VCA waiting list and transplant trends in the US

Introduction: VCA transplantation is progressing despite challenges including the COVID-19 pandemic. Method(s): The OPTN cohort includes 108 VCA candidates listed and 66 recipients transplanted between 7/3/2014 - 4/30/2022. Result(s): Seven VCA candidates were listed in 2021: 3 abdominal wall (AW) and 4 uterus. One AW and 2 uterus candidates were listed in the first 4 months of 2022. AW registrations became the predominant registration type on the VCA waiting list in 2022, surpassing uterus registrations. As of 4/30/2022, the waiting list included 17 candidates: 6 AW, 5 uterus, 4 upper limb (UL;1 bilateral, 3 unilateral), 1 face, and 1 face/scalp. Since 7/3/2014, 66 recipients received 67 VCA transplants, including 14 UL (9 bilateral, 5 unilateral), 9 face, 1 bilateral UL and face, 1 scalp, 1 trachea, 2 AW, 36 uterus (14 deceased donor, 22 living donor), and 2 penis recipients. In 2021, 1 bilateral UL, 1 trachea, and 2 living donor uterus transplants were performed. In the first 4 months of 2022, 3 uterus transplants (2 deceased donor, 1 living donor) were performed. Discussion and Conclusion(s): The composition of the VCA waiting list is changing. VCA transplantation continues to advance despite the COVID-19 pandemic.

Changes in Disease Etiology of Deceased Donor Liver Transplantations Following Acuity Circles Policy Implementation

Introduction: The Acuity Circles (AC) allocation policy was implemented on February 4, 2020, with the primary intent of reducing disparities in access to deceased donor liver transplants (DDLTs). Overall, it has been successful at achieving this goal. However, changes in end-stage liver disease etiology following the policy change have not been well-characterized. Our goal was to understand how primary etiology of disease in DDLTs has changed since implementation of AC. Method(s): Data from the Organ Procurement Transplantation Network (OPTN) and United Network of Organ Sharing (UNOS) were analyzed to compare the primary classified etiologies of liver disease for DDLTs overall and based on allocation Model-for-end-stage-liver-disease (aMELD) categories used for AC sharing: aMELD>=37, aMELD 33-36, aMELD 29-32, aMELD 15-28, and aMELD<=14 DDLTs. Time was divided into four equivalent "eras" of 256 days duration by date of transplantation: 1) 9/10/18-5/23/19 (Era 1);2) 5/24/19-2/3/20 (Era 2);3) 2/4/20-10/16/20 (Era 3);and 4) 10/17/20-6/29/21 (Era 4). Result(s): The percentage of all DDLTs for alcohol-related liver disease (ARLD) increased from 32.3% pre-AC to 38.7% of DDLTs post AC. This was met with a corresponding decrease in the relative percentage of DDLTs related to Hepatitis C Virus (from 17.0% of DDLTs pre-AC to 12.2% post-AC), with the relative differences of other etiologies being a less than 1% difference pre- vs post- AC. There is a consistent increase in the share of DDLTs due to ARLD across each Era. The rise in adult DDLTs for ARLD was most pronounced among aMELD >=37 recipients, although similar trends were seen among aMELD 33-36 and aMELD 29-32 groups, but not aMELD 15-28 and aMELD <=14 groups. The median age of adult DDLTs for ARLD decreased consistently over time for the aMELD >=37 group, but not for the aMELD 33-36 and aMELD 29-32 groups. (Figure) (Table) Conclusion(s): Following implementation of AC, there was a relative increase in DDLTs due to ARLD. The younger age and high aMELD scores of these patients suggests these may be largely among patients with acute alcoholic hepatitis. This would align with published data on the overall increase in liver transplantation due to ARLD during the COVID-19 pandemic. (Figure Presented).

Solid organ graft-versus-host disease in a recipient of a COVID-19 positive liver graft

A 66-year-old male with end-stage liver disease (ESLD) secondary to non-alcoholic fatty liver disease (NAFLD), complicated by hepatocellular carcinoma (HCC), underwent deceased donor liver transplantation from a Coronavirus disease 2019 (COVID-19) positive donor. He presented a month later with fever, diarrhea and pancytopenia which led to hospitalization. The hospital course was notable for respiratory failure, attributed to invasive aspergillosis, as well as a diffuse rash. A bone marrow biopsy revealed hypocellular marrow without specific findings. In the following days, laboratory parameters raised concern for secondary hemophagocytic lymphohistiocytosis (HLH). Clinical concern also grew for solid organ transplant graft-versus-host-disease (SOT-GVHD) based on repeat marrow biopsy with elevated donor-derived CD3+ T cells on chimerism. After, a multidisciplinary discussion, the patient was started on ruxolitinib, in addition to high dose steroids, to address both SOT-GVHD and secondary HLH. Patient developed symptoms concerning for hemorrhagic stroke and was transitioned to comfort care. Although GVHD has been studied extensively in hematopoietic stem cell transplant (HSCT) patients, it is a rare entity in SOT with a lack of guidelines for management. Additionally, whether COVID-19 may play a role in development of SOT-GVDH has not been explored.Copyright © 2023 The Authors

The positive impact of the COVID 19 pandemic on organ utilisation in liver transplantation

Background: As the world recovers from the aftermath of devastating waves of an outbreak, the ongoing Coronavirus disease 2019 pandemic has presented a unique perspective to the transplantation community of ''organ utilisation'' in liver transplantation, a poorly defined term and ongoing hurdle in this field. To this end, we report the key metrics of transplantation activity from a high-volume liver transplantation centre in the United Kingdom over the past two years. Method(s): Between March 2019 and February 2021, details of donor liver offers received by our centre from National Health Service Blood & Transplant, and of transplantation were reviewed. Differences in the activity before and after the outbreak of the pandemic, including short term post-transplant survival, have been reported. Result(s): The pandemic year at our centre witnessed a higher utilisation of Donation after Cardiac Death livers (80.4% vs. 58.3%, p = 0.016) with preserved United Kingdom donor liver indices and median donor age (2.12 vs. 2.02, p = 0.638;55 vs. 57 years, p = 0.541) when compared to the pre-pandemic year. The 1- year patient survival rates for recipients in both the periods were comparable. The pandemic year, that was associated with increased utilisation of Donation after Cardiac Death livers, had an ischaemic cholangiopathy rate of 6%. Conclusion(s): The pressures imposed by the pandemic led to increased utilisation of specific donor livers to meet patient needs and minimise the risk of death on the waiting list, with apparently preserved early post-transplant survival. Optimum organ utilisation is a balancing act between risk and benefit for the potential recipient, and technologies like machine perfusion may allow surgeons to increase utilisation without compromising patient outcomes.Copyright © 2022

Impact of COVID-19 on 2020 transplant activity and waiting lists in France

The COVID-19 pandemic strongly affected organ procurement and transplantation in France, despite the intense efforts of all participants in this domain. In 2020, the identification and procurement of deceased donors fell by 12% and 21% respectively, compared with the mean of the preceding 2 years. Similarly, the number of new registrations on the national waiting list declined by 12% and the number of transplants by 24%. The 3-month cumulative incidence of death or drop out for worsening condition of patients awaiting a liver transplant was significantly greater in 2020 compared to the previous 2 years. Continuous monitoring at the national level of early post-transplant outcomes showed no deterioration for any organ in 2020. At the end of 2020, less than 1% of transplant candidates and less than 1% of graft recipients - of any organ - had died of COVID-19.Copyright © 2021 The Author(s)

Kidney Transplantation during the Three Years (2020-2022) of Covid-19 Pandemic: Single-Center Experience

Introduction: During the first year of coronavirus disease (COVID)-19 outbreak, kidney transplant programs were suspended in several countries in the World. Republic of Belarus did not suspend organ transplant program carefully weighed the risks and benefits of pursuing or postponing kidney transplantation. In cooperation with national-level efforts, our transplant program adopted universal donor and recipient screening using reverse transcriptase polymerase chain reaction for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) with or without chest CT scans before kidney transplantation. Thus, national kidney transplant activities in Republic of Belarus remained stable for both living and deceased donor transplantation compared with the same period during the previous year. The objective was to study the safety of kidney transplantation, the incidence of COVID-19 disease in kidney transplant patients and medical care providing for transplanted patients during this pandemic period. Method(s): A retrospective review of all patients who had received a kidney transplant at State Institution "Minsk Scientific and Practical Center for Surgery, Transplantology and Hematology" in Minsk, Republic of Belarus was performed from January 2020 to November 2022. Result(s): Dynamics of kidney transplantations number, clinical data of recipients during 3 years Covid-19 pandemic compared with the previous year are presented in table 1. The rate of infection in early postoperative period was low: 1,1% (2020), 0,5% (2021) and 0% (November 2022). In case of SARS-CoV2 infection modifications of immunosuppression (IS) therapy were based on the clinical conditions. For asymptomatic patients "wait and see approach" was mostly used;a suspension of antimetabolites drugs was adopted in the majority of patients with symptomatic COVID-19 infections. For CNIs, withdrawal was the preferred choice in severely symptomatic patients. A discontinuation of all IS drugs was used only in severely symptomatic COVID-19 patients on invasive mechanical ventilation. Since 2022 we started to use remdesivir in recipients with symptomatic course of disease with positive results. [Formula presented] From the middle of 2021 we commenced specific vaccination among transplanted patients. Most widely available vaccines in Belarus were CoronaVac (Sinovac Life Sciences, Beijing, China) and Gam-COVID-Vac (Gamaleya Research Institute of Epidemiology and Microbiology, Russia). There were no revealed any adverse effects of vaccination among our group. Conclusion(s): In our experience, the current kidney transplant program seems viable and safe, even during periods of health emergencies. No conflict of interestCopyright © 2023

Successful Kidney Transplantation from Covid-19 Positive Donors

Introduction: Covid-19 results in a wide spectrum of illness ranging from asymptomatic, mild to severe respiratory disease and multi-organ involvement. Transplant recipients are at increased risk of severe Covid-19. The risk of transmission from a Covid-19 positive donor to recipient in kidney transplantation is unknown. National Health Service Blood and Transplant, UK recommended respiratory polymerase chain reaction (PCR) testing for all donors for Covid-19 and advice against organ donation if positive within the last 28 days. However, a recent amendment of guideline (www.odt.nhs.uk, POL304/3) supports organ donation from selected donors with positive or indeterminate SARS-CoV-2 PCR results. Method(s): We report two cases of kidney transplantation including one unvaccinated recipient where donors had tested SARS-CoV-2 PCR positive. Result(s): 1: Mrs A is a 38-year old Caucasian with end-stage kidney disease (ESKD) secondary to reflux nephropathy, established on haemodialysis (HD). She had declined Covid-19 vaccinations. The donor died of traumatic brain injury and he had a positive lateral flow test 3 weeks prior. The PCR test was positive. Decision was made to proceed with deceased donor kidney transplantation. She was high immunological risk with a HLA antibody calculated reaction frequency (CRF) of 79%, donor specific antibody negative. She was given Basiliximab induction followed by Tacrolimus, Mycophenolate Mofetil and steroids. Graft function was immediate and at 3 week post-transplant, she is well with excellent graft function and no evidence of Covid-19. 2: Mrs B is a 63-year old Asian with ESKD secondary to diabetes and hypertension. She was established on HD and fully vaccinated (three doses of Pfizer-BNT162b2 mRNA vaccine). The donor died of subarchnoid haemorrhage. He had a positive lateral flow test 15 days prior with flu-like symptoms. Respiratory PCR for SARS-CoV-2 was positive. The decision was to proceed with deceased donor transplantation. She was low immunological risk with a HLA antibody CRF of 0%. There were no peri-operative complications and she had immediate graft function. She had Basiliximab induction and was discharged on Tacrolimus and Mycophenolate mofetil with prednisolone withdrawn on day 7 (our low immunological risk protocol). At 3 week post-transplant, she is well with no evidence of Covid-19 and excellent graft function. Conclusion(s): We report 2 cases of kidney transplantation from Covid-19 positive donors in whom the cause of death was not Covid-19 pneumonia. Covid-19 status of the donor was discussed with the patients who both consented. Neither recipient developed Covid-19 in the early post-transplant period, despite being heavily immunosuppressed. Although there remains a theoretical risk, there are no reports of transmission of Covid-19 to kidney transplant recipients from positive donors. Prophylactic antivirals or monoclonal antibodies for the recipient post-transplant or spike antibody test to guide decision making are not currently recommended. We used clinical details of the donor and virology advice which accounts for PCR cycle threshold value to make a decision to transplant. The outcomes of 2 patients reported along with similar experience from other centres is encouraging and supports use of kidneys from selected SARS-CoV-2 positive deceased donors after obtaining virological advice and appropriate consent. No conflict of interestCopyright © 2023

Kidney Replacement Therapy in Latin America, 2020 Data

Introduction: The Latin American Dialysis and Renal Transplantation Registry (LADRTR), founded in 1991, has collected data and reports on patients receiving kidney replacement therapy (KRT) since 1993. The main goals of the LADRTR is to promote the development of national registries, consolidate a data system for KRT in Latin America (LA), return the data provided by nephrologist to the different stakeholders that participate in the decision making process, while contributing to the universal knowledge of prevention, incidence and evolution of the disease in the region. This summarizes the registry data for 2020. Method(s): Participating countries complete an annual survey collecting aggregated data on incident and prevalent patients on KRT in all modalities. The different treatment modalities considered were hemodialysis (HD), peritoneal dialysis (PD) and living functioning kidney graft (LFG). National gross domestic product per capita (GDP, expressed in US dollars) and life expectancy at birth (LEB) corresponding to the year 2020 were collected from the World Bank Data Bank. Prevalence and incidence were compared with previous years and were also correlated with GDP and LEB. Result(s): On 31 December 2020 the prevalence of KRT in LA was 848 per million population (pmp), which shows a drop in the rate compared to the previous year (Figure 1). The prevalence ranged from 2129 pmp in Puerto Rico to 111 pmp in Nicaragua. Eight countries had a rate >700 pmp (Argentina, Brazil, Chile, Colombia, Ecuador, Panama, Puerto Rico and Uruguay). The states of Mexico, Jalisco and Aguas Calientes, also had a rate >700 pmp (Figure 2). Regarding treatment modality, 67,0% of the prevalent patients were treated with HD (n= 290 099) and 9.3% with PD (n= 40 450) while 23,6% of the patients had an LFG (n= 102772). The total unadjusted incidence rate of patients that started KRT was 158 pmp. The majority of the patients started KRT with HD modality, while only 6,08% used PD, varying the rate of incidence from 477 pmp in Jalisco and Aguas Calientes to 2 pmp in Bolivia. The kidney transplant rate in the region was 15 pmp, showing a drop from the previous year, and 89% of KT were from a deceased donor (Figure 3). The total prevalence of KRT correlated positively with GDP per capita (r 2 = 0.6, P < 0.01) and LEB (r 2 = 0.27, P < 0.05). The overall unadjusted mortality rate was 18%, cardiac disease was the leading cause of death (31%), followed by infectious diseases (21%) and other causes (16%). [Formula presented] [Formula presented] [Formula presented] Conclusion(s): For the first time in the last decade the overall prevalence and kidney transplant rate decreased, being this associated with COVID-19 pandemic. Although the incidence and prevalence of KRT in the LA region have increased over the years, there is still a need to improve accessibility to KRT, develop programs that facilitate better control of risk factors, early diagnosis and the treatment of chronic kidney disease, as well as the implementation of an effective kidney transplant program, to reduce the gap that exists between the countries of LA. No conflict of interestCopyright © 2023

Renal transplantation

Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. An overall increase in deceased donor numbers has boosted transplant activity in the UK, and it is hoped this will continue with the adoption of the 'opt-out' consent system. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.Copyright © 2022

Renal transplantation

Individuals with kidney failure face a future requiring long-term treatment with either dialysis or renal transplantation. Renal transplantation is the preferred form of renal replacement therapy, and is associated with a better quality of life, and usually increased longevity. Unfortunately, owing to excessive co-morbidities, only 30% of patients who develop end-stage renal failure are fit enough for transplantation. Over 90% of kidney transplants still function after 1 year, and most function for >15 years. Improvements in transplant outcomes are attributable to advances in histocompatibility testing, organ procurement, organ preservation, surgical techniques and perioperative care. Long-term outcomes have shown only minor improvements over the last two decades, although this should be considered in the context of deteriorating organ quality as older deceased donors with increasing co-morbidity are used more often to satisfy the need for donor organs. An overall increase in deceased donor numbers has boosted transplant activity in the UK, and it is hoped this will continue with the adoption of the 'opt-out' consent system. Living donor activity remains stable, but the use of non-directed altruistic donation and the living donor exchange scheme have reduced the need for higher immunological risk incompatible transplantation. The COVID-19 pandemic has reduced transplant rates globally, although national transplant systems are now recovering.Copyright © 2022

The Impact of Capacity Building in the Organ Donation Activity during an International Society of Nephrology -the Transplantation Society Sister Transplant Center (Isn-Tts Stc) Partnership

Introduction: In 2016, the International Society of Nephrology - The Transplantation Society (ISN-TTS) has granted the Sister Transplant Center (STC) to Southern Philippines Medical Center (SPMC) as an emerging center with the University of Barcelona (UB) as the supporting center. As part of capability building, partnership with Donation and Transplantation Institute (DTI) was integrated in the partnership. This has led in doing five (5) Intermediate Transplant Procurement Management courses of health care professionals from SPMC which provided access to strengthen the deceased organ donation activity thru education and training. There is a substantial increase in the number of cadaveric donor transplantation due to changes in the implementation of principles in transplant coordination and organ procurement management (Karatzas 2007). Education of health professionals will improve referral rates for potential donors (ODISSeA 2021). During COVID-19 pandemic, SPMC as end hospital referral facility has stop all donation and transplantation activity. In a report by Nimmo et al., COVID pandemic has shown to be an important limiting factor in the hospital's transplant program. Resumption of training was done and capability building was enhanced by the supporting center. After 6 years of partnership as STC, the impact of training and education in the organ donation activity within the framework of an ISN-TTS and SPMC partnership was then analyzed. Method(s): The hospital database on the organ donation activity and training records were used to analyze the information from 2016 to 2022. The periods were divided as Pre STC partnership in 2016 and the period after the STC implementation from 2017 to 2019. The period from 2020 - 2022 was divided into peri pandemic and pandemic recovery period. An observational descriptive study method was utilized for analysis. Result(s): The results have shown that in 2016 (pre-partnership) there were only 4 donor referrals per year with the partnership's implementation, the number of referrals significantly increased to 54, with a 151.85% increase in 2018 and 474.39% in 2019. The direct impact of COVID-19 pandemic in 2020 and 2021 decreased the number of referrals by 306.3% arriving finally to 7 referrals in 2021. The deceased donation program needed to be reactivated during 2022. Resumption of training for professionals on deceased donation process and management, and monthly evaluation of referred donors from experts from DTI helped achieve 657% increase in number of referrals. Conclusion(s): Implementing the ISN-TTS-STC partnership program of SPMC, UB and DTI has successfully increased the hospital organ donation and transplantation activity. During Covid-19, there is a decrease of activity in organ donation thus also has a direct relationship to the decrease in the number of referrals. Further, resumption of training program in organ donation after the pandemic has increased the program's activity. As a conclusion, capacity building has shown to have a direct impact in the organ donation activity. No conflict of interestCopyright © 2023

Outcomes of keratolimbal allograft from ABO compatible donors for severe bilateral limbal stem cell deficiency.

PURPOSE: To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present. METHODS: Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events. RESULTS: Eight eyes of eight patients with mean age of 48.6 ±â€¯10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ±â€¯22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ±â€¯0.48 to 0.68 ±â€¯0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events. CONCLUSIONS: Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.

Study of Efficacy of Equine Anti Thymocyte Immunoglobulin (Eatg) as Induction and Antirejection Therapeutic Agent in Renal Transplantation

BACKGROUND: Equine Anti-Thymocyte Immunoglobulin (eATG) has been used less as an induction immunosuppressant agent in renal transplantation compared to rabbit ATG (rATG). However, eATG is very economical compared to rATG. The cost of eATG as induction agent in renal transplant on an average is INR. 30 000/- per dose, and cost of rabbit ATG ( rATG) as induction agent is INR 1 20 000/-. AIM OF THE STUDY: To study the efficacy of eATG as induction and anti-rejection therapeutic agent in renal transplantation. METHOD(S): Material(s) and Method(s): Renal transplant recipients were divided into two groups. Group A (GrA) recipients had renal donation from HLA matched first degree relatives and received only injection methylprednisolone (MP) as induction therapy. Group B (GrB) recipients had renal donation from deceased donors (brain dead) or spousal donors were administered eATG 10 mg/kg along with low dose MP as induction therapy. Outcomes were compared between GrA and GrB. Monitoring for eATG therapy-induced blood lymphocyte count depletion post-transplant was also done to assess eATG efficacy. eATG as antirejection therapy agent: eATG was administered in biopsy-proved acute T-cell-mediated rejection (TCMR). Repeat transplant kidney biopsy was done to assess improvement. RESULT(S): Number of renal transplant recipients in GrA were 29 and GrB were 35. All recipients of GrA and GrB had normal renal function by 14th post-transplant day (PTX). There was 20% decrease in blood lymphocyte count following MP therapy (GrA) compared to 85% decrease following therapy with eATG ( GrB) and the difference was statistically significant (p < 0.05). Marked decrease in lymphocyte count indicated efficacy of eATG. Biopsy-proved acute TCMR was seen in 5% of GrA and 4% of GrB (p > 0.05). None from both groups had antibody mediated rejection. All patients with acute TCMR responded to eATG antirejection therapy. Opportunistic infections was noticed in 9% of GrA patients and 11% of GrB patients in the first 180 days PTX (p > 0.05). Two years graft survival was 83% in GrA and 80% in GrB (p > 0.05). During two-year followup one patient from each group died of Covid19 infection (p > 0.05). CONCLUSION(S): Since excellent results were obtained with eATG as an induction and antirejection therapeutic agent, it can be used in renal transplant with high-risk immunological states as a polyclonal antibody. eATG is more economical compared to rATG.

The positive impact of the COVID- 19 Pandemic on Organ Utilisation in Liver Transplantation

Background As the world recovers from the aftermath of devastating waves of an outbreak, the ongoing Coronavirus disease 2019 pandemic has presented a unique perspective to the transplantation community of ‘'organ utilisation'' in liver transplantation, a poorly defined term and ongoing hurdle in this field. To this end, we report the key metrics of transplantation activity from a high-volume liver transplantation centre in the United Kingdom over the past two years. Methods Between March 2019 and February 2021, details of donor liver offers received by our centre from National Health Service Blood & Transplant, and of transplantation were reviewed. Differences in the activity before and after the outbreak of the pandemic, including short term post-transplant survival, have been reported. Results The pandemic year at our centre witnessed a higher utilisation of Donation after Cardiac Death livers (80.4% vs. 58.3%, p=0.016) with preserved United Kingdom donor liver indices and median donor age (2.12 vs. 2.02, p=0.638;55 vs. 57 years, p=0.541) when compared to the pre-pandemic year. The 1- year patient survival rates for recipients in both the periods were comparable. The pandemic year, that was associated with increased utilisation of Donation after Cardiac Death livers, had an ischemic cholangiopathy rate of 6%. Conclusions The pressures imposed by the pandemic led to increased utilisation of specific donor livers to meet patient needs and minimise the risk of death on the waiting list, with apparently preserved early post-transplant survival. Optimum organ utilisation is a balancing act between risk and benefit for the potential recipient, and technologies like machine perfusion may allow surgeons to increase utilisation without compromising patient outcomes.

Differences in Outcomes Between High Dose and Low Dose Belatacept Conversion on Allograft Function in Kidney Transplant Patients

Background: Belatacept, a selective costimulation T cell blocker is used to avoid unwanted side effects from calcineurin inhibitors. Improved allograft function despite increased risk of early rejection and viral infection have been reported. Method(s): This is a single center retrospective study conducted at Mayo Clinic Arizona. We converted patients to the high dose belatacept (10mg/kg) if transplanted within 1 month and to the low dose (5mg/kg) after 1 month if they had significant side effects with calcineurin inhibitors or suboptimal allograft function with chronicity changes on biopsy findings. Tacrolimus dose was discontinued immediately in high dose conversion group but was overlapped and tapered down within 4 weeks in low dose conversion group. We included both deceased donor and living donor transplant recipients from 2013 to 2021. We compared the effect of high dose and low dose on the occurrence of rejection and infection at 1 year. Result(s): Total of 75 patients were switched to belatacept and 56 (74%) was converted to low dose and 17 (26%) were converted to high dose. No statistical difference found in recipient and donor characteristics between 2 groups (Fig 1). There was no statistical significance in allograft function, rejection rate and infection rate at 1 year (Fig 2). However, the ocurrence of COVID 19 infection was statistically significant in high dose conversion group. Conclusion(s): Allograft function was comparable at 12 months between 2 groups for those transplaned within 1 year. It is important to recognize the potential for overimmunosuppression when transitioning to belatacept.

Utilization of SARS-CoV-2 (COVID-19)-Positive Donor Kidneys

Background: The Organ Procurement and Transplantation Network requires documentation of SARS-CoV-2 (COVID) testing status for each potential donor and lower respiratory specimen testing with nucleic acid tests for all donor lungs. In the absence of guidelines for the use of COVID-positive donor kidneys, we sought to examine the clinical characteristics of COVID-positive donors and trends in the utilization of COVID-positive donor kidneys. Method(s): This study used Scientific Registry of Transplant Recipients data and included all deceased donors (n=24,940) and recipients (n= 29,478) from June 1, 2020, through April 2, 2022. Variation in donor and recipient characteristics were considered significant at P<.05. Result(s): 1,310 (5.35%) of donors during the observation period had a positive test for COVID-19 with 1,731 (67.70%) kidneys transplanted, 108 (4.22%) not recovered, and 714 (27.92%) recovered but not transplanted. COVID-positive donors differed from COVID-negative or untested donors in terms of race, ethnicity, cause of death, and donation after circulatory death status (all P < .05). 813 recipients (2.76%) received COVID-positive deceased donor kidneys. Recipients of COVID-positive donor kidneys were more likely to be White, not have received a previous transplant, and had greater cold ischemic times (all P < .05). The number of transplants with COVID-positive donors peaked in early 2022 (Figure 1). Adjusted hazard ratios for all-cause graft failure with COVID-positive donors and death were 0.89 (95% CI, 0.62-1.28) and 0.87 (95% CI, 0.52-1.46), respectively. Conclusion(s): Transplant with COVID-positive donor kidneys increased during the study period and is not associated with increased risks for recipients. However, high discard rates for COVID-positive donors and greater cold ischemic times may suggest that such donor kidneys remain difficult to place. Patient- and transplant program-level interventions targeting decision support and risk aversion may be necessary to reduce discard rates for COVID-positive donor kidneys. (Figure Presented).

Outcome of COVID-19 Infections After Vaccination in Kidney Transplant Patients

Background: Kidney transplant recipients (KT) are a vulnerable population with a risk of death after COVID-19 infection (COV-I) four times higher than in the general population. mRNA COVID-19 vaccines changed the prognosis. Although KT have an impaired immunological response to mRNA vaccines, in March 2021 we started a vaccination campaign. Method(s): Among 1611 KT, 72 (4.2%) had COV-I (positive molecular nasopharyngeal swab) between 31 October 2021 and 15 January 2022 (3rd outbreak). Fourty-one (57%) were male and 58 (80.5%) had a deceased donor transplant, median age was 52 (43-60) years, median transplant vintage 57 (27-159) months, median serum creatinine 1.37 (1.0-1.7) mg/dL. KT were on calcineurin inhibitors, prednisone, mycophenolate (MMF) and mTOR inhibitors in 93-87-79% and 5.6% respectively. At COV-I 43 KT had received 3 doses of Comirnaty (BNT162b2), 21 two and 4 one, 4 were not vaccinated. DELTA variant was present in 36. Treatment included: increase of the daily steroid dosage (69%), MMF withdrawal (70%) or halving (5%) and monoclonal antibodies: Ronapreve or Xevudy (32%). Nine delta positive KT were hospitalized for severe respiratory distress: 2 died (6.6%). Result(s): The variables associated with an increased risk for hospitalization were older age and dyspnea (p=0.023, p<0.0001 respectively). At multivariate analysis, dyspnea (p <0.0001) and MMF (p=0.003) were independently associated with the risk for hospitalization. Combination of the two variables increased the significance (p<0.0001). Comparing this series to the 82/1503 (5.4%) KT infected during the previous waves, hospitalization, mortality and cumulative mortality rates dropped from 45%, 29.3% and 13.4% to 30%, 6.6% and 2.7% respectively, main difference being the absence of vaccination in the first group. Conclusion(s): Vaccinations did not reduce the incidence of COV-I among KT but provided certain protection associated with a significantly better outcome.

Treatment With Monoclonal Antibodies Is Safe and Effective for Kidney Transplant Recipients With COVID-19

Background: Monoclonal antibodies have been the mainstay of treatment of COVID-19 in patients at high-risk of mortality from COVID-19. We aimed to study our experience with monoclonal antibodies (mAb) in kidney transplant recipients with COVID-19 at our center. Method(s): We reviewed 93 of our kidney transplant recipients who were infected with COVID-19 and received mAb treatment. The mAb infusion received was the one active against the variant that was circulating during that period (39 received either bamlanivimab or casirivimab/imdevimab, 41 received sotrovimab and 13 received bebtelovimab). All patients were on standard immunosuppression with tacrolimus and prednisone, and 88% were on mycophenolate prior to COVID-19 diagnosis, which was subsequently reduced or held for at least 2 weeks. Result(s): Of the 93 patients, median age was 54 (IQR 44-64), 44% were male, 42% were Hispanic, 36% were African American. 76% have received deceased donor kidney transplant, 94% had history of hypertension, 47% diabetes mellitus, 18% coronary artery disease. All the patients had mild symptoms without initial hypoxia requiring supplemental O2 and only 5 patients (5.4%) were admitted to the hospital. While 33 patients (35%) were unvaccinated at the time of COVID-19 diagnosis, 60 patients (65%) have received at least 2 doses of COVID vaccination at time of diagnosis and of those 27 patients (29%) have received a third dose. There was only one death (1%) in a patient that was re-hospitalized with severe COVID-19. There was no allograft loss. The rate of re-infection after mAb treatment was 6.5%. There was no serious adverse event related to the mAb infusion. Conclusion(s): Our experience suggests that monoclonal antibodies are a safe therapeutic to reduce the need for COVID-19 related hospitalization in this high-risk kidney transplant population, while one third of those were unvaccinated at the time of COVID-19 diagnosis.

Decreased Mortality From SARS-CoV-2 in Kidney Transplant Recipients Over the Course of the Pandemic

Background: We aimed to investigate the variation in mortality from SARS-CoV-2 infection in kidney transplant recipients Methods: Between March 16, 2020 and May 4, 2022, 537 patients were diagnosed with SARS-CoV-2 infection by RT-PCR. Result(s): 59% were male, median age 58 (IQR: 45-67), predominantly Hispanic (51.2%) and African American (29%). 75.4% received a deceased-donor renal transplant, 55% received anti-thymocyte induction. Most patients were on triple immunosuppression (96% on calcineurin inhibitors, 87% on anti-metabolite, and 99% on prednisone). While the mortality rate was 37 % (47/128) during first peak between March 16 and April 30, 2020, it has significantly decreased to 11% (7/61) from May 1, 2020 to end of December 2020 with social distancing and use of facemask. Between January 1, 2021 and November 5, 2021 with use of vaccination and monoclonal antibodies, the mortality rate further decreased to 7.7% (10/129). Between November 6, 2021 till May 4, 2022 which corresponds to the period when the Omicron variant and subvariants are prevalent, the mortality rate was 5.5% (12/219). Among those diagnosed during the period when Omicron was prevalent, 188/219 (85.8%) have received 2 doses of COVID vaccine and 82/219 (37.4%) have received a third dose. Since the beginning of use of monoclonal antibodies, 93 patients received a combination of casirivimab/imdevimab when initial SARS-CoV-2 variants were dominant and sotrovimab then bebtelovimab during the period of Omicron and its subvariants. Only one death occurred in patients who received monoclonal antibody treatment and that patient was hospitalized for severe COVID-19. We identified 23 re-infections. Most of re-infected patients have already received at least 2 doses of COVID vaccine but only 5 received a third dose. None of the re-infected patients was hospitalized and none of them died. Conclusion(s): In summary, mortality from SARS-CoV-2 infection in kidney transplant recipients has significantly decreased over time. This could be explained by initial exposure to higher viral load due to lack of personal protection and social distancing. However, since the judicious use of monoclonal antibodies and vaccination, in addition to social distancing protocols and use of facemask, the mortality in kidney transplant recipients has decreased over time.