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Dettori M, Riccardi N, Canetti D, Antonello RM, Piana AF, Palmieri A, Castiglia P, Azara AA, Masia MD, Porcu A, Ginesu GC, Cossu ML, Conti M, Pirina P, Fois A, Maida I, Madeddu G, Babudieri S, Saderi L, Sotgiu G. Infections in lung transplanted patients: A review. Pulmonology 2024; 30:287-304. [PMID: 35710714 DOI: 10.1016/j.pulmoe.2022.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 03/29/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023] Open
Abstract
Lung transplantation can improve the survival of patients with severe chronic pulmonary disorders. However, the short- and long-term risk of infections can increase morbidity and mortality rates. A non-systematic review was performed to provide the most updated information on pathogen, host, and environment-related factors associated with the occurrence of bacterial, fungal, and viral infections as well as the most appropriate therapeutic options. Bacterial infections account for about 50% of all infectious diseases in lung transplanted patients, while viruses represent the second cause of infection accounting for one third of all infections. Almost 10% of patients develop invasive fungal infections during the first year after lung transplant. Pre-transplantation comorbidities, disruption of physical barriers during the surgery, and exposure to nosocomial pathogens during the hospital stay are directly associated with the occurrence of life-threatening infections. Empiric antimicrobial treatment after the assessment of individual risk factors, local epidemiology of drug-resistant pathogens and possible drug-drug interactions can improve the clinical outcomes.
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Affiliation(s)
- M Dettori
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - N Riccardi
- StopTB Italia Onlus, Milan, Italy; Department of Clinical and Experimental Medicine, University of Pisa, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - D Canetti
- StopTB Italia Onlus, Milan, Italy; Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R M Antonello
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Trieste, Italy
| | - A F Piana
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - A Palmieri
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - P Castiglia
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - A A Azara
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - M D Masia
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - A Porcu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - G C Ginesu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - M L Cossu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - M Conti
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - P Pirina
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - A Fois
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - I Maida
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - G Madeddu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - S Babudieri
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - L Saderi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - G Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy; StopTB Italia Onlus, Milan, Italy.
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2
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Karki S, Shaw S, Lieberman M, Pérez A, Pincus J, Jakhmola P, Tailor A, Ogunrinde OB, Sill D, Morgan S, Alvarez M, Todd J, Smith D, Mishra N. Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study. JMIR Form Res 2024; 8:e53000. [PMID: 38621237 PMCID: PMC11058559 DOI: 10.2196/53000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/02/2024] [Accepted: 02/21/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP. OBJECTIVE The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic. METHODS We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods. RESULTS Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%). CONCLUSIONS We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.
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Affiliation(s)
- Saugat Karki
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Sarah Shaw
- Public Health Informatics Institute, Decatur, GA, United States
| | - Michael Lieberman
- OCHIN, Portland, OR, United States
- Oregon Health & Sciences University, Portland, OR, United States
| | - Alejandro Pérez
- Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Priya Jakhmola
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Amrita Tailor
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Danielle Sill
- Public Health Informatics Institute, Decatur, GA, United States
| | | | | | | | - Dawn Smith
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Ninad Mishra
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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3
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Park JH, Shin YH, Chang WB. An Anatomically Complicated Living Donor Kidney Transplantation from Hepatitis B Surface Antigen-Positive Donor to Negative Recipient With Size Discrepancy. Transplant Proc 2024; 56:494-498. [PMID: 38342747 DOI: 10.1016/j.transproceed.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/16/2024] [Indexed: 02/13/2024]
Abstract
The deficiency of organ donors remains a barrier to kidney transplantation. Living donor kidney transplantation (LDKT) can overcome graft shortage, resulting in better outcomes. Many efforts are being made to expand the donor pool, such as hepatitis B surface antigen (HBsAg)-positive donors to negative recipients and anatomically complicated donor kidneys with size discrepancies. We report a case in which we overcame various problems in LDKT. The recipient was a 56-year-old, 106-kg, HBsAg negative male with diabetic nephropathy. The donor was a 63-year-old female, 56-kg, hepatitis B virus (HBV) carrier with dual renal arteries. Preoperative antiviral medication was provided to the donor for negative conversion of HBV-DNA. The recipient was given HBV vaccination (antihepatitis B antibody: 2.25-36.16 mIU/mL). Anti-HBV immunoglobulin was intraoperatively administered to prevent transmission. The donor and recipient had an absolute weight difference (50 kg). In addition, the donor's kidney had a main and an accessory artery in the upper pole, which were anastomosed to the recipient's right external iliac and inferior epigastric artery, respectively. Follow-up serum creatinine levels decreased. Doppler ultrasonography showed good vascular flow within the reference range of the resistive index. The recipient's follow-up HBV-DNA titer was negative with antiviral medication. We successfully performed LDKT from an HBV-positive donor to a negative recipient by perioperative antiviral treatment and overcame a significant size discrepancy and anatomic challenges by preserving even a small portion of the kidney graft.
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Affiliation(s)
- Jeong Hyun Park
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Young-Heun Shin
- Department of Surgery, Jeju National University College of Medicine, Jeju National University Hospital, Jeju, South Korea
| | - Won-Bae Chang
- Department of Surgery, Jeju National University College of Medicine, Jeju National University Hospital, Jeju, South Korea.
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Marshall KE, Free RJ, Filardo TD, Schwartz NG, Hernandez-Romieu AC, Thacker TC, Lehman KA, Annambhotla P, Dupree PB, Glowicz JB, Scarpita AM, Brubaker SA, Czaja CA, Basavaraju SV. Incomplete tissue product tracing during an investigation of a tissue-derived tuberculosis outbreak. Am J Transplant 2024; 24:115-122. [PMID: 37717630 DOI: 10.1016/j.ajt.2023.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/31/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
In the United States, there is currently no system to track donated human tissue products to individual recipients. This posed a challenge during an investigation of a nationwide tuberculosis outbreak that occurred when bone allograft contaminated with Mycobacterium tuberculosis (Lot A) was implanted into 113 patients in 18 US states, including 2 patients at 1 health care facility in Colorado. A third patient at the same facility developed spinal tuberculosis with an isolate genetically identical to the Lot A outbreak strain. However, health care records indicated this patient had received bone allograft from a different donor (Lot B). We investigated the source of this newly identified infection, including the possibilities of Lot B donor infection, product switch or contamination during manufacturing, product switch at the health care facility, person-to-person transmission, and laboratory error. The findings included gaps in tissue traceability at the health care facility, creating the possibility for a product switch at the point of care despite detailed tissue-tracking policies. Nationally, 6 (3.9%) of 155 Lot B units could not be traced to final disposition. This investigation highlights the critical need to improve tissue-tracking systems to ensure unbroken traceability, facilitating investigations of recipient adverse events and enabling timely public health responses to prevent morbidity and mortality.
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Affiliation(s)
- Kristen E Marshall
- Colorado Department of Public Health and Environment, Denver, Colorado, USA; Division of State and Local Readiness, Office of Readiness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | - Rebecca J Free
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Thomas D Filardo
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Noah G Schwartz
- Division of Tuberculosis Elimination, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alfonso C Hernandez-Romieu
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tyler C Thacker
- National Veterinary Services Laboratories, Veterinary Services, Animal and Plant Health Inspection Service, U.S. Department of Agriculture, Ames, Iowa, USA
| | - Kimberly A Lehman
- National Veterinary Services Laboratories, Veterinary Services, Animal and Plant Health Inspection Service, U.S. Department of Agriculture, Ames, Iowa, USA
| | - Pallavi Annambhotla
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Peter B Dupree
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Janet Burton Glowicz
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ann M Scarpita
- Colorado Department of Public Health and Environment, Denver, Colorado, USA
| | - Scott A Brubaker
- Division of Human Tissues, Office of Cellular Therapy and Human Tissue CMC, Office of Therapeutic Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Sridhar V Basavaraju
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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Sarvet AL, Wanis KN, Young JG, Hernandez-Alejandro R, Stensrud MJ. Longitudinal incremental propensity score interventions for limited resource settings. Biometrics 2023; 79:3418-3430. [PMID: 36942974 DOI: 10.1111/biom.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 03/03/2023] [Indexed: 03/23/2023]
Abstract
Many real-life treatments are of limited supply and cannot be provided to all individuals in the population. For example, patients on the liver transplant waiting list usually cannot be assigned a liver transplant immediately at the time they reach highest priority because a suitable organ is not immediately available. In settings with limited supply, investigators are often interested in the effects of treatment strategies in which a limited proportion of patients receive an organ at a given time, that is, treatment regimes satisfying resource constraints. Here, we describe an estimand that allows us to define causal effects of treatment strategies that satisfy resource constraints: incremental propensity score interventions (IPSIs) for limited resources. IPSIs flexibly constrain time-varying resource utilization through proportional scaling of patients' natural propensities for treatment, thereby preserving existing propensity rank ordering compared to the status quo. We derive a simple class of inverse-probability-weighted estimators, and we apply one such estimator to evaluate the effect of restricting or expanding utilization of "increased risk" liver organs to treat patients with end-stage liver disease.
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Affiliation(s)
- Aaron L Sarvet
- Department of Mathematics, École polytechnique fédérale de Lausanne, Lausanne, Switzerland
| | - Kerollos N Wanis
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jessica G Young
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Mats J Stensrud
- Department of Mathematics, École polytechnique fédérale de Lausanne, Lausanne, Switzerland
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6
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Barrett M, Sonnenday CJ. CAQ Corner: Deceased donor selection and management. Liver Transpl 2023; 29:1234-1241. [PMID: 37560989 DOI: 10.1097/lvt.0000000000000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/31/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Meredith Barrett
- University of Michigan, Department of Surgery, Section of Transplantation
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7
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Atiemo K, Baudier R, Craig-Schapiro R, Guo K, Mazumder N, Anderson A, Zhao L, Ladner D. Factors Underlying Racial Disparity in Utilization of Hepatitis C-Viremic Kidneys in the United States. J Racial Ethn Health Disparities 2023; 10:2185-2194. [PMID: 35997960 PMCID: PMC10348076 DOI: 10.1007/s40615-022-01398-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Utilization of hepatitis C (HCV) viremic kidneys is increasing in the United States. We examined racial disparity in this utilization using UNOS/OPTN data (2014-2020) and mixed effects models adjusting for donor/recipient/center factors. Included in the study were 58,786 adults receiving a deceased donor kidney transplant from 191 centers. Two thousand six hundred thirteen (4%) received kidneys from HCV-viremic donors. Of these, 1598 (61%) were HCV seronegative and 1015 (49%) were HCV seropositive. Among seronegative recipients, before adjusting for waiting time and education, Blacks (OR 0.69, 95%CI (0.60, 0.80)), Hispanics (OR 0.63, 95%CI (0.51, 0.79)), and Asians (OR 0.69, 95%CI (0.53, 0.90)) were less likely than Whites to receive HCV-viremic kidneys. In final models, effect of race was attenuated. Notably, shorter waiting time (OR 0.65, 95%CI (0.63, 0.67)) and increasing educational level (grade school less likely compared to high school OR 0.67, 95% CI (0.49, 0.92) and college more likely than high school (OR 1.16 95% CI (1.02, 1.31)) were associated with receipt of HCV-viremic kidneys. Among HCV-seropositive recipients, recipient race was not independently associated with receipt of HCV-viremic kidneys; however, centers with larger populations of Black waitlisted patients were more likely to utilize HCV-viremic kidneys (OR 1.71, 95%CI (1.20, 2.45)) compared to other centers. Our results suggest recipient race does not independently determine who receives HCV-viremic kidneys; however, other underlying factors including waiting time, education (among seronegative), and center racial mix (among seropositive) contribute to the current differential distribution of HCV-viremic kidneys among races.
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Affiliation(s)
- Kofi Atiemo
- Division of Transplant Surgery, Weill Cornell Medical Center, 525 East 68 thStreet, Box 98, New York, NY, 10065, USA.
| | - Robin Baudier
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Rebecca Craig-Schapiro
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Kexin Guo
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Nikhilesh Mazumder
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
| | - Amanda Anderson
- Epidemiology Department, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Lihui Zhao
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern Medicine, Chicago, IL, USA
| | - Daniela Ladner
- Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Northwestern University Transplant Research Collaborative (NUTORC), Northwestern University, Chicago, IL, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern Medicine, Chicago, IL, USA
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8
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Vail EA, Schaubel DE, Abt PL, Martin ND, Reese PP, Neuman MD. Organ Transplantation Outcomes of Deceased Organ Donors in Organ Procurement Organization-Based Recovery Facilities Versus Acute-Care Hospitals. Prog Transplant 2023; 33:110-120. [PMID: 36942433 PMCID: PMC10150267 DOI: 10.1177/15269248231164176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Recovery of donated organs at organ procurement organization (OPO)-based recovery facilities has been proposed to improve organ donation outcomes, but few data exist to characterize differences between facilities and acute-care hospitals. RESEARCH QUESTION To compare donation outcomes between organ donors that underwent recovery procedures in OPO-based recovery facilities and hospitals. DESIGN Retrospective study of Organ Procurement and Transplantation Network data. From a population-based sample of deceased donors after brain death April 2017 to June 2021, donation outcomes were examined in 10 OPO regions with organ recovery facilities. Primary exposure was organ recovery procedure in an OPO-based organ recovery. Primary outcome was the number of organs transplanted per donor. Multivariable regression models were used to adjust for donor characteristics and managing OPO. RESULTS Among 5010 cohort donors, 2590 (51.7%) underwent recovery procedures in an OPO-based facility. Donors in facilities differed from those in hospitals, including recovery year, mechanisms of death, and some comorbid diseases. Donors in OPO-based facilities had higher total numbers of organs transplanted per donor (mean 3.5 [SD1.8] vs 3.3 [SD1.8]; adjusted mean difference 0.27, 95% confidence interval 0.18-0.36). Organ recovery at an OPO-based facility was also associated with more lungs, livers, and pancreases transplanted. CONCLUSION Organ recovery procedures at OPO-based facilities were associated with more organs transplanted per donor than in hospitals. Increasing access to OPO-based organ recovery facilities may improve rates of organ transplantation from deceased organ donors, although further data are needed on other important donor management quality metrics.
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Affiliation(s)
- Emily A Vail
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter L Abt
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter P Reese
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Transplant Institute, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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9
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Abstract
Abnormal liver tests are common after liver transplantation. The differential diagnosis depends on the clinical context, particularly the time course, pattern and degree of elevation, and donor and recipient factors. The perioperative period has distinct causes compared with months and years after transplant, including ischemia-reperfusion injury, vascular thrombosis, and primary graft nonfunction. Etiologies seen beyond the perioperative period include biliary complications, rejection, infection, recurrent disease, and non-transplant-specific causes. The evaluation begins with a liver ultrasound with Doppler as well as appropriate laboratory testing and culminates in a liver biopsy if the imaging and laboratory testing is unrevealing.
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Affiliation(s)
- Jacqueline B Henson
- Division of Gastroenterology, Department of Medicine, Duke University, DUMC Box 3913, Durham, NC 27710, USA. https://twitter.com/jackie_henson
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University, DUMC Box 3913, Durham, NC 27710, USA; Duke Clinical Research Institute, Duke University, DUMC Box 3913, Durham, NC 27710, USA.
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10
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Epperson K, Crane C, Ingulli E. Prevention, diagnosis, and management of donor derived infections in pediatric kidney transplant recipients. Front Pediatr 2023; 11:1167069. [PMID: 37152319 PMCID: PMC10162437 DOI: 10.3389/fped.2023.1167069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/16/2023] [Indexed: 05/09/2023] Open
Abstract
Donor derived infections (DDIs) in pediatric kidney transplant recipients remain challenging to diagnose and can result in serious morbidity and mortality. This review summarizes the current guidelines and recommendations for prevention, diagnosis, and treatment of unexpected DDIs in pediatric kidney transplant recipients. We provide a contemporary overview of DDI terminology, surveillance, epidemiology, and recommended approaches for assessing these rare events with an emphasis on the pediatric recipient. To address prevention and risk mitigation, important aspects of donor and pediatric candidate evaluations are reviewed, including current Organ Procurement and Transplantation Network (OPTN) and American Society of Transplantation (AST) recommendations. Common unexpected DDI encountered by pediatric transplant teams including multi-drug resistant organisms, tuberculosis, syphilis, West Nile Virus, toxoplasmosis, Chagas disease, strongyloidiasis, candidiasis, histoplasmosis, coccidioidomycosis, and emerging infections such as COVID-19 are discussed in detail. Finally, we consider the general challenges with management of DDIs and share our experience with a novel application of next generation sequencing (NGS) of microbial cell-free DNA that will likely define a future direction in this field.
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Affiliation(s)
- Katrina Epperson
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
| | - Clarkson Crane
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
| | - Elizabeth Ingulli
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
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11
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Frasco PE, Mathur AK, Chang YH, Alvord JM, Poterack KA, Khurmi N, Bauer I, Aqel B. Days alive and out of hospital after liver transplant: comparing a patient-centered outcome between recipients of grafts from donation after circulatory and brain deaths. Am J Transplant 2023; 23:55-63. [PMID: 36695622 DOI: 10.1016/j.ajt.2022.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
We retrospectively compared outcomes between recipients of donation after circulatory death (DCD) and donation after brain death (DBD) liver allografts using days alive and out of hospital (DAOH), a composite outcome of mortality, morbidity, and burden of care from patient perspective. The initial length of stay and duration of any subsequent readmission for the first year after liver transplantation were recorded. Donor category and perioperative and intraoperative characteristics pertinent to liver transplantation were included. The primary outcome was DAOH365. Secondary outcomes included early allograft dysfunction and hepatic arterial and biliary complications. Although the incidence of both early allograft dysfunction (P < .001) and ischemic cholangiopathy (P < .001) was significantly greater in the recipients of DCD, there were no significant differences in the length of stay and DAOH365. The median DAOH365 was 355 days for recipients of DBD allografts and 353 days for recipients of DCD allografts (P = .34). Increased transfusion burden, longer cold ischemic time, and non-White recipients were associated with decreased DAOH. There were no significant differences in graft failure (P = .67), retransplantation (P = .67), or 1-year mortality (P = .96) between the 2 groups. DAOH is a practical and attainable measure of outcome after liver transplantation. This metric should be considered for quality measurement and reporting in liver transplantation.
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Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA.
| | - Amit K Mathur
- Department of Transplantation Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Bashar Aqel
- Department of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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12
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Ander EH, Kashem A, Zhao H, Montgomery K, Sunagawa G, Yanagida R, Shigemura N, Toyoda Y. Increased Risk Donors Utilized in Lung Transplantation At A Single Center. Prog Transplant 2022; 32:340-344. [PMID: 36039527 DOI: 10.1177/15269248221122893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: In 2013, the US Public Health Service (PHS) updated guidelines for high-risk donor organs and renamed the category increased risk. Project Aims: We compared survival of patients who received increased risk or non-increased risk donor lungs to determine if PHS designated increased risk donor lungs were an underutilized resource. Design: This retrospective cohort analysis compared survival and utilization rates of increased-risk and non-increased-risk donor lungs used in lung transplantation at a single institution over a period of 8 years (Feb-2012 through Mar-2020). Survival was assessed using Kaplan-Meier analysis and compared by log-rank test. Cox proportional hazards modeling was used to analyze impact on survival of variables significantly associated with risk status, including recipient ethnicity, lung allocation score (LAS), donor age, year of transplant procedure, and lung transplant type. Results: Of 744 lung transplant recipients from February 2012 through March 2020, there were 192 (26%) recipients of increased risk designated lungs. In 2012 and 2013, 6% and 0% respectively of the lungs transplanted were increased risk labeled. After the PHS guidelines were nationally implemented in February 2014, the proportion of increased risk lung transplants rose to 7% (2014), 21% (2015), 27% (2016), 35% (2017), 28% (2018), 27% (2019), and 40% (January-March 2020). Kaplan-Meier analysis and log-rank test comparison showed no significant difference in survival between patients that received increased risk versus non-increased risk labeled lungs (P = 0.47). Conclusions: Our analysis suggested the 2013 PHS increased risk designation threatened underutilization of viable donor lungs, providing further support for the 2020 PHS changes.
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Affiliation(s)
- Erik H Ander
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA
| | - Abul Kashem
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA.,Division of Cardiovascular Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Huaqing Zhao
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA
| | - Kelly Montgomery
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA
| | - Gengo Sunagawa
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA.,Division of Cardiovascular Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Roh Yanagida
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA.,Division of Cardiovascular Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Norihisa Shigemura
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA.,Division of Cardiovascular Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Yoshiya Toyoda
- Lewis Katz School of Medicine at 25139Temple University, Philadelphia, PA, USA.,Division of Cardiovascular Surgery, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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13
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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14
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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15
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What's in a name? Higher risks with donation after cardiac death than public health service increased risk livers. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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16
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Free RJ, Levi ME, Bowman JS, Bixler D, Brooks JT, Buchacz K, Moorman A, Berger J, Basavaraju SV. Updated U.S. Public Health Service Guideline for testing of transplant candidates aged <12 years for infection with HIV, hepatitis B virus, and hepatitis C virus - United States, 2022. Am J Transplant 2022; 22:2269-2272. [PMID: 36039545 DOI: 10.1111/ajt.16673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Rebecca J Free
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
| | - Marilyn E Levi
- Division of Transplantation, Health Systems Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland
| | - James S Bowman
- Division of Transplantation, Health Systems Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland
| | - Danae Bixler
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - John T Brooks
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - Kate Buchacz
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - Anne Moorman
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - James Berger
- Office of Infectious Disease and HIV/AIDS Policy, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, D.C
| | - Sridhar V Basavaraju
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
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17
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Free RJ, Levi ME, Bowman JS, Bixler D, Brooks JT, Buchacz K, Moorman A, Berger J, Basavaraju SV. Updated U.S. Public Health Service Guideline for Testing of Transplant Candidates Aged <12 Years for Infection with HIV, Hepatitis B Virus, and Hepatitis C Virus - United States, 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2022; 71:844-846. [PMID: 35771714 DOI: 10.15585/mmwr.mm7126a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The U.S. Public Health Service (PHS) has periodically published recommendations about reducing the risk for transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) through solid organ transplantation (1-4). Updated guidance published in 2020 included the recommendation that all transplant candidates receive HIV, HBV, and HCV testing during hospital admission for transplant surgery to more accurately assess their pretransplant infection status and to better identify donor transmitted infection (4). In 2021, CDC was notified that this recommendation might be unnecessary for pediatric organ transplant candidates because of the low likelihood of infection after the perinatal period and out of concern that the volume of blood drawn for testing could negatively affect critically ill children.* CDC and other partners reviewed surveillance data from CDC on estimates of HIV, HBV, and HCV infection rates in the United States and data from the Organ Procurement & Transplantation Network (OPTN)† on age and weight distributions among U.S. transplant recipients. Feedback from the transplant community was also solicited to understand the impact of changes to the existing policy on organ transplantation. The 2020 PHS guideline was accordingly updated to specify that solid organ transplant candidates aged <12 years at the time of transplantation who have received postnatal infectious disease testing are exempt from the recommendation for HIV, HBV, and HCV testing during hospital admission for transplantation.
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18
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Bacterial and Viral Infections in Liver Transplantation: New Insights from Clinical and Surgical Perspectives. Biomedicines 2022; 10:biomedicines10071561. [PMID: 35884867 PMCID: PMC9313066 DOI: 10.3390/biomedicines10071561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/11/2022] [Accepted: 06/27/2022] [Indexed: 01/03/2023] Open
Abstract
End-stage liver disease patients undergoing liver transplantation are prone to develop numerous infectious complications because of immunosuppression, surgical interventions, and malnutrition. Infections in transplant recipients account for the main cause of mortality and morbidity with rates of up to 80%. The challenges faced in the early post-transplant period tend to be linked to transplant procedures and nosocomial infections commonly in bloodstream, surgical, and intra-abdominal sites. Viral infections represent an additional complication of immunosuppression; they can be donor-derived, reactivated from a latent virus, nosocomial or community-acquired. Bacterial and viral infections in solid organ transplantation are managed by prophylaxis, multi-drug resistant screening, risk assessment, vaccination, infection control and antimicrobial stewardship. The aim of this review was to discuss the epidemiology of bacterial and viral infections in liver transplants, infection control issues, as well as surgical frontiers of ex situ liver perfusion.
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19
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Werbel WA, Brown DM, Kusemiju OT, Doby BL, Seaman SM, Redd AD, Eby Y, Fernandez RE, Desai NM, Miller J, Bismut GA, Kirby CS, Schmidt HA, Clarke WA, Seisa M, Petropoulos CJ, Quinn TC, Florman SS, Huprikar S, Rana MM, Friedman-Moraco RJ, Mehta AK, Stock PG, Price JC, Stosor V, Mehta SG, Gilbert AJ, Elias N, Morris MI, Mehta SA, Small CB, Haidar G, Malinis M, Husson JS, Pereira MR, Gupta G, Hand J, Kirchner VA, Agarwal A, Aslam S, Blumberg EA, Wolfe CR, Myer K, Wood RP, Neidlinger N, Strell S, Shuck M, Wilkins H, Wadsworth M, Motter JD, Odim J, Segev DL, Durand CM, Tobian AAR. National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States. Clin Infect Dis 2022; 74:2010-2019. [PMID: 34453519 PMCID: PMC9187316 DOI: 10.1093/cid/ciab743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.
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Affiliation(s)
- William A Werbel
- Correspondence: W. A. Werbel, Department of Medicine, Johns Hopkins School of Medicine, 725 N Wolfe St, PCTB/Second Floor, Baltimore, MD 21205 ()
| | - Diane M Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Oyinkansola T Kusemiju
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brianna L Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shanti M Seaman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew D Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Yolanda Eby
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reinaldo E Fernandez
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Niraj M Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jernelle Miller
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gilad A Bismut
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles S Kirby
- Department of Biochemistry, Cellular, and Molecular Biology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Haley A Schmidt
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William A Clarke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael Seisa
- Laboratory Corporation of America (LabCorp), South San Francisco, California, USA
| | | | - Thomas C Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, The Mount Sinai Hospital, New York City, New York, USA
| | - Shirish Huprikar
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Meenakshi M Rana
- Department of Medicine, Division of Infectious Diseases, The Mount Sinai Hospital, New York City, New York, USA
| | - Rachel J Friedman-Moraco
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Aneesh K Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Peter G Stock
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C Price
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Valentina Stosor
- Division of Infectious Disease and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shikha G Mehta
- Section of Transplant Nephrology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alexander J Gilbert
- MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, DC, USA
| | - Nahel Elias
- Department of Surgery, Division of Transplant Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami, Miami, Florida, USA
| | - Sapna A Mehta
- New York University Langone Transplant Institute, New York University Grossman School of Medicine, New York, New York, USA
| | - Catherine B Small
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medical College, New York, New York, USA
| | - Ghady Haidar
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maricar Malinis
- Department of Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer S Husson
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marcus R Pereira
- Department of Medicine, Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA
| | - Gaurav Gupta
- Department of Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Varvara A Kirchner
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Avinash Agarwal
- Department of Surgery, Division of Transplantation, University of Virginia, Charlottesville, Virginia, USA
| | - Saima Aslam
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Emily A Blumberg
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cameron R Wolfe
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - R Patrick Wood
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
| | - Nikole Neidlinger
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, Wisconsin, USA
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | - Sara Strell
- UW Health Organ Procurement Organization, Madison, Wisconsin, USA
| | | | | | | | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonah Odim
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - HOPE in Action Investigators
PiquantDominqueLinkKatherineRNHemmersbach-MillerMarionMD, PhDPearsonThomasMDTurgeonNicoleMDLyonG MarshallMD, MMScKitchensWilliamMD PhDHuckabyJerylMSCRA, CCRCLasseterA FrancieRNElbeinRivkaRN, BSNRobersonAprilRNFerryElizabethRNKlockEthanBSCochranWilla VCRNPMorrisonMichelleBSNRasmussenSarahBABollingerJuliMSSugarmanJeremyMDSmithAngela RMBAThomasMargaretBSCoakleyMargaretRNTimponeJosephMDStuckeAlyssaBSHaydelBrandyDieterRebeccaPharmDKleinElizabeth JBANeumannHenryMDGallonLorenzoMDGoudyLeahRNCallegariMichelleMarrazzoIliseRN, BSN, MPHJacksonTowandaPruettTimothyMDFarnsworthMaryCCRCLockeJayme EMD, MPH, FACS, FASTMompoint-WilliamsDarnellCRNP, DNPBasingerKatherineRN, CCRPMekeelKristinMDNguyenPhirumBSKwanJoanneSrisengfaTabChin-HongPeterMDRogersRodneySimkinsJacquesMDMunozCarlosCRCDunnTyMDSawinskiDierdreMDSilveiraFernandaMDHughesKaileyMPHPakstisDiana LynnRN, BSN, MBANagyJamieBABaldecchiMaryMuthukumarThangamaniMDEddieMelissa DMS, RNRobbKatharineRNSalsgiverElizabethMPHWittingBrittaBSAzarMarwan MVillanuevaMerceditasFormicaRichardTomlinRicardaBS, CCRP
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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20
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Hendele JB, Limaye AP, Sibulesky L. Misplaced emphasis, misunderstood risk: a cultural history of Public Health Service infectious disease guidelines. Curr Opin Organ Transplant 2022; 27:159-164. [PMID: 35232929 DOI: 10.1097/mot.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review and summarize the evolution of the Public Health Service (PHS) guidelines and Organ Procurement and Transplantation Network (OPTN) regulations for the prevention of blood borne virus transmission in solid organ transplant through the lens of popular culture, scientific evolution, patient and practitioner bias and outcomes research. RECENT FINDINGS The most recent set of guidelines and regulations were released in 2020 and represent a culmination of decades of opinion, research and debate within the scientific and lay communities. SUMMARY The guidelines were created to address public concern, and the risk of undiagnosed disease transmission in the context of the novel public health crisis of AIDS. We reviewed milestone publications from the scientific and lay press from the first description of AIDS in 1981 to the present to help illustrate the context in which the guidelines were created, the way they changed with subsequent editions, and offer critical consideration of issues with the current set of guidelines and a potential way forward. Further consideration should be given to the way in which the current guidelines identify donors with risk criteria for infectious disease transmission and mandate explanation of donor-specific risk factors to potential recipients, in our era of universal donor screening and recipient surveillance.
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Affiliation(s)
| | - Ajit P Limaye
- Division of Infectious Disease, Department of Medicine, University of Washington, Seattle, Washington, USA
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21
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Kelly YM, Zarinsefat A, Tavakol M, Shui AM, Huang CY, Roberts JP. Consent to organ offers from public health service “Increased Risk” donors decreases time to transplant and waitlist mortality. BMC Med Ethics 2022; 23:20. [PMID: 35248038 PMCID: PMC8898499 DOI: 10.1186/s12910-022-00757-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 02/17/2022] [Indexed: 08/30/2023] Open
Abstract
Background The Public Health Service Increased Risk designation identified organ donors at increased risk of transmitting hepatitis B, hepatitis C, and human immunodeficiency virus. Despite clear data demonstrating a low absolute risk of disease transmission from these donors, patients are hesitant to consent to receiving organs from these donors. We hypothesize that patients who consent to receiving offers from these donors have decreased time to transplant and decreased waitlist mortality. Methods We performed a single-center retrospective review of all-comers waitlisted for liver transplant from 2013 to 2019. The three competing risk events (transplant, death, and removal from transplant list) were analyzed. 1603 patients were included, of which 1244 (77.6%) consented to offers from increased risk donors. Results Compared to those who did not consent, those who did had 2.3 times the rate of transplant (SHR 2.29, 95% CI 1.88–2.79, p < 0.0001), with a median time to transplant of 11 months versus 14 months (p < 0.0001), as well as a 44% decrease in the rate of death on the waitlist (SHR 0.56, 95% CI 0.42–0.74, p < 0.0001). All findings remained significant after controlling for the recipient age, race, gender, blood type, and MELD. Of those who did not consent, 63/359 (17.5%) received a transplant, all of which were from standard criteria donors, and of those who did consent, 615/1244 (49.4%) received a transplant, of which 183/615 (29.8%) were from increased risk donors. Conclusions The findings of decreased rates of transplantation and increased risk of death on the waiting list by patients who were unwilling to accept risks of viral transmission of 1/300–1/1000 in the worst case scenarios suggests that this consent process may be harmful especially when involving “trigger” words such as HIV. The rigor of the consent process for the use of these organs was recently changed but a broader discussion about informed consent in similar situations is important.
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22
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Waller KMJ, De La Mata NL, Rosales BM, Hedley JA, Kelly PJ, Thomson IK, O'Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Wyburn KR, Webster AC. Characteristics and Donation Outcomes of Potential Organ Donors Perceived to Be at Increased Risk for Blood-borne Virus Transmission: An Australian Cohort Study 2010-2018. Transplantation 2022; 106:348-357. [PMID: 33988336 DOI: 10.1097/tp.0000000000003715] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Safely increasing organ donation to meet need is a priority. Potential donors may be declined because of perceived blood-borne virus (BBV) transmission risk. With hepatitis C (HCV) curative therapy, more potential donors may now be suitable. We sought to describe potential deceased donors with increased BBV transmission risk. METHODS We conducted a cohort study of all potential organ donors referred in NSW, Australia, 2010-2018. We compared baseline risk potential donors to potential donors with increased BBV transmission risk, due to history of HIV, HCV or hepatitis B, and/or behavioral risk factors. RESULTS There were 624 of 5749 potential donors (10.9%) perceived to have increased BBV transmission risk. This included 298 of 5749 (5.2%) with HCV (including HBV coinfections) and 239 of 5749 (4.2%) with increased risk behaviors (no known BBV). Potential donors with HCV and those with increased risk behaviors were younger and had fewer comorbidities than baseline risk potential donors (P < 0.001). Many potential donors (82 with HCV, 38 with risk behaviors) were declined for donation purely because of perceived BBV transmission risk. Most were excluded before BBV testing. When potential donors with HCV did donate, they donated fewer organs than baseline risk donors (median 1 versus 3, P < 0.01), especially kidneys (odds ratio 0.08, P < 0.001) and lungs (odds ratio 0.11, P = 0.006). CONCLUSIONS Many potential donors were not accepted because of perceived increased BBV transmission risk, without viral testing, and despite otherwise favorable characteristics. Transplantation could be increased from potential donors with HCV and/or increased risk behaviors.
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Affiliation(s)
- Karen M J Waller
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Nicole L De La Mata
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Brenda M Rosales
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - James A Hedley
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Patrick J Kelly
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Imogen K Thomson
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
| | - Michael J O'Leary
- NSW Organ and Tissue Donation Service, Kogarah, NSW, Australia
- Intensive Care Service, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Elena Cavazzoni
- NSW Organ and Tissue Donation Service, Kogarah, NSW, Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology, Prince of Wales Hospital, Randwick, NSW, Australia
- Schools of SOMS, BABS and Women's and Children's, University of NSW, Randwick, NSW, Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Angela C Webster
- Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Health and Medicine, The University of Sydney, Camperdown, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
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23
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Zaffar D, Muhammad H, Gurakar A. The use of HCV positive donors among non-HCV infected liver transplant recipients. HEPATOLOGY FORUM 2022; 3:1-2. [PMID: 35782374 PMCID: PMC9138910 DOI: 10.14744/hf.2021.2021.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Duha Zaffar
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haris Muhammad
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- Division of Gastroenterology and Hepatology, Transplant Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Kreitman KR, Kothadia JP, Nair SP, Maliakkal BJ. Unexpected hepatitis B virus transmission after liver transplant from nucleic acid testing- and serology-negative liver donors who are hepatitis C viremic. Hepatol Res 2021; 51:1242-1246. [PMID: 34114715 DOI: 10.1111/hepr.13680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 01/15/2023]
Abstract
The opioid epidemic has led to increased availability of organs for liver transplantation. The success of direct-acting antiviral therapy for hepatitis C (HCV) has led to the acceptance of HCV viremic donor organs. Nucleic acid testing (NAT) has led to increased detection of HCV and hepatitis B (HBV) in potential donors. A total of 36 patients underwent liver transplantation from donation after brain death donors who were HCV NAT-positive, and three of them were diagnosed with HBV several months after. All three recipients received livers from HCV viremic donors who were negative for HBV by serology and NAT. Soon after liver transplantation, HCV was treated, and all achieved sustained virologic response. They became HBV DNA-positive shortly thereafter. To date, there have been no reported cases of unexpected HBV transmission since universal donor NAT was implemented in 2013. We postulate that the inhibitory effect of HCV viremia on HBV may have prolonged the "NAT window period" in these donors beyond the 20-22 days quoted for solitary HBV infection. These cases highlight the need for more intensive and prolonged screening for HBV in recipients of livers from HCV viremic donors.
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Affiliation(s)
- Kyle R Kreitman
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Jiten P Kothadia
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Satheesh P Nair
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Benedict J Maliakkal
- MUH James D. Eason Transplant Institute, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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25
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Frasco PE, Aqel B, Alvord JM, Poterack KA, Bauer I, Mathur AK. Statin Therapy and the Incidence of Thromboembolism and Vascular Events Following Liver Transplantation. Liver Transpl 2021; 27:1432-1442. [PMID: 33964102 DOI: 10.1002/lt.26093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/24/2022]
Abstract
Statin therapy may reduce the risk of venous thromboembolism (VTE), which may impact solid organ transplant outcomes. We evaluated the incidence of VTE and other complications after liver transplantation stratified by hyperlipidemia status and statin use using a retrospective cohort study approach. We reviewed all primary orthotopic liver transplantation (OLT) records from January 2014 to December 2019 from our center. Intraoperative deaths were excluded. Recipient, donor clinical and demographic data were collected. We developed risk-adjusted models to assess the effect of statin use on the occurrence of VTE, hepatic artery complications (HACs), graft failure, and death, accounting for clinical covariates and competing risks. A total of 672 OLT recipients were included in the analysis. Of this cohort, 11.9% (n = 80) received statin therapy. A total of 47 patients (7.0%) had VTE events. HACs occurred in 40 patients (6.0%). A total of 42 (6.1%) patients experienced graft loss, whereas 9.1% (n = 61) of the cohort died during the study interval. Eighty OLT recipients (29.8%) were treated with statins. In the statin treated group, 0% of patients had VTE versus 7.9% of those not on statins (P = 0.02). HACs were identified in 1.2% of the statin group and 6.8% of the nonstatin group. Untreated hyperlipidemia was associated with a 2.1-fold higher risk of HACs versus patients with no hyperlipidemia status (P = 0.05). Statin therapy was associated with significantly better risk-adjusted thromboembolic event-free survival (absence of VTE, cerebrovascular accident, myocardial infarction, HACs, and death); hazard ratio, 2.7; P = 0.01. These data indicate that statin therapy is correlated with a lower rate of VTE and HACs after liver transplantation.
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Affiliation(s)
- Peter E Frasco
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Bashar Aqel
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Jeremy M Alvord
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Karl A Poterack
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Isabel Bauer
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
| | - Amit K Mathur
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ
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26
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Bixler D, Annambhotla P, Montgomery MP, Mixon‐Hayden T, Kupronis B, Michaels MG, La Hoz RM, Basavaraju SV, Kamili S, Moorman A. Unexpected hepatitis B virus infection after liver transplantation — United States, 2014–2019. Am J Transplant 2021. [DOI: 10.1111/ajt.16045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Danae Bixler
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
| | - Pallavi Annambhotla
- Office of Blood, Other Organ, and Tissue Safety National Center For Emerging and Zoonotic Infectious Diseases CDC Atlanta GeorgiaUSA
| | - Martha P. Montgomery
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
| | - Tonya Mixon‐Hayden
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
| | - Ben Kupronis
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
| | | | | | - Sridhar V. Basavaraju
- Office of Blood, Other Organ, and Tissue Safety National Center For Emerging and Zoonotic Infectious Diseases CDC Atlanta GeorgiaUSA
| | - Saleem Kamili
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
| | - Anne Moorman
- Division of Viral Hepatitis National Center for HIV/AIDS Viral Hepatitis, STD, and TB Prevention CDC Atlanta GeorgiaUSA
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27
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Srisuwarn P, Sumethkul V. Kidney transplant from donors with hepatitis B: A challenging treatment option. World J Hepatol 2021; 13:853-867. [PMID: 34552692 PMCID: PMC8422915 DOI: 10.4254/wjh.v13.i8.853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/22/2021] [Accepted: 07/29/2021] [Indexed: 02/06/2023] Open
Abstract
Utilizing kidneys from donors with hepatitis B is one way to alleviate the current organ shortage situation. However, the risk of hepatitis B virus (HBV) transmission remains a challenge that undermines the chance of organs being used. This is particularly true with hepatitis B surface antigen (HBsAg) positive donors despite the comparable long-term outcomes when compared with standard donors. To reduce the risk of HBV transmission, a comprehensive approach is needed. This includes assessment of donor risk, optimal allocation to the proper recipient, appropriate immunosuppressive regimen, optimizing the prophylactic therapy, and post-transplant monitoring. This review provides an overview of current evidence of kidney transplants from donors with HBsAg positivity and outlines the challenge of this treatment. The topics include donor risk assessment by adopting the nucleic acid test coupled with HBV DNA as the HBV screening, optimal recipient selection, importance of hepatitis B immunity, role of nucleos(t)ide analogues, and hepatitis B immunoglobulin. A summary of reported long-term outcomes after kidney transplantation and proposed criteria to utilize kidneys from this group of donors was also defined and discussed.
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Affiliation(s)
- Praopilad Srisuwarn
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Vasant Sumethkul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
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28
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Decline of increased risk donor offers increases waitlist mortality in paediatric heart transplantation. Cardiol Young 2021; 31:1228-1237. [PMID: 34429175 DOI: 10.1017/s104795112100353x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Increased risk donors in paediatric heart transplantation have characteristics that may increase the risk of infectious disease transmission despite negative serologic testing. However, the risk of disease transmission is low, and refusing an IRD offer may increase waitlist mortality. We sought to determine the risks of declining an initial IRD organ offer. METHODS AND RESULTS We performed a retrospective analysis of candidates waitlisted for isolated PHT using 20072017 United Network of Organ Sharing datasets. Match runs identified candidates receiving IRD offers. Competing risks analysis was used to determine mortality risk for those that declined an initial IRD offer with stratified Cox regression to estimate the survival benefit associated with accepting initial IRD offers. Overall, 238/1067 (22.3%) initial IRD offers were accepted. Candidates accepting an IRD offer were younger (7.2 versus 9.8 years, p < 0.001), more often female (50 versus 41%, p = 0.021), more often listed status 1A (75.6 versus 61.9%, p < 0.001), and less likely to require mechanical bridge to PHT (16% versus 23%, p = 0.036). At 1- and 5-year follow-up, cumulative mortality was significantly lower for candidates who accepted compared to those that declined (6% versus 13% 1-year mortality and 15% versus 25% 5-year mortality, p = 0.0033). Decline of an IRD offer was associated with an adjusted hazard ratio for mortality of 1.87 (95% CI 1.24, 2.81, p < 0.003). CONCLUSIONS IRD organ acceptance is associated with a substantial survival benefit. Increasing acceptance of IRD organs may provide a targetable opportunity to decrease waitlist mortality in PHT.
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29
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Pereira MR, Dube GK, Tatem L, Burack D, Crew RJ, Cohen DJ, Ratner LE. HIV transmission through living donor kidney transplant: An 11-year follow-up on the recipient and donor. Transpl Infect Dis 2021; 23:e13691. [PMID: 34265862 DOI: 10.1111/tid.13691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/09/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
HIV transmission via solid organ transplant is a rare but serious complication. Here, we describe long-term outcomes in a case of living donor-derived transmission of HIV in a kidney transplant recipient. After 11 years since transplant surgery, the donor shows no evidence of abnormal renal function, while the recipient continues to have a functioning graft. HIV is well controlled in both individuals. This single case report highlights the possibility of acceptable long-term outcomes in living kidney donors with HIV as well as in donor-derived HIV transmission to kidney transplant recipients.
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Affiliation(s)
- Marcus R Pereira
- Division of Infectious Disease, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Geoffrey K Dube
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Luis Tatem
- Division of Infectious Disease, Department of Medicine, SUNY Downstate Health Sciences University, New York, New York, USA
| | - Daniel Burack
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Russell J Crew
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lloyd E Ratner
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA
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30
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Bixler D, Annambhotla P, Montgomery MP, Mixon-Hayden T, Kupronis B, Michaels MG, La Hoz RM, Basavaraju SV, Kamili S, Moorman A. Unexpected Hepatitis B Virus Infection After Liver Transplantation - United States, 2014-2019. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:961-966. [PMID: 34237046 PMCID: PMC8312757 DOI: 10.15585/mmwr.mm7027a1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Unexpected donor-derived hepatitis B virus (HBV) infection is defined as a new HBV infection in a recipient of a transplanted organ from a donor who tested negative for total antihepatitis B core antibody (total anti-HBc), hepatitis B surface antigen (HBsAg), and HBV DNA* before organ procurement. Such infections are rare and are associated with injection drug use among deceased donors (1). During 2014-2019, CDC received 20 reports of HBV infection among recipients of livers from donors who had no evidence of past or current HBV infection. Investigation included review of laboratory data and medical records. Fourteen of these new HBV infections were detected during 2019 alone; infections were detected a median of 38 (range = 5-116) weeks after transplantation. Of the 14 donors, 13 were hepatitis C virus (HCV)-seropositive† and had a history of injection drug use within the year preceding death, a positive toxicology result, or both. Because injection drug use is the most commonly reported risk factor for hepatitis C,§ providers caring for recipients of organs from donors who are HCV-seropositive or recently injected drugs should maintain awareness of infectious complications of injection drug use and monitor recipients accordingly (2). In addition to testing for HBV DNA at 4-6 weeks after transplantation, clinicians caring for liver transplant recipients should consider testing for HBV DNA 1 year after transplantation or at any time if signs and symptoms of viral hepatitis develop, even if previous tests were negative (2).
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31
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Donor and Recipient Matching in Facial Vascularized Composite Allotransplantation: A Closer Look at the Donor Pool. Plast Reconstr Surg 2021; 148:194-202. [PMID: 34181616 DOI: 10.1097/prs.0000000000008094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Identifying a donor for facial vascularized composite allotransplant recipients can be a lengthy, emotionally challenging process. Little is known about the relative distribution of key donor characteristics among potential donors. Data on actual wait times of patients are limited, making it difficult to estimate wait times for future recipients. METHODS The authors retrospectively reviewed charts of nine facial vascularized composite allotransplant patients and provide data on transplant wait times and patient characteristics. In addition, they analyzed the United Network for Organ Sharing database of dead organ donors. After excluding donors with high-risk characteristics (e.g., active cancer or risk factors for blood-borne disease transmission), the authors calculated the distribution of relevant donor-recipient matching criteria (i.e., ethnicity, body mass index, age, ABO blood group, cytomegalovirus, Epstein-Barr virus, hepatitis C virus) among 65,201 potential donors. RESULTS The median wait time for a transplant was 4 months (range, 1 day to 17 months). The large majority of United Network for Organ Sharing-recorded deaths from disease were white (63 percent) and male (58 percent). Female donors of black, Hispanic, or Asian descent are underrepresented, with 7, 5, and 1 percent of all recorded deaths from disease, respectively. Potential donors show cytomegalovirus and Epstein-Barr virus seropositivity of 65 and 95 percent, respectively. The number of annual hepatitis C-positive donors increased over time. CONCLUSIONS Actual facial vascularized composite allotransplant wait times vary considerably. Although most patients experience acceptable wait times, some with underrepresented characteristics exceed acceptable levels. Cytomegalovirus-seropositive donors present a large portion of the donor pool, and exclusion for seronegative patients may increase wait time. Hepatitis C-seropositive donors may constitute a donor pool for underrepresented patient groups in the future.
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32
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Puente MA, Patnaik JL, Lynch AM, Snyder BM, Caplan CM, Pham B, Neves da Silva HV, Chen C, Taravella MJ, Palestine AG. Association of Federal Regulations in the United States and Canada With Potential Corneal Donation by Men Who Have Sex With Men. JAMA Ophthalmol 2021; 138:1143-1149. [PMID: 32970105 PMCID: PMC7516798 DOI: 10.1001/jamaophthalmol.2020.3630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Question Regarding federal policy in the United States that prohibits corneal donation by men who have had sex with another man (MSM) in the preceding 5 years (or 12 months in Canada), what is the association of these policies with the supply of donated corneas? Findings These policies were associated with the disqualification of an estimated 1558 to 3217 corneal donations by otherwise eligible MSM donors in the United States and Canada in 2018. Meaning With reliable modern HIV testing and with many countries experiencing severe corneal shortages, these federal policies may be decreasing the availability of vision-restoring surgery, suggesting these policies should be reevaluated in light of current scientific evidence. Importance Federal policy in the United States prohibits corneal donation by men who have had sex with another man (MSM) in the preceding 5 years, whereas Canada enforces a 12-month ban. The potential consequences of these policies on corneal donations should be evaluated. Objective To estimate the number of potential corneal donations associated with MSM deferral policies in the United States and Canada. Design, Setting, and Participants A nonvalidated telephone survey study was conducted of all 65 eye banks in the United States and Canada to investigate how many potential corneal donors were disqualified in 2018 because of federal MSM restrictions. Published demographic data were also used to arrive at a separate estimate. Survey data were gathered from May 2019 to February 2020. Main Outcomes and Measures Eye banks were asked if they keep records of referrals disqualified specifically because of the federal MSM restrictions and, if so, how many referrals they disqualified in 2018 owing to MSM status. Results Fifty-four of 65 eye banks (83%) responded to the survey, with 30 eye banks reporting they do not keep specific records of MSM deferrals. The remaining 24 eye banks reported disqualifying 360 referrals in 2018 because of MSM status, equating to 720 corneas. The 24 eye banks accounted for 46.2% of corneal donations in the United States and Canada in 2018, yielding an estimate of approximately 1558 corneas rejected that year because of MSM status. A separate estimate using published MSM demographic data indicates that up to 3217 potential corneal donations may have been disqualified in 2018 because of these federal policies. Conclusions and Relevance Findings suggest that between 1558 and 3217 corneal donations were disqualified in 2018 because of federal regulations prohibiting corneal donation by men who have had sex with another man in the preceding 5 years in the United States or 1 year in Canada. With modern virologic testing that is reliable within days of HIV exposure and given the global shortage of corneal tissue, these policies should be reevaluated using current scientific evidence to increase the availability of vision-restoring surgery worldwide.
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Affiliation(s)
- Michael A Puente
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Jennifer L Patnaik
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Anne M Lynch
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Blake M Snyder
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Chad M Caplan
- Department of Ophthalmology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Binhan Pham
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | | | - Conan Chen
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Michael J Taravella
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora
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33
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Bova S, Cameron A, Durand C, Katzianer J, LeGrand M, Boyer L, Glorioso J, Toman LP. Access to direct-acting antivirals for hepatitis C-negative transplant recipients receiving organs from hepatitis C-viremic donors. Am J Health Syst Pharm 2021; 79:173-178. [PMID: 33987658 DOI: 10.1093/ajhp/zxab207] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE A barrier to using organs from hepatitis C virus (HCV)-viremic donors is the high cost of direct-acting antivirals (DAAs) and concerns about access for recipients after transplantation. The purpose of this study was to evaluate access, cost, and timing for HCV DAAs following transplantation. METHODS This was a single-center, retrospective study of HCV-negative adult transplant recipients from June 2017 to December 2019 who received grafts from HCV-viremic and/or HCV-seropositive individuals and became HCV viremic after transplantation. RESULTS Between June 2017 and December 2019, there were 60 HCV-negative transplant recipients who became viremic after receiving grafts from HCV-viremic or HCV-seropositive donors. Thirty-eight patients met the inclusion criteria (n = 25 with liver transplants, n = 6 with lung transplants, n = 4 with simultaneous liver and kidney transplants, and n = 3 with kidney transplants). Of these patients, 23 had commercial insurance, 13 had Medicare, and 2 had Medicaid. All patients ultimately received insurance coverage for treatment; however, 36 (95%) required prior authorization and 9 (24%) required appeals to obtain insurance coverage. The median time from DAA prescription to insurance approval was 6 days. The median time from transplantation to start of treatment was 29 days (range, 0-84 days). Patients with Medicaid insurance had a significantly longer time to insurance approval (31.5 vs 6 days, P = 0.007). The average out-of-pocket cost to patients was less than $10 a month after patient assistance.All patients who completed treatment and 12-week follow-up after treatment achieved a sustained virologic response (n = 36). CONCLUSION In this study, all HCV-negative recipients who developed HCV following transplantation had access to DAA therapy, with the majority starting treatment in the first month after transplantation.
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Affiliation(s)
- Sarah Bova
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Andrew Cameron
- Division of Transplantation, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Christine Durand
- Division of Infectious Disease, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jennifer Katzianer
- Department of Pharmacy, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Meighan LeGrand
- Department of Pharmacy, Johns Hopkins Home Care Group, Baltimore, MD, USA
| | - Lauren Boyer
- Division of Transplantation, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jaime Glorioso
- Transplant Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Lindsey P Toman
- Department of Pharmacy, Johns Hopkins Home Care Group, Baltimore, MD, USA
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34
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Agbim U, Cseprekal O, Yazawa M, Talwar M, Balaraman V, Bhalla A, Podila PSB, Maliakkal B, Nair S, Eason JD, Molnar MZ. Factors associated with hepatitis C antibody seroconversion after transplantation of kidneys from hepatitis C infected donors to hepatitis C naïve recipients. Ren Fail 2021; 42:767-775. [PMID: 32729359 PMCID: PMC7472509 DOI: 10.1080/0886022x.2020.1798784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background We aimed to assess the probability and factors associated with the presence of hepatitis C virus (HCV) antibody among HCV seronegative kidney transplant recipients receiving HCV-infected (nucleic acid testing positive) donor kidneys. Methods This is a retrospective review examining HCV antibody seroconversion of all kidney transplant recipients receiving an organ from an HCV-infected donor between 1 March 2018 and 2 December 2019 at a high-volume kidney transplant center in the southeast United States. Results Of 97 patients receiving HCV-infected kidneys, the final cohort consisted of 85 recipients with 5 (5.9%) recipients noted to have HCV antibody seroconversion in the setting of HCV viremia. The HCV RNA level at closest time of antibody measurement was higher in the seroconverted patients versus the ones who never converted [median and (interquartile range): 1,091,500 (345,000–8,360,000) vs 71,500 (73–313,000), p = 0.02]. No other significant differences including type of immunosuppression were noted between the HCV antibody positive group and HCV antibody negative group. Donor donation after cardiac death status [Odds Ratio (OR) and 95% Confidence Interval (CI) was: 8.22 (1.14–59.14)], donor age [OR (95% CI) (+5 years) was: 3.19 (1.39–7.29)] and Kidney Donor Profile Index [OR (95% CI) (+1) was:1.07 (1.01–1.15)] showed a statistically significant association with HCV seroconversion. Conclusions HCV antibody should not be considered routine screening for presence of infection in previously HCV naïve kidney transplant recipients receiving kidneys from HCV-infected donors, as only a modest percentage have antibody despite active viremia. The assessment of HCV viral load should be routine in all transplant recipients receiving organs from public health service increased risk donors.
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Affiliation(s)
- Uchenna Agbim
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA
| | - Orsolya Cseprekal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Masahiko Yazawa
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Tokyo, Japan
| | - Manish Talwar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Vasanthi Balaraman
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anshul Bhalla
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pradeep S B Podila
- Faith and Health Division, Methodist Le Bonheur Healthcare, Memphis, TN, USA.,Division of Health Systems Management and Policy, School of Public Health, The University of Memphis, Memphis, TN, USA
| | - Benedict Maliakkal
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Satheesh Nair
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James D Eason
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Miklos Z Molnar
- James D. Eason Transplant Institute, Methodist University Hospital, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
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Ellison TA, Clark S, Hong JC, Frick KD, Segev DL. Potential Unintended Consequences of National Infectious Disease Screening Strategies in Deceased Donor Kidney Transplantation: A Cost-Effectiveness Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:403-414. [PMID: 32885353 DOI: 10.1007/s40258-020-00593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND In order to counter the lack of sufficient kidney donors, there has been interest in expanding the utilization of organs from increased infectious-risk donors. Negative nucleic acid testing of increased infectious-risk organs has been shown to increase their use as compared to only enzyme-linked immunosorbent assay negativity. However, it is not known how the expanded use of nucleic acid testing on a national scale might affect total donor utilization. OBJECTIVE The objective of this paper was to determine if a national screening policy requiring the use of nucleic acid testing in both increased infectious-risk and non-increased infectious-risk renal transplant donors would increase the donor organ pool. METHODS This study used decision-tree analysis to determine the cost-effectiveness of four US national screening policies based on an increasingly expansive use of nucleic acid testing for increased infectious-risk and non-increased infectious-risk kidneys. Parameters were taken from the literature. All costs were reported in 2020 US dollars using a Medicare payer perspective and a life-time horizon. RESULTS The use of nucleic acid screening solely for increased infectious-risk organs was the dominant strategy. Our results were robust to deterministic and probabilistic sensitivity analyses. One of the main driving factors of cost-effectiveness was the false-positive rate of nucleic acid testing. CONCLUSION Before implementing nucleic acid screening outside of increased infectious-risk organs, its false-positivity rate should be directly studied to ensure that its use does not detrimentally affect transplantation numbers, quality-adjusted life-years, and costs.
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Affiliation(s)
- Trevor A Ellison
- Department of Cardiothoracic Surgery, Mount Carmel Health System, Columbus, OH, USA.
| | - Samantha Clark
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | - Jonathan C Hong
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Kevin D Frick
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD, USA
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Hepatitis C-Positive Donors in Cardiac Transplantation: Problems and Opportunities. Curr Heart Fail Rep 2021; 17:106-115. [PMID: 32474734 DOI: 10.1007/s11897-020-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW With the growing need for donor hearts and longer transplant waiting lists, there is a growing interest in expanding the donor pool by reconsidering previously excluded donor candidates. There has been an increase in solid organ availability due to drug overdose deaths in the setting of the recent opioid epidemic. However, these donors often have transmissible infections such as hepatitis C. In this review, we discuss the challenges associated with heart transplantation from hepatitis C-infected donors as well as the recent advancements that are making the use of these organs possible. RECENT FINDINGS With the introduction and widespread use of nucleic acid testing (NAT), the ability to distinguish viremic donors and those that have cleared the virus has become a reality. In addition, with the emergence of direct antiviral agents, there is an increase in data showing the short-term outcomes and success of hepatitis C treatment for recipients of viremic donor hearts. As techniques to distinguish donor hepatitis C infection status and successful treatments emerge, the percentage of accepted hepatitis C donor hearts is increasing. A number of studies showing success with hepatitis C organ transplants present a promising new avenue for organ procurement essential to meet the increasing demand for donor hearts.
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Updated View on Kidney Transplant from HCV-Infected Donors and DAAs. Pharmaceutics 2021; 13:pharmaceutics13040496. [PMID: 33917382 PMCID: PMC8067384 DOI: 10.3390/pharmaceutics13040496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 12/20/2022] Open
Abstract
Background: The discrepancy between the number of potential available kidneys and the number of patients listed for kidney transplant continues to widen all over the world. The transplant of kidneys from hepatitis C virus (HCV)-infected donors into HCV naïve recipients has grown recently because of persistent kidney shortage and the availability of direct-acting antiviral agents. This strategy has the potential to reduce both waiting times for transplant and the risk of mortality in dialysis. Aim: We made an extensive review of the scientific literature in order to review the efficacy and safety of kidney transplant from HCV-viremic donors into HCV naïve recipients who received early antiviral therapy with direct-acting antiviral agents (DAAs). Results: Evidence has been rapidly accumulated on this topic and some reports have been published (n = 11 studies, n = 201 patients) over the last three years. Various combinations of DAAs were administered—elbasvir/grazoprevir (n = 38), glecaprevir/pibrentasvir (n = 110), and sofosbuvir-based regimens (n = 53). DAAs were initiated in a range between a few hours before renal transplant (RT) to a median of 76 days after RT. The sustained virological response (SVR) rate was between 97.5% and 100%. A few severe adverse events (SAEs) were noted including fibrosing cholestatic hepatitis (n = 3), raised serum aminotransferase levels (n = 11), and acute rejection (n = 7). It remains unclear whether the AEs were related to the transmission of HCV, the use of DAAs, or kidney transplant per se. It appears that the frequency of AEs was greater in those studies where DAAs were not given in the very early post-kidney transplant phase. Conclusions: The evidence gathered to date encourages the expansion of the kidney donor pool with the adoption of HCV-infected donor organs. We suggest that kidney transplants from HCV-viremic kidneys into HCV-uninfected recipients should be made in the context of research protocols. Many of the studies reported above were externally funded and we need research generating “real-world” evidence. The recent availability of pangenotypic combinations of DAAs, which can be given even in patients with eGFR < 30/min/1.73 m2, will promote the notion that HCV-viremic donors are a significant resource for kidney transplant.
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Innovations in liver transplantation in 2020, position of the Belgian Liver Intestine Advisory Committee (BeLIAC). Acta Gastroenterol Belg 2021; 84:347-359. [PMID: 34217187 DOI: 10.51821/84.2.347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LT) remains the only curative option for patients suffering from end-stage liver disease, acute liver failure and selected hepatocellular carcinomas and access to the LT-waiting list is limited to certain strict indications. However, LT has shown survival advantages for patients in certain indications such as acute alcoholic hepatitis, hepatocellular carcinoma outside Milan criteria and colorectal cancer metastases. These newer indications increase the pressure in an already difficult context of organ shortage. Strategies to increase the transplantable organ pool are therefore needed. We will discuss here the use of HCV positive grafts as the use of normothermic isolated liver perfusion. Belgian Liver Intestine Advisory Committee (BeLIAC) from the Belgian Transplant Society (BTS) aims to guarantee the balance between the new indications and the available resources.
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Halpern SE, McConnell A, Peskoe SB, Raman V, Jawitz OK, Choi AY, Neely ML, Palmer SM, Hartwig MG. A three-tier system for evaluation of organ procurement organizations' willingness to pursue and utilize nonideal donor lungs. Am J Transplant 2021; 21:1269-1277. [PMID: 33048423 PMCID: PMC7920904 DOI: 10.1111/ajt.16347] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 01/25/2023]
Abstract
Lungs from "nonideal," but acceptable donors are underutilized; however, organ procurement organization (OPO) metrics do not reflect the extent to which OPO-specific practices contribute to these trends. We developed a comprehensive system to evaluate nonideal lung donor avoidance, or risk aversion among OPOs. Adult donors in the UNOS registry who donated ≥1 organ for transplantation between 2007 and 2018 were included. Nonideal donors had any of age>50, smoking history ≥20 pack-years, PaO2 /FiO2 ratio ≤350, donation after circulatory death, or increased risk status. OPO-level risk aversion in donor pursuit, consent attainment, lung recovery, and transplantation was assessed. Among 83916 donors, 70372 (83.9%) were nonideal. Unadjusted OPO-level rates of nonideal donor pursuit ranged from 81 to 100%. In a three-tier system of overall risk aversion, tier 3 OPOs (least risk-averse) had the highest rates of nonideal donor pursuit, consent attainment, lung recovery, and transplantation. Tier 1 OPOs (most risk-averse) had the lowest rates of donor pursuit, consent attainment, and lung recovery, but higher rates of transplantation compared to tier 2 OPOs (moderately risk-averse). Risk aversion varies among OPOs and across the donation process. OPO evaluations should reflect early donation process stages to best differentiate over- and underperforming OPOs and encourage optimal OPO-specific performance.
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Affiliation(s)
| | - Alec McConnell
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Sarah B. Peskoe
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oliver K. Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Megan L. Neely
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Scott M. Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Anderson B, Jezewski E, Sela N, Westphal S, Hoffman A. Public health service increased risk donor kidney grafts for transplant into children, a survey of pediatric nephrologists. Pediatr Transplant 2021; 25:e13863. [PMID: 33027552 DOI: 10.1111/petr.13863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Kidney transplant is the best treatment for end-stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS-IRD) represent a significant portion of available organs which are discarded at disproportional rates. METHODS Pediatric nephrologists were surveyed regarding PHS-IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS-IRD acceptance. RESULTS Twenty-two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS-IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS-IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS-IRD as the same, and 90% supported stratifying PHS-IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%). CONCLUSIONS With improved utilization, PHS-IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS-IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.
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Affiliation(s)
- Blaire Anderson
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Emily Jezewski
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nathalie Sela
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott Westphal
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Arika Hoffman
- Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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41
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Dollard SC, Annambhotla P, Wong P, Meneses K, Amin MM, La Hoz RM, Lease ED, Budev M, Arrossi AV, Basavaraju SV, Thomas CP. Donor-derived human herpesvirus 8 and development of Kaposi sarcoma among 6 recipients of organs from donors with high-risk sexual and substance use behavior. Am J Transplant 2021; 21:681-688. [PMID: 32633035 PMCID: PMC7891580 DOI: 10.1111/ajt.16181] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 01/25/2023]
Abstract
Kaposi sarcoma (KS) can develop following organ transplantation through reactivation of recipient human herpesvirus 8 (HHV-8) infection or through donor-derived HHV-8 transmission. We describe 6 cases of donor-derived HHV-8 infection and KS investigated from July 2018 to January 2020. Organs from 6 donors, retrospectively identified as HHV-8-positive, with a history of drug use disorder, were transplanted into 22 recipients. Four of 6 donors had risk factors for HHV-8 infection reported in donor history questionnaires. Fourteen of 22 organ recipients (64%) had evidence of posttransplant HHV-8 infection. Lung recipients were particularly susceptible to KS. Four of the 6 recipients who developed KS died from KS or associated complications. The US opioid crisis has resulted in an increasing number and proportion of organ donors with substance use disorder, and particularly injection drug use history, which may increase the risk of HHV-8 transmission to recipients. Better awareness of the risk of posttransplant KS for recipients of organs from donors with HHV-8 infection risk could be useful for recipient management. Testing donors and recipients for HHV-8 is currently challenging with no validated commercial serology kits available. Limited HHV-8 antibody testing is available through some US reference laboratories and the Centers for Disease Control and Prevention.
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Affiliation(s)
| | | | - Phili Wong
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Katherine Meneses
- Liver Transplant DepartmentUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Minal M. Amin
- Centers for Disease Control and PreventionAtlantaGeorgiaUSA
| | - Ricardo M. La Hoz
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Erika D. Lease
- Division of Pulmonary Critical Care and Sleep MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Maria Budev
- Department of Pulmonary MedicineCleveland Clinic FoundationClevelandOhioUSA
| | | | | | - Christie P. Thomas
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA,Veterans Affairs Medical CenterIowa CityIowaUSA
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Paradigm Shift in Utilization of Livers from Hepatitis C-Viremic Donors into Hepatitis C Virus-Negative Patients. Clin Liver Dis 2021; 25:195-207. [PMID: 33978579 DOI: 10.1016/j.cld.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite record-breaking numbers of liver transplants (LTs) performed in the United States in each of the last 7 years, many patients remain on the wait list as the demand for LT continues to exceed the supply of available donors. The emergence of highly effective and well-tolerated direct-acting antiviral therapy has transformed the clinical course and management of hepatitis C virus (HCV) in both the pretransplant and posttransplant setting. Historically, donor livers infected with HCV were either transplanted into patients already infected with HCV or discarded.
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43
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Abstract
The United States has faced an unprecedented opioid crisis in recent years, which has led to an increase in opioid overdose-related deaths and, consequently, an increase in the number of potential deceased donors available for transplantation. This new pool of potential organ donors is composed of younger donors with higher infectious disease transmission risk. The use of organs from these donors requires appropriate patient education, informed consent, and post-transplant monitoring practices. Prescription opioid use is also an important component of the evaluation of transplant and living donor candidates because it may impact outcomes and eligibility for the procedures. In kidney transplant recipients, prescription opioid use predicts a higher risk of mortality, graft loss, and post-transplant complications. These effects seem to be proportional to the levels of opioid use, and to parallel patterns in other transplant populations such as liver, heart and lung recipients. Among living kidney donors, predonation prescription opioid use is associated with an increased risk of re-admission after nephrectomy. Overall, the opioid epidemic creates educational needs for patients awaiting deceased donor transplant, and also impacts the evaluation and care of transplant candidates. Among transplant candidates and recipients, the identification of patients with chronic opioid use should prompt multidisciplinary evaluation and management strategies to minimize risks.
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Affiliation(s)
- Marie-Camille Lafargue
- Transplantation Research Center, Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Leonardo V. Riella
- Transplantation Research Center, Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
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44
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Hussain Z, Yu M, Wozniak A, Kim D, Krepostman N, Liebo M, Raichlin E, Heroux A, Joyce C, Ilias-Basha H. Impact of donor smoking history on post heart transplant outcomes: A propensity-matched analysis of ISHLT registry. Clin Transplant 2020; 35:e14127. [PMID: 33098160 DOI: 10.1111/ctr.14127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE Smoking is a major public health issue, and its effect on cardiovascular outcomes is well established. This study evaluates the impact of donor smoking on heart transplant (HT) outcomes. METHODS HT recipients between January 1, 2005, and December 31, 2016, with known donor smoking status were queried from the International Society of Heart and Lung Transplantation (ISHLT) registry. The primary outcome was all-cause mortality, and secondary endpoints were graft failure, acute rejection, and cardiac allograft vasculopathy. We utilized propensity-score matching to identify cohorts of recipients with and without a history of donor smoking. Hazard ratios for post-transplant outcomes for the matched sample were estimated from separate Cox proportional hazard models. RESULTS Of 26 390 patients in the cohort, 18.9% had history of donor smoking. Donors with history of smoking were older, predominantly male and had higher incidence of diabetes, hypertension, cocaine use, and "high-risk" status. In propensity-matched analysis, recipients with a history of donor smoking had increased risk of death (HR 1.11, 95% CI 1.03-1.20) and higher risk of graft failure (HR 1.11, 95% CI 1.03-1.20). CONCLUSION Donor smoking was associated with increased mortality and higher incidence of graft failure following HT. Consideration of donor smoking history is warranted while evaluating donor hearts.
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Affiliation(s)
- Zeeshan Hussain
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mingxi Yu
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Amy Wozniak
- Department of Biostatistics, Loyola University Medical Center, Maywood, IL, USA
| | - Daniel Kim
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | | | - Max Liebo
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Eugenia Raichlin
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Alain Heroux
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Cara Joyce
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Haseeb Ilias-Basha
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
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45
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Frye CC, Gauthier JM, Bery A, Gerull WD, Morkan DB, Liu J, Shea Harrison M, Terada Y, Van Zanden JE, Marklin GF, Pasque MK, Nava RG, Meyers BF, Patterson AG, Kozower BD, Hachem R, Byers D, Witt C, Kulkarni H, Kreisel D, Puri V. Donor management using a specialized donor care facility is associated with higher organ utilization from drug overdose donors. Clin Transplant 2020; 35:e14178. [PMID: 33274521 DOI: 10.1111/ctr.14178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/27/2022]
Abstract
Drug overdoses have tripled in the United States over the last two decades. With the increasing demand for donor organs, one potential consequence of the opioid epidemic may be an increase in suitable donor organs. Unfortunately, organs from donors dying of drug overdose have poorer utilization rates than other groups of brain-dead donors, largely due to physician and recipient concerns about viral disease transmission. During the study period of 2011 to 2016, drug overdose donors (DODs) account for an increasingly greater proportion of the national donor pool. We show that a novel model of donor care, known as specialized donor care facility (SDCF), is associated with an increase in organ utilization from DODs compared to the conventional model of hospital-based donor care. This is likely related to the close relationship of the SDCF with the transplant centers, leading to improved communication and highly efficient donor care.
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Affiliation(s)
- Christian Corbin Frye
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - William D Gerull
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Deniz B Morkan
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - M Shea Harrison
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Judith E Van Zanden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Gary F Marklin
- Mid-America Transplant, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Alexander G Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey Hachem
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Derek Byers
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Chad Witt
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hrishikesh Kulkarni
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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Increased-risk donors and solid organ transplantation: current practices and opportunities for improvement. Curr Opin Organ Transplant 2020; 25:139-143. [PMID: 32073497 DOI: 10.1097/mot.0000000000000735] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The development and implementation of 'increased risk donor' (IRD) status by the Centers for Disease Control (CDC) was intended to guide patients and providers in decision making regarding risk of infectious transmission via solid organ transplantation. Several contemporary studies have shown underutilization of these organs. This review summarizes the issues surrounding IRD status as well as recent advances in our understanding of the risks and benefits of increased risk organs and their appropriate utilization. RECENT FINDINGS Risk of window-period infection remains exceedingly low, and implementation of nucleic acid testing for HIV and hepatitis C virus (HCV) has resulted in decreasing risk of window-period infection often by an order of magnitude or more. Surgeons remain hesitant to utilize IRD organs. In addition, surgeon assessment of risk by donor behaviour was often discordant with known risks of those behaviours. Studies investigating outcomes of utilization of IRD organs suggest long-term mortality and graft survival is at least equivalent to non-IRD organs. Contemporary results suggest that IRD organs continue to be underutilized, particularly adult kidneys and lungs, with hundreds of wasted organs per year. SUMMARY CDC IRD labelling has led to an underutilization of organs for transplantation. The risks associated with acceptance of an IRD organ are inflated by surgeons and patients, and outcomes for patients who undergo transplantation with increased risk organs are similar to or better than those for patients whom accept standard risk organs. The rate of transmission of window-period infection from IRD organs is exceptionally low. The harms regarding the utility of Public Health Service increased risk classification outweigh the benefits for patients in need of transplant.
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Prakash K, Wainana C, Trageser J, Hahn A, Lay C, Pretorius V, Adler E, Aslam S. Local and regional variability in utilization and allocation of hepatitis C virus-infected hearts for transplantation. Am J Transplant 2020; 20:2867-2875. [PMID: 32185860 DOI: 10.1111/ajt.15857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/12/2020] [Accepted: 03/15/2020] [Indexed: 01/25/2023]
Abstract
With the advent of direct-acting antiviral agents, there has been a rapid rise in hepatitis C virus-infected (HCV+) heart transplantation. We aimed to understand local and regional differences in utilization and allocation of HCV+ hearts. Using United Network for Organ Sharing (UNOS) de-identified data from January 1, 2016 to September 30, 2019 we compared trends in the utilization rates (hearts transplanted/donors recovered) of HCV-uninfected (HCV-) to those of HCV+ nonviremic (HCV-NV) and viremic (HCV-V) hearts nationally and by UNOS region. We also evaluated allocation rates (hearts successfully allocated/donors recovered) by organ procurement organization (OPO). We found that (1) in 2019, national utilization rates for HCV-NV and HCV-V hearts were the same as HCV- hearts (27.6% for HCV-NV, 30.9 for HCV-V, and 31.7% for HCV-, P = .277); (2) utilization rates of HCV-NV hearts were low in regions 3 and 4 and of HCV-V hearts in regions 3, 4, and 8 even in the contemporary period since 2018; and (3) there was marked variability in allocation of HCV+ hearts at the OPO level even within the same UNOS region. We conclude that despite national strides in the utilization of HCV+ hearts for transplantation, more aggressive allocation of HCV+ hearts at the OPO level may still significantly affect the organ shortage.
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Affiliation(s)
- Katya Prakash
- Division of Infectious Diseases, University of California, San Diego, California, USA
| | | | | | | | - Cecilia Lay
- Clinical Research, University of California, San Diego, California, USA
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, University of California, San Diego, California, USA
| | - Eric Adler
- Division of Cardiology, University of California, San Diego, California, USA
| | - Saima Aslam
- Division of Infectious Diseases, University of California, San Diego, California, USA.,Clinical Research, University of California, San Diego, California, USA
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48
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Theodoropoulos NM, La Hoz RM, Wolfe C, Vece G, Bag R, Berry GJ, Bucio J, Danziger-Isakov L, Florescu DF, Goldberg D, Ho CS, Lilly K, Malinis M, Mehta AK, Nalesnik MA, Sawyer R, Strasfeld L, Wood RP, Michaels MG. Donor derived hepatitis B virus infection: Analysis of the Organ Procurement & Transplantation Network/United Network for Organ Sharing Ad Hoc Disease Transmission Advisory Committee. Transpl Infect Dis 2020; 23:e13458. [PMID: 32894634 DOI: 10.1111/tid.13458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/06/2020] [Accepted: 08/28/2020] [Indexed: 11/29/2022]
Abstract
Hepatitis B virus (HBV) can be transmitted from organ donor to recipient, but details of transmission events are not widely published. The Disease Transmission Advisory Committee (DTAC) evaluated 105 cases of potential donor derived transmission events of HBV between 2009-2017. Proven, probable or possible transmission of HBV occurred in 25 (23.8%) cases. Recipients of liver grafts were most commonly infected (20 of 21 exposed recipients) compared to 9 of 21 exposed non-hepatic recipients. Eleven of 25 donors were HBV core antibody (HBcAb) positive/HBV surface antigen (HBsAg) negative and infected 8/20 recipients. Of the 10 liver recipients and 1 liver-kidney recipient who received organs from these donors: six were not given antiviral prophylaxis, two developed infection after antiviral prophylaxis was discontinued, two developed HBV while on lamivudine prophylaxis, one was on antiviral prophylaxis and did not develop HBV viremia or antigenemia. One recipient of a HBcAb positive/HBsAg negative kidney developed active HBV infection. Unexpected donor-derived transmission of HBV was a rare event in reports to DTAC, but was often detected in the recipient late post-transplant. Six of 11 recipients (54.5%) of a liver from a HBcAb positive donor did not receive prophylaxis; all of these were potentially preventable with the use of anti-viral prophylaxis.
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Affiliation(s)
- Nicole M Theodoropoulos
- Division of Infectious Diseases & Immunology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ricardo M La Hoz
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Gabriel Vece
- United Network for Organ Sharing, Richmond, VA, USA
| | - Remzi Bag
- Section of Pulmonary & Critical Care Medicine, UChicago Medicine, Chicago, IL, USA
| | - Gerald J Berry
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Jamie Bucio
- Lung and Heart Transplant Programs, UChicago Medicine, Chicago, IL, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center &, University of Cincinnati, Cincinnati, OH, USA
| | - Diana F Florescu
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - David Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chak-Sum Ho
- Gift of Hope Organ & Tissue Donor Network, Itasca, IL, USA
| | | | - Maricar Malinis
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Aneesh K Mehta
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Robert Sawyer
- Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Lynne Strasfeld
- Division of Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
| | | | - Marian G Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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49
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Waller KMJ, De La Mata NL, Hedley JA, Rosales BM, O'Leary MJ, Cavazzoni E, Ramachandran V, Rawlinson WD, Kelly PJ, Wyburn KR, Webster AC. New blood-borne virus infections among organ transplant recipients: An Australian data-linked cohort study examining donor transmissions and other HIV, hepatitis C and hepatitis B notifications, 2000-2015. Transpl Infect Dis 2020; 22:e13437. [PMID: 32767859 DOI: 10.1111/tid.13437] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Blood-borne viral infections can complicate organ transplantation. Systematic monitoring to distinguish donor-transmitted infections from other new infections post transplant is challenging. Administrative health data can be informative. We aimed to quantify post-transplant viral infections, specifically those transmitted by donors and those reactivating or arising new in recipients. METHODS We linked transplant registries with administrative health data for all solid organ donor-recipient pairs in New South Wales, Australia, 2000-2015. All new recipient notifications of hepatitis B (HBV), C (HCV), or human immunodeficiency virus (HIV) after transplant were identified. Proven/probable donor transmissions within 12 months of transplant were classified using an international algorithm. RESULTS Of 2120 organ donors, there were 72 with a viral infection (9/72 active, 63/72 past). These 72 donors donated to 173 recipients, of whom 24/173 already had the same infection as their donor, and 149/173 did not, so were at risk of donor transmission. Among those at risk, 3/149 recipients had proven/probable viral transmissions (1 HCV, 2 HBV); none were unrecognized by donation services. There were no deaths from transmissions. There were no donor transmissions from donors without known blood-borne viruses. An additional 68 recipients had new virus notifications, of whom 2/68 died, due to HBV infection. CONCLUSION This work confirms the safety of organ donation in an Australian cohort, with no unrecognized viral transmissions and most donors with viral infections not transmitting the virus. This may support targeted increases in donation from donors with viral infections. However, other new virus notifications post transplant were substantial and are preventable. Data linkage can enhance current biovigilance systems.
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Affiliation(s)
- Karen M J Waller
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Nicole L De La Mata
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - James A Hedley
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Brenda M Rosales
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Michael J O'Leary
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia.,Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Elena Cavazzoni
- New South Wales Organ and Tissue Donation Service, Sydney, NSW, Australia
| | - Vidiya Ramachandran
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia
| | - William D Rawlinson
- Serology and Virology Division, NSW Health Pathology Randwick Prince of Wales Hospital, Randwick, NSW, Australia.,Schools of SOMS, BABS and Women's and Children's, University of NSW, Kensington, NSW, Australia
| | - Patrick J Kelly
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia
| | - Kate R Wyburn
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Health and Medicine, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Angela C Webster
- Faculty of Health and Medicine, Sydney School of Public Health, Centre for Organ Donation Evidence, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
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50
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Short-Term Graft Failure of Organs Procured from Drug-Related Deaths Compared with Other Causes of Death. J Med Toxicol 2020; 17:37-41. [PMID: 32789584 DOI: 10.1007/s13181-020-00801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND A gap exists between the number of patients on the national organ transplant waiting list and the number of transplants performed. Victims of drug and overdose-related death are increasingly utilized as organ donors. We sought to evaluate the suitability of organs from drug and overdose-related death for organ transplantation. This study compares the proportion of short-term allograft failure of organs procured from patients with drug-related deaths with those without drug-related deaths. METHODS Organ donations after drug-related deaths (DDD) were compared with organ donations from non-drug-related donations after brain deaths (DBD) and donations after circulatory deaths (DCD) utilizing the Gift of Hope Organ & Tissue Donor Network for a total of 15 months. RESULTS Eighty-one donors were identified from each of the DDD, DBD, and DCD groups with 264, 234, and 181 organs transplanted, respectively. The proportions of short-term graft failures were 1.15% in the DDD group compared with 2.14% in the DBD group (p = NS) and 5.52% in the DCD group (p = 0.01). The US Public Health Service increased-risk features for transmission of infectious diseases were present in 70.3% of the DDD cases. Donors from the DDD group were younger on average than those in other groups (33 to 42 years). CONCLUSIONS The proportion of graft failures in the drug-related deaths (DDD) group was equal to or less than those from other causes of death on short-term follow-up. Drug-related death does not appear to be a contraindication for organ procurement despite increased risk features for infectious disease transmission.
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