PROviding Better ACcess To ORgans: A comprehensive overview of organ-access initiatives from the ASTS PROACTOR Task Force.

The American Society of Transplant Surgeons (ASTS) PROviding better Access To Organs (PROACTOR) Task Force was created to inform ongoing ASTS organ access efforts. Task force members were charged with comprehensively cataloguing current organ access activities and organizing them according to stakeholder type. This white paper summarizes the task force findings and makes recommendations for future ASTS organ access initiatives.

Ureteral stent placement and BK viremia in kidney transplant recipients.

INTRODUCTION: BK virus (BKV) infection is an important cause of kidney transplant dysfunction. A possible association of double-J ureteral stent placement and BK viremia has been suggested in previous studies; however, risk factors for BK are incompletely understood. We aimed to determine if stent placement is an independent risk factor for BK viremia. METHODS: Data were collected on consecutive kidney-only transplant recipients between December 1, 2006 and June 30, 2010. All patients had at least 12 months of follow-up. RESULTS: Of 600 consecutive kidney transplants, BK viremia within the first post-transplant year was detected in 93 patients (15.5%); in 70 of these cases, the peak BKV polymerase chain reaction was ≥10,000 copies/mL. By multivariate analysis, significant risk factors for BK viremia were recipient age (P = 0.02) and stent placement (P = 0.03). Stents were placed in 49.2% and removed at a median of 46 days (range: 11-284) post transplantation; removals occurred within 0-30, 30-60, 60-90, 90-120, 120-150, and >150 days post transplantation in 18.4%, 67.2%, 10.5%, 2.4%, 1.0%, and 0.3% of cases, respectively. No association was found of BK viremia with stent duration >46 days (P = 0.70) or by the 6-level groupings (P = 0.92). CONCLUSIONS: Although we observed a significant association of BK viremia with stent placement, no dose-dependent effect was seen.

Impact of cold ischemia time on graft survival among ECD transplant recipients: a paired kidney analysis.

Delays in expanded criteria donor (ECD) kidney placement increases cold ischemia times (CIT) potentially leading to discard. The effect of increased CIT on ECD kidney transplant outcomes is unknown. We evaluated paired ECD kidneys (derived from the same donor transplanted to different recipients) from the SRTR registry transplanted between 1995 and 2009 (n = 17,514). To test the effect of CIT, we excluded paired transplants with the same CIT (n = 3286). Of 14,230 recipients (7115 donors) the median difference in CIT was 5 h (Q1 = 3 h, Q3 = 9 h). Delayed graft function (DGF) was significantly more likely between pairs with greater CIT (35% vs. 31%, p < 0.001) including substantially higher rates for CIT differences ≥ 15 h (42%). Overall graft loss was not significantly different between recipients with higher CIT relative to paired donor recipients with lower CIT (p = 0.47) or for pairs with differences of 1-3 h (p = 0.90), 4-9 h (p = 0.41), 10-14 h (p = 0.36) or ≥ 15 h (p = 0.10). Results were consistent in multivariable models adjusted for recipient factors. Although increasing cold ischemia time is a risk factor for DGF among ECD kidney transplants, there is no effect on graft survival which may suggest an important utility for donor kidneys that may not currently be considered viable.

Import kidney transplants from nonmandatory share deceased donors: characteristics, distribution and outcomes.

Outcomes of locally rejected kidneys transplanted at other centers (import KTX) are unknown. SRTR data from 2000 to 2009 of deceased-donor KTXs excluding 0-mismatch, paybacks, and other mandatory shares were compared by location of KTX at local (n = 48,165), regional (n = 4428) or national (n = 4104) centers using multivariable regression models. Compared to nonmandatory share local transplants, import KTX were associated with significantly higher overall risks of patient death (regional aHR 1.15, p < 0.01; national aHR 1.14, p < 0.01), and graft failure (regional aHR 1.17, p < 0.01; national aHR1.21, p < 0.01). In paired analysis, the risk of delayed graft function (DGF) for import KTX was higher compared to locally transplanted mates (regional aOR 1.53, p < 0.01, national aOR 2.14, p < 0.01); however, despite longer ischemia times, overall graft survival was similar. Mean cold ischemia times (CIT) pre- and post-DonorNet were similar for local and regional transplants, but significantly higher for national transplants (28.9 ± 9.9 vs. 29.9 ± 9.7 h, respectively, p = 0.01). Import KTX is associated with increased risks of graft failure, patient death and DGF. In the era of DonorNet cold ischemia times of kidneys imported to regional centers are not improved compared to pre-DonorNet; and, those of national centers are significantly prolonged.

Successful treatment of invasive mucormycosis in a liver transplant patient by arm amputation.

Mucormycosis is an uncommon but frequently fatal infectious complication after solid organ transplantation. We describe successful treatment of invasive mucormycosis in a liver transplant recipient by wound debridement, a right above-elbow arm amputation, and antifungal medications. Early recognition, prompt operative intervention, and initiation of an appropriate antifungal treatment are very important in the management of mucormycosis, a potentially life-threatening infection.

Elevated incidence of posttransplant erythrocytosis after simultaneous pancreas kidney transplantation.

Posttransplant erythrocytosis (PTE) poses a potential risk of thrombosis in kidney transplantation. Clinical observation of our systemically drained simultaneous kidney pancreas transplant (S-SPK) patients showed a higher incidence of PTE and need for phlebotomies. To evaluate the incidence of PTE we analyzed hematocrit (Hct) levels and frequency of phlebotomies in 94 SPK as compared to 174 living donor (LD) recipients and 53 type-I diabetic with kidney transplant only. For study purposes we defined PTE as Hct >50% or the necessity for phlebotomies. Kaplan-Meier plots and Cox proportional hazard models were used to examine the association between the transplant type and PTE. We found an increased incidence of PTE in SPK compared to LD (p < 0.001). In the multivariate model, SPK had a 5-fold risk for the development of PTE (AHR 5.3, 95% CI 1.8, 15.9). The incidence of therapeutic phlebotomy was 13% among SPK patients and 4% in LD kidney recipients; 19 patients altogether. A total of 64 units were phlebotomized (48-SPK and 16-LD). Type I diabetic patients with a kidney transplant showed a 0% incidence of PTE. We observed a greater incidence of PTE and phlebotomies in S-SPK compared to LD with kidney only transplant recipients.

Single kidney transplantation from young pediatric donors in the United States.

Kidney transplantation (KTX) from small pediatric donors is performed as single or en bloc. Criteria to determine when to split pediatric donor kidneys and transplant as singles are not well established. Data reported to the Scientific Registry of Transplant Recipient for donors <10 yrs from 1995 to 2007 were reviewed (n = 5079). Donors were categorized by weight group by 5 kg increments and solitary (n = 3503) versus en bloc (n = 1576). The primary outcome was overall graft survival. Results were compared as adjusted hazard ratios (aHR) relative to ideal standard criteria donors (SCDs) (defined as age 18-39 without other risk factors), non-ideal SCDs (all other SCDs) and expanded criteria donors (age 50-59 with other risk factors or age >or=60). Single KTX from donors >or= 35 kg conferred a similar risk of graft survival as ideal SCDs. Of donors 10-34 kg, risks of en bloc KTX were similar to ideal and risks of single KTX to non-ideal SCDs; single and en bloc KTXs had 7.9 and 5.2 graft losses per 100 follow-up years, respectively. Single KTX from donors >35 kg are similar to ideal SCDs. Single KTX from donors 10-35 kg are similar to non-ideal SCDs. From a resource perspective, pediatric donors 10-35 kg used as singles offer more cumulative graft years than when used en bloc.

The success of continued steroid avoidance after kidney transplantation in the US.

There has been a significant increase in the use of steroid avoidance regimens as initial treatment for kidney transplant recipients. Early results of the effectiveness of this strategy has been mixed with certain prospective trials indicating increased acute rejection but population-based studies indicating similar or better graft survival as compared to steroid maintenance. We conducted a retrospective study of national registry data to evaluate risk factors for discontinuation of steroid avoidance protocols based on patient characteristics and concomitant immunosuppression. We evaluated 84 647 solitary kidney transplant recipients in the US with at least 6 months graft survival including 24 218 initially discharged without maintenance steroids. We utilized logistic models to assess risk factors for new initiation of steroids after initial steroid-avoidance and survival models to describe graft survival for patients after return to steroids. The most prominent risk factors for new initiation of steroids after deceased donor kidney transplantation included African-American race (AOR = 1.32, p < 0.01), retransplants (AOR = 1.81, p < 0.01), highly sensitized recipients (AOR = 1.29, p < 0.01), recipients with Medicaid (AOR = 1.85, p < 0.01), elevated HLA-MM (AOR = 1.26, p < 0.01) and older donor age (AOR = 1.19, p < 0.01). Concomitant medications were also significantly associated with the propensity to newly initiate steroids. Cumulatively the study suggests that both patient characteristics and concomitant medications are strongly associated with the success of steroid avoidance immunosuppressive regimens.

Outcomes and utilization of kidneys from deceased donors with acute kidney injury.

Utilization and long-term outcomes of kidneys from donors with elevated terminal serum creatinine (sCr) levels have not been reported. Using data from the Scientific Registry of Transplant Recipients from 1995 to 2007, recipient outcomes of kidneys from adult donors were evaluated stratified by standard criteria (SCD; n = 82 262) and expanded criteria (ECD; n = 16 978) donor type and by sCr 2.0 mg/dL. Discard rates for SCDs were ascertained. The relative risk of graft loss was similar for recipients of SCD kidneys with sCr of 1.6-2.0 and >2.0 mg/dL, compared to 2.0 mg/dL (adjusted odds ratio [AOR] 7.04, 95% confidence interval [CI] 6.5-7.6) and 1.6-2.0 mg/dL (AOR 2.7; CI 2.5-2.9) relative to sCr

Recovery factors affecting utilization of small pediatric donor kidneys.

UNLABELLED: Kidneys from small pediatric donors are underutilized. Using data from the Scientific Registry of Transplant Recipients for donors <21 kg in which at least one organ was recovered from 1997 to 2007 (n = 3341), donor and recovery factors were evaluated by multivariate analysis for associations with (a) kidney nonrecovery and (b) transplantation of recovered kidneys. RESULTS: The proportion of kidney recoveries were 55% during liver procurements and 40% during intestine procurements amongst donors <10 kg (p < 0.01) compared to 93% and 88%, respectively, for donors weighing 10-20 kg (p = 0.003). Intestine procurement was independently associated with an 81% greater likelihood of kidney nonrecovery (p < 0.0001) and a 48% lower likelihood of transplantation (p = 0.0004). A multivariate Cox model indicated that single kidney recipients had a 63% higher risk of graft failure compared with en bloc kidney recipients (p < 0.0001); however, concurrent intestine recovery was not a significant risk factor for graft loss. Intestine recovery from donors <21 kg of age is strongly associated with higher kidney nonrecovery and lower transplantation rates. Graft survival is worse with single kidney transplantation, but is not significantly affected by intestine recovery. Small pediatric donors procurement teams should strive to increase kidney recoveries overall and en bloc recoveries in particular.

A comparison of alemtuzumab with basiliximab induction in simultaneous pancreas-kidney transplantation.

Alemtuzumab is a humanized, rat monoclonal antibody directed against the CD52 antigen. After binding, alemtuzumab causes profound and durable depletion and has been successfully used as immune induction therapy for organ transplantation. This was a single center, retrospective review of patients who underwent simultaneous pancreas-kidney transplantation at the University of Wisconsin using alemtuzumab induction therapy compared with historical controls that received induction with basiliximab. There were no differences in donor or recipient demographics, rates of patient survival, renal or pancreas allograft survival, renal allograft delayed graft function, EBV infection, BKV infection, PTLD or sepsis. There was a statistically significant increase in the incidence of cytomegalovirus (CMV) infection in the alemtuzumab-treated group. Given the significantly higher incidence of CMV infections, we have since altered our induction protocol to consist of a single 30 mg dose of alemtuzumab instead of two doses. The long-term effects of this change remain to be seen. Due to the results seen in this study, the low initial cost of the drug and the absence of any severe, short-term side effects, alemtuzumab has been selected as the induction drug of choice at our center for patients undergoing SPK.

Long-term medical complications in patients surviving > or = 5 years after liver transplant.

BACKGROUND: Short-term outcomes of liver transplantation are well reported. Little is known, however, about long-term results in liver recipients surviving > or =5 years. We sought to analyze long-term complications in liver recipients surviving > or =5 years after transplant, to assess their medical condition and to compare findings to the general population. METHODS: We analyzed the chart and database records of all patients (n=139) who underwent liver transplantation at a major transplant center before January 1, 1991. Outcome measures included the presence of diabetes, hypertension, heart, renal or neurological disease, osteoporosis, incidence of de novo malignancy or fracture, or other pathology, body mass index, serum cholesterol and glucose, liver function, blood pressure, frequency of laboratory and clinic follow-up, current pharmacological regimen, and late rejection episodes. RESULTS: Ninety-six patients (70%) survived > or =5 years. Compared to numbers expected based on U.S. population rates, transplant recipients had significantly higher overall prevalences of hypertension (standardized prevalence ratio [SPR]=3.07, 95% confidence interval [CI], 2.35-3.93) and diabetes (SPR=5.99, 95% CI, 4.15-8.38), and higher incidences of de novo malignancy (standardized incidence ratio [SIR]=3.94, 95% CI, 2.09-6.73), non-Hodgkin's lymphoma (SIR=28.56, 95% CI, 7.68-73.11), non-melanoma skin cancer (estimated SIR> or =3.16) and fractures in women (SIR=2.05, 95% CI, 1.12-3.43). Forty-one of 87 (47.1%) patients were obese, and 23 patients (27.4%) had elevated serum cholesterol levels (> or =240 mg/dl, 6.22 mmol/L), compared to 33% and 19.5% of U.S. adults, respectively. Prevalences of heart or peptic ulcer disease were not significantly higher. CONCLUSIONS: Liver transplantation is being performed with excellent 5-year survival. Significant comorbidities exist, however, which appear to be related to long-term immunosuppression.

Transmission of factor VII deficiency through liver transplantation.

The liver is the primary site of synthesis for the majority of coagulation factors. There are published accounts of liver donor-to-recipient transmission of protein C deficiency with dysfibrinogenemia and factor XI deficiency. In this article, we report what we believe to be the first observation, of transmission of factor VII deficiency, a rare, autosomal recessive coagulation disorder, from an affected liver donor to a naive liver recipient. At 300 days after transplantation, the recipient remains with an isolated prolongation of the prothrombin time and a below-normal level of factor VII, and has had no bleeding complications.