 vs 38 days (p=0.68), median pulmonary artery pressure was 24 vs 20 mmHg (p=0.5), transpulmonary gradient was 13 vs 8 mmHg (p=0.68). There was no significant difference between groups relative to cardiopulmonary by-pass time (230 vs 163 min, p=0.13), graft ischemic time (196 vs 218 min, p=0.08), and mechanical ventilation time after HT (3.3 days vs 1.08 days, p=0.14). The length of hospital stay was longer for HS patients compared to the control group (99 vs 50 days, p=0.04). At almost one year of post-transplantation follow-up, no patient had rejection or required hospitalization for any infectious etiology in HS group. One patient required cardiac catheterization intervention of the extra-cardiac conduit between superior vena cava and right atrium. To date; all patients in HS are still alive except for one patient who died 8 months post-transplantation. Conclusion HT in infants is feasible with comparable one-year outcomes as other infants undergoing HT. Detailed preoperative planning using computed tomography volumetric analysis to define appropriate donor size and use of extra-cardiac systemic venous conduits facilitates successful HT in small infants with HS.

Waitlist Weight Changes Impact Survival Following Heart Transplantation

<h3>Purpose</h3> The purpose of this study was to investigate the impact of weight change in waitlisted candidates on posttransplant outcomes following orthotopic heart transplantation (OHT). <h3>Methods</h3> The UNOS database was queried to identify adult (≥18 years) patients undergoing isolated, primary OHT from 1/1/2010 to 3/20/2020. Percent weight change was calculated from time of waitlisting to OHT, and patients were stratified into 3 cohorts based on weight change. The primary outcome was one-year survival among cohorts, and multivariable Cox Proportional Hazards modeling was used for risk-adjustment, including adjustment for time spent on waitlist. A secondary analysis was conducted to compare outcomes of recipients waitlisted ≥90 days. <h3>Results</h3> 57,107 patients were included, 48,299 (84.6%) with stable weight, 2,927 (5.1%) with ≥5% weight loss, and 5,881 (10.3%) with ≥5% weight gain. Median age was similar across cohorts with predominantly white recipients with non-ischemic cardiomyopathy. Waitlist time was longest in patients with weight gain and shortest in those with stable weight (417 vs 74 days, P<0.001). Patients with weight loss had higher rates of dialysis dependency, pacemaker, and drug-treated acute rejection at one year (all P<0.05). Ninety-day and one-year posttransplant survival was lowest in the weight loss (Figure). Multivariable modeling identified both ≥5% weight loss (HR 1.26, 95% CI 1.07-1.48) and decreasing weight (per 1%, HR 1.02, 95% CI 1.01-1.03) as risk-adjusted predictors of one-year mortality. In sub-analysis of OHT recipients waitlisted ≥90 days, ≥5% weight loss (HR 1.33, 95% CI 1.11-1.61) and decreasing weight (per 1%, HR 1.02, 95% CI 1.01-1.03) remained significant predictors of one-year mortality. <h3>Conclusion</h3> OHT recipients with ≥5% weight loss while on the waitlist comprise a small, but higher risk population with increased rates of postoperative complications and decreased survival. Efforts focused on nutritional optimization and preventing weight loss while awaiting OHT appear warranted.

A Novel Post-Transplant Multimodal Antibody Management Protocol for Highly Sensitized Lung Transplant Recipients

<h3>Purpose</h3> In lung transplant candidates with a high-calculated panel reactive antibodies (cPRA), the waitlist time and risk of death are considerable. Additionally, the presence of post-transplant HLA antibodies is associated with chronic lung allograft dysfunction (CLAD) and mortality. Our center designed a post-transplant multimodal antibody management protocol (PMAMP) in an effort to alter immune response and minimize antibody development of highly sensitized recipients (cPRA > 80) with the goal of improving transplant outcomes. <h3>Methods</h3> This is a single center, retrospective evaluation of our PMAMP. Lung transplant recipients with cPRA >80% were eligible for our PMAMP (Table 1). From April 2019 to April 2020, there were 5 eligible patients who underwent transplant. For comparison, matched historical control data was collected from 7 highly sensitized patients who underwent transplant from March 2003 to September 2008 but did not receive PMAMP. Demographics and outcome data were collected. <h3>Results</h3> Demographics and outcomes are described in Table 2. To date, all 5 patients who underwent PMAMP are alive with CLAD-free survival and no episodes of rejection with a median transplant follow-up time of 427 days. Of note, all patients in both groups experienced at least one infectious complication following transplant. <h3>Conclusion</h3> Our PMAMP shows promise for mediating CLAD-free survival, rejection, and extending post-transplant survival in highly sensitized candidates undergoing lung transplant; however, more data and follow-up is needed to ensure the safety and efficacy of this protocol.

The Waiting Game: Waitlist Times and Outcomes for Highly Sensitized Patients in the New Heart Transplant Allocation System

<h3>Purpose</h3> In 2018, United Network of Organ Sharing (UNOS) changed the heart allocation system to better stratify higher acuity patients and provide more equitable geographic distribution. However, they did not prioritize recipient allosensitization which can be a barrier to organ access. We analyzed outcomes based on sensitization in the modern era and the impact of the new allocation system on sensitized patients. <h3>Methods</h3> UNOS data from 3/31/2015-6/12/2020 was analyzed. Multi-organ transplants were excluded. Recipient, donor, and transplant characteristics were analyzed. Patients were stratified by cPRA level 0, 1-49, 50-79, and ≥ 80. Waitlist days prior to transplant, survival, and treated rejection pre and post allocation system change were analyzed. Survival was estimated using Kaplan-Meier methods and the log-rank test. <h3>Results</h3> Total of 10598 patients were included and evaluated by cPRA (Table). Patients with higher cPRA were more likely to be younger, African American, and female. Higher cPRA patients weighed less and were more likely to have non-ischemic cardiomyopathy, congenital disease, or be a retransplant. Waitlist days were significantly lower in the new allocation system for cPRA groups 0, 1-49, and 50-79 (p<0.0001) and there was a trend toward fewer waitlist days for cPRA ≥ 80 (p=0.062). Treated rejection during the transplant hospitalization and in the first year was significantly higher as cPRA increased (p<0.0001). However, when compared pre- and post-allocation change, there was no significant difference in long term survival across cPRA groups (p=0.531). <h3>Conclusion</h3> The new heart allocation system did not discriminate against sensitization, but rather facilitated a reduction in wait time for all but the most highly sensitized recipients. This may relate to increased access to appropriately matched donor organs through broader geographic sharing, but further investigation is needed.

Landscape of Heart Transplantation Following Changes in UNOS Donor Allocation Policy

<h3>Purpose</h3> The new donor heart allocation policy in United States, which prioritizes the most urgent patients on the waitlist, may affect post-transplant care and outcomes. The objective of this study was to analyze national transplantation outcomes and the use of temporary mechanical circulatory support before and after the implementation of the new allocation system. <h3>Methods</h3> A retrospective review of the UNOS registry of all heart transplants performed between April 2018 and April 2019 (n=3431) was performed. Patients were divided according to their allocation status and whether they underwent transplantation prior to the allocation change (n=2143) or after (n=1288). <h3>Results</h3> The proportion of patients listed in the urgent status of 1,2 or 3 (77%) was significantly higher than status 1A (69%), while the proportion of patients in status 4 listing (19%) was significantly lower than status 1B (27%). The use of ECMO significantly increased from 1% prior to the change in allocation to 5% after the implementation of the new allocation system, with no differences in survival (76% vs. 79%, respectively). No significant changes in the use of temporary microaxial support devices (Impella) were observed. Survival was reduced from 98% prior to the change in allocation to 77% in the new allocation schema (p=0.006). IABP utilization significantly increased in the new allocation system (8% to 23%), with no significant changes in survival. <h3>Conclusion</h3> The utilization of ECMO and IABP in United States increased under the new donor allocation system, and was associated with high proportion of patients classified as status 1,2 and 3 compared to status 1A. While the new allocation prioritizes reduction in waitlist time and mortality, we observed higher post-transplant mortality in status 1, 2, 3 and 4 patients. Thus, lower mortality on the waitlist may be annulled by higher post-transplant mortality.

Comparison of Six-Month Post-Transplant Survival before and after Implementation of the 2018 UNOS Allocation Policy Change

<h3>Purpose</h3> The intent of the UNOS allocation system change was to better prioritize heart transplantation (HT) for the most critically ill patients. Here, we explore six-month post-transplant survival of HT patients one year before (PRE) and after (POST) the allocation change (10/18/2018). <h3>Methods</h3> We identified all adult patients (N=3776) that underwent HT between 10/18/2017 to 10/17/2019. There were 1741 patients in the PRE group and 2035 in the POST group. Baseline clinical characteristics were compared using Mann-Whitney U test and Chi-square test as appropriate. Survival analysis was performed using Kaplan-Meier analysis and both Univariate and Multivariate Cox Proportional Hazards (PH) regression analysis adjusted for policy change, recipient age, donor age, bilirubin, creatinine, dialysis use, ischemic time, ventilator use, and ECMO use. <h3>Results</h3> There was a significant reduction in six-month survival in the POST vs. PRE group (92% vs 94%, p=0.04). On univariate analysis, the policy change was a significant predictor of mortality (HR 1.30 [1.02, 1.67]), however on multivariate analysis significance was lost (HR 1.16 [0.90, 1.50]). Median ischemic time (3.5 hrs vs. 3.0 hrs, p<0.001) and distance (234 nmi vs. 85 nmi, p<0.001) were both greater in the POST group while waitlist time (17.0 days vs. 38.0 days, p<0.001) and gender mismatch (10.9 % vs. 13.8%, p=0.007) were lower. Otherwise, there were no significant differences in baseline characteristics. Multivariate analysis also showed that pre-transplant dialysis (HR 1.85 [1.13, 3.03]), ischemic time (HR 1.13 [1.02, 1.26]), and ECMO use (HR 1.72 [1.05, 2.82]) were associated with increased mortality in the POST group. <h3>Conclusion</h3> There was a small, but significant reduction in six-month post-transplant survival following implementation of the policy change. Policy change was a significant predictor of mortality on univariate analysis, but significance was lost on multivariate analysis.