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Pagano G, Sastre L, Blasi A, Brugaletta S, Mestres J, Martinez-Ocon J, Ortiz-Pérez JT, Viñals C, Prat-Gonzàlez S, Rivas E, Perea RJ, Rodriguez-Tajes S, Muxí Á, Ortega E, Doltra A, Ruiz P, Vidal B, Martínez-Palli G, Colmenero J, Crespo G. CACS, CCTA and mCAD-LT score in the pre-transplant assessment of coronary artery disease and the prediction of post-transplant cardiovascular events. Liver Int 2024. [PMID: 38591767 DOI: 10.1111/liv.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The optimal cardiovascular assessment of liver transplant (LT) candidates is unclear. We aimed to evaluate the performance of CT-based coronary tests (coronary artery calcium score [CACS] and coronary CT angiography [CCTA]) and a modification of the CAD-LT score (mCAD-LT, excluding family history of CAD) to diagnose significant coronary artery disease (CAD) before LT and predict the incidence of post-LT cardiovascular events (CVE). METHODS We retrospectively analysed a single-centre cohort of LT candidates who underwent non-invasive tests; invasive coronary angiography (ICA) was performed depending on the results of non-invasive tests. mCAD-LT was calculated in all patients. RESULTS Six-hundred-and-thirty-four LT candidates were assessed and 351 of them underwent LT. CACS, CCTA and ICA were performed in 245, 123 and 120 LT candidates, respectively. Significant CAD was found in 30% of patients undergoing ICA. The AUROCs of mCAD-LT (.722) and CCTA (.654) were significantly higher than that of CACS (.502) to predict the presence of significant CAD. Specificity of the tests ranged between 31% for CCTA and 53% for CACS. Among patients who underwent LT, CACS ≥ 400 and mCAD-LT were independently associated with the incidence of CVE; in patients who underwent CCTA before LT, significant CAD at CCTA also predicted post-LT CVE. CONCLUSION In this cohort, mCAD-LT score and CT-based tests detect the presence of significant CAD in LT candidates, although they tend to overestimate it. Both mCAD-LT score and CT-based tests classify LT recipients according to their risk of post-LT CVE and can be used to improve post-LT risk mitigation.
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Affiliation(s)
- Giulia Pagano
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
| | - Lydia Sastre
- Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Salvatore Brugaletta
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Judit Mestres
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | | | - Jose T Ortiz-Pérez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Clara Viñals
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
| | - Susanna Prat-Gonzàlez
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Eva Rivas
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
| | - Rosario J Perea
- IDIBAPS, Barcelona, Spain
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Sergio Rodriguez-Tajes
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - África Muxí
- IDIBAPS, Barcelona, Spain
- Department of Nuclear Medicine, Hospital Clínic, Barcelona, Spain
| | - Emilio Ortega
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain
- CIBER-OBN, Madrid, Spain
| | - Ada Doltra
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Pablo Ruiz
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Bàrbara Vidal
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - Graciela Martínez-Palli
- Department of Anesthesiology, Hospital Clínic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-RES, Madrid, Spain
| | - Jordi Colmenero
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
| | - Gonzalo Crespo
- Liver Transplant Unit, Hospital Clínic, Barcelona, Spain
- Department of Hepatology, Hospital Clínic, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- CIBER-EHD, Madrid, Spain
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2
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Feng S, Roll GR, Rouhani FJ, Sanchez Fueyo A. The future of liver transplantation. Hepatology 2024:01515467-990000000-00817. [PMID: 38537154 DOI: 10.1097/hep.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 06/15/2024]
Abstract
Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.
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Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Garrett R Roll
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Foad J Rouhani
- Tissue Regeneration and Clonal Evolution Laboratory, The Francis Crick Institute, London, UK
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
| | - Alberto Sanchez Fueyo
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
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3
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Sampaio Rodrigues T, Koshy AN, Gow PJ, Weinberg L, Cailes B, Testro A, Smith G, Lim HS, Teh AW, Lim RP, Farouque O. Atherosclerosis on CT coronary angiography and the risk of long-term cardiovascular events after liver transplantation. Liver Transpl 2024; 30:182-191. [PMID: 37432891 DOI: 10.1097/lvt.0000000000000215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
Computed tomography coronary angiography (CTCA) is increasingly utilized for preoperative risk stratification before liver transplantation (LT). We sought to assess the predictors of advanced atherosclerosis on CTCA using the recently developed Coronary Artery Disease-Reporting and Data System (CAD-RADS) score and its impact on the prediction of long-term major adverse cardiovascular events (MACE) following LT. We conducted a retrospective cohort study of consecutive patients who underwent CTCA for LT work-up between 2011 and 2018. Advanced atherosclerosis was defined as coronary artery calcium scores > 400 or CAD-RADS score ≥ 3 (≥50% coronary artery stenosis). MACE was defined as myocardial infarction, heart failure, stroke, or resuscitated cardiac arrest. Overall, 229 patients underwent CTCA (mean age 66 ± 5 y, 82% male). Of these, 157 (68.5%) proceeded with LT. The leading etiology of cirrhosis was hepatitis (47%), and 53% of patients had diabetes before transplant. On adjusted analysis, male sex (OR 4.6, 95% CI 1.5-13.8, p = 0.006), diabetes (OR 2.2, 95% CI 1.2-4.2, p = 0.01) and dyslipidemia (OR 3.1, 95% CI 1.3-6.9, p = 0.005) were predictors of advanced atherosclerosis on CTCA. Thirty-two patients (20%) experienced MACE. At a median follow-up of 4 years, CAD-RADS ≥ 3, but not coronary artery calcium scores, was associated with a heightened risk of MACE (HR 5.8, 95% CI 1.6-20.6, p = 0.006). Based on CTCA results, 71 patients (31%) commenced statin therapy which was associated with a lower risk of all-cause mortality (HR 0.48, 95% CI 0.24-0.97, p = 0.04). The standardized CAD-RADS classification on CTCA predicted the occurrence of cardiovascular outcomes following LT, with a potential to increase the utilization of preventive cardiovascular therapies.
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Affiliation(s)
- Thalys Sampaio Rodrigues
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul J Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- Department of Anesthesiology, Austin Health, Melbourne, Victoria, Australia
| | - Benjamin Cailes
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - Adam Testro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Gerard Smith
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Ruth P Lim
- Department of Radiology, Austin Health, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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4
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Mac Curtain BM, O'Brien L, El Sherif O, Mc Cormack A, Carolan E, Ryan JD, O'Shea D, Gallagher TK. Biguanides and glucagon like peptide 1 receptor agonists in the amelioration of post liver transplant weight gain; a scoping review of the mechanism of action, safety and efficacy. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2024; 17:17-27. [PMID: 38737926 PMCID: PMC11080689 DOI: 10.22037/ghfbb.v17i1.2899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/02/2023] [Indexed: 05/14/2024]
Abstract
Weight gain post-liver transplant can lead to adverse patient outcomes in the post-transplant period. Pharmacotherapy and other measures can be utilised to reduce the burden and occurrence of weight gain in this population. We explored the mechanism of action, safety, and efficacy of these medications, specifically GLP-1 receptor agonists and metformin, focusing on liver transplant patients. This scoping review was conducted in line with the scoping review structure as outlined by the PRISMA guidelines. Metformin and GLP-1 receptor agonists have been observed to be safe and effective in liver transplant patients. Experimental models have found liver-centric weight loss mechanisms in this drug cohort. There is a paucity of evidence about the use of antihyperglycemics in a post-transplant population for weight loss purposes. However, some small studies have shown strong safety and efficacy data. The evidence in relation to using these medications in patients with metabolic syndrome for weight loss warrants further study in a transplant population.
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Affiliation(s)
| | - Luke O'Brien
- Hepatopancreatobiliary Group, St Vincent's University Hospital, Dublin 4, Ireland
| | - Omar El Sherif
- National Liver Transplant Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - Aidan Mc Cormack
- National Liver Transplant Unit, St Vincent's University Hospital, Dublin 4, Ireland
| | - Emer Carolan
- Department of Hepatology, Beaumont Hospital, Dublin 9, Ireland
| | - John D Ryan
- Department of Hepatology, Beaumont Hospital, Dublin 9, Ireland
| | - Donal O'Shea
- Department of Endocrinology, St Vincent's University Hospital, Dublin 4, Ireland
| | - Tom K Gallagher
- Hepatopancreatobiliary Group, St Vincent's University Hospital, Dublin 4, Ireland
- National Liver Transplant Unit, St Vincent's University Hospital, Dublin 4, Ireland
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5
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Sastre L, García R, Viñals C, Amor AJ, Yago G, Hervás A, Sánchez L, Trabal J, Molero J, Escudé L, Pagano G, Blasco M, Gilabert R, Ruiz P, Colmenero J, Navasa M, Ortega E, Crespo G. Results of a multidisciplinary strategy to improve the management of cardiovascular risk factors after liver transplantation. Liver Transpl 2022; 28:1332-1344. [PMID: 35224857 DOI: 10.1002/lt.26443] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 02/07/2023]
Abstract
Although liver transplantation (LT) recipients are at high cardiovascular risk (CVR), the management of CVR factors (CVRF) after LT is far from optimal and needs to be improved. For this reason, we developed a multidisciplinary protocol to standardize the identification, risk stratification, management, and targets of therapy of CVRF during the first post-LT year. The grade of identification and control of CVRF 12 months after LT in the postintervention cohort (LT January 2018-January 2020, n = 150) were compared with a control cohort who underwent LT between July 2015 and December 2016 (n = 100). Before LT, the prevalence of metabolic-associated fatty liver disease as the indication of LT and the presence of obesity were significantly higher in the postintervention cohort, whereas the prevalence of other CVRF and renal dysfunction tended to be higher. Cyclosporine A was used less frequently in the postintervention cohort, whereas everolimus tended to increase. At 12 months after LT, the proportion of patients with measured blood pressure (88% vs. 56%), glycosilated hemoglobin (HbA1c; 96% vs. 72%), and high-density lipoprotein/low-density lipoprotein cholesterol (67% vs. 33%) was higher in the postintervention than in the control cohort (all p < 0.001). Blood pressure (64% vs. 36%, p = 0.02) and HbA1c (85% vs. 70%, p = 0.1) were within target in more individuals with hypertension and diabetes mellitus, respectively, in the postintervention cohort. Median total cholesterol levels were lower in the postintervention (184 mg/dl; interquartile range [IQR], 160-210 mg/dl) than in the control cohort (212 mg/dl; IQR, 186-240 mg/dl; p = 0.02). At 2 years after LT, the incidence of cardiovascular events was 14% in the control cohort and 6% in the postintervention cohort (p = 0.063). In conclusion, a multidisciplinary, multiprofessional strategy can achieve a higher grade of assessment and management of post-LT CVR despite a worsening metabolic profile of LT recipients.
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Affiliation(s)
- Lydia Sastre
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Department of Gastroenterology and Hepatology, Hospital Son Espases, Palma de Mallorca, Spain
| | - Raquel García
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Clara Viñals
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Antonio J Amor
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Gema Yago
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Alicia Hervás
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Lorena Sánchez
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Joan Trabal
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Judit Molero
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain
| | - Laia Escudé
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Giulia Pagano
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplant Department, Hospital Clinic, Barcelona, Spain
| | - Rosa Gilabert
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Pablo Ruiz
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Jordi Colmenero
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Miquel Navasa
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
| | - Emilio Ortega
- Endocrinology and Nutrition Department, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, Spain
| | - Gonzalo Crespo
- Hepatology and Liver Transplant Unit, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red-Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,University of Barcelona, Barcelona, Spain
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6
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A Comprehensive Review on the Risk of Metabolic Syndrome and Cardiovascular Disease after Liver Transplantation. LIVERS 2022. [DOI: 10.3390/livers2020006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Survival rates after liver transplantation have increased dramatically over the past 20 years. Cardiovascular disease is the most common extra-hepatic cause of mortality in the long-term post liver transplant. This is intimately linked with both the higher pre-existing rates of metabolic syndrome in these patients as well as increased propensity to develop de novo metabolic syndrome post-transplant. This unfavorable metabolic profile that contributes to cardiovascular disease is multifactorial and largely preventable. This review explores metabolic syndrome and cardiovascular disease and their contributory factors post liver transplantation to highlight areas for potential intervention and thus reduce the significant morbidity and mortality of patients due to metabolic syndrome and cardiovascular disease.
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7
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The Underutilization, Adverse Reactions and Efficacy of Statins after Liver Transplant: A Meta-Analysis and Systematic Review. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Treatment of dyslipidemia via statin therapy in the non-liver transplant (LT) population is associated with a mortality benefit; however, the impact of statin therapy in post-LT population is not well-defined. This meta-analysis seeks to investigate the safety and efficacy of statin therapy in post-LT patients. (2) Methods: A systematic literature search on Medline and EMBASE database was conducted. A single-arm proportional meta-analysis and conventional pair-wise meta-analysis were performed to compare different outcomes with a random effects model. (3) Results: A total of 11 studies were included in this study, with 697 LT recipients identified to be on statin therapy. Statins were underutilized with only 32% (95% CI: 0.15–0.52) of 1094 post-LT patients on therapy. The incidence of adverse events of 14% (95% CI: 0.05–0.25) related to statin therapy was low. A significant mortality benefit was noted in patients on statin therapy with HR = 0.282 (95% CI: 0.154–0.517, p < 0.001), and improved lipid profiles post LT. The use of statins also significantly decreased odds of graft rejection (OR = 0.33; 95% CI: 0.15–0.73) and hepatocellular carcinoma (HCC) recurrence (HR = 0.32, 95% CI: 0.11–0.89). (4) Conclusions: Statin therapy is safe and efficacious in post-LT patients. Future studies to evaluate the effects of interactions between statins and immunosuppressant therapy are warranted.
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8
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Abstract
Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.
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