Neonatal organ donation: Retrospective audit into potential donation in a single neonatal unit

BACKGROUND

Research has shown that many babies who die in neonatal units could have been potential tissue and/or organ donors. Despite the existence of guidelines supporting its implementation, the incidence of neonatal donation remains rare in the United Kingdom.

AIM

The aim of this audit was to retrospectively determine potential eligibility for neonatal tissue and/or organ donation referral in infants who died in a single UK tertiary-level neonatal unit between 2012 and 2021. Cause of death and documentation of any discussions held regarding referral for donation were also explored.

STUDY DESIGN

An audit was undertaken to identify all neonatal deaths at a single tertiary-level NICU in London from 2012-2021. Infants who retrospectively could have been referred as potential tissue and/or organ donors were identified using current NHS Blood and Transplant inclusion and exclusion criteria.

RESULTS AND CONCLUSION

A significant missed potential for neonatal tissue and/or organ donation referrals was identified, which is likely not just limited to the unit audited. Causes of death were as expected for a tertiary level neonatal unit and centre for therapeutic cooling of babies born with hypoxic perinatal brain injuries. Only one documented conversation was found regarding neonatal donation.

RELEVANCE TO CLINICAL PRACTICE

To enable conversations regarding neonatal donation to become a routine part of end-of-life care discussions with families as appropriate, good links between neonatal healthcare professionals and Specialist Nurses in Organ Donation need to be established. This will facilitate the referral of all suitable neonates as potential donors and ensure that neonatal staff feel supported to care for babies identified as potential donors.

From Patients to Providers: Assessing Impact of Normothermic Machine Perfusion on Liver Transplant Practices in the US

BACKGROUND

Normothermic machine perfusion (NMP) of livers allows for the expansion of the donor pool and minimization of posttransplant complications. Results to date have focused on both donor and recipient outcomes, but there remains potential for NMP to also impact transplant providers.

STUDY DESIGN

Using United Network for Organ Sharing Standard Transplant Analysis file data, adult deceased donors who underwent transplantation between January 1, 2016, and December 31, 2022, were identified. Transplanted livers were divided by preservation methods (static cold storage [SCS] and NMP) and case time (day-reperfusion 8 am to 6 pm ). Patient factors, transplant characteristics, and short-term outcomes were analyzed between Mahalanobis-metric-matched groups.

RESULTS

NMP livers represented 742 (1.4%) of 52,132 transplants. NMP donors were more marginal with higher Donor Risk Index scores (1.78 ± 0.50 NMP vs 1.49 ± 0.38 SCS, p < 0.001) and donation after cardiac death frequency (36.9% vs 8.4%, p < 0.001). NMP recipients more often had model for end-stage liver disease (MELD) exception status (29.9% vs 23.4%, p < 0.001), lower laboratory MELD scores (20.7 ± 9.7 vs 24.3 ± 10.9, p < 0.001), and had been waitlisted longer (111.5 [21.0 to 307.0] vs 60.0 [9.0 to 245.0] days, p < 0.001). One-year graft survival (90.2% vs 91.6%, p = 0.505) was similar between groups, whereas length of stay was lower for NMP recipients (8.0 [6.0 to 14.0] vs 10.0 [6.0 to 16.0], p = 0.017) after adjusting for confounders. Notably, peak case volume occurred at 11 am with NMP livers (vs 9 pm with SCS). Overall, a higher proportion of transplants was performed during daytime hours with NMP (51.5% vs 43.0%, p < 0.001).

CONCLUSIONS

NMP results in increased use of marginal allografts, which facilitated transplantation in lower laboratory MELD recipients who have been waitlisted longer and often have exception points. Importantly, NMP also appeared to shift peak caseloads from nighttime to daytime, which may have significant effects on the quality of life for the entire liver transplant team.

Influence of sex on outcomes of liver transplantation for hepatocellular carcinoma: a multicenter cohort study in China

OBJECTIVE

Sex-specific differences are observed in various liver diseases, but the influence of sex on the outcomes of hepatocellular carcinoma (HCC) after liver transplantation (LT) remains to be determined. This study is the first Chinese nationwide investigation of the role of sex in post-LT outcomes in patients with HCC.

METHODS

Data for recipients with HCC registered in the China Liver Transplant Registry between January 2015 and December 2020 were analyzed. The associations between donor, recipient, or donor-recipient transplant patterns by sex and the post-LT outcomes were studied with propensity score matching (PSM). The survival associated with different sex-based donor-recipient transplant patterns was further studied.

RESULTS

Among 3,769 patients enrolled in this study, the 1-, 3-, and 5-year overall survival (OS) rates of patients with HCC after LT were 96.1%, 86.4%, and 78.5%, respectively, in female recipients, and 95.8%, 79.0%, and 70.7%, respectively, in male recipients after PSM (P = 0.009). However, the OS was comparable between recipients with female donors and male donors. Multivariate analysis indicated that male recipient sex was a risk factor for post-LT survival (HR = 1.381, P = 0.046). Among the donor-recipient transplant patterns, the male-male donor-recipient transplant pattern was associated with the poorest post-LT survival (P < 0.05).

CONCLUSIONS

Our findings highlighted that the post-LT outcomes of female recipients were significantly superior to those of male recipients, and the male-male donor-recipient transplant pattern was associated with the poorest post-LT survival. Livers from male donors may provide the most benefit to female recipients. Our results indicate that sex should be considered as a critical factor in organ allocation.

We want to feel valued: eggs donors' experiences of donation

Egg donation in New Zealand is identity-release, with donor-conceived individuals having the right to access donors' identifying information at the age of 18. It also allows donors and previously unknown recipients to meet prior to donation. Further, donation is altruistic, although reimbursement of costs is possible. In our previous paper we explored the motivations of 21 egg donors in this context and reported that they are motivated to donate as an act of personal gift-giving to recipients who may become known to them through donation, and that they do not want to be compensated for this financially. In this paper, drawing on in-depth interviews, we report on donors' experiences of the donation process and subsequent to donation. Donors understood their donations to be a significant act, both for the recipients and their families, but also for themselves, particularly given the multiple sacrifices which they willingly made. Donors wished for their gift and their role to be valued and acknowledged through being appreciated, informed, involved and supported by recipients and clinics before, during and after their donations. These findings have implications for clinical practice and care, offering insight into how best to support donors prior and subsequent to donation.

Impact of donor kidney biopsy on kidney yield and posttransplant outcomes

Procurement biopsy is performed to determine kidney quality, but evidence supporting such association is poor. We investigated the impact of glomerulosclerosis percentage (GS%) on kidney yield and patient outcomes. Information on deceased kidney donors from July 1, 2017, to June 30, 2019, was collected. Association between GS% and kidney yield (number of kidneys procured per donor) and posttransplant graft and patient outcomes were studied. Maximal GS% and minimal GS% were calculated to determine the relationship between GS% and kidney yield; minimal GS% only for correlation with posttransplant outcomes. Multinomial logistic regression and Cox models with least absolute shrinkage and selection operator were used to analyze the association of GS% with kidney yield and posttransplant outcomes, respectively. The kidney yield was 1.63 when maximal GS% and minimal GS% were <5%, but was 0.88 when both GS% were >20%. The hazard ratio for graft failure 1 year after transplant was 1.05 when minimal GS% was 16% to 20%, but was 1.3 for GS% of >20%. The hazard ratio for mortality increased from 1 to 1.2 when minimal GS% reached >20%. In summary, higher GS% was associated with lower kidney yield and inferior posttransplant outcomes. Incorporation of GS% into Scientific Registry of Transplant Recipients models may reassure organ procurement organizations and transplant centers pursuing kidneys with relatively high GS% levels, thereby reducing kidney discard rates.

Combined Donor-Recipient Obesity and the Risk of Graft Loss After Kidney Transplantation

Background: As the prevalence of obesity increases globally, appreciating the effect of donor and recipient (DR) obesity on graft outcomes is of increasing importance.

Methods: In a cohort of adult, kidney transplant recipients (2000–2017) identified using the SRTR, we used Cox proportional hazards models to examine the association between DR obesity pairing (body mass index (BMI) &gt;30 kg/m2), and death-censored graft loss (DCGL) or all-cause graft loss, and logistic regression to examine risk of delayed graft function (DGF) and ≤30 days graft loss. We also explored the association of DR weight mismatch (&gt;30 kg, 10-30 kg (D&gt;R; D&lt;R) and &lt;10 kg (D = R)) with each outcome, stratifying by DR obesity pairing.

Results: Relative to non-obese DR, obese DR were highest risk for all outcomes (DCGL: HR 1.26, 95% CI 1.22–1.32; all-cause graft loss: HR 1.09, 95% CI 1.06–1.12; DGF: OR 1.98, 95% CI 1.89–2.08; early graft loss: OR 1.34, 95% CI 1.19–1.51). Donor obesity modified the risk of recipient obesity and DCGL [p = 0.001] and all-cause graft loss [p &lt; 0.001] but not DGF or early graft loss. The known association of DR weight mismatch with DCGL was attenuated when either the donor or recipient was obese.

Conclusion: DR obesity status impacts early and late post-transplant outcomes.

Clinical Utility of COVID-19 Real Time-Polymerase Chain Reaction Testing of Ocular Tissues of Non-COVID-19 Cornea Donors Deemed Suitable for Corneal Retrieval and Transplantation

PURPOSE

The purpose of this study was to evaluate the prevalence of SARS-CoV-2 in human postmortem ocular tissues of asymptomatic donors and its implications on our eye banking protocols.

METHODS

The expression of SARS-CoV-2 RNA was assessed by reverse transcription-polymerase chain reaction in corneal rims and conjunctival tissues from 100 donors who were found suitable for transplantation as per the donor screening guidelines of the Global Alliance of Eye Bank Associations. The donor's clinical history and cause of death were assessed for secondary analysis.

RESULTS

Of 200 ocular tissues (100 corneal and 100 conjunctival) from the same 1 eye of 100 surgical-intended donors, between September 2020 and April 2021, the overall positivity rate for SARS-CoV-2 was ∼1% (2/200). Both the ocular samples that tested positive were conjunctival biopsies (2/100, 2%), whereas corneal samples were negative (0/100, 0%) in both donors. The causes of donor death were trauma in 51 donors, suicide in 33, cardiac arrest in 7, electric shock in 5, metabolic cause in 2, malignancy in 1, and snake bite in 1. None of the donors had a medical history suggestive of COVID infection or possible contact. None of the recipients from the donors were reported to have any systemic adverse event after keratoplasty until the follow-up of 6 weeks.

CONCLUSIONS

The overall prevalence of SARS-CoV-2 was 1% (2% for conjunctival and 0% for corneal samples, P value = 0.5) in the donors who were found suitable for cornea recovery and transplantation. The findings of exceptionally low positive rates in our samples validate the criticality of history-based donor screening and do not support the necessity of postmortem PCR testing as a criterion for procurement and subsequent use for corneal transplantation.

Hepatic macrosteatosis in the US pediatric deceased liver donor population

INTRODUCTION

The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors.

METHODS

We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model.

RESULTS

From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05).

CONCLUSION

Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.

Risk and Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Infection on Corneal Transplantation: A Case-Control Study

PURPOSE

The purpose of this study was to evaluate the risk of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection after corneal transplantation surgery, with cataract surgeries as controls, and the impact of the novel coronavirus disease pandemic in the clinical and surgical complications of corneal transplantation and cataract surgeries.

METHODS

A retrospective matched case-control study of 480 consecutive individuals who underwent surgery at the Bascom Palmer Eye Institute between May 2020 and November 2020. A total of 240 patients who underwent corneal transplantation with tissue obtained from the Florida Lions Eye Bank were age, race, ethnicity, and sex matched with 240 patients who underwent cataract surgery during the same day and by the same surgical team. Only the first corneal transplant or cataract surgery during this period was considered for each individual. All donors and recipients were deemed SARS-CoV-2 negative by a nasopharyngeal polymerase chain reaction test before surgery. Postoperative SARS-CoV-2 infections were defined as previously SARS-CoV-2(-) individuals who developed symptoms or had a positive SARS-CoV-2 polymerase chain reaction test during the first postoperative month.

RESULTS

Mean age, sex, race, and ethnicity were similar between groups. There were no differences between the corneal transplant and cataract groups in the rates of SARS-CoV-2 infection before (5.8% vs. 7.5%, P= 0.6) or after surgery (2.9% vs. 2.9%, P = 1). The rates of postoperative complications did not increase during the pandemic, compared with previously reported ranges.

CONCLUSIONS

In this study, postoperative SARS-CoV-2 infection was similar for individuals undergoing corneal transplantation or cataract surgery. Further research is required to evaluate the transmission of SARS-CoV-2 through corneal tissue.

Inactive status is an independent predictor of liver transplant waitlist mortality and is associated with a transplant centers median meld at transplant

BACKGROUND

Approximately 30% of patients on the liver transplant waitlist experience at least one inactive status change which makes them temporarily ineligible to receive a deceased donor transplant. We hypothesized that inactive status would be associated with higher mortality which may differ on a transplant centers' or donor service areas' (DSA) Median MELD at Transplant (MMaT).

METHODS

Multi-state models were constructed (OPTN database;06/18/2013-06/08/2018) using DSA-level and transplant center-level data where MMaT were numerically ranked and categorized into tertiles. Hazards ratios were calculated between DSA and transplant center tertiles, stratified by MELD score, to determine differences in inactive to active transition probabilities.

RESULTS

7,625 (30.2% of sample registrants;25,216 total) experienced at least one inactive status change in the DSA-level cohort and 7,623 experienced at least one inactive status change in the transplant-center level cohort (30.2% of sample registrants;25,211 total). Inactive patients with MELD≤34 had a higher probability of becoming re-activated if they were waitlisted in a low or medium MMaT transplant center or DSA. Transplant rates were higher and lower re-activation probability was associated with higher mortality for the MELD 26-34 group in the high MMaT tertile. There were no significant differences in re-activation, transplant probability, or waitlist mortality for inactivated patients with MELD≥35 regardless of a DSA's or center's MMaT.

CONCLUSION

This study shows that an inactive status change is independently associated with waitlist mortality. This association differs by a centers' and a DSAs' MMaT. Prioritization through care coordination to resolve issues of inactivity is fundamental to improving access.

Impact of human papillomavirus infection on semen parameters and reproductive outcomes

BACKGROUND

Human papillomavirus (HPV) has been shown to adversely affect human reproduction. We aimed to evaluate the prevalence of human papillomavirus (HPV) infection in men and its correlation with semen parameters and reproductive outcomes.

METHODS

Semen samples and penile swabs were collected from potential sperm donors (SD, n = 97) and male partners of infertile couples (IM, n = 328). The presence of HPV DNA in semen samples and penile swabs was analyzed. Associations between hrHPV positive status and fertility outcomes as well as socio-behavioral and health characteristics were evaluated using the R software package.

RESULTS

High-risk HPV (hrHPV) genotypes were detected in 28.9% of SD and 35.1% of IM (P = 0.312). Penile swabs were more frequently positive for hrHPV genotypes than semen samples in both IM (32.3% vs. 11.9%, P < 0.001) and SD (26.8% vs. 6.2%, P = 0.006). Men with hrHPV positive semen samples had lower semen volume (median volume 2.5 ml vs. 3 ml, P = 0.009), sperm concentration (median concentration 16 × 10⁶/ml vs. 31 × 10⁶/ml, P = 0.009) and total sperm count (median count 46 × 10⁶ vs. 82 × 10⁶, P = 0.009) than men with hrHPV negative samples. No association was identified between penile hrHPV status and semen parameters.

CONCLUSIONS

Our findings indicate that penile HPV infection is common in both potential sperm donors and men from infertile couples. Although HPV positivity is higher in penile swabs, only HPV infection in semen samples affects sperm parameters. However, there was no association between hrHPV positivity in semen and fertility outcomes including abortion rate.

Associations Among Different Domains of Quality Among US Liver Transplant Programs

Importance

US liver transplant programs have traditionally been evaluated on 1-year patient and graft survival. However, there is concern that a narrow focus on recipient outcomes may not incentivize programs to improve in other ways that would benefit patients with end-stage liver disease.

Objective

To determine the correlation among different potential domains of quality for adult liver transplant programs.

Design, Setting, and Participants

This retrospective cohort study was conducted from 2014 to 2019 among adult liver transplant programs included in the United Network for Organ Sharing and Scientific Registry of Transplant Recipients program-specific reports. Liver transplant programs in the United States completing at least 10 liver transplants per year were included. Data were analyzed from March 2 to August 13, 2020.

Main Outcomes and Measures

The potential domains of quality examined included recipient outcomes (1-year graft and patient survival), aggressiveness (ie, marginal graft use, defined as the rate of use of donors with body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 40, age older than 65 years, or deceased by cardiac death), and waiting list management (ie, waiting list mortality). The correlation among measures, aggregated at the center level, was evaluated using linear regression to control for mean Model for End Stage Liver Disease-Sodium score at organ allocation. The extent to which programs were able to achieve high quality across multiple domains was also evaluated.

Results

Among 114 transplant programs that performed a total of 44 554 transplants, the mean (SD) 1-year graft and patient survival was 90.3% (3.0%) with a total range of 75.9% to 96.6%. The mean (SD) waiting list mortality rate was 16.7 (6.1) deaths per 100 person-years, with a total range of 6.3 to 53.0 deaths per 100 person years. The mean (SD) marginal graft use rate was 15.8 (8.8) donors per 100 transplants, with a total range of 0 to 49.3 donors. There was no correlation between 1-year graft and patient survival and waiting list mortality (β = -0.053; P = .19) or marginal graft use (β = -0.007; P = .84) after correcting for mean allocation Model for End Stage Liver Disease-Sodium scores. There were 2 transplant programs (1.8%) that performed in the top quartile on all 3 measures, while 4 transplant programs (3.6%) performed in the bottom quartile on all 3 measures.

Conclusions and Relevance

This cohort study found that among US liver transplant programs, there were no correlations among 1-year recipient outcomes, measures of program aggressiveness, or waiting list management. These findings suggest that a program's performance in one domain may be independent and unrelated to its performance on others and that the understanding of factors contributing to these domains is incomplete.

Cytomegalovirus Serostatus and Functional Impairment in Liver Transplant Recipients in the Current Era

BACKGROUND

Whether donor (D+) or recipient (R+) cytomegalovirus (CMV) seropositivity is associated with functional impairment in liver transplant recipients is not known.

METHODS

Patients included adult liver transplant recipients in the Organ Procurement and Transplantation Network database transplanted over a five-year period from 1 January 2014-31 December 2018. Functional status in the database was assessed using Karnofsky performance scale. A logistic regression model that controlled for potential confounders was used to examine the association of CMV serostatus and functional status. Variables significantly associated with functional status (p < 0.05) were then used to develop propensity score and propensity score matched analysis was conducted where each patient was compared with a matched-control with the same propensity score.

RESULTS

Among 30,267 adult liver transplant recipients, D+ or R+ patients had significantly lower functional status at last follow-up than the D-R- cohort (OR 0.88, 95% CI 0.80-0.96, p = 0.007). In propensity score matched model, D+ or R+ patients had significantly lower functional status than matched-controls (p = 0.009). D+ or R+ CMV serostatus (p = 0.018) and low functional level (p < 0.001) were also independently associated with infections as cause-of-death.

CONCLUSIONS

D+ or R+ liver transplant recipients had lower functional status and higher risk of deaths due to infections. Future studies are warranted to examine the mechanistic basis of these findings in the setting of transplantation.

Unexpected Hepatitis B Virus Infection After Liver Transplantation - United States, 2014-2019

Unexpected donor-derived hepatitis B virus (HBV) infection is defined as a new HBV infection in a recipient of a transplanted organ from a donor who tested negative for total antihepatitis B core antibody (total anti-HBc), hepatitis B surface antigen (HBsAg), and HBV DNA* before organ procurement. Such infections are rare and are associated with injection drug use among deceased donors (1). During 2014-2019, CDC received 20 reports of HBV infection among recipients of livers from donors who had no evidence of past or current HBV infection. Investigation included review of laboratory data and medical records. Fourteen of these new HBV infections were detected during 2019 alone; infections were detected a median of 38 (range = 5-116) weeks after transplantation. Of the 14 donors, 13 were hepatitis C virus (HCV)-seropositive^† and had a history of injection drug use within the year preceding death, a positive toxicology result, or both. Because injection drug use is the most commonly reported risk factor for hepatitis C,^§ providers caring for recipients of organs from donors who are HCV-seropositive or recently injected drugs should maintain awareness of infectious complications of injection drug use and monitor recipients accordingly (2). In addition to testing for HBV DNA at 4-6 weeks after transplantation, clinicians caring for liver transplant recipients should consider testing for HBV DNA 1 year after transplantation or at any time if signs and symptoms of viral hepatitis develop, even if previous tests were negative (2).

Effects of the duration of bridge to lung transplantation with extracorporeal membrane oxygenation

Background

Although bridge to lung transplantation (BTT) with extracorporeal membrane oxygenation (ECMO) is increasingly performed, the impact of BTT and its duration on post-transplant outcomes are unclear.

Methods

We retrospectively reviewed medical records of adult patients who underwent lung or heart-lung transplantation in our institution between January 2008 and December 2018. Data were compared in patients who did (n = 41; BTT) and did not (n = 36; non-BTT) require pre-transplant ECMO support. Data were also compared in patients who underwent short-term (<14 days; n = 21; ST-BTT) and long-term (≥14 days; n = 20; LT-BTT) BTTs.

Results

Among 77 patients included, 51 (66.2%) were male and median age was 53 years. The median bridging time in the BTT group was 13 days (interquartile range [IQR], 7–19 days). Although simplified acute physiologic score II was significantly higher in the BTT group (median, 35; IQR, 31–49 in BTT group vs. median, 12; IQR, 7–19 in non-BTT group; p<0.001), 1-year (73.2% vs. 80.6%; p = 0.361) and 5-year (61.5% vs. 61.5%; p = 0.765) post-transplant survival rates were comparable in both groups. Comparison of ST- and LT-BTT subgroups showed that 1-year (90.5% vs. 55.0%; p = 0.009) and 5-year (73.0% vs. 48.1%; p = 0.030) post-transplant survival rates were significantly higher in ST-BTT group. In age and sex adjusted model, the LT-BTT was an independent risk factor for 1-year post-transplant mortality (hazard ratio, 3.019; 95% confidence interval, 1.119–8.146; p = 0.029), whereas the ST-BTT was not.

Conclusions

Despite the severe illness, the BTT group showed favorable post-transplantation outcomes, particularly those bridged for less than 14 days.

Heterogeneous Circles for Liver Allocation

BACKGROUND AND AIMS

In February 2020, the Organ Procurement and Transplantation Network replaced donor service area-based allocation of livers with acuity circles, a system based on three homogeneous circles around each donor hospital. This system has been criticized for neglecting to consider varying population density and proximity to coast and national borders.

APPROACH AND RESULTS

Using Scientific Registry of Transplant Recipients data from July 2013 to June 2017, we designed heterogeneous circles to reduce both circle size and variation in liver supply/demand ratios across transplant centers. We weighted liver demand by Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) because higher MELD/PELD candidates are more likely to be transplanted. Transplant centers in the West had the largest circles; transplant centers in the Midwest and South had the smallest circles. Supply/demand ratios ranged from 0.471 to 0.655 livers per MELD-weighted incident candidate. Our heterogeneous circles had lower variation in supply/demand ratios than homogeneous circles of any radius between 150 and 1,000 nautical miles (nm). Homogeneous circles of 500 nm, the largest circle used in the acuity circles allocation system, had a variance in supply/demand ratios 16 times higher than our heterogeneous circles (0.0156 vs. 0.0009) and a range of supply/demand ratios 2.3 times higher than our heterogeneous circles (0.421 vs. 0.184). Our heterogeneous circles had a median (interquartile range) radius of only 326 (275-470) nm but reduced disparities in supply/demand ratios significantly by accounting for population density, national borders, and geographic variation of supply and demand.

CONCLUSIONS

Large homogeneous circles create logistical burdens on transplant centers that do not need them, whereas small homogeneous circles increase geographic disparity. Using carefully designed heterogeneous circles can reduce geographic disparity in liver supply/demand ratios compared with homogeneous circles of radius ranging from 150 to 1,000 nm.

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.

Long-term adult congenital heart disease survival after heart transplantation: A restricted mean survival time analysis

BACKGROUND

Adult Congenital Heart Disease (ACHD) heart transplant recipients may have lower post-transplant survival resulting from higher peri-operative mortality than non-ACHD patients. However, the late risk of mortality appears lower in ACHD recipients. This study seeks to establish whether long-term heart transplant survival is reduced among ACHD recipients relative to non-ACHD recipients.

METHODS

Adult patients who received a heart transplant between January, 2000 and December, 2019 in the United Network for Organ Sharing database were stratified by the presence of ACHD. Propensity-matched cohorts (1:4) were created to adjust for differences between groups. Graft survival at time points from 1 to 18 years was compared between groups using restricted mean survival time (RMST) analysis.

RESULTS

The matched cohort included 1,139 ACHD and 4,293 non-ACHD patients. Median age was 35 years and 61% were male. Average survival time at 1 year was 0.85 years for ACHD patients and 0.93 years for non-ACHD patients (average difference: -0.08 years, 95% Confidence Interval [CI] -0.10 to -0.06, p < 0.001), reflecting higher immediate post-transplant mortality. Average survival time at 18 years was not clinically or statistically different: 11.14 years for ACHD patients and 11.40 years for non-ACHD patients (average difference: -0.26 years, 95% CI: -0.85 to + 0.32 years, p = 0.38).

CONCLUSIONS

Despite increased medium-term mortality among ACHD patients after heart transplant, differences in long-term survival are minimal. Allocation of hearts to ACHD patients results in acceptable utility of donor hearts.

Donor Factors Associated with Familial Consent for Organ Donation among Trauma Casualties: a 10-Year Retrospective Study

BACKGROUND

Consent rates for organ donation remain one of the most important factors determining the number of organs available for transplantation. Trauma casualties constitute a substantial part of the deceased organ donor pool and have unique characteristics that distinguish them from the general donor population. However, this group has not been extensively studied.

OBJECTIVES

To identify donor factors associated with positive familial consent for solid organ donation among trauma casualties.

METHODS

This retrospective study included all trauma casualties who were admitted to the Rabin Medical Center, Beilinson hospital, during the period from January 2008 to December 2017, who were potential organ donors. Data collected included demographic features, the nature of the injury, surgical interventions, and which organs were donated. Data was collected from the Rabin Medical Center Trauma Registry.

RESULTS

During the study period 24,504 trauma patients were admitted and 556 died over their hospital course. Of these 76 were potential donors, of whom 32 became actual donors and donated their organs. Two factors showed a statistically significant correlation to donation, namely female gender (P = 0.018) and Jewish religion of the deceased (P = 0.032).

CONCLUSIONS

Only a small group of in hospital trauma deaths were potential solid organ donors (13.7%) and less than half of these became actual donors. Consent rates were higher when the deceased was female or Jewish.

Geographic Differences in Lung Transplant Volume and Donor Availability During the COVID-19 Pandemic

BACKGROUND

Regional variation in lung transplantation practices due to local coronavirus disease 2019 (COVID-19) prevalence may cause geographic disparities in access to lung transplantation.

METHODS

Using the United Network for Organ Sharing registry, we conducted a descriptive analysis of lung transplant volume, donor lung volume, new waitlist activations, and waiting list deaths at high-volume lung transplant centers during the first 3 months of the pandemic (March 1. 2020, to May 30, 2020) and we compared it to the same period in the preceding 5 years.

RESULTS

Lung transplant volume decreased by 10% nationally and by a median of 50% in high COVID-19 prevalence centers (range -87% to 80%) compared with a median increase of 10% (range -87% to 80%) in low prevalence centers (P-for-trend 0.006). Donation services areas with high COVID-19 prevalence experienced a greater decrease in organ availability (-28% range, -72% to -11%) compared with low prevalence areas (+7%, range -20% to + 55%, P-for-trend 0.001). Waiting list activations decreased at 18 of 22 centers. Waiting list deaths were similar to the preceding 5 years and independent of local COVID-19 prevalence (P-for-trend 0.36).

CONCLUSIONS

Regional variation in transplantation and donor availability in the early months of the pandemic varied by local COVID-19 activity.

The effect of donor and recipient race on outcomes of assisted reproduction

BACKGROUND

A growing literature suggests that minority races, particularly Black women, have a lower probability of live birth and higher risk of perinatal complications after autologous assisted reproductive technology. However, questions still remain as to whether these racial disparities have arisen because of associations between race and oocyte/embryo quality, the uterine environment, or a combination of the two. Oocyte donation assisted reproductive technology represents a unique approach to examine this question.

OBJECTIVE

This study aimed to evaluate the associations between the race of female oocyte donors and recipients and live birth rates following vitrified donor oocyte assisted reproductive technologies.

STUDY DESIGN

This was a retrospective study conducted at a single, private fertility clinic that included 327 oocyte donors and 899 recipients who underwent 1601 embryo transfer cycles (2008-2015). Self-reported race of the donor and recipient were abstracted from medical records. Live birth was defined as the delivery of at least 1 live-born neonate. We used multivariable cluster weighted generalized estimating equations with binomial distribution and log link function to estimate the adjusted risk ratios of live birth, adjusting for donor age and body mass index, recipient age and body mass index, tubal and uterine factor infertility, and year of oocyte retrieval.

RESULTS

The racial profile of our donors and recipients were similar: 73% white, 13% Black, 4% Hispanic, 8% Asian, and 2% other. Women who received oocytes from Hispanic donors had a significantly higher probability of live birth (adjusted risk ratio, 1.20; 95% confidence interval, 1.05-1.36) than women who received oocytes from white donors. Among Hispanic recipients, however, there was no significant difference in probability of live birth compared with white recipients (adjusted risk ratio, 1.07; 95% confidence interval, 0.90-1.26). Embryo transfer cycles using oocytes from Black donors (adjusted risk ratio, 0.86; 95% confidence interval, 0.72-1.03) and Black recipients (adjusted risk ratio, 0.84; 95% confidence interval, 0.71-0.99) had a lower probability of live birth than white donors and white recipients, respectively. There were no significant differences in the probability of live birth among Hispanic, Asian, and other race recipients compared with white recipients.

CONCLUSION

Black female recipients had a lower probability of live birth following assisted reproductive technology, even when using vitrified oocytes from healthy donors. Female recipients who used vitrified oocytes from Hispanic donors had a higher probability of live birth regardless of their own race.

Metabolomics data complemented drug use information in epidemiological databases: pilot study of potential kidney donors

OBJECTIVE

The objective of this study was to investigate whether clinical metabolomics, which is increasingly applied in population-based and epidemiological studies, can be used to provide analytical evidence of exposures, and whether such information can be useful to strengthen and/or complement corresponding clinical database entries, taking drug use as an example.

STUDY DESIGN AND SETTING

Liquid chromatography-mass spectrometry (LC-MS) metabolomics analyses were performed on urine from 100 randomly-selected control subjects (50% females) from the TransplantLines Food and Nutrition Biobank and Cohort Study (NCT identifier 'NCT02811835'), and drugs were identified through spectral library searching and targeted signal extraction.

RESULTS

In 83 subjects for whom drug use information was available, 22 expected and 26 unexpected prescription-only drugs were identified, while 28 expected prescription-only drugs remained undetected. In addition, 7 prescription-only drugs were found in 17 subjects for whom drug use information was unavailable, and 58 over-the-counter drugs were identified in all 100 subjects.

CONCLUSION

Molecular evidence for many drugs could be retrieved from LC-MS metabolomics data, which could be useful to complement and strengthen epidemiological databases given that considerable discrepancies were found between analytically-identified drugs and drugs listed in the available clinical database.

The Impact of Mortality Salience on Organ Donation Attitude, Beliefs, and Behavior

The current study examines the relationship between mortality salience and attitude, beliefs, and behavior toward organ donor registration. Participants (N = 484) completed a laboratory study in a 2 (mortality salience vs. control) x 2 (processing: distal vs. proximal) between-subjects factorial design. Dependent variables included death thought accessibility, attitude, information seeking, and organ donation beliefs (bodily integrity, ick, jinx, and medical mistrust). Differences between conditions were examined with independent samples t-tests and χ2 analyses. Participants in the mortality salience condition reported greater death thought accessibility than those in the control; however, no difference in attitude nor information seeking (non-donors only) was found between the two conditions. No difference in attitude nor information seeking (non-donors only) was observed between participants engaging in distal versus proximal defensive processing. Participants in the mortality salience condition reported higher medical mistrust and bodily integrity than those in the control condition; no difference between ick or jinx was found between the two conditions. Theoretical and practical implications are discussed.

Evaluation and selection of the liver transplant candidate: updates on a dynamic and evolving process

PURPOSE OF REVIEW

Although conceptually unchanged, the evaluation and selection of the liver transplant candidate has seen significant recent advances. Expanding criteria for transplant candidacy, improved diagnostics for risk stratification and advances in prognostic models have paralleled recent changes in allocation and distribution that require us to revisit core concepts of candidate evaluation and selection while recognizing its now dynamic and continuous nature.

RECENT FINDINGS

The liver transplant evaluation revolves around three interrelated themes: candidate selection, donor selection and transplant outcome. Introduction of dynamic frailty indices, bariatric surgery at the time of liver transplant in obese patients and improved therapies and prognostic tools for hepatobiliary malignancy have transformed candidate selection. Advances in hypothermic organ preservation have improved outcomes in marginal donor organs. Combined with expansion of hepatitis C virus positive and split donor organs, donor selection has become an integral part of candidate evaluation. In addition, with liver transplant for acute alcohol-related hepatitis now widely performed and increasing recognition of acute-on-chronic liver failure, selection of critically ill patients is refining tools to balance futility versus utility.

SUMMARY

Advances in liver transplant candidate evaluation continue to transform the evaluation process and require continued incorporation into our clinical practice amidst a dynamic backdrop of demographic and policy changes.

Heart transplantation candidacy

PURPOSE OF REVIEW

Timely referral of eligible candidates for consideration of advanced therapies, such as a heart transplantation or mechanical circulatory support is essential. The characteristics of heart transplantation candidates have changed significantly over the years, leading to a more complex evaluation process. The present review summarizes recent advances in the evaluation process for heart transplantation eligibility.

RECENT FINDINGS

The heart transplantation allocation policy was recently reviewed in the USA in an effort to reduce waitlist mortality and to ensure fair geographic allocation of organs to the sickest patients. Moreover, patients with chronic infectious diseases, as well as malignancies, are being currently considered acceptable candidates for transplantation. Listing practices for heart transplantation vary between programmes, with a greater willingness to consider high-risk candidates at higher-volume centres.

SUMMARY

The ultimate decision to place high-risk candidates on the heart transplantation waitlist should be based on a combination of quantitative and qualitative data analysis informed by clinical judgement, and the chronic shortage of organ donors makes this process an important ethical concern for any society. Future guidelines should discuss approaches to achieve fair organ allocation while preserving improved outcomes after transplantation.

Liver graft harbouring hydatid disease: how far can we extend our donor pool?

As the current demand for liver transplantation exceeds our donor pool, the donor search is shifted towards the extended donor criteria. The livers harbouring hydatid disease are a controversial source of grafts. We report the use of a liver graft harbouring hydatid disease in urgent liver transplantation in a patient with autoimmune hepatitis. Corroborated with previous experiences, we show that the liver grafts harbouring hydatid cysts provide a rare but valuable source of organs.

Rapid screening for safety of donation from donors with central nervous system malignancies

With the increasing demand on organ transplants, it has become a common practice to include patients with primary central nervous system (CNS) malignancies as donors given the suggested low probability metastatic spread outside of the CNS. However, an extra-CNS spread of the disease cannot be excluded raising potential risks of cancer transmission from those donors. In order to balance between the risk of donor-derived disease transmission and the curative benefit for the recipient, a careful donor and organ selection is important. We performed a literature research and summarized all reported studies of organ transplants from donors suffered from primary CNS malignancies and determined the risk of tumor transmission to recipients. There were 22 cases of transplant-transmitted CNS tumors onto recipients since 1976. The association risks of cancer transmission were attributed to donor tumor histology, disruption of the blood-brain barrier, cerebrospinal fluid extra-CNS, and false diagnosis of primary intracranial tumor as well as the molecular properties of the primary tumor such as the existence of EGFR-amplification. The association risks and features of CNS tumors transmission recipients indicated that we need to reassess our thresholds for the potential fatal consequences of these donors.

Donor Characteristics and Regional Differences in the Utilization of HCV-Positive Donors in Liver Transplantation

IMPORTANCE

Increased utilization of hepatitis C virus (HCV)-positive liver allografts for liver transplant (LT) has been endorsed as one of several ways to combat national organ shortages. However, HCV-positive donors remain poorly characterized, and Organ Procurement and Transplantation Network regional differences in the utilization of HCV-positive liver allografts are unclear.

OBJECTIVE

To characterize HCV-positive donors and the allografts that come from them.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, the Scientific Registry of Transplant Recipients database was queried for all donors who underwent HCV testing from June 2015 to December 2018. Clinical and allograft characteristics were evaluated, and utilization across the United States was studied. Patients with positive or negative results for HCV antibody (Ab) and HCV nucleic acid amplification testing (NAT) were included in this study. Donors utilized for living donor transplant and pediatric (age <18 years) recipients were excluded.

MAIN OUTCOMES AND MEASURES

The primary comparison was between donors who were HCV Ab positive and those who were HCV Ab negative. Regional variations in the utilization of HCV-positive and HCV-negative donors were analyzed.

RESULTS

Of 24 500 donors utilized for LT, 1887 (7.7%) were HCV Ab positive; 64.4% of HCV Ab-positive donors were HCV NAT positive. HCV Ab-positive donors were younger (median [interquartile range] age, 35 [29-46] years vs 40 [27-54] years) and had fewer comorbidities, such as diabetes (8.3% vs 12.0%) and hypertension (25.9% vs 35.2%), compared with HCV Ab-negative donors. These findings were even more pronounced in HCV Ab-positive /NAT-positive compared with HCV Ab-positive/NAT-negative donors. Organ Procurement and Transplantation Network regions 2, 3, 10, and 11 had the highest absolute utilization of HCV Ab-positive donors, accounting for 64.4% of all HCV Ab-positive donors used in the United States. Region 1 had the highest relative utilization of HCV Ab-positive donors (18.7%). The use of HCV Ab-positive donors in some regions was associated with the rate of drug overdose, but this was not always the case. Similar utilization results were found with HCV NAT-positive donors.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, HCV-positive donors were younger and healthier than utilized HCV-negative donors. Significant differences exist in the utilization of HCV-positive donors across the 11 Organ Procurement and Transplantation Network regions, which is not entirely explained by organ demand or by higher availability of HCV-positive livers as per the distribution of the opioid epidemic. Initiatives to increase the use of HCV-positive donors, particularly in regions of high organ demand, should be implemented.

Donor Kidney Quality and Transplant Outcome: An Economic Evaluation of Contemporary Practice

OBJECTIVES

The study had two main aims. First, we assessed the cost-effectiveness of transplanting deceased donor kidneys of differing quality levels based on the Kidney Donor Profile Index (KDPI). Second, we assessed the cost-effectiveness of remaining on the waiting list until a high-quality kidney becomes available compared to transplanting a lower-quality kidney.

METHODS

A decision analytic model to estimate cost-effectiveness was developed using a Markov process. Separate models were developed for 4 separate KDPI bands, with higher values indicating lower quality. Models were simulated in 1-year cycles for a 20-year time horizon, with transitions through distinct health states relevant to the kidney recipient from the healthcare payer's perspective. Weibull regression was used to calculate the time-dependent transition probabilities in the base analysis. The impact uncertainty arising in model parameters was included by probabilistic sensitivity analysis using the Monte Carlo simulation method. Willingness to pay was considered as Australian $28 000.

RESULTS

Transplanting a kidney of any quality is cost-effective compared to remaining on a waitlist. Transplanting a lower KDPI kidney is cost-effective compared to a higher KDPI kidney. Transplanting lower KDPI kidneys to younger patients and higher KDPI kidneys to older patients is also cost-effective. Depending on dialysis in hopes of receiving a lower KDPI kidney is not a cost-effective strategy for any age group.

CONCLUSION

Efforts should be made by the health systems to reduce the discard rates of low-quality kidneys with the view of increasing the transplant rates.

Prognostic Factors on Graft Function in Pediatric Kidney Recipients

BACKGROUND

Graft survival in pediatric kidney transplant recipients has increased in the last decades. Determining prognostic factors for graft function over time allows the identification of patients at risk for graft loss and could lead to improvement of current guidelines.

METHODS

Data were collected among pediatric kidney transplant recipients in a single center during the first 5 years after transplantation. Mixed model analysis was used to indicate possible prognostic factors for the loss of graft function.

RESULTS

A total of 100 pediatric kidney transplant recipients were analyzed. Negative prognostics of graft function are higher donor age and higher recipient age, presence of obstructive uropathology, re-transplant, and occurrence of BK viremia. The negative influence on graft function of both donor age and presence of obstructive uropathology increased over time. In this study, the factors that did not influence graft function over time were the number of HLA mismatches, pre-transplant dialysis, intra-abdominal graft placement, ischemia time, occurrence of acute rejection, presence of lower urinary tract dysfunction, occurrence of urinary tract infections, and infections with cytomegalovirus and Epstein-Barr virus.

CONCLUSIONS

This study showed that a higher donor age and higher recipient age, presence of obstructive uropathology, a re-transplant, and the occurrence of BK viremia were negative prognostic factors of graft function over time, in the first 5 years after transplant. Graft function was comparable between steroid-sparing regimens (preferable in low-risk patients) and regimens including steroids (for special reasons).

Increasing the willingness to participate in organ donation through humorous health communication: (Quasi-) experimental evidence

Increasing people's willingness to donate organs after their death requires effective communication strategies. In two preregistered studies, we assessed whether humorous entertainment education formats on organ donation elicit positive effects on knowledge, fears, attitudes, and behavioral intentions-both immediately after the treatment and four weeks later. We test whether perceived funniness mediates expected effects on attitudes and intentions. Study 1 is a quasi-experiment which uses a live medical comedy show (N = 3,964) as an entertainment education format, which either contained or did not contain information about organ donation. Study 2, a lab experiment, tests humor's causal effect in a pre-post design with a control group (N = 144) in which the same content was provided in either a humorous or non-humorous way in an audio podcast. Results showed that humorous interventions per se were not more effective than neutral information, but that informing people about organ donation in general increased donation intentions, attitudes, and knowledge. However, humorous interventions were especially effective in reducing fears related to organ donation. The findings are discussed regarding the opportunities for sensitive health communication through entertainment education formats, psychological processes that humor triggers, and humor's role in health communication formats.

Knowledge and Attitudes Regarding Organ Transplantation Among Cyprus Residents

BACKGROUND

Organ transplantation was one of the greatest achievements of medical science during the 20th century. Knowledge, education, and culture all play prominent roles in transplantation because of the complexity of the process from donation to transplantation.

PURPOSE

The aim of this research was to determine and analyze the knowledge and attitudes about organ donation and transplantation among the general population in Limassol, Cyprus.

METHODS

A quantitative research approach was followed, and a questionnaire consisting of closed-ended questions was completed by adults from the general population in Limassol.

RESULTS

One thousand two hundred adults out of the 1,346 adults who were contacted responded to the survey (response rate: 89%) and were included as participants. Of the participants, 93.4% (p < .05) considered organ donation to be lifesaving, 57% expressed interest (and 39.8% expressed disinterest) in becoming organ donors, 80.6% (p < .05) expressed awareness of there being a waiting list for people in need of organ transplantation, 50.4% agreed that brain death must be confirmed before organ removal for transplantation, and 47% recalled having been informed about organ donation through the media, with 31.5% stating that they had never been informed about organ donation.

CONCLUSIONS

The participants demonstrated limited awareness regarding the organ donation system in Cyprus. Furthermore, a significant percentage stated that they lacked a source for obtaining related information. The Cypriot society should be informed and encouraged to participate in organ donation to increase the rate of organ transplantation.

Expedited SARS-CoV-2 screening of donors and recipients supports continued solid organ transplantation

Universal screening of potential organ donors and recipients for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is now recommended prior to transplantation in the United States during the coronavirus disease 19 (COVID-19) pandemic. Challenges have included limited testing capacity, short windows of organ viability, brief lead time for notification of potential organ recipients, and the need to test lower respiratory donor specimens to optimize sensitivity. In an early U.S. epicenter of the outbreak, we designed and implemented a system to expedite this testing and the results here from the first 3 weeks. The process included a Laboratory Medicine designee for communication with organ recovery and transplant clinical staff, specialized sample labeling and handoff, and priority processing. Thirty-two organs recovered from 14 of 17 screened donors were transplanted vs 70 recovered from 23 donors during the same period in 2019. No pretransplant or organ donors tested positive for SARS-CoV-2. Median turnaround time from specimen receipt was 6.8 hours (donors), 6.5 hours (recipients): 4.5 hours faster than daily inpatient median. No organ recoveries or transplantations were disrupted by a lack of SARS-CoV-2 testing. Waitlist inactivations for COVID-19 precautions were reduced in our region. Systems that include specialized ordering pathways and adequate testing capacity can support continued organ transplantation, even in a SARS-CoV-2 hyperendemic area.

Deceased donor kidney allocation: an economic evaluation of contemporary longevity matching practices

BACKGROUND

Matching survival of a donor kidney with that of the recipient (longevity matching), is used in some kidney allocation systems to maximize graft-life years. It is not part of the allocation algorithm for Australia. Given the growing evidence of survival benefit due to longevity matching based allocation algorithms, development of a similar kidney allocation system for Australia is currently underway. The aim of this research is to estimate the impact that changes to costs and health outcomes arising from 'longevity matching' on the Australian healthcare system.

METHODS

A decision analytic model to estimate cost-effectiveness was developed using a Markov process. Four plausible competing allocation options were compared to the current kidney allocation practice. Models were simulated in one-year cycles for a 20-year time horizon, with transitions through distinct health states relevant to the kidney recipient. Willingness to pay was considered as AUD 28000.

RESULTS

Base case analysis indicated that allocating the worst 20% of Kidney Donor Risk Index (KDRI) donor kidneys to the worst 20% of estimated post-transplant survival (EPTS) recipients (option 2) and allocating the oldest 25% of donor kidneys to the oldest 25% of recipients are both cost saving and more effective compared to the current Australian allocation practice. Option 2, returned the lowest costs, greatest health benefits and largest gain to net monetary benefits (NMB). Allocating the best 20% of KDRI donor kidneys to the best 20% of EPTS recipients had the lowest expected incremental NMB.

CONCLUSION

Of the four longevity-based kidney allocation practices considered, transplanting the lowest quality kidneys to the worst kidney recipients (option 2), was estimated to return the best value for money for the Australian health system.

Does the heart transplant have a future?

Heart failure has remained the leading cause of death globally for the last 15 years—and its prevalence will continue to rise. Fifty years ago, heart failure management was enriched by the possibility of a heart transplant. Despite impressive improvements in medical treatment for heart failure, a heart transplant remains the most effective long-lasting treatment for advanced heart failure in terms of mortality and quality of life. However, donor and recipient characteristics have changed dramatically in recent years, leading to more complex decision-making regarding organ acceptance and to more demanding operations and postoperative management. With improving pathophysiological understanding in the last decades, today’s scientific interest still focuses on basic knowledge. How to retrieve and conserve organs to minimize ischaemic injury; how best to allocate them, considering the likelihood of success (developing a heart-allocation scoring system similar to that for lung allocation); how to match donor/recipient characteristics (ABO blood-group antigen compatibility versus incompatibility); and how to avoid graft failure, rejection and secondary morbidities such as malignomas and cardiac allograft vasculopathy after the heart transplant—all these factors remain fundamental challenges in today’s transplant medicine. The use of ex vivo perfusion (e.g. via the Organ Care System^®, TransMedics, Andover, MA, USA) may play an important role in this change. Remarkably, there are huge regional divergences in current transplant practices: Whereas the number of transplants continues to rise in most Eurotransplant countries and other major transplant networks, there are some countries in which transplant numbers are static or even dropping (as in Germany). This difference results in wide variations across different countries as to how advanced heart failure is treated using mechanical circulatory-assist devices.

Assessment of High School Students' Participation in Blood Donation and Registration as an Organ Donor

This cross-sectional study assesses the association between blood donation and willingness to register as an organ donor among California high school students.

#BeTheMatch: Assessing How Testimonials on Reddit Promote the Importance of Donating Bone Marrow

This study explores how sharing testimonials on the social media network Reddit may encourage individuals to donate bone marrow. The theory of planned behavior guided a quantitative content analysis of 1,015 Reddit comments about donation. Research questions asked how individuals post about donation and how Redditors engage with this content. Overall, comments addressed more positive than negative outcome, efficacy, and normative beliefs. Comments that discussed beliefs related to registering to donate and the process of donating received significantly higher engagement than other comments. Additionally, comments that included positive outcome beliefs related to registering, positive efficacy beliefs related to registering and donating, and positive normative beliefs related to donating received higher engagement than other comments. Results suggest testimonials may be most effective if they focus on behavior facilitators and if they present donation as a positive norm deviant behavior. Finally, the Reddit forums functioned as places for individuals to seek out and share information. Comments included calls to action and hyperlinks for health resources. This research reveals how organic conversations on Reddit may promote health information seeking and advocacy behavior adoption. Implications for the theory of planned behavior and the use of Reddit as a platform for health promotion are discussed.

Knowledge and Willingness for Organ Donation in the Middle Eastern Region: A Meta-analysis

Medical advancements over the past decades brought organ transplantation as a definitive therapy for different end-stage organ failure. However, non-availability of organs required for transplantation is a major challenge worldwide. We aimed to determine the knowledge and willingness to donate organs in various populations and settings in the Middle Eastern region. Literature searches were conducted on PubMed, MEDLINE, Cochrane, and Google scholar electronic databases. Different combinations of search terms such as "organ donation"; "knowledge", "awareness"; "beliefs", "willingness"; and "attitude" along with the country names were used. Additional searches using reference lists of studies and review articles were conducted. Data were extracted using standardized excel form and pilot tested. Three authors independently abstracted the data using a data collection form. Results from different studies were pooled for the analysis when appropriate. The search yielded 1806 articles; 1000 duplicates and review articles were excluded, and a further 792 articles not relevant were excluded. Finally, 14 original studies met the inclusion criteria. Total pooled sample size for assessing knowledge was 6697 and for willingness was 8714. Pooled overall knowledge regarding organ donation was 69% with a 95% CI [64.5, 73.5]. Pooled overall willingness to donate organ was 49.8% with a 95% CI [41.3, 58.4]. Knowledge about organ donation and willingness to donate organs varies in different population and settings in the Middle East. These in fact are linked to multiple social factors ultimately leads to 'consent' for donating organs by a potential donor. Family's influence; religious, traditional and spiritual beliefs; and status of ethnic, minority, and immigrant populace are the important determinants of the decision for organ donation. Understandings on social determinants in organ donation remain crucial and should be addressed while developing policies and organizational developments.

Wide Variation in the Percentage of Donation After Circulatory Death Donors Across Donor Service Areas: A Potential Target for Improvement

BACKGROUND

Substantial differences exist in the clinical characteristics of donors across the 58 donor service areas (DSAs). Organ procurement organization (OPO) performance metrics incorporate organs donated after circulatory determination of death (DCDD) donors but do not measure potential DCDD donors.

METHODS

Using 2011-2016 United Network for Organ Sharing data, we examined the variability in DCDD donors/all deceased donors (%DCDD) across DSAs. We supplemented United Network for Organ Sharing data with CDC death records and OPO statistics to characterize underlying process and system factors that may correlate with donors and utilization.

RESULTS

Among 52 184 deceased donors, the %DCDD varied widely across DSAs, with a median of 15.1% (interquartile range [9.3%, 20.9%]; range 0.0%-32.0%). The %DCDD had a modest positive correlation with 4 DSA factors: median match model for end-stage liver disease, proportion of white deaths out of total deaths, kidney center competition, and %DCDD livers by a local transplant center (all Spearman coefficients 0.289-0.464), and negative correlation with 1 factor: mean kidney waiting time (Spearman coefficient -0.388). Adjusting for correlated variables in linear regression explained 46.3% of the variability in %DCDD.

CONCLUSIONS

Donor pool demographics, waitlist metrics, center competition, and DCDD utilization explain only a portion of the variability of DCDD donors. This requires further studies and policy changes to encourage consideration of all possible organ donors.

The Impact of Religion and Provision of Information on Increasing Knowledge and Changing Attitudes to Organ Donation: An Intervention Study

One of the most significant developments in recent history has probably been organ donation and organ transplantation. They are frequently the only treatment available in certain cases. However, there is an ever-increasing discrepancy between the number of people needing transplantation and the organs available, because the decision to donate an organ is up to each individual. The study aims to assess the impact of the intervention on knowledge, attitudes and practices on organ donation among religious immigrants in Sweden. Data were collected through three group interviews using open-ended questions and qualitative content analysis. Thirty-six participants, 18 males and 18 females from six countries, participated in the focus group interviews. The analysis of the collected data resulted in two main categories: "Religion in theory and practice" and "More information-more knowledge about organ donation" including seven subcategories. Understanding of religion and religiosity, happiness by taking the class, the practice of religion in everyday life, the overcoming the prejudices in religion, having more information about organ donation and the donations process, as well as that the increased information changes people's minds, were some of things the informants emphasised as predictors of the decision of organ donation. A class dealing with religion, the religious aspects of organ donation and the way the Swedish healthcare system is organised increased people's knowledge and changed their attitudes so they became potential organ donors. More intervention studies are needed in every field of medicine to build confidence and give time to educate and discuss issues with potential organ donors in Sweden.

Improving outcomes for donation after circulatory death kidney transplantation: Science of the times

The use of kidneys donated after circulatory death (DCD) remains controversial due to concerns with regard to high incidences of early graft loss, delayed graft function (DGF), and impaired graft survival. As these concerns are mainly based on data from historical cohorts, they are prone to time-related effects and may therefore not apply to the current timeframe. To assess the impact of time on outcomes, we performed a time-dependent comparative analysis of outcomes of DCD and donation after brain death (DBD) kidney transplantations. Data of all 11,415 deceased-donor kidney transplantations performed in The Netherlands between 1990–2018 were collected. Based on the incidences of early graft loss, two eras were defined (1998–2008 [n = 3,499] and 2008–2018 [n = 3,781]), and potential time-related effects on outcomes evaluated. Multivariate analyses were applied to examine associations between donor type and outcomes. Interaction tests were used to explore presence of effect modification. Results show clear time-related effects on posttransplant outcomes. The 1998–2008 interval showed compromised outcomes for DCD procedures (higher incidences of DGF and early graft loss, impaired 1-year renal function, and inferior graft survival), whereas DBD and DCD outcome equivalence was observed for the 2008–2018 interval. This occurred despite persistently high incidences of DGF in DCD grafts, and more adverse recipient and donor risk profiles (recipients were 6 years older and the KDRI increased from 1.23 to 1.39 and from 1.35 to 1.49 for DBD and DCD donors). In contrast, the median cold ischaemic period decreased from 20 to 15 hours. This national study shows major improvements in outcomes of transplanted DCD kidneys over time. The time-dependent shift underpins that kidney transplantation has come of age and DCD results are nowadays comparable to DBD transplants. It also calls for careful interpretation of conclusions based on historical cohorts, and emphasises that retrospective studies should correct for time-related effects.

Short-course, direct-acting antivirals and ezetimibe to prevent HCV infection in recipients of organs from HCV-infected donors: a phase 3, single-centre, open-label study

BACKGROUND

An increasing percentage of potential organ donors are infected with hepatitis C virus (HCV). After transplantation from an infected donor, establishment of HCV infection in uninfected recipients is near-universal, with the requirement for post-transplant antiviral treatment. The aim of this study was to determine if antiviral drugs combined with an HCV entry blocker given before and for 7 days after transplant would be safe and reduce the likelihood of HCV infection in recipients of organs from HCV-infected donors.

METHODS

HCV-uninfected organ recipients without pre-existing liver disease were treated with ezetimibe (10 mg; an HCV entry inhibitor) and glecaprevir-pibrentasvir (300 mg/120 mg) before and after transplantation from HCV-infected donors aged younger than 70 years without co-infection with HIV, hepatitis B virus, or human T-cell leukaemia virus 1 or 2. Recipients received a single dose 6-12 h before transplant and once a day for 7 days after surgery (eight doses in total). HCV RNA was assessed once a day for 14 days and then once a week until 12 weeks post-transplant. The primary endpoint was prevention of chronic HCV infection, as evidenced by undetectable serum HCV RNA at 12 weeks after transplant, and assessed in the intention-to-treat population. Safety monitoring was according to routine post-transplant practice. 12-week data are reported for the first 30 patients. The trial is registered on ClinicalTrials.gov, NCT04017338. The trial is closed to recruitment but follow-up is ongoing.

FINDINGS

30 patients (23 men and seven women; median age 61 years (IQR 48-66) received transplants (13 lung, ten kidney, six heart, and one kidney-pancreas) from 18 HCV-infected donors. The median donor viral load was 5·11 log10IU/mL (IQR 4·55-5·63) and at least three HCV genotypes were represented (nine [50%] donors with genotype 1, two [11%] with genotype 2, five [28%] with genotype 3, and two [11%] with unknown genotype). All 30 (100%) transplant recipients met the primary endpoint of undetectable HCV RNA at 12 weeks post-transplant, and were HCV RNA-negative at last follow-up (median 36 weeks post-transplant [IQR 25-47]). Low-level viraemia was transiently detectable in 21 (67%) of 30 recipients in the early post-transplant period but not after day 14. Treatment was well tolerated with no dose reductions or treatment discontinuations; 32 serious adverse events occurred in 20 (67%) recipients, with one grade 3 elevation in alanine aminotransferase (ALT) possibly related to treatment. Non-serious transient elevations in ALT and creatine kinase during the study dosing period resolved with treatment completion. Among the serious adverse events were two recipient deaths due to causes unrelated to study drug treatment (sepsis at 49 days and subarachnoid haemorrhage at 109 days post-transplant), with neither patient ever being viraemic for HCV.

INTERPRETATION

Ezetimibe combined with glecaprevir-pibrentasvir given one dose before and for 7 days after transplant prevented the establishment of chronic HCV infection in recipients of different organs from HCV-infected donors. This study shows that an ultra-short course of direct-acting antivirals and ezetimibe can prevent the establishment of chronic HCV infection in the recipient, alleviating many of the concerns with transplanting organs from HCV-infected donors.

FUNDING

Canadian Institutes of Health Research; the Organ Transplant Program, University Health Network.

Assessing Solid Organ Donors and Monitoring Transplant Recipients for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infection - U.S. Public Health Service Guideline, 2020

The recommendations in this report supersede the U.S Public Health Service (PHS) guideline recommendations for reducing transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation (Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep 2013;128:247-343), hereafter referred to as the 2013 PHS guideline. PHS evaluated and revised the 2013 PHS guideline because of several advances in solid organ transplantation, including universal implementation of nucleic acid testing of solid organ donors for HIV, HBV, and HCV; improved understanding of risk factors for undetected organ donor infection with these viruses; and the availability of highly effective treatments for infection with these viruses. PHS solicited feedback from its relevant agencies, subject-matter experts, additional stakeholders, and the public to develop revised guideline recommendations for identification of risk factors for these infections among solid organ donors, implementation of laboratory screening of solid organ donors, and monitoring of solid organ transplant recipients. Recommendations that have changed since the 2013 PHS guideline include updated criteria for identifying donors at risk for undetected donor HIV, HBV, or HCV infection; the removal of any specific term to characterize donors with HIV, HBV, or HCV infection risk factors; universal organ donor HIV, HBV, and HCV nucleic acid testing; and universal posttransplant monitoring of transplant recipients for HIV, HBV, and HCV infections. The recommendations are to be used by organ procurement organization and transplant programs and are intended to apply only to solid organ donors and recipients and not to donors or recipients of other medical products of human origin (e.g., blood products, tissues, corneas, and breast milk). The recommendations pertain to transplantation of solid organs procured from donors without laboratory evidence of HIV, HBV, or HCV infection. Additional considerations when transplanting solid organs procured from donors with laboratory evidence of HCV infection are included but are not required to be incorporated into Organ Procurement and Transplantation Network policy. Transplant centers that transplant organs from HCV-positive donors should develop protocols for obtaining informed consent, testing and treating recipients for HCV, ensuring reimbursement, and reporting new infections to public health authorities.

Donor Klotho KL-VS Polymorphism Predicts Allograft Glomerulosclerosis and Early Post-Transplant Kidney Function

BACKGROUND

The Klotho protein, encoded by the KL (Klotho) gene, exerts antiaging and antifibrotic effects. The KL-VS genotype diminishes Klotho expression and correlates with cardiovascular death, heart failure, and chronic kidney disease progression. The aim of this study was to analyze the contribution of donor Klotho rs9536314 and rs9527025 polymorphisms (KL-VS genotype) to renal allograft morphology and function in the early post-transplant period.

METHODS

Clinical data and biopsy reports of 170 deceased donor transplantations were retrieved from standard medical files. Donor DNA was genotyped for rs9527025 and rs9536314 SNPs using custom TaqMan assays.

RESULTS

As rs9527025 remained in full linkage with rs9536314, we report results for the latter. The analyses were performed for G dominant model (GG+GT vs TT). We found an association between reported SNP alleles, morphologic changes in the peritransplant biopsy, and kidney function 3 months after engraftment. A chronic glomerulopathy score of >0 was found in 12.2% of GG+GT cases and in 3.2% of TT cases (P = .023). For G allele carriers, the third month's median estimated glomerular filtration rate value was 35.0 (range, 20.4-76.6 mL/min), while for TT haplotype, the value was 46.3 (range, 15.5-96.8 mL/min), P = .001. At the third post-transplant month, proteinuria incidence was higher for organs with G allele than with TT haplotype (24.4% vs 9.5%; P = .030; odds ratio 3.09; 95% confidence interval 1.22-7.69).

CONCLUSION

Deceased donor KL-VS polymorphism, altering protein dimerization and coreceptor function, predicts early renal transplant glomerular lesions and function. Further analyses for mentioned effect durability are necessary.

ETHICS STATEMENT

This study complies with the Helsinki Congress and the Istanbul Declaration regarding donor source. Donors were not prisoners, and were not paid or coerced.

Outcomes of kidney transplantation from elderly deceased donors of a Korean registry

To overcome organ shortage, expanded criteria donors, including elderly deceased donors (DDs), should be considered. We analyzed outcomes of kidney transplantation (KT) from elderly DDs in a nationwide study. In total, data of 1049 KTs from DDs using the database of Korean Organ Transplantation Registry (KOTRY) were retrospectively analyzed based on the age of DDs: age ≥60 years vs. <60 years. Clinical information, graft status, and adverse events were reviewed in DDs and recipients. The mean age of the 1006 DDs was 51.04±10.54 years, and 21.5% of donors were aged ≥60 years. Elderly DDs had a significantly higher prevalence of diabetes and hypertension and higher Kidney Donor Risk Index (KDRI) and Kidney Donor Profile Index (KDPI). The mean age of the recipients was 47.45±14.87 years. Patients who received KT from elderly DDs were significantly older (53.12±15.14 vs. 45.88±14.41, P<0.001) and had a higher rate of diabetes (41.9 vs. 24.4%, P<0.001). Graft outcomes were not significantly different. Renal function was similar between the groups at the time of discharge and at 6 months, 1 year, and 2 years after KT. The rate of delayed graft function (DGF) was not significantly different. Risk factors of DGF were significantly different in DDs aged ≥60 years and <60 years. In the multivariable model, male sex (odds ratio: 3.99, 95% confidence interval: 1.42–11.22; P = 0.009) and KDRI (12.17, 2.23–66.34; P = 0.004) were significant risk factors for DGF in DDs aged ≥60 years. In DDs aged <60 years, thymoglobulin induction (2.62, 1.53–4.48; P<0.001) and continuous renal replacement therapy (3.47, 1.52–7.96; P = 0.003) were significant factors. Our data indicated that graft outcomes, including renal function and DGF, were similar for elderly DDs and DDs aged <60 years. Elderly DDs might be considered tolerable donors for KT, with active preoperative surveillance.

Living or deceased-donor kidney transplant: the role of psycho-socioeconomic factors and outcomes associated with each type of transplant

BACKGROUND

Kidney transplant improves patients' survival and quality of life. Worldwide, concern about the equality of access to the renal transplant wait-list is increasing. In Iran, patients have the choice to be placed on either the living or deceased-donor transplant wait-list.

METHODS

This was a prospective study performed on 416 kidney transplant recipients (n = 217 (52.2%) from living donors and n = 199 (47.8%) from deceased donors). Subjects were recruited from four referral kidney transplant centers across Tehran, Iran, during 2016-2017. The primary outcome was to identify the psycho-socioeconomic factors influencing the selection of type of donor (living versus deceased). Secondary objective was to compare the outcomes associated with each type of transplant. The impact of psycho-socioeconomic variables on selecting type of donor was evaluated by using multiple logistic regression and the effect of surgical and non-surgical variables on the early post-transplant creatinine trend was assessed by univariate repeated measure ANOVA.

RESULTS

Based on standardized coefficients, the main predictors for selecting living donor were academic educational level (adjusted OR = 3.25, 95% CI: 1.176-9.005, p = 0.023), psychological status based on general health questionnaire (GHQ) (adjusted OR = 2.46, 95% CI: 1.105-5.489, p = 0.028), and lower monthly income (adjusted OR = 2.20, 95% CI: 1.242-3.916, p = 0.007). The waiting time was substantially shorter in patients who received kidneys from living donors (p < 0.001). The early post-transplant creatinine trend was more desirable in recipients of living donors (β = 0.80, 95% CI: 0.16-1.44, p-value = 0.014), patients with an ICU stay of fewer than five days (β = - 0.583, 95% CI: - 0.643- -0.522, p-value = < 0.001), and those with less dialysis duration time (β = 0.016, 95% CI: 0.004-0.028, p-value = 0.012). Post-operative surgical outcomes were not different across the two groups of recipients (p = 0.08), however, medical complications occurred considerably less in the living-donor group (p = 0.04).

CONCLUSION

Kidney transplant from living donors was associated with shorter transplant wait-list period and better early outcome, however, inequality of access to living donors was observed. Patients with higher socioeconomic status and higher level of education and those suffering from anxiety and sleep disorders were significantly more likely to select living donors.