Evaluation of liver transplantation services in Kazakhstan from 2012 to 2023

There is a scarcity of publications evaluating the performance of the national liver transplantation (LTx) program in Kazakhstan. Spanning from 2012 to 2023, it delves into historical trends in LTx surgeries, liver transplant centers, and the national cohort of patients awaiting LTx. Survival analysis for those awaiting LTx, using life tables and Kaplan-Meier, is complemented by time series analysis projecting developments until 2030. The overall per million population (pmp) LTx rate varied from 0.35 to 3.77, predominantly favoring living donor LTx. Liver transplant center rates ranged from 0.06 to 0.40. Of 474 LTx patients, 364 on the waiting list did not receive transplantation. The 30-day and 1-year survival rates on the waiting list were 87.0% and 68.0%, respectively. Viral hepatitis and cirrhosis prevalence steadily rose from 2015 to 2023, with projections indicating a persistent trend until 2030. Absent targeted interventions, stable pmp rates of LTx and liver transplant centers may exacerbate the backlog of unoperated patients. This study sheds light on critical aspects of the LTx landscape in Kazakhstan, emphasizing the urgency of strategic interventions to alleviate the burden on patients awaiting transplantation.

Outcomes of living liver donors are worse than those of matched healthy controls

BACKGROUND & AIMS

Donor death is the most serious complication of living liver donation but is reported rarely. We investigated the actual mortality of living liver donors (LLDs) compared with matched control groups based on analysis of the Korean National Health Insurance Services (NHIS) database.

METHODS

This cohort study included 12,372 LLDs who donated a liver graft between 2002 and 2018, and were registered in the Korean Network for Organ Sharing. They were compared to 3 matched control groups selected from the Korean NHIS and comprising a total of 123,710 individuals: healthy population (Group I); general population without comorbidities (Group II); and general population with comorbidities (Group III).

RESULTS

In this population, 78.5% of living liver donors were 20-39 years old, and 64.7% of all donors were male. Eighty-nine donors (0.7%) in the LLD group died (68 males and 21 females), a mortality rate (/1,000 person-years) of 0.91 (0.74-1.12). Mortality rate ratio and the adjusted hazard ratio of the LLD group was 2.03 (1.61-2.55) and 1.71 (1.31-2.25) compared to Control Group I, 0.75 (0.60-0.93) and 0.63 (0.49-0.82) compared to Control Group II, and 0.58 (0.46-0.71) and 0.49 (0.39-0.60) compared to Control Group III. LLD group, depression, and lower income were risk factors for adjusted mortality. The incidence of liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the LLD group was significantly higher than in Control Group I.

CONCLUSIONS

Outcomes of the LLD group were worse than those of the matched healthy control group despite the small number of deaths and medical morbidities in this group. LLDs should receive careful medical attention for an extended period after donation.

LAY SUMMARY

The incidence of mortality, liver failure, depression, cancer, diabetes, hypertension, brain infarction, brain hemorrhage, and end-stage renal disease in the living liver donor group was significantly higher than in the matched healthy group. Careful donor evaluation and selection processes can improve donor safety and enable safe living donor liver transplantation.

Why Are Black People Less Likely to Find a Stem Cell Donor Match?

Building trust in the health care system could increase the number of donors.

Intermediate Renal Outcomes, Kidney Failure, and Mortality in Obese Kidney Donors

BACKGROUND

Obesity is associated with the two archetypal kidney disease risk factors: hypertension and diabetes. Concerns that the effects of diabetes and hypertension in obese kidney donors might be magnified in their remaining kidney have led to the exclusion of many obese candidates from kidney donation.

METHODS

We compared mortality, diabetes, hypertension, proteinuria, reduced eGFR and its trajectory, and the development of kidney failure in 8583 kidney donors, according to body mass index (BMI). The study included 6822 individuals with a BMI of <30 kg/m2, 1338 with a BMI of 30-34.9 kg/m2, and 423 with a BMI of ≥35 kg/m2. We used Cox regression models, adjusting for baseline covariates only, and models adjusting for postdonation diabetes, hypertension, and kidney failure as time-varying covariates.

RESULTS

Obese donors were more likely than nonobese donors to develop diabetes, hypertension, and proteinuria. The increase in eGFR in obese versus nonobese donors was significantly higher in the first 10 years (3.5 ml/min per 1.73m2 per year versus 2.4 ml/min per 1.73m2 per year; P<0.001), but comparable thereafter. At a mean±SD follow-up of 19.3±10.3 years after donation, 31 (0.5%) nonobese and 12 (0.7%) obese donors developed ESKD. Of the 12 patients with ESKD in obese donors, 10 occurred in 1445 White donors who were related to the recipient (0.9%). Risk of death in obese donors was not significantly increased compared with nonobese donors.

CONCLUSIONS

Obesity in kidney donors, as in nondonors, is associated with increased risk of developing diabetes and hypertension. The absolute risk of ESKD is small and the risk of death is comparable to that of nonobese donors.

The impact of measuring split kidney function on post-donation kidney function: A retrospective cohort study

Background

Studies have reported agreement between computed tomography (CT) and renography for the determination of split kidney function. However, their correlation with post-donation kidney function remains unclear. We compared CT measurements with renography in assessment of split kidney function (SKF) and their correlations with post-donation kidney function.

Methods

A single-centre, retrospective cohort study of 248 donors from January 1, 2009-July 31, 2019 were assessed. Pearson correlations were used to assess post-donation kidney function with renography and CT-based measurements. Furthermore, we examined high risk groups with SKF difference greater than 10% on renography and donors with post-donation eGFR less than 60 mL/min/1.73m².

Results

62% of donors were women with a mean (standard deviation) pre-donation eGFR 99 (20) and post-donation eGFR 67 (22) mL/min/1.73m² at 31 months of follow-up. Post-donation kidney function was poorly correlated with both CT-based measurements and renography, including the subgroup of donors with post-donation eGFR less than 60 mL/min/1.73m² (r less than 0.4 for all). There was agreement between CT-based measurements and renography for SKF determination (Bland-Altman agreement [bias, 95% limits of agreement] for renography vs: CT volume, 0.76%, -7.60–9.15%; modified ellipsoid,1.01%, -8.38–10.42%; CC dimension, 0.44%, -7.06–7.94); however, CT missed SKF greater than 10% found by renography in 20 out 26 (77%) of donors.

Conclusions

In a single centre study of 248 living donors, we found no correlation between CT or renography and post-donation eGFR. Further research is needed to determine optimal ways to predict remaining kidney function after donation.

Postoperative incision scars and cosmetic satisfaction of living liver donors

Cosmetic appearance is a major concern for living donors. However, little is known about the impact of a surgical scar on body image changes in living liver donors. The aim of this study was to identify potential factors that cause displeasing upper midline incision scar, and to evaluate the overall satisfaction regarding body image and scarring after living donor hepatectomy.Donors who underwent right lobe hepatectomy were recruited. Exclusion criteria included reoperation, refusal to participate, and lost follow-up. All donors were invited to complete the Vancouver Scar Scale (VSS) and the body image questionnaire. According to the VSS results of upper midline incision scar, donors were divided into 2 groups: good scarring group (VSS ≤4) and bad scarring group (VSS >4). we compared the clinical outcomes, including the demographics, preoperation, intraoperation, and postoperation variables. The study also analyzed the results of the body image questionnaire.The proportion of male donors was 48.9%. The bad scarring group consisted of 63% of the donors. On multivariate analysis, being a male donor was found to be an independent predictor of a cosmetically displeasing upper midline incision scar with statistical significance. The results of body image questionnaires, there were significant differences in cosmetic score and confidence score among the 2 groups.The upper midline incision and male donors have higher rates of scarring in comparison with the transverse incision and female donors. Donors who reported having a higher satisfaction with their scar appearance usually had more self-confidence. However, the body image won't be affected. Medical staff should encourage donors to take active participation in wound care and continuously observe the impact of surgical scars on psychological changes in living liver donors.

Association Between Donor-Recipient Biological Relationship and Allograft Outcomes After Living Donor Kidney Transplant

IMPORTANCE

The proportion of living donor kidney transplants from donors unrelated to their recipients is increasing in the US.

OBJECTIVE

To examine the association between donor-recipient biological relationship and allograft survival after living donor kidney transplant.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used Organ Procurement and Transplantation Network data on US adult living donor kidney transplants (n = 86 154) performed from January 1, 2000, to December 31, 2014, excluding cases in which recipients previously received a kidney transplant (n = 10 342) or key data were missing (n = 2832). Last follow-up was March 20, 2020.

EXPOSURES

Donor-recipient biological relationship.

MAIN OUTCOMES AND MEASURES

The primary outcome was death-censored allograft failure. Univariate and multivariable time-to-event analyses were performed for death-censored allograft failure for the overall cohort, then separately for recipients with and without primary diagnoses of cystic kidney disease and for transplants from African American and non-African American donors.

RESULTS

Among the 72 980 transplant donor and recipients included in the study (median donor age, 41 years; interquartile range [IQR], 32-50 years; 43 990 [60%] female; 50 014 [69%] White), 43 174 (59%) donors and recipients were biologically related and 29 806 (41%) were unrelated. Donors related to their recipients were younger (median [IQR] age, 39 [31-48] vs 44 [35-52] years) and less likely to be female (24 848 [58%] vs 19 142 [64%]) or White (26 933 [62%] vs 23 081 [77%]). Recipients related to their donors were younger (median [IQR] age, 48 [34-58] vs 50 [40-58] years), more likely to be female (18 035 [42%] vs 10 530 [35%]), and less likely to have cystic kidney disease (2530 [6%] vs 4600 [15%]). Related pairs had fewer HLA mismatches overall (median [IQR], 3 [2-3] vs 5 [4-5]). After adjustment for HLA mismatches, donor and recipient characteristics, and transplant era, donor-recipient biological relationship was associated with higher death-censored allograft failure (hazard ratio, 1.05; 95% CI, 1.01-1.10; P = .03). When stratified by primary disease, this association persisted only for recipients without cystic kidney disease. When stratified by donor race, this association persisted only for transplants from African American donors.

CONCLUSIONS AND RELEVANCE

In this cohort study, living donor kidney transplants from donors biologically related to their recipients had higher rates of allograft failure than transplants from donors unrelated to their recipients after HLA matching was accounted for. Further study is needed to determine which genetic or socioenvironmental factors are associated with this finding.

Caspase-3-related apoptosis prevents pathological regeneration in a living liver donor rat model

PURPOSE

The main goal of this study was to determine the relationship of cleaved-caspase-3 (C3)-related apoptosis and hepatic proliferation, during the liver repopulation in a living liver donor rat model.

MATERIAL/METHODS

Thirty-three animals were randomized into eleven groups and evaluated on postoperative from 3 ​h until 384 ​h after 30%-partial hepatectomy (30%-PHx). Liver sections (5 ​μm) were processed by hematoxylin-eosin, and immunostaining for C3, accompanied by hepatic function test. C3 content and the hepatic lobule enlargement were analyzed by optical density, followed by cell counting.

RESULTS

Transient variations of alanine transferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) were found. Significant increase in the C3 levels, and cell nuclei number, were detected at 12 ​h and 48 ​h after 30%-PHx, evidencing a correlation of p ​= ​-0.3679.

CONCLUSION

In the 30%-PHx rat model, C3-related apoptosis prevents proliferative pathological conditions during the hepatic lobule re-modeling.

An intersectional gender analysis in kidney transplantation: women who donate a kidney

BACKGROUND

Living-donor transplantation is the best treatment option in patients with chronic kidney failure. Global data show that women are less likely to be kidney recipients than men but are more likely to become living kidney donors. We explored the experience of women who donate a kidney to relatives with biological and socio-cultural ties and to understand the similarities and differences in their experience.

METHODS

A qualitative hermeneutic phenomenological study with an intersectional analysis of gender. Ten women donors accepted in the transplant evaluation period participated, all of whom donated a kidney to a pre-dialysis relative. Two categories were included: women with biological kinship ties (mothers, sisters) and women who have a socio-cultural relationship (wives) with kidney recipient. The data were collected through semi-structured in-depth interviews and analysed using thematic analysis.

RESULTS

Women donate their kidneys in a convinced manner, without worrying about their health, with an optimistic and positive attitude, and without believing that they are acting heroically. Women with biological kinship ties see it as a 'naturalization thing'. In contrast, wives donate conditioned by gender roles, but also as a form of empowerment and as a personal benefit: they donate in order to avoid taking on carer role for their husband and as a way of protecting their children.

CONCLUSION

The study's findings expand the conception of kidney donation as solely altruistic and may help professionals to pay attention to the complexity and intersectionality of features present in women who are living kidney donors.

Prevalence, Mechanisms, Treatment, and Complications of Hypertension Postliving Kidney Donation

Living kidney donors represent a unique population of patients. Potential donors are selected based on the belief that their preoperative fitness is likely to mitigate the risks of long- and short-term harm following uninephrectomy. Studies performed on postdonation outcomes have largely focused on mortality and the risk of end-stage renal failure, but have also investigated secondary outcomes such as cardiovascular morbidity and hypertension. It has been postulated that hypertension is a possible outcome of living kidney donation. A variety of studies have been conducted to investigate the prevalence, epidemiology, mechanisms, treatment strategies, and long-term ramifications of hypertension postdonation. These studies are heterogeneous in their population, design, methodology, and outcome measures and have presented contradicting outcomes. Additionally, the absence of a well-matched control group has made it challenging to interpret and generalise the reported findings. As such, it is not possible to definitively conclude that hypertension occurs at a higher rate among donors than the general population. This article will review the evidence of postdonation hypertension prevalence, mechanisms, treatment, and complications.

Long-Term Financial, Psychosocial, and Overall Health-Related Quality of Life After Living Liver Donation

BACKGROUND

To assess the impact of living liver donation (LD) in a diverse and aging population up to 20 y after donation, particularly with regard to medical, financial, psychosocial, and overall health-related quality of life (HRQOL).

METHODS

Patients undergoing LD between 1999 and 2009 were recruited to respond to the Short-Form 36 and a novel Donor Quality of Life Survey at two time points (2010 and 2018).

RESULTS

Sixty-eight living liver donors (LLDs) completed validated surveys, with a mean follow-up of 11.5 ± 5.1 y. Per Donor Quality of Life Survey data, physical activity or strength was not impacted by LD in most patients. All respondents returned to school or employment, and 82.4% reported that LD had no impact on school or work performance. LD did not impact health insurability in 95.6% of donors, and only one patient experienced difficulty obtaining life insurance. Overall, 97.1% of respondents did not regret LD. Short-Form 36 survey-measured outcomes were similar between LLDs and the general U.S.

POPULATION

LLDs who responded in both 2010 and 2018 were followed for an overall average of 15.4 ± 2.4 y and HRQOL outcomes in these donors also remained statistically equivalent to U.S. population norms.

CONCLUSIONS

This study represents the longest postdonation follow-up and offers unique insight related to HRQOL in a highly diverse patient population. Although LLDs continue to maintain excellent HRQOL outcomes up to 20 y after donation, continued lifetime follow-up is required to accurately provide young, healthy potential donors with an accurate description of the risks that they may incur on aging.

Peripheral Donor-specific Antibodies Are Associated With Histology and Cellular Subtypes in Protocol Liver Biopsies of Pediatric Recipients

BACKGROUND

The cellular infiltrate in protocol liver biopsies (PB) following pediatric liver transplantation remains mostly uncharacterized, yet there is increasing concern about the role of inflammation and fibrosis in long-term liver allografts. We aimed to define cell types in PB and to analyze their relationship with donor-specific antibodies (DSA) and histological phenotype.

METHODS

PB were performed at least 1 year after transplantation. We identified 4 phenotypes: normal, fibrosis, inflammation, inflammation with fibrosis. Cell types were counted after immunostaining for CD3, CD4, CD8, CD68, CD20, MUM1, and FoxP3.

RESULTS

Forty-four patients underwent 1 PB between 2000 and 2015. Eleven percent (5/44) of PB displayed normal histology, 13.6% (6/44) fibrosis, 34.1% (15/44) inflammation, and 40.9% (18/44) inflammation and fibrosis. The main cell types in the portal tracts and lobules were CD3+ and CD68+ cells. Frequency of de novo DSA was 63% (27/44). The presence of CD8+ cells in the lobules was associated with fibrosis. Inflammation and fibrosis in PB were associated with the presence of circulating de novo DSA, number of de novo DSA, and C1q binding activity when compared to other phenotypes.

CONCLUSIONS

T cells (CD3+) and macrophages (CD68+) were the most prevalent cell-types in PB. In the presence of inflammation, portal tracts were enriched in CD3+, CD20+ but displayed fewer CD68+. This coincided with the presence and number of de novo DSA. How these cellular and humoral actors interact is unclear, but peripheral DSA may be a marker of immune cellular activity in the seemingly quiescent allograft.

Has the UK living kidney donor population changed over time? A cross-sectional descriptive analysis of the UK living donor registry between 2006 and 2017

BACKGROUND

A living-donor kidney transplant is the best treatment for most people with kidney failure. Population cohort studies have shown that lifetime living kidney donor risk is modified by sex, age, ethnicity, body mass index (BMI), comorbidity and relationship to the recipient.

OBJECTIVES

We investigated whether the UK population of living kidney donors has changed over time, investigating changes in donor demographics.

DESIGN

We undertook a cross-sectional analysis of the UK living kidney donor registry between January 2006 to December 2017. Data were available on living donor sex, age, ethnicity, BMI, hypertension and relationship to recipient.

SETTING

UK living donor registry.

PARTICIPANTS

11 651 consecutive living kidney donors from January 2006 to December 2017.

OUTCOME MEASURES

Living kidney donor demographic characteristics (sex, age, ethnicity, BMI and relationship to the transplant recipient) were compared across years of donation activity. Donor characteristics were also compared across different ethnic groups.

RESULTS

Over the study period, the mean age of donors increased (from 45.8 to 48.7 years, p<0.001), but this change appears to have been limited to the White population of donors. Black donors were younger than White donors, and a greater proportion were siblings of their intended recipient and male. The proportion of non-genetically related non-partner donations increased over the 12-year period of analysis (p value for linear trend=0.002).

CONCLUSIONS

The increasing age of white living kidney donors in the UK has implications for recipient and donor outcomes. Despite an increase in the number of black, Asian and minority ethnic individuals waitlisted for a kidney transplant, there has been no increase in the ethnic diversity of UK living kidney donors. Black donors in the UK may be at a much greater risk of developing kidney failure due to accumulated risks: whether these risks are being communicated needs to be investigated.

Association Between Living Kidney Donor Postdonation Hypertension and Recipient Graft Failure

BACKGROUND

Recipients of kidneys from living donors who subsequently develop end-stage renal disease (ESRD) also have higher graft failure, suggesting the 2 donor kidneys share risk factors that could inform recipient outcomes. Given that donor ESRD is rare, an earlier and more common postdonation outcome could serve as a surrogate to individualize counseling and management for recipients. Hypertension is a frequent event before donor ESRD; thus, early postdonation hypertension might indicate higher risk of graft failure.

METHODS

We studied Scientific Registry of Transplant Recipients data to quantify the association between early postdonation hypertension and recipient graft failure using propensity score-weighted Cox proportional hazards regression. We also examined the association between postdonation systolic blood pressure and graft failure.

RESULTS

Of 37 901 recipients, 2.4% had a donor who developed hypertension within 2 years postdonation. Controlling for donor and recipient characteristics, recipients whose donors developed hypertension had no higher risk for graft failure (adjusted hazard ratio [aHR] 1.03, 95% confidence interval [CI] 0.85-1.25, P = 0.72). This was consistent among subgroups of recipients at higher risk for adverse outcomes due to hyperfiltration: African American recipients (aHR 1.10, 95% CI 0.70-1.73, P = 0.68) and those with ESRD caused by hypertension (aHR 1.10, 95% CI 0.65-1.85, P = 0.73) or diabetes (aHR 0.80, 95% CI 0.56-1.13, P = 0.20). However, graft failure was associated with postdonation systolic blood pressure (per 10 mm Hg, aHR 1.05, 95% CI 1.03-1.08, P < 0.001).

CONCLUSIONS

Although postdonation systolic blood pressure is associated with graft failure, the reported diagnosis of hypertension as determined by the requirement for blood pressure treatment early postdonation did not portend a higher risk of recipient graft failure in the same way as eventual postdonation ESRD.

[Long-term patient and graft survival in kidney transplant recipients]

BACKGROUND

Kidney transplantation is the therapy of choice for patients with chronic renal failure. In Mexico, good short-term results have been reported for graft survival, which is why it was carried out a study in a third level center in Mexico City to broaden these results.

OBJECTIVE

To identify long-term results of patient and graft survival.

MATERIAL AND METHODS

Retrospective study with first 1600 kidney transplants performed at the Hospital de Especialidades (Specialties Hospital) "Dr. Antonio Fraga Mouret" from La Raza National Medical Center. Patient and graft survival was analyzed at 1, 3, 5, 7 and 10 years. Kaplan Meier survival analysis and log rank test were performed.

RESULTS

Between October 1979 and May 2015, 1600 kidney transplants were performed (1473 [92.1%] of living donor and 127 [7.9%] of deceased donor). Graft survival censored for death with functional graft at 1, 3, 5, 7 and 10 years was 95.4, 91.7, 88.2, 86.6 and 85.5%, respectively. Patient survival was 92.7, 90.4, 89.7, 89.4, and 88.9% at 1, 3, 5, 7 and 10 years, respectively.

CONCLUSIONS

Long-term patient and graft survival in our center is similar to that reported by other centers at an international level.

Mitigating Racial and Sex Disparities in Access to Living Donor Kidney Transplantation: Impact of the Nation's Longest Single-center Kidney Chain

OBJECTIVE

In this study, we sought to assess likelihood of living donor kidney transplantation (LDKT) within a single-center kidney transplant waitlist, by race and sex, after implementation of an incompatible program.

SUMMARY BACKGROUND DATA

Disparities in access to LDKT exist among minority women and may be partially explained by antigen sensitization secondary to prior pregnancies, transplants, or blood transfusions, creating difficulty finding compatible matches. To address these and other obstacles, an incompatible LDKT program, incorporating desensitization and kidney paired donation, was created at our institution.

METHODS

A retrospective cohort study was performed among our kidney transplant waitlist candidates (n = 8895). Multivariable Cox regression was utilized, comparing likelihood of LDKT before (era 1: 01/2007-01/2013) and after (era 2: 01/2013-11/2018) implementation of the incompatible program. Candidates were stratified by race [white vs minority (nonwhite)], sex, and breadth of sensitization.

RESULTS

Program implementation resulted in the nation's longest single-center kidney chain, and likelihood of LDKT increased by 70% for whites [adjusted hazard ratio (aHR) 1.70; 95% confidence interval (CI), 1.46-1.99] and more than 100% for minorities (aHR 2.05; 95% CI, 1.60-2.62). Improvement in access to LDKT was greatest among sensitized minority women [calculated panel reactive antibody (cPRA) 11%-49%: aHR 4.79; 95% CI, 2.27-10.11; cPRA 50%-100%: aHR 4.09; 95% CI, 1.89-8.82].

CONCLUSIONS

Implementation of an incompatible program, and the resulting nation's longest single-center kidney chain, mitigated disparities in access to LDKT among minorities, specifically sensitized women. Extrapolation of this success on a national level may further serve these vulnerable populations.

Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome

In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King's College criteria (KCC). Median admission to transplant time was 48 hours (range, 24-80.5 hours), and median living donor evaluation time was 18 hours (14-20 hours). Median Model for End-Stage Liver Disease score was 37 (32-40) with more than two-thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice-to-encephalopathy time was 15 (9-29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5-year post-LT actuarial survival was 65.57% with a median follow-up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01-6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05-136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24-19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00-1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.

The impact of donor and recipient common clinical and genetic variation on estimated glomerular filtration rate in a European renal transplant population

Genetic variation across the human leukocyte antigen loci is known to influence renal-transplant outcome. However, the impact of genetic variation beyond the human leukocyte antigen loci is less clear. We tested the association of common genetic variation and clinical characteristics, from both the donor and recipient, with posttransplant eGFR at different time-points, out to 5 years posttransplantation. We conducted GWAS meta-analyses across 10 844 donors and recipients from five European ancestry cohorts. We also analyzed the impact of polygenic risk scores (PRS), calculated using genetic variants associated with nontransplant eGFR, on posttransplant eGFR. PRS calculated using the recipient genotype alone, as well as combined donor and recipient genotypes were significantly associated with eGFR at 1-year posttransplant. Thirty-two percent of the variability in eGFR at 1-year posttransplant was explained by our model containing clinical covariates (including weights for death/graft-failure), principal components and combined donor-recipient PRS, with 0.3% contributed by the PRS. No individual genetic variant was significantly associated with eGFR posttransplant in the GWAS. This is the first study to examine PRS, composed of variants that impact kidney function in the general population, in a posttransplant context. Despite PRS being a significant predictor of eGFR posttransplant, the effect size of common genetic factors is limited compared to clinical variables.

Effect of Duration of Intensive Care Unit Stay on Outcomes of Adult Living Donor Liver Transplant Recipients

BACKGROUND AND AIM

Acute kidney injury (AKI) is common in patients undergoing liver transplantation and is associated with reduced patient and graft survival. The aim is to assess the occurrence of AKI following living donor liver transplantation and to evaluate the associated risk factors and outcomes.

SUBJECTS AND METHODS

Forty-nine Egyptian patients with hepatitis C virus who underwent living donor liver transplantation were divided into Group A (17 patients with AKI defined as increased creatinine > 50% of the initial pretransplant level) and Group B (non-AKI patients). Fluid balance, kidney function, preoperative and intraoperative risk factors, outcomes, and 1-year mortality were assessed.

RESULTS

The mean age was 48 ± 7.51 and the majority of patients assessed were men (89.8%). The 17 patients with AKI had higher preoperative creatinine and higher Model for End-Stage Liver Disease scores (1.3 ± 0.16, 15.7 ± 5.07, respectively) than the non-AKI patients (1.1 ± .15, 13.7 ± 4.61, respectively), with P values of .04 and < .01, respectively. They also had significantly lower levels of albumin (2.98 ± .50). AKI patients had longer intensive care unit (ICU) stays (10 ± 3 d) compared to non-AKI patients (5 ± 2), with a P value of .03. A logistic multivariable regression test revealed that only a long ICU stay is a predictor of developing acute kidney injury among patients who have undergone living donor liver transplantation (odds ratio 1.23, 95% confidence interval 1.1-2.1, with a P value of .012).

CONCLUSION

Many pre- and intra-operative factors are associated with AKI development; however, a long ICU stay is an independent potential factor for kidney infection.

Clinical outcomes after ABO-incompatible renal transplantation: a systematic review and meta-analysis

BACKGROUND

ABO-incompatible renal transplantation (ABOi-rTx) is increasingly used to overcome organ shortage. Evidence about its non-inferiority in comparison with ABO-compatible renal transplantation (ABOc-rTx) needs to be analysed at early and late timepoints. We aimed to investigate differences in outcome after ABOi-rTX and ABOc-rTX.

METHODS

We did a systematic review and meta-analysis of observational studies published up until Dec 31, 2017, that reported outcome data (≥1 year of follow-up) after ABOi-rTx and included an ABO-compatible control group, by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Embase Ovid, MEDLINE Ovid, and PubMed. Trials on recipients of ABOi-rTx were assessed, if an ABO-compatible control group was included and if outcome data on at least graft or recipient survival with 1 year or more of follow-up were available. Exclusion criteria included case reports, editorials, reviews and letters, animal studies, meeting papers, studies unable to extract data, non-renal solid organ and bone-marrow transplant studies, and deceased donor ABOc-rTx. Data were extracted from published reports. Primary endpoints were all-cause mortality and graft survival at 1, 3, 5, and more than 8 years after transplantation. In the meta-analysis, we used a fixed-effects model if the I² value was 0, and both a fixed-effects and random-effects model if I² was more than 0. This study is registered with PROSPERO, number CRD42018094550.

FINDINGS

1264 studies were screened and 40 studies including 49 patient groups were identified. 65 063 patients were eligible for analysis, 7098 of whom had undergone ABOi-rTx. Compared with ABOc-rTx, ABOi-rTx was associated with significantly higher 1-year mortality (odds ratio [OR] 2·17 [95% CI 1·63-2·90], p<0·0001; I²=37%), 3 years (OR 1·89 [1·46-2·45], p<0·0001; I²=29%), and 5 years (OR 1·47 [1·08-2·00], p=0·010; I²=68%) following transplantation. Death-censored graft survival was lower with ABOi-rTx than with ABOc-rTx at 1 year (OR 2·52 [1·80-3·54], p<0·0001; I²=61%) and 3 years (OR 1·59 [1·15-2·18], p=0·0040; I²=58%) only. Graft losses were equivalent to that of ABOc-rTx after 5 years and patient survival after 8 years. No publication bias was detected and the results were robust to trial sequential analysis until 5 years after transplantation; thereafter, data became futile or inconclusive.

INTERPRETATION

Despite progress in desensitisation protocols and optimisation of ABOi-rTx procedures, excess mortality and loss of kidney grafts was found compared with ABOc-rTx within the first 3 years after transplantation. Only long-term outcomes after 5 years yielded equivalent survival rates and organ function. Awareness of the increased risks of infection, organ rejection, and bleeding could improve care of patients and promote efforts towards paired kidney exchange programmes.

FUNDING

None.

Assessment of Postdonation Outcomes in US Living Kidney Donors Using Publicly Available Data Sets

Importance

There are limited resources providing postdonation conditions that can occur in living donors (LDs) of solid-organ transplant. Consequently, it is difficult to visualize and understand possible postdonation outcomes in LDs.

Objective

To assemble an open access resource that is representative of the demographic characteristics in the US national registry, maintained by the Organ Procurement and Transplantation Network and administered by the United Network for Organ Sharing, but contains more follow-up information to help to examine postdonation outcomes in LDs.

Design, Setting, and Participants

Cohort study in which the data for the resource and analyses stemmed from the transplant data set derived from 27 clinical studies from the ImmPort database, which is an open access repository for clinical studies. The studies included data collected from 1963 to 2016. Data from the United Network for Organ Sharing Organ Procurement and Transplantation Network national registry collected from October 1987 to March 2016 were used to determine representativeness. Data analysis took place from June 2016 to May 2018. Data from 20 ImmPort clinical studies (including clinical trials and observational studies) were curated, and a cohort of 11 263 LDs was studied, excluding deceased donors, LDs with 95% or more missing data, and studies without a complete data dictionary. The harmonization process involved the extraction of common features from each clinical study based on categories that included demographic characteristics as well as predonation and postdonation data.

Main Outcomes and Measures

Thirty-six postdonation events were identified, represented, and analyzed via a trajectory network analysis.

Results

The curated data contained 10 869 living kidney donors (median [interquartile range] age, 39 [31-48] years; 6175 [56.8%] women; and 9133 [86.6%] of European descent). A total of 9558 living kidney donors with postdonation data were analyzed. Overall, 1406 LDs (14.7%) had postdonation events. The 4 most common events were hypertension (806 [8.4%]), diabetes (190 [2.0%]), proteinuria (171 [1.8%]), and postoperative ileus (147 [1.5%]). Relatively few events (n = 269) occurred before the 2-year postdonation mark. Of the 1746 events that took place 2 years or more after donation, 1575 (90.2%) were nonsurgical; nonsurgical conditions tended to occur in the wide range of 2 to 40 years after donation (odds ratio, 38.3; 95% CI, 4.12-1956.9).

Conclusions and Relevance

Most events that occurred more than 2 years after donation were nonsurgical and could occur up to 40 years after donation. Findings support the construction of a national registry for long-term monitoring of LDs and confirm the value of secondary reanalysis of clinical studies.

Risk of subsequent health disorders among living kidney donors

Few studies have investigated the risk of physiological sequelae in living kidney donors (KDs). We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan, which covers more than 99% of citizens.We comprehensively investigated the risk of medical disorders after kidney donation in living KDs using a maximum follow-up of 13 years. From January 1997 to December 2010, 1081 living KDs and 1082 age- and sex-matched non-KDs were eligible. Primary outcomes comprised end-stage renal disease, chronic kidney disease, stroke, cancer, acute myocardial infarction, acute renal failure (ARF), and diabetes.The adjusted hazard ratios (HRs) for developing ARF, diabetes, hyperlipidemia, hypertension, cancer, end-stage renal disease, acute myocardial infarction, and stroke were similar between the KD and non-KD cohorts (P > .05). Although differences in the adjusted HRs of ARF were nonsignificant, the cumulative incidence rate of ARF 13 years after donation was 7.48 per 1000 person-years in the KD cohort compared with 3.46 in the matched non-KD cohort. The incidence rate ratio for ARF between donors and nondonors significantly increased to 2.16 (95% confidence interval, 1.61-2.71).Living KDs experienced no significant health disorders following kidney donation but should be alert to the higher incidence rate of ARF.

Impact of educational levels on survival rate: A cohort study of 2007 living donor liver transplant recipients at a single large center

Among living donor liver transplantation recipients, the impact of educational levels on survival has rarely explored. Thus, the purpose of study is to analyze the survival rate differences across educational levels among recipients who underwent living donor liver transplantation.We retrospectively analyzed 2007 adult recipients who underwent living donor liver transplantation in a single large center. The educational level was divided into three categories: middle school or lower, high school, and college or higher. The primary outcome was all-cause mortality after living donor liver transplantation. Stratified log-rank test and Cox proportional hazard model were employed for statistical analysis.The incidence rates of all-cause mortality were 23.85, 20.19, and 18.75 per 1000 person-year in recipients with middle school or lower, high school, and college or higher education groups, respectively. However, the gender-stratified log-rank test has not shown a statistically significant difference (P = .3107). In the unadjusted model, hazard ratio (HR) was 1.02 [95% confidence interval (CI) = 0.79-1.33] in high school and 1.23 (95% CI = 0.93-1.64) and in middle school or lower educational level, respectively; In the full adjusted model, the HR of high school was 0.98 (95% CI = 0.75-1.28) and the HR of middle school or lower was 1.01 (95% CI = 0.74-1.37).Although study population of this study is large, we could not find significant survival rate differences by the levels of education. Social selection and high compliance rate might contribute to this result.

Management of urolithiasis in living kidney donors

BACKGROUND

Kidney donors with asymptomatic stones were  previously excluded from the kidney donation list because of a potential increased morbidity risk for both the recipient and the donor. Currently, recent studies tend to consider these risks as overestimated.

AIM

The aim of this study was to analyze our experience in the management of urolithiasis in potential donors.

METHODS

We conducted a retrospective analysis during the period (2008-2015). We included donors with urilithiasis or a family history of urolithiasis whom had urinary biochemical analysis of urolithiasis. We identified the exact location, size, and anatomy of the kidney bearing the stone were identified.

RESULTS

Among 252 potentially proposed living kidney donors (LKD) in two renal transplantation centers, we noted urinary lithiasis in 8 patients (3.17%). The mean age was 40,12±20 years old with a sex-ratio M/F at 0,3. We noted urinary lithiasis on radiographs in one case, on echographs in one case and on computerized tomography kidney angiography in 5 cases. All are not obese and without any medical history. In one case, there was no lithiasis detected but chemical urinary analysis was performed because of family renal stone history. We performed a 24-hours urine test, and examined PH, calcium and oxalate. The urine analysis, showed acidic pH and hypercalciuria in all cases associated to weddelite in 3 cases, hyperoxaluria in all cases. In one case, we noted vitamin D deficiency related hyperparathyroidism. Renal transplantation has been achieved in two cases. After a mean follow up of 11,25 months [range :27-84], no urological complications were noted.

CONCLUSION

Urinary lithiasis may occur in proposed living kidney donors and may not contraindicate this donation.

Management and outcome of latent tuberculosis in living renal transplant donors

In regions where tuberculosis (TB) is endemic, up to 15% of kidney transplant recipients develop Mycobacterium tuberculosis infections (TBI), typically with an increased risk of disseminated disease and allograft loss. To reduce these risks, donors and recipients with latent TB usually receive isoniazid (INH) prophylaxis. However, it is unclear whether latent TB in donors justifies routine prophylaxis of recipients. At our institution, donors and recipients with latent infection receive INH prophylaxis, and those who do not have latent infections are not routinely treated. We retrospectively analyzed the records of 269 living donor kidney transplant recipient and donor pairs in order to determine the risk of posttransplant TB in those whose kidneys were obtained from living donors with latent TB. Three recipients (1.1%) developed active TB, three, 11, and 12 months after transplantation. Neither donors nor recipients in these pairs had evidence of latent TB before transplantation. Of the 224 pairs with complete data, 24 transplant recipients with negative tuberculin skin test received organs from living donors with evidence of latent TB. None developed active TB, and kidney function one and three years later was preserved. Our findings suggest that routine use of prophylaxis in recipients without latent TB who receive organs from positive donors might not add additional benefit.

Rationale and design of TransplantLines: a prospective cohort study and biobank of solid organ transplant recipients

INTRODUCTION

In the past decades, short-term results after solid organ transplantation have markedly improved. Disappointingly, this has not been accompanied by parallel improvements in long-term outcomes after transplantation. To improve graft and recipient outcomes, identification of potentially modifiable risk factors and development of biomarkers are required. We provide the rationale and design of a large prospective cohort study of solid organ transplant recipients (TransplantLines).

METHODS AND ANALYSIS

TransplantLines is designed as a single-centre, prospective cohort study and biobank including all different types of solid organ transplant recipients as well as living organ donors. Data will be collected from transplant candidates before transplantation, during transplantation, at 3 months, 6 months, 1 year, 2 years and 5 years, and subsequently every 5 years after transplantation. Data from living organ donors will be collected before donation, during donation, at 3 months, 1 year and 5 years after donation, and subsequently every 5 years. The primary outcomes are mortality and graft failure. The secondary outcomes will be cause-specific mortality, cause-specific graft failure and rejection. The tertiary outcomes will be other health problems, including diabetes, obesity, hypertension, hypercholesterolaemia and cardiovascular disease, and disturbances that relate to quality of life, that is, physical and psychological functioning, including quality of sleep, and neurological problems such as tremor and polyneuropathy.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the relevant local ethics committee. The TransplantLines cohort study is designed to deliver pioneering insights into transplantation and donation outcomes. The study design allows comprehensive data collection on perioperative care, nutrition, social and psychological functioning, and biochemical parameters. This may provide a rationale for future intervention strategies to more individualised, patient-centred transplant care and individualisation of treatment.

TRIAL REGISTRATION NUMBER

NCT03272841.

National Trends in Liver Transplantation in Older Adults

OBJECTIVES

To explore trends in liver transplantation (LT) and outcomes for older recipients for evaluation, counseling, and appropriate referral of this vulnerable group of older adults.

DESIGN

Prospective national cohort study.

SETTING

Scientific Registry of Transplant Recipients (January 1, 2003-December 31, 2016).

PARTICIPANTS

Older (aged ≥ 65) deceased donor liver-only transplant recipients (n=8,627).

MEASUREMENTS

We evaluated temporal changes in recipient, donor, and transplant characteristics and post-LT length of stay (LOS), acute rejection, graft loss, and mortality using logistic regression and Cox proportional hazards.

RESULTS

LT in older adults almost quadrupled, from 263 in 2003 (9.5% of total LTs that year) to 1,144 in 2016 (20.7% of total LTs). Recent recipients were more likely to be female and African American and have a higher body mass index and Model for End-Stage Liver Disease score. Hepatitis C, nonalcoholic steatohepatitis, and hepatocellular carcinoma were the most common indications for LT in recent recipients. Odds of LOS longer than 2 weeks decreased 34% from 2003-06 to 2013-16 (adjusted odds ratio (aOR)=0.66, 95% confidence interval (CI)=0.57-0.76, P < .001), 1-year acute rejection decreased 30% (aOR=0.70, 95% CI=0.56-0.88, P = .002), all-cause graft loss decreased 54% (adjusted hazard ratio (aHR)=0.46, 95% CI=0.40-0.52, P < .001), and mortality decreased 57% (aHR=0.43, 95% CI=0.38-0.49, P < .001).

CONCLUSION

Despite the substantial increase in the number of older adults undergoing LT and the severity of their condition, LOS, rejection, graft loss, and mortality have significantly decreased over time. These trends can help guide appropriate LT referral and counseling in older adults with end-stage liver disease. J Am Geriatr Soc 66:2321-2326, 2018.

Results of 1001 liver transplantations in 23 years: Ege University experience

BACKGROUND/AIMS

Liver transplantation (LT) is now the standard of care for most end-stage liver diseases. Over the next 30 years, advances in medicine and technology will greatly improve the survival rates of patients after this procedure. The aim of the present study was to analyze retrospectively the results of 1001 patients withLT.

MATERIALS AND METHODS

Medical reports of 989 patients were analyzed retrospectively. Data were obtained from the patient's data chart. Descriptive statistics were used to describe continuous variables (mean, median, and standard deviation).

RESULTS

A total of 1001 LTs for 989 recipients were performed at Ege University Organ Transplantation and Research Center between 1994 and 2017. Therewere 639 male and 350 female recipients. Among 1001 LTs, there were 438 deceased donors and 563 living donors. The age interval of the patients was 4 months to 71 years old. The median Model for End-Stage Liver Disease score was 20. There were 12 deceased liver donors using the split method. There were 12 cases subject to retransplantation. In living donor LT grafts, 423 right lobes, 46 left lobes, and 94 left lateral sectors were used. In the first monitoring,the total annual mortality rate was 130 cases (13%). The mortality rate in retransplantation was found to be 66%. A 1-year survival rate of 87% was generally stablished.

CONCLUSION

LThas been improving consistently over the last two decades. Ege University is one of the biggest liver transplant centers in Turkey for both technical and educational perspective.

Measured Glomerular Filtration Rate After Kidney Donation: No Evidence of Accelerated Decay

BACKGROUND

The rate of measured glomerular filtration rate (GFR) change in kidney donor years after donation has not been adequately addressed. Whether this change is accelerated in the setting of 1 kidney is also understudied.

METHODS

Two hundred fourteen randomly selected donors underwent serial GFR measurements of nonradioactive iohexol. Estimated GFR at each visit was calculated using the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease study equations.

RESULTS

Glomerular filtration rate visits were 4.8 ± 1.3 years apart and the second occurring 16.9 ± 9.1 years after donation. Most (97.7%) were white, 60.8% female, and 78.5% were related to their recipient. Most, 84.6%, had a GFR of 60 mL/min per 1.73 m or higher, 14.0% had a GFR between 45 and 60 mL/min per 1.73 m, and 1.4% had a GFR less than 45 mL/min per 1.73 m. Between visits 1 and 2, 56.5% had a GFR decline, 36.0% increase, and in 7.5%, there was no change. Overall, GFR declined at a rate of -0.42 mL/min per 1.73 m per year. Of GFR estimating models, only Chronic Kidney Disease Epidemiology Collaboration-Creatinine equation produced a slope that was steeper than measured GFR.

CONCLUSIONS

Nearly 2 decades postdonation GFR declined at a rate similar to that seen in the general population, and in one third, GFR continues to increase.

Expanding the donor pool: Donation after circulatory death and living liver donation do not compromise the results of liver transplantation

Because of the shortfall between the number of patients listed for liver transplantation (LT) and the available grafts, strategies to expand the donor pool have been developed. Donation after circulatory death (DCD) and living donor (LD) grafts are not universally used because of the concerns of graft failure, biliary complications, and donor risks. In order to overcome the barriers for the implementation of using all 3 types of grafts, we compared outcomes after LT of DCD, LD, and donation after brain death (DBD) grafts. Patients who received a LD, DCD, or DBD liver graft at the University of Toronto were included. Between January 2009 through April 2017, 1054 patients received a LT at our center. Of these, 77 patients received a DCD graft (DCD group); 271 received a LD graft (LD group); and 706 received a DBD graft (DBD group). Overall biliary complications were higher in the LD group (11.8%) compared with the DCD group (5.2%) and the DBD group (4.8%; P < 0.001). The 1-, 3-, and 5-year graft survival rates were similar between the groups with 88.3%, 83.2%, and 69.2% in the DCD group versus 92.6%, 85.4%, and 84.7% in the LD group versus 90.2%, 84.2%, and 79.9% in the DBD group (P = 0.24). Furthermore, the 1-, 3-, and 5-year patient survival was comparable, with 92.2%, 85.4%, and 71.6% in the DCD group versus 95.2%, 88.8%, and 88.8% in the LD group versus 93.1%, 87.5%, and 83% in the DBD group (P = 0.14). Multivariate Cox regression analysis revealed that the type of graft did not impact graft survival. In conclusion, DCD, LD, and DBD grafts have similar longterm graft survival rates. Increasing the use of LD and DCD grafts may improve access to LT without affecting graft survival rates. Liver Transplantation 24 779-789 2018 AASLD.

Life-threatening or nearly life-threatening complications in living liver donors

OBJECTIVE

To determine the relationship between a transplant center's experience and life-threatening or nearly life-threatening complications during living donor hepatectomy (LDH).

METHODS

The medical records of 1140 patients who underwent LDH were analyzed. To determine the relationship between life-threatening complications and a transplant center's experience, the following comparisons between LDH cases were performed: first 100 vs subsequent 100; first 100 vs subsequent 1040; first 200 vs subsequent 940; right hepatectomy vs left hepatectomy; and first 5 years of experience vs subsequent 5 years.

RESULTS

A total of 36 life-threatening or nearly life-threatening complications developed in 34 of 1140 (2.98%) healthy individuals undergoing LDH. Of these, 5 occurred intraoperatively, 26 within 1 month, and 5 beyond 1 month. The most common complications were biliary problems and postoperative bleeding. None of the donors died at follow-up. One donor underwent deceased donor liver transplantation (DDLT) for severe hepatic failure. Only 2 comparisons were significantly different with regard to life-threatening complications: the first 100 vs the subsequent 1040 (P = .03) and the first 200 vs the subsequent 940 (P = .01).

CONCLUSION

This study indicates that the incidence of life-threatening or nearly life-threatening complications are reduced by increased center experience (>200 LDHs).

Status of Adult Living Donor Liver Transplantation in the United States: Results from the Adult-To-Adult Living Donor Liver Transplantation Cohort Study

This article reviews the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL). The findings show that the number of adult-to-adult living donor liver transplants is consistently increasing. Living donor liver transplantation has an important benefit for patients with acute liver failure, does not compromise donor safety, and has lower rates of acute cellular rejection in biologically related donor and recipient. The conclusions from the A2ALL consortium have been critical in transplant advancement, supporting increased use to help decrease waitlist death and improve long-term survival of transplant recipients.

7 Years Experience of Living Donor Kidney Transplantation in Indonesia: A Retrospective Cohort Study

BACKGROUND

kidney transplantation has been developing rapidly in Indonesia in recent years, yet data on transplants' characteristics and survival is still unavailable. In Indonesia, only living donors are permitted. Living donor are advantageous, but challenging to recruit. This study aimed to establish the graft and patient survival rates and to describe the characteristics of recipient and donor as well as the process of donor recruitment and evaluation of kidney transplantation in Indonesia.

METHODS

the study was a retrospective cohort on all donors and kidney transplant recipients at Cipto Mangunkusumo General Hospital (CMGH) from January 2011 to May 2017. Only recipients from January 2011 to May 2014 were included to establish the 1-year and 3-year graft and patient survival; which were described using Kaplan-Meier method.

RESULTS

data from 492 kidney transplant procedures were obtained (donor median age, 30 (17 - 66) years; 25.1% were family-related. Recipients mean age, 47 (SD 13.18 years). Data from total of 138 kidney transplant recipients were further analyzed. The 1-year death- censored graft survival, all-cause graft survival and patient survival were 92 %, 82.6 % and 87%. The 3-year death-censored graft survival, all-cause graft survival and patient survival were 90.6%, 76.1% and 79.7%. Kaplan-Meier's curve showed the highest mortality rates occured in the early months.

CONCLUSION

the 1-year graft and patient survival rate were 92% and 87%. The 3-year graft and patient survival rate were 90.6% and 79.7%. Only small percentage of donor were family-related. Living donor recruitment and evaluation are still a big challenge in Indonesia.

Nephrolithiasis in living kidney donor: experience of nephrologists

BACKGROUND

Living kidney donation for transplantation has become common practice. The decisions to accept a donor with nephrolithiasis are becoming frequent.

AIM

The aim of our study was to report our experience in the living donor kidney with asymptomatic lithiasis.

METHODS

Over a period of 4 years from 2009 to 2013 we collected 18 cases. From the clinical, metabolic and radiological data, we have determined the etiology of urolithiasis in our patients and established, after a literature review, a decision tree of kidney donation.

RESULTS

Our study included 10 women and 8 men with a mean age of 43 years. The nephrolithiasis was discovered incidentally during radiological assessment through the urinary tract without preparation in 1 case, the abdominal ultrasound in 6 cases and the abdominal CT scan in 11 cases. The donation of kidney in our study was performed in 1 case and disqualified in the others cases especially for metabolic abnormalities. In the single couple donor-recipient, after a follow up of 5 years; we have not identified adverse side effects either in the donor or in the recipient patient.

CONCLUSION

In living donors with nephrolithiasis the final decision of renal transplantation must be based on the confrontation between the clinical, biological and radiological data. Metabolic disorders constituted the mainly contraindication of kidney donation in our patients.

Selection and Short-Term Outcomes of Living Kidney Donors in Singapore - An Analysis of the Donor Care Registry

INTRODUCTION

Transplant rates in Singapore have been falling and there is limited information on baseline characteristics and clinical outcomes of living kidney donors nationally. This study aimed to determine the safety of living kidney donor transplant in Singapore by exploring the proportion of donors that meets international selection guidelines and describing short-term clinical outcomes.

MATERIALS AND METHODS

We analysed 472 donors who underwent nephrectomies from 1 January 2010 to 31 December 2014 from the Donor Care Registry. We described donor characteristics against 5 international guidelines and measured post-nephrectomy outcomes in 150 local donors for up to 24 months. A multivariate analysis was performed to determine the baseline variables associated with poorer outcomes.

RESULTS

There were more foreign than local donors, with differences in gender and hospital types. Selection was generally aligned with international recommendations although 3.0% (using the Chronic Kidney Disease Epidemiology [CKD-EPI] equation) to 8.5% (using radionuclide and creatinine clearance methods) of donors had inappropriate baseline estimated glomerular filtration rates (eGFR) forage. Post-procedure, many foreign donors were lost to follow-up. Over 24 months, eGFR decreased by 33.8% from baseline before recovering gradually to 29.6%. During this period, only 2 donors were admitted for renal or urological conditions and there were no cases of end-stage renal failure or deaths. A lower baseline eGFR (HR: 1.05; 95% Cl, 1.02 to 1.09) and older age (HR: 1.04; 95% Cl, 1.00 to 1.08) were associated with a post-nephrectomy eGFR of less than 60 mL/kg/1.73 m².

CONCLUSION

Kidney donation is safe in Singapore. Donor selection is in keeping with international guidelines and short-term outcomes are comparable to other cohorts.

Apolipoprotein L1 Gene Effects on Kidney Transplantation

The pathogenesis of many common etiologies of nephropathy has been informed by recent molecular genetic breakthroughs. It now is apparent that the ethnic disparity in the risk for nondiabetic chronic kidney disease between African Americans and European Americans is explained largely by variation in the apolipoprotein L1 gene (APOL1). The presence of two APOL1 renal risk variants markedly increases an individual's risk for kidney disease. In transplantation, kidneys from deceased African Americans with two APOL1 renal risk variants have shorter survival intervals after engraftment, regardless of the ethnicity of the recipient. Precision medicine will transform the clinical practice of nephrology and kidney transplantation, and play an important role in the allocation of kidneys from deceased and living kidney donors with recent African ancestry. This article reviews existing data on APOL1 in deceased-donor and living-donor kidney transplantation. It considers the impact of including APOL1 genotyping in decisions on the allocation and discard of deceased-donor kidneys, as well as the selection of living donors.

[Outcome of living kidney donors for transplantation]

Nowadays, several treatments exist to treat terminal chronic renal failure. Best results for the recipients are obtained with kidney transplantation concerning mortality and quality of life. Transplantation is also the cheaper option for society. Living kidney donation raises the issue of the becoming of the donor, an absolutely healthy subject who gets to a surgical procedure. The becoming of living kidney donors has been compared with the one of controls subjects in several studies. The evaluations focused on the complications of nephrectomy in the short and long-term: kidney failure, hypertension, proteinuria, possibility of pregnancy, quality of life, and mortality. The first results did not show any risk linked to kidney donation, compared to general population. However, since 2013, kidney donors were found at higher risk for kidney failure and even for mortality, compared with controls selected like donor candidates. The risk of kidney donation is nevertheless acceptable and minimal, on the condition of rigorous selection of candidates and regular follow-up.

No significant differences in short-term renal prognosis between living kidney donors with and without diabetes

BACKGROUND

Renal prognosis in living kidney donors with diabetes is currently not known. In this study, we sought to investigate renal prognosis in living kidney donors with diabetes.

METHODS

We retrospectively investigated 241 living kidney donors who underwent nephrectomy at Jichi Medical University Hospital between January 2000 and December 2015. Donors with a follow-up period of less than 1 year were excluded. The remaining donors were divided into a diabetic group and a non-diabetic group. Their clinical parameters before donation and renal prognosis after donation were compared.

RESULTS

Of the 241 donors, 16 were excluded due to their follow-up period being less than 1 year. Of the remaining 225 donors, 14 were diabetic and 211 were non-diabetic. There were no significant differences in variables at pre-donation. The median follow-up period was 4.3 (1.5-10.7) and 4.6 (1.0-13.0) years in kidney donors with and without diabetes, respectively. At the end of follow-up, the estimated glomerular filtration rate was 51.7 ± 7.1 ml/min/1.73 m² in the diabetic group and 52.1 ± 12.2 ml/min/1.73 m² (p = 0.906) in the non-diabetic group; urine albumin excretion was 9.5 (2-251) mg/day (or mg/g creatinine) in the diabetic group and 6 (0-626) mg/day (or mg/g creatinine) in the non-diabetic group (p = 0.130); and urine protein excretion was 0.079 (0-0.41) g/day in the diabetic group and 0.051 (0-3.7) g/day in the non-diabetic group (p = 0.455).

CONCLUSIONS

There were no significant differences in short-term renal prognosis between kidney donors with and without diabetes.

Impact of screening for metabolic syndrome on the evaluation of obese living kidney donors

BACKGROUND

We report our experience with metabolic syndrome screening for obese living kidney donor candidates to mitigate the long-term risk of CKD.

METHODS

We retrospectively reviewed 814 obese (BMI≥30) and 993 nonobese living kidney donor evaluations over 12 years. Using logistic regression, we explored interactions between social/clinical variables and candidate acceptance before and after policy implementation.

RESULTS

Obese donor candidate acceptance decreased after metabolic syndrome screening began (56.3%, 46.3%, p < 0.01), while nonobese candidate acceptance remained similar (59.6%, 59.2%, p = 0.59). Adjusting for age, gender, race, BMI, and number of prior evaluations, acceptance of obese candidates decreased significantly more than nonobese (p = 0.025). In candidates without metabolic syndrome, there was no significant change in how age, sex, race, or BMI affected a donor candidate's probability of acceptance.

CONCLUSION

Metabolic syndrome screening is a simple stratification tool for centers with liberal absolute BMI cut-offs to exclude potentially higher-risk obese candidates.

Quantifying Postdonation Risk of ESRD in Living Kidney Donors

Studies have estimated the average risk of postdonation ESRD for living kidney donors in the United States, but personalized estimation on the basis of donor characteristics remains unavailable. We studied 133,824 living kidney donors from 1987 to 2015, as reported to the Organ Procurement and Transplantation Network, with ESRD ascertainment via Centers for Medicare and Medicaid Services linkage, using Cox regression with late entries. Black race (hazard ratio [HR], 2.96; 95% confidence interval [95% CI], 2.25 to 3.89; P<0.001) and male sex (HR, 1.88; 95% CI, 1.50 to 2.35; P<0.001) was associated with higher risk of ESRD in donors. Among nonblack donors, older age was associated with greater risk (HR per 10 years, 1.40; 95% CI, 1.23 to 1.59; P<0.001). Among black donors, older age was not significantly associated with risk (HR, 0.88; 95% CI, 0.72 to 1.09; P=0.3). Greater body mass index was associated with higher risk (HR per 5 kg/m2, 1.61; 95% CI, 1.29 to 2.00; P<0.001). Donors who had a first-degree biological relationship to the recipient had increased risk (HR, 1.70; 95% CI, 1.24 to 2.34; P<0.01). C-statistic of the model was 0.71. Predicted 20-year risk of ESRD for the median donor was only 34 cases per 10,000 donors, but 1% of donors had predicted risk exceeding 256 cases per 10,000 donors. Risk estimation is critical for appropriate informed consent and varies substantially across living kidney donors. Greater permissiveness may be warranted in older black candidate donors; young black candidates should be evaluated carefully.

Donor safety in living donor liver transplantation: The Korean organ transplantation registry study

Major concerns about donor safety cause controversy and limit the use of living donor liver transplantation to overcome organ shortages. The Korean Organ Transplantation Registry established a nationwide organ transplantation registration system in 2014. We reviewed the prospectively collected data of all 832 living liver donors who underwent procedures between April 2014 and December 2015. We allocated the donors to a left lobe group (n = 59) and a right lobe group (n = 773) and analyzed the relations between graft types and remaining liver volumes and complications (graded using the Clavien 5-tier grading system). The median follow-up was 19 months (range, 10-31 months). During the study period, 553 men and 279 women donated livers, and there were no deaths after living liver donation. The overall, biliary, and major complication (grade ≥ III) rates were 9.3%, 1.7%, and 1.9%, respectively. The graft types and remaining liver volume were associated with significantly different overall, biliary, and major complication rates. Of the 16 patients with major complications, 9 (56.3%) involved biliary complications (2 biliary strictures [12.5%] and 7 bile leakages [43.8%]). Among the 832 donors, the mean aspartate transaminase, alanine aminotransferase, and total bilirubin levels were 23.9 ± 8.1 IU/L, 20.9 ± 11.3 IU/L, and 0.8 ± 0.4 mg/dL, respectively, 6 months after liver donation. In conclusion, biliary complications were the most common types of major morbidity in living liver donors. Donor hepatectomy can be performed successfully with minimal and easily controlled complications. Our study shows that prospective, nationwide cohort data provide an important means of investigating the safety in living liver donation. Liver Transplantation 23 999-1006 2017 AASLD.

A Case-Based Analysis of Whether Living Related Donors Listed for Transplant Share ESRD Causes with Their Recipients

BACKGROUND AND OBJECTIVES

Two recent studies reported increased risk of ESRD after kidney donation. In both, the majority of ESRD was seen in those donating to a relative. Confounding this observation is that, in the absence of donation, relatives of those with ESRD are at increased risk for ESRD. Understanding the pathogenesis and risk factors for postdonation ESRD is critical for both donor selection and counseling.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We hypothesized that if familial relationship was an important consideration in pathogenesis, the donor and linked recipient would share ESRD etiology. We obtained information from the Organ Procurement and Transplantation Network (OPTN) on all living kidney donors subsequently waitlisted for a kidney transplant in the United States between January 1, 1996 and November 30, 2015, to determine (1) the donor-recipient relationship and (2) whether related donor-recipient pairs had similar causes of ESRD.

RESULTS

We found that a significant amount of information, potentially available at the time of listing, was not reported to the OPTN. Of 441 kidney donors listed for transplant, only 169 had information allowing determination of interval from donation to listing, and only 99 (22% of the total) had information on the donor-recipient relationship and ESRD etiology. Of the 99 donors, 87 were related to their recipient. Strikingly, of the 87, only a minority (23%) of donor-recipient pairs shared ESRD etiology. Excluding hypertension, only 8% shared etiology.

CONCLUSIONS

A better understanding of ESRD in donors requires complete and detailed data collection, as well as a method to capture all ESRD end points. This study highlights the absence of critical information that is urgently needed to provide a meaningful understanding of ESRD after kidney donation. We found that of living related donors listed for transplant, where both donor and recipient cause of ESRD is recorded, only a minority share ESRD etiology with their recipient.

Characteristics and Evaluation of Geographically Distant vs Geographically Nearby Living Kidney Donors

BACKGROUND

Living donor kidney transplant (LDKT) can be impeded by multiple barriers. One possible barrier to LDKT is a large physical distance between the living donor's home residence and the procuring transplant center.

METHODS

We performed a retrospective, single-center study of living kidney donors in the United States who were geographically distant (residing ≥150 miles) from our transplant center. Each distant donor was matched to 4 geographically nearby donors (<150 miles from our center) as controls.

RESULTS

From 2007 to 2010, of 429 live kidney donors, 55 (12.8%) were geographically distant. Black donors composed a higher proportion of geographically distant vs nearby donors (34.6% vs 15.5%), whereas Hispanic and Asian donors composed a lower proportion (P = .001). Distant vs nearby donors had similar median times from donor referral to actual donation (165 vs 161 days, P = .81). The geographically distant donors lived a median of 703 miles (25% to 75% range, 244 to 1072) from our center and 21.2 miles (25% to 75% range, 9.8 to 49.7) from the nearest kidney transplant center. The proportion of geographically distant donors who had their physician evaluation (21.6%), psychosocial evaluation (21.6%), or computed tomography angiogram (29.4%) performed close to home, rather than at our center, was low.

CONCLUSIONS

Many geographically distant donors live close to transplant centers other than the procuring transplant center, but few of these donors perform parts of their donor evaluation at these closer centers. Black donors comprise a large proportion of geographically distant donors. The evaluation of geographically distant donors, especially among minorities, warrants further study.

Access to Kidney Transplantation among HIV-Infected Waitlist Candidates

BACKGROUND AND OBJECTIVES

Kidney transplantation among HIV-infected patients with ESRD confers a significant survival benefit over remaining on dialysis. Given the high mortality burden associated with dialysis, understanding access to kidney transplantation after waitlisting among HIV+ candidates is warranted.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data from the Scientific Registry of Transplant Recipients were linked to Intercontinental Marketing Statistics pharmacy fills (January 1, 2001 to October 1, 2012) so that we could identify and study 1636 HIV+ (defined as having filled one or more antiretroviral medications unique to HIV treatment) and 72,297 HIV- kidney transplantation candidates.

RESULTS

HIV+ waiting list candidates were more often young (<50 years old: 62.7% versus 37.6%; P<0.001), were more often men (75.2% versus 59.3%; P<0.001), were more often black (73.6% versus 27.9%; P<0.001), had longer time on dialysis (years: 2.5 versus 0.8; P<0.001), were more often coinfected with hepatitis C virus (9.0% versus 3.9%; P<0.001), and were less likely to remain active on the waiting list (37.7% versus 49.4%; P<0.001). Waitlist mortality among HIV+ candidates was similar compared with HIV- candidates (adjusted hazard ratio, 1.03; 95% confidence interval, 0.89 to 1.20; P=0.67). In contrast, likelihood of living donor kidney transplantation was 47% lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.44 to 0.64; P<0.001), and there was a trend toward lower likelihood of deceased donor kidney transplantation (adjusted hazard ratio, 0.87; 95% confidence interval, 0.74 to 1.01; P=0.07) compared with in HIV- candidates.

CONCLUSIONS

Our findings highlight the need for additional study to better understand disparities in access to kidney transplantation, particularly living donor kidney transplantation, among HIV+ kidney waitlist candidates.

Adult to adult right lobe living donor liver transplantation: does biological relationship matter?

The influence of the biological relationship between the donor and the recipient is rarely discussed in living donor liver transplantation (LDLT), although it is believed to be an important risk factor in other types of organ transplantations. A total of 272 consecutive patients undergoing adult to adult right lobe LDLT were retrospectively analyzed and stratified into a nonbiologically related (NBR) group (69 patients) and a biologically related (BR) group (203 patients). The preoperative data and postoperative outcomes of both recipients and donors were evaluated.More than two-thirds of the recipients had histories of HBV infection, and hepatocellular carcinoma (HCC) was the main reason for the patients undergoing LDLT in both groups. The percentage of female donors in the NBR group was more than the percentage in the BR group (P = 0.000). There were no differences between the groups in postoperative laboratory testing or daily immunosuppression dose, and the complication rates in both the recipient and donor surgeries showed no significant differences. For patients with benign diseases, the cumulative 1-, 3-, 5-, and 10-year survival rate were 92.9% in the 4 periods in the NBR group and 89.1%, 87.6%, 83.7%, and 83.7%, respectively, in BR group, while for the patients diagnosed as HCC, if patients exceeding the Milan criteria were involved, the 5-year survival rate was 41.2%, compared to 82% for patients within the Milan criteria, which was nearly the same as for those with the benign disease. In conclusion, our findings suggested that the biological relationship between the donor and the recipient in adult to adult LDLT was not associated with the short- and long-term outcomes of recipients diagnosed with benign liver diseases and early stage HCC. Moreover, the criteria for patients diagnosed with HCC to undergo LDLT should be restrictively selected.

Simple Cysts in Donor Kidney Contribute to Reduced Allograft Function

BACKGROUND

Simple renal cysts may be an early marker of renal disease. We investigated whether simple cysts in donor kidney are associated with the decline of allograft function in living donor kidney transplantation.

METHODS

We retrospectively reviewed records of donors and recipients from 716 living donor kidney transplants performed between April 2007 and April 2015 in our hospital. Ninety-one donors with renal cysts and 64 recipients with cysts in donor kidney were noted. We compared these 64 cases to 128 no cyst-bearing controls matched for the donor gender, recipient gender, donor baseline serum creatinine (sCr), donor/recipient body surface area ratio, donor age, recipient age and the date of kidney transplantation in turn.

RESULTS

The presence of cysts was interrelated with age, gender and renal function independently in donors. Pathological findings of time-zero biopsy revealed that donor kidney harboring cysts existed more glomerular sclerosis compared with no cyst-bearing controls (p = 0.040). The estimating glomerular filtration rate levels of recipients were 80.82 ± 26.61 vs. 88.21 ± 23.12, 66.95 ± 17.42 vs. 72.15 ± 16.42 and 60.92 ± 22.17 vs. 68.72 ± 14.43 ml/min· 1.73 m2 in cyst-bearing and no cyst-bearing group on day 7, month 6 and year 5, respectively, after surgery (p < 0.05). The mean sCr were 112.14 ± 48.32 vs. 98.75 ± 29.71 and 126.28 ± 42.32 vs. 115.05 ± 26.35 μmol/l on the 7th day and a half year after transplant, respectively (p < 0.05). The 2 groups did not significantly differ in terms of the other characteristics.

CONCLUSION

Simple cysts in donor kidney can influence the early and long-term allograft function. In living donor transplantation, kidney presenting cysts should be considered carefully at the time of donor selection.

Delays in Prior Living Kidney Donors Receiving Priority on the Transplant Waiting List

BACKGROUND AND OBJECTIVES

Prior living donors (PLDs) receive very high priority on the Organ Procurement and Transplantation Network (OPTN) kidney waiting list. Program delays in adding PLDs to the waiting list, setting their status to active, and submitting requests for PLD priority can affect timely access to transplantation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used the OPTN and the Centers for Medicare and Medicaid Services data to examine timing of (1) listing relative to start of dialysis, (2) activation on the waiting list, and (3) requests for PLD priority relative to listing date. There were 210 PLDs (221 registrations) added to the OPTN kidney waiting list between January 1, 2010 and July 31, 2015.

RESULTS

As of September 4, 2015, 167 of the 210 PLDs received deceased donor transplants, six received living donor transplants, two died, five were too sick to transplant, and 29 were still waiting. Median waiting time to deceased donor transplant for PLDs was 98 days. Only 40.7% of 221 PLD registrations (n=90) were listed before they began dialysis; 68.3% were in inactive status for <90 days, 17.6% were in inactive status for 90-365 days, 8.6% were in inactive status for 1-2 years, and 5.4% were in inactive status for >2 years. Median time of PLDs waiting in active status before receiving PLD priority was 2 days (range =0-1450); 67.4% of PLDs received PLD priority within 7 days after activation, but 15.4% waited 8-30 days, 8.1% waited 1-3 months, 4.1% waited 3-12 months, and 5.0% waited >1 year in active status for PLD priority. After receiving priority, most were transplanted quickly. Median time in active status with PLD priority before deceased donor transplant was 23 days.

CONCLUSIONS

Fewer than one half of listed PLDs were listed before starting dialysis. Most listed PLDs are immediately set to active status and receive PLD priority quickly, but a substantial number spends time in active status without PLD priority or a large amount of time in inactive status, which affects access to timely transplants.

Long-Term Outcome of Kidney Transplantation in Recipients with Focal Segmental Glomerulosclerosis

BACKGROUND AND OBJECTIVES

FSGS can recur after kidney transplantation and is associated with poor graft outcomes. We aimed to assess the incidence of FSGS recurrence post-transplant and determine the effect of graft source on recurrence and graft survival in patients with biopsy-proven FSGS.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the Australian and New Zealand Dialysis and Transplant Registry, we assessed incidence of FSGS, the influence of donor type on the risk of FSGS recurrence, and graft loss in recipients with ESRD caused by primary FSGS using Kaplan-Meier and logistic regression analyses.

RESULTS

Between 1992 and 2011, 736 first kidney transplants were performed in 666 adults and 70 children (≤20 years old) with biopsy-proven primary FSGS. FSGS recurred in 76 (10.3%) patients. Younger age (P<0.001), nonwhite ethnicity (P=0.02), and having a live donor (P=0.02) were independent risk factors associated with recurrence. Median graft survival was significantly better for live donor compared with deceased donor grafts (14.8 versus 12.1 years; P<0.01). Disease recurrence predicted poor graft outcomes, with 52% (95% confidence interval, 40% to 63%) 5-year graft survival in the recurrence group compared with 83% (95% confidence interval, 79% to 86%) in the group without recurrent disease (P<0.001).

CONCLUSIONS

FSGS recurrence after kidney transplantation was more common in live donor kidneys. Despite this, graft survival in live donor recipients was significantly better for both children and adults with FSGS. We propose that live donor transplantation should not be avoided in patients with FSGS.

Increasing the Quantity of Lungs for Transplantation Using High-Frequency Chest Wall Oscillation: A Proposal

The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.