1
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Furian L, Bestard O, Budde K, Cozzi E, Diekmann F, Mamode N, Naesens M, Pengel LHM, Schwartz Sorensen S, Vistoli F, Thaunat O. European Consensus on the Management of Sensitized Kidney Transplant Recipients: A Delphi Study. Transpl Int 2024; 37:12475. [PMID: 38665475 PMCID: PMC11043529 DOI: 10.3389/ti.2024.12475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
An increasing number of sensitized patients awaiting transplantation face limited options, leading to fatalities during dialysis and higher costs. The absence of established evidence highlights the need for collaborative consensus. Donor-specific antibodies (DSA)-triggered antibody-mediated rejection (AMR) significantly contributes to kidney graft failure, especially in sensitized patients. The European Society for Organ Transplantation (ESOT) launched the ENGAGE initiative, categorizing sensitized candidates by AMR risk to improve patient care. A systematic review assessed induction and maintenance regimens as well as antibody removal strategies, with statements subjected to the Delphi methodology. A Likert-scale survey was distributed to 53 European experts (Nephrologists, Transplant surgeons and Immunologists) with experience in kidney transplant recipient care. A rate ≥75% with the same answer was considered consensus. Consensus was achieved in 95.3% of statements. While most recommendations aligned, two statements related to complement inhibitors for AMR prophylaxis lacked consensus. The ENGAGE consensus presents contemporary recommendations for desensitization and immunomodulation strategies, grounded in predefined risk categories. The adoption of tailored, patient-specific measures is anticipated to streamline the care of sensitized recipients undergoing renal allografts. While this approach holds the promise of enhancing transplant accessibility and fostering long-term success in transplantation outcomes, its efficacy will need to be assessed through dedicated studies.
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Affiliation(s)
- Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Oriol Bestard
- Kidney Transplant Unit, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité University Medicine Berlin, Berlin, Germany
| | - Emanuele Cozzi
- Transplant Immunology Unit, Department of Cardiac, Thoracic and Vascular Sciences, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Fritz Diekmann
- Experimental Nephrology and Transplant Laboratory, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Liset H. M. Pengel
- Erasmus MC Transplant Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Soren Schwartz Sorensen
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Fabio Vistoli
- University of Pisa, Pisa, Italy
- Department of Biothecnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Olivier Thaunat
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hospices Civils de Lyon, Lyon, France
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2
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Ambagtsheer F, Bunnik E, Pengel LHM, Reinders MEJ, Elias JJ, Lacetera N, Macis M. Public Opinions on Removing Disincentives and Introducing Incentives for Organ Donation: Proposing a European Research Agenda. Transpl Int 2024; 37:12483. [PMID: 38644936 PMCID: PMC11027084 DOI: 10.3389/ti.2024.12483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/04/2024] [Indexed: 04/23/2024]
Abstract
The shortage of organs for transplantations is increasing in Europe as well as globally. Many initiatives to the organ shortage, such as opt-out systems for deceased donation and expanding living donation, have been insufficient to meet the rising demand for organs. In recurrent discussions on how to reduce organ shortage, financial incentives and removal of disincentives, have been proposed to stimulate living organ donation and increase the pool of available donor organs. It is important to understand not only the ethical acceptability of (dis)incentives for organ donation, but also its societal acceptance. In this review, we propose a research agenda to help guide future empirical studies on public preferences in Europe towards the removal of disincentives and introduction of incentives for organ donation. We first present a systematic literature review on public opinions concerning (financial) (dis)incentives for organ donation in European countries. Next, we describe the results of a randomized survey experiment conducted in the United States. This experiment is crucial because it suggests that societal support for incentivizing organ donation depends on the specific features and institutional design of the proposed incentive scheme. We conclude by proposing this experiment's framework as a blueprint for European research on this topic.
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Affiliation(s)
- Frederike Ambagtsheer
- Department of Internal Medicine, Nephrology and Kidney Transplantation, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Eline Bunnik
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Liset H. M. Pengel
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marlies EJ Reinders
- Department of Internal Medicine, Nephrology and Kidney Transplantation, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Julio J. Elias
- Department of Economics, School of Business, University of CEMA, Buenos Aires, Argentina
| | | | - Mario Macis
- Carey Business School, Johns Hopkins University, Baltimore, MD, United States
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3
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Rana Magar R, Knight SR, Maggiore U, Lafranca JA, Dor FJMF, Pengel LHM. What are the benefits of preemptive versus non-preemptive kidney transplantation? A systematic review and meta-analysis. Transplant Rev (Orlando) 2023; 37:100798. [PMID: 37801855 DOI: 10.1016/j.trre.2023.100798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
Opting for a preemptive kidney transplant (PKT) can help avoid costs and morbidity associated with dialysis. However, while multiple studies have shown clinical benefits of PKT, other studies have not demonstrated this, leading to controversy in the literature regarding the exact benefits of PKT. Therefore, this study aimed to determine the clinical outcomes of PKT versus non-preemptive kidney transplantation (nPKT) in adult patients. Multiple databases were searched up to May 4, 2022. Independent reviewers selected studies for inclusion and extracted relevant data. Risk of bias was assessed using the Downs and Black checklist. Eighty-seven studies including 859,715 adult kidney transplant patients were included the review. The risk of patient death (relative risk [95% confidence interval] 0.74 [0.60-0.91]) was significantly lower in PKT versus nPKT patients for living donor (LD) transplants, whereas the risk of overall graft loss was significantly lower in PKT compared to nPKT patients for both LD (0.72 [0.62-0.83]) as well as deceased donor (DD) transplants (0.80 [0.69-0.92]). The evidence suggests that LD PKT patients have a lower risk of patient death and graft loss compared to nPKT patients, and DD PKT patients have a lower risk of graft loss than nPKT patients.
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Affiliation(s)
- Reshma Rana Magar
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon R Knight
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Nephrology Operating Unit, University Hospital, Parma, Italy
| | - Jeffrey A Lafranca
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Frank J M F Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Liset H M Pengel
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom; Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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4
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Salih S, O'Callaghan J, Salih M, Walker J, Magar RR, Knight S, Pengel LHM. Trends in systematic reviews of kidney transplantation: A 10-year analysis of the evidence base. Transplant Rev (Orlando) 2023; 37:100759. [PMID: 37031533 DOI: 10.1016/j.trre.2023.100759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Systematic reviews (SRs) are the highest form of evidence for all types of clinical questions in evidence-based practice. For the first time in 2018, the number of SRs in transplantation outstripped those from randomised controlled trials (RCTs). This raises concerns of duplication or increased use of non-RCT evidence. We aimed to analyse the trends, strength and quality of SRs in kidney transplantation over a 10-year period. METHODS SRs in kidney transplantation were identified from the Transplant Library, without language restriction. All full-text citations were exported to a custom Research Electronic Data Capture (REDCap) database prior to evaluation. Quality of evidence in all included SRs was assessed using AMSTAR-2. RESULTS We included 454 SRs, of which, only three were scored as 'high quality'. We found that 96.70% of SRs were identified as 'critically low quality', which increased in number over time. We also found that inclusion of non-RCT data increased in the most recent 5 years. Only 14.12% of SRs had made a clear recommendation for practice. CONCLUSIONS This review highlights several concerning statistics that need to be addressed. In the last 10 years, only three SRs in kidney transplantation were 'high-quality'. The weaknesses identified in critical domains, alongside the increased use of non-RCT data and lack of conclusive recommendations undermines the confidence in the results of the SRs and purpose of publication. As these SRs are instrumental to clinical decision-making and patient care in kidney transplantation, we advocate for improved reporting quality among SRs in kidney transplantation.
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Affiliation(s)
- Sarah Salih
- Keele University School of Medicine, Stoke-on-Trent, United Kingdom; Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Science, Oxford, United Kingdom.
| | - John O'Callaghan
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Science, Oxford, United Kingdom; University Hospitals Coventry & Warwickshire, Coventry, United Kingdom
| | - Marwah Salih
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James Walker
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Reshma Rana Magar
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Science, Oxford, United Kingdom
| | - Simon Knight
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Science, Oxford, United Kingdom
| | - Liset H M Pengel
- Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Science, Oxford, United Kingdom; Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
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5
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Kim I, Maggiore U, Knight SR, Rana Magar R, Pengel LHM, Dor FJMF. Pre-emptive living donor kidney transplantation: A public health justification to change the default. Front Public Health 2023; 11:1124453. [PMID: 37006536 PMCID: PMC10063978 DOI: 10.3389/fpubh.2023.1124453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/28/2023] [Indexed: 03/19/2023] Open
Affiliation(s)
- Isaac Kim
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, Unità Operativa Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Simon R. Knight
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Reshma Rana Magar
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Liset H. M. Pengel
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- *Correspondence: Frank J. M. F. Dor
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Rana Magar R, Knight S, Stojanovic J, Marks SD, Lafranca JA, Turner S, Dor FJMF, Pengel LHM. Is Preemptive Kidney Transplantation Associated With Improved Outcomes when Compared to Non-preemptive Kidney Transplantation in Children? A Systematic Review and Meta-Analysis. Transpl Int 2022; 35:10315. [PMID: 35368639 PMCID: PMC8967954 DOI: 10.3389/ti.2022.10315] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022]
Abstract
Main Problem: Preemptive kidney transplantation (PKT) is performed prior to dialysis initiation to avoid dialysis-related morbidity and mortality in children and adolescents. We undertook a systematic review to compare clinical outcomes in PKT versus kidney transplantation after dialysis initiation in paediatric patients. Methods: The bibliographic search identified studies that compared paediatric recipients of a first or subsequent, living or deceased donor PKT versus non-preemptive kidney transplant. Methodological quality was assessed for all studies. Data were pooled using the random-effects model. Results: Twenty-two studies (n = 22,622) were included. PKT reduced the risk of overall graft loss (relative risk (RR) .57, 95% CI: .49–.66) and acute rejection (RR: .81, 95% CI: .75–.88) compared to transplantation after dialysis. Although no significant difference was observed in overall patient mortality, the risk of patient death was found to be significantly lower in PKT patients with living donor transplants (RR: .53, 95% CI: .34–.83). No significant difference was observed in the incidence of delayed graft function. Conclusion: Evidence from observational studies suggests that PKT is associated with a reduction in the risk of acute rejection and graft loss. Efforts should be made to promote and improve rates of PKT in this group of patients (PROSPERO). Systematic Review Registration:https://clinicaltrials.gov/, CRD42014010565
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Affiliation(s)
- Reshma Rana Magar
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Simon Knight
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | | | - Stephen D. Marks
- Great Ormond Street Hospital for Children, London, United Kingdom
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jeffrey A. Lafranca
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | | | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Liset H. M. Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- *Correspondence: Liset H. M. Pengel, , orcid.org/0000-0001-9620-8639
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7
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De Beule J, Vandendriessche K, Pengel LHM, Bellini MI, Dark JH, Hessheimer AJ, Kimenai HJAN, Knight SR, Neyrinck AP, Paredes D, Watson CJE, Rega F, Jochmans I. A systematic review and meta-analyses of regional perfusion in donation after circulatory death solid organ transplantation. Transpl Int 2021; 34:2046-2060. [PMID: 34570380 DOI: 10.1111/tri.14121] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 12/29/2022]
Abstract
In donation after circulatory death (DCD), (thoraco)abdominal regional perfusion (RP) restores circulation to a region of the body following death declaration. We systematically reviewed outcomes of solid organ transplantation after RP by searching PubMed, Embase, and Cochrane libraries. Eighty-eight articles reporting on outcomes of liver, kidney, pancreas, heart, and lung transplants or donor/organ utilization were identified. Meta-analyses were conducted when possible. Methodological quality was assessed using National Institutes of Health (NIH)-scoring tools. Case reports (13/88), case series (44/88), retrospective cohort studies (35/88), retrospective matched cohort studies (5/88), and case-control studies (2/88) were identified, with overall fair quality. As blood viscosity and rheology change below 20 °C, studies were grouped as hypothermic (HRP, ≤20 °C) or normothermic (NRP, >20 °C) regional perfusion. Data demonstrate that RP is a safe alternative to in situ cold preservation (ISP) in uncontrolled and controlled DCDs. The scarce HRP data are from before 2005. NRP appears to reduce post-transplant complications, especially biliary complications in controlled DCD livers, compared with ISP. Comparisons for kidney and pancreas with ISP are needed but there is no evidence that NRP is detrimental. Additional data on NRP in thoracic organs are needed. Whether RP increases donor or organ utilization needs further research.
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Affiliation(s)
- Julie De Beule
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | | | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Arne P Neyrinck
- Department of Cardiovascular Sciences, Anesthesiology and Algology, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,The NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, Cardiac Surgery, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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8
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Jochmans I, Hessheimer AJ, Neyrinck AP, Paredes D, Bellini MI, Dark JH, Kimenai HJAN, Pengel LHM, Watson CJE. Consensus statement on normothermic regional perfusion in donation after circulatory death: report from the European Society for Organ Transplantation's Transplant Learning Journey. Transpl Int 2021; 34:2019-2030. [PMID: 34145644 DOI: 10.1111/tri.13951] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
Normothermic regional perfusion (NRP) in donation after circulatory death (DCD) is a safe alternative to in situ cooling and rapid procurement. An increasing number of countries and centres are performing NRP, a technically and logistically challenging procedure. This consensus document provides evidence-based recommendations on the use of NRP in uncontrolled and controlled DCDs. It also offers minimal ethical, logistical and technical requirements that form the foundation of a safe and effective NRP programme. The present article is based on evidence and opinions formulated by a panel of European experts of Workstream 04 of the Transplantation Learning Journey project, which is part of the European Society for Organ Transplantation.
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Affiliation(s)
- Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Amelia J Hessheimer
- Department of General & Digestive Surgery, Institut Clínic de Malalties Digestives i Metabòliques (ICMDM), Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Arne P Neyrinck
- Anesthesiology and Algology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - David Paredes
- Donation and Transplant Coordination Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Maria Irene Bellini
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - John H Dark
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Hendrikus J A N Kimenai
- Division of Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christopher J E Watson
- University of Cambridge, Department of Surgery, Addenbrooke's Hospital, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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9
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Masnou N, Bellini MI, Pengel LHM, Feltrin G. It is not only extending donor criteria: it is extending the donor pool. A cross-sectional survey from the European Society of Organ Transplantation. Transpl Int 2021; 34:754-755. [PMID: 33529375 DOI: 10.1111/tri.13838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Nuria Masnou
- University Hospital Dr. Josep Trueta, Girona, Spain
| | - Maria Irene Bellini
- Azienda Ospedaliera San Camillo Forlanini, Rome, Italy.,Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - Liset H M Pengel
- Nuffield Department of Surgical Sciences, Centre for Evidence in Transplantation, University of Oxford, Oxford, UK
| | - Giuseppe Feltrin
- Regional Centre for Transplant Coordination of the Veneto Region, Padua, Italy
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10
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Jochmans I, Akhtar MZ, Nasralla D, Kocabayoglu P, Boffa C, Kaisar M, Brat A, O'Callaghan J, Pengel LHM, Knight S, Ploeg RJ. Past, Present, and Future of Dynamic Kidney and Liver Preservation and Resuscitation. Am J Transplant 2016; 16:2545-55. [PMID: 26946212 DOI: 10.1111/ajt.13778] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 02/03/2016] [Accepted: 02/23/2016] [Indexed: 01/25/2023]
Abstract
The increased demand for organs has led to the increased usage of "higher risk" kidney and liver grafts. These grafts from donation after circulatory death or expanded criteria donors are more susceptible to preservation injury and have a higher risk of unfavorable outcomes. Dynamic, instead of static, preservation could allow for organ optimization, offering a platform for viability assessment, active organ repair and resuscitation. Ex situ machine perfusion and in situ regional perfusion in the donor are emerging as potential tools to preserve and resuscitate vulnerable grafts. Preclinical findings have ignited clinical organ preservation research that investigates dynamic preservation, its various modes (continuous, preimplantation) and temperatures (hypo-, sub, or normothermic). This review outlines the current status of dynamic preservation of kidney and liver grafts and describes ongoing research and emerging clinical trials.
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Affiliation(s)
- I Jochmans
- Abdominal Transplant Surgery, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - M Z Akhtar
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - D Nasralla
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - P Kocabayoglu
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - C Boffa
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - M Kaisar
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - A Brat
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J O'Callaghan
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - L H M Pengel
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - S Knight
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - R J Ploeg
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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11
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Knight SR, Morris PJ, Schneeberger S, Pengel LHM. Trial design and endpoints in clinical transplant research. Transpl Int 2016; 29:870-9. [PMID: 26749215 DOI: 10.1111/tri.12743] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/01/2015] [Accepted: 12/30/2015] [Indexed: 12/11/2022]
Abstract
The number of clinical trials in solid organ transplantation is progressively increasing year on year, but the quality of design and reporting still varies considerably. The constraints on organ availability, improving short-term outcomes, ethics and timescales involved in organ transplantation present unique challenges for trials in this field. An understanding of the methodology and potential pitfalls in clinical research is essential both to interpret trial results and to design robust studies. This review summarizes the scope and quality of reporting in existing transplant clinical trials and details aspects of clinical trial methodology with particular relevance to transplantation. We highlight initiatives designed to improve the quality of this process to ensure that the results of clinical trials are robust, well reported and of use in everyday clinical practice.
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Affiliation(s)
- Simon R Knight
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Peter J Morris
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Stefan Schneeberger
- Department of Visceral Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Talawila N, Pengel LHM. Does belatacept improve outcomes for kidney transplant recipients? A systematic review. Transpl Int 2015; 28:1251-64. [PMID: 25965549 DOI: 10.1111/tri.12605] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/19/2015] [Accepted: 05/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND Belatacept was intended to provide better outcomes for kidney transplant (KT) recipients by allowing minimization/withdrawal of calcineurin inhibitors (CNI) and steroids. METHODS We searched for randomized controlled trials (RCTs) in adult KT comparing belatacept with CNIs. Methodological quality was assessed. Meta-analyses were performed to calculate odds ratios (OR) and mean differences (MD). RESULTS Six RCTs were included. Pooled analyses found no differences for acute rejection at any time point. Renal function [Calculated glomerular filtration rate (cGFR)] was better with belatacept at 12 and 24 months (MD = 11.7 and 13.7 ml/min/1.73 m(2) ). New onset diabetes after transplantation was lower with belatacept at 12 months (OR = 0.43). Systolic and diastolic blood pressures were lower at 12 months (MD -7.2 and -3.1 mmHg) as were triglycerides at 12 and 24 months (MD = -32.9 and -41.7 mg/dl). Total and low-density lipoprotein cholesterol were lower with belatacept at 24 months (MD = -19.8 and -10.6 mg/dl). There were no differences for other outcomes. CONCLUSION Limited available data suggest a potential benefit for belatacept by reducing the risk of CNI toxicity, especially renal function, without evidence of increased acute rejection. There were no safety issues apart from a possible risk of post-transplant lymphoproliferative disorder in Epstein-barr virus-seronegative recipients. Further studies are required to confirm this benefit.
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Affiliation(s)
- Nishanthi Talawila
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Liset H M Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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13
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Liu LQ, Morris PJ, Pengel LHM. Compliance to the CONSORT statement of randomized controlled trials in solid organ transplantation: a 3-year overview. Transpl Int 2013; 26:300-6. [PMID: 23279054 DOI: 10.1111/tri.12034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 10/16/2012] [Accepted: 11/15/2012] [Indexed: 11/30/2022]
Abstract
The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the reporting quality of randomized controlled trials (RCTs). Our primary aim was to assess to what extent reports of RCTs in solid organ transplantation adhere to the 2010 CONSORT statement. Secondly, we investigated the relationship between CONSORT adherence, methodological quality and some other factors. We included 290 RCTs that were published between 2007 and 2009. We examined to what extent trial reports complied with 30 items of the CONSORT statement. Methodological quality was evaluated using the Jadad scale plus allocation concealment and whether data analysis was by randomized group (intention to treat). On average, trial reports addressed 47% of the CONSORT items. Forty-three per cent of RCTs was considered to be of good quality according to Jadad scale, and the items allocation concealment and data analysis were satisfied in approximately one-third of trials. Good quality RCTs reported on more CONSORT items than poor quality trials. The methodological quality and adherence to the CONSORT statement of RCTs published in journals that endorse the CONSORT statement was superior to those in journals without CONSORT endorsement. Overall compliance with the CONSORT statement and the methodological quality of RCTs in organ transplantation remains unsatisfactory.
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Affiliation(s)
- Liang Q Liu
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK
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Pengel LHM, Liu LQ, Morris PJ. Do wound complications or lymphoceles occur more often in solid organ transplant recipients on mTOR inhibitors? A systematic review of randomized controlled trials. Transpl Int 2011; 24:1216-30. [PMID: 21955006 DOI: 10.1111/j.1432-2277.2011.01357.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
mTOR inhibitors have been associated with wound complications and lymphoceles. We systematically reviewed randomized controlled trials (RCTs) to compare these outcomes for solid organ transplant recipients. Relevant medical databases were searched to identify RCTs in solid organ transplantation comparing mTOR inhibitors with an alternative therapy reporting on wound complications and/or lymphoceles. Methodological quality of RCTs was assessed. Pooled analyses were performed to calculate odds ratios (OR) and 95% confidence intervals (CI). Thirty-seven RCTs in kidney, heart, simultaneous pancreas-kidney and liver transplantation were included. Pooled analyses showed a higher incidence of wound complications (OR 1.77, CI 1.31-2.37) and lymphoceles (OR 2.07, CI 1.62-2.65) for kidney transplant recipients on mTOR inhibitors together with calcineurin inhibitors (CNIs). There was also a higher incidence of wound complications (OR 3.00, CI 1.61-5.59) and lymphoceles (OR 2.13, CI 1.57-2.90) for kidney transplant recipients on mTOR inhibitors together with antimetabolites. Heart transplant patients receiving mTOR inhibitors together with CNIs also reported more wound complications (OR 1.82, CI 1.15-2.87). We found a higher incidence of wound complications and lymphoceles after kidney transplantation and a higher incidence of wound complications after heart transplantation for immunosuppressive regimens that included mTOR inhibitors from the time of transplantation.
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Affiliation(s)
- Liset H M Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and the London School of Hygiene and Tropical Medicine, University of London, London, UK.
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Abstract
AIMS Due to their contribution to modulation of intra-abdominal pressure (IAP) and stiffness of the sacroiliac joints, the pelvic floor muscles (PFM) have been argued to provide a contribution to control of the lumbar spine and pelvis. Furthermore, as IAP is modulated during respiration this is likely to be accompanied by changes in PFM activity. METHODS In order to evaluate the postural and respiratory function of the PFM, recordings of anal and vaginal electromyographic activity (EMG) were made with surface electrodes during single and repetitive arm movements that challenge the stability of the spine. EMG recordings were also made during respiratory tasks: quiet breathing and breathing with increased dead-space to induce hypercapnoea. RESULTS EMG activity of the PFM was increased in advance of deltoid muscle activity as a component of the pre-programmed anticipatory postural activity. This activity was independent of the direction of arm movement. During repetitive movements, PFM EMG was tonic with phasic bursts at the frequency of arm movement. This activity was related to the peak acceleration of the arm, and therefore the amplitude of the reactive forces imposed on the spine. Respiratory activity was observed for the anal and vaginal EMG and was primarily expiratory. When subjects moved the arm repetitively while breathing, PFM EMG was primarily modulated in association with arm movement with little respiratory modulation. CONCLUSIONS This study provides evidence that the PFM contribute to both postural and respiratory functions.
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Affiliation(s)
- P W Hodges
- Division of Physiotherapy, the University of Queensland, Brisbane, Queensland, Australia.
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Abstract
BACKGROUND Advice and exercise are widely recommended for subacute low back pain, but the effectiveness of these interventions is unclear. OBJECTIVE To investigate the effectiveness of physiotherapist-prescribed exercise, advice, or both for subacute low back pain. DESIGN Factorial randomized, placebo-controlled trial. SETTING 7 university hospitals and primary care clinics in Australia and New Zealand. PATIENTS 259 persons with subacute low back pain (>6 weeks and <3 months in duration). INTERVENTION Participants received 12 physiotherapist-directed exercise or sham exercise sessions and 3 physiotherapist-directed advice or sham advice sessions over 6 weeks. MEASUREMENTS Primary outcomes were average pain over the past week (scale, 0 to 10), function (Patient-Specific Functional Scale), and global perceived effect (11-point scale) at 6 weeks and 12 months. Secondary outcomes were disability (Roland-Morris Disability Questionnaire), number of health care contacts, and depression (Depression Anxiety Stress Scales-21). RESULTS Exercise and advice were each slightly more effective than placebo at 6 weeks but not at 12 months. The effect of advice on the pain scale was -0.7 point (95% CI, -1.2 to -0.2 point; P = 0.011) at 6 weeks and -0.4 point (CI, -1.0 to 0.3 point; P = 0.27) at 12 months, whereras the effect of exercise was -0.8 point (CI, -1.3 to -0.3 point; P = 0.004) at 6 weeks and -0.5 point (CI, -1.1 to 0.2 point; P = 0.14) at 12 months. The effect of advice on the function scale was 0.7 point (CI, 0.1 to 1.3 points; P = 0.014) at 6 weeks and 0.6 point (CI, 0.1 to 1.2 points; P = 0.023) at 12 months, and the effect of exercise was 0.4 point (CI, -0.2 to 1.0 point; P = 0.174) at 6 weeks and 0.5 point (CI, -0.1 to 1.0 point; P = 0.094) at 12 months. The effect of advice on the global perceived effect scale was 0.8 point (CI, 0.3 to 1.2 points; P < 0.001) at 6 weeks and 0.3 point (CI, -0.2 to 0.9 point; P = 0.24) at 12 months, and the effect of exercise was 0.5 point (CI, 0.1 to 1.0 point; P = 0.017) at 6 weeks and 0.4 point (CI, -0.1 to 1.0 point; P = 0.134) at 12 months. When administered together, exercise and advice had larger effects on all outcomes at 6 weeks (effect on pain, -1.5 [CI -2.2 to -0.7 point; P = 0.001], with similar results for other primary outcomes); however, by 12 months, there was a statistically significant effect only for function (effect, 1.1 points [CI, 0.3 to 1.8 points]; P = 0.005). LIMITATION Physiotherapists were not blinded. CONCLUSIONS In participants with subacute low back pain, physiotherapist-directed exercise and advice were each slightly more effective than placebo at 6 weeks. The effect was greatest when the interventions were combined. At 12 months, the only effect that persisted was a small effect on participant-reported function. AUSTRALIAN CLINICAL TRIALS REGISTRY REGISTRATION NUMBER: 12605000039684.
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Abstract
STUDY DESIGN Cohort study. OBJECTIVE To conduct a head-to-head comparison of the responsiveness of pain, disability, and physical impairment measures in patients with low back pain. SUMMARY OF BACKGROUND DATA Pain, disability, and physical impairment measures are routinely measured in clinical practice and clinical research. However, to date, a head-to-head comparison has not been performed. METHODS A numerical pain scale (0-10), the 24-item and 2 modified 18-item versions of the Roland Morris questionnaire, the patient specific functional scale, and physical impairment measures were completed by 155 patients with low back pain at baseline and then again after 6 weeks together with an 11-point global perceived effect scale. Responsiveness was evaluated by using effect sizes and t tests, correlating the change scores for each outcome with the global perceived effect score and by calculating the Guyatt responsiveness index. RESULTS The most responsive outcome proved to be the patient specific functional scale (effect size = 1.6), followed by the numerical pain scale (effect size = 1.3) and 24-item Roland Morris questionnaire (effect size = 0.8). The responsiveness of the two 18-item Roland Morris versions was equal to the 24-item version. However, the physical impairment measures were not very responsive (effect size 0.1-0.6). The ranking of the responsiveness indices was consistent across all statistical analyses. CONCLUSIONS Physical impairments are routinely measured in clinical practice and clinical research, but the lower responsiveness indicates that this approach is not optimal. Our findings suggest that more emphasis should be placed on change in pain and disability scores than on change in physical impairments.
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Affiliation(s)
- Liset H M Pengel
- School of Physiotherapy, University of Sydney, Lidcombe, NSW, Australia.
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Abstract
OBJECTIVES To describe the course of acute low back pain and sciatica and to identify clinically important prognostic factors for these conditions. DESIGN Systematic review. DATA SOURCES Searches of Medline, Embase, Cinahl, and Science Citation Index and iterative searches of bibliographies. MAIN OUTCOME MEASURES Pain, disability, and return to work. RESULTS 15 studies of variable methodological quality were included. Rapid improvements in pain (mean reduction 58% of initial scores), disability (58%), and return to work (82% of those initially off work) occurred in one month. Further improvement was apparent until about three months. Thereafter levels for pain, disability, and return to work remained almost constant. 73% of patients had at least one recurrence within 12 months. CONCLUSIONS People with acute low back pain and associated disability usually improve rapidly within weeks. None the less, pain and disability are typically ongoing, and recurrences are common.
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Affiliation(s)
- Liset H M Pengel
- School of Physiotherapy, University of Sydney, PO Box 170, Lidcombe NSW 1825, Australia
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Abstract
To investigate the ability of ultrasonography to estimate muscle activity, we measured architectural parameters (pennation angles, fascicle lengths, and muscle thickness) of several human muscles (tibialis anterior, biceps brachii, brachialis, transversus abdominis, obliquus internus abdominis, and obliquus externus abdominis) during isometric contractions of from 0 to 100% maximal voluntary contraction (MVC). Concurrently, electromyographic (EMG) activity was measured with surface (tibialis anterior only) or fine-wire electrodes. Most architectural parameters changed markedly with contractions up to 30% MVC but changed little at higher levels of contraction. Thus, ultrasound imaging can be used to detect low levels of muscle activity but cannot discriminate between moderate and strong contractions. Ultrasound measures could reliably detect changes in EMG of as little as 4% MVC (biceps muscle thickness), 5% MVC (brachialis muscle thickness), or 9% MVC (tibialis anterior pennation angle). They were generally less sensitive to changes in abdominal muscle activity, but it was possible to reliably detect contractions of 12% MVC in transversus abdominis (muscle length) and 22% MVC in obliquus internus (muscle thickness). Obliquus externus abdominis thickness did not change consistently with muscle contraction, so ultrasound measures of thickness cannot be used to detect activity of this muscle. Ultrasound imaging can thus provide a noninvasive method of detecting isometric muscle contractions of certain individual muscles.
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Affiliation(s)
- P W Hodges
- Prince of Wales Medical Research Institute and the University of New South Wales, Sydney, New South Wales 2031, Australia.
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