Variation in DCD Liver Transplant Protocols Among Transplant Centers in the United States.

Background: Variation in donation after circulatory death (DCD) organ recovery and liver transplant practices exist among transplant centers. This study aimed to evaluate these practices among centers in the United States. Methods: Scientific Registry of Transplant Recipients data were accessed to identify centers that performed liver transplantation in 2021 and 2022. Surveys were sent to transplant centers that consistently performed ≥5 DCD liver transplants per year. Results: DCD liver transplants were performed by 95 centers (65.1%) of the 146 liver transplant centers in the United States. Survey results were recorded from 42 centers that consistently performed ≥5 DCD liver transplants per year, with a 59.5% response rate. Withdrawal-to-asystole and agonal time were used to define donor warm ischemia time (WIT) in 16% and 84% centers, respectively. Fifty-six percent of the centers did not use oxygen saturation to define donor WIT. Systolic blood pressure cutoffs used to define agonal time varied between 50 and 80 mm Hg, donor age cutoffs ranged between 55 and 75 y, and cold ischemia times varied between 4 and 10 h. Seventy-six percent of centers used normothermic machine perfusion for DCD liver transplantation. Conclusions: This study highlights the wide variation in use, recovery, and definition of donor WIT. Using national data to rigorously define best practices will encourage greater utilization of this important donor resource.

Spinal Stroke following Kidney Transplant.

Complications are a part of surgery. Spinal infarctions are a dreaded complication of aortic surgery. We present a patient who developed a spinal infarct after a kidney transplant. We were unable to find a causative factor in our search for etiology. In our review of the literature, we were unable to find a similar report. We present this case report to highlight a rare complication of kidney transplantation and to reinforce that patients requiring kidney transplant are complex patients with multiple comorbidities that can cause a multitude of complications in the periop period.

Safely Expanding the Liver Donor Pool by Utilization of Organs from Donation after Circulatory Death with Comparable Results to Donation After Brain Death, a Large Single-Center Experience.

BACKGROUND: Use of livers donated after circulatory death (DCD) is one way to expand the donor pool. Our center has aggressively incorporated use of DCD liver grafts into practice. We examined our center and national outcomes as well as national DCD liver utilization. METHODS: Liver transplants performed at our center and nationally from 11/2016 through 9/2020 were compared. Primary outcomes were patient and graft survival, and national DCD liver utilization. RESULTS: For our center, DCD and donation after brain death (DBD) donors were similar except DCD donors were younger (37 vs 40 years; p < 0.05). Recipient Na-MELD (20 vs 24; p < 0.0001) and cold ischemia time (4.63 vs 5.18 h; p < 0.05) were lower in DCD recipients. There were no significant differences in 1-year patient and graft survival between DCD and DBD liver recipients locally. Nationally, there was a difference in 1-year graft survival year (89.4% vs 92.4%, p < 0.0001) but patient survival was similar between groups. The proportion of DCD livers recovered and transplanted widely varied among organ procurement organizations (OPOs) and transplant centers. CONCLUSIONS: Similar outcomes for DCD and DBD liver recipients should encourage centers and OPOs nationwide to expand utilization of DCD livers.

Tubulocystic Renal Cell Carcinoma of the Native Kidney in a Renal Transplant Recipient: A Rare Case Report.

Tubulocystic renal cell carcinoma (TCC) is a rare and newly recognized variant of renal cell carcinoma, which may mimic benign cystic disease of the kidney. To our knowledge, we present the first reported case of a patient who, despite standard preoperative workup, developed TCC of his native kidney soon after receiving kidney transplantation. He was appropriately treated with native nephrectomy and has had no signs of reoccurrence 7 years postoperatively. Given the significant risk of malignancy in renal transplant patients, this case emphasizes the need for close monitoring of native cystic disease before and after transplantation, with low threshold to proceed with surgical intervention.

How far can we go with hepatocellular carcinoma in living donor liver transplantation?

PURPOSE OF REVIEW: Living donor liver transplantation (LDLT) in the setting of hepatocellular carcinoma (HCC) has been adopted worldwide over the past decade. Many centers have implemented LDLT because of the limited supply of deceased organs, which has also provided an opportunity for centers to expand the indication for transplantation for patients with HCC. RECENT FINDINGS: Center-specific expanded HCC criteria have proven to be well tolerated in terms of overall and disease-free survival when compared with the standard, Milan criteria. There is a need to overcome size and number as the sole limiters. New technologies to better predict outcomes after liver transplantation for HCC, response to treatments and/or bridging therapies while waiting for a liver transplantation, along with determining tumour behaviour are being incorporated into criteria. Improved outcomes of LDLT for all causes has increased utilization of the procedure for HCC patients worldwide. SUMMARY: LDLT has become a great treatment option for HCC patients. Progressively better understanding of tumour behaviour and different surrogates of tumour biology assessments will allow better patient selection for LDLT.

Long-term outcomes and transmission rates in hepatitis C virus-positive donor to hepatitis C virus-negative kidney transplant recipients: Analysis of United States national data.

The use of kidneys from hepatitis C virus (HCV)-positive (D+) deceased donors for HCV-negative recipients (R-) might increase the donor pool. We analyzed the national Organ Procurement and Transplant Network (OPTN) registry from 1994 to 2014 to compare the outcomes of HCV D+/R- (n = 421) to propensity-matched HCV-negative donor (D-)/R- kidney transplants, as well as with waitlisted patients who never received a transplant, in a 1:5 ratio (n = 2105, per matched group). Both 5-year graft survival (44% vs 66%; P < .001) and patient survival (57% vs 79%; P < .001) were inferior for D+/R- group compared to D-/R-. Nevertheless, 5-year patient survival from the time of wait listing was superior for D+/R- when compared to waitlisted controls (68% vs 43%; P < .001). Of the 126 D+/R- with available post-transplant HCV testing, HCV seroconversion was confirmed in 62 (49%), likely donor-derived. Five-year outcomes were similar between D+/R- that seroconverted vs D+/R- that did not (n = 64). Our analysis shows inferior outcomes for D+/R- patients although detailed data on pretransplant risk factors was not available. Limited data suggest that HCV transmission occurred in half of HCV D+/R- patients, although this might not have been the primary factor contributing to the poor observed outcomes.

Outcomes of kidney transplants and risk of infection transmission from increased infectious risk donors.

Concern over transmission of viral infections has been reported to result in higher discard rates of high infectious risk kidneys (HIR) although data on actual viral transmission rates are lacking. At our center, we performed 89 HIR and 533 non-HIR kidney transplants (KTs) between 2004 and 2011. Follow-up screening labs in recipients of HIR kidneys tested for human immunodeficiency virus, hepatitis C virus, and hepatitis B virus did not reveal any cases of viral transmission over median follow-up of 4.3 years. Patient and graft outcomes were similar at 5 years between HIR and non-HIR KTs. An updated analysis of the Organ Procurement and Transplant Network (OPTN) registry of deceased-donor kidney transplants between 2008 and 2012 included 57 526 transplants was performed. Retrospective calculation of KDRI (kidney donor risk index) differed (P<.001) between all groups with median KDRI of 0.99 for HIR kidneys, 1.07 for non-HIR standard criteria donor kidneys, and 1.81 for non-HIR expanded criteria donor (ECD) kidneys. This was reflected in the significantly improved 5-year graft survival for HIR KTs when compared with non-HIR ECD KTs (84% vs 78%; P<.001). Our data can guide counseling of KT candidates about the safety and benefits of HIR kidneys.

Association between Interruptions in Chemical Prophylaxis and VTE Formation.

Venous thromboembolisms (VTE) are considered preventable events with appropriate mechanical or chemical prophylaxis. However, chemical prophylaxis is frequently delayed or interrupted during hospitalization. We investigated the impact of delayed initiation and interruption of chemical prophylaxis on VTE rates. The incidence of VTE at an urban academic medical center was measured in patients hospitalized for >2 days between November 2013 and May 2014. Patients receiving prophylaxis were grouped as complete (started within 24 hours of admission and no interruptions), delayed (started >24 hours and no interruptions), and interrupted (interruption for >24 hours with or without delay). There were 9961 hospital admissions and 33 VTE (3.3 per 1000 admissions). 25.2 per cent had complete, 16.4 per cent had delayed, and 11.8 per cent had interrupted prophylaxis. 36.8 per cent received no prophylaxis. Interrupted prophylaxis was associated with more VTE than complete (10.2 vs 2.0 per 1000, P < 0.01) and 5.2 greater odds. Admission to a surgical service and prolonged hospital stay were independently associated with increased likelihood of VTE. There was a lower likelihood of getting complete prophylaxis among patients admitted to orthopedic, transplant, cardiac, plastic, and vascular surgery. Surgical patients are at higher risk for VTE and interruptions in VTE prophylaxis significantly increase the risk of VTE.