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Annals of Surgery Oct 2023To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD).
OBJECTIVES
To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD).
BACKGROUND
DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation.
METHODS
The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis.
RESULTS
DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation.
CONCLUSIONS
DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
Topics: Adult; Humans; United States; Treatment Outcome; Tissue and Organ Procurement; Organ Transplantation; Tissue Donors; Liver Transplantation; Brain Death; Graft Survival; Retrospective Studies; Death
PubMed: 37334722
DOI: 10.1097/SLA.0000000000005947 -
Arquivos Brasileiros de Cirurgia... 2024Lower urinary tract abnormalities are directly implicated in the etiology of renal dysfunction in 6 to 24% of dialytic patients. These patients require bladder capacity... (Review)
Review
Lower urinary tract abnormalities are directly implicated in the etiology of renal dysfunction in 6 to 24% of dialytic patients. These patients require bladder capacity and compliance readjustment before being considered viable candidates for renal transplantation. Vesical augmentation surgeries often involve the use of intestinal segments. Although these procedures can effectively restore bladder capacity and compliance, they present various issues related to maintaining mucous absorption and secretion capacity. Acidosis, recurrent urinary tract infections, and stone formation are extremely common, leading to frequent hospitalizations and graft function loss. Urinary tissue is certainly ideal for these reconstructions; however, bladder augmentation using ureter and renal pelvis are feasible only in a minority of cases. Experimental studies have been conducted to establish the groundwork for vascularized bladder transplantation. Last year, for the first time, this procedure was performed on a brain-dead patient. During this intervention, cystectomy was performed with preservation the vascular pedicle, followed by organ reimplantation. The graft remained viable for a period of 12 hours post-transplant. However, this intervention utilized a robotic platform, making it less reproducible in a multi-organ procurement setting as well as for most transplant centers. Moreover, it is debatable whether the benefits of exclusive bladder transplantation outweigh the risks associated with immunosuppression. For patients needing renal transplantation and requiring lower urinary tract reconstruction, however, utilizing the donor's bladder may offer an attractive alternative, avoiding the inherent complications of enterocystoplasty without increasing immunological risk. Combined kidney and bladder transplantation has the potential to emerge as the next frontier in abdominal organ transplants.
Topics: Humans; Urinary Bladder; Kidney Transplantation; Organ Transplantation
PubMed: 38896703
DOI: 10.1590/0102-6720202400015e1808 -
Clinical Infectious Diseases : An... Feb 2024The use of assays detecting cytomegalovirus (CMV)-specific T cell-mediated immunity may individualize the duration of antiviral prophylaxis after transplantation. (Randomized Controlled Trial)
Randomized Controlled Trial
Immune Monitoring-Guided Versus Fixed Duration of Antiviral Prophylaxis Against Cytomegalovirus in Solid-Organ Transplant Recipients: A Multicenter, Randomized Clinical Trial.
BACKGROUND
The use of assays detecting cytomegalovirus (CMV)-specific T cell-mediated immunity may individualize the duration of antiviral prophylaxis after transplantation.
METHODS
In this randomized trial, kidney and liver transplant recipients from 6 centers in Switzerland were enrolled if they were CMV-seronegative with seropositive donors or CMV-seropositive receiving antithymocyte globulins. Patients were randomized to a duration of antiviral prophylaxis based on immune monitoring (intervention) or a fixed duration (control). Patients in the control group were planned to receive 180 days (CMV-seronegative) or 90 days (CMV-seropositive) of valganciclovir. Patients were assessed monthly with a CMV ELISpot assay (T-Track CMV); prophylaxis in the intervention group was stopped if the assay was positive. The co-primary outcomes were the proportion of patients with clinically significant CMV infection and reduction in days of prophylaxis. Between-group differences were adjusted for CMV serostatus.
RESULTS
Overall, 193 patients were randomized (92 in the immune-monitoring group and 101 in the control group), of whom 185 had evaluation of the primary outcome (87 and 98 patients). CMV infection occurred in 26 of 87 (adjusted percentage, 30.9%) in the immune-monitoring group and in 32 of 98 (adjusted percentage, 31.1%) in the control group (adjusted risk difference, -0.1; 95% confidence interval [CI], -13.0% to 12.7%; P = .064). The duration of prophylaxis was shorter in the immune-monitoring group (adjusted difference, -26.0 days; 95%, CI, -41.1 to -10.8 days; P < .001).
CONCLUSIONS
Immune monitoring resulted in a significant reduction of antiviral prophylaxis, but we were unable to establish noninferiority of this approach on the co-primary outcome of CMV infection.
CLINICAL TRIALS REGISTRATION
NCT02538172.
Topics: Humans; Cytomegalovirus; Antiviral Agents; Monitoring, Immunologic; Cytomegalovirus Infections; Transplant Recipients; Organ Transplantation; Ganciclovir
PubMed: 37738676
DOI: 10.1093/cid/ciad575 -
The Journal of Hand Surgery Sep 2023As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare...
PURPOSE
As the duration of lifetime survival after organ transplantation continues to increase, the consequences of long-term immunosuppression, such as opportunistic and rare infections, are a high-risk reality. This study examined upper extremity infections in the transplant population to determine the current clinical risk profile, management, and outcomes.
METHODS
An institutional database of 16,640 patients who underwent transplantation was queried for upper extremity infections from 2005 to 2017, defined as the presence of infection from the shoulder to the fingertips. The resulting data were analyzed using multivariable linear and logistic regression modeling.
RESULTS
A total of 230 eligible patients experienced upper extremity infections at a mean age of 54.1 ± 15.3 years, occurring, on average, 7.9 ± 8.6 years after transplantation. The most commonly transplanted organ was the kidney (51.3%), followed by the liver (20%). The most common location of infection was the forearm (31.7%), digits (27.4%), and upper arm (17%). The most common types of infection were cellulitis (69.1%), abscess (33.5%), joint sepsis (6.5%), infectious tenosynovitis (3.9%), and osteomyelitis (1.3%). Patients taking an antifungal medication, those who had a joint infection, or those who had undergone lung transplantation had an approximately 2.5-day longer stay in the hospital. For every 1-year increase in age at the time of transplantation, the time from transplantation to infection decreased by 0.21 years. Those who had undergone bone marrow transplantation or those who were taking tacrolimus were expected to have approximately 8- and 6-year decreases, respectively, in the time from transplantation to infection.
CONCLUSIONS
Upper extremity infections should be individually evaluated and treated because of the heterogeneity of transplant type, immunosuppression medications, the age of the patient, and infection characteristics.
TYPE OF STUDY/LEVEL OF EVIDENCE
Prognostic IV.
Topics: Humans; Adult; Middle Aged; Aged; Infant; Upper Extremity; Tacrolimus; Organ Transplantation; Arm; Forearm
PubMed: 35525682
DOI: 10.1016/j.jhsa.2022.03.001 -
Progress in Transplantation (Aliso... Dec 2023Organ recovery facilities address the logistical challenges of hospital-based deceased organ donor management. While more organs are transplanted from donors in...
Organ recovery facilities address the logistical challenges of hospital-based deceased organ donor management. While more organs are transplanted from donors in facilities, differences in donor management and donation processes are not fully characterized. Does deceased donor management and organ transport distance differ between organ procurement organization (OPO)-based recovery facilities versus hospitals? Retrospective analysis of Organ Procurement and Transplant Network data, including adults after brain death in 10 procurement regions (April 2017-June 2021). The primary outcomes were ischemic times of transplanted hearts, kidneys, livers, and lungs. Secondary outcomes included transport distances (between the facility or hospital and the transplant program) for each transplanted organ. Among 5010 deceased donors, 51.7% underwent recovery in an OPO-based recovery facility. After adjustment for recipient and system factors, mean differences in ischemic times of any transplanted organ were not significantly different between donors in facilities and hospitals. Transplanted hearts recovered from donors in facilities were transported further than hearts from hospital donors (median 255 mi [IQR 27, 475] versus 174 [IQR 42, 365], = .002); transport distances for livers and kidneys were significantly shorter ( < .001 for both). Organ recovery procedures performed in OPO-based recovery facilities were not associated with differences in ischemic times in transplanted organs from organs recovered in hospitals, but differences in organ transport distances exist. Further work is needed to determine whether other observed differences in donor management and organ distribution meaningfully impact donation and transplantation outcomes.
Topics: Adult; Humans; Retrospective Studies; Tissue and Organ Procurement; Tissue Donors; Organ Transplantation; Hospitals
PubMed: 37941335
DOI: 10.1177/15269248231212918 -
La Revue Du Praticien Nov 2023INFECTION AFTER SOLID-ORGAN-TRANSPLANTATION. Infections is one the most cause for hospitalization after solid-organ-transplantation. We distinguish donor-derived...
INFECTION AFTER SOLID-ORGAN-TRANSPLANTATION. Infections is one the most cause for hospitalization after solid-organ-transplantation. We distinguish donor-derived infections, reactivation of latent infection in recipients, nosocomial infections and community infections. The first three types are observed mainly in the early period post-transplantation, while community infections can occur at any time after transplantation. Opportunistic infections and some specific infections should be assessed systematically and rapidly. This often requires invasive diagnostic procedures. Prevention altered the incidence and severity of post-transplant infections. It included vaccination, use of universal prophylaxis, systematic monitoring of some agents after transplantation and safer living.
Topics: Humans; Cross Infection; Hospitalization; Postoperative Complications; Tissue Donors; Organ Transplantation
PubMed: 38294445
DOI: No ID Found -
Transplantation Oct 2023Solid organ transplantation saves thousands of lives suffering from end-stage diseases. Although early transplants experienced acute organ injury, medical breakthroughs,... (Review)
Review
Solid organ transplantation saves thousands of lives suffering from end-stage diseases. Although early transplants experienced acute organ injury, medical breakthroughs, such as tissue typing, and use of immunosuppressive agents have considerably improved graft survival. However, the overall incidence of allograft injury and chronic rejection remains high. Often the clinical manifestations of organ injury or rejection are nonspecific and late. Current requirement for successful organ transplantation is the identification of reliable, accurate, disease-specific, noninvasive methods for the early diagnosis of graft injury or rejection. Development of noninvasive techniques is important to allow routine follow-ups without the discomfort and risks associated with a graft biopsy. Multiple biofluids have been successfully tested for the presence of potential proteomic biomarkers; these include serum, plasma, urine, and whole blood. Kidney transplant research has provided significant evidence to the potential of proteomics-based biomarkers for acute and chronic kidney rejection, delayed graft function, early detection of declining allograft health. Multiple proteins have been implicated as biomarkers; however, recent observations implicate the use of similar canonical pathways and biofunctions associated with graft injury/rejection with altered proteins as potential biomarkers. Unfortunately, the current biomarker studies lack high sensitivity and specificity, adding to the complexity of their utility in the clinical space. In this review, we first describe the high-throughput proteomics technologies and then discuss the outcomes of proteomics profiling studies in the transplantation of several organs. Existing literature provides hope that novel biomarkers will emerge from ongoing efforts and guide physicians in delivering specific therapies to prolong graft survival.
Topics: Proteomics; Kidney Transplantation; Organ Transplantation; Transplantation, Homologous; Graft Rejection; Biomarkers
PubMed: 36814094
DOI: 10.1097/TP.0000000000004542 -
Transplantation Feb 2024The long-term function of transplanted organs, even under immunosuppression, is hindered by rejection, especially chronic rejection. Chronic rejection occurs more... (Review)
Review
The long-term function of transplanted organs, even under immunosuppression, is hindered by rejection, especially chronic rejection. Chronic rejection occurs more frequently after lung transplantation, termed chronic lung allograft dysfunction (CLAD), than after transplantation of other solid organs. Pulmonary infection is a known risk factor for CLAD, as transplanted lungs are constantly exposed to the external environment; however, the mechanisms by which respiratory infections lead to CLAD are poorly understood. The role of extracellular vesicles (EVs) in transplantation remains largely unknown. Current evidence suggests that EVs released from transplanted organs can serve as friend and foe. EVs carry not only major histocompatibility complex antigens but also tissue-restricted self-antigens and various transcription factors, costimulatory molecules, and microRNAs capable of regulating alloimmune responses. EVs play an important role in antigen presentation by direct, indirect, and semidirect pathways in which CD8 and CD4 cells can be activated. During viral infections, exosomes (small EVs <200 nm in diameter) can express viral antigens and regulate immune responses. Circulating exosomes may also be a viable biomarker for other diseases and rejection after organ transplantation. Bioengineering the surface of exosomes has been proposed as a tool for targeted delivery of drugs and personalized medicine. This review focuses on recent studies demonstrating the role of EVs with a focus on exosomes and their dual role (immune activation or tolerance induction) after organ transplantation, more specifically, lung transplantation.
Topics: Graft Rejection; Organ Transplantation; Extracellular Vesicles; Lung Transplantation; Histocompatibility Antigens; Exosomes
PubMed: 37482627
DOI: 10.1097/TP.0000000000004693 -
Pediatric Transplantation Jun 2024There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face... (Review)
Review
BACKGROUND
There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face complications of childhood organ failure and long-term immunosuppression.
AIMS
This is an educational review of existing literature.
RESULTS
Pediatric solid organ transplant recipients are at increased risk for risk for cardiovascular and kidney disease, skin cancers, and growth problems, though the severity of impact may vary by organ type. Pediatric recipients often are able to complete schooling, maintain a job, and form family and social networks in adulthood, though at somewhat lower rates than the general population, but face additional challenges related to neurocognitive deficits, mental health disorders, and discrimination.
CONCLUSIONS
Transplant centers and research programs should expand their focus to include long-term well-being. Increased collaboration between pediatric and adult transplant specialists will be necessary to better understand and manage long-term complications.
Topics: Humans; Organ Transplantation; Adolescent; Child; Adult; Postoperative Complications; United States; Survivors
PubMed: 38682744
DOI: 10.1111/petr.14766 -
Transplant International : Official... 2023Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an... (Review)
Review
Inequities in Organ Donation and Transplantation Among Immigrant Populations in Italy: A Narrative Review of Evidence, Gaps in Research and Potential Areas for Intervention.
Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an increased number of immigrants with end-stage organ diseases. In this narrative review, we reviewed evidence of the gaps between native-born and immigrant populations in the Organ Donation and Transplantation (ODT) process in Italy. Consistent with prior studies, despite the availability of a publicly funded health system with universal healthcare coverage, non-European-born individuals living in Italy are less likely to receive living donor kidney transplantation and more likely to have inferior long-term kidney graft function compared with EU-born and Eastern European-born individuals. While these patients are increasingly represented among transplant recipients (especially kidney and liver transplants), refusal rates for organ donation are higher in some ethnic groups compared with native-born and other foreign-born referents, with the potential downstream effects of prolonged waiting times and inferior transplant outcomes. In the process, we identified gaps in relevant research and biases in existing studies. Given the Italian National Transplant Center's (CNT) commitment to fighting inequities in ODT, we illustrated actions taken by CNT to tackle inequities in ODT among immigrant communities in Italy.
Topics: Humans; Organ Transplantation; Italy; Liver Transplantation; Emigrants and Immigrants; Tissue and Organ Procurement
PubMed: 37636900
DOI: 10.3389/ti.2023.11216