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The coronavirus disease 2019 pandemic has significantly impacted liver tran splantation worldwide, leading to major effects on the transplant process, including the pretransplant, perioperative, and post-transplant periods. It is believed that patients with chronic liver disease, especially those with cirrhosis, have a higher risk of complications from coronavirus disease 2019 infection compared to the general population. However, evaluation of coronavirus disease 2019 effects on liver transplant patients has not uniformly demonstrated worse outcomes. Nonetheless, the pandemic created significant challenges and restrictions on transplant policies and organ allocation.
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Introduction: Liver transplantation (LT) is the second most common solid organ transplantation, however, less than 10% of global transplantation needs are achieved. Low- and middle- income countries (LMIC's) are the most affected. A university- based Center for Global Surgery and our LT team joined efforts in 2017 to create an international alliance for clinical care and academic endeavors. Here we describe our experience establishing a LT mentoring group within an academic Center for Global Surgery. Method(s): This is a retrospective observational study. We evaluated the number of clinical, research and educational activities that our program did with LMICs from 2009 to 2022. Surgeries, patient evaluation, and follow-up were done in a multidisciplinary fashion with protocols from our LT program in partnership with LMIC's teams and via telehealth. Most educational and research activities were done online. Result(s): We performed 15 surgeries in pediatric and adult patients, including cadaveric, living donor LT, portosystemic shunts, and resections, and evaluated 27 patients from LMIC's. We have submitted 2 articles, presented 5 s, and obtained 1 grant. Our group received support to sponsor 1 research scholar per year and we had 15 bilateral exchange visits and organized 27 online multidisciplinary education sessions in collaboration with centers from LMIC'S. Conclusion(s): Our data shows that global transplant efforts with a multidisciplinary model can have clinical and academic impact. It is feasible to partner and mentor LT programs in LMICs through telehealth and exchange programs. Funding of these efforts remains challenging, and COVID-19 has limited academic and clinical activities.
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In Japan, since the revision of the Organ Transplant Law in July 2010, donation after brain death (DBD) has increased, while donation after cardiac death (DCD), which has been mainly used by kidney transplantation, has decreased. The number of DCD donors decreased from 98 in 2009 to 28 in 2019. There is no clear reason for the decrease in DCD donors. Furthermore, since 2020, there has been a marked decrease in DCD due to the influence of the COVID-19 pandemic. On the other hand, the outcomes after kidney transplantation from DCD donors are improving year by year. The outcomes of kidney transplantation from DCD donors in Japan are comparable to those of kidney transplantation from DBD donors in Western countries. In order to further improve transplantation outcomes from DCD donors, the clinical introduction of continuous machine perfusion preservation technology, for the purpose of reducing ischemic reperfusion injury, is expected in Japan.
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Purpose: Primary focal segmental glomerulosclerosis (FSGS) recurs after kidney transplantation (KT) in 30-50% of recipients with a median time of 1.5 months post- KT. Recurrence is associated with early graft loss in 60% of cases. The aim of this study is to assess the efficacy of pre-emptive therapeutic plasma exchange (TPE) and rituximab for the prevention of FSGS recurrence post-KT. Method(s): This single-center, retrospective study included patients receiving KT for primary FSGS between May 2016 and August 2021. Living-donor KT recipients received three sessions of TPE prior to scheduled transplant. Recipients of both living and deceased donor KT received 3 postoperative sessions of TPE followed by one dose of 375 mg/m2 rituximab with or without intravenous immune globulin (IVIG) 0.5 g/kg. Recipients underwent protocol biopsy at one month to screen for FSGS recurrence. The primary endpoint was a composite for disease recurrence including proteinuria (>=1 g/day) or/and biopsy-proven FSGS within one month. Result(s): 54 patients received KT for FSGS during the study period using the TPE/ rituximab protocol. 5 patients (9%) experienced FSGS recurrence within one month of transplant. A total of 10 patients (19%) were found to have disease recurrence within a year, with median (IQR) time to recurrence of 37 days (27-66). White race and history of hypertension were independent risk factors for recurrence, whereas African American race and diabetes were associated with a reduced risk of recurrence. 31 patients (57%) also received IVIG prior to discharge due to concerns for hypogammaglobulinemia. There were 18 documented infections in 13 patients (24%) within 3 months of transplant. Patients who received IVIG had significantly fewer cases of infection (3 cases: 1 viral and 2 COVID-19) compared to patients who did not receive IVIG (15 cases: 4 bacterial, 9 viral, 1 fungal, and 1 COVID-19), p<0.001. At one year, 9 patients (19%) had biopsy-proven rejection (5 acute cellular rejection, 1 antibody-mediated rejection, and 3 mixed rejection). There were no instances of graft loss or mortality observed at one year. Conclusion(s): The utilization of plasma exchange and rituximab may prevent early disease recurrence of FSGS without significant rates of infection, graft loss, or mortality.
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Purpose: Administration of mRNA-based SARS-CoV-2 vaccines confers protection from SARS-CoV-2 infection and reduces its severity in the general population. It has been suggested that mounting a coordinated adaptive immune response characterized by production of neutralizing antibodies and SARS-CoV-2 spike proteinspecific T-cells correlates with protection from infection. Studies in organ transplant recipients have demonstrated suboptimal responses after 2 doses of SARS-CoV-2 vaccination;however, the impact of different immunosuppressive regimens (IS) on T-cell responses is not well described. This study prospectively evaluated the impact of IS on T-cell responses in a kidney transplant (KTx) population and compared these to 26 healthy controls. Method(s): In this single-centre, prospective study, 92 KTx on follow-up at our centre were enrolled after informed consent. T-cell responses were evaluated before and after each of 2 doses of BNT162b2 SARS-CoV-2 vaccine administered 21 days apart: before each dose, 10-14 days after Dose1 and 21-24 days after Dose2. The study population included 69.6% Live-Donor and 30.4% Deceased-Donor KTx. Longitudinal assessment of the quantity of spike-specific T-cells was performed by stimulating whole blood with peptides covering the SARS-CoV-2 spike protein, followed by cytokine (IFN-gamma, IL-2) measurement (JCI, Tan et al, 2021). KTx were stratified by maintenance IS into 4 groups and T-cell responses compared between groups. Result(s): As shown (Figures 1A, 1B), in comparison to healthy controls, KTx displayed poor spike-specific T-cell responses as measured by IFN-gamma and IL-2 release. Percent responders were significantly lower for KTx vs. healthy controls: 6.5% vs. 92.3% after Dose1 (P<0.00001) and 27.2% vs. 100% after Dose2 respectively. There was a significant impact of different IS regimens (Figure 1C);percent responders after Dose2 were 19%, 43%, 40% and 71% for KTx receiving CNI-MPA-Pred, CNI-Aza-Pred, mTORi and Other regimens respectively (P=0.013). Conclusion(s): Our results highlight the critical role of IS on T-cell responses to SARS-CoV-2 vaccination. In the context of the COVID-19 pandemic, monitoring T-cell and antibody responses over time after vaccination, modulating IS and modifying vaccination strategies are clearly needed to protect this vulnerable population.
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Purpose: The Organ Procurement and Transplantation Network (OPTN) created a research variance allowing for transplantation of HIV+ donor kidneys and livers into HIV+ recipients after passage of the HIV Organ Policy Equity (HOPE) Act legislation in 2013 and subsequent published research criteria in November 2015. In May 2020 the OPTN modified the variance to include all solid organs. Method(s): The OPTN database was used to analyze temporal trends in waiting list registrations, HIV+ donors, HOPE transplant recipients, and program participation in the OPTN HOPE Act variance. HIV+ donors were identified through HIV serology/ NAT fields collected by the OPTN;recipients of these organs are HOPE recipients. Result(s): Transplant program participation saw consistent growth but has remained stable for the two years (Fig A). Despite this, patient demand for HOPE kidneys has been simultaneously declining, perhaps driven by a decline in listings related to Hypertensive Nephrosclerosis and DM Type II (listings for HIV Nephropathy remained stable), while liver demand remains low but stable (Fig B). Concurrently, there has been a consistent volume of recovered HIV+ donors and organs transplanted (Fig C, D). Transplant volume recently exceeded 300 organs transplanted (300 deceased donor, 3 living donor), largely driven by kidney (236 kidney, 67 liver;11 SLK) from 187 recovered HIV+ donors. Living donation of HIV+ organs remains limited to kidney. Among HIV+ deceased donors, the kidney discard rate was 32% while the liver discard rate was 4%. Twenty-nine recovered deceased donors had no organs transplanted, and associated common discard reasons for these donors were exhausted match runs and biopsy findings. Conclusion(s): The OPTN database does not include HIV status at listing;therefore, the decline in demand cannot be attributed to potential access changes for HIV+ patients, but may be related to the impacts of the COVID-19 pandemic. The impacts of the COVID-19 pandemic have not noticeably affected HOPE Act transplant volumes, highlighting the resiliency of the US transplant system. Based on consistent activity and positive data and safety analyses through five years, the OPTN recommended removal of the research criteria as a potential barrier to expanded utilization of the HOPE Act to HHS, in turn making HIV-to-HIV transplantation standard of care;the result of that recommendation is pending. (Figure Presented).
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Purpose: Adverse events of a novel mRNA vaccine are not well described in Kidney Transplant Recipients(KTR), especially the risk of immune activation or recurrent glomerulonephritis(GN), which has been described in native GN after COVID-19 vaccines. Method(s): In this single-center prospective study, 147 KTR were enrolled after informed consent and administered 2 doses of Pfizer/BioNTech vaccine 21 days apart. Follow-up was 3 weeks after Dose2. Result(s): Mean age of KTR was 51 years;55.1% male;65.3% Chinese, 19% Malay, 11.6% Indian;69.5% Living donor, 29.9% Deceased donor, 0.7% Pancreas-kidney transplants;71.5% had biopsy-proven or presumptive chronic GN(CGN), 12.9% diabetic nephropathy, 15.6% other causes. 11(7.5%) KTR had delayed Dose2 administered at median 29 days(range 24-93) after Dose1. 7(4.8%)were delayed due to renal events: rise in creatinine(n=3), or proteinuria(n=2), or both creatinine and proteinuria with allograft biopsy showing acute T-cell and antibody-mediated rejection(n=1), new BK viraemia(n=1). Other reasons were possible anaphylaxis(n=1), intercurrent infection(n=2), and inability to attend due to quarantine(n=1). 27 KTR had new microhaematuria(MH) after Dose1;9 persisted after Dose2. Additional 18 had new MH after Dose2. Of 45 KTR with new MH, 7 had underlying IgAN, 5 had other biopsy-proven-CGN and 22 had presumed CGN, suggesting 34/45 with possible immune activation. 12 KTR had new onset proteinuria (rise in urine protein:creatinine ratio (UPCR) <=30 to >30mg/mmol);5/7 who developed a rise after Dose1 remained elevated;additional 5 had a rise after Dose2. 7 KTR had rise in proteinuria from UPCR <=100 to >100mg/mmol. Conclusion(s): Subclinical changes in allograft monitoring parameters are frequent after COVID-19 mRNA vaccines with up to 40.1% of KTRs showing rises in creatinine, proteinuria or new MH. Although overt recurrent GN and acute rejection are infrequent, high vigilance and monitoring for these occurrences should be undertaken in KTRs receiving mRNA vaccines.
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Purpose: The SARS-CoV-2 or coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted racial and ethnic minority groups in the United States. Although, kidney transplant procedures decreased following onset of the pandemic, the differential impact of the pandemic on racial and ethnic minority groups remains unknown. Method(s): We examined kidney-alone procedures captured in the national Scientific Registry of Transplant Recipients (SRTR) analytic files and compared the change in deceased donor kidney transplant (DDKT) and living donor kidney transplant (LDKT) pre- and post- pandemic and the associated factors. Result(s): We found that the counts of LDKT declined more for Black patients in the 12 months following onset of the pandemic, March 2020 to Feb 2021, compared with counts in the same period in the preceding 12 months. LDKT counts among Black patients fell by 42.6% compared with 33.3% in White patients (P=0.02). This pattern of decrease in LDKT counts among Black patients occurred in all geographic areas of the country (based on current UNOS COVID-19 reporting) except for the Northeast and South Midwest (Figure 1). Along with recipient race, other factors associated with a significant decline in LDKT counts included public insurance, Black living donor race, and location of residence. In contrast, DDKT counts for both Black and White candidates declined initially (10% vs. 5.9% lower respectively, P=0.11) during the pandemic and then recovered closer to pre-pandemic levels. Conclusion(s): The COVID-19 pandemic disproportionately impacted Black patients' access to LDKT. While the current rate of DDKT procedures has recovered in 2021, it is unclear whether LDKT rates will recover to parity. As locoregional surge conditions can have differential effects, ongoing attention to transplant disparities resulting from the pandemic, with appropriately targeted interventions, is warranted.
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Purpose: The global COVID-19 pandemic has significantly altered delivery of healthcare. Hospital resource utilization has been impacted on multiple levels including solid organ transplantation and overall access to transplant care. In the United States, significant regional variation and decreased living donor transplantation occurred during the initial 6 months of the pandemic. We examined the multi-year impact of COVID-19 on pediatric organ donation and transplantation. Method(s): Pediatric (<18 years of age) organ donation and transplant data was obtained from the Organ Procurement and Transplantation Network (OPTN). Data included pediatric donors after brain death (pDBD), donors after circulatory death (pDCD), living donors (LD), and recipient details including total number of transplants, waitlist deaths, and removals were reviewed between January 2019 to December 2021. Result(s): Total pediatric transplants performed in 2019, 2020, and 2021 were 1923, 1766, and 1890 (p=0.004) respectively. Organ specific data is outlined in Table 1. In 2019, 2020, and 2021, living donor transplantation accounted for 320, 288, and 311 (p=0.838) cases, while 1579, 1456, and 1552 (p=<0.0001) deceased donor allografts were utilized. There were 171, 176, and 209 pDCD and 746, 684, and 713 pediatric pDBD donors. Living donors across all recipient ages were 7391, 5725, and 6539. 2392, 2337, and 2430 pediatric patients were added to all organ waitlists during the study period. 2347, 2198, and 2288 children were removed from the waitlist with 93, 82, and 76 of those cases due to patient death. There was no statistically significant difference in the proportion of pediatric patients added to the waitlist vs those removed during 2019-2021 (p=0.505) Conclusion(s): Transplant volume transiently decreased in the first six months of the COVID-19 pandemic. However, transplantation rates in children, specifically abdominal organ transplantation, increased to nearly pre-pandemic levels in 2021. Lung transplants were significantly decreased during the study period. Pediatric donation remained relatively steady from 2019-2021. Living donor transplantation in children was significantly impacted in 2020. Waitlist additions/removals remained consistent throughout the study period. (Table Presented).
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Purpose: Despite several policy reforms over the years, disparities in the access to solid organ transplantation continues to exist remains a significant barrier to liver transplant. The MELD Allocation system and subsequently the Share-35 policy (adopted June 2013) were implemented to address the inequitable access to liver transplantation (LT). The implication of these changes on adult and pediatric LT among ethnic groups is uncertain. Therefore the aim of this study, is to explore the factors associated with access to LT across ethnic groups of all age groups. Method(s): The study period (2014 -2019) included the period after Share-35 policy (June 2013) implementation and prior to implantation of Acuity Circle and COVID pandemic (Feb/March 2020). Using the UNOS database, we identified all candidates (Pediatrics and Adults), who received liver Transplant during the study period. Data extracted included type of transplant, liver diagnosis, age, MELD/PELD score, gender and race/ethnicity. Chi square test and anova were used for comparative analysis. Result(s): During the study period, 46,926 candidates received liver transplant of which 96% were Adults, living donor LT (5%) and ethnic distribution (White 69%, Hispanic 15%, Black 9%, Asian 4% and others 3%). In contrast to the Adult recipients in which there is a gender variation with male predominance (65%), among pediatric group there was similar distribution (Male 51% and Female 49%). There was significant ethnic variation in type of insurance payor (Figure 1) and proportion of LT (Figure 2) across age groups. Among pediatric recipients, no significant difference in LT trends across ethnic groups. In contrary, among the adult recipients, though there was no change among White (71% in 2014 and 71% in 2019) and Asian (4% in 2014 and 4% in 2019), there was slight increase among Hispanic ( 13 % in 2014 and 16% in 2019) and a steady decline among Blacks ( 10% in 2014 and 7.3% in 2019). Conclusion(s): Ethnic Variation in Access to Liver Transplantation exists in both Adult and Pediatric Candidates. Future studies to explore the observed difference in Insurance payors, gender gaps among ethnic groups will provide useful insights to the non-medical factors contributing to inequitable LT access irrespective of age. Identification and understanding the key social determinants that impact LT access will be key in developing strategies to reduce and eliminate these barriers across age groups.
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Purpose: This study aimed to characterize the management and impact of respiratory viral infections on pediatric kidney transplantation waitlisted candidates. Method(s): An IRB-approved, anonymous REDCap survey was distributed to pediatric transplant nephrologist and infectious diseases practitioners from November 2021-January 2022 to members of the Pediatric Nephrology Research Consortium and the Pediatric Infectious Diseases Society via email. If multiple providers from the same center responded, questions related to center-wide practices were combined. Result(s): Sixty-six providers, 65 physicians and 1 nurse practitioner, responded to the survey from forty-eight different institutions (47 centers were in the United States). Providers estimated that respiratory viral infections were the most common cause of delays in transplant due to recipient infection. This fact has been highlighted during the pandemic with 46% of centers reporting they had delayed transplants for institutional reasons related to the pandemic and 38% had delayed transplants for active SARS-CoV-2 infection in a recipient, even before the omicron surge. Despite the impact of respiratory viral detection in waitlisted patients, over 80% of centers did not have a policy regarding delays for respiratory viral infections including SARS-CoV-2. Pre-transplant recipient screening for non-SARS-CoV-2 viral infections was not routine in 77% of centers but 45% of providers indicated they would delay a living donor transplant if they knew the recipient had an asymptomatic respiratory viral infection. For recipients with symptomatic respiratory viral infection, 95% and 87% of providers would delay transplant (living donor and deceased donor transplants respectively). Fifty-nine percent of providers indicated they would proceed with transplant after a waiting period ranging from one week to two months. Conclusion(s): Providers recognize that respiratory viral infections, not limited to SARS-CoV-2, are a common cause of pediatric kidney transplant delay. Most centers do not have defined approaches to screening and management of non-SARS CoV-2. Prospective studies and policies for screening and management of respiratory viral infections in waitlisted pediatric kidney transplant should be considered.
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Purpose: Kidney transplant recipients (KTRs) are at higher risk for severe COVID- 19 caused by the severe acute respiratory syndrome coronavirus-2 (SARS646 All Infections (Excluding Kidney & Viral Hepatitis) I CoV-2). Sotrovimab decreases the risk of disease progression in the general population, but efficacy and safety in KTRs is unknown. Herein, we describe our experience in treating COVID-19 infected KTRs with sotrovimab. Method(s): We performed a retrospective, single-center cohort study of KTRs diagnosed with COVID-19 by polymerase chain reaction from 07/15/21-11/30/21. KTRs with COVID-19 were admitted to the hospital to expedite evaluation and treatment. KTRs with COVID-19 were eligible for sotrovimab if they 1) were not requiring oxygen at admission, 2) were unvaccinated or if SARS-CoV-2 spike antibody (SAb) after vaccination was <100 U/mL, and 3) duration of symptoms/day of illness (DOI) was <=7 days. COVID-19 disease requiring oxygen therapy was treated with remdesevir + dexamethasone. Immunomodulator therapy (baricitinib or tocilizimab) was given for rapidly progressive disease requiring high-flow oxygen or ICU care. Baseline characteristics, treatments, and outcomes including oxygen supplementation, ICU admission, and mortality were manually ed and evaluated. Result(s): In all, 36 KTRs were diagnosed with COVID-19 - mean age 59 years, 72% male, 67% Chinese, 64% diabetic and 17% obese;72% were deceased donor and 28% were living donor KTRs presenting a mean 11 years from transplant. The majority (69%) were vaccinated with >=2 doses of mRNA-based SARS-CoV-2 vaccines, 22% received 3 doses, and 15% were unvaccinated. Among KTRs who received >=2 doses, SAb was reactive in 36% and >100 U/mL in 16%. In all, 14 (39%) required oxygen, 11 (31%) required ICU admission, 5 (14%) were mechanically ventilated, and 4 (11%) died (Table). Sotrovimab was given to 27 eligible KTRs at median DOI 2 (range 0-6). Of these, 8 (30%) required oxygen, 5 (19%) required ICU admission, 2 (7%) were mechanically ventilated, and 1 died (4%). KTRs receiving sotrovimab at DOI <=3 vs >3 were less likely to require oxygen (p=0.01) or ICU admission (p=0.02). Sotrovimab was well tolerated with one associated adverse event (self-limiting diarrhea). Conclusion(s): KTRs remain at high risk for severe COVID-19. Sotrovimab administered early in the disease course is associated with a lower rate of severe COVID-19. Outcomes of KTRs with COVID-19 overall and among those receiving sotrovimab by day of illness (Figure Presented).
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Purpose: The coronavirus disease 2019 (COVID-19) pandemic has created unprecedented challenges and there are practice differences for solid organ transplant programs worldwide. We sought to assess an international perspective on COVID-19 vaccine mandates and rationales for or against a mandate policy. Method(s): We administered an electronic survey instrument to staff at transplant programs outside the United States (October-November 2021) that comprised of 23 questions addressing the reasons cited by centers for or against implementing a vaccine mandate. Each responding transplant program was represented once in the analysis. Result(s): Respondents (n=63) represented 19 countries on 5 continents. More than half (52.6%) of centers reported implementing a vaccine mandate, however 37.2% reported that their center has not considered (27.1%) or unsure (10.2%) on vaccination requirement. The main rationale for centers not implementing a vaccine mandate were concerns for undue pressure to transplant candidates, equity and legal considerations. (Fig. 1) The main rationale for centers with a vaccine mandate were efficacy of pre-transplant vaccination then post-transplant, importance for public health and minimizing exposure of other patients. (Fig. 2) The majority (79%) of the centers mandate vaccine regardless of prior SARS-CoV-2 infection status, and regardless of pre-vaccination spike-protein antibody titer or other markers or prior infection. Only 24.4% of centers with a vaccine mandate for transplant candidates also extended a vaccine requirement to potential living donors. Conclusion(s): The approach to pre-transplant COVID-19 vaccination mandate is heterogeneous across different countries and centers. More than one third of centers are reluctant to consider vaccine mandates for a varies of reasons including ethical, legal and equity concerns. (Figure Presented).
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Purpose: Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine has the potential to facilitate care delivery/ coordination for donors. We aimed to understand center practices and provider attitudes and perceived barriers of telemedicine services for living kidney donation. Method(s): We conducted a national survey of multidisciplinary providers from 194 U.S. active adult living donor kidney transplant centers in 2020. The survey was distributed with an online link from 2/18/2021 to 5/13/2021, and up to two reminders were provided. The target population included nephrologists, surgeons, nurse coordinators, social workers or independent living donor advocates, and psychiatrists or psychologists. We used descriptive statistics and analysis of variance. Result(s): Two hundred ninety-three providers from 128 unique centers responded to the survey, a center representation rate of 66.0%, reflecting 82.9% of U.S. practice by donor volume and 91.5% of U.S. states/territories. Most centers (70.3%) will continue using telemedicine beyond the COVID-19 pandemic. Video only was mostly used for donor evaluation by nephrologists, surgeons, psychiatrists or psychologists. Telephone and video were mostly used by social workers, while no mutual modality was used by coordinators. Vital signs and weight were obtained largely using self-reported measures or a local provider/primary care physician, and a physical exam was mostly completed at a subsequent in-person visit to the transplant center. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation for potential donors. These attitudes were consistent across provider roles (p>0.05). Providers were favorably disposed to use telemedicine beyond the pandemic for donor evaluation and followup care. Out-of-state licensing and reimbursements were key regulatory barriers. Conclusion(s): These findings help inform clinical practice and policy expanding telemedicine services to enhance access to living donation and may be extended to other medical specialties.
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Purpose: VCA transplantation has grown and changed, encountering challenges such as scarce funding sources and the COVID-19 pandemic. Method(s): The OPTN cohort includes 105 candidates listed and 62 recipients transplanted 7/4/14-10/31/21. Result(s): VCA candidates included 47 uterus, 26 upper limb (UL, 14 bilateral, 12 unilateral), 1 UL/face, 12 face, 1 scalp, 2 face/scalp, 1 trachea, 12 abdominal wall (AW), and 3 penis candidates. Waiting list additions increased in 2016 after uterus transplants began in the US. Head and neck and UL additions held relatively steady through 2019. The COVID-19 pandemic caused a decrease in VCA waiting list additions in 2020 - 1 AW, 1 uterus, and two UL candidates. In the first 10 months of 2021, 5 VCA candidates were added - 2 AW and 3 uterus candidates. In April 2020, 11 of 23 VCA candidates were inactive;on 10/31/2021, 8 of 21 were inactive. 62 candidates received 64 transplants (including 1 uterus re-transplant and 1 face/ UL transplant). Others refused transplant (n=7), became ineligible (n=4), could not be contacted (n=2), condition improved (n=1), were too sick (n=2), died (n=3), or were removed for other reasons (n=2). Median time on the waiting list for recipients was 217 days (IQR: 76.0-404.25 days). VCA transplants in the U.S. 7/3/14-10/31/21 include 14 UL (9 bilateral;5 unilateral), 9 face, 1 UL/face, 1 scalp, 1 trachea, 2 AW, 2 penis, and 33 uterus (12 deceased donor;21 living donor). In 2016, VCA shifted from mostly UL and face to a larger proportion of uterus transplants. UL and face transplants decreased in 2017, then increased and held steady through 2019. VCA transplants decreased in 2020 with the COVID-19 crisis and included 2 uterus transplants, the first U.S. face re-transplant, and the first successful UL/face transplant in the U.S. In the first 10 months of 2021, 2 living donor uterus, 1 bilateral UL, and the first trachea transplant in the US occurred. Out of 62 recipients, 21 were funded by the hospital, 15 by donations, 7 by Medicare/ Medicaid, 1 by Dept of Veterans Affairs, 3 by private insurance, and 2 by recipient. Conclusion(s): VCA transplantation continues to faces challenges such as the COVID-19 pandemic and chronic issues such as funding sources, but has shown signs of resilience in 2021. (Figure Presented).
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Purpose: The OPTN DTAC, a multidisciplinary group, evaluates potential donor derived transmission events (PDDTE) to assess the likelihood of disease transmission. Method(s): Retrospective study of PDDTE cases reported to the OPTN between 01/20 and 12/20. DTAC reviewed cases using a standardized classification algorithm. Result(s): During 2020, there were 18,318 donors and 37,583 unique recipients. DTAC reviewed 261/427 PDDTE from donor (111) or recipient (150) findings. 64/261 (25%) donors had proven/probable transmission (P/P Tr) of infection, malignancies or other to 84/206 (41%) exposed recipients [figure]. 12 involved living donors. Infection occurred with 44/64 P/P cases affecting 63 recipients. Viruses were most frequent P/P infections with 29 recipients having P/P Tr from 19 donors. COVID-19 PDDTE represented 11% (29/261) of all cases reviewed involving 29 donors and 15 lung and 76 non-lung recipients. One lung recipient had P/P Tr and died;none of the non-lung recipients developed P/P Tr. For bacteria, 20 recipients had P/P Tr from 14 donors. Deaths from infection (N=10) occurred at a median of 20 days (5-89 days). Attributable death was highest for fungal (4/12, 33%) and bacterial infections (6/20, 30%). 7 donors with malignancies were classified as P/P impacting 15 recipients with 1 attributable death. 53 non-infection, non-malignancy PDDTE were reported;13 resulted in P/P Tr to 14 recipients. Conclusion(s): Although P/P events remain rare, 1/4 reviewed cases resulted in unanticipated P/P Tr. This is a conservative estimate due to passive reporting and empiric interventions. In 29 COVID-19 PDDTE only 1 lung recipient had P/P Tr. The DTAC continues to evaluate PDDTE to maximize organ use and minimize the risk of transmission. (Table Presented).
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Purpose: We surveyed current policies of transplant centers regarding a COVID-19 vaccine mandate, and rationales for or against a mandate policy. Method(s): An electronic survey was distributed to clinicians at U.S. solid organ transplant programs from 2020-2021. Result(s): 56.4% of transplant programs representing 78.5% of all kidney transplant volume and 82.4% of liver transplant volume in the US from 9/1/20-9/1/21 responded to the survey. 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported not that vaccination was not required and 3.6% were uncertain. Centers without a vaccine mandate policy cited administrative, equity, and legal considerations (Figure A). Centers with a vaccine mandate cited clinical evidence supporting the efficacy of pre-transplant vaccination (82.0%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64.0%) (Figure B). Among centers with a mandate, few required confirmation of vaccine responsiveness through antibody testing (2.6%), required a support person (10.0%) or co-habitants (5.0%) to be vaccinated. 42.5% of centers with a mandate also required living donor candidates to be vaccinated. There was no correlation between the presence or absence of a vaccine mandate and the point prevalence rate of COVID-19 vaccination by the home State of the transplant center. Conclusion(s): Solid organ transplant centers in the US exhibit significant heterogeneity in the requirement for a COVID-19 vaccination prior to receiving an organ. While all centers encourage vaccination, most programs do not require all candidates and living donors to receive the COVID-19 vaccine prior to surgery, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants. Among the minority of centers mandating COVID-19 vaccination for candidates, few centers also mandate vaccination for support persons or co-habitants, require additional testing to demonstrate adequate vaccine responsiveness, and less than half of these centers also mandate vaccination for living donor candidates. (Figure Presented).
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Purpose: Over the last years, the number of kidney transplants from living donors (LD) increased. However, more male than female patients received a LD transplant while increasing more females donated a kidney. Method(s): This study included all 109,038 primary adult living donor kidney transplants reported to UNOS/OPTN and performed between 2000 and 2021. To account for annual fluctuations, 2-year intervals were assessed. Comprehensive univariate and multivariate analyses were performed to describe changes and risk factors for female living donor kidneys transplants. Result(s): Figures 1 and 2 show the proportion of female donor and kidney recipients over time. Table 1 and 2 show the gender differences for donor and recipients. Women continued to donate more even during the COVID-19 years 2020/21. For female kidney recipients increased the relative disparity index constantly from 1.39 in 2000/01 to 1.75 in 2020/21. The likelihood for a woman to receive a LD kidney increased by not having diabetes as underlying disease, being Black , and having a high PRA level, and being not working;the likelihood decreased with increasing age and being on dialysis. almost 3 times more often donated female spouses a kidney. Conclusion(s): (1) the disparity of receiving a LDK has continued in favor of men;(2) the likelihood to receive a LDK kidney was higher for a black vs white woman;(3) the likelihood to receive a non-biological LDK (spouse) was significantly lower for women vs men;(4) while women are significantly more often sensitized, the likelihood to receive a LDK was higher for sensitized women vs men. Gender disparity in 2020/21 remains real in LDK transplantation. (Figure Presented).
ABSTRACT
Background: With the highly effective direct-acting antiviral (DAA) therapy, the number of liver transplants for hepatitis C virus (HCV) has decreased worldwide. However, similar to the phenomenon occurring in COVID-19 infection, the residual virus reservoirs in target organ is warranted to be explored due to the potential replication and disease recurrence. Hence, we aim to investigate the significance of hepatic HCV RNA identification as well as the discrepancy between HCV RNA and HCV core antigen (HCV Ag) in native liver of chronic hepatitis C recipients undergoing living donor liver transplantation (LDLT). Methods: Between Feb 2016 to Aug 2019, we prospectively enrolled 80 serum anti-HCV positive recipients who underwent LDLT. HCV RNA extracted from the native liver tissues was subjected to one-step reverse transcribed qPCR, using the TopScript One Step qRT PCR Probe Kit with HCV qPCR probe assay and human GAPDH qPCR probe assay on ViiA 7 Real Time PCR System. Hepatic HCV Ag was identified from the native liver tissues by employing the qualitative enzyme immunoassay technique. All experimental steps were based on the protocol provided by Human HCV Ag ELISA Kit (Cat. No. MBS167758). Results: Among 80 recipients, 85% (68/80) positive HCV-RNA was significantly higher in the native liver tissues than in the serum before (29/80, 36.3%;p = 0.000) and after LDLT (3/80, 4.4%;p = 0.000). In contrast, hepatic HCV Ag was 100% negative identified in all 80 explanted native liver. Conclusions: Significant positive HCV-RNA identification in the native liver suggested that pre-LDLT serum HCV RNA should be underestimated in the real status of HCV activity. HCV Ag assay may have lack of sensitivity and negative predictive value in liver tissues. In contrast to serum HCV RNA and HCV Ag, a great discrepancy might be described between hepatic HCV RNA and HCV Ag in the liver tissue. (Figure Presented).
ABSTRACT
Background: Two million adults and children die each year of liver disease. Liver transplantation (LT) is the second most common solid organ transplantation, however, less than 10% of global transplantation needs are achieved. Low- and Middle-income Countries (LMIC's) are the most affected. A University based Center for Global Surgery and our LT team, started collaborations with counterparts in LMIC's over a decade ago and joined efforts in 2017 to create an international alliance that allows clinical care, education and research endeavors. We aim to describe our experience establishing a LT mentoring group within an academic Center for Global Surgery. Methods: This is a retrospective observational study. We evaluated the number of clinical, research and educational activities that our program did in collaboration with LMIC's for more than a decade (2009 -2022).Surgeries, patient evaluation and follow-up were done in a multidisciplinary fashion with protocols and guidelines from our LT program in partnership with LMIC's LT teams and via telehealth. Most educational and research activities were done online. Results: We performed 15 surgeries in pediatric and adult patients, including cadaveric and living donor LT, portosystemic shunts and resections and evaluated 27 patients from LMIC's. We published 1 article, presented 5 s and obtained 1 grant. Our group received support to sponsor one research scholar per year and we had 15 bilateral exchange visits and organized 27 online multidisciplinary education sessions in collaboration with centers from LMIC'S. Conclusions: Our data shows that global efforts with a multidisciplinary model supported by international societies can have clinical and academic impact. It is feasible to partner and mentor the academic and clinical development of LT programs in LMIC's through telehealth and exchange programs. Funding of these efforts remains challenging, and COVID-19 has limited academic and clinical activities.