Graft survival and mortality outcomes after kidney transplant in patients with lupus nephritis: a systematic review and meta-analysis

To explore the effect of lupus nephritis (LN) on graft survival in renal transplant patients. Literature search was conducted in PubMed, EMBASE and Scopus database for randomized controlled trials (RCTs), cohort, and case-control studies. The target population of interest was adult patients (aged >18 years) with end-stage renal disease (ESRD) and no history of previous renal transplants. Primary outcomes of interest were graft survival and patient survival. Pooled effect estimates were calculated using random-effects models and reported as hazard ratio (HR) with 95% confidence intervals (CI). A total of 15 studies were included. Compared to patients with ESRD due to other causes, patients with LN undergoing kidney transplant had lower patient survival rate (HR 1.15, 95% CI: 1.01, 1.31; N = 15, I2=34.3%) and worse graft survival (HR 1.06, 95% CI: 1.01, 1.11; N = 16, I2=0.0%), especially when studies with deceased donor were pooled together. Studies with a larger sample size (>200) showed that LN was strongly associated with lower graft and patient survival rates. Elevated risk of mortality in LN patients was detected in case-control studies, but not RCTs. On the other hand, RCTs, but not case-control studies, showed an increased risk of poor graft survival in LN patients. The findings suggest that the presence of LN might have a negative impact on both the graft survival and the overall patient survival of post-transplant ESRD patients. Further studies that account for factors such as study methodology, donor characteristics, and sample size are needed to reach definitive conclusions. Renal transplant patients with LN should undergo regular follow-up examinations.

A Comprehensive Analysis of Litigation in Organ Transplantation for Allegations of Insufficient Policy Coverage, Discrimination and Malpractice

Introduction: Transplantation is a field with unique medical and administrative challenges that involve an equally diverse array of stakeholders. Expectantly, the litigation stemming from this field should be similarly nuanced. There is a paucity of comprehensive reviews characterizing this medicolegal landscape. Design: The Caselaw Access Project Database was used to collect official court briefs of 2053 lawsuits related to kidney, liver, heart, lung, and pancreas transplantation. A thematic analysis was undertaken to characterize grounds for litigation, defendant type, and outcomes. Cases were grouped into policy, discrimination, poor or unsuccessful outcome, or other categories. Results: One hundred sixty-four court cases were included for analysis. Cases involving disputes over policy coverage were the most common across all organ types (N = 55, 33.5%). This was followed by poor outcomes (N = 51, 31.1%), allegations of discrimination against prison systems and employers (N = 37, 22.6%) and other (N = 21, 12.8%). Defendants involved in discrimination trials won with the greatest frequency (N = 29, 90.62%). Defendants implicated in policy suits won 65.3% (N = 32), poor outcomes 62.2% (N = 28), and other 70% (N = 14). Of the 51 cases involving poor outcomes, plaintiffs indicated lack of informed consent in 23 (45.1%). Conclusion: Reconsidering the informed consent process may be a viable means of mitigating future legal action. Most discrimination suits favoring defendants suggested previous concerns of structural injustices in transplantation may not be founded. The prevalence of policy-related cases could be an indication of financial burden on patients. Future work and advocacy will need to substantiate these concerns and address change where legal recourse falls short.

Strategies for choosing the best living donor: A review of the literature and a proposal of a decision-making paradigm

Transplantation remains the gold-standard treatment for pediatric end-stage kidney disease. While living donor transplant is the preferred option for most pediatric patients, it is not the right choice for all. For those who have the option to choose between deceased donor and living donor transplantation, or from among multiple potential living donors, the transplant clinician must weigh multiple dynamic factors to identify the most optimal donor. This review will cover the key considerations when choosing between potential living donors and will propose a decision-making algorithm.

Factors associated with the quality of life of living kidney donors in Korea: A cross-sectional study

This study investigated the relationship between self-determination, physical health status, and Health related Quality of Life (=HRQoL) among living kidney donors. A descriptive survey was conducted between 2019 and 2020 and included 111 kidney donors. Data were collected using a self-report questionnaire on general and donation-related characteristics, self-determination, and HRQoL. The data also included medical records reflecting the physical health status at the time of the survey. Data were analyzed using a multiple regression model. Factors associated with HRQoL were perceived health recovery after donation (β = 0.42, P < .001), up to 1 year since donation (β = 0.33, P = .008), more than 1 up to 5 years since donation (β = 0.52, P < .001), more than 5 up to 10 years since donation (β = 0.53, P < .001), and competence of self-determination (β = 0.23, P = .033). The explanatory power of these variables was 43.3%. HRQoL of living kidney donors can be affected by subjective and psychological factors. Therefore, health care providers should help living kidney donors have high self-determination during pre and post donation and concentrate on the subjective and psychological factors as well as objective health status.

Cost-effectiveness analysis of adult living-donor liver transplantation in Japan

AIM

Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan.

METHODS

We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer.

RESULTS

After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B.

CONCLUSIONS

Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.

Liver regeneration of living donor after liver donation for transplantation: Disparity in the left and right remnant liver

Donor safety is crucial for living donor liver transplantation (LDLT), and sufficient liver regeneration significantly affects outcomes of living donors. This study aimed to investigate clinical factors associated with liver regeneration in living donors. The study retrospectively reviewed 380 living donors who underwent liver donation at Chang Gung Memorial Hospital in Linkou. The clinical characteristics and medical parameters of donors were analyzed and compared according to liver donation graft type. There were 355 donors (93.4%) with right hemi-liver donations and 25 donors (6.6%) with left hemi-liver donations. Left hemi-liver donors had a higher body mass index (BMI) and a larger ratio of remnant liver volume (RLV) to total liver volume (TLV). However, the 2 groups showed no significant difference in the liver regeneration ratio. The type of remnant liver (P < .001), RLV/body weight (P = .027), RLV/TLV (P < .001), serum albumin on postoperative day 7 and total bilirubin levels on postoperative day 30 were the most significant factors affecting liver regeneration in living donors. In conclusion, adequate liver regeneration is essential for donor outcome after liver donation. The remnant liver could eventually regenerate to an adequate volume similar to the initial TLV before liver donation. However, the remnant left hemi-liver had a faster growth rate than the remnant right hemi-liver in donors.

Utilization of older deceased donors for pediatric liver transplant may negatively impact long-term survival

BACKGROUND

Multiple adult studies have investigated the role of older donors (ODs) in expanding the donor pool. However, the impact of donor age on pediatric liver transplantation (LT) has not been fully elucidated.

METHODS

UNOS database was used to identify pediatric (≤18 years) LTs performed in the United States during 2002-22. Donors ≥40 years at donation were classified as older donors (ODs). Propensity analysis was performed with 1:1 matching for potentially confounding variables.

RESULTS

A total of 10,024 pediatric liver transplantation (PLT) patients met inclusion criteria; 669 received liver grafts from ODs. Candidates receiving OD liver grafts were more likely to be transplanted for acute liver failure, have higher Model End-Stage Liver Disease/Pediatric End-Stage Liver Disease (MELD/PELD) scores at LT, listed as Status 1/1A at LT, and be in the intensive care unit (ICU) at time of LT (all p < 0.001). Kaplan-Meier (KM) analyses showed that recipients of OD grafts had worse patient and graft survival (p < 0.001) compared to recipients of younger donor (YD) grafts. KM analyses performed on candidates matched for acuity at LT revealed inferior patient and graft survival in recipients of deceased donor grafts (p < 0.001), but not living donor grafts (p > 0.1) from ODs. Cox regression analysis demonstrated that living donor LT, diagnosis of biliary atresia and first liver transplant were favorable predictors of recipient outcomes, whereas ICU stay before LT and transplantation during 2002-12 were unfavorable.

CONCLUSION

Livers from ODs were used for candidates with higher acuity. Pediatric recipients of livers from ODs had worse outcome compared to YDs; however, living donor LT from ODs had the least negative impact on recipient outcomes.

National Attitudes Toward Living Kidney Donation in the United States: Results of a Public Opinion Survey

Rationale & Objective

Understanding national attitudes about living kidney donation will enable us to identify and address existing disincentives to living kidney donation. We performed a national survey to describe living kidney donation perceptions, perceived factors that affect the willingness to donate, and analyzed differences by demographic subgroups.

Study Design

The survey items captured living kidney donation awareness, living kidney donation knowledge, willingness to donate, and barriers and facilitators to living kidney donation.

Setting & Population

We surveyed 802 US adults (aged 25-65 years) in June 2021, randomly selected from an online platform with diverse representation.

Analytical Approach

We developed summed, scaled indices to assess the association between the living kidney donation knowledge (9 items) and the willingness to donate (8 items) to self-reported demographic characteristics and other variables of interest using analysis of variance. All other associations for categorical questions were calculated using Pearson's χ2 and Fisher exact tests. We inductively evaluated free-text responses to identify additional barriers and facilitators to living kidney donation.

Results

Most (86.6%) of the respondents reported that they might or would definitely consider donating a kidney while they were still living. Barriers to living kidney donation included concerns about the risk of the surgery, paying for medical expenses, and potential health effects. Facilitators to living kidney donation included having information on the donation surgery's safety, knowing that the donor would not have to pay for medical expenses related to the donation, and hearing living kidney donation success stories. Awareness of the ability to participate in kidney-paired donation was associated with a higher willingness to donate.

Limitations

Potential for selection bias resulting from the use of survey panels and varied incentive amounts, and measurement error related to respondents' attention level.

Conclusions

Most people would consider becoming a living kidney donor. Increased rates of living kidney donation may be possible with investment in culturally competent educational interventions that address risks associated with donating, policies that reduce financial disincentives, and communication campaigns that raise awareness of kidney-paired donation and living kidney donation.

Clinical performance of the iPREDICTLIVING tool for the prediction of the post-transplant recipient and living donor outcomes in a European cohort

A living donor kidney transplant (LDKT) is the best treatment for ESRD. A prediction tool based on clinical and demographic data available pre-KT was developed in a Norwegian cohort with three different models to predict graft loss, recipient death, and donor candidate's risk of death, the iPREDICTLIVING tool. No external validations are yet available. We sought to evaluate its predictive performance in our cohort of 352 pairs LKDT submitted to KT from 1998 to 2019. The model for censored graft failure (CGF) showed the worse discriminative performance with Harrell's C of .665 and a time-dependent AUC of .566, with a calibration slope of .998. For recipient death, at 10 years, the model had a Harrell's C of .776, a time-dependent AUC of .773, and a calibration slope of 1.003. The models for donor death were reasonably discriminative, although with a poor calibration, particularly for 20 years of death, with a Harrell's C of .712 and AUC of .694 with a calibration slope of .955. These models have moderate discriminative and calibration performance in our population. The tool was validated in this Northern Portuguese cohort, Caucasian, with a low incidence of diabetes and other comorbidities. It can improve the informed decision-making process at the living donor consultation joining clinical and other relevant information.

Pregnancy after deceased donor vs living donor kidney transplant: associated obstetric and graft outcomes

BACKGROUND

Outside of pregnancy, recipients of a deceased donor kidney transplant experience worse graft and overall survival compared with recipients of a living donor kidney transplant. In pregnancy, it is unknown whether the type of donor graft modifies either graft health in the peripartum period or pregnancy outcomes.

OBJECTIVE

This study aimed to define characteristics and outcomes in pregnancy based on donor type in kidney transplant recipients.

STUDY DESIGN

This was a retrospective cohort study of adult kidney transplant recipients who received their graft between 2000 and 2019 with a subsequent pregnancy enrolled in the Transplant Pregnancy Registry International. The primary outcome was graft loss within 2 years of delivery. The secondary outcomes included severe maternal morbidity and neonatal composite morbidity. Univariate, multivariable logistic regression, and Cox proportional-hazards models were constructed for statistical analysis, with recipients of a living unrelated donor as the referent.

RESULTS

Overall, 638 pregnant patients after kidney transplant had pregnancy outcomes that met our inclusion criteria. Of these patients, 168 (26.3%) received a graft from a deceased donor, 310 (48.6%) received a graft from a living related donor, and 160 (25.1%) received a graft from a living unrelated donor. Recipients of a deceased donor were more likely to be nulliparous, have an unplanned pregnancy, and self-identify as non-White. Moreover, recipients of a deceased donor were more likely to experience urinary tract infections (deceased donor: 21.8%; living related donor: 10.1%; living unrelated donor: 20.6%; P=.018). Severe maternal morbidity (deceased donor: 3.4%; living related donor: 2.8%; living unrelated donor: 7.2%) and neonatal composite morbidity (deceased donor: 8.4%; living related donor: 17.1%; living unrelated donor: 14.4%) did not differ by donor type. Deceased donor transplant was associated with graft loss within 2 years of delivery (deceased donor: 6.7%; living related donor: 3.7%; living unrelated donor: 1.3%; adjusted odds ratio, 7.52; 95% confidence interval, 1.53-60.8) and long-term graft loss from transplant (adjusted hazard ratio, 2.08; 95% confidence interval, 1.10-3.95).

CONCLUSION

Although our study demonstrated an association between deceased donor transplant and graft loss after pregnancy, it did not provide evidence that pregnancy itself causes graft loss. Recipients of a deceased donor kidney transplant should not be discouraged from pursuing pregnancy based on their donor type, but these patients should undergo preconception counseling with a discussion of their individualized obstetrical and graft risks, close intrapartum monitoring for infection and hypertensive disease, and continued surveillance for at least 2 years after delivery with a multidisciplinary obstetrics and transplant team.

The impact of high volumes of COVID-related lung transplant on waitlist mortality for non-COVID candidates in the United States

Some patients with coronavirus disease 19 (COVID) develop serious, irreversible lung disease, including acute respiratory distress syndrome or pulmonary fibrosis. For select candidates, lung transplant is the only option to improve quality and length of life. Because of the severity of end-stage COVID-related lung disease, these candidates receive high allocation priority in the United States, including higher priority than many patients without COVID-related lung disease. This study assessed whether transplant centers with a large volume of COVID-related lung transplants experienced an increase in waitlist mortality for non-COVID transplant candidates. Nineteen centers were included as high-volume programs, defined as being in the top third of centers who transplanted COVID patients. Of the 2867 non-COVID patients waitlisted at these centers, there was no significant difference in waitlist mortalities of non-COVID transplant candidates between the pre-COVID transplant era (January 2018-February 2020) and during the period of high COVID transplant volume (March 2020-October 2022) (subhazard ratio: .92 [95% CI = .81-1.05], p = .22). Among high volume centers, the decision to transplant and to prioritize patients with COVID-related lung disease did not significantly impact the waitlist mortality of other candidates.

Recanalization of portal vein thrombosis after pediatric liver transplantation: Efficacy and safety of the transsplenic access

BACKGROUND

Endovascular management of portal vein thrombosis (PVT) is challenging. Transsplenic access (TSA) is growing as an access option to the portal system but with higher rates of bleeding complications. The aim of this article is to evaluate the efficacy and safety of transsplenic portal vein recanalization (PVR) using a metallic stent after pediatric liver transplantation.

MATERIALS AND METHODS

This is a retrospective review of 15 patients with chronic PVT who underwent PVR via TSA between February 2016 and December 2020. Two children who had undergone catheterization of a mesenteric vein tributary by minilaparotomy were excluded from the patency analysis but included in the splenic access analysis. The technical and clinical success of PVR and complications related to the procedure via TSA were evaluated.

RESULTS

Thirteen children with PVT were treated primarily using the TSA. The mean age was 4.1 years (range, 1.5-13.7 years), and the most common clinical presentation was hypersplenism (60%). Technically successful PVR was performed in 11/13 (84.6%) children, and clinical success was achieved in 9/11 (81.8%) children. No major complications were observed, and one child presented moderate pain in the TSA (from a total of 17 TSA). The median follow-up was 48.2 months. The median primary patency was 9.9 months. Primary patency in the first 4 years was 75%, and primary assisted patency was 100% in the follow-up period.

CONCLUSIONS

Transsplenic PVR is a safe and effective method for the treatment of PVT after pediatric liver transplantation.

Evaluation of rapid optimized flow cytometry crossmatch (Halifaster) in living donor kidney transplantation

Kidney transplantation is often the preferred treatment for end-stage renal disease. However, the presence of preformed donor-specific antibodies (DSA), including those against HLA, can lead to antibody-mediated rejection and significantly impact transplant outcomes. The Flow Cytometry Crossmatch (FCXM) is a crucial tool in kidney transplantation, as it also enables the measurement of low levels of anti-HLA DSA antibodies. However, current methodologies for detecting these antibodies, however, are time-consuming and require extensive reagents. In this study, we analyzed the performance of the Halifaster FCXM protocol in 133 consecutive living kidney donor pairs, correlating these results with single antigen-based anti-HLA DSA results. Anti-HLA DSA was identified in 31 patients (23.3%). Both T and B lymphocyte FCXM assays demonstrated high sensitivity and specificity in detecting anti-HLA DSA. Furthermore, a Tree model to determine the levels of anti-HLA DSA to produce a flow crossmatch positivity, was developed offering an accuracy of 93% and 90% for T and B lymphocytes, respectively. Both approaches point to a thresh old of 1000-2000 MFI for T lymphocytes and 3000 MFI for B lymphocytes. Our findings indicate that the Halifaster protocol facilitates fast and efficient FCXM testing without compromising accuracy, marking a significant advancement in the field of kidney transplantation. The inclusion of HLA-specific antibody analysis underscores the protocol's comprehensive approach to improving transplant outcomes.

Combined liver-kidney transplantation in pediatric patients

Combined liver-kidney transplantation (CLKT) is a surgical procedure that involves transplanting both liver and kidney organs. There are two types of CLKT: simultaneous liver-kidney transplantation (smLKT) and sequential LKT (sqLKT). CLKT accounts for a small percentage of liver transplantations (LTs), particularly in pediatric cases. Nevertheless, the procedure has demonstrated excellent outcomes, with high survival rates and lower rejection rates. The main indications for CLKT in pediatric patients differ somewhat from that in adults, in which end-stage kidney disease after LT is the major indication. In children, congenital diseases are common reason for performing CLKT; the examples of such diseases include autosomal recessive polycystic kidney disease with congenital hepatic fibrosis which equally affects both organs, and primary hyperoxaluria type 1, a primary liver disease leading kidney failure. The decision between smLKT or sqLKT depends on the dominant organ failure, the specific pathophysiology, and available organ sources. However, there remain significant surgical and societal challenges surrounding CLKT. Innovations in pharmacology and genetic engineering have decreased the necessity for CLKT in early-diagnosed cases without portal hypertension or kidney replacement therapy. Nonetheless, these advancements are not universally accessible. Therefore, decision-making algorithms should be crafted, considering region-specific organ allocation systems and prevailing medical environments.

Performance of estimated glomerular filtration rate equations in Black living kidney donor candidates

INTRODUCTION

New estimated glomerular filtration rate (eGFR) equations using serum creatinine and/or cystatin C have been derived to eliminate adjustment by perceived Black ancestry. We sought to analyze the performance of newer eGFR equations among Black living kidney donor candidates.

METHODS

Black candidates (n = 64) who had measured iothalamate GFR between January 2015 and October 2021 were included, and eGFR was calculated using race adjusted (eGFRcr2009 and eGFRcr-cys2012) and race unadjusted (eGFRcys2012, eGFRcr2021, and eGFRcr-cys2021) CKD-EPI equations. Bias and accuracy were calculated.

RESULTS

The eGFRcr2021 equation had a negative bias of 9 mL/min/1.73 m2 , while other equations showed a modest positive bias. Accuracy within 10% and 30% was greatest using the eGFRcr-cys2021 equation. With the eGFRcr2021 equation, 9.4% of donors with an mGFR > 80 mL/min/1.73 m2 were misclassified as having an eGFR < 80 mL/min/1.73 m2 . eGFR was also compared among 18 kidney donors at 6-24 months post-donation. Post-donation, the percentage of donors with an eGFR < 60 mL/min/1.73 m2 was 44% using the eGFRcr2021 equation compared to 11% using the eGFRcr-cys2021 equation.

CONCLUSION

The CKD-EPICr2021 equation appears to underestimate true GFR in Black living donor candidates. Alternatively, compared to CKD-EPICr2021, the CKD-EPICr-CysC2021 equation appears to perform with less bias and improved accuracy.

Living-Donor Liver Transplantation for a Large Hepatocellular Carcinoma in a Genetically Identical Twin Sister

Hepatocellular carcinoma (HCC) is, to date, the most common malignant tumor of the liver and is commonly staged with the Milan criteria. While deceased-donor liver transplantations (DDLT) are reserved for patients within the Milan criteria, living-donor liver transplantation (LDLT) might be a curative option for patients outside the Milan criteria. We here report a case of a 32-year-old woman who developed a giant, unresectable HCC out of a hepatocellular adenoma (HCA) after a pregnancy. The genetically identical twin sister donated her left hemi-liver after ethical approval and preoperative screening. No long-term immunosuppressive therapy was necessary, and after more than eight years, both are in perfect health and the recipient gave birth to a second child. This case shows that in certain situations large HCCs outside the standard criteria can be cured by LT. Careful evaluation of both donor and recipient should be performed for indications like this to assure optimal clinical outcome.

Is Salvage of a Kidney Graft Possible as a Result of Hyperacute Rejection Immediately After Kidney Transplantation?

Hyperacute rejection is a rare complication of renal transplantation. It is mainly caused by preformed human leukocyte antigen antibodies and can lead to the loss of the transplanted kidney. Renal transplantation is a highly beneficial treatment for people with end-stage renal disease, greatly improving their quality of life. However, antibody-mediated rejection is a significant challenge for the long-term survival of transplanted kidneys. An 18-year-old male with nephrotic syndrome, who underwent bilateral renal nephrectomy due to severe proteinuria, received a living donor kidney. Pretransplant panel reactive antibodies were low. Cytotoxic T- and B-cell and non-HLA cross-match was negative. The graft became cyanotic and mottled within half an hour of transplantation. Allograft was quickly extracted, and a biopsy showed hyperacute rejection. The patient was treated with plasmapheresis, intravenous immunoglobulin, and eculizumab. The graft was successfully re-implanted after 18 hours. Further treatment included additional sessions of plasmapheresis, intravenous immunoglobulin, eculizumab, T-cell-depleting agent, and immunosuppressive therapy. Serum creatinine became stable, and renal biopsy after one month demonstrated intact parenchyma with no inflammation or fibrosis. This case highlights the critical importance of promptly removing the transplanted kidney and using aggressive immunotherapy to save renal allografts in cases of hyperacute rejection.

Laparoscopic to robotic living donor nephrectomy: Is it time to change surgical technique?

BACKGROUND

We aimed to explore differences in outcomes of robotic and laparoscopic donor nephrectomies (LDN).

METHODS

This study compared robotic and laparoscopic surgical techniques for live donor nephrectomies in 153 patients at a single centre.

RESULTS

Left nephrectomies were more common in both groups, but with no significant difference between the groups (76.6% vs. 77.6%, p = 0.88). The robotic donor nephrectomies (RDN) group experienced significantly less blood loss (60 vs. 134 mL, p < 0.01), but warm ischaemia time was similar between groups (3.2 vs. 3.7 min, p = 0.54).The RDN group had decreased subjective pain scores (3.54 vs. 4.21, p = 0.04) and shorter length of hospitalisation (2.22 vs. 3.04 days, p < 0.01).There were also fewer complications in the RDN than the LDN group (4 vs. 8, p = 0.186).

CONCLUSION

This study demonstrated that RDN is a safe and alternative to LDN. Decreased blood loss and hospital stays and fewer complications may reflect decreased tissue manipulation with robotic assistance.

The Determinants and Consequences of Living Donor Discussion Direction

Introduction: Living donor discussions in which kidney transplant candidates discuss living kidney donation with their social network are an important step in the living donor kidney transplant process. No prior research has investigated whether who initiates discussion or influences evaluation agreement rates or how these processes may contribute to disparities. Research Questions: This study aimed to determine how common candidate- and potential-donor-initiated discussions were, at what rate each discussion type resulted in agreement to be evaluated for living donation, and what sociodemographic characteristics predicted living donor discussion and agreements. Design: A 2015 cross-sectional survey at a single, large Southeastern US transplant center measured kidney transplant candidates' social networks, including whether they had a donor discussion, who initiated it, and whether the discussion resulted in the donor evaluation agreement. Candidate-network member pairs' probability of having a candidate-initiated discussion, potential-living donor-initiated discussion, or no discussions were compared in multinomial logistic regression, and the probability of the discussion resulted in evaluation agreement was evaluated in multinomial logistic regression. Results: Sixty-six kidney transplant candidates reported on 1421 social network members. Most (80%) candidate/network-member pairs did not have a living donor discussion, with candidate-initiated discussions (11%) slightly more common than potential-donor-initiated discussions (10%). Evaluation agreement was much more common for potential-donor-initiated (72%) than for candidate-initiated discussions (39%). Potential-donor-initiated discussions were more common for White candidates (16%) than for Black candidates (7%). Conclusion: Potential-donor-initiated discussions resulted in evaluation agreement much more frequently than candidate-initiated discussions. This dynamic may contribute to racial living donation disparities.

Characterizing the risk of human leukocyte antigen-incompatible living donor kidney transplantation in older recipients

Older compatible living donor kidney transplant (CLDKT) recipients have higher mortality and death-censored graft failure (DCGF) compared to younger recipients. These risks may be amplified in older incompatible living donor kidney transplant (ILDKT) recipients who undergo desensitization and intense immunosuppression. In a 25-center cohort of ILDKT recipients transplanted between September 24, 1997, and December 15, 2016, we compared mortality, DCGF, delayed graft function (DGF), acute rejection (AR), and length of stay (LOS) between 234 older (age ≥60 years) and 1172 younger (age 18-59 years) recipients. To investigate whether the impact of age was different for ILDKT recipients compared to 17 542 CLDKT recipients, we used an interaction term to determine whether the relationship between posttransplant outcomes and transplant type (ILDKT vs CLDKT) was modified by age. Overall, older recipients had higher mortality (hazard ratio: 1.632.072.65, P < .001), lower DCGF (hazard ratio: 0.360.530.77, P = .001), and AR (odds ratio: 0.390.540.74, P < .001), and similar DGF (odds ratio: 0.461.032.33, P = .9) and LOS (incidence rate ratio: 0.880.981.10, P = 0.8) compared to younger recipients. The impact of age on mortality (interaction P = .052), DCGF (interaction P = .7), AR interaction P = .2), DGF (interaction P = .9), and LOS (interaction P = .5) were similar in ILDKT and CLDKT recipients. Age alone should not preclude eligibility for ILDKT.

Association of Age and Gender With Concerns About Live Donor Kidney Transplantation Among Black Individuals

Black individuals are less likely to receive live donor kidney transplantation (LDKT) compared to others. This may be partly related to their concerns about LDKT, which can vary based on age and gender. We conducted a cross-sectional, secondary analysis of the baseline enrollment data from the Talking about Living Kidney Donation Support trial, which studied the effectiveness of social workers and financial interventions on activation towards LDKT among 300 Black individuals from a deceased donor waiting list. We assessed concerns regarding the LDKT process, including their potential need for postoperative social support, future reproductive potential, recipient and donor money matters, recipient and donor safety, and interpersonal concerns. Answers ranged from 0 ("not at all concerned") to 10 ("extremely concerned"). We described and compared participants' concerns both overall and stratified by age (≥45 years old vs <45 years old) and self-reported gender ("male" versus "female"). The participants' top concerns were donor safety (median [IQR] score 10 [5-10]), recipient safety (5 [0-10]), money matters (5 [0-9]), and guilt/indebtedness (5 [0-9]). Younger females had statistically significantly higher odds of being concerned about future reproductive potential (odds ratio [OR] 3.77, 95% CI 2.77, 4.77), and older males had statistically higher mean concern about postoperative social support (OR 1.79, 95% CI 0.19, 3.38). Interventions to improve rates of LDKT among Black individuals should include education and counseling about the safety of LDKT for both recipients and donors, reproductive counseling for female LDKT candidates of childbearing age, and addressing older males' needs for increased social support.

Norepinephrine boluses for the prevention of post-reperfusion syndrome in living donor liver transplantation: A prospective, open-label, single-arm feasibility trial

Background and Aims

Post-reperfusion syndrome (PRS) is a serious haemodynamic event during liver transplantation (LT), which increases early graft dysfunction and mortality. This study aimed to test the efficacy and safety of norepinephrine (NE) boluses to prevent PRS during orthotopic LT.

Methods

This feasibility phase II trial prospectively recruited a single arm of 40 patients undergoing living donor LT. The intervention was an escalated protocol of NE boluses starting at 20 µg. The primary outcome was the incidence of PRS. The secondary outcomes were arrhythmia, electrocardiographic (EKG) ischaemic changes, mean pulmonary pressure after reperfusion, 3-month survival and 1-year survival.

Results

PRS occurred in 28 (70%) cases [95% confidence interval (CI) 54% to 83%, P < 0.001], with a relative risk reduction of 0.22 when compared to our previous results (90%). Twelve cases developed transient EKG ischaemic changes. All EKG ischaemic changes returned to baseline after correction of hypotension. There was no significant arrhythmia or bradycardia (95% CI 0 to 0.9). After reperfusion, the mean pulmonary artery pressure was not significantly higher than the normal limit (20 mmHg) (P = 0.88). The 3-month survival was 0.95 (95% CI 0.83 to 0.99), and the 1-year survival was 0.93 (95% CI 0.8 to 0.98).

Conclusion

Our findings suggest that NE boluses starting with 20 μg is feasible and effective in lowering the risk of PRS during living donor LT. Additionally, NE boluses were not associated with significant myocardial ischaemic events, arrhythmia or a rise in pulmonary pressure.

Living Donors' Age Modifies the Impact of Pre-Donation Estimated Glomerular Filtration Rate on Graft Survival

BACKGROUND

The global scarcity of organs for kidney transplants (KTs) has led to the increased acceptance of living donors (LDs) with minor abnormalities to increase the donor pool.. We sought to evaluate the effects of some of these LDs' clinical characteristics (older age, borderline renal function, hypertension, dyslipidemia, smoking, and obesity) on graft outcomes.

METHODS

We studied 352 recipients of LDKTs (1998-2020). Firstly, considering the recipients and KT variables, we identified relevant predictors of overall and censored graft failure (GF). Then, adjusting for these predictors, we explored LD variables as predictors of overall and censored GF in a multivariable Cox model.

RESULTS

The recipients from LD with higher eGFR (≥90 mL/min/1.73 m2) had significantly better overall and censored graft survival GS) at 15 y after KT (respectively, 67 and 75% vs. 46 and 46%, p < 0.001). Importantly, none of the remaining LD factors which were evaluated (hypertension, dyslipidemia, smoking, proteinuria, and obesity) were independent predictors of GF. In recipients from LDs < 50 y, having an eGFR < 90 was an independent predictor of overall GF [adjusted HR (95%CI) of 2.578 (1.120-5.795)] and censored GF [adjusted HR (95%CI) of 3.216 (1.300-7.959)], compared to recipients from LDs with eGFR ≥ 90. Contrarily, when donors were older, no difference in the risk of GF was observed between eGFR categories.

CONCLUSION

In our cohort, lower pre-donation eGFR had an impact on GS only in younger LDs. An age-adjusted eGFR cutoff may be pursued for improved donor admissibility.

A novel scoring system to predict survival in cirrhotic patients undergoing isolated lung transplantation: The PENS-CEPT score

Cirrhosis is usually regarded as a contraindication to isolated lung transplantation (ILT). We sought to determine which patients with cirrhosis could safely undergo ILT. Based on a retrospective analysis of patients with cirrhosis who underwent ILT at our center between 2007 and 2020, we developed an exclusionary algorithm (PENS-CEPT: Pittsburgh ExclusioN Score in Cirrhotics Evaluated for Pulmonary Transplant) to help determine which patients can undergo ILT with minimal incurred risk from their underlying liver disease. The score utilizes a combination of readily available clinical data and the presence (or absence) of spontaneous portosystemic shunts on preoperative cross-sectional imaging. Sixteen patients underwent ILT with a diagnosis of cirrhosis: nine with cystic fibrosis. On univariate analysis, only our model was able to predict 1 year survival. Of the nine patients that would have been approved using our model, there was only one short term death. Of the seven patients that would have been rejected by the model, all but one died within the first year with six dying of complications from liver failure. We are proposing a simple score utilizing routine clinical parameters and pre-operative imaging to determine the safety of ILT in cirrhotic patients. Further studies are required to validate this scoring system with the goal of safely increasing the opportunity for cirrhotic patients who would otherwise be rejected for ILT.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

INTRODUCTION

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

METHODS

Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

RESULTS

Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

CONCLUSIONS

The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Donor safety of remnant liver volumes of less than 30% in living donor liver transplantation: A systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to investigate the acceptability of donor remnant liver volume (RLV) to total liver volume (TLV) ratio (RLV/TLV) being <30% as safe in living donor liver transplantations (LDLTs).

METHODS

Online databases were searched from January 2000 to June 2022. Pooled odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects model.

RESULTS

One prospective and seven retrospective studies comprising 1935 patients (164 RLV/TLV <30% vs. 1771 RLV/TLV ≥30%) were included. Overall (OR = 1.82; 95% CI [1.24, 2.67]; p = .002) and minor (OR = 1.88; 95% CI [1.23, 2.88]; p = .004) morbidities were significantly lower in the RLV/TLV ≥30% group than in the RLV/TLV <30% group (OR = 1.82; 95% CI [1.24, 2.67]; p = .002). No significant differences were noted in the major morbidity, biliary complications, and hepatic dysfunction. Peak levels of bilirubin (SMD = .50; 95% CI [.07, .93]; p = .02) and international normalized ratio (SMD = .68; 95% CI [.04, 1.32]; p = .04) were significantly lower in the RLV/TLV ≥ 30% group than in the RLV/TLV <30% group. No significant differences were noted in the peak alanine transferase and aspartate transaminase levels and hospital stay.

CONCLUSIONS

Considering the safety of the donor as the top priority, the eligibility of a potential liver donor in LDLT whose RLV/TLV is expected to be <30% should not be accepted.

Kidney paired donation in developing countries: A global perspective

Purpose of review

We review the key principles of kidney paired donation (KPD) and discuss the status and unique considerations for KPD in developing countries.

Recent findings

Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need world-wide.

[Organ donation is not a gift]

If the obligation to donate as defined by French law ("we are all donors") remains in the wake of sociologist Marcel Mauss's Essai sur le don (Essay on donation), there the similarity ends. How do you make a counter-donation to a deceased person? In the case of inter vivos organ donation, the act is more akin to mutualization than donation.

Liver Transplantation: Protocol for Recipient Selection, Evaluation, and Assessment

Liver transplantation (LT) is the definitive therapy for patients with end-stage liver disease, acute liver failure, acute-on-chronic liver failure, hepatocellular carcinoma, and metabolic liver diseases. The acceptance of LT in Asia has been gradually increasing and so is the expertise to perform LT. Preparing a patient with cirrhosis for LT is the most important aspect of a successful LT. The preparation for LT begins with the first index decompensation for a patient with cirrhosis. Patients planned for LT should undergo a thorough screening for infections, and a complete cardiac, pulmonology, and psychosocial evaluation pre-LT. In this review, we discuss the indications and contraindications of LT and the evaluation and assessment of patients with liver disease planned for LT.

The first successful case of ABO-incompatible living-donor lobar lung transplantation following desensitization therapy

ABO-incompatible (ABO-I) living-donor lobar lung transplantation (LDLLT) was successfully performed in a 14-year-old girl who suffered from bronchiolitis obliterans due to graft-versus-host disease following hematopoietic stem cell transplantation. In the ABO-I LDLLT procedure, the blood type O patient received a right lower lobe donated from her blood type B father and a left lower lobe donated from her blood type O mother. Desensitization therapy, using rituximab, immunosuppressants, and plasmapheresis, was implemented for 3 weeks prior to transplantation to reduce the production of anti-B antibodies in the recipient and prevent acute antibody-mediated rejection after ABO-I LDLLT.

Decisional Needs of People From Minority Ethnic Groups Around Living Donor Kidney Transplantation: A UK Healthcare Professionals' Perspective

Despite improved patient and clinical outcomes, living donor kidney transplantation is underutilized in the United Kingdom, particularly among minority ethnic groups, compared to deceased donor kidney transplantation. This may in part be due to the way in which kidney services present information about treatment options. With a focus on ethnicity, semi structured interviews captured the views of 19 kidney healthcare professionals from two renal centres in West Yorkshire, about the decisional needs and context within which people with advanced kidney disease make transplant decisions. Data were analysed using thematic analysis. Themes were categorized into three groups: 1) Kidney healthcare professionals: language, cultural awareness, trusted personnel, and staff diversity, 2) Patient information resources: timing and setting of education and suitability of patient-facing information and, 3) People with advanced kidney disease: knowledge, risk perception, and cultural/religious beliefs. To our knowledge, this is the first study in the United Kingdom to investigate in depth, healthcare professionals' views on living donor kidney transplantation decision making. Six recommendations for service improvement/delivery to support decision making around living donor kidney transplantation among minority ethnic groups are described.

Prediction tool for renal adaptation after living kidney donation using interpretable machine learning

Introduction

Post-donation renal outcomes are a crucial issue for living kidney donors considering young donors' high life expectancy and elderly donors' comorbidities that affect kidney function. We developed a prediction model for renal adaptation after living kidney donation using interpretable machine learning.

Methods

The study included 823 living kidney donors who underwent nephrectomy in 2009-2020. AutoScore, a machine learning-based score generator, was used to develop a prediction model. Fair and good renal adaptation were defined as post-donation estimated glomerular filtration rate (eGFR) of ≥ 60 mL/min/1.73 m² and ≥ 65% of the pre-donation values, respectively.

Results

The mean age was 45.2 years; 51.6% were female. The model included pre-donation demographic and laboratory variables, GFR measured by diethylenetriamine pentaacetate scan, and computed tomography kidney volume/body weight of both kidneys and the remaining kidney. The areas under the receiver operating characteristic curve were 0.846 (95% confidence interval, 0.762-0.930) and 0.626 (0.541-0.712), while the areas under the precision-recall curve were 0.965 (0.944-0.978) and 0.709 (0.647-0.788) for fair and good renal adaptation, respectively. An interactive clinical decision support system was developed.

Conclusion

The prediction tool for post-donation renal adaptation showed good predictive capability and may help clinical decisions through an easy-to-use web-based application.

Long-term risk of a fatty liver in liver donors

Aim

Approximately 30 years have passed since the first experience of living donor liver transplantation. The time to evaluate the long-term safety of living donors has been fulfilled. Meanwhile, nonalcoholic fatty liver disease is increasingly common and a critical problem. The aim of this study was to evaluate the safety of living donor, focusing on fatty liver postdonation hepatectomy.

Methods

Living donors (n = 212, 1997-2019) were evaluated by computed tomography (CT) at >1-year postdonation. A liver to spleen (L/S) ratio of <1.1 was defined as fatty liver.

Results

Among 212 living liver donors, 30 (14.2%) detected fatty liver at 5.3 ± 4.2 years postdonation. The cumulative incidence rates of fatty liver were 3.1%, 12.1%, 22.1%, and 27.7% at 2, 5, 10, and 15 years postdonation, respectively. Of 30 subjects who developed fatty liver, 18 (60%) displayed a severe steatosis (L/S ratio <0.9). Five (16.7%) had a prior history of excessive alcohol abuse. More than 30% developed metabolic syndrome including obesity, hyperlipidemia, and diabetes. Although six (20%) had a Fib-4 index of >1.3, which included a case with a Fib-4 index of >2.67, no significant increased Fib-4 index was observed in the subjects with fatty liver as compared to those without fatty liver (p = 0.66). The independent predictive risk factors for developing fatty liver were male sex, pediatric recipient, and higher body mass index (>25) at donation.

Conclusion

Living donors with risk factors for developing fatty liver should be carefully followed-up for the prevention and management of metabolic syndrome.

Comparison of GFR measurement with a two-blood sample technique using [99mTc]Tc-DTPA vs. creatinine-based equations in potential kidney donors

INTRODUCTION

Accurate determination of glomerular filtration rate (GFR) is crucial for selection of kidney donors. Nuclear medicine methods are considered accurate in measuring GFR but are not always easily available. The four-variable Modification of Diet in Renal Disease (MDRD4), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Full Age Spectrum (FAS) formulas are common equations for estimating GFR and are recommended for initial assessment of kidney donors. The aim of this study was to evaluate the performance of these GFR estimation equations compared with technetium-99m diethylenetriaminepentaacetic acid ([99mTc]Tc-DTPA) clearance.

METHODS

We compared GFR estimation by [99mTc]Tc-DTPA clearance using a two-blood sample method with estimation by MDRD4, CKD-EPI, and FAS creatinine-based equations in a population of healthy potential kidney donors.

RESULTS

A total of 195 potential kidney donors (68.2% female; mean age 49 years, range 21-75 years) were included in this study. Mean [99mTc]Tc-DTPA measured GFR (mGFR) was 101.5 ± 19.1 mL/min/1.73 m2. All three equations underestimated the GFR value measured by [99mTc]Tc-DTPA (MDRD4: -11.5 ± 18.8 mL/min/1.73 m2; CKD-EPI: -5.0 ± 17.4 mL/min/1.73 m2; FAS: -8.3 ± 17.4 mL/min/1.73 m2). Accuracy within 30% and 10% of the measured GFR value was highest for CKD-EPI.

CONCLUSION

The CKD-EPI equation showed better performance in estimating GFR in healthy potential kidney donors, proving to be a more accurate tool in the initial assessment of kidney donors. However, creatinine-based equations tended to underestimate kidney function. Therefore, GFR should be confirmed by another method in potential kidney donors.

Awareness and Interest in Uterus Transplantation over Time: Analysis of Those Seeking Surgical Correction for Uterine-Factor Infertility in the US

This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.

Dialysis Patients' Social Networks and Living Donation Offers

Rationale & Objective

Most living kidney donors are members of a hemodialysis patient's social network. Network members are divided into core members, those strongly connected to the patient and other members; and peripheral members, those weakly connected to the patient and other members. We identify how many hemodialysis patients' network members offered to become kidney donors, whether these offers were from core or peripheral network members, and whose offers the patients accepted.

Study Design

A cross-sectional interviewer-administered hemodialysis patient social network survey.

Setting & Participants

Prevalent hemodialysis patients in 2 facilities.

Predictors

Network size and constraint, a donation from a peripheral network member.

Outcomes

Number of living donor offers, accepting an offer.

Analytical Approach

We performed egocentric network analyses for all participants. Poisson regression models evaluated associations between network measures and number of offers. Logistic regression models determined the associations between network factors and accepting a donation offer.

Results

The mean age of the 106 participants was 60 years. Forty-five percent were female, and 75% self-identified as Black. Fifty-two percent of participants received at least one living donor offer (range 1-6); 42% of the offers were from peripheral members. Participants with larger networks received more offers (incident rate ratio [IRR], 1.26; 95% CI, 1.12-1.42; P = 0.001), including networks with more peripheral members (constraint, IRR, 0.97; 95% CI, 0.96-0.98; P < 0.001). Participants who received a peripheral member offer had 3.6 times greater odds of accepting an offer (OR, 3.56; 95% CI, 1.15-10.8; P = 0.02) than those who did not receive a peripheral member offer.

Limitations

A small sample of only hemodialysis patients.

Conclusions

Most participants received at least one living donor offer, often from peripheral network members. Future living donor interventions should focus on both core and peripheral network members.

Meta-analysis of postoperative myocardial injury as a predictor of mortality after living donor liver transplantation

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis to investigate postoperative myocardial injury, as expressed by the postoperative concentration of high-sensitivity cardiac troponin I (hs-cTnI) as a predictor of mortality among living donor liver transplantation (LDLT) patients.

METHODS

PubMed, Scopus, Embase and the Cochrane Library were searched through to September 1st 2022. The primary endpoint included in-hospital mortality. Secondary endpoints were 1-year mortality and re-transplantation occurrence. Estimates are expressed as risk ratios (RRs) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with the I² test.

RESULTS

During the search, 2 studies were found that fit the criteria and had a total of 527 patients. Pooled analysis showed that in-hospital mortality in patients with myocardial injury was 9.9%, compared to 5.0% for patients without myocardial injury (RR = 3.01; 95% CI: 0.97-9.36; p = 0.06). Mortality among 1-year follow-up was 5.0% vs. 2.4%, respectively (RR = 1.90; 95% CI: 0.41-8.81; p = 0.41).

CONCLUSIONS

In recipients with normal preoperative cTnI, myocardial injury LDLT may be associated with adverse clinical outcomes during a hospital stay, but the results were inconsistent at 1-year follow-up. Although routine follow-up of postoperative hs-cTnI, even in patients with normal preoperative levels, might still help predict the clinical outcome of LDLT. In future large and more representative studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.

Living well or not? Quality of life of parental living liver donors: A cross-sectional study

AIM

The aim of this study was to gain comprehensive insight into the quality of life of parental living liver donors after liver donation.

BACKGROUND

Several studies reported good quality of life of living liver donors with the SF-36 scale. Care demand from the recipient and responsibility of being parent might make a difference in parental donors' personal experienced quality of life after transplantation surgery.

METHODS

It is a cross-sectional study. The parental donors' demographics, clinical data and post-donation complications were obtained. Quality of life was assessed using the Medical Outcomes Study SF-36 and the Quality of Life Scale of Living Organ Donors-Common Module.

PATIENT OR PUBLIC CONTRIBUTION

The enrolled participants were contacted by electronic questionnaires and telephonic interview.

RESULTS

A total of 345 parental donors were included, with recruited period ranging from 3 to 85 months post-donation. 8.1% of donors had post-operative complications, mostly classified as Clavien grade II. Donors' general quality of life was higher than the Chinese general norm. Issues related to surgical incision, fatigue, worries about income and personal health, effects on work capability, increased medical expenses and difficult reimbursement and suspected donation decision were the prominent problems among donors. Mother-son relationship (OR = 1.87) and equal or less than 2 years after donation (OR = 3.08) were the influencing factors for poor physical quality of life, while unmarried status (e.g. divorced or widowed) was found negatively associated with mental quality of life (adjusted OR = 3.61).

CONCLUSIONS

General health among parental donors is good but those female, unmarried and near post-donation might in low life quality. Incision, fatigue, finance, reimbursement and donation decision are prominent problems.

RELEVANCE TO CLINICAL PRACTICE

Post-donation care of living donors should cover social and financial domain besides physical and mental dimension. Providing follow-up care and counselling is necessary to ensure their life quality.

A Systematic Review of Opioid Use and Multimodal Strategies in Solid Organ Transplant Recipients and Living Donors

BACKGROUND

The opioid epidemic has impacted analgesia in the post-operative period for solid organ transplant (SOT) donors and recipients. However, optimal pain management and opioid stewardship strategies have not been identified across this unique population.

OBJECTIVE

the purpose of this systematic review is to evaluate the impact of perioperative opioid use and to describe multimodal analgesic strategies to reduce opiate use in SOT recipients and living donors.

METHODS

A systematic review was conducted. Electronic searches were performed in Medline, Embase, Google Scholar, and Web of Science through December 31, 2021. Title and abstracts were screened. Relevant articles underwent full text review. Literature was separated into effects of opioid exposure on post-transplant outcomes, recipient pain management strategies, and living donor pain management strategies.

RESULTS

Search yielded 25,190 records, and 63 were ultimately included. The impact of opioid use on post-transplant outcomes were assessed in 19 publications. The risk of graft loss in pre-transplant opioid users was assessed in six reports and was found to be higher in the majority (66%) of publications. Opioid minimization strategies were reported in 20 studies in transplant recipients. Twenty-four studies evaluated pain management strategies in living donors. Both populations used a combination of multimodal strategies to minimize opioid use throughout the hospitalization and on discharge.

CONCLUSIONS

1.1.1. OPIOIDS ARE ASSOCIATED WITH SELECT NEGATIVE OUTCOMES IN POST-TRANSPLANT RECIPIENTS. TO MINIMIZE THEIR USE WHILE ALSO MAINTAINING APPROPRIATE ANALGESIA, MULTIMODAL PAIN REGIMENS SHOULD BE CONSIDERED IN SOT RECIPIENTS AND DONORS.

Testing the Differential Access Hypothesis That Black Kidney Transplant Candidates Perceive Social Network Access to Fewer Potential Living Donors Than White Candidates

INTRODUCTION

Many studies of Black-White disparities in living donor kidney transplantation hypothesize that they were partially due to Black-White differences in candidate social network access to healthy, willing donors. This differential access hypothesis has not been tested using directly measured social network data.

RESEARCH QUESTIONS

Do black kidney transplant candidates have perceived lower social network access to health and/or willing living donors than white candidates?

DESIGN

A cross-sectional survey that measured the social network members was collected in 2015. Black-White differences in patient counts of perceived healthy and/or willing potential donors in social networks, and individual network members' probability of being perceived healthy and/or willing, were compared using logistic and negative binomial regression models.

RESULTS

The survey included 66 kidney transplant candidates reporting on 1474 social network members at a large Southeastern US transplant center in 2015. Black and White patients had similar access to perceived healthy, likely potential donors (86% vs 87% had 1 or more, P = .92; 5.91 vs 4.13 mean counts, P = .20) and perceived healthy, agreed potential donors (56% vs 48%, P = .54; 1.77 vs 1.74, P = .97). Black patients' network members were individually more likely to be perceived healthy and likely potential donors (26% vs 21%, P = .04), and White patients' network members were more likely to have agreed (13% vs 9%, P = .03), but these differences were statistically insignificant in demographically adjusted models.

CONCLUSION

Black and White transplant candidates perceived access to similar numbers of potential donors in their social networks. This result does not support the differential access hypothesis.

Can non-directed living liver donation help improve access to grafts and correct socioeconomic disparities in pediatric liver transplantation?

BACKGROUND

Each year, children die awaiting LT as the demand for grafts exceeds the available supply. Candidates with public health insurance are significantly less likely to undergo both deceased donor LT and D-LLD LT. ND-LLD is another option to gain access to a graft. The aim of this study was to evaluate if recipient insurance type is associated with likelihood of D-LLD versus ND-LLD LT.

METHODS

The SRTR/OPTN database was reviewed for pediatric LDLT performed between January 1, 2014 (Medicaid expansion era) and December 31, 2019 at centers that performed ≥1 ND-LLD LDLT during the study period. A multivariable logistic regression was performed to assess relationship between type of living donor (directed vs. non-directed) and recipient insurance.

RESULTS

Of 299 pediatric LDLT, 46 (15%) were from ND-LLD performed at 18 transplant centers. Fifty-nine percent of ND-LLD recipients had public insurance in comparison to 40% of D-LLD recipients (p = .02). Public insurance was associated with greater odds of ND-LLD in comparison to D-LLD upon multivariable logistic regression (OR 2.37, 95% CI 1.23-4.58, p = .01).

CONCLUSIONS

ND-LLD allows additional children to receive LTs and may help address some of the socioeconomic disparity in pediatric LDLT, but currently account for only a minority of LDLT and are only performed at a few institutions. Initiatives to improve access to both D-LLD and ND-LLD transplants are needed.

Delayed graft function in pediatric living donor kidney transplantation

BACKGROUND

Pediatric recipients of living donor kidneys have a low rate of delayed graft function (DGF). We examined the incidence, risk factors and outcomes of DGF in pediatric patients who received a living donor allograft.

METHODS

The STARfile was queried to examine all pediatric patients transplanted with a living donor kidney between 2000 and 2020. Donor and recipient demographic data were examined, as were survival and outcomes. Recipients were stratified into DGF and no DGF groups. DGF was defined as the need for dialysis within the first week after transplant.

RESULTS

6480 pediatric patients received a living donor (LD) kidney transplant during the study period. 269 (4.2%) developed DGF post-transplant. Donors were similar in age, creatinine, and cold ischemia time. Recipients of kidneys with DGF were similar in age, sensitization status and HLA mismatch. Focal segmental glomerulosclerosis (FSGS) was the most common diagnosis in recipients with DGF, and allograft thrombosis was the most common cause of graft loss in this group. Small recipients (weight < 15 kg) were found to have a significantly higher rate of DGF. Length of stay doubled in recipients with DGF, and rejection rates were higher post-transplant. Recipients of LD kidneys who developed DGF had significantly worse 1 year allograft survival (67% vs. 98%, p < .0001).

CONCLUSIONS

Pediatric living donor kidney transplant recipients who experience DGF have significantly poorer allograft survival. Optimizing the donor and recipient matching to avoid compounding risks may allow for better outcomes.

Genetic evaluation of living kidney donor candidates: a review and recommendations for best practices

The growing accessibility and falling costs of genetic sequencing techniques has expanded the utilization of genetic testing in clinical practice. For living kidney donation, genetic evaluation has been increasingly used to identify genetic kidney disease in potential candidates, especially in those of younger ages. However, genetic testing on asymptomatic living kidney donors remains fraught with many challenges and uncertainties. Not all transplant practitioners are aware of the limitations of genetic testing, are comfortable with selecting testing methods, comprehending test results, or providing counsel, and many do not have access to a renal genetic counselor or a clinical geneticist. Although genetic testing can be a valuable tool in living kidney donor evaluation, its overall benefit in donor evaluation has not been demonstrated and it can also lead to confusion, inappropriate donor exclusion, or misleading reassurance. Until more published data become available, this practice resource should provide guidance for centers and transplant practitioners on the responsible use of genetic testing in the evaluation of living kidney donor candidates.

The Impact of Hepatic Artery Thrombosis on the Outcome of Pediatric Living Donor Liver Transplantations

The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.

Our Experience in Tracking the Tract: Normal Biliary Anatomy and Variants on Magnetic Resonance Cholangiopancreatography in Living Donor Liver Transplantation

Objective Biliary anatomy is of paramount importance for hepatobiliary pancreatic surgeons for operative planning. Preoperative assessment with magnetic resonance cholangiopancreatography (MRCP) to evaluate the biliary anatomy plays a vital role, especially for prospective liver donors in living donor liver transplantation (LDLT). Our objective was to evaluate the diagnostic accuracy of MRCP in assessing the anatomical variations of the biliary system and the frequency of biliary variation in the donors of LDLT. Materials and Methods Sixty-five donors of living donor liver transplantation in the age range of 20 to 51 years were studied retrospectively to evaluate the anatomical variations of the biliary tree. As a part of the pre-transplantation donor workup, MRI with MRCP was performed in a 1.5T machine for all these candidates. MRCP source data sets were processed with maximum intensity projections, surface shading, and multi-planar reconstructions. Images were reviewed by two radiologists, and the classification system of Huang et al. was utilized to evaluate the biliary anatomy. The results were compared with the intraoperative cholangiogram, considered the gold standard. Results We identified standard biliary anatomy in 34 candidates (52.3%), and variant biliary anatomy was observed in 31 candidates (47.7%) on MRCP. An intraoperative cholangiogram showed standard anatomy in 36 candidates (55.4%) and biliary variation in 29 candidates (44.6%). Our study showed a sensitivity of 100% and a specificity of 94.5% for identifying biliary variant anatomy on MRCP in comparison with the gold standard intraoperative cholangiogram. The accuracy of MRCP in detecting the variant biliary anatomy in our study was 96.9%. The most common biliary variation was the right posterior sectoral duct draining into the left hepatic duct, Huang type A3. Conclusion The frequency of biliary variations is high in potential liver donors. MRCP is sensitive and highly accurate in identifying the biliary variations of surgical significance.

Elevation of Lipid Metabolites in Deceased Liver Donors Reflects Graft Suffering

Liver transplantation can be performed with deceased or living donor allografts. Deceased liver grafts are donated from brain- or circulation-death patients, and they have usually suffered from a certain degree of damage. Post-transplant graft function and patient survival are closely related to liver allograft recovery. How to define the damage of liver grafts is unclear. A total of 47 liver donors, 23 deceased and 24 living, were enrolled in this study. All deceased donors had suffered from severe brain damage, and six of them had experienced cardio-pulmonary-cerebral resuscitation (CPR). The exploration of liver graft metabolomics was conducted by liquid chromatography coupled with mass spectrometry. Compared with living donor grafts, the deceased liver grafts expressed higher levels of various diacylglycerol, lysophosphatidylcholine, lysophosphatidylethanolamine, oleoylcarnitine and linoleylcarnitine; and lower levels of cardiolipin and phosphatidylcholine. The liver grafts from the donors with CPR had higher levels of cardiolipin, phosphatidic acid, phosphatidylcholine, phatidylethanolamine and amiodarone than the donors without CPR. When focusing on amino acids, the deceased livers had higher levels of histidine, taurine and tryptophan than the living donor livers. In conclusion, the deceased donors had suffered from cardio-circulation instability, and their lipid metabolites were increased. The elevation of lipid metabolites can be employed as an indicator of liver graft suffering.

A machine-learning approach to estimating public intentions to become a living kidney donor in England: Evidence from repeated cross-sectional survey data

Background

Living kidney organ donors offer a cost-effective alternative to deceased organ donation. They enable patients with life-threatening conditions to receive grafts that would otherwise not be available, thereby creating space for other patients waiting for organs and contributing to reducing overall waiting times for organs. There is an emerging consensus that an increase in living donation could contribute even more than deceased donation to reducing inequalities in organ donation between different population sub-groups in England. Increasing living donation is thus a priority for National Health Service Blood and Transplant (NHSBT) in the United Kingdom.

Methods

Using the random forest model, a machine learning (ML) approach, this study analyzed eight waves of repeated cross-sectional survey data collected from 2017 to 2021 (n = 14,278) as part of the organ donation attitudinal tracker survey commissioned by NHSBT in England to identify and help predict key factors that inform public intentions to become living donors.

Results

Overall, around 58.8% of the population would consider donating their kidney to a family member (50.5%), a friend (28%) or an unknown person (13.2%). The ML algorithm identified important factors that influence intentions to become a living kidney donor. They include, in reducing order of importance, support for organ donation, awareness of organ donation publicity campaigns, gender, age, occupation, religion, number of children in the household, and ethnic origin. Support for organ donation, awareness of public campaigns, and being younger were all positively associated with predicted propensity for living donation. The variable importance scores show that ethnic origin and religion were less important than the other variables in predicting living donor intention.

Conclusion

Factors influencing intentions to become a living donor are complex and highly individual in nature. Machine learning methods that allow for complex interactions between characteristics can be helpful in explaining these decisions. This work has identified important factors and subgroups that have higher propensity for living donation. Interventions should target both potential live donors and recipients. Research is needed to explore the extent to which these preferences are malleable to better understand what works and in which contexts to increase live organ donation.

Incisional Hernia Development after Live Donor Nephrectomy: Impact of Surgical Technique

BACKGROUND

Characteristics of incisional hernia (IH) formation after live donor nephrectomy (LDN) are not well-defined. The goal of this study was to describe the incidence of IH within 3 years after LDN and identify risk factors contributing to their formation.

METHODS

We performed a single-center, retrospective review of all LDN between February 2013 and October 2018. Patients with and without IH were compared based on donor and operative variables. Data were analyzed using chi-square tests with column proportions. Multivariable logistic regression with backward elimination was used to evaluate the likelihood of IH on the basis of potential risk factors.

RESULTS

Three hundred one individuals underwent live donor nephrectomy. Twenty-eight patients (9.3%) developed an IH, with a median time to development of 7 months (range: 2-24 months). Obesity (body mass index ≥30), periumbilical hand port, and vertical infraumbilical hand port were associated with increased risk of IH development on univariate analysis. On multivariate analysis, obesity and periumbilical hand port location were persistent risk factors for IH.

CONCLUSIONS

The incidence of IH after LDN is prevalent and associated with obesity and operative technique. Placing the hand port infraumbilical with a transverse fascial incision may reduce the risk of IH after LDN.