ABSTRACT
Objectives: We would like to report a case in which a COVID-19 patient who was transferred to our hospital due to a lack of medical resources due to the COVID-19 outbreak in Daegu, South Korea, on February, 2020, underwent double lung transplantation after 110 days with VV-ECMO support and performed double lung re-transplantation 865 days after lung transplantation. Method(s): ECMO was performed on a total of 69 patients with COVID-19-related acute circulatory/ respiratory failure from February 2020 to December 2022. Among them, 16 patients were registered for lung transplantation, and 5 out of 16 registered patients performed lung transplants. One in five people who performed lung transplantation performed retransplantation on the 865thday after transplantation. Result(s): A 52-year-old female patient was transferred to our hospital, and VV-ECMO was performed the next day. The double lung transplantation was performed 112 days after hospitalization and was discharged 238 days after surgery. 668 days after lung transplantation, home O2 was applied as bronchitis obliterans syndrome, and her lung function deteriorated rapidly later, and re-transplantation was decided. In the patient;s HLA test, HLA class I cPRA% was 32% and HLA class II cPRA% was 100%. Desensitization was performed six times plasmapheresis with administrating Botezomib and immunoglobulin, and then re-transplantation was performed on the 865th day after lung transplantation. The patient has maintained her daily life without any special complications other than the occurrence of central DI after surgery. The pathological findings of the lung previously transplanted to the patient were acute rejection (ISHLT grade A2), chronic airway rejection (ISHLT grade C1, B0), and chronic vascular rejection (ISHLT grade D1). Conclusion(s): The long term result of patients who performed lung transplantation with COVID 19 related respiratory failure is still unknown. Therefore, even patients who have undergone long-term VV-ECMO support due to COVID 19 related respiratory failure are expected to achieve good results if lung transplantation is needed by carefully approaching and treating with a multidisciplinary approach.
ABSTRACT
Purpose: Viral infections (VI) commonly occur in the post-transplant period and higher cumulative doses of rATG have been correlated with higher rates of infection. However, basiliximab (BAS) has decreased risk of infection but increased risk of rejection due to a lower immunosuppressive profile. There is a shortage of literature evaluating choice and dosing of induction agent and the incidence of VI in kidney transplant recipients (KTR) receiving tacrolimus, mycophenolate and early steroid withdrawal. This study evaluated the incidence of VI in KTR receiving BAS, rATG low (< 3mg/kg), or high dose (> 3mg/kg) within 180 days post-transplant. Method(s): This single-center, retrospective study included adult KTR from July 2020-March 2021. KTR were excluded if they received a multi-organ transplant, no induction, or maintenance immunosuppression other than tacrolimus and mycophenolate. Induction was given based on patients' immunologic risk factors for rejection which included: age, race, cPRA, retransplantation, and DR HLA mismatch. The primary objective compared the incidence of VI with BAS, rATG low and high dose. Secondary outcomes included incidence of CMV, BKV, EBV, HSV, COVID-19, DGF, BPAR, de novo DSA, eGFR, tacrolimus levels, graft loss, and mortality within 180 days post-transplant. Result(s): There were 44 KTR who received BAS, 43 who received low rATG dose, and 129 who received high rATG dose. Statistically significant differences in baseline demographics included age, race, mean peak cPRA, and mean KDPI (due to institutional induction guidelines) [Table 1]. A larger proportion of high rATG patients experienced VI, followed by low rATG patients, p<0.01 [Table 2]. Increased incidence of CMV, BKV, and COVID-19 occurred in patients receiving rATG [Table 2]. Infections generally occurred earlier in the rATG groups [Table 2]. DSA was highest in the high dose rATG (14%) which was attributed to high risk factors for rejection, p=0.0146 [Table 3]. No differences in BPAR, DGF, graft failure, or mortality were seen between all groups within 180 days. Conclusion(s): KTR that received induction with any rATG dose had a higher incidence of viral infections compared to basiliximab. Induction with rATG may lead to an earlier onset of viral infections compared to basiliximab. Further review of data at one year post-transplant is planned to strengthen the results of this study.
ABSTRACT
Primary sclerosing cholangitis (PSC) is a cholestatic disorder wherein liver transplant is the definitive treatment for advance stages. However, recurrence of PSC after liver transplant is of concern which can leads to graft failure and may require retransplant. There is limited data on outcomes of living donor liver transplant (LDLT) in PSC. Also, in LDLT as donors are related there is possibility of disease recurrence. So, we conducted this retrospective study to analyse the outcomes of LDLT in PSC at a tertiary liver transplant centre in north India. Methods: We conducted a retrospective analysis of 3213 transplant recipients who underwent LDLT from January 2006 to May 2021. Of these 26 (0.80%) patients has PSC as indication for liver transplantation (PSC=24, PSC/AIH overlaP=2). Data analysis was done to look for baseline demographics, clinical details, transplant outcomes, PSC recurrence and survival. Results: Mean age of study group was 42(±13.8) years and 19 (73.1%) were males. All patients had decompensated cirrhosis at time of transplant. Mean CTP score and MELD score were 9.5(±1.8) and 18.9(±7.1) respectively. 16 patients received modified right lobe graft, 7 extended right lobe graft and 5 patients received left lateral graft. Average graft weight and GRWR were 633.5(IQR 473.5-633.5) grams and 1.23(SD±0.42) respectively. Most common biliary anastomosis was hepaticojejunostomy, done in 19(73.1%) while duct to duct anastomosis was performed in 7(26.9%) patients. Median follow- up was 96(36-123) months. One patient had ulcerative colitis and none had cholangiocarcinoma. Two (7.7%) patients had bile leak during early post-transplant period. Three (11.1%) patients developed graft rejection and managed successfully with steroid pulses. Three patients died during early post-transplant period while 7 deaths occurred during long term follow-up including one death due to COVID-19. Five (19.2%) patients had recurrence of PSC of which 2 patients lost their grafts including one after retransplantation. The overall 1 year and 5-year survival rates were 88.5% and 75% respectively. Conclusion: LDLT can be performed in PSC with good long-term outcomes with a risk of PSC recurrence in about 1/5th patients.
ABSTRACT
Purpose: Many acceptable donor hearts are turned down by pediatric centers with varying criteria for an acceptable donor. Advanced Cardiac Therapy Improving Outcome Network (ACTION) and Pediatric Heart Transplant Society (PHTS) centers convened a multi-institutional donor decision discussion forum (DDDF) aimed at assessing donor acceptance practice and reducing practice variation across centers. Methods: The team hosted an hour-long monthly virtual DDDF among pediatric transplant centers across North America, UK and Brazil. Each call had two case presentations posing a donor decision challenge for the presenting center at the time of donor offer. Following each presentation, the attendee group was polled to obtain insight on donor acceptance practices after which the presenting center's decision was revealed. Then, group discussion occurred including a review of relevant literature and latest PHTS data related to the case. Metrics of participation, participant agreement with presenting center decision and impact on future decision making were collected and analyzed. Results: Over 14 months, 23 cases were discussed;an average of 50 physicians, nurses and fellows attended each call. The mean donor age was 8.2 ± 3.3 years (28.6% infants, 52.4% young adults), and the mean recipient age was 8.36 ± 3.3 years (27.3% infants and 40.9% teenagers). Reason for listing was congenital heart disease in 10, cardiomyopathy in 5 and retransplantation in 3. Risk factors influencing decision making included size discrepancy (4), Infection (5), COVID (2), Prolonged QT (2), Malignancy (2), Drugs (2), Distance (1) Prolonged CPR (1) high inotrope use (1) Dialysis (1) Diabetes (1) HLA mismatch (1). Of the 23 cases, 15 were declined by presenting center. Donor characteristics influenced 45% of the decisions and recipient only 20%, with rest being other factors. Participants agreed with the decision made by the presenting center 55% of the times. The post-presentation discussion resulted in 30% of participants changing their original decision. Conclusion: DDDF identified significant variation in pediatric donor acceptance practices;with donor characteristics most influential in decision-making. Given that the discussions changed decisions in 1/3rd of the participants, DDDF may be a useful format to reduce practice variation, provide education to decision makers and eventually increase donor utilization.