1
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Lee YK, Shukman M, Biniwale R, Ardehali A, Kamath M, Nsair A, Schaenman JM, Goldwater D. Benefits of both physical assessment and electronic health record review to assess frailty prior to heart transplant. Clin Transplant 2022; 36:e14559. [PMID: 34923657 PMCID: PMC9366897 DOI: 10.1111/ctr.14559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 04/20/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Frailty status affects outcomes after heart transplantation, but the optimal way to assess frailty prior to transplant remains unknown. METHODS This single-center, observational study assessed 44 heart transplant candidates for frailty using three methods. The Short Physical Performance Battery (SPPB) and Fried Frailty Phenotype (FFP) were used as two physical assessments of frailty. The Frailty Risk Score (FRS) was used as a chart-review based assessment measuring 20 different biopsychosocial and functional components, including biomarkers, depression, cognitive impairment, and sleep. RESULTS We determined the correlation between FRS, SPPB, and FFP and how each correlated with clinical outcomes. Of 44 participants, mean age was 60 years. FRS correlated with SPPB and FFP (P = .043, P < .001, respectively). Higher frailty as measured by SPPB and FRS was significantly associated with lack of achieving waitlist status (P = .022; P = .002) and not being transplanted (P = .026; P = .008). Higher frailty by SPPB and FFP was also associated with mortality (P = .010; P = .025). CONCLUSION SPPB and chart-review FRS showed potential for predicting waitlist and transplant status of heart transplant candidates, while SPPB and FFP were associated with mortality. Additional studies may serve to validate these observations.
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Affiliation(s)
- Yoon Kyung Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marina Shukman
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Reshma Biniwale
- Department of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Abbas Ardehali
- Department of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Megan Kamath
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Ali Nsair
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joanna M. Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Deena Goldwater
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA,Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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2
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Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant 2021; 21:2824-2832. [PMID: 33346917 DOI: 10.1111/ajt.16463] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [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: 07/17/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Current short-term kidney post-transplant survival rates are excellent, but longer-term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1-year and 5-year graft survival and half-lives for kidney transplant recipients in the US. All adult (≥18 years) solitary kidney transplants (n = 331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4 years (SD +/-13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000-2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014-2017 (1995-1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2 years in era 1995-1999 to an estimated 11.7 years in the most recent era. Living kidney donor transplant median survival increased from 12.1 years in 1995-1999 to an estimated 19.2 years for transplants in 2014-2017. In conclusion, these data show continuous improvement in long-term outcomes with more notable improvement among higher-risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation.
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Affiliation(s)
- Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Joshua J Augustine
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel C Brennan
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Jesse D Schold
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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3
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Pruett TL. COVID-19 and transplantation: Fatigue and responsibility. Am J Transplant 2021; 21:2002-2003. [PMID: 33350576 PMCID: PMC9800485 DOI: 10.1111/ajt.16467] [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: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
The US transplantation and donation community needs COVID-19–specific information to guide safe and effective transplant care during the pandemic. Goff et al.’s article is on page 2100.
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Affiliation(s)
- Timothy L. Pruett
- Surgery and Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA,Correspondence Timothy L. Pruett
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4
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Schaenman JM, Diamond JM, Greenland JR, Gries C, Kennedy CC, Parulekar AD, Rozenberg D, Singer JP, Singer LG, Snyder LD, Bhorade S. Frailty and aging-associated syndromes in lung transplant candidates and recipients. Am J Transplant 2021; 21:2018-2024. [PMID: 33296550 PMCID: PMC8178173 DOI: 10.1111/ajt.16439] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [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: 09/24/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/25/2023]
Abstract
Many lung transplant candidates and recipients are older and frailer compared to previous eras. Older patients are at increased risk for pre- and posttransplant mortality, but this risk is not explained by numerical age alone. This manuscript represents the product of the American Society of Transplantation (AST) conference on frailty. Experts in the field reviewed the latest published research on assessment of elderly and frail lung transplant candidates. Physical frailty, often defined as slowness, weakness, low physical activity, shrinking, and exhaustion, and frailty evaluation is an important tool for evaluation of age-associated dysfunction. Another approach is assessment by cumulative deficits, and both types of frailty are common in lung transplant candidates. Frailty is associated with death or delisting before transplant, and may be associated with posttransplant mortality. Sarcopenia, cognitive dysfunction, depression, and nutrition are other important components for patient evaluation. Aging-associated inflammation, telomere dysfunction, and adaptive immune system senescence may also contribute to frailty. Developing tools for frailty assessment and interventions holds promise for improving patient outcomes before and after lung transplantation.
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Affiliation(s)
- Joanna M. Schaenman
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Joshua M. Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John R. Greenland
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA and University of California, San Francisco CA
| | - Cynthia Gries
- Department of Medicine, AdventHealth Transplant Institute, Orlando FL
| | | | | | - Dmitry Rozenberg
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan P. Singer
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA and University of California, San Francisco CA
| | - Lianne G. Singer
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sangeeta Bhorade
- Medical Affairs-Pulmonary, Veracyte Inc, South San Francisco, CA
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5
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Wiebe C, Rush DN, Gibson IW, Pochinco D, Birk PE, Goldberg A, Blydt‐Hansen T, Karpinski M, Shaw J, Ho J, Nickerson PW. Evidence for the alloimmune basis and prognostic significance of Borderline T cell-mediated rejection. Am J Transplant 2020; 20:2499-2508. [PMID: 32185878 PMCID: PMC7496654 DOI: 10.1111/ajt.15860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Prognostic biomarkers of T cell-mediated rejection (TCMR) have not been adequately studied in the modern era. We evaluated 803 renal transplant recipients and correlated HLA-DR/DQ molecular mismatch alloimmune risk categories (low, intermediate, high) with the severity, frequency, and persistence of TCMR. Allograft survival was reduced in recipients with Banff Borderline (hazard ratio [HR] 2.4, P = .003) and Banff ≥ IA TCMR (HR 4.3, P < .0001) including a subset who never developed de novo donor-specific antibodies (P = .002). HLA-DR/DQ molecular mismatch alloimmune risk categories were multivariate correlates of Banff Borderline and Banff ≥ IA TCMR and correlated with the severity and frequency of rejection episodes. Recipient age, HLA-DR/DQ molecular mismatch category, and cyclosporin vs tacrolimus immunosuppression were independent correlates of Banff Borderline and Banff ≥ IA TCMR. In the subset treated with tacrolimus (720/803) recipient age, HLA-DR/DQ molecular mismatch category, and tacrolimus coefficient of variation were independent correlates of TCMR. The correlation of HLA-DR/DQ molecular mismatch category with TCMR, including Borderline, provides evidence for their alloimmune basis. HLA-DR/DQ molecular mismatch may represent a precise prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegCanada
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | | | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Tom Blydt‐Hansen
- Department of PediatricsUniversity of British ColumbiaWinnipegCanada
| | | | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
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6
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Gueta I, Markovits N, Yarden-Bilavsky H, Raichlin E, Freimark D, Lavee J, Loebstein R, Peled Y. High tacrolimus trough level variability is associated with rejections after heart transplant. Am J Transplant 2018; 18:2571-2578. [PMID: 29989311 DOI: 10.1111/ajt.15016] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [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: 03/16/2018] [Revised: 06/11/2018] [Accepted: 07/01/2018] [Indexed: 01/25/2023]
Abstract
Tacrolimus, the major immunosuppressant after heart transplant (HTx) therapy, is a narrow therapeutic index drug. Hence, achieving stable therapeutic steady state plasma concentrations is essential to ensure efficacy while avoiding toxicity. Whether high variability in steady state concentrations is associated with poor outcomes is unknown. We investigated the association between tacrolimus trough level variability during the first year post-HTx and outcomes during and beyond the first postoperative year. Overall, 72 patients were analyzed for mortality, of whom 65 and 61 were available for rejection analysis during and beyond the first year post-HTx, respectively. Patients were divided into high (median >28.8%) and low tacrolimus level variability (<28.8%) groups. Mean tacrolimus levels did not differ between the groups (12.7 ± 3.4 ng/mL vs 12.8 ± 2.4 ng/mL, P = .930). Patients in the high variability group exhibited higher long-term rejection rate (median total rejection score: 0.33 vs 0, P = .04) with no difference in rejection scores within the first year post-HTx. Multivariate analysis showed that high tacrolimus trough level variability was associated with >8-fold increased risk for any rejection beyond the first year post-HTx (P = .011). Mortality was associated only with cardiovascular complications (P = .018), with no effect of tacrolimus through level variability.
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Affiliation(s)
- Itai Gueta
- The Institute of Clinical Pharmacology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Markovits
- The Institute of Clinical Pharmacology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Havatzelet Yarden-Bilavsky
- The Institute of Clinical Pharmacology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eugenia Raichlin
- Division of Cardiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dov Freimark
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Jacob Lavee
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Ronen Loebstein
- The Institute of Clinical Pharmacology, Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Olga and Lev Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
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7
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Gruessner RWG, Gruessner AC. Pancreas After Islet Transplantation: A First Report of the International Pancreas Transplant Registry. Am J Transplant 2016; 16:688-93. [PMID: 26436323 DOI: 10.1111/ajt.13468] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 05/13/2015] [Revised: 07/19/2015] [Accepted: 07/21/2015] [Indexed: 01/25/2023]
Abstract
Pancreas after islet (PAI) transplantation is a treatment option for patients seeking insulin independence through a whole-organ transplant after a failed cellular transplant. This report from the International Pancreas Transplant Registry (IPTR) and the United Network for Organ Sharing (UNOS) studied PAI transplant outcomes over a 10-year time period. Forty recipients of a failed alloislet transplant subsequently underwent pancreas transplant alone (50%), pancreas after previous kidney transplant (22.5%), or simultaneous pancreas and kidney (SPK) transplant (27.5%). Graft and patient survival rates were not statistically significantly different compared with matched primary pancreas transplants. Regardless of the recipient category, overall 1- and 5-year PAI patient survival rates for all 40 cases were 97% and 83%, respectively; graft survival rates were 84% and 65%, respectively. A failed previous islet transplant had no negative impact on kidney graft survival in the SPK category: It was the same as for primary SPK transplants. According to this IPTR/UNOS analysis, a PAI transplant is a safe procedure with low recipient mortality, high graft-function rates in both the short and long term and excellent kidney graft outcomes. Patients with a failed islet transplant should know about this alternative in their quest for insulin independence through transplantation.
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Affiliation(s)
- R W G Gruessner
- University of Arizona, Tucson, AZ.,SUNY Upstate Medical University, Syracuse, NY
| | - A C Gruessner
- SUNY Upstate Medical University, Syracuse, NY.,College of Public Health, University of Arizona, Tucson, AZ
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8
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Allen MB, Billig E, Reese PP, Shults J, Hasz R, West S, Abt PL. Donor Hemodynamics as a Predictor of Outcomes After Kidney Transplantation From Donors After Cardiac Death. Am J Transplant 2016; 16:181-93. [PMID: 26361242 DOI: 10.1111/ajt.13432] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 01/30/2015] [Revised: 05/22/2015] [Accepted: 06/22/2015] [Indexed: 01/25/2023]
Abstract
Donation after cardiac death is an important source of transplantable organs, but evidence suggests donor warm ischemia contributes to inferior outcomes. Attempts to predict recipient outcome using donor hemodynamic measurements have not yielded statistically significant results. We evaluated novel measures of donor hemodynamics as predictors of delayed graft function and graft failure in a cohort of 1050 kidneys from 566 donors. Hemodynamics were described using regression line slopes, areas under the curve, and time beyond thresholds for systolic blood pressure, oxygen saturation, and shock index (heart rate divided by systolic blood pressure). A logistic generalized estimation equation model showed that area under the curve for systolic blood pressure was predictive of delayed graft function (above median: odds ratio 1.42, 95% confidence interval [CI] 1.06-1.90). Multivariable Cox regression demonstrated that slope of oxygen saturation during the first 10 minutes after extubation was associated with graft failure (below median: hazard ratio 1.30, 95% CI 1.03-1.64), with 5-year graft survival of 70.0% (95%CI 64.5%-74.8%) for donors above the median versus 61.4% (95%CI 55.5%-66.7%) for those below the median. Among older donors, increased shock index slope was associated with increased hazard of graft failure. Validation of these findings is necessary to determine the utility of characterizing donor warm ischemia to predict recipient outcome.
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Affiliation(s)
- M B Allen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E Billig
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - P P Reese
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA.,Renal Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - R Hasz
- Gift of Life Donor Program, Philadelphia, PA
| | - S West
- Gift of Life Donor Program, Philadelphia, PA
| | - P L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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9
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Chen CY, Liu CJ, Feng JY, Loong CC, Liu C, Hsia CY, Hu LY, Lin NC, Hu YW, Yeh CM, Chen TJ, Yang CC. Incidence and Risk Factors for Tuberculosis After Liver Transplantation in an Endemic Area: A Nationwide Population-Based Matched Cohort Study. Am J Transplant 2015; 15:2180-7. [PMID: 25872600 DOI: 10.1111/ajt.13235] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [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: 07/28/2014] [Revised: 01/05/2015] [Accepted: 01/16/2015] [Indexed: 01/25/2023]
Abstract
Morbidity and mortality from tuberculosis (TB) are high in Taiwan. We conducted a nationwide population-based matched cohort study using data retrieved from the Taiwan's National Health Insurance Research Database to determine the impact of TB after liver transplantation (LT). During 2000-2011, we identified 3202 liver transplant recipients and selected subjects from the general population matched for age, sex, and comorbidities on the same index date of recognition of LT with a 1:10 ratio. The data were analyzed using Cox proportional hazards models. Compared to the matched cohort, liver transplant patients had a higher risk for TB (adjusted HR 2.25, 95% CI 1.65-3.05, p < 0.001), and those with TB showed higher mortality (HR 2.27, 95% CI 1.30-3.97, p = 0.004). Old age (HR 2.64, 95% CI 1.25-5.54, p = 0.011) and mammalian target of rapamycin inhibitors (mTORis) (HR 3.09, 95% CI 1.68-5.69, p < 0.001) were significant risk factors for TB in LT; mTORis were also associated with mortality after adjusting for confounders (HR 2.13, 95% CI 1.73-2.62, p < 0.001). Therefore, regular surveillance of TB and treatment of latent TB infection in high-risk patients after LT are important, especially in TB-endemic areas.
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Affiliation(s)
- C-Y Chen
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - C-J Liu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - J-Y Feng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Pulmonary Immunology & Infectious Diseases, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - C-C Loong
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - C Liu
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - C-Y Hsia
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - L-Y Hu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - N-C Lin
- Division of Transplantation Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Y-W Hu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C-M Yeh
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - T-J Chen
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - C-C Yang
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Environmental & Occupational Health Sciences, National Yang-Ming University, Taipei, Taiwan
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