History of Solid Organ Transplantation and Organ Donation

Radiologic evaluation of the kidney transplant donor and recipient

The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.

The impact of heart valve and partial heart transplant models on the development of banking methods for tissues and organs: A concise review

Cryopreserved human heart valves fill a crucial role in the treatment for congenital cardiac anomalies, since the use of alternative mechanical and xenogeneic tissue valves have historically been limited in babies. Heart valve models have been used since 1998 to better understand the impact of cryopreservation variables on the heart valve tissue components with the ultimate goals of improving cryopreserved tissue outcomes and potentially extrapolating results with tissues to organs. Cryopreservation traditionally relies on conventional freezing, employing cryoprotective agents, and slow cooling to sub-zero centigrade temperatures; but it is plagued by the formation of ice crystals and cell damage upon thawing. Researchers have identified ice-free vitrification procedures and developed a new rapid warming method termed nanowarming. Nanowarming is an emerging method that utilizes targeted application of energy at the nanoscale level to rapidly rewarm vitrified tissues, such as heart valves, uniformly for transplantation. Vitrification and nanowarming methods hold great promise for surgery, enabling the storage and transplantation of tissues for various applications, including tissue repair and replacement. These innovations have the potential to revolutionize complex tissue and organ transplantation, including partial heart transplantation. Banking these grafts addresses organ scarcity by extending preservation duration while preserving biological activity with maintenance of structural fidelity. While ice-free vitrification and nanowarming show remarkable potential, they are still in early development. Further interdisciplinary research must be dedicated to exploring the remaining challenges that include scalability, optimizing cryoprotectant solutions, and ensuring long-term viability upon rewarming in vitro and in vivo.

Hip, knee, and shoulder arthroplasty in patients with a history of solid organ transplant: A review

Solid organ transplants (SOT) have evolved into life-saving interventions for end-stage diseases affecting vital organs. Advances in transplantation techniques, donor selection, and immunosuppressive therapies have enhanced outcomes, leading to a growing demand for SOT. Patients with a solid organ transplant are living long enough to develop the same pathologies which are indicated for joint replacement surgery in the general population. SOT patients who undergo a total hip, knee, or shoulder arthroplasty do similarly in the context of clinical outcomes and implant survival when compared to the general population. These immunosuppressed patients tend to have higher complication rates in the short-term following surgery. Prudent management of these patients in the short-term may be necessary, but patients can expect to do well otherwise.

A Framework for Examining Bioethical Issues from a Sunni Perspective: Maslaha

All religions should develop convincing responses to emerging bioethical problems stemming from medical and technological advancements. Additionally, believers need to know their faiths' interpretations of bioethical issues to be able to make medical decisions in line with their religious values. Therefore, Islamic bioethics should provide Muslims with conclusive and credible answers regarding newly rising problems in health care by revisiting the religious norms and decrees. However, the diversity in the Islamic denominations, the traditionalist aspect of the Sunni jurisprudence demanding strict compliance with the scriptural texts, the lack of unanimously accepted authority, and the limited number of academic works in Islamic bioethics (at least in English) complicate exploring new standards or rules for new ethical matters. In this view, the present paper aims to delineate two primary Islamic theological schools and propose al-Ghazali's maslaha as a general framework to analyze bioethical issues in the Sunni tradition. Maslaha allows exercising discretion in light of the protection of five fundamental values: religion, life, reason, lineage, and property. Maslaha has the potential to enable Sunni Muslims to appraise contemporary ethical questions, concerns, and dilemmas through an Islamic view and make more autonomous decisions by having religious guidelines.

Immunosuppressive protocols after laryngeal transplantation: a systematic review

BACKGROUNDS

Larynx transplantation has been successfully performed four times, in 1998, 2010, 2015 and 2023 remained the ultimate goal of voice, feeding and breathing rehabilitation.

OBJECTIVE

Immunosuppressive protocols used during the previous successful larynx allotransplantation are detailed.

MATERIAL AND METHODS

A systematic review of the literature on PUBMED/Medline, Cochrane and Embase was conducted. Articles relating to actual human larynx transplantations were included.

RESULTS

Bibliography search gathered N = 10 publications related to the performance and follow-up of human laryngeal transplantations. N = 8 publications were included corresponding to N = 3 actual human larynx transplantations performed in 1998 and 2010 in the USA and in 2015 in Poland. Immunosuppression protocols, induction and maintenance strategies, rejection monitoring and history of all the three previous laryngeal grafts were detailed.

CONCLUSIONS

Beyond the surgical prowess, larynx transplantation is feasible and associated with a reasonably successful outcome when compared to other solid organ transplants. Immunosuppressive regimen protocols and technologies for the monitoring of the organ viability have evolved.

SIGNIFICANCE

The reevaluation of this surgical option serves as the reminder of the critical necessity to implement a meticulous immunosuppression protocol when transplanting this inherently immunogenic composite organ, the larynx.

An Emerging Issue: Carbapenem-Resistant Enterobacteriaceae in Solid-Organ Transplantation

OBJECTIVES

Bloodstream infections caused by carbapenem-resistant bacteria have increased globally. Solid-organ transplant recipients are more prone to these infections. This study aimed to compare the clinical courses of carbapenem-susceptible and carbapenem-resistant Enterobacteriaceae bloodstream infections and to identify risk factors for carbapenem resistance in solid-organ transplant recipients.

MATERIALS AND METHODS

For this retrospective descriptive study, data for solid-organ transplant recipients (age ≥18) treated from 2015 to 2022 were obtained from medical records. Enterobacteriaceaepositive blood culture was screened from laboratory data.

RESULTS

Among 72 patients, there were 100 bacteremia episodes. Patients included 40 kidney (55.6%), 21 liver (29.2%), 7 heart (9.7%), and 4 combined liver and kidney (5.6%) transplant recipients. Fifty-seven bacteremia episodes were recorded between 2015 and 2020, and 43 bacteremia episodes were recorded between 2020 and 2022. Carbapenem resistance was reported in 15.8% of patients before 2020, whereas this rate increased to 39.5% after 2020 (P = .007). Pitt bacteremia score ≥4 (P < .001), Charlson comorbidity index ≥4 (P = .021), chronic liver disease (P = .015), septic shock at admission (P = .001), hypotension at admission (P = .006), bacteremia episodes 48 hours after hospitalization (P = .004), hospitalization in the past 3 months (P = .004), and prior invasive procedure (P = .043) were significant factors for carbapenem resistance. Logistic regression analysis showed that bacteremia 48 hours after hospitalization (P = .002) and hospitalization in the past 3 months (P = .006) were independent risk factors.

CONCLUSIONS

Carbapenem resistance increased significantly over the years. Bacteremia 48 hours after hospitalization and hospitalization within the past 3 months were determined to be risk factors for carbapenem resistance. Carbapenem-resistant infections are still nosocomial infections. Patients should be hospitalized for as a short time as possible, and both patients and their physicians should follow infection control and prevention methods.

Modulatory immune responses in fungal infection associated with organ transplant - advancements, management, and challenges

Organ transplantation stands as a pivotal achievement in modern medicine, offering hope to individuals with end-stage organ diseases. Advancements in immunology led to improved organ transplant survival through the development of immunosuppressants, but this heightened susceptibility to fungal infections with nonspecific symptoms in recipients. This review aims to establish an intricate balance between immune responses and fungal infections in organ transplant recipients. It explores the fundamental immune mechanisms, recent advances in immune response dynamics, and strategies for immune modulation, encompassing responses to fungal infections, immunomodulatory approaches, diagnostics, treatment challenges, and management. Early diagnosis of fungal infections in transplant patients is emphasized with the understanding that innate immune responses could potentially reduce immunosuppression and promise efficient and safe immuno-modulating treatments. Advances in fungal research and genetic influences on immune-fungal interactions are underscored, as well as the potential of single-cell technologies integrated with machine learning for biomarker discovery. This review provides a snapshot of the complex interplay between immune responses and fungal infections in organ transplantation and underscores key research directions.

A joint program of antimicrobial stewardship and hospital-acquired infection control to reduce healthcare-associated infections after kidney transplantation: The Hipomenes study

Infection is a common complication in kidney transplant recipients (KTRs). The usefulness of antimicrobial stewardship programs (ASP) and hospital-acquired infection control (HAIC) initiatives in the general inpatient population is well established. We performed a quasi-experimental study to evaluate a joint ASP/HAIC initiative focused on KTRs. A dedicated ASP team optimized antimicrobial prescriptions in consecutive KTRs during the intervention period (June 2015-March 2016). A multifaceted, evidence-based HAIC program was concurrently implemented. Results were compared with the preceding period (June 2014-March 2015). We included 96 and 100 KTRs in the intervention and preintervention periods, respectively. There was a reduction in the consumption of meropenem (rate ratio [RR]: 0.63; 95% confidence interval [CI]: 0.53-0.75; P <.0001), ceftazidime (RR: 0.31; 95% CI: 0.21-0.45; P <.0001), vancomycin (RR: 0.65; 95% CI: 0.53-0.8; P <.0001), and ciprofloxacin (RR: 0.66; 95% CI: 0.55-0.81; P <.0001) and an increase of fosfomycin (RR: 1.80; 95% CI: 1.17-2.76; P =.008) during the intervention period. The incidence of cystitis (RR: 0.30; 95% CI: 0.28-0.33; P <.001) and upper urinary tract infection (RR: 0.56; 95% CI: 0.33-0.95; P =.04) decreased. A specific ASP/HAIC initiative was effective in optimizing antimicrobial use and reducing the incidence of common bacterial infections among KTRs.

The role of efferocytosis and transplant rejection: Strategies in promoting transplantation tolerance using apoptotic cell therapy and/or synthetic particles

Recently, efforts have been made to recognize the precise reason(s) for transplant failure and the process of rejection utilizing the molecular signature. Most transplant recipients do not appreciate the unknown length of survival of allogeneic grafts with the existing standard of care. Two noteworthy immunological pathways occur during allogeneic transplant rejection. A nonspecific innate immune response predominates in the early stages of the immune reaction, and allogeneic antigens initiate a donor-specific adaptive reaction. Though the adaptive response is the major cause of allograft rejection, earlier pro-inflammatory responses that are part of the innate immune response are also regarded as significant in graft loss. The onset of the innate and adaptive immune response causes chronic and acute transplant rejection. Currently employed immunosuppressive medications have shown little or no influence on chronic rejection and, as a result, on overall long-term transplant survival. Furthermore, long-term pharmaceutical immunosuppression is associated with side effects, toxicity, and an increased risk of developing diseases, both infectious and metabolic. As a result, there is a need for the development of innovative donor-specific immunosuppressive medications to regulate the allorecognition pathways that induce graft loss and to reduce the side effects of immunosuppression. Efferocytosis is an immunomodulatory mechanism with fast and efficient clearance of apoptotic cells (ACs). As such, AC therapy strategies have been suggested to limit transplant-related sequelae. Efferocytosis-based medicines/treatments can also decrease the use of immunosuppressive drugs and have no detrimental side effects. Thus, this review aims to investigate the impact of efferocytosis on transplant rejection/tolerance and identify approaches using AC clearance to increase transplant viability.

Life beyond life: Perceptions of post-mortem organ donation and consent to donate-A focus group study in Italy

OBJECTIVES

Many factors such as personal and cultural beliefs, misinformation, fear of death and inadequate will registering procedures can influence post-mortem organ donation. The present study aimed to explore the perceptions, beliefs and information around post-mortem donation and will expression in different groups of the Italian population, to orient future interventions and raise awareness.

DESIGN

Qualitative research with focus groups.

METHODS

A total of 38 focus groups involving 353 participants including the general population (young adults: 18-39, mature adults: 40-70), local and hospital health professionals, critical area health professionals (emergency room and intensive care), registry office employees and opinion leaders, were conducted in six regions from different parts of Italy between June and November 2021. Thematic analysis was conducted with the use of Atlas.ti9.

RESULTS

Five overarching themes were identified: dilemmas regarding donation, resistance to donation, facilitators of donation, difficulties in terms of will expression and proposals to encourage will expression. Possible facilitators were having personal and professional experiences with organ donation, feeling useful for society, having reliable information and trust in the health care system. Potential barriers to donation were doubts and fears about brain death, bodily integrity concerns, religious beliefs, misinformation and distrust in the health care system.

CONCLUSIONS

These results highlighted the significance of a bottom-up perspective with regard to identifying the personal perceptions and beliefs with regard to donation, underlining the urgency of creating tailored interventions to sensitize different groups of the population in terms of promoting an informed choice and a culture of donation.

Application possibilities of artificial intelligence in facial vascularized composite allotransplantation-a narrative review

Facial vascularized composite allotransplantation (FVCA) is an emerging field of reconstructive surgery that represents a dogmatic shift in the surgical treatment of patients with severe facial disfigurements. While conventional reconstructive strategies were previously considered the goldstandard for patients with devastating facial trauma, FVCA has demonstrated promising short- and long-term outcomes. Yet, there remain several obstacles that complicate the integration of FVCA procedures into the standard workflow for facial trauma patients. Artificial intelligence (AI) has been shown to provide targeted and resource-effective solutions for persisting clinical challenges in various specialties. However, there is a paucity of studies elucidating the combination of FVCA and AI to overcome such hurdles. Here, we delineate the application possibilities of AI in the field of FVCA and discuss the use of AI technology for FVCA outcome simulation, diagnosis and prediction of rejection episodes, and malignancy screening. This line of research may serve as a fundament for future studies linking these two revolutionary biotechnologies.

Examining the Performance of the MMPI-2-RF in a Sample of Pretransplant Military Veterans

The present study aimed to describe the personality and psychopathology dimensions reported by veterans seeking organ transplantation, as well as to identify those dimensions associated with subsequent presurgical recommendations and transplant outcomes. Data were collected from 245 veterans undergoing a pretransplant psychological evaluation that included the MMPI-2-RF. Three treatment recommendations resulting from these evaluations, three recommendation adherence variables, and two transplant outcomes were extracted from electronic medical records. The sample's MMPI-2-RF scale scores were compared to the normative sample and two other presurgical samples and contrasted across subgroups defined by organ transplanted. Point-biserial correlations and logistic regression analyses examined associations between MMPI-2-RF scale scores and the eight measured outcomes. Results indicated that over-reporting, internalizing tendencies, negative emotionality, and a lack of positive emotions were uniquely predictive of mental health treatment recommendation, whereas somatic over-reporting, externalizing tendencies, and disinhibition were predictive of substance use treatment recommendation. Veterans who reported higher levels of activation were less likely to initiate mental health treatment. Finally, veterans with greater somatic preoccupation were less likely to be listed for organ transplant. More suspicious and mistrustful veterans were less likely to receive the transplant. These findings offer support for the role of the MMPI-2-RF in veteran pretransplant evaluations.

Decellularized Extracellular Matrix: The Role of This Complex Biomaterial in Regeneration

Organ transplantation is understood as a technique where an organ from a donor patient is transferred to a recipient patient. This practice gained strength in the 20th century and ensured advances in areas of knowledge such as immunology and tissue engineering. The main problems that comprise the practice of transplants involve the demand for viable organs and immunological aspects related to organ rejection. In this review, we address advances in tissue engineering for reversing the current challenges of transplants, focusing on the possible use of decellularized tissues in tissue engineering. We address the interaction of acellular tissues with immune cells, especially macrophages and stem cells, due to their potential use in regenerative medicine. Our goal is to exhibit data that demonstrate the use of decellularized tissues as alternative biomaterials that can be applied clinically as partial or complete organ substitutes.

Messaging strategies for communicating health-related information in social media-a content and effectiveness analysis of organ donation posts on Instagram in Germany

BACKGROUND

Although organ transplantation is a very effective clinical solution to save the lives of patients suffering from organ failure, the supply of donated organs still cannot meet its growing demand. Educating the society about organ donation is a critical success factor in increasing donation rates, especially in countries that require potential donors to proactively register and opt-in (e.g., Germany). While social media has emerged as an effective tool for disseminating health information, recent evidence suggests that published organ donation content (both online and offline), aimed at raising awareness, still lacks effectiveness. To develop recommendations for optimizing organ donation messaging via social media, this study not only examines the current state of organ donation communication on Instagram, but also identifies factors that contribute to message effectiveness.

METHODS

We conducted a retrospective content analysis to in-depth assess organ donation-related content published on Instagram in Germany between January and March 2022. Systematic coding allowed to identify common themes, sentiments, and communication strategies, which were analyzed for their effectiveness using linear regression analyses.

RESULTS

Of the 500 organ donation posts, 57% were published by institutional authors while the remainder was shared by private accounts. Most content was aimed at the general population and shared neutral (80%) or positive sentiments (17%). Transformative messages, positive emotions, posts published by the transplant recipient and the image of a human served as predictors for post effectiveness measured in terms of likes (p < 0.001) and comments (p < 0.01). Sharing personal experiences (p < 0.01) and highlighting the meaning of organ donations (p < 0.05) resulted in significantly higher audience engagement than any other topic discussed.

CONCLUSION

Our findings highlight the need for health officials to work closely with organ transplant recipients to publicly advocate for organ donations by sharing personal and transformative messages. The high share of posts published by transplant recipients indicates a certain openness to share personal experiences with broad audiences. Different message characteristics served as predictors for message effectiveness (i.e., increased audience engagement) which can likely be extrapolated to other health-related use cases (e.g., cancer screening).

Cutaneous infections from viral sources in solid organ transplant recipients

INTRODUCTION

Solid organ transplant recipients (SOTRs) are susceptible to various dermatological complications caused by long-term immunosuppressive therapy. Of these complications, viral infections are noteworthy because of their high prevalence and the potential morbidity associated with viral carcinogenesis.

OBJECTIVES

To evaluate the occurrence of cutaneous viral infections in SOTRs and their correlation with clinical features, transplant type, and the length and intensity of immunosuppressive therapy.

METHODS

This retrospective cohort study included SOTRs followed up at the Department of Dermatology in a tertiary hospital. The outcomes analyzed were the occurrence of cutaneous viral infections, including human papillomavirus (HPV) infection, herpes simplex, herpes zoster, molluscum contagiosum, Merkel cell carcinoma, Kaposi's sarcoma, and cytomegalovirus, and the occurrence of HPV-related neoplasms. Clinical variables, such as length and intensity of immunosuppression, type of transplanted organ, and comorbidities, were analyzed as possible risk factors for cutaneous viral infections in SOTRs.

RESULTS

A total of 528 SOTRs were included in this study, among which 53.8% had one or more viral infections. Of these, 10% developed a virus-associated malignancy (HPV-associated carcinoma, Merkel cell carcinoma, or Kaposi's sarcoma). The higher risk of viral infections among SOTRs was associated with cyclosporine intake (1.40-fold higher risk) and younger age at transplantation. The use of an immunosuppressive regimen, including additional drugs, was associated with a higher risk of genital HPV infection (1.50-fold higher risk for each incremental drug).

CONCLUSIONS

The occurrence of cutaneous viral infections in SOTRs is directly associated with the duration and intensity of immunosuppressive therapy. Patients at higher risk were those taking drugs with a stronger impact on cellular immunity and/or those on an immunosuppressive regimen comprising various drugs.

Infections after organ transplantation and immune response

Organ transplantation has provided another chance of survival for end-stage organ failure patients. Yet, transplant rejection is still a main challenging factor. Immunosuppressive drugs have been used to avoid rejection and suppress the immune response against allografts. Thus, immunosuppressants increase the risk of infection in immunocompromised organ transplant recipients. The infection risk reflects the relationship between the nature and severity of immunosuppression and infectious diseases. Furthermore, immunosuppressants show an immunological impact on the genetics of innate and adaptive immune responses. This effect usually reactivates the post-transplant infection in the donor and recipient tissues since T-cell activation has a substantial role in allograft rejection. Meanwhile, different infections have been found to activate the T-cells into CD₄⁺ helper T-cell subset and CD₈⁺ cytotoxic T-lymphocyte that affect the infection and the allograft. Therefore, the best management and preventive strategies of immunosuppression, antimicrobial prophylaxis, and intensive medical care are required for successful organ transplantation. This review addresses the activation of immune responses against different infections in immunocompromised individuals after organ transplantation.

Thoracic organ machine perfusion: A review of concepts with a focus on reconditioning therapies

Thoracic organ transplantation, including lung, heart, and heart-lung transplants are highly regarded as gold standard treatments for patients suffering from heart failure or chronic end stage lung conditions. The relatively high prevalence of conditions necessitating thoracic organ transplants combined with the lack of available organs has resulted in many either dying or becoming too ill to receive a transplant while on the waiting list. There is a dire need to increase both the number of organs available and the utilization of such organs. Improved preservation techniques beyond static storage have shown great potential to lengthen the current period of viability of thoracic organs while outside the body, promising better utilization rates, increased donation distance, and improved matching of donors to recipients. Ex-situ organ perfusion (ESOP) can also make some novel therapeutic strategies viable, and the combination of the ESOP platform with such reconditioning therapies endeavors to better improve functional preservation of organs in addition to making more organs viable for transplantation. Given the abundance of clinical and pre-clinical studies surrounding reconditioning of thoracic organs in combination with ESOP, we summarize in this review important concepts and research regarding thoracic organ machine perfusion in combination with reconditioning therapies.

Self-management in adults after solid-organ transplantation: a scoping review protocol

INTRODUCTION

After solid-organ transplantation (SOTx), recipients must adhere to a lifelong medical regimen, change their lifestyle and cope with physiological and psychosocial challenges. This requires active participation in their care and self-management abilities. The concept of self-management after SOTx has only been described regarding specific organs and focused on adherence to medical treatment. A comprehensive conceptualisation of self-management entailing all solid organs and beyond medical aspects does not exist. This might lead to unmet self-management support needs of SOTx recipients and hinder a more holistic and integrative approach in self-management support. Therefore, a better understanding of the concept of self-management after SOTx is needed to facilitate a comprehensive evidence base for healthcare providers and researchers. The purpose of this scoping review is to explore existing evidence on self-management in adults after SOTx.

METHODS AND ANALYSIS

To identify relevant evidence, six electronic databases and three study registers will be searched, supplemented by handsearches, reference checking and expert recommendations. Screening and selection of available evidence will be carried out in a two-step process by two independent reviewers. International evidence published in English or German reporting on adults after heart, lung, liver, pancreas, kidney or small bowel transplantation will be considered. To meet inclusion criteria, articles have to focus on either: self-management, self-management support or recipients' or healthcare providers' perspectives of challenges and needs potentially addressable by self-management. Data extraction will be performed by two reviewers independently using a structured form. Data will be analysed descriptively and using content analysis procedures. Findings will be summarised narratively and presented in tabular format.

ETHICS AND DISSEMINATION

The consultation and approval of an ethics committee is not required for this scoping review. Findings of the scoping review will be published in a peer-reviewed open-access journal and presented at conferences.

Assessment of Community Knowledge of and Attitude Toward Organ Donation in Saudi Arabia

BACKGROUND

The demand for organ donation has increased because of the sharp rise in the number of transplant candidates worldwide. The main influences on the organ donation rate in Saudi Arabia were religious considerations and a lack of knowledge. The aim of this study was to explore community knowledge of and attitude toward organ donation in Saudi Arabia.

METHODS

An online cross-sectional survey study was conducted to assess community knowledge of and attitude toward organ donation in Saudi Arabia in January 2022. The study population consisted of everyone who is currently residing in Saudi Arabia and is aged ≥18 years. The participants were questioned regarding the types of organs that might be donated, the potential health risks associated with organ donation, and the Saudi Arabian system for organ donation. Logistic regression was used to identify predictors of better knowledge of and attitude toward organ donation.

RESULTS

The study involved 1208 participants, of which 63% reported that they would be willing to donate their organs for a family member. The most reported organs for which the participants reported they are willing to donate were the kidneys (48%), liver (25%), and heart (21%). Most reported that they would donate their organs to save someone's life (93%). The study participants showed mild to moderate level of knowledge about organ donation with a mean score of 5.4 (standard deviation [SD] 1.6), which is equal to 68% of the maximum obtainable score (which is 8). The study participants showed a mild positive attitude toward organ donation with a mean score of 3.3 (SD 1.3), which is equal to 47% of the maximum obtainable score (which is 7). Younger participants (aged 19-30 years) and those who work in the health care sector were more likely than others to be knowledgeable about organ donation (P ≤ .01). At the same time, participants aged 31 to 40 years were more likely than others to have positive attitudes toward organ donation (P ≤ .01).

CONCLUSIONS

The present study participants showed mild to moderate level of knowledge of and mild positive attitude toward organs donation. Awareness campaigns should be directed toward the elderly population to enhance their awareness and attitude toward this important lifesaving practice.

Synbiotics, prebiotics and probiotics for solid organ transplant recipients

BACKGROUND

Solid organ transplantation has seen improvements in both surgical techniques and immunosuppression, achieving prolonged survival. Essential to graft acceptance and post-transplant recovery, immunosuppressive medications are often accompanied by a high prevalence of gastrointestinal (GI) symptoms and side effects. Apart from GI side effects, long-term exposure to immunosuppressive medications has seen an increase in drug-related morbidities such as diabetes mellitus, hyperlipidaemia, hypertension, and malignancy. Non-adherence to immunosuppression can lead to an increased risk of graft failure. Recent research has indicated that any microbial imbalances (otherwise known as gut dysbiosis or leaky gut) may be associated with cardiometabolic diseases in the long term. Current evidence suggests a link between the gut microbiome and the production of putative uraemic toxins, increased gut permeability, and transmural movement of bacteria and endotoxins and inflammation. Early observational and intervention studies have been investigating food-intake patterns, various synbiotic interventions (antibiotics, prebiotics, or probiotics), and faecal transplants to measure their effects on microbiota in treating cardiometabolic diseases. It is believed high doses of synbiotics, prebiotics and probiotics are able to modify and improve dysbiosis of gut micro-organisms by altering the population of the micro-organisms. With the right balance in the gut flora, a primary benefit is believed to be the suppression of pathogens through immunostimulation and gut barrier enhancement (less permeability of the gut).

OBJECTIVES

To assess the benefits and harms of synbiotics, prebiotics, and probiotics for recipients of solid organ transplantation.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 9 March 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials measuring and reporting the effects of synbiotics, prebiotics, or probiotics, in any combination and any formulation given to solid organ transplant recipients (any age and setting). Two authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data extraction was independently carried out by two authors using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Five studies (250 participants) were included in this review. Study participants were adults with a kidney (one study) or liver (four studies) transplant. One study compared a synbiotic to placebo, two studies compared a probiotic to placebo, and two studies compared a synbiotic to a prebiotic. Overall, the quality of the evidence is poor. Most studies were judged to have unclear (or high) risk of bias across most domains. Of the available evidence, meta-analyses undertaken were of limited data from small studies. Across all comparisons, GRADE evaluations for all outcomes were judged to be very low certainty evidence. Very low certainty evidence implies that we are very uncertain about results (not estimable due to lack of data or poor quality). Synbiotics had uncertain effects on the change in microbiota composition (total plasma p-cresol), faecal characteristics, adverse events, kidney function or albumin concentration (1 study, 34 participants) compared to placebo. Probiotics had uncertain effects on GI side effects, infection rates immediately post-transplant, liver function, blood pressure, change in fatty liver, and lipids (1 study, 30 participants) compared to placebo. Synbiotics had uncertain effects on graft health (acute liver rejection) (2 studies, 129 participants: RR 0.73, 95% CI 0.43 to 1.25; 2 studies, 129 participants; I² = 0%), the use of immunosuppression, infection (2 studies, 129 participants: RR 0.18, 95% CI 0.03 to 1.17; I² = 66%), GI function (time to first bowel movement), adverse events (2 studies, 129 participants: RR 0.79, 95% CI 0.40 to 1.59; I² = 20%), serious adverse events (2 studies, 129 participants: RR 1.49, 95% CI 0.42 to 5.36; I² = 81%), death (2 studies, 129 participants), and organ function measures (2 studies; 129 participants) compared to prebiotics.

AUTHORS' CONCLUSIONS

This review highlights the severe lack of high-quality RCTs testing the efficacy of synbiotics, prebiotics or probiotics in solid organ transplant recipients. We have identified significant gaps in the evidence. Despite GI symptoms and postoperative infection being the most common reasons for high antibiotic use in this patient population, along with increased morbidity and the growing antimicrobial resistance, we found very few studies that adequately tested these as alternative treatments. There is currently no evidence to support or refute the use of synbiotics, prebiotics, or probiotics in solid organ transplant recipients, and findings should be viewed with caution. We have identified an area of significant uncertainty about the efficacy of synbiotics, prebiotics, or probiotics in solid organ transplant recipients. Future research in this field requires adequately powered RCTs comparing synbiotics, prebiotics, and probiotics separately and with placebo measuring a standard set of core transplant outcomes. Six studies are currently ongoing (822 proposed participants); therefore, it is possible that findings may change with their inclusion in future updates.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients

BACKGROUND

Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy.

OBJECTIVES

This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results.

MAIN RESULTS

Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported.

AUTHORS' CONCLUSIONS

Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

Decisions around Deceased Organ Donation in Young South Asian Individuals in the United Kingdom

There is a large disparity between the demand and availability of organs for transplantation from within the UK's ethnic minority groups. Our aims were to identify the perceptions, knowledge of and level of engagement with organ donation since the law changed in England in 2020. A questionnaire survey using Google Forms was designed based on prior literature and information on NHSBT website. It was distributed through media outlets and cultural/professional organizations. Status on Organ Donation Registry and Quiz scores were analyzed against multiple variables. Three hundred and sixty-five people between 18 and 24 years old completed the questionnaire. 72.3% were female, 57% were health-care students, 86.3% were of South Asian ethnicity, and 11% were immigrant respondents. Overall, 43.6% were registered to donate. South Asian groups, particularly those of Pakistani ethnicity and migrant students, were less likely to register to donate. Being more knowledgeable about the organ donation process, females, nonreligious groups, and health-care students are more likely to be registered to donate. This study identified barriers around deceased organ donation decisions and demonstrates the need for further targeted and continual education to the young South Asians individuals, to produce positive associations that will percolate to older and future generations.

Is the Organ Care System (OCS) Still the First Choice With Emerging New Strategies for Donation After Circulatory Death (DCD) in Heart Transplant?

The scarcity of donor hearts continues to be a challenge in transplants for advanced heart failure patients. With an increasing number of patients on the waiting list for a heart transplant, the discrepancy in the number between donors and recipients is gradually increasing and poses a new challenge that plagues the healthcare systems when it comes to the heart. Several technologies have been developed to expand the donor pool in recent years. One such method is the organ care system (OCS). The standard method of organ preservation is the static cold storage (SCS) method which allows up to four hours of safe preservation of the heart. However, beyond four hours of cold ischemia, the incidence of primary graft dysfunction increases significantly. OCS keeps the heart perfused close to the physiological state beyond the four hours with superior results, which allows us to travel further and longer distances, leading to expansion in the donor pool. In this review, we discuss the OCS system, its advantages, and shortcomings.

nnU-Net Deep Learning Method for Segmenting Parenchyma and Determining Liver Volume From Computed Tomography Images

Background

Recipient donor matching in liver transplantation can require precise estimations of liver volume. Currently utilized demographic-based organ volume estimates are imprecise and nonspecific. Manual image organ annotation from medical imaging is effective; however, this process is cumbersome, often taking an undesirable length of time to complete. Additionally, manual organ segmentation and volume measurement incurs additional direct costs to payers for either a clinician or trained technician to complete. Deep learning-based image automatic segmentation tools are well positioned to address this clinical need.

Objectives

To build a deep learning model that could accurately estimate liver volumes and create 3D organ renderings from computed tomography (CT) medical images.

Methods

We trained a nnU-Net deep learning model to identify liver borders in images of the abdominal cavity. We used 151 publicly available CT scans. For each CT scan, a board-certified radiologist annotated the liver margins (ground truth annotations). We split our image dataset into training, validation, and test sets. We trained our nnU-Net model on these data to identify liver borders in 3D voxels and integrated these to reconstruct a total organ volume estimate.

Results

The nnU-Net model accurately identified the border of the liver with a mean overlap accuracy of 97.5% compared with ground truth annotations. Our calculated volume estimates achieved a mean percent error of 1.92% + 1.54% on the test set.

Conclusions

Precise volume estimation of livers from CT scans is accurate using a nnU-Net deep learning architecture. Appropriately deployed, a nnU-Net algorithm is accurate and quick, making it suitable for incorporation into the pretransplant clinical decision-making workflow.

Hand Transplants, Daily Functioning, and the Human Capacity for Limb Regeneration

Unlike some of our invertebrate and vertebrate cousins with the capacity to regenerate limbs after traumatic loss, humans do not have the ability to regrow arms or legs lost to injury or disease. For the millions of people worldwide who have lost a limb after birth, the primary route to regaining function and minimizing future complications is via rehabilitation, prosthetic devices, assistive aids, health system robustness, and social safety net structures. The majority of limbs lost are lower limbs (legs), with diabetes and vascular disorders being significant causal contributors. Upper limbs (arms) are lost primarily because of trauma; digits and hands are the most common levels of loss. Even if much of the arm remains intact, upper limb amputation significantly impacts function, largely due to the loss of the hand. Human hands are marvels of evolution and permit a dexterity that enables a wide variety of function not readily replaced by devices. It is not surprising, therefore, for some individuals, dissatisfaction with available prosthetic options coupled with remarkable advances in hand surgery techniques is resulting in patients undertaking the rigors of a hand transplantation. While not “regeneration” in the sense of the enviable ability with which Axolotls can replace a lost limb, hand transplants do require significant regeneration of tissues and nerves. Regaining sophisticated hand functions also depends on “reconnecting” the donated hand with the areas of the human brain responsible for the sensory and motor processing required for complex actions. Human hand transplants are not without controversy and raise interesting challenges regarding the human regenerative capacity and the status of transplants for enabling function. More investigation is needed to address medical and ethical questions prior to expansion of hand transplants to a wider patient population.

Graph Neural Networks as a Potential Tool in Improving Virtual Screening Programs

Despite the increasing number of pharmaceutical companies, university laboratories and funding, less than one percent of initially researched drugs enter the commercial market. In this context, virtual screening (VS) has gained much attention due to several advantages, including timesaving, reduced reagent and consumable costs and the performance of selective analyses regarding the affinity between test molecules and pharmacological targets. Currently, VS is based mainly on algorithms that apply physical and chemistry principles and quantum mechanics to estimate molecule affinities and conformations, among others. Nevertheless, VS has not reached the expected results concerning the improvement of market-approved drugs, comprising less than twenty drugs that have reached this goal to date. In this context, graph neural networks (GNN), a recent deep-learning subtype, may comprise a powerful tool to improve VS results concerning natural products that may be used both simultaneously with standard algorithms or isolated. This review discusses the pros and cons of GNN applied to VS and the future perspectives of this learnable algorithm, which may revolutionize drug discovery if certain obstacles concerning spatial coordinates and adequate datasets, among others, can be overcome.

Brain stem death induces pro-inflammatory cytokine production and cardiac dysfunction in sheep model

Introduction

Organs procured following brain stem death (BSD) are the main source of organ grafts for transplantation. However, BSD is associated with inflammatory responses that may damage the organ and affect both the quantity and quality of organs available for transplant. Therefore, we aimed to investigate plasma and bronchoalveolar lavage (BAL) pro-inflammatory cytokine profiles and cardiovascular physiology in a clinically relevant 6-h ovine model of BSD.

Methods

Twelve healthy female sheep (37–42 Kg) were anaesthetized and mechanically ventilated prior to undergoing BSD induction and then monitored for 6 h. Plasma and BAL endothelin-1 and cytokines (IL-1β, 6, 8 and tumour necrosis factor alpha (TNF-α)) were assessed by ELISA. Differential white blood cell counts were performed. Cardiac function during BSD was also examined using echocardiography, and cardiac biomarkers (A-type natriuretic peptide and troponin I were measured in plasma.

Results

Plasma concentrations big ET-1, IL-6, IL-8, TNF-α and BAL IL-8 were significantly (p < 0.01) increased over baseline at 6 h post-BSD. Increased numbers of neutrophils were observed in the whole blood (3.1 × 10⁹ cells/L [95% confidence interval (CI) 2.06–4.14] vs. 6 × 10⁹ cells/L [95%CI 3.92–7.97]; p < 0.01) and BAL (4.5 × 10⁹ cells/L [95%CI 0.41–9.41] vs. 26 [95%CI 12.29–39.80]; p = 0.03) after 6 h of BSD induction vs baseline. A significant increase in ANP production (20.28 pM [95%CI 16.18–24.37] vs. 78.68 pM [95%CI 53.16–104.21]; p < 0.0001) and cTnI release (0.039 ng/mL vs. 4.26 [95%CI 2.69–5.83] ng/mL; p < 0.0001), associated with a significant reduction in heart contractile function, were observed between baseline and 6 h.

Conclusions

BSD induced systemic pro-inflammatory responses, characterized by increased neutrophil infiltration and cytokine production in the circulation and BAL fluid, and associated with reduced heart contractile function in ovine model of BSD.

The effect of perceived social support on psychological resilience in liver transplant patients receiving immunosuppression therapy

OBJECTIVE

This study was conducted to investigate the effect of social support on psychological resilience in liver transplant patients receiving immunosuppression therapy.

METHOD

This study was carried out as a descriptive and cross-sectional study with the participation of 290 liver transplant patients hospitalized in the liver transplant center of a research and application hospital. Personal Information Form, Multidimensional Scale of Perceived Social Support (MSPSS) and Brief Resilience Scale (BRS) were used in data collection. The data analysis was performed with IBM Statistical Package for the Social Sciences Statistics 25.

RESULTS

According to the data obtained, it was determined that 30.4% of the patients were 58 years old and over, 81% of them were male and 92.8% of them were married. It was found that all of the patients used antimetabolites and corticosteroids, and 82.8% of them used calcineurin inhibitors. It was determined that 32.8% of the patients experienced infection, neuropsychiatric problems and nephrotoxicity at the same time. The psychological resilience of the patients was found to be moderate, and their perceived social support was found to be low.

CONCLUSION

It is not always possible for liver transplant patients to deal with their situation effectively. The psychological resilience and social support levels of patients who have undergone liver transplantation should be noticed, and social, economic and psychological support should be provided.

The effect of immunosuppressive therapy after liver transplantation on activities of daily living and fear of death during the COVID-19 pandemic

BACKGROUND

In our study, we aimed to investigate the effect of immunosuppressive therapy after liver transplantation on activities of daily living and fear of death during the COVID-19 pandemic.

METHODS

This study was conducted as a cross-sectional study with the participation of 213 liver transplant patients hospitalized in the liver transplant center of a university hospital. The data analysis was performed with IBM SPSS (Statistical Package for the Social Sciences) Statistics 25.

RESULTS

Katz's Activities of Daily Living (ADL) were semi-independent and the total score was 11.07 ± 1.59, and the Death Attitude Profile-Revised (DAP-R) total score was 152.23 ± 5.34. It was determined that the DAP-R score was around 150 points in the minimum and maximum score ranges of Katz ADL after liver transplantation.

CONCLUSIONS

High fear of death threatens resilience and can make patients feel lonely, helpless, sad, abandoned and stressed. Clinicians should spend more time with their patients.

A rapid and simple procedure for the isolation and cultivation of fibroblast-like cells from medaka and zebrafish embryos and fin clip biopsies

In many human diseases, the molecular pathophysiological mechanisms are not understood, which makes the development and testing of new therapeutic approaches difficult. The generation and characterization of animal models such as mice, rats, fruit flies, worms or fish offers the possibility for in detail studies of a disease's development, its course and potential therapies in an organismal context, which considerably minimizes the risk of therapeutic side effects for patients. Nevertheless, due to the high numbers of experimental animals used in research worldwide, attempts to develop alternative test systems will help in reducing their count. In this regard, the cell culture system displays a suitable option due to its potential of delivering nearly unlimited material and the good opportunities for high-throughput studies such as drug testing. Here, we describe a quick and simple method to isolate and cultivate vital fibroblast-like cells from embryos and adults of two popular teleost model organisms, the Japanese rice fish medaka (Oryzias latipes) and the zebrafish (Danio rerio).

Uterine Tissue Engineering: Where We Stand and the Challenges Ahead

Tissue engineering is an innovative approach to develop allogeneic tissues and organs. The uterus is a very sensitive and complex organ, which requires refined techniques to properly regenerate and even, to rebuild itself. Many therapies were developed in 20th century to solve reproductive issues related to uterus failure and, more recently, tissue engineering techniques provided a significant evolution in this issue. Herein we aim to provide a broad overview and highlights of the general concepts involved in bioengineering to reconstruct the uterus and its tissues, focusing on strategies for tissue repair, production of uterine scaffolds, biomaterials and reproductive animal models, highlighting the most recent and effective tissue engineering protocols in literature and their application in regenerative medicine. In addition, we provide a discussion about what was achieved in uterine tissue engineering, the main limitations, the challenges to overcome and future perspectives in this research field.

Successful strategies to increase organ donation: the Gift of Life Donor Program Philadelphia model

Organ donation connects the ending of one life with the renewal of another. Acute care hospitals care for the organ donor and transplant organizations complete life-saving surgeries. Between them is a vital component: a less-known medical team dedicated to ensuring that organ donation and transplantation are possible. Organ procurement organizations (OPOs) support grieving families during a painful time of loss, providing a rare and precious opportunity in donation. The OPO is simultaneously poised to ensure that organs successfully begin their journey to renewing life and restoring hope for recipients and their loved ones. Every OPO faces a myriad of challenges in meeting its responsibilities. A recognized leader in the field, Gift of Life Donor Program (GLDP) in Philadelphia, Pennsylvania has been committed to meeting these challenges for nearly fifty years. The successes of this OPO reflect the legacies of organ donors, recipients, and their cherished loved ones.

Perceptions held by healthcare professionals concerning organ donation after circulatory death in an Australian intensive care unit without a local thoracic transplant service: A descriptive exploratory study

BACKGROUND AND OBJECTIVE

Organ donation rates continue to be low in Australia compared with demand. Donation after circulatory death (DCD) has been an important strategy to increase donation rates, facilitated by advances in cardiopulmonary support in intensive care units (ICUs). However, DCD may harbour greater logistical challenges and unfavourable perceptions amongst some ICU healthcare professionals. The aim of this study was to evaluate and understand DCD perceptions at an Australian tertiary hospital.

METHODS

This descriptive exploratory study was conducted at an Australian tertiary hospital. Participants were recruited voluntarily for interview via email and word-of-mouth through the hospital's ICU network. The study used a mixed-methods approach; five close-ended questions were included in the form of Likert scales followed by a semistructured interview with open-ended questions designed to understand participants' perceptions of DCD. Interviews were recorded, transcribed, and thematically analysed.

RESULTS

Sixteen participants were interviewed including eight intensive care doctors, four donation specialist nursing coordinators (DSNCs), and four bedside nurses. Likert responses demonstrated clinicians' support for both DCD and donation after brain death (DBD). Thematic analysis of the transcripts yielded three overarching themes including 'Contextual and environmental influences on DCD decision-making', 'Personal difficulties faced by clinicians in DCD decision-making', and 'Family influences on DCD decision-making'. Significant geographical separation between donation and organ retrieval teams, incurring significant resource utilisation, impacted the donation team's decision-making around DCD, as did a perceived disruption of ICU care to facilitate donation especially for cases where successful DCD was identified to be unlikely.

CONCLUSIONS

Overall, DCD was as acceptable to participants as DBD. However, the geographical separation of this centre meant that logistical barriers potentially impacted the DCD process. Open lines of communication with transplant centres, local resourcing, and a culture of education, experience, and leadership may facilitate the DCD programs where distant retrieval is commonplace.

Volumetric Microsampling of Capillary Blood Spot vs Whole Blood Sampling for Therapeutic Drug Monitoring of Tacrolimus and Cyclosporin A: Accuracy and Patient Satisfaction

BACKGROUND

Immunosuppressant therapeutic drug monitoring (TDM) usually requires outpatient travel to hospitals or phlebotomy sites for venous blood collection; however Mitra® Microsampling Device (MSD) sampling could allow self-collection and shipping of samples to a laboratory for analysis. This study examined the feasibility of using volumetric microsampling by MSD for TDM of tacrolimus (TaC) and cyclosporin A (CsA) in transplant patients, along with their feedback on the process.

METHODS

MSD was used to collect TaC and CsA from venous (VB) or capillary (CB) blood. The MSDs were rehydrated, extracted, and analyzed using on-line solid phase extraction coupled to tandem mass spectrometry (SPE-MS/MS). We report an abbreviated method validation of the MSD including: accuracy, precision, linearity, carry-over, and stability using residual venous whole blood (VB) samples. Subsequent clinical validation compared serially collected MSD + CB against VB (200 µL) from transplant patients.

RESULTS

Accuracy comparing VB vs. MSD+VB showed high clinical concordance (TaC = 89% and CsA = 98%). Inter- and intra-precision was ≤11.5 %CV for TaC and CsA. Samples were stable for up to 7 days at room temperature with an average difference of <10%. Clinical validation with MSD+CB correlated well with VB for CsA (slope = 0.95, r2 = 0.88, n = 47) and TaC (slope = 0.98, r2 = 0.82, n = 49). CB vs. VB gave concordance of 94% for CsA and 79% for TaC. A satisfaction survey showed 82% of patients preferred having the capillary collection option.

CONCLUSION

Transplant patients favored having the ability to collect capillary samples at home for TaC/CsA monitoring. Our results demonstrate good concordance between MSD+CB and VB for TaC and CsA TDM, but additional studies are warranted.

Complications and safety of the transplanted organ after upper extremity surgery in patients receiving immunosuppressant therapy after solid organ transplantation

PURPOSE

The purpose of this study was to evaluate the complications and safety of transplanted organs after upper extremity surgery in patients taking immunosuppressants after solid organ transplantation (SOT).

METHODS

Seventy-two transplant recipients underwent 99 upper extremity surgeries while on immunosuppressants after SOT at our institution between January 2009 and December 2018. We retrospectively reviewed the clinical data of these patients, including their demographic information and data related to the SOT and upper extremity surgery.

RESULTS

Trigger/tendon release (n = 31, 31.3%) was the most frequently performed upper extremity surgery, followed by incision and drainage for an infection (n = 16, 16.2%). Post-operative complications occurred after ten upper extremity operative procedures (10.1%), among which uncontrolled infection after surgery for an infection (n = 4) was the most common. According to the Clavien-Dindo classification, the complications of three surgical procedures were grade I, three were grade II, and four were grade III, and all were treatable. The occurrence rate of the complications was not significantly different between emergent and elective surgery. All transplanted organ-specific indicators did not worsen significantly after emergent or elective upper extremity surgery.

CONCLUSIONS

Since the function of the transplanted organ was well-preserved after emergent or elective upper extremity surgery, common upper extremity procedures do not seem to be a worrisome practice for SOT patients. However, when treating hand and upper extremity infections in SOT patients, surgeons should explain the possible need for multiple operations  and the high complication rate.

Burnout and compassion fatigue among organ donation coordinators: a scoping review protocol

OBJECTIVE

The objective of this review is to develop a comprehensive description of burnout and compassion fatigue, including risk/protective factors, among organ and tissue donation coordinators worldwide.

INTRODUCTION

Research on turnover rates among organ and tissue donation coordinators has shown that job tenure generally lasts less than three years, a possible consequence of burnout and compassion fatigue. Increased turnover rates of organ and tissue donation coordinators have significant impact on the ability of ODOs to optimize organ donation. This current scoping review will help inform understanding of the nature of burnout and compassion fatigue in this population as well as the available strategies for managing it.

INCLUSION CRITERIA

Articles examining health care professionals working as organ and tissue donation coordinators, with the main concepts of interest being burnout and/or compassion fatigue, will be considered. Articles within the context of organ and tissue donation coordinators in acute care settings at any part of the organ donation process will also be considered for inclusion in this review. Quantitative and qualitative studies, text and opinion papers, unpublished material (eg, unpublished research data, reports, institutional protocols, government documents) provided by researchers in the organ donation field worldwide will also be examined for possible inclusion.

METHODS

The scoping review will be performed in accordance with JBI methodology. Published and unpublished papers from 1980 to the present will be searched. Databases will include MEDLINE (Ovid), CINAHL, Embase, LILACS, PsycINFO, and PTSDpubs, while appropriate gray literature will be searched. Two reviewers will screen the papers according to predefined inclusion and exclusion criteria, extract data for specific variables, and perform descriptive examination.

Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review

Background

Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes.

Objective

To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes.

Design

Scoping Review using a mixed methods approach for data extraction.

Setting

Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused.

Sample

Organ donation programs or processes.

Methods

We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results.

Results

A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%).

Limitations

Consistent with scoping review methodology, the methodological quality of included studies was not assessed.

Conclusions

This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically.

Trial Registration

Not applicable.

Immunosuppressant-induced cutaneous drug reactions in solid organ transplant recipients

Solid organ transplant recipients (SOTRs) are susceptible to various cutaneous side effects as a consequence of long-term immunosuppressive therapy. Skin cancers and infections are well-studied complications that can cause death and/or allograft rejection. Other cutaneous drug reactions, such as inflammatory manifestations, have a high prevalence but are rarely studied. We analyzed these manifestations' prevalence and their association with immunosuppressants in transplant recipients from a Brazilian tertiary center. Among 532 SOTRs followed at our dermatology clinic, 60 (11.3%) developed some cutaneous adverse reactions to the immunosuppressants, with a median age at transplantation of 50.5 years and a median life span posttransplantation of seven years. Acneiform eruption was the most common drug reaction found (21 patients, 30.4%), followed by diffuse non-scarring alopecia (16 patients, 23.1%), lymphedema (10 patients, 14.5%), gingival hyperplasia (7 patients, 10.1%), hypertrichosis (6 patients, 8.7%) and sebaceous hyperplasia (9 patients, 13.1%). Adequate immunosuppression is an essential prerequisite for successful organ transplantation. In the immediate post-transplant period, significant immunosuppression is needed, but after that, the complications of excessive immunosuppression outweigh the risk of organ rejection. SORTs may present with a broad spectrum of inflammatory and cosmetic findings due to immunosuppressants that can impair life quality.

Organ donation in the US and Europe: The supply vs demand imbalance

Organ donation and transplantation remain the best and most cost-effective clinical solution for end-stage organ failure. Several agencies across the US and Europe provide legislative, regulatory, and humanitarian services to generate smoother applications in all transplantation processes and donor-recipient relationships. US and European statistics present nine types of grafts, with kidneys being the most transplanted organ worldwide. However, organ shortage, religion, underrepresented minority groups, difficulties in obtaining consent, lack of understanding, and general ethical concerns present challenging barriers to organ donation, reflecting the complexity of graft procurement and allocation. Breaking down these barriers to reduce the organ-supply imbalance requires an appropriate multifaceted approach. Some of the key areas include increasing the potential donor pool and consent rates, apt organ allocation, and improving organ health. Additionally, suitable policies and standardized guidelines for both donors and recipients, alongside educational initiatives, are needed to ensure patient safety and global awareness. Looking forward, novel and effective research plans and initiatives are needed if we are to avoid a colossal supply-demand gap.

Endothelin receptor antagonist improves donor lung function in an ex vivo perfusion system

BACKGROUND

A lung transplant is the last resort treatment for many patients with advanced lung disease. The majority of donated lungs come from donors following brain death (BD). The endothelin axis is upregulated in the blood and lung of the donor after BD resulting in systemic inflammation, lung damage and poor lung graft outcomes in the recipient. Tezosentan (endothelin receptor blocker) improves the pulmonary haemodynamic profile; however, it induces adverse effects on other organs at high doses. Application of ex vivo lung perfusion (EVLP) allows the development of organ-specific hormone resuscitation, to maximise and optimise the donor pool. Therefore, we investigate whether the combination of EVLP and tezosentan administration could improve the quality of donor lungs in a clinically relevant 6-h ovine model of brain stem death (BSD).

METHODS

After 6 h of BSD, lungs obtained from 12 sheep were divided into two groups, control and tezosentan-treated group, and cannulated for EVLP. The lungs were monitored for 6 h and lung perfusate and tissue samples were processed and analysed. Blood gas variables were measured in perfusate samples as well as total proteins and pro-inflammatory biomarkers, IL-6 and IL-8. Lung tissues were collected at the end of EVLP experiments for histology analysis and wet-dry weight ratio (a measure of oedema).

RESULTS

Our results showed a significant improvement in gas exchange [elevated partial pressure of oxygen (P = 0.02) and reduced partial pressure of carbon dioxide (P = 0.03)] in tezosentan-treated lungs compared to controls. However, the lungs hematoxylin-eosin staining histology results showed minimum lung injuries and there was no difference between both control and tezosentan-treated lungs. Similarly, IL-6 and IL-8 levels in lung perfusate showed no difference between control and tezosentan-treated lungs throughout the EVLP. Histological and tissue analysis showed a non-significant reduction in wet/dry weight ratio in tezosentan-treated lung tissues (P = 0.09) when compared to control.

CONCLUSIONS

These data indicate that administration of tezosentan could improve pulmonary gas exchange during EVLP.

Mitochondria as Therapeutic Targets in Transplantation

Advances in surgical procedures, technology, and immune suppression have transformed organ transplantation. However, the metabolic changes that occur during organ retrieval, storage, and implantation have been relatively neglected since the developments many decades ago of cold storage organ preservation solutions. In this review we discuss how the metabolic changes that occur within the organ during transplantation, particularly those associated with mitochondria, may contribute to the outcome. We show how a better understanding of these processes can lead to changes in surgical practice and the development of new drug classes to improve the function and longevity of transplanted grafts, while increasing the pool of organs available for transplantation.

Crosslinking Strategies for 3D Bioprinting of Polymeric Hydrogels

Three-dimensional (3D) bioprinting has recently advanced as an important tool to produce viable constructs that can be used for regenerative purposes or as tissue models. To develop biomimetic and sustainable 3D constructs, several important processing aspects need to be considered, among which crosslinking is most important for achieving desirable biomechanical stability of printed structures, which is reflected in subsequent behavior and use of these constructs. In this work, crosslinking methods used in 3D bioprinting studies are reviewed, parameters that affect bioink chemistry are discussed, and the potential toward improving crosslinking outcomes and construct performance is highlighted. Furthermore, current challenges and future prospects are discussed. Due to the direct connection between crosslinking methods and properties of 3D bioprinted structures, this Review can provide a basis for developing necessary modifications to the design and manufacturing process of advanced tissue-like constructs in future.

Cellular Mechanisms of Rejection of Optic and Sciatic Nerve Transplants: An Observational Study

Background.

Organ transplantation is a standard therapeutic strategy for irreversible organ damage, but the utility of nerve transplantation remains generally unexplored, despite its potential benefit to a large patient population. Here, we aimed to establish a feasible preclinical mouse model for understanding the cellular mechanisms behind the rejection of peripheral and optic nerves.

Methods.

We performed syngenic and allogenic transplantation of optic and sciatic nerves in mice by inserting the nerve grafts inside the kidney capsule, and we assessed the allografts for signs of rejection through 14 d following transplantation. Then, we assessed the efficacy of CTLA4 Ig, Rapamycin, and anti-CD3 antibody in suppressing immune cell infiltration of the nerve allografts.

Results.

By 3 d posttransplantation, both sciatic and optic nerves transplanted from BALB/c mice into C57BL/6J recipients contained immune cell infiltrates, which included more CD11b⁺ macrophages than CD3⁺ T cells or B220⁺ B cells. Ex vivo immunogenicity assays demonstrated that sciatic nerves demonstrated higher alloreactivity in comparison with optic nerves. Interestingly, optic nerves contained higher populations of anti-inflammatory PD-L1⁺ cells than sciatic nerves. Treatment with anti-CD3 antibody reduced immune cell infiltrates in the optic nerve allograft, but exerted no significant effect in the sciatic nerve allograft.

Conclusions.

These findings establish the feasibility of a preclinical allogenic nerve transplantation model and provide the basis for future testing of directed, high-intensity immunosuppression in these mice.

Rapid, highly accurate and cost-effective open-source simultaneous complete HLA typing and phasing of class I and II alleles using nanopore sequencing

Accurate rapid genotyping of the genes within the HLA region presents many difficulties because of the complexity of this region. Here we present the results of our proof of concept nanopore-based long read polymerase chain reaction (PCR) solution for HLA genotyping. For 15 HLA anthropology-based samples and 13 NHS Blood and Transplant derived samples 40 ng of genomic DNA underwent long-range PCR for class I and II HLA alleles. Pooled PCR products were sequenced on the Oxford Nanopore MinIoON R9.4.1 flow cell. Sequenced reads had HLA genotype assigned with HLA-LA. Called genotypes were compared with reference derived from a combination of short-read next-generation sequencing, Sanger sequence and/or single-site polymorphism (SSP) typing. For concordance, accuracy was 100%, 98.4%, 97.5% and 95.1% for the first, second, third and fourth fields, respectively, to four field accuracy where it was available, otherwise three field in 28 samples for class I calls and 17 samples for class II calls. Phasing of maternal and paternal alleles, as well as phasing based identification of runs of homozygosity, was shown successfully. Time for assay run was 8 hours and the reconstruction of HLA typing data was 15 minutes. Assay cost was £55 ($80USD)/sample. We have developed a rapid and cost-effective long-range PCR and nanopore sequencing-based assay that can genotype the genes within HLA region to up to four field accuracy, identify runs of homozygosity in HLA, reconstruct maternal and paternal haplotypes and can be scaled from multi-sample runs to a single sample.

De Novo Malignancy After Heart, Kidney, and Liver Transplant: A Nationwide Study in Taiwan

OBJECTIVES

In the Asian population, patterns and risk factors for de novo malignancies after solid-organ transplant are not well understood.

MATERIALS AND METHODS

Insurance claims from Taiwan's National Health Institute Research Database from 1997 to 2011 revealed 687 deceased-donor heart transplant recipients, 5038 kidney transplant recipients (50% living related-donor, 50% deceased-donor transplants), and 2127 liver transplant recipients (mainly living related-donor transplants, 30% deceased-donor transplants). During the follow-up period, rates of malignancy incidence were calculated with standardization based on national age, sex, and year-specific incidence. We used multivariate regression analyses to determine risk factors of posttransplant de novo malignancies.

RESULTS

Compared with the general population, several de novo cancers were more common posttransplant (P < .05): lung cancer (2.6-fold), non-melanoma skin cancer (5.8-fold), and non-Hodgkin lymphoma (5.4-fold) in heart recipients; transitional cell carcinoma (31.4-fold), renal cell carcinoma (37.3-fold), and non-Hodgkin lymphoma (3.6-fold) in kidney recipients; and gastric cancer (3.0-fold) and lymphatic-hematopoietic malignancy (4.5-fold) in liver recipients. Independent risk factors for posttransplant malignancy in kidney transplant recipients were increased age, female, hepatitis B virus, and mycophenolate use (adjusted hazard ratio 1.5; 95% confidence interval, 1.2-1.8; P < .001). In liver transplant recipients, old age was an independent risk factor. Kidney transplant recipients without diabetes or hypertension had higher risk of transitional cell carcinoma (adjusted hazard ratio 3.0; 95% confidence interval, 2.1-4.4; P < .001) and renal cell carcinoma (adjusted hazard ratio 1.9; 95% confidence interval, 1.1-3.3; P < .05).

CONCLUSIONS

Regional endemic epidemiologic factors play significant roles in the development of de novo cancers, particularly in kidney transplant recipients due to causes of renal failure other than diabetes and hypertension. Each regional organ transplant program should tailor and establish its surveillance protocol based on epidemiologic data. However, the type and intensity of surveillance require further and long-term investigations in this patient cohort.